Pay-it-forward approaches in global health could bring big returns

Can 'contagious' kindness improve public health around the world?
COVID-19 messages focused on kindness identified through a crowdsourcing open call of the WHO and UN.

Many are still struggling in the disruptive wake of COVID-19. An open call from the World Health Organization (WHO) and the United Nations underlines the importance of social solidarity and ‘contagious’ kindness in communities response to COVID-19.

Kindness and generosity, defined as the capacity to give more than is necessary or expected, that are driving people to help others are essential for us to getting through the gloomy, long-lasting fight against the pandemic.

‘Pay-it-forward’ (PIF) is one of the innovative approaches underlining enduring generosity in the face of the COVID-19 crisis. The initiative sees individuals receive a gift from a local person, ‘someone who cares’, and they can then consider supporting subsequent individuals in various different ways. This could include using a health service, like getting a vaccine, or donating a gift (for example, money or hand written messages).

It is an example of upstream reciprocity theory, which suggests that people who are helped by someone feel a ‘warm glow’ that makes them more likely to help other, unspecified people. After a person receives help from someone, there is a perceived social obligation to help another person who needs it. This approach can increase community solidarity and decrease some of the financial barriers to health services.

The pay-it-forward philosophy dates back to ancient Greece, while Benjamin Franklin popularised paying for someone else in 1784. Franklin described how he lent money to others without the expectation of their paying it back, but instead with the notion that this act of generosity could ripple forward among friends. In the past decades, PIF programmes are increasingly implemented in a variety of settings and disciplines, including education, business, and public health.

PIF can be an effective, innovative strategy to solve public health challenges, especially in resource-limited contexts. In partnership with local people and health professionals, we developed a pay-it-forward intervention to promote public health services uptake.

Our pilot study in China saw a 54% increase in testing for sexually transmitted infections among men who have sex with men when the PIF approach was used, compared to 6% in the control group.

Since then, this approach has been expanded and used to improve influenza vaccine uptake among at-risk Chinese sub-groups, with older people and children given a free influenza vaccine for others in the local community. As a result, 83% of people received an influenza vaccination after the PIF intervention, compared to only 35% who were offered a fee-based influenza vaccine. After receiving a vaccine, all but one individual donated money to support subsequent people to receive a vaccine. In addition, many local people created texts, images or videos supporting flu vaccination.

As a novel community-based financial mode, pay-it-forward holds potential to garner community contributions to a global health emergency by fundraising or co-creating messaging. There have been successful examples of using these principles to gather community support to tackle COVID-19 crisis, with implications for further expanding the approach in other global health issues.

While the real win is improving public health, we are thrilled that our project was recognised for its potential in wider application in health and health research by the World Health Organization’s as one of two awardees of the Re-Boot Health and Wellbeing Award in 2021. Join us and register to watch the event here.

However, pay-it-forward is not a silver bullet. While these approaches can expand access to services associated with a fee and serve as a transitioning fee-based service to government service, it’s not intended to replace government services.

Financial sustainability of these programmes are vital and must be researched further. For future scale-up, integrating pay-it-forward into community-based programmes and practices requires a better understanding of the implementation process from different stakeholders’ perspectives.

All things considered, there is no doubt that pay-it-forward approaches could yield big returns in global health.


Tang W, Wu D, Yang F, Wang C, Gong W, Gray K, Tucker, JD. How kindness can be contagious in healthcare. Nature Medicine. DOI: 10.1038/s41591-021-01401-x


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