Wednesday, June 8, 2011

Cash incentives for HIV prevention (part I)

Conditional cash transfer programs are gaining steam as an intervention to prevent HIV infection. Under these programs, health authorities offer people money to increase incentives for healthy behaviors. For instance, in Malawi, the World Bank recently tested a program for HIV prevention among young women. In this program, if you were a girl randomized to the intervention arm, your parents received $4-10/month and, if you attended school regularly, you received $1-5. In the study, the intervention cut HIV incidence by more than half. Additional studies testing similar interventions are underway.

These interventions are being considered for large-scale rollout. They're also pretty controversial: USAID considered the topic as part of its debate series on emerging issues in HIV response. In particular, opponents object to the conditioning of the cash transfer. Inevitably somebody will use the word "bribe" to describe what happens: some people will alter their behavior in order to obtain the incentive. (If the incentive is unconditional, then the mechanism of action seems a little different: perhaps access to greater resources reduces young women's dependence on men, a likely reason that some of them engage in risky sexual behaviors.) But suppose that the program is cost-effective (or even cost-saving)--what's wrong with using money to get people to do what you want them to?

Well, we can start by looking at a program that looks pretty bad to most people: the attempt by a U.S.-based nonprofit to increase contraceptive use in Kenya by offering HIV-positive women $40 to have an intrauterine device implanted. The founder of the program, Barbara Harris--who gained notoriety in the '90s for offering $300 to drug-using California women to be sterilized--says the goal of the program is to reduce the transmission of HIV to newborns. An observer says this program is "coercive and discriminatory." Can we distinguish it from other conditional cash transfer programs?

2 comments:

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