Material incentives in HIV prevention programs

Are you willing to take an HIV test? Maybe if you’d be offered some cash in exchange? In many developing countries material incentives have become the norm in HIV testing programs. What are the drawbacks?

For one, the introduction of incentives has, in some countries, lead to corruption and fraud within the health care system. This isn’t just bad for the state of the health care but also makes evaluation and monitoring of material incentive programs difficult.

There are more objections. We might agree on material inducement for a certain group at risk of HIV, like heterosexual couples, but could disagree on others, for example sex workers. By selecting certain clients material incentive programs exclude people from particularly vulnerable social groups who might have an increased risk of contracting HIV. And what about other complex health problems like cardiovascular diseases? Is it ethical to use material incentives against unhealthy dietary habits and smoking? Should individuals, once they are aware of health risks, not take responsibility for their own health and risk behavior? Surely, incentives are not intended to become the primary reason to stay healthy. This has caused concerns about the long-term health impact of material incentive programs: does risk behavior return once these programs stop?

Finally, material incentive programs can damage the professional ethos of health care professionals. Incentives distract a physician or nurse from their duty to patients and profoundly alter the confidential nature of their relation. Nothing should stand between a patient and medical care, is the argument.

The objections against material incentives seem serious, yet incentives have become omnipresent in health care delivery. A HIV testing and counseling campaign in South Africa, First Things First, might have found a way around the ethical dilemmas. Participants of the campaign could enter a lucky draw and win a car, laptop or smart phone. Then a survey was undertaken to find out whether the material incentive worked as a kind of coercion. It appeared that the ‘buzz’ around the campaign as well as encouragements by friends was what prompted most participants to take the HIV test: not the prizes.

One can imagine that material incentives in combination with a participation survey could actually benefit HIV projects, providing an extra opportunity for counseling. Did you take the HIV test because of the cash offered? How much is your health to you, actually?

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