Category Archives: Health

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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Female genital mutilation: why Geneva University should care

A woman who has undergone genital mutilation can have a great sex life, her health won’t be affected and she has almost no chance of dying from the procedure – according to a course given at the Geneva University. A student contacted my employer, the Geneva Foundation for Medical Education and Research, to ask whether this is a correct account of current scientific evidence. “In my opinion even one woman dying because of female genital mutilation is unacceptable,” the student wrote in an email, “or am I overreacting?”

Female genital mutilation are procedures (the World Health Organization distinguishes four different types) involving partial or total removal of the external female genitalia or other injury to the female genital organs. It is practiced mostly in Africa for non-medical reasons and is often regarded as a cultural requirement. Numerous governmental and non-governmental organizations have developed approaches to motivate people to abandon female genital mutilation. Nevertheless it’s been estimated that 130  to 140 million girls and women had been subjected to FGM worldwide and that, each year, 3 million girls undergo the practice – part of whom live in the migrant communities in Europe.

The severe health effects of female genital mutilation are both immediate and long-term: bleeding, problems urinating, cysts, infections, infertility, complications in childbirth and increased risk of maternal and newborn deaths. The serious mental effects of the painful procedures, performed without anesthesia using instruments such as broken glass and scissors, are well-documented. Despite the mounting evidence of the health consequences, Geneva University teaches students that we  have to consider female genital mutilation as a cultural practice that we can’t judge with ‘Western’ moral codes. But well-being is not a Western concept: it’s a basic human right.

Last December the United Nations passed a resolution condemning the practice of female genital mutilation and urging enforced legislation, awareness-raising and the protection of women and girls. The resolution was sponsored by the Group of African States that considers female genital mutilation not as cultural heritage, but as violence. Supporting them in their efforts to stop female genital mutilation is not western imperialism.

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