Tag Archives: research

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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Health and research

Ibrahim has a problem. The bright young doctor from Mali is doing research on sexual health of adolescents in a big French city but finds his work obstructed by the local government. Ibrahim has been forbidden to ask his research subjects about their sexual life. High rates of teenage pregnancy and sexually transmitted infections give the city a bad rep and the government deems it better to hush things up.

I met Ibrahim at the World Health Organization in Geneva at the annual workshop on sexual and reproductive health organized by the organization I work for, the Geneva Foundation for Medical Education and Research. All participants were from countries facing huge challenges in this respect: lack of care for pregnant women and newborns, few family planning services, unsafe abortions, high rates of sexually transmitted infections and a general lack of sexual health.

The workshop brought together a group of health professionals committed to improving the situation in their country and offered them a platform to discuss some of their many challenges. Where do you find teenagers to discuss sexual health in a country where school attendance is low? Is it ethical to teach community workers to administer contraceptive injections in a region where there’s a lack of nurses and doctors? To what extent are projects fighting female genital mutilation in one country useful for another country with a different social setting?

Particularly exasperating for the workshop’s participants is sabotage of their research by the government. Doctor S. is studying child wishes of HIV infected people in Iran. Her government refuses to acknowledge there’s such a thing as HIV and, if there is, then those infected are drug users so they’re not supposed to want children. As a consequence, Doctor S. keeps a low profile for the safety of her research subjects and herself.

So doctor S. could not to be in the group picture we took of all the workshop participants, lecturers and organizers. Ibrahim could: he will soon return to Mali. France will lose a smart doctor and the opportunity to improve the health of a particularly vulnerable group of people.

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