Tag Archives: sexual and reproductive 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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Working (out) in Ethiopia

“No problem!” My Ethiopian colleague smiled encouragingly. He had just welcomed me to the medical centre of Gondar University, in the north of Ethiopia, where I was to give a training. Then he showed me the computer room I was expected to use. I looked at the dodgy PCs and felt slightly concerned. The training’s e-learning tools were developed in the UK with the best intentions but not quite the same system requirements as in Africa. “What if we get a blackout?” I asked him. “We have a generator,” my colleague replied. “No problem!”

I work for the Geneva Foundation for Medical Education and Research, a non-profit organization focusing on sexual and reproductive health. My colleagues and I provide health professionals in developing countries with trainings and help them conduct and publish their research. We often work together with other organizations and institutions. In Ethiopia, I represented my NGO as well as Oxford University. I was expected to gather health professionals, facilitate a digital training on a certain complication of pregnancy and reward the participants with a certificate.

There proved to be a few challenges. More people showed up than had inscribed for the trainings so there were not enough PCs available. Internet slowed down or halted completely. Plan B was to hand out CDs with the course material. But many computers lacked the software required for the training’s complicated graphs. Or the CD was not compatible with the brand-new Macintosh computers that had been donated by a well-wisher. Or passwords to allow updates were missing. Wireless keyboards and mice that didn’t match proved another problem. During my visit to Ethiopia, I became accustomed to running around in hot, stuffy computer rooms, explaining the course here, pointing out the proper side of a CD there and updating software everywhere. As soon as I had everything up and running, a blackout would mess things up. And generators never worked.

After the last training I sank to the floor. My Ethiopian colleague stooped over me. “That went really well,” he said casually. I nodded, panting and wiping the sweat of my brow. He shook his head. “Crazy Dutch girl.”

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