Now For Something Completely Different

“Insanity: doing the same thing over and over again and expecting different results.” 
Albert Einstein

Back in 2005, I wrote a piece for a US healthcare magazine with the hugely pretentious title, ‘Of Hamlet and Per Diem’, I am now embarrased about the name, but article itself attracted considerable email flak, which was fun, It began as a discussion of Uganda’s long battle against HIV/AIDS and went on to describe how the focus had been lost, through a mixture of corruption, ideology and above all, a lack of original thinking, particularly in the hugely lucrative arena of HIV/AIDS Prevention. As a finale, I offered what I considered to be an original idea. Here it is in its in edited form:

“If, as I have argued, Uganda’s HIV/AIDS strategy is dysfunctional, what is to be done? Well, we cannot continue doing what we have always done and when it shows not to be working, try harder and throw more money at it. The time has come for original thinking and novel approaches. The key must be to reduce the opportunities for misappropriation, get more of every dollar donated, to land on the final target and develop long-term independence by making individual Ugandans responsible for their own health and future.”

“Here is my ‘out of the box’ idea. Somebody out there give me $1m, no strings attached. I will put it in a Ugandan Bank. I will then advertise for 1,000 volunteers from the next intake of Freshers at Makerere University. All will be required to undergo an HIV test. The first 1,000 ‘negatives’ will have a bank account opened in their name, a ‘health savings account’, containing $900.”

The contract will be they remain negative until they graduate. Immediately before graduation, they will be tested again and those still negative will have unrestricted access to their savings account, to do whatever they please with both the original sum and the interest accrued. How individuals stay healthy - ABC or any variation thereof - is a personal and private concern. If the project is a success, it will be repeated and widened, dependent on donor interest and funding ( if I had access to the $200m from the Global Fund I could impact on 200,000 people). This may seem a lot of money for a relatively small number of people, but in my time in Africa I have seen much more spent for much less impact.”

“I can hear the howls of indignation from the politically correct. ‘This concept smacks of bribery, it has no place in respectable social science’ etc. I offer the following for consideration:
Many more than 1,000 will volunteer; the ‘Positives’ will be able to seek treatment and long-term care, the ‘Negatives’ will know their status and adjust their lives accordingly
1,000 ‘at risk’ individuals will be trying to stay out of the ‘risk pool’ for three years
Money spent on administration will be minimal (much less than most current prevention programs).
Opportunities for misappropriation and mismanagement of funds will be negligible
On successful graduation, the capital sum plus interest accrued, will go directly to the individual, without caveat.
The money will probably be spent in-country on an individual basis.
Each individual will be incentivized to make personal decisions regarding their current and future health status.
Individuals will recognize that they are capable of determining their own future.”

“I doubt that, at first blush, I have convinced many that this idea is anything more than the crude use of financial reward to manipulate social behaviour. That might be true, but is it any more odious than many current schemes? At least it has no moral or ideological strings attached, requires minimum administration and does not lend itself easily to misappropriation. Has anyone out there got a better idea?”

Now why have I reprised this piece of public health apostasy “bordering on the immoral” (as one critic described it) at this time?
Well it seems that not everyone thinks it’s nonsense, the World Bank appears to have at least one person who inhabits the same parallel universe as me. This report by the Financial Times in late April 2008 outlines a program that aims to provide a financial incentive to encourage people in Tanzania to ‘avoid unsafe sex’:

[T]housands of people in Africa will be paid to avoid unsafe sex, under a groundbreaking World Bank- backed experiment aimed at halting the spread of Aids. The $1.8m trial – to be launched this year – will counsel 3,000 men and women aged 15-30 in southern
rural Tanzania over three years, paying them on condition that periodic laboratory test results prove they have not contracted sexually transmitted infections.
The proposed payments of $45 equate to a quarter of annual income for some participants. The programme, jointly funded by the World Bank, the William and Flora Hewlett Foundation, the Population Reference Bureau and the Spanish Impact Evaluation Fund, marks an important step in the fight to tackle Aids, which claims 2m lives a year.
In spite of billions of dollars spent annually on treatment and prevention worldwide, there were about 2.5m new HIV infections in 2007, predominantly in Africa. Carol Medlin from the University of California, San Francisco, one of the researchers, said: “We hope
this ‘reverse prostitution’ will make people think hard about the long-term consequences of their short- term behaviour.”
The Tanzanian experiment is a big advance in efforts to test public health ideas more rigorously, with some participants placed in a control arm not offered payment in order to track the effects of the
programme precisely.
“Conditional cash transfers” have already been used in Latin America to motivate poor parents to attend health clinics, and have their children vaccinated and schooled. The designers of the Tanzanian programme believe that payments of $45 when combined with careful counselling could play an important role in reducing HIV infection, especially for vulnerable young women.

The study will be conducted by the Ifakara Health Research and Development Centre in Tanzania, in conjunction with researchers from the University of California, Berkeley, the University of California, San Francisco and the World Bank. The Tanzanian trial programme, which is still subject to fine-tuning and ethical approval, will not specifically test for HIV, which is costly and already widely conducted in the country. It will use proxies , including gonorrhoea, and guarantees any participant found to be infected receives state treatment.
By Andrew Jack in London
Published: April 25 2008
The Financial Times Limited 2008

Whilst I am not yet saying, “I told you so!” I am encouraged that the HIV/AIDS industry might at last , after 20 years and countless billions of dollars, be trying to find alternatives to wornout and anemic ‘prevention’ activities encapsulated in meaningless jargon like, ‘sensitization’, ‘community mobilization’, ‘user-friendly youth services’ and ‘behavioral change’. Prevention strategies that are rarely if ever rigorously evaluated and yet judging by the numbers ( 2.5 m new cases in 2007) appear to be as effective as African road-signs.

In researching this article I came across one of the key architects of this concept of ‘conditional cash transfers, a chap with the splendid name of Meade Over., a Senior Fellow at the Center for Global Development, where he works on issues related to the economics of efficient, effective and cost-effective health interventions in developing countries. And his work is very impressive. His thinking is refreshingly original. Anyone who has an interest in HIV/AIDS would do well to visit his blogsite at: http://blogs.cgdev.org/globalhealth/2008/04/pay_for_prevention_a_1.php

I recommend not only the short article on ‘Pay for Prevention’ but also his working paper on the failure of Prevention and its future impact on the President’s Emergency Plan for AIDS Relief (PEPFAR)

After six years in East Africa peering closely at a disease that has killed millions, brought out the best and the worst in people and made many of the latter wealthy, I know I am at risk of incurable cynicsm. This glimmer of new thinking gives me fresh hope. I am still looking for a donor!