On April 26 the Financial Times reported that the World Bank was supporting a $1.8 million dollar experimental approach to reduce the new cases of HIV in Africa, in this case, specifically Tanzania. The program, jointly funded by the World Bank, the William and Flora Hewlett Foundation, the Population Reference Bureau and the Spanish Impact Evaluation Fund, essentially seeks to decrease new cases of HIV acquisition by paying people not to contract the virus. Briefly, the study enlists 3000 men and women in the southern rural regions of Tanzania who will each receive $45 if they continue to test negative for HIV in periodic testing over the course of 3 years. I could not determine if the participants received $45 each time they tested over the course of the 3 year trial or if this was a one-time payment to be received at the end of 3 years.
One of the things that surprises me the most about this announcement is the lack of discourse about this issue, both in op/ed pieces in national newspapers and in the blog community. In fact, I am stunned at the seeming complete absence of notice this news item has received. Paying people NOT to engage in a given activity, particularly on this scale, has to be one of the most unusual and controversial approaches in modern behavior change theories and models. So, let’s look solely at the economics of this approach. Currently there are about 800 million people living on the African continent. I will use Africa here only because the high incidence of HIV in Africa underscores the economics of such an approach but still leaves the numbers sufficiently manageable to establish estimates. Roughly 23 million people on the African continent are currently infected with the HIV virus. If we estimate that approximately half of the 800 million people in Africa are at an age in which they are likely to engage in sexual activity, and this is probably a low estimate, we are considering 400 million people who are at risk for contracting HIV. If you subtract the 23 million people in Africa who are currently living with HIV, that leaves 377 million people that are at some risk for developing HIV. At $45/person, if we were paying them not to contract HIV, that totals approximately 16,965,000,000.00, or roughly 17 billion dollars. Ok, so the Iraq War is estimated to have cost the American tax payers about 500 billion dollars in 5 years, averaging to 100 billion a year. Hmmm, 17 billion, especially over 3 years, seems like a bargain.
An article in the Journal of Acquired Immune Deficiency Syndromes estimates that the economic cost of HIV/AIDS in Africa is about 36.4 billion dollars a year. If you divide that figure by the 23 million people in Africa currently infected by the HIV virus, you come out with a figure of just under $1600.00 per person per year. God, is that right? The total figure includes loss of productivity, economic impact, etc. I think it’s about 10 – 20 billion dollars per year that actually comes in as direct funds, from governments and private organizations. Certainly that money doesn’t all go toward individuals with HIV. Some of that money goes toward programs for prevention, programs for orphans, organizations established to mitigate the ravages of the HIV pandemic, etc. Actually, most of that money goes down the drain. But, nonetheless, we have a figure of about $1600/HIV infected individual/year in Africa. Well, quite frankly, $45 per person, whether it is over one year or 3 years, if the program actually worked, would be a screaming deal. I have to admit, although I initially found this program conceptually repugnant, fiscally it would make sense. If it works. Even if it works somewhat.
So, what’s wrong with the idea? Paying people to make decisions that are for their own good as well as the good of society seems inherently wrong. Do we start paying people to stop smoking or to eat less? I suspect if we look at the cost to society, both in medical costs and with respect to lost productivity, if such programs were successful we would pay much less in the long run. And, if behavior change can be bought, do we then start paying people not to sell drugs or not to commit crimes? I think it’s a bad idea born of absolute desperation as the World Bank continues to pour billions of dollars into the HIV pandemic only to see the problem worsen as each year goes by. And I don’t think it will work over the long haul. The approach may enjoy marginal success in Tanzania, across 3000 people, but behavior change doesn’t come easy and sustaining it is challenging. As a former smoker I can attest to that.
The bottom line is that this approach sets a bad precedent. I have seen people in Africa refusing to come to an HIV workshop or seminar unless they receive a hefty stipend/allowance, a buffet lunch, and a t-shirt. I have been told that NGOs in Lilongwe, Malawi, won’t come to a meeting in Lilongwe itself because the daily allowance they receive is too low unless the meeting is held out of town. We have made HIV a lucrative business, perhaps the fastest growing industry in Africa, with Eastern Europe and Asia following suit. Whatever the outcome, I had hoped to see more debate about this approach in the popular media. So start talking about it and please feel free to leave a comment (below) and engage in a dialogue.
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