"Pay for Prevention" and Other Innovative Ways to Reduce the Spread of Disease

April 30, 2008
The front page of the weekend edition of the Financial Times reports a Tanzanian research proposal with the breathless fanfare usually reserved for a medical or scientific breakthrough. In fact, the FT is not announcing a new research finding, but is prematurely publicizing a planned research project which the Tanzanian government has yet to authorize. The researchers propose to offer payments to women who repeatedly test negative for curable sexually transmitted infections, such as gonorrhea and syphilis. The hope is that reductions in unsafe sexual contacts will protect the women not only from the curable STIs but also from contracting or spreading HIV, and the research project will measure whether this happens. To help them achieve these objectives and also to contribute to the womens' success in other dimensions of their lives, the intervention includes substantial gender and life-skills counseling. To measure success in dimensions beyond safe sex, the researchers will collect data on the women's labor force participation and on other economic outcomes. The FT article makes clear that the payments are unrelated to the HIV status of the women in the study. Since I am a member of the research team, it's not surprising that I think this is a good idea. Although no one knows whether the idea can be shown to work in the proposed Tanzanian location or elsewhere, there are reasons to be optimistic. First, so-called "conditional cash transfers" have previously been shown to be successful in changing health-related behaviors and improving health. For example, in Mexico's Progresa program (See the CGD evaluation in Millions Saved) cash grants conditional on a poor family's preventive health visits are associated with improved health of the family, adults and children alike. Second, transfers which are conditional on remaining free of the curable STIs reward safe behavior among those who are already HIV-positive as as well as those who are not. This is in contrast to conventional HIV testing and counseling programs, which urge safe sex by appealing to the self-interest of those who test negative, but can only appeal to the altruism of those who are already infected. I discuss these themes in a CGD working paper that will be posted on our website shortly (5/5/08 UPDATE: this paper is now availble here). The paper addresses the possible unintended consequences of expanded HIV testing of individuals and argues that testing of couples would be more deserving of widespread support. It also suggests a way to use successful AIDS treatment programs to strengthen prevention programs, by rewarding AIDS treatment groups for their HIV prevention results in the community at large. I hope that Tanzania and other countries with AIDS epidemics will follow the example of Mexico in rigorously testing innovative ways to prevent HIV infection. I also hope that the next U.S. president will support such innovative ideas and their evaluation with PEPFAR funding. If rigorous evaluation proves that some of these efforts to slow the AIDS epidemic actually work, the unbridled enthusiasm of journalists will be truly justified.


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.