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Can you buy changes in health behaviors?

By Stuart Rennie

And the girl behind the counter has a tattooed tear
One for every year he's away she said
Such a crumbling beauty,
Ach there's nothing wrong with her
That a hundred dollars won't fix

Those are lyrics from Tom Waits' song '9th and Hennepin.' They slipped involuntarily into my consciousness when I read about a World Bank study that is being planned in Tanzania. According to the report in the Financial Times, the study involves 'incentivizing' sexual behavior change by means of cold hard cash. Participants, if they do not pick up sexually transmitted infections during the study period, are told that they will receive $45 for their efforts. The study also will have a comparative control arm in which participants will also be tested for STIs, but will not receive any money. One of the researchers from the University of California-San Francisco is reported as saying: “We hope this ‘reverse prostitution’ will make people think hard about the long-term consequences of their short-term behaviour.” An intriguing statement, since it implies that the problem with Tanzanians, in regard to sexually transmitted infections, is that they are just not thinking hard enough. Nothing like 45 dollars to get you to think straight. If the question is -- as the accompanying Editorial puts it -- "Are the funders saying young Tanzanians cannot be trusted to do what is good for them without a bribe?", it looks like the answer is a resounding yes.

Now before you say that the World Bank is throwing money at a problem again -- because, in a sense, they are -- it is necessary to point out that a similar program has had some success. In Mexico's Progresa program, parents were paid educational grants if their children attended school and regularly visited medical clinics, and the program seems to have had positive educational outcomes and also favorable health results. Such 'conditional cash transfer' programs have become increasingly popular in development circles, and have even been imitated in New York City. And if you can make it there, you can make it anywhere, even Tanzania.

Or perhaps not. Educational grants are one thing, cash-in-hand is another. Incentivizing the improvement of your child's health and education is one thing, incentivizing your own sexual activities is another. Some might say that giving money to young women will empower them in negotiating sex with male partners, but others may suspect the women may be targets of violence on payday. Hard to say. And even if the study shows some association between getting money and lower sexually transmitted infections, what then? What are the policy implications? Is paying people off a sustainable way of tackling disease in a population? Should people be paid to prevent themselves from developing chronic illnesses too? Where does it stop?

It is important to note that this 'bold initiative' comes at a time of diminished hopes regarding sexual behavior change. Over the last decades, a great many programs and interventions have been devised, studied and implemented to effect healthy sexual behavior, with only limited success. Millions of sexually transmitted infections continue to occur. Not long ago, the idea of using money to promote safe sex would have been considered simply crassly inappropriate. The current zeitgeist seems to be: hell, we have tried so many things to promote healthy sexual behavior among the poor, why not dangle money in front of them?

Stuart Rennie is a Research Assistant Professor in bioethics at UNC-Chapel Hill. He's project manager for the NIH/Fogarty bioethics grant and ethics consultant for UNC-Gap projects in the Democratic Republic of Congo and Madagascar.