A post I wrote last week described a “push” approach to AIDS prevention – circumcise men, tell people to use condoms, encourage them not to sleep around too much etc. The World Bank is trying a different tack, using a “pull” method instead: pay people not to get infected and let them work out for themselves how to stay safe. The Bank will pay 3,000 Tanzanians $45 – good money in Tanzania – if they regularly test negative for sexually transmitted infections (though not HIV, which is more expensive to test for but for which diseases like gonorrhoea are a good proxy). “Reverse prostitution,” they call it, rather alarmingly.
Conditional cash transfers are the new new thing in the development world. The success of Mexico’s Oportunidades scheme, which gives cash to poor families if they participate in health programmes, has sparked a wave of imitations in both developing and developed countries – even New York has got in on the act. A randomised controlled study of Oportunidades found that it reduced illness among children in the programme by 23% compared to a control group. The children’s height increased by 1-4%, and the health of adults also improved. Similar programmes to reduce drug dependency in the US by giving cash to cocaine and methamphetamine abusers in return for clean urine samples have cut stimulant use.
The World Bank scheme relies on a crucial insight, which LSE AIDS guru Tony Barnett and I discuss in a paper to be published in ‘AIDS‘ this summer. In order to take decisions now that will benefit them in the future, people need to value that future. In other words, they need hope:
People with hope for the future are less likely to engage in activities that put them at risk of illness or death in the present…Without future goals, there is little reason to avoid actions that may cause harm in the future but do not do so in the present. People may therefore forfeit future gains in favour of present benefits.
Studies of hope have found strong effects on quality of life. Hopeful children do better in skills tests; adults who have goals have better mental health; and those without hope of career advancement have higher rates of mortality. And it’s not just about money; drug users in the US programmes reported that having something to aim for and receiving rewards for achievement spurred them to quit.
In much of Africa, where HIV is rife, people lack hope and therefore take risks. They exchange safety for pleasure by having unprotected sex with multiple sexual partners. They know they might one day die as a result of this, but the concerns of the present are too pressing, the future too remote. Cash can make a difference – a study in South Africa found that poor women women who received small loans in return for participating in HIV and gender programmes reported increased hope and reduced violence at the hands of their partners.
You might think that not dying of AIDS would be reward enough for practising safe sex. In an environment where people have little to hope for, however, and thus no reason to make plans, you’d be wrong.