Defend Truth


Carrots, sticks and Zille’s latest HIV misstep

Osiame Molefe is a writer with a keen interest in the space where personal and societal ambitions intersect with technology, politics and economics. That intersect right now, in South Africa, has brought him to observing, researching and writing on racial and gender inequality, and how well, or poorly, dialogue around these issues takes place. His column deals with these and issues tangential. When he is not writing news, analysis and opinion, he reads speculative fiction and writes some, too. Rumour is he single-handedly keeps the South African sparkling wine industry afloat. In a former life, he worked as a chartered accountant in New York, Bermuda and Johannesburg, but has since fled that industry in pursuit of a life less grey. He holds a bachelors degree in accountancy from Rhodes University, but don’t let that fool you into believing he has a head for numbers. He does not.

The Democratic Alliance on Friday launched its “Get Tested To Win” campaign as part of the Western Cape government’s 16 Days of Activism. If you get tested for HIV at a provincial testing station, you can win R50,000. Five prizes of R10,000 are also up for grabs. Though not a new idea, some behavioural economists don’t find it exciting.

The Get Tested campaign is, in a way, the carrot to the stick that was DA leader Helen Zille wanting to charge men who knowingly have unprotected sex with multiple partners with attempted murder – a suggestion that even the sole researcher whose work Zille relied on described as “human rights abuses that and must be totally off the menu.”

As with Zille’s stick, the carrot comes from a valid place. HIV testing targets are not being reached and far too few people know their HIV status or are getting tested at least twice a year as recommended. Because of this, President Jacob Zuma and health minister Aaron Motsoaledi last year launched the HIV and counselling and testing (HCT) campaign, billed as the world’s most ambitious HIV testing campaign. If you recall, it was at the campaign’s launch on 26 April where Zuma announced to the nation his HIV status after he’d undergone a public test a couple of weeks earlier.

The HCT campaign aimed to counsel and test 15 million South Africans for HIV and other chronic diseases by June 2011. At its conclusion, just over 14 million people had undergone counselling, but only 12 million of those were tested.  By March, Western Cape had tested 770,000 of the targeted 1 million.

The target was always over-ambitious so 80% isn’t that bad. Sindisiwe van Zyl, a doctor  in the project, knows words could never explain the seriousness of the HIV pandemic in our country. “People are dying needlessly. We need people to test for HIV. Once you know your status, you can make decisions about your life,” she said, vouching for the efficacy of anti-retroviral treatment, but says the only way for people to access it is to get tested.

In a statement linking her Get Tested campaign to the 16 Days of Activism for No Violence Against Women and Children, Zille set out the impact of HIV and Aids on women and children. This included StatsSA’s 2008 general household survey that estimated that there were around 100,000 children living in approximately 56,000 child-headed households. The inclusion of this statistic suggests Zille is presenting HIV as a primary cause of child-headed households when, according to research by the UCT Children’s Institute, the vast majority of child-headed households have at least one living parent, indicating some other primary cause for the statistic. But it would be nitpicking to harp on this.

“Often women and young girls become infected as a result of being coerced into having unprotected sex with men who are ignorant of their HIV-positive status and who believe it is their right to have inter-generational sex with multiple concurrent partners. This is violence against women and young girls,” she said.

Echoing Van Zyl’s argument, Zille said the starting point to ending this violence is for everyone to get tested, know their HIV status and take necessary steps to prevent the spread of the virus. Any person who receives counselling and gets tested at any of the Western Cape provincial government testing stations between 25 November and 10 December will be entered into the draw to win a R50,000 prize or one of five R10,000 prizes. The prize money comes from the premier’s budget for the 16 Days campaign.

Constitutional law professor Pierre de Vos asked, in his reply to Zille’s idea to criminalise intentional HIV transmission, “It is unclear whether Premier Helen Zille relied on advisors before making truly astonishing statements about the criminalisation of sex or whether she came up with her hare-brained scheme all by herself.”

As was the case then, so the case is now. Zille did indeed rely on advisors. Massachusetts-based consultancy firm Ideas42 – which draws its name from The Hitchhiker’s Guide to the Galaxy’s answer to the “great question of life” – held workshops with the Western Cape provincial government where they presented some new, novel approaches to healthcare.

This isn’t the first time a provincial department has gone this route. Diamond Management and Technology Consultants, a Chicago-based firm, working for the Gauteng provincial department, used a combination of education, clinics, online services and mobile phone reminders to get diabetic patients to follow their doctors’ advice. According to Diamond, this immediately reduced missed appointments from 70% to 30%.

So to be fair, this may not be as much of a misstep on Zille’s part as it is a stumble into a nascent, fast-changing world of behavioural economics and its application to health and healthcare. And Zille recognises this. Her spokesman, Zak Mbhele, said, “We want to fully accept and appreciate that there are things that are unknown and unpredictable, and comparisons [given that this is the application principles learnt elsewhere to the healthcare sector] are difficult to make.”

The Leonard Davis Institute of Health Economics at the University of Pennsylvania perhaps summed it up best, “The idea is that many people are irrational in predictable ways, and that this both contributes to unhealthy behaviours, like smoking, and holds one of the keys to changing those behaviours. Because healthcare costs continue to increase and a substantial portion of costs are incurred because of unhealthy behaviours, employers and insurers have great interest in using financial incentives to change behaviours.”

A Johns Hopkins Health and Education in South Africa paper on how social and behavioural interventions are integral to fight Aids argues that, while clinical methods (male circumcision, post-exposure prophylaxis and prevention of mother-to-child transmission) are important, HIV communication programmes in South Africa have had measurable results despite working from smaller budgets.

HIV (and other social and behavioural) communication programmes, by changing behaviour and pre-determinants to behaviour, aim to tackle specific aspects of knowledge, motivation, attitudes, norms or behaviours in a way that will have a knock-on effect by reducing new infections, argues the paper.

The Get Tested campaign, which at this stage is a pilot, deals mainly with the motivation aspect. It takes the view, as the Leonard Davis Institute put it, that financial incentives will change behaviours.

But the problem is that the science on which this is based, namely behavioural economics, is engaged in an internal war of sorts over what actually motivates people to change behaviour.

“If you look at the science of how we motivate people, it is built entirely around these extrinsic motivators, around carrots and sticks,” said author Daniel Pink during his presentation at TED on the science of motivation.

Carrots and sticks were fine for many 20th century tasks, but for 21st century ones, the mechanistic reward-and-punishment approach often doesn’t work, says Pink.

He says – expressing what is viewed as “radical” in the field – contingent “if-then” motivators work well for tasks where there is a clear set of rules and a clear destination. But for complex problems where tasks and the destination are unclear – Pink uses Dunker’s candle problem to illustrate – “if-then” rewards can even do harm.

So what harm could come of a campaign like Get Tested’s tacking a complex problem like HIV testing? For one thing, it sends the unintentional message that HIV testing, something which is an incentive in itself, is so abnormal and exceptional a behaviour that those who get tested are entitled to a reward. It may be true in South Africa that the behaviour is not the norm, but this approach switches the emphasis of the importance of getting tested from health to monetary benefits.

Mbhele says this was considered, but given the proportions of the crisis faced, greater importance was placed on getting people into clinics and getting them there now. He argued there exists a gulf between people’s health desires (being fit, quitting smoking, etc.) and where they are currently. The incentive, which is more about its immediacy rather than the size or amount, helps bridge that gulf.

Which leads to another problem. Get Tested is likely neither sustainable nor will it get to the root of behaviour.

Pink again, using the example of a study into the motivational effect of cash bonuses, says the incentive might achieve the desired result, but “all these lovely results disappeared when the incentive programme was taken away. Or, as the researchers put it: these effects did not survive after the intervention was stopped at the end of our experiment.”

Get Tested might instantly increase the number of people getting tested, but as soon as the financial incentive falls away, the numbers will fall. Without understating the effects of the counselling that comes with the testing, the individuals who participated likely did not internalise the importance of HIV screening, which meant that as soon as the incentive was taken away, they stopped getting tested regularly and, worse, the behaviour and pre-determinants of behaviour that spread HIV remained unaddressed, especially for those who tested negative.

But Get Tested is part of the provincial government’s longer-term strategy to reduce the burden of disease in Western Cape through increasing wellness and disease prevention, Zille said. The longer-term strategy will be contained in the provincial department of health’s “Vision 2020” plan, which is under development.

Could Get Tested be repeated twice yearly indefinitely? Could the same approach be applied to other social issues with behavioural underpinnings, like drunk driving, gangsterism and teen pregnancies? Maybe, says Mbhele. It depends on the results of the pilot.

“We need to inculcate a mindset of personal responsibility when it comes to HIV/Aids and, in particular, the spread of the virus. There is nothing ‘uncompassionate’ about society requiring individuals to take personal responsibility for their health,” Zille said.

So given this sentiment, her ready appetite for extrinsic motivators – cold, hard cash, jail time, carrots and sticks – perhaps illustrates again the conundrum the party of liberals she leads faces. Core to the philosophy, whether in the classical or the newer social form, is individuals thinking for themselves and taking responsibility for their own actions. With Get Tested, compulsory HIV testing and criminalising sex, Zille is trying to achieve individual thought and responsibility by taking away thought and usurping responsibility.

Said another way, one which she might better understand, you can lead an entitlement horse to water and it may drink alright. But you’ll have to lead that entitlement horse right back to water again the next time it is thirsty. DM


Read more:

  • Daniel Pink on the surprising science of motivation, on TED;
  • Presenting the evidence for Social and Behavioural Communication, by JHHESA;
  • Zille’s unprotected tweets, on Storify.

Please peer review 3 community comments before your comment can be posted