And now for something completely different: Contraceptional Cash Transfers

This blog first appeared on the Wahenga website, under the pseudonym of Sissy Teese

The World Bank can only be doing this to provoke me! Just when I had vowed never to take up my pen in anger again (and when Wahenga had vowed never to air my pseudonymical rants) … they do this!!

We already know, because the Bank has told us, that Conditional Cash Transfers (CCT) can do everything! First we had Conspirational Cash Transfers. Then we had Connubial Cash Transfers. And now we have Contraceptional Cash Transfers. A paper just launched describes an experiment - “Rewarding STI Prevention and Control in Tanzania” (with the horrendously contrived acronym of RESPECT, no less!), which provides quarterly cash transfers, each equivalent to nearly one-tenth of average annual income, to those who avoid unsafe sex!

We hear that the study “has three separate arms [all the better to hold you with, my dear!!] – a control arm and two intervention arms (low-value cash rewards and high-value cash rewards).  Study participants were randomly allocated across the three study arms. All participants have been monitored on a regular basis (every 4 months over a 12 month period) for the presence of common sexually-transmitted infections (STIs) that are transmitted through unprotected sexual contact and therefore serve as a proxy for risky sexual behavior and vulnerability to HIV infection.  A small payment has been provided to all participants (regardless of arm assignment) to minimize attrition from the study.  Anyone testing positive for an STI (again, regardless of arm) received free STI treatment and counseling. Individual pre-test and post-test counseling was provided to study enrollees [the word “enrollees” has a wonderful ring to it in this context!!] at each testing interval, and monthly group counseling sessions were also made available to all study participants in all villages.”

And it works! And, what is more, it seems that the more you pay, the better it works!

By the end of one year, “study participants who were randomly selected to be eligible for a $20 payment every 4 months if they tested negative for a set of curable STIs, experienced a 25% reduction in the incidence of those STIs. After one year, 9% of individuals in the group that received the $20 quarterly payment were positive for one of the STIs, compared to 12% in the control group”.

We also learn that “the two year study cost $1.8m”, which must surely make it the most expensive condom in African history. And maybe this is where the reality check comes in: the finances. Let us look at this from two different perspectives.

First, the experiment. We have a sample of 2399 (why not 2400?). Of these, let’s assume one-third (remember the three arms?) received the higher transfer value - i.e. 800 people. Of these, 3% (i.e. the difference between 9% and 12%) avoided STIs as a result of the transfer - that is 24 individuals. So it cost probably 800 x $60 in transfers, plus all the costs of testing and administration - let’s say conservatively $100,000 in total annually - to prevent 24 individuals from getting an STI. That is over $4,000 each. Condoms would have been a cheaper option.

Second, consider this programme scaled up, nationally, to cover the whole of Tanzania. To be effective, it would need to be targeted universally, at all who were sexually active, so between the ages of 12 and 60. That is more than 22 million people. The pilot cost $750 per person, but we can assume some economies of scale, so let’s say $500 per person. That is a total programme cost of $11 billion, equivalent to 50% of GDP at official exchange rates. By way of comparison, the ILO calculated that Tanzania could afford a full “basic social protection package”, comprising a universal pension for all over-65s and all persons with disabilities, a universal child benefit to all under-15s and universal access to basic health care … all for 17% of GDP. Alternatively, $11 billion could buy you 110 billion condoms, more than five times the number currently produced worldwide annually!

But - since money is no object - what next for the World Bank? How else might they influence people’s behaviour for the better? My vote is for some form of Conflagrational Cash Transfer, providing nicotine vouchers to all who refrain from smoking cigarettes … or maybe Congregational Cash Transfers, distributing multiples of the collection plate to all who faithfully attend church every Sunday … or a Consumptional Transfer of unlimited maize meal to all who eschew junk food for the month … or a Convivial Cash Transfer to those who moderate their alcohol intake … or perhaps Constipational Cash Transfers, providing monthly supplies of suppositories to all those performing their ablutions regularly on a daily basis.

Maybe my writing days aren’t over yet …