In South Africa the signs of AIDS are subtle, but ever present. Dispensers with free condoms in every university washroom. A red AIDS ribbon painted on the wall of the Knysna hospital. Another on the entrance to the Muizenberg cemetery, where wooden crosses and flowers in plastic bottles mark the resting places of those who die young, and are much missed.
Condoms are simple, cheap and effective weapons against AIDS. The South African government has developed its own brand, Choice, which is given away for free. In Cape Town, for example, the government aims to distribute an average of 104 condoms per year for every man over 15. The problem is, people don't like them. The government-issue condoms are seen as low status. People complain that they are too small, or that they aren't reliable.
As a public finance economist, the question that puzzles me is this: does the dissatisfaction with the South African governmental condom reflect some unique failing on that government's part? Or does the intrinsic nature of government mean that no government-issue condom will ever be seen as truly satisfactory?
A "benevolent government" - one that acts solely to maximize the well-being of the people - faces the following maximization problem:
maximize social welfare, which is a function of condom effectiveness, condom wearability, other government financed goods and services, and tax cuts, subject to the constraint that total government spending on all goods, services, and tax cuts does not exceed revenue available.
Creating a more wearable condom - one that is ultra-thin, ribbed, or comes with special pleasure-enhancing lubricants - costs money. A benevolent government might conclude, after careful analysis, that there are better uses for government funds than enhancing condom wearability, such as financing clean water, solar panels or decent accommodation for people living in the townships. The calculation is the same as that of the landlord or hotel owner who installs high efficiency lightbulbs and low flow shower heads - yes, the user experience may be slightly compromised, but the cost savings are worth it.
Yet making condoms that people won't use is a waste of money, and a better condom could save tens or hundreds of thousands of lives, as well as huge amounts of human suffering. So perhaps there is another explanation? I can only speculate, but here are some possibilities that cross my mind.
First, if the government-issue condoms were too good, people who could afford to buy their own condoms would use free, government-issue ones instead. This would make it more difficult to direct government condoms to the poorest South Africans, cause government condom shortages (or increase the total cost of the program), and alienate businesses - like Dr Long's - who sell and produce condoms.
Second, governments face another constraint: they can't squander their credibility. Dr Long can purvey climax control condoms, with all sorts of claims about enhanced staying power, and no one is likely to subject them to serious scientific scrutiny. If the South African government attempted to make and market performance enhancing condoms, someone would be bound to test them to see if they actually work, and discover that they don't.
Yet, because government-issue condoms are free, and because of the way they're marketed, using them sends a signal: I don't have enough money (or I don't care for you enough) to buy the very best, most pleasure-enhancing prophylactic. As one young South African put it in an interview:
You feel shy, you know, if you’re going to have to take out a free condom. At least, when you’re taking out, let’s say Lovers Plus, you’re proud. The chick must see it and everything, you know. When you roll it on, whatever, you don’t mind. You don’t mind her seeing that.
[Though my favourite line about the government-issue Choice condoms in that interview was this comment on the packaging and marketing: "However, at 28 years, my first impression when a promoter offered me a pack of ‘Choice’ at a taxi-rank was to immediately mistake it for a packet of biscuits and I politely declined."]
Another issue is that governments must not only be fiscally responsible, they must be seen to be responsible. That's my theory as to why government buildings in Ottawa and Gatineau are so uniformly bland - stunning architecture or stone facing or anything other than glass and concrete would be seen as wasteful extravagance. Ribbed condoms are not perceived as fiscally prudent.
A final possibility is that the government is simply incompetent or, worse, corrupt. There have been media allegations that a manager at the South African Bureau of Standards accepted money from the manufacturer in exchange for certifying defective condoms. However, as this study points out, "it is difficult to disentangle corruption from mismanagement and system failure."
Can government-issue condoms ever be sufficiently sensitive? I don't know. But at least the South African has made massive progress from the days when former president Thabo Mbeki denied that AIDS was a sexually transmitted disease. Things aren't perfect, but they're better.
104 condoms per man, per year? Why do suddenly feel very inadequate.
It's a tricky problem, because none of the usual policy responses to the underlying market failure (namely that the price of condoms doesn't reflect the positive externalities associated with condom use - though "externality" isn't really the right word since the condom user is one of the beneficiaries, even if he doesn't believe that he is).
Income transfers won't work - people aren't likely to spend the extra income on condoms. You could subsidize all condoms, but as you noted that'll be expensive and inefficient since you end up subsidizing existing users. A voucher/coupon system (exchangeable for free/discounted condoms) would address that concern (since you can target who receives the voucher), and partly addresses the stigma issues (your pharmacist might know you're a no account lose, but your girl won't). On the other hand, in the voucher/subsidy arrangement, you have to retailers for distributing the condoms, which might increase costs (although who knows what the distribution of "free" condoms costs). And as a practical matter, handing free condoms cuts out a step/transaction in getting comdoms to people who need them (a bird in the hand is worth two in... well... you get it).
But I wonder if at least part of the problem is that people who run government programs tend to have different world-views/skillsets that people working in the private sector. Take the name of the "GI" brand condoms "choice" does that strike anyone as an odd name for a condom compared to say "Trojan", "Magnum", "Dr. Long's" or "Lovers Plus"? You'd think a marketing genius could have come up with a South African themed name that might actually appeal to its target market, maybe "Bull Elephant" or "Rhino" (Tagline: "For use when you're horny"), bothbof which play to nationalism and male ego.
Instead, I suspect "Choice" was dreamed up by a committee of public health experts and social workers whose members are well removed from the poor young men they're trying to appeal to. Moreover, this hypothetical's committee's mandate was probably to improve sexual health in South Africa, not to sell condoms, which makes a difference. Consider the tagline for Choice brand condoms "no choice, no play". That's clearly targeted at the very issue of sexual assault in South Africa (which my hypothetical committee would be worried about), but it isn't going to sell Choice condoms to their target market. I suspect my "Rhino" brand tagline would get a better reception.
Posted by: Bob Smith | February 03, 2013 at 10:39 AM
Bob - "for use when you're horny" - groan!
I think you're right about the marketing, though not about elephants - doesn't work for reasons that would take too long to explain.
One thing that's an issue seems to be the colour - many condoms match European skin tones, not African ones (much like bandaids, or those pale pink crayons that were called 'flesh" when I was a kid). Rainbow bright colours seem to appeal more, be seen as sexier, here. [update: the government's Choice condoms come in multiple colours, see here].
There are ways of introducing choice (so to speak), even when condoms are given away free. E.g. it would be possible to have three or five different types in circulation, get people to try all of them, text in to vote for which one they prefer, and give out random prizes to people who participate.
Posted by: Frances Woolley | February 03, 2013 at 11:06 AM
This is a very cool ad that markets condoms for an African market: http://www.youtube.com/watch?v=5dgyKiCe3xQ
Posted by: Frances Woolley | February 03, 2013 at 03:28 PM
An additional problem is likely that the condoms are distributed without regards to human capital. The really dysfunctional beliefs cited in one of your links (condoms transmit HIV, religious beliefs, etc) are probably concentrated among the less educated, poorer part of society. So many of them aren't going to get the message anyway, or don't want to hear it. You can compare this to gov campaigns like nutritional guides that have zero impact on the poor, whose nutritional profiles and propensity for overweight are the worst. If you pride yourself on consuming information and preening your lifestyle to obtain maximum health (and want to believe in government benevolence), the Canada Food Guide is a dream. If your health habits are guided primarily by habit and convenience, it won't interest you. The problem is that the Canada Food Guide is almost a true public good, whereas free condoms are still a private one.
Posted by: Shangwen | February 03, 2013 at 03:36 PM
Is it possible that marketing low status condoms is still achieving the goal of increasing condom use? If you create an environment where there's pressure to have higher quality condoms available if you want to get laid, then there's the expectation that condoms will be worn, which may be plenty adequate.
If the free ones are actually defective, as opposed to simply undesireable, then that's a separate issue, but providing free condoms that perform their minimum disease-protection function with no added value might be a perfectly adequate role for the government.
Posted by: Neil | February 03, 2013 at 04:16 PM
Here Student's Services provide brand names condoms by the crates (the real menace for middle-class college students is chlamydia, not AIDS but it is a good scare issue). The condoms come in a small plastic bag with a packet of gum...). Is it to avoid low-status material lefy unused or because only good-quality ones are available in Canada? Anyway, providing condoms to anyway is very cheap compared to even a few thousands cases of STDs, the way we don't meter drinking water or most roads, as the administrative costs are too high compared to the cost of the service.
Posted by: Jacques René Giguère | February 03, 2013 at 07:05 PM
As a voluntary good, marketing is a crucial component and Bob Smith is on to something. A better strategy might be to subsidize the three lowest-cost manufacturers of condoms and distribute them for a nominal fee (a penny a pop, or whatever). People still spent money so they feel they bought it and you get the crucial benefit of a marketing campaign.
I am a person who is too relentlessly logical sometimes, much like those government bureaucrats. Emotion matters.
Posted by: Determinant | February 03, 2013 at 07:09 PM
What is happening to all of those condoms if they are spurned by those who might use them?? While I accept that there is a status question, the relevant margin is free condom vs. no condom. That is where the government should focus.
Posted by: blink | February 03, 2013 at 08:05 PM
Shangwen - ignorance is one thing that makes marketing so difficult for governments. So much of marketing is about reinforcing people's beliefs or playing on them (selling snake oil like performance enhancing condoms) - but when people's beliefs are just plain wrong, how does one play to them without lying or...?
blink "what is happening to all of those condoms" On the first day of class, the condom dispenser in the women's washroom at Wits University was empty (though it had been full the day before) - some people are getting the message and using them. Students seem to be a a big part of the market - see, e.g. here At the risk of traumatizing any of my students who might be reading this, may I observe that 104 per year isn't a lot for a healthy young person in a relationship?
The government issue Choice brand is marketed - before Choice, there was another condom that came in AIDS packaging with HIV warnings - now that one really didn't go over well. It's just that it's not marketed as well as it might be.
Determinant: "People still spent money so they feel they bought it " The poverty here has to be seen to be believed, and it's not like people have ready access to shops or transport.
Jacques Rene - interesting observation.
Posted by: Frances Woolley | February 03, 2013 at 11:58 PM
"At the risk of traumatizing any of my students who might be reading this, may I observe that 104 per year isn't a lot for a healthy young person in a relationship?"
Damn! Shoulda gone to Carleton.
"before Choice, there was another condom that came in AIDS packaging with HIV warnings - now that one really didn't go over well"
Which would be consistent with the hypothesis that the people marketing GI-brand condoms are public health experts, not marketing gurus. (As an aside, here's a name for government issued condoms - GI-Johnny. Think Hasbro would be upset?)
Posted by: Bob Smith | February 04, 2013 at 08:35 AM
Frances, I question your assumption "Yet making condoms that people won't use is a waste of money."
As pointed out by Blink, the question is "condom vs. no-condom". As suggested by Neil, if the unacceptable condom leads to "if you want to get laid, then there's the expectation that condoms will be worn" then the government goal is achieved - even if it is at the cost of wasted plastic bags. (I presume that not-getting-laid and using-a-condom are equally desirable to the government in preventing STDs.)
Along similar lines, I heard that one foreign jurisdiction (not in Canada) had successfully installed the same Electronic Medical Record (EMR) within its jurisdiction - but the usage was poor. Clinicians were then given the freedom to choose any EMR they wanted which has lead to a mishmash of health records that are incompatible across clinics & hospitals as nearly all abandoned the existing EMR. Some analysts think the existing EMR was rejected because it was provided by the government and (just like the condoms) had to be rejected on those grounds alone. The question now is does high usage of a localized EMR trump low usage of a universal EMR?
It is unfair to assess government intervention by solely measuring the direct consumption; you need to look at what caused the government to intervene in the first place and tease out what effect government intervention had on that.
Posted by: Peter | February 04, 2013 at 02:32 PM
What about the theory at AIDS in Africa is caused by their poor medical infrastructure?
http://www.overcomingbias.com/2010/02/africa-hiv-perverts-or-bad-med.html
Posted by: Wonks Anonymous | February 04, 2013 at 02:47 PM
Wonks - is it caused by poor medical infrastructure? The overcoming bias article argues "Much of the transmission may be due to sloppy medical procedures, in particular the reuse of needles for injections."
From what I've read I understand that some people believe reuse of needles for vaccinations helped to get AIDS started in the first place. So reuse of needles does play a role - some people bring needles with them when travelling to Africa to be sure of getting 100% new and sterile ones. But is it "much" as in the majority of transmission? I'd be surprised. I just wouldn't figure people get enough medical care, and especially in South Africa the standard of care isn't that bad.
Posted by: Frances Woolley | February 04, 2013 at 04:02 PM
"The problem is, people don't like them. The government-issue condoms are seen as low status. People complain that they are too small, or that they aren't reliable."
http://www.youtube.com/watch?v=zkvPZ94Yrrc
Posted by: jb | February 06, 2013 at 06:55 AM
http://www.theage.com.au/articles/2004/08/13/1092340459567.html
I thought you might enjoy this article, Frances.
Posted by: Rachel Goddyn | February 06, 2013 at 10:11 AM
Rachel - love it! That's classic.
Posted by: Frances Woolley | February 06, 2013 at 11:21 AM