If you type “global health” into the search box on the New York Times website, you get an impression of the frequency with which positive and negative news on this topic alternate. One can read about falling rates of infant deaths on the African continent, promising new Malaria drugs, and the record low of worldwide measles death. On the other side, headlines about drug-resistance, the worst Listeria outbreak in history and yellow and Lassa fever in Brazil and Nigeria are reason for concern. The history of global health is one of promising medical enhancement and severe drawbacks.
Health- a challenge particularly for the poor
While health challenges do not only affect countries of the global south, they can hit people living in poverty more severely than citizens of the industrialized countries. As health is a fundamental part of happiness and well-being and leads to a more productive society in the long-term (WHO 2008), it is integrated in many indices that aim at measuring development. Due to its geography and poverty, many countries of the global south face additional challenges in the area of health. That includes a higher frequency of tropical diseases such as Malaria and Dengue, but also insufficient sanitary facilities and polluted drinking water. Despite high chances of healing or prevention through vaccinations, mosquito-nets or disinfection of drinking water, a main challenge is the insufficient demand of these products. An additional burden is the high costs of treatment and prevention. Countries with a lower HDI spend a significantly higher percentage of their income on health measures. While 5% of the income is already perceived intolerable in the US, people in Kenya spend about 8% of their income on health measures (Dupas 2011, p.2f.).
Potential of the behavioural approach
Critics of the traditional approach argue that financial resources have been used falsely and that experts have not paid much attention on efficiency and coordination of the measures. Critics plead for a stronger support of local initiatives to enhance the situation on-site instead of targeting macroeconomic figures through exclusively monetary engagement (Karlan and Appel 2011, p.4ff.). Here, the behavioural approach can help to re-interpret the behaviour of actors and understand their decision-making processes. The scientific community basically agrees that poverty as such does not lead to a higher degree of irrationality, or that people systematically make worse decisions (Mullainathan 2004, p.1f). Nevertheless, behavioural insights are especially valid in the sense that the surroundings in the global south tend to determine worse decisions: People tend to be less informed and cannot necessarily count on a stable institutional environment, which affects the quality of decisions positively in other countries. In addition, irregular income can be an additional burden on the quality of the individual decision (The Economist 2014).
Nobel-prize winner Richard Thaler suggests that behavioural insights can help to effectively enhance the participation in organ-donation and preventive health measures. Many policy-makers in industrialized countries are experimenting with different approaches to healthier diets, quit smoking or the use of sunscreen (Thaler and Sunstein 2011).
The main question is, to what extent are behavioural biases such as limited mental capacity, the present bias or sunk-cost effect relevant in countries of the global south with regard to health challenges. Can the alteration of the architecture of choice, framing, nudging and the change of default options be promising instruments to tackle important burdens?
Increasing vaccination rates
A study conducted by Banerjee, Duflo and others in India in 2010 gives a first impression on how behavioural insight in the health sector can help policymakers to improve their health systems. They tested the influence of non-monetary incentives (a bag of lentils as reward) on the compliance of a vaccination schedule for children. The initial vaccination rate was below 2% even though the cost for the immunization against diphtheria, pertussis, tetanus, polio and measles is completely covered by the government. The researchers found that 39% of the children whose parents got the incentive were fully immunized (Banerjee et al. 2010, p. 5). The overall vaccination rate increased between 17% and 38% in different communities compared to a control group. The number of vaccinations per day increased nine fold. Additionally, the growth of the rate led to a decrease of the average cost per vaccine (Banerjee et al. 2010, p.6).
Whether the decrease of the average cost was higher than the additional cost of the lentils remains unknown. However, it is clear that a small change in the incentive structure can lead to large positive effects for whole communities. This gives a first indication on how insights from behavioural experiments can help to understand individual decision-making processes and alter existing programmes so that they address challenges in the health sector more effectively.
Banerjee, Abhijit Vinayak; Duflo, Esther; Glennerster, Rachel; Kothari, Dhruva (2010): Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives. In: BMJ (Clinical research ed.) 340.
The Economist (2014): Poor behaviour. Behavioural economics meets development policy. In: The Economist 2014, 06.12.2014.
Mullainathan, Sendhil (2004): Development economics through the lens of psychology. In: Washington, DC: World Bank.
Karlan, Dean S.; Appel, Jacob (2011): More than good intentions. How a new economics is helping to solve global poverty. New York: Dutton.
Thaler, Richard H.; Sunstein, Cass R. (2011): Nudge. Wie man kluge Entscheidungen anstösst. Ungekürzte Ausg., 1. Aufl. Berlin: Ullstein
Dupas, Pascaline (2011): Health Behavior in Developing Countries. In: Annu. Rev. Econ. 3 (1)
WHO (2008): Health and development. Online available from http://www.who.int/hdp/en/. Last checked on 23.05.2018