Banerjee and Duflo
Health: unpicked low-hanging fruit

Free exchange

Over the next few days, our bloggers will be discussing "Poor Economics", a new book by Abhijit Banerjee and Esther Duflo about their work in experimental economics. You can read the first post here.

IN HIS post introducing our series on Abhijit Banerjee and Esther Duflo's new book “Poor Economics” (reviewed here), my colleague mentions that the book's genesis lies in a 2006 article on the economic lives of the poor, which drew upon the results of a large number of household surveys in various countries.

One of these is a household survey the pair carried out in the rural areas of Udaipur district in India's western state of Rajasthan to which they refer several times in their discussion of health. Reading about this brought back some very pleasant memories: as one of their (then) students, I spent a very interesting summer helping their team refine that survey. But quite apart from that, reading the book shows how what emerged from that survey, as well as from the huge amount of research they and others have done on the challenges of getting healthcare to people like those interviewed in Udaipur, is a picture that is a lot more complex, and nuanced, than debates about these things tend to be.

One theme that runs through this section of the book is that a lot of the basic problems in the area of health are ones for which the technology, so to speak, is very simple. So at the level of “knowing what to do” or “knowing which drug will work”, these are very simple problems. For diarrhoea, Oral Rehydration Solution (ORS) is a simple, cheap, effective, and readily available cure. In any case, it and other water-borne diseases can be kept at bay by chlorinating water using very cheap and readily available technology.

So there's a lot of what I'll call “unpicked low-hanging fruit” in this area. In a way an idea like this is the basis of Jeffrey Sachs's call to action. To simplify a bit, Mr Sachs argues that people are trapped in poverty in part because of ill-health; give them the capacity to fight sickness and they will be so much more productive that they will no longer be poor. Indeed, there seems to be plenty of evidence that health improvements, particularly from the sorts of low levels that most poor people are beginning from, can have big economic payoffs. So Sachs's argument in some sense is that a small push can have big effects. (If you look down to my colleague's introductory post, one might think about something like vaccination or deworming or better nutrition or anti-malaria measures as the kinds of things that could, in theory, push people onto the “good” part of that S-shaped curve).

Yet—and this is a recurring theme—these supposedly easy solutions are very little used. In Zambia, where a big NGO distributes subsidised chlorine tablets widely, only 10% of families use it. In India, only a third of children under 5 who get diarrhoea are given ORS. This despite it being virtually free. Instead, 1.5m Indian children die each year of something both easily prevented and treated. In the places that Banerjee and Duflo and others they cite have studied, the problem isn't either availability, or cost, or (usually) knowledge. In Zambia, everyone seemed to know about the chlorine tablet: 98% named it as a good way to clean drinking water. Then they proceeded not to buy any.

More generally—and perhaps more worryingly—poor people seem to worry a lot about health but also to be reluctant to spend small amounts on easy preventive steps, or even take things provided free. Worse, they then spend vast sums of money on “healthcare” provided by unqualified quacks, which is usually ineffective and sometimes downright harmful. (The book provides some rather disturbing data on what passes for medical advice in the slums of Indian cities).

So the real question is not whether there are low-hanging fruit, but why so few of them are picked. The sense one gets from the book is that this is, in some sense, the really important question in lots of bits of development. Yet the conventional answers—that these “fixes” aren't readily available, or that people don't know about them—don't seem to be the whole story or even the most important part. Neither is it always the case that they are too expensive. Cutting prices for some things does seem to help. Certainly, there is little evidence for the counter-hypothesis that giving people things like anti-malaria bednets for free makes them value them less. But even giving stuff away for free doesn't always increase take-up as much as one might expect.

This sort of thing seems to be a particularly big problem when it comes to things that are essentially preventive in nature. Take water chlorination. It's something you do to keep yourself or your child from getting diarrhoea. But it does involve a small cost, and it takes time, and you have to remember to do it. It's really easy to put off, particularly because your child isn't getting sick all the time. Add to that the fact that you probably don't really know that chlorination will work as well as the “experts” say it will. So even if you're half convinced, and sort of think you ought to do it, it probably doesn't seem terribly urgent. It's easy to procrastinate, to say "I'll get around to it". Everyone does this kind of thing. It's just that the consequences the poor face are usually a bit more damning than my putting off finishing this blog post last night.

So one thing that emerges from looking closely at what actually happens when you see why development programmes so often fail or achieve far less than intended is that you really have to work on making it as easy as possible for people to avail of them. This might sound entirely obvious, but it really isn't the way those designing programmes think about these things. You have to count on the fact that people will procastinate and forget and make excuses—and find ways to work around this instead of excoriating them for doing something which is perfectly natural. Small nudges might help. But as the authors point out, those on the “right” tend to abhor such nudges as paternalism, while those on the “left” tend to decry them as patronising. They would argue that both have it wrong.

The authors recount an absolutely fascinating series of experiments designed to get more people to immunise their children in rural Rajasthan. Again: hugely beneficial action, and thanks to the NGO they worked with, readily and freely and reliably available. But also something with a small cost—perhaps a couple of hours off work and the trudge to the clinic, and benefits that are intangible and lie in the future. Result: abysmal immunisation rates.

Their idea: a small bag of lentils given as a sort of “reward”. This was opposed by public health officials, who thought “bribing” people to do what they should do anyway was a bad way to go. Yet it had a dramatic effect—and actually reduced the cost per immunisation to the NGO, because the nurses who had to be paid for the whole day anyway were now busier. Yes, convincing people of the benefits is probably useful in the long run, but this does the trick much better and more quickly—and, possibly, experience with immunisation is a pretty valuable kind of "convincing". And yes, it's paternalistic. But a whole host of things are essentially done for us—often by a paternalistic state, which purifies our drinking water and provides sewage systems and so on. There are many, many areas where we simply do not have to take responsibility because stuff is done for us, or made incredibly easy. But the poor must actively decide to "do" them.

Another insight from this particular study, and one that I rather liked, is that while people's beliefs matter, not all of them are necessarily very strongly held. So yes, another problem with vaccination is that people are sceptical of the benefits - after all, your child gets a fever today, and you are being asked to believe that somehow she will not get some terrible illness in the future. You really have no way of knowing if this is true and by its very nature, the counterfactual in such cases isn't observable. And quite possibly, you were not immunised, and you still never got measles or whatever the disease in question is. So why bother?

But the great thing about the lentils study is that it took very little to get people to take a chance on the vaccination. As the authors point out, not all beliefs are so malleable: in India, people have strong opinions about caste and marriage, and these are strongly held. But others—the benefits of vaccination, or chlorinating water, or not pulling your daughter out of school for another year—may be ones where people's beliefs (which they hold for perfectly understandable reasons) are a barrier, but a small one. And finding a small way to nudge them in the other direction can be surprisingly effective. But those nudges have to be designed to push the right buttons in terms of how people actually make the relevant decisions. Fascinating stuff.

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