The logic of preventive medicine is tangible: Spend a little on prevention now to reduce the later risk of coming down with a serious illness whose treatment is much more costly. That logic becomes even stronger when we acknowledge that individual health behavior has social implications – for example, if you contract an infectious disease, it becomes more likely that others around you will contract it as well.
We have a lot of ideas about how to spur health improvements through preventive “investment” in the developing world. Immunizations; condom usage; insecticide-treated bed nets; clean cooking stoves – the list goes on. The science behind these investments is sound. And yet, in spite of major programs devoted to their availability, take-up is low. Why is that? Understanding the binding constraints on the take-up of seemingly-effective health strategies is a necessary step in the development of improved public health delivery.
The evidence suggests that curative – the opposite of preventive – health expenditures in the developing world aren’t low (see Dupas (2011) for an excellent review of this and other evidence). So it’s not that the poor are not willing to spend; it’s that they do not spend on preventive measures. As for the obstacles to increasing this spending, development economics research has zeroed in on three primary categories: information; credit constraints; and time preferences.
Households in developing countries often lack information relevant to important health decisions. In order to make a sound decision, one needs information on the effectiveness of a given investment – how well it works. Research, for example, shows that Egyptian health outcomes improved dramatically in response to information campaigns about the prevention of diarrhea-induced dehydration, and that take-up of insecticide-treated bed nets (ITNs) in Mali responded positively to education programs. Moreover, one needs information on the costs of not making a given health investment – what the risks actually are. For instance, Indian households changed their water-purification and water-storage behavior in response to information from tests of drinking water contamination, and Kenyan woman engaged in less unsafe sex in response to information on age- and gender-specific HIV risk.
However, the type of information, as well as the identities of both the giver and receiver of that information, matters. While Kenyan woman in the aforementioned study did alter their behavior when given information on relative risk of partners, they did not respond to average risk information, nor to abstinence education. And while Egypt’s informational campaign drove a steep rise in the use of oral rehydration therapy (ORT) to prevent dehydration, an analogous campaign in India found no such success – Dupas hypothesizes that this can be explained by Indian citizens’ lack of trust when it comes to government intervention on family issues. Still other research focuses on who receives the information: A randomized bed-net intervention in Kenya found that households were more likely to use a voucher for an ITN if it was offered in the presence of both heads of household rather than just the female head or just the male head.
Take-up of effective preventive health strategies is further impeded by financial constraints. Investments in health often involve up-front, “lumpy” expenditures. For a household living on US$1 per day, an ITN costing US$7 or a water filter costing US$15 is very expensive. Covering that expense requires access to substantial credit or savings. Such access cannot be taken for granted; indeed, research shows that it is very much a barrier to preventive health investment. In randomized trials, the opportunity to purchase a health product on credit vastly increased take-up of ITNs in India and private water connections in Morocco; in both cases, there was little delinquency in loan repayment. Meanwhile, the receipt of a basic, metal safe box for private savings increased preventive health investments among rural Kenyan households. Why? Bank accounts are rare among the poor in low-income countries, and the ability – and incentive – to save are compromised by both the risk of theft and the pressure to share cash on hand with community members. Anything that makes it easier to save, or easier to borrow, has the potential to increase investment in preventive health measures.
A third obstacle to preventive health behavior, which exacerbates the financial obstacles described above, is procrastination. It is not a problem unique to the developing world; research (not to mention self-reflection) shows that people – in the U.S. just as much as anywhere else – often want to adopt healthy behaviors in the long run but are unable to make the required sacrifice. Policies and interventions that target this phenomenon have been found to improve take-up of preventive health strategies. Consider, for example, the Indian ITN experiment highlighted in the last paragraph. ITNs need to be retreated every six months in order to be effective. Some households were randomly selected to have the option of a prepaid contract for two retreatments; in this group of households, retreatment rates were much higher, perhaps because prepayment is a commitment that removes the risk of procrastination.
A different study shows how a simple nudge might also help neutralize procrastination. A recent experiment in India built reliable immunization camps in randomly selected villages (a lack of reliability is thought to seriously hamper efforts to immunize). Introduction of these camps increased full immunization rates from 6% to 17%. A subset of these camps also offered a small financial incentive to visit: 1 kg of lentils per immunization administered and a set of metal meal plates upon completion of a full immunization course. The value of the lentils was less than US$1. And yet, full immunization rates in the camps jumped from 17% to 38% with the addition of the incentive. Few would argue that the incentive made a previously bad investment into a good one; immunization was very likely a worthwhile strategy even before the incentive, but the offer of upfront benefits was required to overcome a natural tendency to delay.
Lack of information, financial constraints, and procrastination are by no means the only barriers to improving health in the developing world. The studies and observations above almost exclusively targeted preventive health measures; curative health measures are, for better or worse, a much larger proportion of health expenditure in low-income countries, and they come with a whole host of their own obstacles and issues. Furthermore, the patterns of behavior described here are, in essence, demand-side stories – problems afflicting the consumers of health products. The supply side (which creates and/or offers the products) has problems of its own – for instance, immunization camps are unreliable in large part because staff have weak incentives to actually attend.
Nonetheless, elucidating the binding constraints on take-up of preventive health investments is a massive contribution to development policy. Sustainable development, in the context of public health, is about going beyond a technology or a treatment that works according to mere logic and lab tests. It is about making that technology or treatment consistently work in a real-world system of provision, amidst real-world imperfections. Only when we have identified those imperfections can we adjust the system to address them.
Image Credit: Julien Harneis via Wikimedia Commons, showing the distribution of mosquito nets in Kibati.