Name your price: it’s your life

Published online January 25, 2012.

Why small increases in price can lead to a steep decline in demand for essential products

A piece of nylon netting is a useful thing. It can be cast as a fishing net, hung as a curtain, or draped over a seedbed as protective covering. Netting can make a stunningly white wedding dress, or even a make-shift chicken coop.

One can also sleep under it, of course, to keep mosquitos from biting at night. Though insecticide treated nets (ITNs) are routinely distributed in malaria endemic regions, often subsidized by major donors such as the Global Fund, many worry that such campaigns are frequently futile. Anecdotal evidence from the Kenyan shores of Lake Victoria to the alters of Ugandan churches suggest that these bednets are sometimes quite literally cast aside or otherwise misused.

While misuse is certainly problematic from the perspective of those funding mosquito net campaigns, it also raises a broader question, and one with serious implications for public policy in malaria prevention and beyond: Do people value and use things that are given to them for free?

There are two competing arguments used to answer this question. The first argument says that people value more that on which they spend their own money or resources. Furthermore, people will spend some money, when they can afford it, on those objects that they perceive to be useful. A second argument says that if an object is perceived to be useful or of value, people will use that object regardless of whether they purchased it or whether it was given to them for free. The ubiquity of incumbent presidents’ campaign t-shirts in both opposition and stronghold areas is supporting evidence for those in the latter camp.

The mosquito net-cum-wedding dress is a classic illustration of the dilemma of freebies. The protective power of mosquito nets against mosquito bites and thus, malaria, is rather less effective when the net becomes a nuptial adornment or is tossed into a river, much less left in its packaging and stashed in a corner. The creative use of nets is thus often the go-to anecdote for those in the first camp of the freebie question.

Anecdotal evidence, unfortunately, can only get us so far in adjudicating between these two perspectives. Fortunately, a number of development economists have been systematically evaluating the extent to which people use services or tools given to them for free and those provided at a cost. While there is still no definitive answer, and while context matters, much of the evidence seems to suggest that people use many free goods at high rates, and often will not purchase the same products when provided even at very low prices.

A group of researchers at the Abdul Latif Jameel Poverty Action Lab, based at the Massachusetts Institute for Technology (MIT), recently wrote a report summarizing ten studies examining the question of whether user fees and cost-sharing increase or decrease the use of health and education services and products. The majority of the studies were conducted in Kenya, although some were also conducted in Uganda, Zambia, and India. Their findings are striking, and the title of the report says it all: “The price is wrong.”

Time and again, small increases in price lead to a massive decline in demand for products including water disinfectant, deworming medicine, mosquito nets, and soap. For example, one study in Kenya found that while over 80% of people used a mosquito net if they received it for free in a prenatal clinic, only 20% would purchase the net for $.60 (approximately 50 Kenyan shillings or 360 Rwanda Francs). Similarly, another study in Kenya found that while nearly 60% of people used water disinfectant when it was given to them for free, less than 10% would use disinfectant if charged $.30 for the same product. This general pattern appears to repeat itself in different locations and with different products.

Two things are thus evident. First, people are often unwilling to purchase a number of goods and services that promote health and education even at highly subsidized rates. Second, people often use those same goods and services at high rates if they are provided for free. Clearly, receiving something for free does not preclude its use. If we think back to the wedding veil problem however, it is also clear that some products may not be used as prescribed, fee or no fee.

Why are people so sensitive to price when it comes to potentially life-saving goods and services? Individuals and families weigh the costs, monetary or otherwise, of procuring and using goods and services against the expected benefits from using those goods. Bednet wedding veils notwithstanding, in most cases it appears that families perceive some benefit from using goods like mosquito nets and soap, since rates of usage are quite high when the product is free. Some speculate that people may not physically have the cash on hand to buy even very inexpensive products, or that other inconveniences, such as the time it takes to procure a product, may affect their decision. But these are only partial explanations. It is also possible that people do not believe products will be as efficacious as researchers and policymakers think they will be in promoting their health.

Available evidence suggests that people who receive goods and services for free often do use them, although the extent to which they will use them and how they will use them is subject to some debate. Even if there are large benefits to providing free bednets, water disinfectant, soap and the like, products that often provide benefits that extend beyond the individual recipient, the question of sustainability comes to the fore. In the short term, the provision of free goods and services, particularly those that promote preventive health behaviors (like hand-washing) may have large and positive effects on the health of families and communities. But ultimately, we need to better understand why people are often so unwilling to spend even small amounts on products that have the potential to keep their families much healthier.

Do medical injections spread HIV in Uganda?

A study by Mishra et al (2008) using data from the 2004-5 Uganda HIV/AIDS Sero-Behavioral Survey (UHSBS) suggests medical injections are positively associated with HIV status among Ugandan adults, even after taking into account other HIV risk factors and reverse causality (i.e. HIV positive individuals seek more medical care). Even if iatrogenic transmission is not the primary mode of transmission of HIV today (though Pepin argues it played a pivotal role in the early spread of HIV), this finding is worrisome. The authors conclude:

Our analysis showed a strong positive association between number of medical injections and HIV infection. Receiving frequent medical injections was significantly positively associated with HIV positive serostatus among Ugandan adults. Even after controlling for several potential confounders, and accounting for possible reverse causality from HIV infection to increased use of medical injections, men who received five or more medical injections in the previous 12 months were 2.3 times more likely to be HIV infected, and women 1.5 times more likely to be infected, compared with men and women who received no medical injections.
Our results are consistent with the literature showing a positive association between medical injections and HIV infection (Mann et al. 1986; Deuchert and Brody 2006; Barongo et al. 1992), and provide further evidence that medical injections may increase the risk of HIV infection.

…our finding of consistent and strong positive association between multiple medical injections and HIV infection reinforces the need to strengthen programs to promote injection safety and reduce non-sexual modes of HIV transmission. Medical injection as a potential mode of HIV transmission deserves continued research and programmatic attention. Program priorities for Uganda may include focus on rational use of injections, implementation of the national injection safety guidelines, and further scale up of medical injection safety programs.

Rwanda’s next president

Published online January 16, 2011.

There was quite a kerfuffle following President Kagame’s last visit to Uganda in December 2011. The hoo-ha that played out over the airwaves, news pages and Twitter had nothing to do with the trip per se – relations between Presidents Kagame and Museveni have been warming over the past six months and such visits are becoming the norm – but rather with repeated questions about presidential term limits in Rwanda. Amending the constitution to lift term limits is a relatively new trick in the handbook of institutional manipulations. President Museveni, together with the Ugandan parliament, steamrolled right through term limits in 2005, paving the way for a 30-plus-year reign for the former rebel leader. By the time Uganda marks its Jubilee in October of this year, just a few months after Rwanda’s 50-year celebration, Yoweri Museveni and the National Resistance Movement will have held power for over half of the post-independence period.

Whether or not Kagame will attempt to follow in the footsteps of Museveni and lift term limits in advance of the next presidential elections in 2017 is a tired argument. Personally, I doubt that he will do so, but neither do I think it would be at all a difficult task. But that is neither here nor there. Just as there will be a South Africa without Nelson Mandela, there will be a Uganda without Museveni and a Rwanda without Kagame. Though there will undoubtedly continue to be discussion regarding Kagame’s candidacy up until 2017, ultimately the more productive debate is the extent to which promising and talented individuals have opportunities today to become tomorrow’s leaders.

I’m not going speculate who the next president will be, but I’d like to float the idea that Rwanda’s next head of state will be a woman. Rwanda has led the way in bringing women into politics and positions of power, and women around the world are making inroads every day into politics, business, academia, and beyond. As in Uganda’s National Resistance Army and Movement (NRA/M), women have held key positions in the government and party of the Rwanda Patriotic Front (RPF). The presence of women in politics has been steadily increasing since 1994, and in 2003 Rwanda joined Uganda, Namibia, Mozambique, South Africa, and several other countries in implementing a gender-based quota for legislative seats. In the 2003 election, women won nearly half of all seats in the legislature.

Women have also been well represented in other areas of government and civil society in Rwanda, and have played key roles in rebuilding society in the aftermath of the genocide. Many women have been elected gacaca judges, and women groups have worked to address a wide array of issues, from health to microfinance. As of 2008, Rwanda is home to the only majority female parliament in the world. Women today hold several key ministries, including the Ministry of Foreign Affairs (Louise Mushikiwabo) and the Ministry of Health (Agnes Binagwaho), as well as senior management positions in institutions such as the Rwanda Development Board (RDB). And regardless of your view of her, Victoire Ingabire has emerged as the figurehead of the official opposition in Rwanda.

While women representatives do not alter policy or the playing field overnight, research suggests that women’s participation in politics has the potential to affect both policy and perceptions about women’s abilities. Studies in India found that local politicians invest in public goods that are most important to their lives, and that types of investment differ by gender and location. For example, women tend to invest more in drinking water than their male counterparts. In Rwanda, women parliamentarians have been credited with pushing for the reform of laws regarding issues such as inheritance, discrimination against women and sexual assault.

In addition to the possibility of affecting policy outcomes, some research shows that the presence of women in politics helps to alter perceptions and prejudices about women’s ability to lead and govern. A group of researchers from the US and India found that where women in India held elected positions in local government, initially with the help of gender quotas for these positions, men tended to hold less negative stereotypes about the efficacy of women in positions of authority.

Additionally, exposure to female leaders tended to increase people’s perceptions of women’s abilities over time. Although community members may rate poorly the first woman elected to a position, her successor would generally be rated more favorably. Exposure to women in politics, at least in some settings, appears to reduce negative stereotypes about women’s abilities to govern, and will likely encourage more women to enter the ring.

In Rwanda, many women have had opportunities to develop the skills and experience to lead. While the debate on term limits rages on, it is important to think beyond personalities—however formative or influential—and focus on the processes through which leadership is reproduced. Rwanda’s political system, its many flaws notwithstanding, has allowed women to participate in government and policymaking to a greater extent than in many other countries. These opportunities for leadership will help shape the next generation and next era of Rwanda’s history. It would not be surprising, therefore, if Rwanda’s next president comes out of this network of powerful and promising women leaders.

Women’s leadership in Rwanda has evolved alongside the innovative approaches the country has tested in its recovery from conflict. Like other challenges Rwanda faces, both general and gender-specific, from poverty to maternal mortality, it is to processes and not individuals that attention should be paid.  Despite urgent challenges, real opportunities exist for ordinary citizens, men and women alike, to grow up in good health with a good education. The impact of public health and education policies on Rwanda’s political development may not be obvious now, but will eventually become evident. The democratic space in Rwanda is still being tested and shaped, discussed and critiqued, pushed and pulled. Ultimately the future lies not with an individual, but with a system that allows the next generation of leaders to emerge.

Explaining health behavior

Pascaline Dupas has an excellent paper in the Annual Review of Economics: Health Behavior in Developing Countries. It’s well worth reading. Conclusion below:

Good health is both an input into one’s ability to generate income and an end in itself. As such, it is not surprising that a relatively vast literature is devoted to understanding the determinants of health behaviors. This literature has recently expanded to the study of health behaviors in low-income settings, for which good data are becoming increasingly available. This review is too short to be exhaustive, but it tries to present the most compelling evidence to date on this issue. The important thing to take away from this review is that when it comes to health behavior in developing countries, there are a substantial number of deviations from the neoclassical model. First of all, people seem to lack basic information, and sometimes have limited ability to process information, because of low education levels. Second, there are market imperfections and frictions, especially credit constraints, affecting people’s ability to invest in health. Finally, there seem to be some deviations from the rational model, with, as has been widely shown in developed countries, a nontrivial share of people exhibiting time-inconsistent preferences as well as myopia.
Overall, this suggests an important role for public policy when it comes to health. Above we identify four important demand-side policy tools: information, mandates, price subsidies, and financial incentives. All appear to have the potential to increase the sustained adoption of preventive behavior. But the success of these demand-side strategies is contingent on the supply side being adequate: on health services and products being available, with delivery and/or enforcement institutions that are effective. The issue of how to improve service delivery in health is outside the scope of this review, but it has been the focus of a number of recent and ongoing studies that will soon need a review of their own.

Science in the time of cholera (and nodding syndrome)

Published online January 11, 2012.

In August 1854 a terrible illness tore through a London neighborhood, killing hundreds in a matter of days. The terrifying disease emptied the body of fluid until vital organs shut down, after which point the petrified soul would succumb to the illness. Death often arrived less than twelve hours after the first signs of an upset stomach. Londoners of the day had a name for this illness, but did not understand its cause. They called it cholera.

Though cholera outbreaks had hit London before the mid-1800s, the Broad Street Pump outbreak of 1854 is now perhaps the best known. It was during this scourge that physician John Snow was able to demonstrate that cholera was not an airborne disease, as was the popular and professional opinion at the time, but rather a waterborne disease. This insight proved critical to improving public health in London and beyond. Londoners had been emptying their waste into the Thames, often just upstream of intake pipes for water companies. Their water and city stunk. But because disease was thought to be airborne, they doused smelly sidewalks in chloride of lime in attempt to purify the air. They made few attempts to purify the water so obviously contaminated with their own waste.

When cholera inevitably struck, they applied all manner of remedies, most of them useless at best. Castor oil, opium, and leeches were all espoused to treat cholera, not just by ordinary folks, but also by doctors. Worse still were treatments such as laxatives or bleeding. The extreme dehydration facilitated by cholera was often “treated” by attempts to further remove fluids from the body.

In hindsight, both the cause and the treatments for cholera are straightforward, if not obvious. Cholera is a waterborne illness that spreads when one person ingests the cholera-infected waste of another person. The treatment for the extreme dehydration that ensues is most fundamentally rehydration – consuming copious amounts of fluid to replace those that are lost. Yet at its emergence, a series of facts and observations did not at first fit together in a single theory about the cause of cholera. When cholera struck a household, sometimes it struck everyone, sometimes just a single person. In a neighborhood, some homes would be hard hit, while others escaped untouched. Whether you survived or not seemed random.

So it is with another illness in our midst – nodding disease. Nodding disease sounds like a folksy and tabloid-inspired syndrome. Its name describes the telltale symptoms of the disease, a rhythmic head nodding in children. The fact that unlike many diseases its name does not betray anything about its likely causes demonstrates just how little we know about its transmission. For example, HIV (human immunodeficiency virus) is named for the virus that causes AIDS. The name malaria comes from the Italian mala aria, meaning “bad air”, so named because the illness we now know is caused by a parasite was originally thought to be airborne.

But despite its odd name, nodding disease is far from folksy or fake. It is often fatal. First reported in Tanzania in 1962, nodding disease has since spread throughout what is now South Sudan, and has been rapidly spreading in northern Uganda as well.

The pattern of incidence of nodding disease and its symptoms are puzzling, as were those of cholera in the early nineteenth century. First, the onset of nodding disease appears to occur almost exclusively in children between the ages of 5 and 15.

Second, nodding is reportedly often triggered by the presence or eating of familiar foods, or when a child becomes cold. Unfamiliar foods, such as chocolate candy bars, do not induce nodding. Third, when untreated, those with nodding syndrome cease developing both physically and mentally. They are often stunted and experience mental retardation. Fourth, most children affected come from very poor families. There are now thousands of children in South Sudan and northern Uganda who experience symptoms of nodding disease, and the incidence of the syndrome appears to be increasing.

Several theories regarding the cause of the syndrome have been mooted, but none proven. For the past several years, teams of experts from the U.S. Centers for Disease Control (CDC) and World Health Organization (WHO) have travelled to South Sudan and northern Uganda in an attempt to better understand the causes of nodding disease, and possible treatments. Their work suggests that nodding disease is a new epilepsy syndrome, and that the characteristic head nodding is caused by seizures that lead to temporary lapses in neck muscle tone.

A vast majority of children experiencing symptoms of nodding disease are also infected with a parasite called Onchocerca volvulus, which causes river blindness. The high prevalence of this parasite in victims of nodding disease means that the most plausible (published) theory about the cause of nodding disease links the syndrome to O. volvulus, but how and why remain unclear. Moreover, there are a number of children both in and outside the region who are infected with the parasite and do not acquire nodding disease, so the link between the two is not straightforward.

So far, therefore, we have accumulated a series of facts about the mysterious syndrome, which have yet to be pieced together in a coherent theory. We have many more tools at our disposal than did the Londoners of the 1800s, but answers to pressing medical and public health questions do not usually come without time and resources. Nodding disease is a terrifying prospect for those living in South Sudan and northern Uganda not only because of the debilitating effect it has on children, but also because families and communities do not understand why their children are falling ill in the first place. A confusing array of facts, theories, and observations are unnerving both to those in the midst of the outbreak, but also those who see its spread as a very serious health issue for the region.

Misunderstanding the causes of nodding disease can have disastrous consequences, as was the case with cholera some 150 years ago. So far, anti-epilepsy treatments appear to be helping children experiencing nodding disease, but supplies of these treatments are often scarce, and determining the ultimate cause of epilepsy in these children should be a high priority for health officials. Cases of epilepsy are often documented at high rates in hospitals in the region, and there is thought to be a link between epilepsy and cerebral malaria as well. In Arua Regional Referral Hospital, in northwestern Uganda at the border with Sudan and DRC, 7 percent of all outpatient children over age 5 in April 2009 were diagnosed with epilepsy. In 2004/05, 74 percent (nearly 4500) of all cases in the Mental Ward were diagnosed as epilepsy.

Clearly, epilepsy, whether nodding disease or otherwise, is a condition that deserves the utmost attention from public health and medical professionals. The sooner we understand the causes of this new breed of epileptic seizures, the sooner we can take steps to both treat it and prevent its spread. In the absence of a compelling theory about its cause, however, fear and futile treatments are likely to ensue.

Gender and Development

A topic worth exploring. From the 2012 World Development Report, Gender Equality and Development:

The lives of girls and women have changed dramatically over the past quarter century. Today, more girls and women are literate than ever before, and in a third of developing countries, there are more girls in school than boys. Women now make up over 40 percent of the global labor force. Moreover, women live longer than men in all regions of the world. The pace of change has been astonishing—indeed, in many developing countries, they have been faster than the equivalent changes in developed countries: What took the United States 40 years to achieve in increasing girls’ school enrollment has taken Morocco just a decade.

In some areas, however, progress toward gender equality has been limited—even in developed countries. Girls and women who are poor, live in remote areas, are disabled, or belong to minority groups continue to lag behind. Too many girls and women are still dying in childhood and in the reproductive ages. Women still fall behind in earnings and productivity, and in the strength of their voices in society. In some areas, such as education, there is now a gender gap to the disadvantage of men and boys.

The main message of this year’s World Development Report: Gender Equality and Development is that these patterns of progress and persistence in gender equality matter, both for development outcomes and policy making.

African Literature Conference 2012, Makerere University

The Department of Literature at Makerere University in Kampala, Uganda, will be hosting an African Literature Conference July 12-14, 2012. Submissions for abstracts and panel proposals are due January 14, 2012 to litconference@chuss.mak.ac.ug. More information available here (h/t @alleneli).