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.

Analyzing Africa: The Audacity of Despair

A new, defiant image

Published online at The Independent, Rwanda Edition, December 17, 2011

In 2000, the cover of The Economist pictured a boy wielding an AK47 inside the outline of the African continent, surrounded by black. “The hopeless continent,” the cover ominously read. At the time a combination of factors led the magazine and a whole host of bystanders to throw up their hands in despair, and mentally close the door to hope for the future of “Africa.” A decade later, The Economist, whose cover this week reads, “Africa rising” and many others, are waking up, wide-eyed, to realize the tremendous growth and progress that has been taking place on the continent all along. Progress has not been even, or without crushing reversals along the way. But given the history of development across the globe, it is entirely unclear why we should have anticipated linear progress, or lament its absence. Political, social, and economic development will carry on with or without handwringing at one extreme, or ululations at the other.

There have been at least two common mistakes in assessing progress (or the lack thereof) in “Africa,” which together have made for some rather wrongheaded analyses. First, there is a danger in conflating levels of development with development itself. It is obvious to all that levels of per capita income, education, and mortality, for example are lower on average in Africa than anywhere else. The issue of levels, however, is entirely different from change over time. Contrary to popular belief, improvement in both human and economic development was occurring in Africa before the dawn of the new millennium, just not everywhere. This leads me to the second analytic pitfall – the “Africa is a country” problem.

It is obvious to all that Africa is not a country but a continent, but analysis nonetheless often treats Africa as if it were one political, economic, or social unit. It is not. There is tremendous variation across the continent in both levels of development and rates of improvement over time. A failure to acknowledge the divergent paths countries have taken leads to the kind of essentialisation one tends to regret.

It is all too easy to essentialize. The mind recalls the most extreme cases, and remembers those that support prior beliefs. So in 2000, near the height of the HIV/AIDS epidemic, with flooding, drought, the Second Congo War, political crisis in Sierra Leone and a waffling UN Security Council, it was easy to create an image of Africa that was tearing itself to pieces. “Africa was weak before the Europeans touched its coasts. Nature is not kind to it,” wrote The Economist. “This may be the birthplace of mankind, but it is hardly surprising that humans sought other continents to live in.” Ouch.

As noted, it is true that levels of development, that is, income per capita, literacy, infant mortality, and many other measures of development, are comparatively far lower in sub-Saharan Africa, but all of this ignores the changes that have been taking place. In the 1990s, for instance, despite much pessimism, a number of countries held multi-party elections, a wave that started with Benin in 1991. While these countries would not become flourishing liberal democracies overnight, the 1990s would mark the beginning of the end of dictatorship as we know it.

There was also an effort to improve access to education, and the percentage of children completing primary school grew in a number of countries, including Benin, Burkina Faso, Cape Verde, The Gambia, Guinea, Guinea-Bissau, Liberia, Mali, Malawi, Togo, and Uganda, albeit occasionally starting at very low levels. Gains in education were not achieved everywhere, and schooling declined in some countries, but this fact only further demonstrates the variation in performance across African countries.

The best news is that although improvement in education varied, improvements in health over the past several decades have been nearly universal. Since 1960, child mortality has fallen in every single African country for which there is data, with the possible exception of Somalia. Even in a country like the Central African Republic (CAR), notorious for its poor governance, under-5 mortality fell by half over the past fifty years, from 300 to just over 150 deaths per 1000 births. In 1960, just over one in three children born in CAR would not live to see their fifth birthday; today six out of seven will survive childhood. Moreover, in spite of the devastating HIV/AIDS pandemic, which has claimed millions of lives, the hardest hit African countries are rebounding, and child and maternal mortality rates are again declining in countries like Botswana, Namibia, South Africa, and Zimbabwe.

Economically, the performance of African countries has been diverse for decades, with some countries consistently growing and others wallowing in economic misery. A number of African countries experienced periods of negative economic growth throughout the 1970s, 1980s, and into the 1990s, which, along with population growth throughout, meant that several had the same or even lower levels of per capita income in the 1990s than they had at independence.

Still, many countries began to see positive economic growth in the 1990s or earlier, including countries as diverse as Angola, Burkina Faso, Cameroon, Congo (Brazzaville), Ethiopia, Ghana, Guinea, Mali, Mozambique, Rwanda, Senegal, Uganda, and Zambia. Some of these economies are reliant on commodities such as oil and minerals, but service and other sectors comprise an increasing share of the economy in many countries, and regional trade has grown as well.

Average levels of development give Africa a bad name, but initial conditions were different from most of the rest of the world, and rates of improvement have often equaled or exceeded those in the developed world. As interest in Africa is piqued by double-digit economic growth figures and opportunities for investment, we will continue to see discussion of a part of the world most people inadvertently essentialize. Fortunately, I think the audacity of despair that has pervaded western thinking on Africa has left little in its wake other than egg on some faces. The audacity of hope has now come to the fore.

Uganda’s entrepreneurs

In Uganda it seems like everyone and their mother (I do mean that literally) has their own business. In fact, the 2010 Global Entrepreneurship Monitor Report on Uganda finds that 31 of every 100 working age Ugandans are involved in some kind of entrepreneurial activity, making Uganda the 6th highest in terms of entrepreneurship out of the 59 countries surveyed.

Interestingly, there appears to be a strong relationship between GDP per capita and entrepreneurial activity, as can be seen below.

Source: 2010 GEM Uganda report, page 32. Download here.

So what does this mean?

High TEAs [Early Stage Entrepreneurial Activity] are mainly registered in developing countries. And there’s a group of scholars that have argued that the greater the poverty, the higher the TEA of the country concerned. GEM Uganda team does not wholly agree with these scholars as its number of entrepreneurs motivated by opportunity is also high and so is that of Ghana, Zambia and Angola.

Although the team believes that necessity is a factor in Uganda’s high TEA, some entrepreneurs are keen to pursue business opportunities in the country. The positive relationship between economic growth and entrepreneurship is unquestioned; it is the causality, the measures used, and the role of the state that need to be explored further.

I’m curious about the relationship between the Doing Business scores and entrepreneurship as well. I would imagine that while it may be difficult to set up a business formally (i.e. following all the rules/wading through bureaucracy) in countries like Uganda, the relative lack of regulation encourages entrepreneurs to try their luck in business, especially in the informal sector.

Your thoughts?

What do people care about?

I love knowledge for the sake of knowledge, but as I embark on this five-year journey otherwise known as grad school, one thing I don’t want to do is get stuck inside, both literally and figuratively. Literally, I don’t want to see the sky for only 20 minutes a day on the walk to and from the car, and figuratively (and more importantly), I don’t want to get stuck in a world where only other academics or econ-y types find my work interesting/palatable/intelligible. This has been on my mind a lot recently as I have been trying to home in on a specific research question for my first major research project/paper (which I will hereafter refer to as a field paper). I can think of lots of research questions, but certainly not all of equal pertinence to the lives of ordinary people. Which got me thinking, what would be of most pertinence? I am not a doctor, I am not a teacher (yet, anyway), I am not a civil engineer…there are many things I can’t do to improve people’s lives. So what can I do? Well, hopefully (and this is the goal anyway, I think), I will be able to provide some small insight or suggestion to help solve problems people care about.  So what do people care about?

Since Uganda is mostly on my mind, I remembered a recent Afrobarometer survey asked exactly this question. Ok, not exactly. The exact question was, “What are the most important problems facing this country that the government should address?” The answers? (according to % of people who listed this concern first)

Poverty/Destitution: 43%

Unemployment: 28%

Health: 27%

Food shortage: 20%

Infrastructure/Roads: 20%

Seems pretty obvious in retrospect. But what wasn’t in the top 5? Democracy/Political Rights (3%), Orphans (2%), Political Instability/Ethnic Tensions (2%), International War (0%), AIDS (5%), and Inequality (2%), among others. Less obvious now, right? This is not to say that no one cares about these things, just that they are not the most important things for most people. Of course these things are also related to the above “most important problems”, and it could be that democracy (or something else) will solve all of these problems (I am skeptical though). Still, I think it’s always good to keep in mind what people are struggling with on a daily basis even while trying to figure out what’s up with democratic peace (for example).

Now, back to that field paper…

Dr. Tajudeen’s final column

Below is the last column Dr. Tajudeen Abdul-Raheem wrote for the Daily Monitor, which he had written last week before a car accident took his life on May 25, 2009.

Govts discourage enterprise and penalise those fighting poverty

The irony of Africa being a very rich continent but Africans being some of the poorest peoples in the world is no longer lost to anyone. While we can argue about the historical, structural, attitudinal, personal and institutional causes of this state of affairs, the fact remains that majority of our peoples remain in need amidst plenty.

Decades of aid, humanitarian intervention, prayers, activism, development plans, action plans, government declarations and so many other initiatives have not produced fundamental change for the poorest and weakest sections of our societies. Yet Africans remain one of the most optimistic peoples, perpetually believing that tomorrow will be better. It is always a miracle how majority of the poor, whether in our urban slums or impoverished rural areas, survive.

Our cities’ overburdened road infrastructures have spurned entrepreneurship in the form of shops on roads and legs meandering between armies of pedestrians and impatient vehicle drivers frustrated at the gridlock traffic. Similarly informal settlements have developed, several times the size of our capital cities with little or no infrastructures. Some of them like Kibera Slum in Nairobi are even becoming ‘famous’ globally for poverty tourism. Unfortunately, it is not the impoverished peoples in these settlements who are even the beneficiaries of their own poverty.

The majority of Africans continue to survive not because of government but in spite of governments. They eke out a living to keep body and soul together, provide for their families, doing all kinds of dirty work with little pay or selling anything that is buyable; hawking all kinds of household wares, fruits, vegetables and myriad of consumer items.

The concept of informal settlements in Africa is not just about where people live but extends to informal markets in all kinds of goods and services.

As the son of a hardworking woman who was a ‘petty trader’, I confess to a bias in favour of these small entrepreneurs who do not depend on any connections with government officials, politicians and big business influence. You go to many neighbourhoods rich or poor and you will find these largely female entrepreneurs, selling food to those working on construction sites, cheap vegetables to other poor members of the society from their baskets, trays or single tables at the corners of roads and streets.

So living in Kenya, a settler, apartheid type state in all but name, I find myself in solidarity with ‘Mama Mboga’. These are women who sell vegetables from their trays, or traditional load carriers tied to their heads, carried on their backs.

From Mama Mboga selling daily perishable vegetables, the ambition is to own a kiosk where you can have storage for more goods , stock more, put a fridge and freezer that can preserve perishable items. When Mama Mboga becomes a kiosk owner, it is a personal triumph of hope over adversity- a long journey from grinding poverty to bearable survival and foundations for permanent exit from poverty. The bigger the kiosk and the better stocked it is, the further away the owner is from poverty. Government policy is threatening the survival of the Mama Mbogas across this continent. In the name of ridding cities of illegal constructions, returning to the original city plans and ‘beautifying’ our cities, city councils and central governments are creating more poverty. Of what use is a ‘beautiful city’ inhabited by people who have lost their livelihoods? Would they appreciate the beauty?

The Mama Mbogas are on the street and in kiosks because they cannot afford the malls and most of their clientele cannot afford the price in the malls.

Our elite are embarrassed by the mass poverty that surrounds us but they are unwilling to provide leadership and appropriate policies to take our peoples to prosperity. Instead they engage in avoidance and denial mechanisms to pretend to visitors that ‘everything is okay’.

That’s why they rid our capitals of beggars, hawkers, and other undesirables before any major ‘international’ conference, but out of sight is not out of mind for the Mama/Baba Mbogas in our midst. You can pull down their kiosks and destroy their tables but they will come back with new tables, under umbrellas and their clientele will know where to find them. By no means are there clients all wretched of the earth. I still call my favourite Mama Mboga, Mama Sarah, or her husband , Martin, to send me top up cards from wherever Nairobi City Council have forced them to.