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.
Best wishes to you and yours as we bring 2011 to a close and ring in the new year. Thanks for reading and sharing, and I look forward to another year with you in 2012.
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An excerpt from my final column of 2011 for The Independent (Rwanda Edition):
Shuffling through memories of the past twelve months, one is reminded of the heaving, tumultuous and heady days that made up the molding of global and local politics, innovation, and society. Almost every year feels exceptional at its end, and this one is no different. Exceptional for the unexpected uprisings, reassuring surprises, and most of all, the untimely, or perhaps just sobering, deaths.
A remarkable feature of the human brain is that emotion triggers extraordinary powers of memory – emotional events, traumatic or ecstatic, are captured in a different way from ordinary occurrences. I have many such memories this year. I can recall vividly the walls and tables of a classroom at the moment I heard that Tunisia’s Ben Ali stepped down, the living room and footage on Al Jazeera of Mubarak’s fall, the computer screen announcing Bin Laden’s death, and the Twitter feed of my phone as I scrolled through news of Gaddafi’s brutal demise early one morning, all in 140 characters or less. I also recall the unusually grey and rainy Palo Alto morning marking the first day in 57 years of a world without Steve Jobs, just a few days after the passing of Wangari Maathai. I see clearly the words of Christopher Hitchen’s last column staring back at me, in stark and final relief.
There are of course many other memories, moments captured with friends and family, as well as moments alone, preserved not as events in their entirety, but as a series of snapshots. At the end of every year, as now, there is more time to sit and shuffle through them. It feels like an exceptional year, and the past ten have felt like an exceptional decade.
The pace of progress, innovation, and change makes each decade, and increasingly, each year, feel remarkably different from the previous. In the first decade of the twenty-first century, we experienced tremendous economic growth worldwide, a sharp break from the previous several decades. By the mid-2000s, nearly every single country in the world experienced positive economic growth. The number of new infections of HIV is falling by the year, and deaths due to HIV peaked in sub-Saharan Africa and worldwide in 2004/5. Around the same time, Google went public, and together with Facebook, is now a household name in the global village. Mobile phone use has increased exponentially worldwide. In 2000, there were 12 mobile phone users for every 100 people. Today, there are around 69 mobile phone subscribers for every 100 individuals around the globe.
Change, therefore, is brazenly constant. Anyone who suggests otherwise is either deluding themselves or not paying attention. This is as true in Africa as in the rest of the world, although many both in and outside of the continent have been slow to recognize that the former has not, in fact, been standing in place while the latter dashes on.
The churning and surging marketplace for ideas is open. The stepping-stones placed by yesterday’s innovators serve as a launching pads for vaulting into the next year and decade. Even in the destruction strewn by mad and ordinary men lie the pieces that will build society anew. One can pick them up, or stargaze at glittering towers and soaring skylines far from home.
Entering the new year, we are without many of those who began 2011 with us just one year ago. The most memorable deaths on the news circuit were violent, painful, or both, untimely or just-in-time. The world is short a few tyrants, but short a good many great and beautiful minds too. Their exit is a reminder of the inexorable march forward that spares no one. There is no standing still, but there are choices, and our own expectations.
Here is to the raw and promising new year.
I’ve been reading “An overview of research on the effects of results-based financing,” published by the Norwegian Knowledge Centre for Health Services, which discusses ten reviews of RBF schemes in low and middle-income countries (LMIC). What did they find?
- “Conditional cash transfer (CCT) programmes have been found to be effective at increasing the uptake of some preventive services which were already free.”
- “The success of CCT depends on the existence of effective primary health services and local infrastructures.”
- “Although financial incentives are considered to be an important element of strategies to change professional practice, there are relatively few well-designed studies and overall the evidence is weak.“
- “A small number of more rigorous evaluations have examined relatively simple preventive interventions, such as the impact on rates of immunizations and screenings, as opposed to more complex interventions. The success of a financial incentive is likely to be inversely related to the complexity of the tasks it seeks to motivate.”
Overall, it appears the quality of evaluation of RBF schemes has been relatively poor. The available evidence suggests we need to look more carefully at the (perhaps very specific) conditions under which RBF can work. I’m afraid RBF might not work well in the public sector in the absence of fairly strong government support and political commitment to the project. But that is something to be explored…
Several months ago I downloaded ACCESS: How do good health technologies get to poor people in poor countries?, a book listed on Karen Grepin‘s excellent global health recommended reading list, but only just now have gotten around to reading it.
What is “access” in this context?
Stated simply, access refers to people’s ability to obtain and appropriately use good quality health technologies when they are needed. Access is not only a technical issue involving the logistics of transporting a technology from the manufacturer to the end-user. Access also involves social values, economic interests, and political processes. Access requires a product as well as services and is linked to how health systems perform in practice. We think of access not as a single event but as a process involving many activities and actors over time. Access is not a yes-or-no dichotomous condition, but rather a continuous condition of different degrees; more like a rheostat than an on-off switch.
Understanding the factors that help or hinder access to health technologies is a topic I am hoping to explore further in my own dissertation, so I’m looking forward to reading the rest of the book. ACCESS is available as a free download.
Earlier this summer, I read another of Karen Grepin’s suggestions, The Making of a Tropical Disease: A Short History of Malaria. It was fascinating, and highly recommended. I will post some excerpts and “fun” facts I learned soon. This one isn’t available as a free download, but is available on Kindle. And yes, I am a Kindle Convert.
This summer has been a time for reflection and celebration, and for welcoming new beginnings. As some of you may know, my best friend and partner, Angelo Izama and I got married…twice! And along with the name change has come a blog change – I am happy to announce the arrival of http://platas-izama.com!
There are many exciting goings on at the moment, from a health journalism conference sponsored by the Health Journalists Network in Uganda, to the upcoming Young Achievers Awards, and of course, (for me) the ever-looming teenage poetry.
In Uganda, we are encountering the Mabira forest saga afresh and the continuing blossoming of districts, but also some fresh faces in new places that are already encountering resistance from the powers that be. Walk to work protests in April showed the more brutal side of a regime that should have been riding high on the tails of a landslide election win, inflation has hit an 18-year high of 21.4%, and the Uganda shilling is the worst performing currency of 2011.
And the world around us is changing fast too, for better or for worse. Just a year ago I attended the African Union summit meeting in Kampala, during which Gaddafi set up his own personal tent on the compounds of a resort hotel and his guards clashed with Ugandan security forces. Today the same man is on the run and reporters are touring his jet. What a difference a year can make.
With the relaunch of this blog/website I look forward to a lively discussion with you on all of this and much more — politics, development, research, and other tid bits. My hope is to be able to make this space more useful and informative for you (and me!), and to have some fun while doing so. I look forward to your comments, feedback, questions, and opinions. Thanks for reading!