ECON351 CH3: Low Hanging Fruit For Better Health Outcomes

Chapter 3: Low-Hanging Fruit For Better Health

Structure of Notes

This chapter explores issues impacting health outcomes, focusing on:

  • Demand Side Issues

  • Supply Side Issues

  • Brain Drain in Low and Middle-Income Countries (LMICs)

Demand Side Issues

Causes of Death in Children Under Five (World, 2021)

Data from the IHME Global Burden of Disease (2024) highlights significant causes of mortality in children under five. It is important to note that estimates come with wide uncertainties, particularly for countries with poor vital registration systems (CRVS).

Key causes include:

  • Neonatal preterm birth: 739,671739,671

  • Neonatal asphyxia & trauma: 603,606603,606

  • Lower respiratory infections: 501,910501,910

  • Congenital birth defects: 443,282443,282

  • Malaria: 424,386424,386

  • Diarrheal diseases: 340,429340,429

  • Neonatal sepsis & infections: 232,656232,656

  • Other neonatal disorders: 221,941221,941

  • Meningitis: 91,14791,147

  • Nutritional deficiencies: 76,79576,795

Unsafe Water

Unsafe water sources represent one of the largest health and environmental problems globally. As of 2015, approximately 30%30\% of the world's population lacked access to safe drinking water.

Health impacts associated with unsafe water:

  • Microbes or pathogens: Leading to diseases such as diarrhea, cholera, hepatitis, and polio.

  • Arsenic-contaminated water: Long-term exposure can cause cancers, cardiovascular diseases, and affect cognitive function.

  • Lead in drinking water.

Diarrheal Diseases

Diarrheal diseases are a significant concern, especially in children. Prevention strategies include:

  • Chlorination

  • Boiling Water

  • Water Filtration

Treatment primarily involves Oral Rehydration Solution (ORS), which is a mixture of salt and sugar dissolved in clean water, used to treat dehydration. It can be easily prepared by community health workers and caregivers at home. Despite its simplicity and effectiveness, data from 2021 shows varying shares of children with diarrhea receiving ORS across different regions.

Malaria

Malaria is a life-threatening disease caused by parasites transmitted by female Anopheles mosquitoes. P. falciparum and P. vivax are the most dangerous species. Symptoms (fever, headache, chills) typically appear 1010- 1515 days after an infective bite. Untreated P. falciparum malaria can progress to severe illness and death within 24 hours.

Prevention methods:

  • Insecticide-treated nets (ITNs): Sleeping under ITNs reduces malaria mortality by approximately 40%40\%.

  • Indoor residual spraying (IRS).

  • Malaria vaccine: Since October 2021, the WHO recommends the use of a malaria vaccine among children living in regions with moderate to high P. falciparum malaria transmission.

Despite their effectiveness, the share of children sleeping under ITNs varies globally (2021 data). The cost of bednets ranges from around US 55- 77 in Kenya to US 55- 2525 in Nepal.

Anemia

Anemia is a condition characterized by a lack of healthy red blood cells or hemoglobin. It is most commonly caused by iron deficiency, but also by deficiencies in vitamin A, B12, and folic acid.

Prevention:

  • Balanced Diet

  • Fortified Cereals

  • Iron supplementation: This is a cost-effective intervention, costing only 11- 22 per pregnancy.

In 2019, various shares of children and women of reproductive age suffered from anemia, with the condition defined as hemoglobin levels lower than 110110 grams per liter at sea level (adjusted for altitude).

Public Health Technologies: "Low Hanging Fruit"

These are interventions that are cheap, simple, and easily accessible, offering small costs but high expected returns. Often, they are effective but face low demand.

Examples of such technologies include:

  • Bed nets

  • Deworming pills

  • Chlorine for water purification

  • Iron pills and iron-fortified flour for anemia

  • Exclusive breastfeeding until six months of age

  • Tetanus shot during pregnancy

  • Vitamin B to prevent night blindness

Cost-Benefit Analysis Examples:

  • Bednets in Kenya: The average yearly income is 590590 USD PPP. A bednet costs around 1414 USD PPP and lasts for about 55 years. Sleeping under bednets reduces the risk of malaria infection in children between birth and age two by 30\%$. The financial return from investing in bednets is high, meaning costs are less than benefits.

  • Chlorine in Zambia: Only 10\%ofthepopulationusesbleachtotreattheirwater.Abottleofchlorinethatlastsforamonthcostsof the population uses bleach to treat their water. A bottle of chlorine that lasts for a month costs800Kwachas.Thecostsaresignificantlylessthanthebenefitsderivedfromsafewater.</p></li></ul><h5id="5f9b46c8−7975−4ffa−8472−5e301a89720b"data−toc−id="5f9b46c8−7975−4ffa−8472−5e301a89720b"collapsed="false"seolevelmigrated="true">WhyLowDemandforEffectiveTechnologies?</h5><p>Despiteclearbenefits,demandforthese"low−hangingfruit"technologiesremainslow.Potentialreasonsconsideredincludediscomfort(e.g.,sleepingunderbednetsinhotweather,awfultasteofchlorinatedwater)andotherfactorsinvestigatedthroughfourmainarguments:</p><h4id="d187ef08−06d9−4be3−94c9−4bc2eb4cd9c7"data−toc−id="d187ef08−06d9−4be3−94c9−4bc2eb4cd9c7"collapsed="false"seolevelmigrated="true">ReasonsforLowDemand</h4><h5id="0b575756−2fa3−43e2−ae39−dd3a23a04d5e"data−toc−id="0b575756−2fa3−43e2−ae39−dd3a23a04d5e"collapsed="false"seolevelmigrated="true">1.Isitculturallyconsideredbadtousethesetechnologies?</h5><p><strong>Notreally.</strong>Evidencesuggeststhatpeoplewouldusethesetechnologiesiftheywereofferedatacheaperpriceorforfree,indicatingthatculturalbarriersarenottheprimaryobstacle.</p><h5id="57819ea5−fcd3−4dc2−a146−6e95cf0e7b4c"data−toc−id="57819ea5−fcd3−4dc2−a146−6e95cf0e7b4c"collapsed="false"seolevelmigrated="true">2.Dopoorpeoplenotcareabouthealth?</h5><p><strong>Thisisincorrect.</strong>SurveysfromUdaipurandSouthAfricaindicatethatpeoplearedeeplyworriedandstressedabouthealthissues,boththeirownandtheirfamily′s.Theyalsospendasignificantportionoftheirincomeontreatingillnesses(e.g.,Kwachas. The costs are significantly less than the benefits derived from safe water.</p></li></ul><h5 id="5f9b46c8-7975-4ffa-8472-5e301a89720b" data-toc-id="5f9b46c8-7975-4ffa-8472-5e301a89720b" collapsed="false" seolevelmigrated="true">Why Low Demand for Effective Technologies?</h5><p>Despite clear benefits, demand for these "low-hanging fruit" technologies remains low. Potential reasons considered include discomfort (e.g., sleeping under bednets in hot weather, awful taste of chlorinated water) and other factors investigated through four main arguments:</p><h4 id="d187ef08-06d9-4be3-94c9-4bc2eb4cd9c7" data-toc-id="d187ef08-06d9-4be3-94c9-4bc2eb4cd9c7" collapsed="false" seolevelmigrated="true">Reasons for Low Demand</h4><h5 id="0b575756-2fa3-43e2-ae39-dd3a23a04d5e" data-toc-id="0b575756-2fa3-43e2-ae39-dd3a23a04d5e" collapsed="false" seolevelmigrated="true">1. Is it culturally considered bad to use these technologies?</h5><p><strong>Not really.</strong> Evidence suggests that people would use these technologies if they were offered at a cheaper price or for free, indicating that cultural barriers are not the primary obstacle.</p><h5 id="57819ea5-fcd3-4dc2-a146-6e95cf0e7b4c" data-toc-id="57819ea5-fcd3-4dc2-a146-6e95cf0e7b4c" collapsed="false" seolevelmigrated="true">2. Do poor people not care about health?</h5><p><strong>This is incorrect.</strong> Surveys from Udaipur and South Africa indicate that people are deeply worried and stressed about health issues, both their own and their family's. They also spend a significant portion of their income on treating illnesses (e.g.,5\%ofmonthlybudgetinruralIndia,of monthly budget in rural India,4\%inPakistan/Nicaragua/Panama).Iffacedwithserioushealthissues,poorhouseholdsoftencutspendingorsellassetstoaffordtreatment.</p><p><strong>However,thereisapreferencefortreatmentoverprevention.</strong>Peopletendtospendmoreontreatingillnesses(e.g.,intravenousdripsandantibiotics)ratherthanpayinglessforprevention(e.g.,ORS).Thisislargelybecausepreventionlacksurgency.</p><h5id="96ca1999−1eab−41bf−ba20−52063ba80f31"data−toc−id="96ca1999−1eab−41bf−ba20−52063ba80f31"collapsed="false"seolevelmigrated="true">3.Arepeopleliquidityconstrained(lowabilitytopay)?</h5><p><strong>Insomecases,yes.</strong>Forexample,exclusivebreastfeeding,whichcostsnothing,isoftenunderutilized.Peopletendtobehaveasiftheyarefinanciallyconstrained.</p><p>AnexperimentinIndiashowedthataccesstocreditsignificantlyincreasedthepurchaseofbednets;amicro−loanschemeincreasedtake−upfromin Pakistan/Nicaragua/Panama). If faced with serious health issues, poor households often cut spending or sell assets to afford treatment.</p><p><strong>However, there is a preference for treatment over prevention.</strong> People tend to spend more on treating illnesses (e.g., intravenous drips and antibiotics) rather than paying less for prevention (e.g., ORS). This is largely because prevention lacks urgency.</p><h5 id="96ca1999-1eab-41bf-ba20-52063ba80f31" data-toc-id="96ca1999-1eab-41bf-ba20-52063ba80f31" collapsed="false" seolevelmigrated="true">3. Are people liquidity constrained (low ability to pay)?</h5><p><strong>In some cases, yes.</strong> For example, exclusive breastfeeding, which costs nothing, is often underutilized. People tend to behave as if they are financially constrained.</p><p>An experiment in India showed that access to credit significantly increased the purchase of bednets; a micro-loan scheme increased take-up from10\%toto55\%$. This suggests that financial barriers, even small ones, can impact demand.

    Furthermore, many public health technologies generate positive externalities:

    • ITN Bednets: Protect the user and reduce malaria transmission, thus protecting bystanders and communities.

    • Vaccinations: Prevent individuals from infection and contribute to herd immunity.

    Given this underutilization and the presence of externalities, subsidies are often considered a viable solution.

    4. Is it because they lack information?

    Possibly. People may lack reliable information about health risks and effective ways to reduce them, potentially underestimating the long-run benefits of these technologies.

    Evidence suggests that providing information can work:

    • A study by Bennear et al. (2013) involving a Randomized Controlled Trial (RCT) provided information about arsenic levels in wells.

    • Jalan and Somanathan (2008) conducted an RCT in India where a randomly selected group of households was informed about fecal contamination in their drinking water. The treatment group was 1111 percentage points more likely to implement home water purification than the control group.

    The TAMTAM Experiment (Kenya)

    "Together Against Malaria, Tunapenda Afya na Maisha" (TAMTAM) is a non-profit organization founded in 2003 by Jessica Cohen and Pascaline Dupas.

    Pascaline Dupas, Carolyn Nekesa, and Jessica Cohen (2004) conducted an intervention to distribute ITNs to pregnant women using an RCT randomized at the clinic level (20 clinics):

    • Treatment Group 1 (5 clinics): ITNs provided free of charge.

    • Treatment Group 2 (5 clinics): ITNs with 97.5%97.5\% subsidy (10 Ksh).

    • Treatment Group 3 (3 clinics): ITNs with 95%95\% subsidy (20 Ksh).

    • Treatment Group 4 (3 clinics): ITNs with 90%90\% subsidy (40 Ksh).

    • Control Group (4 clinics).

    Results:

    • Usage did not increase with price: women who received ITNs for free were just as likely to use them as those who paid.

    • However, ITN take-up dropped by 6060 percentage points when the price increased from zero to 40 Ksh (approximately 0 to 60 cents).

    This highlights consumers' price sensitivity in low-income settings. Dupas et al. (2010) found that a 10%10\% co-pay for ITNs reduced demand by 90%90\% relative to free distribution. Small financial barriers can lead to significant underutilization of beneficial health interventions, indicating a high price elasticity of demand for such goods.

    Conversely, Poulos et al. (2009) found that in Ethiopia, a 10%10\% increase in income increased the demand for bednets by only 1\%$, suggesting a very low income elasticity of demand. This implies that even as people become wealthier, their demand for bednets does not change significantly.

    Supply Side Issues

    Several supply-side challenges hinder access to and quality of healthcare:

    • Insufficient private or public health facilities.

    • Poor infrastructure.

    • Issues with drugs (affordability, quality, and misuse).

    • Absenteeism among health workers.

    • High out-of-pocket (OOP) expenses for patients.

    Health Facilities

    • Distance and Quality: Many people live far from health facilities, and the quality of existing centers can be poor.

    • Rural areas: Governmental health centers are often closed, with small centers typically staffed by only one health worker.

    • India: Local health facilities, supposed to be open 6daysaweek,werefoundcloseddays a week, were found closed56\%ofthetime.</p></li><li><p><strong>Preferenceforprivatefacilities</strong>:Privatehealthfacilitiesareoftenpreferredbecausetheyprovidereassurancethathealthworkers(doctors,nurses)willbepresent.</p></li></ul><h5id="ec466ec9−41ce−4edb−a1a6−2319edb12799"data−toc−id="ec466ec9−41ce−4edb−a1a6−2319edb12799"collapsed="false"seolevelmigrated="true">HealthWorkers</h5><ul><li><p><strong>QualityofMedicalCare</strong>:StudiesintheslumsofDelhirevealedthatonlyof the time.</p></li><li><p><strong>Preference for private facilities</strong>: Private health facilities are often preferred because they provide reassurance that health workers (doctors, nurses) will be present.</p></li></ul><h5 id="ec466ec9-41ce-4edb-a1a6-2319edb12799" data-toc-id="ec466ec9-41ce-4edb-a1a6-2319edb12799" collapsed="false" seolevelmigrated="true">Health Workers</h5><ul><li><p><strong>Quality of Medical Care</strong>: Studies in the slums of Delhi revealed that only34\%ofdoctorshadaformalmedicaldegree.</p></li><li><p><strong>UnderdiagnosisandOvermedication</strong>:Doctorsoftenunderdiagnoseandovermedicate,characterizedbya"3minutes,3questions,and3medicines"approach.</p><ul><li><p>Theyaskfewerquestionsthannecessary(onlyof doctors had a formal medical degree.</p></li><li><p><strong>Underdiagnosis and Overmedication</strong>: Doctors often underdiagnose and overmedicate, characterized by a "3 minutes, 3 questions, and 3 medicines" approach.</p><ul><li><p>They ask fewer questions than necessary (only1/6ofwhattheyshould).</p></li><li><p>Spendinsufficienttimewithpatients.</p></li><li><p>Prescribeantibioticswhennotnecessary,contributingtodrugresistance.</p></li></ul></li><li><p><strong>IncentivesMatter</strong>:AnexperimentinUdaipurinvolvingSevaMandir(NGO)andlocaladministratorsdemonstratedtheimpactofincentivesonhealthworkerattendance.</p><ul><li><p>Attendancewasrecordedviarandomunannouncedvisits.</p></li><li><p><strong>Punishmentstructure</strong>:</p><ul><li><p>Ifabsentformorethanof what they should).</p></li><li><p>Spend insufficient time with patients.</p></li><li><p>Prescribe antibiotics when not necessary, contributing to drug resistance.</p></li></ul></li><li><p><strong>Incentives Matter</strong>: An experiment in Udaipur involving Seva Mandir (NGO) and local administrators demonstrated the impact of incentives on health worker attendance.</p><ul><li><p>Attendance was recorded via random unannounced visits.</p></li><li><p><strong>Punishment structure</strong>:</p><ul><li><p>If absent for more than50\%ofmonitoreddaysinthefirstmonth,paywasreducedproportionally.</p></li><li><p>Ifabsentformorethanof monitored days in the first month, pay was reduced proportionally.</p></li><li><p>If absent for more than50\%ofmonitoreddaysforasecondconsecutivemonth,suspensionoccurred.</p></li></ul></li><li><p><strong>Result</strong>:Thepresencerateofhealthworkersinthetreatmentgroupwasapproximatelyof monitored days for a second consecutive month, suspension occurred.</p></li></ul></li><li><p><strong>Result</strong>: The presence rate of health workers in the treatment group was approximately15percentagepointshigherthaninthecontrolgroup.</p></li></ul></li></ul><h5id="94bdb0ca−e297−4a8c−95e3−3a29c9b2c40a"data−toc−id="94bdb0ca−e297−4a8c−95e3−3a29c9b2c40a"collapsed="false"seolevelmigrated="true">Medicine−RelatedIssues</h5><p>Challengesrelatedtomedicinesinclude:</p><ul><li><p><strong>Unaffordability</strong>.</p></li><li><p><strong>Overuseofantibiotics</strong>:Thispracticefuelsdeadlydrug−resistantinfections,aproblemexacerbatedindevelopingcountrieswhereantibioticsareoftendispensedwithoutaprescription.</p></li><li><p><strong>Qualityofdrugs</strong>:Acriticalconcernincludes:</p><ul><li><p><strong>Counterfeitdrugs</strong>:Containingwrongingredientsoreventoxins.</p></li><li><p><strong>Substandarddrugs</strong>:Poorlymanufacturedwithinadequateamountsofactiveingredients.</p></li></ul></li></ul><p>Statisticshighlighttheseverity:</p><ul><li><p>TheWHOestimatesthatpercentage points higher than in the control group.</p></li></ul></li></ul><h5 id="94bdb0ca-e297-4a8c-95e3-3a29c9b2c40a" data-toc-id="94bdb0ca-e297-4a8c-95e3-3a29c9b2c40a" collapsed="false" seolevelmigrated="true">Medicine-Related Issues</h5><p>Challenges related to medicines include:</p><ul><li><p><strong>Unaffordability</strong>.</p></li><li><p><strong>Overuse of antibiotics</strong>: This practice fuels deadly drug-resistant infections, a problem exacerbated in developing countries where antibiotics are often dispensed without a prescription.</p></li><li><p><strong>Quality of drugs</strong>: A critical concern includes:</p><ul><li><p><strong>Counterfeit drugs</strong>: Containing wrong ingredients or even toxins.</p></li><li><p><strong>Substandard drugs</strong>: Poorly manufactured with inadequate amounts of active ingredients.</p></li></ul></li></ul><p>Statistics highlight the severity:</p><ul><li><p>The WHO estimates that1inin10medicalproductsindevelopingcountriesissubstandardorfalsified.</p></li><li><p>TheUNreportsthataroundmedical products in developing countries is substandard or falsified.</p></li><li><p>The UN reports that around500,000peopledieannuallyfromcounterfeitdrugsinsub−SaharanAfrica.Recentevents,suchasIndia′sprobeintocoughsyrupslinkedtodeathsinTheGambia,underscorethisglobalproblem.</p></li></ul><h4id="0a23d82a−99ae−4941−a008−6f6070167c93"data−toc−id="0a23d82a−99ae−4941−a008−6f6070167c93"collapsed="false"seolevelmigrated="true">BrainDraininLMICs</h4><h5id="fb9e56c8−a924−4614−b1c0−454d0d43bb1a"data−toc−id="fb9e56c8−a924−4614−b1c0−454d0d43bb1a"collapsed="false"seolevelmigrated="true">InternationalMigrationinLMICs</h5><p><strong>Braindrain</strong>referstotheemigrationofhighlyskilledworkersfromtheirhomecountrytoforeigncountriesinsearchofbetterjobopportunitiesandhigherwages.ThisphenomenonisparticularlycriticalinLMICs,whichalreadyfacesevereshortagesofhealthworkers,includingdoctors,nurses,midwives,pharmacists,andlabtechnicians.</p><p>Examples:</p><ul><li><p><strong>Nepal</strong>:The2021Censusreportedpeople die annually from counterfeit drugs in sub-Saharan Africa. Recent events, such as India's probe into cough syrups linked to deaths in The Gambia, underscore this global problem.</p></li></ul><h4 id="0a23d82a-99ae-4941-a008-6f6070167c93" data-toc-id="0a23d82a-99ae-4941-a008-6f6070167c93" collapsed="false" seolevelmigrated="true">Brain Drain in LMICs</h4><h5 id="fb9e56c8-a924-4614-b1c0-454d0d43bb1a" data-toc-id="fb9e56c8-a924-4614-b1c0-454d0d43bb1a" collapsed="false" seolevelmigrated="true">International Migration in LMICs</h5><p><strong>Brain drain</strong> refers to the emigration of highly skilled workers from their home country to foreign countries in search of better job opportunities and higher wages. This phenomenon is particularly critical in LMICs, which already face severe shortages of health workers, including doctors, nurses, midwives, pharmacists, and lab technicians.</p><p>Examples:</p><ul><li><p><strong>Nepal</strong>: The 2021 Census reported2.2millionNepalis(mostlyagedmillion Nepalis (mostly aged25 −-35)migrated,withapproximately) migrated, with approximately2000youthleavingdaily.</p></li><li><p><strong>Nigeria</strong>:BeforeCOVID−19,youth leaving daily.</p></li><li><p><strong>Nigeria</strong>: Before COVID-19,9inin10NigeriandoctorsandNigerian doctors and50\%$$ of Nigerian nurses had migrated or intended to migrate.

    Factors Driving Brain Drain

    1. Pull Factors (attracting professionals to foreign countries):

    • Enhanced career opportunities, including higher wages and better education systems.

    • Improved prospects for family members.

    • Access to improved technology and resources.

    2. Push Factors (driving professionals away from home countries):

    • Limited career opportunities and lower salaries.

    • Corruption and nepotism.

    • Political instability, war, and violence.

    What Can Be Done?

    Addressing brain drain requires comprehensive strategies:

    • Provide incentives: Offer incentives for professionals to stay or return to their home countries.

    • Better career opportunities: Create and improve career progression paths and professional development within LMICs.

    • Good governance: Implement policies that promote transparency, rule of law, and reduce corruption and nepotism.

    • Invest in Telemedicine: Utilize telemedicine to extend healthcare access and potentially create new professional opportunities within LMICs, bridging gaps left by physical migration.