Improving Impact: Health Lessons from an MIT/EdX Course

Why Some Health Interventions Fail In Developing Interventions And How To Do Better

Evan Pye

This week I worked on an online class through EdX from MIT called “The Challenges of Global Poverty.” The course is taught by Esther Duflo and Abhijit Banerjee, who wrote a book together called Poor Economics. They focus on finding the most impactful interventions to reduce extreme poverty through randomized controlled trials.

I have been learning from this course in small chunks. This week I completed the “Health” section and began the “Education” section. The Health section investigated why there is a low supply and demand for health in poor areas. The low supply shows itself in the form of understaffed clinics or hospitals, where absenteeism among doctors and nurses is high. This leads patients to rely less on formal health services and more on traditional health practices. In countries where health care and medicines are less regulated, it is easy to visit a semi-trained physician and receive drugs from them to cure a minor illness. In fact, more people visit doctors of any kind for minor illnesses compared to more life-threatening ones. Patients lose faith in the health system’s ability to treat dangerous diseases, because the outcomes are often less favorable.

Patients in developing countries also have a hard time investing their time or money into preventive care for a variety of reasons. First, it is difficult to appreciate the benefits of preventive care, because the results go unnoticed if it is successful. To make matters worse, one might see a person who goes unimmunized stay healthy in a community of people who have been immunized and conclude that immunizations are unnecessary. However, the fact that the rest of the community has been immunized is the very reason that a few might remain healthy without immunizations. Finally, trust in the health care professionals is often weak in developing countries. Esther Duflo explains one example from India in which people were hesitant to get immunizations because they remembered a period of time when the Indian government used the administering of vaccines to deceive people into getting sterilized in order to control population growth.

Although poor people may have reasons not to trust formal the health care system or adopt what are generally regarded as best practices when it comes to prevention and treatment, well-designed policies and interventions can still be effective. Making certain health practices compulsory, such as most of the world does with immunizations, is a good way to take the decisionmaking process out of the hands of a population. Otherwise, interventions should be made convenient and cheap. Most people are not so against immunizations or doctor’s visits that they will go out of their way to avoid them. The problem is that they often have to go out of their way just to get  those services. Professor Duflo provides the example of a chlorine dispenser placed right at a water source as a method of getting people to chlorinate their water. It eliminates all effort and decisionmaking, because the act of fetching water reminds people to use chlorine right at the source.

Health interventions, like many development efforts in poor countries, can fail very easily despite the best of intentions. It is important to understand the communities being served and certain principles of economic behavior and rational decision-making when designing interventions of any kind. And instead of attributing failure to the beneficiaries or the deliverers or culturally incompetent outsiders, it is useful to have experimental trials that help identify the weaknesses and potential solutions, rather than labeling certain places or people as “difficult to work with.”

A Mix of International Affairs

International Affairs from a Variety of Online Articles

By: Evan Pye

This week I read and took notes on several online articles that I have been bookmarking over the past few weeks. The topics covered in the articles range from elections in the Democratic Republic of Congo to American foreign policy to innovative solutions in global health and education.

Governance in Africa (Link)There are signs that President Joseph Kabila from the Democratic Republic of Congo may violate the country’s constitution by running for a third term this December. Kabila took over power in the DRC after his father’s assassination in 2001. Since the DRC achieved independence in the 1960s, it has never enjoyed a democratic transfer of executive power, which is why the United Nations and Secretary of State John Kerry from the United States is strongly urging Kabila’s government to step down in December.

These events echo what has transpired recently in Burundi. There, President Nkurunziza ran for an unconstitutional third term in July of 2015 and won with 70% of a farce election. Protests and violence erupted in Burundi last year, so fear of even more instability in the DRC are well-warranted with its decades-long track record of violence.

American Foreign Policy (Link)In this article critiquing America’s foreign policy strategy, Jeffrey Sachs lays out a comprehensive overview of the United States’ failed meddling in other countries’ affairs over the past 60 years. Since the creation of the CIA in 1947 with the National Security Act, the covert agency has led coups, assassinations, or general destabilization in 20 different countries. Sachs ties this interventionist approach to the fall of four major empires after World War I – the Prussian, Russian, Hapsburg, and Ottoman Empires. Britain and France quickly filled the gaps that these empires left and misguidedly divided up the Middle East between themselves with the Sykes-Picot agreement. After World War II, the United States took Britain’s place as the world’s superpower and used the CIA to influence international events. Sachs argues that the US viewed every country in the world as a potential “first domino” that could fall to the Soviet Union and start a dangerous chain reaction. Yet, even after the Soviet Union collapsed in 1991, the United States strengthened NATO and tried to extend its reach to post-Soviet countries all the way up to the Russian border. The US invited Georgia and Ukraine to join NATO in 2008. Subsequently, Russia invaded Georgia, annexed Crimea from Ukraine, and destabilized much of eastern Ukraine. Russia has acted similarly when the United States has shown signs of dismantling the Soviet-friendly dictators of Syria and Iran. Sachs also goes into the CIA involvement with Osama bin Laden and the Saudi Arabian-backed mujahideen, which mobilized jihadist Sunni Muslims in Afghanistan after the failed Soviet invasion in 1979.

Education in Developing Countries (Link) This article on education by Bjorn Lomborg lists some common-sense ideas for education interventions in developing countries that actually haven’t been shown to work: smaller class sizes, extending the school day, adding computers to the classroom, and providing textbooks to students. On the other hand, two less conventional interventions have proven to be quite beneficial to educational outcomes: providing two years of weekly home visits to teach parenting techniques to families with stunted children, and streaming students into low-performing and high-performing classes so that teachers can more easily tailor lessons to certain groups of students.

Global Health – I also read two global health articles on tuberculosis and antibiotic resistance. The tuberculosis article listed five steps that should be taken in order to eliminate all tuberculosis deaths around the world. They include ramping up data collection efforts, preventing new infections, controlling the sources of the disease, developing a better vaccine, and tackling the social determinants of the disease. The antibiotic resistance article provides ideas for two innovative financing mechanisms for pharmaceutical research and development, which is vital to staying ahead of the antibiotic resistance threat. The first is a billion dollar reward scheme for companies that develop new versions of the most-needed antibiotics, while the second is an access-to-market fee that pharmaceutical industry regulators would impose upon the industry to raise money to support R&D.