The Key to Closing the Gap on Maternal, Newborn and Child Survival for Millennium Development Goals 4 and 5? A. M. Buttenheim Ying Zhao 11/6/14

Outline  Millennium Development Goals (MDGs)  Specific objectives of MDGs 4 and 5  Applying Behavior Economics to Maternal, newborn and child health (MNCH) Interventions 5 behavioral economic principles

Millennium Development Goals (MDGs)  8 international development goals  established following the Millennium Summit of the United Nations in 2000  followed the adoption of the United Nations Millennium Declaration.  All 189 United Nations member states at the time (there are 193 currently) and at least 23 international organizations committed to help achieve the following Millennium Development Goals by 2015

MDGs 4 and 5 specific objectives  MDG 4 and 5 set ambitious targets to reduce by 2/3 the mortality rate for children under 5, and to reduce by three quarters the maternal mortality rate ( )  With 2015 nearing, MNCH communities aims to close the gap of the targets above.

Applying Behavioral Economics to MNCH Interventions  Framing Effects  Present Bias  Zero Price Effects  Bandwagoning and Social Norms  Loss Aversion

Framing Effects  Logical equivalence within pairs of statements but evokes different responses  Generally, loss-frame message are more persuasive than grain-framed messages.  Gain frames preventive behaviors  Loss frames screening or detection behaviors  Most people avoid risks (when a positive frame is used), but seek risks (when a negative frame is used)

Framing Effects  MNCH interventions are based on social marketing principles, “sell” target products and behavior, like(immunizations, through aspirational gain-framed messages. However, recent studies have found that loss frames can induce stronger interventions to vaccinate children and to purchase point-of-use water treatment systems. Training community health workers and clinic staff to incorporate loss frames into promotion campaigns for targeted MNCH behaviors may boost utilization more than current social marketing or health education approach

Present Bias  Generally, individuals place more weight on costs and benefits realized today, and less weight on costs and benefits realized in the future.  These present-biases create barriers to investments in the future.  To counter present bias, interventions can be designed so that the benefits of desired behavior are as immediate and as tangible as the costs. (financial incentives, well-designed incentive schemes)

Present Bias e.g. parents make an immediate investment of time, lose wages, and transportation costs to get a child vaccinated (even if the vaccination itself is free), the protection from disease is in the future and intangible. HIV An intervention to improve long-term use of insecticide-treated Bed nets found higher rates of treatment of nets when households were given the option to prepay for a retreatment contract at the time of initial net purchase, compared to paying for retreatment as needed.

Zero Price Effects Free is a unique price Marketing research demonstrates that the demand for a product or service drops off considerably when the price moves from zero to a price just slightly above zero. (This suggests that charging even small user fees for health services or products with clear long- term benefits is often counterproductive, due both to zero price effects and to present bias) Several experimental studies of MNCH-relevant health product pricing have demonstrated steep declines in uptake when prices are non-zero.

Zero Price Effects Policy makers have raised concerns about the financial sustainability of providing targeted MNCH products or services for free, researchers have identified a set of conditions under which zero prices (or even negative prices or financial incentives) make sense: when widespread uptake is required to achieve maximum health benefits; when the product is clearly cost- effective; when the desired behavior or technology is preventive, requiring an upfront investment for a long-term health benefit ( Immunizations)

Zero Price Effects Other MNCH interventions: bed nets, deworming, and water treatment. e.g. Demand-side voucher schemes for maternal care, which give pregnant women vouchers or coupons to cover the costs associated with medical delivery, also exploit zero price effects. Voucher schemes may therefore both improve delivery care and generate competition across the private and public sectors.

Bandwagoning and Social Norms  The “bandwagon effect “ is a specific example of more general power of social norms to change behavior.  In MNCH field, the diffusion of social norms is a crucial component of the success of participatory women’s groups in improving health outcomes. e.g. Nepal, only 8 % of women of reproductive age and 37 % of pregnant women joined groups, and yet neonatal mortality rates dropped by 30 % and maternal mortality by a factor of five.

Loss Aversion  Individuals weight losses more heavily than gains.  Encourage behaviors by putting assets at risk. In well-resourced areas, commitment contract interventions explicitly leverage loss aversion.(e.g.)

Loss Aversion In under-resourced environments, deposit contracts, participants could be provided with funds “on account”, and told they may keep them only if certain behavioral targets are met. e.g. all pregnant women should deliver with a skilled birth attendant. Birth vouchers for safe delivery (price zero), and MNCH set up a Savings account, and only turned over to parents only if with a skilled birth attendant or in a medical setting.

Discussion Change is needed across several stakeholder groups:  Conveners of MNCH consensus and framework initiatives should elevate behavioral uptake and effectiveness alongside coverage, cost, and technology innovation when setting MNCH priorities.  Researchers must unite the theory and approaches of behavioral economics with MNCH expertise. Meanwhile, MNCH experts should be open to the innovations and potential of behavioral economics.  Government health ministries should seek out research partnerships, fund and reward innovation on the front lines, and prioritize and disseminate high-quality evaluations of behavior change interventions.  NGO and health program staff need training to think in new ways about behavior change, and resources for innovation.  Funders must maintain their enthusiasm for research on incentives design and behavioral economic nudges beyond the current period of low-hanging fruit.

Discussion Two caveats ware in order here as well. 1.Interventions based on behavioral economic principles must overcome two common forms of resistance: pushback on the idea of financial incentives and reluctance to do randomized field trials 2. Many researchers and practitioners in the MNCH field were trained in and remain loyal to conventional health behavior change models (HBM, TPB, AND TTM)

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