Nutrition and Health Flashcards
(20 cards)
Is poverty = hunger?
The debate about if poverty still equals hunger. Is it an outdated thought. Have we passed this point, and it would be a to simplistic way of thingking about poverty, that you can just fix poverty of you give enoough food.
SDG2 institutionalises this: End hunger, achieve food security
and improved nutrition and promote sustainable agriculture
* Hence, many development programmes focus on food:
* Food subsidies are very common in places like the Middle-East
* India distributes subsidised rice
The proffessor argues that giving food is a very wearthy goal in the beginning, but become to simplistic if we continuie to only think in that way.
What is the original thought about the poverty trap?
The nutrition trap
* The idea that food matters for development is based on a very
powerful idea
* The poor cannot work productively because they are hungry and,
therefore, remain poor. This kind of vicious cycle is called a
poverty-trap.
* Poverty traps can be linked to other factors as well (e.g., the poor
cannot invest in their businesses, which remain small,
unproductive, poor…).
Much development economics is about identifying constraints
that may generate poverty traps and devise policies to relax
them. But remember that theory and reality is not the same.
What is the so-called S-shape graph.
See figure 9
The concept of a poverty trap is captured very powerfully
by the so-called S-Shape graph
* The graph shows the relationship between
income today and income tomorrow
* Above the 45-degree line income
tomorrow is higher than income today
* On the 45-degree line, the two are the same (i.e. we are in equilibrium)
* To the left of the intersection between the S-shape and the 45-degree
line, a certain level of income today results in a lower level of income
tomorrow, which in turn results in an even lower level the day after
tomorrow, and so on…
* To the right of the intersection…
What if we then combine nutrition with the S-shape. What happens?
In the case of nutrition, the S-shape is due to the fact that the first few
calories your body absorbs are used to survive and don’t make you
more productive.
- With very little income today, a worker is going to generate an even
lower income tomorrow, which will result in an even lower income the
day after tomorrow, etc. - Only if your income today is past the point when the S-shape crosses
the 45 degree line from below, you will get out of the trap, since your
income today will result in a higher income tomorrow, which will result
in an even higher income the day after tomorrow, and so on…
Getting over A, is when you can buy the sewing machine, get the amount of nutrition, getting the bag of fertilizer.
The world is full of S-shapes!
* Investing in a business
* Buying a mosquito net
* Paying for a doctor
The S-shap graph is a theory! Rember that. Its a beutifal graph, but does it stand real life experiments.
Some places it holds, other not. Its an average measure, so somewhere people are veryyyy poor.
But does the trap exist?
But does the trap exist?
* So far, very powerful theoretical ideas
* Modern development economics is about testing such ideas
rigorously!
* In the case of nutrition-based policy traps, the evidence suggests
this may not be the case, in practice, for the majority of people.
* The poor only spend up to 70% of their budget on food (if starvation
was a fundamental issue, would they not spend more?)
* The money spent on food is not spent on maximising calories (but,
rather, on better-tasting more expensive calories).
How much does calorie intake increase as
household expenditure increases?
A 10% increase in
household expenditure
corresponds to only a 3.5%
increase in calorie intake.
* Not a very steep increase
* Inconsistent with the
existence of a poverty trap
Nutrition is not just about calories: from
quantity to quality of food. Explain?
- Policies that place all the emphasis on the quantity of food
consumed may be misguided, since the trap is not necessarily
there (e.g., an RCT in China shows that reducing the price of rice
led to a reduction in its consumption). - Rather, the poor lack quality calories (i.e. food rich in
micronutrients) - This may be partly due to habits, social pressure, culture, lack of
information, all mechanisms that are far more complex than simply
“not having enough food” and deserve careful scrutiny.
What is the hidden-hunger trap?
- Lack of micronutrients (hidden hunger) can lead to poverty traps.
- Iron deficiency (anaemia) is believed to affect 1bn people
- An RCT provided iron supplements in Indonesia (WISE study)
- Earnings among the self-employed rose by 40$ per year. The cost of fortified
fish sauce for one year was 6$. - The detrimental effects of poor nutrition can be particularly severe
for unborn and very young children. - Better nourished children have better health
- Better nourished children attain better educational outcomes
- The fact that the gains from early-childhood nutrition are realised
much later (and not by the parents, who need to make the
investment), makes the challenge even harder.
What are the implications for policy?
Shifting the paradigm from quantity to quality has important
implications. Most importantly, a shift from subsidising grains
to “smarter” alternatives such as:
* Subsidising double-fortified salt purchases
* Create good food people like to eat (improved yam)
* Sprinkle school meals with micronutrients
The old Idea of development eco, parasuite droping food, musquito nets, shelter on poor people. What people think development eco is, but it is not. It should be way more nuanced.
Crucially, the policy lever cannot simply be lowering costs:
* e.g. Evidence from Kenya that introducing a minimal cost for a
deworming programme reduced take-up to almost 0.
* People do not maximise their productivity, but their utility
(preferences, tastes, social norms, are all part of the utility
function! And beliefs matter). This requires a deeper rigorous
understanding of human decisions.
- And nudging gets into the picture (more later).
SUPPLY: A problem of poor services?
Poor health outcomes may be a result of low-quality
services.
And they often are:
* High rates of personnel absenteeism recorded in a range of
developing countries (Chaudhury et al., 2006).
* Doctors often under-diagnose and over-treat:
* Excessive use of antibiotics
* Excessive use of steroids
Putting a Band-Aid on a Corpse
(Banerjee et al., 2008)
- India has a comprehensive public-health system, but
outcomes are very poor. - Nurse absenteeism is a major problem. When they are absent from work.
- An experiment introduced penalties for absenteeism
(Banerjee et al., 2008), se figure 11.
The gap between the two lines, is the difference of presence of nurses at work. - The incentive increases presence in the short run…
- … but does not increase the number of patients treated; Never an increase in the patients outcome, meaning that the policy of increase presence does not matter then. More nurses are at work, but the nursing was not better.
- … and patients do not attend more frequently
- Crucially, the effect on absenteeism disappears after a
few months. - Why? se figure 12, Machine problems, due to machines breaking down over time. Mysterically breaking down, those machines that stamps people coming on to work.
The incentives was potential promising, but in the end not worth anything.
- The incentive is undermined from the inside
- The number of days with technical problems (i.e., broken
machine) increases. - The number of “exempt” days increases.
- An cautionary tale about the importance of political
economy considerations. - It also indicates that in this case the solution is not
pumping more resources.
It also indicates that building more shcools, hozpitals, roads, maybe not solve the problem.
The people inside the system in some how are working against the system, this can due to a lot of things. We have to understand what this is.
Be carefull when thinking about these supply side incentives is just fixing everything. Remeber the picture of the teacher sleeping in a classroom.
Is poor supply the whole story??
- Low take-up of cheap preventive solutions is often
puzzling - Expensive cures preferred to cheaper preventive
measures that are often more effective.
Indications that the demand side plays an important role
Do the poor care about their health?
Yes
- Large amount of money spent on health care (up to 7% per
month in the Udaipur survey) - But most of this is spent on curative, rather than preventive
care (with evidence of excessively invasive care and over-
treatment). - Given how cheap preventive care is and considering its massively
high returns, this poses a puzzle
Why is take up often low and highly sensitive to price?
Key preventive solutions are cheap
* One basic wrinkle in the big push (aka, supply-side)
approach à la J. Sachs is that some of the most effective
solutions against major health problems are very cheap:
* Deworming treatment
* Chlorine tablets
* Bednets
*
…
* Of course, some people may still be unable to afford
them, but the vast majority of people can, even in
developing countries.
* Yet, take-up is often low and highly sensitive to price.
- Does cheap mean worthless?
- Psychological sunk costs
- Price as an indicator of quality
Easterly uses this example to warn against the risks of
handouts
Bednets: Free Distribution or Cost Sharing?
(Cohen and Dupas, 2010). Outline the paper
A classic debate on the merits of cost-sharing, relative to
free distribution
Key Hypothesis: Cost sharing increases usage despite
the potential reductions in overall demand.
* Because patients are better selected/more motivated
* Due to sunk-cost fallacy
Strong positions that are hard to reconcile on the basis
of theory.
This requires an empirical test: Cohen and Dupas, 2010.
What they did: They randomized bednet of different prices to people. By randomizing the treatment we see
Results:
Cost-Sharing Lowers Demand, se figure 12, Higher price cause lower demand.
Cost-Sharing Does Not Increase Usage, see figure 13, People who buy it for more money is not more willng to use it.
Paying more does not induce psychological
sunk costs, figure 14. Paying more does not increase usage. Same as the previous slide.
Smooking gun result: Cost-sharing does not induce selection of the
neediest, see figure 15. People in the free net group are healthier than the control group. Far from the expectation, we show that the people who are going for the free nets are doing the best. Evidence against the main claim - People who had better health go for the free nets. Disaproaving the hypothesis, that the better healthy you are the more you want to pay for the net.
Hemoglobin - if you have malaria, you have low hemoglobin. If you have a high level, you are doing better.
Read the article …
The identification that free are good, better then making it costly. But this results may not fit all places, ofc.
Why do people not care about their health, this and the next two slides.
Wrong priors and difficult learning from experience on health
Many people may lack a rudimentary understanding of
the human body (like many of us, but in our societies we
can more confidently delegate that to doctors!). The idea is in one case we do not learn something from getting a flue an it just disapears. But if we got a pill then we would learn something, the pill worked, now in the future we should take this pill or vacinate.
Learning from experience is difficult due to a
fundamental asymmetry:
* People commonly attribute to treatment (e.g. antibiotics) an effect
that is simply due to a disease self-limiting
* By contrast, if a flu disappears after deciding not to treat, this is
attributed to sheer luck. The result is over-treatment.
* Even more difficult for immunization (i.e., a child who is not
immunised benefits form the fact that the others are, but parents
may infer that not immunising was safe).
Sometimes weak priors may be a necessity
* If I can’t afford an expensive cure, I will convince myself that
there is an alternative (e.g. traditional medicine I can use).
* Some of these beliefs, however, may be surprisingly weak and
easy to change with simple nudges.
* An experiment in Udaipur (India) provided families with a small
non-financial incentive to immunise their children, which one
might have thought would be insufficient to change people’s
behaviour (Banerjee et al. 2010). But it worked!
Even correct beliefs may not be followed by
correct actions
* Time inconsistency is
one fundamental reason
* The costs of immunisation are incurred today, the benefits are in the
future.
* Humans tend to put a lot of weight on the present and postpone
costly actions. When the future becomes the present, however, they
will have the same urge to postpone… Ever heard someone say “just
one more episode” when watching Netflix?
* If this is the case, subsidising virtuous behaviour by compensating
for its most immediate costs is desirable.
What can we use to counter peoples actions on health?
If people (not only the poor!) suffer from self-control
problems, time-inconsistency, etc., we should make it as
easy as possible for them to do the “right thing”
* Dispensers of chlorine near water sources
* Iron fortification of flour
*
…
This is the core idea behind nudging
A powerful idea is the one of default
options
Does all of this sound paternalistic?
- Well, it is.
- But one big difference between developed and developing
countries is that paternalism is engrained in richer societies,
in ways we do not even notice. - For instance, we do not need to remember to put chlorine in
water!
We are knowing better! Paternalism. Provocative. But the proffessor argue that this is what also happens in our society, that someone, the goverment system, making overall good decisions. If we did not have this, we would relaying on our own judgment, which might be the same as people in development countries.
This is controverstial, but imagine how nice it is to live in a country where most of these decision has been taken for us. Frees up a lot of mental space.
Example If we did not have forced education then we would have a debate on why we should have it or not. Because it differ from the way we lived before.
