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January 15, 2008

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Ken Houghton

This was reported for Tanzania by Maxwell et al. in the Malaria Journal in 2006.* Maybe Sachs read that piece?

*It's one of the pieces I've been citing in my graduate school applications on how advances in health and developmental economics, and the corresponding empirical data from the sciences, will make economics more interesting, so I doubt it's obscure.

april

Dani - I believe this entry seriously overstates what one can conclude from Jessica and Pascaline’s fine paper. With regard to the important role that positive prices play in generating public sector supply of goods and services, I urge your readers to read my colleague Mead Over’s comments on the paper over at the Center for Global Development’s Global Health blog. http://blogs.cgdev.org/globalhealth/2008/01/user_fees_for_health.php
With respect to bednets specifically the evidence shows that positive prices play an important role in motivating commercial actors to import, distribute and sell bednets. The goal of malaria programs is to not only achieve high coverage of bednets today (catch up) but to maintain high coverage levels after donor attention and support wanes (keep up) – and this interest and development of the commercial sector plays a very important role in this sustainability. I have elaborated on these points in this blog entry (also at CGD)
http://blogs.cgdev.org/globalhealth/2007/10/battle_over_bednets.php

Gulzar

Dani,
While not exactly related to bed nets, we at the Vijayawada Municipal Corporation, Andhra Pradesh, India have, over the past two years, initiated a campaign to eradicate Malaria from this endemic City by 2011. We have analysed the information available for the 2000-05 period to arrive at a focussed, area specific, malaria action plan. The results have been truly spectacular, and the methodology is very easily replicable. I have posted the same in my blog at http://gulzar05.blogspot.com/2008/01/empirical-analysis-in-anti-malaria.html

While the number of positive cases detected across Vijayawada were 6271 in 2005, it fell 53.4% to 2921 in 2006, and 40.15% to 1748 in 2007. In the 10 most endemic sections where these methods were initiated in mid-2005, it fell 54.4% from 2652 in 2005 to 1129 in 2006, and 28.6% to 805 in 2007. In the 12 next vulnerable sections where the campaign was initiated in January 2007, it fell 34.4% from 752 to 493.

paul

How much should it change our priors? Certainly it should change our priors on bednet distribution in Western Kenya.

But what does this tell us about bed net distribution in other parts of world, with different attitudes toward corruption, different perceptions of malaria and availability of treatment, different levels of poverty and willingness to pay?

It would be a mistake to overstate these results and suggest that the case is closed, and free distribution is the superior approach.

The lesson to me is on the value of randomized experiments to create region-specific knowledge. This experiment shouldn't be seen as final, rather it should be replicated in other areas where policy-makers are debating whether bed nets should be distributed for free or for a price.

Aditi

Hi Dani: When Jessica Cohen presented this paper at the Center for Global Development, there was a discussion about the results from this bed net study versus work done on the same topic (whether or not to charge for health products in the developing world) by Nava Ashraf and others that leads to the opposite conclusion. Ashraf et al study a different product – a home water purification solution – and find that there is evidence that the act of paying for the product does increase use. In our discussion, we considered whether the conclusions from the two studies could be based on a difference in methodology of distribution of the product (clinic-based for the nets, door-to-door for the water purification solution), the difference in the products themselves, etc. I’d be interested to know your thoughts on the two studies and their results.

Ken Houghton

The appropriate links for the above comment, I believe:

http://blogs.cgdev.org/globalhealth/2008/01/user_fees_for_health.php

Dave

I agree with the comments that jumping to policy decisions from the results of a single study are premature. The real question in my mind is the supply chain and delivery mechanisms on a widespread scale. I think business in general has a better track record than government in efficient systems. Either way, I think additional studies will come out and the debate will continue.

Mead

Dani, like April Harding, I think you jumped the gun on this one. At the CGD we had the benefit of a very clear presentation by Jessica Cohen last week, which revealed that her paper with Pascaline Dupas, while fascinating, falls short of vindicating Jeff Sachs' sweeping assertion that free distribution of bed nets should be the sole subsidized distribution policy in any poor malarious country. I explain why in my new blog at: http://blogs.cgdev.org/globalhealth/2008/01/sachs_not_vindicated.php

Ken Houghton

I'm not certain what was "revealed" to Mr. Over that was not at least implicit in the paper itself. (I presume that I'm not the only one to have read the available draft.)

It is implicit in Ms. Cohen and Ms.(?) Dupas's paper that there may be an optimal price point for bed nets. It is also clear that it probably significantly below 20 Ksh and possibly below 10 Ksh (see Figs 1a and 1b).

Since the cost of the bednets is 400 Ksh, and the current "market" price (see p. 6) is 50 Ksh, defenders of the don't-make-it-free argument are left to argue that the subsidy should be approximately 96.5-97% instead of 100%, or--from the Kenyans pov--that the cost of the nets should be reduced by at least 76-88%, if not a full 100%.

But under no condition does it appear that an increased subsidy from is not in itself cost effective, cet. par. And the argument that a 97% subsidy is preferable to a 100% one--especially given that the incremental administrative costs are not likely denominated in Ksh--likely will be based more on theory than balance sheet accuracy.

Ken Houghton

I should have made clear from the start: the response above is more aimed at Dave than Mead Over.

To Mead Over, I would note that the optimal effect is when the nets are distributed and used, and looking at Mses. Cohen & Dupas's paper, it appears that USAGE rates are higher at 0 Ksh than at 10 Ksh.

Figs 2a and 2b indicate 60-70% usage at 0 Ksh, but only 45-55% usage at 10 Ksh. That small spike you rightly think deserves more attention probably doesn't balance the 15% decline in usage rates.

Paul

I agree with Ken. The best result is when the nets are distributed and used

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*Homework question for development students: Can randomized experiments ever settle an important policy question?*

I think the answer is a bit more complicated than the question. This is often the case with deceptively simple questions.

The short answer would be no. Randomized experiments cannot settle policy questions in and of themselves. But the potential is there to inform and create further policy by providing the answers needed to make informed policy decisions.

Without the basic knowledge that these studies provide, how will policymakers know that what they are legislating will have the desired affect, or any affect - positive or negative - at all? The answer is, they wouldn't; they would only be guessing based on the information they have.

Randomized experiments help provide that information. But the problem being is what does the research show? Is it relevant for policy-making? Is the data accurate, or is it a fluke? Or does it only describe one region properly, and not able to be applied to other regions?

Randomized experiments, in and of themselves, are ineffective for the creation of policy, but highly effective for informing policymakers on possible outcomes and results based on policy.

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Can randomized experiments ever settle an important policy question?

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Regarding the debate as to whether or not ITNs (Insecticide Treated Nets) should be given free or not, I suppose cost is an inhibition to the acquisition of any product so it does appear to me that giving these ITNs free will result in better coverage. Furthermore, it has to be kept in mind that the vast majority of those who need these ITNs are in the poorer parts of the world. Lastly, anyone who knows the importance of ITNs would would use them whether or not he/she purchased or got them free.

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Given the results of randomized experiments can always be contested,I doubt they can ever settle an important policy question.They are invaluable though as inputs for policy formulation.

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Randomized experiments might shed light on certain aspects or issues when drawing policies, but I do not think that they can settle anything for good. They are part of a more complex body of analysis and data to be considered and needed to approach any given issue.

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Randomized experiments offer an approximation to the real causes of a problem and thus enrich the process of public policy making.

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Thus, randomized experiments serve to enrich public policy but can not be the only basis of a public policy for themselves.

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I prefer that ITN should can be free. because it is through ITN, people who are unable to get proper health care can get a better health care.

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Well for me it's interesting, maybe because in my country there are many needs in terms of health, but both the authorities and the staff responsible for carrying out the delivery of humanitarian aid, have a very irresponsible attitude and bureaucracy, so that aid is late or never reaches its destination . Difference can be social or perhaps cultural?

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