Nudges may be especially helpful when, for whatever reason, households are somewhat dubious about the benefits of what is being proposed to them. This makes preventive care a doubly appropriate candidate for such policies: The benefits are in the future, and in any case, it is hard to understand exactly what they are. The good news is that nudges may also help with the convincing, which may jump-start a positive feedback loop. Remember the bed nets that were given to a poor Kenyan family? We argued earlier that, on its own, the income gain from the first bed net was not large enough to make the child who got one buy one for his own children: Even if the bed net led to an increase in income of 15 percent for a child, that income gain increases their probability to buy a net only by 5 percent. However, the income effect is not the whole story: The family may observe that when they use a net, their children are sick less often. Moreover, they may also learn that it is easier to use bed nets and less unpleasant to sleep under bed nets than they had initially believed. In one experiment, Pascaline Dupas tested this hypothesis by making a second attempt to sell bed nets to the families that were previously offered very cheap or free nets, as well as to the families that were offered nets at full price and mostly did not buy one.41 She found that families that were offered a free or sharply reduced net were more likely to buy a second net (even though they had one already) than the families that were asked to pay full price for the first one. Moreover, she also found that knowledge travels: Friends and neighbors of those who were given a free net were also more likely to buy a net themselves.
THE VIEW FROM OUR COUCH
The poor seem to be trapped by the same kinds of problems that afflict the rest of us—lack of information, weak beliefs, and procrastination among them. It is true that we who are not poor are somewhat better educated and informed, but the difference is small because, in the end, we actually know very little, and almost surely less than we imagine.
Our real advantage comes from the many things that we take as given. We live in houses where clean water gets piped in—we do not need to remember to add Chlorin to the water supply every morning. The sewage goes away on its own—we do not actually know how. We can (mostly) trust our doctors to do the best they can and can trust the public health system to figure out what we should and should not do. We have no choice but to get our children immunized—public schools will not take them if they aren’t—and even if we somehow manage to fail to do it, our children will probably be safe because everyone else is immunized. Our health insurers reward us for joining the gym, because they are concerned that we will not do it otherwise. And perhaps most important, most of us do not have to worry where our next meal will come from. In other words, we rarely need to draw upon our limited endowment of self-control and decisiveness, while the poor are constantly being required to do so.
We should recognize that no one is wise, patient, or knowledgeable enough to be fully responsible for making the right decisions for his or her own health. For the same reason that those who live in rich countries live a life surrounded by invisible nudges, the primary goal of health-care policy in poor countries should be to make it as easy as possible for the poor to obtain preventive care, while at the same time regulating the quality of treatment that people can get. An obvious place to start, given the high sensitivity to prices, is delivering preventive services for free or even rewarding households for getting them, and making getting them the natural default option when possible. Free Chlorin dispensers should be put next to water sources; parents should be rewarded for immunizing their children; children should be given free deworming medicines and nutritional supplements at school; and there should be public investment in water and sanitation infrastructure, at least in densely populated areas.
As public health investments, many of these subsidies will more than pay for themselves in the value of reduced illness and death, and higher wages—children who are sick less often go to school more and earn more as adults. This does not mean that we can assume that these will automatically happen without intervention, however. Imperfect information about benefits and the strong emphasis people put on the immediate present limit how much effort and money people are willing to invest even in very inexpensive preventive strategies. And when they are not inexpensive, there is of course always the question of money. As far as treatment is concerned, the challenge is twofold: making sure that people can afford the medicines they need (Ibu Emptat, for one, clearly could not afford the asthma medicine that her son needed), but also restricting access to medicines they don’t need as a way to prevent growing drug resistance. Because regulating who sets up a practice and decides to call himself a doctor seems to be beyond the control of most governments in developing countries, the only way to reduce the spread of antibiotic resistance and the overuse of high-potency drugs may be to put maximal effort into controlling the sale of these drugs.
All this sounds paternalistic, and in a way, it certainly is. But then it is easy, too easy, to sermonize about the dangers of paternalism and the need to take responsibility for our own lives, from the comfort of our couch in our safe and sanitary home. Aren’t we, those who live in the rich world, the constant beneficiaries of a paternalism now so thoroughly embedded into the system that we hardly notice it? It not only ensures that we take care of ourselves better than we would if we had to be on top of every decision, but also, by freeing us from having to think about these issues, it gives us the mental space we need to focus on the rest of our lives. This does not absolve us of the responsibility of educating people about public health. We do owe everyone, the poor included, as clear an explanation as possible of why immunization is important and why they have to complete their course of antibiotics. But we should recognize—indeed assume—that information alone will not do the trick. This is just how things are, for the poor, as for us.
4
Top of the Class
In summer 2009, in the village of Naganadgi in the state of Karnataka, India, we met Shantarama, a forty-year-old widow and mother of six. Her husband had died four years before, entirely unexpectedly, of appendicitis. His life was not insured, nor was there any pension that the family was entitled to. The three eldest children had each gone to school at least until eighth grade, but the next two—a ten-year-old boy and a fourteen-year-old girl—had dropped out. The girl was working in a neighbor’s field. We assumed that the death of the father had forced the family to withdraw the children from school and send all the older ones to work.
Shantarama set us straight. After her husband died, she had rented out the fields they owned and started to work as a casual laborer. She earned enough to take care of their basic needs. The girl was indeed sent to work in the fields, but only after she dropped out, because the mother did not want her idling at home. The rest of the children had stayed on in school—out of the three oldest children, two were still students when we met them (the oldest, who was married and twenty-two, was expecting her first child).We learned that the oldest boy was in college in Yatgir, the nearest town, studying to be ... a teacher. The two middle children were out of school only because they absolutely refused to go. There were several schools near the village, including a government school and a few private schools. Those two children had been enrolled at the government school, but they had both run away countless times before their mother abandoned any hope of being able to make them attend. The ten-year-old boy, who was with his mother when we interviewed her, mumbled something about school being boring.
Schools are available. In most countries, they are free, at least at the primary level. Most children are enrolled. And yet in the various surveys that we have conducted around the world, child absentee rates vary between 14 percent and 50 percent.1 Absence often does not seem to be driven by an obvious need at home. Although some of it might reflect ill health—for example, in Kenya when children were treated for intestinal worms, they missed fewer days of school2—much of it probably reflects children’s unwillingness to be in school (which might well
be universal, as most of us will remember from our childhood) and also the fact that their parents do not seem to be able, or willing, to make them go.
For some critics, this is a sign of the catastrophic failure of an establishment-led effort to increase education from the top down: Building schools and hiring teachers is useless if there is no strong underlying demand for education; conversely, if there is real demand for skill, a demand for education will naturally emerge, and supply will follow. However, this optimistic view seems to be inconsistent with the story of Shantarama’s children. There is certainly no shortage of demand for educated people in Karnataka, whose capital is Bangalore, India’s IT hub. The family, with a future teacher among its members, was both aware of the value of education and willing to invest in it.
So if the failure of schools in developing countries to attract children can’t be explained by problems of access, or lack of demand for educated labor, or parental resistance to educating their children, then where is the snag?
SUPPLY-DEMAND WARS
Education policy, like aid, has been the subject of intense policy debates. As in the case of aid, the debate is not about whether education per se is good or bad (everyone probably agrees it is better to be educated than not educated). It centers instead on whether governments ought to, or know how to, intervene. And though the specific reasons invoked are different, the fault line divides the field essentially in the same place it divides it on the subject of aid, with the aid optimists being generally education interventionists, and the aid pessimists being in favor of laissez-faire.
A large majority of policy makers, at least in international policy circles, have traditionally taken the view that the problem is essentially simple: We have to find a way to get the children into a classroom, ideally taught by a well-trained teacher, and the rest will take care of itself. We will call these people, who emphasize the “supply of schooling,” the “supply wallahs,” appropriating the Indian term for “purveyor of” (as in the western Indian surnames Lakdawala [wood supplier], Daruwala [booze supplier], and Bandukwala [gun seller]), to avoid confusing them with supply-siders, the economists who think Keynes got everything wrong and are in fact largely opposed to any form of government intervention.
Perhaps the most visible articulation of the supply wallah position can be found in the UN’s Millennium Development Goals (MDG), the eight goals that the world’s nations agreed in 2000 to reach by 2015. The second and third MDGs are, respectively, to “ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling” and to “eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015.” Most national governments seem to have bought into this idea. In India, 95 percent of children now have a school within a half mile or so.3 Several African countries (including Kenya, Uganda, and Ghana) have made primary education free, and children have flooded the schools. According to UNICEF, between 1999 and 2006, enrollment rates in primary school in sub-Saharan Africa increased from 54 percent to 70 percent. In East and South Asia, they increased from 75 percent to 88 percent over the same period. Worldwide, the number of children of school age who were out of school fell from 103 million in 1999 to 73 million in 2006. In our eighteen-country data set, even among the extremely poor (those who live on less than 99 cents a day), enrollment rates are now above 80 percent in at least half the countries for which we have data.
Access to secondary school (ninth grade and above) is not part of the MDGs, but even there, progress has been made. Between 1995 and 2008, secondary gross enrollment ratios increased from 25 percent to 34 percent in sub-Saharan Africa, from 44 percent to 51 percent in South Asia, and from 64 percent to 74 percent in East Asia,4 despite the fact that the costs of secondary schools are much higher: Teachers are expensive, because they need to be better qualified, and for parents and children the value of the forgone earnings, and the forgone labormarket experience, is much larger because teenage children can work and earn money.
Getting children into school is a very important first step: This is where learning starts. But it isn’t very useful if they learn little or nothing once they’re there. Somewhat bizarrely, the issue of learning is not very prominently positioned in international declarations: The Millennium Development Goals do not specify that children should learn anything in school, just that they should complete a basic cycle of education. In the final declaration of the Education for All Summit in Dakar in 2000, sponsored by the United Nations Educational, Scientific and Cultural Organization (UNESCO), the goal of improving the quality of education is mentioned only in the sixth position—out of six goals. The implicit assumption, presumably, was that learning would follow from enrollment. But unfortunately things aren’t that simple.
In 2002 and 2003, the World Absenteeism Survey, led by the World Bank, sent unannounced surveyors to a nationally representative sample of schools in six countries. Their basic conclusion was that teachers in Bangladesh, Ecuador, India, Indonesia, Peru, and Uganda miss one day of work out of five on average, and the ratio is even higher in India and Uganda. Moreover, the evidence from India suggests that even when teachers are in school and are supposed to be in class, they are often found drinking tea, reading the newspaper, or talking to a colleague. Overall, 50 percent of teachers in Indian public schools are not in front of a class at a time they should be.5 How are the children supposed to learn?
In 2005, Pratham, an Indian NGO focused on education, decided to go one step further and find out what children were really learning. Pratham was founded in 1994 by Madhav Chavan, a U.S.—educated chemical engineer with an unflappable belief that all children should, and can, learn to read and read to learn. He has taken Pratham from a small Mumbai-based UNICEF-sponsored charity to one of the largest NGOs in India, perhaps in the world: Pratham’s programs reach close to 34.5 million children all over India and are now venturing into the rest of the world. Under the banner of the Annual State of Education Report (ASER), Pratham formed volunteer teams in all 600 Indian districts. These teams tested more than 1,000 children in randomly chosen villages in every district—700,000 children overall—and came up with a report card. One of the leading lights of the ruling Congress-led government, Montek Singh Ahluwalia, launched the report, but what he read could not have made him happy. Close to 35 percent of children in the seven-to-fourteen age group could not read a simple paragraph (first-grade level) and almost 60 percent of children could not read a simple story (second-grade level). Only 30 percent could do second-grade mathematics (basic division).6 The math results are particularly stunning—all over the Third World, little boys and girls who help their parents in their family stall or store do much more complicated calculations all the time, without the help of pen and paper. Are schools actually making them unlearn?
Not everyone in the government was as gracious as Mr. Ahluwalia. The government of the state of Tamil Nadu refused to believe that it was really doing as badly as the ASER data seemed to imply and ordered its own teams to conduct a retest, which unfortunately only served to reinforce the bad news. These days in India, in an annual ritual in January, ASER results are released. Newspapers express dismay at the poor scores, academics talk about the statistics in panel discussions, and very little changes.
Unfortunately, India is not unique: Very similar results have been found in neighboring Pakistan, in distant Kenya, and in several other countries. In Kenya, the Uwezo Survey, modeled on ASER, found that 27 percent of children in fifth grade could not read a simple paragraph in English, and 23 percent could not read in Kiswahili (the two languages of instruction in primary school). Thirty percent could not do basic division.7 In Pakistan, 80 percent of children in third grade could not read a first-grade-level paragraph.8
The Demand Wallahs’ Case
For the “demand wallahs,” a set of critics (including William Easterly) who believe that there is no point in supplying education unles
s there is a clear demand for it, these results encapsulate everything that has been wrong with education policy in the last few decades. In their view, the quality of education is low because parents do not care enough about it, and they don’t because they know that the actual benefits (what economists call the “returns” to education) are low. When the benefits of education become high enough, enrollment will go up, without the state having to push it. People will send their children to private schools that will be set up for them, or if that is too expensive, they will demand that local governments set up schools.
The role of demand is indeed critical. School enrollment is sensitive to the rate of returns to education: During the Green Revolution in India, which raised the level of technical know-how needed to be a successful farmer and thereby increased the value of learning, education increased faster in regions that were better suited to the new seeds introduced by the Green Revolution.9 More recently, there is the example of the offshore call centers. In Europe and the United States, they are usually vilified for taking away local jobs, but they have been part of a small social revolution in India by dramatically expanding young women’s employment opportunities. In 2002, Robert Jensen of the University of California at Los Angeles teamed up with some of these centers to organize recruiting sessions for young women in randomly selected villages in rural areas where recruiters would typically not go, in three states in northern India. Not surprisingly, compared to other randomly chosen villages that did not see any such recruiting efforts, there was an increase in the employment of young women in business process outsourcing centers (BPOs) in these villages. Much more remarkably, given that this is the part of India probably most notorious for discrimination against women, three years after the recruiting started, girls age five to eleven were about 5 percentage points more likely to be enrolled in school in the villages where there was recruiting. They also weighed more, suggesting that parents were taking better care of them: They had discovered that educating girls had economic value, and were happy to invest.10
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