Resisting The Cure: How Are Health Public Goods Best Distributed?
By Fiorenzo Conte
Imagine you have a medicine which has the potential to prevent a debilitating disease and even mortality. The question you ask is: what is the most effective distribution method to maximize uptake and if necessary utilization? In other words, should you charge a price or should you give it for free? When scholars explored this question with regard to insecticide treated nets (ITNs) in Western Kenya they found that the uptake drops by 75% when the price increases from 0 to $0.75 and that free distribution does not increase the wastage of nets as demonstrated by the fact that women receiving free nets were as likely to use them as those who paid a subsidized price. The conclusion drawn was that free distribution is a more effective way to distribute ITNs compared to cost sharing.
On the basis of studies like this, free distribution can be considered as a condition sine qua non to increase the uptake and utilization of a health public good. But is free distribution enough? The cases of the polio vaccination campaigns in Northern Nigeria and of water filters distribution in Western Kenya tell us that the answer is no.
The Polio Eradication Initiative with the ambitious goal to eradicate polio succeeded in majority of the countries, however in Northern Nigeria vaccines were surprisingly turned down by the locals. The question which troubled health officers is why would poor people resist a vaccine for their children that is designed to prevent a debilitating disease that may result in paralysis or even death?. The price charged cannot account for this resistance as vaccines were given for free. The answer lies in other factors. In Northern Nigeria, some people believed that the vaccine was contaminated by anti-fertility substance, others questioned the focus on polio when malaria and measles were considered more harmful. The dichotomy between perceived and actual priorities is epitomized in the following quote:
There are problems concerning healthcare, housing, hunger, unemployment that bother people. With all these problems, they now say that they want to help us with polio. My people will never be able to understand this.
Such resistance has been interpreted by some authors as a tool which poor and marginalized people dispose to impose “their” priorities, which have been traditionally neglected by the government.
The resort to an exit strategy as a bargaining chip could have also played a role in Western Kenya. As a previous post pointed out, water filters are being distributed for free in this region. Households are visited by Life Straw personnel who install the filters in the house after having explained how it needs to be used. When I visited some of the beneficiary communities of this distribution I found water filters hanging in the living rooms. When I asked why they were not used two reasons stand out. First, some believes that water filters are used as sterilization tools by the government. Such suspicion stems from the dichotomy between perceived and actual priorities. There is little knowledge about water borne disease and therefore the reasons why water filters are distributed remains obscure to the community. Secondly, and influencing the first factor, the identity and background of the Life Straw staff distributing the filters is fuelling this distrust. Each community has two or three people who are perceived to be health ambassadors insofar as they have traditionally served as a point of contact between the health facilities and the communities. If a health good is brought to a household by anyone other than these health ambassadors, it will be met with skepticism. This is arguably the mistake that Life Straw committed, at least in the communities I visited.
To sum up, the cases of Northern Nigeria and Western Kenya illustrate why poor people sometimes resist a cure that could prevent disease and mortality. Firstly, communities who have been traditionally marginalized will be more likely to resist vertical public health interventions (distributing vaccines or water filters) when they do not see the target of the intervention in line with “their” priorities. Secondly, who is carrying out distribution plays an important role: to bypass those key figures who serve as a bridge between the community and the health facilities is bound to raise suspicions and distrust among the local recipients.