T17aP09 - Implications of behavioural policy making in health promotion

Topic : Sectorial Policy - Health

Panel Chair : Benjamin Ewert - ewert@ph-heidelberg.de

Panel Second Chair : Kathrin Loer - kathrin.loer@fernuni-hagen.de

Objectives and Scientific Relevance of the panel

Call for papers

Session 1

Thursday, June 29th 10:30 to 12:30 (Block B 3 - 6 (35))


Benjamin Ewert - ewert@ph-heidelberg.de - Heidelberg School of Education - Germany

Kathrin Loer - kathrin.loer@fernuni-hagen.de - Fernuniversität Hagen - Germany

Evaluating the (in)Efficacy of Behavioural Levers on Field Agents’ Performance under Rural Sanitation Policy in India

Shuchi Srinivasan - shuchis@iima.ac.in - Indian Institute of Mangement Ahmedabad - India

The delivery of public goods relies on the active involvement and effort of field agents, who become critical conduits for policy implementation. This is particularly the case in a developing country such as India, where field agents become the face of public policies. The role of these agents assumes great importance due to the stakeholders associated with their performance – namely, the beneficiaries under various public policies, and other agents under the administrative infrastructure. But, what encourages them to invest costly effort? Especially in the absence of any financial incentives, monitoring mechanisms and decision-making discretion? Further, can field agent performance be improved for efficient and effective delivery of public goods?


The current research investigates this puzzle by applying Prospect Theory (Tversky & Kahneman, 1992), Agency Theory (Eisenhardt, 1989), Motivation Theory (Frey, 1994), and the concept of limited attention (Karlan, Mc Connell & Mullainathan, 2010) to the challenge of focusing volunteer agents on a new policy in rural India. While there are a host of socio-economic and political reasons for poor field agent performance (Lipsky, 1980), this study focuses on the behavioural dimension. The investigation is situated in the context of field agents under India’s Rural Sanitation Policy. The policy was undertaken to address the massive public health challenge associated with poor sanitation. A UN report suggested that, of a billion people across the world who defecate in the open, 60% reside in India (UNICEF & WHO, 2012). This trend has been associated with poor health, nutrition and frequent morbidity (Waterkeyn & Cairncross, 2005; Fewtrell et al., 2005; Chambers & Von Medeazza, 2013). The policy attempted to circumvent these challenges through incentivized toilet construction in each rural household. The policy entrusts “volunteer” agents with the task of improving rural sanitation by “motivating” households to construct toilets. In practice, few toilets have been constructed, and fewer are in use (Coffey et al., 2014). 


This enquiry examines the performance of 1400 field agents across four districts in western India through a set of randomized field experiments, to provide causal estimates on whether periodic, framed reminders related to self and public benefit (tied to performance), can influence field agents to motivate more households towards improved sanitation. The experiments employed prerecorded voice reminders that were sent to the participants over a period of three months. The impact of these interventions was measured using administrative data, sub-sample survey data, qualitative interviews, and field notes.


The study proposes the use of behavioural levers as potentially low-cost tactics to improve agent performance under various public policies. We also discuss the implementational challenges with respect to low-cost nudges in developing country contexts.  In answering the questions posed above, this research contributes to the literature on the role of material and prosocial incentives driving agent behaviour.



Chambers, R., & Von Medeazza, G. (2013). Sanitation and stunting in India. Economic & Political Weekly, 48(25), 15.


Coffey, D., Gupta, A., Hathi, P., Khurana, N., Spears, D., Srivastav, N., & Vyas, S. (2014). Revealed preference for open defecation. Economic & Political Weekly, 49(38), 43.


Eisenhardt, K. M. (1989). Agency theory: An assessment and review. Academy of management review, 14(1), 57-74.


Fewtrell, L., Kaufmann, R. B., Kay, D., Enanoria, W., Haller, L., & Colford, J. M. (2005). Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. The Lancet infectious diseases, 5(1), 42-52.


Frey, B. S. (1994). How intrinsic motivation is crowded out and in. Rationality and society, 6(3), 334-352.


Karlan, D., McConnell, M., Mullainathan, S., & Zinman, J. (2016). Getting to the top of mind: How reminders increase saving. Management Science.


Lipsky, M. (1980). Street-level bureaucracy: The critical role of street-level bureaucrats. Classics of public administration, 414-422.


Tversky, A., & Kahneman, D. (1992). Advances in prospect theory: Cumulative representation of uncertainty. Journal of Risk and uncertainty, 5(4), 297-323.


UNICEF, N., World Health Organization, & UNICEF. (2012). WHO (2012). Progress on drinking water and sanitation.


Waterkeyn, J., & Cairncross, S. (2005). Creating demand for sanitation and hygiene through Community Health Clubs: A cost-effective intervention in two districts in Zimbabwe. Social science & medicine, 61(9), 1958-1970.


Personal and social responsibility for health: A cross-sectional study of attitudes in a Norwegian population

Gloria Traina - gloria.traina@medisin.uio.no - University of Oslo - Norway

Eli Feiring - eli.feiring@medisin.uio.no - Norway

Lifestyle-induced diseases put strain on public healthcare and there is an increasing recognition that non-communicable diseases (NCDs) are overtaking infectious diseases as the world’s leading cause of morbidity and mortality. This situation has spurred two distinct debates internationally on the role of individual responsibility for health. First, small reductions of population exposure to lifestyle related risks may yield substantial health gains. Still, controversies persist about governments’ role in protecting people from the adverse consequences of individual lifestyles, as interventions aiming at preventing people from adopting unhealthy behaviours may be seen to infringe respect for autonomy, including liberty of action. Second, healthcare authorities face difficult priority setting problems due to resource scarcity. In publicly funded health care systems, there is a recurrent debate on the possibility to ration healthcare based on individual health behaviours. Yet, greater knowledge on the attitudes towards the division of individual and public responsibilities, and the expectations attached to them, is required for developing the system in a way that reflects the population’s values and preferences. In particular, how do citizens conceive the role of the state in health promotion and treatment and at what extent should individuals be held responsible for health care costs that can in some way be attributed to their own choices of lifestyle?  

Building on a national survey among 7,500 Norwegians in 2014, this cross-sectional study aims at investigating the Norwegian population’s attitude towards individual responsibility in health promotion interventions and in the context of healthcare rationing. Moreover, by aid of an extended questionnaire covering a range of related issues, the variation in the attitudes towards responsibility is analysed in light of the individual’s health condition and health-related behaviour, political beliefs and socioeconomic status.


Nudging and population-based cancer screening

Eli Feiring - eli.feiring@medisin.uio.no - Norway

Regulatory tools that are targeting peoples’ biases in decision-making, such as the disposition to postpone decisions and to focus on short term rather than future gains, are increasingly being used and justified through the influence of insights from behavioral economics on policy-making. Advances in behavioral economics and cognitive psychology have revealed how individual decision-making is boundedly rational, habitual and systematically biased and sometimes result in outcomes that are suboptimal according to the individual’s values and long-time preferences. These findings have prompted policy-makers to develop decision aid to correct behavior through conscious and reflective processes, but also to utilize biases that are common when people make decisions.

The literature on the theory and practice of nudging has spurred much debate on understanding the psychological processes that drives behavior and decision making as well as the development, implementation and evaluation of the effectiveness of using nudging as a policy tool in many different sectors of public policy. Further, a growing literature is emerging about the ethics of nudging. The ethical debate has first and foremost evolved around the assumption that decisional nudging infringes upon individual autonomy. Governmental nudging may be seen to intrude into areas of personal responsibility and the worry has been raised that people are being manipulated by subtle interventions in choice situations.

While the debate on the ethics of nudging has informed some analyses of public health initiatives, ethical analysis of nudging in the context of screening is sparse. This paper aims to assess the legitimacy of using nudges as a regulatory tool to increase participation in cancer screening programs. Screening healthy, non-symptomatic individuals is expected to reduce mortality rates of cancer at the population level and is seen to be an essential part of modern cancer care. In women, breast cancer has high incident rates and population-based screening programs are introduced in many countries in the world. High acceptance rate is an explicitly stated goal in most programs. Governments may intervene to improve the attractiveness of participation in screening. One option is the modification of the environment in which choices are made so that the choice to participate becomes more likely than non-participation.

This is the first study that offers an analysis of nudging and breast cancer screening in a Norwegian context. The paper analyses how different nudging techniques are used to maximize screening uptake by a content analysis of textual material such as invitation letter and informational leaflets. Further, the paper explores whether it is normatively justifiable to nudge women to participate in breast cancer screening.


Approaches and instruments in health promotion and disease prevention

Kathrin Loer - kathrin.loer@fernuni-hagen.de - Fernuniversität Hagen - Germany

This theoretical paper analyses the debate on instruments that are used by policy-makers focusing on health promotion and prevention. In doing so it will systemize to what purpose, how and why certain instruments or mixtures of instruments have been used. It starts by a

cursory assessment of public policies for health recapitulating the interplay and complex tension of approaches and instruments aiming at individuals’ behaviour – in other words: individualistic interventions – (e.g. by making healthier choices easier) and those societal

interventions that focus on social determinants of health (i.e. political, spatial and social factors shaping health and health behaviour) over time. Hence, the paper discusses key principles, guiding rationales and current challenges of setting-based and ‘Health in all Policies’ approaches (as they are pursued by the WHO). It therefore considers neighbouring fields of public policy to be influential and unfolds cross-sectorial overlapping. The paper will explain how the current debate can be explained in light of seminal works of public health (e.g. Milo 1981, Evans / Barer / Marmor 1994, Weiss / Tschirhart 1994, Nutbeam 1998). Thus, the well-established or even traditional principles and rationales of promoting public health and their instrument choices are discussed in relation to recent behavioural policies as they are attached with the theory of libertarian paternalism and the concept of nudging. It will be asked whether nudge-based instruments represent a new strand of behavioural health promotion and how they fit in existing policies for public health.

From protected citizens to nudged consumers? Re-examining rationales of public health policies in the light of the behavioural turn

Benjamin Ewert - ewert@ph-heidelberg.de - Heidelberg School of Education - Germany

Traditionally, public health policies rely on a mix, recurrently negotiated and reviewed by policymakers, between societal and individualistic interventions. The former includes state-based regulations for the prevention of health risks and the provision of public healthcare while the latter is characterized by the degree of agency and responsibility ascribed to individuals in health promotion and maintenance. Facing an

increase of non-communicable diseases (such as diabetes and obesity) policymakers identify people’s lifestyles as key leverage factors for improving public health and (re)discover the armoury of behavioural policy tools (e.g. nudges or default rules). This present ‘behavioural turn’ in health policies could be labelled as the latest of four phases, shaping public health policies in western welfare states. The paper starts by reflecting these, partly overlapping and coexisting, policy phases: the creation of safe publics and universal healthcare provision (phase 1), the promotion of healthy public policies (phase 2), the individualization of health and the deregulation of healthcare systems

(phase 3) and, currently, the making of knowledge- and behaviour-based health societies (phase 4). As it is argued, each phase rests on a dominating policy rationale – protection, participation, choice and competition and behavioural change – determining policy goals but also the state-citizen relationship. Based on European policy examples the four phases’ policy rationales are reflected with a special emphasis on the meaning ascribed to individual health behaviour. Moreover, the question will be posed in which direction future public health policies are heading. Are behaviour health policies at large-scale inevitably or are blended approaches combining (and, thus, rebalancing) several policy rationales possible? The paper closes by arguing for integrated approaches adapting behavioural tools to pre-existing health policy frameworks.

The Politics of Behavioural Policy-Making in Health Promotion: Exploring Recent Developments in Australia

Anne-Maree Farrell - D.Pakendorf@latrobe.edu.au - La Trobe University - Australia

This paper explores the political dynamics influencing the use behavioural public policy-making in health promotion. Promoting beneficial behaviour change in health is not new and this paper considers what recent political interest in behavioural public policy might mean in this area. It draws on Australia by way of country case study, examining the dynamics of growing political enthusiasm for the use of behavioural public policy at both state and federal levels. In particular, it explores its use in health promotion, with a particular focus on recent work undertaken in the area by members of the UK Behavioural Insights Team (BIT) in the state of Victoria. Drawing on the findings from the case study, it is argued that particular attention needs to be paid to how the political context frames the use of behavioural public policy, the ways in which such framing may contribute to a mismatch between policy intent and implementation, and what the broader implications of this might be for addressing complex public problems.


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