PHM-Exch> [PHM NEWS] WHO's new focus on behavioural science (actually behavioural economics) is flawed

[Claudio Schuftan]

*From:* People's Health Movement [mailto:dlegge at phmovement.org]

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WHO's new focus on behavioural science raises concerns

WHO's Executive Board, meeting in Geneva this week, will consider EB152/25
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=902dd24102&e=a2777af914>
which
reports on the development  of the ‘behavioural sciences for better health
initiative’.

The ‘behavioural sciences for better health initiative’ involves
establishing a permanent capacity within the Secretariat, and on contract,
to provide ‘behavioural insights services’. The board will also consider a
draft resolution contained in EB152/CONF./6
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=2bd1a606c5&e=a2777af914>
which urges both member states and the Secretariat to invest in behavioural
insights services.
The selective strengthening of behavioural science in comparison to other
scientific disciplines is not explained; why not anthropology or political
science?

The evidence cited in EB152/19 to support this selective strengthening of
one particular scientific discipline within the Secretariat is thin.  There
has not been any assessment of the relative strengths of different
disciplines within WHO.

There are several references to an initiative in Euro Region to a
'behavioural and cultural insights' project and an initiative in the Afro
Region to social and behavioural insights’ but the current initiative has
nothing about cultural or social insights. This present initiative is
solely about behavioural insights.

There is no suggestion that there has been a comparative analysis of the
contribution of behavioural, social, or cultural insights (or those of
other disciplines such as political economy, gender studies, or media
studies) to the work of the Secretariat. In view of the criticism of WHO's
performance in the Ebola response in 2014 regarding its lack of
anthropological expertise it is surprising that the present scientific
strengthening is solely focused on behavioural science.

The call should be for using appropriately all the tools of social
sciences; behavioural sciences is but one tool.
Evidence of need is weak

There is a reference in para 18 to an external assessment of WHO products
which allegedly found a selective deficiency with respect to behavioural
insights but it does not appear to have been published.

Para 8 presents a long list of areas where WHO has (according to EB152/25)
integrated social and behavioural sciences into its work. No evidence is
presented to show that the inclusion of behavioural insights in these areas
has been suboptimal.

Para 12 cites an increasing number of "requests from Member States for
technical support for the application of behavioural sciences to public
health". No further documentation provided. Is the increased number of
requests statistically significant?

Para 13 refers to an 'urgent need for action and rapid learning' which
leads to 'the creation and “incubation” of a cross-cutting,
multidisciplinary, demand-driven behavioural science function at WHO
headquarters'. However, no firm evidence is presented for this selective
urgency.

Para 25 identifies, as one of the priorities for 2022-23, "compiling and
disseminating evidence on improved outcomes resulting from the application
of the behavioural sciences to public health". This implies that the
evidence will be restricted to cases where behavioural insights contributed
to ‘improved outcomes’. So presumably if the research finds evidence where
the application of behavioural sciences to public health has not led to
improved outcomes, it will not be compiled or disseminated.

This suggests public relations spin rather than evidence based capacity
building.
Public health programs have used social marketing for ever

Many would be surprised to find that the application of behavioural
insights to public health has been lacking. Public health programs have
used social marketing (generally informed by extensive behavioural
research) as one element of campaign strategy for many years. Examples
include not spitting (early TB message), road safety, tobacco use, breast
feeding, medication use, STI prevention, vaccination, insecticide treated
bednets, etc.
The development of behavioural sciences is being promoted across the UN
system and through the OECD and the World Bank

While EB152/25
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=6aa6bd9bae&e=a2777af914>
claims to respond to an urgent need for WHO in particular to invest in
‘behavioural insights services’ it also advises that the development of
behavioural sciences is being driven, from the top, across the UN system
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=e6a841baab&e=a2777af914>.
However strong (or weak) the case might be for ‘behavioural insights
services’ in public health, WHO is under pressure to comply with this UN
wide initiative.

Not just in the UN system.  Both the OECD
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=a354d6b059&e=a2777af914>
and the World Bank
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=f33037b8d7&e=a2777af914>
have invested significant resources over the last decade into strengthening
the application of behavioural economics and a wide range of national
governments have followed the UK lead in setting up ‘behavioural insight
teams’ (‘nudge units’) in government departments. (See also OECD 2017
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=ef44ca9100&e=a2777af914>,
WDR 2015
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=e03c851d68&e=a2777af914>,
Afif et al 2019
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=667e5e107d&e=a2777af914>
.)
Behavioural sciences initiative is closely linked to behavioural economics

Some further background is needed. While WHO and the UN are talking about
‘behavioural sciences’ it is evident that the drive is closely linked to
the behavioural economics initiatives of the OECD and the WB.

Recognising that behavioural science has contributed to public health for
many years we therefore need to ask what is the value being added by the
new behavioural economics influence.

Behavioural economics criticises simplistic assumptions about how markets
work and promotes nudging instead of (or to supplement) regulation

Behavioural economics emerged originally as a critique of neoclassical
economics, in particular, criticising assumptions about how markets work (Earl
2018
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=36c703f009&e=a2777af914>).
Neoclassical economics treats consumers as rational, fully informed,
utility maximising, individual agents. It treats the firm likewise as a
rational, profit maximising agents. Behavioural economics points out that
consumers bring various biases to their decisions, are not fully informed,
often approach their decisions in ‘irrational’ ways and are shaped by
social influences such as advertising and culture. Likewise the decisions
of businesses are often not rational, or at least not as rational as
posited by neoclassical economics (Earl 2005
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=367b718041&e=a2777af914>,
Primrose 2017
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=4cb01d412b&e=a2777af914>
).
Defending marketisation as a design principle for public policy and
protecting business from intrusive regulation

It appears that behavioural economics has risen to new prominence in public
policy and program design for two reasons: first because of
contension regarding market failure, and second, because of contension
regarding over-intrusive regulation.

In recent decades there has been increasing public dissatisfaction with
neoliberalism and in particular with the promotion of marketisation and
privatisation as design principles for public policy. In the face of such
dissatisfaction, earlier debates have resurged regarding the appropriate
roles for, and boundaries between, the market and public administration.

However, behavioural economics complements rather than threatens
neoclassical hegemony. The reference to behavioural insights is an
invitation to the neoclassical economist to adjust the outcomes of their
core theory with insights from behavioural economics. Behavioural economics
recognises that markets fail because people are not ‘rational’. However, it
seeks not to redress the neoliberal focus on markets, but to make people
themselves better adjusted to play their proper role in markets by
promoting behaviour closer to that of the neoclassical hyper-rational actor.

Thus in the context of policy and program design where the delivery of
goods and services through the public sector might be under consideration,
the insights of behavioural economics serve to to support the use of market
mechanisms rather than public sector delivery by promising the reduce the
likelihood of market failure by tweaking market mechanisms through the
insights of behavioural economics and by deploying the ‘nudge’ to correct
any tendencies to market failure (Primrose 2017
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=d1e4d47234&e=a2777af914>
).

Concerns from the private sector about the intrusiveness of public policy
and regulation (red tape) are a second driver behind the rise of
behavioural economics in public policy. In this context, the ‘nudge’ is
being promoted as a preferred alternative to more structural regulation.

There is nothing intrinsically wrong with the use of the nudge in public
policy generally or public health in particular. Public health advocates
have argued for ‘making healthy choices easier choices’ since at least the
Ottawa Charter in 1986.

Nevertheless, there have been concerns in public health for many years
about the ethics and propriety of deploying the resources of government to
covertly shape people’s choices. It is not easy to draw a sharp boundary
between respect for autonomy and coercive paternalism but the boundary
needs to be subject to continuing review.

There are also choices to be made between the individual focus of the nudge
and a more social approach to building the culture and institutions which
might support a more collective engagement with issues of health care
delivery or the social determination of health. The market as a model for
program design is necessarily focused on the individual or family. In this
respect it differs from comprehensive primary health care which looks for
modes of engagement which go beyond the individual and family to the wider
community or other constituencies. The nudge, where the agent is the policy
maker and the object is the consumer, is not well suited to a more
community oriented approach.

The prospect that the nudge might reduce the need for more intrusive
regulation needs to be treated with caution.  In one of the leading
jurisdictions promoting behavioural economics, game day advertisements for
online gambling (to sporting crowds including many children) are not
prohibited, on the grounds that they are accompanied by a brief exhortation
(nudge?) to ‘gamble responsibly’. (Or smoke responsibly or drink
responsibly or be responsible about wearing seatbelts.)  In relation to
nutrition and health, the nudge focuses on individual behaviour (such as
changing the location of chocolates at a supermarket cashier) rather than
regulating junk-food advertising to children or deploying tariff or pricing
policies to ‘make healthier choices easier choices’.
Creating a public policy discourse which is market-friendly and
regulation-resistant

It is self-evident that market relations can work well in certain
circumstances and that over-intrusive regulation has costs which can
outweigh any benefits. It is also true that there are many concerns of
accountability and performance and quality of care that public health
systems grapple with.

However, the poverty of evidence in EB152/25, and the UN wide drive to
embed behavioural economics in inter-governmental policy making provide
grounds for concern about a system wide reshaping of global policy
discourse, directed to defending neoliberal marketisation policies and
discouraging consideration of regulatory strategies regardless of the
circumstances of particular policies.

*PHM urges the Executive Board to reject the resolution* contained in
EB152/CONF./6
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=bb87526708&e=a2777af914>
.

*PHM urges the DG to create a new unit* focused on policy capacity and
regulatory strategies with responsibilities which include promoting a
balanced, evidence informed approach to policy capacity and regulatory
policy and to include the behavioural sciences function in that unit.
------------------------------

See our more detailed commentary on this item here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=4f1cf3fa9e&e=a2777af914>.
The Tracker page for EB152 is here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=3764b0e69b&e=a2777af914>
.

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