We recently published a new review of GiveDirectly, a “standout” charity that gives cash directly to poor people in Kenya. As we were going through the process of discussing and vetting the new review, I found myself wondering how I would defend my preference to donate to distribute insecticide-treated bednets (ITNs) against a serious advocate for cash transfers. We’ve written before about the theoretical appeal of giving out cash, and the fact that there is a promising charity doing so renews the question of whether we should.
I continue to worry about the potential “paternalism” of giving bednets rather than cash (i.e., the implication that donors are making decisions on behalf of recipients). I believe that by default, we should assume that recipients are best positioned to make their own decisions. However, I see a few reasons to think bednets can overcome this presumption:
- The positive externalities of ITNs
- The fact that bednets protect children rather than adults
- The fact that ITNs may be unavailable in local markets or that people may reasonably expect to be given them for free.
I address each of these reasons in more depth below. Note, however, that this discussion is meant to be primarily about the theoretical question of giving cash versus giving bednets; a more practical discussion of giving to the Against Malaria Foundation versus giving to GiveDirectly would focus on the specifics of the two organizations.
The positive externalities of ITNs
We discussed the evidence that ITNs have benefits for community members other than those using the ITNs in our review of the evidence for ITNs. After speaking with several malaria scholars and reviewing the literature, we concluded:
- The evidence for the efficacy of ITNs is based on studies of universal coverage programs, not targeted programs. In particular, all five studies relevant to the impact of ITNs on mortality involved distribution of ITNs to the community at large, not targeted coverage… Thus, there is little basis available for determining how the impact of ITNs divides between individual-level effects (protection of the person sleeping under the net, due to blockage of mosquitoes) and community-level effects (protection of everyone in communities where ITN coverage is high, due to reduction in the number of infected mosquitoes, caused either by mosquitoes’ being killed by insecticide or by mosquitoes’ becoming exhausted when they have trouble finding a host).
- The people we spoke to all believe that the community-level effect of ITNs is likely to be a significant component of their effect, though none believe that this effect has been conclusively demonstrated or well quantified.
- There is some empirical evidence suggesting that the community-level impact of ITNs is significant.
In our main model of the cost-effectiveness of distributing ITNs (XLS), we assumed that 50% of the benefits of ITNs come from the total community coverage of ITNs.
To the extent that ITNs have positive externalities, private actors may underinvest in them, meaning that it may be a good idea to distribute them freely even if individuals would choose not to purchase them at the available price. More generally, since we care about helping whole populations and not any particular specific individual, providing “public goods” of this sort amplifies our impact relative to giving the same amount of money to individuals.
Although it is conceptually possible that giving a large number of individuals small cash grants also has positive externalities, e.g. by boosting the local economy, we haven’t seen any evidence of this, and we doubt that the magnitude of the externality would be as large.
Bednets protect children rather than adults
One of the central reasons that I appreciate cash transfers is that they avoid paternalism. But sometimes, especially with regard to children, paternalism seems morally justifiable. I believe this is one of those cases.
Although AMF distributes ITNs universally, not just to children, the main benefits of ITNs—averting mortality—accrue to children under the age of 5. Children under the age of 5 lack bargaining power, income, and access to credit, not to mention the cognitive faculties to make decisions about their own long-term welfare. Accordingly, purchasing something that is reasonably likely to keep young children alive, even if they don’t or can’t decide to purchase it for themselves, seems to be a justifiable form of paternalism. In general, paternalism towards such young children is unobjectionable.
By distributing bednets, we might be spending money to benefit kids in a way that their parents wouldn’t spend it if we gave it to them instead. Given the magnitude of the benefits to the children, this seems to be justified.
People may not purchase ITNs because they are unavailable in local markets or because they expect to be given them for free
This point is more anecdotal, but Natalie, Holden and I remember being told while we were in Malawi that long-lasting insecticide-treated bednets, of the sort that AMF distributes, are essentially not available for purchase in local markets. Unfortunately this is not in our published notes (DOC) from the conversation where we recollect it occurring.
In another case, an RCT in Kenya in which researchers experimentally subsidized the cost of bednets (PDF), even very small increases in prices led to substantial reductions in bednet purchases by mothers (e.g. charging $0.60 led to a 60% reduction in take-up). Two different people told us in off-the-record conversations that they thought that this occurred because the mothers offered subsidized bednets believed that they would be able to acquire free nets at some other point. There have been periodic free ITN distributions in many sub-Saharan African countries over the last decade, and the international consensus seems to be that governments should distribute ITNs free of charge in malaria-endemic areas. Accordingly, it should not be especially surprising that citizens may expect bednets to be provided free of charge, and may not move to purchase them even if they are available at subsidized prices in the marketplace. If we reasonably expect to be given something for free in a relatively short time window, why buy it now?
This wouldn’t necessarily have been the case if philanthropy had never funded bednets, but having started down this path, I think it provides another consideration in favor of continuing. If we could credibly and cheaply communicate that no more bednets would be forthcoming, this consideration wouldn’t matter, but there is no obvious way to do so.
This is something to keep in mind in the future: philanthropic funding decisions may create an unanticipated a form of “lock-in,” in which future philanthropists become effectively committed to continued funding, even if it would not have been necessary in a counterfactual world of no philanthropic support. Although unlikely to be crucial, this consideration may counsel against certain undertaking some marginal philanthropic activities.
I think that in order to avoid paternalism, philanthropists working to improve the lives of the global poor should have fairly strong presumption in favor of cash transfers, and that those who advocate other strategies should have a convincing story to tell about why they beat cash. Above, I’ve tried to justify my view that bednet distributions are one of those philanthropic strategies that may beat cash. In searching for future top charities, I’d like to see a similarly strong case.