Thank you for hosting this AMA. I have been very impressed by New Incentives' work, especially when it comes to pulling off and scaling up such a complex behavior-change program.
My questions are about the factors behind your program's cost-effectiveness, how it may change over time, and how it may or may not translate to other settings. 1. My understanding is that Northern Nigeria may have significantly lower operational costs than other parts of sub-Saharan Africa, and that the cheap Naira has helped New Incentives achieve more per dollar than was the case a few years ago. Is that correct? 2. Are there other parts of sub-Saharan Africa where you expect similar levels of cost-effectiveness may be achievable? And are you planning to expand there? Why/why not? 3. How do you expect cost-effectiveness of your program in Northern Nigeria to evolve going forward?
In my view, this will also depend on how exactly the charity is delivering its intervention. Two examples come to mind where I'd expect much higher cost-effectiveness later on than early on: (1) Tech-enabled charities (e.g. delivering digital healthcare training or facilitating migration) - you need to initially invest a lot into building the tech product, getting users, building partnerships etc. but then, if things go well, you might scale your impact exponentially while only growing your costs linearly. (2) Government advocacy and technical-assistance-type projects (e.g. advocacy to introduce tobacco taxes or assistance with rolling out syphilis screening) - you need to initially invest money into building partnerships and/or running pilots with no or minimal impact but, if your work is successful, you'll have big impact later on, with comparable annual costs.
A lot of the recent discussion in the lead space has focused on sources such as paint, spices, ceramics, and cookware. In terms of trends, my (low-confidence) sense is that these sources of exposure are likely either plateauing or decreasing. But the use of lead in batteries is expected to increase a lot (based on a quick search, the market may double in the next 10-15 years).
1) How much do you think we should be focusing on batteries – and informal ULAB recycling – compared to other sources of exposure?
2) Are there any prevention/mitigation strategies in this space that people are pursuing that you're excited about? Or approaches that you'd be keen for people to explore?
Just adding that I would also be keen to see this model. At AIM, we haven't done any detailed modeling of skilled migration, but if/when we do look into it, quantifying these sorts of tradeoffs will be one of our key considerations.
Thanks for raising this point, Nick, and for the many good arguments you’re making!
Out of all the forms of labor emigration, I find physician and nurse migration to be the most concerning. I’d stress that the idea proposed in our report doesn’t focus on skilled workers (only as a potential later extension, needing careful consideration), so it largely avoids this concern. We focus on low- and mid-skilled workers, as those are poorer to begin with, much more numerous, and there’s an oversupply of them in many LMICs (as opposed to shortages).
I did spend a little bit of time looking into the literature on brain drain and didn’t arrive at a clear conclusion. There are many factors pointing in different directions, and whether the overall effect is net positive or net negative may vary between countries and professions.
Aside from the considerations that you and David mentioned, there are also remittances, the effects of return migration (the rates of which vary a lot) and associated "brain gain", or the fact emigrating physicians are more likely to come from well-staffed urban areas. E.g. this (very old) article by Clemens and McKenzie says that, in Kenya, some 66% of physicians live in Nairobi where only 8% of the national population lives. They argue that low incentives to work in rural areas are a much bigger problem than the total supply of physicians (and how that supply is affected by emigration).
Concerning the CGD, I’m actually quite excited about their efforts to push for so-called global skills partnerships in the skilled space. Within these programs, countries like the UK would pay countries like Nigeria to train nurses and have agreed quotas on how many nurses can stay vs migrate. This seems like a more sophisticated solution to the issue than saying “nurse emigration is good.” Here is their proposal specifically for Nigeria.
In any case, this is not a topic that we at CE decided to focus on at this point. If we do look into skilled migration in the future, we will do a much more thorough dive (and will be keen to get your input!).
Hi Gemma, thanks for sharing! That platform indeed has several similarities with our proposed nonprofit idea (though also some differences, such as our focus low- and mid-skilled workers and on a specific country of origin rather than a specific destination country). Exciting to see more work being done in this otherwise quite neglected space!
To add, we at Charity Entrepreneurship have been experimenting with using Dagger/Carlo for our cost-effectiveness analyses of new charity ideas. We've put together this (very rough, work-in-progress) guide on how to use Dagger – sharing in case others find it helpful.
Hi Nick, thank you very much for your thoughtful feedback! I researched the syphilis idea so will address those questions.
1. The dual tests have recently become very cheap too, costing some $0.95 each (largely thanks to CHAI's work in this area). In our understanding, this is only some $0.15 more expensive than a single HIV test – though I'm sure prices will vary geographically. If there are places where the dual tests are more expensive than two separate rapid tests, then I agree that the dual tests wouldn't make sense there.
2. You are right that changing the existing system (including updating diagnostic algorithms and training the relevant health workers) is one of the main challenges and one of the reasons why this idea has not already been implemented more widely. However, it seems that what is currently lacking is technical assistance for countries' health systems to make this switch – and this is exactly the sort of implementational work that we think strong charity entrepreneurs can do well!
Hi Svetha,
Thank you for hosting this AMA. I have been very impressed by New Incentives' work, especially when it comes to pulling off and scaling up such a complex behavior-change program.
My questions are about the factors behind your program's cost-effectiveness, how it may change over time, and how it may or may not translate to other settings.
1. My understanding is that Northern Nigeria may have significantly lower operational costs than other parts of sub-Saharan Africa, and that the cheap Naira has helped New Incentives achieve more per dollar than was the case a few years ago. Is that correct?
2. Are there other parts of sub-Saharan Africa where you expect similar levels of cost-effectiveness may be achievable? And are you planning to expand there? Why/why not?
3. How do you expect cost-effectiveness of your program in Northern Nigeria to evolve going forward?
My quick guess is that turning something from a "waste product" to a "certified-safe supplement for human consumption" is still costly.
In my view, this will also depend on how exactly the charity is delivering its intervention. Two examples come to mind where I'd expect much higher cost-effectiveness later on than early on:
(1) Tech-enabled charities (e.g. delivering digital healthcare training or facilitating migration) - you need to initially invest a lot into building the tech product, getting users, building partnerships etc. but then, if things go well, you might scale your impact exponentially while only growing your costs linearly.
(2) Government advocacy and technical-assistance-type projects (e.g. advocacy to introduce tobacco taxes or assistance with rolling out syphilis screening) - you need to initially invest money into building partnerships and/or running pilots with no or minimal impact but, if your work is successful, you'll have big impact later on, with comparable annual costs.
That's really helpful. Thank you!
A lot of the recent discussion in the lead space has focused on sources such as paint, spices, ceramics, and cookware. In terms of trends, my (low-confidence) sense is that these sources of exposure are likely either plateauing or decreasing. But the use of lead in batteries is expected to increase a lot (based on a quick search, the market may double in the next 10-15 years).
1) How much do you think we should be focusing on batteries – and informal ULAB recycling – compared to other sources of exposure?
2) Are there any prevention/mitigation strategies in this space that people are pursuing that you're excited about? Or approaches that you'd be keen for people to explore?
Just adding that I would also be keen to see this model. At AIM, we haven't done any detailed modeling of skilled migration, but if/when we do look into it, quantifying these sorts of tradeoffs will be one of our key considerations.
Thanks for raising this point, Nick, and for the many good arguments you’re making!
Out of all the forms of labor emigration, I find physician and nurse migration to be the most concerning. I’d stress that the idea proposed in our report doesn’t focus on skilled workers (only as a potential later extension, needing careful consideration), so it largely avoids this concern. We focus on low- and mid-skilled workers, as those are poorer to begin with, much more numerous, and there’s an oversupply of them in many LMICs (as opposed to shortages).
I did spend a little bit of time looking into the literature on brain drain and didn’t arrive at a clear conclusion. There are many factors pointing in different directions, and whether the overall effect is net positive or net negative may vary between countries and professions.
Aside from the considerations that you and David mentioned, there are also remittances, the effects of return migration (the rates of which vary a lot) and associated "brain gain", or the fact emigrating physicians are more likely to come from well-staffed urban areas. E.g. this (very old) article by Clemens and McKenzie says that, in Kenya, some 66% of physicians live in Nairobi where only 8% of the national population lives. They argue that low incentives to work in rural areas are a much bigger problem than the total supply of physicians (and how that supply is affected by emigration).
Concerning the CGD, I’m actually quite excited about their efforts to push for so-called global skills partnerships in the skilled space. Within these programs, countries like the UK would pay countries like Nigeria to train nurses and have agreed quotas on how many nurses can stay vs migrate. This seems like a more sophisticated solution to the issue than saying “nurse emigration is good.” Here is their proposal specifically for Nigeria.
In any case, this is not a topic that we at CE decided to focus on at this point. If we do look into skilled migration in the future, we will do a much more thorough dive (and will be keen to get your input!).
Hi Gemma, thanks for sharing! That platform indeed has several similarities with our proposed nonprofit idea (though also some differences, such as our focus low- and mid-skilled workers and on a specific country of origin rather than a specific destination country). Exciting to see more work being done in this otherwise quite neglected space!
To add, we at Charity Entrepreneurship have been experimenting with using Dagger/Carlo for our cost-effectiveness analyses of new charity ideas. We've put together this (very rough, work-in-progress) guide on how to use Dagger – sharing in case others find it helpful.
Hi Nick, thank you very much for your thoughtful feedback! I researched the syphilis idea so will address those questions.
1. The dual tests have recently become very cheap too, costing some $0.95 each (largely thanks to CHAI's work in this area). In our understanding, this is only some $0.15 more expensive than a single HIV test – though I'm sure prices will vary geographically. If there are places where the dual tests are more expensive than two separate rapid tests, then I agree that the dual tests wouldn't make sense there.
2. You are right that changing the existing system (including updating diagnostic algorithms and training the relevant health workers) is one of the main challenges and one of the reasons why this idea has not already been implemented more widely. However, it seems that what is currently lacking is technical assistance for countries' health systems to make this switch – and this is exactly the sort of implementational work that we think strong charity entrepreneurs can do well!