Managing Global Health: Applying Behavioral Economics to Create Impact (2230)

COURSE OVERVIEW & SYLLABUS Managing Global Health: Applying Behavioral Economics to Create Impact (2230)

Professor Nava Ashraf Harvard Business School

Introduction to the Course

Every year, nearly 13 million people worldwide die from conditions for which simple, affordable preventions and treatments exist. Condoms can prevent transmission of HIV/AIDS; mosquito nets can impede the spread of malaria; and water purification tablets can avert a slew of debilitating and deadly water-borne illnesses. Indeed, 63% of the deaths of children under age five could be averted with simple health products.1

The conventional response to dire health conditions in the developing world is to look for technological solutions or to galvanize greater financial resources. But the problems described above are ones for which effective technologies are available. Conservatively estimated, this sector attracts more than $20 billion each year.a So if the bottleneck is not technological or financial, what keeps us from helping individuals to access and use existing solutions?

This course argues that a significant part of the challenge is the way we have approached health. Conventionally, health—and, indeed, all of development—has been thought of as something given to people through a top-down approach. This course takes the perspective that health is neither simply given to nor simply acquired by individuals. Rather, health is co-produced by patients (customers) and a host of supply-side factors, which include providers, suppliers, and technologies, among others.2 In contrast with traditional models of service provision, instead of passive beneficiaries, end users are active agents in the co-production process of their own health.b

Consider the patient in the photograph in Figure A—a woman who has sought care at a public health clinic in Zambia. Arriving at this point was anything but effortless for her. The path to treatment is occluded with decision points and effort-expending measures, such as deciding that she needed care and traveling to the clinic. In Zambia, where the closest hospital is, on average, a six- hour drive away, the lack of transportation can discourage end users from seeking treatment. Moreover, seeking treatment can be influenced and even, in some cases, vetoed by spouses. The important aspect of health co-production is that the patient—the end user—must often go to great lengths to become healthy, independent of clinicians’ best efforts to provide care. A patient’s path to health is a chain of its own, replete with discouragement, failure points, human error, and institutional roadblocks, particularly in the developing world.

aThe Institute for Health Metrics and Evaluation (2012) estimates $28.1 billion in spending on development assistance for health (DAH), worldwide in 2012. The IHME also shows DAH growing from $5.74 billion in 1990, with average annual spending of $14.23 billion per year since. See Institute for Health Metrics and Evaluation, “Financing Global Health 2012: The End of the Golden Age?” (Seattle, WA: IHME, 2012), http://issuu.com/ihme/docs/fgh12/5?e=0, accessed February 2014. bThis is similar in nature to the phenomenon of customer participation in the production process in the service industry See Frei, Frances X. “The Four Things a Service Business Must Get Right.” Harvard Business Review 86, no. 4 (April 2008).

Figure A Co-Producing Health

Now consider the supply (or provider) side of public health: the doctor, the nurse, the pharmacist, or the community health worker. They too are subject to the same biases, incentives, and tradeoffs, that affect the health outcomes of their constituents. What are their motivations and incentives? On a broader scale, the provider side is not always a human practitioner; it could be a device, a medication, a digital app, and so on. In the end, we must determine the optimal design and delivery channel for the end user’s needs. This course will teach you methods and frameworks with which to address these challenges.

You will be challenged to take the end user’s needs as the starting point, not as an afterthought, but as the first and most important perspective to understand. Many development organizations seek to apply their exciting new product, service, or innovation to a problem. Starting with a solution and trying to find a problem to match it overshadows the needs of those we ultimately care about: the end users.

While this course dives deeply into the global health field, the principles and skills taught apply to a host of pressing social challenges, such as education, public safety, and conservation, all of which, like health, are co-produced. For instance, in education, the student must co-produce learning with the teacher by taking action and expending effort to acquire knowledge. In this course, students co- produce learning, knowledge, and action within the classroom and the MGH alumni network.

Harnessing Behavioral Economics

The underlying principle of behavioral economics is that humans are far from perfect decision makers. Research in both psychology and economics has shown that we behave against our own self- interest, even when we commit to behaving otherwise. We eat unhealthy foods, and we fail to take medications as prescribed. We regret our mistakes, yet we repeat them. Luckily, predictable patterns, such as present bias and limited attention, can help us anticipate and preempt with interventions that make it easier for both patients and providers to make better decisions. Behavioral economics provides a framework for understanding what drives our decisions, especially those that are

incongruent with our own goals.c The challenges of global health provide a fertile context in which to study the tenets of behavioral economics in practice and harness them to create positive impact.

An Iterative Process: Diagnose, Design, Deliver, and Test

Behavioral economists have developed a systematic approach to addressing some universal behavioral problems like those we will encounter in this course. The approach allows us to carefully and rigorously diagnose the problem (by understanding the end user’s needs); design interventions that allow natural, human behavioral tendencies to work with these needs; deliver those solutions via concrete implementation; and then test, using a scientific process—that is, whether the intervention delivered has “moved the needle” on the measure we’ve sought to effect. It is crucial to note that these steps often take multiple iterations before the desired outcome is reached. We must find ways of testing our interventions before we make policy recommendations or large-scale implementations—a process that often calls for a repeated cycle of diagnosing, designing, delivering, and testing.

Applying this cycle allows you to become a behavioral economics engineer. A process of listening intently and evaluating rigorously underpins and sustains the entire cycle. In MGH, you will study and practice the iterative process of diagnose, design, deliver, and test (see Figure B) via case studies, guest speakers, and a final paper or project. Your skills as listeners and evaluators will be honed through learning methods such as interviews, focus groups, and field experiments.

Figure B Applying Behavioral Economics

Course Structure

The course consists of four modules: (1) Putting the End User First, (2) Designing Solutions, (3) Measuring Success, and (4) Execution. During the first module, you will learn how to take the end user’s perspective and diagnose the challenges in health production. Then, in the second module, you

c It is important to understand what behavioral economics adds to a more traditional economic worldview and the updated assumptions it makes in response to the rational actor model. For example, a more standard economics approach would assume that for people who eat unhealthy foods, the utility gains of eating something tasty outweigh the utility loss of future health problems. A behavioral economics model could suggest a number of other things at play—e.g., that we discount future health costs, that under certain states of mind we eat more than we realize, etc.—which make us act against our own interest (let alone society’s or someone else’s). These decisions are suboptimal because they are incongruent with our own preferences.

learn how to design solutions using the principles of behavioral economics and leveraging standard market mechanisms like prices and incentives in an innovative way. Module 3 is the next step in the process: testing the effectiveness of a designed product or program and determining the best way to measure success. The first three modules make a repeating loop, illustrated in Figure B, allowing deeper understanding and better design through each iteration. However, often even good ideas with substantial evidence behind them are not turned into large-scale action. The fourth (mini) module helps provide you with the concepts and tools to transform good ideas into action and policy, when such action requires coordination among many actors.

Module 1: Putting the End User First

This module looks at health interventions through the lens of the individual who must decide to seek and adopt a solution (treatment, healthy behavior). Akin to customers in any market, health-care consumers and producers both perceive and make choices within a broad framework of trade-offs that must be understood and used in the design, implementation, and evaluation of health programs. Because we now know that choices are influenced, often subconsciously, by seemingly arbitrary characteristics of one’s environment, we will draw on choice architecture, or the use of behavioral economics principles to intelligently design the choice environment to foster healthy decisions. In this module, we learn how to:

Recognize Co-production A key case in this course is “Oral Rehydration Therapy (ORT).” ORT, a simple and effective measure to treat dehydration, has been called “potentially the most important medical advance [of the twentieth] century.”3 Yet nearly 400,000 people die annually of diarrhea-related ailments in India alone. We might assume that the solution is simple: a child suffering from diarrhea should, without question, take the ORT remedy. But we need to consider three important stress points of ORT usage. First is the need to purchase the remedy. When a bout of diarrhea occurs, a family may not have this remedy on hand. Second, the ORT remedy does not instantly stop diarrhea, and in fact, it is only meant to rehydrate, so the family may falsely believe that the salts are not working. Third, the salts have a disagreeable taste that makes it particularly difficult for a child to take. In this case, the user must aid in the co-production of his or her own health (or the health of their child), and products must be designed with this in mind.

Identify the End User The end user faces significant trade-offs, each of which guides his or her behavior. We ask: Who is the decision maker? What are her goals, values, and trade-offs? What (and who) influences her decisions? Above all, as a behavioral economics engineer, you need to consider the decision makers as they are—not as they should be in theory—and consider the circumstances in which they find themselves. The end user is often the patient, but providers or family members can be the end users as well. In the “PSI: The Social Marketing Project in Bangladesh” case, you will learn how to distinguish between different end users and which factors, such as preferences, beliefs, and even spouses, can affect their decisions. Remember that all of these circumstances—perhaps unbeknownst to the user—drive her decisions. You are not designing in a vacuum, so you need to start with them.

Understand the End User: Behavioral Economics I We learn how to put the end user first by considering his or her actual behavior and biases. In this part of the course, we will explore universal human behavioral tendencies, such as present bias, time consistency, and limited attention, and learn to employ techniques that actually take advantage of these biases, explained in detail in the Harvard Business Review article, “Rx: Human Nature.”4

Diagnose the Provider Providers are subject to the same cognitive and behavioral biases as anyone else. Just as we design around the patient’s behavior, we also design around the practitioner’s (although both must be driven by the interests of the patient). In 2004, the “Institute for Healthcare Improvement: The Campaign to Save 100,000 Lives” case describes the launch of a campaign aimed at saving 100,000 lives by preventing error-related deaths. What made the initiative unique was its unconventional approach to the problem of doctor/practitioner error. A year and a half later, the institute announced that an estimated 122,300 deaths related to medical error were successfully prevented in participating hospitals. Given the scope of work, providers greatly benefit from a reduction in the immediate cost of actions that are best for the patient, and from the implementation of simple guidelines to keep them on track, such as reminders and checklists.

Leverage Human Nature into Solutions Human nature does not have to be the obstacle; the behavioral principles driving end users and providers can be leveraged into effective solutions for co-producing health. A central tenet of this section is the realization that design choices are made in any environment. For instance, when planning a cafeteria menu, you would need to decide the order in which menu items are presented, which has implications for which items people are more likely to choose. We focus on how to use behavioral insights to both overcome and leverage these inherent human biases, such as time inconsistency, social inclusion, and cognitive overload, through creative design.

We gain insight into design through our own experiences as well. Together, we set individual, semester-long commitments using the website Stickk.com. This commitment device helps you reach your goals by letting you choose the stakes. A popular option is to choose an anti-charity, a charity you do not support, that receives a donation if you fail. The Stickk exercise helps you develop humility and insight to better diagnose the challenges of others—in particular, the biases and constraints that shape your actions and beliefs. These insights will allow you to empathize with the end user(s) and ultimately meet their needs with the best behavioral-economic levers.

It is not fair to ask of others what you are not willing to do yourself.

— Eleanor Roosevelt

Module 2: Designing Solutions

Once we recognize end users’ biases and the levers that can overcome them, we must design solutions that are optimized to the end user’s needs. It is worth stressing that the process of designing a solution is not taking a great product, service, or solution and seeking a problem to which it could be applied. Rather, the solution is subjugated to and entirely driven by the problem. This means understanding the best channel through which to provide service. It is here that we design solutions, taking into account the principles described below.

Set Price Effectively for Consumers Price is a powerful economic tool that managers can use to influence both demand and usage of a product.5 This module will delve into an important policy debate: whether to charge users for life-saving health products, give the products for free, or pay people to use them. As per the law of demand, reducing price increases the volume sold. So one solution, if we wish to get more people to buy something, is to set a low price. In fact, with the proper resources, we could provide the product for free or even set a negative price—that is, pay people to take the product home. But with health-care products, the story is a bit more complex. We explore the principles underlying pricing strategy for vitally needed health products. 5

Design Powerful Incentives for Providers The delivery system can be integral to behavior change and the co-production of health. Community health workers, for example, have a vital role to play in compliance with protocols, adherence to medication, and accompanimentd to support patients. You will learn how delivery systems can be optimized to have an impact on behavioral change and health outcomes, and to influence technology adoption.

The structure of incentives—including compensation—can affect both the selection and effort of providers. The alignment of incentives to motivate positive behavioral change is a particularly important theme. As we will explore in the “Community Health Workers in Zambia: Incentive Design and Management” case, while performance-based pay can motivate, it is dependent on the ability to monitor workers, and it can sometimes have perverse consequences.6 Nonfinancial incentives often rely on the intrinsic goodwill of employees, which we call altruistic capital. This can be found in individuals and organizations, and can be leveraged or depleted, depending on how you as a manager design incentives and the work environment. By the end of this module, you will understand how to set prices to influence product acquisition and use, and how to design powerful incentives for optimal performance.

Module 3: Measuring Success

Careful measurement is critical in all businesses, but particularly in nonprofit service delivery, for three reasons:

1. The success (or failure) of a commercial product is quite easy to see. Sales, price, and volume will tell us quite easily whether a business is doing its job. The gains from health care, though, are much less visible and much more difficult to measure. Program evaluation allows us listen to the end user. 2. Public services organizations that deliver health care often rely on the benevolence of mission-driven people who are often motivated by cherished beliefs. 3. Metrics focus an organization’s direction. Selecting incorrect metrics will affect the value chain, trickling down to the end user’s health and well-being.

During this module, we will examine how to evaluate the solutions you and your classmates design. This class aims to establish a culture of experimentation and discourage relying on self- established beliefs. We will learn how to determine the right measures for designing effective solutions and how to evaluate programs and outcome measures through iterative testing.

Choosing the Right Outcome Measures The chosen performance metrics not only will determine whether a delivery system is deemed successful, but will also determine where both providers and end users focus their attention. This is illustrated by the metrics Novartis used to judge the success of its Coartem program in “The Coartem Challenge” case. The system itself faces limited attention, implying the need to focus on concrete outcome measures on which all parties can agree and which all can collectively strive to affect. In exploring the “Deworming Kenya: Translating Research into Action” case, you will learn how to design research that is relevant for policymakers by choosing measures that are both truthful and strategic and learn how to randomize for policy-

d “To accompany someone is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end. . . . We’re not sure exactly where the beginning might be, and we’re almost never sure about the end. There’s an element of mystery, of openness, in accompaniment: I’ll go with you and support you on your journey wherever it leads. I’ll keep you company and share your fate for [a while]. And by ‘a while,’ I don’t mean a little while. Accompaniment is much more often about sticking with a task until [it is] deemed completed by the person or people being accompanied, rather than by the accompagnateur.”—Dr. Paul Farmer, address to Harvard Kennedy School of Government, May 2011. 6

relevant results. We will see how a cost-effectiveness analysis done well can be key to encouraging policymakers to adopt an evidence-based policy for nationwide programs.

Causal Inference (Reconstructing a Parallel Universe) In becoming an effective manager, you will need to understand how to rigorously evaluate your solution through measurement and inference. Indeed, determining causality (i.e., whether it is our product or some other factor causing the change in some measurement) is difficult in the absence of careful training. Using the “Green Bank” case as a guide, we uncover the importance of choosing the right outcome measures and designing an evaluation for inference.

In the past year, I have been struck by how important measurement is to improving the human condition. You can achieve incredible progress if you set a clear goal and find a measure that will drive progress toward that goal.

— Bill Gates

Module 4: Execution

Overcoming Challenges in Execution Sadly, a great deal of fruitful academic and design- driven research fails to enter the policy-making sphere, meaning there are still conditions to be improved and lives to be saved, if we could only find a way to bridge the gap between the worlds of research, small-scale action, and policy.

Fostering Accompaniment The “Roll Back Malaria and BCG: The Change Initiative” case illustrates how collaboration can be fostered to bring solutions into action at the multinational stakeholder level by leveraging human nature into creating productive partnerships. Those wishing to effect large-scale change must understand the key stakeholders’ perspective: what they value, who influences them, and how they perceive trade-offs. In the “Deworming Kenya” case, we will explore how to foster government collaboration and political will by getting commitment at each level of the program implementation, from the prime minister to parents and teachers in villages. In addition to political will, you will learn about the critical role of accompaniment, or the idea of accompanying another person through a task from the beginning to end, in implementing ideas into action.

Co-producing Learning and Action The idea of collaboration is a core part of this course. We seek to promote co-production beyond the university setting by engaging you with the course’s social networking site, www.mghalum.org. This hub of collaboration is a place to find inspiration and possible collaborators across generations of professionals in global development and health. If you are starting projects or companies in certain industries, sub-sectors, or regions of the world, the site will provide an easy way to identify individuals in the MGH network who may be able to support your work, and for you to support the work of others. Your member profile will be your calling card for others in the broader MGH community. Your participation will live beyond this course assessment and potentially inform future projects and products. Your abstracts and blog posts will be seen by the MGH community and can serve as starting points for action in the real world. You are pioneers in the creation of this knowledge base and part of a budding community of designers and problem solvers.

Course Requirements

Most class sessions in this course employ the case method. You will be asked to prepare a case prior to the session, which serves as the basis for class discussion. By learning these themes through the case method, you embark on a journey through which learning is co-produced with other members of the class when you work together to listen, ask questions, and engage deeply in each other’s viewpoints. By collaborating on your papers and projects, both during the semester and after the course concludes, students of MGH co-produce action in the world. Also interspersed throughout the course are practical exercises, such as moderating your own focus groups, which are designed to drive home key lessons about behavior preferences, deep listening, and collaboration.

Final Paper/Project

For the final project, you will apply the diagnose, design, deliver framework to a “puzzle” of your choosing.e You will select a practical problem related to adoption, compliance, behavior change, access, or effectiveness. This puzzle does not necessarily have to address a public health issue, as long as it clearly relates to the themes of the class. You will be required to diagnose the problem, design a solution using behavioral economics, and create a delivery plan that provides for iterated testing. The topic should be well defined and narrow in scope. The more specific the puzzle, the stronger your proposed solution, and the paper, will be. For detailed, structured guidelines on this project, see the

e See Professor Ashraf’s article in the Harvard Business Review for a succinct overview of the diagnose, design, and deliver framework, and Saugato Datta and Sendhil Mullainathan, “Behavioral Design: A New Approach to Development Policy,” CGD Policy Paper 016, November 2012,” for more insight into behavioral design. 8

Appendix A Cases and Materials

Module 1: The End User First

 Session 1 – ORT o “Oral Rehydration Therapy,” Nava Ashraf and Claire Qureshi. 2010. Harvard Business School Case No. 911-035.  “Slow Ideas,” Atul Gawande. The New Yorker, July 29, 2013 o Session 2 – Population Services International: The Social Marketing Project in Bangladesh o “Population Services International: The Social Marketing Project in Bangladesh,” V. Kasturi Rangan. 2007. Harvard Business School Case No. 586-013  Session 3 – Behavioral Economics I: Diagnosis o “Rx: Human Nature,” Nava Ashraf. Harvard Business Review, April 2013 o Chapter One: “Putting the Customer First,” Alan R. Andreasen. Marketing Social Change: Changing Behavior to Promote Health, Social Development, and the Environment, pp. 37–67 o (Optional) “Willpower, Poverty, and Financial Decision-Making,” American Psychological Association website, https://www.apa.org/helpcenter/willpower-poverty-financial.pdf  Session 4 – Boston Fights Drugs o “Boston Fights Drugs (A): Designing Communications Research,” V. Kasturi Rangan and Jennifer Lawrence. 1994. Harvard Business School Case No. 588-031 o (Optional) “Focus Group Research,” Matthew W. Hughey o (Optional) “Gathering Rich Data,” Kathy Charmaz. In Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis (2006)  Session 5 – Update of Malaria Rapid Diagnostic Tests o “Uptake of Malaria Rapid Diagnostic Tests: A Development Challenge (A),” Nava Ashraf and Natalie Kindred. 2013. Harvard Business School Case No. 911- 007 o (Optional) “Disseminating Innovations in Health Care,” Donald Berwick. JAMA (2003)  Session 6 – Behavioral Economics II: Becoming a Choice Architect o “Adam Smith, Behavioral Economist,” Nava Ashraf, Colin F. Camerer, and George Loewenstein. Journal of Economic Perspectives (2005): 19 o (Optional) “Behavioral Design: A New Approach to Development Policy” (Saugato Datta and Sendhil Mullainathan) CGD Policy Paper 016, November 2012

Module 2: Designing Solutions

 Session 7 – Institute for Healthcare Improvement: The Campaign to Save 100,000 Lives o “Institute for Healthcare Improvement: The Campaign to Save 100,000 Lives,” Hayagreeva Rao and David W. Hoyt. 2008. Stanford Graduate School of Business Case No. L13 o Chapter Four: “Understanding How Customer Behavior Changes,” Marketing Social Change: Changing Behavior to Promote Health, Social Development and the Environment (Alan R. Andreasen)  Session 8 – PSI Social Marketing Clean Water

o “Finding the Right Job for your Product” (Clayton M. Christensen, Scott D. Anthony, Gerald Berstell, and Denise Nitterhouse) MIT Sloan Management Review, Spring 2007 o “PSI: Social Marketing Clean Water,” V. Katsuri Rangan, Nava Ashraf, and Marie Bell. 2007. Harvard Business School Case No. 507-052  Session 9 – Pricing o “Setting Price Effectively,” Nava Ashraf and Kristin Johnson. 2014. Harvard Business School Background Note No. 914-037  Session 10 – Partners in Health: HIV Care in Rwanda o “Partners in Health: HIV Care in Rwanda,” Michael E. Porter, Scott Lee, Joseph Rhatigan, and Jim Yong Kim  Session 11 – BRAC’s Tuberculosis Program: Pioneering DOTS for Treatment for TB in Rural Bangladesh o “BRAC’s Tuberculosis Program: Pioneering DOTS Treatment for TB in Rural Bangladesh” (Maria May, Joseph Rhatigan, and Richard Cash) o “Incentives at the Bangladesh Rural Advancement Committee (BRAC),” Nava Ashraf and Kristin Johnson. 2014. Harvard Business School Case No. 914-036  Session 12 – Community Health Workers in Zambia: Incentive Design and Management o “Community Health Workers in Zambia: Incentive Design and Management,” Nava Ashraf and Natalie Kindred. 2014. Harvard Business School Case No. 910- 030 o “What Makes Community Healthcare Work?” (Tina Rosenberg) New York Times, February 18, 2011

Module 3: Measuring Success

 Session 13 – Evaluating Microsavings Programs: Green Bank of the Philippines I o “Evaluating Microsavings Programs: Green Bank of the Philippines (A),” Nava Ashraf, Dean Karlan, Wesley Yin, and Marc Shotland. 2010; Revised 2014. Harvard Business School Case 909-062 o (Optional) “Commitment Devices,” Gharad Bryan, Dean Karlan, and Scott Nelson The Annual Review of Economics 2 (2010): pp. 671–698  Session 14 – Green Bank of the Philippines II: How to Rigorously Evaluate o “Evaluating Microsavings Programs: Green Bank of the Philippines (B),” Nava Ashraf, Dean Karlan and Wesley Yin. 2014. Harvard Business School Case No. 914-002 o “Evaluating Microsavings Programs: Green Bank of the Philippines (C),” Nava Ashraf, Dean Karlan and Wesley Yin. 2014. Harvard Business School Case No. 914-003  Session 15 – Hard-to-measure Indicators and Paper Workshop  Session 16 – Deworming Kenya: Translating Research into Action o “Deworming Kenya: Translating Research into Action (A),” Nava Ashraf, Neil Buddy Shah, and Rachel Gordon. 2010. Harvard Business School Case No. 910- 001

Module 4: Execution

 Session 17 – The Coartem Challenge

o “The Coartem Challenge (A),” Deborah L. Spar and Brian J. Delacey. 2008. Harvard Business School Case No. 9-706-037.  Informal collaboration meetings for final projects/papers for four class periods  Session 18 – Roll Back Malaria and BCG: The Change Initiative o “Roll Back Malaria and BCG: The Change Initiative,” Nava Ashraf, Rachel Gordon, and Cathy Ross. 2014. Harvard Business School Case No. 910-023  Session 19 – Class Guest: Paul Farmer o “The Right to Claim Rights,” from Partner to the Poor: A Paul Farmer Reader (Haun Saussy), April 2010  Session 20 – Final Class Wrap-up

Appendix B: The Paper/Project

Paper/Project Guidelines

1. Define your puzzle and your end user: a. Find a problem to define; find a puzzling behavior that seems irrational (e.g., why don’t people exercise when they know they want to be healthy?). b. Define the target population or end user/“customer” for whom you are designing your intervention/product. This includes collecting research about that user’s behavior, and circumstances and characteristics from existing literature and data.

2. Diagnose: a. Map out the end user’s process that is at the root of the puzzle. b. What behavioral stress points does your behavioral mapping reveal? c. How can behavioral economics be leveraged to explain why the puzzling behavior happens and why those behavioral stress points exist? d. What work have others done to try to address this problem? What impact have they found? How solid are their conclusions and data? You should examine the secondary literature with a critical eye.

3. Design and Deliver: a. How can you leverage the tools of behavioral economics to design a solution to the puzzle? b. How does your product/intervention solve the problem you’ve identified (i.e., what is your theory of change?). How does it improve upon previous attempts to address the problem? c. How will you test your theory of change?

4. Test: a. What measures will you use to track outcomes and success? What instruments will you use to define your measures? b. How will you test and evaluate whether you’ve solved the problem? c. What is your iterative strategy for implementation and testing?

Endnotes

1 Gareth Jones, Richard W. Steketee, Robert E. Black, Zulfiqar A. Bhutta, Saul S. Morris, and the Bellagio Child Survival Study Group, “How Many Child Deaths Can We Prevent This Year?” Lancet 362, no. 9377 (2003): 65-71.

2 Ostrom, Elinor, Roger B. Parks, Gordon P. Whitaker, and Stephen L. Percy. “The public service production process: a framework for analyzing police services.” Policy Studies Journal 7, no. s1 (1978): 381-381.

3 “Water with Sugar and Salt,” Lancet 312, no. 8084 (1978): 300.

4 Nava Ashraf, “Rx: Human Nature. How Behavioral Economics is Promoting Better Health Around the World,” Harvard Business Review, April, 2013.

5 Nava Ashraf and Kristin Johnson, “Setting Price Effectively,” HBS No. 914-037 (Boston: Harvard Business School Publishing, 2014).

6 Nava Ashraf and Kristin Johnson, “Community Health Workers in Zambia: Incentive Design and Management,” HBS No. 5- 9104-024 (Boston: Harvard Business School Publishing, 2014).