In a panel discussion at the 2019 Qatar Public Health Conference, organized by the Ministry of Public Health, B4Development took the stage to discuss opportunities and challenges for policy experimentation in the field. Under the theme “10 Years of Public Health: Looking Back & Moving Forward”, the two-day conference was held on November 18 and 19 at The Ritz Carlton in Doha.
Dr. Fadi Makki, Head of B4Development, was joined on stage by Dr. Roberto Bertollini, Advisor to the Minister of Public Health of Qatar, and Dr. Hanan Abdul Rahim, Head of the Department of Public Health, College of Health Sciences at Qatar University, for an insightful discussion on the convergence of traditional and behaviorally informed policy models for impact in public health education. The discussion centered on four topical axes pertaining to public health: barriers for health education and awareness, behavioral interventions influencing policymakers and interest groups, structural change supporting the implementation of health initiatives at scale, and cross-sector collaboration.
Opening the session with alarming figures on the ad dollars FMCG marketers put behind unhealthy products and the clout they exercise on consumers’ lifestyles, Bertollini noted that “we are immersed in a world of ads and messages going in the wrong direction. Coca Cola spends $ 5.8 billion per year on global advertising,” compared with $4.42 billion as the World Health Organization’s total proposed budget for 2018-2019 – covering the entire world, that is. This disproportionate investment between those advocating healthy lifestyles and those advertising against them is a central challenge to public health education and awareness initiatives. But it is not the only one.
Many answers to the failure of such initiatives can be found in behavioral science and, more specifically, in the notion that people have “bounded rationality” with limited processing power. This means that despite their best intentions, people do not always act rationally in their own interests, but are rather often triggered by their subconscious emotions and instincts.
“The provision of information is one of the conventional tools [to raise awareness and influence behaviour]. And that is typical within policymaking. We add to the basic provision of information two other types of tools: either sanctions – more rules, more command and control approaches, heavy penalties – or what we call ‘pouring money at the problem’ – financial incentives and subsidies. All these tools have one thing common: they all assume that we are perfectly rational beings,” said Makki. Cognitive dissonance and biases are psychological determinants that must accounted for during the design stages of public policy, emphasized Makki, particularly as some directly impact people’s commitment to a healthy lifestyle. For instance, people’s present bias, their preference for immediate gratification over bigger rewards in the long term, can hinder their commitment to healthy dietary and fitness regimens. Optimism bias, people’s penchant to overestimate their immunity to harm, renders people more vulnerable to taking risks on their health and less preventive measures to protect it.
The danger, adds Bertollini, is that big interest groups and manufacturers of unhealthy products have traditionally used such biases in their favour, playing on the guilty pleasures and instinctive cravings of consumers. “The tobacco fast food industries are quite adept at using psychological layers, as well as social and environmental cues, creating and reinforcing in a sense [people’s] cognitive biases. So, here is the question: is it time to take a leaf out of their book and use their tactics for the good of public health? Or is this a separate domain?” asked Dr. Abdul Rahim.
The onus, of course, does not fall entirely on behaviorally informed policy models. For any such model to succeed, infrastructural opportunities and challenges must also be tackled to ensure that social change is possible in the first place, independently of people’s behavioral barriers. For instance, people cannot walk more if there are no pedestrian-friendly streets in their communities.
In tandem, health reform must rally not only the end consumers, but equally – if not more importantly – interest groups and manufacturers themselves behind win-win solutions. A proof point in this area, Makki noted, was in the UK last year, where the Behavioural Insights Team collaborated with policymakers to enact ‘smarter’ sugar tax legislation. The multi-tiered tax was levied on manufacturers based on the sugar content of their products. As a result, 15% of the market reformulated its sugar-rich products.
At a more conscious level, people and interest groups must also be actively engaged in behavioral change, but more so, accountable for it. In the tobacco industry, Bertollini argued, the privatization of revenues and public diffusion of costs is unethical and unfair. Policy frameworks must be more coherent in ensuring that interest group profits do not grow at the expense of national health initiatives, he asserted.
Policymakers, Makki added, must also allocate more time and money for trial and error. “At a strategic planning level, the multiplier effect of our biases and intuition can be detrimental to effective policymaking five, ten years down the line. What works is not what we think works, but what has been tested to work,” he concluded.
Healthy and sustainable living was central to B4D’s experimental work in Qatar this past year, focally in the FLW (Food Loss and Waste) space. In January 2019, B4D partnered with one of the largest international luxury hotel chains in Qatar for an experiment aimed at gaging patrons’ propensity to waste food when updated daily on the amount and impact of their waste. In September, the unit’s behavioral intervention with the Qatar Green Building Council tested the impact of smaller plate sizes on food waste among students during an event for the Eco-Schools Sustainability Program. In partnership with one of the biggest supermarket retailers in the country, B4D also conducted a two-month experiment in June 2019, prompting grocery shoppers in Qatar to adopt healthier food choices by increasing their purchases of fruits and vegetables.