A community advocacy group worker and peer educator talks to women in Makeni, Bombali District in Sierra Leone on reproductive health and family planning matters. How can behavioral economics improve family planning services? Photo by: Abbie Trayler-Smith / H4+ Partnership / CC BY-NC-ND

A crowd of mothers hold screaming babies and chase crawling toddlers. At the center of this open air pavilion, in the Thies region of Senegal, a health worker calls women up one by one to determine what immunizations their children need. As forms and needles circulate, a midwife asks these women if she can cut in for a causerie — a chat — about the range of family planning methods available to them.

There has been a movement over the last decade to integrate family planning into other services, so that no opportunity is lost. But when a team from ideas42, a design and consulting firm that applies behavioral sciences to social problems, visited this health clinic, they questioned how these women could reflect thoughtfully on family planning options in the midst of such apparent chaos.

Their feedback was rooted in a field of research that seeks to explain why people make decisions that are inconsistent with what they claim to want, in this case as a result of the effect of cognitive overload.

“I had always referred to the immunization service as an assembly line, like a factory, where you have your baby weighed then you hand in your vaccination form, but there was that element of chaos that I had never noticed,” said Jennifer Wesson, an adviser at IntraHealth International, which works closely with the Senegalese Ministry of Health on family planning services and brought ideas42 staff to this health clinic.

“There is evidence in the social psychology field that decision making is hard when things are chaotic, which maybe sounds obvious, but there’s something very compelling about being able to attach your observation to scientific literature,” Wesson added.

ideas42 and partner organizations funded by the William and Flora Hewlett Foundation will present on behavioral economics as a tool for improving family planning services at the International Conference on Family Planning, taking place in Nusa Dua, Indonesia, this week.

There is growing recognition of the need for development policy and program design to take human decision making into account. The cofounder of ideas42 was one of the early thought leaders on how behavioral design principles could improve the reach and effectiveness of development programs. More recently, the World Bank focused its 2015 World Development Report on how researchers and practitioners can account for psychological and social influences in their approaches.

While behavioral economics has been applied to efforts to encourage people to use fertilizer or take malaria medication, the Hewlett Foundation saw an opportunity to try the tactic in the relatively mature field of family planning and reproductive health, said Helena Choi, a program officer in the population program a the foundation.

“You tap into the tendency people have to emphasize short term and near term gains and discount future risks,” she said. “You have to really change that for young people to make the right choices and behavioral economics has tremendous potential to shape those decision moments for young people.”

With every decision we make, we fall somewhere along a spectrum of opposing forces: self and other, today and tomorrow, illusion and reality, and thinking fast and thinking slow. A behavioral economics framework can help the global development community unpack the factors that influence decision making, then apply tools so that individuals make better decisions. An example includes micro incentives, like gifts to acknowledge patient compliance or health worker performance, which can be more motivating than monetary rewards.

“What behavioral economics tries to do is look at the institutions around decision making,” said Nava Ashraf, an associate professor at Harvard Business School currently working in Zambia on the the gap in preferences between men and women when it comes to the number of children they desire. “We all have these choices we’re making within an institutional framework, and if you shift those incentives, can you then shift choices people make?”

Behavioral economics is not exactly the same as behavior change, which focuses on long term change, resulting from adjustments to underlying norms and preferences or big macro factors like education. The discipline is more focused on immediate term decision making. Ashraf said she hopes these two fields can come together in such a way that adjusting behaviors gives way to shifting beliefs and changing norms with better outcomes in the immediate and long term.

“My own take on it is that we use behavioral economics as a structure to help us understand the decision making process and the levers you can pull and then we go deeper to understand the underlying factors,” she said. “You start to undertake some behaviors, like using contraception and realizing it is possible to do it and that you’re happy with fewer children, and then that changes your underlying demand for family size, for example.”

“You start to undertake take some behaviors, like using contraception and realizing it is possible to do it and that you’re happy with less children, and then that changes your underlying demand for family size, for example,” she added.

One of the tenets of behavioral economics is that people do not always act in their own best interests, that they are subject to biases and shortcuts and attention gaps. Some argue that family planning services have prioritized health systems strengthening, like staffing up clinics, at the expense of decision points like the moment when a young person decides to have unprotected sex.

“If your diagnostics suggest that behavioral biases are part of the problem, you can work with a researcher on an intervention like a nudge or default to achieve different outcomes,” said Temina Madon, executive director of the Center for Effective Global Action, the University of California’s center for research on global development. The funding CEGA and other partners have received from the Hewlett Foundation, totaling $4.5 million since 2012, will add to the body of research and programming on health choices in addition to health services.

It is too early to tell whether behavioral economics will have the impact on family planning the Hewlett Foundation hopes to bring about with its investments. Tulane University is conducting an external evaluation to assess what, if any, contribution this behavioral economics approach is making to the reproductive health field, and how promising the early results are from the projects carried out by CEGA, ideas 42, and their partners.

“Incorporating behavioral economics into family planning could help us identify and address the real bottlenecks at individual and community levels that reduce the adoption of family planning methods,” Hawa Talla, who works in Senegal for IntraHealth International, told Devex. “At a small scale, this is feasible in the short term. But the biggest challenge will be scaling it up.”

But Choi said the global development community should stay tuned and take note of the need to pivot toward thinking more about choices. “Too often when you get into development work, you tend to think about cost benefit analysis and the budgets and the political context, and you lose sight of the people,” she said. “By thinking about how behavioral insights could optimize program design, you really bring back the human element.”

But barriers stand in the way of behavioral economics becoming as entrenched as behavior change in the field of family planning. First, there are the broader criticisms of behavioral economics, like how observations in experiments might not translate to real world situations. Plus, as Madon and her coauthors explain in a review paper on the topic, when it comes to reproductive health, other factors like persuasion or even coercion can complicate individual choice.

There is a scarcity of research on the effectiveness of behavioral economics in developing countries, which makes it all the more difficult to apply these tools to policy and program design. That is something the Hewlett Foundation, along with CEGA, ideas42, and partners that may emerge, is looking to change.

“There are a lot of behavior change paradigms out there, so trying to convey the value add of this approach, and how this can actually be a complementary tool in the toolkit, has been something that we’ve had to take on as part of the project development process,” Karina Lorenzana, a vice president at ideas42, told Devex.

“It’s not just jumping in and doing projects, but it’s making sure everyone is on board.”

Follow the discussion taking place at the International Conference on Family Planning in Indonesia, where @DevexLeanAS and @richard_devex are on the ground bringing you updates and interviews. Join the conversation @devex using #ICFP2016.