An Account of Collective Actions in Public Health
Solutions to many of the problems confronted by public health policymakers depend on getting people to behave in a way that promotes the common interest even though the desired conduct may not serve the self-interest of each individual. If individuals make choices that undermine a public good (PG), society faces the choice of either giving up the desired good, or finding a way to influence individual decisionmaking to guarantee a sufficient level of cooperation. Economists characterize these challenges as “collective action problems” (CAPs). We argue in this paper that framing common challenges in public health as collective action problems would help policy planners draw on a large body of literature and insights in behavioral and social sciences that has not yet been incorporated into the mainstream of the field.
The traditional economic account of collective action problems stems from the premise that sub-optimal participation in collective efforts to create and preserve public goods, such as a clean environment, is a direct result of rational decisions made by individuals to advance their own interests over those of the group, while often consuming the benefits of investments made by others (i.e., “free riding”). Yet, emerging scholarship in the behavioral and social sciences sheds new light on the choices that people make, and especially on what is ostensibly “free riding” behavior, leading to the general conclusion that failures to create and sustain are often attributable to cognitive and behavioral tendencies that can be modified. These insights should be harnessed within the field of public health policy to help us understand how to reduce the number of people who shirk responsibilities to larger groups. Importantly, these studies lead to the conclusion that CAPs are often imperfectly conceptualized as simple “free rider” problems. This developing body of knowledge also highlights the more complex composition of CAPs.
This paper analyzes several public health issues using an enriched CAPs framework in order to illustrate its advantages in prescribing public policies. In planning for solving CAPs in public health, we advocate a more prominent incorporation of behavioral components. Interestingly, the literatures in medicine and public health have thus far given little attention to CAPs in many situations that would fit well with the body of knowledge gained in the fields of behavioral law and economics. We also believe that lessons learned in resolving CAPs in bio-medicine could foster a more general discussion of the obligations of citizenship and individual as well as communal responsibilities, but space limitations preclude a more detailed exposition of this thesis here.
In this paper, we use two case studies. One regards vaccination, an archetypal example of collective action in public health. The other regards organ donation. In the immunization case, collective action is necessary in order to achieve herd immunity; once such immunity is achieved, the benefits of decreased mortality and morbidity are available to all. However, given the reality of herd immunity, those who refrain from vaccination are nevertheless protected by the actions of their vaccinated peers. Nonvaccinated people hence enjoy a free ride — they are provided protection (herd immunity) at no cost (the injection and possible adverse sequelae). Exemptors from vaccination do expose themselves to possible outbreaks of the pertinent disease, but such eventualities are considered rare. Yet if a sufficiently large number of people avoid vaccination, then there will be insufficient herd immunity. Indeed, in recent decades decreased vaccination rates have led to outbreaks. Policy remedies have concentrated on the use of mandatory vaccination laws (mostly pre-school vaccination requirements), coupled with legislation (the Vaccine Injury Compensation Program in the US and similar laws in other countries) that provides no-fault, administrative compensation for adverse effects that have been scientifically linked to covered vaccines. Still, a tendency to relax mandatory vaccination laws by introducing exemption clauses has decreased the number of vaccinated children. This is a constant source of worry for those interested in maintaining herd immunity.
In the case of organ donation, we have the technology to save lives, but the waiting list for organs is growing (numbering more than 100,000 people), waiting periods on the lists are frustratingly long, and more than 7,000 people die while awaiting an organ.
Noticeably, the number of people who die in circumstances that make them potential organ donors is sufficient to eliminate death while awaiting an organ and significantly reducing the length of the waiting lists. Yet in many countries, including the US, the actual retrieval rate based on donor cards or families' consent is only 50% of the potential, though the public's expressed support for organ donation reaches 90 percent or more. Policy solutions developed in the US include, among others, improved identification systems, organ procurement organization best practice guidelines, and massive public education campaigns. The results are encouraging but these measures alone will nevertheless remain insufficient.
In the following, we briefly summarize salient concepts as they relate to decisionmaking of individuals and groups bearing on the resolution of CAPs. Our goal is to identify and incorporate additional tools that may aid public health policymakers to deal with less-than ideal collective action outcomes. We start with a succinct description of PGs, CAs, and resulting CAPs as they relate to choice-making. We then turn our attention to behavioral economics and end by highlighting a few key conclusions.