I think we should generally not be surprised that people are somewhat irrational in their spending on public health instead of other things, relative to their own CEV: we should expect to see both bias (in the sense of underspending) and error (in the sense that sometimes they spend too much and sometimes they spend too little). Is bias surprising? I dunno, I guess I shouldn't be surprising. Like ex ante maybe if I didn't look at any data and I want to guess the direction of marginal spending on health I'd guess maybe 60/40 for underspending being more likely than overspending, and high probability there's some nontrivial bias in either direction (just seems like a really hard question to get right! And the feedback loops aren't amazing) To explain error, I should note that malaria nets are basically chosen as the ~best health consumption good that aren't already purchased on the margin after combing through the literature a lot, so it should imo not be that surprising that people underspend on it relative to what the research says you "should". I feel like this shouldn't be a huge surprise in even rich countries (like I'm a nerd who cares way more about this than most people and I won't be shocked if some of my health spending is systematically quite irrational), and the reasons you mention make it more likely to see higher skew in poor countries than rich countries. Now if you have strongly libertarian priors, maybe you should say that we ought to give direct cash transfers anyway and just try to educate people on the relevant benefits of malaria nets so they can make an informed decision yourself. I think implicitly this is the decision of at least some people donate to Give Directly. But broadly this level of libertarianism isn't shared by GiveWell or The Against Malaria Foundation. Another angle here is that GiveWell and/or western donors may have moral paternalism in addition to epistemic paternalism. Eg their moral weights on infant/maternal lives more th