Antibiotics and vaccines are undoubtedly among the greatest milestone discoveries in human history. The introduction of antibiotics and vaccines has revolutionized modern medicine by arming health care workers with prevention and curative tools across a wide spectrum of infectious diseases. However, the appropriate use of both antibiotics and vaccines has been a subject of scrutiny and debate within the health and development literature. As a matter of fact, while antibiotics are misused and overused, vaccines – which have the potential to reduce the need for antibiotics – are underutilized. Recent decades have witnessed a rise in antibiotic resistance attributed to burgeoning antibiotic consumption along with failures in implementing antibiotic stewardship in health care settings. Studies have shown that regulatory and socioeconomic environments in developing countries encourage unregulated and indiscriminate use of antibiotics. In this thesis, we propose a novel approach to tackle the unjustified sales of antibiotics in community pharmacies. The first chapter reports the results of a field experiment aimed at reducing the non-prescription sale of antibiotics in the developing world. Using a randomized controlled trial in Ethiopia we examine, in collaboration with the Addis Ababa Food Medicine Health Care Administration and Control Authority (AAFMHACA), the effectiveness of three types of nudges – namely, a coercive letter, a moral appeal letter, and an informational sticker with evocative messages placed in pharmacies – in reducing over-the-counter sales of antibiotics. The results of an audit study, conducted two to three weeks after the intervention, indicate that all three inexpensive nudges lead to a significant decrease in the sale of antibiotics without prescription, compared to the control (untreated) group of pharmacies. The coercive letter has the highest impact (reducing over-the-counter sales of antibiotics by 23.3 percent in comparison to the control group), followed by the appeal letter and the sticker treatment (with a reduction of 17.5 and 15.7 percent compared to the control, respectively). The second chapter is a sequel to the first one and reports on the persistent and heterogeneous effects of the treatments five months after the intervention. The results show that our treatments persisted well into the fifth month, despite some waning down of the effects of the letter treatments. The heterogeneity analysis indicates that the findings are robust across different subgroups of characteristics. The third chapter assesses the determinants of inequities in child immunization status. One approach to reducing excessive antibiotic use is through investing resources in protection strategies that reduce the need for antibiotic prescription in the first place. One strategy is the wider use of vaccines in the population particularly through childhood immunization programs. Tragically, not all children of tantamount age partake in the fruit of vaccines as the odds of getting immunized largely depend on several socioeconomic factors. In the last chapter of the thesis, we quantify and study the determinants and decomposition of immunization inequality in Ethiopia using two rounds of Demographic and Health Surveys (DHS) data. We find that while the Human Opportunity Index (HOI) increased from 18 per cent to 28.1 per cent, the inequality index only showed a marginal improvement of declining by a meagre 2 per cent. These improvements are largely appropriated by the urban population as inequality remains constant in rural areas over the study period. The Shapley decomposition analysis reveals that regional variations, distance to health facilities, religion affiliations, household economic status and maternal education consistently contribute to the inequality.

Essays in Experimental and Health Economics

Saba Yifredew Getnet
2021

Abstract

Antibiotics and vaccines are undoubtedly among the greatest milestone discoveries in human history. The introduction of antibiotics and vaccines has revolutionized modern medicine by arming health care workers with prevention and curative tools across a wide spectrum of infectious diseases. However, the appropriate use of both antibiotics and vaccines has been a subject of scrutiny and debate within the health and development literature. As a matter of fact, while antibiotics are misused and overused, vaccines – which have the potential to reduce the need for antibiotics – are underutilized. Recent decades have witnessed a rise in antibiotic resistance attributed to burgeoning antibiotic consumption along with failures in implementing antibiotic stewardship in health care settings. Studies have shown that regulatory and socioeconomic environments in developing countries encourage unregulated and indiscriminate use of antibiotics. In this thesis, we propose a novel approach to tackle the unjustified sales of antibiotics in community pharmacies. The first chapter reports the results of a field experiment aimed at reducing the non-prescription sale of antibiotics in the developing world. Using a randomized controlled trial in Ethiopia we examine, in collaboration with the Addis Ababa Food Medicine Health Care Administration and Control Authority (AAFMHACA), the effectiveness of three types of nudges – namely, a coercive letter, a moral appeal letter, and an informational sticker with evocative messages placed in pharmacies – in reducing over-the-counter sales of antibiotics. The results of an audit study, conducted two to three weeks after the intervention, indicate that all three inexpensive nudges lead to a significant decrease in the sale of antibiotics without prescription, compared to the control (untreated) group of pharmacies. The coercive letter has the highest impact (reducing over-the-counter sales of antibiotics by 23.3 percent in comparison to the control group), followed by the appeal letter and the sticker treatment (with a reduction of 17.5 and 15.7 percent compared to the control, respectively). The second chapter is a sequel to the first one and reports on the persistent and heterogeneous effects of the treatments five months after the intervention. The results show that our treatments persisted well into the fifth month, despite some waning down of the effects of the letter treatments. The heterogeneity analysis indicates that the findings are robust across different subgroups of characteristics. The third chapter assesses the determinants of inequities in child immunization status. One approach to reducing excessive antibiotic use is through investing resources in protection strategies that reduce the need for antibiotic prescription in the first place. One strategy is the wider use of vaccines in the population particularly through childhood immunization programs. Tragically, not all children of tantamount age partake in the fruit of vaccines as the odds of getting immunized largely depend on several socioeconomic factors. In the last chapter of the thesis, we quantify and study the determinants and decomposition of immunization inequality in Ethiopia using two rounds of Demographic and Health Surveys (DHS) data. We find that while the Human Opportunity Index (HOI) increased from 18 per cent to 28.1 per cent, the inequality index only showed a marginal improvement of declining by a meagre 2 per cent. These improvements are largely appropriated by the urban population as inequality remains constant in rural areas over the study period. The Shapley decomposition analysis reveals that regional variations, distance to health facilities, religion affiliations, household economic status and maternal education consistently contribute to the inequality.
Nudges, Randomized Control trial, Experimental Economics, Antibiotic Resistance, Immunization Inequality
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11562/1052962
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