Working papers

Patient vs. provider incentives for malaria care in Kenyan pharmacies: A cluster randomized controlled trial

A key aim of health policy is to ensure that patients are able to access high quality care when appropriate while minimizing the over-use of unnecessary treatments. Achieving this balance requires aligned decision-making between patients and providers, which can be hindered if incentives are incompatible with this aim. I study how patient and pharmacist decision-making in the context of malaria case management is affected by financial incentives. I test whether demand- or supply-side incentives for rapid tests and high quality antimalarials only to malaria-positive cases improve malaria case management and align incentives towards socially-optimal antimalarial use. Using a cluster randomized trial design in 140 pharmacies in malaria-endemic zones in Kenya, I randomize patient discounts and pharmacist performance incentives and compare their effectiveness and cost-effectiveness to the status quo standard of care. I find that both patient subsidies and pharmacy incentives for diagnostic testing significantly increase usage of testing and may encourage malaria positive individuals to purchase high quality antimalarials. These results suggest that appropriately calibrated and targeted financial incentives are promising for changing patient and provider behavior, with implications for quality of care. Additionally, the fact that supply- and demand-side incentives lead to comparable effects on diagnostic testing and treatment targeting suggests that both patients and pharmacists are effective channels for incentive targeting.

Trial pre-registration:
  • AEARegistry
  • Current draft:
  • Click here

  • Ongoing projects

    Increasing access to contraceptive choice through targeted incentives

    We investigate how targeted subsidies for long-acting injectable contraception and provider incentives impact initial uptake, sustained adoption, pricing and stocking decisions for contraceptive products in local markets, sales, and user health outcomes. Following prior work on the effectiveness of subsidies to promote the adoption of new technologies and experience goods, we aim to test if subsidies lead to sustained adoption of injectable contraception as well as to study possible mechanisms for continued usage (or lack of) such as learning, price anchoring, and information effects. We propose a market-level cluster randomized controlled trial in 140 pharmacies in Kenya to answer these questions. Patient subsidies and pharmacist incentives will be cross-randomized and compared against the status quo to evaluate their effectiveness in promoting sustained adoption. Funding has been obtained. Collaborators are Paul Gertler and Carlos Paramo.

    Extreme weather, parental investments, and child health in Madagascar

    Using panel microdata on household inputs and child health outcomes and high-resolution gridded climate data from Madagascar, I investigate how weather-induced income shocks affect parental investments and child nutrition and cognition outcomes. In particular, I explore the link between maternal depression and child investment decisions at critical developmental stages.

    Integrating early stimulation and play at scale: Mahay Mikolo cluster RCT in Madagascar

    Programs to promote nurturing and responsive caregiving, such as those in which community health workers (CHWs) conduct home visits to support optimal early child development (ECD), have been effective in small trials, but have not achieved similar success at scale. This study will explore two approaches to scale-up: converting a home-visiting model to a group-based model; and integrating the ECD curriculum into an existing government program. The objectives of the study are to: 1) Measure how the integration of ECD activities affects time and task allocation of CHWs and CHW psychosocial wellbeing; 2) Examine how the integration of ECD activities affects caregiver-child dyad participation in standard health and nutrition activities; and 3) Explore how the availability of age-appropriate play materials at home affects caregiver-child dyad participation rates in a group-based ECD program. Collaborators are Lia C.H. Fernald, Emanuela Galasso, Ann Weber, Caitlin Hemlock, and Lisy Ratsifandrihamanana.
    Study protocol (under review):
  • Protocol
  • Trial pre-registration:
  • AEARegistry

  • Publications

    Dieci, Maria, Juan J. Llibre-Rodriguez, Daisy Acosta, and William H. Dow. "Cuba’s cardiovascular risk factors: International comparison of levels and education gradients." Plos one 16, no. 3 (2021): e0247831.
  • Link
  • Dieci, Maria, Zachary Wagner, Willa Friedman, Sarah Burgess, Jessica Vandermark, Sandra I McCoy, Manisha Shah, and William H. Dow. "Measuring Family Planning Provider Bias: A Discrete Choice Experiment among Burkinabé, Pakistani, and Tanzanian Providers." Studies in Family Planning, 52: 299-320 (2021).
  • Link to submitted article
  • Rosen, Daniel, Jessica Vernon, Rachel Silverman, Elizabeth Juma, Maria Dieci, and Prashant Yadav. "Malaria Case Management After the Affordable Medicines Facility for Malaria (AMFm): Availability, Quality, and Market Share for ACTs in Kenya’s Private Pharmacies." Center for Global Development Working Paper Series 561 (2020).
  • Link