Relying on Unregulated Firms to Achieve Public Health Goals: Evidence from Pharmacies in Kenya

Last registered on September 24, 2024

Pre-Trial

Trial Information

General Information

Title
Relying on Unregulated Firms to Achieve Public Health Goals: Evidence from Pharmacies in Kenya
RCT ID
AEARCTR-0014333
Initial registration date
September 18, 2024

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
September 24, 2024, 3:29 PM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Locations

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Primary Investigator

Affiliation
Duke University

Other Primary Investigator(s)

PI Affiliation
University of Chicago
PI Affiliation
University of Chicago
PI Affiliation
Cornerstone Research

Additional Trial Information

Status
On going
Start date
2024-07-01
End date
2025-12-31
Secondary IDs
Prior work
This trial does not extend or rely on any prior RCTs.
Abstract
We study how pharmacies and clinics in Western Kenya make decisions that are critical to local health outcomes and antimicrobial resistance, such as the appropriateness of provided medications, diagnostic efforts, diagnostic accuracy, and the provision of partial dosages. We send standardized patients in multiple visits to a sample of 200 providers where we randomly vary the standardized patient's reported symptoms, willingness to provide symptoms, drug requests, and expressed price sensitivity. We plan to assess whether the actions a standardized patient takes influences the provider's willingness to ask diagnostic questions, the recommended drug, and the transaction price.
External Link(s)

Registration Citation

Citation
Dinerstein, Michael et al. 2024. "Relying on Unregulated Firms to Achieve Public Health Goals: Evidence from Pharmacies in Kenya." AEA RCT Registry. September 24. https://doi.org/10.1257/rct.14333-1.0
Sponsors & Partners

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Experimental Details

Interventions

Intervention(s)
We send trained standardized patients (SPs) to pharmacies and clinics and record data associated with each part of the interaction. We randomly vary four elements of the interaction: the SP's described symptoms, the drug the SP requests (if any), the order in which the SP describes symptoms or makes requests, and whether the SP presents as price sensitive.

The specific elements are:

Described symptoms (associated disease)
1. Acute Rhinitis
2. Cold
3. UTI
4. Typhoid
5. Bacterial Pneumonia

Drug request:
1. An antibiotic
2. A specific antibiotic
3. A non-antibiotic

Order in which describing symptoms or making requests:
1. Request of drug immediately
2. Asking for a price of a drug immediately
3. Presenting symptoms and then requesting a drug
4. Just presenting symptoms

Extra element:
1. Asking what is the most important drug
2. Requesting price discount
3. Requesting partial dosage
4. None

Our interventions combine an element from each of these four categories. We vary these combinations across facilities and rounds.
Intervention Start Date
2024-07-30
Intervention End Date
2024-10-31

Primary Outcomes

Primary Outcomes (end points)
Whether the purchased drug is appropriate for the SP's described symptoms
Primary Outcomes (explanation)
For each case (described symptoms), we determine an appropriate drug as one that (a) treats the condition, (b) does not overtreat the condition, and (c) does not have known resistance issues such that providers are advised against using drug. In some cases, this appropriateness is codified as a "first-line treatment."

Secondary Outcomes

Secondary Outcomes (end points)
Diagnostic efforts (whether the provider asks diagnostic questions or suggests a diagnostic step like a test)
Diagnostic accuracy
Whether the provider sells a partial dose of an antibiotic
Characteristics of transacted products (price, number)
Secondary Outcomes (explanation)
Diagnostic efforts: we collect data on whether providers asked specific questions.
Diagnostic accuracy: we ask the provider what his/her diagnosis is
Partial dose: only applicable for some drugs
Characteristics of transacted products: may include characteristics derived from administrative data (outside of the interaction)

Experimental Design

Experimental Design
We visit providers over the course of multiple rounds, where a round describes a period of time when each provider receives exactly 1 SP visit.

Our rounds are structured as follows:
1. Acute rhinitis, describe symptoms only, no drug request, ask for the most important drug if offered multiple
2-3. (Acute rhinitis / cold), (describe symptoms only / describe symptoms then request drug), (none / "an antibiotic"), ask for the most important drug if offered multiple
4. (Acute rhinitis / cold), describe symptoms then request drug, (cheap non-antibiotic / expensive non-antibiotic), none
5-6. (UTI / typhoid), (describe symptoms only / describe symptoms then request drug), (none / drug with established resistance / drug with growing resistance), (none / request price discount)
7. Bacterial pneumonia, (immediate request / immediate price request), Amoxicillin, partial dosage request
8. (UTI / typhoid), (immediate request / immediate price request), (drug with established resistance / drug with growing resistance), request price discount

Rounds 2-3: Providers will receive the same case (symptoms) but across rounds, (describe symptoms only / describe symptoms then request drug) varies. Half of providers receive "describe symptoms only" in round 2 while the other half receive it in round 3.

Round 4: Providers receive the same case they received in rounds 2-3.

Round 5-6: Providers will receive the same case (symptoms) but across rounds, (describe symptoms only / describe symptoms then request drug) varies. Half of providers receive "describe symptoms only" in round 5 while the other half receive it in round 6. Price discount request occurs in round 6 only.

Round 8: Providers receive the same drug request they had in rounds 5-6.
Experimental Design Details
Not available
Randomization Method
Randomization by a computer
Randomization Unit
Randomization at the level of the provider. Providers will receive different treatments within rounds and different sequences of treatments across rounds.
Was the treatment clustered?
No

Experiment Characteristics

Sample size: planned number of clusters
200 Facilities (3 Hospitals, 63 Clinics, 134 Pharmacies)
Sample size: planned number of observations
1,600 SP Visits (8 rounds of visits for each of 200 facilities in the sample)
Sample size (or number of clusters) by treatment arms
Varies by round, but generally 50 facilities into each of 4 disease case/requested drug combinations.
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
IRB

Institutional Review Boards (IRBs)

IRB Name
Maseno University Scientific and Ethics Review Committee
IRB Approval Date
2024-07-22
IRB Approval Number
MUSERC/01199/23
IRB Name
The University of Chicago Social and Behavioral Sciences Institutional Review Board
IRB Approval Date
2023-03-08
IRB Approval Number
IRB23-0370