Health, Behavior & Economic Analysis: Preference Elicitation Biases and the Welfare Consequences of Health Interventions in Sub-Saharan Africa

Abstract

Understanding the behavioral responses and external economic consequences of health and development interventions is essential for creating successful, effective, and sustainable policy. My research utilizes both applied econometric techniques and behavioral economics theory to examine some of the psychological and external effects of specific health interventions and general health state utility elicitation. Utilizing a combination of primary and secondary data as well as both experimental and quasi- experimental methods, I evaluate external welfare consequences of early antiretroviral (ART) initiation on household food security and demonstrate new behavioral biases in health state utility assessment with direct application to health policy prioritization. The first chapter of this research employs a regression discontinuity design over longitudinal data from the Africa Health Research Institute in KwaZulu-Natal, South Africa to measure the causal impact of early ART initiation on household food security. The study examines the direct impact of ART on household food security, a fundamental development indicator, to demonstrate the implications of expanding treatment as prevention. This project finds that for a one to two year period following ART initiation, there is a significant increase in the probability of reported household food insecurity, which afterward diminishes to zero. This finding is consistent with the literature on economic recovery post-ART initiation and improves upon previous observational studies by utilizing a quasi-experimental structure to more precisely target valid counterfactuals for those initiating ART utilizing the 200 cells/μL CD4 rationing threshold. Results from this study can be used to help inform policy-makers of relevant potential external effects of scaling up ART initiation on other aspects of household socioeconomic welfare within a treatment-as-prevention paradigm. The second and third chapters deal with the theoretical formulation and empirical testing of two behavioral biases in health state utility elicitation utilizing a quality-adjusted life years (QALY) approach. The second chapter presents a qualitative study where subjects are asked to respond to standard gamble and time-tradeoff preference elicitation questions over two reduced health states, chronic severe depression and complete blindness. Using the post-survey cognitive interviews, and tools from salience theory in behavioral economics, I identify and formalize models for two types of biases: salient impact bias and salient treatment bias. The third chapter takes the qualitative results and theory formulated in chapter two and empirically tests the impact of utilizing a potential impact checklist on responses to standard gamble questions over 4,000 individuals in Dar es Salaam, Tanzania. This study utilizes an experimental structure and randomly assigns survey respondents to receive or not receive a prompt immediately before responding to the preference elicitation questions. Results show that for all participants prompting aligns responses from the standard gamble technique with those obtained in a pre-prompting time-tradeoff question. Additionally, subgroups demonstrated in the qualitative research to have different types of salient impact biases were all shown significantly to reduce cognitive biases. These results demonstrate that prompting for relevant impact dimensions can reduce the effect of cognitive biases on health state preference elicitation surveys and should be employed to more accurately assess quality weights for reduced health states applied to effectiveness measurement.