BACKGROUND: India—one of the most significant antibiotic users in the world with a high burden of antibiotic resistance—does not have a formal antibiotic surveillance system. No formal studies exist on the sub-national differences in antibiotic use in India except for small hospital or community-based studies. Informed by the WHO Global Action Plan, India developed a national action plan; however only two states have state action plans so far. This suggests that it is important to understand existing antibiotic consumption patterns, sub- national differences and trends over time, and the determinants of antibiotic use so that evidence-informed action plans and programs can be developed in India. AIM: To understand the changing landscape of antibiotic use in India and contribute to relevant policy and programmatic interventions that can improve the appropriate use of antibiotics in the country. Specific objectives included examining the use of systemic antibiotic consumption at the national level, analyzing geographical and temporal variations across states between 2011 and 2019, and understanding the determinants of antibiotic consumption. Additionally, we examined Kerala as a case study to understand the use and availability of data in designing, implementing, and monitoring the state antibiotic action plan. METHODOLOGY: First, we conducted a cross-sectional analysis of antibiotic use in 2019 using the WHO Access-Watch-Reserve (AWaRe) and Defined Daily Doses (DDD) matrices at the national level across product type (Fixed-Dose Combinations [FDCs]; and single formulations [SF]), essentiality (listed in the national list of essential medicines [NLEM]; and not listed), and central regulatory approval status (approved and unapproved). Second, we analyzed trends in consumption rates and patterns at the national, state, and groups of states at different levels of health achievements (‘high focus’ [HF]; and ‘non-high focus’ [nHF]) and compared the appropriateness of use between states and state groups. Third, using a cross-sectional, time series (panel) dataset on antibiotic use, per-capita GDP, per-capita government spending on health, girls' tertiary education enrollment ratio, measles vaccination coverage, and lower respiratory tract infection incidence for the period 2011- 2019, we conducted a quasi- experimental fixed-effects analysis to understand the critical determinants of antibiotic use. Finally, we conducted key-informant interviews and document analysis to understand the use of data in policy formulation, implementation, monitoring, and evaluation of the Kerala state action plan. RESULTS: India's per-capita private-sector antibiotic consumption rate was lower than global rates, but the country has a high consumption rate of broad-spectrum antibiotics, FDCs discouraged by WHO, formulations outside NLEM in FDCs, and unapproved formulations. The overall rate increased from 2011 to 2016 and decreased between 2016 and 2019, registering a net decrease of 3.6%. State consumption rates varied widely— with HF states reporting lower rates. The inappropriate use increased over the years, the share of Access antibiotics decreased (13.1%), and the access-to-watch ratio declined (from 0.59 to 0.49). HF and nHF states showed convergence in the share of the Access and the Access-Watch ratio, while they showed divergence in the use of WHO Discouraged FDCs. The most critical independent determinant of antibiotic use was government spending on health—for every US$12.9 increase in per-capita government spending on health, antibiotic use decreased by 461.4 doses per 1000 population per year after adjusting for other factors. Economic progress (increase in per-capita GDP) and social progress (increase in girls' higher education) were also found to reduce antibiotic use independently. The qualitative case study showed that stakeholders understand and express interest in generating and using data for decision- making, and the action plan document mentions some basic monitoring plans. However, a monitoring and evaluation framework is missing, there is a lack of engagement with the private sector, and there is a lack of understanding among key government policymakers on the importance of using data for surveillance and policy implementation. CONCLUSION AND IMPLICATIONS: There is significant and increasing inappropriate antibiotic use in India's private sector, accounting for 85-90% of total antibiotic use. Increased government spending on health is critical in reducing private-sector antibiotic use. The dearth of data on public sector use is a significant challenge in understanding the total consumption rate. Developing a monitoring and evaluation system through stakeholder engagement is necessary for Indian States to inform, monitor, and evaluate effective antibiotic action plans. We need global efforts to improve the science and methods to measure antibiotic use. / 2023-08-30T00:00:00Z

This dissertation focuses on identifying the poor in Sub-Saharan Africa (SSA) and the potential of social assistance programs to address their condition. Each essay is related to one particular key step of the poverty alleviation agenda: poverty definition and measurement in Zimbabwe; targeting poor households in Cameroon; and impact evaluation of anti-poverty interventions in Niger. The first essay explores changes in poverty across multiple dimensions in a period of dramatic economic crisis and recovery in Zimbabwe. The essay analyzes changes in household well-being between 2001, 2007 and 2011/12, using an Alkire-Foster multidimensional poverty index. Results indicate a large increase in multidimensional poverty across between 2001 and 2007, followed by a (smaller) decrease in poverty between 2007 and 2011/12 (recovery period after the hyperinflation peak in 2008). However, decomposition of the index shows significantly different trends in poverty dimensions over time, as for instance health related dimensions continued to deteriorate after 2007. The second essay contributes to the policy debate on targeting by studying the ex-post efficiency of two targeting mechanisms employed in a cash transfer project in rural Cameroon: Proxy Means Testing (PMT) and community targeting. Results show a poor performance of community targeting in selecting households with low per capita consumption, compared to PMT targeting—whose errors remain high nonetheless. Communities tend to select small, isolated households with low physical and human capital, regardless of their actual consumption level, but produce variable outcomes. Overall results suggest that a higher coverage contributes to reducing targeting errors, and that better guidance should be provided to communities if the policy objective is to select low per capita consumption individuals. The third essay investigate whether cash transfers induce investments in assets and productive activities that survive the termination of program payments using data from an unconditional cash transfer project in Niger 18 months after its termination. Based on quasi-experimental methods, results indicate that local saving/credit systems (tontines) participation and livestock ownership significantly increased among project participants. There is also evidence of improvement in private assets, micro-enterprises and agriculture. The findings imply that cash transfer programs can have long-term sustainable impacts in rural SSA. / Ph. D.

La thèse comporte sept chapitres. Nous présentons, dans le premier chapitre, une étude qui montre les traits particuliers des pauvres et la façon dont ils perçoivent leur propre pauvreté. Le second chapitre est consacré à une revue de la littérature sur l'utilisation d'agenda de gestion du temps comme outil de collecte de données en recherche qualitative. Le troisième chapitre propose une version modifiée du "modèle de portefeuille économique du ménage” (HEP) de Chen et Dunn (1996). Le modèle modifié (M-HEP) permet une évaluation non expérimentale de 1’impact de la microfinance. Nous l’avons mis en place via la collecte d’informations simples auto-déclarées sur 1’utilisation quotidienne du temps et de l’argent auprès d'un échantillon de femmes pauvres du Caire (Egypte). Le quatrième chapitre propose une étude testant ce modèle (M-HEP) auprès de personnes en situation de handicap. Le cinquième chapitre s'attache à une étude qui souligne une limite des journaux combinés "non stylisés" ou "non-directifs". Le sixième chapitre expose l’utilisation de jeux expérimentaux sur un échantillon de population du Caire en comparant le comportement des clients de la microfinance à celui de non-clients. Le dernier chapitre expose une étude d’évaluation d’impact de la microfinance sur le genre au Mali, utilisant une méthode quasi-expérimentale. Enfin, en guise de conclusion, nous préconisons 1’utilisation du modèle M-HEP dans l’étude de l’évaluation de I’impact de la microfinance. Nous avons effectué’ une étude comparative des trois méthodes utilisées dans la thèse à savoir la méthode qualitative non-expérimentale et les méthodes quantitatives expérimentales et quasi-expérimentales. / The thesis is built on seven chapters. In chapter 1, we explore the views on poverty of a sample of poor women. In chapter 2, we review the literature on the use of time-diary in research. Chapter 3 develops and investigates the diary method as a qualitative non-experimental impact evaluation tool. For this objective, we study "the household economic portfolio model (HEP)“ a comprehensive impact evaluation model designed by Chen and Dunn (1996) that overcomes the obstacle of fungibility of money. We propose a modified version (M-HEP), a simplified framework for non- experimental evaluation of impact with clear assessment units and efficient measurement tools. The collection of simple self-reported information on the daily use of time and money is suggested for implementing the model. We test our proposition with a case study from Cairo. In chapter 4, we provide another test of the combined diaries through a case study on two poor single mothers one of whom is handicapped. In chapter 5, we present a fina1 example on the combined diary of a poor woman. The study highlights one limitation in the non-stylized combined diary approach. In chapter 6, we use experimental games in Cairo to study two aspects of behavioral microfinance by comparing microfinance clients to non-clients. In chapter 7, we present an impact evaluation study on microfinance in Mali, using the quasi-experimental statistical technique. Finally, we conclude the thesis suggesting applications of the M-HEP, and comparing the three methods used in the thesis. This comparisons aims to evaluate the advantages and disadvantages of each of the methods when used for evaluating microfinance impact.