A cost-effective solution could prevent many children from dying because of diarrhoea, but health professionals often fail to recommend it. David Levine, a health economist at the University of California, Berkeley, acknowledges the persistent gap between knowing and doing the right thing, which is brought to light by a study published in Science1. Every year, half a million children under the age of five succumb to diarrhoea globally but many doctors and pharmacists do not prescribe a low-cost life-saving treatment. A study from India suggests that this is due to the belief that patients do not wish to access the treatment.
Most private doctors and pharmacists acknowledge the benefits of an oral rehydration solution (ORS), a pre-mixed sachet of salts and sugars that is mixed with water to prevent dehydration and significantly reduce the risk of children dying from diarrhoea. To gain deeper insights into why ORS is underutilized, Zachary Wagner, a health economist at the RAND Corporation, and his colleagues conducted a large experimental intervention in two Indian states, Karnataka and Bihar.
They sent actors posing as the fathers of a sick two-year-old child to over 2,000 randomly selected private doctors and pharmacists in mid-sized towns. The goal was to investigate whether low levels of ORS prescription were due to supply shortages, incentives to sell more expensive drugs, or sensitivity to patient desires. The actors arrived unannounced at the facilities and presented varying scenarios to assess the response, while a six-week supply of ORS was sent to half of the facilities.
The study revealed that a patient’s treatment preference played a significant role in the under-prescription of ORS, outweighing the clinic or pharmacy’s financial incentives and accessible stock. Actors expressing a preference for ORS were twice as likely to receive it compared to those not mentioning any treatment. A survey of over 1,000 carers and representatives from the clinics and pharmacies in the two states indicated that although 48% of carers perceive ORS as the best treatment for diarrhoea, only 16% express this preference when visiting clinics. Similarly, only 18% of doctors and pharmacists believe that their patients prefer ORS.
Karen Grépin, a health economist at the University of Hong Kong, finds the results intriguing as they challenge the notion that financial incentives are of utmost importance, highlighting instead the significance of informational barriers. However, Ramanan Laxminarayan, an epidemiologist at Princeton University in New Jersey, asserts that financial motives are often intertwined with other decision-making factors for doctors. On the other hand, Wagner intends to design further studies to examine interventions for altering the perceptions of doctors and pharmacists, and also how patients convey their preferences.
