What drives poor quality of care for child diarrhoea? Experimental evidence from India

Journal: Science, 9 February 2024 Vol. 383(6683): 606 – 615.

Abstract: Diarrhoea is a leading cause of death in children, with nearly 500,000 young lives lost to diarrhoea each year. It becomes deadly when excretions exacerbate severe dehydration and loss of electrolytes. Almost all these lives could be saved with a low-cost and widely available treatment: Oral Rehydration Salts (ORS). However, nearly half of diarrhoea cases around the world do not receive ORS. 

Most health care providers in India know that ORS is an inexpensive, lifesaving treatment for child diarrhoea, yet they are widely underused. Even when children seek care from a health care provider for their diarrhoea, as most do, they often do not receive ORS. This know-do gap has puzzled experts for decades and cost millions of lives. Existing research documents several potential explanations for this. The authors used a randomized controlled trial to simultaneously study the role of three leading explanations for ORS underprescription.  

More than 2000 providers across 253 medium-sized towns in the states of Karnataka and Bihar participated in the study. To measure the effect of the first barrier, perceived patient preferences, the authors used actors trained to act as caregivers of a 2-year-old child, who made unannounced visits seeking care for their ward. The authors randomly assigned whether they expressed a preference for ORS, a preference for antibiotics, or no preference. To measure the effect of the second barrier, financial incentives, some of the standardized patients assigned to the no-preference arm informed the provider that they would purchase medicines from a different location, thereby eliminating the provider’s financial incentive to recommend more-lucrative treatments. Finally, to estimate the effect of the third barrier, ORS stock-outs, the authors randomly assigned all providers in half of the 253 towns to receive a 6-week supply of ORS. 

The authors found that expressing a preference for ORS increased ORS prescribing by 27 percentage points compared with no preference. They further found that it is mainly because providers think only 18% of their patients want ORS on average, when, in reality, ORS was the most preferred treatment reported by patients in household surveys. By combining results from different study arms for each barrier, they estimate that provider misperceptions that patients do not want ORS explains 42% of underprescribing, whereas stock-outs and financial incentives explain only 6% and 5%, respectively. 

Provider misperceptions that patients do not want ORS plays the biggest role in the underprescribing of ORS. These results suggest that interventions to change provider misperceptions of patients’ ORS preferences should be aggressively explored because they have the potential to substantially increase ORS use and to save lives.