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Close-up of a Bangladeshi mother holding her warmly wrapped baby

A salty-sweet solution is a cheap and effective way to prevent children’s death from diarrheal diseases. Yet doctors did not always recommend them.Credit: Jewel Samad/AFP/Getty

“The gap between knowing the right thing and doing the right thing is a persistent problem,” says David Levine, a health economist at the University of California, Berkeley. That gap is highlighted by a study published today in Science1.

Every year, half a million children under five die of diarrhoea globally — but doctors and pharmacists often don’t prescribe a cheap lifesaving treatment for the condition. A large Indian study suggests that this happens because prescribers don’t think that their patients want the therapy.

Most private doctors and pharmacists in the study understand the benefits of an oral rehydration solution (ORS). The treatment, a pre-mixed sachet of salts and sugars that is mixed with water, has been around for more than half a century. It prevents dehydration and drastically reduces the risk of children dying from diarrhoea.

To better understand why more children aren’t given ORS, Zachary Wagner, a health economist at the RAND Corporation, a non-profit research and policy organization in Santa Monica, California, and his colleagues launched a large experimental intervention in two Indian states, Karnataka and Bihar.

They sent actors pretending to be the fathers of a sick two-year-old child to more than 2,000 randomly selected private doctors and pharmacists in mid-sized towns. Three-quarters of carers in India seek help for their sick children from private clinics and pharmacies.

The interactions were designed to assess whether low levels of ORS prescription were due to supply shortages, incentives to sell more expensive drugs, such as antibiotics, or sensitivity to patient desires.

Each actor arrived at a facility unannounced and explained that their child had been experiencing diarrhoea for two days. Some told the provider that they had previously used ORS to treat their child and asked whether they should use it again. Some instead mentioned antibiotics, and others brought up no earlier treatments. Some actors noted that they would not be purchasing any medications at the facility and just wanted advice. The researchers also sent a six-week supply of ORS to half of the facilities.

The researchers found that a patient’s treatment preference was much more important than the clinic or pharmacy’s financial incentives and accessible stock in explaining why ORS is under-prescribed.

Actors who expressed a preference for ORS were twice as likely to get it as those who mentioned no treatment. A survey of more than 1,000 carers across the two states and representatives from the clinics and pharmacies revealed that 48% of carers feel that ORS is the best treatment for diarrhoea, but only 16% express that preference when visiting clinics. In turn, only 18% of doctors and pharmacists think that their patients want ORS.

“It is a very elegant study,” says Levine.

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The results “somewhat go against the belief among economists that financial incentives matter an awful lot”, says Karen Grépin, a health economist at the University of Hong Kong. Instead, informational barriers were more important.

But Ramanan Laxminarayan, an epidemiologist at Princeton University in New Jersey, says that financial incentives can be hard to disentangle from other motives. “We think of doctors as neutral decision-makers based on what is best for the patient, and that is often not the case,” says Laxminarayan. “Doctors make decisions based on what makes a patient happy,” he says, which has an underlying financial motive. “If a patient is not happy with you, they are not going to keep coming back.”

Overall, Grépin says the study is impressive, but there is still a lot more to unpack. For example, it is not clear why some patients don’t communicate their preference for ORS to their providers. The study also doesn’t offer a clear path forward on how to improve ORS uptake, she says. “It doesn’t really tell me what to do next.”

Wagner plans to design studies to test interventions for changing the perception of doctors and pharmacists, and how patients express their preferences. “Just telling people that ORS is a lifesaving medicine — we’ve hit the ceiling on what that can do.”

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