Are providers responsive to patients’ preferences? Evidence from antibiotic prescribing in South Africa

Antibiotic resistance constitutes a significant threat to global public health. The problem is even more critical in low- and middle-income countries which have more infectious diseases, less access to diagnostic tools, and fewer financial resources to purchase effective antibiotics. In the medical literature on antibiotic prescribing, one of the most consistent reasons expressed by providers for prescribing antibiotics are patients’ actual demands for antibiotics (or providers’ perceptions that patients expect antibiotics). In other words, unnecessary prescribing is mainly a response to what patients value, a problem that might be particularly acute if healthcare delivery is market-based. However, there is hardly evidence about the proportion of unnecessary prescribing that is due to patient demand, and whether public and private respond differently to patients’ demand.

We study antibiotic prescribing of primary care providers in South Africa, and the extent to which patient demand drives unnecessary prescribing. Antibiotic resistance is particularly high in South Africa and the majority of antibiotics are prescribed by public and private primary care providers.

We create an exogenous variation in patient demand for antibiotics in a random sample of about 200 public and private primary care providers in Johannesburg. Specifically, each provider receives a pair of standardised patients (SPs), who visit them in a random order. In this study, SPs are fake patients trained to follow a detailed script to portray accurately and consistently a case of acute bronchitis, and to subsequently record the content of the consultation and treatment received. In one of the two visits, the SP mentions at the beginning of the consultation that they would only agree to take antibiotics if they are really necessary. According to national and international guidelines, the mild symptoms of acute bronchitis portrayed by the SP should be treated with symptomatic relief drugs, but no antibiotic should be prescribed.

We find that the rate of unnecessary prescribing of antibiotics is significantly lower when patients clearly mention their reluctance to antibiotics, although it remains very high (57% vs 73%). This change occurs while all measures of effort and quality of care (consultation duration, number of questions asked and examinations undertaken) is the same whatever the attitude of the patient. The only notable difference is that more providers volunteer a diagnosis to the ‘reluctant’ patient (67% vs. 58%). We find that private providers are slightly more responsive to patients’ preferences, as they reduce their unnecessary prescribing by 22.5%, while public providers reduce it by 20.5%.

The results suggest that even though part of unnecessary prescribing of antibiotics may be due to perceived patient demand by providers, unnecessary prescribing remains largely due to providers’ own decision. Hence, while a *successful* public awareness campaign would contribute to reduce unnecessary prescribing, most of it is driven by provider behaviour.