A critical challenge for developing country health systems is to craft policy that gives individuals with curable diseases like malaria and pneumonia access to potentially life-saving medical care, while avoiding that patients consume unnecessary medical treatment or get treated for the wrong illness. Such overtreatment wastes scarce resources and health care subsidies, drains patients’ time and money, and contributes to the rise of drug-resistant diseases.
Our previous blog highlights how overtreatment is a particular concern where disease prevalence is relatively low, but access to low-cost medication is high. In Bamako, Mali, for example, we found high rates of unnecessary antimalarial prescription. This occurred even though patients tested negative for malaria before the prescription, and Malian guidelines specify that antimalarials should only be prescribed to those with a positive test result.
What, then, is driving overtreatment?
Most of the existing literature focuses on doctor-driven reasons, such as financial incentives to increase clinic revenues, or a lack of awareness of correct treatment protocols. But there may be an alternative explanation: patient preference. Indeed, over half the health providers we surveyed during our project reported feeling pressure to prescribe unnecessary medications from patients.
To test how patient preferences influence malaria treatment decisions, we conducted a randomized evaluation among 60 public health clinics and 2,055 patients in Bamako. On randomly selected “Patient Days,” we provided free treatment vouchers to all patients entering the clinic. On other “Doctor Days,” we provided these vouchers to doctors to dispense at their discretion, without informing patients upfront that treatment was free. All vouchers provided a discount on the same treatment (artemisinin combination therapy for uncomplicated malaria) and required a doctor’s signature and prescription to be valid. We did not give out vouchers on control days. Finally, to keep doctors’ financial incentives constant across all three groups, we reimbursed clinics for all medication redeemed via vouchers. Hence, the sole difference between the “Doctor” and “Patient” days was whether patients knew about the voucher before their consultation (and therefore had the ability to actively demand the discounted medication from the doctor).
Strong indications that a share of excess prescriptions is driven by patient preferences
Our results are a strong indication that a share of excess prescriptions of antimalarials is driven by patient preferences. Patients were 35 percent more likely to redeem the vouchers and receive malaria treatment on “Patient Days” than on “Doctor Days,” with extra demand driven by patients with the fewest malaria symptoms. Meanwhile, we found no evidence of doctors strategically using information about the vouchers on “Doctor Days” to increase clinic revenue, for example by selling more expensive antimalarial injections. These results indicate that doctors and patients have different preferences for treatment, with doctors preferring to withhold unnecessary treatment. When faced with heightened demand for medication from low-risk patients, however, some doctors give in, despite their own preferences.
There are potentially important policy implications to these findings. Providing access to highly-subsidised antimalarials is an essential component of effective malaria policy. However, the value of these subsidies will be limited by the extent to which doctors target treatment to those who need it. It is therefore critical for policymakers to understand how well doctors fulfill their gatekeeping role in only providing antimalarials to those who need them, and why they fall short.
We expect that causes of overtreatment will vary by context and even intersect – for example, doctors may not properly diagnose a suspected malaria case if a patient expresses a strong demand for an antimalarial. In settings where patients drive overtreatment, interventions that make it easier for doctors to resist patient demands (like patient communication tools) could help sustain subsidies and reduce overtreatment. In settings where doctors drive overtreatment, other policy instruments (like changing doctors’ financial incentives) may be required. Further research on doctor-patient dynamics in other contexts, as well as testing of interventions to strengthen doctors’ gatekeeping capacity, could help generate important new policy insights for the fight against malaria.
This article is based on: Carolina Lopez, Anja Sautmann and Simone Schaner. “The Contribution of Patients and Providers to the Overuse of Prescription Drugs.” NBER Working Paper 25284, November 2018.