Why do Indian doctors keep prescribing antibiotics when they know they shouldn’t? – The South First

India issues over half a billion antibiotic prescriptions in the private sector alone, placing it at the center of this global crisis.

Synopsis: In India, 70% of childhood diarrhoea cases receive unnecessary antibiotics, fueling antimicrobial resistance. A study in Karnataka and Bihar revealed a “know-do gap”: 62% of providers knowingly prescribe wrongly due to perceived patient expectations. Despite patients valuing kindness and affordability over antibiotics, fear of losing clients drives misuse, particularly among pharmacists and untrained practitioners.

Antimicrobial resistance threatens to render modern medicine powerless. Scientists warn of “superbugs” that no antibiotic can kill. Millions die each year from infections that once responded to treatment. Yet despite knowing these dangers, healthcare providers continue fueling the crisis.

To uncover why, researchers focused on childhood diarrhoea, a condition that strikes Indians regularly and rarely needs antibiotics. For this, the researchers chose two states that represent different worlds within India: Karnataka, with its above-average income and urban centers, and Bihar, one of the country’s poorest and most rural regions.

What they discovered reveals the gap between what doctors know and what they do. India issues over half a billion antibiotic prescriptions in the private sector alone, placing the country at the center of this global crisis. Childhood diarrhoea, often viral in nature, rarely requires antibiotics. Yet 70 percent of such cases in India receive them, contributing to drug resistance that makes bacterial infections harder to treat.

The study, published in Science Advances, deployed an unusual strategy. Researchers sent trained actors—”standardised patients”—to pose as caregivers seeking treatment for childhood diarrhoea.

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These patients visited 2,282 private healthcare providers across 253 towns in both states, creating more than 2,000 interactions that mirrored real medical consultations.

The results exposed a troubling reality: 70 percent of providers prescribed antibiotics without medical need. The bigger shock came when researchers realised most providers knew these prescriptions were wrong.

‘Know-do gap’ emerges as primary challenge

Researchers identified a mismatch between knowledge and practice, terming it the “know-do gap.” About 50 percent of providers did not know that antibiotics are inappropriate for routine diarrhoea cases, representing a clear knowledge gap.

Among those who did possess correct knowledge, 62 percent still prescribed antibiotics to patients who clearly did not need them.

The study determined that closing the knowledge gap—by simply educating providers—would only reduce antibiotic misuse by about 6 percentage points. However, closing the know-do gap—ensuring doctors act on what they already know—could reduce misuse by 30 percentage points.

Why do doctors ignore their own knowledge?

The study tested multiple theories about why providers prescribe inappropriately. Was it money? Lack of proper medicine? Or something deeper?

Patient expectations emerged as the primary culprit. When the trained actors expressed a preference for antibiotics, providers obliged. But when patients asked for the correct treatment—ORS (oral rehydration salts)—antibiotic prescribing plummeted by 17 percentage points.

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The effect proved most dramatic in pharmacies, where antibiotic prescriptions dropped by 25 points when patients requested ORS instead of antibiotics.

Money did not drive the behaviour. Even when patients explicitly stated they would not purchase medicines from the provider, doctors still prescribed antibiotics. Researchers also supplied free ORS to some providers, eliminating any supply shortage excuse. This intervention had no effect on prescribing patterns.

The real driver was fear–fear that patients would leave dissatisfied without “strong medicine.” One provider revealed the mindset: “[If we only prescribe ORS] they will change the doctor. They might think that we don’t have adequate knowledge. [Some providers] prescribe multivitamin drops or a tonic (antibiotic syrup) or something expensive so that they think he is prescribing good medicines and come back next time.”

This fear spans decades and regions. Researchers found an almost identical quote from a New Delhi study conducted 15 years earlier: “Of course, the WHO and others keep saying that we should only give ORS. But if I tell the mother that she should go home and only give the child water with salt and sugar, she will never come back to me; she will only go to the next doctor who will give her all the medicines and then she will think that he is better than me.”

Patients don’t prefer antibiotic-prescribing doctors

The study examined patients as well as providers. Through a “discrete choice experiment” with over 1,100 caregivers, researchers found that patients do not actually prefer doctors who prescribe antibiotics.

Instead, they value kindness, quality of care, and affordability. Patients were just as likely—or sometimes more likely—to choose doctors who prescribed ORS and zinc instead of antibiotics.

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This means doctors are prescribing unnecessary medicines based on a mistaken belief. The problem spreads across provider types, but some groups offend more than others. Pharmacists and Rural Medical Practitioners (RMPs) also known as quacks—who often lack formal training—showed the largest know-do gaps.

AYUSH practitioners (Ayurveda, Unani, Siddha, Homeopathy) and MBBS doctors also overprescribed, though to a lesser degree.

Since nearly one-third of childhood diarrhoea cases in India first go to pharmacies, tackling misuse here could make the biggest difference.

Two worlds: Bihar and Karnataka

The researchers deliberately chose states that represent India’s diversity. Bihar ranks among the nation’s poorest, with mostly rural populations struggling with basic healthcare access. Meanwhile, Karnataka boasts above-average per capita income and better infrastructure. If the problem existed in both places, researchers reasoned, it likely plagued the entire country.

Their sample captured India’s healthcare reality: 2,282 providers spanning from formally trained MBBS doctors to village pharmacists with no medical education. 92 percent were male, averaging 44 years of age with 18.5 years of experience. They treated an average of 24.7 patients daily and saw 6.3 diarrhoea cases weekly.

The sample included four different provider types: 20 percent were providers with an MBBS degree; 37 percent were providers with a degree in traditional medicine including Ayurveda, yoga and naturopathy, Unani, Siddha, and homeopathy (AYUSH); 21 percent were rural medical practitioners (RMPs) who typically lack formal training but still practice medicine; and 22 percent were pharmacies.

Financial incentives and supply issues show no impact

The study investigated the role of financial incentives at the point of sale and supply of correct treatment on antibiotics prescribing and the know-do gap. Results showed that ensuring stock of correct treatment or eliminating the financial incentive to sell more lucrative treatments had no effect on antibiotics prescribing.

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When standardised patients told providers that they would not purchase treatment from them and only wanted a recommendation—thus eliminating the financial incentive to sell one treatment over another—this did not significantly change antibiotics prescribing or the know-do gap.

Similarly, when providers were given free supply of ORS, thus increasing the likelihood that they had it available when the standardised patient visited, this had no effect on antibiotics prescribing.

The qualitative work suggests that providers think that patients have a preference for strong medicine and not antibiotics specifically. However, providers think that antibiotics are strong medicine because they provide symptomatic relief for bacterial diarrhoea, while ORS does not reduce diarrhoea.

A provider quote from this study mirrors one presented more than 15 years ago when researchers examined quality of care in New Delhi India. When they asked a healthcare provider why ORS was not enough for treating childhood diarrhoea, the provider responded: “Of course, the WHO and others keep saying that we should only give ORS. But if I tell the mother that she should go home and only give the child water with salt and sugar, she will never come back to me; she will only go to the next doctor who will give her all the medicines and then she will think that he is better than me.”

The remarkable similarity of these quotes taken 15 years apart in two separate regions of India highlights the persistence and ubiquity of these beliefs.

(Edited by Amit Vasudev)