Providers, particularly in low and middle income countries
prescribe unnecessary antibiotics
and I think it is quite an interesting topic because generally speaking
people have been looking at the issue of underuse of care in low and middle income countries
so why do people not get treatment when they need it
but actually there is a huge problem relating to overuse of care.
It is a waste of resources for the system and or for the patients
who also have very limited means
and so I've been looking at this issue of overtreatment,
and specifically looking at the question of
antibiotics, because prescribing antibiotics when they are not necessary means that
there will be problems in the future
so economists talk about negative externalities
with bacteria becoming resistant to these antibiotics
and having diseases that we can no longer treat properly.
And so I've been looking at this question so far
in South Africa where it's quite an interesting context
to try and test a number of ideas, of hypotheses to try and understand
well, why do we see this overprescribing of antibiotics.
So the first thing we wanted to test is that
when we talk to providers, when we talk to doctors and nurses
they say "oh, the reason why there are too many antibiotics being prescribed,
is because patients are asking for it, patients are requesting antibiotics,
so we have to do that!"
And so we put that theory to the test by using standardised patients.
So we trained people, normal people, to go and visit doctors
in the public and private sector in South Africa
and present themselves with the symptoms and the history of a very uncomplicated
viral infection, bronchitis,
that does not require any antibiotics at all.
And so what happened was a huge overprescription of antibiotics
so I think in total we had about 72% of our patients
who received antibiotics for a condition that did not require any antibiotics at all,
so the providers who had seen our patients
were interviewed, we tried to interview as many as we could,
and the vast majority of our providers who had been prescribing antibiotics
were still telling us that "no, no, no, this person (this fake patient!)
suffers from a viral infection and therefore should not get antibiotics".
So it was not a problem of knowledge for the majority of these providers.
What we realised is that if we looked at the probability of prescribing an antibiotic
it was much higher in the afternoon than it was in the morning visits.
And this is consistent with some findings from other settings
which show that it's when habits kick in, or kick back,
when providers, doctors, have been busy and a bit more tired
and then they sort of, then bad habits come back.
We tested two different ways of trying to limit this overprescription of antibiotics.
So the first thing we tested was what would happen
if we had an incredibly successful public awareness campaign
which would sort of empower patients and raise awareness
within patients to question the appropriateness
of having antibiotics or not.
So we sent these standardised patients and we trained them to tell
the provider that they would not want antibiotics unless it was really necessary.
There was a significant decrease in the proportion of patients
who received antibiotics but we still had about 1 in 2 patients
who still got these unnecessary antibiotics.
And then we tested another potential solution
to try to reduce unnecessary prescribing of antibiotics.
So that particular study was limited to the private sector.
We do see that these dispensing doctors tend to prescribe
cheaper treatment, tend to prescribe less antibiotics than doctors who don't,
who can just write a prescription and give it to patients.
So when the price of the treatment was included as part of the consultation fee
and was effectively reducing the profit of the doctor,
we found that doctors recommended cheaper drugs,
fewer drugs, however unfortunately there was no change for antibiotics specifically.
Unfortunately as a result of our study we could not provide a sort of
silver bullet solution or a magical answer to policymakers,
the local and national policymakers we were talking to in South Africa.
And so we are currently testing and hopefully we will get a study funded
to test a new idea that we have to limit overprescription of antibiotics
by working with the local clinicians,
the local policymakers in Johannesburg to try to create
a way to limit unnecessary prescription of antibiotics by making it a little bit harder
for providers to decide to give antibiotics to patients.