Antibiotic over prescription - The alarming state of health care in rural India

Consider these stats. Nearly 60% of healthcare spending in India is out of pocket. 47% of hospital admissions in rural areas and 31% in urban areas are financed by sale of assets. 30% of those needing care in rural India and 20% in urban areas go untreated because of inability to pay. Health care  costs push 40 million people into poverty every year.  These are alarming figures by any standards.

While this highlights the financial burden on the poor due to health care costs,  there's another danger looming in India, unnoticed. It's the irresponsible and excessive prescription of drugs. Antibiotics have a unique property. Bacteria builds resistant to these drugs. So, each time, you need to increase the dosage. It means that if you end up taking high dose for something that could have been dealt with low dosage, next time you need to take a higher dosage (higher than previous high dose). The ladder escalates. The worst part is that once the bacteria develops resistance, even a person who has never taken antibiotics has to take high dosage if infected with drug resistant bacteria.

India is being called the superbug (bacteria resistant to all known antibiotics) capital of the world. "While antibiotic usage worldwide in the first decade of the 21st century rose by 36%, in India, the count went up by 62%." Consequently the drug resistant strains also increased and the number of people dying from such infections. For instance, consider this: The resistance to Klebsiella pneumonia to carbapenems, the antibiotic of last resort is 57% in India, as compared to below 5% across Europe.

The over prescription of drugs is rampant in rural India, where there is a proliferation of quacks (untrained medical doctors). Manoj Mohanan of Duke University finds that only 20% of children suffering from diarrhoea are given appropriate drugs in his study in Bihar. The drugs prescribed to the rest 80% are "scandalous" and "criminal". The rest are given powerful antibiotics even for those diarrhoea cases that don't require antibiotics. In a significant number of cases, they are even given steroids and even chemotherapy drugs. It wrecks the health of children in long term.

One may then infer that the trained medical doctors are better at this. Unfortunately it's not so. They are no better than the untrained quacks as found in several studies.

One might then infer that giving short term training to the quacks on these aspects will constrain their quackery. Abhijeet Banerjee, Jishnu Das et al. conducted an experiment in West Bengal that provided training to quacks. While it improved their adherence to medical protocols on other aspects, it didn't reduce the over prescription of drugs.

'Competition', the need to attract patients seems to be the main reason behind this. Powerful antibiotics and steroids give instant relief while causing long term damage. Patients can only feel short term pain relief but not long term damage. Hence, they prefer to go to those doctors who give them short term relief. Doctors act accordingly by over prescribing drugs. It's a supply induced demand! It's also the reason why some doctors answer appropriately in tests of knowledge but act differently while treating.

It's thus a difficult problem that calls for doctor's self regulation, which is difficult to achieve on a large scale. Standardization and use of technology like tele medicine could be a hope to address self regulation issues. Bihar tried a social franchise model trying to standardize treatment protocols and use tele medicine. The idea is that a medical practitioner can get a franchise - s/he gets list of protocols to be followed. The doctor can observe their mentor's clinical practice remotely and also seek help from them whenever required. It was hoped that this could help to that extent.

Mahanan's large scale RCT finds that this approach also didn't help. To start with, the take up was low. It's because no one has an incentive to invest in getting a franchise, adhering to protocols and invest in gaining extra knowledge because they already have a thriving practice.

Though the attempts to standardize protocols and use of technology are limited, the existing one's don't show positive picture, in their current state. Self regulation seems to happen only in some top tier hospitals. For instance, in some top tier hospitals, prescription of antibiotics beyond certain strength has to be approved by a senior doctor.

The larger picture is that arresting over prescription of drugs is a complex problem. It's not yielding to any traditional instruments  - training informal doctors, using technology etc. The commonly used instrument of getting rid of discrepancies with competition also doesn't help in this case because competition is the primary culprit here.

In an ideal world, this should call for high levels of government attention and some urgent steps with innovative thinking. You know what our governments did instead? They banned transport of blood samples outside the country arguing that western researchers are spoiling India's name by highlighting the antibiotic resistance problem, hurting its medical tourism! 

Not stopping this problem is a criminal negligence to say the least.

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