Audit Study of Antibiotic Prescribing in South Africa, 2017-2019

In this audit study, we aimed to answer the following questions: 1) How much unnecessary prescribing of antibiotics is there for RTIs in the private and public primary care sectors? 2) Can unnecessary prescription of antibiotics be reduced by increasing patient awareness? 3) Can unnecessary prescription of antibiotics be reduced using financial incentives? To answer question (1), we conducted an audit study in 100 private practices and 80 public clinics, by sending standardised patients (see method) portraying a case of Acute Bronchitis. Such an uncomplicated case should not receive antibiotics. To answer question (2), we developed a new SP scenario to create an exogeneous change in the attitude of the standardised patient towards antibiotics. After describing his/her main complaint, this ‘reluctant’ patient was trained to tell the doctor: “I do not want antibiotics, unless you think it is really necessary”. A total of 199 visits were carried out by such ‘reluctant’ patients, half in the public sector and half in the private sector, 5 to 10 days apart from the visits carried out by ‘normal’ standardised patients to the same providers. The dataset To answer question (3), we leveraged the existence of dispensing doctors in South Africa, who charge a flat consultation fee which includes both the consultation itself and basic drugs dispensed. As a result, this potentially creates a natural rationing supply-side cost-sharing incentives for doctors. To understand whether this mechanism contributes to reduce unnecessary prescribing, we selected a sub-group of 120 prescribing doctors and sent them two SPs, in a random order: one who acted normally and one who asked the GP to write him a prescription instead of dispensing the drugs. In other words, the dispensing GP faces a rationing incentive with the first patient, as the drugs dispensed reduce their profit, but not with the patient who asks for a separate script.