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.Because it increases the morbidity and mortality of bacterial infection, as well as the duration and cost of antibacterial treatment, antibiotic resistance constitutes a significant threat to global public health. The problem is even more critical in low- and middle-income countries which have higher infectious disease burdens, often higher rates of antibiotic resistance, less access to diagnostic tools, and fewer financial resources to purchase newer more effective antibiotics. In South Africa, antibiotic resistance is particularly high, despite an effective drug regulatory system and various initiatives to tackle the problem. Antibiotic resistance is accelerated by the overuse and over-prescription of antibiotics, which is the product of complex interactions between providers' decisions and knowledge, and patients' expectations. Yet research on the determinants of prescribing behaviours from LMICs in general, and South Africa in particular, is limited, and has been criticised for being too descriptive and superficial, with limited insight into the relative importance of different behavioural determinants to be able to prioritise interventions. In South Africa, most research efforts have focused on hospitals rather than primary care, despite the fact the majority of antibiotics are prescribed in primary care, mostly for respiratory infections. This study aims to explore how the interactions between providers and patients influence inappropriate antibiotic prescribing for URTIs in public and private primary care in South Africa. The study will include three components. First, drawing on medical anthropology, we will explore qualitatively providers' and patients' perceptions an experiences of antibiotic prescribing. This will be done through observations of consultations, interviews with providers and focus group discussions with patients. Second, building on the first part and drawing on methods from marketing research, we will design a survey consisting of a series of hypothetical clinical cases where clinical and patient characteristics will be systematically varied; for each case, the providers taking part will be asked indicate what drugs they would prescribe in a list of proposed drugs. The results will allow us to quantify the relative importance of the factors influencing antibiotic prescribing, with a view to inform policy-makers design future interventions. Finally, drawing on recent economics and medical education research, we will move beyond observational research and design a small randomised field study to test the impact of patients' knowledge and financial incentives on the prescribing practices of public and private primary care providers. This will be achieved with the use of standardised patients, who are healthy subjects trained to portray specific symptoms and disclose a rehearsed medical history. These patients will be sent to visit providers who agreed to take part in the research, at a time and under an identity unknown to them. The standardised patients will only differ in their expectations of antibiotics and the insurance status they will disclose. This will allow us to test the impact of these different characteristics on the likelihood of antibiotic prescription. We anticipate that the results will provide invaluable insights into our understanding of prescribing decisions in the public and private sector in South Africa, thereby informing the stewardship programmes for antimicrobial resistance in this country. Beyond this setting, these findings will be useful to other middle-income countries with a similar mix of public and private providers. More generally, we aim to produce high-quality research and develop innovative methods that could be replicated in other low-income settings to study antibiotic prescribing.

We used the standardised patient method to measure the rate of unnecessary antibiotic prescribing in primary care. A standardised patient (SP) is a fieldworker who has been trained to represent consistently a specific clinical case, and is then sent as to act as a real patient and visit primary care providers. The SPs are also trained to remember all the details of their consultation which they record immediately after completing the visit. The SP method is seen as the gold standard method for evaluating the quality of primary care. SPs portrayed a case of Acute Bronchitis. Such an uncomplicated case should not receive antibiotics.