In practice, none of the providers gave the correct treatment that includes only ORS, with or without zinc, and no other potentially harmful drugs. Instead, almost 72 percent of providers gave antibiotics or potentially harmful treatments without ORS. “Massive over-prescription of antibiotics is a major contributor to rising antibiotic resistance worldwide,” Mr Mohanan said. “Our ongoing studies aim to understand why providers who know they shouldn’t be prescribing antibiotics for conditions like simple diarrhea continue to do so,” he added. “It clearly is not demand from patients alone, which is a common explanation, since none of our standardized patients asked for antibiotics but almost all of them got them,” he said. Providers with formal medical training still had large gaps between what they knew and did, but were significantly less likely to prescribe harmful medical treatments.

“Our results show that in order to reduce child mortality, we need new strategies to improve diagnosis and treatment of these key childhood illnesses,” Mr Mohanan said. “Our evidence on the gap between knowledge and practice suggests that training alone will be insufficient. We need to understand what incentives cause providers to diverge from proper diagnosis and treatment.”

Mohanan also holds appointments with the Duke Global Health Institute and the Department of Economics. His co-authors are Mr Marcos Vera-Hernandez and Ms Soledad Giardili of University College London; Ms Veena Das of Johns Hopkins University; Mr Jeremy D. Goldhaber-Fiebert of Stanford University School of Medicine; Tracy L. Rabin and Mr Jeremy I. Schwartz of Yale School of Medicine; Mr Sunil S. Raj of the Indian Institute of Public Health and Ms Aparna Seth of Sambodhi Research and Communications. Funding for the study was provided by the Bill and Melinda Gates Foundation as part of the Bihar Evaluation of Social Franchising and Telemedicine (BEST) project.