How do social norms impede correct medical treatment? 

Rural Medical Practitioners and the treatment of diarrhea in young children

In India, dehydration due to diarrhea causes a significant number of deaths among children under five years of age. Giving oral rehydration salts (ORS) and zinc is a proven way to protect against dehydration and lower the risk of death, but in Uttar Pradesh state, few young children with diarrhea receive ORS and zinc. 


In most cases, parents or caregivers seek treatment from Rural Medical Practitioners (RMPs) – unlicensed private providers with no formal medical training. Efforts to help children under five with diarrhea have typically focused on influencing RMPs to dispense more ORS and zinc. The assumption has been that RMPs can be persuaded to prescribe ORS and zinc by increasing its availability (supply) and providing training on its proper use and profit margins (incentive). So why wasn’t this working as well as it should? 

Surgo Foundation addressed the problem in a new way. Working in partnership with the Clinton Health Access Initiative and the Bill & Melinda Gates Foundation, we applied a behavioral science approach to investigate and identify the mental models that influence RMPs’ decisions about dispensing ORS and zinc for children under five with diarrhea. We also looked at the context of the RMPs’ broader practice, and evaluated the perspectives of key influencers such as RMPs’ mentors and the children’s caregivers. 


The results revealed something unexpected: RMPs would often not prescribe ORS and zinc, not because they did not understand or believe in the benefits, but because children’s caregivers thought antibiotics were the best treatment for all illnesses, and expected to receive them.

The undiscovered but simple leverage point was that RMPs wanted to meet caregivers’ expectations of what a “good doctor” would do, and feared losing customers.

This insight helped us redefine strategies to increase ORS and zinc coverage – including messages and other interventions to change caregivers’ treatment expectations. 

Through our study we developed a framework describing the three “P factors” that dictate RMPs’ decision-making: Patient expectations, Profit, and Perceived correct treatment. These factors have broader implications for the efforts to influence RMPs and other private providers. We gained crucial insights into how RMPs could be leveraged as a platform for the delivery of other health services, for an even wider impact on rural health care.