Under-Delivery of Preventive Care and Patient Influence on Clinician Behavior: Evidence from India

Abstract
Clinicians in low- and middle-income countries (LMICs) often deviate from care guidelines and under-deliver high-value preventive care. One explanation for this service-delivery failure is that clinicians are incentivized to meet patients' requests and immediate concerns rather than follow guidelines and deliver services that patients may not value. Conversely, patients requesting preventive services should significantly influence clinician behavior. Focusing on hypertension screening, we investigate these predictions using a randomized experiment with standardized patients (SPs) across 600 Indian clinics. We found that clinicians substantially under-delivered screenings when SPs did not explicitly request it- even though screening is highly cost-effective and universally recommended by Indian guidelines. However, patients requesting a screening significantly changed clinician behavior, resulting in near-universal screening and improved care quality. Our results reveal that healthcare quality and clinician effort in India are highly influenced by patients' stated concerns and preferences rather than by medical guidelines or long-term patient welfare.