Drivers of Preventive Care (Under-)Delivery for Cardiovascular Diseases: Evidence from a Randomized Study with Standardized Patients in India

Clinicians in low- and middle-income countries (LMICs) often deviate from care guidelines andunder-deliver high-value preventive care. Focusing on hypertension screening, we investigate severalexplanations for under-delivery using a randomized experiment with standardized patients (SPs).Across 600 clinics in two major Indian cities, we found that nearly half of clinicians failed toscreen SPs - even though screening is highly cost-effective and universally recommended by Indianguidelines. We did not find evidence that under-screening was driven by an absence of resourcessuch as equipment and staff or a lack of clinicians’ knowledge on how to screen for hypertension. Our results also suggest that time pressure or clinicians’ personal judgment on which patients shouldbe screened does not drive screening rates. However, we find notable differences in care betweenpublic and private facilities, with private facilities screening significantly more often. Overall, wefind that conventional explanations for under-delivery - such as screening knowledge, resources, ortime pressure - may not be the prime drivers of inadequate preventive care provision in the Indiansetting. Rather, our results suggest that clinician effort in India is highly influenced by providercare environments and incentive structures.