Patient trust is an important driver of the demand for healthcare. But it may also impact supply: doctors who realize that patients may not trust them may adjust their behavior in response. The authors assemble a large dataset that assesses clinical performance using standardized-patients (akin to audit studies in economics) in low-income countries to investigate this possibility; most of these data are on healthcare providers who practice in the private sector on a fee-for-service basis.

The authors establish that patients receive low quality of care, with a generous definition suggesting that fewer than 50% of cases are correctly managed, and between 70% and 90% of expenditures are medically unnecessary. Strikingly, and in contrast to literature suggesting that the main problem with fee-for-service provision is over-treatment, the majority of these unnecessary expenditures are incurred because patients are incorrectly rather than over-treated.

The authors then rule-out two plausible explanations for low quality of care: low levels of medical knowledge and low market incentives to invest effort. In this data, there are many healthcare providers who know how to correctly treat the patient and could substantially increase their revenue by doing so given the price-quality gradients the authors estimate, but still treat the patient incorrectly.

A model of the patient-provider relationship in which patients have incomplete information about the quality of providers generates predictions consistent with the authors' findings. The theory additionally suggests that issuing a credible signal of quality should raise average quality of care among providers, even if their underlying ability remains unchanged.

The authors assess this prediction through an evaluation of a highly-publicized training program with informal healthcare providers in West Bengal, India. The program has no impact on knowledge, yet substantially raises quality of care, leading to an increase in the likelihood of correct treatment, a 19% decline in unnecessary expenditures for patients and a 9% increase in revenues for providers. The authors conclude that low trust undermines clinical performance in an economically and medically significant manner.

Reshmaan Hussam is an assistant professor of business administration in the Business, Government and International Economy Unit at Harvard University's Business School, a Faculty Research Fellow at the National Bureau of Economic Research (NBER), and a faculty affiliate at the Abdul Latif Jameel Poverty Action Lab (J-PAL) and the Bureau for Research and Economic Analysis of Development (BREAD).

Her research explores questions at the intersection of development and behavioral economics, with research in three areas: migration, health, and finance. Her most recent work engages refugee populations including the Rohingya in Bangladesh, examining the psychosocial value of employment in contexts of mass unemployment, the role of home in migration decision-making, and refugee preferences for repatriation, integration, and resettlement. In her work in health, which involves field experiments across South Asia, she considers the puzzle of the ubiquitously low adoption of low cost, high return goods, behaviors, and technologies in the developing world, exploring the role of learning and habit formation in behavior change. Her work in finance explores how to identify high-return microentrepreneurs using local community knowledge in India and how to increase credit access and returns to capital among refugee communities in Uganda.

Prior to joining HBS, Professor Hussam was a postdoctoral fellow at the Economic Growth Center at Yale University. She received her SB and PhD in economics from MIT.