A competition that paid Bangladeshi public hospitals to cut antibiotic prescriptions has delivered a striking result — and an unsettling one. Across 48 hospitals, prescriptions for uncomplicated fever fell by 31% over four months, while a review of 12 participating clinics found that the share of patients returning within seven days rose from 9% to 17%.
The Clear Fever Challenge, organised by the Dhaka-based charity CareMeasure Bangladesh, began on 1 June. Its Tk8 million prize pool (about €56,000) is due to go to six hospitals, scored chiefly on reductions in antibiotic use. The results were presented on Wednesday; organisers say the contest was designed to make doctors think twice before prescribing drugs that do not treat viral infections.
A scoreboard with a blind spot
Dorcas Heller, an epidemiologist who reviewed 12,400 outpatient visits at the clinics, said the rise in return visits was not proof that patients were harmed by the contest. The figures compare this year’s four-month period with the same months in 2025, and do not account for changes in fever cases or patient mix. But she said the pattern deserved urgent scrutiny because the contest did not score follow-up care.
“A prescription count is not a patient outcome, and the scoreboard treated it as if it were,” Heller said. Clinics did not have to report whether returning patients were later diagnosed with bacterial infections, admitted to hospital or simply given more time to recover. That gap leaves doctors and public-health officials unable to tell whether fewer prescriptions meant better judgement or missed treatment.
A prescription count is not a patient outcome, and the scoreboard treated it as if it were.
Dorcas Heller, epidemiologist
Ewa Wegener, a physician who helped design the contest, said the fall in prescriptions was welcome because antibiotics cannot clear dengue or other viral fevers. Yet she warned that Bangladesh’s busy outpatient services often have limited time for reassessment, and that fever can have several causes. “The safe decision is not always ‘no antibiotic’; it is a careful examination, clear advice and a way back to care,” she said.
Clinics face a harder test
CareMeasure programme director Kim Driessen said the prize money was intended to help hospitals improve laboratory access and patient follow-up, not to push doctors into withholding necessary treatment. The charity will hold back the awards until a clinical panel reviews the return-visit data, Driessen said. It will also add a measure of follow-up care to any future contest, though no date has been set.
That change may come too late to settle what happened during this round. Heller said clinics should now check a sample of returning patients’ records and contact those still needing care, while making sure no one is told to avoid antibiotics when a clinician judges them necessary. The contest has shown that a cash prize can shift prescribing quickly; its next test is whether hospitals can prove patients are better off.
