India faces the paradox of overtreatment and undertreatment at the same time. Examine the drivers of this dual burden and suggest health-system reforms.

Overtreatment means tests, drugs and procedures that give the patient no net benefit. It often begins with an incidental finding that leads to more tests and sometimes to a lifelong prescription. In India this sits alongside undertreatment, where many people still lack basic primary care. Both problems come from the same health-system failures, not from patient behaviour alone.

Drivers of overtreatment

• Supplier-induced demand: Delhi's AMR plan names economic incentives from pharmaceutical companies as a driver of irrational prescribing [2].
• Weak penalties for companies: the UCPMP 2024 bars gifts, cash and travel for doctors, but its penalties are mainly reprimands and recovery of the benefit [3].
• Price distortion: gemifloxacin, a reserve antibiotic, is priced below first-line drugs, which encourages its misuse [2].
• Defensive and hurried practice: heavy OPD load, diagnostic uncertainty, perceived patient demand and fear of losing patients all push doctors to prescribe [2].
• Health-check packages sold as "more tests = better value" lead to false positives, anxiety and overdiagnosis.

Drivers of undertreatment

• Thin primary care and regulation: rural areas have few trained pharmacists, so OTC antibiotics take the place of proper consultation [1].
• Spotty enforcement of controls on OTC and invalid-prescription antibiotic sales [1].
• Resource diversion: out-of-pocket money spent on unneeded tests and drugs is not spent on needed care. Misused antibiotics also feed AMR, so effective treatment is lost for those who need it later [1].

Health-system reforms

• Centre: give the marketing code legal backing, with financial penalties for companies as well as discipline for doctors [3].
• NPPA: price drugs by class so that reserve antibiotics never cost less than first-line ones [2].
• States: copy Delhi's SAP-CARD model of mapping local drivers [2], and post pharmacists in rural areas [1].
• Medical regulators: require CME on rational prescribing, and increase primary-care staff so each doctor has fewer patients [2].
• Standard treatment guidelines and risk-based screening norms for diagnostic packages.
• Measure the problem: India has no national data on how much overtreatment occurs. Audits of prescriptions and procedures should be built into Ayushman Arogya Mandirs.

Overtreatment and undertreatment share the same roots: misaligned incentives, weak regulation and overstretched primary care. The aim should be appropriate care, meaning the right test and drug for the right patient, rather than simply "less care". This advances Article 47's duty to improve public health and SDG 3.8 on universal health coverage.