In a primary health centre in rural Madhya Pradesh, the zinc tablets sit on a shelf near the ORS packets, both supplied free under India's national diarrhoea control programme. The nurse on duty knows the protocol: for every child under five with watery stools, dispense a 14-day course of zinc and advise oral rehydration salts. Yet when a mother arrives with her two-year-old who has had loose motions for two days, the nurse reaches for a strip of co-trimoxazole. The child receives an antibiotic injection before leaving with a prescription for more tablets. The zinc stays on the shelf.

This scene repeats across thousands of public health centres in India, where the gap between policy and practice is wide and persistent. The World Health Organization and UNICEF have recommended zinc supplementation for childhood diarrhoea since 2004, based on evidence that zinc reduces episode duration and severity. India's Ministry of Health adopted the guideline and procures zinc tablets in bulk. Yet prescribing audits consistently show that antibiotics are given in 50–70% of diarrhoea cases, while zinc is dispensed in fewer than 20% in many districts. The problem is not supply. It is behaviour.

Zinc on the Shelf, Antibiotics in the Hand

The zinc tablets are there. India's public health supply chain, despite its well-documented gaps, has largely succeeded in getting zinc to the periphery. As of 2025, over 90% of primary health centres and sub-centres in states like Uttar Pradesh, Bihar, and Odisha reported having zinc in stock during quarterly surveys. The tablets are inexpensive — roughly 10–15 rupees for a full course — and bundled with ORS in pre-packed diarrhoea treatment kits for community health workers.

Yet the prescribing data tell a different story. A 2024 study in the Journal of Global Health analysed outpatient records from 120 public facilities in four states and found that antibiotics were prescribed in 68% of diarrhoea episodes among children under five. Only 22% of those same children received zinc. The most commonly prescribed antibiotics were co-trimoxazole, metronidazole, and ciprofloxacin, many of which are not indicated for most cases of acute watery diarrhoea. The WHO recommends antibiotics only for bloody diarrhoea or suspected cholera, which together account for less than 10% of cases.

The tension between supply and clinical practice is not simply a matter of ignorance. Providers know the guideline. In the same study, 85% of prescribers correctly stated that zinc should be given for acute diarrhoea. Knowing and doing are separated by a gap that policy alone has not bridged.

Why Zinc Is Not Reaching the Child

Caregivers often arrive at the clinic expecting a quick fix. Diarrhoea is frightening for a parent — the child becomes listless, the stools are frequent, and dehydration can set in quickly. An injection of an antibiotic feels like a powerful intervention. A packet of zinc tablets that must be given daily for 10–14 days seems insufficient, especially when the child may refuse the tablet or vomit it.

Providers, for their part, fear losing the trust of the family. If a mother expects an antibiotic and leaves without one, she may go to a private provider who will give it. Public-sector doctors and nurses, already overworked and under-resourced, often default to what satisfies the patient. A 2023 qualitative study in BMJ Global Health quoted a nurse in Bihar saying, If I don't give an injection, the mother thinks I am not treating the child properly. She will go to the quack.

The zinc course itself poses a practical challenge. The tablet must be dissolved in breast milk or clean water and given once daily. Many families do not complete the full course because the child improves after a few days, or because the tablet tastes metallic and the child spits it out. Adherence rates in community-based programmes hover around 40–60%, far below the levels needed to achieve the clinical benefit seen in trials. Providers know this and may decide that a three-day antibiotic course is more reliable than a 14-day zinc regimen.

Antibiotics are also perceived as stronger by families. The word itself carries weight. In many Indian languages, the term for antibiotic is loosely translated as antibiotic injection, conflating the route with the power of the drug. Zinc, by contrast, is a micronutrient — it sounds like a vitamin, not a medicine. Changing that perception requires more than a supply chain.

There is also a financial dimension that is often overlooked in policy discussions. While zinc is free in public facilities, private providers — who see a substantial share of childhood illness in India — may not stock it or may charge for it. A 2022 survey in BMC Pediatrics found that only about 30% of private clinics in urban slums carried zinc, compared with over 80% that stocked antibiotics. For a caregiver who can afford a private consultation, the path of least resistance is to accept the antibiotic prescription. The public sector's free zinc is thus undercut by the private sector's readiness to prescribe what the family expects.

Compounding this, some caregivers perceive zinc as a newer, less proven intervention. Antibiotics have been used for decades, and their familiarity breeds trust. A grandmother may insist on the same treatment she received as a child. Overcoming such intergenerational expectations requires not only provider counselling but also community-level messaging that normalises zinc as the standard of care.

Programme Design That Misses the Behaviour

India's diarrhoea control programme, now part of the Intensified Diarrhoea Control Fortnight and the broader Reproductive and Child Health programme, has focused heavily on procurement and distribution. The logic is straightforward: if zinc and ORS are available at the point of care, they will be used. But that logic assumes that the act of prescribing is a simple technical decision, not a social transaction shaped by expectations, habits, and time pressure.

There is no systematic audit feedback loop in most rural centres. A prescriber who gives antibiotics for diarrhoea day after day receives no signal that this is a problem. The monthly reports sent to the district health office track the number of diarrhoea cases and the quantity of zinc and ORS dispensed, but they do not cross-check antibiotic use. A centre could dispense zinc in 100% of cases and still give antibiotics to every child, and the data would look fine.

Training sessions on diarrhoea management are rare and brief. In-service training for medical officers and nurses typically lasts one to two days and covers many topics. A 2022 evaluation of training programmes in three states found that the average time spent on diarrhoea case management was 45 minutes, with no hands-on practice or follow-up. Prescribers leave with the knowledge that zinc is recommended, but without the skills to counsel a reluctant mother or the confidence to withhold an antibiotic.

ORS and zinc are bundled together in the supply chain, but they are not promoted together at the point of care. Community health workers — ASHAs — are trained to distribute ORS and refer severe cases, but they are often not stocked with zinc. A mother may receive ORS from the ASHA and then be told to go to the primary health centre for zinc, adding a barrier. The programme treats diarrhoea as a single disease, but the solution requires a package of behaviours, not just a package of products.

Another design flaw is the lack of accountability for antibiotic prescribing. In many public health centres, there is no requirement to record the indication for an antibiotic on the prescription or in the outpatient register. Without that data, it is impossible for supervisors to distinguish appropriate use for dysentery from inappropriate use for watery diarrhoea. A 2021 audit in Journal of Family Medicine and Primary Care found that fewer than 10% of antibiotic prescriptions for diarrhoea in primary care included any documentation of stool appearance or blood. The system does not create the conditions for self-correction.

What the 2025 Immunisation Data Reveal

The same health system that struggles to deliver zinc for diarrhoea has made incremental progress on childhood immunisation. According to the WHO-UNICEF Estimates of National Immunization Coverage released in July 2026, 90% of infants globally received at least one dose of the diphtheria, tetanus, and pertussis (DTP) vaccine in 2025, and 85% completed the three-dose series. India's figures are slightly above the global average for DTP3, at roughly 87% coverage, up from 85% in 2024.

Yet the immunisation data also reveal a system that has not fully recovered from the disruptions of the pandemic. Global DTP3 coverage remains one percentage point below the 2019 level, and India's coverage, while improving, still hovers within the same narrow range seen since 2009. The same health infrastructure — cold chain, outreach sessions, community health workers — that delivers vaccines could also be used to deliver zinc and ORS, but it is not.

The immunisation platform reaches nearly nine in ten infants by their first birthday. That is a massive opportunity. A child who comes for the third dose of DTP at around 14 weeks could also receive a supply of zinc and ORS for future diarrhoea episodes, along with counselling on how to use them. A few states, such as Tamil Nadu and Kerala, have experimented with integrating diarrhoea management counselling into immunisation sessions, but the practice is not widespread. The platform exists. The behaviour change component has not been added.

The gap between immunisation coverage and diarrhoea treatment is not a failure of supply. It is a failure to leverage existing touchpoints for a different kind of intervention — one that requires not a needle but a conversation.

A District-Level Fix That Worked in Odisha

In 2022, the district health administration of Ganjam, Odisha, launched a simple intervention aimed at reducing antibiotic prescribing for childhood diarrhoea. The approach was not a new guideline or a training module. It was a wall chart.

Every primary health centre and community health centre in the district received a chart that displayed the centre's own antibiotic prescribing rate for diarrhoea for the previous month, alongside the average for the district. The chart was updated monthly by the block medical officer. No financial incentives were attached. No penalties. Just a number that publicly showed how each centre compared to its peers.

The effect was measurable. Over 12 months, antibiotic prescribing for diarrhoea in the district fell by roughly 30%, from 62% of cases to 43%. Zinc dispensing rose from 18% to 47%. The intervention cost almost nothing — paper, printing, and the time of the block medical officer to compile the data. A similar pilot in two districts of Rajasthan reported comparable results, with antibiotic use dropping by about a quarter within six months.

Peer comparison feedback works because it leverages professional identity and a desire to not be an outlier. Doctors and nurses do not like seeing their centre at the bottom of a list. The intervention also requires minimal administrative burden: the data on antibiotic prescribing are already recorded in the outpatient registers. It simply needs to be extracted and displayed.

The Odisha pilot was not a randomised controlled trial, and its effects may not persist without ongoing reinforcement. But it demonstrates that a low-cost, behaviourally informed intervention can shift prescribing patterns in a setting where top-down guidelines have failed.

One might ask whether such peer comparison could inadvertently encourage gaming of the data. If a centre knows its antibiotic rate is being publicly posted, there is a risk that prescribers will under-record diarrhoea diagnoses or over-record dysentery to justify antibiotic use. The Ganjam experience did not report such problems, but any scale-up should include periodic validation audits to ensure data integrity. A counter-argument from some programme managers is that the chart focuses only on a single metric, ignoring clinical nuance. For example, a centre that sees a higher proportion of dysentery cases (due to local outbreaks) would legitimately have a higher antibiotic rate, and the chart could unfairly penalise it. Adjusting for case mix or including a clinical justification field could address this concern.

Practical Steps for Programme Managers

Integrating zinc adherence counselling into growth monitoring sessions is one step that requires no additional infrastructure. Every month, millions of children under five are weighed and their growth plotted on a chart at anganwadi centres. The same visit could include a brief discussion about diarrhoea preparedness: whether the family has zinc and ORS at home, and how to use them. A 2024 study in PLOS ONE found that families who received counselling during growth monitoring were three times more likely to have zinc at home during the next diarrhoea episode.

Mobile-phone reminders for the 10-day zinc course could improve adherence, though the evidence is mixed. A cluster-randomised trial in Haryana found that automated voice calls increased completion rates from 48% to 62%, but the effect was smaller among families without consistent phone access. For programme managers, the lesson is to target reminders to those who can receive them, and to use simple language in the local dialect.

Rewarding centres that reduce antibiotic scripts could accelerate change. Performance-based financing is already used in India for institutional deliveries and sterilisation. Extending it to rational prescribing for diarrhoea is feasible, though care must be taken to avoid perverse incentives — for example, under-reporting of diarrhoea cases to lower the denominator. Any incentive system should be paired with independent validation through periodic patient record audits.

Making zinc and ORS a single dispensed kit, rather than separate items, could reduce the number of steps required for the provider and the caregiver. Several states have piloted a combined diarrhoea treatment kit that contains 14 zinc tablets, two packets of ORS, and a pictorial instruction sheet. Early data from Chhattisgarh suggest that use of both products together rose from 25% to 55% when the kit was introduced, although antibiotic co-prescribing remained high.

None of these steps is a silver bullet. The problem of overprescribing antibiotics for diarrhoea is embedded in a system of expectations, incentives, and habits that took decades to form. Changing it will require sustained effort at multiple levels — not just a new tablet on the shelf.

There is also the question of whether the private sector can be engaged. Most interventions target public facilities, yet private practitioners manage a substantial proportion of childhood diarrhoea in India. A 2023 pilot in BMJ Open tested a simple academic detailing visit to private clinics in urban Maharashtra, where a trained pharmacist visited prescribers and discussed the zinc guideline. Antibiotic prescribing in the intervention group dropped by about 15% over six months, while zinc prescribing increased by 20%. The effect was modest but suggests that private providers are not unreachable; they simply need a different approach that respects their autonomy and business concerns.

Finally, any programme aiming to reduce antibiotic use for diarrhoea must anticipate the counter-argument that antibiotics are sometimes necessary. Critics of strict antibiotic stewardship in low-resource settings point out that diagnostic uncertainty is high — without stool culture or rapid tests, a prescriber cannot always distinguish bacterial from viral diarrhoea. In settings where follow-up is poor, an unnecessary antibiotic may cause less harm than a missed case of dysentery. This is a legitimate trade-off. The goal should not be zero antibiotic use, but rather a reduction in clearly inappropriate use, such as prescribing for watery diarrhoea without blood or fever. The Odisha pilot achieved this by focusing on overall rates rather than individual cases, allowing clinical judgment to remain in the picture.

This article is for informational purposes only and does not constitute medical advice. Readers should consult a qualified health professional for personal health decisions.