People with lower income and less education get sick more often, have worse access to care, and don’t live as long. This is one of the most consistent findings in health research across the world.

But do doctors themselves amplify these inequalities?

As health economists interested in the behaviour of healthcare providers, we sought to explore an understudied driver of health inequalities in Tunisia: whether doctors treat patients from different socioeconomic backgrounds differently during a clinical encounter.

We chose Tunisia because it’s a middle-income country where socioeconomic and health inequalities are growing. Until recently, there has been little robust evidence on discrimination by health providers in low- and middle-income countries, where health inequalities are often wider and health systems more strained than in wealthier countries.

We designed an audit experiment in the country, by sending standardised patients (fieldworkers trained to act as covert patients) with identical symptoms to public and private primary care doctors.

We varied the attitude and appearance of the patients so that they appeared to be “poor” or “middle-class”. The patients’ profiles were developed through earlier qualitative research to reflect how doctors commonly perceive socioeconomic differences. Because the medical problem was identical in every visit, any difference in how doctors behaved could be traced to how they perceived the patient’s socioeconomic background.

We found no evidence that doctors managed patients differently. Diagnosis and treatment decisions were similar across social profiles. But our research revealed a more subtle form of inequality: while poorer patients received similar medical treatment to wealthier patients, they were less likely to:

• have their illness explained and be given reasons for the treatment offered
• get correct medical advice about future recommendations.

We concluded that, by communicating less effectively with poorer patients, doctors might be indirectly contributing to health inequalities.

Health inequalities don’t stop at the clinic door

Research from high-income settings has shown that doctors’ judgments can sometimes be influenced (often unconsciously) by a patient’s social background. This affects how much time doctors spend explaining a diagnosis, how seriously they take concerns, and how clearly they communicate next steps.

To explore this question, we carried out a field experiment with 130 primary care doctors in Tunisia. Two standardised patients visited each doctor. They all followed the same carefully crafted script and presented with the same medical problem: symptoms of acute bronchitis, a common condition that usually does not require antibiotics.

The only difference was how the patient actors presented themselves socially.

Some patients looked and came across poorer, using hesitant speech and wearing inexpensive clothing. Others appeared middle class, with more confident communication and smarter clothes.

What we found

The results were mixed and revealing.

First, there was no evidence that doctors provided worse medical treatment to poorer patients. Diagnosis and treatment decisions were similar across social profiles. This is reassuring, and suggests that doctors were not deliberately giving inferior care to patients they perceived as poorer.

However, overall quality of care was low for everyone. Only about one in three patients was managed according to best practice. More than 90% received unnecessary treatments, most often antibiotics or steroids.

Second, poorer patients were less likely to be asked to pay for their medicines. Doctors often gave them free samples, usually provided by pharmaceutical companies. While this may appear generous, most of these medicines were unnecessary. Free drugs do not improve health if they should not have been prescribed in the first place.

The most striking difference appeared elsewhere.

The hidden inequality: communication

Poorer patients were less likely to receive a clear explanation of what was wrong with them. They were given less information on why a medication was prescribed. They were less likely to be advised on what to do if symptoms worsened or when to return for follow-up care. These gaps were more pronounced in private clinics. It may be that the doctors there tailor their communication to patients with a higher ability to pay, who are more likely to return.

It is only through carefully designed research that these inequalities in communication can be captured. This form of inequality is “hidden” because it is less visible than differences in diagnosis or treatment: it rarely appears in medical records, when such records exist, and has been far less documented than other inequalities in healthcare.

Good communication is not simply a courtesy; it is an important part of care. Understanding an illness helps patients follow treatment, avoid unnecessary worry, and know when to seek help. When explanations are missing, patients are left to guess, misunderstand, or delay care.

Over time, these small differences can accumulate. Patients who consistently leave consultations with less information may struggle to manage their health, even if the initial medical decision was correct.

Why these findings matter

Our study does not suggest that doctors in Tunisia are intentionally discriminating against poorer patients in their clinical decisions. But differences in the quality of communication and advice can still reinforce inequality.

A prescription without explanation is not the same as care that empowers patients to understand and manage their condition.

The findings also highlight the urgency of addressing inappropriate prescribing. The widespread use of unnecessary antibiotics seen in this study mirrors patterns observed in countries such as India, China, and South Africa.
This contributes to drug resistance, higher costs and avoidable side effects: problems that affect everyone, but often hit poorer populations hardest.

Moving forward

As Tunisia reforms medical education and health system practices, there is a clear opportunity to place patient communication at the centre of care. However, the implications extend beyond Tunisia. Across much of Africa, health systems operate under huge capacity constraints, with short consultations, varied workloads, and deep social divides. These conditions can shape clinical encounters and widen communication gaps.

Strengthening doctors’ ability to explain, listen and adapt to patients from different social backgrounds could help reduce these hidden inequalities. Encouraging clearer explanations, better guidance on follow-up, and greater awareness of unconscious bias are relatively low-cost changes with potentially high returns. Continuity of care, where patients regularly see the same doctor, may further reduce reliance on quick social judgments in clinical decision-making.

This article is based on the PhD research of Dr Rym Ghouma. She led the conceptualisation of the study, the fieldwork, the analysis of the data and the writing of the academic paper. She is currently a health economics consultant for the OECD Health Directorate.