Quality and Accountability in Healthcare Delivery: Audit Evidence from Primary Care Providers in India

By Jishnu Das, Alaka Holla, Aakash Mohpal, and Karthik Muralidharan
27 February 2015

We present among the first direct evidence on the quality of healthcare in low-income settings using a unique and original set of audit studies, where standardized patients were presented to a nearly-representative sample of rural public and private primary care providers in the Indian state of Madhya Pradesh. We report three main findings. First, private providers are mostly unqualified but spent more time with patients, and completed more items on a checklist of essential history and examination items than public providers, while being no different in their diagnostic and treatment accuracy. Second, we identify the private practices of qualified public sector doctors, and show that the same doctors exert higher effort and are more likely to provide correct treatment in their private practices. Third, we find a strong positive correlation between provider effort and prices charged in the private sector, whereas we find no correlation between effort and wages in the public sector. Our results suggest that market-based accountability in the unregulated private sector may be providing better incentives for provider effort than administrative accountability in the public sector in this setting. While the overall quality of care is low in both the public and private sectors, these differences in provider effort may partly explain the dominant market share of fee-charging private providers even in the presence of a system of free public healthcare.