NYTimes writes about the realities in rural India, with absentism driving people to quacks:
India has a vast primary health care system to serve its billion people, with clinics for every 3,000 to 5,000. But the system is often just a skeleton. New studies have documented the startling, damaging dimensions of chronic absenteeism and not just in India.
Researchers from the Massachusetts Institute of Technology and Princeton, in a detailed survey of 100 villages here in Rajasthan, in north India, found a no-show rate of 44 percent. When combined with absences for meetings and other work-related reasons, these vital clinics were closed more than half the time.
What is starkly clear in India, home to more poor people than any other country, is that the health system is both starved for resources and desperately in need of reform.
India’s public health spending is among the lowest in the world $4 a person per year, less than 1 percent of its gross domestic product, the United Nations Development Program says. The United States spends about $2,000 a person, or almost 6 percent of gross domestic product.
But India’s experience also shows that more money alone is not the answer. India sharply increased its health spending in the 1990’s, but most went for new hiring and for pay raises to those doctors and nurses who are not showing up for work, according to a World Bank analysis.
The economists coordinating the research [in Rajasthan] Professors Abhijit Banerjee and Esther Duflo, co-founders of the Poverty Action Lab at M.I.T., and Angus Deaton at Princeton will work with 120 villages and 100 clinics.
They will add a nurse to each clinic and monitor attendance through a punch clock or dated digital photographs. They also will try chlorinating contaminated well water, fortifying flour with iron to fight anemia and paying parents to have their children immunized.
They will try each strategy in half the villages or clinics, then compare the health of people in villages that got the help with those that did not.
Because the public service is so undependable, the survey found, even the poorest turn to private doctors or traditional healers 79 percent of the time, spending 7 percent of their monthly budget on medical care. Four out of 10 private doctors surveyed had no medical degree.
Chronic absenteeism among government doctors and nurses is a hard thing to stop in widely scattered villages. The clinics have no phones, so it is impossible to check on the staff’s presence with a simple call. The local village councils are supposed to ensure attendance, but they have no authority over the medical staff, whose salaries, transfers and promotions are controlled at the district and state levels.