Doctor Absenteeism and Low Quality of Care in India: Analyzing Incentive Structures, Intervention Options, and Keys to Future Success in Public Healthcare Facilities

Abstract

Though India has made remarkable progress in the sphere of public healthcare in recent decades, it is still faced with many challenges in healthcare service delivery. Currently, most researchers and policymakers in India argue for an even greater focus on primary care. This paper questions this approach and argues that the current system—crippled by severe market and government failures—is flawed and failing the poor. Government doctors have no incentive to show up— demonstrated by the high rate of absenteeism—and work to the best of their ability—demonstrated by the low effort exerted by public doctors—and provide high quality of care—demonstrated by the poor heath care outcomes in India. As such, based on both empirical and theoretical evidence—including evidence from semi-formal interviews conducted in Delhi in December 2015—I present the effects and determinants of the current incentive framework of healthcare providers in India, with a focus towards public hospitals. This thesis demonstrates that understanding the underlying incentive structure that prompts the behavior of healthcare providers is central to improving healthcare in the coming years. Furthermore, the goal of this thesis is to provide policymakers with the knowledge to understand and address the currently inefficient incentive structure, and ultimately provide both options and minimal requirements to improve these structures. Therefore, the paper assesses the different levers—such as technology, different payment structures, non-financial incentives, and dual practice policies—to influence motivations of providers and change the current incentive framework. Additionally, the paper makes a case for three prerequisites that should be the foundation for any future proposals to reform the Indian public healthcare system: enforcement of human resource guidelines, increased patient and community input, and better data management. Ultimately, it is essential that more research is conducted to analyze the current incentive framework for public healthcare providers and the institutional factors that can be reformed to demand better provider behavior, higher quality of care, and eventually better outcomes for patients.