Money for Nothing
The issue is therefore not how much the poor spend on health, but what the money is spent on, which is often expensive cures rather than cheap prevention. To make health care less expensive, many developing countries officially have a triage system to ensure that affordable (often free) basic curative services are available to the poor relatively close to their homes. The nearest center typically does not have a doctor, but the person there is trained to treat simple conditions and detect more serious ones, in which case the person is sent up to the next level. There are countries where this system is under severe strain for lack of manpower, but in many countries, like India, the facilities do exist, and the positions are filled. Even in Udaipur District, which is particularly remote and sparsely populated, a family needs to walk only a mile and a half to find a subcenter staffed with a trained nurse. Yet we have collected data that suggest that this system is not working. The poor mostly shun the free public health-care system. The average adult we interviewed in an extremely poor household saw a health-care provider once every two months. Of these visits, less than one-fourth were to a public facility.21 More than one-half were to private facilities. The remainder were to bhopas—traditional healers who primarily offer exorcism from evil spirits.
The poor in Udaipur seem to select the doubly expensive plan: cure, rather than prevention, and cure from private doctors rather than from the trained nurses and doctors the government provides for free. That might make sense if the private doctors were better qualified, but this does not seem to be the case: Just over half of the private “doctors” have a medical college degree (this includes unconventional degrees like BAMS [Bachelor of Ayurvedic Medical Science] and BUMS [Bachelor of Unani Medical Science]), and one-third have no college education whatsoever. When we look at the people who “help the doctor,” most of whom also see patients, the picture becomes even bleaker: Two—thirds have no formal qualification in medicine at all.22
In the local parlance, unqualified doctors like these are referred to as “Bengali doctors,” because one of the earliest medical colleges in India was in Bengal and doctors from Bengal fanned across northern India looking for places to practice medicine. That tradition has continued—people continue to show up in a village with little more than a stethoscope and a bag of standard medications and set up as Bengali doctors, irrespective of whether they are from Bengal or not. We interviewed one who explained how he became a doctor: “I graduated from high school and couldn’t find a job, which is when I decided to set up as a doctor.” He very graciously showed us his high school diploma. His qualifications were in geography, psychology, and Sanskrit, the ancient Indian language. Bengali doctors are not only a rural phenomenon. In the slums of Delhi, a study found that only 34 percent of the “doctors” had a formal medical degree.23
Of course, not having a degree is not necessarily synonymous with being incompetent: These doctors could very well have learned to treat easy cases and to refer the rest to a real hospital. Another of the Bengali doctors we talked to (who really was from Bengal) was very clear that he knew his limits—he gave out paracetamols (like Tylenol) and antimalarials, perhaps some antibiotics when the disease looked like it might respond to it. If it looked like a difficult case, he referred patients to the Primary Health Center (PHC) or to a private hospital.
However, this kind of self-awareness is unfortunately not universal. In urban Delhi, Jishnu Das and Jeff Hammer, two World Bank economists, set out to find out what doctors actually know.24 They started with a sample of doctors of all kinds (public and private, qualified and unqualified) and presented each of them with five health-related “vignettes.” For example, a hypothetical child patient arrives with symptoms of diarrhea: The recommended medical practice is for the doctor to first ask enough questions to figure out whether the child has been running a high fever or vomiting, and if the answer is no, so that more serious conditions are ruled out, to prescribe ORS. Another vignette involves a pregnant woman arriving with the visible symptoms of preeclampsia, a potentially fatal condition that requires immediate referral to a hospital. The doctors’ answers and the questions they chose to ask were compared to the “ideal” questions and responses to form an index of each doctor’s competence. The average competence in the sample was remarkably low. Even the very best doctors (the top twenty out of 100) asked fewer than half the questions they should have, and the worst (the bottom twenty) asked only one-sixth of those questions. Moreover, the large majority of these doctors would have recommended a course of action that, based on the assessment of an expert panel of doctors, was more likely to do harm than good. The unqualified private doctors were by far the worst, particularly those who worked in poor neighborhoods. The best were the qualified private doctors. The public doctors were somewhere in the middle.
There was also a clear pattern in the errors: Doctors tended to underdiagnose and overmedicate. In our health survey in Udaipur, we found that a patient was given a shot in 66 percent of the visits to a private facility and a drip in 12 percent of the visits. A test is performed in only 3 percent of the visits. The usual form of treatment for diarrhea, fever, or vomiting is to prescribe antibiotics or steroids, or both, usually injected.25
This is not only unnecessary in most cases, but potentially dangerous. First, there is the issue of sterilizing needles: Some friends of ours used to run a primary school in a small village on the outskirts of Delhi, where there was a doctor of unknown credentials but with a flourishing practice. Outside his dispensary was a huge drum that was always kept filled with water, with a little tap attached to it. After every patient left, the doctor would come outside and make a show of washing his needle with water from the drum. This was his way of signaling that he was being careful. We do not know whether he actually infected anyone with his syringe, but doctors in Udaipur talk about a particular doctor who infected an entire village with Hepatitis B by reusing the same unsterilized needle.
The misuse of antibiotics increases the likelihood of the emergence of drug-resistant strains of bacteria.26 This is particularly true if, as many of these doctors are wont to do to save their patients money, the advised course is shorter than the standard regimen. Across the developing world, we are seeing a rise in antibiotic resistance. Similarly, incorrect dosage and poor patient compliance explain the emergence, in several African countries, of strains of malaria parasites that are resistant to mainstream medications, which has the makings of a public health disaster. 27 In the case of steroids, the damage from overuse is even more insidious. Any researchers of age forty or older who have surveyed the poor in countries like India can recall an occasion when they were surprised to discover that someone they thought was much older than they were was in fact significantly younger. Premature aging can result from many causes, but steroid use is definitely one of them—and it is not just that affected individuals look older, they also die sooner. Yet because the immediate effect of the medicine is to make the patient feel rapidly better and she is not told what might happen later, she goes home happy.
What is going on here? Why do the poor sometimes reject inexpensive effective sanitation—the cheap and easy way to dramatically improve people’s health—in favor of spending a lot of money on things that don’t help and might actually hurt?
Are Governments to Blame?
A part of the answer is that a lot of the cheap gains are in prevention, and prevention has traditionally been the area where the government is the main player. The trouble is that governments have a way of making easy things much less easy than they should be. The high absenteeism rates and low motivation among government health providers are certainly two reasons we don’t see more preventive care being delivered.
Government health centers are often closed when they are supposed to be open. In India, the local health posts are supposed to be open six days a week, six hours a day. But in Udaipur, we visited over 100 facilities once a week at some random time during working hours for a year. We
found them closed 56 percent of the time. And in only 12 percent of the cases was this because the nurse was on duty somewhere else near the center. The rest of the time, she was simply absent. This rate of absence is similar elsewhere. In 2002–2003, the World Bank conducted a World Absenteeism Survey in Bangladesh, Ecuador, India, Indonesia, Peru, and Uganda and found that the average absentee rate of health workers (doctors and nurses) was 35 percent (it was 43 percent in India).28 In Udaipur, we found that these absences are also unpredictable, which makes it even harder for the poor to rely on these facilities. Private facilities offer the assurance that the doctor will be there. If he isn’t, he won’t get paid, whereas the absent government employee on a salary will.
Furthermore, even when government doctors and nurses are around, they do not treat their patients particularly well. Working with the same group of doctors who had responded to the vignette questions, one member of Das and Hammer’s research team sat with each provider for a whole day. For each patient, the researcher recorded details about the visit, including the number of questions the doctor asked concerning the history of the problem, the examinations performed, medicines prescribed or given, and (for the private sector) prices charged. The overall sense we get from their study about health care in India, both public and private, is frightening. Das and Hammer describe it as the 3-3-3 rule: The median interaction lasts three minutes; the provider asks three questions and occasionally performs some examinations. The patient is then provided with three medicines (providers usually dispense medicine directly rather than writing prescriptions). Referrals are rare (fewer than 7 percent of the time); patients are given instructions only about half the time and only about one-third of doctors offer any guidance regarding follow-up. As if this is not bad enough, things are much worse in the public sector than in the private sector. Public providers spend about two minutes per patient on average. They ask fewer questions, and in most cases don’t touch the patient at all. Mostly, they just ask the patient for a diagnosis and then treat the patient’s self-diagnosis. Similar findings were discovered in several countries.29
So perhaps the answer is relatively simple: People avoid the public health system because it does not work well. This could also explain why other services that are provided through the government system, like immunizations and antenatal checks for prospective mothers, are underused.
But we know that this cannot be the whole story. Bed nets are not exclusively distributed by the government; neither is Chlorin for purifying water. And even when government nurses do come to work, the number of patients demanding their services does not go up. There was a period of about six months when a collaborative effort by Seva Mandir, a local NGO, and the district authorities was effective in sharply reducing absenteeism—the probability of finding someone in the health center went up from a dismal 40 percent to over 60 percent. But that had no effect on the number of clients who came to the facilities.30
In another Seva Mandir initiative, the NGO organized monthly immunization camps in the same set of villages. This was in reaction to abysmally low immunization rates in the area: less than 5 percent of the children had been receiving the basic package of immunizations (as defined by WHO and UNICEF) before the NGO got involved. Given the very broad consensus that immunization saves lives (2 to 3 million people are estimated to die from vaccine-preventable diseases every year) and the low cost (for the villagers, it is free), this seems like something that would be a priority for every parent. The low immunization rates, it was widely held, must have been the result of the delinquency of the nurses. Mothers would just get tired of walking all the way there with a young child and not finding the nurse.
To solve this problem, in 2003, Seva Mandir decided to start its own camps, which were widely advertised, held monthly on the same date, and as our data confirm, took place with clocklike regularity. This led to some increase in the immunization rate: In the camp villages, on average 77 percent of children received at least one shot. But the problem was in completing the course. Overall, from the 6 percent in a set of control villages, full immunization rates increased to 17 percent in the camp villages. But even with high-quality, privately provided free immunization services, available right at the parents’ doorsteps, eight out of ten children remained without full immunization.
We must therefore accept the possibility that if people do not go to the public health centers, it is also in part because they are not particularly interested in receiving the services they offer, including immunizations. Why do poor people demand so much (bad) health care, but show such indifference toward these preventive services, and more generally toward all the wonderful, cheap gains that the medical profession has invented for them?
UNDERSTANDING HEALTH-SEEKING BEHAVIOR
Does Free Mean Worthless?
If people do not take advantage of cheap preventive technologies to improve their health, could it be precisely because the cheap technologies are cheap?
This is not as implausible as it might seem. Plain vanilla economic rationality dictates that the cost, once paid or “sunk,” should not have any effect on usage, but there are many who claim that as is often the case, economic rationality gets it wrong. In fact, there is a “psychological sunk cost” effect—people are more likely to make use of something they have paid a lot for. In addition, people may judge quality by price: Things may be judged to be valueless precisely because they are cheap.
All of these possibilities are important because health is one place where even free market economists have traditionally supported subsidies and, as a result, most of these cheap gains are made available at below-market prices. The logic is simple: A bed net protects not only the child who sleeps under it, but also other kids who are not getting malaria from that child. A nurse who treats diarrhea with ORS rather than antibiotics prevents the spread of drug resistance. The immunized child who avoids mumps helps protect his or her classmates as well. If making these technologies cheaper ensures that more people use them, everyone else will gain, too.
On the other hand, if people are subject to a sunk-cost effect, for example, these subsidies can backfire—usage will be low because the price is so low. In The White Man’s Burden,31 William Easterly seems to suggest that this is what is going on. He points to examples of subsidized bed nets being used as wedding veils. Others talk about toilets being used as flowerpots or, more graphically, condoms being used as balloons.
However, there are now a number of careful experiments that suggest that such anecdotes are oversold. Several studies that have tested whether people use things less because they got them for free found no evidence of such behavior. Recall Cohen and Dupas’s TAMTAM experiments, which found that people are much more likely to buy bed nets when they are very cheap or free. Do these subsidized bed nets actually get used? To figure this out, a few weeks after the initial experiment, TAMTAM sent field officers to the homes of people who had purchased nets at the various subsidized prices. They found that between 60 percent and 70 percent of women who had acquired a net were indeed using it. In another experiment, over time usage went up to about 90 percent. Furthermore, they found no difference in usage rates among those who had paid for them and those who had not. The same kinds of results, which rule out the possibility that subsidies are to blame for low usage, have now been found in other settings.
But if subsidies are not the cause, what is?
Faith?
Abhijit grew up in a family that came from two different ends of India. His mother was from Mumbai, and in her family no meal could be considered complete without the unleavened breads called chapatis and bhakris, made from wheat and millets. His father was from Bengal, where people eat rice with pretty much every meal. The two regions also have very different views about how to treat fevers. Every Maharashtrian mother knows that rice aids in a fast recovery. In Bengal, on the other hand, rice is forbidden: When a Bengali wants to say that someone has recovered from a fever, he says that “he was allowed rice toda
y.” When a puzzled six-year-old Abhijit asked his Bengali aunt about this apparent contradiction, she said that it had to do with faith.
Faith, or to use the more secular equivalents, a combination of beliefs and theories, is clearly a very important part of how we all navigate the health system. How else do we know that the medicine that we were prescribed will make the rash better and that we shouldn’t apply leeches instead? In all likelihood, none of us has observed a randomized trial where some people with, say, pneumonia were given antibiotics and others were offered leeches. Indeed, we do not even have any direct evidence that such a trial ever took place. What assures us is a belief in the way drugs get certified by the Food and Drug Administration (FDA) or its equivalent. We feel that an antibiotic would not be on the market if it had not gone through some kind of trial and, sometimes wrongly, given the financial incentives to manipulate medical trials, we trust the FDA to make sure the studies are reliable and the antibiotic is safe and effective.
The point is not at all to imply that our decision to trust doctors’ prescriptions is wrong, but rather to underscore the fact that a lot of beliefs and theories for which we have little or no direct evidence contribute to that trust. Whenever this trust erodes for some reason in rich countries, we witness backlashes against conventionally accepted best practices. Despite the continuous reassurance by high-powered medical panels that vaccines are safe, there are a number of people in the United States and the United Kingdom, for example, who refuse to immunize their children against measles because of a supposed link with autism. The number of measles cases is growing in the United States, even as it is declining everywhere else.32 Consider the circumstances of average citizens of a poor country. If people in the West, with all of the insights of the best scientists in the world at their disposal, find it hard to base their choices on hard evidence, how hard must it be for the poor, who have much less access to information? People make their choices based on what makes sense to them, but given that most of them have not had rudimentary high school biology and have no reason, as we saw, to trust the competence and professionalism of their doctors, their decision is pretty much a shot in the dark.
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