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Research Program in Development Studies

Deserted by Doctors, India's Poor Turn to Quacks

New York Times

HOMATAWARA, India - The sturdy little public clinic in this poor, sickly village was locked up one recent afternoon, but that is nothing remarkable. Rampant absenteeism among government doctors and nurses is an open secret across India and much of the developing world, and they virtually never get in trouble for not showing up.

"Sometimes the nurse is here, sometime she's not," said Nagji Lal Pandore, a skinny old man in a saffron turban. "Sometimes she has medicines, sometimes she doesn't. Why take a chance?"

So, like many people here, his family has turned to amateur private "doctors" who have regular hours and plentiful medications to sell.

His daughter-in-law Shanti Bai, 30, went to such a doctor for a fever six months ago. He gave her an injection. The next day, she was dead and her children motherless.

Villagers blamed the doctor and he fled, but the heartache remains. Mr. Pandore and his wife have broken the news to their 5-year-old grandson, but they are still telling their 3-year-old granddaughter that her mother is away on a trip. "She cries and cries and asks, `Where is my mother?' " he said.

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 for the World Bank discovered through large national surveys that medical personnel were absent from their public posts 35 to 40 percent of the time in India, Bangladesh, Indonesia and Uganda, and about a quarter of the time in Peru.

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.

As the United Nations leads a global effort to prevent millions of deaths from AIDS, tuberculosis, malaria and a range of childhood illnesses, the fissures in public health systems are emerging as a main obstacle.

There is an increasingly heated debate among experts about whether multibillion-dollar infusions of foreign aid or politically sensitive domestic reforms are more central to repairing public health systems.

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.

Here in the villages outside Udaipur, one of India's loveliest tourist destinations, rough-hewn clinics for the rural poor generally have no phones, no vehicles, no running water. Most have no electricity. On a recent day, they lacked syrup-based medicines to treat young children for fevers, vomiting, coughs and respiratory infections. Some nurses said they had run out of the basic pills provided by the government.

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 dramatic progress in reducing infant mortality in the 1980's slowed in the 1990's, while mortality for children under 5 did not improve at all.

The economists coordinating the research here — 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.

What is here now is not working very well. The survey and accompanying blood tests of villagers found that most people were scrawny and weakened by anemia. Three out of 10 said they had trouble mustering the strength to walk a couple of miles or draw water from a well.

But when asked to rate their health on a scale of 1 to 10, most placed themselves in the middle.

"Their health is awful and their health care even worse," said Professor Deaton, an expert on Indian poverty. "They know they're really poor, but they don't know they're really sick. One of the things that drives some of us to despair is that this isn't a political issue among them."

In Bhomatawara, where the young mother, Shanti Bai, died, villagers say the government nurse is often not at the clinic. On three visits to the village, she was never there.

So when Ms. Bai developed a fever, her family turned to the amateur doctor. He gave her a shot and used the same syringe to give her brother-in-law an injection, her husband said. She developed an infection at the site of the injection.

The next day she died. The doctor paid the family $930 before he left town. A post-mortem found the underlying cause of her death was severe anemia.

The government nurse, Tulsi Meghwal, was located at her home in a town about 12 miles away. She said she had given Ms. Bai iron pills a couple of times, but declined to go to the clinic and show the notations in the register.

The only medical training the amateur doctor had was what he had picked up doing menial work for a real doctor, Ms. Meghwal said.

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.

No one around here could remember any doctor or nurse ever being disciplined for failing to go to work.

At the same time, there are powerful forces pulling the medical staff away from the small, backward villages where they are assigned to work. Their desire to see their own children well educated is the strongest. Doctors and nurses interviewed in half a dozen villages sent their children to the city for school. Some commuted from the city; others sent their families to live there.

"When government doctors are posted here, they want out as quickly as possible," said Dr. Mahindra Parmar, who serves in Chhani village and has two sons, 3 and 4. "Everyone wants to live in the city. I'd like a transfer to Udaipur. If not, I'll have to move my children there. I'm an educated person. What opportunity is there for my children here? If you allow them to mix with local children, they begin to use the local bad words."

The failings of both public and private health care were on display in Dabaycha. The clinic's metal doors were bolted and padlocked one recent afternoon. Some villagers said they did not even know a government nurse was assigned to the village.

"Sometimes she's here, sometimes she's not," said Jivi Mohan, a mother of four who was smoothing a mixture of dung and mud on the walls of her home. "Laxman is always there."

Laxman Damor, 49, is the most popular "doctor" in the village, though he never got past the seventh grade. The way to his house lies through wheat and lentil fields and past grazing cows.

"By and large, whoever comes to me, I give them an injection," he said. "Often, tablets are better, but they want injections. If I don't give them one, they'll go to someone else. I'll lose my customer."

He is also liberal with the intravenous glucose drip, which gives a person sapped by anemia a temporary sugar surge. He charges more than $2 for a drip, in an area where people spend on average $10 a month per person for total household expenses.

A young laborer, Babu Lal, walked into Mr. Damor's courtyard, complaining of a chest cold. He had hiked several miles. Mr. Damor immediately put him on the examining table. In no time, the needle was out and Mr. Damor stuck him in the hip with an antibiotic.

That same afternoon, the public health nurse, Kesara Ahari, returned to the village, saying she had been working in the fields. But she did not unlock the clinic. She said she always works out of her home.

She acknowledged she has trouble competing with Mr. Damor. He has medicines that she does not. She does not give the injections and intravenous drips that people want.

She brought out the empty tins that should have held her stock of medicines. She was even out of oral rehydration salts, which can cheaply prevent dehydration from diarrhea, a leading killer of children in developing countries. Many of those who come to her for care wind up going to Mr. Damor to buy the pills they need.

Her register showed entries only intermittently, sometimes with gaps of almost a week.

"I don't have medicines, so what do I give them?" she asked, shrugging. "What is the point of filling the register?"

Copyright © 2004 by The New York Times Co. Reprinted with permission.