In India at least there is no obvious shortage of primary health care facilities.
A survey of health facilities in rural Rajasthan finds that infrastructure is oper-
ational. The average household is within 2 km of the nearest public facility and
qualified medical personnel are employed by the government to staff them.
Yet, the system fails to deliver good care and patients prefer the more expen-
sive private sector. In an intervention to try and address nurse absence the
Indian NGO Seva Mandir used time-clocks to monitor attendance of nurses at
small rural health clinics. The government used the attendance data with a
specific schedule of fines and penalties (introduced for this programme) to
determine the wages for any nurse. In the first six months the incentives led to
dramatic improvement in attendance (doubling by some measures). After the
first six months the local health administration deliberately undermined the
incentive system by allowing more exempt days for nurses and not sanctioning
them for absences. After sixteen months there was no difference between the
absence rates in treatment and comparison centres, both reaching around 60
per cent. These results show that nurses, like other public service providers, are
responsive to properly administered incentives. But they also show that ensur-
ing nurses come to work is a low priority for the local health administration and
incentive systems can be quickly distorted where sufficient political will is
lacking. Resources are not the main limitation and pumping in more money
without attendant reform to reduce absenteeism will not solve the underlying
problem (Banerjee et al.,2008). The root problem here was that there was no
countervailing pressure working through the political system to actually
deliver better-functioning primary health care.
Large hospitals may offer advantages not often considered by advocates of
primary health care. Peer monitoring among a larger staff often leads to better
attendance. A significant determinant of attendance is whether doctors/nurses
are able to live in a nearby town (hospitals tend to be in larger urban areas).
These results and research more generally show that doctors tend to appear for
work where they have colleagues to work with as well as equipment and
opportunities to use their skills and education. Together these factors mean that
hospitals are a plausible second-best solution in the absence of functioning
universal health insurance programmes and can potentially provide protection
for all against financially catastrophic loss (Hammer et al.,2007). Box 6.4
shows how the presence of hospitals combined with affordable forms of insur-
ance can make a big difference.
Donors
The Commission for Macroeconomics and Health (CMH) chaired by Jeffrey
Sachs in 2001 costed a range of health interventions that would by 2015
(among many other aims) raise the worldwide coverage of immunization from
70 per cent to 80–90 per cent, skilled birth attendance from 45 per cent to 90
per cent,diarrhoea treatment from 52 per cent to 80 per cent, tuberculosis treat-
ment from 44 per cent to 70 per cent, and malaria treatment from 31 per cent to
70 per cent (CMH,2001:54). The costs included the ‘full economic price of
142 Sources of Growth in the Modern World Economy since 1950