Deal with the Devil: The Successes and Limitations of Bureaucratic Reform in India
Employing a technological solution to monitor the attendance of public-sector health care workers in India resulted in a 15 percent increase in the attendance of the medical staff. Health outcomes improved, with a 16 percent increase in the delivery of infants by a doctor and a 26 percent reduction in the likelihood of infants born under 2500 grams. However, women in treatment areas substituted away from the newly monitored health centers towards delivery in the (unmonitored) larger public hospitals and private hospitals. Several explanations may help explain this shift: better triage by the more present health care staff; increased patients' perception of absenteeism in the treatment health centers; and the ability of staff in treatment areas to gain additional rents by moving women to their private practices and by siphoning off the state-sponsored entitlements that women would normally receive at the health center at the time of delivery. Despite initiating the reform on their own, there was a low demand among all levels of government-state officials, local level bureaucrats, and locally-elected bodies--to use the better quality attendance data to enforce the government's human resource policies due to a fear of generating discord among the staff. These fears were not entirely unfounded: staff at the treatment health centers expressed greater dissatisfaction at their jobs and it was also harder to hire new nurses, lab technicians and pharmacists at the treatment health centers after the intervention. Thus, this illustrates the implicit deal that governments make on non-monetary dimensions--truancy, allowance of private practices--to retain staff at rural outposts in the face of limited budgets and staff shortages.
This project was a collaboration involving many people. We gratefully acknowledge our research managers Manaswini Rao and KB Prathap for their outstanding overseeing of the field research work. We also thank Kanika Dua, Manisha Pandita, Gowramma, Srini Vasudevan and Priyanka Kanth for their excellent work coordinating the field surveyors. We thank Jonathan Holmes, Susanna Berkouwer, and Claire Walsh for outstanding research assistance. We thank the National Rural Health Mission of the State of Karnataka (particularly its director, Selva Kumar) for their cooperation implementing this project. We thank Rohini Pande and Asim Khwaja for helpful comments on the study. This project was generously funded by grants from the Abdul Latif Jameel Poverty Action Lab at MIT (JPAL) and the United States AID's Development Innovation Ventures (DIV). All views expressed are those of the authors and do not necessarily reflect the views of the Government of Karnataka, NRHM, USAID or JPAL. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.
Disclosure Statement: Rema Hanna
• For financial support, we thank the Abdul Latif Jameel Poverty Action Lab at MIT (JPAL) and the United States AID’s Development Innovation Ventures (DIV).
• The Government of Karnataka state in India (the implementing field partner on this project) was provided with a copy of the paper, but there was no right to review the paper before it was circulated and had no right to make any changes to the paper.
• Dr. Hanna is on the board of J-PAL and a Scientific Director of the JPAL-South East Asia Office. J-PAL has no stake in the outcomes of any given evaluation results and no stake in improving delivery of health services in Karnataka; however, J-PAL does have a position on what is considered a rigorous evaluation methodology.
• IRB Approval was received from Harvard University
Iqbal Dhaliwal, Rema Hanna, The devil is in the details: The successes and limitations of bureaucratic reform in India, Journal of Development Economics, Volume 124, 2017, Pages 1-21, ISSN 0304-3878, https://doi.org/10.1016/j.jdeveco.2016.08.008.