Quality and Accountability in Healthcare Delivery: Audit-Study Evidence from Primary Care in India

Jishnu Das, Alaka Holla, Aakash Mohpal, Karthik Muralidharan

NBER Working Paper No. 21405
Issued in July 2015
NBER Program(s):Development Economics, Health Care, Health Economics, Labor Studies, Public Economics

We present the first direct evidence on the relative quality of public and private healthcare in a low-income setting, using a unique set of audit studies. We sent standardized (fake) patients to rural primary care providers in the Indian state of Madhya Pradesh, and recorded the quality of care provided and prices charged in each interaction. We report three main findings. First, most private providers lacked formal medical training, but they spent more time with patients and completed more essential checklist items than public providers, and were equally likely to provide a correct treatment. Second, we compare the performance of qualified public doctors across their public and private practices, and find that the same doctors exerted higher effort and were more likely to provide a correct treatment in their private practices. Third, in the private sector, we find that prices charged are positively correlated with provider effort and correct treatment, but also with unnecessary treatments. In the public sector, we find no correlation between provider salaries and any measure of quality. We develop a simple theoretical framework to interpret our results and show that in settings with low levels of effort in the public sector, the benefits of higher diagnostic effort in the private sector may outweigh the costs of market incentives to over treat. These differences in provider effort may partly explain the dominant market share of fee-charging private providers even in the presence of a system of free public healthcare.

download in pdf format
   (1311 K)

email paper

Machine-readable bibliographic record - MARC, RIS, BibTeX

Document Object Identifier (DOI): 10.3386/w21405

Published: Jishnu Das & Alaka Holla & Aakash Mohpal & Karthik Muralidharan, 2016. "Quality and Accountability in Health Care Delivery: Audit-Study Evidence from Primary Care in India," American Economic Review, American Economic Association, vol. 106(12), pages 3765-3799, December. citation courtesy of

Users who downloaded this paper also downloaded* these:
Baird, Hicks, Kremer, and Miguel w21428 Worms at Work: Long-run Impacts of a Child Health Investment
Bloom, Kuhn, and Prettner w21411 The Contribution of Female Health to Economic Development
Barnhardt, Field, and Pande w21419 Moving to Opportunity or Isolation? Network Effects of a Randomized Housing Lottery in Urban India
Dhar, Jain, and Jayachandran w21429 Intergenerational Transmission of Gender Attitudes: Evidence from India
Ash, Morelli, and Van Weelden w21422 Elections and Divisiveness: Theory and Evidence
NBER Videos

National Bureau of Economic Research, 1050 Massachusetts Ave., Cambridge, MA 02138; 617-868-3900; email:

Contact Us