Indians love to boast about the quality of Indian doctors. “The best in the world! And now India is becoming a center for world class health care, even Americans are flying to India now!” But just between us brown folks, we also know the other side of the story. Many of the best doctors leave the country, and if they come back, they come back only to some high end establishment. The quality of the average doctor in India is … well … rather hit or miss.

As a matter of public policy, what should be done? A study of doctors in Delhi finds that increased training helps, but even then the quality of health care remains sensitive to the right incentives:

The quality of medical care received by patients varies for two reasons: Differences in doctors’ competence or differences in doctors’ incentives.  We find three patterns in the data.

First, what doctors do is less than what they know they should do-doctors operate well inside their knowledge frontier.

Second, competence and effort are complementary so that doctors who know more also do more.

Third, the gap between what doctors do and what they know responds to incentives: Doctors in the fee-for-service private sector are closer in practice to their knowledge frontier than those in the fixed-salary public sector. Under-qualified private sector doctors, even though they know less, provide better care on average than their better-qualified counterparts in the public sector. These results indicate that to improve medical services, at least for poor people, there should be greater emphasis on changing the incentives of public providers rather than increasing provider competence through training. [cite]

Although doctors love to tell you that they work out of a sense of seva, and that the quality of care has little to do with the fee structure, it simply isn’t true. Surprising as it seems, the researchers find that you’re better off with a less trained private doctor than a better trained public doctor. Why? Because the private doctors try harder. The difference in quality was significant:

Public sector doctors did less than a third of what they knew to be important in terms of diagnosis, taking about fifteen percent of the time required to fully diagnose complaints. Over-prescribing and mis-prescribing were also rampant. [cite]

It’s still not clear to me how you channel these better doctors to the poor. The best tactic would be to give poor people vouchers, but that gets tricky. If you subsidize the private doctors directly, will they still provide good service? Does health insurance decrease the quality of coverage? Given the relative shortage of doctors in India, how do you provide higher quality private health care to the indigent?

Disclaimer: One of the researchers, Jishnu Das, is a friend of mine, although he might not recognize me by the handle I use while blogging.

Hat Tip: via PSDBlog