Abhijit Banerjee, Angus Deaton and Ester Duflos work* which is based on a field survey in Udaipur one of the poorest districts in Rajasthan with a high tribal population finds that there is an extensive system of healthcare delivery, but it is quite dysfunctional. Official policy provides for subcentres staffed by one nurse for every 3,600 individuals, while primary health centres serve 48,000 individuals with an average of 5.8 appointed medical personnel, including 1.5 doctors.
What they find is that 45% of personnel are absent in the subcentres while 36% are absent in PHCs on a weekly basis. Since the subcentres are staffed by only one nurse, the high rate of absenteeism implies that the facilities are often closed.
These results are similar to those found in nationally representative studies. The World Bank has, in fact, found absenteeism rates for PHC workers to be as high as 58% in the poorer states like Bihar and Assam.
Back in rural Udaipur, these infrequently open, if not shut, public facilities make the poor villagers wonder whether it is worth their while to walk the average distance of 1.4 miles to the nearest such facility. The other interesting point is that a visit to a public health facility is not a costless affair either as households spend an average of Rs 110, even though medicines and services are supposed to be free. Even those below the poverty line end up paying 40% less in public facilities than others.
It is hardly surprising, therefore, that people in rural Udaipur bypass public health facilities and use the private sector instead. But matters are no different in this regard either as private health personnel are untrained and largely unregulated. 40% of those who call themselves are doctors have no medical degrees. However, despite all these problems with health facilities, the villagers feel that a visit does make them feel better. Paradoxically, they do not perceive their health to be bad, even though it is on objective measures. Sadly, any improvement in this state of affairs is unlikely as long as the public apathy towards health persists.
*Wealth, health and health services in rural Rajasthan, forthcoming in the American Economic Review, May 2004) and Health care delivery in rural Rajasthan, Economic and Political Weekly, February 28, 2004