Jishnu Das is a Lead Economist in the Development Research Group (Human Development and Public Services Team) at the World Bank and a Visiting Fellow at the Center for Policy Research, New Delhi. Jishnu’s work focuses on the delivery of basic services, particularly health and education. He has worked on the quality of health care, mental health, information in health and education markets, child learning and test-scores and the determinants of trust. His work has been published in leading economics, health and education journals and widely covered in the media and policy forums. In 2011 he was part of the core team on the World Development Report on Gender and Development. He received the George Bereday Award from the Comparative and International Education Society and the Stockholm Challenge Award for the best ICT project in the public administration category in 2006, and the Research Academy award from the World Bank in 2013. He is currently working on long-term projects on health and education markets in India and Pakistan.
This paper presents direct evidence on the quality of health care in low-income settings using a unique and original set of audit studies, where standardized patients were presented to a nearly representative sample of rural public and private primary care providers in the Indian state of Madhya Pradesh. Three main findings are reported. First, private providers are mostly unqualified, but they spent more time with patients and completed more items on a checklist of essential history and examination items than public providers, while being no different in their diagnostic and treatment accuracy. Second, the private practices of qualified public sector doctors were identified and the same doctors exerted higher effort and were more likely to provide correct treatment in their private practices. Third, there is a strong positive correlation between provider effort and prices charged in the private sector, whereas there is no correlation between effort and wages in the public sector. The results suggest that market-based accountability in the unregulated private sector may be providing better incentives for provider effort than administrative accountability in the public sector in this setting. While the overall quality of care is low both sectors, the 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.
Even as primary-school enrollments have increased in most low-income countries, levels of learning remain low and highly unequal. Responding to greater parental demand for quality, low-cost private schools have emerged as one of the fastest growing schooling options, challenging the monopoly of state-provided education and broadening the set of educational providers. Historically, the rise of private schooling is always deeply intertwined with debates around who chooses what schooling is about and who represents the interests of children. This time is no different. But rather than first resolve the question of how child welfare is to be adjudicated, this paper argues instead for a `pragmatic framework? In this pragmatic framework, policy takes into account the full schooling environment, which includes public, private and other types of providers, and is actively concerned with first alleviating constraints that prohibit parents and schools from fulfilling their own stated objectives. Using policy actionable experiments as examples, this paper shows that the pragmatic approach can lead to better schooling for children. Alleviating constraints by providing better information, better access to finance or greater access to skilled teachers brings more children into school and increases test-scores in language and mathematics. These areas of improvement are very similar to those where there is already a broad societal consensus that improvement is required.