The last mile challenge with public service delivery

The latest edition of IMF's Finance and Development monthly has an article by Jorge Coarasa, Jishnu Das, and Jeff Hammer which urges caution against expansion of public health care and advocates focussing on improving existing systems, public and private. This assumes great significance in view of private, formal and the less-than-fully-qualified informal, care providers forming the majority of point of contact in developing countries.

In particular, it points to recent studies involving vignettes and survey which highlight the quality problem - less time spent with patients, non-adherence to treatment protocols, wrong treatment prescriptions, over-treatment etc - being faced by health care systems in developing countries. They write,

Consultation time varies from as little as 1.5 minutes (public sector, urban India) to 8 minutes (private sector, urban Kenya). Providers ask on average between three and five questions and perform between one and three routine examinations, such as checking temperature, pulse, and blood pressure. In rural and urban India, important conditions are treated correctly less than 40 percent of the time; when patients receive a diagnosis, it is correct less than 15 percent of the time. Unnecessary and even harmful treatments are widely used by all providers and in all sectors, and potentially lifesaving treatments, such as oral rehydration therapy in children with diarrhea, are used in less than a third of interactions with highly qualified providers. Less than 5 percent of patients receive only the correct treatment when they visit a provider... Public doctors in primary health clinics prescribed antibiotics for diarrhea 75.9 percent of the time, spending 1.5 minutes to reach a treatment decision.­

However, while the quality of care is poor in both private and public sectors, it is far less inferior in the former. Interestingly, they also find that "patient-centered interactions and treatment accuracy were highest in private sector clinics with public doctors", underlining the higher median quality of doctors in public systems.

 

All this highlights the challenge associated with achievement of desired outcomes in sectors where the quality of human interface is the critical determinant. Like with poor quality of learning outcomes in school education, this is an example of the frustrating last-mile deficiencies with some public service delivery challenges that are not amenable to readily available, off-the-shelf solutions.

Such activities, what Lant Prtichett has described as "thick" activities, are more transactional, requiring continuous engagement by human agents, and difficult to script into monitorable actions which can be supervised with information. They stand in contrast to "thin" activities that are informational and involve some form of logistics which can be readily monitored using information.

This assumes great significance as the government in India grapples with the scaling up of transactional activities like Clean India, Skill India, Open-defecation Free India, and so on.