That is the title of a recent paper in the Journal of Development Economics (NBER version here, 2013 ungated version here), and although the piece does not feel dramatic at first it is one of my favorite articles of the year. It pins down some critical features of economic underdevelopment better than any study I know. The subtitle, by the way, is “The Successes and Limitations of Bureaucratic Reform in India,” the authors are Iqbal Dhaliwal and Rema Hanna, and the work is set in rural Karnataka.
It is not easy to excerpt from, so I will summarize the narrative:
1. Using biometric technology — thumbprints — to monitor absenteeism induces staff attendance for public health workers to rise by almost 15 percent.
2. That in turn leads to a reduction in low-birth weight babies.
3. Yet the government proved not so interested in monitoring attendance on a more regular basis, not even to enforce their pre-existing human resource policies. Potential penalties against late or absent doctors were not, for the most part, enforced.
4. Following the implementation of monitoring, the doctors showed the least improvement in attendance of all the workers, in fact virtually no improvement. The entire positive effect came from nurses, lab technicians, and lower level staff.
5. The government was reluctant to continue the monitoring because it feared staff attrition and staff discord, especially from the doctors. There is growing private sector demand for doctors, and many doctors are considering leaving these clinics for superior pay elsewhere, and perhaps also superior location. Therefore the doctors are given, de facto, a very lenient absence and lateness policy, in lieu of a pay hike.
6. It is already the case that many of these doctors moonlight on the side, or have separate private practices, and that spending more time at the public clinic is not their major priority.
7. It is not easy for the underfunded local government to pay these doctors more, and thus a high level of lateness and absenteeism continues. I wonder also what would be the morale costs on the non-doctors, if the monitoring were to be continued to be enforced in this differential manner over a longer period of time.