Understanding the Puzzle of Primary Health-care Use: Evidence from India Pramod Kumar Sur Asian Growth Research Institute (AGI) and Osaka University
[email protected] Abstract In India, households’ use of primary health-care services presents a puzzle. Even though most private health-care providers have no formal medical qualifications, a significant fraction of households use fee-charging private health-care services, which are not covered by insurance. Although the absence of public health-care providers could partially explain the high use of the private sector, this cannot be the only explanation. The private share of health-care use is even higher in markets where qualified doctors offer free care through public clinics; despite this free service, the majority of health-care visits are made to providers with no formal medical qualifications. This paper examines the reasons for the existence of this puzzle in India. Combining contemporary household-level data with archival records, I examine the aggressive family planning program implemented during the emergency rule in the 1970s and explore whether the coercion, disinformation, and carelessness involved in implementing the program could partly explain the puzzle. Exploiting the timing of the emergency rule, state-level variation in the number of sterilizations, and an instrumental variable approach, I show that the states heavily affected by the sterilization policy have a lower level of public health-care usage today. I demonstrate the mechanism for this practice by showing that the states heavily affected by forced sterilizations have a lower level of confidence in government hospitals and doctors and a higher level of confidence in private hospitals and doctors in providing good treatment.