who are supposed to act on well-intentioned advice may be
as much a part of the problem, and the many attempts to
rectify these inefficiencies may backfire precisely because
those in charge are not grappling with the institutional
causes of the poverty in the first place.
These problems are illustrated by intervention
engineered by the nongovernmental organization (NGO)
Seva Mandir to improve health care delivery in the state of
Rajasthan in India. The story of health care delivery in India
is one of deep-rooted inefficiency and failure. Government-
provided health care is, at least in theory, widely available
and cheap, and the personnel are generally qualified. But
even the poorest Indians do not use government health
care facilities, opting instead for the much more expensive,
unregulated, and sometimes even deficient private
providers. This is not because of some type of irrationality:
people are unable to get any care from government
facilities, which are plagued by absenteeism. If an Indian
visited his government-run facility, not only would there be
no nurses there, but he would probably not even be able to
get in the building, because health care facilities are closed
most of the time.
In 2006 Seva Mandir, together with a group of
economists, designed an incentive scheme to encourage
nurses to turn up for work in the Udaipur district of
Rajasthan. The idea was simple: Seva Mandir introduced
time clocks that would stamp the date and time when
nurses were in the facility. Nurses were supposed to stamp
their time cards three times a day, to ensure that they
arrived on time, stayed around, and left on time. If such a
scheme worked, and increased the quality and quantity of
health care provision, it would be a strong illustration of the
theory that there were easy solutions to key problems in
development.
In the event, the intervention revealed something very
different. Shortly after the program was implemented, there
was a sharp increase in nurse attendance. But this was
very short lived. In a little more than a year, the local health
administration of the district deliberately undermined the
incentive scheme introduced by Seva Mandir.
Absenteeism was back to its usual level, yet there was a
sharp increase in “exempt days,” which meant that nurses