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Quality of Primary Care in Low-Income Countries: Facts and Economics


  • Jishnu Das

    () (World Bank, Washington, DC 20433
    Centre for Policy Research, New Delhi 110021, India)

  • Jeffrey Hammer

    () (Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, New Jersey 08544)


New research on the quality of care in public and private primary care facilities has significantly enriched our understanding of how health care is delivered in low- and middle-income countries. First, this article summarizes recent advances in the measurement of quality, distinguishing between measurements of provider knowledge and provider effort. Second, it looks at the determinants of practice quality variation in low-income settings, highlighting the limited role of structural constraints such as infrastructure, the supply of materials including drugs, and provider training—the mainstay of much of global health policy today. In contrast, practice quality variation is clearly linked to provider effort, an aspect of provider behavior that can be altered through a variety of means. Third, it provides a broad economic framework to interpret the findings. We look for evidence of specific market failures in the provision of primary care and emphasize that the key difficulty is (and always was) the transaction-specific nature of medical advice. Providers can do too much or too little (or both), and the extent of either depends on the specific patient and the specific disease. We document specific ways in which it is difficult for both consumers and governments to monitor every transaction to detect potentially errant behavior.

Suggested Citation

  • Jishnu Das & Jeffrey Hammer, 2014. "Quality of Primary Care in Low-Income Countries: Facts and Economics," Annual Review of Economics, Annual Reviews, vol. 6(1), pages 525-553, August.
  • Handle: RePEc:anr:reveco:v:6:y:2014:p:525-553

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    Cited by:

    1. Paddy Carter & Alex Cobham, 2016. "Are taxes good for your health?," WIDER Working Paper Series wp-2016-171, World Institute for Development Economic Research (UNU-WIDER).
    2. Dizon-Ross, Rebecca & Dupas, Pascaline & Robinson, Jonathan, 2015. "Governance and the Effectiveness of Public Health Subsidies," CEPR Discussion Papers 10690, C.E.P.R. Discussion Papers.
    3. Anja Sautmann & Samuel Brown & Mark Dean, 2016. "Subsidies, Information, and the Timing of Children's Health Care in Mali," CESifo Working Paper Series 6057, CESifo.
    4. Cammett, Melani & Şaşmaz, Aytuğ, 2017. "Political Context, Organizational Mission, and the Quality of Social Services: Insights from the Health Sector in Lebanon," World Development, Elsevier, vol. 98(C), pages 120-132.
    5. Rao, Krishna D. & Sheffel, Ashley, 2018. "Quality of clinical care and bypassing of primary health centers in India," Social Science & Medicine, Elsevier, vol. 207(C), pages 80-88.
    6. Paula González & Gabriel Montes-Rojas & Sarmistha Pal, 2017. "Dual Practice by Health Workers: Theory and Evidence from Indonesia," Working Papers 17.12, Universidad Pablo de Olavide, Department of Economics.
    7. I Ochoa-Moreno & S Bautista-Arredondo & S I McCoy & R Buzdugan & C Mangenah & N S Padian & F M Cowan, 2020. "Costs and economies of scale in the accelerated program for prevention of mother-to-child transmission of HIV in Zimbabwe," PLOS ONE, Public Library of Science, vol. 15(5), pages 1-18, May.
    8. Dizon-Ross, Rebecca & Dupas, Pascaline & Robinson, Jonathan, 2017. "Governance and the effectiveness of public health subsidies: Evidence from Ghana, Kenya and Uganda," Journal of Public Economics, Elsevier, vol. 156(C), pages 150-169.
    9. Jorge Coarasa & Jishnu Das, 2015. "Primary Care for the Poor," World Bank Other Operational Studies 23657, The World Bank.
    10. Okeke, Edward N. & Abubakar, Isa S., 2020. "Healthcare at the beginning of life and child survival: Evidence from a cash transfer experiment in Nigeria," Journal of Development Economics, Elsevier, vol. 143(C).
    11. Carolina Lopez & Anja Sautmann & Simone Schaner, 2018. "The Contribution of Patients and Providers to the Overuse of Prescription Drugs," NBER Working Papers 25284, National Bureau of Economic Research, Inc.
    12. Mbiti, Isaac M. & Serra, Danila, 2018. "Health Workers' Behavior, Patient Reporting and Reputational Concerns: Lab-in-the-Field Experimental Evidence from Kenya," IZA Discussion Papers 11352, Institute of Labor Economics (IZA).
    13. Manoj Mohanan & Katherine Donato & Grant Miller & Yulya Truskinovsky & Marcos Vera-Hernández, 2019. "Different Strokes for Different Folks: Experimental Evidence on the Effectiveness of Input and Output Incentive Contracts for Health Care Providers with Varying Skills," NBER Working Papers 25499, National Bureau of Economic Research, Inc.
    14. Vinaytosh Mishra & Cherian Samuel & S. K. Sharma, 2019. "Patient’s Utility for Various Attributes of Diabetes Care Services," IIM Kozhikode Society & Management Review, , vol. 8(1), pages 1-9, January.
    15. Paddy Carter & Alex Cobham, 2016. "Are taxes good for your health?," WIDER Working Paper Series 171, World Institute for Development Economic Research (UNU-WIDER).
    16. Pascaline Dupas & Edward Miguel, 2016. "Impacts and Determinants of Health Levels in Low-Income Countries," NBER Working Papers 22235, National Bureau of Economic Research, Inc.
    17. Jigyasa Sharma & Hannah H Leslie & Francis Kundu & Margaret E Kruk, 2017. "Poor Quality for Poor Women? Inequities in the Quality of Antenatal and Delivery Care in Kenya," PLOS ONE, Public Library of Science, vol. 12(1), pages 1-14, January.

    More about this item


    health markets; credence goods; audit studies; public and private care;

    JEL classification:

    • I10 - Health, Education, and Welfare - - Health - - - General
    • I11 - Health, Education, and Welfare - - Health - - - Analysis of Health Care Markets
    • I15 - Health, Education, and Welfare - - Health - - - Health and Economic Development
    • L15 - Industrial Organization - - Market Structure, Firm Strategy, and Market Performance - - - Information and Product Quality


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