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Studies across low- and middle-income countries document quality shortfalls in both public and private sector health care. They notably highlight a “know-do” gap in primary care delivery: doctors possess requisite medical knowledge but do not expend adequate effort to treat patients. In explaining low quality, researchers have largely emphasized transactional aspects of health care, viewing doctors’ actions as shaped by their skills and incentives to perform and arguing that the micro-institutions that drive doctors’ clinical behavior are faulty. In contrast, in this project I analyze the social and political conditions in which public sector doctors deliver primary care in urban India. Viewing the doctors as both medical practitioners and state agents, I argue that health service outcomes depend on how doctors interpret policy mandates and relate to the communities they serve. I conceptualize their actions not just as medical transactions but also as social acts, shaped by the meanings they attach to their experiences and informed by the institutional history and social imaginary of state-provided care. During a year of ethnographic fieldwork (2013-2014), I observed clinical and non-clinical encounters of doctors employed in municipal government clinics and hospitals in a midsize Indian city; interviewed doctors, other health workers, elected officials, administrators, and staff of non-governmental organizations; and examined policies and administrative arrangements for urban health care since India’s independence. I demonstrate that municipal doctors confront a trifecta of challenges: a legal obligation to deliver urban primary care from within an outdated urban governance structure; a largely unregulated private sector that residents widely prefer; and rising commercialization in medical practice, under which specialized medicine has crowded out primary care in popular ideas about “good” medical care. Unable to remedy the low legitimacy of their services, doctors circumscribe their actions, seeking, as one doctor put it, only to ensure the ordinary. My findings suggest that transaction-specific interventions to improve quality, such as focused on skills and incentives alone, may do little to circumvent these local effects of the policy neglect of urban health care. |
