A startling statistic keeps Ali Hasanain, an assistant professor of economics at the Lahore University of Management Sciences (LUMS), awake at night: one out of five children in the four poorest districts of Punjab die from health complications before their fifth birthday.

That’s just one of the many numbers that show how dire health outcomes are in Pakistan. 22 percent of Pakistanis are malnourished due to low access to nutritious food, and that figure doubles in children. The increased risk of disease and death that comes with malnutrition has given Pakistan the highest infant and second highest maternal mortality rates in South Asia.

To make things worse, families seeking treatment have a hard time finding a doctor.

A study conducted by Ali Hasanain, Michael Callen (University of California, San Diego), Saad Gulzar (New York University) and Yasir Khan (University of California, Berkeley) found that nearly 70 percent of doctors are absent during normal working hours.

The research titled "The Political Economy of Public Sector Absence: Experimental Evidence from Pakistan" is based on data collected from interviews with senior health officials and inspectors, attendance audits, election data and surveys of Punjab's health clinics through random visits between 2011 and 2012.

Doctor Absenteeism

Low doctor attendance is an important reason Pakistan’s public health clinics are under-utilised. Hasanain made this observation while visiting Basic Health Units (BHUs) – the lowest-tier public health clinics for primary care – during the survey.

“Even though options outside the BHU are not great, you don’t always find a long line of people waiting at BHUs either,” said Hasanain.

One solution has been to improve doctor inspections through the use of technology. Instead of using an outdated, paper-based system for monitoring doctor attendance, inspectors would be given smartphones to feed attendance information to the provincial government, which would be updated in real-time.

Senior officials can then identify which clinics need to be held accountable, for low attendance rates.

The researchers designed and implemented such a system in collaboration with the Punjab Health Department.

The study ultimately found mixed results from the smartphone powered intervention. While monthly inspections of clinics nearly doubled, there was no impact on doctor attendance on average and outcomes varied across different districts.

The link between politics and attendance

The researchers suspected that politics had a role to play in uneven attendance, so they compared data from the smartphone-based monitoring system with voting data from the 2008 provincial assembly elections.

They found that doctor attendance closely reflected the local political scenario. Doctors were 21 percent more likely to be absent in constituencies where one political party achieved a strong victory. Where competition between parties was higher, smartphone-based inspections show increased attendance by an average 10 percent.

Interviews with public health officials allowed the researchers to put forth a likely explanation of how these mechanisms work.

Candidates contesting an election often need the support of prominent community members to secure victory. In exchange for their support, politicians make sure that these community members or their relatives are awarded postings as doctors regardless of whether they come to work or not.

Out of the officials interviewed, 44 percent reported that politicians continue to interfere in their work in this manner.

In this circumstance, political patronage deflects penalties for doctors who miss work. While undergoing smartphone monitoring training, an inspector explained to Hasanain how this plays out in his job.

“He said, ‘you’re giving me this smartphone for monitoring, but it’s useless. I already know who is not showing up to work, the issue is not that I don’t know who is absent, it’s that I don’t have the ability to reprimand them, because they have political cover,’” Hasanain recalled.

Another intervention was tested; the data collected through the smartphone monitoring system was used to generate visualisations that flagged clinics with low attendance to alert senior health officials, who could then discipline the worst performing clinics.

Flagging improved overall attendance by 27 percent. But again, there was a larger impact in competitive constituencies while remaining comparatively insignificant in the least competitive.

All of this suggests that while technology-based solutions can certainly make more doctors show up to work, they can only do so in the right political climate.

Is there a viable solution?

If technical solutions have their limits, can the political problem be fixed?

The results of the study suggest that the key to service delivery improvements may lie in making politics more evenly competitive.

Since doctor attendance was higher in districts where one candidate did not dominate the vote, greater competition between political parties could mean that they try to win votes by offering better policies and services.

As a result, politicians are held accountable by voters based on how well they deliver public services, meaning doctors who want to miss work would no longer have a political safety net.

Hasanain thinks that since urban politics is relatively competitive and issue-driven, the media should serve as an educating force to make urban residents care more about the well-being of residents from rural areas and put pressure on politicians to improve health outcomes across the province.

It has also been argued that governance needs to be more localised: Rather than having a centralised government structure in Lahore, enforce attendance at health clinics across the Punjab whereby doctors should be held accountable by Tehsil or District level managers.

Some contend that the best solution is to reduce risk factors to health such as poor sanitation and low access to nutrition, rather than starting with the public health care system on its own. This would prevent the onset of illnesses, reducing the need for public health clinics. There are some large-scale initiatives addressing this, such as the government’s food fortification program and the Saaf Pani Company.

But if a poor family is exposed to a hazardous environment and has the bad luck of living in a patronage-heavy constituency, their first defense from developing a severe illness will likely remain out of sight.

The writer is a communications associate at the Consortium for Development Policy Research, a Lahore-based research dissemination organization.