In many developing countries, public sector absence is both common and highly intractable. One explanation for this is that politicians provide public jobs with limited work requirements as patronage. We test this explanation for absence in Pakistan using: (i) a controlled evaluation of a novel smartphone technology designed to increase inspections at rural clinics; (ii) data on election outcomes in the 241 constituencies where the experiment took place; (iii) attendance recorded during unannounced visits and; (iv) surveys of connections between local politicians and health staff. Three results suggest that absence is linked to patronage. First, while doctors are present at 40 percent of facilities during unannounced visits in highly competitive electoral districts, they are almost always absent in captured districts. Second, doctors who know their local parliamentarian personally are present during an average of 0.727 of three unannounced visits, while unconnected doctors are present at 1.309 of the three visits. Last, the effects of the smartphone monitoring technology, which almost doubled inspection rates, are highly localized to competitive electoral districts. We also find evidence that program impact is in part due to the transmission of information to senior officers using manipulations of an online dashboard.
Callen, M.; Gulzar, S.; Hasanain, A.; Khan, Y. The Political Economy of Health Worker Absence: ExperimentalEvidence from Pakistan (IGC Working Paper). International Growth Centre (IGC), London, UK (2013) 34 pp.