lack of evidence on the actual quality of care provided in public and private health facilities in low-income settings.<sup>3</sup> This paper addresses this gap by presenting among the first direct measures of quality of care using condition-specific metrics in low-income countries, using data from an audit study conducted in rural areas of the Indian state of Madhya Pradesh (MP). Specifically, standardized patients (SPs) were coached to accurately present symptoms for three different conditions - unstable angina, asthma, and dysentery in a child (who is at home) - to multiple healthcare providers. SPs then made over 1,100 unannounced visits to a near-representative sample of public and private providers of primary healthcare services and recorded conditionspecific metrics of care for each interaction.<sup>4</sup> These metrics include the providers’ adherence to a checklist of questions and examinations deemed essential for making a correct diagnosis in each case, their likelihood of pronouncing a correct diagnosis, and the appropriateness of the treatments. For brevity, we refer to these metrics as “quality of care”.

We present results from two sets of comparisons. First, we sent SPs to a near-representative sample of public and private health facilities and we use these data to compare the representative patient experience across public and private clinics. These differences reflect variation in both provider composition (including knowledge and intrinsic motivation) as well as differential incentives across public and private clinics. To isolate the effect of practicing in the private sector holding provider characteristics constant, we identified the private practices of qualified public doctors (the majority of whom have one) and sent SPs to present the same medical case to the same set of doctors in both their public and private practices. Our second comparison uses this “dual practice sample” and compares the quality of care across the public and private practices of the same doctors on the same set of cases.

> We report three main findings. First, while the majority of private providers in the representative sample have no medical qualifications, they exerted significantly higher effort than public providers and performed no worse on diagnosis and treatment. Private providers spent 1.5 minutes more with patients (62 percent more), and completed 7.4 percentage point more items on a checklist of essential history and examination items (47 percent more) than

> 3Banerjee, Deaton and Duflo (2004); Chaudhury et al. (2006); Das and Hammer (2007) highlight the problem of low doctor effort in the public sector (high absence, low time spent with patients) and low training in the private sector. There is also a large medical literature on quality of care in the public and private sector. However, Coarasa, Das and Gummerson (2014) examine 182 cited studies in two systematic reviews of this literature and find only one study that adjusts for differences in patients using an audit methodology (as we do here), and no study that adjusts for differences in providers across public and private practices (which we also do here).

> 4Typically used in medical education, SPs are coached to consistently portray a medical case and all of its physical and pyscho-social aspects. When used to evaluate care in hospitals and clinics, they are also trained to accurately recall all aspects of their interactions with the provider. See details of the measurement protocols in section 3.

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