a Bachelor of Medicine and Bachelor of Surgery (MBBS) degree or not. The MBBS is a rough equivalent to a MD in the United States. However, only 52 percent of visits are to MBBS doctors. The remainder are to a wide range of alternatives available in the city. These may include practitioners with formal training in alternative medicine, those with no formal training but with degrees recognized by the government, and those with no formal degrees or government recognition.<sup>6</sup> Providers in the public sector all hold a MBBS degree, but work in two different settings: Public dispensaries or primary health care centers and hospitals. Since hospitals in Delhi historically re fl ected the highest standard of care in the country, the competence and effort of these two groups may differ substantially.

Although the average public sector provider is more quali fi ed (with an MBBS degree), households overwhelmingly favor private sector practitioners. The private sector accounts for 82 percent of all visits nationwide (Mahal and others 2001); for our sample this is slightly lower at 75 percent. Since there is no medical insurance apart from the provision of government health care, families frequently incur high out-of-pocket expenditures. The World Health Organization estimates that 82 percent of total spending on health care in the country is out-of-pocket spending on primary and in-patient care.

The recently elected government’s (2004) promise of a Common Minimum Program guarantees quality education and health for all. One hotly debated topic is the relative quality of providers in the private and the public sector. Some say that private providers are mostly “quacks” with little training and medical competence; others believe that the public sector is full of lazy doctors who do not work. As it turns out, each view has an element of truth.

# 2.2 Data Collection

Details of the sampling frame and data collection exercise are described in Das and Hammer (2005). Highlights relevant for this paper are as follows. In 2001, the Institute of Socio-Economic Research on Democracy and Development (ISERDD) began a longitudinal study of households in seven neighborhoods of Delhi. Three of the neighborhoods were poor, two middle income and two relatively wealthy. Over two years, 300 households were interviewed once a week for 35 weeks and once a month for another 8 months. Information was collected on health and health-care seeking behavior and demographic, income and consumption modules were administered twice in the two years. Less than 4 percent of the households approached refused to participate and the demographic, educational and expenditure pro fi les of the households in the study is very similar to representative samples of Delhi residents in the National Sample Survey and the National Family Health Survey (Das and Sánchez 2004).

These data on health care were used to construct a universe of relevant providers in the seven neighborhoods of the ISERDD study in two steps. First, all providers that anyone in the 300 households visited during the fi rst year of the survey was included. Second, research teams were sent on a reconnaissance visit in which

> 6 Following the Alma-Ata declaration on Primary Health Care in 1978, the Government of India established training courses for providers drawing on different traditions in Indian medicine. These were Bachelors of Ayurvedic Medicine and Surgery (BAMS), Bachelors of Integrated Medicine and Surgery (BIMS) and Bachelors of Unani Medicine and Surgery (BUMS). These providers were to provide basic care and refer serious cases to facilities with MBBS doctors. Further down the pecking order are the Registered Medical Practitioners (paramedics with some rudimentary training). However, given the limited regulatory power of government authorities, some providers have no formal training at all.

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