A study conducted among a very poor rural population in Rajasthan, in the north of India, reveals that less than a quarter of medical visits take place in a public dispensary. In a quarter of cases, the visits take place with a traditional healer, others with private care providers who are not subject to any regulation: 41% have no medical degree, 20% have no medical or paramedical training, and 17% don't even have a high school diploma! 

The care received from these charlatans is often inadequate, even dangerous: in two thirds of cases, regardless of the illness, the patient receives an injection of antibiotics, steroids, or both. That leads to disasters (an epidemic of hepatitis B was traced back to a practitioner who used improperly sterilized syringes) and to resistance to an ever greater spectrum of antibiotics. Children and adults die in great numbers from illnesses that could be prevented or cured: less than a quarter of children receive the BCG (tuberculosis) vaccine, less than 2%, the measles vaccine. Tuberculosis, which demands a long and regular treatment, is rarely properly treated, and those who are ill with it usually die from it. 
The absence of a network of reliable practitioners also makes it virtually impossible to establish health insurance. The poorest people end up spending a significant part of their income on healthcare. Healthcare expenses are the most frequent reason families are plunged into excess debt. 

Yet there exists in India, as in many developing countries, an infrastructure that is supposed to be adapted to these needs: every group of villages is served by a primary health center staffed by a nurse. The nurse is responsible to vaccinate children, distribute food supplements to pregnant women, assist at births, administer primary care for frequent illness such as diarrhea or malaria, and to refer the cases she cannot treat to a more important health center. The primary center is also the distribution point for medicines that fight illnesses such as tuberculosis, after diagnosis has been made in a hospital. This system, if it worked, would allow the poor access to free healthcare delivered by competent care-providers. 

One of the major reasons for the present disastrous situation is the extremely high level of absenteeism among doctors and nurses. In India, 40% of nurses and doctors in public health centers are absent from their posts when inspectors arrive without notice during the hours when the centers are supposed to be open. Absenteeism is 35% in Bangladesh, 40% in Indonesia, 37% in Uganda.... The problem is the same among teachers: in primary schools, absenteeism reaches 19% in Indonesia, 25% in India, 27% in Uganda.... These absences are rarely justified by official reasons or home visits: usually these officials have simply stayed at home. The high level of absence is not due to a small number of lazy officials either: in fact practically all of them are regularly absent. 

Translated into Euros, this rampant corruption is as impressive as the Swiss bank accounts of African dictators: the healthcare budget in India is 5 billion dollars a year, or 0.9% of GDP. Salaries comprise 75% of the budget. The daily theft perpetrated by doctors and nurses who receive their salary without working consequently represents 1.54 billion dollars a year, the equivalent of half the foreign aid India receives. 

This generalized absenteeism is partly the product of a vicious circle: "patients," in the face of the dysfunction of a system over which they have no control, desert it or are no longer interested in it. That makes the job of nurses, doctors, and teachers particularly ungrateful: when parents don't bring their children to be vaccinated or when someone ill with tuberculosis doesn't take the antibiotics he's been given, it becomes off-putting for a nurse to get up at dawn to take the bus or walk 5 kilometers to get to work. If the fight against absenteeism became a priority, this circle could be broken in several places: by defining and enforcing very strict rules about being present (in the event of not returning to a good old fashioned clocking-in system or daily wages), by giving users a voice in promotions, raises, or firings to allow them to express their displeasure without leaving the public sector, by encouraging the use of public services to force users to demand that they function (as in Mexico, where social allocations are conditional on regular medical visits). The impact of each one of these interventions has the potential to be multiplied and to transform the vicious circle into a virtuous one.