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Sep 26, 2005,
F. Halsey Rogers

Provider absenteeism is high in poorer countries and states. A recent study shows that absence ranges from 11 to 27 percent among primary-school teachers, and from 23 to 40 percent among medical personnel. What do the levels and patterns of these data tell us?

Absenteeism of teachers and medical personnel is widely cited as a barrier to improvement of education and health outcomes in developing countries, especially in South Asia. Consider this anecdote from the PROBE report on basic education in India, a path-breaking study of barriers to educational advances in several Indian states:

When the investigators reached the primary school in Jotri Peepal shortly after noon, no teacher was in sight. One teacher, who had apparently left for lunch, soon appeared. He said that the school actually had three teachers, but that the headmaster and another teacher had gone elsewhere on official duty. The villagers contradicted this story. They said that the two absconding teachers did not turn up at all. The only one who did was the one the investigators had met . . . . He too was highly irregular and opened the school at will [1].

Governments and donors may construct school buildings and supply textbooks, but if teachers are repeatedly absent, students are unlikely to learn. Moreover, high levels of teacher absence are likely to be symptomatic of other problems of quality control and accountability in education. Developing-country governments often spend 80 to 90 percent of their recurrent education budgets on teachers. A government that cannot ensure that its largest expenditure is yielding even the most basic of returns–getting teachers into classrooms–is unlikely to be effective at ensuring that students are learning.

Measuring provider absence

But how severe is the problem of absent teachers–and in health care, absent medical personnel? This research project set out to answer that question definitively in six countries: Bangladesh, Ecuador, India, Indonesia, Peru, and Uganda.

Survey teams made unannounced visits to random national samples of primary schools and health clinics and recorded whether they found teachers and health workers in the facilities. This is the first project to measure absence directly using a common approach across multiple countries [2].

We found that, averaging across the six countries, about 19 percent of teachers and 35 percent of health workers were absent from their facilities [3]. Even these figures may present too favorable a picture of service delivery. Providers were marked as “present” if they could be found anywhere in their schools and clinics, but some of these were not working. For example, in India, one-quarter of government primary school teachers were absent from school, but only about one-half of the teachers were actually teaching when enumerators arrived at the schools.

Beyond the high overall absence rates, there are other indications that provider absence reflects systemwide problems. First, absence is typically fairly widespread: in most countries and states, it is not just a small number of "ghost" workers who are responsible for the high average absence rates. Second, higher-ranking and more powerful providers, such as headmasters and doctors, are absent more often than lower-ranking ones. For example, averaging across countries, 39 percent of doctors were absent, while only 31 percent of other health workers were absent. This may reflect the difficulties of holding more powerful providers accountable.

Absence rates are generally higher in poorer regions, as these graphs show. The figures illustrates this point, graphing Indian states (green circles) and other survey countries (blue triangles), for both the primary education and primary health sectors. The relationship between income and absence is quite strong in the education sector: doubling a state or country’s per-capita income is associated with a decline of 8 percentage points in the predicted absence rate.

Factors correlatedwith absence: incentives that matter

But the absence-income correlation does not mean poorer regions are powerless to reduce absenteeism. Indeed, these graphs show that poorer regions sometimes achieve much lower absence. It is therefore important to know what factors are correlated with lower absence, so that countries can explore possible interventions. One obvious intervention is raising pay; in the multicountry sample, however, there is little evidence that pay strongly affects absence in the range where we have data. By contrast, we do find evidence suggesting that facilities with better infrastructure have lower absence.

This is consistent with our finding that teachers and health workers are extremely unlikely to be fired for absence, so that their decisions about whether to go to work are influenced more by their working conditions than by fear of losing pay. Contract teachers, who are not subject to civil service protection and earn a fraction of what civil service teachers earn, do not have lower absence.

State-level teacher absence rates in India, 2003
(click on image for full size graph)

This analysis can besharpened further when we confine our attention to a single country and sector, as in our companion paper focusing on absence among Indian teachers [4]. Overall, 25 percent of teachers were absent from school, but the state absence rates varied from 15 percent in Maharashtra to 42 percent in Jharkhand as this map of India shows.

As in the multicountry sample, we do not find that higher pay is associated with lower absence. Older teachers, more educated teachers, and head teachers are all paid more but are also more frequently absent; contract teachers are paid much less than regular teachers but have similar absence rates; and although relative teacher salaries are higher in poorer states, absence rates are also higher. One reason for these patterns may be the lack of discipline: in our survey, only 1 in 3,000 head teachers had ever fired a teacher for repeated absence.

Responses to absence: work-arounds and possible solutions

Faced with high absence rates, policymakers have two challenges. First, how can education and health policy be adapted to minimize the cost of absence? Second, how can absence be reduced?
On the first point, policies in education and health should be designed to take into account high absence rates. For instance, doctor absence may be difficult to prevent, but possible to work around.

Very high salaries (combined with effective monitoring) may be required to induce well-trained medical personnel–doctors in particular–to live in rural areas. And to conserve on the permanently posted rural workers who are absent at such high rates, health policy might shift budgets toward activities that do not require doctors to be posted to remote areas. This could include immunization campaigns, pest control to limit infectious disease, health education, providing safe water, and providing periodic doctor visits rather than continuous service [5,6].

On the second point–how to reduce absence–our results can provide only tentative guidance. Conceptually, there seem to be three broad strategies for moving forward. One approach would be to increase local control, for example by giving local institutions like school committees new powers to hire and fire teachers. However, the high absence rates among contract teachers and among teachers in community-controlled Indian schools suggest that this may not be enough.

The second approach would be to improve the existing civil service system. Our analysis suggests a range of possible interventions that might be worth testing. Some, such as upgrading school and clinic infrastructure, would involve extra budget outlays. Others, such as increasing the frequency and bite of inspections, could be implemented using existing rules already on the books. More politically difficult may be changes in incentive structures [7], perhaps complemented with technical approaches allowing objective monitoring of attendance [8].

The final approach would be to experiment more with systems in which parents choose among schools and public money follows the pupils.This choice could either be within the public system or could encompass private schools. A similar approach could be employed in health with money following patients as opposed to facilities.

But will there be pressure for any of these reforms? There is some evidence that surveys that monitor and publicize absence levels, such as surveys we conducted, can focus policymakers' attention on the issue–even if the problem of absence is already well known to students and clinic patients. In Bangladesh, for example, the Ministry of Health cracked down on absent doctors after newspaper reports highlighted the results of the health survey described in The Daily Star [9].

Whether or not this type of one-time crackdown is effective, the problem of provider absence warrants further attention. Failures in “street-level” institutions and governance have received much less notice from development thinkers and policymakers than have weaknesses in macro institutions like democracy and high-level governance. Yet for many people, one of the most important indicators of their country’s level of economic and social development is the quality of their day-to-day transactions with those delivering public services.

The findings, interpretations, and conclusions expressed in this brief are entirely those of the authors. They do not necessarily represent the view of the World Bank, its Executive Directors, or the countries they represent.

HALSEY ROGERS is a Senior Economist in the Development Research Group (Human Development and Public Services Team). His current research focuses on understanding the quality and determinants of service delivery, particularly through exploration of the incentives for and behavior of teachers, doctors, and other service providers. *

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[ 1] PROBE Team, Public Report on Basic Education in India. New Delhi: Oxford University Press, 1999.

[ 2] This methodology was similar to the one used in Jeffrey S. Hammer and Nazmul Chaudhury, "Ghost Doctors: Absenteeism in Bangladeshi Health Facilities." World Bank Economic Review 18: 423-441, 2004, (based on Policy Research Working Paper 3065).

[ 3] Chaudhury, Nazmul, Jeffrey S. Hammer, Michael Kremer, Karthik Muralidharan, and F. Halsey Rogers, "Missing in Action: Teacher and Health Worker Absence in Developing Countries." Journal of Economic Perspectives (forthcoming Fall 2005).

4] Kremer, Michael, Karthik Muralidharan, Nazmul Chaudhury, Jeffrey S. Hammer, and F. Halsey Rogers, "Teacher Absence in India: A Snapshot." Journal of the European Economic Association 3:2-3, 2004.

[ 5] Filmer, Deon, Jeffrey S. Hammer, and Lant H. Pritchett, "Weak Links in the Chain: A Diagnosis of Health Policy in Poor Countries," World Bank Research Observer 15(2): 199-224, 2000.

[ 6] Filmer, Deon, Jeffrey S. Hammer, and Lant H. Pritchett, "Weak Links in the Chain II: A Prescription for Health Policy in Poor Countries," World Bank Research Observer 17(1): 47-66, 2002.

[7] Banerjee, Abhijit, and Esther Duflo, "Addressing Absence," Journal of Economic Perspectives (forthcoming).

[ 8] Duflo, Esther and Rema Hanna,"Monitoring Works: Getting Children to Come to School." Massachusetts Institute of Technology, Cambridge, Mass, 2005.

[9] The Daily Star, "24 of 28 Docs Shunted Out for Absence: DG Health Surprised at Surprise Visit to NICVD," The Daily Star: Bangladesh, 2003.