The Absenteeism Issue in Education and Health Sectors

One can build schools and clinics, and stock them up with books, drugs and equipment, but if the teachers, nurses and other service providers are chronically absent, all the investment is basically wasted. Absenteeism in the education and health sectors is a big issue in the development world – especially in sub-Saharan Africa and India. And in order to improve the quality of education and health services in those regions, it is crucial that the absenteeism issue is addressed immediately.

Some Statistics on Absenteeism:

Absenteeism of service providers in the education and healthcare sectors in developing countries is widespread and unpredictable. On an average day, 27 percent of teachers in Uganda do not come to class. Primary health centers in Indonesia and India experience 40 percent absence rates. Widespread absenteeism suggests supervisors are already unable or unwilling to combat absenteeism.

A survey in 2006 made almost 70,000 surprise visits to primary schools and clinics across six poor countries in 3 continents. It found teachers were absent 19% of the time on average, and documented 35% absence rates for health care providers. In another cross-country study of teacher absenteeism, observed through unannounced visits to about 100 randomly selected schools per country in 7 countries, found a wide variation of teacher absenteeism, with an average of 20% of teachers absent in Ecuador and Peru compared with an average of 51% of teachers absent in India. India’s high rate of teacher absenteeism is an eye-opener, and it is more that 13% points higher than the next highest country.

In general, absence rates are higher in poorer countries, are unpredictable, and not easy to plan around. They are as likely on Wednesday as on Friday. Worse still, even teachers who are at school might not be in class; in India, only two-thirds of teachers present in school were actually teaching. Few service providers face a serious threat of being fired for excessive absences. In a survey of 3000 Indian government schools, only one head teacher reported a teacher being fired for poor attendance.

Does Absence Matter?

If a teacher is absent, children will automatically lose days at school. For adolescent girls enrolled in school in rural Bangladesh, the most common reason for missing school was teacher absenteeism.

Health may be different from education; if a nurse is not there one day a patient may simply come back the next and get treated. In the case of vaccinations, patients may not be that much worse off for waiting a day. On the other hand, most people have to travel much further to a clinic than a school. If there is a high probability that the clinic will be closed, patients may not even bother trying in the first place.

Most importantly, the most successful program for reducing teacher absenteeism significantly improved learning. In a program that increased teacher attendance from 58% to 79%, 7% more girls were able to write.

Incentives and External Monitoring:

Supervisors are in a good position to judge whether someone is absent for a good reason. But a couple of absenteeism monitoring programs in Kenya (in education) and India (in health) showed that after initial success, the supervisors failed to abide by the program monitoring, and undercut the program. As a result, the effect of the program dissipated. Hence incentives are only effective when strictly implemented without supervisor discretion.

One way to circumvent supervisor discretion is to tie rewards to final outcomes. ICS Africa rewarded teachers in 50 rural schools in Kenya with prizes once a year based on their performances on standardized tests. These incentives were significant (almost half of monthly salary), and they did motivate teachers. But, because the reward was not closely tied to attendance, neither was the result. Teacher attendance did not go up, and teaching did not improve.

The Girls Scholarship program in Kenya, offered scholarships to sixth-grade girls who scored highest on tests, and showed that teachers responded to students’increased motivation to learn. The program found that girls eligible for the scholarship showed academic improvement—as did girls who were unlikely to win and boys, who could not win. Teachers—who received no incentives themselves from the program—responded to students’ increased motivation to learn and were absent 4.8% points less than teachers in control schools.

In rural Udaipur, India, teachers in 60 schools were given a camera with a tamper-proof date and time stamp. They received a base pay of$11.50 per month, and were told they would receive$1.15 more for each day they were present,as documented by two photos of the teacher with students taken at least five hours apart. Teacher absence fell quickly (dropped by 20%) and stayed low. Extreme delinquency was eradicated, and 36% of program teachers had better than 90% attendance rates. A year later, student test scores were significantly higher in the treatment schools. Strictly administered incentives worked.

Local Monitoring and Accountability:

One popular recommendation for improving services is to mobilize and empower communities to hold providers accountable. Service recipients may be unaware of the quality of their care, or of available opportunities for improvements. If so, information and mobilization campaigns could improve service delivery. But evidence of this approach in a couple of programs run in Uganda and India showed mixed results. This is not surprising because the goal of community monitoring is ambitious: to make providers more accountable by making communities more active without actually changing who hires and fires providers. In addition the community members are usually poorer, less educated, and less connected than providers—in other words they have less power. Hence often, the supervisors care more about the interests of providers than those of the beneficiaries.

Accountability with Teeth:

If government supervisors of health and education systems care more about their staff than about the local population, why not make the local population responsible for hiring and firing providers? The Extra Teacher Program, run by ICS in Kenya, tested a program by hiring locally accountable teachers, tracking students by ability level, and training the local school committees that oversaw these teachers. The result? – locally accountable teachers had much lower absence rates than centrally hired teachers and were paid a fraction of the salary. Hence the program saved money, reduced absenteeism and also raised test scores.

Making these teachers truly accountable to the local community—with short-term renewable contracts—appears to be a promising option for addressing the chronic problem of absenteeism, and is becoming an increasingly popular option in Africa and Asia. But the accountability mechanism must have teeth.

It is also important to note that a lot of programs implemented to reduce absenteeism do not work, but from the ones that do, most are surprisingly cheap.

Conclusions:

– As the ICS run program in Kenya showed us, teachers can respond to students’ increased motivation to learn. Thus in addition to attaching financial rewards to monitoring, a natural strategy is to encourage teachers to want to teach. Is an appreciated or contented teacher less likely to be absent? If so, a program carefully designed around a teacher’s situation could be successful without being financially expensive.

– A common concern with incentive schemes is that they destroy the intrinsic motivation of those involved. Incentivizing attendance may generate mere attendance—and no work. The experiments stated in the earlier sections of this blog found no evidence of this: if a program increased the attendance of teachers or health workers it also improved final outcomes. This was true in the Girls Scholarship program in Kenya, the Citizen Report Card in Uganda, the Extra Teacher program in Kenya, and the camera program in India.

– Absenteeism of teachers and healthcare service providers is a serious problem for the world’s poor.

– Supervisors can undermine the effectiveness of incentive programs if they are given any discretion about whether providers are rewarded for attendance.

– Taking out supervisor discretion and basing rewards for attendance on impersonal,objective monitoring significantly improved attendance.

– Community empowering, accountability with teeth – where the service providers are hired and fired by local communities – can be very promising.

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About pritamkabe

Originally from Bombay, India. Relocated to the United States in 1997 for attending graduate school at The University of Texas. Completed my Masters in Electrical Engineering in 1999 and then worked in the Hi-Tech industry for the next 11 years in Austin, Texas. I have a passion for travelling, meeting new people, and experiencing new cultures...and i've been very fortunate to have gotten the opportunity to travel quite a bit. Sports and food are my other big passions in life. Some life-changing experiences in my life a years ago changed my perspective of life, after which, just have an engineering job was not meaningful to me anymore. Hence i quit my engineering career, and I'm now motivated to give back to society and make a positive impact in some way. To get started on that journey, i went back in graduate school, and recently graduated as a "Mid-Career Fellow in Foreign Service", from the Edmund A. Walsh School of Foreign Service, at Georgetown University, Washington DC. Currently in New Delhi, India, on a research fellowship, to learn about the educational issues in India, and brainstorm my ideas about technological interventions for resolving those issues.
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