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Missing in Action: Teacher and Medical Provider Absence in Developing Countries

March 6, 2006

Absenteeism of teachers and medical personnel is widely acknowledged as a barrier to improvement of education and health outcomes in developing countries, especially in South Asia.

Developing-country governments often spend 80 to 90 percent of their recurrent education budgets on teachers, without the most basic of returns – getting all teachers to show up at work. 

Absenteeism in school image
"Senior student" leads class in
the absence of a teacher in a classroom in Indonesia

A World Bank research project on absenteeism that set out to measure the extent of the problem (using, for the first time, a common random-sample approach in multiple countries1) reports that on an average 19 percent of teachers and 35 percent of health workers were absent from their facilities in Bangladesh, Ecuador, India, Indonesia, Peru, and Uganda2. Of those present, not all were actually 'working'. In India, for example, only half the teachers were actually teaching when the survey teams arrived.

"Beyond the widespread overall absence rates, we found that provider absence was worse in poorer regions, and that higher-ranking and more powerful providers such as headmasters and doctors were absent more often than lower-ranking ones," said Halsey Rogers, Senior Economist with the World Bank's Development Research Group (Human Development and Public Services Team).  

Given this situation, the research team suggests that education and health policies need to be adapted to take into account and minimize the cost of absence. For instance, to conserve on permanently posted rural workers who are absent at such high rates, health policy could shift budgets towards programs such as immunization campaigns and periodic doctor visits – activities that do not require permanent posting of staff to remote areas3 4.

Absenteeism generally higher in poorer regions

Absence rates are generally higher in poorer regions, as these graphs show.


The figures illustrate 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.  

Higher salaries don't go with lower absence, but better incentives do

A seemingly obvious intervention to improve provider attendance in poorer regions is raising pay. However, the multicountry sample shows little evidence that relatively high salaries strongly affect absence.In fact, evidence suggests that facilities that offer better daily incentives to attend work such as recent school inspections, better infrastructure, and proximity to a paved road have lower absence rates. 

This is consistent with the finding that teachers and health workers are extremely unlikely to be fired for absence, so that their attendance decisions 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, also do not have lower absence.  

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



A companion research paper focusing on absence among Indian teachers5 supports in greater detail the finding that higher pay is not associated with lower absence. For instance, older teachers, more educated teachers, and head teachers are all paid more but are also more frequently absent.

Another finding from the Indian case is that attempting to strengthen local community ties does not really reduce absence. Teachers from the local area have similar absence rates as teachers from outside; locally controlled nonformal schools have higher absence rates than government-run schools; and the existence of a parent-teacher association is not correlated with lower absence. The evidence from other countries is mixed – for instance, in Peru, hiring local teachers does correlate with lower absence6

 There is, however, some suggestion from India that rural private schools could help to raise low educational standards. Private-school teachers are only slightly less likely to be absent than public-school teachers in general, but are 8 percentage points less likely to be absent than public-school teachers in the same village.

Challenges faced by policymakers – and possible solutions

Faced with high absence rates, policymakers have two challenges. (i) How can education and health policy be adapted to minimize the cost of absence? (ii) How can provider absence be reduced? 

Policies in education and health should be designed to take into account high absence rates. For instance, 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
 3 4.

The research results provide only tentative guidance on how to reduce absence. Conceptually, there seem to be three broad strategies for moving forward. The first 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. Some interventions, 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 structures7, perhaps complemented with technical approaches allowing objective monitoring of attendance8.

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 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," said Rogers. "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 researchers

Nazmul Chaudhury is an Education Economist with the World Bank's South Asia Human Development Sector.

Jeffrey Hammer is a Lead Economist with the World Bank's South Asia Environment and Social Unit.

Michael Kremer is a Professor at Harvard University's Economics Department. His research interests include economic growth, education and development, and research incentives.

Karthik Muralidharan is a PhD student in economics at Harvard University.

Halsey Rogers is a Senior Economist in the Development Research Group. 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.

1     This methodology was similar to the one used in Jeffrey S. Hammer and Nazmul Chaudhury. 2004. "Ghost Doctors: Absenteeism in Bangladeshi Health Facilities." World Bank Economic Review 18: 423-441.  Working paper version

Other recent work by World Bank researchers that measures teacher absence using similar approaches includes: 

2     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).

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

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

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

6      Alcázar, Lorena, Chaudhury, Nazmul, Hammer, Jeffrey, Kremer, Michael, Muralidharan, Karthik, Rogers, Halsey. March, 2006  "Why are Teachers Absent? Probing Service Delivery in Peruvian Primary Schools".

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

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

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


Article by Halsey RogersMore detailed version of this feature

More related papers: World Bank research project on absenteeism website.









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