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Turning Research Into Practice: Measuring absence of teachers and medical providers

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December 2009 Halsey Rogers

The most immediate channel through which World Bank researchers can have an impact is when their methods and results influence work undertaken in Operations. Halsey Rogers reflects below on how DECRG’s research on absenteeism—undertaken in part in collaboration with Operations staff—not only received extensive attention in the media and academia, but also led to shifts in the focus of lending and analytic work by Bank Operations. 

High levels of absence of teachers and doctors from schools and clinics are not only a direct barrier to better human development outcomes, but also a symptom of poor governance and accountability. Only over the past decade, however, has absenteeism become a focus in monitoring and research, thanks to collaboration between staff from DECRG and the Regional vice-presidencies.

One of the first studies to directly observe absence was the 2001 Public Expenditure Review for Honduras [1]. Two DECRG researchers, Nazmul Chaudhury and Jeff Hammer, then made the problem of absence the central focus of their study of doctor behavior in Bangladesh, where their survey of a representative national sample of health centers showed that 74 percent of doctors posted to the smallest rural clinics were absent at any given time [2]. That study developed the methodology further by using only unannounced visits, to ensure that the enumerators observed “typical” behavior of service providers; in doing so, it paralleled studies that were beginning to emerge from academic researchers [3]. Other DECRG staff also began to use this methodology in studies of health and education service delivery soon afterwards, in both ESW carried out with Regional staff [4, which Deon Filmer co-authored] and research studies [5].

The power of multicountry studies

What propelled this research on provider attendance into the mainstream of HD governance work was the multicountry research project on teacher and doctor absence, launched as part of the background research for the World Development Report 2004: Making Services Work for Poor People [6]. A core team of DEC researchers and Harvard academics, funded by a generous grant from the UK’s DfID, worked with Regional staff and local consultants to carry out surprise visits to representative samples of primary schools and primary health care in six countries, with a focus on measuring absence and understanding its sources. The findings were surprising to many people: absence rates averaged 19 percent among teachers and 35 percent among medical workers in the six countries, and were far higher still in some Indian states [78].

That study’s impact showed the power of careful measurement inspired by real-world problems. By allowing benchmarking across countries and across states in India (where the most intensive data-gathering took place), the project highlighted the problem of provider motivation in a way that resonated widely. Helped by the WDR dissemination process and by Regional collaboration, the findings were not only published in academic journals [7-9] but also influenced policy dialogue, public opinion, and operational work in the countries studied. Well over 100 newspaper and magazine articles cited the studies and absence estimates – not only in international publications such as the FT, Economist, and New York Times, but also in many publications in countries studied, such as the Times of India, Business Standard (India), Jakarta Post, and All Africa. Most of these articles cited absence rates as evidence for the need for reform of education and health systems.

Since those initial studies, provider absence rates have become widely accepted as an observable measure of staff motivation, and the methodology advocated by researchers – direct observation of absence during unannounced visits to service delivery facilities – is widely used by HD and PREM staff in the Regions, especially in education. Three early examples of AAA that used this methodology are education-sector studies in Ecuador [10], Mongolia [11], and Lao PDR [12], but there have been numerous others in the past few years in all the regions. With the increasing attention to governance reform in HD, independently-measured absence rates are now also being incorporated as project monitoring indicators (as in the case of the BERMUTU teacher-upgrading project in Indonesia). And Regional staff have moved beyond monitoring with innovative experiments aimed at reducing absence and improving provider motivation and performance [13]. The South Asia Region reported in 2007 that “estimates of teacher absenteeism in India . . . have contributed to a shift in the focus of India's major primary education program towards improved education quality.” Research staff have collaborated in these advances in numerous ways – as team members, peer reviewers, or go-betweens with academic consultants.

From micro-level research to macro-level Operations

From this micro-level use of the indicator for particular projects and studies, the Bank is now moving to use it at the macro level for Operational work. As HD staff in the Regions and Networks wrestle with how to apply the Actionable Governance Indicators to their sector, staff absence rates tend to be one of the first measures they propose. Three examples within the Bank are the recent proposals for governance indicators in health [1415] and in human development broadly [16]. Absence is also one of the core indicators adopted in the multi-country governance measurement effort being launched by the African Economic Research Consortium, with the assistance of AFR staff.

Measuring attendance is not an analytically sophisticated idea; indeed, one reason it has caught on is that it is so easily interpretable, including by laypeople. While there is debate over whether 4 percent or 8 percent is a reasonable baseline level for absence, nobody argues that an education sector is working right when 25 to 40 percent of teachers are absent. But this is an area where DECRG staff were able to help move the sector forward – by recognizing the potential of good ideas from the field and from academia, putting together a strong analytical team that could scale the idea up and apply it carefully and consistently across countries, and then working with Regional, Network, and academic colleagues to disseminate the approach widely in policy and research circles.


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.

References

1. World Bank, Honduras: Public Expenditure Management for Poverty Reduction and Fiscal Sustainability. 2001, World Bank, LAC PREM Unit: Washington, DC.
2. Chaudhury, N. and J.S. Hammer, Ghost Doctors: Absenteeism in Rural Bangladeshi Health Facilities. World Bank Economic Review, 2004. 18(3): p. 423-41.
3. Glewwe, P., N. Ilias, and M. Kremer, Teacher Incentives. 2003, National Bureau of Economic Research Working Paper 9671.
4. World Bank, Papua New Guinea: Public Expenditure and Service Delivery. 2004, World Bank: Washington, DC.
5. Das, J., S. Dercon, J. Habyarimana, and P. Krishnan, Teacher Shocks and Student Learning: Evidence from Zambia. Journal of Human Resources, 2007. 42 4: p. 820-62.
6. World Bank, World Development Report 2004: Making services work for poor people. 2003, Washington, DC: Oxford University Press for the World Bank.
7. Chaudhury, N., J. Hammer, M. Kremer, K. Muralidharan, and F.H. Rogers, Missing in Action: Teacher and Health Worker Absence in Developing Countries. Journal of Economic Perspectives, 2006. 20(1): p. 91-116.
8. Kremer, M., K. Muralidharan, N. Chaudhury, J. Hammer, and F.H. Rogers, Teacher absence in India: A snapshot. Journal of the European Economic Association, 2005. 3(2-3): p. 658-67.
9. Alcázar, L., F.H. Rogers, N. Chaudhury, J. Hammer, M. Kremer, and K. Muralidharan, Why Are Teachers Absent? Probing Service Delivery in Peruvian Primary Schools. International Journal of Education Research, 2006. 45: p. 117-136.
10. Rogers, F.H., J.R. Lopez-Calix, N. Cordoba, N. Chaudhury, J. Hammer, M. Kremer, and K. Muralidharan, Teacher Absence and Incentives in Primary Education: Results from a New National Teacher Tracking Survey in Ecuador, in Ecuador: Creating Fiscal Space for Poverty Reduction. 2004, World Bank: Washington, DC.
11. World Bank, Mongolia: Public Financing of Education: Equity and Efficiency Implications. 2006, World Bank East Asia and Pacific Region: Washington, DC.
12. World Bank, Lao PDR: Public Expenditure Tracking Survey in Primary Education and Primary Health -- Making Services Reach Poor People, in Poverty Reduction and Economic Management Unit, East Asia and Pacific Region, World Bank. 2008.
13. Muralidharan, K. and V. Sundararaman, Teacher Performance Pay: Experimental Evidence from India. 2009: NBER Working Paper 15323.
14. Lewis, M. and G. Pettersson, Governance in Health Care Delivery: Raising Performance. 2009, World Bank: Washington, DC.
15. Savedoff, W.D., Governance in the Health Sector: Authority, Information and Motivation. 2009, Social Insight: Portland.
16. Fiszbein, A., D. Ringold, and F.H. Rogers, Making Services Work: Indicators, Assessments, and Benchmarking of the Quality and Governance of Public Service Delivery in the Human Development Sectors. 2009, World Bank: Washington, DC.

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