Given that India has better infrastructure for schooling relative to healthcare, and near universal primary school enrolment rates, many believe that providing basic health services through schools rather than clinics may be more cost effective. This column finds that coverage achieved by health programmes administered through schools is also low, even lower than the average school attendance rates. The key constraint on coverage is shortage of healthcare personnel.
Given the very low quality of government health institutions in developing economies, and their consequent failure to deliver even basic health services such as vaccinations and annual checkups, many researchers advocate providing these services to children through schools, capitalising on near universal primary enrolments. For example, Jamison et al (2006) argue that low-income countries typically have more teachers than nurses and more schools than clinics, often by an order of magnitude. This greater availability of schooling infrastructure leads them to suggest that providing basic health services through schools, rather than through local clinics, may be more cost effective. The provision of health services through schools constitutes the primary message of FRESH (Focusing Resources on Effective School Health), the inter-agency framework developed by the United Nations Educational, Scientific and Cultural Organization (UNESCO), United Nations Children’s Fund (UNICEF), World Health Organization (WHO) and the World Bank, launched at the Dakar Education Forum 2000.
Yet, the coverage achieved by health programmes administered through schools is also low. Consider, for example, the school health checkups provided by the state Government of Bihar, one of India’s poorest states, through a programme entitled Nayi Pidhi Swasthya Guarantee Programme (NPSGY). The programme, introduced in the 2011-2012 school year, was intended to provide universal health checkups to the 34 million children of pre-school and school-going age in the state. However, despite near universal enrollment in Bihar’s primary schools, coverage of students under the scheme was disappointingly low in its first year, at only 43.6% of the targeted population. In three districts of the state, coverage rates were less than 10%, and in an additional six, health checkups could only be provided to less than 30% of the school population.
These low coverage rates are widely believed to reflect the high absenteeism levels that characterise rural government schools in the state. Survey data we collected in 2012 on students enrolled in grade 2 in 32 schools spread over two districts of the state reveal an average attendance rate of only 57%, suggesting that students attend school for just over half of official school days (Kochar 2013). Data from other sources support this finding. For example, 2005-2006 data from the National Family Health Survey (NFHS) reveals an attendance rate of 64.6% for boys and 55.4% for girls in rural schools of the state. Figure 1 also reveals the significant monthly variation in attendance. Average attendance is very low at the beginning of the school year, at only 46%. While this number increases slowly over the next few months, it falls again in August, rises in September and October, and then falls again in November and December. The seasonality in attendance reflects a combination of factors, including religious holidays and the agricultural crop cycle.
That high absenteeism explains low coverage seems obvious; if a student is absent on the day of the health checkup, he or she will be unable to avail of the services provided. Aggregating up, this suggests that schools with high overall absenteeism must record lower than average coverage under the programme. In fact, this is not always the case. Some districts with better functioning schools and higher attendance rates actually record lower-than-average coverage. And, the very low programme coverage rates in some districts, discussed previously, are far lower than school attendance rates. Indeed, the overall coverage rate achieved by the programme is significantly lower than the average attendance rate in schools.
Figure 1. Monthly variation in attendance, grade 2 students, 2011-2012
Resource constraints in the health sector
An alternative explanation relates low coverage to the resource constraints that characterise local health institutions, namely a lack of health personnel relative to the population that has to be served. These constraints are widely believed to explain the relative failure of government clinics to deliver basic health services to the population. Health services in India are delivered through a federated structure of institutions, with Health Sub-centers (HSCs) at the base and Primary Health Centers (PHCs) at the next level. While national norms stipulate that there should be one HSC per 5,000 population (and one per 3,000 population in hilly, tribal or desert areas), the average population covered by HSCs in the state is more than four times this norm (24,600). In several districts, the population per HSC exceeds 80,000. Similarly, the inability of the state to meet national norms for PHCs (one PHC per 30,000 population) has required the state to invest in a set of intermediate institutions, termed “Additional” PHCS (APHCs). Even these new institutions, however, are serving much higher populations than planned. In one of our survey districts, for example, data from the 2012-2013 District Health Action Plan reveals a population of 61,000 per APHC, which is double the intended level.
More consequential than the large populations served by health institutions is the shortage of medical personnel. Each PHC is required to have at least one medical officer. However, 12% of the PHCs in Bihar operate without any associated medical doctor. In the PHCs that fall within our survey area, 27% had less than the required number of doctors, and less than half had the required number of nurses, laboratory technicians or pharmacists.
The photograph below gives some sense of the extent of resource constraints at the PHC, with two long lines of men and women waiting to see the one doctor on duty. With more than 70 people waiting at any given time to see the doctor, most of them are unlikely to be able to do so.
Figure 2. Waiting to meet the doctor at a PHC in Bihar
What constraints the Bihar’s School Health Programme?
The resource constraints that plague PHCs and HSCs affect the functioning of the NPSGY school health programme, because the programme is staffed by a team of medical personnel drawn from these two institutions. In 2011-2012, the programme was operated at the level of a PHC, with each PHC being required to draw up an annual plan that provided a health camp in each school within its jurisdiction over the course of the school year. Typically, the team of doctors would move from one HSC to the next, covering all the schools in the first HSC before moving to the next. While most visits to schools within a HSC would occur over the course of a month, the entire programme of coverage of all HSCs in a PHC could take several months, depending on the number of schools in the geographical zone covered by the PHC.
A striking feature of the implementation of the programme is that the time allocated to any given school did not vary with the number of children enrolled in the school. Instead, the programme allowed just one day per school.1 This practice of allocating only one day to each school was undoubtedly a consequence of the scarcity of doctors in PHCs; withdrawing doctors to visit schools meant exacerbating the acute shortage of doctors available at the PHC.
This practice, combined with the relatively large size of schools in rural areas of the state, meant that unreasonably large numbers of children had to be covered in the course of a day. To give some idea of the numbers involved, Table 1 abstracts data from the plan for one PHC. For the PHC as a whole, the average number of children targeted per day was 370. Assuming 7 hours of work in a day, if all targeted children were indeed covered, this would imply that the time available for an individual child’s checkup would be only 1.14 minutes. Even a 50% absenteeism rate would imply only 2.3 minutes per child.
Aggregate school attendance and programme coverage
Given this resource constraint, it is more than likely that low coverage rates reflect the inability of the medical team to provide health checkups, even to students who were present on the day of the checkup. If this is the case, then any increase in attendance in schools, rather than increasing coverage under the programme, may very well decrease it; an increase in the number of students to be examined by the health team would lower the probability of any given child receiving a check-up.
I tested this hypothesis, using survey data on students enrolled in 32 schools of the state (Kochar 2013). The data provided detailed monthly information on attendance of students in grade 2, as well as information on whether each child received a health checkup or not. Using this data, I explored the effects of the student’s individual probability of attendance in the month of the school visit as well as that of aggregate attendance at the school level. Inferring the causal effect of both individual and aggregate levels of attendance on coverage is rendered difficult by the fact that programme coverage could cause attendance, rather than the other way around. Kochar (2013) outlines the methodology used to deal with this issue.
The research reveals that individual attendance does, as expected, increase the probability of coverage. However, consistent with binding resource constraints caused by the large number of students to be examined relative to the availability of doctors, higher aggregate attendance in a school in the month of the school visit significantly lowers the probability that any given individual student will receive a health checkup.
A policy paradox
The results therefore present a policy paradox - Improved coverage requires improvements in attendance. Yet, improvements in average attendance, if unaccompanied by investments in additional health and schooling personnel, will only lower coverage. Essentially, coverage of the programme is constrained by the lack of sufficient number of health personnel, a constraint that cannot be reduced by shifting the delivery point of health programmes from health institutions to schools.
In the case of very large schools, two teams were sometimes assigned to the same school for the day. Conversely, small schools were frequently combined with other small schools, with one day being stipulated for the coverage of the combined population of these schools.
- Jamison, Dean T., Joel G. Breman, Anthony R. Measham, George Alleyne, Mariam Claeson, David B. Evans, Prabhat Jha, Anne Millsand, Philip Musgrove (eds.) (2006), ‘School Based Health and Nutrition Programs’, in Disease Control Priorities in Developing Countries, 2nd Edition, Washington, D.C.: The World Bank.
- Kochar, Anjini (2013), “Providing Health Checkups Through Schools: An Evaluation of Coverage in Bihar’s School Health Program”, Stanford University, Manuscript