Tackling Corruption in the Health Sector

This blog is part of a series. The first blog can be found here.

In my previous blog, I explored petty and grand corruption in the health sector. In this blog, I look at the main causes of corruption in the sector which arise from the following:

First, there is a lack of useful information available to users of the health protection system. In many health institutions, there is lack of information on what services are provided, where and when they are provided, who provides them and the procedures to be followed. This creates an environment for soliciting and paying bribes and also tempts many lower and middle level staff to turn into middlemen and accept a cut for making such services available.

Second, there is excessive red tape, understaffing and therefore, long queues. Some processes and procedures, even if they are necessary, can result in long queues if there are shortages and inefficiency. This again leads to speed money bribes for jumping queues. This again arises due to  unrestricted influx of patients to government hospitals and a weakly functioning referral system (even if it exists on paper) within the government health care hierarchy of institutions.

Third, shortage of medicines and other medical supplies results in long waiting lists, including for elective services like surgical operations. Bribes are collected for jumping the queue. Sometimes, shortages can force hospitals to only perform emergency operations, leading to a higher premia for queue jumping.  

Fourth, comparatively poor salaries might lead health workers (including doctors) to take bribes. One way to overcome this is to allow doctors to engage in private medical practice after their official hours of service, so that they can increase their income even when retained in Government Service. However, this move has had some negative consequences, as follows:

  • Doctors spending official hours in their private clinics, whilst absenting themselves from government hospitals, leaving patients unattended.
  • Doctors using government facilities and medical supplies to treat their private patients on priority basis.
  • Doctors using public facilities as a conduit to channel clients to their private facilities.
  • Doctors prescribing medicines that they know are not available in government facilities, and advising patients to procure them from their private facilities.
  • Theft and pilferage of medicines, equipment and consumables from public health facilities.

Fifth, poor management and supervision of health workers leaves them unchecked to do whatever they want to do. This leads to a breakdown of the management structure within a health institution. For example, the head of the institution may hesitate to take action against a junior staffer, who becomes more influential due to closeness to a powerful politician or bureaucrat (doctors who treat VIP patients are often treated leniently by their politically powerful patients). These become poor examples of good management for junior staff and more doctors attempting to build their influence through cultivating rich, famous and politically influential patients.

Sometimes, institutions that are designed for improving management, themselves become institutions of exploitation and corruption. For instance, local politicians and newly constituted local advisory bodies have the potential of improving the management of institutions. Instead, they often increase mismanagement by using their influence and power to seek individual favours. Sometimes, they build unholy alliances with corrupt interests and increase, rather than decrease the prevalence of unethical and corrupt practices at all levels. The media, through their potential for undertaking sting operations, can become institutions of exploitation and extortion too.

Unionisation of staff can lead to arm-twisting of hospital managers, unprofessional behaviour and mafia style running of corrupt syndicates that can powerfully resist reforms. They can also influence postings and transfers of senior managers.

Sixth, some kinds of corruption arise out of disregard of the law and/or its intentional breach. In many such cases, there is also collusion from the public and therefore, rarely do such instances come to light. Examples are as follows:

  • Pre natal sex determination tests;
  • Submission of false post-mortem reports, or doctors looking the other way, when the police falsify dying declarations in the case of victims of dowry related offences;
  • Trading in organs for transplantation;
  • Undertaking tests of medicines on patients, without authorisation or their consent. Sometimes, these battery of unnecessary tests are made expensive in the name of doctors giving themselves protection against accusations of negligent treatment later on.

In my next blog, I discuss various strategies for the reduction and hopefully, the elimination of corruption in the health sector.

Also Read: How the Lack of Information Can Affect Health Insurance Schemes

Policy Buzz: Budget Special

Keep up-to-date with all that is happening in welfare policy with this curated selection of news, published every fortnight. Our first edition is a Budget 2019 special, and focuses on the budget and social sector spending. 

Policy News

General

  • The Union government has shortlisted 167 big bang ideas that are to be implemented in the first 100 days of its tenure. These ideas will be selected after several rounds of presentations by all ministries. Additionally, they have also been asked to put out performance monitoring dashboards on all major schemes to enable public access to the progress made on these schemes.

Education

  • In a bid to improve teaching-learning outcomes and give a boost to the teaching profession, the Government of India is introducing a four year course – the Integrated Teacher Education Programme (ITEP) for pre-service training. The course will offer graduation in Primary and Secondary education.
  • The deadline for public feedback on the draft New Education Policy (NEP) has been extended by the government. The new deadline is 31 July 2019. NEP will be the lodestar for school education in the country. We have put out two blogs for you on why ‘non-teaching’ work in government schools and  grade-specific learning  warrant more attention in the new policy.

Health

  • The draft National Digital Health Blueprint (NDHB) has now been released for public comments. NDHB will focus on digital technologies to widen the provision of healthcare services. It has “specific details of the building blocks required to fulfill the vision of National Health Policy 2017”. 

Water

  • Finance Minister Nirmala Sitharaman has made the provision of piped water supply to every rural household a top priority by promising Har Ghar Jal by 2024 under the National Rural Drinking Water Mission in her Budget speech. Meanwhile, the Meghalaya Cabinet passed a draft water policy, making the state first among its peers to formulate such a policy. The need for coherent policy action on water is apparent given acute water shortages in parts of the country, including Chennai and Bengaluru.

Opinion 

Budget 2019 has been widely discussed, critiqued and appreciated. But what does the Budget hold for the social sector? A detailed analysis by the Accountability Initiative team on social sector schemes run by the Government of India can be found here, and features trends in allocations, expenditures and outcomes. This time, we have put together an interactive resource to provide you with a comprehensive overview of 10 major welfare schemes and their progress. Explore the new website for easy-to-understand facts from our latest Budget Briefs.

Calling Budget 2019 a ‘lost opportunity’, Yamini Aiyar (Founder, Accountability Initiative) writes, “with its resounding mandate, the government could have embarked on structural reforms, but instead has chosen an incrementalist approach, making clear- Modi 2.0 is going to steer the familiar course.”

Avani Kapur (Director, Accountability Initiative) opines that, on the one hand, allocations for welfare schemes in education, health and supplementary nutrition have increased from the 2018-19 Revised Estimates, there haven’t been many changes from the Interim Budget in February. In another piece, she and Ritwik Shukla (Research Associate, Accountability Initiative) discuss how the health budget seems to have prioritised Health System Strengthening under the National Health Mission, which will assist on public health facilities meeting Indian Public Health Standards (IPHS) and providing quality care. There is, however, a need to intensify public expenditure on health.

 

How the Lack of Information Can Affect Health Insurance Schemes

The roll-out of the Pradhan Mantri Jan Arogya Yojana (PMJAY) has been a frenetic affair (over 4 crore e-cards issued in less than 10 months). PMJAY is a massive health insurance scheme which aims to protect poor and deprived families from catastrophic expenditure arising out of health shocks by providing up to ₹5 lakh as cover. The apparatus for the scheme is complicated with several moving parts – private and public hospitals, insurance agencies, government-run trusts, a cadre of 1 lakh frontline workers, and over 50 crore insurees.

Running a health insurance scheme of this magnitude requires the availability of a vast amount of information – on who can provide quality health services, who is eligible to avail claims, which illnesses are covered, who requires what treatment, etc. However, access to information is limited as it is not a freely available public good, and usually one individual or group possesses more information than others.

Information asymmetry can be defined as a situation wherein one party in a transaction possesses more information and knowledge than the other party. Information asymmetry is intrinsic to everyday life. It is practically impossible for both parties in a conversation, exchange, or transaction to possess the exact same level of information. One party possessing more information than the other can enable that party defrauding or taking advantage of the other party.

One of the fundamental problems in healthcare systems across the world is the vast information asymmetry that exists between doctors and patients. Doctors obviously know more about medical practices than their patients due to their extensive educational background and training. Hence, patients facing life threatening illnesses need to believe, and do believe, that the power of physicians is greater than it actually is.

The lack of medical knowledge among people, in some cases, puts them in vulnerable positions prone to abuse and exploitation by a profit-minded healthcare provider. In India, widespread illiteracy and the absence of basic medical knowledge makes matters even worse. The imbalance of information thus leads to a power imbalance.

 

It is crucial to pay attention to regulatory measures and awareness generation if we are to see the scheme achieve its full potential.

 

One such example is that of Caesarean Section Deliveries. In India, caesarean section rates are amongst the fastest rising in the world and are much higher in private institutions than in public institutions, with information asymmetry and profit seeking by private institutions being contributing factors. Over 40% of all deliveries in the private sector are C-section while the same is only 11.9% in the public sector (National Family Health Survey-4, 2015-16). The proportion of C-section deliveries in the private sector are much higher than the WHO recommended maximum limit of 15%.  In the states, the proportion of C-section deliveries are as high as 58% in Telangana, and in Andhra Pradesh they are more than 40%.

Most women are unaware of the health implications of a C-section.

Though C-sections are crucial under certain medical conditions, a rate as high as 40% is virtually impossible to attain if C-sections are conducted based solely on medical evidence. The disastrous consequences are listed in a 2018 report in The Lancet, which pointed out that unnecessary caesarean sections increase the prevalence of maternal and child mortality and morbidity.

A cautious note on health insurance 

Health insurance can complicate matters. When individuals have tight budget constraint or have less to spend, they are far more vigilant while spending. With health cover, that budget constraint is lifted, and people are willing to spend more. The Lancet study points out people with more money are likelier to spend on a procedure like a C-section, even when it may not be necessary. Therefore, the fact that people have more to spend on their healthcare is welcome, but the accompanying challenges within the context of an information imbalance (discussed above) must be acknowledged and addressed. 

Insurance coverage increases a person’s health budget, and they are tempted to go to an expensive, private hospital. As per the National Health Family Survey 2015, 55% of households prefer private hospitals over public hospitals. Apart from the poor infrastructure and poor quality of services provided by public hospitals, the perception of high cost treatment as quality treatment contributes to this trend. 

Package rates under PMJAY are fixed, so people may not exhaust their cover by going to a private hospital but are likely to incur higher out-of-pocket expenditure. This is because several health issues require multiple check-ups that typically occur 15 days after hospitalisation ends, the point after which outpatient care is no longer covered by PMJAY. Non-hospitalised treatment is far costlier in private hospitals, compared to government hospitals. While some outpatient care costs are covered, people may inadvertently spend more than they want to, if they aren’t provided adequate information about treatment options and the costs involved upfront. In some cases, this may lead to people having to borrow, or worse, stop treatment.

 

Also Read: India’s new tryst with government health insurance here

 

Furthermore, insurees are rarely aware of the services covered under the health insurance schemes. Both RSBY and PMJAY provide insurance coverage only for hospitalisation expenses and day care surgeries. Consultation fees, costs of diagnostic tests, expenses on medicine have to be paid by the patient if it doesn’t lead to hospitalisation. This is damaging especially if one is unclear about terms and conditions of insurance and has false expectations about what is covered. This situation breeds mistrust and resentment. There have been many instances reported of insurees feeling denied of insurance benefits they feel are due to them. People may be unwilling to use health insurance, even though they acknowledge the risks and rising costs of healthcare.

Thus, given that lives are at stake, information asymmetry in medicine and health needs to be addressed with greater incisiveness. There are some ways to bridge these information gaps.

Steps to address the issue 

Firstly, ‘trust’ has a role to play in managing the problem of information asymmetry. For the system to work, people need to trust that doctors will provide the right care and that the government will ensure that those eligible will receive cover, etc. Fraud and medical malpractices are a feature of health insurance schemes across the world. Therefore, to build trust, the government needs to act as a strong regulator.

Under PMJAY, an anti-fraud cell has been set up at the national level and officers under the cell are responsible for assessing fraud management capacity of states, liaising with anti-fraud cells of SHAs and developing state specific recommendations to strengthen anti-fraud measures. District Vigilance and Investigation officers under SHA undertake fraud investigations to ensure strict compliance to beneficiary identification, hospital empanelment and pre-authorisation guidelines. Additionally, a grievance cell and helpline has been set up. Their work will not be easy. While the government has put regulatory mechanisms in place, deep-rooted and systemic corruption is likely to pose a challenge to the implementation and enforcement of anti-fraud provisions exacerbated by weak capacity of the union and state governments.

Providing information directly to users is another option. People who reach empanelled hospitals can talk to Pradhan Mantri Arogya Mitras, the frontline cadre for PMJAY. However, if one wants to reach people, especially in the most deprived areas of the country, then the existing cadre of frontline health workers should be mobilised. Training frontline workers like Anganwadi Workers, ASHAs, and Auxiliary Nurse Midwives to disseminate information and interact closely with beneficiaries has been a step towards behaviour change in the domain of health, especially in rural India.

The functions and mandate of ASHAs, ANMs and Anganwadi workers can be expanded to include generating awareness about health insurance schemes. Visual aids and refresher training can be used to simplify complex information and improve retention, and providing frontline workers with pictorial job aids will assist them in conveying information effectively. However, frontline workers are often overworked and underpaid, and it is necessary to address these issues. Reaching out to several people at their homes is a mammoth task and expecting frontline workers to conduct this exercise on top of their other work might be unfair.

The stakes are high, and only time will tell whether health insurance in India can successfully deal with informational asymmetry. It is, however, crucial to pay attention to regulatory measures and awareness generation if we are to see the scheme achieve its full potential.

Ritwik is a Research Associate at Accountability Initiative and Shaivya is an intern. 

Types of Corruption in the Health Sector

As with most other sectors, corruption in the health sector can be classified into two categories, petty corruption and grand corruption. In addition, there could be another category, namely, the widespread prevalence of unethical and abusive practices. Each is described below.

Petty corruption refers to relatively small amounts paid in order to get services that are either free, or subsidised. While these amounts might be individually small, they amount to a big burden because they are usually demanded of poor people.

The typical petty corruption related to the health sector that people experience are as follows:

  • Bribes to gain access (to wards, to enter restricted areas such as labour wards)
  • Bribes to jump queues, (out-patient department, laboratory sampling)
  • Bribes to get free services (for X-ray, medicines, diet supplements)
  • Bribes to get admission or discharge from the hospital, or to release bodies from the mortuary.
  • Bribes to obtain certificates on medical condition, such as fitness certificates, disability certificates etc., which are required for various purposes such as foreign travel, professional recruitments etc.

Such bribes are usually picked up by the staff in medical institutions and doctors might not be directly involved (except in the case of the issue of medical certificates). However, the passing on of cuts to doctors might not be ruled out. 

Grand Corruption relates to large volume corruption, often involving a team of officials, doctors, private sector agents and politicians. Instances of grand corruption in the health sector are:

  • Procurement corruption (to win tenders for supply of pharmaceuticals, medical equipment and hospital supplies, civil construction or repair contracts). This can result in over-invoicing, supply of substandard equipment, supplies etc., sometimes having shorter life span or shelf life in case of medicines, over-supply of some items in excess of requirements. This might also result in excessive preference shown for one of the other brand of a drug, when cheaper generic (and equally effective) products are available.
  • Corruption for postings and transfers of doctors and other staff to ‘lucrative’ positions, (where they have access to better private practice, more openings for diversion of medicines, or cultivation of influence).
  • Corruption in certification of facilities and the provision of mandatory recognition of departments and medical colleges, following inspection.
  • Corruption in admissions, examination marking and passing students in medical colleges, particularly in respect of specialty and super-specialty post-graduation courses.

An even more serious phenomenon is when grand corruption snowballs into increased petty corruption, because of artificial shortages, or more expensive medicines and other supplies, leading to a more bribes being paid for these at the customer interface level. Grand Corruption can also be integrated with petty corruption. Typically, this happens when profits from bribes taken at lower levels is shared up the ladder, through ‘pre-paid’ arrangements – a lump sum payment to secure a lucrative posting and regular monthly payments, collected from below, channelised upwards with a cut for everybody involved.

Other Unethical and Abusive practices:

Apart from the usually adopted classification of corruption into petty and Grand corruption, there is another category of corruption prevalent, which is in the nature of corrupt practices arising from the breach of the very same internal code of ethics that give doctors their credibility and status. I once held discussions a few years back with experts having a high moral foundation from a well-reputed health care institution in Bangalore. From this educative discussion, one pieced together some of these practices that are typically seen:

  • Accepting percentages or gifts from other doctors, hospitals, laboratories, imaging centres, pharmacies, pharmaceutical companies and medical equipment companies for referring patients to them or using their products. Known as ‘cut’ practice, this is a widespread phenomenon, with both doctors and those who give them such gifts or percentage, not considering these to be bribery in any form.
  • Suggesting unnecessary laboratory tests.
  • Undertaking unnecessary treatments, such as Caesarians, when normal deliveries are possible.

Amongst doctors, there is very little understanding of the distinction between unethical and (corrupt) practices. There is a significant prevalence of unethical practices, with most doctors who indulge in these believing that these are not wrong at all. There is a group of doctors (probably a majority) who actually believe that there is nothing wrong with earning from kickbacks and cuts.

Unethical and monopolistic practices in the pharmaceutical business:

The pharmaceutical profession generates a large portion of the grand corruption seen in the health sector, largely because of extortionate and disproportional pricing of medicines beyond the raw material and production cost, in the name of covering R&D costs and IP protection and bribes in cash and kind paid to doctors for prescribing medicines.

Yet, in conclusion, it must be emphasised that many of these practices are certainly not considered to be ‘corruption’ within the strict framework of the law. For example, high prices by pharmaceutical companies are perfectly legal, even though one may call it a way to obtain windfall profits, through seductive advertising, cartelisation and ‘persuasion’ of doctors to prescribe such drugs. Furthermore, it is not as if all doctors are corrupt, if the strict definition of corruption to be an unacceptable act performed by a public servant is taken into consideration. Yet, there is a natural and moral understanding of the meaning of the word, ‘corruption’. Plenty of professional acts in the private sector, in the view of a reasonable man or woman, would certainly be considered as corruption.

In my next blog, I look at how such ‘grey areas’ of corruption may be tackled. I continue with my case study of the health sector.

This blog is part of a series. The first blog can be found here.

श्रृंगार से बढ़कर स्वच्छता

कहते हैं कि जब इंसान किसी चीज को एक बार करने की ठान लेता है तो फिर कोई चीज उसे वह हासिल करने से नहीं रोक सकती|

एक ऐसी ही वास्तविक कहानी बिहार के वैशाली जिला में स्वयं सहायता समूह की एक दीदी की है जिसने स्वच्छता के अर्थ को समझा और उसे हासिल किया|

दीदी के अनुसार उसने खुले में शौच जाने का वहिष्कार ऐसी स्थिति में किया जब एक तरफ उसका विकलांग पति तथा ऊपर से गरीबी इस कदर थी कि अपने परिवार के लिए दो वक्त की रोटी जुटाने के लिए भी संघर्ष करना पड़ता था| दीदी ने स्वयं सहायता समूह से जुड़कर बचत का काम शुरू किया था| जब वह स्वच्छता के महत्व को समझ गई तो उसने मन में यह ठान लिया कि चाहे अब कुछ भी हो लेकिन अब वह भी शौचालय का निर्माण करायेगी|

स्वच्छ भारत अभियान के तहत शौचालय निर्माण हेतु सहयोग राशि के रूप में प्रत्येक परिवार को 12000/ रुपये देने का प्रावधान है| दीदी का कहना है कि इसके लिए उसने हर तरह का प्रयास किया, सरकारी दफ्तर के चक्कर लगाये, अपने पंचायत के मुखिया से अनुरोध किया और अंत में अपने परिवार वाले से सहयोग माँगा| काफी लोगों ने उसे पूर्वजों का उदाहरण दिया कि पूर्वज मल त्याग के लिए खेत खलिहान में खुले में शौच के लिए जाते थे|

दीदी बताती हैं कि उसे अपने विवाह में कुछ गहने/जेवर मिले थे, जिन्हें उसने संभालकर रखा था ताकि जरुरत आने पर वह उनका इस्तेमाल कर सके| दीदी के अनुसार, उसने सरकार की तरफ से मिलने वाली राशि का कुछ दिनों तक इंतजार किया परन्तु सरकार की तरफ से स्वच्छता दूत के माध्यम से शौचालय निर्माण के लिए कितनी सामग्री की जरूरत होगी, यह दीदी को पता था| अंत में जाकर उसने पति और परिवार से चुपके अपने गहने/जेवर बेच डाले और उन पैसों से शौचालय का निर्माण के लिए आवश्यक सामग्री खरीद डाली|

स्वयं दिन-रात मेहनत कर गढ्ढा खोदा और शौचालय का निर्माण करवाया| फिर क्या दीदी समाज के लिए एक उदाहरण बन गयी| दीदी बताती हैं कि अब उसे तथा उसके पति को घर से बाहर खुले में शौच के लिए नहीं जाना पड़ता| इस तरह दीदी ने अपने शौक की वस्तु को त्याग कर स्वच्छता को अपना लिया| दीदी समूह से जुड़े होने की वजह से दूसरों को प्रेरित करने में सक्षम हैं|

दीदी बताती है कि अब उन्हें सरकार से मिलने वाली 12000 रुपये की राशि भी प्राप्त हो चुकी है| देरी हुई लेकिन मिल गयी| अपने गहने जेवरात बेचे जाने को लेकर दीदी बोलती हैं कि श्रृंगार से कहीं बढ़कर ही तो स्वच्छता है|

अतः इस प्रेरणादायक कहानी से एक चीज़ समझ में आती है कि यदि हमें सामाजिक कुरीतियों के खिलाफ़ लड़ना है तो स्वयं भी जागरूक होना जरुरी है तथा दूसरों को भी उसके प्रति प्रेरित करना होगा| यह अवश्य ध्यान में रखना होगा कि सरकार ने यदि किसी योजना के तहत जो भी मानक तय किये हैं, उनका अवश्य अनुसरण करते हुए योजना का लाभ उठाना चाहिए|

Going Beyond Foundational Learning is a Need

“By 2025, every student in Grade 5 and beyond has achieved foundational literacy and numeracy”

The above quoted objective is the crux of National Education Policy Draft’s chapter on Foundational Literacy and Numeracy, which begins with an acknowledgment of the learning crisis that has been plaguing the Indian education system for years. In making this argument, it seconds ASER documents and World Bank reports, wherein they point out alarming data on how more than 50 % of India’s population is unable to adequately read, write or engage with numbers. The draft concedes the immediacy of this crisis as it wastes no time in establishing the ways in which it hopes the government would tackle this problem. Despite this recognition and a well-intended objective, one observes that the draft is vague in its proposed solutions, alongside certain factors that propagate the learning crisis.

In order to get to these issues, one will have to first understand their proposed solutions.

In this draft, the K Kasturirangan Committee set about resolving the problem by claiming that a major cause for the crisis is the “lack of school preparedness” or the lack of early childhood care. They lay out a framework for parents and anganwadis in the draft’s previous chapter to account for this care and preparedness. A school preparation module will be introduced for the first 3 months of grade 1 to ensure that students are equipped with the necessary cognitive tools to start their syllabus. The draft also argues for an increased focus on foundational skills in these early grades as they plan to redesign classroom material, hold language/mathematics weeks and melas etc (59). This will be accompanied by the National Tutors programme, wherein senior students with good academic records will tutor their junior counterparts.

The committee has also recognised the importance of nutrition and health in a child’s education. It puts forth an expanded mid-day meal programme to ensure that the classroom is more productive than usual (58). In this context, they have had much wider perspective on trying to understand what factors affect education.

They propose “a mission-mode dedication to remediation” for all students who are already in school, having fallen behind their expected level. They hope to achieve this through the “Remedial Instructions Aides Programme,” a temporary project of 10 years that will draw instructors from local communities to hold special remediation classes, during and after school hours (60).  While the idea in itself is necessary, it is not expanded on in the draft and therein lies the vagueness of this chapter. The programme is meant to help students “who have fallen behind” but there is no clarity on whether the help is restricted to foundational education. Does this mean that the programme will help a 7th grader in reading or writing but will not be equipped to help them reach their grade level? In such a situation, the learning crisis will not be resolved as the transition from foundational to their required level of academics will not take place.

There is a mention of “second chance education programmes” in the following chapter on dropouts. Dropouts who are of the age 15 and above will be enrolled in adult education schemes to attain foundational literacy. However, they could also follow this up with vocational training programmes and an elaboration on how transition can take place to ensure the student is able to stay on his/her required level (70). The draft is lacking in a discussion on transition from foundational basics.

Educationist Anita Rampal, in her comments on the draft would point out that while the draft accepts the problems of rote learning in primary education, it does not address the fact that this mechanical mode of pedagogy looms over the Indian education system in general. This is important as it highlights the fact that even if one assumes that the proposed solutions will produce students with strong foundational skills, they will still have to enter a system in their secondary school wherein the focus is on lecture based rote learning. Therefore, it is not just dropouts who would struggle with transitioning to their level of academic expectation. The students coming up might also face the same set of issues as this point calls for the need to address pedagogy across the system to minimise the significance of rote learning. The issue of transition is not just in terms of content, it could also be in the context of teaching methods.

In conclusion, the point being made is that our nation’s learning crisis is not limited to attaining foundational literacy. While it is of the utmost importance and the draft has put thought into tackling that issue, it is incomplete without a plan to help students transition to their existing levels.

Gokulnath is a Research Associate with the Centre for Policy Research.

Perspective is of the author and does not represent an institutional stand.

Why ‘Non-Teaching’ Work should be Clearly Defined in the New Education Policy

In my previous blog I discussed the burden of non-teaching tasks that teachers routinely engage in and findings from a self-reported time use study and perception survey we conducted with government teachers in Delhi (link to the report here). The study involved 200 teachers from two of the largest education departments in Delhi i.e. the Municipal Corporation of Delhi (MCD) and Directorate of Education (DoE).

Here I will address how the new National Education Policy draft addresses the question of non-teaching tasks and what changes it proposes in this regard.                                                             

Election and survey duties remain

The draft NEP retains teachers’ role in election and survey duties. Election duty, particularly BLO (Booth Level Officer) duty, has been a longstanding sore point for teachers because it involves going to door-to-door updating the electoral roll. In our perception survey, female teachers in particular often raised issues of personal safety, having to travel to far-off localities and working well into the night for election duties. While some states have banned the involvement of teachers in BLO work outright, others continue to engage teachers in the same. Recently, NITI Aayog recommended stopping the deployment of teachers as BLOs, however the Election Commission stated this was ‘unwarranted’.1

The involvement of teachers in official surveys has been a contentious issue for similar reasons. In Delhi, we found that MCD school teachers in particular were more occupied with surveys, reportedly spending 14 days on average on the same. Teachers were mostly involved in conducting the Child Census, as well as an unofficial door-to-door survey around admissions season to increase enrolment in their school’s locality. At times, teachers also reported being pulled into surveys that were removed from the sphere of education entirely, such as a survey of functional streetlights in the locality.

The MDM burden doubled

While the NEP clearly specifies teachers are not to be involved in cooking mid-day meals (MDM), it fails to account for the time teachers spend on managing MDM every day. Time use data from Delhi, showed that MDM routinely exceeded the allotted 20 minutes, with teachers spending upwards of half an hour on average on the task. This was due to the time taken to queue up the class, assist children in washing their hands, taste and distribute food, wash their tiffins and help clean up afterwards. Furthermore, teachers are then required to record and upload MDM data online. The time required for this daily activity remains underestimated and could potentially be doubled with the introduction of breakfast in schools, as proposed in the draft NEP.

School complexes – a boon or bane?

The draft proposes the creation of school complexes, which will include one secondary school along with other schools offering lower classes within the same neighbourhood. Among other things, the school complex will be an organisational unit allowing for the sharing of resources across schools in the complex. However, the responsibility for managing the complex, and handling its administrative, financial and academic affairs has been handed to the principal of the secondary school, who will also be the head of the complex. The effects of the burden placed on one school, will inevitably trickle down to its teachers who could potentially be pulled into additional school complex management related charges, for instance maintaining records of resources and staff shared across the complex. Our study found that teachers who were given heavy ‘additional charges’ generally ended up delegating the work among other teachers, therefore affecting multiple teachers’ teaching time and leading to a collective feeling of being overwhelmed with administrative work.

The responsibility of recordkeeping and data management

Findings from our perception survey showed that 93% of teachers felt paperwork took up a lot of time. This was due to data duplication, records being maintained in both hardcopy and softcopy, as well as lack of or poor quality of clerical and IT staff. Overall recordkeeping reportedly occupied 9% and 11% of time in MCD and DoE schools respectively.

The NEP draft proposes support staff to handle general administration and “any non-teaching tasks”. While this is a welcome move, particularly in schools where there is presently no administrative staff, it should be noted that having support staff alone may not suffice. Our teacher time use study in Delhi, found that despite having clerical and IT staff for instance, teachers in DoE schools remained heavily involved in recordkeeping and data management. Clerks in DoE schools often willfully stayed away from maintaining and managing school records and data, instead limiting themselves to handling salary records. It is crucial therefore, to clearly define non-teaching tasks to include work such as recordkeeping and data management, and simultaneously expand the role of clerical staff to incorporate the same.

Arriving at a definition of “non-teaching” work

Findings from our perception survey, highlighted confusion among teachers regarding the exact range of their roles and responsibilities. This was particularly the case for work that was neither directly teaching-learning related nor entirely clerical and far removed from their core job as teachers, but fell somewhere between the two extremes. This included for example, teachers’ involvement in MDM, health check-ups and responding to official mails and circulars.

A reason for this confusion is the RTE Act itself. While Section 27 of the RTE states that teachers are prohibited from being deployed for “non-educational purposes other than the decennial population census, disaster relief and election duties”, Section 24 lists the duties of a teacher and vaguely states that teachers must “perform such other duties as may be prescribed.” Meanwhile, the NEP draft only uses the term “non-teaching work”, and vaguely defines this as “any time-consuming administrative assignments”. This leaves enough wiggle room and does not help in moving towards a clearer definition of the work teachers should and should not be doing.

In order to make its proposal of removing teachers from all non-teaching work actionable, the NEP should first consider clearly defining what the terms ‘non-teaching’ and ‘non-educational’ work entail. Additionally, in its proposed comprehensive review of the RTE Act, the drafting committee should consider including this definition and addressing the issue of RTE exempt duties like election and survey work, so as to further emphasise its commitment to freeing teachers from non-academic tasks and allowing them to focus squarely on their core role of enabling teaching-learning.

Also read our second piece on NEP: Going Beyond Foundational Learning 

 

References

  1. Kalra, A. (2019, May 8). In Elections, Teachers are like Malko from ‘Newton’, Supportive and Unsung. The Wire. Retrieved from https://thewire.in/

The Grey Area of Professional Corruption

In my blog of 14 June, I referred to the phenomenon of private sector corruption and listed four categories of such corruption. One of the important areas of private sector corruption is the corruption engaged in by those in professional occupations in the private sector.

It is difficult to define Professional Corruption with any degree of precision, for two reasons. First, as private sector corruption is not criminalised, there is no definition of the kinds of corruption that is engaged in by professionals in the private sector. Second, many of those who carry on occupations of professionals holding a position of a fiduciary nature in the private sector, do not even think that what they engage in constitutes corruption. They at worst, think of what they do as a business sharp practice, never corruption.

What exactly do I mean by those who are in fiduciary positions? By this, I refer to doctors, media persons, chartered accountants, lawyers, company secretaries and such like. These professions are governed by strict codes of conduct; indeed, these can be considered as codes of honour, to which professionals who practice these are to strictly comply. These professionals are also governed by voluntary associations of themselves, such as the Institute of Chartered Accountants, the Bar Councils, the Indian Medical Council and the Press Council. These professional bodies lay down the yardsticks to define integrity with reference to their respective areas of professional skill. Violation of these codes of conduct can lead to various degrees of punishment, which depend upon the extent to which unethical and corrupt acts of those belonging to the guild constitute unacceptable behaviour.

In the case of lawyers, for example, a transgressor of the do’s and don’ts of conduct laid down by the Bar Council, can be punished through censuring, or in the most grave of cases, with deregistration and the withdrawal of permission to practice in various courts. In the case of doctors too, there can be a withdrawal of registration, which results in those de-registered not being able to carry out their practice as doctors.

Are these effective?

Not by a long shot, even though the extent of compliance can vary from one profession to another. Two examples will suffice to show the patterns of compliance or lack of it, in selected professional guilds.

The first case study is of corruption in the health sector, and in particular, that which is prevalent amongst doctors, both as individuals and as part of an institution.

The health sector has been identified in many countries as being relatively more prone to corruption. In developing countries, this is often attributed to the fact that health services are in great demand, while the resources to provide adequate services are often inadequate, leading to a premium on their availability. This can also be attributed to the relative concentration of medical services in urban areas in such countries, which drives rural people to come to urban areas for treatment, where they are more vulnerable to fall prey to demands for bribes.

Extent of Corruption in the Health Sector:

According to the India Corruption Study 2007 undertaken by Transparency International and the Centre for Media Studies, Health stands at the seventh position in terms of most corrupt services, out of 11 studied. (Above health comes, Police, Land Records/Registration, Housing, Water Supply Service, NREGS, Forest and Electricity. Health ranks worse than PDS, Banking and School Education). The corruption in the sector is mostly to do with non-availability of medicines, getting admission into hospitals, consultation with doctors and availing of diagnostic services. In particular, the survey revealed the following particulars (Box 1):

More about health sector-related corruption in my next blog.

This blog is part of a series. The first blog can be found here.

Relooking ‘Non-Teaching’ Roles of Government School Teachers

“We have to be counsellors, teachers, government servants, surveyors, mothers and clerks, all at once.”

This statement by a primary school teacher in Delhi, encapsulates the various roles teachers fulfill, many of which are far removed from their core role of enabling teaching-learning. The teacher in question described feeling guilty and frustrated about not being able to spend enough time with her students, and instead having to divert more time towards administrative and other non-academic tasks.

This sentiment is a common one and as a result, recent years have seen an increased focus on understanding the non-teaching tasks teachers do and how this impacts the classroom.

Teachers across the country are found to be engaged in a range of non-teaching work such as election duties, vaccination campaigns, cattle census, government surveys, as well as Aadhaar or ration card verification. Last year, a study by the National Institute of Educational Planning and Administration (NIEPA), found that teachers spend only 19% of their time on teaching and teaching-related activities. Meanwhile the rest of their time is spent on non-teaching core activities (over 42%), as well as school management and other education department related work (38%). 

The newly released draft National Education Policy (NEP), acknowledges non-teaching work as one of the biggest problems facing teachers and attempts to address the issue, stating:

“…aside from the minimal Supreme Court directives related to election duty and conducting surveys, teachers will not be requested nor allowed to participate in any non-teaching activities during school hours that affect their capacities as teachers.”

The draft goes on to cite some specific examples of non-teaching work teachers will be removed from, including: “Cooking midday meals, participating in vaccination campaigns, procuring school supplies”, which is a start, particularly in light of NIEPA’s findings. However, it fails to go into sufficient detail about the range of non-teaching work teachers are engaged in, vaguely including “any other time-consuming administrative assignments.” The NEP does not specify a benchmark for what is considered ‘time-consuming’ in the average teaching day.

Findings from Delhi

In order to understand how teachers spend their time in school, Accountability Initiative conducted a time use study with 200 teachers from both Municipal Council of Delhi (MCD) and Department of Education (DoE) schools across all 13 education districts of Delhi (the report can be found here). The study included a self-reported time use component which measured the time teachers spent on various activities during a school day, and a perception survey to understand how teachers view their roles and responsibilities, their professional identity and workload, as well as their overall experience of working in Delhi’s government schools. Using purposive sampling, teachers who were identified as the ‘busiest’ by their Head of School and colleagues, were selected. This was done in order to capture just how high teachers’ workload can get.

The perception survey showed that 66% of teachers identified non-academic work as the biggest hurdle they face in school. Majority of teachers identified administrative tasks not directly related to teaching-learning as ‘clerical’ and felt they should not be doing them. For example, 87% and 89% of respondents felt they should not have any role in seeding student Aadhaar cards and the opening or closing of student bank accounts, respectively.

Meanwhile, the time-use data showed that teachers were only able to teach for less than half their time in school. MCD and DoE teachers spent 49% and 52% of time in school, on academic activities (ref. figure below), respectively. However, if other academic tasks like sports, classroom management and teaching-learning supporting activities are excluded, the data shows that teaching alone comprised only 41% of time in MCD schools and 39% of time in DoE schoolsSchool management tasks meanwhile took up 39% and 36% of time in MCD and DoE schools respectively.

 

 

Teachers regularly faced disruptions while teaching and this was found to be largely due to routine, essential school management work such as marking and uploading student attendance and mid-day meal (MDM) data. Since MCD schools are only for primary classes, this also included activities like safely handing over students to the parents at the end of the day or staying back after school with students whose parents were late to collect them. In the case of DoE schools, start-of-day classroom management, timetabling and absentee teacher arrangements, as well as checking and responding to mails and circulars, made up the bulk of school management time.

Teachers were also found to be engaged in recordkeeping and data management work, which was often needlessly time consuming due to student data being maintained in multiple formats, as well infrastructure and resource constraints.

Finally, school management tasks often spilled beyond official school hours. Of the 39 hours DoE teachers reported working beyond school timings, 51% time was spent on finishing school management tasks. In the case of MCD schools which reported 49 hours of teachers working beyond school timings, school management work constituted a whopping 94%. Furthermore, instances were found of teachers being sent out of school during school hours, to run errands at the local market, bank and in the case of MCD schools, to the tax office to file income tax returns for all school staff.

The scope of non-teaching work is broad, and there is variation in the types of non-teaching tasks teachers are pulled into, from state to state. In part two of this blog, I look at what the draft NEP proposes to change, and why there is a need for determining exactly what constitute ‘non-teaching’ tasks.

Anupriya Singh is a Research Associate at Accountability Initiative.

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References

  1. Puppala, A. (2018, September 22). Teachers spend only 19.1 per cent time teaching. Deccan Chronicle, Retrieved from http://www.deccanchronicle.com NIEPA