Governance measures to reduce absenteeism

Following the structure of Lewis and Pettersson’s four elements of governance, the authors recommend a diverse range of interventions and mechanisms to engage stakeholders to more effectively reduce health worker absenteeism. Some of the interventions proposed may not succeed if implemented in isolation; combining multiple efforts will be more likely to produce a positive outcome. In large part, the effectiveness of interventions for improving standards, incentives, and information will ultimately provide the foundation for stakeholders to justify the accountability measures they seek to make.

Standards

  • Encouraging participation to set and communicate standards. Leaders and managers should take a participatory approach to set appropriate human resources (HR) standards related to attendance and other relevant performance management areas that will make workers’ and managers’ roles more explicit. Professional councils can play a specific role in reviewing and determining reasonable expectations for each cadre and then advocating for these standards. At the facility level, teams should work together to ensure more equitable shifts, so that workers are not unfairly scheduled or resentful of their hours. Once established, a facility’s patient/provider bill of rights and hours of operation should be posted, communicating them to lower-literacy populations with visual illustrations and through traditional community channels (e.g., at community meetings, with traditional village chiefs) when possible. These lower-cost efforts will help inform communities about what they should expect and demand of the health workforce in their locale, which will encourage workers to be present.
  • Improving working conditions. Work climate plays a critical role in health worker motivation and job satisfaction. There are many low-cost interventions that can be implemented at the local level to improve working conditions. In Kenya, facility-based teams assessed their own working conditions and implemented action plans to improve their environment and job satisfaction. These included making waste disposal safer, improving inventory management, creating staff lounges with free tea, painting and refurbishing facilities, posting facility signage, cleaning yards, and offering continuing education opportunities, all of which motivated health workers to come to work and perform well (Capacity Project 2009). Community involvement and contributions to improve the facility can increase health worker motivation and reduce the likelihood of health worker absenteeism, which in turn enhances the quality of the services they access. For example, community health associations in Mali have helped construct clinic staff housing; provide potable water, cleaning, or laundry services for a more hygienic environment; and offer transport for commuting health workers (Hilhorst et al. 2005).

Incentives

  • Implementing effective incentive packages can greatly contribute to health worker motivation and productivity, including reducing absenteeism. This requires a solid comprehension of workers’ preferences within specific contexts. CapacityPlus’s Rapid Retention Survey Toolkit applies an evidence-based method to determine the optimal package of incentives based on health workers’ motivational preferences. Providing housing near the workplace has been a helpful incentive in rural settings. In Bangladesh, lower rates of absenteeism were recorded among health workers residing close to the facility compared to health workers living farther away (Chaudhury and Hammer 2003). Evaluating working conditions and worker satisfaction may also reveal reasons for skipping work.
  • Recognizing dual employment or authorizing certain hours for health workers to conduct private practice can accommodate for the limitations of public-sector remuneration. In the Dominican Republic, policy-makers incentivized doctors by reducing their official public-sector hours to 20 hours a week so that they could also practice privately (Vujicic 2010). In Indonesia, health workers are permitted to engage in dual employment after completing three years of exclusive public service (Berman 2004). Italy, Austria, Germany, England, and Ireland have introduced privileges for private practice to health workers that meet public-sector performance standards (Kiwanuka et al. 2010). These examples indicate that developing guidelines on dual practice can help reduce absenteeism as well as attract and retain more rural health workers (Macq et al. 2001).
  • Implementing performance-based financing (PBF) can incentivize individuals, teams, or entire facilities. Because these schemes pay based on the results of performance, health workers need to be present and work effectively to receive the financial incentives directly, as a share of a team disbursement or to raise the chances for a facility to receive its eligible benefits. As such, PBF encourages peer-to-peer accountability and increases remuneration and health worker motivation. This approach, used in several low-income countries, can directly influence productivity and access to health services when compensation eligibility criteria are presented to facilities, coupled with strong leadership and technical support in a decentralized health system. The provision of financial incentives through PBF in Rwanda led to significant gains in facility productivity: in the Kabutare district the number of institutional deliveries increased by 233% and the number of referred deliveries by 459% while in another district the number of contacts per inhabitant increased from 0.39 to 0.66 per year (Meessen et al. 2006). Community evaluation of quality indicators in PBF can also motivate health workers to fulfill their contractual obligations.

Information

  • Customizing HR information systems (HRIS) can assist HR managers with information on absenteeism. CapacityPlus’s iHRIS Suite of free open source software has been used in many countries to facilitate evidence-based decision-making in health workforce planning and management. Version 4.1 of iHRIS offers capabilities for district and facility managers to track leave balances and timesheets, and distinguish unexcused absences from approved leave. An integrated electronic payroll helps managers pay workers on time, which can maintain motivation and reduce absenteeism resulting from repeated efforts to obtain paychecks. In eastern Africa, mobile banking has expanded to the rural health worker payroll. Paying nurses and community workers with mobile money has shown to improve health worker retention and reduce tardiness (Doerr 2012).
  • Initiating mHealth innovations. Health workers or communities can use mobile phones with SMS texting capabilities to encourage reporting the presence or absence of health workers, in addition to facility standards, patient waiting times, availability of medicines, and other quality or productivity indicators. Such crowdsourcing applications have the potential to provide managers and health workers with quantitative and qualitative information to develop action plans to address productivity (and/or quality) issues, such as absenteeism. Crowdsourcing can also empower communities to engage with the health system and hold it accountable to meet minimum quality and access standards for service delivery. Anonymous mobile-phone surveys, toll-free phone lines, or e-mail addresses provide outlets of communication for health workers to describe their work environment and housing conditions, make anonymous reports of absent colleagues or cases of harassment, or bring attention to other related components of their work climate. This can be effective, assuming that managers respond in a timely and confidential manner.

Accountability

  • Leveraging political will. Taking a stand to increase health worker productivity through a reduction of absenteeism often requires a high level of commitment and authority as the decision and repercussions can be political in nature. In light of this, stakeholders should evaluate which leaders could be willing to take a stand against absenteeism. To the extent possible, the information they present to these leaders should include the specific factors leading to and consequences of absenteeism in their context, especially in regards to their economic impact and effect on health outcomes. Potential risks and risk mitigation measures should be thoughtfully considered. Advocates for improved accountability measures should consider how the timing of elections and political appointment cycles may affect a leader’s willingness to support their cause. Advocacy efforts should also focus on professional councils and associations to engage them in fomenting high levels of professionalism among their cadres and supporting political decisions and appropriate mechanisms to address absenteeism of the health workforce.
  • Enforcing sanctions. Managers and communities should be committed to hold health service providers accountable for their processes and outcomes. Transparency is essential in defining the indicators and processes for enforcing HR standards and applying appropriate disciplinary measures. If standards and rules are established but not enforced, health workers could actually be disincentivized to follow them, which can slowly unravel other efforts to reduce absenteeism. While it is never a pleasant undertaking, sanctions must be imposed if specified outputs and outcomes are not delivered (Lewis and Pettersson 2009). Professional councils, managers, and health facility teams can work together to decide what consequences are reasonable for occasional, chronic, and severely chronic absenteeism. Punitive measures should allow for adequate recourse, with step-wise warnings to avoid firing workers and leaving posts vacant for long periods (Vujicic 2010). It may be easier to take small disciplinary measures that respond to minor infractions to set the tone of “zero tolerance” than to impose serious sanctions after absenteeism has been taking place for a long time.

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