Stakeholders in governance

Stakeholders in governance graphicReducing absenteeism requires a decentralized approach involving broad stakeholder groups to reinforce accountability mechanisms for addressing governance issues. These stakeholders include: 1) management, 2) health professional schools, 3) health professional councils and associations, 4) health facility teams, and 5) communities (see figure at right).

  • Management (e.g., Ministry of Health officials, regional directorates, district health management teams, facility managers) can more effectively address absenteeism by making it a political priority. Policies against absenteeism must be reasonable, widely communicated, and enforced through transparent processes and with methods for recourse. In turn, health workers should be able to hold their managers accountable for setting standards, providing promised incentives, and addressing their concerns about compensation, posting, working conditions, and incentives.
  • Health professional schools can play a formative role in reducing absenteeism if they are selective and strategic in whom they recruit and train. Recruiting applicants from rural backgrounds, as well as integrating rural clinical practica and modules on rural health and professional ethics in training curricula, can instill in health workers the value of and need for rural service.
  • Health professional councils and associations can organize members into communities of practice to help define sustainable standards as well as advocate for enabling working environments. Staying connected to a broader network of colleagues can motivate workers and increase job satisfaction. The councils and associations should be the primary advocates for ensuring professionalism of their cadres, instilling respect for their vocation. They are well placed to combat absenteeism, deeming it as “unprofessional” behavior, and thus to endorse and follow through on appropriate sanctions. For example, in Rwanda and Zambia, some sanctions have been successfully conducted by civil service associations (Vujicic et al. 2009).
  • Health facility teams can promote peer perception and collegial pride, cited as reasons motivating health workers to report to work (Chaudhury et al. 2006). Given their quotidian involvement, facility managers have the opportunity to understand and address the underlying causes of staff absenteeism. In Rwanda, health facility managers have been instrumental in implementing appropriate measures (Vujicic et al. 2009). Peer or team supervision can also be an effective first-line approach for holding colleagues accountable to fulfill their duties.
  • Communities (e.g., municipal authorities, traditional leaders, civil society groups, community health associations, patients), as the beneficiaries of health services, should play a strong role in gathering information and providing feedback on health worker absenteeism. In Mali, where some communities may directly hire nurses for rural posts, members are more likely to demand a return on investment (Hilhorst et al. 2005).

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