Underlying governance issues affecting health worker absenteeism

Unexcused absences within the health workforce perpetuate in part because there are insufficient governance mechanisms to address the underlying issues (Lewis and Pettersson 2009; Vujicic et al. 2009). Building on Lewis and Pettersson’s (2009) definition of governance, the reasons for absenteeism can be attributed to a breakdown in one or more of these fundamental elements: standards, incentives, information, and accountability.

Failure to meet health worker and facility standards

  • Standards that are not transparent or well known: Staffing norms may not be known or adhered to. Workers may have unclear job descriptions and inappropriately structured assignments. Many health systems do not adhere to a fixed number of allowable days or hours for employees to take off, or schedule workers’ shifts equitably. Further, standards of service quality are compromised when staff with inadequate skills are required to perform the jobs of absent workers.
  • Insufficient supervision: Inefficient organization, prohibitive costs, inadequate skills, and insufficient time prevent supervisors from providing supportive supervision to staff, especially in rural and remote areas. Supervisors are often not located at the same facility so they are unaware of or unable to adequately document their supervisees’ absenteeism. Health workers do not receive sufficient professional support for needed skills trainings and mentoring. Further, centralized supervision limits their participation in problem-solving and decision-making at health facilities.
  • Poor working conditions: Inadequate supplies, outdated or missing equipment, and lack of potable water and/or electricity demotivate workers. Unsafe work environments as well as workplace violence and insecurity—including isolated overnight shifts, harassment, and gender inequities—may result in absenteeism.

Ineffective health worker incentives

  • Inadequate financial and nonfinancial incentives: Many health workers conduct other income-generation activities, particularly private medical practices, which are performed during or after their public-sector shifts (Dobalen and Wane 2008). A study of health workers from developing countries found that 87% of respondents had at least one other job. Half of those respondents were not available more than 25% of the expected working time (Macq et al. 2001). In Uganda, absenteeism spiked on market days, when health workers would abscond from their duties in order to sell wares and compensate for inadequate salaries; in addition, 55% of health workers surveyed responded that inadequate housing or transport were reasons they missed work (Matsiko 2011). Lack of work-related benefits contributes to absenteeism. In Bangladesh and Uganda, health workers provided with housing were less likely to be absent (Chaudhury et al. 2006).
  • Delayed remuneration: Ineffective payroll mechanisms force health workers to travel long distances to receive their paychecks. In some countries, a health worker’s first paycheck may take up to six months to process, which could incentivize the health worker to take on other jobs to cover living expenses in the meantime.
  • Lack of performance incentives and limited opportunities for personal or career development can erode workers’ motivation, leading to absenteeism. Oftentimes there is insufficient reward for good performance at the individual or team level. For example, most facilities send their service statistics to a central authority but rarely receive feedback or recognition if targets were achieved. Too often, promotions are not based on merit but on favoritism or for political means.

Insufficient information

  • Limited quantity and quality of data: Few developing countries have quantified absenteeism, which limits evidence-based decision-making. Paper records are slow to collect. Facility records and even electronic time-stamping to monitor attendance can be manipulated. Most facilities do not have a system for providing substitute health workers for either planned or unplanned leave.
  • Ineffective supervision: Traditional top-down supervisory measures to get information about absenteeism—such as time and motion studies, quantitative service delivery surveys, surprise visits, focus groups with facility managers and patients, or direct observation—can be time-consuming and costly, and tend to perpetuate systemic hierarchies. They are often interpreted by workers as policing or punitive actions, resulting in workers’ resentment of their supervisors. Finally, very few health workers are terminated or sanctioned for being absent (Vujicic et al. 2009).

Lack of accountability

  • Insufficient political will: In large part, accountability measures are often not enforced due to limited political will at high levels of leadership to take a stand against absenteeism. Many leaders are aware of absenteeism as a perennial issue, but more must be done at their level to effectively address it. The significant political weight of professional councils to protect their cadres stymies efforts to enforce punitive measures against absenteeism.
  • Few consequences: Colleagues tend to protect others on their team and are not likely to report those who are absent. Supervisors often do not report supervisee absenteeism because they do not want their own absenteeism revealed or because it is rare for corrective action to be taken against the chronically absent health worker. In addition, managers may avoid firing workers because the process for replacing them is difficult and slow (Vujicic 2010). There are also anecdotal reports of supervisors not reporting supervisees’ absenteeism for fear of retaliation, especially from high-ranking relatives of the supervisee.

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