Holding Health Workers Accountable: Governance Approaches to Reducing Absenteeism

"...a mother carries a feverish child on her back and walks 15 kilometers to the health center, only to find it empty. She returns the next day to find the waiting room overwhelmed with patients. The mother waits all day, but when the time comes for the child to be seen, the doctor has already left. An overworked nurse rushes through the appointment, speaking harshly. Unsatisfied, the mother returns home and tells her neighbors about the negative experience. The next time one of her children falls ill, instead of visiting the clinic, she buys medicine from the drug peddler in town."

This brief explores strategies for addressing absenteeism - defined as chronic, unexcused absence from work - which is described here as adversely affecting health worker productivity, undermining health service quality, and (as indicated in the example above), impacting health service demand.

As described here, the most common characteristics for absenteeism are when the health worker: is a higher-level cadre/has higher authority (e.g., doctors and managers); is male; has greater opportunity to earn money in private practice (e.g., doctors, pharmacists, lab technicians); is posted in an economically poor, remote, or rural community; is posted at a lower-level health facility; and/or was recruited to a post without being informed of the post's geographical location. The reasons for absenteeism can be attributed to a breakdown in one or more of these fundamental elements of governance:

• Failure to meet health worker and facility standards - staffing standards that are not transparent or well known, insufficient supervision (e.g., health workers not receiving sufficient professional support for needed skills trainings and mentoring, which limits their participation in problem-solving and decision-making at health facilities), and poor working conditions.
  One suggested solution: Encouraging participation to set and communicate standards - for example, 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.
• Ineffective health worker incentives - inadequate financial and nonfinancial incentives, delayed remuneration, and lack of performance incentives and limited opportunities for personal or career development, which can erode workers' motivation.
  One suggested solution: Implementing effective incentive packages - "This requires a solid comprehension of workers' preferences within specific contexts. CapacityPlus's Rapid Retention Survey Toolkit [PDF] applies an evidence-based method to determine the optimal package of incentives based on health workers' motivational preferences..."
• Insufficient information - limited quantity and quality of data about absenteeism, which limits evidence-based decision-making, and ineffective (top-down) supervision.
  One suggested solution: Initiating mHealth innovations - for example, 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.
• Lack of accountability - insufficient political will to take a stand against absenteeism and few consequences for reporting those who are absent.
  One suggested solution: Enforcing sanctions - "Transparency is essential in defining the indicators and processes for enforcing HR [human resources] standards and applying appropriate disciplinary measures."

It is suggested that reducing absenteeism requires a decentralised approach involving broad stakeholder groups to reinforce accountability mechanisms for addressing governance issues. These stakeholders include:

• Management: "Policies against absenteeism must be reasonable, widely communicated, and enforced through transparent processes and with methods for recourse.
• Health professional schools: "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: "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."
• Health facility teams: "Peer or team supervision can also be an effective first-line approach for holding colleagues accountable to fulfill their duties."
• Communities: "[They] should play a strong role in gathering information and providing feedback on health worker absenteeism."