Examining the Organizational Factors That Affect Health Workers' Attendance: Findings from Southwestern Uganda

Background: Sub-Saharan Africa experiences human resources crisis in the health sector which ultimately underscores achieving UN’s sustainable development goals on health. Uganda in particular faces significant shortages of health workers at all levels of the health care system with worse trends in the rural areas. The doctor to patient ratio is 1:24,725 and nurse to patient ratio is 1:11,000. Although, 85% of the population reside in rural area, about 71% of doctors and 41% of nurses and midwives work urban areas. As a result, health worker vacancies have thus reached 60% in rural Uganda but even those already in the system do not show up for work. Given the aforementioned, there are direct and indirect costs on health worker absenteeism. Absenteeism leads to economic loss, maternal mortality and related morbidities. Specifically, absenteeism costs 26 billion shillings and the poor quality of service delivery has negative health outcomes for patients. There is limited literature on factors contributing to health absenteeism especially in low income countries. This study aims to explore reasons for absenteeism among health workers in rural Uganda.

Methods: Data used in this study was derived from a qualitative study with participants purposively selected from 39 selected health centers partnering with the Suubi+Adherence study, a five year NIH funded study measuring medical adherence among HIV positive adolescents. There were a total of 8 focus groups for health workers (N = 27). Forty four percent of these were males (n=12) and 56% of these were women (n=15). To ensure participation from all members, group size was limited to four participants per group. The relatively small number per group was intended to maximize active participation of members. Data was collected in two formats: a demographic questionnaire focusing on demographic information like age, gender and job title and focus groups exploring the experiences of health workers in rural Uganda.

Findings: Four main themes emerged from coding of data in regards to absenteeism among health workers. These included, personal/family related responsibilities, distance to the health centers or transport difficulties, meager salaries and poor support supervision. The themes can be categorized as structural or individual impediments to the delivery of a coherent and robust health care and services. In particular, receiving meager salaries forces health care workers to look for alternative means to supplement their incomes to support their families. This is exacerbated by poor transport to rural health facilities. Most roads are impassable during the rainy season, therefore, health workers have to weigh the odds of going to the health facility and staying home to look for additional income during such seasons.

Conclusion and Implications: A combination of structural and individual level factors perpetuate absenteeism of health workers. These findings are critical in formulating and developing strategic interventions towards addressing absenteeism of health workers but also make rural health facilities more attractive to highly trained health care workers. Specifically, policy makers can provide more benefits targeting rural health care workers as well provide coherent support supervision especially in hard to reach areas.