When No One Is There: Uganda’s Absent Health Workers

Preliminary results from a recent study in Uganda suggest that health workers may be absent from their posts as much as 35% of the time. The health workers most likely to be absent are often the more highly trained workers such as doctors or clinical officers.

The study presents a stark, quantitative answer to a question that has been the theme of many of our recent publications, “Who’s there?”

Too often, no one.

Uganda is a country in health workforce crisis—it falls far short of the minimum of 23 doctors, nurses, and midwives for every 10,000 people that the World Health Organization recommends. In public health facilities, only about half of approved nursing positions are filled. Severe understaffing can engender a lack of motivation and accountability in health workers who are there, further compounding the problem.

Why Are Uganda's Health Workers Absent?

With the recent study, IntraHealth researchers, including Charles Wycliffe Matsiko and colleagues, sought to better understand how often health workers in Uganda were missing work, for what reasons, and what was being done about it.

The data for this analysis was collected as a part of the annual human resources for health audit study. Senior health facility personnel were interviewed in 70 of Uganda’s 112 districts on how often health workers were absent and for what reasons. The most common reasons given were: sickness, problems with housing or transport, social obligations such as a funeral or wedding, and disaster-related problems.

The interviewees were also asked if there was a government policy on absenteeism; 67% responded ‘yes,’ but 33% responded ‘no’ although in fact the Ministry of Public Service has human resource policies that govern public servants across the entire government, including the health sector. Respondents were asked if they monitored whether staff members came to work and when they left and if they used a reporting book for staff to sign in and out. Eleven percent of respondents said they did not monitor staff comings and goings, and 14% did not use a reporting book. Antecdotal evidence also suggests that many health workers are seeking continuing education and training and may be absent from their health facility to pursue education or for other reasons. Facility managers were asked whether they are involved in the decisions allowing their staff to be away for long periods of time such as long-term training, to which 12% of respondents said ‘no.’

Health facility managers were also asked if they disciplined health workers who were excessively absent without explanation, to which 89% said they did. However, in the cases where a health worker is absent from the health facility to pursue further studies, that health worker may be doing so with the permission and knowledge of a supervisor, but the absence still slows service delivery.

Absenteeism Problem Widely Recognized

The extent and effects of health worker abseenteeism are wide-reaching and have been regularly covered in Uganda’s media:

Leadership Taking Action to Stop Absenteeism

Ministry of Health officials are clearly concerned about health worker absenteeism and its effect on patients and the health system. The Minister of Health, Dr. Christine Ondoa, directed hospital directors and district officials to sack doctors and other health workers who spend three months away from duty without approval. Dr. Ondoa was quoted by a leading Ugandan newspaper, New Vision, as saying, “We will enforce disciplinary actions. We have been crying of working under bad working conditions, but this should not be an excuse for being unethical…There are doctors who go to the extent of getting study leave and when they come back they take months to report on duty.”

In addition to quantifying the absenteeism rate and reasons behind health worker absences, IntraHealth International is also collaborating with the Ministry of Health and local health facilities to publicize the Ugandan government policies that govern workers’ absences and support the national commitment to train human resource leaders and managers in leadership and management. In some of districts, where human resource managers have completed this course, they have also committed to completing the assignment of reducing absenteeism over the next year.