Nigerian health workers and absenteeism: study shows how personal and political relationships protect offenders

Absenteeism of health workers contributes to poor quality of care. A study in Uganda, for example, showed that it reduced the likelihood of people using primary health centres by 30%. Absenteeism also increases the workload for available staff. This adds to work-related stress.

Absenteeism is when workers report late to work, leave before the scheduled time or do not show up, without formal permission. It is frequently reported as a problem in health systems in resource-limited settings. A Nigerian study in 2021 found that about 80% of 412 health workers in primary healthcare centres reported engaging in absenteeism.

There are many drivers of this. Previous research has shown that health workers sometimes take on private money-making activities to augment their low wages. Female health workers with families often leave early to care for children, cook and clean their homes. Poor supervision, lack of equipment, understaffing and a lack of security have also been linked to absenteeism.

Until now, however, the influence of politics on health worker absenteeism in Nigeria has received relatively little attention. In a recent paper we share the findings of our research into this aspect of absenteeism. Our research was part of the Anti-Corruption Evidence research consortium led by SOAS University of London, which provides high-impact strategies to tackle corruption.

We found that health workers with relatives in positions of power were frequently absent from work. Similarly, health workers who promoted the interests of politically influential people also enjoyed some protection when they were absent from duty. This explains why interventions aiming to reduce absenteeism have had little success. New interventions must look for solutions outside the health system. This could include involving local actors who stand to benefit from a functioning health system.

Beneficial relationships

The study was conducted in Enugu State in Nigeria. We interviewed 30 frontline health workers, three health managers and six community representatives about the influence of politics and power on absenteeism of healthcare workers.

Our study identified two types of relationships of significance between health workers and influential individuals. The first was family ties. This reflects the relationship between members of the same family but may extend to close friends. The second was political connections. These relationships are based on shared political interest.

We found that the protection happened in a number of ways:

through a direct relationship – for example, a health worker could have an immediate link to a political actor

relationships could also be indirect – a health worker could be related to someone who could push political actors to work for their interests.

Various benefits could accrue from these relationships. These included:

finding a job with the help of a political figure

refusing to be directed by their supervisors

influencing or distorting workplace relationships

affecting the decision-making process of health managers

the absence of any enforcement of rules around absenteeism.

When politically connected health workers were reported for being absent they would appeal to their “sponsor” for protection. Health managers often failed to take action against the absent health worker out of fear or in the hope of earning their goodwill for future benefits. This could be in the form of being recommended for limited opportunities, like training and workshops.

We found that the administrative heads of primary healthcare centres reported being ignored by health managers at the local government level when they reported health workers who were backed by political actors.

They also reported being persecuted (promotions could be blocked or delayed) for continuing the attempt to bring politically protected staff to order. They could be transferred to an unfavourable health facility and prevented from benefiting from available opportunities.

Such relationships sometimes also involved obeying requests that might be contrary to formal rules.

Way forward

Top-down enforcement of rules does not seem to be working effectively in this context. We believe this is because breaking rules has become entrenched and structural.

In this context, we advocate peer pressure on rule violators to eliminate absenteeism in primary healthcare centres. This means working with health workers who are regularly at their duty posts, community members who want an improved healthcare system and leaders interested in a functioning healthcare system. These people are directly affected by health worker absenteeism. They would not only report rule violators, but also follow up to make sure they were punished.

In this way, politically connected health workers could be brought to account by locally powerful traditional leaders and other influential community actors with the support of other health workers. These outside actors would serve to support the internal enforcement of rules in health facilities.