Table 3 Illustration of application of framework: Considering the determinants for unauthorized health worker absenteeism in public facilities
From: An approach to addressing governance from a health system framework perspective
Governance Element | Building Block | ||||
|---|---|---|---|---|---|
| Â | Financing Governance | Human Resources Governance | Information Governance | Medicines & Technology Governance | Governance |
Participation & Consensus Orientation | Low participation from health workers in setting appropriate salary scales | Few ways of including community in health facility boards which provide oversight or advice to management. | Information on how community can participate in human resource decisions is not clear | Â | Limited channels (such as health boards) for community or health workers to participate and have their voices heard |
Strategic Vision & System Design | The system does not allow for incentives to be provided for working in less attractive areas; Salary increases not based on performance | No overtime payments structured in; Lack of performance appraisals; Distribution of staff is not based on service population making some environments more stressful | The design of the system does not require that data are regularly collected on staff attendance and transmitted to the district or above | Medicine delivery system is poorly designed leading to a lack of resources at health facility which make working environments less attractive as there are fewer resources available to staff. | System not designed to include sanctions that can be placed on health worker by management unit thereby reducing the ability to hold absent staff accountable |
Addressing corruption | "Ghost" workers continually receive payments and are not identified by the system | Inability to replace ghost workers | Information on absenteeism is altered at health facility before it is transmitted, therefore hiding the problem | Absent staff may be taking publicly funded resources with them to sell in the private sector thus increasing incentive to be absent | Lack of supervision to ensure that health workers are present |
Being transparent | Transparent information on salary scales and overtime payments is not available to staff | A list of staff who are supposed to be on call or at work is not available to the public | Information on staff attendance is not transferred to the authorities | Knowledge on future stock and flow is not transparent which could reduce the motivation for health staff to be present | Decisions made by health facility boards or management unit on hiring, promotions and firing are not made available to community |
Being accountable | Ministry of Finance is not held to account when salary or bonus payments are late | Staff are not held to account when absent | No one is accountable for ensuring that regular, transparent data on staff attendance is collected and turned into information; Lack of information on sanctions options available to management unit to hold staff accountable | No one is held accountable if medicines go missing | Lack of enforcement options to hold absent staff accountable at the community or district level when staff are absent |