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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
  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   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