Understanding absenteeism among frontline healthcare workers and their supervisors in the rural Ugandan setting: a qualitative study

Abstract

The University of Manchester, Raymond Tweheyo, Doctor of Philosophy ‘Understanding absenteeism among frontline healthcare workers and their supervisors in the rural Ugandan setting - a qualitative study’ 2017 Introduction: There is a global shortage of the health workforce in virtually all countries, and more severely in sub-Saharan Africa where the burden of disease is also highest. Global policy prioritises workforce shortages through advocacy for increased training from medical and nursing schools, regulating migration, improving retention, skill-mix, and care delivery models. There is less attention to workforce productivity concerns such as absenteeism, presenteeism, and turnover, yet if prioritised, could improve the efficiency of the existing workforce. The evidence base on health workforce absenteeism is limited, especially for sub-Saharan Africa where knowledge is reliant on manager perspectives. This study purposed to understand absenteeism from the perspective of healthcare workers (HCWs) and their supervisors in rural Uganda. Methods: The study was conducted in four phases: (i) a scoping review of literature on the global health workforce, and employee absenteeism in various sectors, (ii) a narrative synthesis synthesising influences of HCW absenteeism, (iii) a qualitative study exploring: reasons for, negotiation and legitimation of, and coping with absenteeism, (iv) a theoretical analysis of empirical findings. The empirical qualitative study used case study methodology for the sampling strategy, and principles of grounded theory for data collection and analysis. A case was defined as a rural healthcare facility (health centre or hospital) accessed from three districts in central Uganda. Five cases (three public, and two private not-for-profit were selected, from which ninety-five HCWs were recruited): 19 in four exploratory focus groups (FGs), 47 through in-depth interviews (including 11 supervisors), and 29 in four credibility check FGs. Results: Attributes of health workforce absenteeism relate to the individual, the job, and the organisation of care, which inter-dependently operate through the ‘withdrawal’ and ‘stress’ models. Empirical findings suggest that workforce absenteeism is facilitated mainly by health system inefficiencies such as delays in payment or omission of worker salaries, absence of staff housing, poor supervision and weak sector governance. Contributory individual needs include: perceived low salary, career advancement, child-care responsibility and sickness. Additionally, absenteeism is facilitated by collective norms accepting of, and covering for absentees. Coping strategies contrasted: private sector HCWs reported more emotion-focussed stress reactions such as retaliatory absence, while public sector HCWs reported mostly problem-focussed strategies such as informal task-shifting and deliberate lowering of service quality standards. Conclusions: This thesis challenges the ‘withdrawal’ and ‘stress’ models, suggesting that workplace conflict is the main contributor to health workforce absenteeism, especially in the public sector. ‘Collective’ rather than ‘individual’ social learning and exchanges through negotiation and legitimation facilitate sustenance of absenteeism in both sectors, while planned behaviour (relating to ‘withdrawal’) explains the less pronounced individual motives for absenteeism. Interventions for health workforce efficiency in resource-constrained settings should consider evaluating the existence of workplace conflict alongside withdrawal and stress.

Date of Award	31 Dec 2017
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Stephen Campbell (Supervisor), Catherine Reed (Supervisor), Linda Davies (Supervisor) & Gavin Daker-White (Supervisor)