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Health worker absenteeism undermines staff morale and the quality of care patients receive. It wastes health-sector resources and has even been linked to patient deaths.  In Uganda, which has a severe shortage of health workers, a 2015 study by IntraHealth International revealed that 68.8% of health workers in the public sector either weren’t showing up or were leaving work early so they could collect a second paycheck at a different health site or job.

This put pressure on other health workers, who were already thinly stretched, to do more than their share of work. In worst-case scenarios, people would arrive in some Ugandan health centers and find that there was no one on staff, because everyone had decided to take unauthorized holidays

Absenteeism was exceptionally high among night-or weekend-shift workers due to lack of supervision at their facilities, often forcing patients who could afford it to pay for private duty services. In Amolatar District in 2012, clients who couldn’t get care at a health center rioted and stormed the office of the resident district commissioner

Tracking Attendance to Reduce Absenteeism

Tracking attendance is the first step to ensuring health workers are there to deliver critical services and that staff workloads are equitable and safe. A team of information technology and performance management experts on the IntraHealth-led, USAID-funded Strengthening Human Resources for Health activity piloted a package of attendance-tracking tools, starting with Amolatar District in January 2016 and gradually expanding to other districts.

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The backbone of the tracking system is Uganda’s unified Human Resources for Health Information System (HRHIS), which the Ministry of Health uses to collect data to make crucial decisions about public-sector health workforce funding, deployment, and development.  Uganda’s HRHIS is built on iHRIS software, a suite of open source tools developed and supported by IntraHealth for managing and planning the health workforce

Attendance tracking process:

• Facility managers track attendance on a daily basis using paper forms or biometric scanners.
• They enter it monthly into HRHIS and share it with the respective district health officers and the District Service Commission.
• Payroll managers in each district run attendance reports every month and immediately see who reported to work fewer than the standard number of required days per month (usually 20) or who arrived late.
• Payroll managers check with facility heads to see if there are legitimate reasons for absenteeism, such as sickness or transportation problems, before recommending sanctions to the district health officer and chief administrative officer, who oversee public health facilities.
• Health officers issue relevant sanctions, including paying prorated salaries based on the number of days absent, disciplining chronically absent staff, and removing “ghost” workers from district payrolls.

Validating Electronic Data with Site Visits

IntraHealth’s SHRH team also conducted annual longitudinal analyses of health worker absenteeism rates in sampled districts and health facilities from 2015 to 2018. Absenteeism was defined as the number of health workers who are not off duty who are absent from the health facility during an unannounced visit and during the previous five working days. Survey teams:

• Made unannounced visits to health facilities and recorded whether they found workers on the job that day.
• Looked to see if workers had been on the job during the previous five working days.
• Collected additional information from interviews with health managers at facility and district levels.
• Analyzed unauthorized absenteeism to better understand the problem, underlying causes, and effective strategies to address it

Attendance Tracking Led to Immediate Results

The attendance tracking tools led to immediate results.  Once employees realized they were being monitored, unapproved absences fell significantly in just a few months. During 2015-2018, overall health worker absenteeism (with and without approval) fell from 69% to 41%

The success of the pilot initiative prompted the Ministry of Health to ask the team to roll out the approach to 4,507 facilities in all of Uganda’s 122 districts by August 2018, and soon absenteeism without approval was down to 11.1% in 432 sampled health facilities. The monitoring system allowed Ugandan health officials to comprehensively track and analyze attendance data and take appropriate actions against chronically absent staff.

By mid-2018, informatics developers at IntraHealth had begun encouraging facilities to use biometric machines that scan thumbprints of each and every medical worker and register time of arrival and departure.

This eliminates any chance of a health worker gaming the system by signing in for a workmate, as fingerprints are unique to each individual and require staff members to be physically present to sign in or out. By the end of that year, all 14 regional referral hospitals and 14 health center IVs (mini hospitals, each serving a population of roughly 100,000) in Gombe, Adjumani, Kalanga, and Katakwi districts had added biometric systems to monitor employees.

The Office of the Prime Minister is helping add biometric systems to 37 district hospitals and health center IVs in 22 districts in eastern Uganda. Another 173 of the smaller health center 3s (subcounty-level clinics with maternity wards) and 2s (parish-level facilities that treat common diseases and offer antenatal care) in the same districts received mobile phones to capture attendance. The phones work in the same way as the biometric machines, but don’t require reliable electricity.

Today, the district of Amolator, where the pilot project began, is known to have some of the best medical personnel in the country. The HRHIS monthly report put absenteeism in Amolatar at only 3.2% as of May 2018

Lessons Learned in Tracking Attendance with Technology

Governments can effectively reduce absenteeism rates through regular tracking and analysis of data using technology-based tools. However, fully addressing the issue of absenteeism requires a holistic and multipronged strategy that employs different management interventions beyond a tracking system, such as involving key stakeholders, creating supportive supervision, and using appropriate rewards and sanctions. A supportive environment increases buy-in and participation from health workers.

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The tracking tools revealed systems-related causes for absenteeism in Uganda, including weak supervision, a lack of clear job expectations, delays in getting paid, and poor working conditions. Data collected helped create appropriate sanctions or rewards to improve performance, retention, and health care delivery. District authorities can also better identify workers who are due to retire and determine where recruitment efforts are needed.

This program faced substantial hurdles, beginning with inadequate IT infrastructure, including computers, Internet, and inconsistent electrical power at health facilities. Health facilities often did not comply with taking attendance, resulting in low or delayed reporting of data. The system is only as good as the data that are shared. If managers don’t use the data to promote health worker productivity, no gains are made in service delivery

The system is still mostly manual and some administrators at the ministry found it difficult to digitize paper records. Workers who arrive late have to track down data collectors when attendance books are removed, taking valuable time away from other tasks.  The continued reliance on a paper-based system in many facilities makes tracking more easily compromised as it is still relatively easy for one person to sign in on behalf of another

Future plans call for rolling out biometric tracking to more districts to replace the paper-based systems and to link HRHIS, including the attendance-tracking system, with the open source District Health Information System (DHIS2) to better assess health worker productivity. An estimation of the financial cost of absenteeism to the health system is in progress.

A lightly edited excerpt from Holding Health Workers Accountable, one of our 7 Creative Approaches to Health Workforce Challenges