Nigerians are accustomed to headlines about government officials, including governors, making unannounced visits to health facilities and finding them often nonfunctional. In one case, the Borno State governor suspended 23 health workers who were absent from their posts. Unfortunately, similar situations are widespread across Nigeria, with some health workers holding public-sector jobs while also working elsewhere.
“Doctors do a lot of private practice, and they can work in many places… That is why it is hard to see them around. Today they are here, tomorrow they are somewhere else”, said a health worker in one of our studies.
Although there is no nationwide absenteeism rate for health workers, some reports indicate that one in three workers was absent during unannounced facility visits. Another study found that absenteeism among 412 health workers exceeded 70%. Beyond disrupting services and increasing the workload of staff who are present, these figures suggest that absenteeism is not merely an individual problem; it also points to broader health-system weaknesses that require government attention.
The ACE approach offers hope for addressing health workers’ absenteeism
In Nigeria, public primary healthcare facilities make up about 70% of the over 34,000 primary health centres. However, their functionality is highly debated, with estimates suggesting that more than half are not operating at optimal levels. A recent report revealed that 97% of these facilities in 16 states failed to meet national staffing standards. These figures reveal notable gaps between government commitments and the real state of public primary healthcare, which is meant to serve up to 80% of Nigeria’s 230 million people.
To help improve the functioning of public primary healthcare facilities, a different approach is being implemented, using simulated government actions to support locally-led strategies. This method, embedded in the Anticorruption Evidence Approach (ACE), is being tested across health facilities in several local government areas in Nigeria, combining locally sourced interests and initiatives with government-like support to address absenteeism. Subsequent sections explain the approach, its real-life application, and its achievements.
The ACE Approach combines locally-led strategies and simulated government actions in addressing absenteeism of health workers
The ACE approach looks beyond punishment to understand why absenteeism occurs, who can help address it, and what skills and resources are needed. In Nigeria, this involved working with health workers, communities, and government actors to identify practical solutions within the existing health system. The result was a combination of locally-led actions based on existing resources and targeted support to address some of the barriers keeping health workers away from their posts.
Locally-led actions began with people already working within the health system and communities. We used peer-support networks to bring health workers together to discuss attendance challenges, support one another, and find practical solutions. Meanwhile, we also established Community Monitoring and Support Committees, which brought community members closer to their health facilities, allowing them to monitor attendance and raise concerns with facility leaders.
Although the committees had no formal powers to discipline health workers, their presence still mattered. Regular visits to the facility to enquire about health workers’ attendance through dialogue, note-taking, and a show of pastoral support improved attendance. A service user mentioned that:
“Since the community leaders started coming to the facilities to enquire about things from time to time, we noticed that health workers changed […] even on Saturdays and Sundays, you see health workers doing their jobs seriously.”
The involvement of the community monitors soon went beyond monitoring. Some communities mobilised support for electricity, lighting and security, and in doing so developed a stronger sense of ownership of their facilities. For one community member, that sense of shared responsibility was simple:
“The facility is our own. So, we will continue to do our part as community leaders and community members.”
These experiences offer important insights into strengthening existing community structures, such as health facility committees and Ward Development Committees.
Simulated government support backing locally-led actions
It is important to note that the locally-led actions were not left to be implemented on their own. We also piloted interventions that the government could gradually take on. For instance, we provided supplementary transport support for health workers, as well as snacks and incentives for peer forums and community monitoring. These targeted investments show how the government can support locally driven approaches, helping them succeed and, where effective, expand.
This support should strengthen local action, not shift government responsibilities to communities. Communities cannot finance major infrastructure or ensure that medicines are available, just as peer networks cannot solve persistent staff shortages. Government must therefore continue to address these wider health-system challenges while supporting communities and health workers to act where they can.
Ultimately, the value of bringing these efforts together is reflected in people’s experience of care. A community member explained:
“Before now, women complained that when they came they would not meet anybody. Now when they come, they see health workers attending to them.”
This is what the combination should achieve: not simply better attendance figures, but more reliable primary healthcare for the people who depend on it.
Conclusion
These efforts have so far been codified in the Power, Capabilities and Interests (PCI) approach, which asks three questions: (a) Who has the power to address absenteeism? (b) Are the skills, character, and resources needed to address absenteeism available? And (c) Is there an interest in addressing absenteeism?
In our experience, the government alone cannot address absenteeism at the primary healthcare level, so it must team up with horizontal forces in the community. Community actors, including health workers, need the skills and resources to support them in addressing absenteeism. These skills could include pastoral orientation, record-keeping, studying and understanding human resources for health policies, and peer engagement, while resources could be transportation incentives and a light lunch during meetings.
All healthcare stakeholders tend to express interest in addressing health workers’ absenteeism, as this will improve healthcare service delivery, work satisfaction and fulfilment, and help the government get more value from its healthcare investments. Adopting this tested intervention is one way the government can demonstrate its interest, which it can also back by ensuring that primary healthcare facilities are well staffed, equipped, and provided with the conditions needed to function optimally.
Authors’ biographies
Chinelo Obi is a Health Policy and Systems Researcher with the Health Policy Research Group (HPRG), College of Medicine, University of Nigeria, and a Lecturer in the Department of Health Administration and Management, University of Nigeria, Enugu Campus. Her research interests span health economics, health policy and systems research, with a focus on generating evidence to inform health policy and strengthen health systems.
Pamela Adaobi Ogbozor is a Lecturer in the Department of Psychology at Enugu State University of Science and Technology and a researcher with the Health Policy Research Group (HPRG), College of Medicine, University of Nigeria. She holds a PhD in Organisational and Occupational Health Psychology. Her research interests include organisational psychology, health systems research, health workforce performance and healthcare delivery.
Okechukwu Ozor is a Clinical Psychologist and Health Policy and Systems Researcher with the Health Policy Research Group (HPRG), College of Medicine, University of Nigeria. A Best Graduating Student in Psychology (2016), he holds a distinction in MSc Clinical Psychology. His work focuses on health systems governance, accountability, primary healthcare strengthening, and mental health.
Prince Agwu is a Lecturer at the University of Dundee, United Kingdom; a Senior Research Fellow at the Health Policy Research Group, University of Nigeria; and Communications Lead for the African Health Observatory Platform, Nigeria. He holds a doctorate in Social Policy and is Editor for Health Research Policy and Systems & Health Economics, Policy and Law. Agwu’s research interests include social policy in health systems governance and organisation and human trafficking.
Obinna Onwujekwe is a Professor of Health Economics, Policy and Pharmacoeconomics at the College of Medicine, University of Nigeria, and Coordinator of the Health Policy Research Group (HPRG) and the Nigeria National Centre of the African Health Observatory Platform. He is a Fellow of the Nigerian Academy of Science and the Academy of Medicine Specialties of Nigeria. His research focuses on health financing, health systems strengthening, equity and health policy.
Acknowledgement
This publication is an output of the SOAS-ACE research consortium in partnership with the London School of Hygiene and Tropical Medicine (LSHTM). The views presented are those of the author(s) and do not necessarily reflect the UK government’s official policies or the views of SOAS-ACE or other partner organisations.
