“Every morning before you come to work, you will see somebody who has been seated there watching. Before you dismiss, another person has come […] everybody sat up”, an Officer in Charge (OIC) of a health facility said to the research team.
When people think about enforcing rules against absenteeism in public health facilities, they usually picture government supervisors, local government officials, attendance registers, or digital clocking systems. And rightly so, because power is often tied to formal authority—who hires and disciplines staff, pays salaries, or sets the rules.
But our research found that this was not always the case. We saw individuals without formal authority exerting influence that encouraged health workers to commit more fully to their duty posts. Although these individuals could not directly punish health workers, they commanded respect and obedience, rooted more in their indigenous influence and local relevance. This offers an important lesson in how accountability can be achieved when formal authorities face supervision constraints or neglect their supervisory responsibilities.
Community-led accountability for healthcare can be a part of community development
In many Nigerian communities, community development is seen mainly as a matter of providing infrastructure and, in some cases, physical security. For various reasons, which may be tied to awareness, education, or culture, organising the services these infrastructures provide, whether schools or health centres, often take a back seat in community development. As a result, some communities may have well-built facilities that fail to deliver effective services.
This has been the case at many primary health facilities in Nigeria, where health workers may be unavailable to provide needed care. One study found that health workers’ absenteeism rate exceeded 70%, and another report highlighted how health facilities were not functional during unannounced supervisory visits by government officials. The literature has documented various reasons for absenteeism, including a lack of equipment and consumables, low wages, and political protection. However, these reasons do not justify leaving a health facility without functional, committed staff, especially when they are employed and paid to work.
Our research, conducted under the Anti-corruption Evidence Consortium, is working with community leaders to improve the organisation of health services by encouraging health workers to fulfil their commitments. The work began by showing community leaders the impact of absenteeism and co-creating a plan with them to address the issue. Community leaders have since taken ownership of the plan and incorporated its expectations into their broader community development efforts. In this blog, we discuss how they have done this and the progress they have made in ensuring health workers are committed to their work.
“Our presence alone made the health workers to sit up. As soon as they came to the understanding that the community leaders are serious about monitoring their attendance and curbing absenteeism, the health workers started being serious”, a community leader narrated to the research team.
How community leaders structured operations to check health workers’ absenteeism
Through our research, we identified existing, influential community leaders in four communities to work closely with their primary health facilities. These leaders represented traditional health facility committees, women’s groups, youth groups, and the community chief’s cabinet. We brought them together into a single committee called the Community Monitoring and Support Committees (CMSCs).
They already understood the problem they were designed to address and had a co-created plan informed by their local knowledge of the context and its influences. The CMSCs visited health facilities to monitor attendance, engage health workers, identify service delivery challenges, and mobilise community support.
They held routine meetings to discuss their operations and experiences at the health facilities, and they consulted established health authorities and researchers when needed. Our research provided incentives, such as snacks, to support the routine meetings. Overall, their work brought them closer to the health facilities than ever before and positioned them as active partners in improving them.
Not watchdogs, but custodians
One reason community monitoring worked was that CMSC members did not see themselves as inspectors searching for offenders. Instead, they saw themselves as custodians of a shared institution and worked to keep it efficient. This same ideal was evident in how they communicated their responsibilities to health workers.
“We have not come to witch-hunt any of you but to make sure you are doing the jobs assigned to you, because you are dealing with human lives”, A quoted statement from one of the CMSC members, described as the line they used to communicate their presence and responsibility to the health workers.
Rather than creating an adversarial relationship with the health workers, community actors combined accountability with support. They monitored attendance, engaged health workers, and sought solutions to challenges affecting service delivery. Accountability therefore became less about policing and more about shared responsibility towards efficiency.
This sense of responsibility was closely linked to ownership. Community members increasingly described the health facility not as government property, but as something that belonged to them.
“We see this facility as our own, and when people take ownership of something, they will not allow it to deteriorate”, A CMSC member said.
From monitoring to action
The role of community actors quickly expanded beyond monitoring attendance. As CMSCs became more involved, they began identifying and addressing practical challenges affecting service delivery. In some facilities, they mobilised support to improve electricity supply; in others, they helped strengthen security. By combining monitoring with practical support to feasibly address work-related challenges in the health facilities, they strengthened the legitimacy of their role and made accountability more acceptable.
CMSC members could not suspend health workers, deduct salaries, or issue official warnings. Instead, their influence came from their social legitimacy, their interest in improving services and working conditions, and their ability to mobilise local support to improve health facility efficiency.
Lessons for health policymakers and the health system in Nigeria
Our experience through this research under the Anticorruption Evidence Consortium, supported by the School of Oriental and African Studies (SOAS) and the London School of Hygiene and Tropical Medicine (LSHTM), offers three practical lessons for strengthening community-led accountability in primary healthcare:
Institutionalise community monitoring as a support mechanism. It is crucial to include ‘support’ in the naming of existing health facility committees and compose their membership to reflect their capacity to provide support. Then integrate the CMSCs into routine primary healthcare governance, with roles that emphasise pastoral support for health workers, improve working conditions in health facilities using local resources, maintain dispassionate concern for healthcare, uphold the committee’s dignity, and strengthen links to responsive health authorities.
Build accountability through partnership, not punishment. Encourage community structures to work with health workers to identify challenges and develop practical solutions, rather than relying on sanctions alone.
Strengthen and incentivise community ownership of health facilities. Involve communities directly in governance and decision-making so health centres are viewed as shared community assets, not government property. Health authorities could attend CMSC meetings from time to time, and these meetings should receive a small budget for snacks and drinks. State primary healthcare agencies should embed a tracking system for CMSC activities for publicity and rewards, while the most effective CMSCs can be recognised at state- or federal-level award ceremonies for their healthcare impact.
Authors’ bios
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 an MSc in Clinical Psychology with distinction. His work focuses on health systems governance, accountability, primary healthcare strengthening, and mental health.
Pamela Ogbozor is a Chartered Psychologist and lecturer in the Department of Psychology at Enugu State University of Science and Technology, Nigeria. She holds a PhD in Organisational and Occupational Health Psychology and is a Research Fellow with the Health Policy Research Group, University of Nigeria. Her research interests include health system strengthening and governance, occupational health psychology, organisational policies, and positive psychology.
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.
Obinna Onwujekwe is a Professor of Health Economics and Policy at the University of Nigeria and Coordinator of the Health Policy Research Group (HPRG). A medically trained physician and health economist, his work focuses on health systems, financing, governance, accountability, and evidence-informed policymaking. He has led research on health-sector governance, corruption, and health worker absenteeism through the Anti-Corruption Evidence (ACE) programme. He is a Fellow of the Nigerian Academy of Science and has been recognised among Africa’s top 100 researchers.
Acknowledgment
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. Special thanks to Dr. Prince Agwu for his valuable review and feedback.
