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82 Fighting the Diseases of Poverty
Staffing health care delivery
Staffing is arguably the single most important element of health
care delivery as little can be achieved without it. Training of the
staff, their competencies and ability to function all determine
whether labor can drive the expected results. Training typically is
adequate if not well beyond that needed in the lowest income countries,
especially for physicians. Availability of the full range of competencies,
however, often lags with particular inattention to
management needs, and lower paid staff with minimal skills can
proliferate.
Among the most serious issues in developing countries is the
high rate of absenteeism, which undermines service delivery and
leads to closed public clinics that compromise the equity and health
objectives of publicly financed health care. Two other commonly
observed constraints include low productivity of public medical
staff, and the outright corruption that underlies the buying and
selling of official positions. Capturing low productivity and poor
service poses greater difficulties; absenteeism already reflects
reduced output, and underperformance. Patient satisfaction
provides an additional window into adequacy of staff services.
Absenteeism
Absenteeism poses a chronic, but often unmeasured, problem in
publicly financed health care, and can severely limit patient access
to services (McPake et. al., 1999; Lewis, Eskeland and Traa-Valarezo,
2004; Narayan, 2000), reduce quality (McPake et. al., 1999; Lewis, La
Forgia and Sulvetta, 1996), and suggest corruption (DiTella and
Savedoff, 2001).
Absenteeism occurs for various reasons, many of them legitimate
or necessary. For example, rural health workers often need to travel
to larger towns to receive their paycheck, fetch supplies or drugs or
are delayed by poor infrastructure or weather. All lead to absences
but are necessitated by inadequate management or other shortcoming
of the country context. On the other hand, some staff have
other commitments or preferences and don’t show up. In effect they