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Corruption in public health 87
Focus groups in Ethiopia among health workers revealed
common understaffing due to late arrivals, long breaks and a
general disregard for the necessity of staffing clinics. Absences are
frequently motivated by responsibilities at second jobs. Lack of management
and manager’s reluctance to confront physicians inspires
lower level workers to behave accordingly, leading to high absenteeism
and low productivity at all levels. (Lindelow, Serneels and
Lemma, 2003)
Where absenteeism is endemic, as was the case in Uganda,
Rajasthan India and the Dominican Republic, such explanations are
far less compelling. One factor shared by all of the examples above
is that absent health workers face almost no consequences. There is
no accountability for public servants. Without accountability,
abuses are more likely to proliferate and eventually undermine the
health care system.
Multivariate evidence for education provides some important
insights. The correlates of teacher absences in five countries
produced mixed findings but in at least three countries infrastructure
quality mattered consistently, and, in some, Ministry of Education
inspections were also associated with lower absenteeism.
Education of mothers, community oversight, location of schools and
the training of teachers, had perverse or insignificant effects on
absenteeism. To the extent that inspectors were indeed a tool of
accountability, they had some effect in Ecuador, India and Indonesia
but no effect at all in Peru and Uganda. The consequences of high
absenteeism were not discussed nor were any other forms of
accountability (Chaudhury et al., 2004).
Absenteeism is symptomatic of an unaccountable and ineffective
government, and leads to contempt for government, its
policies and practices, and compromises both access to and quality
of health care services. Unproductive or absent workers who do
not receive any punishment for substandard performance and
whose promotion and pay remain the same as those with better
performance, undermine morale and reduce output, which in turn
leads to a spiral of overall poor performance. Accountability is