resources and have a direct negative impact on health service delivery. One estimate for Colombian hospitals put the cost of time lost due to absenteeism at more than US$1 million per year (Giedion, Morales, and Acosta 2001). The effect of health worker absenteeism on the quality of health services is more difficult to assess but is no doubt substantial, especially in cases where facilities are staffed by only one provider meaning that the when he/she is absent there are no services at all.

Absenteeism occurs for various reasons, several of which are legitimate or necessary. For example, rural health workers often need to travel to larger towns to receive their paycheck, or to fetch supplies and drugs (Lewis 2006). However, many health workers are absent without authorization, and, in effect, receive wages without providing even minimal services. This is a form of corruption.

Two important factors affecting attendance is the physical state of health facilities and the availability of medical supplies and drugs. A World Bank study of health worker absenteeism in six countries: Bangladesh, Ecuador, India, Indonesia, Peru, and Uganda, showed that well-equipped health facilities with better infrastructure had absentee rates roughly half those of facilities with poor infrastructure (Chaudhury et al. 2006).

Low pay per se does not appear to be the reason for the high and endemic physician and nurse absenteeism observed in many developing countries. Being a contract health worker in Peru is highly correlated with lower absenteeism even though contract workers are paid wages just like their civil-service counterparts (Chaudhury et al. 2006). Within health facilities, higher paid health workers such as physicians and pharmacists tend to be absent more frequently than lower paid clinicians and nurses (World Bank 2001a; Chaudhury et al. 2006). Because most public health workers are civil servants with high job security their incentives to abide by the rules when there is no supervision is limited.

The six-country study on absenteeism discussed above used surprise visits to a random sample of health facilities and recorded average absenteeism of 35 percent (Chaudhury et al. 2006). Across countries health staff absenteeism ranges from 6 percent in Cameroon, to 25 percent in Peru, to 74 percent for physicians in small clinics in Bangladesh (Table 8). Observed absenteeism has considerable advantage over administrative records as there are no discrepancies or the need to “report” on fellow workers (Rogers and Vegas 2008).

In Honduras the average absentee rate for health workers was 32 percent in 2001, although specialists and GPs had by far the highest absentee rate at 48 percent, and the most remote facilities saw absentee rates of close to 68 percent (Table 9) (World Bank 2001a). Findings for other countries also suggest that absenteeism is higher in facilities where health workers are less likely to be monitored or held accountable. Moreover, patients in poorer and remote communities are ill equipped to oversee public health workers as they have neither the authority nor the status nor education to ensure that physicians and nurses provide services.

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