2006).<sup>15</sup> Given the size of payments, which represent a multiple of an average annual wages for public sector employees, these payments constitute a substantial investment that the employee must somehow recoup.

# _Improving job assignment procedures_

Health workers who do not want to be assigned to remote areas may resort to paying informally to be assigned to more attractive locations, or to be transferred out of locations. Concerns over not being able to participate in career development programs and networking opportunities that help build careers, poor living conditions, language barriers, lack of good schools for their children, and possibly risks to health and safety, are all important and real factors in health workers’ reluctance to transfer to remote areas (Lehmann, Dieleman, and Martineau 2008).

Job migration, i.e. health workers not working in their assigned location, frequently takes the form of migration of posts from rural/primary health care facilities to urban areas/hospitals, which generates imbalances in the geographic and skill distributions of health staff. Certain types of health systems are more prone to this problem. Where staffing systems assign individuals to the central ministry, rather than specific facilities, and there is discretion over the geographic distribution of posts, frontline staff may lobby to have their posts transferred to more attractive locations leading to overstaffing in urban areas and understaffing in rural areas, or inappropriate skill mixes (Dehn, Reinikka, and Svensson 2003).

A Honduras public expenditure review illustrates the problem (World Bank 2001a). In this particular case more than 5 percent of surveyed health staff had migrated to posts other than those they were initially assigned to as recorded in the central database; health promoters and physicians were the most likely to have migrated. Moreover, job migration was always lateral or from a lower to a higher level. In addition to the geographic imbalance this generated, about 20 percent of staff functions did not correspond to the formal education or training of the assigned professional (World Bank 2001a; Dehn, Reinikka, and Svensson 2003).

# **Why and how often are health workers absent?**

Health worker performance relies on their being at work during contracted hours yet absenteeism is a chronic although often unmeasured problem in health systems in developing and transition countries (Lewis 2006).<sup>16</sup> When it is widespread it can severely limit access to and quality of health services, and constitutes fraud when absences are unauthorized (Lewis, La Forgia, and Sulvetta 1996; McPake et al. 1999; Di Tella and Savedoff 2001). Here, health worker absenteeism is defined as unauthorized absences by health workers during contracted hours.

Health workers who fail to show up for work, arrive late and/or leave early, or do not carry out their assigned duties while at the health facility constitute a drag on health

> 15 The average annual wages of a public sector employee are about US$480 (Prevenslik-Takeda 2006). 16 Dual practice, when public sector physicians supplement their incomes by working in the private sector, is not discussed in this paper. This practice only becomes an issue if it affects the work undertaken by the physician in the public sector.

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