Uganda & Rwanda
Key country characteristics
- Uganda: Low income country, and among lead developed landlocked states in Sub-Saharan Africa
- Rwanda: Low-income country in Sub-Saharan Africa
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Absenteeism in Uganda is estimated at between 37% and 48%, and although it is recognized to be a significant health system challenge and priority for improvement, there remains no clear strategy to address this barrier.1 A qualitative study explored the reasons for absenteeism in both the public and private sector in Uganda. Public sector providers reported that a common cause for absenteeism was lack of regular and appropriate payment, which motivated them to seek dual pay elsewhere. Particularly upon hire, payments were often delayed for up to a year, and when providers did receive payments, they often did not receive back pay. Managers were aware of this problem, and they often did not report absent employees because they acknowledged and understood providers’ need to seek supplemental income. Additionally, providers and managers noted that funds were often not well allocated to basic inputs, resulting in stock-outs and insufficient supplies for providers to carry out their duties. Providers also often missed work for personal reasons such as the expectation to care for the elderly or children or the need to attend a burial on short notice without the ability to communicate absences with their managers. Although the study did not discuss solutions or interventions, it highlights the multiple health system influences that affect health worker motivation, suggesting that solutions must be considered from a whole-system perspective.1
Like Uganda, Rwanda has experienced significant absenteeism among the health workforce, primarily due to a lack of financial incentives. Previously, providers in Rwanda were paid regardless of attendance and were rarely reprimanded for absenteeism.2 In 2005, the Government of Rwanda introduced a performance-based financing scheme where health worker payment was linked to attendance, services provided, and referrals. This new scheme not only incentivized providers to be present during their scheduled shifts but it also incentivized specific services. For instance, providing a facility-based delivery was highly monetarily incentivized, and as a result providers encouraged community health workers to conduct active outreach to pregnant women in the communities and encourage them to deliver in facilities.3 This is an example of the ways in which performance-based financing can incentivize specific behavior, and in some cases, this can result in perverse incentives or over-provision of specific services if the measured outcomes are not well designed.4 More details on performance-based financing can be found in the provider motivation section of this module. The information systems used for the performance-based financing schemes in Rwanda enabled managers to identify and terminate workers who did not show up for their planned shifts. This intervention benefited from close coordination with the Government of Rwanda to implement changes such as those to the national payment systems.