A study of absenteeism among doctors in rural Bangladesh

Absenteeism – unauthorised employee absence from the workplace – is one of the most common forms of corruption among frontline health workers. Despite having an extensive infrastructure, the healthcare system in Bangladesh suffers from staff shortages, maldistribution of the workforce, and poor retention of employees and service providers, especially in rural and remote areas. Among doctors in particular, absenteeism has also been a long-standing problem. Although absenteeism has long been recognised by the Bangladesh national authorities, and multi-lateral and donor agencies, the regulatory approaches that they have employed have so far failed to yield successful results. This is, in part, because they have largely failed to consider or manage the challenges of implementing transparency and accountability measures in the face of poorly funded health systems, misaligned incentives and the influence of socio-political networks on the distribution of urban and rural positions. This study has been conducted to support the development of a new approach to anticorruption that takes the socio-economic and political context into account in the construction of novel interventions. It is a qualitative study that seeks to explore the realities of working in the Bangladesh health system, with a particular focus on the factors that influence and shape the nature of doctors’ absenteeism in rural facilities. We conducted 30 in-depth interviews with doctors of various levels (junior = 18, mid-level = 5, senior = 7) from three divisions: Sylhet (northern), Barisal (southern) and Dhaka (central). Rural facilities with higher vacancy rates were purposively selected from these divisions. The findings show that poor working conditions, threats to career progression, desires for private practice, gender inequality, poor social relations with the local community and weak regulatory mechanisms are important underlying factors influencing absenteeism. In addition, local political systems and poor infrastructure make rural placements difficult and, on some occasions, dangerous for health workers. Despite the equal distribution of these problems, challenges and threats in rural health centres, absenteeism among doctors manifests in different ways. Those doctors who are linked to political and economic elites manage to avoid rural placements easily; others who are from less powerful backgrounds but who have some useful political connections and financial resources manage absence from health centres by making unofficial payments to bureaucrats. In contrast, some doctors rarely take unauthorised time away from their work. Some adjust to their rural position; these doctors usually belong to that locality and/or have maintained good relations with the local community. Our findings indicate that the most important contributory factors that influence doctors’ absenteeism in rural Bangladesh can be traced to structural and health system issues. Those with influence, power and access to networks are able to be absent for longer periods, which overburdens and de-motivates the doctors who are present. A possible solution lies in the design of feasible incentives that tackle the most difficult health systems issues (relating to infrastructure and safety) and career progression, and that draw together forms of collective action among doctors who are differently positioned in the social and political networks.