Design, Implementation and Testing Feasible Interventions to Address Absenteeism of Frontline Health Workers in Nigeria

Absenteeism among health workers in Nigeria’s primary health-care (PHC) facilities had become an urgent policy concern, significantly constraining progress toward Universal Health Coverage (UHC). The research found that frequent absence from publicly funded posts had reduced both accessibility and affordability of essential health services, particularly for low-income patients who depended on PHC as their primary point of care. The study classified absenteeism driven by health workers pursuing private income-earning activities during official work hours as corruption, consistent with the definition of abuse of public office for private gain. Empirical research across Nigeria had revealed persistently high absenteeism rates. In southern Nigeria the study found that 77.7 per cent of health workers had been absent at least once within a one-year period. Comparable research in northern Nigeria had reported absenteeism rates of approximately 50 per cent. The documented consequences had included heavier workloads for present staff, delayed care, declining service quality, and poorer patient outcomes, with the wider literature linking these failures to increased morbidity and mortality. The research applied the Power, Capabilities, and Interest framework to understand why conventional anti-corruption strategies had delivered limited improvements. The study argued that standard formal policy-based vertical enforcement approaches had implicitly assumed impartial rule enforcement and predictable sanctions for violations. The research showed that this assumption had not held in Nigeria, where selective enforcement, widespread informality, and uneven organisational power had frequently frustrated top-down compliance. The findings indicated that enforcement capacity had been shaped not only by formal authority but by existing power asymmetries and the incentive compatibility of compliance itself. To test the findings we are implementing three promising interventions: - The first tackles structural economic factors—by providing small cash transfers to pay for care and transportation – both major factors underpinning absenteeism especially among health workers. - The second seeks to enable some mechanisms of local enforcement (e.g. community monitors) with the support of district and locally powerful political actors. - The third intervention promotes new forms of collective action through peer-to-peer networks of health workers and community members to tackle persistent absenteeism. Rather than rejecting formal, vertical enforcement, the research demonstrates that attendance and payment compliance were more likely to improve when local horizontal enforcement incentives are activated among workers and aligned with existing power structures. It shows that where health workers possessed sufficient capability to sustain livelihoods within formal employment, and where shared interests in enforcing compliance existed among peers, rule-following behaviour had strengthened without sole dependence on hierarchical monitoring. Very few interventions have previously demonstrated measurable effects on absenteeism in PHC in Nigeria or across sub-Saharan Africa, making feasibility testing a critical contribution. The interventions have been designed to align with national health frameworks, political and institutional structures, and local incentive conditions, ensuring operational and scaling feasibility. The research points to a conclusion that a scalable compliance-enhancing model has to work with power asymmetries and livelihood realities, while creating peer enforcement interests in order to deliver sustained improvements in PHC attendance