An innovative approach to tackle ‘absenteeism’ of doctors in Bangladesh

In Bangladesh, healthcare service delivery remains significantly challenged by staff shortages, maldistribution of workforce, and absenteeism, especially of doctors. The health system has an extensive infrastructure in urban and rural areas, but the dynamic intersection of the pluralistic health system, large informal sector, and poor regulatory environment have provided conditions favourable for ‘corruption,’ especially in remote rural areas. Although data are scarce, it has been estimated that 40% of doctors are absent from their posts at any one time, and when a facility is staffed by a single doctor, as is often the case in rural areas with underserved communities, absenteeism can be as high as 74%. The Bangladesh government is well aware of the problems posed by absenteeism within the health system and have enacted several regulatory approaches, such as compulsory rural service after graduation and introducing biometric fingerprint in all sub-district and district-level government hospitals, to retain doctors at rural postings. 

Despite these initiatives, publicly available health systems data suggests that absenteeism among doctors continues to be a very significant problem across the country. The failure of these policies is driven in large part by a reliance on universal top-down approach for action (accountability and transparency mechanisms) and not paying attention to the structural drivers of absenteeism. 

From SOAS Anti-Corruption Evidence consortium Bangladesh health study platform, a study was designed to understand these drivers among junior doctors in rural health facilities in Bangladesh for potential policy interventions. The approach adopted by the SOAS-ACE Consortium is to design sector-specific anti-corruption strategies that enable the enforcement of the rule of law supported by players affected by those rules; this makes the enforcement of anti-corruption strategies more feasible. ACE suggested four broad strategies (aligning incentives, designing for different, building coalitions, and resolving rights) to develop this ‘horizontal’ support for successful anti-corruption outcomes. 

Based on the ACE strategy, in the first phase, a qualitative study was conducted to understand the socio-economic and political structures that drive absenteeism, a common form of rule-breaking among junior doctors in Bangladesh based in rural health facilities. Developing appropriate strategies requires an understanding of the determinants of absenteeism, doctors’ preferences over different components of their job and trade-offs they would be willing to make between them. Discrete choice experiments (DCEs) offer a means to do so and they have been shown to be useful for informing policies in a range of areas including health worker motivation and retention in many countries. Therefore, in the second phase, through a novel application of a discrete choice experiment, we elicited doctor preferences over key drivers of absenteeism and potential policy interventions and identified how this varied across our sample. 

An outcome mapping exercise was conducted in the beginning to identify the boundary partners (those with whom the program will work directly) so that they can contribute to the vision. In this process, the authorities of the Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare were approached, oriented and involved through stakeholder dialogue. DGHS's engagement in the project was critical for its success because the intervention aimed to explore root causes and feasible solutions to address the absenteeism of healthcare providers in public facilities administrated by DGHS. 

The qualitative study involved 30 doctors (senior specialist doctors, junior general practice doctors, and mid-level doctors to ensure diverse perspectives on the issue) in three divisions of Bangladesh (Sylhet, Barishal and Dhaka), most of whom worked in medical college hospitals and sub-district facilities. The study included doctors in positions of ‘facility in-charge’ to enable the analysis of administrative issues. It also included doctors who managed long-term authorised absenteeism and/or quit their job as they failed to cope with the system. 

 The qualitative results explored how poor local social relations, working conditions, and threats to career progression drove junior doctors to seek ways to leave rural facilities. Their absence was facilitated by weak regulatory mechanisms, bribery, and socio-political networks. These findings reveal how doctors’ absenteeism can be traced to structural issues in the health system and the socio-political networks that widely shape access to resources in Bangladesh. Providers with influence, power and access to networks can be absent for long periods, overburdening and de-motivating their colleagues who lack connections and thus remain in post. Those in authority in the health system can take measures to address existing problems in the weak infrastructure and work environment, including measures for career progression. These are expected to support collective action by doctors who cannot use powerful social and political networks. 

The DCE was conducted on 300 doctors working at four tertiary hospitals in Dhaka with experience working at rural facilities within the past ten years. Almost all of them were married (92%), 46% were female, 76% were under 35 years and 14% had completed postgraduate training. The DCE identified a subset of doctors who appear susceptible to behaviour change through feasible levels of policy intervention. The most important finding is that there are significant differences in preferences and, therefore, in the likely response to incentives and sanctions across different groups of doctors. A supportive relationship with the community was the most preferred attribute. Doctors preferred higher incentive payments but were willing to sacrifice higher payments in exchange for other positive incentives like opportunities for higher education. This finding is important for informing the development of a package of feasible interventions to overcome absenteeism highlighting the importance of moving beyond traditional top-down regulatory and accountability-focused approaches to addressing absenteeism. [from a study on drivers of absenteeism of doctors in rural areas]