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Background Absenteeism is widespread across the Nigerian health sector among all cadres of providers. Little is known about the health worker incentives and drivers of absenteeism among staff working in primary health care settings in rural areas in Enugu State. Methods We focused on six primary care centers in rural and urban regions in Enugu State, south-east Nigeria. We conducted in-depth interviews and focus group discussions with 70 respondents living nearby: comprising 12 frontline health workers, 12 healthcare managers, 6 Health Facility Committee leaders and 40 service users. We used thematic data analysis, drawing on conceptualisations of culture and gender. Results Socio-cultural causes of absenteeism included gender roles (caregiving responsibilities, home keeping, child bearing issues, etc.), marital status, attending to social events and cultural ceremonies. Consequently, women were more likely to be absent than men, given traditional roles (e.g. home keeping, caregiving, farming) and child bearing. Male absenteeism reflected a need to generate additional income through dual practice and other jobs. Sanctions against those absent was similar for men and women. Individual health workers who were connected to politically powerful individuals “godmothers” or “godfathers” were able to use these connections to improve their placements and protect themselves from potential sanction. Conclusions Effective strategies to tackle absenteeism will require socio-economic and these factors to be taken into account when addressing health systems and structural factors. Long-term change also requires addressing the power imbalances that give rise to these conditions, something that is likely to be especially challenging.

Influence of social-cultural factors and gender on health workforce absenteeism: a qualitative study from Nigeria