36 The double-edged sword of volunteer labour in primary health care in Nigeria

Background Health worker shortages are common in low-resource settings and this affects the range and quality of services delivered. Health facility try to adapt by utilizing volunteers to ensure modest service delivery. We deployed ethnographic observations and other qualitative approaches to understand the issues around volunteer recruitment and engagement. We focused to identifying accountability challenges in the engagement of volunteers. Method Six primary health centres and 3 local government administrative posts in a Southeastern Nigerian state were purposively selected for the study. Health facilities, host communities, and district offices were observed using ethnographic approaches. In-depth interviews of 30 health workers and volunteers and focus group discussions with service users across communities (n = 60) were conducted to understand concerns identified during ethnography. The multiple sources of data provided for quality triangulation of data. Thematic analysis was deployed in analyzing the data. Results Volunteers were typically as qualified as regular health workers, the only difference being that they are yet to find regular employment. Facility managers consider volunteers to be a pliable and useful group that can cover for health system inefficiencies. Policies are vague on how to recruit and engage volunteers. Higher placed stakeholders and district managers in a bid to maintain good political standings, transmit pressure from political platforms to frontline workers. Facility managers face pressure from community and district offices to sustain services. The outcome is that availability of health services improves, but absenteeism worsens for regular health workers. In some places, volunteers completely run the PHCs. Health managers become more aggressive with revenue generation to be able to pay the volunteers, meaning that informal payments are tolerated. Conclusion Volunteering in health facilities could be helpful in improving health services, but also have the potentials to be abused. Volunteer specific policies should emerge to regulate recruitment and engagement.