BACKGROUND:
Health worker absenteeism is a persistent health systems and governance challenge that undermines primary healthcare performance and slows progress towards Universal Health Coverage in many low and middle income countries. In Nigeria, absenteeism at the primary healthcare level disrupts service availability, weakens accountability, and erodes community trust. While existing studies document the scale and drivers of absenteeism, less is known about how frontline managers experience and govern absenteeism in routine practice.

METHODS:
We conducted a qualitative study in two Nigerian states Enugu in the southeast and Kano in the northwest to capture variation in primary healthcare governance contexts. Twenty four Officers in Charge of primary healthcare facilities across urban semi urban and rural local government areas were purposively selected. In depth interviews explored managerial practices, accountability arrangements, and governance constraints related to absenteeism. Data were audio recorded, transcribed verbatim, and analysed thematically using NVivo through team based iterative coding.

RESULTS:
Participants consistently framed absenteeism as a systemic governance problem rather than solely an individual behavioural issue. Absenteeism disrupted service delivery, increased workload for present staff, and reduced community confidence in primary healthcare facilities. Attendance was sustained by intrinsic motivations such as professional duty and commitment to saving lives, alongside extrinsic factors including salary. Existing governance tools such as attendance registers, duty rosters, verbal sanctions, and external supervision were applied inconsistently and constrained by weak oversight and limited managerial authority. Respondents emphasised system level solutions including timely and harmonised remuneration, improved working conditions, strengthened supervision, community linked accountability, and transparent enforcement of attendance rules.

CONCLUSIONS:
Reducing absenteeism in Nigeria’s primary healthcare system requires strengthening frontline managerial authority and embedding accountability within broader health systems governance reforms to improve service reliability and advance Universal Health Coverage.