DETERMINANTS OF MOTIVATION AND JOB SATISFACTION AMONG PRIMARY HEALTH WORKERS: CASE STUDIES FROM NIGERIA AND INDIA
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Date
2014-07-14
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Johns Hopkins University
Abstract
Objective: In addition to a numerically adequate and skilled workforce, a well functioning health system relies on motivated and high performing health workers. Current efforts to motivate primary health workers, particularly in the public sector, in low-resource settings commonly focus on extrinsic measures such as better financial incentives. While these are necessary given low salaries and an expenditure-income mismatch, the role of intrinsic factors and organizational determinants need to be studied in greater detail, specific for each context, and integrated more comprehensively in such strategies. The objective of this dissertation is to explore individual and organizational determinants of motivation and job satisfaction among alternate cadres of public sector primary health workers using examples from Nigeria and India. It aims to answer the following research questions:
1. What are primary health workers’ perceptions of motivating factors in the work environment, particularly supervision and leadership, in Nasarawa and Ondo states in Nigeria? (Paper 1)
2. How does the introduction of a performance-based financing (PBF) scheme change the perceived motivation of health workers in Wamba district, Nigeria? (Paper 2)
3. What are the factors of job satisfaction among primary-level clinicians in the state of Chhattisgarh, India? What is the association between job satisfaction and intention to leave? (Paper 3)
Methods: This thesis uses three case studies to understand determinants of motivation and job satisfaction among primary health workers in rural parts of Nigeria and India.
• Paper 1 uses a qualitative design to explore perceptions of health workers about motivating factors in their working environment in two states in Nigeria. The study included 38 in-depth interviews with primary health workers and district level managers. Thematic content analysis was used to identify motivating and demotivating factors across cadres and location of health workers.
• Paper 2 describes a qualitative assessment of changes in perceived motivation of health workers with the introduction of a performance-based financing scheme in a pilot district in Nigeria. In-depth interviews were conducted with 34 health workers and five PBF project managers and data were analyzed using the framework approach.
• Paper 3 uses exploratory factor analysis to identify domains of job satisfaction using data from a cross-sectional survey conducted among 146 primary-level providers, belonging to four distinct cadres (Medical Officers, AYUSH Officers, Rural Medical Assistants, Paramedical staff) in the state of Chhattisgarh. It identified individual and organizational predictors of job satisfaction using multiple linear regression and measured the association between job satisfaction and intention to leave.
Results: Three case studies identify determinants of motivation and job satisfaction at individual and organizational levels:
• In Paper 1, findings show that health workers perceive to be motivated by both intrinsic (self-efficacy, religion, choice of profession) and extrinsic (good working environment including supportive supervision, monetary incentives, recognition, organizational justice) factors. Moreover, they considered supervision and leadership from within the facility, provided by the officer in-charge, to be more effective than from the district health management team. In addition to inadequate remuneration, health workers were dissatisfied by an unequal salary structure.
• In Paper 2, results indicate that health workers receiving PBF payments reported to be 'awakened' by performance bonuses and improved working environments including routine supportive supervision, availability of essential drugs and greater cohesion among staff. They recounted being more punctual, hard working, committed and proud of providing better services to their communities. In comparison, health workers in non-PBF facilities complained about the dearth of basic equipment and lack of motivating strategies. However, health workers from both sets of facilities considered there to be a severe shortage of manpower resulting in excessive workload, fatigue and general dissatisfaction.
• In Paper 3, domains identified for job satisfaction among health workers included job attributes supporting family life, working abilities and extrinsic incentives. Higher job satisfaction was found to be associated with receiving supervision and permanent employment. It was found to be significantly different between cadres of health workers with Rural Medical Assistants having the lowest score. It was also highly correlated with health workers’ intention to leave their current position.
Conclusions: Results from this dissertation suggest that motivation and job satisfaction of primary health workers in Nigeria and India are influenced by certain individual characteristics (vocation, self-efficacy, religion), financial and non-financial extrinsic incentives, and several organizational structures and processes including supervision, leadership, fairness in distribution of resources and responsibility, staff dynamics and team cohesion. In each case study the broader socio-political climate also plays a dominant role, either directly or indirectly, in affecting health worker behavior. Although latent phenomena, understanding motivation and job satisfaction can generate research leading to programmatic recommendations that strengthen health systems performance.
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Keywords
Primary health worker motivation, job satisfaction, Nigeria, India