Which mechanisms explain the motivation of primary health workers? Insights from the realist evaluation of a maternal and child health programme in Nigeria

Abstract

IntroductionWell-trained, adequately skilled and motivated primary healthcare (PHC) workers are essential for attaining universal health coverage (UHC). While there is abundant literature on the drivers of workforce motivation, published knowledge on the mechanisms of motivation within different contexts is limited, particularly in resource-limited countries. This paper contributes to health workforce literature by reporting on how motivation works among PHC workers in a maternal and child health (MCH) programme in Nigeria.MethodsWe adopted a realist evaluation design combining document review with 56 in-depth interviews of PHC workers, facility managers and policy-makers to assess the impact of the MCH programme in Anambra State, Nigeria. A realist process of theory development, testing and consolidation was used to understand how and under what circumstances the MCH programme impacted on workers’ motivation and which mechanisms explain how motivation works. We drew on Herzberg’s two-factor and Adam’s equity theories to unpack how context shapes worker motivation.ResultsA complex and dynamic interaction between the MCH programme and organisational and wider contexts triggered five mechanisms which explain PHC worker motivation: (1) feeling supported, (2) feeling comfortable with work environment, (3) feeling valued, (4) morale and confidence to perform tasks and (5) companionship. Some mechanisms were mutually reinforcing while others operated in parallel. Other conditions that enabled worker motivation were organisational values of fairness, recognition of workers’ contributions and culture of task-sharing and teamwork.ConclusionsPolicy designs and management strategies for improving workforce performance, particularly in resource-constrained settings should create working environments that foster feelings of being valued and supported while enabling workers to apply their knowledge and skills to improve healthcare delivery and promote UHC. Future research can test the explanatory framework generated by this study and explore differences in motivational mechanisms among different cadres of PHC workers to inform cadre-related motivational interventions.

Village health worker motivation for better performance in a maternal and child health programme in Nigeria: A realist evaluation

“…This highlights that VHWs require a supportive environment to perform well. Our study supports other work that has highlighted the role of organisational capacity, culture and policies for health worker motivation, 28 and we have identified the importance of teamwork, task sharing and collegial support in this context. Our findings also support work that has found that CHWs are motivated when their peers and supervisors are supportive and encouraging, 20 and that skilled health facility managers and health workers create opportunities for CHWs to acquire new knowledge and skills.…”

“…This highlights that VHWs require a supportive environment to perform well. Our study supports other work that has highlighted the role of organizational capacity, culture and policies for health worker motivation, 28 and we have identified the importance of teamwork, task sharing and collegial support in this context.…”

“…Our observation informed the development of a theoretical framework of CHW motivation, which is illustrated in Figure 2.

Figure 2.Theoretical framework of village health workers motivation (adapted from Ebenso et al, 2020). 28

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“…Theoretical framework of village health workers motivation (adapted from Ebenso et al, 2020). 28 communities. Community acceptance, trust and support are critical for the success of community health worker programmes.…”

Evaluation of antenatal services at Family welfare Centre under RMNCH+A Programme in Delhi

“…In a study similar to ours in Nigeria, 5 mechanisms were proposed to motivate ANC health care workers, (1) feeling supported, (2) feeling comfortable with work environment, (3) feeling valued, (4) morale and confidence to perform tasks and (5) companionship. [ 23 ]…”