Review

iMedPub Journals Health Systems and Policy Research 2019

www.imedpub.com Vol.6 No.3:85
ISSN 2254-9137

Health Care Workers Motivation and Retention Approaches of Health Workers

in Ethiopia: A Scoping Review
Abonesh Taye1, Sudhakar Morankar2,3, Misra Abdulahi1, Bitiya Admasu1 and Afework Tadele1*
1Department of Population and Family Health, Jimma University, Jimma, Ethiopia
2Ethiopian Evidence Based Health Care Center, Jimma University, Jimma, Ethiopia
3Department of Health, Behavior and Society, Jimma University, Jimma, Ethiopia
*Corresponding author: Afework Tadele, Department of population and Family Health, Jimma University, Jimma, Ethiopia, Tel: +251 917 98 39;
E-mail: [email protected]
Received date: October 10, 2019; Accepted date: December 05, 2019; Published date: December 12, 2019
Citation: Taye A, Morankar S, Abdulahi M, Admasu B, Tadele A (2019) Health Care Workers Motivation and Retention Approaches of Health
Workers in Ethiopia: A Scoping Review. Health Res Polocy Sy. Vol.6 No. 3:85

staff retention. Intention to leave was associated with job

satisfaction.
Abstract
Conclusion: Economic factors (Incentives), and structural
Background: Verifying health care workers job satisfaction factors (staff promotion through different mechanisms,
and motivation in developing countries are important if working environments) were found to be significant
they must be retained and deliver efficient health services association with health workers ’ motivation to work.
either in the public or private sectors. Nowadays, in Health system interventions should consider also intrinsic
Ethiopia issues of accessibility of skilled health care factors (age, sex, the professional category) for the
providers were still challenging. retention of health workers in Ethiopia.

Objective: To identify factors, context, and processes that Keywords: Motivation; Retention; Health worker; Ethiopia
influence work motivation and retention approaches of
health care workers in Ethiopia. Abbreviations: JBI: Joanna Briggs Institute; NGO: Non-
Governmental Organizations; HRM: Human Resource
Methods: Scoping review methodology of Joanna Briggs Management
Institute (JBI) was used to identify and collate evidence
from studies included in the review. PubMed, Cochrane
library, Google scholar and Google for articles examining
mechanism of motivation and retention of health care Introduction
workers in public institution in Ethiopia data bases were
searched. Titles and abstracts were examined for the Ensuring health care workers job satisfaction and motivation
following search terms; “ motivation ” , “ retention ” , in developing countries are important if they must be retained
“ mechanism, ” “ satisfaction ” , “ health care worker ” , and deliver efficient health services either in the public or
“public”, “institution”, and “Ethiopia”. private sectors. As the backbone of the health system, health
workers usually account for the largest share of public
Results: A total of seven studies were included in the expenditure on health. The presence of high quality, motivated
review and the studies are cross-sectional study design. staff is a key aspect of health system performance, but also
Pleasant nature of work, fair payment/salary, conducive one of the most difficult inputs to ensure [1].
working condition, fair supervision accessible
Policy-makers in all countries, regardless of their level of
administration and policies, fair workload, care to
standard, better achievements, and job content are
economic development, struggle to achieve health equity and
factors associated with health care workers’ motivation. meet the health needs of their populations, especially
Intrinsic motivation factors like socio demographic vulnerable and disadvantaged groups. One of their most
variables were found to be significant predictors that complex challenges is ensuring people living in rural and
explain the variability in the intrinsic motivation factor remote areas have access to trained health workers [1].
score; such as age, sex, the professional category of the Skilled and motivated health workers in sufficient numbers
respondents and type of health facility where they work, at the right place and at the right time are critical to deliver
professional training, staffing and work schedule,
effective health services and improve health outcomes.
availability of necessary resources and communication.
Insufficient numbers and types of qualified health workers in
Continuous development of skill and knowledge through
training and satisfaction assessment were associated with
remote and rural areas impedes access to health care services
for a significant percentage of the population; slowing the

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progress towards attaining one of the sustainable workers through retention, recruitment, and training if they
development goals of ensuring healthy lives and wellbeing for are to come close to approaching the goal of health for all [8].
all at all ages [2].
Applying a realist perspective to the review of published
Health worker motivation and retention is critical for a well- human resource management interventions offers an
functioning health system and remains an important challenge opportunity to gain a better understanding of how different
due to absence or shortage of properly trained and motivated human resource management interventions can improve
workforce, loss of clinical staff from low and middle-income performance, under which circumstances and for which groups
countries to developed countries [3]. of health workers is needed, So that health managers need
insight into the context within which interventions achieved
The effectiveness, efficiency, and quality of the health care
results and an understanding of the mechanisms that triggered
delivery system are closely dependent upon the willingness
change to improve health workers' performance [9].
and capability of health personnel to undertake the tasks
assigned to them diligently according to the proposed theory. Through the preliminary search with databases listed, we
Different study implies that the compelling factors that would found no current systematic review or a systematic review that
lead health care workers to leave include dissatisfaction with is underway on health worker motivation and retention in
salary, political interference, lack of infrastructure and Ethiopia. Hence, this review was aimed at mapping and
medicines, dissatisfaction with promotion opportunities, lack describing evidence on factors affecting motivation and
of effective planning, limited health budgets, migration of retention of health workers and the mechanism of overcoming
health workers, inadequate numbers of students entering these problems in Ethiopia.
and/or completing professional training, limited employment
opportunities, low salaries, poor working conditions, weak
support and supervision, and limited opportunities for
Literature Review
professional development [4].
Objectives
The severe shortage of health workers in countries is a
critical issue that must be addressed as an integral part of To map and describe available evidence on mechanism of
strengthening health systems to work on. Health workers are motivation and retention of health care workers in public
vital to health systems but are often neglected, this results in institutions of Ethiopia.
inappropriate skill mixes in the health sector as well as gaps in
the distribution of health workers, this is especially so in rural Types of participants
and remote areas where the provision of services is difficult
because of limited health budgets and scattered populations In this review the participants considered were health
living in isolated villages [5]. professionals working in public health institutions regardless of
their age, sex and profession type.
The 2006 World Health Report estimated 57 countries, in
exceptional case Sab-Saharan Africa, faced critical shortages of Concept
Health personnel totaling 2.4 million doctors, nurses and
midwives [6]. Health worker motivation crosses many The core concept of this review was mechanism used to
disciplinary boundaries, including economics, psychology, motivate and retain health professionals in public health care
organizational development, and others, such that the many institutions in Ethiopia. The concept of motivation in this
phases of influences upon health worker motivation suggests review is directed to health care workers’ willingness or desire
that worker motivation will be affected not only by specific to do their job as needed as per the work place standard. This
incentive schemes, but also by the whole range of health in turn explained as individual's degree of willingness to exert
sector reforms which potentially affect organizational culture, and maintain an effort towards organizational goals. For
reporting structures, channels of accountability [7]. instance, health workers’ participation on the strategic and
annual plan of the facility. Motivation is closely linked to job
In the analysis of the global workforce, the Joint Learning
satisfaction, which retains workers at their jobs over time. The
Initiative a union of more than 100 health leaders conclude
concept of retention in this review is the various policies,
that mobilization and strengthening of human resources for
measures and practices which let the employees stick to an
health is neglected, yet critical and central to combating health
organization for a longer/maximum period of time.
crises in some of the world’s poorest countries and for building
sustainable health systems in all countries. Nearly all countries
are challenged by worker shortage, skill mix imbalance, mal- Context
distribution, negative work environment, and weak knowledge The context of the review was Ethiopian public health
base [8]. facilities such as health centers and hospitals.
There is a massive global shortage of health workers
estimated to be approximately more than 4 million workers. Criteria for inclusion and exclusion
Sub-Saharan countries must nearly triple their current
numbers of workers by increasing the equivalent of one million Systematic reviews and primary studies of any design
reported in English language were considered for inclusion.

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Studies conducted in private or non-governmental

organizations (NGO) were not included in the review (Figure
1).

Figure 1 Studies conducted in private or non-governmental organizations (NGO)

Search strategy motivation”, “retention”, “mechanism,” “satisfaction”,” health

care worker ” , ” public ” , ” institution ” , and ” Ethiopia ” . The
A three-step search strategy was utilized in this review. An search strategy identified 345 citations from three identified
initial limited search of PubMed was undertaken followed by data bases. After duplicates were then removed, leaving 140
an analysis of the text words contained in the title and citations. Titles and abstracts were examined and selected 26
abstract, and of the index terms used to describe article. Then, publications for full text review. Thus, a total of 26 full text
a second search using all identified keywords and index terms publications were screened independently by two reviewers
were undertaken across all included databases. Thirdly, the based on inclusion criteria, of which 7 were ultimately
reference list of all identified reports and articles was searched included in the review see appendix.
for additional studies. Four databases were searched PubMed,
Cochrane library, Google scholar and Google for articles Data extraction and analysis
examining mechanism of motivation and retention of health
care workers in public institution in Ethiopia. Titles and A standard template was developed and used to organize
abstracts were examined for the following search terms; ” and identify themes in the literature that were aligned with
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the research objective. The template contained categories for collection, results, and limitations. This iterative process
descriptive characteristics of the included studies: authors, involved reading, annotating, highlighting, and evaluating the
year, study design, method, sample population, sampling, data literature in the included studies (Table 1).

Table 1 Summary of data extraction and analysis.

Author Countr Aim/purpose Study Methodology Outcomes and details of these (e.g. How Key finding that relate to
and year y population and measured) the scoping review
of sample size question
publicatio
n

Eyasu et Addis To assess job Midwives Institution Among the satisfying

al. (2017) Ababa satisfaction and working in gov’t based cross- factors family/workplace
its determinants hospitals and sectional study balance, coworker ’ s
among midwives health center in relation, interaction
working at gov’t Addis Ababa, opportunities and control
health facilities (n=234) and responsibility. The
dissatisfying factors
reported includes;
professional opportunity,
extrinsic reward,
scheduling and praise
and recognitions

Zemichael West To assess the Categories of Facility based Intrinsic motivation factors; age, duration of
et al. Amhara overall health health cross sectional services, category of health professionals;
(2016) Public professional ’ s professionals study, using Five-point Likert scale was used for
Hospita motivation score working in the 8 systematic measuring outcome.
l in public public hospitals. random
hospitals and (n=304) sampling
factors method.
associated.

Tesfaye et Ambo, To identify the All permanently Facility based Factors affecting motivation include; Health professionals
al. (2015) Gedo level of employed health cross-sectional Supervisor related, Financial benefits, Job earning monthly financial
and motivation and professionals, in survey content, Professional qualification and benefits had higher
Gindeb factors affecting three hospitals Location of the hospital, the five Likert scale motivation score when
eret it. used for measurement. Health compared with health
professionals earning monthly financial professionals who did not
benefits had higher motivation score when obtain any financial
compared with health professionals who did benefits; qualification of
not obtain any financial benefits; health professionals was
qualification of health professionals was associated with their
associated with their motivation. motivation.

Ayele et al. Harari To assess the Randomly Facility based Domain of Job Satisfaction; leadership and
(2015) region level of job selected health cross sectional planning, Institutional culture, and
satisfaction and care providers; study communication, Employee’s role, pay and
associated those working benefits, work environment, training and
factors for more than 6 development, relationship with supervisor,
months (n=405) each domain measured by Likert scale

Hailay et Jimma To assess the Health care Cross Retention activities, Job Satisfaction, Staff Absence of continuous
al. (2016) zone health work providers sectional study turnover measured with different scales development of HWs skill
health force working in with such as five sub scales and Cronbatch’s and knowledge, absence
Instituti acquisition, hospitals and quantitative alpha of training, absence of
on retention, health centers in and qualitative satisfaction assessment
turnover rate Jimma zone data was some of the reasons
and intention to (n=367) for frustrating the staff
leave retention. Intention to
leave was associated
with job satisfaction

Alemshet Jimma To determine the All health Cross Job satisfaction future plan, suggestion For retention: incentives,
et al. universi level and factors professionals sectional study given to retain, reason to stay/leave health increasing salary and
(2011) ty affecting job who were on job institution and intension after leaving the income generating
speciali satisfaction and during the study institution was assessed options, free health care,
zed retention period(n=145) provision of housing/
hospital housing allowance,
improve training and
further education, more
frequent promotion,
establish good
relationship.

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Takele Nagele To assess All health Cross Health professional motivation in relation to Factors affecting
(2014) and factors affecting professionals sectional study social organizational and Individual variable motivation of health
Adola health who were on design with assessed; Five-point Likert scale used professional includes;
public professional ’ s their job during both electricity, water, transfer
Hospita motivation study period in qualitative and system, sick live and
ls of two Hospitals. quantitative maternity leave process,
Guji For in depth data opportunity for further
Zone interview 12 education, Incentives,
health low salaries, lack of
professionals frequent promotion
who have housing; intention of job
position are options after leaving
purposively public institution is
selected. joining; NGO /private,
non-health institution,
running own business

Results the age of respondents increased the intrinsic motivation was

lowered.
All the seven studies are Cross sectional studies and two of In the study conducted among midwives working at health
the studies used mixed (qualitative and quantitative) data facilities in Addis Abeba city female health professionals were
collection method. From the total studies, four study about four times more likely to be satisfied than male
conducted in public hospital and the rest three conducted counterparties. Similarly, in the study conducted among health
both in public hospital and health center. The study uses five- workers in Jimma University specialized hospital male health
point Likert scale with different number of components to workers were dissatisfied than female health professionals.
measure job satisfaction and measures to increase retention.
The included studies all except one which is conducted among Among the satisfying factors family or workplace balance,
midwives working in government health facilities in Addis coworker’s relation, interaction opportunities and control and
Abeba the rest involves all types of health professionals responsibility. The dissatisfying factors reported includes;
working in public health Institutions. The total number of professional opportunity, extrinsic reward, scheduling and
health care professionals participated from the seven studies praise and recognitions. Socio demographic variables were
accounts for 1886 which is collection of variety of health care found to be significant predictors that explain the variability in
workers. The socio demographic factors included in the the intrinsic motivation facto score; such as age, sex, the
selected articles were Age, Sex, Educational status, profession professional category of the respondents and type of hospital
type, which is uniform throughout all included article. where they work, professional training, staffing and work
schedule, availability of necessary resources and
Factors associated with health workers work communication.
motivation and Retention Health professionals earning monthly financial benefits had
higher motivation score when compared with health
Findings from the included article reveal that out comes professionals who did not obtain any financial benefits,
including; pleasant nature of work, fair payment/salary, qualification of health professionals was associated with their
conducive working condition, fair supervision accessible motivation. Profession, working area, motivation system
administration and policies, fair workload, care to standard, payment leadership style and communication training and
better achievements, job content are factors directly development opportunities are some factors associated with
associated with health care workers motivation to their Job satisfaction or motivation on job. Absence of continuous
each factor are measured using 5-point Likert scale having development of HWs skill and knowledge, absence of training,
different items. absence of satisfaction assessment was some of the reasons
The study also assessed the intrinsic motivation factors; age, for frustrating the staff retention. For job satisfaction
duration of services, category of health professionals, whether organizational factor was marginally identified. Intention to
these factors are associated with the motivation of health leave was associated with job satisfaction.
workers using the five-point Likert scale and the result reveal To retain health professionals the following suggestion was
that socio demographic variables were found to be significant given in these study by the participants of the study;
predictors that explain the variability in the intrinsic incentives, increasing salary and income generating options,
motivation factor score; such as age, sex, the professional free health care, provision of housing/housing allowance,
category of the respondents and type of hospital where they improve training and further education, more frequent
work, professional training, staffing and work schedule, promotion, establish good relationship, majority of health
availability of necessary resources and communication. The worker plan to leave their job because they want to get chance
result showed that female respondents had higher intrinsic for further education, job dissatisfaction, family or personal
motivation score compared to males and also age was found related issue after leaving public health institution health
to be a negative predictor of the intrinsic motivation score as professionals want to join; NGO ’ s, working in non -health
institutions, running their own business. Factors affecting

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motivation of health professional includes; electricity, water, provider. Improving salary, incentives, house allowance/
transfer system, sick live and maternity leave process, provision of house, relationship with supervisors,
opportunity for further education, Incentives, low salaries, lack opportunities to get training can motivate and retain the
of frequent promotion housing; intention of job options after health care workers in public healthcare institution. Convincing
leaving public institution is joining; NGO or private, non-health policy should be designed for the implementation of economic
institution, running own business. and non-economic interventions in realizing human resource
gap especially in emerging regions in Ethiopia. Salary,
Discussion incentives, house allowance/provision of house, relationship
with supervisors, opportunities to get training were factors
The current review identified factors associated with positively associated with motivation and retention of health
motivation among healthcare workers in Ethiopia public care workers in public healthcare institution.
healthcare settings. The studies included in the review were of
low-quality design due to absence study conducted with the Recommendations
topic of interest using gold standard designs; mainly the
included are cross-sectional studies. The result reveals that Policy makers may use findings reported in the review to
human resources are vital to an effective health care system. guide practice and to design appropriate health workers
Any motivation and retention strategy are not complete retention and job motivation approaches. Capacity building
without a cost-benefit analysis. The result of the study implies such as training, further education should be incorporated into
that there is high level of job dissatisfaction and intention to retention mechanism of health care providers. Due attention
leave job in the coming years which can greatly affect the should be given for health care workers with lower level of
quality of health services provided by the hospital and needs education such as Diploma holders. Further health system
wide scale further study to maintain the quality of the health studies are required to inform effective interventions for
services [10]. retention of health workers especially in rural parts of the
country practice was recommended.
The studies also reveal that more than half of the health
professionals were not motivated with their job. The major
reasons can be perception of poor fringe benefits received, Author Contributions
inadequacy of financial payments, poor in management
supportiveness, poor in infrastructures, insufficiency of Abonesh Taye made substantial contributions to conception
resources and supplies in the hospitals, lack of continuously and design, or analysis and interpretation of data and drafting
recognition and appreciation for those who have good the manuscript. Misra Abdulahi and Bitiya Admasu involved
accomplishments in their work and poor Human resource analysis and interpretation of data. Sudhakar Morankar
management (HRM) in the hospitals [11]. involved in the design and analysis of data. Afework Tadele
involved in revising the manuscript it critically for important
More than half of health professionals working in public intellectual content. All authors read and approved the final
health institutions in different regions were dissatisfied with manuscript.
their job. Payment and benefit, lack of training and
development, relationship with organizational leaders, poorly
designed working environment and organizational culture and
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