"I found myself staying" - A case study of the job embeddedness and retention of qualified health workers in rural and remote areas of Uganda

Abstract

Global health worker maldistribution affects poor countries and rural areas most adversely, despite their high disease burden. Health workers reject rural areas due to isolation, and lack of facilities. Recommended extrinsic interventions to address rural-urban imbalance are costly and not sustainable in most developing countries. However, some health workers serve in rural areas without such interventions, suggesting existence of strong intrinsic motives for rural practice choice and retention, knowledge of which could be used to select retainable staff. This PhD research, a mixed-methods case study of 50 purposively-selected doctors and nurses retained in 12 Ugandan rural government and private general hospitals for three or more years, sought to find the reasons some qualified health workers get retained in rural areas, and the role of job embeddedness, a construct which predicts employee turnover, in their retention. Rural practice choices were made for personal or altruistic reasons and in obedience to authorities. Rural integration and embeddedness depended upon social and pre-service technical preparation, leading to cultural competence, adaptability, self-efficacy and resilience to shocks. Retention depended on feeling satisfied with achievements or self-adjustment. Despite a modest average degree of rural job embeddedness, rural retention averaged 19 years and most participants did not intend to leave soon. Job embeddedness predicted the duration of retention but not intention to leave. The strongest dimensions of job embeddedness were “fit-organisation” and “fit-community”. Prosocial behaviour and self-efficacy in rural practice influence rural practice choice and retention, and job embeddedness generally increases with retention. The study contributes the job embeddedness construct to the theory of health worker retention research. It also extends the use of the construct to mixed-methods studies, raises rural retention to the policy and research agendas and highlights the role of prosocial behaviour, self-efficacy and good managerial practices in rural practice choice and retention.