Health Worker Motivation Research Articles

Coming Full Circle: How Health Worker Motivation and Performance in Results-Based Financing Arrangements Hinges on Strong and Adaptive Health Systems.

Background: This paper presents findings from a study which sought to understand why health workers working under the results-based financing (RBF) arrangements in Zimbabwe reported being satisfied with the improvements in working conditions and compensation, but paradoxically reported lower motivation levels compared to those not working under RBF arrangements. Methods: A qualitative study was conducted amongst health workers and managers working in health facilities that were implementing the RBF arrangements and those that were not. Through purposeful sampling, 4 facilities in RBF implementing districts that reported poor motivation and satisfaction, were included as study sites. Four facilities located in non-RBF districts which reported high motivation and satisfaction were also included. Data was collected through in-depth interviews and analyzed using the framework approach. Results: Results based financing arrangements introduce a wide range of new institutional arrangements, roles, tasks, and ways of doing things, for facility staff, facility managers and, district and provincial health management teams. Findings reveal that insufficient preparedness of people and processes for this change, constrained managers and workers performance. Results based financing arrangements introduce explicit and tacit changes, including but not limited to, incentive logics, in the system. Findings show that unless systematic efforts are made to enable the absorption of these changes in the system: eg, through reconfiguring the decision space available at various levels, through clarification of accountability relationships, through building personnel and process capacities, before instituting changes, the full potential of the RBF arrangements cannot be realised. Conclusion: Our study demonstrates the importance of analysing existing institutional, management and governance arrangements and capabilities and taking these into account when designing and implementing RBF interventions. Introducing RBF arrangements cannot alone overcome chronic systemic weaknesses. For a system wide change, as RBF arguably is, to be effected, explicit organisational change management processes need to be put in place, across the system. Carefully designed processes, which take into account the interest and willingness of various actors to change, and which are cognizant of and constructively engage with potential bottlenecks and points of resistance, should accompany any health system change initiative.

Performance-based financing kick-starts motivational \u201cfeedback loop\u201d: findings from a process evaluation in Mozambique

BackgroundPerformance-based financing (PBF) reforms aim to directly influence health worker behavior through changes to institutional arrangements, accountability structures, and financial incentives based on performance. While there is still some debate about whether PBF influences extrinsic or intrinsic motivators, recent research finds that PBF affects both. Against this backdrop, our study presents findings from a process evaluation of a PBF program in Mozambique, exploring the perceived changes to both internal and external drivers of health worker motivation associated with PBF.MethodsWe used a qualitative research design with in-depth, semi-structured interviews with health workers, which included a rank order exercise and focus group discussions. Interviews were analyzed by two researchers using thematic analysis techniques. Rank order frequency was calculated using weighted average methodology.ResultsHealth workers reported that PBF, overall, positively influenced their motivation by introducing or reinforcing both internal and external motivational drivers. Internal drivers included enhanced self-efficacy driven by goal orientation, healthy competition among colleagues, and job satisfaction. External drivers included an organized work environment, enhanced access to equipment and supplies, financial incentives, teamwork, and regular consultations with verifiers (a type of supervision). PBF stimulates an interactive relationship between internal and external motivational drivers, creating a feedback loop involving responsibility, achievement, and recognition, which increased perceived motivation.ConclusionsThe PBF program helped workers feel that they had well-defined and achievable goals and that they received recognition from verification teams, management committees, and colleagues due to enhanced accountability and governance. Our paper shows that financial incentives could serve as the “driver” to kick-start the feedback loop, of responsibility, achievement, and recognition, in environments that lack other drivers. Understanding how PBF programs can be designed and refined to reinforce this feedback loop could be a powerful tool to further enhance and track positive motivational changes. For countries thinking about PBF, we recommend that policymakers assess the loop in their contexts, identify drivers, determine whether these drivers are sufficient, and consider PBF if they are not.Trial registrationWe obtained ethical approval for the study protocol, data collection instruments, and informed consent forms from the Ethics Review Committee of the Centers for Disease Control and Prevention (CDC) [IRB 2015–190] and the Ethics Review Committee of the Mozambique Ministry of Health.

Factors Affecting Motivation and Retention of Village Health Workers and Recommended Strategies: a systematic review from 11 developing countries

Introduction: Motivation and retention of village health workers (VHWs) are crucial for the continuity, sustainability, and success of health programs. VHWs are the first point of contact for rural communities, providing health services to improve access and health coverage which, for a variety of logistical reasons, cannot be reached by the district health care system. Thus VHWs are critical for ultimately ensuring universal health coverage. However, systematic review revealed that there are numerous factors that affects their motivation and retention, leading to high dropout rates and hampering the delivery of health services to the community. This review intends to examine contextual factors affecting motivation and retention of VHWs in their roles and identify recommendations and strategies to motivate and retain them in the systems.
 Method: Five electronic databases and two search engines were accessed. Nineteen studies met the inclusion criteria for the final review. An in-depth reading of all the articles was undertaken to gather and compile the relevant themes. Content analysis was done based on the list of specific categories that are relevant to motivation and retention. 
 Result: Findings from the systematic review revealed different levels of factor affecting motivation and retention of village health workers. It was finally contextualized and categorized into four main domains such as individual, family, social or community and organizational or systems levels. Financial incentives under the organizational factors was highlighted for the demotivation and the discontentment for the VHWs.
 Conclusion: Financial factors under the organization were often key in the studies reviewed. However, there were also many other factors, sometimes surprising or unintuitive, influencing the motivation and retention of village health workers.

Does supportive supervision enhance community health worker motivation? A mixed-methods study in four African countries.

Supportive supervision is an important element of community health worker (CHW) programmes and is believed to improve CHW motivation and performance. A group supervision intervention, which included training and mentorship of supervisors, was implemented in Ethiopia, Kenya, Malawi and Mozambique. In three of the countries, this was combined with individual and/or peer supervision. A mixed-methods implementation study was conducted to assess the effect of the supervision intervention on CHWs’ perceptions of supervision and CHW motivation-related outcomes. In total, 153 in-depth interviews were conducted with CHWs, their supervisors and managers. In addition, questionnaires assessing perceived supervision and motivation-related outcomes (organizational and community commitment, job satisfaction and conscientiousness) were administered to a total of 278 CHWs pre- and post-intervention, and again after 1 year. Interview transcripts were thematically analysed using a coding framework. Changes in perceived supervision and motivation-related outcomes were assessed using Friedman’s ANOVA and post hoc Wilcoxon signed-rank tests. Interview participants reported that the supervision intervention improved CHW motivation. In contrast, the quantitative survey found no significant changes for measures of perceived supervision and inconsistent changes in motivation-related outcomes. With regard to the process of supervision, the problem-solving focus, the sense of joint responsibilities and team work, cross-learning and skill sharing, as well as the facilitating and coaching role of the supervisor, were valued. The empowerment and participation of supervisees in decision making also emerged in the analysis, albeit to a lesser extent. Although qualitative and quantitative findings differed, which could be related to the slightly different focus of methods used and a ‘ceiling effect’ limiting the detection of observable differences from the survey, the study suggests that there is potential for integrating supportive group supervision models in CHW programmes. A combination of group with individual or peer supervision, preferably accompanied with methods that assess CHW performance and corresponding feedback systems, could yield improved motivation and performance.

Strengthening Care Delivery in Primary Care Facilities: Perspectives of Facility Managers on the Immunization Program in Kenya.

Background: Primary healthcare facility managers (PHFMs) occupy a unique position in the primary healthcare system, as the only cadre combining frontline clinical activities with managerial responsibilities. Often serving as ‘street-level bureaucrats,’ their perspectives can provide contextually relevant information about interventions for strengthening primary healthcare delivery, yet such perspectives are under-represented in the literature on primary healthcare strengthening. Our objective in this study was to explore perspectives of PHFMs in western Kenya regarding how to leverage human resource factors to improve immunization programs, in order to draw lessons for strengthening of primary healthcare delivery. Methods: We employed a sequential mixed methods approach. We conducted in-depth interviews with key informants in Kakamega County. Emergent themes guided questionnaire development for a cross-sectional survey. We randomly selected 94 facility managers for the survey which included questions about workload, effects of workload on immunization program, and appropriate measures to address workload effects. Participants provided self-assessment of their general motivation at work, their specific motivation to ensure that all children in their catchment areas were fully immunized, and recommendations to improve motivation. Participants were asked about frequency of supervisory visits, supervisor activities during those visits, and how to improve supervision. Results: The most frequently reported consequences of high workload were reduced accuracy of vaccination records (47%) and poor client counseling (47%). Hiring more clinical staff was identified as an effective remedy to high workload (69%). Few respondents (20%) felt highly motivated to ensure full immunization coverage and only 13% reported being very motivated to execute their role as a health worker generally. Increasing frequency of supervisory visits and acting on the feedback received during those visits were mostly perceived as important measures to improve program effectiveness. Conclusion: Besides increasing the number of staff providing clinical care, PHFMs endorsed introducing some financial incentives contingent on specified targets and making supervisory visits meaningful with action on feedback as strategies to increase program effectiveness in primary healthcare facilities in Kenya. Targeting health worker motivation and promoting supportive supervision may reduce missed opportunities and poor client counseling in primary healthcare facilities in Kenya.

'We pledge to improve the health of our entire community': Improving health worker motivation and performance in Bihar, India through teamwork, recognition, and non-financial incentives.

BackgroundMotivation is critical to health worker performance and work quality. In Bihar, India, frontline health workers provide essential health services for the state’s poorest citizens. Yet, there is a shortfall of motivated and skilled providers and a lack of coordination between two cadres of frontline health workers and their supervisors. CARE India developed an approach aimed at improving health workers’ performance by shifting work culture and strengthening teamwork and motivation. The intervention—“Team-Based Goals and Incentives”—supported health workers to work as teams towards collective goals and rewarded success with public recognition and non-financial incentives.MethodsThirty months after initiating the intervention, 885 health workers and 98 supervisors completed an interviewer-administered questionnaire in 38 intervention and 38 control health sub-centers in one district. The questionnaire included measures of social cohesion, teamwork attitudes, self-efficacy, job satisfaction, teamwork behaviors, equitable service delivery, taking initiative, and supervisory support. We conducted bivariate analyses to examine the impact of the intervention on these psychosocial and behavioral outcomes.ResultsResults show statistically significant differences across several measures between intervention and control frontline health workers, including improved teamwork (mean = 8.8 vs. 7.3), empowerment (8.5 vs. 7.4), job satisfaction (7.1 vs. 5.99) and equitable service delivery (6.7 vs. 4.99). While fewer significant differences were found for supervisors, they reported improved teamwork (8.4 vs. 5.3), and frontline health workers reported improved fulfillment of supervisory duties by their supervisors (8.9 vs. 7.6). Both frontline health workers and supervisors found public recognition and enhanced teamwork more motivating than the non-financial incentives.ConclusionsThe Team-Based Goals and Incentives model reinforces intrinsic motivation and supports improvements in the teamwork, motivation, and performance of health workers. It offers an approach to practitioners and governments for improving the work environment in a resource-constrained setting and where there are multiple cadres of health workers.

Exploring a motivation of medical staff.

This paper aims to identify the true motivators (needs) of medical staff, compare them with the current labor incentives, and detect possible differences in motivators for main groups of medical staff. Observing personnel of 5 hospitals and students of the medical institute by special questionnaires, the author confirmed the hypothesis of different motivators for groups of medical staff with different ages, professions, and gender. The author used special questionnaires to collect the data. Study results confirmed the hypothesis of different motivators for groups of medical staff with different ages, professions, and gender. The author also found significant differences between the motivation of Ukrainian health workers and their colleagues from other countries. The main conclusion is that no matter how we would like to satisfy gender and age equality, all people are individual and what is good for an elderly male doctor cannot be acceptable for a young female nurse. Therefore, forming the motivation system for employees of medical institutions, it is necessary to take into account the age, gender, professions, and other characteristics of each employee. In this way, we can achieve the highest health-care performance.

The relationship between leadership style and health worker motivation, job satisfaction and teamwork in Uganda.

BackgroundLeadership is key to strengthening performance of Health Systems. Leadership styles are important organizational antecedents, especially in influencing employee’s motivation, job satisfaction, and teamwork. There is limited research exploring this relationship among health workers in resource-limited settings such as Uganda. The aim of this study was to examine the relationship between transformational, transactional, and laissez-faire leadership styles and motivation, job satisfaction, and teamwork of health workers in Uganda.MethodWe conducted a cross-sectional study in 3 geographic regions of Uganda in November 2015, using self-administered questionnaires with 564 health workers from 228 health facilities. Data were collected on health workers’ perception of leadership styles displayed by their facility leaders, their level of motivation, job satisfaction, and team work. Using Pearson correlation, relationships among variables were identified and associations of the components of leadership styles with motivation, job satisfaction, and teamwork was found using multivariable logistic regression.ResultsHealth workers in Uganda preferred leaders who were transformational (62%) compared with being transactional (42%) or laissez-faire (14%). Transformational leadership was positively correlated with motivation (r=0.32), job satisfaction (r=0.38), and team work (r=0.48), while transactional leadership was positively correlated with job satisfaction (r=0.21) and teamwork (r=0.18). Motivation was positively associated with leaders who displayed idealized influence-behavior (odds ratio [OR]=3.7; 95% CI, 1.33–10.48) and intellectual stimulation (OR=2.4; 95% CI, 1.13–5.15) but negatively associated with management by exception (OR=0.4; 95% CI, 0.19–0.82). Job satisfaction was positively associated with intellectual stimulation (OR=5.7; 95% CI, 1.83–17.79). Teamwork was positively associated with idealized influence-behavior (OR=1.07–8.57), idealized influence-attributed (OR=3.9; 95% CI, 1.24–12.36), and contingent reward (OR=5.6; 95% CI, 1.87–17.01).ConclusionTransformational styles had a positive impact on stimulating motivation, assuring job satisfaction, and consolidating teamwork among health workers compared with those who demonstrated transactional skills or laissez-faire styles.RecommendationSupporting transformational leadership skills development in health facility leaders could encourage health worker motivation, strengthen job satisfaction, and maintain cohesion among health workers for better service delivery.

Motivation of Strategic Health Workers to Work in Remote, Border, and Outer Island Areas (RBOIA) of Indonesia

.

Pushing the boundaries of research on human resources for health: fresh approaches to understanding health worker motivation.

A country's health workforce plays a vital role not only in serving the health needs of the population but also in supporting economic prosperity. Moreover, a well-funded and well-supported health workforce is vital to achieving universal health coverage and Sustainable Development Goal 3 to ensure healthy lives and promote well-being for all at all ages. This perspective article highlights the potential of underutilized health policy and systems research (HPSR) approaches for developing more effective human resources for health policy. The example of health worker motivation is used to showcase four types of HPSR (exploratory, influence, explanatory and emancipatory) that move beyond describing the extent of a problem. Most of the current literature aiming to understand determinants and dynamics of motivation is descriptive in nature. While this is an important basis for all research pursuits, it often gives little information about mechanisms to improve motivation and strategies for intervention. Motivation is an essential determinant of health worker performance, particularly for those working in difficult conditions, such as those facing many health workers in low- and middle-income countries. Motivation mediates health workforce performance in multiple ways: internally governing health worker behaviour; informing decisions on becoming a health worker; workplace location and ability to perform; and influencing willingness to engage politically. The four fresh research approaches described can help policy-makers better understand why health workers behave the way they do, how interventions can improve performance, the mechanisms that lead to change, and strategies for empowering health workers to be agents of change themselves.

Performance-Based Financing Empowers Health Workers Delivering Prevention of Vertical Transmission of HIV Services and Decreases Desire to Leave in Mozambique.

Background: Despite increased access to treatment and reduced incidence, vertical transmission of HIV continues to pose a risk to maternal and child health in sub-Saharan Africa. Performance-based financing (PBF) directed at healthcare providers has shown potential to improve quantity and quality of maternal and child health services. However, the ways in which these PBF initiatives lead to improved service delivery are still under investigation. Methods: Therefore, we implemented a longitudinal-controlled proof-of-concept PBF intervention at health facilities and with community-based associations focused on preventing vertical transmission of HIV (PVT) in rural Mozambique. We hypothesized that PBF would increase worker motivation and other aspects of the workplace environment in order to achieve service delivery goals. In this paper, we present two objectives from the PBF intervention with public health facilities (n=6): first, we describe the implementation of the PBF intervention and second, we assess the impact of the PBF on health worker motivation, key factors in the workplace environment, health worker satisfaction, and thoughts of leaving. Implementation (objective 1) was evaluated through quantitative service delivery data and multiple forms of qualitative data (eg, quarterly meetings, participant observation (n=120), exit interviews (n=11)). The impact of PBF on intermediary constructs (objective 2) was evaluated using these qualitative data and quantitative surveys of health workers (n=83) at intervention baseline, midline, and endline. Results: We found that implementation was challenged by administrative barriers, delayed disbursement of incentives, and poor timing of evaluation relative to incentive disbursement (objective 1). Although we did not find an impact on the motivation constructs measured, PBF increased collegial support and worker empowerment, and, in a time of transitioning implementing partners, decreased against desire to leave (objective 2). Conclusion: Areas for future research include incentivizing meaningful quality- and process-based performance indicators and evaluating how PBF affects the pathway to service delivery, including interactions between motivation and workplace environment factors.

Factors Affecting Motivation of Primary Health Care Workers in West Arsi Zone, Oromia Region, South East of Ethiopia

Background: There is the fact that low health worker motivation may affect the success of health care system. Therefore this study is aimed at identifying factors affecting motivation of primary health workers working at public health centers of West Arsi zone of Ethiopia. Methods: This facility based was a cross-sectional study, pretested questionnaire were self-administered to 307 health workers from various clinical specialties. The responses were collected and analyzed; results were presented in frequency and tables. Results: This study revealed that considerable proportions, 41.7% of the participants were demotivated towards providing routine health care of clients. Job satisfaction and professional advancements were factors positively affecting motivation of the respondents. Respondents’ attained professional advancements were 3.5 times more likely motivated than those not advanced providers. Likewise, the odd of being motivated for those satisfied at their job was 5 times higher than those unsatisfied at their jobs. Conclusions: Significant numbers of the primary health care providers participated in this study were found to be demotivated towards jobs. Job satisfaction and professional advancements were factors influencing job motivation among the primary health care providers. Therefore, administrative measures aiming at raising the primary health care providers’ motivation should be placed.

'The money can be a motivator, to me a little, but mostly PBF just helps me to do better in my job.' An exploration of the motivational mechanisms of performance-based financing for health workers in Malawi.

Performance-based financing (PBF) is assumed to improve health care delivery by motivating health workers to enhance their work performance. However, the exact motivational mechanisms through which PBF is assumed to produce such changes are poorly understood to date. Although PBF is increasingly recognized as a complex health systems intervention, its motivational effect for individual health workers is still often reduced to financial 'carrots and sticks' in the literature and discourse. Aiming to contribute to the development of a more comprehensive understanding of the motivational mechanisms, we explored how PBF impacted health worker motivation in the context of the Malawian Results-based Financing for Maternal and Newborn Health (RBF4MNH) Initiative. We conducted in-depth interviews with 41 nurses, medical assistants and clinical officers from primary- and secondary-level health facilities 1 and 2years after the introduction of RBF4MNH in 2013. Six categories of motivational mechanisms emerged: RBF4MNH motivated health workers to improve their performance (1) by acting as a periodic wake-up call to deficiencies in their day-to-day practice; (2) by providing direction and goals to work towards; (3) by strengthening perceived ability to perform successfully at work and triggering a sense of accomplishment; (4) by instilling feelings of recognition; (5) by altering social dynamics, improving team work towards a common goal, but also introducing social pressure; and (6) by offering a 'nice to have' opportunity to earn extra income. However, respondents also perceived weaknesses of the intervention design, implementation-related challenges and contextual constraints that kept RBF4MNH from developing its full motivating potential. Our results underline PBF's potential to affect health workers' motivation in ways which go far beyond the direct effects of financial rewards to individuals. We strongly recommend considering all motivational mechanisms more explicitly in future PBF design to fully exploit the approach's capacity for enhancing health worker performance.

How to do (or not to do)… Measuring health worker motivation in surveys in low- and middle-income countries.

A health system’s ability to deliver quality health care depends on the availability of motivated health workers, which are insufficient in many low income settings. Increasing policy and researcher attention is directed towards understanding what drives health worker motivation and how different policy interventions affect motivation, as motivation is key to performance and quality of care outcomes. As a result, there is growing interest among researchers in measuring motivation within health worker surveys. However, there is currently limited guidance on how to conceptualize and approach measurement and how to validate or analyse motivation data collected from health worker surveys, resulting in inconsistent and sometimes poor quality measures. This paper begins by discussing how motivation can be conceptualized, then sets out the steps in developing questions to measure motivation within health worker surveys and in ensuring data quality through validity and reliability tests. The paper also discusses analysis of the resulting motivation measure/s. This paper aims to promote high quality research that will generate policy relevant and useful evidence.

Healthworkers’ motivation in low- and middle-income countries: A systematic review of the literature

Healthcare systems in low- and middle-income countries (LMICs) face a double burden of workforce challenges: low availability of healthworkers, and poor performance of many in post. Knowledge of what motivates healthworkers in their work may help address both challenges. To understand developments in this area, a systematic review of f literature was conducted. From an initial 4341 papers, 73 met the review’s inclusion criteria, encompassing a mix of focuses, methodologies, and geographical areas. Five themes are identified by healthworkers in the studies reviewed as influencing their motivation: working conditions (54 studies), financial incentives (46 studies), social incentives (37 studies), career development (31 studies) and living conditions (28 studies). As in previous reviews, there is a lack of evidence on the effectiveness of interventions for improving the availability, performance and motivation of healthworkers. A number of areas for further research are highlighted such as: developing effective interventions, understanding the role of context, and analysing the cost-effectiveness of different approaches to attracting and motivating healthworkers.

The Tobacco-Free Village Program: Helping Rural Areas Implement and Achieve Goals of Tobacco Control Policies in India.

India has 274 million tobacco users and a tobacco use prevalence of 38% in rural areas. Tobacco consumption causes 1 million deaths and costs the health system nearly US$23 billion annually. Tobacco control policies exist but lack proper implementation. In this article, we review the Tobacco-free Village (TfV) program conducted in Maharashtra state in India and describe its process to help villages in rural India achieve "tobacco-free" status (i.e., the sale and use of tobacco are prohibited by law). We reviewed program documents and conducted 22 qualitative interviews with program staff and village-level stakeholders. From 2008 to 2014, Salaam Mumbai Foundation implemented the TfV program in 60 villages in Maharashtra state. The program used a number of strategies to help villages become tobacco free, including collaborating with a community-based organization, leveraging existing health workers, conducting a situation analysis, training health workers, engaging stakeholders, developing TfV assessment criteria, mobilizing the community, conducting health education, imposing sanctions, and offering incentives. By 2014, 4 villages had achieved tobacco-free status according to 11 assessment criteria. Successful villages demonstrated strong local leader involvement, ownership of the program, and commitment to the cause by residents. The TfV program faced barriers including poor motivation of health workers, difficulty in changing social norms of tobacco use, and refusal of local vendors to stop tobacco sales due to financial losses. This low-cost, community-driven program holds promise for helping public health practitioners and governments implement and achieve the goals of tobacco control policies, especially in resource-scarce settings.

Measuring health workers\u2019 motivation composition: validation of a scale based on Self-Determination Theory in Burkina Faso

BackgroundAlthough motivation of health workers in low- and middle-income countries (LMICs) has become a topic of increasing interest by policy makers and researchers in recent years, many aspects are not well understood to date. This is partly due to a lack of appropriate measurement instruments. This article presents evidence on the construct validity of a psychometric scale developed to measure motivation composition, i.e., the extent to which motivation of different origin within and outside of a person contributes to their overall work motivation. It is theoretically grounded in Self-Determination Theory (SDT).MethodsWe conducted a cross-sectional survey of 1142 nurses in 522 government health facilities in 24 districts of Burkina Faso. We assessed the scale’s validity in a confirmatory factor analysis framework, investigating whether the scale measures what it was intended to measure (content, structural, and convergent/discriminant validity) and whether it does so equally well across health worker subgroups (measurement invariance).ResultsOur results show that the scale measures a slightly modified version of the SDT continuum of motivation well. Measurements were overall comparable between subgroups, but results indicate that caution is warranted if a comparison of motivation scores between groups is the focus of analysis.ConclusionsThe scale is a valuable addition to the repository of measurement tools for health worker motivation in LMICs. We expect it to prove useful in the quest for a more comprehensive understanding of motivation as well as of the effects and potential side effects of interventions intended to enhance motivation.

Measuring three aspects of motivation among health workers at primary level health facilities in rural Tanzania.

BackgroundThe threshold of 2.3 skilled health workers per 1,000 population, published in the World Health Report in 2006, has galvanized resources and efforts to attain high coverage of skilled birth attendance. With the inception of the Sustainable Development Goals (SDGs), a new threshold of 4.45 doctors, nurses, and midwives per 1,000 population has been identified. This SDG index threshold indicates the minimum density to respond to the needs of health workers to deliver a much broader range of health services, such as management of non-communicable diseases to meet the targets under Goal 3: Ensure healthy lives and promote well-being for all people of all ages. In the United Republic of Tanzania, the density of skilled health workers in 2012 was 0.5 per 1,000 population, which more than doubled from 0.2 per 1,000 in 2002. However, this showed that Tanzania still faced a critical shortage of skilled health workers. While training, deployment, and retention are important, motivation is also necessary for all health workers, particularly those who serve in rural areas. This study measured the motivation of health workers who were posted at government-run rural primary health facilities.ObjectivesWe sought to measure three aspects of motivation—Management, Performance, and Individual Aspects—among health workers deployed in rural primary level government health facilities. In addition, we also sought to identify the job-related attributes associated with each of these three aspects. Two regions in Tanzania were selected for our research. In each region, we further selected two districts in which we carried out our investigation. The two regions were Lindi, where we carried out our study in the Nachingwea District and the Ruangwa District, and Mbeya, within which the Mbarali and Rungwe Districts were selected for research. All four districts are considered rural.MethodsThis cross-sectional study was conducted by administering a two-part questionnaire in the Kiswahili language. The first part was administered by a researcher, and contained questions for gaining socio-demographic and occupational information. The second part was a self-administered questionnaire that contained 45 statements used to measure three aspects of motivation among health workers. For analyzing the data, we performed multivariate regression analysis in order to evaluate the simultaneous effects of factors on the outcomes of the motivation scores in the three areas of Management, Performance, and Individual Aspects.ResultsMotivation was associated with marital status (p = 0.009), having a job description (p<0.001), and number of years in the current profession (<1 year: p = 0.043, >7 years: p = 0.042) for Management Aspects; having a job description (p<0.001) for Performance Aspects; and salary scale (p = 0.029) for Individual Aspects.ConclusionHaving a clear job description motivates health workers. The existing Open Performance Review and Appraisal System, of which job descriptions are the foundation, needs to be institutionalized in order to effectively manage the health workforce in resource-limited settings.

Motivating and Demotivating Factors for Community Health Workers Engaged in Maternal, Newborn and Child Health Programs in Low and Middle-Income Countries: A Systematic Review.

This systematic review aimed to synthesize primary research on motivating factors of community health workers (CHWs) for maternal, neonatal, and child health (MNCH) in low and middle-income countries (LMICs). Peer-reviewed literatures were systematically searched in five databases. Identified studies were then screened and selected for inclusion. The eligibility criteria were reported primary qualitative, quantitative, or mixed methods research, with participants being CHWs in LMICs who address MNCH, which investigated motivation or related concepts of retention, attrition, and performance. A thematic synthesis process was used to analyze findings of motivating factors, reported by included studies. Seventeen qualitative, quantitative, or mixed methods studies met inclusion criteria. Two overarching themes were developed: Levels of motivation (i.e. individual, community, and health system) and stages of motivation (i.e. recruitment, retention, and attrition). Nine sub-themes were further developed at the intersection of each level and stage of motivation. Each subtheme comprises the motivating factors that are influential to community health workers at each stage and level. These themes and sub-themes are presented in a Community Health Worker Motivation Model. The motivation model can be used to identify what motivating factors are relevant to community health workers motivation and the stakeholders necessary to address each motivating factor. Recruitment of community health workers for maternal, neonatal, and child health relies largely on individual level of motivation. At retention, individual level motivating factors remain influential; and community and health system begin to influence motivation positively. But, overall health systems in low and middleincome countries are demotivating the health workers rather than motivating them.

Towards an agenda for implementation science in global health: there is nothing more practical than good (social science) theories

### Summary box Ridde recently called for a commitment to implementation science and for ‘better quality research in order to have a greater understanding of how to implement health interventions’.1...