THE INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT

Int J Health Plann Mgmt 2017; 32: 217–233

Published online 6 April 2016 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/hpm.2342

Primary health care workers’ views of

motivating factors at individual, community
and organizational levels: a qualitative study
from Nasarawa and Ondo states, Nigeria
Aarushi Bhatnagar*, Shivam Gupta, Olakunle Alonge and Asha S. George
Department of International Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, USA

ABSTRACT
Background Current efforts to motivate primary health workers in Nigeria focus on better
financial incentives, and the role of other motivating factors has received less attention. The
aim of this study is to explore individual and organizational determinants, their interactions
and effects on motivation.
Methods Exploratory qualitative research, involving semi-structured interviews with 29 pri-
mary health workers (doctors, nurses, midwives and community health workers), was con-
ducted in Nasarawa and Ondo states in Nigeria. Nine key informant interviews were
conducted with government officials. Interviews were digitally recorded, transcribed and
coded. Thematic analysis was conducted to identify common themes, as well as unique
narratives.
Results Results from this study suggest that health workers are motivated by individual (vo-
cation, religion, humanity and self-efficacy) and organizational (monetary incentives, good
working environment) factors and community recognition. Supervision and leadership pro-
vided by the officer in charge as compared with that by external agencies appeared to have
a positive effect on motivation.
Conclusions Policy makers and donor agencies should take into account a broader range of
factors while designing strategies to motivate the health workforce. The study also under-
scores how officer in charges with enhanced skills are likely to motivate health workers by cre-
ating a more supportive environment.

KEY WORDS: primary health worker; work motivation; Nigeria

INTRODUCTION

Given the labor-intensive nature of health care, health worker motivation is critical
for health worker performance. Motivation is the “conscious or unconscious stimu-
lus, incentive or motives for action toward a goal resulting from psychological or

*Correspondence to: Aarushi Bhatnagar, Department of International Health, Johns Hopkins Bloomberg
School of Public Health, Baltimore, USA 21205. E-mail: abhatna4@jhmi.edu

Copyright © 2016 John Wiley & Sons, Ltd.

218 A. BHATNAGAR ET AL.

social factors, the factors giving the purpose or direction to behavior” (Borkowski,
2005). While some define work motivation as “willingness to exert and maintain
an effort to succeed at work, achieve the organization’s goals or to help the team
reach its goals” (Franco and Bennett, 2000), it is also “conditioned to satisfy individ-
ual needs” and occurs in a situation “when esteem, feelings of growth and compe-
tence are tied to performance” (Tummers et al., 2006). Thus, work motivation is a
psychological process aimed at achieving organizational goals and is shaped by
the workers’ personal needs and desires, the organizational context and the broader
socio-political community.
Determinants of motivation among health workers in low- and middle-income
countries (LMICs) operate at the individual, community and organizational levels.
Health workers at the individual level are motivated by altruism, the “sense
of responsibility,” their academic and career aspirations, social and educational ex-
posures and the desire for respect and recognition (Chandler et al., 2009; Franco
and Bennett, 2000; Mathauer and Imhoff, 2006; Mbindyo et al., 2009; Prytherch
et al., 2013; Sheikh et al., 2012). Among organizational factors, some argue that sal-
ary is one of, if not, the most important pre-requisite for motivating health workers
(Agyepong et al., 2004; Chandler et al., 2009). In most LMICs, low salaries are con-
sidered to be a major source of grievance among health workers and are associated
with high attrition (Agyepong et al., 2004; Akwataghibe et al., 2013; Willis-
Shattuck et al., 2008). Nonetheless, extrinsic incentives for motivation do not always
have to be financial in nature. Provision of good housing has motivating effects and
plays a significant role in shaping employment preferences especially for remote
areas (Kotzee and Couper, 2006; Mangham and Hanson, 2008). Similarly, further
education and professional opportunities provide avenues to gain more knowledge
and improve skills (Mangham and Hanson, 2008; Mathauer and Imhoff, 2006;
Rao et al., 2013; Zinnen et al., 2012). Supportive supervision, good management
practices and cordial interpersonal relationships also have a strong influence in mo-
tivating health workers (Chandler et al., 2009; Dieleman et al., 2003; Dieleman
et al., 2009; Willis-Shattuck et al., 2008). On the other hand, lack of essential med-
icines and equipment, insufficient staffing and inadequate working conditions are
demotivating factors (Agyepong et al., 2004; Chandler et al., 2009; Mathauer and
Imhoff, 2006; Mbindyo et al., 2009).
Current policy efforts on improving health worker motivation in Nigeria focus on
financial incentives (Federal Ministry of Health Nigeria, 2007). While these are nec-
essary given an expenditure-income mismatch (Akwataghibe et al., 2013), the role
of other individual and organizational determinants have received less attention.
The aim of this study is to explore the range of factors at individual and organiza-
tional levels, their interactions and effects on health worker motivation within the
context of the Nigerian primary health care system.

Study setting
This study was conducted in two of the 36 states in Nigeria—Nasarawa and Ondo—
as part of a larger baseline situational analysis of the health workforce prior to the
launch of a performance-based financing scheme. Nasarawa and Ondo belong to

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2017; 32: 217–233
DOI: 10.1002/hpm
 PRIMARY HEALTH CARE WORKERS’ VIEWS OF MOTIVATING FACTORS 219
two distinct geopolitical regions in Nigeria, northcentral and southwest respectively,
and there are wide variations between these regions with respect to socio-economic
and health indicators (Table 1). The Nigerian Ward Minimum Health Care Package
prescribes one community health officer (CHO), one public health nurse, three com-
munity health extension workers (CHEWs) and four nurse/midwives in a primary
health center (PHC) in Nigeria (National Primary Health Care Development Agency,
August 2007). Each cadre is responsible for providing specific services and has a
distinct career path in the Nigerian civil service (Federal Ministry of Health Nigeria,
2007). Health facility mapping data indicates that the national standards for human
resources for health are not met in almost all PHC centers across the country (Federal
Ministry of Health Nigeria, 2012).

METHODS

This study followed an exploratory qualitative research design based on in-depth

semi-structured interviews with doctors, nurses, CHOs and CHEWs at PHCs and gen-
eral hospitals, as well as key informant interviews with ministry of health officials. To
gain a holistic comprehension of health workers’ motivation, maximal variation
(Creswell and Clark, 2007) in facility and working environment was sought. The
study was conducted in four local government areas (LGAs) (equivalent to districts)
in Nasarawa and Ondo states. In each state, one better- and one poor-performing
LGA were selected; performance was based on immunization and antenatal care
services and extent of manpower. Within a LGA, three facilities were purposively
selected based on their (1) level: comprehensive versus basic; (2) location: urban
versus remote; and (3) performance: service utilization level. Additionally, one general
hospital from each state was also included. In each selected facility, the officer in

Table 1. Description of study site

Nasarawa Ondo Nigeria Source

Population (in millions) 1.9 3.9 160 (National Planning
Commission of Nigeria, 2012)
% Literate 42 66 51 (UNESCO, 2012)
% Delivered in a facility 40 56 36 (Demographic and Health
Survey, 2013)
% Children fully 20 47 25
vaccinated
% Children stunted 35 24 37
# Public primary health 609 458 13,000 (Federal Ministry of Health
centers Nigeria, 2011)
# Doctors 215 250 16, (Akwataghibe et al., 2013;
572 Federal Ministry of Health
Nigeria, 2007)
# Nurse/midwives 1021 1475 121,
243
# Community health 3420 1337 19,
workers 268

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DOI: 10.1002/hpm
220 A. BHATNAGAR ET AL.

charge (OIC) was purposively interviewed and another health worker was randomly
selected from the staff roster.
Interviews with health workers covered a range of topics: reasons for joining the
profession, factors that enabled and deterred accomplishment of professional goals
and individual and organizational determinants of motivation. They were also asked
to describe their perceptions of and experiences with supervision and leadership. In
addition, experiences of OICs were also documented to identify their attitudes and
behaviors as a leader and their efforts for team building and motivating subordinates.
Key informant interviews with the Federal Ministry of Health, state Hospital Man-
agement Board, Local Government Area Primary Health Care (LGA PHC) Depart-
ment and National Primary Health Care Development Agency were also carried
out to understand existing health worker remuneration and incentive structures, pro-
cess of recruitment, qualifications and training received by different cadres. Addi-
tional contextual information was also collated from official documents maintained
by the federal and state government agencies.
All interviews were conducted by a team of two study investigators between 15
July and 6 August 2011, in a private setting in English and were audiorecorded after
receiving verbal consent from the respondent. In addition, a field manual was main-
tained to include responses, verbal and facial reactions of respondents and notes on
the condition of the facility. The investigators also kept a journal to record their

Table 2. Selected characteristics of respondents

Characteristics of respondents N = 29

Sex
Female 21

Cadre of health worker

Doctor 2
Nurse/midwives 14
Community health officers/technicians 4
Community health extension workers 9

Local government area (district)

Remote and poor performer, Ondo 8
Peri-urban and better performer, Ondo 8
Remote and poor performer, Nasarawa 5
Peri-urban and better performer, Nasarawa 8

Type of health facility

General hospital 6
Comprehensive PHC 8
Basic PHC 15

Key informants N=9

LGA PHC Directors 4
Hospital Management Board Directors 2
Ministry of Health Officials 3

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 PRIMARY HEALTH CARE WORKERS’ VIEWS OF MOTIVATING FACTORS 221
reflexivity while conducting interviews and data analysis. All digital recordings of
interviews were transcribed verbatim and checked for quality.
A codebook containing a priori, based on research objectives, and emergent codes
was developed and validated by the investigators following which all transcripts
were coded using Atlas.ti. Interview data were further organized and examined for
patterns and variations across geographical areas and between cadres of health
workers. Validation of the thematic analysis was achieved by periodic discussions
with local collaborators and research team members.

RESULTS

The final sample of respondents included 2 doctors, 14 nurse/midwives, 9 CHEWs

and 4 CHOs (Table2). Of the 29 respondents, 21 were women, 16 were from Ondo
while the remaining 13 from Nasarawa. Most had been in service for 10–20 years
and had worked previously within the same state. All, except three, had been work-
ing in their respective facility for at least 2 years. A majority originally belonged to
the state they were working in.
Study findings are reported following the theoretical framework by Franco et al.
(Franco et al., 2002), categorizing sources of motivation at the individual, commu-
nity and organizational level (remuneration, working conditions, staff dynamics
and supervision) (Table 3).

Table 3. Summary of perceived factors of work motivation

Motivating factors De-motivating factors

Individual • Vocation
• Desire to improve health
• Desire to help community
• Service to God
• Enhance self-knowledge

Community • Recognition and appreciation • Low utilization of services

from community • Resistance from community

Organizational • Teamwork
• “Confidence-building” • Inadequate remuneration
supervision
• “Problem-solving” leadership • Lack of hardship allowances
• Small perks like meals and • Unequal salary structure
beverages
• Staff shortages
• Lack of drugs and equipment
• Absence of basic amenities:
electricity, water
• Poor infrastructure including lack of
housing, toilets
• Poor access to health facility
•Poor security at work place

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222 A. BHATNAGAR ET AL.

INDIVIDUAL VOCATION AND SELF-EFFICACY

Most of the respondents wanted to join the health profession given their desire to im-
prove community health and to be “answerable to their god” for serving humanity.
An overwhelming majority considered the ability to help people, teach better health
practices and save lives, particularly those of pregnant women and children, to be a
significant motivating factor. Many nurses also reported to be attracted to nursing be-
cause of the white uniforms and how nurses were perceived in the community.
“Why I became a nurse is that I just like to care for people. And I also like their
way of dressing and their neatness because they are always neat anywhere you
see them. Their purpose of saving lives is helpful both in health institution and
at home, they help to save lives.” [Nurse, General Hospital, Ondo]
My motivation to stay here is just to enlighten them (community) and let them
know what health is.” [CHEW, PHC, Ondo]
A few respondents, particularly younger ones, also listed the importance of learn-
ing to advance professionally. They were ambitious about improving their skill set to
learn how to tackle commonly seen diseases, conduct deliveries safely to prevent
maternal and infant deaths and also grow professionally.
“The reason I became a CHO is that I want to improve technically about my work,
to be the head of a place like where I am today”. [CHO, PHC, Nasarawa]

COMMUNITY RECOGNITION

Many respondents mentioned being encouraged by the recognition that they re-
ceived from the community for their services. They were happy to be greeted and
appreciated by members of the community when they saw them outside the health
facility. Many health workers talked about being welcomed by the community even
if there were not residents of the area.
“When they get home, they will still remember and come to thank us that we have
really tried and we will be happy because by the time we see them that they have
recovered, we will be happy that at least our job is moving (ahead).” [Nurse, gen-
eral hospital, Ondo]
They were pleased that the community was responsive to them and their outreach
efforts led to more people utilizing services offered at the health facility. A health
worker reported that the community went to his employer to retain him back when
he was being transferred.
“The community, I can remember the first place that I worked, they appreciated it.
Because when I was going, some of them even, they wanted to go to my employer
so that they can retain me back that they don’t want me to go. So they appreciated
my efforts. And though this place is a very small unit, this area and we don’t have
enough patients before but when we started doing outreach, when we went out to

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 PRIMARY HEALTH CARE WORKERS’ VIEWS OF MOTIVATING FACTORS 223
introduce ourselves, people are trooping in and I am now even enjoying them.”
[CHEW, PHC, Nasarawa]

INADEQUATE AND UNEQUAL REMUNERATION

In general, respondents were dissatisfied with low wages. In addition, some health
workers believed that they should receive additional compensation for being posted
in rural areas because they were away from their families, work under difficult con-
ditions and risk their personal safety. They also thought that they should receive an
extra allowance as their work exposed them to many dangerous illnesses such as
HIV/AIDS, hepatitis, etc.
“Being in this rural area is not easy, so there should be another benefit apart from
our salary for us. For somebody to be here for 24 hours, leaving home, children at
home is not easy but it’s your job and you have to do it. But to encourage us to put
all our heart on this work, there should be another preferential care for
us.”[CHEW, PHC, Ondo]
A few respondents were very agitated by the discordance in base salaries between
LGA, state and federal government levels. Even with the same basic training, those
working in primary health centers earned substantially less than their colleagues in
state secondary hospitals and federal tertiary hospitals.
“I’m a midwife, I may have my mate in a federal hospital, we did the same mid-
wifery, we started together we qualified the same day, the same certificate, but be-
cause they are with the federal, they are taking N100,000 and because I’m in the
state, I’m collecting N50,000. Is that fair? You don’t expect me to perform much.”
[Midwife, General Hospital, Nasarawa]

DIFFICULT WORKING CONDITIONS

Shortage of staff
According to most respondents, facilities were inadequately staffed to manage pa-
tient volume and health problems in catchment areas. Most respondents talked about
spillover effects of this in their personal lives, particularly among women because of
their additional “job as a woman at home.” They had to work hard, often doing con-
tinuous shifts without any break and complained of exhaustion. In addition, lack of
doctors at PHCs implied referral of critical patients and complicated deliveries to
general hospitals, reportedly creating a feeling of incapability among nurses and
CHEWs.
“We need more fund, so that the government will be able to recruit more staff, then
put the right people in the right position. Where nurses, midwives are supposed to
be, should not be where they will be replaced by community health workers be-
cause most of the time when patient comes in labor, especially in the middle of

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224 A. BHATNAGAR ET AL.

the night and there are cases beyond the person on duty, they have to call us.”
[OIC/Nurse, PHC, Ondo]
“We don’t have neither a visiting or resident doctor because when you have a ter-
rible situation that needs urgent you will not have a doctor to attend to that situ-
ation, of which it pains us a lot, referring patient from this place to a general
hospital…this 5 minutes means a lot to a life so that is a challenge.” [Nurse,
PHC, Nasarawa]
The situation seemed to be similar in the two general hospitals visited during data
collection. While the hospitals were staffed with at least one or two doctors, the in-
terviewees did not think it was sufficient to cater to the volume of patients.
“Take for instance you can see these…here, one of my doctors is in Lafia for a
workshop and I’m left with only one and you see how crowded the place is, the
patients will get tired, I will get tired too and at the end of it I will not be able
to see or assess my patients as required because I’m already tired and they are
also tired of waiting, some may even leave at the end of the day because they
may wait and wait with nobody to attend to them.” [Doctor, General Hospital,
Nasarawa]

Lack of essential drugs and equipment

A majority of health workers talked about their frustration with the shortage of
drugs, equipment and infrastructure. They felt that they were a “consulting unit” in-
stead of a health center as they had to turn away patients without giving them treat-
ment. They also reported to be working without necessary equipment required for
safe deliveries, beds to admit patients or vehicles for emergency transportation. Their
emotions ranged from deep anger with the government for not providing drugs and
equipment to sheer helplessness on turning away their patients.
“And we don’t even have the drugs. This community…we are poor. To come to the
hospital to seek medical care, they don’t have money. Sometimes they come, they
beg.” [CHEW, PHC, Nasarawa]
“There is poor equipment here, plain truth. Let’s say this one, this sphygmoma-
nometer, I bought it with my own money. Not long ago, it was spoilt. I will still
rebuy it because the government does not have it.” [CHEW/OIC, PHC, Nasarawa]

Absence of basic amenities

Health workers criticized lack of housing amenities provided to them, including un-
hygienic state of toilets. They complained about lack of electricity and water and re-
ported to have conducted deliveries in candle or torch light. All health centers visited
did not have any electricity at the time of data collection, and the staff reported the
lack of it for days prior to the visit as well.
“And sometimes the generator is not working. Sometimes we use torch light to
take deliveries, that is not encouraging. There is no rest. It discourages some-
times.” [Nurse, PHC, Ondo]

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 PRIMARY HEALTH CARE WORKERS’ VIEWS OF MOTIVATING FACTORS 225
Another major source of discontentment, particularly among women, was poor se-
curity at the facilities given that most did not have a proper fence or guards. Many
found it extremely difficult to reach their place of work because of lack of transpor-
tation. They also feared for their safety given terrible conditions of the roads and
wanted insurance as a part of their salary package.
“Sometimes we meet patients that are violent, some very uncooperative. Some,
you cannot satisfy. But if you have good security, at least you know when a patient
is becoming violent, you know somebody who is trying to instigate others will be
silenced or attended to. At night we have just one night guard and being a govern-
ment worker he will feel that this work is not my father’s job or its not even worth
risking my life for.” [Nurse, PHC, Ondo]

STAFF DYNAMICS

Despite poor working conditions, health workers seemed to exhibit a sense of team-
work among their colleagues with most reporting that they had cordial relations.
They considered themselves to be part of a family, helping each other and working
toward achieving the “same goals.” They often relied on one another to do proce-
dures that they were not confident of doing themselves and were not shy in asking
for help irrespective of their cadre or grade level.
“Because we work towards the same goal, so we are working together. If I am
around I will take delivery, not that I will call the midwife to come and do it.
No I will do it, so we work together any time any moment. We are very friendly
and we work towards the same goal.” [Nurse, PHC, Ondo]
“We work as a team, as you can see now, I’m the only CHO on duty, she is the
only nurse on duty, we work together. If I’m seeing an antenatal case, I will say
ok my sister, this is an antenatal case, how do we handle it, so you see the working
relationship is good.” [CHEW, PHC, Nasarawa]

SUPERVISION

Health workers reported that external supervision, from the local, state and fed-
eral government levels, usually consisted of infrequent and brief visits to mostly
check health facility records without providing any written feedback on perfor-
mance. A few also complained that supervisors did not acknowledge their
complaints regarding lack of essential supplies. Although many considered su-
pervision to be a form of motivation, they seemed to be discontent with their
experiences with it. A nurse described a typical description of a supervision
visit as follows:
“The data collected for the health center, they normally go through it. If the thing
is low, they say ‘ahn ahn, this thing is low, improve on it’. If the data is okay, they
will say it’s okay and that we should keep it up.” [Nurse/OIC, PHC, Ondo]

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226 A. BHATNAGAR ET AL.

“I’m the officer in-charge of the maternity section, we don’t have a delivery bed
that’s a secret I’m telling you….so we make that requisition, nothing is done,
we made a requisition about forceps, nothing is done. This manual aspirator,
nothing is done. So we are tired, we made requisitions we are tired, we don’t
know.” [Nurse, PHC, Nasarawa]
Internal supervision provided by OICs, on the other hand, was reported as more
helpful to health workers for gaining knowledge, correcting mistakes, improving
quality of care and boosting confidence.
“If you are supervised, you get to know the areas you are lacking and next time
you will want to do it right. That’s motivation.” [Nurse, PHC, Nasarawa]
“It (supervision) matters a lot because nobody has all the knowledge, so working
under supervision is good because the supervisor may detect any mistakes I have
done so as to pick correction.” [Nurse, PHC, Nasarawa]
Almost all health workers talked about having a positive experience with their
OICs who they considered their leader and role model. They looked up to their
OIC to solve their problems including managing patients, conflicts with colleagues
or communicating grievances with higher authorities. They also talked about their
OICs encouraging them with occasional meals, transportation allowances or medi-
cines. They looked for certain traits in their leaders such as the ability to teach, super-
vise, discipline, build good interpersonal relationships and trouble shoot problems.
“It (leadership from OIC) helps me to work better because I wish to be like him.
To have the knowledge and even more.” [CHEW, PHC, Ondo]
“The way she does things, I like it and she is very good. She always imparts
knowledge and corrects. If there is anywhere to correct, she corrects with love.
She is not harsh and she loves us like sisters.” [CHEW, PHC, Ondo]
Discussions with supervisors (including key informant interviews with external
supervisors) corroborated perceptions of health workers, to a large extent, that super-
vision was not usually supportive in nature and insufficient in terms of frequency,
structure and feedback. External supervisors complained of lack of resources, partic-
ularly transportation support, for being able to effectively supervise. OICs, on the
other hand, had better access to health workers for providing supervision, but a cou-
ple also talked about facing challenges in terms of balancing their responsibilities as
a teacher, manager and health provider. However, they understood the importance of
supervision and considered it to be crucial to motivate health workers.
“If we don’t go out they relax, they are not motivated then they feel left out. Because
when they see you the feel, “aah, our people are here”, you know. If we want things
to improve at the local level, fulcrum is supervision.” [Key informant, Nasarawa]

DIFFERENCES ACROSS STATES, GEOGRAPHIC AREAS AND CADRES

On the whole, most health workers appeared to be facing the same difficulties in
their work environments and reported similar challenges, namely inadequate salaries

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 PRIMARY HEALTH CARE WORKERS’ VIEWS OF MOTIVATING FACTORS 227
and lack of equipment. However, there were subtle differences in the responses of
health workers interviewed across different states. For example, the presence of a
medical doctor as the PHC Coordinator at the LGA PHC Departments in both LGAs
in Ondo seemed to make a difference to the respondents—they had more confidence
of being able to handle complicated cases, had greater opportunities to gain more
technical knowledge and were satisfied that their PHC Coordinator was able to solve
their problems and provide assistance from the LGA. In addition, they looked up to
the doctor as a role model and were inspired by his efforts to help the community and
patients. Respondents in Nasarawa, especially those from primary health centers, did
not have a similar experience, as there were no doctors at the LGA PHC Department.
In fact, a couple of them mentioned how not having a doctor to supervise and guide
them was often detrimental to their work.
At the time this study was conducted, Ondo state was implementing, in selected
LGAs, the National Health Insurance Scheme-Millennium Development Goals
(NHIS-MDG) project for maternal and child health providing capitation payments
to health facilities for purchasing drugs, equipment and carrying out renovations.
The scheme was operational in one of the chosen LGAs for this study, and many re-
spondents from the LGA talked about its beneficial nature and the difference it made
in their abilities of providing care to their patients. Specifically, they were very con-
tent with having a stock of essential medicines that they could prescribe to patients
free of charge. Many proudly showed the renovations, including tiled floors and
newly bought furniture for their office spaces, which were made possible because
of the funds given by NHIS-MDG. On the other hand, the second LGA in Ondo
and the two in Nasarawa state did not have this scheme resulting in health facilities
suffering from an acute shortage of drugs. Almost all respondents from these facili-
ties were discouraged by the lack of essential drugs.
Apart from variations among respondents across states, there was also a difference
between health workers’ responses depending upon the degree of remoteness of the
location of their health facility. While most health facilities visited were in rural
areas, they were not very far from the main road and had fairly good accessibility.
However, there were at least a couple of facilities in each state that took more than
an hour to get to on very bad roads. Health workers positioned in these facilities
expressed a much stronger desire for housing and transportation support as com-
pared with the others. They usually worked at the PHCs on a weekly shift and had
to live, away from their families, either at the facility itself (using in-patient wards)
or were accommodated by someone in the community. Their working conditions
were typically poorer, and they dealt with a community that was more likely to be
unaware and resistant to using services provided by them. These circumstances fur-
ther deteriorated their desire to perform their best.
There were also differences in responses between cadres of health workers. The
doctors interviewed were either the LGA PHC Coordinators in Ondo State or the
Medical Officer in charge of the General Hospitals. They were the figures of author-
ity, the supervisors and leaders to other cadres, and hence, their experiences of lead-
ing the LGA/hospitals were naturally very different. They described their work to be
taxing, providing both curative consultations as well as looking after the administra-
tion and management of the LGA/hospital. They also had the easiest access to higher

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228 A. BHATNAGAR ET AL.

levels of government but at the same time bore the brunt of its inefficiencies and bu-
reaucracies. Their source of motivation lay in being able to provide good quality
health services and to further improve their facilities.
Senior nurses/midwives appeared to be the most perturbed by the discrepancies in
salary structures across states and level of facilities. They were very angered by the
fact that their classmates working either in the neighboring state or a state govern-
ment owned facility earned more than them for providing the same services. Nurses
and midwives also had more interactions with pregnant women and were encouraged
by their abilities to be able to conduct safe deliveries and prevent maternal mortality
and morbidity. CHEWs, on the other hand, were motivated by being able to provide
a range of services and wanted to gain additional clinical knowledge in order to be
able to prosper both academically and financially. Younger health workers, although
a minority in the sample interviewed, were keen to learn more and acquire higher
qualifications.

DISCUSSION

Results from this study suggest that health workers are motivated by both intrinsic
(self-efficacy, religion, vocation, humanity) and extrinsic (good working environ-
ment, monetary incentives, recognition, organizational justice) factors. Moreover,
supervision and leadership from within (provided by the OIC) and outside (from
the district health management team) of the health facility appeared to have a differ-
ent effect on health worker motivation.
A limitation of this study was that the research team had made initial contact with
potential respondents via the LGA PHC Department. Given that this information
was narrated to them through higher authorities, it is likely that health workers were
cautious about what they said during the interview and perhaps sugar coated some of
the challenges that they faced particularly pertaining to supervision and their rela-
tions with higher authorities. As this was the only way to reach the health facilities
and take appointments with the staff, it could not be avoided. However, discussions
with key informants at the LGA, state and federal level, as well as a document re-
view of existing reports by the government and other agencies, confirmed most of
these findings. In many cases, health workers insisted on taking the interviewer
around the facility to show the poor working conditions. Lack of essential drugs
and equipment, inadequate supervision and weak management practices in Nigerian
PHCs is also documented in other studies (World Bank, 2010). Key informants from
the LGA and state corroborated that supervision was indeed insufficient in terms of
frequency, structure and feedback. These supervisors complained of lack of re-
sources, particularly transportation support, for being able to effectively supervise
facilities under them. In addition, a couple of respondents, although consented to
participate, were clearly uncomfortable to communicate freely. This could have been
a combination of language barriers as well as discomfort with a foreign researcher.
Despite the limitations, these findings reiterate the importance of intrinsic motiva-
tion and how it could affect health workers’ performance. The sense of vocation, al-
truism and professionalism expressed by health workers in this study is also

Copyright © 2016 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2017; 32: 217–233
DOI: 10.1002/hpm
 PRIMARY HEALTH CARE WORKERS’ VIEWS OF MOTIVATING FACTORS 229
documented from other settings (Chandler et al., 2009; Franco and Bennett, 2000;
Malik et al., 2010; Mathauer and Imhoff, 2006; Mbindyo et al., 2009; Prytherch
et al., 2013; Ruano et al., 2012). Among factors in the work environment, health
workers’ responses also largely corroborated with those from other LMICs. While
many mentioned inadequate salaries and lack of allowances (Agyepong et al.,
2004; Akwataghibe et al., 2013; Chandler et al., 2009; Joint Learning Initiative,
2004; Lakra et al., 2012; Malik et al., 2010; Willis-Shattuck et al., 2008), the most
recurring grievance among them was the shortage of drugs making them incapable
of providing proper treatment to their patients. In addition, supervision, particularly
one that involved coaching, providing feedback on performance and boosting confi-
dence went a long way in motivating them (Dieleman et al., 2003; Dieleman et al.,
2009; Dieleman et al., 2006). Similarly, a sense of belonging to their facility, spirit
of teamwork and problem-solving leadership also encouraged them further. Recog-
nition from their supervisors and community also motivated them (Chandler et al.,
2009; Greenspan et al., 2013; Malik et al., 2010).
While low salaries were not brought up to a large extent, the fact that there was a
disparity either across states or the level of health facilities was a major grievance
among health workers. In line with equity and organizational justice theories of mo-
tivation and related empirical evidence (Heponiemi et al., 2011; Heponiemi et al.,
2013; McAuliffe et al., 2009; Robbins, 2007), this is of crucial importance. The em-
bitterment of not being treated equally by the government was de-motivating. Other
studies have also shown that such disparities have resulted in health workers migrat-
ing from state-owned rural facilities to federal-owned tertiary ones located in urban
areas (Akinyemi and Atilola, 2013). Key informant interviews also confirmed that
remuneration packages for the same cadre and grade of health worker differed by
the type of facility, typically being higher for tertiary and secondary. According to
them, the government had been in the process of providing equal pay for the same
grade of civil servants; however, the mandate was still under review and not ob-
served by all states yet.
Most health workers considered their OIC to be their leader and immediate super-
visor and in general were content with the level of support they were receiving. This
is an important finding for further improving the management of health centers.
Given that frontline health workers are indeed looking up to their OICs as their
leaders, then it is essential that the leadership skills of OICs are further enhanced.
At present, however, OICs interviewed had not received any additional leadership
or management training either during their degree programs or as a part of in-service
training. Most OICs reported challenges of balancing their responsibilities as a
teacher, manager and health provider. Furthermore, they were constrained by lack
of adequate resources to ensure smooth functioning of their facility and to incentiv-
ize their staff. Lastly, the hierarchical structure of the health system did not give them
any autonomy to run their facility, making them dependent on higher authorities for
both resources and directive for day-to-day running.
Results from this study provide insight into health workers’ perceptions of several
organizational determinants of motivation and performance, existing at the frontline,
which need to be studied further and streamlined into human resource management
policies.

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DOI: 10.1002/hpm
230 A. BHATNAGAR ET AL.

• Designing a combination of financial and non-financial extrinsic incentives: While

it would not be prudent, based on these data, to state that financial incentives or ad-
ditional monetary payments would not affect health workers, particularly in a coun-
try like Nigeria, this study supports current evidence in emphasizing the
importance of non-financial extrinsic factors in motivating health workers.
Changes to existing supervision instruments to include performance feedback, ad-
ditional training opportunities tied to performance (particularly for CHEWs that are
not trained in many services) and enhancing community engagement by creating
accountability and re-dressal mechanisms could deepen the appreciation and rec-
ognition health workers receive from their supervisors, peers and clients.
• Making managers better leaders: As leaders of frontline health workers, OICs and
district-level managers require additional training particularly in a resource-
constrained environment, to strengthen their capacities to innovate, plan, direct
and motivate their staff. Further research on the effects of different styles of lead-
ership on motivation could also influence designing such training programs for
managers (Morrison et al., 1997; Shortell and Kaluzny, 2006; World health Orga-
nization, 2007).
• Deeper exploration of role of organizational justice: While this study captured the
narratives of several health workers, further research on causes and implications of
“distributive organizational justice,” that is, variations in salaries, needs to be con-
ducted. Of crucial importance is to understand whether this is a phenomenon
among specific types of health workers, how is it changing behavior and attitudes
of health workers toward their jobs and colleagues, what implications does it have
on staffing norms and what are the interim solutions in the absence of political re-
forms changing salary structures.
• Strategies to improve intrinsic motivation particularly pertaining to vocation and
value systems, including religion: Given that most health workers talked about
joining the profession to save lives and as a service to God, further research is re-
quired to strategize how policy makers could better cater to these intrinsic desires
of health workers. In particular, researchers need to identify whether teaching in-
stitutions, faith-based organizations and government recruiting agencies can play a
role in internalizing and strengthening these values among health workers.

CONCLUSION

These findings add to the knowledge base of health worker motivation studies, par-
ticularly in Nigeria where such research is scarce. These results are indicative of the
importance of intrinsic and non-financial extrinsic factors in motivating health
workers. Health planners, policy makers and donor agencies should take into ac-
count these factors, particularly those at the organizational level, while designing
strategies to motivate the health workforce. The conclusions of the study also point
toward improving the leadership and managerial capacity of OICs of health facili-
ties. OICs with such enhanced skills are likely to motivate health workers by provid-
ing better supervision as well as creating a more conducive and supportive
environment.

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DOI: 10.1002/hpm
 PRIMARY HEALTH CARE WORKERS’ VIEWS OF MOTIVATING FACTORS 231
AUTHOR CONTRIBUTIONS

AB and SG conceived the study and designed the study protocol; AB and OA carried
out the interviews; AB and AG conducted the analysis and interpretation of these
data; AB drafted the manuscript and SG, OA, AG critically revised it. All authors
read and approved the final manuscript. AB and AG are guarantors of the paper.

ACKNOWLEDGEMENTS

The authors would like to thank Dr. Dinesh Nair, Senior Health Specialist at the
World Bank for providing logistical support for the study. They would also like
to thank colleagues from Johns Hopkins Bloomberg School of Public Health:
Dr. William Brieger, Dr. Krit Pongirul and Dr. Catherine Lee for their technical in-
puts. They are also grateful to colleagues at the Nigerian Federal Ministry of Health,
National Primary Health Care Development Agency and the ministries of health in
Nasarawa and Ondo states for their support: Dr. Akin Oyemakinde, Dr. Lekan
Olubajo, Mr. Gosho and Dr. Durojaiye respectively. Finally, authors would like to
appreciate and thank all health workers and key informants for their support and
patience during the study period.

FUNDING

The study received funding from the World Bank Country Office in Nigeria.

CONFLICT OF INTEREST

None

ETHICAL APPROVAL

The ethical approval for this study was received from the Institutional Review Board
at Johns Hopkins School of Public Health.

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