Listening to the rural health workers in Papua New Guinea – The social factors that influence their motivation to work

Abstract

Despite rural health services being situated and integrated within communities in which people work and live, the complex interaction of the social environment on health worker motivation and performance in Low Middle Income Countries has been neglected in research. In this article we investigate how social factors impact on health worker motivation and performance in rural health services in Papua New Guinea (PNG). Face-to-face in-depth interviews were conducted with 33 health workers from three provinces (Central, Madang, and Milne Bay) in PNG between August and November 2009. They included health extension officers, community health workers and nursing officers, some of whom were in charge of the health centres. The health centres were a selection across church based, government and private enterprise health facilities. Qualitative analysis identified the key social factors impacting on health worker motivation and performance to be the local community context, gender roles and family related issues, safety and security and health beliefs and attitudes of patients and community members. Our study identified the importance of strong supportive communities on health worker motivation. These findings have implications for developing sustainable strategies for motivation and performance enhancement of rural health workers in resource poor settings.

Introduction

The Millennium Development Goals have renewed global attention on human resources management in the health sector and strengthening of health systems. There is some recognition that the present underperformance of health systems and their progress is the result of a “legacy of chronic under-investment in human resources” (Chen et al., 2004, p. 1984). Responses to this ‘health human resources crisis’ have been focused upon quantity and distribution of health workers (HW), their incentives, retention and issues of migration and their effects upon global distribution of HWs (Dolea, Stormont, & Braichet, 2010; Pena, Ramirez, Becerra, Carabantes, & Arteaga, 2010; Vujicic, Zurn, Diallo, Adams, & Dal Poz, 2004). The current health human resource crisis is not just an issue of availability of staff and retention. Motivation and performance of existing HWs is equally important, yet much less attention has been given to these areas particularly the social context.

Franco, Bennett, and Kanfer (2002) in their conceptual model for HW motivation and performance define worker motivation “as an individual's degree of willingness to exert and maintain an effort towards organizational goals” (p. 1255). Our study design was informed by this conceptual model and definition.

The WHO framework for HW performance (WHO, 2006) considered “performance to be a combination of staff being available, competent, productive and responsive” (p. 5). Distinction needs to be made between workforce performance and individual HW performance. Literature in organizational behaviour recognises that individual performance consists of process (what people do at work) and outcome (results of the individual's behaviour) aspects (Campbell, McCloy, Oppler, & Sager, 1993). Our study draws on both aspects of performance.

Most research on worker motivation and performance has occurred in high income country settings (Rowe, de Savigny, Lanata, & Victora, 2005) and few on lower or middle income (LMIC) settings (Lindelow & Serneels, 2006). The workforce in rural areas is critical to the delivery of primary health care in most LMIC and their performance among other factors impact directly on health related millennium development goals (WHO, 2006).

A review of the literature (Jayasuriya et al., 2011) shows Franco et al.'s (2002) model or its adaptation is the predominant framework (based on Kanfer's theory) (Kanfer & Ackerman, 2000) used in studies of HW motivation and performance in LMIC settings. This framework identified cultural and community influences as distal determinants to motivation. However, most studies that utilised this framework did not investigate these social factors (Chandler, Chonya, Mtei, Reyburn, & Whitty, 2009; Franco, Bennett, Kanfer, & Stubblebine, 2004) or regarded it outside the scope of human resource management (Mathauer & Imhoff, 2006). In their study of non physician clinicians in Tanzania Chandler et al. (2009) excluded social environment, but based on qualitative and quantitative findings identified social status (which gave respect from peers and lay community) as a key motivating factor.

Lehmann, Dieleman, and Martineau (2008) review and Mullei et al.'s (2010) study identified infrastructure as contributing to improving attraction and retention of rural HWs. None of these authors referred to social factors. Dussault (2006) mentioned socio-cultural environment as a broad factor for poor retention. Dieleman, Cuong, Anh, and Martineau (2003) in Vietnam identified the community's respect as an important factor for HW motivation. Ashwell and Barclay (2009) in evaluating a community health promotion project in PNG found stronger relationships between communities and HW resulted in better outcomes. Other studies we reviewed (Jayasuriya et al., 2011) do not utilise a model of worker motivation encompassing social factors, to investigate its determinants. In summary, though literature states social factors are determinants of HW motivation this has not been investigated sufficiently. Moreover there is a gap in published literature of how the complex interaction of society, family and person impinge on HW's lifestyles and work, and especially in LMIC settings.

In this paper, we examine social factors leading to motivation of staff working in and affect performance of lower level health facilities in rural Papua New Guinea (PNG). Selecting our findings “for richness and depth rather than breadth” (Blignault & Ritchie, 2009, p. 143) we discuss key relationships between various social factors and the impact on rural health workers and their motivations to work in difficult and isolated settings in a developing country.