A HEALTH POLICY AND SYSTEMS

RESEARCH READER ON
HUMAN RESOURCES FOR HEALTH
Edited by Asha George, Kerry Scott, Veloshnee Govender
A health policy and systems research reader on human resources for health / Asha George,
Kerry Scott, Veloshnee Govender, editors

ISBN 978-92-4-151335-7

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Printed in South Africa
Key for classifying research inference

Descriptive

? Exploratory

Explanatory

Emancipatory

Predictive
Chapter 5.
Health worker motivation: individual,
organizational and cultural factors
Aarushi Bhatnagar

5.1 Defining the chapter

Motivation is both a driver and a consequence of health worker performance (Bhatnagar, 2014;
Borkowski, 2009). Motivated health workers are likely to attend to their clients and provide
better care, and their improved performance affirms and drives them to achieve their goals
further. This relationship between motivation and performance is influenced further by the
organizational climate and social context within which health workers are positioned. The
objective of this chapter is to present innovative health policy and systems research (HPSR)
carried out to understand what motivates human resources for health (HRH). It aims to
describe research that has used different theoretical and methodological approaches to
measure motivation among various health worker cadres. In particular, this chapter describes
research that has studied the role of organizational and social environments within which
health workers perform in affecting their motivation, including specific interventions such as
performance-based financing. Finally, it seeks to collate research carried out to understand job
preferences for and retention in remote and rural areas, because these in turn are influenced
by motivation to serve in such conditions. This chapter excludes primary research on the role
of meso-level determinants such as leadership, management, governance, and the policy and
political environment in motivating HRH, because these themes are covered in other chapters
of this reader.

5.2 Background on health worker motivation

Motivation can be understood as a psychological process aimed at achieving both personal
and organizational goals, developed among workers due to a combination of their personal
needs and desires, the organizational context within which they work, and the community of
which they are a part (Bhatnagar, 2014). Motivation has been studied extensively in a variety
of disciplines, including psychology, organizational behaviour and economics, particularly in
high-income countries. In the context of organizational psychology and behaviour, motivation
is generally explained by two sets of overlapping theories classified as content and process
theories. Classic textbooks in these fields by Borkowski (2009) and Burns et al. (2012) provide
a rich summary of these theories and their inception, and also present empirical evidence from
the health sector that supports them. Content theories of motivation postulate that people
are motivated by the desire to satisfy their inner needs and values. On the other hand, process
theories of motivation focus more on the cognitive processes underlying motivation, including
factors that initiate, direct, sustain and halt behaviour. These cognitive processes shed light
on the overall context, highlighting practices and interactions in which work is done and the
reactions of employees to work (Burns et al., 2012). While the empirical evidence presented
in these textbooks is predominantly from high-income countries, Dolea and Adams (2005),
in their review of motivation theories, highlight their application in several low- and middle-
income countries.
Part C. How are human resources for health governed? 91
 Motivation is a complex construct, closely interrelated with the concepts of job satisfaction,
retention and performance. While motivation in the context of work is typically defined as
“willingness to exert and maintain an effort towards organizational goals” (Franco et al.,
2002), job satisfaction is referred to as “a pleasurable or positive emotional state resulting
from the appraisal of one’s job or job experience” (Locke, 1976, p. 1300). Although highly
related, and often used interchangeably, motivation and job satisfaction are distinct constructs
(Cummings and Bigelow, 1976). While the former pertains to a person’s intention to achieve
organizational goals, the latter is a reference to his or her attitude or emotional state related
to that organizational setting. Despite these differences, the two concepts, fundamental to
any human resource, are interdependent and hence influenced by a similar set of individual,
organizational and sociocultural factors (Dolea and Adams, 2005; Franco et al., 2002). Given
that motivated individuals are likely to remain in their jobs for longer and perform better,
determinants of retention and performance of health workers are also associated closely with
factors influencing motivation.

The seminal work carried out by Franco et al. (2002) was one of the first to apply various
theories of motivation to develop a conceptual framework for understanding determinants of
motivation for the health workforce, especially people working in low-resource settings. As
described above, Franco et al. (2002, p. 1255) defined motivation in the work context as the
“willingness to exert and maintain an effort towards organizational goals”. The key attribute
of their conceptual framework, however, was the postulation that motivation develops in
individuals as a result of the interaction between individual processes, immediate organizational
work context and cultural dynamics. Individual processes pertain to a person’s goals, values
and expectations along with self-efficacy. The framework further characterizes organizational
factors into organizational resources (infrastructure, medicines, supplies, human resources,
monetary funds), structures (hierarchies, autonomy, management, feedback), processes
(communication, procedures of work) and culture (set of shared norms, leadership). The
broader cultural factors include association between existing social norms and functioning of
an organization as well as societal values and expectations manifested as relationships between
clients and health workers. Most of the subsequent research on health worker motivation has
adapted and used Franco et al.’s framework.

Many economists have also applied psychological theories of motivation to better understand
labour markets. The most common postulation pertains to “crowding out” of intrinsic motivation
due to extrinsic incentives (Frey and Jegen, 2000). It is assumed that individuals are motivated
from within and by external stimuli of different kinds (Gagné and Deci, 2005); and while higher
motivation from intrinsic and extrinsic factors results in greater efforts exerted for a task, there
could also be certain instances in which the two types of motivation may not move in the same
direction (Frey, 1997). This has relevant application for the health workforce as well, especially
in the context of low- and middle-income countries, where low wages are systemic. Several
performance-based financing schemes have been initiated to improve performance of service
delivery indicators, and these affect motivation of health workers. While performance-based
financing has typically been criticized for crowding out intrinsic motivation of health workers,
an article by Lohmann et al. (2016), by applying the self-determination theory of motivation,
argues that performance-based financing does not necessarily have an adverse effect on
intrinsic motivation but could in fact affect both intrinsic and extrinsic motivations, depending
on how it is designed, implemented and evaluated.

Several reviews and international agency reports have attempted to collate research carried
out on understanding what motivates health workers in low- and middle-income countries.
Willis-Shattuck et al. (2008), in their review of primary research articles based in low- and
middle-income countries, concluded that financial rewards, career development, continuing

92 A HEALTH POLICY AND SYSTEMS RESEARCH READER ON HUMAN RESOURCES FOR HEALTH
education, facility infrastructure, resource availability, facility management, and recognition
and appreciation were some of the main motivating factors among health workers. Similarly,
Mathauer and Imhoff (2006) synthesized studies that have explored the role of non-financial
incentives in motivating health workers across African countries. More recently, Okello and
Gilson (2015) carried out a review to ascertain the role of trust relationships between health
workers and their supervisors, managers, employing organizations, co-workers and patients in
directly or indirectly motivating health workers. Hongoro and Normand (2006) and Singh et
al. (2015) have studied community health worker programmes in various contexts to review
organizational factors, including incentive schemes, for motivating community health workers.
Given that community health workers across low- and middle-income countries typically come
from a different socioeconomic background than professional health workers such as doctors,
nurses and midwives, and have a different mandate in terms of the services that they provide,
understanding their motivation to work warrants special attention and efforts.

In addition, several reviews have been carried out to synthesize evidence on retention and
job preferences of health workers. Dieleman et al. (2011) conducted a realist review to collate
findings on factors that influence health workers to remain and work in rural and remote
postings. Similarly, a systematic review of discrete choice experiments, a technique to elicit
stated job preferences, particularly in the context of rural and remote postings, concluded that
bonus payments and postgraduate training opportunities were the most sought after choices,
typically among doctors and medical students (Mandeville et al., 2014). While these reviews
do not directly address the question of what motivates health workers, they do provide a
comprehensive understanding of various individual, organizational and cultural factors that
influence job preferences of health workers. Many of these factors in turn are closely interlinked
with motivation of health workers and drive them towards achieving their professional goals.

As complex as it may be to define and measure, motivation is an essential ingredient for

determining the performance of health workers and is key to any effort towards strengthening
the health workforce. While several reviews and studies have gathered evidence on factors
influencing motivation of health workers, this chapter aims to describe selected primary
research on health worker motivation carried out in recent years across different low- and
middle-income countries and pertaining to various cadres of the health workforce. These
articles were selected from a pool collated from a doctoral seminar at the Johns Hopkins
School of Public Health, a crowdsourcing exercise supported by Health Systems Global and
subsequent searches using the bibliography of key articles and on relevant databases and
search engines (PubMed and Google Scholar). The main criteria used to select the articles
included diversity in region, cadre and methods, as well as the quality of the studies based on
standard guidelines.

5.3 Illustrative primary research articles

This section describes the seven articles selected for this reader that demonstrate innovative
research carried out to understand motivation of health workers over the past decade. An
attempt has been made to showcase articles using different quantitative and qualitative
methodologies, focusing on various types of health provider working in low-resource settings
across different geographical regions. The first two articles (Chandler et al., 2009; Smith et
al., 2013) illustrate different techniques to measure motivation, while the next two articles
(Huicho et al., 2015; Razee et al., 2012) focus on factors that inspire health workers to serve
in rural and remote areas. The fifth article (Shen et al., 2017) describes an impact evaluation
of a specific intervention, namely performance-based financing, designed to improve health
service delivery and motivation of health workers. The final two articles (Aberese-Ako et al.,
2014; Choi et al., 2016) highlight the role of meso-level determinants such as leadership and
organizational justice in creating a more enabling environment for health workers.

Part C. How are human resources for health governed? 93

 5.3.1 Measuring health worker motivation
Chandler CIR, et al. (2009). Motivation, money and respect: a mixed-method study of Tanzanian
non-physician clinicians. Soc Sci Med. 68(11):2078–2088
?
Health workers Public sector non-physician clinicians
Geographical area United Republic of Tanzania
Research methods Mixed: ethnography in two district public hospitals over 6
months and Likert scale development with clinical officers
in 13 public hospitals and assistant medical officers in other
smaller public hospitals
Research inference Exploratory

This article adapted the Franco et al. (2002) framework to measure motivation among non-
physician clinicians working in district hospitals with poor-quality service delivery in two
regions of the United Republic of Tanzania. Using a combination of ethnographic research to
understand the working environment of non-physician clinicians and quantitative measurement
of motivation constructs, the authors distinguished between intrinsic and environmental factors
of motivation. The ethnographic research included interviews with clinicians and observations
of clinician–patient consultations, meetings attended by clinicians, and clinician daily routines.
Based on these qualitative findings, and using existing quantitative questionnaires, the authors
developed a scale, with 62 items on a five-point Likert scale, to measure various constructs
of motivation for non-physician clinicians. While various studies attempting to measure
motivation have used context-specific scales (Mbindyo et al., 2009; Peters et al., 2010; Purohit
et al., 2016), this study is distinctive in its adaptation of the Franco et al. (2002) conceptual
framework and subsequent application of the measurement scale, given the rich ethnographic
research carried out to validate the above-mentioned framework. Additionally, the article
focused on motivation of non-physician clinicians, a cadre rarely studied, especially given its
relevance to task-shifting in low- and middle-income countries.

Smith R, et al. (2013). Appealing to altruism: an alternative strategy to address the health
workforce crisis in developing countries? J Publ Health. 35(1):164–170
?

Health workers Nursing students

Geographical area South Africa, Kenya, Thailand
Research methods Quantitative dictator games
Research inference Exploratory

This article describes the use of economic field experiments to measure intrinsic motivation of
health workers, thereby contributing to evidence on the role of personal values such as altruism
in encouraging health workers to work in the public sector. This study was based in three low- and
middle-income countries (Kenya, South Africa, Thailand) and used a standard dictator game,
where nursing students were given a real financial endowment to split between themselves and
others in order to detect “the presence and power of altruism in decision-making” (p. 165). Each
nursing student was asked to split the endowment between him- or herself, a patient and a poor
person. In general, the study found nursing students demonstrate greater altruistic behaviour
compared with other professionals, although there were variations across countries, genders and
age groups. The innovative techniques used in this study to measure altruistic behaviour allow for
greater consideration for personal values, rather than only job characteristics, in order to understand
determinants of motivation. The cross-country comparison also reveals the significance of

94 A HEALTH POLICY AND SYSTEMS RESEARCH READER ON HUMAN RESOURCES FOR HEALTH
socioeconomic contexts for influencing altruistic behaviour. For example, the authors conclude
that the relatively lower levels of altruism exhibited by respondents in South Africa and Kenya
compared with Thailand could be due to higher inequalities and lower solidarity existing in
those societies.

5.3.2 Social factors of motivation and job preferences

Razee H, et al. (2012). Listening to the rural health workers in Papua New Guinea: the social
factors that influence their motivation to work. Soc Sci Med. 75(5):828–835 ?

Health workers Public and private sector health extension workers, community
health workers, nurses
Geographical area Papua New Guinea
Research methods Qualitative: in-depth interviews
Research inference Exploratory

This article describes the social environment and its interactions with health worker motivation
and performance of health extension workers, community health workers and nurses in Papua
New Guinea. Using a qualitative research design, Razee et al. (2012) carried out in-depth
interviews with and observations of several types of primary health-care provider serving in
rural Papua New Guinea in both government and private facilities. The article concludes that the
identity of health workers and perceptions of the community about them are important factors
contributing to their motivation. In particular, the article highlights how respect received from
the community and community ownership of health service delivery are significant enablers.
The authors also describe the process of building trust and cooperation between health
workers and the community. The article explores the role of health worker gender and family
life, shedding light on the dual burden of managing work and family responsibilities, particularly
among female health workers. Furthermore, this study describes how violence in the workplace
and in the community at large results in demotivation of female health workers. On the whole,
this article provides a rich narrative on the social context and interactions affecting health
worker motivation in a very diverse country, where the evidence base for HRH is limited.

Huicho L, et al. (2015). Factors behind job preferences of Peruvian medical, nursing and midwifery
students: a qualitative study focused on rural deployment. Hum Resour Health. 13(1):90

Health workers Medical, nursing and midwifery public university students

Geographical area Peru
Research methods Qualitative: in-depth interviews and focus group discussions
Research inference Explanatory

This article focuses on a similar topic as above but uses a different methodological approach.
The authors interview medical, nursing and midwifery students to understand reasons behind
their career choices and their preferences for rural postings in Peru. Using a rich qualitative
study design, from two distinct regions in the country, the article describes career choices
among medical, nursing and midwifery students to be driven mostly by vocation and for the
opportunity to improve the health of their communities. Interestingly, medical students also
considered that their profession would improve their socioeconomic status in the society, a
belief not validated by labour market conditions in Peru, as noted by the authors. In addition,
the study found a mixed reaction to rural postings. While medical students understood the

Part C. How are human resources for health governed? 95

 importance of such postings, both from the point of view of serving people most in need
and as valuable professional experience, they expressed reservations about difficult working
environments and in general had a stronger predilection for working in urban areas. Nursing and
midwifery students, however, especially those from rural backgrounds, expressed a stronger
willingness to serve in rural areas.

Although preferences of students are likely to be different from people who are actually serving
in remote areas, this article opens a discussion for policy-makers and medical education
institutions to acknowledge these preferences and incorporate them in HRH policies and
interventions to attract students to work in difficult-to-serve areas. A study conducted in a rural
Indian setting aiming to understand why doctors have stayed on to serve in remote areas finds
some similarities to the above findings, namely geographical and ethnic tribal affinities, rural
origins and personal values of service (Sheikh et al., 2012); however, it also sheds light on a host
of other factors, including benefits to family life (location of spouse, availability of school for
children), relationships with co-workers and surrounding communities, and “acclimatization
over time to rural life” (p. 192).

5.3.3 Evaluating the impact of motivation interventions

Shen GC, et al. 2017. Incentives to change: effects of performance-based financing on health
workers in Zambia. Hum Resour Health. 15(1):20

Health workers Multiple public sector facility based health workers

Geographical area Zambia
Research methods Quantitative: randomized control design for pre-post changes

Research inference Influence/Explanatory

Shen at al. (2017) describe a quantitative impact assessment of a performance-based financing

scheme on the motivation of health workers in Zambia. While several studies have tried to
assess the effectiveness of performance-based financing on service delivery and quality of
care outcomes (Basinga et al., 2011; Binyaruka et al., 2015; Engineer et al., 2016), very few
have attempted to measure its impact on health worker motivation, although a few studies
have aimed to understand the mechanisms through which performance-based financing
affects motivation (Bertone et al., 2016; Bhatnagar & George, 2016; Witter et al., 2011). This
article is one of the first to measure impact of performance-based financing on motivation,
job satisfaction and retention and to understand the pathways that explain the changes in a
low- and middle-income country setting. This study, based on a quasi-experimental design,
used existing theoretical frameworks and instruments, albeit not developed originally in a
low- and middle-income country setting, to measure motivation and job satisfaction of health
workers receiving performance-based financing compared with those who are not. The study
subsequently carried out qualitative interviews to explore the channels through which incentive
payments affected motivation, thereby filling in an obvious lacuna in the performance-based
financing evidence base. The authors found that performance-based financing had a positive
impact on job satisfaction and a negative impact on attrition, although it did not have “marked
effects on motivation” (p. 10). The qualitative study corroborated not only these findings but
also more recent postulation that performance-based financing could improve both extrinsic
and intrinsic motivations by providing a better platform for serving the community and
opportunities for professional development and professional dedication.

96 A HEALTH POLICY AND SYSTEMS RESEARCH READER ON HUMAN RESOURCES FOR HEALTH
While the previous article demonstrates the role of financial incentives in bringing about a
change, a case study by Ruck and Darwish (1991) (described in detail in Chapter 3) explains
how the introduction of a training programme for improving nutrition services increased
motivation and lowered absenteeism among health workers in Egypt. The training programme
not only was didactic but also included regular feedback and reinforced supervision, thereby
appreciating the value of health workers’ efforts to a greater extent.

In addition to the articles above, two articles included in Chapter 6 on leadership and
management explore the role of meso-level organizational determinants in motivating health
workers (Aberese-Ako et al., 2014; Choi et al., 2016). These are described briefly below.

5.3.4 Meso-level determinants of motivation

Aberese-Ako M, et al. (2014). “Your health our concern, our health whose concern?”: perceptions
of injustice in organizational relationships and processes and frontline health worker motivation in
Ghana. Health Policy Plan. 29(Suppl. 2):ii15–ii28 ?

Health workers Multiple public sector hospital based health workers

Geographical area Ghana
Research methods Qualitative: Ethnography; participant observation, conversation
and in depth interviews over 16 months in two public hospitals
Research inference Exploratory

Aberese-Ako et al. (2014) conducted an ethnographic study including direct observations,

conversations and in-depth interviews to understand the level and nature of perceived
organizational justice and its implications on motivation and responsiveness of health workers
in Ghana. The authors found that health workers perceived procedural, distributive and
interactional injustice at the national policy level in terms of poor conditions of service, and
inequitable distribution of incentives, lack of respect and protection at the organizational level.
The authors described that while those who were intrinsically motivated were able to overcome
their discontentment with these attributes in their working environment and respond to the
needs of their clients, there were some health workers, especially those on the front line, who
were not as responsive. The authors argued that health workers should be considered internal
clients of a health system, and their perceptions of fairness and justice in organizational and
governance structures should be given importance.

Choi SL, et al. (2016). Transformational leadership, empowerment, and job satisfaction: the
mediating role of employee empowerment. Hum Resour Health. 14(1):73
?
Health workers Public and private sector nurses
Geographical area Malaysia
Research methods Quantitative: provider Likert survey and regression analysis
Research inference Exploratory

Choi et al. (2016) measured the role of transformational leadership and employee empowerment
in improving job satisfaction perceived by nurses in Malaysia. The authors hypothesized
and subsequently proved, using data from a cross-sectional survey, that transformational
leadership enhances empowerment, especially among the nursing cadre, which is considered

Part C. How are human resources for health governed? 97

 to be of relatively low status. They also found that transformational leadership has a positive
association with job satisfaction. Moreover, they showed that there was a partial mediating
effect, suggesting that employee empowerment explained at least some component of
the positive association between transformational leadership and job satisfaction. The
contribution of this article extends from using innovating and rigorous methods to measure
these complex constructs, to explaining that transformational leadership must be encouraged
among managers of nursing staff while empowerment among the nursing cadre should be
simultaneously inculcated.

5.4 Research challenges

The main difficulty faced in selecting articles for this chapter was the complexity of how
motivation is defined, given its various theoretical underpinnings and influencing factors.
Similarly, various theories of motivation have their own definition of what constitutes intrinsic
versus extrinsic motivation, or what determinants are from within the individual and what
belong to the broader context within which he or she is working. This also made it difficult
to compare and contrast studies that used different theoretical paradigms for understanding
motivation. In addition, it was difficult to select among studies that used similar methods,
albeit in varied contexts and for different cadres of HRH. For example, most studies measured
motivation using qualitative or ethnographic methods, or descriptive quantitative techniques
using self-reported responses on structured scales.

In addition, this section attempted to put forth research from across all regions but did not
succeed in generating a pool of good-quality articles that were equally representative of all
parts of the world. A large proportion of research on the issue of health worker motivation was
based in sub-Saharan Africa and south Asia, with a smaller regional focus on other middle-
income country settings such as those in Latin America and eastern and central Asia. Although
contributions from all languages were invited during crowdsourcing of articles for the reader, all
subsequent searches were carried out among articles published in English, resulting in excluding
those in, for example, Spanish, Portuguese and Russian. Similarly, the bulk of the current
evidence base focused on medical doctors and nurses; there is an emerging body of work on
community health workers, but less on other cadres of the health workforce. Additionally, most
of the research on health worker motivation uses cross-sectional study designs. Longitudinal
study designs, such as following a cohort of students over a period of time to see how their
attitudes and choices evolve, would enable research to account for the dynamic and complex
nature of human behaviours.

5.5 Future research directions and gaps

As mentioned above, there is no agreement in the literature on the correct course for defining
and measuring motivation. Moreover, to date no study has critically examined the existing
methods, especially in the context of low- and middle-income countries, used for doing the
same. As researchers in the field of HPSR, it is necessary for us to take a step back and question
whether we are using appropriate methodologies, drawing adequately from theoretical
disciplines and understanding motivation of health workers as a set of human behaviours
and not only as organizational processes. In this regard, future endeavours for measuring
motivation of health workers should be critical of existing methods and strive continuously to
develop more innovative techniques to measure this complex construct. For example, further
experimentation could be done with existing techniques to elicit choice, building on classic
dictator games, to understand motivation for performing different tasks. In addition, measures
such as speed, accuracy and persistence with which tasks are completed could also be used
to gauge motivation of health workers (Touré-Tillery & Fishbach, 2014). It is also important to

98 A HEALTH POLICY AND SYSTEMS RESEARCH READER ON HUMAN RESOURCES FOR HEALTH
move beyond descriptive studies on what motivates health workers to assess effectiveness of
different interventions for improving motivation. Future research of this nature should use a
mixed-methods approach, aiming not only to assess interventions but also to understand why
and how changes are taking place.

As described above, most of the evidence base for health worker motivation studies, using
quantitative methods, is based on self-reported responses on structured scales measured at
a give timepoint. Very few of these scales, however, have been validated using appropriate
statistical methodologies or measured with advanced techniques such as structural equation
modelling (Lohmann et al., 2017). For future researchers attempting to design context-specific
scales for measuring motivation, it is essential to follow a theoretical framework and validate
the scale against that framework using appropriate techniques. It is also important to note that
these ratings are likely to be influenced by social desirability bias as well as events that have
taken place just before the conduct of the study (such as an altercation in the workplace or a
positive patient outcome) and may not necessarily reflect the true opinions of the respondents.
Similarly, the rigour in qualitative methods for measuring motivation needs to be strengthened,
with studies demonstrating various ways in which the trustworthiness, namely credibility,
dependability, transferability and confirmability (Jensen, 2008), of their findings were assessed.

As mentioned above, most of the literature on health worker motivation includes studies
exploring determinants of motivation, but very few studies have aimed to measure the impact
of specific programmes carried out to motivate health workers. This is particularly puzzling as
there have been many initiatives, especially in low-resource settings, targeted at improving
motivation and performance of health workers, such as but not restricted to performance-
based financing and performance management interventions (Dieleman et al., 2006; Shen et
al., 2017). While impact evaluations are methodologically difficult for social science research,
time-consuming and resource-intensive, there is a need to expand the current evidence base
for such studies and hence an area for future investigation and investment.

Acknowledgements
The author is grateful to Marjolein Dieleman, Asha George, Kerry Scott and Veloshnee
Govender for guidance and inputs in writing this chapter.

Part C. How are human resources for health governed? 99

 References
Aberese-Ako M, et al. (2014). “Your health our concern, our health whose concern?”: perceptions of
injustice in organizational relationships and processes and frontline health worker motivation in
Ghana. Health Policy Plan. 29(Suppl. 2):ii15–ii28. doi:10.1093/heapol/czu068.
Basinga P, et al. (2011). Effect on maternal and child health services in Rwanda of payment to primary
healthcare providers for performance: an impact evaluation. Lancet. 377(9775):1421–1428.
doi:10.1016/S0140-6736(11)60177-3.
Bertone MP, Lagarde M, Witter S (2016). Performance-based financing in the context of the complex
remuneration of health workers: findings from a mixed-method study in rural Sierra Leone. BMC
Health Serv Res. 16(1):286. doi:10.1186/s12913-016-1546-8.
Bhatnagar A (2014). Determinants of motivation and job satisfaction among primary health workers:
case studies from Nigeria and India. Baltimore, MD: Johns Hopkins School of Public Health.
Bhatnagar A, George AS (2016). Motivating health workers up to a limit: partial effects of performance-
based financing on working environments in Nigeria. Health Policy Plan. 31(7):868–877.
doi:10.1093/heapol/czw002.
Binyaruka P, et al. (2015). Effect of paying for performance on utilisation, quality, and user costs
of health services in Tanzania: a controlled before and after study. PLoS ONE. 10(8):e0135013.
doi:10.1371/journal.pone.0135013.
Borkowski N (2009). Organizational behavior in health care. Burlington, MA: Jones & Bartlett Learning.
Burns LR, Bradley EH, Weiner BJ (2012). Shortell and Kaluzny’s health care management: organization
design and behavior, 6th edn. Clifton Park, NY: Delmar.
Chandler CIR, et al. (2009). Motivation, money and respect: a mixed-method study of Tanzanian non-
physician clinicians. Soc Sci Med. 68(11):2078–2088. doi:10.1016/j.socscimed.2009.03.007.
Choi SL, et al. (2016). Transformational leadership, empowerment, and job satisfaction: the mediating
role of employee empowerment. Hum Resour Health. 14(1):73. doi:10.1186/s12960-016-0171-2.
Cummings TG, Bigelow J (1976). Satisfaction, job involvement, and intrinsic motivation: an extension of
Lawler and Hall’s factor analysis. J Appl Psychol. 61(4):523–525. doi:10.1037/0021-9010.61.4.523.
Dieleman M, et al. (2006). The match between motivation and performance management of health
sector workers in Mali. Hum Resour Health. 4:2. doi:10.1186/1478-4491-4-2.
Dieleman M, et al. (2011). Realist review and synthesis of retention studies for health workers in rural
and remote areas: increasing access to health workers in rural and remote areas. Technical report
no. 1. Geneva: World Health Organization.
Dolea C, Adams O (2005). Motivation of health care workers: review of theories and empirical
evidence. Cah Sociol Demogr Med. 45(1):135–161.
Engineer CY, et al. (2016). Effectiveness of a pay-for-performance intervention to improve maternal
and child health services in Afghanistan: a cluster-randomized trial. Int J Epidemiol. 45(2):451–459.
doi:10.1093/ije/dyv362.
Franco LM, Bennett S, Kanfer R (2002). Health sector reform and public sector health worker
motivation: a conceptual framework. Soc Sci Med. 54(8):1255–1266.
doi:10.1016/S0277-9536(01)00094-6.
Frey BS (1997). Not just for the money: an economic theory of personal motivation. Cheltenham, UK,
Northampton, MA: Edward Elgar.
Frey BS, Jegen R (2000). Motivation crowding theory: a survey of empirical evidence, revised version.
Working paper no. 49. Zurich: Institute for Empirical Research in Economics
(https://ideas.repec.org/p/zur/iewwpx/049.html).
Gagné, M, Deci EL (2005). Self-determination theory and work motivation. J Organ Behav. 26(4):331–362.
doi:10.1002/job.322.
Hongoro C, Normand C (2006). Health workers: building and motivating the workforce. In: Jamison
DT, et al., editors. Disease control priorities in developing countries, 2nd edn. New York: Oxford
University Press: 1309–1322.
Huicho L, et al. (2015). Factors behind job preferences of Peruvian medical, nursing and midwifery
students: a qualitative study focused on rural deployment. Hum Resour Health. 13(1):90.
doi:10.1186/s12960-015-0091-6.

100 A HEALTH POLICY AND SYSTEMS RESEARCH READER ON HUMAN RESOURCES FOR HEALTH
Jensen D (2008). Credibility. In: The SAGE encyclopedia of qualitative research methods. Thousand
Oaks, CA: SAGE Publications.
Locke EA (1976). The nature and causes of job satisfaction. In: Dunnette MD, editor. Handbook of
industrial and organizational psychology. Chicago, IL: Rand McNally: 1297–1349.
Lohmann J, Houlfort N, De Allegri M. (2016). Crowding out or no crowding out? A self-determination
theory approach to health worker motivation in performance-based financing. Soc Sci Med. 169:1–8.
doi:10.1016/j.socscimed.2016.09.006.
Lohmann J, et al. (2017). Measuring health workers’ motivation composition: validation of a scale
based on self-determination theory in Burkina Faso. Hum Resour Health. 15(1):33.
doi:10.1186/s12960-017-0208-1.
Mandeville KL, Lagarde M, Hanson K (2014). The use of discrete choice experiments to inform
health workforce policy: a systematic review. BMC Health Serv Res. 14(1):367.
doi:10.1186/1472-6963-14-367.
Mathauer I, Imhoff I (2006). Health worker motivation in Africa: the role of non-financial incentives
and human resource management tools. Hum Resour Health. 4:24. doi:10.1186/1478-4491-4-24.
Mbindyo PM, et al. (2009). Developing a tool to measure health worker motivation in district hospitals
in Kenya. Hum Resour Health. 7(1):40. doi:10.1186/1478-4491-7-40.
Okello DRO, Gilson L (2015). Exploring the influence of trust relationships on motivation in the health
sector: a systematic review. Hum Resour Health. 13(1):16. doi:10.1186/s12960-015-0007-5.
Peters DH, et al. (2010). Job satisfaction and motivation of health workers in public and private sectors:
cross-sectional analysis from two Indian states. Hum Resour Health. 8:27. doi:10.1186/1478-4491-8-27.
Purohit B, Maneskar A, Saxena D (2016). Developing a tool to assess motivation among health service
providers working with public health system in India. Hum Resour Health. 14(1):15.
doi:10.1186/s12960-016-0111-1.
Razee H, et al. (2012). Listening to the rural health workers in Papua New Guinea: the social factors
that influence their motivation to work. Soc Sci Med. 75(5):828–835.
doi:10.1016/j.socscimed.2012.04.013.
Ruck NF, Darwish OA (1991). Motivating health workers through nutrition training: an example from
Egypt. Health Policy Plan. 6(2):130–140. doi:10.1093/heapol/6.2.130.
Sheikh K, et al. (2012). Location and vocation: why some government doctors stay on in rural
Chhattisgarh, India. Int Health. 4(3):192–199. doi:10.1016/j.inhe.2012.03.004.
Shen GC, et al. (2017). Incentives to change: effects of performance-based financing on health workers
in Zambia. Hum Resour Health. 15(1):20. doi:10.1186/s12960-017-0179-2.
Singh D, et al. (2015). The effect of payment and incentives on motivation and focus of community
health workers: five case studies from low- and middle-income countries. Hum Resour Health.
doi:10.1186/s12960-015-0051-1.
Smith R, et al. (2013). Appealing to altruism: an alternative strategy to address the health workforce
crisis in developing countries? J Publ Health. 35(1):164–170. doi:10.1093/pubmed/fds066.
Touré-Tillery M, Fishbach A (2014). How to measure motivation: a guide for the experimental social
psychologist. Soc Personal Psychol Compass. 8(7):328–341. doi:10.1111/spc3.12110.
Willis-Shattuck M, et al. (2008). Motivation and retention of health workers in developing countries: a
systematic review. BMC Health Serv Res. 8(1):247. doi:10.1186/1472-6963-8-247.
Witter S, et al. (2011). Paying health workers for performance in Battagram district, Pakistan. Hum
Resour Health. 9(23):1–12. doi:10.1186/1478-4491-9-23.

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