We report findings following the Realist And Meta‐narrative Evidence Syntheses Evolving Standards (RAMESES) II guidelines for realist evaluations (34) which recommend, in line with a realist approach, that substantive theory is mixed with programme theory to enhance the explanatory endeavour of the study.
The programme theory developed from testing and verification of IPTs during this study is:
“In the context of human and material resource shortages, the SURE-P/MCH programme deploys adequate numbers of skilled workers, drugs and equipment and decent housing whilst ensuring regular remuneration, training, supervision and recognition for good performance. These inputs/resources generate a feeling of support, self-worth, empowerment and sense of camaraderie among PHC workers, leading to positive work behaviour and improved service delivery”.
Our findings revealed that a complex interplay of individual, organisational, and wider social factors affected PHC worker motivation during programme implementation in Anambra State. Individual-level (intrinsic) motivation factors were workers’ interest in their vocation and concern for the welfare of patients. This supports other studies’ findings of altruistic behaviour among health workers who are energized by a desire to provide a good quality service to users’ (35) and to communities they served (19). In our evaluation, seven organizational (extrinsic) drivers of worker motivation were: i) increased availability and adequacy of material resources; ii) mentorship iii) on-the-job training and supportive supervision; iv) regular payment of salaries v) recognition for good performance (33); vi) adequacy and good staff mix and vii) renovation of facilities (36-38). Societal-level motivators included community appreciation for and recognition of workers’ roles.
The synthesis of data from CMO analytical templates (see Fig 1) identified five significant explanatory patterns (or mechanisms) through which motivation worked in this programme: i) staff feeling supported, ii) feeling valued and committed, iii) morale and confidence to perform tasks, iv) companionship and, v) feeling comfortable. The five mechanisms are discussed next, beginning with narrative propositions, crafted as sub-theories of the consolidated programme theory above, and informed by linkages between/among Contexts, Mechanisms and Outcomes and illustrated with supporting quotes from our qualitative data.
Explaining mechanisms of PHC worker motivation
a) Supporting PHC Staff
In a context where health workers enjoy cordial working relationships and mentorship from senior colleagues, the provision of equipment and constant supply of drugs and consumables to PHCs increases PHC workers’ feeling of being supported as they have the necessary tools to work. The following quote from a CHEW illustrates how this mechanism was often explained by staff interviewed:
During SURE-P there were drugs and equipment. They also used to supply drugs and mama kits to the facility...This made me feel better and happy because when our clients come, we had drugs to give to them. They [availability of resources] really motivated me to work and put more effort into caring for our clients because I had all it takes to work and give out those services…I was more motivated during SURE-P because those things that we needed to work were available but now [after the end of SURE-P] we don't have them again. (Female Community Health Extension Worker)
In the context of Nigeria, where lack of basic work tools is common, the availability of resources (drugs, equipment and delivery kit) at PHC facilities stimulates health workers to provide quality MCH services whereas resource shortages can cause dissatisfaction and reduced performance.
b) Feeling Valued and Committed
Where PHC workers are underpaid and their efforts remain unacknowledged, regular payment of salaries and recognition of staff who perform well increases morale and commitment to work.
The SURE-P programme appeared to ensure regular payment of salaries, which triggered mechanisms of satisfaction and commitment to work. In explaining the benefits derived from the SURE-P programme, a community health extension worker stated:
I benefitted from the SURE-P programme in many ways. [The] first is that I was committed to my work during SURE-P programme. I was working happily because the payment [salary] we received at the time helped [sustained my commitment]. (Female Community Health Extension Worker)
Many health workers explained that salaries were paid promptly during the SURE-P programme, yet some complained that the salary scale for paying workers in Anambra state was lower than at national level (See Adam’s equity theory). They cited disparity in salary scales as a cause of worker dissatisfaction. A few health workers also reported that salaries were either delayed or unpaid after SURE-P ended. The next quote explains how nonpayment of salaries creates dissatisfaction:
Non-payment of salaries after SURE-P really affects it [i.e. work effort] because when staff are demoralized they won't come to work when they are supposed to come… [W]hen you come to the health facility you won't see them because they don’t feel appreciated.... [T]hey will tell you that they have not been paid for the work they have done, and that there are no drugs [in the facility] for them to work with. (Female, Community Health Extension Worker)
Here the non-payment of salaries generated feelings of being under-valued by the health system, leading to diminished organizational loyalty manifesting as absenteeism and non-delivery of service. Nevertheless, some PHC workers interviewed reported that community support for and roles recognition helped to sustain motivation when salaries were unpaid.
Taken together, the preceding subsections demonstrate how the combination of availability of material resources (drugs and consumables) and regular payment of salaries prevented dissatisfaction through making PHC workers feel supported and valued by the health system and their host community, thus leading to enhanced satisfaction and commitment to increase work effort in Nigeria. Next, we explore the impact of physical working environment on motivation.
c) Physical, Functional and Psychological Comfort
Prior to implementing SURE-P programme, many PHC facilities were rundown, lacking staff accommodation or supply of water and electricity. Renovating health facilities and providing staff accommodation within facility premises created a positive working environment that made staff comfortable and enthusiastic to work:
SURE-P gave us all the things we needed such as light [i.e. electricity], water and the other things too [see material resources in previous section]. When these things are provided the nurses are happy [satisfied] doing their work, no matter the little amount [i.e. low salary] they are getting, because our job is to save lives, whether you eat or you don't eat, you will try to put more effort to save lives [i.e. a sense of duty]. (Female, Midwife).
This mechanism relates to the workplace built environment framework (39) that relates optimal staff performance to physical, functional (because it enables workers to do their tasks) and psychological comfort in workspace environments. The physical condition of the workplace (e.g., refurbished facilities and availability of running water and electricity) prevents dissatisfaction and enables PHC workers to achieve their clinical goals of improving healthcare outcomes.
d) Improving Staff Morale and Self-confidence
In a context of irregular supervision and reduced prospects for professional training, the provision of supportive supervision and equitable opportunities for training to improve staff knowledge and skills make staff feel more confident to provide services.
We feel happy when we have regular training and supervision. The reason is that during SURE-P programme they used to train us for like five days every so often, [and] then we will step-down the training to other PHC staff. It is very necessary that, as a health professional, you update yourself with ongoing changes and things in the profession, or else you go out for continuous study. Regular training boosts one’s morale [self-worth] and motivates one. After going for those trainings you'd come back with new knowledge that you will put into the work, and things [health service] improve. (Female Community Health Extension Worker)
However, not all PHC workers enjoyed regular training opportunities, as reported by a facility manager:
I didn’t benefit anything from SURE-P: no regular training, nothing, though there was a time we were called to Abuja for two to three days’ workshop – that’s all. But other staff working with me did benefit. They were paid [for attending trainings]. But we, the local government staff, we didn’t benefit anything. (Female Facility Manager)
While the SURE-P policy aimed to promote a culture of equal access to training, the last quote suggests that, in practice, only workers deployed by the SURE-P programme enjoyed retraining opportunities. In Anambra, the SURE-P programme deployed six new health staff (comprising 1 midwife, 2 CHEWs and 3 village health workers) to complement already existing staff at each participating PHC facility (40). Prioritizing newly posted staff for training (i.e. organizational inequity) seemed to cause feelings of inequality and tension between facility managers employed by the local government and SURE-P deployed staff.
e) Camaraderie and Shared Workload
In Nigeria, given a chronic shortage and mal-distribution of primary healthcare workers, deploying sufficient numbers and right skill mix of PHC workers to underserved areas generates a sense of camaraderie and shared workload during shifts, which enables health workers to spend quality time in service provision for clients:
The way I feel is the way everybody [i.e. PHC workers) feels. When you have many staff in the facility, there will be division of labor and work will be smooth and easy. When you are working with somebody, you become friends with that person. Among the permanent staff, I was the only midwife as it is now, but when they were here there were four other SURE-P workers and I felt better. We used to discuss, you know, work was flowing. (Female Midwife)
The abrupt reduction in staff numbers following the withdrawal of programme funding resulted in increased work stress:
The staff strength in this facility is very poor now but during the SURE-P programme, I had 21 staff under me (4 midwives, 2 CHEWs, 9 nurses and 6 village health workers), but as of now, I have only one staff…. Although we are managing but it is stressful on us…. Because the workforce has been reduced so low, it is affecting me and the other health workers. We are almost working round the clock. (Female Facility Manager)
Despite the manager’s attempt to manage increasing workload, the stress of working round the clock is beginning to constrain health workers’ motivation. Most workers interviewed emphasized the significance of interaction, peer-support and convenient working hours as important functional factors that enabled them to do their work effectively, communicate and connect with other professionals.
Apart from the five mechanisms explained above, our analysis identified four contextual conditions at micro, meso and macro levels that enabled workforce motivation to occur: a sense of duty to care for patients (individual level), the values of fairness and a culture of task-sharing and team work (organizational level), and recognition of workers’ contribution to improve the health and well-being of the local community (organizational and societal levels).