Since leavers were the key population of interest in the study, we first describe the jobs that they were engaged in now, and summarize factors that speeded up their exit from HEW positions. Key factors influencing HEW motivation and labour choices are then presented in detail.
We found significant variation in the type of employment that the leavers were currently engaged in. Migration to non-health jobs in the Middle East, due to better pay was a particularly unanticipated finding. Notably, no participant reported leaving or wanting to leave Ethiopia to work in a health system abroad, perhaps because HEWs are relatively low skilled by international standards.
"Most HEWs think about going to foreign countries. Like Arab countries. The salary in Arab country is relatively good in comparison with HEWs. […] They think, here the workload is very high and the salary is very low so, why don’t I go to an Arab country? And why don’t I change my life in a short time?"
– Active HEW, SNNPR
A significant number of leavers reported to have become full-time homemakers. “I raise my children, I am a housewife” said a leaver from Tigray. Some women were currently self-employed and owned small businesses highlighting increased earnings and autonomy. “I have my own grocery. If you are an excellent worker, it provides higher income. It also has freedom; nobody can come and shout at you” reported a leaver from Tigray. Other respondents remained working in different health system roles, including as lab technicians and administrators in government health facilities.
Catalysts influencing exit: pro-social preferences
While HEWs did not generally anticipate leaving their jobs, they did leave when they felt they had lost the appreciation of their community or supervisors. These were the two main reasons for leavers to finally quit their jobs, despite other challenging working conditions reported by active HEWs and leavers alike. We call these factors catalysts, or the triggers that speeded up the process of attrition:
Failure to receive support and validation from supervisors and senior staff
Conflict with supervisors and senior managers was the main reason why leavers claim to have quit. These ‘conflicts’ often seem to have started with a senior official disrespecting the HEW, resulting in a negative shift in their status, social standing and esteem, and thus in their identity as a HEW. Supportive supervision, with appropriate acknowledgement and validation from their managers was identified as a critical factor in the retention of HEWs in Ethiopia.
"…the director came to my home and insulted me when I was very sick. He said this institution is neither your mother’s nor father’s; either perform your job appropriately or leave. I immediately left my job, and didn’t even take my monthly salary"
Reduced acceptance and validation from the community
Another key element for retention was receiving respect, acceptance and validation from the community for whom the HEWs worked. Despite tough working conditions, the opportunity to improve community health attracted many to their jobs. A negative shift in their social identity, due to low community acceptance, influenced working conditions and status, and their exit.
"There is no appreciation from the people in my woreda (district)… always they will criticize the HEW and service delivery… they are fault finders."
Key factors influencing HEW motivation and retention
Numerous factors reported by HEWs, leavers, and KIs were identified as those influencing HEW motivation, and retention in the workforce. Using our conceptual model from Fig. 1, we classified these into two categories: Extrinsic and Intrinsic.
Extrinsic motivational factors
Financial incentives in the form of salaries or wages were found to be important among active HEWs as well as leavers. Current salaries were not considered to be commensurate with workload, their compensation not being enough to cover monthly household expenditure.
"HEWs do many overlapping tasks, but salary doesn’t balance the work we do…the salary does not reflect living conditions of HEWs. Since we don’t have additional income, and spend all our time at work, it’s difficult to live on existing salary."
- Active HEW, SNNPR
Key informants, including HEW supervisors and senior officials at health centers agreed that HEW salaries were inadequate. HEWs cater to a large population, often in topographically difficult terrains and on foot, so physical strain due to their job came up as a common theme and a constraint to their motivation. “I still remember how horrible it was…the 4 hour walk in the mountains. It rains over us, and the sun burns so bad”, remembers a leaver from SNNPR.
Material factors were also seen as important in influencing HEW motivation and retention. These often took the form of adequate drugs, equipment and infrastructure available at the health post. Such factors were found to be critical not only to support their daily work, but important to sustain the rapport and faith the community had in them by managing to do the tasks entrusted to them. Sometimes facilities were perceived so lacking that faith was the only answer:
“Sometimes I support the labouring mothers by praying to Gebriel (Angel), because what we learn is different from what we apply. The materials that we have are inadequate; we only have delivery kit, which contains scissor, and cord tie. When a mother delivers at hospital, many things are provided to her and her baby, but here we have nothing to give her”.
In addition, HEWs and leavers suggested that material incentives such as motorcycles for transportation should be provided as part of their work package, to decrease their physical burden.
Furthermore, the gender of HEWs results in a double burden, as many mothers with infants mentioned that it was hard for them to do their daily tasks as a HEW, alongside caring for their infants.
"It is very difficult having a child. I leave from my home early morning at 6 am […] I may stay up to 6 pm, sometimes I don’t even have time to drink water after coming back from field work. So, imagine doing all things having a baby
For HEWs with young children, the absence of childcare was a disincentive to continue in their jobs after giving birth.
HEWs also mentioned not always feeling safe in travelling to rural areas. “Facilities like motor for transportation should be fulfilled. This security issue also needs attention since in rural areas females can be abused,” stated a leaver from Tigray.
Most importantly, HEWs and leavers mentioned highly appreciating the non-material factors such as appreciation from their communities and supervisors. The opportunity to improve community health, especially that of mothers and children, and gain their community’s trust, respect and acceptance, was unanimously described as the top factor motivating them in their jobs.
“When I get the acceptance of healthy mothers and children, I am satisfied. Otherwise, the salary is not enough; the high workload is as I told you before”.
- Active HEW, SNNPR
Sometimes, HEWs were not as easily accepted by their community, which demotivated them. Often respondents claimed that these demand-side barriers existed because of low levels of education and awareness among community members, which also led them to reject healthcare interventions such as family planning and latrine construction.
"The community’s behaviour is difficult. For example, when we go to their home to educate them about environmental hygiene, they may close their door and leave from home. They say, oh! She is coming! When I enter through the front door, they will leave the house from the back door. It is for them but they do not understand. To teach them about something we will take many days. They have a shortage of knowledge."
- Leaver, Tigray
Other non-material demotivating factors were things that HEWs and leavers identified as lacking in HEW jobs. For example, the placement of HEWs in health posts, often far away from their hometowns where their husband and children are based, limited their motivation and retention. All three study populations agreed that the absence of opportunities to transfer to a facility closer to their family was frustrating, unfair, and led HEWs to leave their positions. “This was my main reason to leave my job… Imagine that you can’t meet with your husband as well as your children for a long time because there is no transfer (opportunity)”, mentioned a leaver from Tigray.
In addition, two key issues around career progression were identified. First, HEWs that were keen to upskill to the next level had to take a competitive exam in English – a language they are not generally proficient in and do not normally use in their jobs, and on topics in which they had not received enough training. The success rate for these exams was thus found to be low. HEWs complained that while many of them are excellent field workers with many years of experience in delivering healthcare, their inability to do well in an exam should not be the sole determinant of career progression.
The second key issue was for HEWs who did manage to upgrade to the next level, but despite upskilling, were expected to return to their old jobs at the health post. Many HEWs agreed that while after upgrading, their remuneration increased (or was expected to increase in the following months); they were expected to undertake the same tasks, in the same health post as before.
“After we get back from our level 4 study, we will be placed to the same kebele (village) as before. We need to be refreshed, be in a new place! Alongside with transfer, we should also be assigned to health centres (promoted to a higher health facility)”,
-Active HEW, SNNPR
Another reason why HEWs and leavers felt de-motivated was the lack of support, oversight, and acknowledgement from supervisors and managers, who said that supervision was based on a model of faultfinding, not mentorship.
"…[…]. I was so tired that night that I could not clean all the blood and every mess (after single- headedly doing a delivery at the health post). Next morning the woreda (district) officials showed up and insulted me without considering what I have been through. It was so painful not to be understood to this level."
- Leaver, SNNPR
Intrinsic motivational factors
Many HEWs mentioned that the key reason for joining the profession was to serve the community where they were raised.
“Most of the time in our environment, the mothers don’t use contraceptives, they don’t give birth in health centres and they don’t get ante-natal care. The mothers normally give birth in their home with a traditional birth attendant. Because of this, many mothers die. When I saw these types of problems in my community, I decided to become a HEW."
- Active HEW, SNNPR
Some HEWs also insisted that financial incentives were less important than intrinsic factors and that the profession requires women to be truly dedicated to the community’s health improvement, to survive in their jobs.
Many leavers mentioned having left their jobs out of frustration with challenging conditions, but confessed to have really enjoyed working towards improving community health. “Regarding the profession, health extension work itself has no concerns. I believe as a HEW you get to serve or work for the community which is great... it’s the working conditions that are problematic,” said a leaver from Tigray.