There is a global widespread shortage of health workers, especially in rural and remote areas, and this necessitates the implementation of strategies to increase access of the rural population to people-centered health services[1–3]. Numerous factors influence the choice of health workers to take up or stay in positions. These factors are often due to personal choices or related to the characteristics of the work. Personal choices include responsibilities, motivation, and financial incentives, and the effect of institutional factors on job performance. Factors relating to characteristics of the workplace include access to capacity enhancement interventions, scope of practice, staffing and workload, work environment, and the availability of equipment and medical commodities. These factors have resulted in difficulties for health managers to plan for health workers effectively as in most instances, the health workers do not take up or stay in the positions. In instances where they take them up, they do not stay in the positions for a long time or do not report for duty. Health managers have a very important role in ensuring that qualified, skilled, and motivated health workers are available to provide integrated people-centered health services in all areas if universal health coverage will be achieved.
The current policy thrust in Nigeria is to ensure that there exists qualified, skilled, and adequate human resources for health at primary, secondary, and tertiary levels of care towards the achievement of universal health coverage for all Nigerians[5, 6]. To achieve this, the government has established a policy framework to generate evidence and implement strategies aimed at ensuring the availability, equitable distribution, and retention of health workers with a focus on the rural areas [5–7]. The current situation in Nigeria indicates that health workers are not motivated and this is negatively impacting their performance and efficiency. Several factors, including poor remuneration, inadequate staffing levels with resultant high workloads, lack of social amenities, poor working environments, inadequate medical supplies and equipment, and delayed salaries and emoluments payment have been documented [8–17]. Additionally, institutionalized attraction, retention, posting, and motivation mechanisms are absent, especially for primary level facilities often located in rural and remote areas[6, 18]. To improve the attraction, retention, and motivation of health workers, investments have to be made in the work environment, performance management and recognition systems, work environment, infrastructure, career development, and staffing levels with a focus on rural areas are needed[6, 9]. Evidence suggests that attraction and retention are informed by a complex interaction of factors and thus bundles/ sets of strategies/interventions are needed (4).
As Nigeria is on the path of improving the health system towards achieving the national health sector goals and universal health coverage, policymakers need contextual evidence to improve human resources for health (HRH) policy and management. Information on factors influencing attraction, retention, and motivation of the health workforce is key in ensuring the equitable distribution of the health workforce across the nation for quality service delivery, especially at the primary level. There is, however, limited evidence on these factors as well as the combination of strategies/interventions. This informed this study using the discrete choice technique to ascertain the applicable combinations. This technique has been applied in several settings globally with essential evidence generated for policy and planning [11, 19–22].
The objective of this study was to determine the combinations of incentives that may increase the retention of frontline health workers in rural and remote areas.