|Year : 2018 | Volume
| Issue : 1 | Page : 13-17
Pushing the boundaries of research on human resources for health: fresh approaches to understanding health worker motivation
Aarushi Bhatnagar1, Kerry Scott2, Veloshnee Govender3, Asha George4
1 Oxford Policy Management Ltd., New Delhi, India
2 Independent researcher, Bengalaru, India
3 Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
4 University of the Western Cape, Bellville, Cape Town, South Africa
|Date of Web Publication||27-Mar-2018|
Independent researcher, Bengalaru
Source of Support: This work was financially supported by a grant from the WHO Alliance for Health Policy and Systems Research, Geneva, Switzerland. Health Systems Global provided support in kind by providing a platform through which to foster a broader community engaged with raising the profile of research on human resources for health, while constructively revisiting its character and boundaries. Asha George is supported by the South African Research Chair's Initiative of the Department of Science and Technology and National Research Foundation (NRF) of South Africa (Grant No. 82769). Any opinion, finding and conclusion or recommendation expressed in this material is that of the author and the NRF does not accept any liability in this regard, Conflict of Interest: Veloshnee Govender is a technical officer at the Alliance for Health Policy and Systems Research, which is an international partnership hosted by the World Health Organization
A country's health workforce plays a vital role not only in serving the health needs of the population but also in supporting economic prosperity. Moreover, a well-funded and well-supported health workforce is vital to achieving universal health coverage and Sustainable Development Goal 3 to ensure healthy lives and promote well-being for all at all ages. This perspective article highlights the potential of underutilized health policy and systems research (HPSR) approaches for developing more effective human resources for health policy. The example of health worker motivation is used to showcase four types of HPSR (exploratory, influence, explanatory and emancipatory) that move beyond describing the extent of a problem. Most of the current literature aiming to understand determinants and dynamics of motivation is descriptive in nature. While this is an important basis for all research pursuits, it often gives little information about mechanisms to improve motivation and strategies for intervention. Motivation is an essential determinant of health worker performance, particularly for those working in difficult conditions, such as those facing many health workers in low- and middle-income countries. Motivation mediates health workforce performance in multiple ways: internally governing health worker behaviour; informing decisions on becoming a health worker; workplace location and ability to perform; and influencing willingness to engage politically. The four fresh research approaches described can help policy-makers better understand why health workers behave the way they do, how interventions can improve performance, the mechanisms that lead to change, and strategies for empowering health workers to be agents of change themselves.
Keywords: health policy and systems research, human resources for health, migration, motivation, performance, supervision
|How to cite this article:|
Bhatnagar A, Scott K, Govender V, George A. Pushing the boundaries of research on human resources for health: fresh approaches to understanding health worker motivation. WHO South-East Asia J Public Health 2018;7:13-7
|How to cite this URL:|
Bhatnagar A, Scott K, Govender V, George A. Pushing the boundaries of research on human resources for health: fresh approaches to understanding health worker motivation. WHO South-East Asia J Public Health [serial online] 2018 [cited 2018 Oct 20];7:13-7. Available from: http://www.who-seajph.org/text.asp?2018/7/1/13/228422
| Background|| |
Human resources for health (HRH) encompass “all people engaged in actions whose primary intent is to enhance health”. Human resources form the heart of health systems, whether doctors and nurses, clinic managers, sanitation workers, health information data-entry officers, or community health workers. Major reports in recent years have highlighted the vital role that the health workforce plays, not only in serving the health needs of populations but also in supporting economic prosperity, especially as a major employer of women.,,, Moreover, a well-funded and well-supported health workforce is vital to achieving universal health coverage and Sustainable Development Goal 3 to ensure healthy lives and promote well-being for all at all ages.
However, there are persistent HRH challenges, especially in low- and middle-income countries, that continue to frustrate progress towards universal health coverage.,, These challenges include a lack of stewardship; limited data and strategies to assess workforce performance; and HRH shortages, maldistribution and outward migration.,, Those working in health-care roles often struggle with low pay, limited opportunities for career progression, violence, poor health system support, and, for some, lack of recognition in the health system.,, Furthermore, health systems in low- and middle-income countries are challenged to accommodate increasingly mobile populations; rapid social and technological changes; expanding private sectors; complex governance issues; increasing health system fluidity, such as across private and public sectors; multiple systems of medicine; and formal and informal health worker roles.
Although the overall challenges are similar, a country's unique political and social structure may make it difficult to draw lessons from research done on HRH elsewhere, especially if the research was done in a high-income setting. Thus, policy-makers need to be equipped to commission research that will directly inform their local health workforce policy-making and decision-making. Health policy and systems research (HPSR) approaches to HRH can provide the data and analytical insight necessary, by drawing from a multitude of disciplines (i.e. public health, sociology, psychology, anthropology, organizational sciences, public administration and management studies) and applying appropriate methodologies to answer pressing research questions., HPSR focuses on choosing a method, or mix of methods, that fits the research question asked,, whether evaluating programmes to improve health worker performance and motivation, determining mechanisms to strengthen training and supervision, or assessing the factors that influence migration.
Despite the important potential contribution of HPSR approaches, there remains little guidance on how HPSR can be applied to HRH. In addition, researchers and policy-makers may not be aware of the research methods available. The purpose of this paper is to highlight some underused research approaches that could help provide this vital information for policy-makers. The examples are drawn from A health policy and systems research reader on human resources for health (hereafter referred to as the HRH reader), a compendium of examples of best-practice research for HRH. Supported by the World Health Organization's Alliance for Health Policy and Systems Research, the HRH reader was developed to highlight the existence of a wide range of research methods and encourage their use. A particular aim was to illustrate how HSPR can be applied to HRH to produce information that moves beyond describing the problem or simply assessing whether an intervention “works” or not.
This perspective article uses the example of health worker motivation to highlight how different types of HPSR can assist policy-makers in acquiring a deeper understanding of the factors influencing what motivates and demotivates health workers.
| Using health policy and systems research: the example of health worker motivation|| |
Motivation can be defined as the “conscious or unconscious stimulus, incentive or motives for action towards a goal resulting from psychological or social factors, the factors giving the purpose or direction to behavior”. Motivation influences an individual's decision to join a profession, the effort they put into their performance in it, and their willingness to remain in it. Motivation is an essential determinant of performance, particularly for those working in difficult conditions, such as the conditions facing many health workers in low- and middle-income countries. Motivated health workers are more likely to be available, to be responsive to their patients, and to provide a better quality of care. The relationship between motivation and performance is influenced by the health workers' organizational environment and social context. For example, a health worker who is motivated to provide high-quality patient care may face performance limitations because of resource shortages, and these resource shortages may in turn reduce health worker motivation. In fact, all inputs for improving performance – such as improving supervision, remuneration, resource availability or other supportive policies – work via the pathway of motivation. Motivation mediates health workforce performance in multiple ways, and influences, or is influenced by, where health workers work, what they do, how they are supported, and how they are governed (see [Figure 1]).
|Figure 1: Motivation as a theme that cuts across all aspects of human resources for health |
Click here to view
Given that motivation lies at the core of health worker performance in terms of availability, responsiveness and quality of care, it is crucial for policy-makers, implementers and researchers alike to understand what motivates health workers to join their profession, and perform and remain in it despite difficult circumstances. Most of the current literature aiming to understand determinants and dynamics of motivation is descriptive in nature, using either qualitative interviews or self-reported responses on structured scales. While such descriptive research is an important basis for all HRH research,, the results may reveal little about mechanisms to improve motivation and strategies for intervention. It is necessary to push the boundaries to understand causal pathways further, i.e. the reasons why things change, and how those mechanisms work, by using theories to guide and test these approaches. This perspective article highlights the use of underutilized research approaches – exploratory, influence, explanatory, emancipatory – showcased in the HRH reader, for understanding health worker motivation and providing the information policy-makers need to make decisions.
| Exploratory research|| |
Exploratory research seeks to understand phenomena in order to build hypotheses, concepts and theories. For instance, exploratory research may ask what drives corrupt behaviour by health workers or about the gendered experiences of health workers in humanitarian contexts. The HRH reader highlights some examples of exploratory research aimed at understanding what motivates health workers to join, perform and remain in their current profession. For example, Smith et al. used a “dictator game”, which is a standard technique in experimental economics for detecting the presence and power of altruism in decision-making, in a health setting. In the game, final-year nursing students in Kenya, South Africa and Thailand were asked to allocate a real financial endowment between themselves and another student, a patient or a poor person. Respondents in all three countries showed greater generosity to patients and poor individuals than to fellow students. This measurement technique allowed greater consideration of the altruistic values of the nursing students, rather than only job characteristics, for understanding determinants of their motivation.
Previous research has established that transformational leadership has a direct positive effect on health workers' job satisfaction. An analysis by Choi et al. provided a deeper understanding of this effect. They found that the increased job satisfaction arising from transformative leadership for medical assistants and nurses in Malaysia was attributable to their increased empowerment. Similarly, a study by Aberese-Ako et al. exploring organizational justice showed how meeting the needs of front-line health workers as internal clients of the facilities and organizations within which they work is essential if they are to be motivated to provide quality and responsive care to patients. More broadly, Razee et al. explored how social context influenced the motivation of primary health workers in Papua New Guinea, expanding consideration beyond the immediate work environment to the communities within which health workers live. These researchers found that trust and cooperation between health workers and the community, as well as gender norms, contribute to motivating health workers to perform in difficult conditions.
Thus, exploratory research provides an opportunity to understand associations in order to develop hypotheses. From there, policy-makers can design and introduce interventions that can be tested using influence or impact studies.
| Influence research|| |
Influence research focuses on measuring the impact of one variable on another, by carrying out adequacy, plausibility and probability analyses. For example, a study may measure the extent to which an intervention or programme improved health worker motivation and performance. The HRH reader highlights examples of different methodologies used to measure programme effectiveness, including a study by Shen et al., which was the first to measure the impact of performance-based financing on motivation, job satisfaction and retention among hospital-based health workers. Using an experimental design, this study concluded that performance-based financing did not improve health workers' motivation, but did improve their job satisfaction and retention. On the other hand, Leonard et al. used clinical vignettes to measure the degree to which peer scrutiny influences the application of skills and knowledge of physicians, along with highlighting the role of intrinsic motivation in performance. The findings from these studies reiterate the need for innovative techniques for measuring health worker motivation and performance, in order to develop effective performance-improvement interventions.
While the above-mentioned studies are able to establish linkages between intervention and outcomes, they are often not able to explain the reasons influencing why a change takes place. This requires an explanatory approach, using different research methodologies to unpack the black box of health worker performance.
| Explanatory research|| |
Explanatory research is a form of in-depth research for using, testing and advancing theory to explain causal mechanisms. It contributes to a deeper understanding of reasons behind the success and failure of reforms and new initiatives. For example, a mixed-methods study by Witter et al. in Pakistan demonstrated how performance-based financing programmes often make assumptions about the effect on health worker motivation and showed how traditional performance-improvement evaluations might be enhanced. Similarly, using realist evaluation techniques, Prashanth et al. evaluated the outcomes of a capacity-strengthening training programme for mid-level managers in India and developed an explanation for why the programme seemed to have worked in some settings and not in others.
Explanatory research also sets out to comprehend the multifaceted nature and dynamics of social systems, to provide a richer description and a more nuanced understanding of the context within which health workers are carrying out their tasks. For example, by triangulating information from civil service agencies and creating job histories based on interviews, Purohit et al. examined the reality of the posting and transfer system for medical officers in an Indian state. They found that the guidance on posting and transfer of medical officers was not only weakly implemented but also undermined by a parallel system in which desirable posts were attained by the use of political connections and money. Relatedly, a study by Rocha at al. aimed to understand and explain the organizational culture existing in a Brazilian public hospital, and how this, in turn, influences workplace functioning for nurses and midwives in particular.
Although explanatory research aims to understand the context and pathways of change that affect health worker motivation, it typically does not engage health workers to collaborate or co-produce solutions.
| Emancipatory research|| |
Emancipatory research focuses on how stakeholders jointly understand a problem, act on it, and can learn from working collaboratively to contest power relations and effect change. For example, emancipatory research could examine the root causes of disrespectful treatment within a district hospital staff team, and how staff can construct more respectful norms. The key aspect of emancipatory research is its intent to use stakeholder participation in the creation of knowledge within a process of change. Emancipatory research is centred on sharing power between the researchers and participants, thereby empowering participants to bring about change. The HRH reader highlights examples of how emancipatory research can describe life histories of health workers,, as well as develop collaborative approaches for strengthening the support provided to them. For example, Namakula and Witter created life histories of health workers in Uganda to understand how they experienced the 20-year conflict, and their motivation to continue working. Hernández et al. carried out a concept-mapping exercise with public sector managers and health workers in a vulnerable region of Guatemala. Through this exercise, health workers and managers developed a shared and context-specific understanding of the actions needed to better support auxiliary nurses' performance.
| Conclusion|| |
These research typologies – exploratory, influence, explana–tory and emancipatory – suggest new ways to look at HRH challenges and new types of research that can be commissioned to support health systems policy-making. Descriptive research, such as the use of traditional surveys, is a valuable component of health systems research. However, it cannot tell us why health workers behave the way they do, what interventions can improve performance, the mechanisms that lead to change, and strategies for empowering health workers to be agents of change themselves. Exploratory research enables deeper understanding of motivation, through identification of the importance of intrinsic values, relationships between health workers and their communities, and organizational leadership and justice., Research studying the influence of interventions on outcomes has, for example, highlighted that performance-based financing did not improve motivation in one trial, while explanatory research unpacked a range of reasons why performance-based financing did not influence health worker motivation. Emancipatory research, which produces knowledge about HRH issues while also engaging health workers to identify and solve their own challenges, was showcased as a tool for health workers to identify the support needed to stay motivated in challenging working environments., As illustrated in this paper, the HRH reader offers guidance to policy-makers and researchers when addressing the need for human resources for health to achieve universal health coverage in the SDG-era, and demonstrates how they can use a wider range of research approaches to gain deeper understanding of HRH challenges and identify pathways for innovative and effective HRH solutions.
We would like to thank the many contributors who supported the development of the HRH reader, starting with Sara Bennett from the Johns Hopkins School of Public Health, Baltimore, United States of America. Subsequently, Abdul Ghaffar at the Alliance for Health Policy and Systems Research, World Health Organization (WHO), Geneva, Switzerland, generously supported the endeavour. James Campbell and his team at the Health Workforce Department, WHO, Geneva, Switzerland, also welcomed the HRH reader and hosted its formal launch at the Fourth Global Forum on Human Resources for Health, ,,,, November 2017, Dublin, Ireland. We are grateful to the WHO Collaborating Centre for Research and Training in Human Resources for Health anchored by the School of Public Health at the University of the Western Cape, Bellville, Cape Town, South Africa, and to the WHO Collaborating Centre for Nursing Development at Jordan University of Science and Technology, Irbid, Jordan.
Source of support: This work was financially supported by a grant from the WHO Alliance for Health Policy and Systems Research, Geneva, Switzerland. Health Systems Global provided support in kind by providing a platform through which to foster a broader community engaged with raising the profile of research on human resources for health, while constructively revisiting its character and boundaries. Asha George is supported by the South African Research Chair's Initiative of the Department of Science and Technology and National Research Foundation (NRF) of South Africa (Grant No. 82769). Any opinion, finding and conclusion or recommendation expressed in this material is that of the author and the NRF does not accept any liability in this regard.
Conflict of interest: Veloshnee Govender is a technical officer at the Alliance for Health Policy and Systems Research, which is an international partnership hosted by the World Health Organization.
Authorship: AB, KS and AG developed the idea for this perspective paper. AB and KS drafted the manuscript. VG and AG provided intellectual input for the paper's revision.
| References|| |
Pozo-Martin F, Nove A, Lopes SC, Campbell J, Buchan J, Dussault G et al. Health workforce metrics pre- and post-2015: a stimulus to public policy and planning. Hum Resour Health. 2017;15(1):14. doi:10.1186/s12960-017-0190-7.
Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M et al. Human resources for health: overcoming the crisis. Lancet. 2004;364(9449):1984–90. doi:10.1016/s0140-6736(04)17482-5.
Campbell J, Buchan J, Cometto G, David B, Dussault G, Fogstad H et al. Human resources for health and universal health coverage: fostering equity and effective coverage. Bull World Health Organ. 2013;91(11):853–63. doi:10.2471/BLT.13.118729.
Ranson MK, Chopra M, Atkins S, Dal Poz MR, Bennett S. Priorities for research into human resources for health in low- and middle-income countries. Bull World Health Organ. 2010;88(6):435–43. doi:10.2471/BLT.09.066290.
Scheffler RM, Campbell J, Cometto G, Maeda A, Liu J, Bruckner TA et al. Forecasting imbalances in the global health labor market and devising policy responses. Hum Resour Health. 2018;16(1):5. doi:10.1186/s12960-017-0264-6.
Hazarika I. Health workforce in India: assessment of availability, production and distribution. WHO South-East Asia J Public Health. 2013;2(2):106. doi:10.4103/2224-3151.122944.
Henderson LN, Tulloch J. Incentives for retaining and motivating health workers in Pacific and Asian countries. Hum Resour Health. 2008;6(1):18. doi:10.1186/1478-4491-6-18.
George A. Nurses, community health workers, and home carers: gendered human resources compensating for skewed health systems. Glob Public Health. 2008;3(Suppl. 1):75–89. doi:10.1080/17441690801892240.
Hernandez-Peña P, Poullier J, Van Mosseveld C, Van de Maele N, Cherilova V, Indikadahena C et al. Health worker remuneration in WHO Member States. Bull World Health Organ. 2013;91(11):808–15. doi:10.2471/BLT.13.120840.
Sheikh K, Josyula LK, Zhang X, Bigdeli M, Ahmed SM. Governing the mixed health workforce: learning from Asian experiences. BMJ Glob Health. 2017;2(2):e000267. doi:10.1136/bmjgh-2016-000267.
Gilson L, Hanson K, Sheikh K, Agyepong IA, Ssengooba F, Bennett S. Building the field of health policy and systems research: social science matters. PLoS Med. 2011;8(8):e1001079. doi:10.1371/journal.pmed.1001079.
Sheikh K, Gilson L, Agyepong IA, Hanson K, Ssengooba F, Bennett S. Building the field of health policy and systems research: framing the questions. PLoS Med. 2011;8(8):e1001073. doi:10.1371/journal.pmed.1001073.
Borkowski N. Organizational behavior in health care, 2nd ed. Sudbury (MA): Jones and Bartlett Publishers; 2009.
Dieleman M, Toonen J, Touré H, Martineau T. The match between motivation and performance management of health sector workers in Mali. Hum Resour Health. 2006;4(1):2. doi:10.1186/1478-4491-4-2.
Lohmann J, Souares A, Tiendrebéogo J, Houlfort N, Robyn PJ, Somda SM et al. Measuring health workers' motivation composition: validation of a scale based on Self-Determination Theory in Burkina Faso. Hum Resour Health. 2017;15(1):33. doi:10.1186/s12960-017-0208-1.
Borghi J, Lohmann J, Dale E, Meheus F, Goudge J, Oboirien K et al. How to do (or not to do) … measuring health worker motivation in surveys in low- and middle-income countries. Health Policy Plan. 2017;20 November epub ahead of print. doi:10.1093/heapol/czx153.
Smith R, Lagarde M, Blaauw D, Goodman C, English M, Mullei K et al. Appealing to altruism: an alternative strategy to address the health workforce crisis in developing countries? J Public Health (Oxf). 2013 Mar;35(1):164–70. doi:10.1093/pubmed/fds066.
Choi SL, Goh CF, Adam MB, Tan OK. Transformational leadership, empowerment, and job satisfaction: the mediating role of employee empowerment. Hum Resour Health. 2016;14(1):73. doi:10.1186/s12960-016-0171-2.
Aberese-Ako M, Van Dijk H, Gerrits T, Arhinful DK, Agyepong IA. ‘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. 2014; 29 Suppl. 2:ii15–28. doi:10.1093/heapol/czu068.
Razee H, Whittaker M, Jayasuriya R, Yap L, Brentnall L. Listening to the rural health workers in Papua New Guinea – the social factors that influence their motivation to work. Soc Sci Med. 2012;75(5): 828–35. doi:10.1016/j.socscimed.2012.04.013.
Shen GC, Nguyen HT, Das A, Sachingongu N, Chansa C, Qamruddin J et al. Incentives to change: effects of performance-based financing on health workers in Zambia. Hum Resour Health. 2017;15(1):20. doi:10.1186/s12960-017-0179-2.
Leonard KL, Masatu MC. Professionalism and the know-do gap: exploring intrinsic motivation among health workers in Tanzania. Health Econ. 2010;19(12):1461–77. doi:10.1002/hec.1564.
Witter S, Zulfiqur T, Javeed S, Khan A, Bari A. Paying health workers for performance in Battagram district, Pakistan. Hum Resour Health. 2011;9(23):1–12. doi:10.1186/1478-4491-9-23.
Prashanth NS, Marchal B, Devadasan N, Kegels G, Criel B. Advancing the application of systems thinking in health: a realist evaluation of a capacity building programme for district managers in Tumkur, India. Health Res Policy Syst. 2014;12(1):42. doi:10.1186/1478-4505-12-42.
Purohit B, Martineau T, Sheikh K. Opening the black box of transfer systems in public sector health services in a Western state in India. BMC Health Serv Res. 2016;16(1):419. doi:10.1186/s12913-016-1675-0.
Rocha FLR, Marziale MHP, de Carvalho MC, Cardeal Id S de F, De Campos MCT. The organizational culture of a Brazilian public hospital. Rev Esc Enferm USP. 2014;48(2):308–14. doi:10.1590/S0080-6234201400002000016.
Namakula J, Witter S. Living through conflict and post-conflict: experiences of health workers in northern Uganda and lessons for people-centred health systems. Health Policy Plan. 2014;29 Suppl. 2:ii6–14. doi:10.1093/heapol/czu022.
Hernández AR, Hurtig AK, Dahlblom K, San Sebastián M. Integrating views on support for mid-level health worker performance: a concept mapping study with regional health system actors in rural Guatemala. Int J Equity Health. 2015;14(1):91. doi:10.1186/s12939-015-0225-4.