A critical factor in addressing the human resources crisis in low and middle income countries (LMIC) is the ability to recruit, motivate, and retain health workers. Failure in this area is one of the main causes of decline in availability of services and quality of care. Various financial and non-financial incentives have been implemented and this chapter will explore available evidence to see whether they have influenced motivation. Additionally, Maslow’s hierarchy of needs is used to determine if there is a hierarchy of how incentives are valued. While Maslow’s model is a useful tool to classify themes of health worker needs, it would appear that workers are motivated without each level having to be fulfilled in turn. While financial incentives may help with retention, they can cause erosion of professional ethos, do not increase job satisfaction, or act as motivators to perform well. More research needs to be done in order to design more effective human resources strategies.
TopBackground And Current Understanding
Efforts to improve access to health services across the world are being constrained by severe shortages of health workers. Without the appropriate number of health workers it is not possible to deliver services effectively and efficiently. The human resources crisis is particularly evident in sub-Saharan Africa, where triple the current number of health workers, or at least 1 million more, are needed if they are to come close to approaching the Millennium Development Goals (MDGs) for health (Chen et al., 2004).
There are three major factors affecting health workers, namely the AIDS epidemic, the migration of skilled labour (the “brain drain”), and a history of massive underinvestment in human resources. These factors are affecting the low and middle income countries (LMICs) the most and placing additional strains on already fragile health systems (Chen et al., 2004).
The AIDS epidemic is challenging capacity particularly in sub-Saharan Africa where services are being completely overwhelmed with people who need treatment, as well as by reducing the number of health workers, who are themselves dying from the disease. Health workers are directly impacted through increased workloads and increased exposure to the risk of contracting HIV through a work related injury. Morale is further reduced as health workers see increased numbers of their patients dying (Chen et al., 2004).
Health worker migration is not confined to international movement; internal migration is also widespread, with workers moving from rural to urban areas and from public to private practice. Rural areas have been worst hit by migration leaving many rural facilities understaffed, and this is affecting the morale of staff who remain there (Awases, Gbary, Nyoni, & Chatora, 2003). Despite evidence showing the detrimental effect of migration of health workers from LMICs, many high income countries have grown reliant on importing health workers from these countries (Hongoro & Normand, 2006).
Early responses to the shortage of skilled health workers in LMICs have focused mainly on issues of training capacity, but it has become increasingly clear that the more important issues are of incentives, retention, and motivation of those who remain. Until issues that are leading to “de-motivation” of health workers are addressed, high quality care cannot be provided (Agyepong et al., 2004). There is evidence, particularly in Thailand (Wibulpolprasert & Pengpaibon, 2003), of incentives that can retain and motivate health workers. Both financial and other incentives are important in motivating professionals, but such research also shows that the necessary financial incentives may involve very large increases in salaries. This is often not a sustainable option and so alternative incentives must be found and put into place.
It is important to note that the human resources crisis is a worldwide phenomenon and all countries, rich or poor, are affected by imbalances in their health workforce. It is estimated that by 2011 Canada will have a shortage of 78,000 nurses (Gagnon, Ritchie, Lynch, & Dronin, 2006). The shortage is being created by not enough people being attracted to the profession, in addition to the increased care demands created by an aging population. A study of nurse retention found that only 50% had a firm intention to stay in nursing. The main sources of dissatisfaction cited included lack of professional support and recognition, heavy workload, lack of equipment, and poor physical work environment (Gagnon et al., 2006).
While this chapter will focus mainly on the situation in LMICs, as they are affected by the greatest burden of disease, migration, and chronic underinvestment in health care, we will also look at challenges surrounding motivation and retention of health workers in high income countries. It is critical that all countries implement health plans to reflect the heath needs of their population and workforce strategies must be put in place to facilitate this. Furthermore, if issues surrounding motivation and retention were to be addressed in high income countries it may reduce their dependency on recruiting health workers from LMICs. Therefore, it is clear that a better understanding of the critical factors influencing human resources capacity is needed globally in order to deliver equitable, effective health care.