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Factors influencing motivation of health extension workers in Sidama zone, south Ethiopia: A qualitative study

The REACHOUT project is funded by the European Union

Aschenaki Zerihun (BSc, MPH)REACH EthiopiaFebruary 2017

Background

• After Alma-Ata declaration

• Primary health care has taken as a strategy to assure universal

health coverage

• Ethiopia-one of the countries hit by shortage of human resource

for health

• In 2014 the country launched a community based health

program known as the health extension program (HEP)

• The HEP run by cadre of female health extension workers (HEWs)

Background

• HEWs trained for one year and salaried

• 2 HEWs deployed per a village to serve about 5000 population

• 16 health extension packages in four major areas

• Supervised by catchment health center professionals

• Services connected by a referral system within primary health

care unit

• Supported by volunteer community members known as

health development army (HDA)

CHWs Symposium, Kampala Uganda 21-2-17 4

FMOH

Regional Health

Bureau

Zonal health dept.

District Health Office

Health Center

Health post

(2HEWs)

Health post

(2HEWs)

Health post

(2HEWs

Health post

2HEWs

Health post

(2HEWs)

HDA (one to five network): voluntary community members

Perennial challenges in community health worker programs• How to engage community members in CHW program• How to motivate and retain CHWs

This study was conducted with the aim of exploring factors influencing motivation and performance of HEWs in maternal health

Methods

The study area and design

• Sidama zone; south Ethiopia with a population of 3. 4

million and has 19 rural districts

• Purposively selected six districts

• Focus group discussion and in-depth interview was held

with HEWs, women, men, traditional birth attendants, HEP

coordinator at various level and village administration

SNNPR

Ethiopia Sidama Zone

South Omo

Keffa

Gamo GofaBench Maji

Sidama

Gurage

Dawro

Selti

Wolayita

KTHadiya

Segen Peoples'

Konta

Sheka

Gedio

Yem

AlabaHadiya

Basketo

SomaliOromia

AfarAmhara

SNNPR

Tigray

Gambela

Benshangul GumuzDire Dawa

Addis Ababa

LegendSidamawr

Context Analysis Study DistrictNon Study Area

Study Area

Aroresa

Bensa

Loka Abaya

Boricha

Chire

Dale

Hulla

Dara

Chuko

Bursa

Malga

Gorche

Arbe Gonna

Shebe Dino

Hawasa Town

Wonosho

Aleta Wendo

Bona Zuria

Hawassa ZuriaWondo-Genet

• Transcripts read independently by four researchers

• Key themes identified and coding frame work developed

• Coded using Nvivo 10

• Each theme and sub theme analyzed and summarized in

narratives

Results

Factors influencing motivation of HEWs categorized in four levels• Individual, community , organizational and

administrative/political Intrinsic/individual level motivators• Interest to the profession• Sense of belongingness• Positive changes• Worthiness of the service

Results

Individual…

“The most interesting thing is saving the life of women and children. I feel happy when one mother calls me at her delivery” HEW IDI

“…I am interested in working in the activities of prevention and control of communicable diseases like TB, acute watery diarrhea…” HEWs FGD

“ ....we are serving our own community. Their children are our children, and the community is my community.” HEW IDI

Results

Community related motivators Recognition and thanks , community trust, satisfaction and support from community volunteers: health development army (HDA) “When I see the result (the sick gets better); I feel happy, and the community also thanks us after we saved their life.” HEWs FGD

“We (HDA) teach women in our community. We the leaders of one to five network give our advice to convince pregnant mothers. When their labour starts we call to the health extension worker ‘Adanech’ to inform and conduct the delivery.” Women FGD

Results

Organizational motivators

Support from district health office “If the district supervisors come and see our work, we will be happy. We need encouragement from the district officials” (HEWs-IDI)

Results

Community related de-motivatorsLack/minimal support from village administrators and expectation of more curative services

“...the village administration helps us after many negotiations and begging. Otherwise they don’t support us by their own initiative. They consider many things as our business.” HEW IDI

Results

Organizational de-motivators

Unsupportive supervision: fault finding, auditing registers and collecting reports, lack of skill and unhealthy communication

“There is a focal person to supervise and support our health post. But he is not supporting; he is doing nothing except looking at our records/registers. He should have supported us properly.” HEW IDI

Results

Organizational de-motivatorsLow salary: un-proportional compared to high workload, other equivalent government employees, not enough to cover their daily expenses

“We have a lot of workload, but the payment is not equal to the workload. This always discourages us to work hard.” HEW FGD

“When we come to our salary, we are getting below 30 birr per day. With this salary I can’t cover my expenses, and I am not able to support my family with my money. If I prepare a coffee to sell in town I can make 50 birr per day.” HEW FGD

Results

Organizational de-motivatorsWorkload: 16 packages services, new additions, big population and difficult topography, obligation to engage in non health activities, unsupported by workmate

“Some days we get crazy because of workload, “I work in my village alone. Previously there was one health extension worker assigned to work with me. But the district health office gave her a transfer. After that I have been working alone in the village, which is known by its large area. I can’t address and cover all the population . The topography is also very difficult” HEW FGD

Results

Organizational de-motivator

Lack of educational opportunities: Low intake, difficulty in passing the entrance exam, favoritism, no difference in salary and career after upgrading their education

“The government is not providing us education to develop ourselves. ...taking one or two health extension workers per year to the school. The other problem with the education is the health extension worker should pass the entrance examination, but many health extension workers are failing to pass the examination” HEW FGD

Results

Organizational de-motivatorsLack of transfer from work place: Not supported by the policy but required for social and other reasons and sometimes done in favoritism

“The transfer is against the government policy. When we joined the programme we knew that the health extension workers can’t claim transfers. However, those health extension workers who are the relatives of influential people and officials are getting the transfers. I am not comfortable about this thing, and it affects my motivation.” HEW IDI

Results

Organizational de-motivatorsLack of logistics, infrastructure and basic facilities

“...Lack of water is a great challenge, if there was water we can clean our equipment and room.” HEWs FGD

“...we trained on safe and clean delivery, but the room of the health post is not enough, and the health post itself is not clean. Our bed is not clean and safe; no surgical gloves and no complete delivery sets ...” HEW FGD

Results

Administrative/political level de-motivators

Little or preferential support from district political leaders/administrators and obligation for HEWs to engage in political matters/affairs

Summary of motivataors and demotivators

Level Motivataors De-motivatosr

Individula Prestige towards the job/profession

Feeling of belongingness

Witnessing positive results in the community

Undestanding the worthiness of the service

Community Trust of the community in the HEWs Lack of support from village administrators

Community satisfaction Expectation of curative services by the community

Recognition and thanks

Support of health development army (HDA)

Organizational Support from district health office Unsupportive supervision

Low salary

Workload

Lack of career advancemen

Lack of educational opportunities

Lack of opportunities to transfer

Favoritism /prefencial treatment

Inadequate pre-service and in-service training

Lack of logistics, supplies and basic facilities

Adminstartive/political Little or preferential support from political officials

obligation for HEWs to engage in political matters

Conclusions

• Factors influencing the motivation of HEWs interplay at different level

• HEWs were found to be motivated by Individual and community level factors despite the prevailing de-motivators from the health system

• The health system should be responsive to address organizational related factors to improve the motivation and performance of HEWs and hence capitalize their key role in the sustainable development goals

Acknowledgment

• EU for funding the study

• Liverpool school of tropical medicine

• KIT: Netherlands

• South regional health bureau and Sidama zone

health department

• HEWs and other study participants