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Motivation of Health Workers and Associated Factors in Public Hospitals of West Amhara, Northwest Ethiopia

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Open Access Full Text Article Original Research

Motivation of health workers and associated


factors in public hospitals of West Amhara,
Northwest Ethiopia
This article was published in the following Dove Press journal:
Patient Preference and Adherence
15 February 2016
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Zemichael Weldegebriel 1 Background: Health professionals’ motivation reflects the interaction between health
Yohannes Ejigu 2 professionals and their work environment. It can potentially affect the provision of health
Fitsum Weldegebreal 3 services; however, this important attribute of the workplace climate in public hospitals is not
Mirkuzie Woldie 2 usually given serious attention to the desired level. For this reason, the authors of this study
have assessed the level of motivation of health professionals and associated factors in public
1
Public Planning Department, Debark
Hospital, Debark, North Gondar, hospitals of West Amhara, Northwest Ethiopia.
Amhara Region, 2Department of Methods: A facility based cross-sectional study was conducted in eight public hospitals of
Health Services Management, College
West Amhara from June 1 to July 30, 2013. A total of 304 health professionals were included
of Public Health and Medical Sciences,
Jimma University, Jimma, Ethiopia; in this study. The collected data were analyzed using SPSS software version 20. The reliability
3
Department of Medical Laboratory of the instrument was assessed through Cronbach’s α. Factor scores were generated for the
Science, College of Health and
Medical Science, Haramaya University,
items found to represent the scales (eigenvalue greater than one in varimax rotation) used in
Harar, Ethiopia the measurement of the variables. The scores were further analyzed using one-way analysis of
variance, t-tests, Pearson’s correlation, and hierarchical multiple linear regression analyses. The
cut-off point for the regression analysis to determine significance was set at β (95% confidence
interval, P0.05).
Results: Mean motivation scores (as the percentage of maximum scale scores) were 58.6% for
the overall motivation score, 71.0% for the conscientiousness scale, 52.8% for the organiza-
tional commitment scale, 58.3% for the intrinsic motivation scale, and 64.0% for organizational
burnout scale. Professional category, age, type of the hospital, nonfinancial motivators like
performance evaluation and management, staffing and work schedule, staff development and
promotion, availability of necessary resources, and ease of communication were found to be
strong predictors of health worker motivation. Across the hospitals and professional catego-
ries, health workers’ overall level of motivation with absolute level of compensation was not
significantly associated with their overall level of motivation.
Conclusion: The strongest drivers of all motivation dimensions were found to be nonfinancial
human resource management tools, so policy makers and health workforce stake holders should
focus on these tools to alleviate motivation problems.
Keywords: motivation, health workers, public hospitals, West Amhara, Northwest Ethiopia

Introduction
Motivation can be defined as a person’s degree of willingness toward achieving an
Correspondence: Zemichael individual goal that is consistent with that of the organization and the reasons underly-
Weldegebriel
Debark Hospital, Lemalimo Street,
ing behavior which can be either intrinsic or extrinsic.1,2
Debark, North Gondar, Amhara The health system is labor and capital intensive. But it is the health workers’
Region 33, Ethiopia
Tel +251 93 740 8660
motivation, manifested in their behavior in the workplace, that greatly affects the
Email zemchuwg@gmail.com outcome of the health system.3–5 Low morale among the workforce can undermine
submit your manuscript | www.dovepress.com Patient Preference and Adherence 2016:10 159–169 159
Dovepress © 2016 Weldegebriel et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php
http://dx.doi.org/10.2147/PPA.S90323
and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you
hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission
for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
Weldegebriel et al Dovepress

the quality of service provision and drive workers away data is available on the extent to which these theories have
from the profession. The quality of health services, their been used to address motivation-related issues among health-
efficacy, efficiency, accessibility, and viability depend on care workers in Africa, even if there is enormous evidence
the performance of health professionals delivering these of poor health professionals’ achievement.3,9
services, so it is important to consider personnel motivation Evidence from Ethiopia shows that the health system has
and development a central issue in health policy.6 been trying to improve the quality of health-care services
The health and human service industry is undergoing one through undertaking massive health sector-wide reforms
of the most massive transformations of any industry in our such as business processing and re-engineering, health-care
history, due, in part, to mergers, reorganizations, cost con- financing, and health information systems. Even though there
tainment, a changing workforce, and technological changes is a human resource crisis in the sector, 82% of nurses and
that are doubling every 3 years.7 Health-care delivery is 73% of doctors work for the public sector. But the public
highly labor-intensive, and service quality, efficiency, and health sector which uses a large amount of human resource
equity are all directly mediated by the workers’ willingness is ineffective and inefficient, and the health service being
to accomplish their tasks. Despite the fact that the availability delivered through it has been seriously affected by poor
of resources and worker competencies are not sufficient by human resource management. As part of the sector wide
themselves to ascertain the desired worker performance. But reform effort aimed at improving the quality and accessibil-
the objectives of the health system are not being attained in ity of health services through decentralization system, the
most countries because of serious human resource policy Ethiopian Federal Ministry of Health recognized the problem
crises, particularly of poor motivation.2,6,8 So, it is increasingly and gave priority to build management capacity of hospitals
becoming important that policymakers should be aware of through pioneering blue print standards and made progress in
health worker motivation and its impact on health sector per- establishing health management by chief executive officers
formance. Yet, little concern has been given to the issue.9 (CEO) as profession.21 But all these efforts were not as such
Sub-Saharan Africa is coping with 24% of the world’s satisfactory in achieving the anticipated objectives, due to
disease burden, while concurrently local health systems are different reasons. The health system is still suffering from
unresponsive, inefficient, inequitable, and even unsafe. Even human resource crisis. Many trained health professionals are
though the reasons for this underperformance are multiple, migrating overseas or leaving to work in the private sector
health workers’ motivation has been suggested as the main because motivated health professionals are more likely to
determinant of health-care service quality.10 For many years, work for profit in private sectors and nongovernmental orga-
the continent has been conducting efforts to provide effec- nizations as opposed to working in the public sectors,22,23 and
tive, equitable, and affordable health care services, but health this appears to be a critical problem of the health sectors.
indices in Africa have either remained unchanged or have Low level of health professionals’ work motivation is
declined. It is believed that this underperformance threat- a critical challenge for many countries’ health system, yet
ens the achievement of Millennium Development Goals to surprisingly very little attention has been given to this topic.
“reduce child mortality, improve maternal health and combat While a few studies have explored particular aspects of the
HIV/AIDS and malaria”.10–13 Poor implementation of system- motivation question, such as staff retention or satisfaction,
atic improvements is the critical challenge, and personnel virtually no comprehensive studies fully investigated the
motivation is a key component in this functional failure.14–16 health workers’ motivation in the developing countries and
Health workers of the health sector have specific features it is questionable to use the findings of studies of industrial-
either internal to themselves or extrinsic to the work or are ized countries which vary in context.9
facing challenges that cannot be ignored. At this time, motiva- With the challenges facing this sector, including tech-
tion can play an integral role in many of the compelling chal- nological advancements, the metamorphosis occurring
lenges of health care by providing direction and purpose.17 in the demographic and diversity of the workforce, the
The quality of performance in health facilities to a large re-structuring, re-engineering, downsizing, the current
extent depends on the available human resource mix and their events facing professionals in the health sector, and the
motivation.10,18 The workforce is among the most important ever changing customer needs, understanding the needs of
inputs to any health system and has a strong impact on the per- the worker becomes more essential than ever to promote a
formance of health facilities.19 Despite the existence of several quality health service and to create healthy work environ-
theories of motivation in the workplace,9,10,20 little empirical ment. Understanding the motivation scores, identifying the

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Dovepress Motivation of health workers in Ethiopian public hospitals

motivating factors for the health professionals, and recog- professional present in the public hospitals which means
nizing how the manager and the leaders can successfully potential source population during the study period.
motivate the staff is a question of increasing concern.9,24 Sample size was increased by 5% to compensate for
Therefore, this study has tried to assess the overall health nonrespondents, resulting in the final sample size of 325. The
professionals’ motivation score in public hospitals of West total sample size that was allocated to each of the categories
Amhara and the factors associated with the scores. was proportional to the size method. From each health profes-
sional category, the respondents were then selected through
Methods and materials systematic random sampling method. If a sampled person
Study setting and design was not available and it was not possible to make arrange-
A cross-sectional study was carried out from June 1, 2013 to ments to meet him/her later, data collectors were informed
July 30, 2013 in West Amhara public hospitals in the north in advance to collect data from the next health professional
western part of Ethiopia. In this subregion, there were three given in the list.
referral hospitals, two general hospitals, and three primary
hospitals at the time of data collection. There were also Instruments and measures
225 health-care professionals working in the three primary The starting point for potential constructs and questions to
hospitals, 207 health professionals working in the two general be included in the self-administered close-ended question-
hospitals, and 827 health professionals working in the three naire was a questionnaire designed for developing a tool to
referral hospitals. measure motivation among health professionals; as seen in
our previous work which was based on earlier work in a
Participants of the study and sample size Kenyan study on health professionals.25 Additionally, studies
estimation on motivation of health workers were reviewed by taking
The source population for the study was made up of categories particular notes on the most relevant ones to the Ethiopian
of health professionals working in the eight public hospitals situation.26–29 From these sources, and review of studies that
of West Amhara region. The list of health workers of each used motivation theory in health, we identified constructs
hospital was obtained from the human resource managers, which were considered to be categorized as likely deter-
and the human resource managers were also asked to indicate minants and outcomes of motivation. The questionnaires
whether an employee was on leave, education, or long-term contained sociodemographic variables (age, sex, marital
training during the data collection. The categories included: status, religion, perceived religiosity, salary, educational sta-
doctors, nurses, laboratory personnel, pharmacists, X-ray tus, ethnicity, profession, time in post). Performance review
technicians, environmental health experts, physiotherapists, and performance appraisal result utilization, on-site training,
health officers, and anesthetists. additional remunerations and benefits, staffing pattern and
Sample size was estimated using single population flexible work schedule, opportunity of staff development,
proportion formula. There was no previous information on availability of necessary materials, working space, and ease
health workers’ motivation scores and factors associated of communication in the organization were the institution-
with health professionals’ motivation scores in the area of related variables included in the tools. All the determinants
this study. Hence, it was hypothesized that at least 50% of and outcome constructs were measured in the form of a
the health workers were assumed to be motivated, and the five-point Likert scale (1= strongly disagree, 2= disagree,
sample size was estimated taking this as the starting point 3= neutral, 4= agree, 5= strongly agree). The questionnaire
with 95% confidence level and 5% degree of accuracy. was translated into Amharic and then back into English to
Since the study population was less than 10,000 (1,259), ensure semantic equivalence. It was then pretested on 5% of
population correction formula was used to adjust sample the study population in a hospital found in East Amhara.
size that is: The internal consistency of the scales was assured, and
a Cronbach’s alpha of 0.70 or greater was the cut-off point
n (1) to judge the internal consistency of each scale. Correlation
NF = ,
1 + [ n/N ] was performed, and Pearson’s correlation coefficient r0.4
was used as the cut-off point. This cut-off means that each
where NF is the final sample size, n is the initial sample size item has a shared variance of at least 16% with the factor
without correction formula, N is the total number of health under consideration.28,29 Factor analysis was performed, and

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Weldegebriel et al Dovepress

factors with eigenvalues greater than one were taken for in a step-by-step selection to avoid multicollinearity, which
further analysis. is commonly associated with multiple regression analysis;
The clarity and cultural acceptance of each of the items furthermore, other assumptions like linearity and normality
was tested. So, major revision was not required. The validity were also checked.
and reliability of the scales used in this study are reported To facilitate comparison between the motivation dimen-
elsewhere. sions, scores were reported as both raw mean scores and
the standardized percentage of the maximum scale (%SM)
Data collection procedure scores. This also enables future researchers to easily com-
Data were collected by two health professionals with diplo- pare their findings with those in this study even if they
mas, who took training on how to use the instruments and make use of different number of items and/or response
techniques of consent requisition. To adhere to confiden- categories. These scores lie between 0 and 100.30 (%SM)
tiality, the names in the questionnaires were replaced by was calculated as:
codes, and the participants were informed about these so
that they had a record of their own codes to facilitate track-
Standardized
ing of the completeness of their respective questionnaires. Actual score – minimum score
% of maximum = × 100%
The supervisors and the principal investigator were respon- Maximum score – minimum score
scale (%SM)
sible for checking on the completeness of the data on site.
Incomplete questionnaires were put in offices arranged for  (2)
this purpose so that participants could complete their own
questionnaires. All participants were acknowledged for their Ethical considerations
time and assistance. Clearance to carry out this study was obtained from the
Ethical Clearance Review Committee of Jimma University,
Data analysis College of Public Health and Medical Sciences. To carry
The scales for negatively worded questions were reverse out the study, permission was obtained from the Amhara
coded so that 1 was “strongly agree” and 5 “strongly disagree” Regional Health Bureau and the CEOs of the respec-
before analysis. Thus, a high score shows disagreement with a tive hospitals. Written informed consent was obtained
negative statement and is therefore suggestive of higher moti- from each participant before enrollment as respondents.
vation. The data were analyzed using SPSS software version The participants were well informed that they had the right
20. Explanatory variables like time in post were recoded and to participate or not in the study. Neither the respondents’
recategorized before computing. Variance analysis through name nor other personal data were included in the research
analysis of variance and Student’s t-test was done for compar- report.
ing health workers’ motivational scores across the categories.
Multiple linear regressions were used for identifying deter- Results
minants of health workers’ motivation. A significance level Characteristics of respondents
P-value 0.05 was used in all cases as a cut-off point. After a month of data collection, 304 completed question-
Because of many explanatory variables, stepwise regres- naires were received, representing a response rate of 93.5%.
sion method was used to examine the relationship between Most of the participants were from referral hospitals;
independent and dependent variables in the preceding a reflection of the number of health professionals in those
models and enter method in the last model. Sociodemo- hospitals was compared to the other two levels of hospitals.
graphic variables were entered into the first linear regression Seventy-five (24.7%) of the respondents were from pri-
model, while the institutional and system related variables mary hospitals. General hospitals had the lowest number of
were entered into the second one. The variables found to participants 49 (16.1%). The skill mix included 152 (50%)
be significantly associated with the dependent variable in nurses, 54 (17.8%) doctors, 40 (13.2%) laboratory person-
the preceding models (r0.4, P0.05) were entered into the nel, 28 (9.2%) pharmacy staff, and 9.9% others. Out of the
final model. Those variables which had P-value of less than total respondents, 153 (50.3%) were diploma holders and the
0.05 were the important predictors of health workers’ motiva- remaining 151 (49.7%) were medical doctor/degree holders
tion. In stepwise regression, each independent measure was and above. The majority (79.9%) of the respondents had been
selected as a predictor based on the significance of t-statistics in their current post for less than 5 years (Table 1).

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Dovepress Motivation of health workers in Ethiopian public hospitals

Table 1 Characteristics of professionals in public hospitals of Table 1 (Continued)


West Amhara, Northwest Ethiopia, 2013 Characteristics n (%)
Characteristics n (%) Results of performance utilized for
Sex Training 23 (7.6)
Male 189 (62.2) Promotion 90 (29.8)
Female 115 (37.8) Rotation 25 (8.2)
Age (years) Demotion 12 (3.9)
Multipurpose 22 (7.2)
25 136 (44.7)
Not used 132 (43.4)
26–35 139 (45.7)
Notes: n=304. aOthers: X-ray, environmental, physiotherapy, ophthalmic nurse,
36–45 19 (6.3)
anesthesia. “Master” refers to professional who complete their second degree.
46–55 9 (3) Abbreviation: MD, medical doctor.
56 1 (0.3)
Net salary (ETB)
1,400 68 (22.4)
Motivational levels of respondents
1,401–3,500 223 (73.4)
3,501–5,000 11 (3.6) (%SM) of the overall motivation of respondents was 58.6%.
5,001 2 (0.7) When comparison was made among the dimensions of moti-
Remuneration (ETB) vation, motivation was found to be the highest for consci-
0–100 111 (36.5)
entiousness dimension with (%SM) 71%, while it was least
101–500 153 (50.3)
501–1,000 34 (11.2) for the organizational commitment dimension of motivation
1,001 6 (2.0) which had (%SM) 52.8% (Table 2).
Perceived religiosity
Very religious
Religious
78 (25.7)
131 (43.1)
Predictors of motivation
Somewhat religious 88 (28.9) The intrinsic motivation dimension
Not at all religious 7 (2.3) Sociodemographic variables were found to be significant pre-
Educational status
dictors that explain the variability in the intrinsic motivation
Diploma 153 (50.3)
Degree/MD 145 (47.7) factor score. Accordingly, age, sex, the professional category
Master or specialist 6 (2.0) of the respondents, and the type of the hospitals where the
Profession category respondents work were found to be statistically associated
Doctor 54 (17.8)
Nurses all type 152 (50)
with intrinsic motivation score. The intrinsic motivation fac-
Laboratory all type 40 (13.2) tor for doctors was higher on average by 0.399 units (95%
Pharmacy all type 28 (9.2) confidence interval [95% CI]: 0.017–0.780) compared to the
Othersa 27 (8.9)
nurses. The result showed female respondents had 0.129 units
Marital status
Single 128 (42.1) (95% CI: 0.104–0.421) higher intrinsic motivation score
Married 171 (56.2) compared to males. Those health-care professionals from pri-
Separated 5 (1.7)
mary hospitals had an average of 0.143 units (95% CI: -0.755
Management position
Yes 83 (27.3) to -0.077) lower intrinsic motivation scores when compared
No 221 (72.7) to those from referral hospitals. In this study, age was found
Hospital to be a negative predictor of the intrinsic motivation score.
Primary 75 (24.7)
General 49 (16.1)
Referral 180 (59.2) Table 2 Raw mean scores and (%SM) for the motivation
Performance review dimensions among respondents recruited from public hospitals of
Formal system 170 (55.9)
West Amhara, Northwest Ethiopia, 2013
Informal 76 (25)
Not reviewed 58 (19.1) Motivation dimension Raw mean score ± SD (%SM)
Training Intrinsic motivation 3.79±1.257 58.33%
Yes 136 (44.7) Conscientiousness 4.06±1.081 71.00%
No 168 (55.3) Organizational commitment 52.82%
3.26±1.356
Years of service
Organizational burnout 3.56±1.268 64.00%
1 year 152 (50)
Overall motivation score 10.03±1.975 58.61%
1–5 years 76 (25)
5–10 years 57 (18.8) Notes: n=304. (%SM) is the standardized score as the percentage of possible maximum
scale score, and it lies between 0 and 100.
10 years 19 (6.3)
Abbreviations: SD, standard deviation; %SM, standardized percentage of the
(Continued) maximum scale.

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As the age of respondents increased by 1 year, the intrinsic units. The category of hospitals, the perception of respondents
motivation was lowered by 0.116 units (95% CI: -0.0046 in the performance report utilization, the respondents’ per-
to -0.001). ception in the staff development and career opportunities,
The relationship between sociodemographic and insti- and the perception on the availability of easy communication
tutional variables with intrinsic motivation factor score were significantly associated with organizational commit-
is quantified. Since we used stepwise regression analysis, ment motivation. But in the final model, when confounders
only variables found to be significantly associated with the were treated, they were found to be insignificant predictors
dependent variable in the preceding models (r0.4, P0.05) of organizational commitment motivation (Table 4).
were entered into a final model (Table 3).
Burnout dimension
Organizational commitment and motivation Performance review was the only single predictor of the
The significant predictors of motivation as demonstrated by burnout dimension of motivation in the simple linear regres-
the organizational commitment of motivation were working sion model. So, multiple linear regression analysis was not
in general hospitals (P0.001), the perception of the respon- needed. Respondents who claimed performance review had
dents at the staffing pattern and flexible work schedule, the never been conducted had an average decrease of 0.155 units
perception of respondents in the professional and career (95% CI: -0.875 to -0.122) in burnout motivation score as
development and the perception of respondents in the avail- compared to those who claimed existence of formal perfor-
ability of resources, and the performance management and mance assessment (Table 5).
utilization for decision making (P0.05) were significant
predictors of organizational commitment dimension of The conscientiousness dimension
motivation. Table 6 shows the regression estimates and the relative effect
A unit change in the perception of respondents about the of each predictor variable with organizational conscientious-
availability of necessary materials and the staffing pattern and ness dimension of motivation.
flexible work schedule increased organizational motivation The significant predictors of motivation as demonstrated
score by an average of 0.150 units (95% CI: 0.042–0.262) by the organizational conscientiousness of motivation were
and 0.134 units (95% CI: 0.016–0.272), respectively. A unit age of respondents (P0.05), professional training in the
change in the perception of staff development and career previous 1 year (P0.05), perception on availability of
opportunities increased the organizational commitment resources (P0.05), and perception on staffing and flexible
motivation by 0.084 units. A unit change in the perception of work schedule (P0.05). A unit increment in the age of the
performance management and supervision increased organi- respondents lowered the motivation scores by 0.129 units
zational score by an average of 0.214 (95% CI: 0.108–0.367) (95% CI: -0.042 to -0.004). In this study, a unit change in the

Table 3 Sociodemographic and institutional variables as predictors of intrinsic motivation at public hospitals of West Amhara,
Northwest Ethiopia, 2013
Explanatory variables Category n (%) Unstandardized β (95% CI for β) Standardized β (95% CI for β)
Age -0.08 (-0.039, -0.007)* -0.116 (-0.41, -0.001)*
Sex Male 189 (62.2)a – –
Female 115 (37.8) 0.134 (0.042, 0.345)* 0.129 (0.104, 0.421)*
Profession Doctor 54 (17.8) 0.121 (0.017, 0.780)* 0.399 (0.017, 0.780)*
Nurse 152 (50.0)a – –
Laboratory 40 (13.2) -0.025 (-0.520, 0.336) -0.017 (-0.490, 0.366)
Pharmacy 28 (9.2) -0.194 (-1.337, -0.347)** -0.192 (-0.489, 0.357)
Others 30 (9.8) -0.081 (-0.165, 0.028) -0.060 (-1.340, -0.329)
Hospital level Primary 75 (24.7) -0.187 (-0.880, -0.211)** -0.143 (-0.755, -0.077)*
General 49 (16.1) 0.034 (-0.277, -0.507) 0.070 (-0.151, 0.629)
Referral 180 (59.2)a – –
Adj R2 0.037
Notes: n=304. aReferences category (categories with highest frequency taken as reference categories). *Significant at P0.05, **significant at P0.01. Negative values of
standard β indicate negative predictors of HPs motivation and positive values indicate positive predictors of HPs motivation.
Abbreviations: Adj, adjusted; CI, confidence interval; HPs, health professionals.

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Table 4 Sociodemographic and institutional variables as predictors of organizational commitment among health professionals in public
hospitals of West Amhara, Northwest Ethiopia, 2013
Explanatory variables Category n (%) Unstandardized β (95% CI for β) Standardized β (95% CI for β)
Utilization of performance report Used 172 (56.6)a – –
Not used 132 (43.4) -0.138 (-0.133, -0.044)* -0.051 (-0.422, -0.145)
Hospital level Primary 75 (24.7) -0.087 (-0.086, 0.631) -0.004 (-0.348, 0.321)
General 49 (16.1) 0.227 (0.416, 1.257)* 0.096 (-0.046, 0.751)*
Referral 180 (59.2)a – –
Performance management and supervision – – 0.380 (0.306, 0.539)*** 0.214 (0.108, 0.367)***
Staffing and work schedule – – 0.346 (0.256, 0.487)* 0.134 (0.016, 0.272)*
Staff development – – 0.191 (0.079, 0.298)* 0.069 (-0.035, 0.170)
Availability of necessary resources – – 0.309 (0.206, 0.426)* 0.150 (0.042, 0.262)*
Communication – – 0.293 (0.211, 0.457)* 0.109 (-0.001, 0.251)
Adj R2 – – – 0.226
Notes: n=304. aReferences category (categories with highest frequency taken as reference categories). *Significant at P0.05, ***significant at P0.001. Negative values of
standard β indicate negative predictors of HPs motivation and positive values indicate positive predictors of HPs motivation.
Abbreviations: Adj, adjusted; CI, confidence interval; HPs, health professionals.

perception on the availability of necessary materials increased which indicates that the health professionals were just
the motivation score by 0.118 units (95% CI: 0.003–0.188), motivated. The finding of this study is comparable with the
and a change in the perception of easy communication in results of the study conducted in Malawi and Gaza.28,30
the organization increased the conscientiousness motivation The overall motivation results showed significant
by 0.142 units (95% CI: 0.024–0.234). Those professionals variation in mean motivation scores by sociodemographic
who had not received professional training in the past year variables such as sex, age, professional category of respon-
had 0.151 units (95% CI: -0.562 to -0.093) lower conscien- dents, type of the hospitals, and duration of services, and
tiousness motivation as compared to those who had received the institutional factors such as performance management
training (Table 6). system, staffing and work schedule, staff development
opportunities, furnishing necessary materials, communica-
Discussion tion, and training were found to be significant predictors of
The quality of health services, their efficacy, efficiency, health professionals’ motivation scores. In terms of variation
accessibility, and viability highly depend on the motivation between the sexes, motivation scores for females were likely
of health workers who provide the services, so it is important to be higher than that of the male participants. Regression
to seriously consider health workers’ motivation as a central analysis showed significant association between motivation
issue in the health policy.6 The results of this study could be and female sex. The same results have been reported from
useful, especially in the Ethiopian context where health-care previous studies in Zambia and Ethiopia, where female
human resource challenges continue to hamper the provision health workers were more likely to report higher work moti-
of quality health-care services.21 vation as compared to males.26,31 In the study conducted in
In general, the overall motivation score of health workers Zambia, it was hypothesized that men are more motivated
in this study was 58.6% above the standardized mean (50) by higher wages and prestigious jobs, while women are

Table 5 Predictors of motivation in the organizational burnout dimension of health workers’ motivation at public hospitals of West
Amhara, 2013
Explanatory variables n (%) Unstandardized β 95% CI for β
Upper bound Lower bound
Performance
Formally reviewed 170 (55.9)a – – –
Informally reviewed 76 (25) -0.027 -0.420 0.263
Not reviewed at all 58 (19.1) -0.155 -0.875* -0.122*
Adj R2 – – 0.016 –
Notes: n=304. aReferences category (categories with highest frequency taken as reference categories). *Significant at P0.05. Negative values of standard β indicate negative
predictors of HPs motivation and positive values indicate positive predictors of HPs motivation.
Abbreviations: Adj, adjusted; CI, confidence interval; HPs, health professionals.

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Table 6 Sociodemographic and institutional variables as predictors of conscientiousness among health professionals in public hospitals
of West Amhara, Northwest Ethiopia, 2013
Explanatory variables Category n (%) Unstandardized β (95% CI for β) Standardized β (95% CI for β)
Age – – -0.120 (-0.41, -0.001)* -0.129 (-0.042, -0.004)*
Have you taken training in the past year? Yes 136 (44.7)a – –
No 168 (55.3) -0.327 (-0.464, -0.025)* -0.151 (-0.562, -0.093)*
Is performance reviewed? Yes 246 (80.1)a – –
No 58 (19.1) 0.183 (0.198, 0.809)* 0.130 (0.062, 0.653)*
Staffing and work schedule – – 0.224 (0.097, 0.286)** 0.142 (0.023, 0.221)**
Availability of necessary resources – – 0.205 (0.077, 0.257)* 0.118 (0.003, 0.188)*
Communication – – 0.224 (0.103, 0.305)* 0.142 (0.024, 0.234)*
Adj R2 – – – 0.126
Notes: n=304. aReferences category (categories with highest frequency taken as reference categories). *Significant at P0.05, **significant at P0.01. Negative values of
standard β indicate negative predictors of HPs motivation and positive values indicate positive predictors of HPs motivation.
Abbreviations: Adj, adjusted; CI, confidence interval; HPs, health professionals.

more concerned with job security and community value for employees’ attitudes, and decline in organization’s social
the work they do.26 and psychological environment leads to a decrease in the
The overall mean motivation in the intrinsic dimension individual workers’ effort to maintain and work toward
was 3.79 and %SM was 58.3%; just above the standardized organizational goals.35
and raw mean scores, indicating that health profession- Health worker organizational commitment motivation
als were motivated. This finding is comparable with the score as measured by the mean of 3.26 and %SM was 52.8%.
findings of the study in Malawi and Gaza strip which also This is greater than the standardized mean of 50% indicating
revealed that public health workers were motivated to highly that the health workers were committed to exert and maintain
motivated.28,30 Age, type of the hospitals, and the professional efforts on their organizational goal(s), but this is lower than
category were significant predictors of the intrinsic motiva- the earlier findings.26,30 Management and leadership capacity
tion dimension. in the hospitals were reported as significant factors affecting
Age of respondents was found to be a negative predic- motivation. Ineffective management and leadership practices
tor of motivation in the conscientiousness dimension. The in the organization highly affect the commitment of employ-
motivation level of respondents was found to be lowered by ees to serve and remain in post.36
0.129 units as their age increases a year. This was not the case Working in general hospitals, perception of respondents
in the Zambian study where motivation level was reported on the staffing pattern and flexible work schedule, furnishing
to increase as age increases.26 This could be related to the and supplying necessary materials, and the performance man-
absence of professional and career development schemes agement and utilization for decision making were significant
in the study areas that affect the enjoyment of work and predictors of the organizational commitment dimension of
achievement as stated by Daniel Pink.32 motivation.
Doctors had higher intrinsic motivation as compared to In this study, performance management was a posi-
other professional categories. This finding of our study is tive predictor of health workers’ motivation as measured
in line with the findings of similar study conducted in a dif- by organizational commitment. In this study, 80.9% of
ferent cultural and socioeconomic environment of Cyprus; respondents reported that there was performance evalua-
Cyprus General Hospital.33 However, the study conducted tion, but only 56.4% of them reported that the performance
in Zambia, which was cited earlier, indicated that nurses appraisal was being used for decision making. This finding
were highly motivated as compared to physicians and is in agreement with the finding of the study done in Mali
other paramedics. 34 This could partly be explained by by Dieleman et al,18 which stated appropriate performance
the social recognition given to doctors in the Ethiopian management (ie, job descriptions, supervisions, continuous
context, their decision making power, and creativity and education, and performance appraisal) can positively influ-
skill exploration they possess due to their higher academic ence the motivation of health workers. In this study, a unit
status.33 In this study, health professionals working in the increment in the perception of staff development and career
primary hospitals had lower motivation scores as compared opportunities had increased the commitment by 0.084 units.
to those working in the referral and specialized hospi- This finding is in agreement with the findings of the study
tals. A decline in the varieties of profession, lowering of done in Ogun State, Nigeria which revealed that the extent to

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Dovepress Motivation of health workers in Ethiopian public hospitals

which health workers are exposed to career and professional dimension. This finding is comparable with the findings of
development has a strong motivational effect on achieving the study done in districts of Benin and Kenya.41
organizational goals.37 A considerable part of good management is ease of com-
The mean motivation score in the burnout dimension munication between hospital management and subordinates.
was 3.56, which shows that health workers in this regard Smooth information flow in a hospital is vital to minimize
were just motivated. In this study, performance management personal and organizational problems. In this study, a unit
system was a significant predictor of burnout dimension of increase in the perception of fairness in communication
motivation. Respondents who claimed their performance increased the conscientiousness motivation of the respon-
had never been reviewed had 0.155 units lower motivation dents by 0.187 units. This finding is in agreement with the
score compared to those whose performance was measured previous studies done in Kenya and Uganda that revealed
formally. This is in agreement with the literature of World that health workers feel better motivated when managers
Health Organization’s report, which states “job descrip- give them the opportunity to participate in meetings to
tion, criteria for promotion and career progression have discuss issues of their hospital.37,42 This supports the fact
positive association with inspiring motivation of health that successful strategies to encourage goal performance
professionals”.38 partly rest on the ability of health managers to strengthen
The highest %SM (71.0%) in health worker motivation their relationship with subordinates. The environment of
score was found to be that of the conscientiousness dimen- the health-care facility, its infrastructure, and availability of
sion; moreover, the mean score for this dimension was as medical equipment have emerged in this study as predictive
high as 4.06, which was also the case in a study done in factors of organizational commitment and conscientiousness
Malawi.28 But this finding is not consistent with the findings dimensions of motivation. This finding is in agreement with
of the study done in Addis Ababa, Ethiopia,39 which showed the findings documented in the previous researches in Mali
that the most significant motivation predictors for nurses were and Namibia.18,43
absolute payments which were insignificant in the current In this study, basic net monthly salary, remunerations like
study. The age of the professionals, performance manage- housing and additional work other than their normal job and
ment practices, perception about staffing pattern and work other benefits were insignificant predictors of health workers
schedule flexibility, perception about availability of neces- motivation. This is consistent with the findings of the studies
sary materials, and perception about ease of communication carried out in different countries.27,38,41,43–46 But this finding is
were significant predictors of health worker motivation as inconsistent with findings of other studies done in the capital
measured by the conscientiousness dimension. of Ethiopia, Addis Ababa which revealed that health workers
Age of the respondents was found to be a strong negative appeared to be more motivated by the payment and fringe
predictor of motivation in the conscientiousness dimension. benefits rather than extrinsic nonfinancial and intrinsic fac-
One year increment in age lowered the motivation level of tors of motivation.39 This difference could partly be due to
respondents by 0.129 units. This supports the Maslow’s the difference in the study settings.47
hierarchy of needs, which revealed that the already existing The study design and methods used to obtain relevant
goals no longer motivate workers.40 So, as age and time in data for this study are scientifically sound. Since the purpose
post increase, needs should be modified. This is inconsistent of the study was to assess motivation, cross-sectional study
with the study done in Zambia which revealed that as age of design was employed. The study subjects were enrolled to the
respondents increased, the motivation level increased.26 The study proportionally through sample weight calculation from
mechanism is not clear. all professional and hospital categories. Hence, respondents
In this study, a unit increment in the perception of staff were selected proportionally from all categories of health
development and career opportunities increased the consci- professionals. Therefore, findings are comprehensive for the
entiousness by 0.142 units. This finding is in agreement with Amhara Regional Health Bureau and all hospitals of West
the findings of the study done in four local governmental Amhara for planning, monitoring and evaluation of the on-
agents in Ogun State, Nigeria, which revealed that the extent going human resource management (HRM) activities for
to which health workers are exposed to career and profes- improving the quality of health care services. Continuous
sional development has a strong motivational effect on data were properly treated by employing factor analysis,
achieving organizational goals.37 In this study, an increase in and %SM was also computed, which enables comparison
the perception of furnishing and supplying necessary materi- between the motivational constructs and the finding of other
als increased the motivation score in the conscientiousness studies. The tools used for this study were also used in other

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167
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Weldegebriel et al Dovepress

studies, and pretests of the contextually adopted tools were supervision, better use of performance appraisal for decision
carried out before the actual data collection. Furthermore, making, creating opportunities for professional develop-
this study was ethically cleared. ment, supplying the necessary materials, and communicating
However, this study was limited in linking motivation smoothly and improving the feedback mechanisms.
to service delivery in order to establish any possible causal
link and this study did not measure performance of health Acknowledgments
workers. Response bias may result from the fact that the The authors are grateful to the study participants and the
respondents were the health workers themselves, in which CEOs of the respective hospitals. The study was financially
case it was possible for the respondents to report higher supported by the Jimma University, College of Public Health
scores, thus biasing the results. Moreover, this study does and Medical Sciences.
not have the nature of in-depth description which could
have been achieved if qualitative methods were employed. Author contributions
Therefore, the findings of this study are applicable to ZW designed the study, participated in data collection, analy-
the study area and to other similar settings with cautious sis, interpretation, and write-up, drafted the manuscript, and
generalization. critically revised the manuscript. YE participated in study
design, analysis and interpretation, and critically revised
Conclusion the manuscript. MW participated in study design, analysis
The standardized mean motivation score of the respondents and interpretation, and critically revised the manuscript.
was greater than the standardized mean of the tool ie, 50%. FW participated in data collection, analysis, interpretation,
Thus, health professionals are just motivated to exert and drafted the manuscript, and critically revised the manuscript.
maintain efforts up to their organizational goal(s). Extrinsic All authors read and approved the final manuscript.
nonfinancial incentives and HRM tools like improving lead-
ership and supportive supervision, better use of performance Disclosure
appraisal for decision making, creating opportunities of The authors report no conflicts of interest in this work.
clearer and professional development, improving staffing
pattern and work schedule, supplying the necessary materi- References
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