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Which mechanisms explain the motivation of primary health workers? Insights from the realist evaluation of a maternal and child health programme in Nigeria
  1. Bassey Ebenso1,
  2. Chinyere Mbachu2,
  3. Enyi Etiaba2,
  4. Reinhard Huss3,
  5. Ana Manzano4,
  6. Obinna Onwujekwe2,
  7. Benjamin Uzochukwu2,
  8. Nkoli Ezumah5,
  9. Timothy Ensor1,
  10. Joseph Paul Hicks1,
  11. Tolib Mirzoev1
  1. 1Nuffield Centre for International Health and Development, University of Leeds School of Medicine, Leeds, UK
  2. 2Health Policy Research Group, University of Nigeria Faculty of Medical Sciences, Nsukka, Enugu, Nigeria
  3. 3Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
  4. 4Sociology & Social Policy, University of Leeds School of Sociology and Social Policy, Leeds, UK
  5. 5Faculty of Social Sciences, University of Nigeria, Nsukka, Enugu, Nigeria
  1. Correspondence to Dr Bassey Ebenso; b.e.ebenso{at}


Introduction Well-trained, adequately skilled and motivated primary healthcare (PHC) workers are essential for attaining universal health coverage (UHC). While there is abundant literature on the drivers of workforce motivation, published knowledge on the mechanisms of motivation within different contexts is limited, particularly in resource-limited countries. This paper contributes to health workforce literature by reporting on how motivation works among PHC workers in a maternal and child health (MCH) programme in Nigeria.

Methods We adopted a realist evaluation design combining document review with 56 in-depth interviews of PHC workers, facility managers and policy-makers to assess the impact of the MCH programme in Anambra State, Nigeria. A realist process of theory development, testing and consolidation was used to understand how and under what circumstances the MCH programme impacted on workers’ motivation and which mechanisms explain how motivation works. We drew on Herzberg’s two-factor and Adam’s equity theories to unpack how context shapes worker motivation.

Results A complex and dynamic interaction between the MCH programme and organisational and wider contexts triggered five mechanisms which explain PHC worker motivation: (1) feeling supported, (2) feeling comfortable with work environment, (3) feeling valued, (4) morale and confidence to perform tasks and (5) companionship. Some mechanisms were mutually reinforcing while others operated in parallel. Other conditions that enabled worker motivation were organisational values of fairness, recognition of workers’ contributions and culture of task-sharing and teamwork.

Conclusions Policy designs and management strategies for improving workforce performance, particularly in resource-constrained settings should create working environments that foster feelings of being valued and supported while enabling workers to apply their knowledge and skills to improve healthcare delivery and promote UHC. Future research can test the explanatory framework generated by this study and explore differences in motivational mechanisms among different cadres of PHC workers to inform cadre-related motivational interventions.

  • qualitative study
  • health systems evaluation
  • health policy
  • maternal health
  • child health

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  • Handling editor Seye Abimbola

  • Twitter @B_Ebenso

  • Contributors TM, BU, OO, AM and RH have jointly conceived the study. EE, CM, NE conducted data collection with support and guidance from BE, TM, RH, AM and TE. BE led the writing of this paper with contributions from CM, TM, EE, AM, BU, AM, OO, RH, NE, JPH, TE. All authors read and approved the final version of the manuscript.

  • Funding This work was supported by the Joint MRC/ESRC/DFID/Wellcome Trust health systems research initiative (grant ref: MR/M01472X/1). The views summarised in this manuscript are of the authors only and do not necessarily represent those of the funders.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval for the wider study were obtained from the School of Medicine Research Ethics Committee at the Faculty of Medicine and Health at the University of Leeds (ref: SoMREC/14/097) and the Health Research Ethics Committee at the University of Nigeria Teaching Hospital (ref: NHREC/05/02/2008B-FWA00002458-1RB00002323).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. The datasets generated and/or analyzed during the current study are available in the University of Leeds Research Data repository: