“We wouldn't leave if our jobs changed a little”: Understanding the labour market choices of community health workers in Ethiopia

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Abstract Background The motivation and retention of community health workers is a challenge and inadequately addressed in research and policy. In Ethiopia, as part of the country’s Health Extension Program, Health Extension Workers (HEWs) deliver essential primary healthcare services to communities, but low retention of experienced HEWs threatens sustained service delivery and efficient use of their health budget. We sought to identify factors influencing HEW retention and ways to mitigate their exit. Methods Following a review of literature on work motivation and community health worker (CHW) retention to identify a conceptual and theoretical framework to guide analysis, exploratory qualitative work was conducted using in-depth interviews with leavers of HEW positions (n=20), active HEWs (n=16), and key informants (n=11) in two regions in Ethiopia. Interviews were audio recorded, and simultaneously translated into English and transcribed for analysis. Data were analysed in NVivo 12 using an iterative inductive-deductive approach. Results The conceptual framework by Ormel et al, 2019, was adapted to analyse our results thematically. We identified a number of extrinsic and intrinsic motivational factors affecting the retention and labour market choices of HEWs. While financial incentives in the form of salaries, and material incentives in the form of improvements in health facility infrastructure and provision of childcare were reported to be important, non-material factors like HEWs’ self-image, acceptance and validation by the community were found to be critical. A reduction or loss of these non-material factors proved to be the catalysts for many HEWs to leave their jobs. We also found a strong professional self-identity among HEWs, which influenced their willingness to remain in their jobs. Conclusion This is the first study to include job leavers in an analysis of factors affecting motivation of CHWs, aimed to improve retention. In addition to material incentives, our findings suggest that these workers are also socially motivated and identify strongly with their profession. Policy interventions, which also appeal to their social needs, could represent a simpler and more cost-effective means of improving retention of this workforce, especially in resource-constrained settings. Keywords Community health workers, labour market choices, motivation, Ethiopia, pro-social preferences, retention

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