Improving the retention of the health workforce in rural and remote areas is of concern for all countries worldwide[1]. Improved retention of health workers contributes to the provision of quality health care because it builds up competencies, optimizes team relations, and strengthens the relationship of health workers with local communities[2]. In contrast, poor retention or high staff turnover negatively affects health care by increasing workload, undermining team morale, creating disruptions and inefficiencies in work processes, and causing a loss of institutional knowledge[3].

Several factors influence the decision of health workers to stay in or leave their posts. Among these are low pay, poor career structures, lack of opportunities for postgraduate training, and inadequate working and living conditions[4–7]. The challenge of retaining health workers is greatest in rural and remote areas, because health practitioners in these areas often face higher workloads, unsustainable work environments, and poor infrastructure, causing them to leave the workplace in search of more satisfactory working and living conditions in urban areas or abroad[8].

This study was carried out within the framework of the health human resource management (HRM) intervention ‘Supporting decentralized management to improve health workforce performance in Ghana, Uganda and Tanzania (PERFORM)’. The intervention aims at identifying ways of strengthening district management in order to address health workforce inadequacies by improving health workforce performance in sub-Saharan Africa. By taking into account national and local human resource (HR) and health system (HS) policies and practices already in place, ‘bundles’ of HR/HS strategies - such as task shifting, training, supervision and monitoring - are developed with respect to specific health workforce problems in the study districts. These strategies must be feasible within the context and affordable within the districts’ budgets to strengthen priority areas of health workforce performance[9].

Typically, an important share of HRM activities takes place at district level. In countries with implemented health sector decentralization policies, district health managers have, as Bossert[10] calls it, a broadened ‘decision space’, which refers to effective decision-making or range of choice within the various functions of finance, service organization, HR, targeting and governance. Although key functions of HRM - such as recruitment, remuneration patterns, and promotion - often remain highly centralized[11], district health managers in decentralized contexts have the potential to improve retention and performance outcomes in their districts. Their powers include exact posting and performance management such as in-service training, supportive supervision, and staff appraisal[12–14]. Generally, it is assumed that these aspects result in lower turnover respectively improved retention at district level.

Work motivation and job satisfaction have been identified as key factors of health worker retention and turnover in low- and middle-income countries (LMICs)[15–21]. Motivation has been described as a set of psychological and transactional processes: psychological, because it gives behaviour purpose and direction; transactional, because it is the result of the interactions between individuals and their work environment[22]. The conceptual framework of health worker motivation proposed by Kanfer[23] and Franco et al.[24] describes these motivational processes as being affected by determinants of motivation (for example, incentives, values, expectations) and mediated into motivational outcomes such as performance and job satisfaction.

As motivation per se cannot be observed directly[25], previous research has concentrated on the determinants and outcomes of motivation[13, 15, 26]. Willis-Shattuck et al.[15] conducted a systematic review on motivation and retention in LMICs and identified monetary and non-monetary incentives as core factors affecting motivation and retention in these countries. This is in line with the World Health Organization (WHO), which recommended a mix or ‘bundle’ of interventions in the areas of education, regulation, financial incentives, and professional and personal support in order to improve retention of health workers in rural and remote areas[1]. Many of these interventions are targeting at improving health worker motivation, job satisfaction and performance.

Job satisfaction is a frequently studied motivational outcome in health systems research. Due to its relation to performance and turnover, it is of concern to researchers and health service managers alike[27–29]. As Lu et al.[26] have pointed out, job satisfaction depends both on the nature of the job and on the expectations health workers have of what their job should provide, and is thus the affective orientation that employees have towards their work. Job satisfaction can be measured globally or in a multi-faceted way, with the former approach being used when the interest is on overall attitude toward the job, and the latter when specific aspects of job dissatisfaction are evaluated[28]. Important facets of job satisfaction having been identified in previous research include salary and benefits, career development, in-service training, work relationships, management, work environment, recognition and supervision[19, 30–32].

So to explore health worker motivation and job satisfaction and their effects on turnover intention, we conducted a cross-sectional survey in three districts of the Eastern Region in Ghana. A better knowledge of factors that impact on workforce performance was needed in order to inform district health managers who are essential at the operational level of health systems and important drivers for performance outcomes in their districts.

Our study in Ghana showed that motivation and job satisfaction were significantly associated with turnover intention and that higher levels of both reduced the risk of health workers having this intention. Health workers in the study districts achieved a good mean score of overall motivation and a moderate mean score of overall job satisfaction. Moderate mean scores were also achieved in most of the motivational outcomes, but health workers rated themselves generally positive in ‘timeliness and attendance’ and ‘conscientiousness’. The good mean scores achieved in these two areas, however, should be taken with caution, as it is possible that they are subject to social desirability bias in a way that respondents were reluctant to denote themselves negative attributes, such as being inefficient or reporting late to work.

With regard to job satisfaction, health workers in the study districts were least satisfied with their remuneration, career development, management and work environment. Dissatisfaction with these determinants was also reported in similar studies conducted in sub-Saharan Africa in recent years[15, 19, 30, 44, 45]. Even though health workers in Ghana belong to the best paid in Western Africa[46], salary levels, including benefits, are still regarded as being too low - a perception, which is also shared by health workers in other parts of Ghana[47, 48].

Concerning dissatisfaction with career development, it was suggested that this has much to do with the current promotion practices in Ghana which seem to favour health workers from the urban centres over those from rural areas[18, 30]. In a qualitative study conducted by Snow et al.[49] in Ghana, health workers also mentioned disadvantages in career development as a major disincentive to accept postings to rural areas. Dissatisfaction with the work environment was mainly related to the availability of medical and technical equipment and the condition of workplaces. Agyepong et al.[30] stressed the lack of essential tools and equipment as being among the major workplace obstacles for health workers in the public health sector. They suggest, however, that this has less to do with the absolute unavailability of resources, but rather with a lack of awareness and with capacity regarding supplies management and maintenance.

Health workers achieved a good mean score with regard to intrinsic job satisfaction, such as believing that the own work is valuable, or that something worthwhile is accomplished in the job. According to Franco et al.[24], these factors belong to the higher-order motivating factors, meaning factors that stimulate worker motivation even in the absence of extrinsic rewards. Intrinsic job satisfaction primarily impacts on motivation, when extrinsic needs, such as good working conditions or a satisfactory salary, have been met, but also when the work is intrinsically rewarding, for instance, when it provides high social recognition or recognition of achievement by supervisors or colleagues. In other words, being intrinsically satisfied with one’s job may also lead to improved motivation even when health workers are not satisfied with extrinsic work-related factors. This offers an explanation as to why overall motivation was rather good even though health workers were dissatisfied with extrinsic factors, especially with regard to their remuneration, career development and work environment.

Although satisfaction with remuneration was low among the surveyed health workers, it had not been identified as a determinant of turnover intention in this study. In Ghana’s public health sector there is no difference in base salaries between urban or rural areas. In addition, implementation of monetary and non-monetary incentives for health workers working in rural and remote areas have been seriously neglected by the government, even though experiments with such schemes, such as deprived area allowances and car incentives, have been conducted[50, 51]. Because remuneration often remains the same also when health workers are transferred to other health facilities, remuneration alone does not seem to provide the necessary condition for health workers in Ghana having turnover intentions. This assumption is supported by Antwi and Philips[52] who found that salary in Ghana is only a determinant of attrition for those health workers who seek employment abroad.

The results in our univariate analysis showed that being a health/ward assistant, aged older than 39 years of age, and working more than 5 years in the current health facility decreased significantly the odds for turnover intention. Health/ward assistants are typically recruited locally and it can be assumed that older health workers are often able in the course of their professional career to get posted close to their spouses, children and/or other family members. Thus, these categories of health workers are often rooted around the workplace through social and family relations and, in consequence, may have a strong rationale to keep their workplace. This was supported by the finding that the odds of having turnover intentions were much higher for health workers who lived separated from their families.

In our multivariate analysis, however, age and the health/ward assistant category were no longer significantly associated with turnover intention. We also did not find statistical evidence for differences in turnover intention among the other surveyed categories of health workers. Although there are a number of studies on turnover intention and turnover that involved different categories of health workers in sub-Saharan Africa[45, 53–55], we have identified only two studies that assessed the association between turnover intention and different cadres in this region through regression analysis, but the authors also did not find evidence for differences in this intention in their multivariate analyses[21, 56]. However, we did find evidence for the association between turnover intention and district as the place of work. The risk of health workers having turnover intentions was greatest in Upper Manya Krobo, which is an underdeveloped rural and remote district. This finding adds to the evidence that health workers are reluctant to work in such areas, especially in countries with insufficient rural incentive schemes, which has led to the current imbalance of health workers in favour of urban centres in many parts of the world[57, 58].

With regard to HRM, the ‘decision space’ of district health managers is limited in Ghana, as key factors for retention, such as salary, access to further education and promotions are under the authority of the national and regional administration. However, district managers do have a role to play: they recommend district staffs for study courses and promotions to their superiors, which both usually lead to higher salaries after completion. Beside recommendations, it is in the authority of district managers to decide on intra-district postings, to conduct supervision and performance appraisals, and to conduct in-service training[59–62]. Evidence compiled by the WHO[1] suggests that these ‘decision spaces’, if performed effectively, positively influence workplace stability through improved motivation and job satisfaction.

Our findings, therefore, suggest that many of the identified motivational outcomes and job satisfaction determinants significantly associated with turnover intention can be influenced by DHMTs. Such factors include job satisfaction, organizational commitment, and satisfaction with management, career development, workload, tasks, and morale. For instance, regular in-service training that focuses on the expressed needs of rural health workers does not only improve staff competence, but it enables health workers to achieve personal goals of career advancement, increases morale and organizational commitment through an improved sense of belonging, and may contribute to reduce workload[1, 11, 14, 29]. Moran et al.[63] also found in a recent review on health worker support strategies that access to in-service training contributes to confidence in practicing in rural and remote areas, strongly alleviates professional isolation, and improves retention. Another example is supportive supervision, which is regarded as a key element of HRM for improving motivation, job satisfaction, performance and retention in rural areas[3, 11, 12].

The position of the District Director of Health Services is ideally held by purpose-trained administrative personnel with qualifications in management and public health. In Ghana, however, many district directors lack these qualifications, as they are often clinicians who did not receive formal management and leadership training[59]. Furthermore, many DHMTs in rural areas are severely understaffed and frequently lack HR officers and other essential managerial staffs, whose tasks are carried out by present team members in addition to their own duties. As a consequence, rural DHMTs in Ghana often lack the skills as well as the capacity to adequately managing their districts, which is reflected in the motivation and job satisfaction outcomes described in our study.

This study has demonstrated the link between motivation, job satisfaction and turnover intention in Ghana. Although the HR ‘decision spaces’ at district level in Ghana are limited, our findings indicate that adequate HRM may have the potential to influence motivation and job satisfaction, which in turn will make health workers more likely to remain at their current position. However, district managers in Ghana have typically undergone clinical training and had only limited exposure to general management and HRM. In consequence, there is a need for specific trainings and capacity building measures in this area so that district managers can adequately cope with the requirements and daily tasks of the position they hold.

So to increase motivation and job satisfaction of health workers, district managers should give emphasis on an enabling environment for example through listening to and acting on staff problems and priorities or fostering team building. They may also engage in assisting the career planning and paths of their subordinates. In-service training that is focused on the expressed needs of health workers should be conducted. A supportive supervision system should also be developed that includes experienced and dedicated health workers as supervisors. As such measures are promising in terms of improving motivation and job satisfaction, it is, therefore, worth strengthening HRM skills at district level and supporting district health managers to implement retention strategies.