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Table 3 Summary of interview and FGD findings

From: ‘We are planning to leave, all of us’—a realist study of mechanisms explaining healthcare employee turnover in rural Ethiopia

 

Factor

Relevance

Detailed workings

Mechanisms

Pull

Learning opportunities

Dominant

-Founding Semera University reduces turnover to other regions because of learning opportunities

P-RE-M

-While most employees come from other regions, local employees/management are favoured for education programmes

Dis-Log

-Employees unlearn; lose skills because of poor facilities

SOP

Career opportunities

 

-Employees perceive big Ethiopian cities as better places for career opportunities

P-RE-M, SOP, Fin

-Non-local employees perceive promotion as unlikely for them in local public organisations

P-RE-M, Dis-Log, Fin

Recruitment

 

-New international companies arriving in region offer better paid positions

Fin

Push

Salary

Dominant

-Employees leave to earn up to four times higher salaries in private sector, or start their own business

Fin

-Low public sector salaries are even less attractive because of payment difficulties

Dis-Log, Fin

-Complementary salary (e.g. moonlighting) can prevent turnover, but opportunities are scarce in the Afar Region

P-RE-M

-Overtime work is perceived as excessively long and poorly paid in the Afar Region (potentially because of understaffing)

Dis-Log, Fin

Facilities

Dominant

-Employees leave because of low health service standards, which they perceive to be better at NGOs and private clinics

SOP

-Employees feel frustrated and get emotionally drained by not being able to provide health services due to lack of equipment & medicine

SOP, Dis-Log

-Employees unlearn/lose skills because of lack of equipment.

SOP

-Exposure to chemicals, unhygienic conditions, for employees, technicians and patients (P-HS)

SOP

Location

Dominant

-Public sector workers seek locations with good moonlighting opportunities to supplement low base salary

P-RE-M, Fin

-Employees and their families dislike the harsh climate and dull social infrastructure

P-RE-M

-Lack of good schools and health services for family

P-RE-M

-Professional and social life is complicated by language difficulties

P-RE-M

-Cultural differences and distances inhibit bonding with patients, colleagues, community

P-RE-M

-Perceived discrimination and unfairness by local management

Dis-Log

Personal health and safety

 

-Aggression by patients because of poor services (resulting from poor facilities)

SOP

-Exposure to chemicals, unhygienic conditions

SOP

-Violence by management

Dis-Log

-Poor access to health services for employees and family

P-RE-M, Fin

Workload

 

-Emotional burden to not being able to provide health service due to poor facilities

SOP

-Cascading effect when others leave as workload increases for the remaining workforce resulting in long, poorly paid overtime

Dis-Log, Fin

-Perceived workload may be higher because of lack of control and autonomy

Dis-Log, SOP

Management support

Dominant

-Demotivation through management’s lack of interest in the well-being of the primary process employee

Dis-Log

-Personal relationships may outweigh professional ability in hiring/promotion

Dis-Log

-Little recognition of professional abilities and autonomy

Dis-Log

-Employees leave because they feel badly treated, sometimes even violently.

Dis-Log

-Good management support drives retention

Dis-Log

  1. Abbreviations of mechanisms (column 5): P-RE-M lack of social and personal opportunities valued by the healthcare employees, Dis-log dissonance between management logic and professional logic, SOP standards of service operations are hard to accept, Fin lack of financial improvement opportunities