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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