The systemic nature of negative provider behaviors in LMICs contributes to poor quality of care which, in turn, likely contributes to low service utilization and poor health outcomes. Additionally, as patients become increasingly dissatisfied with, and distrustful of, the medical community, providers in some countries are experiencing verbal harassment, physical attack, and death threats . As such, failure to identify and address negative provider behavior could have wide-reaching consequences for both patients and health professionals. Finding feasible and sustainable means of redressing negative provider behaviors, therefore, warrants greater attention.
Identifying promising solutions necessitates consideration of the many potential factors that impact provider motivation. Factors that impact work motivation are both internal to the worker—such as self-concept, or expectation of reward or punishment—and external to the worker such as environment or equipment . Below we discuss factors that we hypothesize impact provider motivations in health settings in LMICs, informed by personal observation, first-hand experience, and review of previous studies. We consider the role of both extrinsic and intrinsic motivating factors. We also consider how extrinsic and intrinsic factors differ as points of feasible and sustainable intervention and offer our recommendations for reform.
Extrinsic motivational factors
Extrinsic motivational factors are those factors that are largely outside of the individual clinician’s control, but which effect their work environment or job satisfaction. Most people are impacted at least to a small degree by extrinsic factors but those who are highly driven by external rewards and personal profit may be more susceptible to engaging in harmful practices while employed in suboptimal work environments. Extrinsic factors impact provider behavior and are often embedded in the larger health system of LMICs. Intervening to change or improve the extrinsic factors impacting provider behavior (such as increased supervision, better infrastructure, or higher wages) can be costly and therefore may be challenging or unfeasible in resource-constrained areas .
Examples of extrinsic factors impacting provider behavior:
Infrequent or inadequate supervision with poor accountability. Providers in many LMICs do not have routine and supportive supervision . Remote facilities may also be staffed by a single provider, eliminating the possibility that a colleague may impose accountability. Additionally, public-sector providers are unlikely to be rewarded for good behavior or punished for bad behavior, providing little external motivation to excel within the workplace.
Poor facility infrastructure. Unreliable electricity, lack of running water, and absence of critical supplies, equipment, and commodities all negatively impact the quality of service delivery. Additionally, poor infrastructure can make it difficult to maintain high performance standards when faced with the reality of not having the necessary tools or resources to deliver services.
Inadequate compensation. Providers in many LMICs complain that their wages have been static for long periods of time and have failed to keep pace with the rising cost of living. Many also complain that their wages do not honor or reflect the high degree of skill and effort required for quality services . Additionally, healthcare providers who do not receive scheduled promotions (or who complete additional studies and are not promoted to reflect that effort) are likely to be demoralized. Further, perceptions around the adequacy of wages may be impacted by societal expectations. In many LMICs, there is a societal belief that healthcare providers are wealthy, yet public-sector wages may be modest. To meet this expectation of prosperity, healthcare providers may top up public-sector wages by neglecting their government post to pursue simultaneous wages in the private sector.
Compromised personal safety. Some healthcare providers may have to contend with a lack of proper accommodation, reliable transportation, or threats to their personal safety and security . As a result, providers may feel more entitled to engage in behaviors that result in high personal profit while reducing commitment to serving the needs of the community.
Intrinsic motivational factors
In contrast to the factors described above, intrinsic motivation is grounded in the personal enjoyment and satisfaction of the individual provider rather than for the achievement of financial reward or other extrinsic incentives. Further, high levels of intrinsic motivation are linked to self-efficacy, with the result that healthcare providers will strive for high-quality service delivery even when the external environment is not ideal . We suggest that providers with a strong sense of professional identity are less likely to engage in negative behaviors. We further suggest that changes to the admission process for medical and nursing schools in LMICs, along with some curriculum reform, can result in a workforce that is more intrinsically motivated. Although reform will require cooperation and consensus among ministry of health officials, and institutions of health professionals’ education, once in place, the financial and logistical resources required to impact intrinsic motivation are low relative to the cost of altering extrinsic factors.