Motivation and retention of primary healthcare workers in rural health facilities: An exploratory qualitative study of Chipata and Chadiza Districts, Zambia

ABSTRACT

Rural areas have the greatest health needs and yet they face the largest shortage of human resources for health which negatively impacts health systems capacity to deliver quality care as they struggle to motivate and retain healthcare workers in such settings. This study explored factors that shape motivation and retention of primary healthcare workers in rural health facilities in Chipata and Chadiza Districts of Zambia using a phenomenological research design. The data consisted 28 in-depth interviews with rural primary healthcare workers and were analysed using thematic analysis. Three main themes of factors shaping motivation and retention of rural primary healthcare workers were identified. Firstly, professional development with emergent themes of career advancement and opportunities for attending capacity-building workshops. Secondly, the work environment with emergent themes of challenging and stimulating tasks, availability of opportunities for promotion and co-workers’ recognition and supportive relationships. Thirdly, rural community dynamics with emergent themes of reduced cost of living, community recognition and support, and easy access to farmland for economic and consumption purposes. Interventions that are contextually relavant, which can streamline career progression pathways, enhance rural working environments, offer suitable incentives, and rally community support for rural primary healthcare workers are required.

KEYWORDS:

• human resources
• healthcare workers
• motivation
• retention
• primary healthcare
• Zambia

ABBREVIATIONS:

• EHT
• environmental health technician
• HW
• healthcare worker
• HRH
• human resources for health; IDI
• in-depth interviews; MoH
• Ministry of Health; WHO
• World Health Organization

Background

Healthcare is centrally positioned within the United Nations 2030 sustainable development agenda under sustainable development goal (SDG 3) which seeks to guarantee good health and well-being (Colglazier, 2015). Central to the attainment of this goal is a motivated human resource for health (HRH) workforce that delivers quality healthcare to the world’s population (Freer, 2017). This is aptly acknowledged in the World Health Organization (WHO) Global Strategy on HRH which seeks to support SDG 3c, by increasing financing, recruitment, training, and retention of the health workforce (World Health Organization, 2016).

The global demand for HRH will rise to 80 million by 2030, while the supply is expected to reach 65 million, resulting in a worldwide net shortage of 15 million healthcare workers (Liu et al., 2017). Low-income countries will face low growth in HRH supply, which is estimated to be far below what is needed to achieve equitable coverage of essential health services (Liu et al., 2017).

Rural areas have the most pressing health needs and yet face the largest shortage of HRH (World Health Organization, 2016). Numerous challenges, some of which include difficult terrain, poor working conditions, emotional and financial costs of separation from families, and long working hours make rural areas unattractive to work in (Cosgrave et al., 2019; Jaeger et al., 2018). Several other factors such as training opportunities, financial incentives, living conditions, social and work support systems account for the motivation and retention of HRH in rural areas (Belaid et al., 2017; Goel et al., 2016; Liu et al., 2019; Nagai et al., 2017; Prust et al., 2019; Sirili et al., 2021; Wurie et al., 2016).

Zambia, like many other African countries, is experiencing a HRH crisis, with 11.2 doctors, nurses, and midwives per 10,000 persons, which is below the WHO minimum recommended threshold of 22.8 doctors, nurses, and midwives per 10,000 persons(Ministry of Health, 2017). Data from the Ministry of Health (MoH) shows that the estimated shortage of doctors, nurses, and midwives is about 14,960 (Ministry of Health, 2017). However, with Zambia’s projected population growth, the deficit will be about 46,000 healthcare workers by 2035, with the most acute shortages occurring in rural areas (Kamwanga et al., 2013).

In 2003, the Zambian government introduced a HRH worker retention scheme whose aim was to address staff shortages through the recruitment and retention of healthcare workers in rural areas (Gow et al., 2013). The scheme provided several financial and non-financial incentives such as career development and housing. However, the scheme was withdrawn because it was unsustainable and unable to recruit nor retain sufficient HRH (Gow et al., 2013). In 2017, both the 7th National Development Plan and the National Health Strategic Plan underscored HRH development and deployment as critical for the attainment of the SDGs (Ministry of Health, 2017–2021; Ministry of National Development Planning, 2017–2021).

While numerous studies have documented the motivation and retention of rural healthcare workers in other countries (Jaeger et al., 2018; Jegede et al., 2013; Nagai et al., 2017; Ojakaa et al., 2014; Wurie et al., 2016), there has been little done in Zambia. We identified three studies about health workers’ motivation and retention in Zambia. Firstly, Prust et al., conducted a discrete choice experiment on healthcare workers and health students, and found; housing, education, and facility improvements to be important motivators of health worker retention in rural areas (Prust et al., 2019). Secondly, Mutale et al. quantitatively assessed healthcare worker motivation in three rural areas and found variation in the motivation score by sex, type of health worker, training, and time in post (Mutale et al., 2013). Lastly, Shen et al. examined the effect of performance-based financing (PBF) on healthcare workers’ job satisfaction, motivation, and attrition and found that PBF had a significant increase on job satisfaction and a decrease in attrition, but had no effect on motivation (Shen et al., 2017). However, these studies do not fully explore the contextual factors that influence the motivation and retention of primary healthcare workers in rural facilities.

This study explored factors that shape motivation and retention of primary healthcare workers in rural health facilities in Chipata and Chadiza Districts, Zambia.

Methods

Study design

A phenomenological qualitative research design was used to understand the factors that shape motivation and retention of primary healthcare workers in rural health facilities. This study design is best suited to explore and describe the lived and working experiences of primary healthcare workers in such settings (Groenewald, 2004). Furthermore, this study design is suited for exploring and understanding social processes such as HRH management.

Study setting

The study was conducted in two rural health facilities of Chadiza and Chipata Districts, Eastern Province, Zambia. Chadiza District has 14 health facilities – including four health posts, six rural health centers, two zonal community health centers, one urban community health center, and one level-1 (district) hospital – that serve a population of about 92,300. In contrast, Chipata District has 42 health facilities – including seven health posts, 30 rural health centers, four urban health centers, and one level-2 (provincial) hospital – that serve an estimated population of 486,500. The two districts were chosen owing to several reasons. For instance, Chipata District continues to face a myriad of socio-economic challenges including unemployment, poor road network and limited water and sanitation facilities. Chadiza District is one of the poorest in Eastern Province (Zambia Statistics Agency, 2018). In addition, most of the health facilities in Chadiza District are not connected to electricity. Both districts share a lot of similarities such as poor access to clean water; limited inpatient capacity of the facilities, high poverty levels and lack of critical supplies and infrastructure like rural feeder roads among others.

Study population, sampling, and recruitment of participants

The study sample was drawn from a population of diverse rural primary healthcare workers. These included the health facility in-charges, nurses, clinical officers, public health officers, lab technicians, nursing officers, and environmental health technicians. The study targeted healthcare workers who had been posted by the government and worked at a rural primary health facility for at least 2 years and were on the government payroll.

Purposive sampling was used to recruit the study participants. A purposive sample is a non-probability sample that is selected because it possesses characteristics that answer the study question. A total of 18 rural primary health facilities (Table 1) from the two study districts were sampled based on the guidance of the district health office. The facilities were considered rural if they were at least 15 km from district health office and served a population less than 2500 with the households’ economic activity predominantly subsistence agriculture farming. The district health office introduced the research team to the in-charges of the sampled health facilities who helped the research team recruit healthcare workers fitting the research criteria. The invitation to participate in the study was made face-to-face, and by phone, for those who were unavailable at the time of recruitment. There were no dropouts and no refusals in this study. The number of primary healthcare workers across the selected rural health facilities was guided by the principle of theoretical saturation (Rowlands et al., 2016) – no further interviews were conducted once we could not gather any new additional information (Table 2).

Table 1. Distribution of health facility types.

Type of facility	District
	Chipata	Chadiza
Rural Health Centers	5	6
Rural Health Posts	4	3
Total rural facilities	9	9

Data collection

Data were collected using face-to-face in-depth interviews (IDIs) that were guided by conversational interview questions developed for this study. A total of 28 IDIs were conducted (Table 2). The questions were open-ended to prompt the participants to give detailed experiences, and as complete a description as possible of their challenges, and perceived opportunities of working in rural health facilities. The IDIs lasted between 30 and 45 min and were conducted in English by (KM), and (AS), as the note-taker. To ensure that the health workers were free to express themselves, we conducted the interviews away from their designated office space in a separate room at the health facilities. An audio recorder was used to capture the data gathered during the interviews. Additionally, a participant observation tool, administered by (AS), was employed to document the expressions of the participants during the interviews. This combination of methods provided a better understanding of the study context.

Table 2. Categories of healthcare workers.

Categories of healthcare workers	Number of participants
Managerial health workers
District Medical Health Office	2
Nursing officer	3
Registered nurse	3
Public health officer	2
Total	10
Frontline health workers
General nurses	2
Enrolled nurses	4
Midwives	3
Psychiatric nurse	1
Biomedical technician	2
Environmental health technician	4
Total	18
Total participants	28

Data analysis

Manual thematic analysis approach was used to analyse the data (Braun & Clarke, 2012). Data included verbatim transcripts, interview notes, and observation reports. The transcription was done by (KM) and (AS) then cross-checked by (MMK) and (PH) to ensure accurate capturing of participant views. The analysis started by familiarisation with the data through reading of the transcripts and noting initial ideas. The entire research team undertook a preliminary reading of transcripts and developed a coding framework using the main and emergent themes (Table 3). The first (KM) and the second (AS) authors undertook extensive coding of all the transcripts. The coded data were shared with the other authors (MMK and PH) for their independent review and then discussed with all research team to resolve of any coding discrepancies. This was an iterative, interactive, analytical process involving recategorisation and combining of codes into themes (Milford et al., 2017). Specific themes that were unique to one or a few participants that had experiences that varied from others were attributed to the stated groups. The data analysis followed an inductive thematic analysis approach.

Table 3. Factors affecting motivation and retention of rural primary health workers.

Main themes	Sub-themes − 1	Sub-themes – 2
Professional development	Career advancement	Flexible professional advancement program Easy to upgrade qualifications Prioritized for human resource development opportunities
	Opportunities for attending workshops	Short -term trainings through workshops and seminars Certificate for acquiring new skills Networking and creating partnerships Financial allowances provided for attendance
Work environment	Stimulating tasks	Passion for service to rural communities Learning to handle complex health conditions Exploring innovative ways of providing health services to rural communities Providing services in limited resource areas with vast healthcare needs
	Promotion opportunities	Easily ascend to leadership positions Enhanced delegation, and general management skills
	Co-workers’ recognition and supportive relationships	Recognition of efforts by the district health office and facility leadership Strong/dependable co-worker relationships within and outside the facilities
Rural community dynamics	Reduced cost of living	Low cost of living in rural areas allows for saving Cheaper to borrow among fellow co-workers than from an institution
	Community recognition and support	Recognition and respect from rural communities Primary health workers are held in high esteem Power to preside over health and community issues
	Easy access to farmland for economic and consumption purposes	Opportunity to own larger portions of land Owning a farm helps to grow food for sale and consumption

Ethical consideration

The University of Zambia's Biomedical Research Ethics Committee (REF. No. 303-2019) and the Zambia National Health Research Authority provided ethical approval for this study. During data collection, participants were provided with sufficient information about the study to make informed decisions on whether or not to participate. Both written and verbal informed consent were provided by the participants. They were neither dropouts nor refusals in this study. All the participants were identified by numbers as opposed to using their actual names during both data collection and analysis for confidentiality. The researchers asked the participants for permission to record the interviews and assured them that the recordings were for research purposes. The data collected were treated with outmost privacy and securely stored on a password-protected computer.

Results

Three main themes related to motivation and retention of rural primary healthcare workers were identified from the data (Table 3). Firstly, professional development with sub-themes of career advancement and opportunities for attending workshops. Secondly, the work environment with sub-themes of stimulating tasks, opportunities for promotion and co-workers’ recognition and supportive relationships. Lastly, rural community dynamics with sub-themes of reduced cost of living, community recognition and support as well as access to farmland for economic and consumption purposes. The results are presented according to the healthcare workers’ categories.

Professional development

Career advancement

The environmental health technicians (EHT), general nurses and midwives said that professional advancement was important in motivating rural primary healthcare workers. They narrated that working from rural areas allowed them to upgrade their qualifications much earlier than their counterparts in urban areas because they were prioritised by the Ministry of Health policy on human resource for health development. Further, career advancement was motivating because it not only accorded rural primary healthcare workers an opportunity to improve professionally, but also, provide the much-needed health services to rural communities. A sister in-charge who upgraded to midwifery while working in a rural area described her delight at being able to contribute to addressing maternal problems in her district.

Working in a maternity ward, a lot of mothers have been served through efforts and skills that have been imparted in me through training that I got when I went back to school. At some point, I had a mother who started bleeding, and through skills, I got when I upgraded my knowledge, I was able to note the problem and notify the district. (Managerial health worker 33, Midwife, Chadiza)

When I was not a midwife, and I lost a baby. This made me upgrade my career by doing midwifery because I lacked a skill. I appreciate I was allowed to upgrade my skills. (Managerial health worker 33, Midwife, Chadiza)

Opportunities for attending capacity-building workshops

Both the EHTs and midwives acknowledged that the opportunity to attend capacity-building workshops motivated them to work in rural areas. This is contrary to what obtains in urban areas, where such capacity-building opportunities are only accorded to a selected few. They stated that non-governmental organisations implementing interventions in rural areas usually provide short-term capacity-building workshops and seminars. These workshops not only provided new information but also financial and non-financial incentives such as allowances, certificates of attendance, as well as opportunities to network and create partnerships. However, it was noted that the workshops were not as frequent as they used to be in the past because of reduced donor funding to Zambia during to the COVID-19 pandemic.

There are a lot of opportunities and I have attended certain training like new-born care and how to manage logistics for the health facility. Being at a rural health facility gives me the opportunity to attend capacity building meetings where they teach us lot of things. It’s much easier in a rural area to attend training workshops than urban areas because they have more staff there. (Frontline health worker 28, Midwife, Chadiza)

Work environment

Stimulating and challenging tasks

The EHTs, nurses and midwives stated that they were motivated by the love and challenging task of serving people in rural primary health facilities. Some of their duties were performed in very difficult circumstances characterised by limited resources with vast healthcare needs. However, stimulating tasks such as handling complex health conditions were motivating as they encouraged primary healthcare workers to explore innovative ways of providing health services to rural communities. For example, the midwives stated that successful management and delivery of women with pregnancy complications gave them joy and therefore motivated them to work harder. A public health nurse and sister in-charge described their views regarding stimulating and challenging tasks as follows.

The passion I have for the job, challenging tasks and patients is what keeps me going. There is that bond that we have created for more than 30 years with these mental patients, and they don’t have relatives here. Some of them have been abandoned and so I am their first relative. (Frontline health worker 14, Public Health Nurse, Chadiza)

I love my work, especially in the nursing part. The experience of working in rural has made me come across conditions that we never learned in school and maybe here we have different people of different backgrounds. (Managerial health worker 6, Sister in-charge, Chipata)

Promotion opportunities

All the primary healthcare workers across the two study districts stated that it was motivating to be in rural areas as they were accorded an opportunity to occupy leadership positions compared to their counterparts in urban areas. They indicated that working in a rural area provided a quicker platform to ascend to leadership positions at the facility level regardless of ones’ qualifications. For most rural primary healthcare nurses, it was revealed that they aspired to reach the level of a facility in-charge and that being in leadership positions enhanced their experience, delegation, and general management skills. One EHT said:

Most of us in rural facilities are in leadership positions which helps me to grow as a person, be responsible, learn how to delegate and make decisions. I am the only trained health worker running this health facility and no one pushes me because I am responsible for everything that happens here. (Frontline health worker 45, EHT, Chipata)

In Chadiza District, one public health officer said:

Whatever happens here I have got an upper hand before my supervisors at the district. I am a leader to these supporting staff, and I feel personal growth in terms of responsibility as far as work is concerned. (Managerial health worker, 38, Public Health, Chadiza)

Co-worker recognition and supportive relationships

All the study participants stated that recognition by management and fellow workers played a key role in the motivation and retention of rural primary health workers. They noted that recognition in the form of awards by the district health team and primary health facility leaders kept them going despite the challenges. It was revealed that recognition improves the social working aspects of rural primary healthcare workers which subsequently benefits the local health systems. However, some primary healthcare workers complained that they seldom received any recognition from the district health office despite submitting their appraisal forms. They underscored that it was important for rural primary healthcare workers to be often recognised to make them feel appreciated by management. One nurse from a rural primary health facility in Chadiza narrated how she felt after being recognised by the district.

I was once recognized by the district because of the hard work, and that was motivating. I remember vividly how I felt that day and I can imagine if health workers are recognized more often, it would give other health workers the impetus to work hard. (Frontline health worker 27, Registered Nurse, Chadiza)

Most nurses in the two study districts stated that good and supportive relationships with one another at the workplace were a source of motivation. Some of the rural primary healthcare workers had managed to forge dependable relationships with follow co-workers to leverage socioeconomic challenges that may otherwise be difficult to address individually. All the rural primary healthcare workers reported that they conducted social activities such as cooking or taking trips together to strengthen their relationships. One of the in-charges at a facility in Chipata acknowledged the value of relationships in creating a good and dependable working environment.

The working relationship among us is very good. There are times when you are home and you have forgotten maybe to check the temperature of a particular patient, we can call someone on duty, and they are able to do it with one heart. This is motivating because we rely on each other in making sure the clients receive the best care at facility level. (Managerial health worker,40, Chipata)

Rural community dynamics

Reduced cost of living

Both the enrolled nurses and midwives agreed that the cost of living in rural areas was low. They described the low cost of living in terms of cheap food and housing when compared to their urban areas. The low cost of living allowed them to save more financial resources compared to the urban counterparts. Further, it enabled them to afford items that they would not be able to acquire in urban areas because their meager income would be consumed by the high cost of living. Additionally, the enrolled nurses and midwives stated that it was easier to borrow money amongst themselves compared to an institution in an urban area where they charged high-interest rates. An enrolled nurse from Chadiza had this to say about the low cost of housing in her area.

When I first came, I thought it was a bad place but now I realized it is a good place and you can save a lot. Here you are provided with accommodation in most cases and if you were to rent a house it is not as expensive as you may think. I have learned a lot of things through interaction with different people of different backgrounds. (Frontline health worker28, Enrolled nurse, Chadiza)

Community recognition and social support

All the primary healthcare workers indicated that the recognition and respect they received from the surrounding communities motivated them to work in rural areas. They noted that there was a sense in which rural communities held primary health workers in high esteem to the extent that they were elected as cooperative leaders in society. This gave them the power to not only preside over health issues, but also, key community decisions. Some community members would name their children after a primary healthcare worker to show appreciation and recognition for their services. Further, the primary healthcare workers indicated that it was better to be in an area where they were recognised and valued than where they were unnoticed like in urban areas. One EHT described this perspective as follows.

I feel recognized and appreciated in this community. They give you certain respect that you cannot have in Lusaka for instance. In Lusaka even if you are a medical doctor, so what? because there are a lot of medical doctors there. (Frontline health worker 25, EHT, Chadiza)

Community participation and support in the provision of health services was said to motivate and contribute to retention of rural primary healthcare workers. For example, the sister in-charges at several primary health facilities revealed how some structures were built using community contributions. They also stated that community members and their respective leaders always supported the programs of the primary health facilities. This kind of support reinvigorated primary healthcare worker’s resolve to provide health services to rural health communities despite the challenges. A sister in-charge at one of the rural primary health facilities had this to say.

The surrounding of this facility is clean. You have seen some bricks outside. It is the community that is doing that. They have built a shelter outside for patients to rest in. I can safely say that the community here is supportive towards their health facility. (Managerial health worker, Sister In-charge 23, Chadiza)

Easy access to farmland for economic and consumption purposes

Most of the rural primary healthcare workers narrated that the opportunity to own farmland motivated them to work in rural health settings. They remarked how easy and cheap it was to acquire farmland in rural areas compared to urban areas. Owning a farm allowed rural primary healthcare workers to grow crops for income-generating purposes and household consumption. Further, farming was said to not only guarantee household nutrition, but also, cushion the primary healthcare workers monthly expenses as one EHT narrated.

This place is good for business and agriculture if you are business oriented. It is a place where people from town come and buy Maize. Most people here cultivate but I prefer buying and selling. Through that I add something on top of the salary. This place is rural, and people here are farmers and even me, I have bought in the idea as well. (Frontline health worker 39, EHT, Chipata)

Another primary healthcare worker indicated that indicated how being in a rural area allowed them to farm and avoid the high prices of food prevailing in the urban towns.

The soil is a great connector of lives, the source, and destination of all. It is the healer and restorer and resurrector by which disease passes into health, ages into youth, and death into life. Here if we have food, shelter other problems that come with life can be avoided. This is rural and I don’t buy meal-meal [corn floor used to prepare staple food] because I farm. I have gone back to the soil just like Dr Kenneth Kaunda advocated for a way back. (frontline health worker 8, Nurse, Chadiza)

Discussion

This study explored factors that shape motivation and retention of rural primary healthcare workers in Chipata and Chadiza Districts in the Eastern Province of Zambia. The data shows that several organisational and community-level factors account for motivation and retention of primary healthcare workers including professional development, the work environment, and the rural community dynamics which interact in various ways.

Professional development

Opportunity to upgrade qualifications with ease motivated and retained rural primary healthcare workers. This was facilitated by the MoH strategic HRH policy 2018–2024 which seeks to promote capacity in rural settings by giving rural health workers priority to advance their studies (Ministry of Health, n.d.). Similar findings have been reported in other settings where motivation and retention of primary rural healthcare workers was shaped by a range of factors including professional development, and career advancement opportunities, which intersect in unique ways (Cosgrave et al., 2018; Jaeger et al., 2018). Further, we found that attending capacity-building workshops sponsored by international donor partners provided an opportunity to network, create partnerships, and collect financial allowances which motivated and retained rural primary healthcare workers. However, the effect of financial allowances on motivation of rural primary health workers has been disputed in a study on performance-based financing in Zambia which found a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation (Shen et al., 2017). In addition, while they are career progression opportunities created by international donor partners for healthcare providers to work on their projects in rural areas, and receive better pay, this does not support retention of healthcare providers in rural primary facilities because some healthcare providers tend to switch to better paying partner funded jobs which negatively affects continuity of services at government primary health facilities.

Work environment

Co-worker recognition and supportive relationships were important factors in motivating and retaining rural primary healthcare workers. This is because they have been shown to mitigate stressful tasks leading to a more positive work environment (Liu et al., 2019). Good co-worker relationships and recognition enable task-sharing and team building which motivates healthcare staff and increases their job satisfaction (Liu et al., 2019). A similar study of public health workers found that relationships with their colleagues and the level of achievement were key motivators of their retention (Kitsios & Kamariotou, 2021). In addition, positive co-worker relationships and recognition contribute to building a social environment among rural primary healthcare workers that transcends the health facility settings. These relationships also engender trust within the communities (Okello & Gilson, 2015). Further, co-worker relationships and recognition of efforts by management give rise to prospects of promotion which motivates rural primary healthcare workers. Although rural primary healthcare facilities have few qualified personnel, who usually occupy leadership positions, recognition of efforts is important to keep staff motivated(Weldegebriel et al., 2016).

Challenging and stimulating job requirements are motivating to rural primary healthcare providers. Resource-limited settings challenge the primary healthcare workers to do their best to address complex patient conditions. Rural areas expose primary health providers to a wide range of complex health situations to the point that even though they are challenging, the fulfillment that comes with overcoming them is exciting. Our findings may signify that some primary healthcare workers in rural areas accept their postings to take an active role in patient care, gain experience, hone their clinical skills, and ultimately gain professional independence. Similar findings have been reported in a study that explored enablers of, and barriers to transition to rural practice by allied health professionals across South Australia (Kumar et al., 2020). In Zambia, various studies on community health workers have shown that intrinsic benefits such as providing healthcare to vulnerable populations are a major motivation among this cadre of primary healthcare workers (Topp et al., 2015; Zulu et al., 2014; Zulu et al., 2015). However, adverse working conditions, the impact of rural postings on private life and poor working conditions are a major challenge in rural areas (Jaeger et al., 2018).

Rural community dynamics

Reduced cost of living, social recognition from community members, access to land, and community support to the health facilities influence primary healthcare provider retention in rural settings. Similar findings have been reported in a study from Papua New Guinea that identified the importance of strong supportive communities on health worker motivation (Razee et al., 2012). Two studies from Tanzania also highlight that the motivation of community health workers is often derived from the support by their families and communities (Greenspan et al., 2013; Sirili et al., 2021). Furthermore, when primary healthcare workers are supported by the community, they feel part of the community to the point that they are motivated and subsequently retained to continue working in rural areas. The respect and recognition by society can be seen through gestures of community appreciation (Cosgrave et al., 2019; Sirili et al., 2021). For example, the naming of children after healthcare workers. Such gestures not only imply acceptance by the rural communities but also, a show of trust in the primary healthcare systems (Okello & Gilson, 2015). In addition, we found that it’s easy for rural primary healthcare providers to engage in income-generating activities such as farming because of accessible land which affords them cheaper lifestyles compared to their urban counterparts. However, one study highlights that negative community dynamics can be a major challenge of working in rural areas (Jaeger et al., 2018). Another study highlights community dynamics that help to retain and motivate staff including providing social, financial, accommodation support to healthcare workers (Abimbola et al., 2015). Additionally, communities also take the initiative to co-finance and co-manage primary healthcare services in order to ensure that primary healthcare facilities are functional.

Study strengths and limitations

The study had several strengths and limitations. Data were gathered from a varied group of rural primary healthcare workers which facilitated the triangulation of perspectives. The iterative nature of the data analysis process increased the reliability of our findings on key thematic areas. The phenomenological study design allowed for detailed contextual exploration of rural primary healthcare workers experiences. Another strength was that the research team comprised a mix of qualitative (KM, AS and MMK) and quantitative researchers (PH and AS) with experience of having conducted similar work.

Although generalisability was not the intention, conducting our study in two districts, with a small sample of respondents limits the transferability of the findings to similar settings. The purposive selection of study participants may have inherent biases that could affect the study results. For example, the in-charges may have only selected participants that were highly motivated to work in rural areas. The motivations of primary healthcare workers who leave and what might have convinced them to stay in rural areas weren’t explored but would be important to understand the overall topic. Further, it is possible that the study participants gave us reasons that they might believe but aren’t really driving their choice because they may not yet have had the opportunity to move to an urban area.

Despite these limitations, our findings contribute valuable knowledge to the study of human resource for health management in rural primary health facilities.

Conclusion

This study identified several factors shaping motivation and retention of rural primary healthcare workers clustered around opportunities for professional development, the nature of the work environment, and rural community dynamics. These factors interact in various ways with the potential to shape both long-and short-term policy options to enhance retention and motivation of primary healthcare workers. Interventions that are contexually relevant, which can streamline career progression pathways, enhance rural working environments, offer suitable incentives, and rally community support for rural primary healthcare workers are required. Although this study identified some factors affecting motivation and retention of HRH in rural Zambia, they are many more other factors that may act differently in similar settings. Future research may seek to qualitatively explore such issues as gender and age and how they shape motivation and retention of HRH in rural primary health facilities.

Ethics approval and consent to participate

The University of Zambia's Biomedical Research Ethics Committee (REF. No. 303-2019) and the Zambia National Health Research Authority provided ethical approval for this study. During data collection, participants were provided with sufficient information about the study for them to make informed decisions on whether to participate or not. Both written and verbal informed consent were provided by the participants. All the participants were identified by numbers as opposed to using their actual names during both data collection and analysis confidentiality. The researcher asked the participants for approval to record the interviews and assured them that the recordings were for the research purposes. The data collected were treated with outmost privacy and securely stored on a password-protected computer.

Acknowledgments

The authors are grateful for the support provided by the Department of Health Policy and Management, School of Public Health, University of Zambia. The authors also wish to thank Dr Simon Manda, Tulani Matenga, Margarate Nzala Munakampe for the contribution made to this study. The authors are indebted to the leadership at the district health office in Chipata and Chadiza for authorising the study, health facility, as well as rural health workers for participating in the study. K. M., M. M. K., A. M., and P. H. contributed to the study design. K. M. and A. S. conducted the data collection. K. M. and A. M. analysed the data. K. M. drafted the manuscript. A. M., M. M. K., and P. H. contributed to the revision and refining of the manuscript. P. H. gave approval for the final version of the manuscript. All authors read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The datasets during and/or analysed during the current study are available from the corresponding author on reasonable request.