International Choice Modelling Conference, International Choice Modelling Conference 2017

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What makes you happy? The role of intrinsic motivation on health workers’ decisions to stay in rural areas
Ayako Honda, Nicolas Krucien, Mandy Ryan

Last modified: 28 March 2017



One of the biggest challenges for policy makers in the health sector in both developed and developing countries is attracting health workers to rural areas. Globally, approximately one-half of the population lives in rural areas, but these areas are served by only 38 percent of the total nursing workforce and by less 25 percent of the total physician workforce. This lack of qualified health workers in rural areas is a significant barrier to service delivery, impeding access to health care services for a significant proportion of the population. In low- and middle-income countries (LMICs) such shortages slow progress toward reaching the Sustainable Development Goals (SDGs) and challenge the aspirations of achieving health for all. Recent literature suggests that the intrinsic motivation of health professionals plays an important role in their decisions to work in rural areas of LMICs.


The study aims to investigate the effects of intrinsic motivational factors on health professionals’ choice of job positions. More specifically, it examines health professionals’ preferences for work conditions in the ‘difficult’ regions of Senegal, linking choices to ‘enjoyment’ and positive ‘self-norms’ (e.g., altruism, professionalism) and how these factors influence health professionals’ choice to stay in remote job posts.


A discrete choice experiment (DCE) was used to assess the preferences of paramedics (nurses and midwifes) for working in “difficult” areas of Senegal. While DCEs have been applied to address issues associated with the recruitment and retention of health workers in LMICs, to our knowledge, this is the first study to explore the role of intrinsic motivations in professional decisions.

247 respondents were recruited via quota sampling and the DCE questionnaire was administered face-to-face by trained interviewers. Each respondent answered 16 pairwise tasks: Which job do you prefer (job A vs. job B). Attributes for the job options included: (1) period of rural job assignment; (2) provision of a rural job allowance; (3) availability of basic equipment in health facilities; (4) provision of accommodation; (5) provision of further training opportunities; (6) type of contract; and (7) provision of professional and managerial support. In addition to the choice tasks, the questionnaire included 13 attitudinal questions (4-points rating scale) to capture the motivation of paramedics when they selected a job post. Exploratory factorial analysis was used to divide eight questions into two types of intrinsic motivation, namely “enjoyment” and “self-norms”. Using a hybrid choice multinomial logit model, we modelled the impact of these qualitative constructs related to intrinsic motivation on preferences for job-related features. Analysis was conducted at the aggregate level, then for nurses and midwifes separately.


Sample level results were in line with a priori assumptions. In general, paramedics (nurses and midwives) preferred a shorter stay in rural areas; they valued rural allowances, availability of adequate equipment, provision of accommodation, opportunities for training, and managerial support.

Intrinsic motivation was a predictor of preferences. Those with stronger intrinsic motivation, both in terms of enjoyment and positive self-norms, were less concerned about the period of assignment to jobs in ‘difficult’ regions. In particular, those who enjoy rural life are willing to stay longer in posts in difficult regions. The result indicates that intrinsic motivation positively influences health professionals’ decisions to stay in remote job posts.

However, ‘self-norms’ and ‘enjoyment’ affect preferences differently. Those with more positive ‘self-norms,’ as expressed through altruism and professionalism, place less value on the provision of material incentives and a lower value on the provision of a rural allowance and accommodation. Those who ‘enjoy’ their assignment to a remote area more strongly value factors that make it easier for them to work at the post, including the availability of basic equipment in health facilities and the provision of opportunities to improve skills through training.

Health workers who showed a high level of intrinsic motivation in terms of both positive ‘self norms’ and ‘enjoyment’ placed a higher value on the provision of a permanent contract than their counterparts with lower intrinsic motivation, which may indicate that security in employment is important for health professionals working in remote areas.


This study provides important insights that can feed into rural job retention policies in LMICs. Currently, many LMICs focus on providing economic incentives to improve the retention of rural health professionals. Less attention is given to improving aspects of the work environment that could enhance intrinsic satisfaction. Our results indicate that rural retention policy should enable the creation of a work environment that fosters and develops professionalism and appreciation of rural life and/or work in health professionals. Further investigation of the interaction between intrinsic motivation and extrinsic incentives, and crowding out effects between the two, is required to help policy makers identify the best mix of rural retention reform options. In addition, factors that foster the appreciation of rural life and/ or work by health professionals should be investigated, including the effects of managerial support and improving physical work conditions, as suggested in our study.

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