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               This paper delves into the issue of motivation of Health Workers in Nigeria, reviewed importance of motivation and how motivation can be a management tool to increase workers’ productivity. Various opinions of the scholars were collated and reviewed for objective assessment; thereafter the paper concluded that motivation remains an important management tool and recommended the use of motivation as a tool to secure job satisfaction and increase the health workers productivity in Nigeria.

INTRODUCTION

             There have been efforts towards improving health system performance in Nigeria and other developing countries by improving the availability and allocation of resources, promoting more efficient management and rationalizing the role of government. Various international communities have also shown concern and have been contributing to its improvement overtime (WHO, 2017:7). However, experiences, especially, in Nigeria health sector have shown that the positive impact of such efforts and commitment anticipated has not been realized but thwarted by the behavior patterns of health workers. Workers are central and critical in the realization of effective and quality health delivery anywhere in the world. Sara and Lynne (1999: 1) argue that “Effective and efficient health care systems depend critically upon actions taken by individuals working in the system”. And this services could best be realized only when the individuals employed to deliver this service are willing and ready to do so. How does the organization propel the workers psychological process, essentially in the health sector, to realise the best performance and service delivery?

Worker motivation is of critical importance in the health sector which is highly labor intensive and quality service oriented. Therefore quality, efficiency and effectiveness of healthcare service are directly related to and affected by workers motivation. Factors such as technical know-how, resource availability and good working environment are not sufficient enough to produce a desired result, but it also includes intrinsic abilities of workers at work. Human capacity is of paramount important in controlling other resources in production for a desired result. Scholars have shown evidence that motivated workers come to work more regularly, work more diligently, and are more flexible and willing to work. They tend to become result-oriented workers. According to Hornby and Sidney (1988), increased motivation creates the conditions for a more effective workforce, but because work motivation is an interactive process between workers and their work environment, good management system and supervision are still critical factors in reaching organizational goals.Motivation is an internal psychological process. It is not possible to motivate people directly (at times through robust and prompt salary and wages payment), only to create an environment conducive to high degrees of motivation.

               While accepting the fact that work motivation is an important part of ensuring a desired goals of the organization, this paper offers an analytical, but participatory discussion on how best to use motivation as a management’s tools for increasing the productivity of health workers in Nigeria, having understood that lack of motivation is one major important problem of health sector in the country.

SITUATIONAL ANALYSIS AND MOTIVATIONAL-RESOURCE FACTORS IN NIGERIA’S HEALTH INSTITUTION

               In the recent years, scholars and professionals have associated major factors igniting the continual drain and incessant strike actions of health workers associated with Nigeria health sector to motivational-resource issues constantly absent in Nigeria’s health institutions. According to Eriki et al. (2015:11), health workers in Nigeria are paid meagre salaries, often work in insecure areas, and have heavy workloads, yet they lack the most basic resources, including drugs and medical equipment and have little chance of career development. Their reports stated further that doctors complain of “brain waste”, and seek opportunities for professional development in countries with better medical infrastructure. The rate of attrition from the health sector in Nigeria is significant with an estimated annual loss of 2.4% of Nigeria’s skilled health workforce. A newspaper reported in 2018 that an average of 2000 medical personnel leave the shore of Nigeria yearly for better opportunities abroad (The Guardian Newspaper, April 22, 2018). 

               The data available point to European Region as a destination for Nigerian medical and dental practitioners (African Centre for Global Health and Social Transformation, 2015). All these are imminent among the factors advance by the scholars of management to reduce rate of turnout and increase the performance level in any organization. The character of the health institution that is resulted into a continual brain drain is being caused by total lack of motivation and thus affecting the productivity and loss of workforce. While few ones have sought for greener pasture, better condition with good infrastructure elsewhere, several others behind are constantly going on strike, to press for a better welfare. Ladi Hamalai, Aremu Fatai and Aminu Umar in their 2015 reports on Industrial Strike in the Health Sector: Incidences, Causes and solutions claimed that between May 29 1999 and December 2014, there have been not less than sixty (60) strike incidents in tertiary health system alone. According to them, the frequency and intensity of strikes in various public health facilities have risen sharply and this had ruptured the operations of hospitals and completely blocks citizens’ access to healthcare usually for extended period of time, and thus, caused thousands of preventable deaths. As a matter of fact, Joint Health Sector Union (JOHESU) just suspended its more than a month national indefinite strike in June, 2018 because of the welfare related industrial issues (Figure 1). These are fundamental problem that requires urgent attention. Meanwhile, proper management and motivation technique could resolve them and thus foster higher quality services in Nigeria’s Health Institutions.

Motivation

Motivation whether intrinsic or extrinsic is generally perceived as conditions that boost workers performance and directs their behavior towards accomplishment of organizational goals. Motivation is regarded as the best strategy management can deploy to stimulate the interest of employees to do their best, perform most challenging jobs at acceptable level and to retain them in the organization. Business dictionary defined motivation as internal and external factors that stimulate desire and energy in people to be continually interested and committed to a job, role or subject or to make an effort to attain a goal. Motivation can also be described as the driving force which helps and causes us to achieve goals, it is said to be intrinsic or extrinsic. From these definitions we can see how important motivation is and how much influence it has on the achievement of organizational goals. Scott (June, 2018) in his article titled “Motivation and Productivity in the Workplace” said that most employees need motivation to feel good about their jobs and perform optimally. He observed that some employees are money motivated while others find recognition and rewards personally motivating and that motivation levels within the workplace have a direct impact on employee productivity. He concluded that workers who are motivated and excited about their jobs carry out their responsibilities to the best of their ability and production numbers increase as a result.

Previous Scholars had worked on motivation and how it affected and influenced the productivity of workers at work; notable among these people was Maslow who propounded motivation theory of needs in 1943, he identified 5 hierarchies level of needs namely physiological/basic needs, safety needs, love and belonging, self-esteem and self-actualization. Maslow’s theory is saying that in order to get the most out of your team, you should also make sure you support them in other aspects of their lives outside work. Perhaps you could offer flexible working hours to give employees time to focus on their families and make sure they are paid fairly to help them feel financially stable. In their own opinions, Abah and Nwokwu (2016) said that Maslow’s theory clearly shows that an individual’s motivation to work depends on the urgency of his needs and the extent to which his needs are fulfilled through the organization in which he works. Maslow’s ideas influenced many humanist and behavioural scientists such as McClelland, Herzberg, Vroom and other renowned scholars. To Herzberg, five factors are strong determinants of job satisfaction and motivation which include: achievement, recognition, the attraction of the work itself, responsibility and advancement.

Management Tools

Management tools are strategies, system or control employed by the management to drive the business of the organization so as to improve the performance. Wikipedia online  defined business management tools as all the systems, applications, controls, calculating solutions, methodologies, etc. used by organizations to be able to cope with changing markets, ensure a competitive position in them and improve business performance. Bernard (2013) observed that management tools, if they are used appropriately, can be powerful enablers of change and actions in companies. He said they can, for example, help define and execute the strategy, engage with customers and employees and monitor performance. Motivation is seen as one of such tools that can be used to monitor and increase workers’ productivity. This position was underscored by Ian et al. (2015) when they said that motivation is an important tool that is often under-utilized by managers in today's workplace. Managers use motivation in the workplace to inspire people to work individually or in groups to produce the best results for business in the most efficient and effective manner. Motivation has been variously seen overtime as the most vital tool, yet overlooked means of turning on the workers to give their best to attain organizational goals as well as achieve job satisfaction at the workplace (Abah & Nwokwu, 2016). Today, the focus of the management of any organization is how to cope with current trends in business environment. Every organization has a designed function to meet the Human Resources Management Trends strategic objectives and maximize the performance of the employee. Therefore, it is imperative that Human Resource Management is operating appropriately and in accordance with the latest trends and technology to be able to deal with the business life challenges. To be able to retain and sustain workers in complex business environment driven by competition and technology, management need to deploy motivation as one of the strategies as only motivated workforce will stay to do their best.

Motivation and Productivity

Motivation is crucial for good performance and therefore it is increasingly important to know what motivates employees for better performance. Motivation as an innate force that drives individual to continue doing his best has serious relationship with productivity. Business Dictionary (2018) defined Productivity as a measure of the efficiency of a person, machine, factory, system, etc., in converting inputs into useful outputs. Productivity is computed by dividing average output per period by the total costs incurred or resources (capital, energy, material, personnel) consumed in that period. It is the effectiveness of productive effort, especially in industry, as measured in terms of the rate of output per unit of input. Productivity describes various measures of the efficiency of production and it is a crucial factor in production performance of firms and nations. There seems to be positive correlation between Motivation and Productivity as agreed by most reseachers (Charles, 2008). That is to say, when motivation increases, we should expect productivity to rise as a result. This reflects the belief that an increased motivation level causes an increase in productivity; it is a direct cause and effect relationship. He concluded and said “I see motivation and productivity as being mutually causative. I regard them as interactive. One impacts on the other, then the other impacts on it in turn, or even simultaneously. They feed off each other.” Aderibigbe (2017) agreed with this assertion when he concluded that there is a significant positive relationship between employee motivation and productivity and therefore, recommended that the personal needs of employees must be given a consideration when applying motivation so that each employee will be able to concentrate at work and consequently, give their best to the organizational outputs. Similarly, Paul (2006) also concluded that although no relationship was found between motivation and work rate but motivation has a significant influence on the proportion of working time bricklayers spend productively.

Motivation and Health Workers Productivity

The relationships between proper human resource management in an organization and positive employee attitudes have been widely analyzed (Sara & Lynne, 1999; Silvestro, 2002). Several have posited that securing workers loyalty and commitment is a function of underlining motivation factors ranges from intrinsic to extrinsic (Friederike, 2009; Hornby & Sidney, 1988). They brought out liberal self-igniting performance instrument that increases productivity longer than expected. It is also suggested that treating employees as a valuable asset improves their commitment and loyalty which leads to higher performance and quality (Silvestro, 2002). Tomar and Shamar (2013) argued that motivation is a kind of force which energizes people to achieve some common goals. Every organization either public or private is goal oriented and all efforts are geared towards the successful attainment of their goals and objectives. Rothberg (2005) also concluded that that unless individual employees are motivated to make efficient use of the potentials, the organization may not achieve the level of performance that is desired from them. The satisfaction of the employee represents an indispensable dimension of the motivational process. A satisfied individual would certainly contribute positively to the realization of organizational goals and objectives, while a dissatisfied employee may not only contribute but can even act in such a way that the realization of such goals and objectives could be completely destroyed. This underlines the importance of employees’ satisfaction to the organization (Anka, 1988).

Because of the above substantiated statements, managers often ask some fundamental questions: what can we do to motivate our workforce? Meanwhile, there is no single technique that answers this question. Aluko (2000) noted that the major motivational factor is monetary reward, good take home. Other factors includes frequent training and retraining, promotion, awards and recognition for a job well done, job security, upgrading and advancement, etc. go a long way to boost the morale of workers. It is true that the main reason behind running activities in an organization is to achieve organizational goals and organizational performance plays the major role in attaining such goals. Meeting personal goals help an employee stay motivated and give up their best; therefore achievement of organizational goal depends largely on workers motivation. 

MOTIVATION AND WORKERS PERFORMANCE: INTERROGATING THE MAJOR CAUSES OF DETERIORATING HEALTH SERVICES IN NIGERIA

Nigeria is facing a health crisis occasioned by a number of factors, essentially welfare of the staff and infrastructural issues, which have affected the sector over the past few decades. Both major causes bore down to the issues of motivation. According to the former Nigeria Federal Minister of Health, Professor Babatunde Osotimehin, while attempting to trace the causal pathway to the rapidly declining performance of Nigeria’s health sector stated in the forward of the National Strategic Health Development Plan Framework (2009-2015, p. 2) that:

‘Currently, the health sector is characterized by lack of effective stewardship role of government, fragmented health service delivery, inadequate and inefficient financing, weak health infrastructure, mal-distribution of health work force and poor coordination amongst key players.’

Associated with what the Minister highlighted above and other findings in literature, there is monetary and non-monetary factor in the definition of motivation. Monetary has to do with the increase and prompt payment of salary and allowances of the workers while non-monetary include good working environment, promotion and carrier advancement, education and training opportunities, awards and honors, recognition devoid from nepotism, insurance, housing, etc. The monetary and non-monetary have constituted into motivating menace affecting the performance level of the staff and consequentially, quality health care delivery in Nigeria. It has amounted into brain drain and strike actions.

The causes of brain drain in Nigerian health institutions and incessant strike actions, why health workers are leaving the shore of the country for other countries, what is missing in Nigerian health sector and what is present in other countries that serve as points of attractions were underscored and summarized in the Table 1.

 The critical analysis of the above table when comparing push and pull factors, showed that those factors still remain majorly motivational factors.

Looking at the problem of motivation in Nigerian health care sector, Barbara et al. (2004) agreed that health-care systems in developing countries are suffering from years of underinvestment, and health workers were subjected to low wages, poor working conditions, a lack of leadership and few incentives of any kind. Korte et al. (2003) in their findings studying the motivation of health-care workers in four developing countries in Africa have observed that low job satisfaction and motivation affect the performance of health workers as well as acting to push people to migrate. Their study has found that non-financial incentives are important in motivating health care workers both to do a good job and to continue working in public health services; these incentives include training, study leave, the opportunity to work in a team and supports and feedback from supervisors. In their report, some incentives were found to work well to retain staff in rural areas. These included providing housing and transport, agreeing the number of years that will be spent in a rural location (rather than expecting a worker to remain there indefinitely), offering further training and offering financial incentive. These findings and others support previous work on motivation according to Stilwell (2001) and indicate that even simple, relative low-cost measures may have positive effect on the motivation of health workers and on retention.   

Nevertheless, the prospect of making substantially more money is thought to be pivotal factor in the decision to migrate (Stalker, 2000; Xaba & Philips, 2001) and in many source countries, introducing a competitive wage will be impossible. Targeted incentives may be a more realistic possibility. In another way round, moral teaching should be offered to various health workers and thus would enhance their readiness and willingness to do thorough job in the rural areas. For example, Barbara et al. (2004) posits that educating a group of community-based health workers to offer health advice and simple treatments may improve accessibility to health services, especially in rural areas and such workers are far less likely to migrate internationally.

CONCLUSION AND RECOMMENDATION

Obviously, Nigeria’s poor health status is attributable to the incessant strikes, brain drain, and infrastructure decay in the healthcare system; all of which are strong factors of motivation. While many of the workers have resulted to search for better service condition beyond the shore of Nigeria, others are engaging into strike actions. And this has been responsible for poor health care service delivery, thus, preventable deaths are rampant and vulnerable, women and children, are suffering from preventable diseases. Meanwhile, it is a common knowledge that quality and effective health service delivery is a fundamental right of the citizens. In fact, access to quality and affordable healthcare is a basic human right and matter of constitutions.

Article 25 (1) of United Nations Universal Declaration of Human Rights provides that ‘everyone has the right to a standard of living adequate for  the health and well-being of himself and of his family…including medical care and necessary social services.’ Chapter two section 17 (3 c & d) of the Constitution of Federal Republic of Nigeria identifies health as one of the fundamental objectives of state policy in which the state is obliged to provide ‘adequate medical and health facilities for all persons.’ In consonance with international and national emphasis on health, the National Health Act (2014) seeks to guarantee uninterrupted and effective functioning of the healthcare system. Part V S. 5(1) classifies health as “Essential Service”.

In a forward to The National Strategic Health Development Plan Framework (2009-2015), the former Minister for Health, Professor Babatunde Osotimehin poignantly observed:

‘Health is Wealth’ goes the popular saying and therefore in every country, the health sector is critical to social and economic development with ample evidence linking productivity to quality of health care. In Nigeria, the vision of becoming one of the leading 20 economies of the world by the year 2020 is closely tied to the development of its human capital through the health sector. However, the health indicators in Nigeria have remained below country targets and internationally-set benchmarks including the MDGs, which have recorded very slow progress over the years.

Meanwhile, successive government has been finding a lasting solution to the poor service delivery in the health sector. There were Committees set up by the Federal Government. “Presidential Committee in 2011 headed by Justice Abdullahi Bello Gusau and that of 2013 headed by former Secretary to the Government of the Federation Yayale Ahmed. The Yayale Ahmed Committee streamlined the issue into nine (9) broad issue areas. These are: organizational management issues; leadership and teamwork issues; remuneration parity/relativity and motivational issues; career and management issues; capacity building issues; professional practice issues; labour issues; legal issues and governance/policy issues. However, virtually all nine broad issues highlighted by Yayale Ahmed are elements of motivational factors and reasons behind the brain drain and incessant strike actions in the health sector. This shows that motivation remains the only tool available to stabilize and increase the productivity of the workers in Nigeria health sector.

Therefore, one may advance an argument that motivation is critical to retaining the workers and to ignite their readiness to perform optimally in Nigeria health sector. For increasing the productivity of health workers, it is recommended that government and managements of health institutions in Nigeria should focus more on motivation issues such as remuneration, good working environment, training and retraining of workers, infrastructure development, career progression, recognition and award based on meritocracy, and many more others. From this review therefore we can conclude that motivation remains the only management tool available to retain and sustain health workers as well as increase the productivity of the workers in Nigeria health sector. 

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