Motivational determinants of frontline health extension workers in East Hararge Zone, Ethiopia: implications for primary health care systems in low-resource settings

Background: Health worker motivation affects service quality, retention, and the performance of primary health systems, especially in low-income settings. In Ethiopia, Health Extension Workers (HEWs) form the backbone of the rural health system, yet limited empirical evidence exists on the factors influencing their motivation across diverse regional contexts. Methods: A survey was conducted with 314 HEWs from six Woreda (Districts) and one town administration in the Oromia Region of Ethiopia, between July 1 and August 14, 2024. Motivation was operationally defined as the capacity of HEWs to initiate, direct, and maintain goal-oriented working behaviors. Descriptive statistics and logistic regression analyses were performed to identify significant associations between key socio-demographic and institutional factors with motivation, with results expressed as adjusted odds ratios (AOR). Results: Overall level of motivation among the HEWs was 74.8%. Both intrinsic (socio-demographic) and extrinsic (institutional) factors were significantly associated with motivation. Being married was strongly associated with motivation compared to being single (AOR = 222.93; CI:95%; p 15 years of service (AOR = 5.79; CI:95%; p 1 year of service. Institutional factors: satisfaction with performance related incentives (AOR = 2.46; CI: 95%; p < 0.05), knowledge and skill sharing with co-workers (AOR: 3.52; CI:95%; p < 0.05) and decision-making autonomy (AOR = 3.114; CI:95%; p < 0.05) were strong predictors of higher motivation. In contrast, inadequate implementation of the career development system (AOR = 0.510; CL:95%; p < 0.05), routine supervision and feedback (AOR = 0.503; CI: 95%; p < 0.05), and access to on-the-job or off-the-job training (AOR: 0.44; CI:95%; p < 0.05) were linked with lower motivation. Conclusion: We found a relatively high motivation among HEWs in East Hararge compared to other regions in Ethiopia and Africa. Both intrinsic and extrinsic motivators identified play a key role in shaping the motivation levels of HEWs. To enhance worker motivation and productivity in the primary health care system, policymakers and health sector authorities need to implement targeted and evidence-based strategies, including structured career development pathways, performance-based incentives, strong collegial knowledge and skill sharing schemes, and decision-making autonomy.