March 31, 2020

Recent studies have found that doctors and nurses in low- and middle-income countries are often absent from work, sometimes seek unauthorized payments for services, and may treat patients in disrespectful or abusive ways.

A recent commentary in Human Resources for Health points out that while improving work environments might help the overall situation, that solution isn’t always feasible in low-resource settings.

Instead, the authors suggest reforming medical education practices to focus on admitting students who are motivated by a strong desire to serve the needs of their community, rather than by receiving external rewards. These providers are, per the authors, less likely to engage in negative behaviors and more likely to deliver high quality care even in tough circumstances.

Dr. Katherine Tumlinson

Dr. Katherine Tumlinson

Dr. Dilshad Jaff

Dr. Dilshad Jaff

Lead author Katherine Tumlinson, PhD, is an assistant professor of maternal and child at the UNC Gillings School of Global Public Health and a faculty fellow at the Carolina Population Center. Co-author Dilshad Jaff, MD, MPH, is an adjunct assistant professor of maternal and child health and the Gillings Humanitarian Fellow.


“The objective of this commentary is to describe promising, feasible and sustainable recommendations for correcting negative provider behaviors,” they write in the commentary. “Our recommendations are designed to address the systemic challenge of low intrinsic motivation among providers in developing countries.”

Extrinsic motivational factors — such as salary and title — are largely outside of an individual clinician’s control but can greatly affect their work environment and job satisfaction. Most people are impacted at least to a small degree by extrinsic factors, but those who are highly driven by rewards and personal profit may be more susceptible to engaging in harmful practices when frustrated by their working conditions.

In contrast, intrinsic motivation is grounded in an individual providers personal enjoyment and satisfaction in “a job well done.” High levels of intrinsic motivation are linked to self-efficacy, with the result that this type of health care provider will strive to deliver high-quality service even when their environment is not ideal.

“We suggest that providers with a strong sense of professional identity are less likely to engage in negative behaviors,” the co-authors write. “We further suggest that changes to the admission process for medical and nursing schools in low-to-middle-income countries, along with 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 educational institutions, the financial and logistical resources required to increase intrinsic motivation are low relative to the cost of drastically improving extrinsic factors.”

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