INTRODUCTION 3000 per year after 2018 from

Qualified and motivated human resources (HR) are essential for adequate health service provision, but HR shortages have now reached critical levels in many in rural areas (WHO, 2006) worse in developing countries (Manipleb, 2009b) particularly in Africa(Imhoff, 2006). As a result, the shortage of doctors and their mal-distribution between urban and rural areas contribute to inequitable health care delivery (Van Wyk J, 2010).
Ethiopia is the second most populous (more than one hundred million) sub-Saharan country in Africa next to Nigeria. About 80% of the country’s total populations live in rural areas and urbanization rate increased by 4.64% so that the rural to urban migration is high (Ethiopia, 2018). The number of medical schools is more than 24 and the annual undergraduate medical students were more than 2000 currently and it was more than 3000 per year after 2018 from the level of only 336 in 2010(WHO, 2015).
However, there are major HRH management challenges including shortage, urban/rural and regional disparities, poor motivation, retention and performance hence enhancing human resources management practice including motivation, and retention schemes is the main component (Health, 2016). Shortages and imbalances in physician workforce distribution between urban and rural areas among the different regions in Ethiopia are enormous (Tsion Assefa and Enbiale, 2007).The doctor to population ratio is 0.7 per 1000 population (Health, 2016).
Studies identified that medical students have low positive attitudes towards to work in rural area as well as low confidence in overall competency to work in the rural area in five Asian countries (Wanicha L. Chuenkongkaew, 2016). In Uganda, medical students had a negative perception about the rural areas and did not intend to practice medicine in rural area after their qualification (Manipleb, 2009a). The intentions of the majority of Ethiopian medical students in the capital city towards practicing medicine in rural areas were found to be poor, and the intent to migrate after completing medical training was found to be very high (and and Azazh, 2012)
Different intrinsic example work itself and extrinsic factors like financial and non-financial incentives that pull or push affect the attitude of medical students towards rural area practicing after their graduation (Imhoff, 2006, Uta Lehmann1Email author et al., 2008b, Johansson, 2014, Minda, 2016).
However, limited evidences are available on intentions of medical students to work in rural area and influential factors that associate with practicing rural area after their qualification in Ethiopia.
The health workforce crisis is a worldwide phenomenon. It includes: difficulties in attracting and retaining health professionals to work in rural and remote areas, geographical mal?distribution and high turnover of health staff particularly phy¬sicians(1 et al., 2017, Settle, 2009) and serious shortage of these workers in the rural area particularly high in sub-Saharan Africa(Memon et al., 2015).
Most of the medical students were expected to migrate abroad, rural to urban but small number of students anticipated a rural career and then increase physician shortage in rural areas(Uta Lehmann1Email author et al., 2008a, Kumah, 2017). Similarly, medical students with urban background were hate rural area work (Erfan Yeganeh-Arani, 2017, Azazh, 2012, Hussein Dossajee1, 2016, Tsion Assefa and Enbiale, 2007). The staffing of public sector health facilities in remote rural areas is a serious challenge for many ministries of health because medical doctors left the rural public health sector mainly male, young and less experienced physicians (esus Gonzalez-Garcia and Yenice, 2016, Berhan, 2006, Tsion Assefa and Enbiale, 2007).
Low production capacity of medical doctors, limited health workforce management systems, which include lack of adequate retention and motivation mechanisms, Limited capacity of enrolling students remain responsible in most and the consequence has been geographical imbalances (urban/rural, interregional and Male/Female) (FMOH, 2019).
To improve the urban-rural distribution of physicians’ measures were introduced to increase the uptake of medical students considered quotas from different disadvantaged regions; medical education schools outside of regional capitals and emphasis of the curriculum on family and community medicine. National health systems response included accelerated (NIMEI) training program requires an undergraduate degree in natural science for program and candidates selected on the basis of entrance exam result(WHO, 2015).
However, the magnitude of the problem is still high. Accordingly, the aim of this study was to assess the intention to work in the rural area, identify major associated factors with their intention and to explore factors to motivate to work in the rural area.

Different findings from different studies on the same topic were indicated but they were contradicting each other. Very few studies were conducted among medical students regarding their intention to work rural area and factors that associated in Ethiopia. Hence, there is limited availability of evidence.
Therefore; the findings of this research add new information and knowledge regarding this area and give direction for the other researchers interested on this area. The finding of the study will also help to provide equitable health service for rural community and increase the interest of medical students to work in the rural settings. Moreover, the new message come through the study will help to fill the gap of motivation. Furthermore, the findings of this study will help Universities to give focus on rural health program for producing motivated medical students and Ministry Of Health to design motivating strategies for medical doctors in order to attract towards rural area. Finally, this paper will give new knowledge for program developers and policy formulators regarding this area.

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Migration is a phenomenon where health workers leave from rural to urban regions within a country, from developing to developed countries or from public to the private sector. It can be defined as a form of relocation diffusion (the spread of ideas, innovations, behaviors, from one place to another) involving a permanent move to a new location.
The World Health Organization estimates the current global shortage of health workers at more than 4 million(WHO, 2009). Because, health professionals migrate from rural to urban, from low to middle and middle to high-income countries, from developed countries with lower wages to those with higher ones. Less developed countries are most likely to be net suppliers, and although other developed countries are also net recipients the main receiver appears to be the US (Wanicha L. Chuenkongkaew, 2016, Grignon et al., 2012
The Global pattern reflects the importance of migration from less developed countries to more developed countries. Migrants from countries with relatively low-income and high natural increase rate tend to head for wealthier countries where job prospects are higher (APHG, 2016). The migration of health workers from developing countries to developed ones is a well-recognized contributor to weak health systems in low income countries and is considered a primary threat to achieving the health-related millennium development goals (Shehla Jabbar Memon, 2011, Elena TOADER, 2013b, Karima Chaabna, 2017). The emigration of doctors from developing countries to developed countries could be considered deleterious for the low income countries of departure but more associated with the amount of remittances sent home by migrants (Moullan, 2014).
From a global perspective, therefore, the medical brain drain could be seen as a matching process through which workers are allocated to places and jobs where they are most productive (WHO, 2009). The drain of health resources from low income countries to richer ones is not a new phenomenon, and Ethiopia is one of the countries with the lowest density of physicians in the world & health migration is a problem in several categories of health workers in Ethiopia (Johansson, 2014).

The literature shows that the brain drain of medical professionals is threatening the very existence of the countries’ health services. The problem of brain drain has reached quite disturbing proportions in certain African countries, with Ethiopia ranked first in the continent in terms of rate of loss of human capital, followed by Nigeria and Ghana (Minda, 2016)
Motivation is a driving force that influences individuals to act in a certain way in their workplace. It can be defined both intrinsically and extrinsically. Intrinsically, self-generated like self- feeling, the freedom to act, to choose the goals, to develop one’s goals, interesting and stimulating tasks, promotion and development opportunities. But extrinsically, comes from outside, to motivate the employees such as incentives as raising the salary, recognition of one’s work (Riley, 2005).
The increased focus on health workers’ motivation as vital to ensure good quality health services is a very important shift from seeing quality of service delivery in the health sector as a function of the number of health workers and their qualifications (Songstad, 2012).
Human resources management focuses on recruitment as per the need, deployment of staff, performance management and motivation. In order to improve development and management of human resources for health-enhancing human resources management practice including motivation and retention schemes can be taken as a strategy (Health, 2016, Franceschini, 2006). The motivation of health professionals is one of the key ways to ensuring efficient provision of health services. Improving the motivation of health workers in rural and remote areas is of greatest concern to all countries worldwide (Kumah, 2017).
It is better to state different theories of motivation in order to confirm the study finding whether agree or disagree with them because the study approach was deductive. Behavioral theories, such as those developed by Maslow and Herzberg, show a more complex decision-making process regarding the movement of labour (Riley, 2005, Maslow, 1970) with a particular emphasis on the importance of job satisfaction. They stated as follows
Maslow’s Hierarchy of Need: Maslow (1954) postulated a hierarchy of needs that progresses from the lowest, subsistence level needs to the highest level of self-awareness and self-actualization. The five levels of Maslow’s are Physiological, Safety, belonging, Esteem, and Self-actualization. The movement from one level to another level is satisfactory progress according to the theory (Maslow, 1970).
Alderfer’s ERG Theory: the three components (Existence, Relatedness, and Growth) identified by Alderfer (1972) drew upon Maslow’s theory, but also suggested that individuals were motivated to move forward and backward through the levels in terms of motivations. The three levels are: 1Existence related to Physiological and Safety needs 2. Relatedness addresses the belonging needs 3. Growth pertains to the last two needs, thereby combining Esteem and Self-actualization (Alderfer, 1997).
Herzberg’s Two Factors Theory: Herzberg (2003) further modified Maslow’s needs theory and consolidated down to two areas of needs that motivated employees. These were characterized as lower level motivators called Hygiene’s and higher level factors and focused on aspects of works known as motivators. This theory easily understood the approach that suggests that individuals have desire beyond the Hygiene’s and that motivators are very important to them (Riley, 2005).
McClelland’s Acquired Needs Theory (1985): the idea here is that needs are acquired throughout life. That is, needs are not innate but are learned or developed as a result of one’s life experiences. This theory focuses on three types of needs for achievement, affiliation, and power.
The above theories of motivation were understood employees’ motivation on the basis of needs. But from other considerations is an extrinsic and intrinsic theory of motivation (Uduji, 2013).
Reinforcement Theory: B.F. Skinner (1953) studied human behaviors and proposed that individuals are motivated when their behaviors are reinforced which are associated with desirable and undesirable (Skinner, 1965).
These theories deal with a particular aspect of motivation, it seems unrealistic to address them in isolation, since these factors often do come into play in and are important to employee motivation at one time or another. Other approaches to motivation are driven by aspects of management, such as productivity, human resources, like Scientific Management Theory, McGregor’s Theory X and Theory Y, Ouch’s Theory Z these theories are helpful in understanding management and motivation from the conceptual perspective, it is important to recognize that most managers draw upon a combination of needs, extrinsic factors and intrinsic factors in an effort to help motivate employees, to help employees meet their own personal needs and goals. Managers should focus on expectancy, goal setting, performance, feedback, equity, satisfaction, commitment, and other characteristics (McGregor, 1960, Taylor, 1911, Ouchi, 1981).

The healthcare sector at the rural community level is important for many reasons. Living in a rural area is appealing to many people, primarily for the quiet lifestyle and strong community relationships. These “quality of life” variables are important not only to those who want to continue living in a rural area, but also to urban residents that are searching for a change. However, for a rural community to survive, the local economy must be sustainable which will allow for the provision of important local services (Memon et al., 2015). Typically, rural communities pay little attention to their health care system until they need it. As a result, many people have little idea of the non-medical importance of the health care system to the local communities. The employment opportunities and the resulting wages and salaries make the health care system an extremely important part of the local economy and strong viable hospital must have support from local physicians to maintain sufficient utilization. Lack of local physician support will significantly impact the financial stability of the hospital. In addition to the inpatient visits, physicians can generate significant outpatient activity that increases hospital net revenue (Fred C. Eilrichq, 2007, Shehla Jabbar Memon, 2011). However, unpopularity for rural lifestyle indicated by medical students were: it is difficult or uncomfortable, it is backward, lack of social and family networks, poor accessibility of services and facilities, more fun and interesting in urban areas, financially is not as good, change from original lifestyle , and concern regarding children and schools (Erfan Yeganeh-Arani, 2017).
The Neoclassic Wage Theory, which suggests that the choice is driven largely by financial motives and by the probability of finding employment (Uta Lehmann1Email author et al., 2008a). On the other hand, people are motivated by a complex structure of rewards, in which non-financial benefits and move quickly to another job or place if their expectations are not met (WHO, 2009).
Retention of health workers, particularly in rural areas of LICs (Low Income Countries), was great agenda, due to the severe staff shortages that hamper the attainment of the MDGs (Millennium Development Goal). As a result, the study done on Germany and France24% of physicians were found in rural area(Memon et al., 2015), correspondingly in USA, Canada, South Africa, and Kenya, only 9% , 9.3% , 12% and 36% of physicians were found in rural areas respectively (WHO, 2009). So that, there were fewer health workers in rural areas, loss of health workers in these areas will severely contribute to accessibility problems (Harnmeijer, 2006).
Based on study done on China, among 4,669 medical students, (33%) had a positive attitude and (55%) had a neutral attitude toward working in rural THCs (Township Health Centers). Twenty-one per cent of medical students showed a strong willingness to work in a deprived area, 57.3% manifested weak willingness and 21.5% unwillingness to work in a low-resource setting (RA Borracci1 and Cerezo, 2015). There was a significant increase in students’ perceptions of rural primary care physicians’ primary care service features and medical expertise.
In the majority of countries, rural and remote areas are usually lacking sufficient numbers of health workers. Approximately one half of the global population lives in rural areas, but these areas are served by less than a quarter of the total physicians’ workforce and then at the country level, imbalances are even more prominent. Some countries have apparently a sufficient numbers on average, but with shortages in rural areas (Germany, France) as a result 24% and 76% of physicians were found in rural and urban areas respectively (WHO, 2009).
Medical students preferring to work in rural areas were more likely to believe there are good opportunities for employment, to practice variety of skills, to get clinical practice autonomy in rural areas than those intending to work in urban areas. On the other hand, students preferring urban areas versus rural locations in the future were more likely to believe that working in rural areas would be more isolated (Walker JH, 2011, Gibson Erick Kapanda1 and Bartlett, 2016).But in Bangladesh 43% of medical students had positive attitude towards working in rural areas, and attitude about overall competency (Wanicha L. Chuenkongkaew, 2016). Almost half the participant’s students chosen regional or rural practice, with the balance (majority) of the students preferring an urban Centre (Walker JH, 2011). Though, female students had negative attitude to practice rural area than male students. Students who lived in urban areas during their high school period had significantly lower positive attitude compared to those living in rural areas. Students whose parents lived in semi-urban areas had significantly higher positive attitude compared to those living in rural areas (Wanicha L. Chuenkongkaew, 2016, RA Borracci1 and Cerezo, 2015, Darra Ballance et al., 2008, Ian Huntington, 2011).
Studies conducted in Bulgarian and Germany describes that, students prefer to specialize and to work in other European countries due to the better payment and they have intention to return and practice their profession in their country of origin (Vanya Asenikova, 2017). Conversely, Students perceived the physicians’ work demands more positively, and there was no change in students’ perceptions of the physicians’ income potential (Amy V. Blue and David R. Garr, 2004).
The only factor significantly associated with positive attitudes towards their school in terms of preparing or inspiring them to work in rural areas is parents? residence. Factors significantly associated with intention to work in public sector five years after graduation includes residence during childhood and mode of admission into medical schools. Students living in urban areas during their childhood period had significantly less intention to work for public sector while (Wanicha L. Chuenkongkaew, 2016, Darra Ballance et al., 2008, RA Borracci1 and Cerezo, 2015, Ian Huntington, 2011).
Rural medical recruitment and retention through education and training, with important insights into the factors affecting preference for future rural practice was essential (Franceschini, 2006, Walker JH, 2011). In Thailand, the government has aimed to annually produce 300 doctors specifically for rural areas (Franceschini, 2006).
Selecting medical students through interviews to identify their family support and intentions to work in THCs would increase recruitment and retention (Yunbo Qing, 2015). A rural background (i.e being brought up in a rural area) training with a community-based curriculum, was early exposure to the community during medical training and rural location of medical school motivate medical students to work in rural areas (Shyam Sundar Budhathoki, 2017).
Migration from and within sub-Saharan Africa (SSA) is an important macroeconomic issue for both sending and receiving countries. Amid rapid population growth countries, migration in sub-Saharan Africa has been increasing briskly over the last 20 years (esus Gonzalez-Garcia and Yenice, 2016). Most of the medical students were expected to migrate abroad, but small number of students anticipated a rural career (Kumah, 2017). From the African and Asian context, 28% expected to migrate abroad, while only 18% anticipated a rural career. There were more nursing than medical students desired professions abroad (David M Silvestri and Mwapatsa Mipando, 2014).
There are sub-Saharan African countries (Cote d’Ivoire, Mali, Democratic Republic of Congo), where there is large overproduction of health workers, with medical unemployment in urban areas, and at the same time with shortages in the rural areas (WHO, 2009). For the reason that, a minor proportion of the students (13.6%) were willing to practice in the rural area after graduation and only (22.5%) were satisfied with rural community posting due to lack of interest in rural communities (EN Ossai, 2015). Majority of the students (80.1%) were of the opinion that doctors working in rural area should earn more than their urban counterparts (Ekeke, 2014). Almost half (49.7% or 167/336) of all the respondents who answered the research questionnaire did not intend to work in rural health units after training. A quarter (25% or 84/336) of the respondents intended to work in rural facilities. Intention of medical students to work in rural health facilities decreased progressively from the first academic year to graduation even if, none of the fourth and fifth year respondents had any intention to work in rural units after training (Manipleb, 2009b).
In Malawi, medical students with rural background and small towns, and whose parents were ‘non-professionals’, were more likely to intend working in rural areas and small towns than students from urban and professional families (Erfan Yeganeh-Arani, 2017). Medical students and young doctors were eager about working at district level, although this is curtailed by their desire for specialist training and frustration with resource shortages. There is currently little intention to move into the private sector. In Tanzania, the presence of family members in rural and remote areas also increases the probability that an individual will consider these areas for the establishment of his/her practice (Gibson Erick Kapanda1 and Bartlett, 2016). Time spent in rural areas before matriculation predicted the preference for a rural career and against work abroad (David M Silvestri and Mwapatsa Mipando, 2014). Satisfaction with the rural rotation program was associated with increased likelihood of rural practice after graduation (Gibson Erick Kapanda1 and Bartlett, 2016). So that, admissions standards favoring medical and nursing students with rural backgrounds could promote greater graduate retention in the country of training and in rural areas in Ghana (Kumah, 2017).

The public health sector physician workforce largely constituted of male physicians, young and less experienced due to high turnover rate among females, the young and less experienced physicians, and those working in distant places (district hospitals) indicate the need for special attention in devising human resources management and retention strategies (Tsion Assefa and Enbiale, 2007). Female physicians were 1.4 times more likely to move out from their duty stations compared to their counterparts. On the other hand, as the age of physicians increased, the incidence of physician turnover decreased. In terms of educational levels, Graduate Programs (GPs) had more incidence of turnover compared to specialists/subspecialists, in addition, turnover variations were observed between health service delivery settings that mean physicians working in referral hospitals and those working in the general hospitals were 1.39 times more likely to move out than physicians working in district hospitals. The incidence of physician migration was 2 times higher in Amhara region than capital AAU (Tsion Assefa and Enbiale, 2007).
In Ethiopia, physicians’ first placements occur through a lottery, leading to self-selection into the lottery while non-lottery participants apply mainly to private institutions. The authors argue that such random placement does not allow for efficient signaling of individual ability and therefore leads to adverse selection into the lottery, which is indeed what they find using career and wage records of physicians who remain in the public sector. They also find that within the group of lottery participants, the most able tend to leave and are likely to account for a substantial part (one third) of the physician brain drain out of Ethiopia(Rapoport).
From the total respondents 67% (i.e. 63) of physicians express their wish to go abroad if they got the opportunity (Minda, 2016). The attitudes of the majority of Ethiopian medical students in the capital city, towards practicing medicine in rural areas were found to be poor, and the intent to migrate after completing medical training was found to be very high among the study participants, creating a huge potential for brain drain (Azazh, 2012). About 30% of the study participants would like to practice in rural areas of the country after completing their training, while 28% preferred to work in urban areas. However, 21% of the participants would prefer to work abroad following graduation, without serving in the country. Among the participants, (44%) of them preferred to initially practice medicine in public sector compared with NGOs (17%) or private sector (6%) (Azazh, 2012).
Descriptive characteristics about medics’ migration designate, through the representative components for financial aspects, health system, and professional career, those important aspects that are relevant for a medic’s career, related to the migration phenomenon. The possibility of emigrating in more developed countries was mainly for economic reasons but also in search for better career advancement opportunities (Elena TOADER, 2013a). Demographic characteristics, personal job concerns, and knowledge of THCs were associated with the choice of a career in rural THCs (Yunbo Qing, 2015).
Financial rewards as the number one motivator; followed by promotion, growth and development; job security; acknowledgment, praise, and recognition; and working environment in that order but doctors were motivated by their working environment mostly (Kumah, 2017). Low salaries and unsatisfactory working conditions are often cited as reasons for not practicing in rural and remote areas (Franceschini, 2006).
Motivational factors (satisfaction, intrinsically or content factors): events usually associated with positive attitudes regarding the workplace. These events are usually linked to the professional activities (realization, work itself, responsibility and promotion), which means they are intrinsic to the activity itself Hygiene factors (dissatisfaction, extrinsically or context factors). The events associated with negative attitudes regarding the workplace are extrinsically to the work itself and are more likely associated with the context of the activity (the organization’s administration and policy, job security, salary, management, interpersonal relationships and general work conditions) (Laurentiu-Stelian, Kumah, 2017). Factors associated with satisfaction with rural community posting included being a student in a federal institution, being a male student and intention to specialize in community medicine after graduation (EN Ossai, 2015). Being female, of older age, not having a university-trained professional parent, previous exposure or service in a poor area, choice of pediatrics as a specialty and strong altruistic motivations were highly associated with the willingness to practice medicine in rural or underprivileged areas. Only 21.5% of respondents considered that medical schools encourage the practice of medicine in poor deprived regions. Likewise, only 6.2% of students considered that national public health authorities suitably stimulate physician distribution in poorer districts (RA Borracci1 and Cerezo, 2015).
Factors associated with willingness to practice in the rural area included family residence in an urban area, work experience before admission into medical school, intention to specialize in Community Medicine and satisfaction with rural community posting (Ekeke, 2014). Marital status, some perceived difficulty of getting a job, having family support, sufficient knowledge of THCs, optimism toward THC development, seeking lower working pressure and a lower expected monthly salary affect intention of medical students to practice in rural area (Yunbo Qing, 2015) however, another study opposed that medical students pursuit of postgraduate study rather than higher salaries (Nicola Bailey, 2012). Exposure of facilitators to rural location, role models, working conditions; income, prestige, medical school environment, understanding of rural needs, intellectual challenge, attitude towards social problems, voluntary work, the influence of family, and length of residency impact the medical students to work in rural areas (E. Benjamín Puertas, 2013).
Most of the existing literatures recognize that the decision to migrate is the result of the interaction between several identifiable factors both from home and abroad which are expressed as push and pull factors. Different kinds of literature like, (Boyo, 2013, Harnmeijer, 2006, Gebremariam, 2010) push factors are conditions that can drive people to leave their homes, they are forceful and relate to the country from which a person migrates. A few examples of push factors are not enough jobs in your country; few opportunities; “Primitive” conditions; desertification; famine/drought; political fear/persecution; poor medical care; loss of wealth; and natural disasters. low pay (absolute or relative), poor working conditions, lack of resources to perform work in an efficient manner, limited career opportunities, limited education and further training opportunities, the burden of infectious diseases such as HIV/AIDS, unstable and dangerous working environment, economic instability (Minda, 2016, APHG, 2016, Harnmeijer, 2006, Maslow, 1970). Examples of pull factors are; better living conditions; religious freedom; enjoyment; education; better medical care; and security. Higher payment, better working conditions, well-financed health systems, attractive career opportunities, further education opportunities, political stability, travel opportunities (R Baral, 2015, APHG, 2016).
According to study conducted in public Hospitals of West Amhara, Northwest Ethiopia, Professional category, age, type of the hospital, non-financial motivators like performance evaluation and management, staffing and work schedule, staff development and promotion, availability of necessary resources, and ease of communication were found to be strong predictors of health worker motivation. Across the hospitals and professional categories, health workers’ overall level of motivation with the absolute level of compensation was not significantly associated with their overall level of motivation (Zemichael Weldegebriel, 2016).
All job satisfaction subscales like professional training, autonomy, and work environment and cohesion, promotion, recognition at work, perceived alternative employment opportunity and leadership relationship except benefit and salary subscale were significant predictors of overall job satisfaction. Satisfactions with the work environment and group cohesion, single cohesion, and working in the hospital were the final significant predictors of anticipated turnover of Sidama zone nurses (Agezegn Asegid, 2010).
Even though factors influencing health worker motivation are well established in the literature, little is known about the motivational factors that are of relevance to different categories of rural health workers in developing countries (Kumah, 2017).


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