Having a better understanding of employees' job motivation is essential for public organizations.organizations yearn for job satisfaction from their workers, and per the eminent role of human resource on organization performance, the organizations endeavor to sustain utmost satisfaction of their employees. It is estimated that highly pleased employees would produce greater performance in best possible time which will boost income. When employees are content with their work, they will be more creative and innovative and offer progress that allows the company to evolve positively over time. More so, lack of job contentment will result in a low level of employee commitment and it will affect the performance and the success of organizational objectives. When employees are content with work, it will reduce the occurrence of stress and other bad attitudes towards work and thereby increase productivity. Therefore, it behooves on organizations that desire to advance their customer satisfaction to be highly anxious about its internal concerns related to employees' satisfaction and view their employees as their immediate customers (Oshagbemi, 2003; Farrell and Stamm, 1988).

Moreover, employees are the first customers and their behaviors have direct impacts on the image of the various institutions where they work, and due to that, bad treatment of employees will have a negative influence on institutions. It must, however, be noted that there are similar companies in the private sector offering similar services and so there is intense competition between private and public companies to gain higher portion of market shares. Moreover, since public organizations provide services directly to the general public without the aim of maximizing profit, quality services must be offered so that the citizens will get the satisfaction they deserve (Wright, 2007). It is, therefore, essential that the public institutions do well to motivate their employees if they seek an enhancement in performance and output. Public service motivation is the concept that encompasses individual motives that are chiefly, but not entirely, altruistic and grounded in public institutions (Perry, 2008). Understanding the needs of employees will inform companies to design an effective human resource management system that is able to motivate, attract, and retain their employees. This paper I will further look at the human resource management and then go ahead to describe how employees are motivated, and the empirical evidence of motivated employees which are fundamentally found in job satisfaction and theories related to job motivation, and determinants of job motivation.

The case study of this research is Ghana and so it is prudent to do a little introduction on Ghana. The Republic of Ghana is an independent country located along the Gulf of Guinea and the Atlantic Ocean in the sub-region of West Africa. Ghana covers approximately 238,535 km² with Burkina Faso, Ivory Coast, and Togo as neighboring countries. It is bordered on the south by the Gulf of Guinea. Ghana literally stands for `Warrior King' with its first state dating back to the 11^th Century. There were numerous kingdoms and empires that emerged over the years with the Ashanti kingdom standing out as the most powerful kingdom among the others. The British established their control over the then Gold Coast in the 19^th century and Ghana formally gained her independence on the 6^th of March, 1957 and became the first sub-Saharan African nation to be independent. With a population of about 27 million and 10 administrative regions, Ghana has oil reserves and produces petroleum gas, and is also regarded among top cocoa, diamond and gold producers in the world. Ghana is one of the sub-Saharan African countries making significant progress towards universal access to quality healthcare. However, there was a challenge and as a result, she could not attain set targets for the health-related Millennium Development Goals (MDGs) partly due to health sector human resource challenges such as low staff motivation. According to WHO estimates in 2008, there are certain major causes of death in Ghana. The graph below indicates the health risks and/or causes of death in Ghana:

Source: WHO, 2011

Purpose of the study

Hypothesis

Methodology

Research questions

1. What are the motivation indicators in the Ghana Public Health Sector?

Scope of the research

This research delves into the various theories of job motivation and motivation indicators in the public health sector of Ghana and makes an analysis on the effectiveness of job motivation in the Ghana Health Sector. The research shall probe into the issue of health worker migration in the Ghana health sector and examine the externalities there are. An evaluation will be made whether motivation and migration have effects on the provision of quality healthcare in Ghana.

Chapter one. Literature review

1.1 Introduction

1.2 Human resource management (HRM)

1.2.2 Human Resources in the Health Sector

Human resources are extremely important in the healthcare sector because it has an indelible effect on effective healthcare systems. It must be noted that the salaries of health professionals have a greater share of health budgets in many countries including Ghana. Human resource management systems in the healthcare systems are bound to lure health professionals to be motivated in order to ensure quality healthcare provision. When there are weak human resource managements systems that fail to motivate health workers, the greater impacts are felt in the rural areas where there are few health workers who work long hours. Unlike the urban centers that have many human and material resources, rural areas have limited resources for work and health workers in the rural areas feel isolated, and as a result, they tend to be demotivated. When these health workers are demotivated, they tend to either leave their jobs or migrate to the urban areas or even overseas when the need arises.

According to Campbell et. al., performance-based human resource management systems may decrease the probability that employees will make the decision to engage in altruistic helping behaviors (Campbell et. al., 2015). This confirms that if the human resource management systems in the health sector do not adequately meet the needs of the health workers, the health workers will not be willing to put in extra effort outside their prescribed duties. For example, doctors and nurses will not be willing to work for extra hours in times of emergencies if the available human resource management systems do not meet their needs. Good human resource management systems in the health sector will seek to address if not all, most of the concerns of health workers and it will ensure professionalism where physicians and nurses are willing to put in their maximum best on their jobs to ensure provision of quality healthcare to all persons.

1.3.1 Job Motivation

Motivating employees is a fundamental responsibility of employers if employers desire to attain their set targets within a set period of time. This paper begins with the meaning of motivation and then continues to establish some of the basic means or mediums by which employers can motivate their employees in a way that will cause the employees to feel highly motivated which will cause an increase in the organizational work output. The word motivation, traditionally coined from the word motus, from the verb movere, means to move, encourage or enthuse. Although job motivation is just a single factor in a chain of indicators, however, it is the most basic as the other indicators are fueled by it (Wright, 2001). Motivation is an art of compelling an individual towards achieving a particular goal. When someone is motivated to perform an assignment, he/she does it perfectly without thinking so much about the energy that will be exerted before the task is accomplished. More often than not, when a person feels motivated, the feeling drives him to put up his best as a means of showing his appreciation for the recognition shown him (Robbins, 2008). For example, if an employee is given a gold medal for being named as the employee for a particular month, it is hardly the case to see such an employee becoming lazy or unproductive on his job. That motivation stays with him all the time and he will always show his gratitude by working even much harder so that his employer will realize that he is really worth the honor, and also for the purposes of winning the award again and again. According to a research work by Wright in 2001, public managers can and must motivate public employees to pursue important purposes with intelligence and energy. It must also be noted that motivation is an individual phenomenon and as such, what motivates one person may not necessarily motivate the other. Individuals have different ideologies, ways of life, history, backgrounds and expectations and this is the main reason why it is difficult to assume unanimously that what motivates one employee will in the same case motivate the other employee.

The primary motive of job motivation is not to evaluate why employees act the way they do but to find out how best to motivate employees in order for them to perform their duties in a more precise and beneficial way (Wright, 2001). Another aspect of motivation is that it pertains to purpose, objective, and personal choice. Since motivation pertains to personal choice, it means that motivation is under the employee's control and he chooses to put in much effort and take action or vice versa. That notwithstanding, an employee's level of motivation can be influenced, however, only the employee himself chooses to be influenced. Due to this, managers cannot actually motivate employees and the best they can do is to influence employees to have them feel motivated (Bruce and Pepitone, 1998). This means that managers only have to provide the opportunities that will lure their employees to feel motivated so that the employees will put in their maximum efforts that will help attain organizational goals. It doesn't take millions of money to make an employee feel motivated and managers can simply extend a warm handshake, a smile, words of appreciation and encouragement, a small amount of money as a token, a bottle of drink or a small medal to hardworking employees as means of appreciation, and this will motivate the employee to act well on his job.

1.3.2 Types of Motivation

The concept of motivation can be explained as a fundamentally obscured act that comes from within an individual and causes him to be internally stimulated. This is what is called intrinsic motivation. When employees do best what they do without being influenced by external factors like money, fame or pressure from superiors, they are said to be intrinsically motivated (Bruce 1998). Intrinsic motivation, as the name implies, comes from within, and it is something that is innate in an individual and it is not influenced by external things. Workers who are less influenced by pay or physical motivating factors and who perform excellently on their jobs are those who are driven by intrinsic motivation and are therefore considered as altruistic employees. It is this internal passion they have that does not cause them to be influenced by their superiors or managers with money or other motivation incentives before they are challenged or cajoled to put up better performances on their jobs.

Moreover, Frey and Osterloh (2002) distinguish between three forms of intrinsic motivation - the first form of intrinsic motivation is when a person engages himself in an activity for its own sake just because they find the activity itself as a source of joy and satisfaction. Certain people love to do best what they do and in most cases, they don't rely on external things for inspiration. For example, a footballer - say Cristiano Ronaldo, or a musician - say Lil Wayne or J. Cole performs his playing of football or singing of songs so excellently well with much passion that is drawn from within themselves and not because their managers motivate them to do so. The second type of intrinsic motivation is drawn from activities which are dreary and unexciting, but their accomplishment is a source of pleasure to the employee. For example, when a worker, say a surgeon, is able to make an unusually delicate surgery on a dying patient - for example when surgeons at the Komfo Anokye Hospital in Kumasi performed a daring yet successful operation of a Siamese twins - or when a midwife is able to help a pregnant woman deliver her baby in a complicated labor. In both cases, the health practitioners realize a sense of achievement though the process was strenuous. This achievement motivates them and makes them know that they are capable of doing tedious and risky tasks and it even challenges them to work harder and harder on their jobs. The last but not least, the third form of intrinsic motivation is as a result of obedience to standards that drive people to act, and this may be ethical norms one feels the need to revere, or a form of commitment to group members. Despite its significance, many a time people act not merely because they are intrinsically motivated, but rather because external factors prompt them to take action (Ryan, 2000). The external factor that prompts or compels people to take action is labeled as extrinsic motivation. When an outcome of an activity is separable from the activity itself, it is the force called extrinsic motivation that caused it to be achieved. In other words, extrinsic motivation means the desire to satisfy needs or goals that are not related to the work itself, such as a work executed as a mere tool for earning money. Motivation, in a nutshell, is not an end in itself but rather a means to an end. This means that motivation is a form of tool that is used to get something done, and the ultimate goal of motivation is to influence an action that is geared towards output maximization.

Motivation is key in every workplace but that notwithstanding, motivation alone does not determine performance and that it is important to pay attention not to automatically team motivation with performance. This is because motivation is only one factor in a series of components that contribute to the level of employee performance. Motivation is also not to be confused with job satisfaction and performance should not be erroneously understood as productivity because certain bad work ethics count as motivated behaviors. In certain cases, in the public sectors, an employee may be extremely satisfied with work and yet he does not feel motivated to do his best on his job. This can empirically be verified in most public sector jobs where some employees are very pleased with the comfortability on their work such as good salaries and the security of their jobs, and yet have very little motivation to work. This particular problem is very inherent in almost all the public sector jobs in Ghana because, except for criminal cases or fraud, public sector employees in Ghana cannot be dismissed from their jobs - there is firm job security. Moreover, due to corruption, there is little or no supervision or checks at all, and so the employees, safe altruistic ones, don't exert required efforts toward work and they spend productive working hours surfing the web or interacting with their friends and families on social network platforms. Motivation may not necessarily have a direct effect on job satisfaction, performance, and productivity, but it has undoubtedly been found to be related to employee retention, thus indirectly influencing organizational costs associated with employee absenteeism and turnovers.

1.3.3 Effects of Motivation on Performances

Motivation is a very necessary tool for managers of institutions and organizations if they seek to increase the work input and output of their various organizations. In this section, this paper will identify and discuss some of the benefits that managers and their organizations as a whole will accrue if they resort to better means of motivating their employees. What makes motivation so important can be found in its relation to performance. Work performance has often been misrepresented as job motivation, and other indicators of performance such as task comprehension and environmental influences have been misrepresented. Most often than not, limited attention is given to job motivation while the primary concern revolves around performance. According to a research work by Wright, 2001, job motivation includes determinants such as job satisfaction, job characteristics (work content), employee motives as well as sector employment choice. Managers strive to attain organizational set targets by increasing efficiency and effectiveness, and although many factors contribute to productivity, job performance is viewed to be the most influential factor (Mitchell, 1982). As noted earlier, work motivation does not determine an employee's level of performance, but it merely influences his effort toward performing his given task. The role of motivation in performance, as noted in Mitchell (1982) can be summarized in the formula below:

Performance = Ability x Understanding of the task x Motivation x Environment

From the formula above, in order for an employee to perform well on his job, he/she first needs to have the knowledge and skills that are required for the particular job. Then, he must understand what he is required of him to do, and have the motivation to expand the effort to do so. Lastly, employees need to work in an environment that allows them to carry out the tasks given them effectively. The multiplication signs in the equation emphasize the importance of motivation - if motivation equals zero, even the most talented employee will not deliver his utmost best.

Moreover, there are certain characteristics that are particular of motivated employees. Most often than not, when employees are well motivated, there is always little or no incidence of employee turnovers, absenteeism, and low performance, among others. It is evident that when an employee is well motivated, he feels less stress, enjoys his work and as a result, has a better physical and mental health. Also, a well-motivated employee is probable to be more committed to his work and the organization and he shows less defiance to authorities. It can be empirically verified that when employees are highly motivated, they tend to be more creative, innovative, and responsive to customers, thus indirectly contributing to the long-term success of the organization (MANforum, 2009). It must, however, be noted that when employees are constantly neglected, their motivation to work decreases and they are likely to switch-off and resign inwardly which in the long run will go against productivity. Despite the fact that many employees are highly motivated when joining an organization, the majority of resignations tendered can be attributed to disappointments with/in their immediate supervisors (Robinson, 1997).

Many reasons have been identified as evidence why most managers in the public sectors fail to appropriately motivate their employees. Among some of the reasons include the inability of some managers to comprehensively understand the concept of motivation, how to appropriately administer motivation as a tool in order to effectively influence their employees to act properly on their jobs in order to attain organizational set targets. According to Wright, 2007, job motivation is a difficult concept and most people don't fully comprehend. Most public managers fail to appropriately motivate their employees because they take performance to mean motivation and they miss the opportunity to motivate their employees which later yields negative or bad consequences with negative externalities. In the milieu of motivation, a lot of theories results in poor implementation, and regardless of excuses, managers have to consent that employee performance, productivity, and retention are all depending notably on their ability to motivate. This applies to both the public and the private sectors, however, it takes more importance in the public sphere because the performance of governments and their administrations directly affect our society much more than any other private sector organization. It must, however, be noted that public sector jobs not only have greater variety but they also have more task significance as they serve the entire people in a given country or community. With such a large number of subscribers or consumers, it is therefore an opportunity for managers of public sector organizations and institutions to use that as an opportunity to put in place good mechanisms that will lure employees to put in their maximum efforts in order to get the best out of the employees which will, in the long run, ensure the provision of quality goods and services to the public.

1.4.1 The Number of Migrating Health Workers

Hitherto, movement of health workers in Africa was mainly internal and/or to other neighboring African countries, however, international migration, especially to Europe and USA, has become idealized as the only path to success, despite the hardship many migrants have to endure during the migration and integration processes. Africa as a continent is in need of many health workers in order for the continent to be able to meet the needed number of practitioners who will help to curb the pressures that are on health facilities across the continent. Ghana as a country in Africa is faced with this problem. Most often than not, there are extreme health problems in the rural areas in the country. According to the 2008 and 2014 Ghana Demographic and Health Survey (GDHS), a majority of health practitioners are found in the urban centers such as Accra in the Greater Accra Region and Kumasi in the Ashanti Region. In 2007, the national doctor-patient ratio was 10, 452, while each nurse took care of 1,251 patients. In the Upper East and Upper West Regions, the doctor-patient ratio was 40,502 in 2012 and 39,697 in 2014. According to the 2014 GDHS, the number of midwives reduced marginally from 4,032 to 3,863 in 2012 which predicted a negative consequence for maternal and child health. According to the 2003 Ghana Demographic and Health Survey, infant mortality, as well as mortality of children under 5 years, worsened due to the unprecedented rapid increase in recorded health worker emigration during that period. Health practitioners from Ghana keep emigrating and a research work by Stilwell in 2003 shows the huge numbers of registered health practitioners in the UK who were originally from Ghana, South Africa, and Zimbabwe.1.1 percent of the total number of registered doctors in the UK in 2003 were from Ghana (Stilwell, 2003). This is a huge deficit for Ghana because such a number of emigrated doctors will obviously cause a loophole in the health system of Ghana. The Ghana National Medical Council in 2003 came out with a list of health workers who emigrated from Ghana to different countries. The table below shows a verification of registered Ghanaian nurses in different countries as of 2004;

Source: Ghana National Medical Council (cited in DFID 2004)

Another research by Joseph Kofi Teye1 et. al, 2015, which captured a survey of 198 nurses and 46 doctors showed that 60 percent of nurses and 28 percent of doctors surveyed had the intentions of emigrating (Kofi Teye et. al, 2015). Many African countries find it difficult to retain their health workers and this has led to the high emigration of health professionals from Africa. This goes on to verify why there are serious health risks and high doctor-patient ratios across Africa. It is, therefore, important that countries across Africa try as much as possible to retain the few health workers they have and also to try as much as possible to draw other people to enter into the health field and help make the situation better across the continent. International migration is a major cause of this labor crisis in the health sector as significant numbers of health professionals are leaving Africa for Europe and America.