Table 2.
Illustrative quotations
| Categories and sub-categories | Relevant studies (vote-counting) | Supporting quotations |
| I.Work environment | ||
| 1. Physical | Nine studies 31 38 40–46 | |
| 1.1. Working conditions | Eight studies 31 38 40–42 44–46 | |
| 1.1.2. Hospital infrastructure | Seven studies 31 38 40 42 44–46 | “Yes, it’s [the hospital] not really good for really working…” (Kotzee and Couper, 2006) |
| “I think we make our patients more sick in the hospital - somebody can come with one disease and go away with five diseases. The infection control is very poor mainly because the facility is so bad. Sometimes you have no soap to wash the hands. These are the hopeless situations when you are working in such a place that you feel very disgusted when you look at the bed, you look at the mattress on bed and you look at the bed sheets the patient is sleeping in.”(Luboga et al., 2011) | ||
| “Okay, you just go and look at the lavatories, especially in the public areas … That’s the consumer, but you know there are ways you can deal with that, and one of the ways to deal is that you have some sort of attendant, and constant cleaning of the lavatories. I mean a lot of patients come to me and … refuse to go to the lavatory because they say it’s so filthy… And that makes one feel very ashamed … Telephones get stolen… bed linen gets stolen, and you’re working in that environment… where there isn’t a blanket to put on the patient, there isn’t a pillow for her head and it’ s because things have been nicked. So and all of that you know is difficult.” (Ashmore, 2013) | ||
| “When you are engaged in work, it is difficult to survive in summer without air conditioning, because it is extremely hot in the summer in Guangxi, with peak temperatures even up to 40°C sometimes.” (Chen et al., 2017) | ||
| 1.1.3. Availability of resources | Seven studies 31 38 41 42 44–46 | “Okay firstly… our casualty… there is virtually nothing you know related to emergency…if you want to attend to an emergency patient there isn’t much you can use except maybe things like… IV lines…may be a drip stand; since I came here we didn’t have simple things like glucometers. So every time a patient comes and you want to do the glucose level you have wait for the lab to do it. Recently they have introduced some glucometers but they wok only for a few months… maybe there is one BP machine, which is used by two or three different wards. They have to wait until the other ward is done so they can go and borrow so it is – yeah – it is a problem” (Kotzee and Couper, 2006) |
| “Then another thing is equipment. We are doing operations but we do not have some equipment like theatre lights. After complaining we were given a tube for operation, but even in the whole ward we do not have enough lights. And can you imagine the whole of this hospital with only two oxygen concentrators? At least every ward should be having one or two. We have only one for the paediatric ward after complaining so long. So if you are using it on the child, and someone else needs it you either remove the child to die or you wait for the other to die.” (Luboga et al, 2011) | ||
| “…you are in the teaching facility. I mean you would love to have all the modern things like the books the overseas people are talking about and you would love to impart that knowledge onto your students. But we don’t have the equipment, I mean we have but you will find that they are outdated…” (Ashmore, 2013) | ||
| 1.2. Living conditions | Three studies 31 40 46 | “… the other most important thing is good accommodation; but anybody is going to struggle with accommodation they are not going to enjoy working there… you don’t want to wake up in the morning and know that you are going to share your bathroom with four other people and staff like that…” (Kotzee and Couper, 2006) |
| “…I joined BHU because I hoped to get a house to live; but the BHU residence is not worth living…” (Shah et al, 2006) | ||
| “Who will w willing to work in a BHU which doesn’t even have road access? I have to walk two kilometres daily to reach the main road leading to the BHU where I work.” (Shah et al, 2006) | ||
| 2. Social | Nine studies 31 38 40–46 | |
| 2.1. Relationships with nurses and auxiliary staff | Five studies 31 40 41 44 45 | “There is a difficulty I terms of the nursing staff and I don’t think when I was a registrar it was better. I think the staff were trained differently, they were trained in general nursing and then midwifery so the midwives instead of doing 3 months or whatever it is in midwifery and a general training so they’re less competent… the doctors picking up a lot of duties which the nurses should do automatically and they don’t…Which makes it far less satisfying for the doctor, and far more stressful because… you can’t trust the instructions are definitely going to be carried out.” (Ashmore, 2013) |
| “…it was shock to me, because in training people did not exist the nurse with as much power as she has today in the family health unit, it was a very big shock when I arrived… I see nurse being a doctor, I was horrified, so I asked myself: what I am doing here, what is left for me?” (Feliciano et al, 2011) | ||
| 2.2. Relationships with other physicians | Two studies 40 44 | “… it is very stimulating to work in a collegial and academic environment where you’re going to, you know, X-ray meetings and you’re on wards rounds, with consultants that are giving their different inputs…” (Ashmore, 2013) |
| “…what has helped keep me stimulated is even though we are in rural area there are so many visiting consultants coming from Wits and Garankuwa and Polokwane… Just knowing that there’s people coming every month or so that are interested in what you’re doing: that can support you and you can always ask them; it definitely improves the quality of your work and the job satisfaction and you feel less out of touch and that you’re doing the right thing, sometimes you need a bit of reassurance that you are doing the right things under the circumstances.” (Kotzee and Couper, 2006) | ||
| 2.3. Relationships with patients | Five studies 31 38 42–44 | “…some of my patients do not want to be informed or listen to me.” (Wallace and Brinister, 2010) |
| “Most patients with hypertension do not understand it. It is hard to convince them to come back to the clinic.” Wallace and Brinister, 2010 | ||
| “Sometimes they cursed and shouted at us. Even worse, some patients doubted the value of our medical services,” (Chen et al, 2017) | ||
| 2.4. Relationships with managers/supervisors | Five studies 31 40 43 44 46 | |
| 2.4.1 Respect | Two studies 40 44 | “I don’t think… [the administration]” quite realise the human resources they have available to them. I think sometimes they don’t actually realise they’re working with professionals, and they don’t treat us as such…” (Ashmore, 2013) |
| 2.4.2. Support | Two studies 44 46 | “You feel that you’re being hamstrung at every turn by the state you’re trying to do. They don’t make an effort to find out what’s required by people who are actually doing the job…” (Ashmore,2013) |
| 2.4.3. Recognition | Two studies 31 44 | “…In many other organizations, people with our skills and experience would be very highly valued and perceived as such. But you know here we don’t get perceived or treated like that at all… ” (Ashmore,2013) |
| 2.4.4. Autonomy | Two studies 43 46 | “…management gave appropriate autonomy to staff, while still providing adequate supervision.” (Luboga et al, 2011) |
| II. Rewards | ||
| 1. Financial | Eight studies 31 38–40 43–46 | “I am really willing to be a village doctor; it’s a good job, you know. However, the income is too low to subsist on. I must earn what I need for living. ” (Li et al, 2017) |
| “Now there are more and more people breeding silkworms. They even earn more than us (village doctors). ” (Li et al, 2017) | ||
| “Our main purpose (to work in BHUs) is salary; which does not match with our qualifications…” (Shah et al, 2006) | ||
| “I earned below 2000 RMB (USD 303) per month, and sometimes I work more than 14 hours in 1 day.” (Chen et al, 2017) | ||
| 2. Non-financial | ||
| 2.1. Career development | Five studies 31 40 44–46 | “… when you go into a job you need something that’s got a career path, and there aren’t career paths [in public]. There’s a few, a small little cadre at the top, a small group of people who get to principal or chief or specialist, and the rest of the people can spend their entire career as a senior specialist no matter how brilliant they are and much of a contribution they make.” (Ashmore, 2013) |
| 2.2. Professional development | ||
| 2.2.1.Learning opportunities | Five studies 31 40 41 44 45 | “…one of the things that is really distressing me for a few years, because [Family Healthcare Strategy] stopped doing the education work…” (translation) (Feliciano et al, 2011) |
| “Job satisfaction includes professional development, and there is no provision to allow us to further our qualification.” (Luboga et al, 2010) | ||
| 2.2.2.Teaching/research opportunities | One study 44 | “… it is good and interesting to have students around you. So the teaching component of it I’ve always found just varies your day. It adds a little bit of an extra dynamic to what your routines are, so it can be quite fan and it’s… a little bit challenging, and it just…adds spice to all your humdrum things.” (Ashmore, 2013) |
| 3. Social respect | Four studies 31 38 39 42 | “Although there have been many changes along with rapid development, patients still looks for me when they get sick because of my reputation. All their family members know me and come to me for help.” (Li et al, 2017) |
| “People hardly knew me when I just came back home for the job in 1998. At that time, patients didn’t know of my abilities. Everything was difficult. It got better several years later, as I worked longer.” (Li et al, 2017) | ||
| “Wherever we go, people respect us, just like we have some guarantee. We’re certainly satisfied by this.” (Li et al, 2017) | ||
| “People don’t consider a family physician important in their lives. They don’t appreciate their family physician, but they do specialists.”(Wallace and Brinister, 2008) | ||
| “Most of the patients here are local farmers. They are honest and full of integrity. They followed our advice and showed their appreciation to us.” (Chen et al, 2017) | ||
| III. Work content | ||
| 1. Workload | Eight studies 31 39 41–46 | “Too much workload now. I am in charge of only one village, with about 1500 residents. However, thy live dispersedly. One is here, while another is quite far away. I run around all day long, but still can only offer public health services for several households.” (Li et al, 2017) |
| “There is no time for my family and children.” (Wallace and Brinister, 2008) | ||
| “…the number of patients and the little time for consultation, so I have no conditions…” (translation) (Feliciano et al, 2011) | ||
| 2. Nature of work | Five studies 31 38 39 42 44 | |
| 2.1. Serving people | Four studies 31 38 39 42 44 | “…you feel like you’re making a tangible difference to people’s lives” (Ashmore, 2013) |
| “I like the work because you get to know entire families. My patients are like my extended family. When I get results, it makes me very happy.” (Wallace an Brinister, 2010) | ||
| “When my patients are cured after treatment, I feel so fulfilled and delighted. One patient still maintains contact with me. Our friendship began when he came to me with appendicitis. He has been well for 5 years now.” (Chen et al, 2017) | ||
| 2.2. Diversity | Two studies 42 44 | “You never know what the next case is. [Family medicine] forces you to use all the knowledge you learned at university” (Wallace an Brinister, 2010) |
| 3. Job security/stability | Three studies 31 44 45 | “…the public sector is rick solid, so you basically have to do something bad to get fired. So there is a high degree of certainty in your job…” (Ashmore, 2013) |
| 3.1.Safety | Three studies 31 44 45 | |
| 3.2.Physical | Two studies 31 45 | “Female physicians usually do not like to work in BHUs. The reason may be the lack of security…” (Shah et al, 2006) |
| 3.3.Legal | One study 44 | “In state you’ve got three levels of people below you, so if you’re…a state consultant, yes, you’ve got different stresses, you’ve got to give a lecture and you’ve got to give that, but I’m saying that’s a different type of stress. But on a clinical responsibility level, between you and the patients, there is an intern and registrar… So the family’s complaining… and that comes all the way through those two people before it gets you. So that’s like you’re three degrees removed.” (Ashmore, 2013) |
| IV. Managerial context | ||
| 1. Staffing levels | Seven studies 31 38 40 42–44 46 | |
| 1.1. Doctors’ and assistants’ deficiency | Five studies 31 38 40 44 46 | “…If you fell you can’t go away because there aren’t people to cover your work then it creates tension in your ability to care for people. So resources around you do matter…The deficit falls on you to work hard.” (Ashmore, 2013) |
| “There is only one medical assistant per family physician. That’s just not enough.” (Wallace and Brinister, 2010) | ||
| “We lack the doctors we need to provide adequate services. The shortage has pushed us to work longer. If more doctors could join us, that may ease our burdens.” (Chen et al, 2017) | ||
| 1.1.1. Retention | One study 44 | “I mean… in our department…to retain people is quite difficult, people work for a year or two then they go to private or they go off somewhere else. And for those posts to be filled again, it takes a lot of time… and in between people are frustrated.” (Ashmore, 2013) |
| 1.1.2. Absenteeism | Two studies 31 46 | “…30% posts of physicians in the province are filled and most of them do no attend to their duties regularly.” (Shah et al, 2006) |
| 1.1.3. Recruitment | Two studies 40 46 | “…They (managers) don’t advertise posts that are available, they’ll tell you in human resources that the posts are there but even if you qualify for the posts they tell that because it hasn’t been advertised, you can’t get into.” (Kotzee and Couper, 2006) |
| 1.2. Administrative staff deficiency | Three studies 42 44 | “…within every department there are the obvious managerial requirements that some people take up. So somebody might do the roster allocation, somebody might do the leave allocation, somebody might do the budgeting, all that kind of stuff within any department. And that is left mostly to the members of the department to do even though we have very little training or no training whatsoever in management.” (Ashmore, 2013) |
| *“There’s lots of paperwork, but it is easier now with the electronic medical record.” (Wallace and Brinister, 2010) | ||
| 2. Protocols and guidelines consistency | Four studies 31 41 44 46 | “…if the performance reports are not analysed properly, then no actions are expected. The performance appraisals currently in practice must be updated. Job descriptions do not exist in health department; older version of the documents needs to be updated.” (Shah et al, 2006) |
| “I think, medication prescription should be at the discretion of the physician…”(translation) (Feliciano et al, 2011) | ||
| 3. Political interference | Two studies 31 46 | “…Every patient is equal to us and we cannot give preference to a relative of a member of any political party. They try to influence us in several ways or they often threaten us to get us transferred to a remote BHU [Basic Healthcare Unit]” (Shah et al, 2016) |
| “We get political interference under decentralization…They look at negative aspects of our work and comment badly, coming anytime even after midnight to our homes. This is a member of parliament…” (Luboga et al, 2011) | ||