Beyond pay: how facility quality and career incentives shape rural health worker preferences in Ghana

Shortages and maldistribution of frontline health workers remain a major barrier to rural health service delivery in Ghana. While pay increases are often viewed as the primary lever for improving recruitment and retention, fiscal constraints have intensified interest in non-wage incentives. We conducted cadre-specific discrete choice experiments with 206 community health officers (CHOs) and 404 community health volunteers (CHVs) across eight districts in four regions to elicit preferences for job attributes. For CHOs, although higher salaries increase job attractiveness, facility quality—including reliable utilities, essential equipment, and staff accommodation—exerts the strongest influence on job choice, followed by career development opportunities and transport support; increased supervision has no measurable effect. For CHVs, facility quality is also most valued, followed by training opportunities and recognition-based incentives, whereas small stipends have comparatively limited marginal effects. Willingness-to-pay estimates and policy simulations indicate that upgrading facilities can generate larger increases in predicted job acceptance than comparable increases in compensation. These findings suggest that, beyond pay, improvements in working and living conditions and structured professional development can play a central role in multi-faceted strategies to recruit and retain rural frontline health workers.