Perceived reward adequacy as a key mechanism for retaining medical doctors in health systems: A structural equation modelling study

Background: Retaining medical doctors remains a major challenge for health systems, particularly in low- and middle-income countries (LMICs), where workforce instability undermines continuity of care and service delivery. Although total rewards are widely used to improve retention, it remains unclear whether doctors stay because rewards are available or because they perceive them as fair and adequate. Aim: To examine whether reward adequacy and reward expectation mediate the relationship between total rewards and medical doctor retention. Setting: The study was conducted in public healthcare facilities in Ghana. Methods: A quantitative cross-sectional survey was conducted among 400 medical doctors recruited through stratified facility-level sampling. Data were collected using a structured questionnaire and analysed using Statistical Package for the Social Sciences (SPSS) version 26 and SmartPLS version 4. Partial least squares structural equation modelling assessed measurement validity and bootstrapped direct and indirect effects. Results: Total rewards had no significant direct effect on retention intention (β = 0.048, p = 0.507). Total rewards positively influenced reward adequacy (β = 0.689, p < 0.001), and reward adequacy positively influenced retention intention (β = 0.623, p < 0.001). Reward adequacy significantly mediated the total rewards–retention relationship (β = 0.429, p < 0.001), whereas reward expectation did not. Conclusion: The retention value of total rewards depends primarily on doctors’ perceptions of adequacy, fairness and sufficiency. Health systems should prioritise transparent and equitable reward structures rather than relying solely on financial and non-financial incentives. Contribution: The study identifies reward adequacy as the principal mechanism through which total rewards influence medical doctor retention in an LMIC primary healthcare context.