Higher age, career development and financial motivation were the determining factors of job satisfaction in our study population. Motivational score was the lowest for financial motivation. The qualitative findings confirmed that the existing remuneration was inadequate to cover health workers’ living expenses, including schooling for their children. A significant proportion of service providers in our study worked in private clinics for additional income. This shows that health workers perceived that the existing salary and incentives were inadequate. Financial factors have been reported as associated with job satisfaction in studies around the world, including in China , Kenya , Ethiopia  and South Africa . As remuneration is linked with meeting personal and family needs, we suggest the government increases the salaries of health workers to improve job satisfaction.
In this study, career development was associated with job satisfaction, which is in line with previous studies conducted in Nepal [15, 24]. Unpaid leave and lack of quotas for government staff for further education has affected the career ladder for these health workers. Interestingly, there are government quotas only for pursuing post-graduate studies, which has hampered the professional growth of mid-level health workers. Health workers perceived training opportunities as scarce and inequitable, which was similar to a finding from a study done in Nepal in 2012 . Inadequate career development opportunities affects job satisfaction and ultimately the performance of health workers and the health system as a whole; this is supported by studies done in Nepal , India , Pakistan  and Ethiopia . We thus suggest the need of in-service interventions such as further education and training opportunities for health workers working in primary health facility settings. Older health workers were more satisfied than younger health workers in our study, which might be due to lower expectations. Studies from China , Cyprus  and Nepal  had similar findings while younger health workers were more satisfied in Ethiopia .
The HRH in primary health facilities are the major service providers for rural Nepal. This is also true for other developing countries including Tanzania, Malawi and South Africa . The job satisfaction of these cadres is essential for obtaining desired health outcomes, particularly as specialized health workforce like doctors are scarce and are more likely to work in private hospitals  and urban areas or migrate to foreign countries because of limited opportunities [32, 33]. Health workers at primary health facilities stayed longer in the job. Similar phenomena were observed in Tanzania and Malawi where health workers worked for more than 10 years in their position . They are less likely to migrate to other countries because of the permanent nature of the job and non-transferable degree, which is better suited to the local context .
Nepal’s National Health Policy 2019  has identified further education, in-service training and professional development opportunities for HRH development. However, there is little focus on improving working conditions and providing management support  and there is more concentration on primary health facilities and their health workers, where the burden of the health system lies . Lack of a formal motivation scheme can leave these health workers feeling abandoned . A motivated and satisfied health workforce is thus crucial to attaining policy objectives and efforts should be made to design interventions taking into account the contextual realities of the country. In the context of federal governance in Nepal, provincial and local governments (municipalities) can play an important role for addressing HRH issues with a focus on financial and non-financial motivation, and distribution [38, 39].
Interestingly, a large proportion of health workers were satisfied with their job although overall perception of work motivation was neither favorable nor unfavorable. Though quantitative results showed type of service (permanent or temporary) not associated with job satisfaction, qualitative finding indicated that permanent nature of the job contribute to job satisfaction. Further study might be required to validate permanent nature of job as a determinant of job satisfaction. In the qualitative results, health workers perceived inadequate availability of resources as a factor affecting their work motivation. Health workers were not satisfied with the infrastructure, shortage of drugs, equipment and supplies, which in turn affect community, trust in them. This spells out the need to invest in primary health facilities for improving the work environment and work morale of health workers, and increasing community trust. The study findings are in accordance with the published research in developing countries suggesting that the identified issues are genuine and require appropriate interventions.
Strengths and limitations
This paper provides a comprehensive perspective regarding work motivation and job satisfaction among primary health workers by employing both quantitative and qualitative methods in a low resource setting. The study limitations include the small sample size and heterogeneous nature of health workers, which hindered quantitative analysis by professional group. Self-reporting bias might have occurred in the responses.