Work motivation and job satisfaction among health workers at primary health facilities: a cross-sectional study from Nepal

Abstract


Background
Human resources for health (HRH) is one of the six building blocks of an effective health system [1] and is considered strategic capital and input to attain health outcomes [2].Developing countries face a shortage of HRH both geographically and professionally, and their health systems are largely supported by mid-level heath workers.Further, skill mix imbalance, inadequate competency, migration and deployment, and performance and retention related issues are major HRH problems in developing countries [3] .
Work motivation and job satisfaction are related but different aspects which affect the performance of health workers [4].Work motivation is affected by extrinsic and intrinsic factors [5] and nancial factors alone are not su cient to motivate health workers [6,7].Job satisfaction improves retention and is achieved by improving working conditions, participation in decision making, responsibility for work, supportive leadership and management and professional development [4].Although neither job satisfaction nor motivation is directly observable, they are critical to the retention and performance of health workers [8,9].
Nepal is a country among 57 global and six South East Asia Region (SEAR) nations with a critical shortage of HRH [6,10].Nepal has only 0.17 physicians and 0.50 nurses per 1000 population and the health workforce mainly comprises non-clinical supporting personnel (37.65%) and paramedical practitioners (18.16%) [11].Primary health facilities comprise 198 Primary Health Centers (PHCs) and 3808 Health Posts (HPs) throughout the country; these are based at community level [12].The PHCs have sanctioned posts for one medical doctor, one staff nurse, one lab personnel and paramedical practitioners while HPs have paramedical practitioners only [13].The paramedical practitioners include Health Assistants (HAs), Auxiliary Health Workers (AHWs) and Auxiliary Nurse Midwives (ANMs).The vocational training periods of HAs, AHWs and ANMs are 36, 15 and 18 months, respectively.Similarly, staff nurses and medical laboratory technician have a 3-year training period in their respective areas.
There are also cadres like Village Health Workers (VHWs) and Maternal and Child Health Workers (MCHWs) who are responsible for community-based services in the area of maternal and child health including immunization, and reproductive health.
Before the implementation of federalism in 2017, District Public Health O ces (DPHOs) had a central role in managing primary health facilities, which are now overseen by local governments with technical support from health o ces in district level [14].Health workers working in primary health facilities cater to the needs of the majority of people.The performance of health workers depends on their work motivation and job satisfaction.There is inadequate evidence to guide performance management of health workers in Nepal and other similar settings [15,16].Although several studies have been conducted on motivation and job satisfaction in other developing countries [6], very little is known about health workers in Nepal.Similarly, job satisfaction of those working in primary health facilities is often missed in such studies.This study addresses the research gap by identifying the determinants of job satisfaction of health personnel working in primary health facilities.The evidence will be useful for informing human resource management policy in Nepal and countries that share similar settings.

Study design and setting
This was a health facility based cross-sectional study conducted in Jhapa district of Eastern Nepal.
Jhapa district was chosen because the health sector performance of the district ranked in average among 75 districts of Nepal.According to the census of 2011, the district had a population of 812,650 [17].There were 246 health workers in 50 primary health facilities (six PHCs and 44 HPs) in Jhapa.
Additionally, Jhapa has one secondary hospital and private sector hospitals and clinics.Though different types of HRH work in health system of Nepal like general practitioner and medical specialists, public health professionals, Ayurveda and other complementary medicine practitioner, pharmacists and diagnostic personnel, they are not included in the study as the PHCs and HPs do not comprise of such human resource.

Sampling and study participants
Among the total six PHCs and 44 HPs, 5 PHCs and 35 HPs were randomly selected.The study participants included all health workers working in the selected health facilities at the time of the study.

Study tools
For the quantitative study, a structured self-administered questionnaire was used comprising three sections (i) socio-demographic characteristics and job related information; (ii) 21 Likert scale items under seven domains to measure work motivation and (iii) one item questionnaire to measure job satisfaction.
The tool to measure work motivation was developed based on motivational theories [5,18] and earlier work [6,19] .
The items of work motivation were analyzed across seven domains: career development (three items), recognition (three items), responsibility (three items), nancial motivation (two items), organization and management support (four items), availability of resources (two items) and team support (four items).
Study participants were asked to indicate their level of work motivation on a ve-point Likert scale: strongly disagree (1), disagree (2), neither agree nor disagree (3), agree (4) and strongly agree (5).Job satisfaction was the outcome variable and was assessed on a four-point Likert scale: strongly dissatis ed (1), dissatis ed (2), satis ed (3) and strongly satis ed (4).Extensive literature review, pretesting of the tool and consultation with subject experts was done to re ne the tool.The internal consistency of the items was assessed using Cronbach's alpha (0.72) and was considered su cient [20].A guideline was provided to the study participants for completing the self-administered questionnaire.To minimize the response bias, balance of negatively worded questions was maintained in Likert scale items.

Data collection
Before data collection, we conducted a meeting with the respective in-charges and health workers of the selected health facilities to share study objectives and seek permission.The questionnaire was distributed to health workers in their o ce and lled questionnaires were collected the same day or the next day.A total of 151 of 175 health workers (86.3%) completed the questionnaire.In-depth interviews were conducted concurrently with 16 health workers who were selected purposively from different professional categories -one District Public Health O cer, two health assistants, two staff nurses, two ANMs and nine AHWs.
For the qualitative study, in-depth interviews were conducted using the interview guideline, which focused on the motivating factors present in the job, job satisfaction status and actions required to improve work motivation and job satisfaction.Data were collected from January to March2016.

Data management and analysis
Data entry was done in EpiData (version 3.1) and data were analyzed using IBM SPSS Statistics 20.
Descriptive statistics were presented as frequencies, percentages, mean and median.Work motivation for individual items and each domain was represented by mean and standard deviation.In the work motivation domains, the value equal to or above the mean score was categorized as 'satis ed' and those below as 'not satis ed'.The difference in work motivation among participants who were or who were not satis ed with their job was assessed using an independent t-test.A Chi-square test was run to demonstrate the association between categorical independent and dependent variables.Thereafter, those variables signi cant in the bivariate analysis were tted in a logistic regression model to measure the predictors of job satisfaction.To check co-linearity, we calculated the variance in ation factor (VIF) and detected no problem among the independent variables (highest, VIF, 2.02) that would bar their inclusion in analysis.Both unadjusted and adjusted Odds Ratios (OR) were calculated.Statistical signi cance was set at p < 0.05.
The in-depth interviews were transcribed from audio scripts by the rst author and then translated from Nepali into English Transcripts were studied and analyzed under three main themes (Table 1).

Ethical considerations
Written informed consent was obtained from the research participants before data collection.
Participants were assured of con dentiality of their information by explaining the objectives of the study and the use of information for the study purpose.Study participants were informed clearly about their ability to opt out of the study at any point without providing justi cation for doing so.Ethical approval was obtained from the Institutional Review Board of the Institute of Medicine, Tribhuvan University, Kathmandu (Reference number: 159/2016).

Socio-demographic and job related characteristics
The median age of the study participants was 38 years and 50.3% were male.Ethnicity wise, 70.2% of health workers belonged to the Brahmin/Chhetri group.Most of the health workers were AHWs (41.1%) and ANMs (37.1%).The median period of employment in government service and current health facility was 174 months (IQ range: 80-228 months) and 25 months (IQ range: 10-86 months), respectively.The majority of the health workers (86.8%) held permanent jobs.Similarly, 41.1% of health workers had alternative source of income; 61.9% were engaged in private practice in clinics whereas 28.6% pursued agriculture to supplement their income (Table 2).3).
Work motivation as per domains was higher for team work (3.99) and responsibility (3.50) while it was lower for nancial motivation (2.21) and career development (2.41).The overall perception of work motivation was 3.11 ± 0.48 which indicates that health workers were neither motivated nor demotivated in their job.Work motivation was higher among health workers who were satis ed with their job than those not satis ed across all domains except availability of resources (Table 4).Factors associated with job satisfaction Overall, 7.9% of respondents were very satis ed with their job and 68.2% were satis ed with their job.Similarly, 1.3% of health workers were very dissatis ed with their job and 22.5% were dissatis ed with their job.
In the bivariate analysis, age and time period of employment was signi cantly associated with job satisfaction while sex, ethnicity, professional category, educational quali cation, position, type of health facility, working in home district and alternative income were not signi cantly associated with job satisfaction.Among seven motivation domains, availability of resources was not signi cantly associated with job satisfaction (p > 0.05) while all other domains of work motivation were signi cantly associated (p < 0.05).Overall motivation level was statistically signi cantly related to job satisfaction.
Factors which were signi cantly associated with job satisfaction in the bivariate analysis (p < 0.05) were included in the multivariate model.Multiple logistic regression analysis demonstrated that, after adjusting the effect of duration of employment and work motivation domains, health workers of age 40-59 years (AOR = 6.75, 95% CI: 1.25-36.45)were signi cantly more likely to be satis ed than those aged 20-29 years.Similarly, health workers who were satis ed with career development (AOR = 5.03, 95% CI: 1.62-15.67)and nancial motivation (AOR = 3.08, 95% CI = 1.01-9.38)had signi cantly higher odds of job satisfaction compared with those who were not satis ed (Table 5).

Availability of resources
The majority the health workers mentioned that their health facilities lacked adequate resourcesmainly proper infrastructure and necessary medicines and equipment.Inadequate availability of resources has decreased public trust in primary health facilities, and hence affected their work motivation.
'We demand for medicines and equipments but there is no timely supply from the district public health o ce.We have to bear the complaints of the public'.[Staff nurse] 'The government is busy with announcements like hypertension drugs will be given for free.But the government does not see the shortage of drugs.We have to give answers to the public that we don't have su cient drugs.' [AHW] Financial factor Most of the health workers perceived that current remuneration was inadequate to meet their living expenses, including child care and education, and suggested revision based on the cost of living.
'Government provides low salary, does not promote us and does not take care of our further education.
Then, how shall we be accountable for the government?Only if health workers are staying is because of their private clinics.' [Health Assistant] "Financial motivation is low for health workers.However, increasing salary alone will not help to increase stay of health workers in health facilities unless proper code of conduct for health workers are made and implemented".[District Public Health O cer] Recognition Some health workers were dissatis ed with the higher authorities due to lack of proper recognition of their work.They complained that performance of health workers was not assessed and reward system was non-functional.They however expressed happiness with the support received from people in the community.
'There is no appreciation and encouragement from the DPHO.Performance of health workers is not assessed.What cost will it take to give a certi cate to recognize the work done by us?'[AHW]

Management support
Health workers demanded regular supervision and a feedback system, evaluation of performance, availability of o ce operation expenses and encouragement from the DPHO.
'Health system in district level is running as it is.Through review meeting, we are given feedback but this does not help much'. [AHW] Besides those mentioned above, other factors that affected work motivation were: low priority given to the health sector by the local governments, trade union politics in case of transfer and those close to power receiving training opportunities, and seniority row between health assistant and Senior AHW in taking leadership of the health facility.

Discussion
Higher age, career development and nancial motivation were the determining factors of job satisfaction in our study population.Motivational score was the lowest for nancial motivation.The qualitative ndings con rmed that the existing remuneration was inadequate to cover health workers' living expenses, including schooling for their children.A signi cant 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 [19], Kenya [21], Ethiopia [22] and South Africa [23].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 nding from a study done in Nepal in 2012 [25].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 [26], India [27], Pakistan [28] and Ethiopia [22].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 satis ed than younger health workers in our study, which might be due to lower expectations.Studies from China [19], Cyprus [29] and Nepal [24] had similar ndings while younger health workers were more satis ed in Ethiopia [30].
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 [31].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 [11] 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 Regarding job satisfaction, permanent nature of the job was perceived as a in uencing factor.However, health workers expressed that there was inadequate investment of government in primary health facilities and the government was focusing only on health indicators and not on health system issues.Moreover, they were burdened with administrative tasks.They also expressed dissatisfaction with the transfer system and government attention toward health workers working in primary health facilities.
'If there is anything satisfying about the job, it is the permanent job.Once you enter into the service, it will be di cult to leave the job.Only ambitious people leave their job.In our context, at least for paramedics, very few leave their job'.[Health Assistant] health workers worked for more than 10 years in their position [31].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 [3].
Nepal's National Health Policy 2019 [34] has identi ed 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 [35] and there is more concentration on primary health facilities and their health workers, where the burden of the health system lies [36].Lack of a formal motivation scheme can leave these health workers feeling abandoned [37].A motivated and satis ed 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 nancial and non-nancial motivation, and distribution [38,39].
Interestingly, a large proportion of health workers were satis ed 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 nding 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 satis ed 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 ndings are in accordance with the published research in developing countries [6] suggesting that the identi ed issues are genuine and require appropriate interventions.

Strengths and limitations
This paper 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.

Conclusion
Higher age of health workers and satisfaction with career development and nancial motivation signi cantly increased job satisfaction among health workers.Additionally, resource availability in the health facility, recognition of work and management support affected work motivation of health workers and eventually job satisfaction.Based on the study ndings, it is recommended to improve nancial motivation and career development opportunities as well as increase investment in primary health PK conceived the study, conducted the survey and wrote the rst draft of the manuscript.PA supported in data analysis and reviewing the manuscript.BPC and SO provided academic supervision of the study and made critical revision on the manuscript.the authors reviewed, read and nalized the manuscript.

Table 1
Themes and categories for data analysis.

Table 3
Mean scores of individual items of motivation a denotes negative statements and has been reversed during analysis a Independent samples t-test was computed with p value less than 0.05 considered as statistically signi cant