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 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. Majority of the health workers (86.8%) held permanent jobs. Similarly, 41.1% of health workers had alternative source of income among which 61.9% were engaged in private practice in clinics whereas 28.6% pursued agriculture to supplement their income. (Table 2).
Table 2 Socio-demographic and job related characteristics of the participant (n=151)
Variables
|
Frequency
|
Percentage
|
Age (IQ range: 32-44 years)
|
|
|
20-29
|
29
|
19.2
|
30-39
|
58
|
38.4
|
40 and above
|
64
|
42.4
|
Sex
|
|
|
Male
|
76
|
50.3
|
Female
|
75
|
49.7
|
Ethnicity
|
|
|
Brahmin/Chhetri
|
106
|
70.2
|
Janajati
|
22
|
14.6
|
Madheshi
|
19
|
12.6
|
Muslim
|
2
|
1.3
|
Dalit
|
2
|
1.3
|
Type of Health Facility
|
|
|
HP
|
119
|
78.8
|
PHC
|
32
|
21.2
|
Professional category
|
|
|
Sr. AHW and AHW
|
62
|
41.1
|
Sr. ANM and ANM
|
56
|
37.1
|
Health Assistant
|
12
|
7.9
|
Lab Assistant
|
12
|
7.9
|
Staff Nurse
|
5
|
3.3
|
Medical Officer
|
4
|
2.7
|
Type of service
|
|
|
Permanent
|
131
|
86.8
|
Temporary
|
20
|
13.2
|
Position level
|
|
|
Assistant
|
85
|
56.3
|
Officer
|
66
|
44.7
|
Working in home district
|
|
|
Yes
|
117
|
77.5
|
Higher qualification other than health science
|
|
|
Yes
|
67
|
44.4
|
Alternative Source of income
|
|
|
Yes
|
63
|
41.1
|
Source of alternative income (n=63)
|
|
|
Have own private clinic
|
39
|
61.9
|
Agriculture
|
18
|
28.6
|
Others
|
6
|
9.5
|
IQ, interquartile range
Work motivation status
The mean score of work motivation for individual items was higher for ‘team work’ (4.17) , ‘relationship between co-workers’ (4.15), and ‘clear work roles’ (3.97) while it was lower for ‘training’ (1.90), ‘available equipment’ (2.10) and ‘salary’ (2.13) (Table 3).
Work motivation as per domains was higher for team work (3.99) and responsibility (3.50) while it was lower for financial motivation (2.21) and career development (2.41). Work motivation was higher among health workers who were satisfied with their job than those not satisfied across all domains except availability of resources (Table 4).
Table 3 Mean scores of individual items of motivation
Item
|
Motivation items
|
Domain
|
Mean
|
SD
|
12
|
I enjoy the team with which I work at the health facility
|
Team work
|
4.17
|
0.67
|
15
|
There is a good relationship between co-workers in my health facility
|
Team work
|
4.15
|
0.68
|
16
|
Everyone working in the health facility have clear work roles.
|
Team work
|
3.97
|
0.83
|
5
|
I am happy with the amount of responsibility I am given.
|
Responsibility
|
3.95
|
0.98
|
14
|
There is a good collaboration between my facility and District Public health Office.
|
Organization and management support
|
3.89
|
0.74
|
13
|
I have a role while taking important decisions about the health facility where I work.
|
Responsibility
|
3.74
|
1.01
|
2
|
I feel that the work I do is not appreciated by the community. a
|
Recognition
|
3.72
|
1.02
|
19
|
Female Community Health Volunteers are doing a good job
|
Team work
|
3.66
|
0.97
|
21
|
Health is a priority of this Village Development Committee/Municipality
|
Organization and management support
|
3.45
|
1.08
|
11
|
Supervision from District health Office is in a supportive manner.
|
Organization and management support
|
3.17
|
1.11
|
20
|
My suggestions for the improvement of the health facility are not taken seriously by health facility in charge/District Public Health Office a
|
Organization and management support
|
3.13
|
0.99
|
18
|
There are enough staffs to provide quality care in the health facility.
|
Availability of resources
|
2.97
|
1.25
|
17
|
I do not get the opportunity to use my abilities at work. a
|
Responsibility
|
2.84
|
1.26
|
8
|
When I do a good job, I receive recognition from District Public Health Office for my work.
|
Recognition
|
2.78
|
1.22
|
1
|
I am satisfied with the government’s policy for further education for its employees.
|
Career development
|
2.66
|
1.43
|
7
|
Opportunity for promotion in the health service is so frustrating. a
|
Career development
|
2.53
|
1.30
|
3
|
Apart from salary, i am satisfied with the incentives i get.
|
Financial motivation
|
2.30
|
1.22
|
9
|
There are too few rewards for those who work at primary health facilities. a
|
Recognition
|
2.15
|
1.12
|
6
|
Remuneration for my job is adequate.
|
Financial motivation
|
2.13
|
1.17
|
10
|
The equipments in my working station are adequate and in good working condition.
|
Availability of resources
|
2.10
|
0.97
|
4
|
There are limited training opportunities for health personnel working in the community. a
|
Career development
|
1.90
|
0.96
|
a denotes negative statements and has been reversed during analysis
Table 4 Mean score of the overall perception and domains of work motivation with respect to job satisfaction level
Work motivation
|
Mean±SD
Total (n=151)
|
Job Satisfaction
|
p-value b
|
Not-Satisfied (n=36, 23.8%)
|
Satisfied (n=115, 76.2%)
|
Over all perception
|
3.11±0.48
|
2.74±0.51
|
3.23±0.40
|
<0.001
|
Team work
|
3.99±0.56
|
3.79±0.65
|
4.05±0.51
|
0.015
|
Responsibility
|
3.50±0.70
|
2.93±0.86
|
3.69±0.59
|
<0.001
|
Organization and Management Support
|
3.41±0.67
|
3.03±0.81
|
3.53±0.58
|
<0.001
|
Recognition
|
2.88±0.67
|
2.64±0.77
|
2.96±0.66
|
0.016
|
Availability of resources
|
2.53±0.87
|
2.33±0.77
|
2.60±0.90
|
0.115
|
Career development
|
2.36±0.88
|
1.86±0.72
|
2.52±0.87
|
<0.001
|
Financial
|
2.21±0.97
|
1.67±0.86
|
2.39±0.94
|
<0.001
|
b Independent samples t-test was computed with p value less than 0.05 considered as statistically significant
Factors associated with job satisfaction
Overall, 7.9% were very satisfied with their job and 68.2% were satisfied with their job. Similarly, 1.3% of health workers were very dissatisfied with their job and 22.5% were dissatisfied with their job (Table not shown).
In the bivariate analysis, age and time period of employment was significantly associated with job satisfaction while sex, ethnicity, professional category, educational qualification, position, type of health facility, working in home district and alternative income were not significantly associated with job satisfaction. Among seven motivation domains, availability of resources was not significantly associated with job satisfaction (p>0.05) while all other domains of work motivation were significantly associated (p<0.05). Overall motivation level was also statistically significant with job satisfaction (p<0.001).
Those factors which were significantly associated with job satisfaction in the bivariate analysis (p <0.05) were included in the multivariate model. Multiple logistic regression analysis found, after adjusting the effect of age, duration of employment and work motivation domains, health workers of age 40-59 years (AOR=6.75, 95% CI: 1.25-36.45) were significantly more likely to be satisfied than 20-29 years. Similarly, health workers who were not satisfied with career development (AOR=0.20, 95% CI: 0.06-0.62 -) and financial motivation (AOR= 0.33, 95% CI= 0.11-0.99) had significantly lower odds of job satisfaction as compared to those who were satisfied (Table 5).
Table 5 Factors associated with job satisfaction
Variables
|
Job Satisfaction
N (%)
|
Crude OR
(95%CI)
|
Adjusted OR
(95%CI)
|
Yes (n=115)
|
No (n=36)
|
Age
|
|
|
|
|
20-29
|
17 (58.6)
|
12 (41.4)
|
Ref
|
Ref
|
30-39
|
41 (70.7)
|
17 (29.3)
|
1.70 (0.67-4.32)
|
2.19 (0.62-7.32)
|
40 and above
|
57 (89.1)
|
7 (10.9)
|
5.75⃰ (1.96-16.89)
|
6.75⃰ (1.25-36.45)
|
Time period of employment
|
|
|
|
|
0-15 years
|
52 (68.4)
|
24 (31.6)
|
Ref
|
Ref
|
>15 years
|
63 (84.0)
|
12 (16.0)
|
2.42⃰ (1.11-5.31)
|
1.16 (0.34-3.94)
|
Career development
|
|
|
|
|
Not satisfied
|
57 (64.8)
|
31 (35.2)
|
0.16 (0.06-0.44)
|
0.20 (0.06-0.62)
|
Satisfied
|
58 (92.1)
|
5 (7.9)
|
Ref
|
Ref
|
Recognition
|
|
|
|
|
Not satisfied
|
47 (68.1)
|
22 (31.9)
|
0.44 (0.20-0.95)
|
0.57 (0.22-1.47)
|
Satisfied
|
68 (82.9)
|
14 (17.1)
|
Ref
|
Ref
|
Responsibility
|
|
|
|
|
Not satisfied
|
43 (63.2)
|
25 (36.8)
|
0.26 (0.12-0.59)
|
1.78 (0.68-4.69)
|
Satisfied
|
72 (86.7)
|
11 (13.3)
|
Ref
|
Ref
|
Financial
|
|
|
|
|
Not satisfied
|
60 (66.7)
|
30 (33.7)
|
0.22 (0.08-0.56)
|
0.33 (0.11-0.99)
|
Satisfied
|
55 (90.2)
|
6 (9.8)
|
Ref
|
Ref
|
Organizational and management Support
|
|
|
|
|
Not satisfied
|
40 (64.5)
|
22 (35.5)
|
0.34 (0.16-0.74)
|
1.12 (0.40-3.12)
|
Satisfied
|
75(84.3)
|
14 (15.7)
|
Ref
|
Ref
|
Team Support
|
|
|
|
|
Not satisfied
|
28 (59.6)
|
19 (40.4)
|
0.29 (0.13-0.63)
|
0.50 (0.19-1.34)
|
Satisfied
|
87 (83.7)
|
17 (16.3)
|
Ref
|
Ref
|
⃰ Significant at p value <0.05
Findings from the in-depth interview
Work motivation status among health workers
Career development
Majority of the health workers mentioned that inadequate career development opportunities affected their work motivation. Unpaid study leave and lack of reservation for public sector health workers in the academic institutions were identified as hindrance for further education and promotion. Similarly, selection for training opportunity did not consider equity, young age and performance.
‘The government does not let us develop our skills and it does not promote to higher position. Those who want to study will have to take unpaid leave. Who will study in this environment?’ [Health assistant]
Availability of resources
Majority of the health workers mentioned that their health facilities lacked adequate resources mainly proper infrastructure and, necessary medicines and equipment. Inadequate availability of resources has decreased public trust on 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 office. 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 sufficient 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 market rises.
‘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 Officer]
Recognition
Some health workers were dissatisfied 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 the community people.
‘There is no appreciation and encouragement from the DPHO. Performance of health workers is not assessed. What cost will it take to give a certificate to recognize the work done by us?’[AHW]
Management support
Health workers demanded the need of regular supervision and feedback system, evaluation of performance, availability of office 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 mentioned above, the other factors that affected work motivation was 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 Sr. AHW in taking leadership of the health facility.
In qualitative analysis, permanent nature of the job was perceived as a factor for job satisfaction. However, health workers expressed that there was inadequate investment of government in primary health facilities and the government was focusing only on the health indicators and not on the health system issues. Moreover, they were burdened with administrative works. They also expressed dissatisfaction with the transfer system and government attention towards health workers working in primary health facilities.
‘If there is anything to motivate about the job, it is the permanent job. Once you enter into the service, it will be difficult to leave the job. Only ambitious people leave their job. In our context, at least for paramedics, very few leave their job’. [Health Assistant]