Improving Job Satisfaction and Motivation Among Health Professionals in the Public Health Sectors in Ethiopia: Evidence from a Repeated Cross-Sectional Study

Improving Job Satisfaction and Motivation Among Health Professionals in the Public Health Sectors in Ethiopia: Evidence from a Repeated Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Improving Job Satisfaction and Motivation Among Health Professionals in the Public Health Sectors in Ethiopia: Evidence from a Repeated Cross-Sectional Study Zeine Abosse Anore, Jemal Mohammed Ali, Tegbar Yigzaw Sendekie, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7150387/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Healthcare professional satisfaction is a critical component of effective health service delivery. However, many low-income countries face persistent challenges in maintaining high levels of job satisfaction among their health workforces. This study aims to assess changes in job satisfaction and motivational factors among health professionals in Ethiopia by comparing data collected in 2022 with baseline data from 2014. Methods : A repeated cross-sectional study design was employed to compare job satisfaction and motivational factors among health professionals in 2014 (n = 1,356) and 2022 (n = 1,655). Data was collected using a validated 35-item job satisfaction tool and key informant interviews. Quantitative data were analyzed using descriptive statistics, t-tests, and point-biserial correlation coefficients. Qualitative data were analyzed using thematic approaches. Results : Overall job satisfaction increased significantly by 16 percentage points (50.8% in 2014, 66.8% in 2022, p<0.001). Significant improvements were observed in salary and benefits (mean score 0.5, 95% CI [0.44, 0.56], p < 0.001), professional and career development (mean score 0.4, 95% CI [0.03, 0.33], p < 0.001), workload (mean score 0.2, 95% CI [0.14, 0.26], p < 0.001), Human Resources for health management (mean score=0.1, 95% CI [0.04, 0.16], p = 0.009), and working conditions (mean score 0.1, 95% CI [0.06, 0.14], p < 0.001). Qualitative findings also revealed perceived improvements in salary, financial incentives, and performance evaluations but highlighted persistent dissatisfaction with salary levels and inconsistencies in the performance evaluation process. Conclusion : Ethiopia has made notable progress in enhancing job satisfaction among health professionals by strengthening human resources for health (HRH) management, increasing financial incentives, and expanding opportunities for career development. Despite this progress, challenges remain, including gender, age, and regional disparities, low salary levels, and inadequate education opportunities. Addressing these issues with targeted interventions and integrating comprehensive incentive schemes into the broader developmental agenda will be crucial for fostering a resilient and motivated health workforce, ultimately enhancing health service delivery and contributing to the country's health sector transformation. Health professionals Job satisfaction Health facility HRM intervention Ethiopia Background Health professionals are the foundation of the healthcare system [ 1 ]. Health systems perform well in delivering standard health services only when they have sufficient, competent, motivated, and equitably distributed health professionals [ 2 ]. Globally, the health sector continues to grapple with critical challenges, including shortages of health professionals and their uneven distribution across regions [ 3 ]. The problem is significant and serious in low- and middle-income countries, including Africa. Africa's health professional crisis is driven by multiple factors including insufficient training capacity, rapid population growth, weak leadership and management of health professionals, and ineffective retention strategies [ 4 , 5 ]. Ethiopia is one of the low-income countries listed by the World Health Organization as facing health professional challenges [ 6 ]. Employees spend a significant portion of their time at work, so if their job does not provide adequate satisfaction or worse, leads to dissatisfaction they may feel unhappy or unfulfilled for much of the workday [ 7 , 8 ]. Job satisfaction refers to a positive or enjoyable emotional response that arises from evaluating one's job or work-related experiences [ 8 ]. It can also be described as the degree to which health professionals are satisfied or dissatisfied with their jobs based on their assessment of the work or job along a continuum from favorable to unfavorable, including everyone's work experiences, feelings about their job, and various aspects of their job [ 8 , 9 ]. Employee satisfaction is crucial, as it can significantly influence the behavior of healthcare workers, affecting both their well-being and the performance of the organizations [ 9 ]. Job dissatisfaction may harm an organization by increasing absenteeism, turnover, and inefficiency, potentially reducing productivity and performance [ 10 ]. In contrast, high levels of job satisfaction among employees can enhance organizational productivity and effectiveness [ 9 , 11 ]. Healthcare organizations continue to face challenges in sustaining high levels of employee satisfaction [ 1 ]. Studies show that job satisfaction levels among health professionals in low- and middle-income countries differ significantly. A systematic review revealed that 32% of physicians and dentists in middle-income countries experienced burnout levels exceeding the high-risk threshold, while 60% expressed overall satisfaction with their jobs [ 12 ]. In Ethiopia, many health professionals report dissatisfaction with their jobs and existing incentive structures, which is consistent with findings from other low-income countries [ 13 ]. Moreover, recent studies and systematic reviews in Ethiopia revealed notable variability in job satisfaction across regions, professional categories, and public and private healthcare settings [ 14 – 18 ]. Specifically, healthcare professionals working in primary and general hospitals in Ethiopia report higher job satisfaction than their counterparts in tertiary hospitals [ 19 ]. Analyzing the determinants of job satisfaction and motivation is crucial to fostering optimal work environments, as it contributes to increased productivity, reduced stress and employee turnover, and improved standards of patient care [ 1 , 3 ]. Studies in sub-Saharan African countries have identified various factors influencing the job satisfaction of health professionals, including age, job category, years of service, perceived preparedness, communication and recognition from managers, high stress levels and burnout, the work environment, and the number of hours worked each week [ 1 , 3 , 4 ]. In Ethiopia, employee satisfaction has been positively influenced by factors such as effective supervision, a conducive work environment, and access to professional growth opportunities. Additionally, the security of the working environment, coworker relationships, good relationships between supervisors and staff, and opportunities for further education play significant roles in improving healthcare workers' job satisfaction. Adequate supportive supervision and rewards such as recognition have been documented as key drivers of health professionals' job satisfaction [ 16 , 20 , 21 ]. Over the past eight years, the Ministry of Health in Ethiopia, in collaboration with stakeholders, has implemented human resource for health management interventions aimed at enhancing job satisfaction, motivation, performance, and productivity of health professionals. The key interventions included the development of tailored financial and nonfinancial incentives, creating a supportive work environment, improving availability and access to professional development opportunities, and reviewing career structures. These comprehensive interventions were designed and implemented to create a robust, well-supported, and highly motivated workforce capable of meeting Ethiopia's growing healthcare needs and contributing to the overarching goal of achieving universal health coverage (UHC) [ 22 ]. Despite ongoing efforts to improve working conditions for the health workforce in Ethiopia, there is limited evaluative evidence on whether these interventions effectively enhance job satisfaction and motivational drivers among health professionals. Therefore, we conducted a study to assess improvements in job satisfaction among health professionals and to identify the motivational drivers influencing job satisfaction over time. Our goal was to generate insights that could inform the design and implementation of the next iteration of the Human resources for health (HRH) strategy. Using healthcare management frameworks, we analyzed changes in job satisfaction and the key factors contributing to it among health professionals in the public sector. By comparing our findings with baseline data from 2014, we offer a comprehensive view of the evolving dynamics within the health workforce. Methods Study Design and Setting The study employed a repeated cross-sectional design to assess and compare improvements in job satisfaction among health professionals in 2022 with findings from 2014. Study Population and Sampling In both the 2014 and 2022 studies, the study populations included medical doctors, nurses, midwives, anesthetists, and health officers. In addition, the 2022 study included pharmacists’ pharmacy technicians, and medical laboratory professionals and technicians upon recommendation by the Ministry of Health. In 2014, the estimated population of targeted health professionals consisted of 1,544 medical doctors, 38,916 nurses, 5,203 midwives, 417 anesthetists, and 4,782 health officers across 3,465 public health facilities [ 23 ]. In 2022, these numbers significantly increased to 17,665 medical doctors, 103,107 nurses, 23,333 midwives, 1,879 anesthetists, 33,172 health officers, 20,673 medical laboratory professionals/technicians, and 32,374 pharmacists/pharmacy technicians operating in 4,207 public health facilities (health centers and hospitals) [ 24 ]. Workplace distributions indicated that medical doctors and anesthetists predominantly worked in hospitals, whereas nurses, midwives, health officers, pharmacists, and medical laboratory professionals were deployed in hospitals and health centers. The study employed a two-stage cluster sampling design in both study periods. In the first stage, health facilities were selected, followed by the selection of health workers within those facilities. Nationally representative sample sizes for health professionals were calculated separately for each study period. The sample sizes were determined based on a 95% confidence level, a 5% margin of error, a design effect of 1.2, and a 10% nonresponse rate [ 25 ]. In the absence of prior national-level estimates on job satisfaction, a sample size of 1,356 health professionals was determined in 2014. The calculation was based on an assumed job satisfaction prevalence of 50%, which is a standard approach when no reliable baseline data are available. For the 2022 study, the sample size was adjusted to 1,655 health workers, considering the job satisfaction levels from the 2014 study, which were 41.6% at the hospital level and 60.2% at the health center level [ 26 ]. A total of 224 health facilities comprising 107 hospitals and 117 health centers were randomly selected for the 2014 study. In 2022, a new sample of 165 facilities, including 85 hospitals and 80 health centers, was used to assess progress and changes over time. The list of facilities was provided to the data collectors, who randomly chose individual health workers to participate in the study. In 2014, 16 health professionals (four from each profession) were randomly selected from each facility. In the 2022 study, 12 health professionals (two from each profession) were sampled from each hospital, and six health professionals (one from each profession) sampled from each health center. Owing to the limited number of anesthetists, all available anesthetists working in the hospitals on the day of data collection were included in both study periods. In 2022, 24 human resources managers and 18 senior health professionals from 32 health facilities, the Ministry of Health, and eight regional health bureaus were invited to participate as key informants in in-depth interviews. The objective of these interviews was to gather qualitative insights into the changes in motivational factors following the implementation of the human resources management intervention over the last six-year period. Data collection tools and procedures The 2022 study employed a validated job satisfaction tool created by Management Science for Health (MSH) and previously used in the 2014 study [ 26 ]. The tool consists of 35 questions that address various job-related attributes, including salary, benefits, professional development, human resources for health (HRH) management, working and living conditions, workload, and job security (Table 1 ). Responses were captured via a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Overall job satisfaction was assessed via a global job satisfaction scale developed by Warr, Cook, and Wall [ 27 ] that evaluates overall job satisfaction with the following statement: "Considering everything, I am satisfied with my job," rated on a scale from 1 (strongly disagree) to 5 (strongly agree). Additionally, key informants and in-depth interview guides were developed and employed to gather insights from human resources managers and health workers regarding their perceptions of improvements in both financial and non-financial incentives since the implementation of the National Human Resources for Health (HRH) strategic plan (2016–2025). All questionnaires were translated into local languages to ensure that the participants understood the questions. Electronic data collection was conducted from May to June 2014 and again from June to July 2022 via the Kobo Toolbox. Qualitative data were collected in addition to quantitative data. Data collectors received training on how to administer the tools and adhere to research ethics. They explained the study's objectives to participants and provided written consent forms. Face-to-face interviews were conducted in private settings to ensure secrecy. Qualitative interviews (KIIs) were audio-recorded and supplemented with field notes. The research team monitored the data collection procedures daily to maintain quality. Table 1 The 35 items of job satisfaction grouped across nine domains Satisfaction domain and items Salary and benefits (3 items) - My salary package is fair - My salary is fair compared to other staff with the same level of responsibility - My benefits are fair compared with other staff at my level Professional and career development (2 items) - I feel there are sufficient opportunities for promotion with my employer - I have access to coaching and mentoring when needed Job (3 items) - The job is a good match for my skills and experience - My job description is clear and up to date - I have been given the training that I need to succeed in my position HRH management (7 items) - I receive recognition for doing good work - My supervisor applies personnel policies and practices fairly to me - I have a current work plan developed with my supervisor - My annual performance appraisal is based on my work plan - I feel that the organization values my work - My supervisor is available when I need support - The head of this health facility is competent and committed Moral satisfaction (3 Items) - I would encourage my friends and family to seek care here - I consider myself a part of the local community that I am serving as a health worker - I feel that the community values my work Working conditions (10 Items) - The facility takes specific measures to protect me against HIV/AIDS and other occupational hazards - I have a good relationship with my coworkers. - Overall, the morale level in my team or work group is good - I have the working equipment I need to do my job well and efficiently, such as ultrasound, X-ray, and blood pressure cuffs - This facility has good access to drugs and medications - My workspace is clean - At work, I have access to safe, clean water - At work, I have good access to electricity - At work, I have good internet connectivity - Safe and efficient transportation to work Living conditions (4 Items) - At home, I have access to safe, clean water - At home, I have good access to electricity - I have access to good schooling for my children - The community where I live has good shopping and entertainment Workload (2 Item) - My workload is reasonable - I can take time to eat lunch every day Job security (1 Item) - I am not worried about losing my job Data Management and Analysis The data were exported from the Kobo Toolbox to SPSS to conduct both descriptive and inferential statistical analyses. Means, percentages, and standard deviations were calculated to ensure the consistency and completeness of the data. The outcome variable "overall job satisfaction" was categorized into "satisfied" (combining "strongly agree" and "agree") and "not satisfied" (combining "strongly disagree," "disagree," and "neutral"). The motivational factors were organized into nine subscale categories: salary and benefits (3 items), professional and career development (2 items), job (3 items), HRH management (7 items), moral satisfaction (3 items), working conditions (10 items), living conditions (4 items), workload (2 items), and job security (1 item) (see Table 1 ). Composite mean scores for each subscale were calculated, with scores ranging from 1 to 5. Descriptive and inferential statistical analyses were performed, and an independent samples t-test was used to compare the proportions of job satisfaction and composite mean scores of the motivational factors across the two study periods. The point-biserial correlation coefficient (r pb) was calculated to assess the relationship between job satisfaction level (a dichotomous variable) and the composite mean scores of motivational factors (continuous variables). This analysis aimed to determine the contributions of human resource management interventions (motivational factors) to improving job satisfaction levels across the two study periods. Following Cohen's guidelines for assessing effect size, we computed the coefficient of determination (CD = r²) to quantify the proportion of variance in job satisfaction explained by variation in motivational factors. This proportion ranges from 0 (indicating no shared variance) to 100% (indicating complete shared variance), which helps to identify key contributors to job satisfaction improvement. We used Cohen's effect size benchmarks for correlation coefficients (r-family) to interpret the results: A correlation coefficient of less than 0.1 (C D < 1%) has no effect. 0.1 < = r < 0.3 (1%<=CD < = 9%) has a small effect. 0.3 < = r < 0.5 (9%<=CD = 0.5 (CD > = 25%) has a large effect [ 28 ]. P values < 0.05 and 95% confidence intervals were also used for making statistically significant decisions. We utilized NVivo 12 software for qualitative data analysis, employing thematic approaches to examine, code, display, and interpret the interviews. To ensure trustworthiness, methodological integrity, and comprehensive documentation while avoiding reductionism, we meticulously documented each step of our process. We selected health professionals and human resource directors for their rich experiences and diverse insights into job satisfaction among health professionals. The qualitative interview questions were designed to ensure that the findings apply to both groups. Verbatim quotations and detailed narratives were incorporated to represent participants lived experiences and ensure the credibility of the qualitative findings. Ethical considerations Ethical clearance was obtained from the Institutional Review Boards of both the Ethiopian Public Health Institute (EPHI) and Johns Hopkins University. Support letters from the Ministry of Health were sent to the Regional Health Bureaus and the participating health facilities to facilitate effective communication between the data collectors and facility managers. Before participation, eligible individuals were provided with comprehensive information about the study, including its potential benefits and risks, and were informed that participation was entirely voluntary. Confidentiality and privacy were rigorously maintained throughout the study. The data collectors adopted a nonjudgmental and empathetic approach, ensuring that the participants fully understood their rights, including the freedom to decline participation or withdraw from the study at any time without consequence. Results Characteristics of Study Participants In the 2014 study, a total of 1,356 health workers from 222 health facilities participated, whereas in the 2022 study, 1,655 health workers from 165 facilities were included. The response rate was 100% in 2014 and 94.4% in 2022. In both studies, more than half of the participants were male: 60.2% in 2014 and 68.9% in 2022. The proportion of young adults aged 20–29 years was 72.4% in 2014, whereas it was 47.1% in 2022. Most participants held undergraduate qualifications in both years, with 95% in 2014 and 96% in 2022 (Table 2 ). Table 2 Characteristics of the study participants by study period Characteristics 2014 2022 N = 1356 N = 1655 P value (Chi-square) n (%) n (%) Sex Female 540 (39.8) 515 (31.1) < 0.001 Male 816 (60.2) 1140 (68.9) Age in years 20–29 982 (72.4) 780 (47.1) 30–39 250 (18.4) 763 (46.1) < 0.001 40+ 124 (9.1) 112 (6.8) Profession Medical Doctor 375 (27.7) 224 (13.5) Nurse 424(31.3) 260 (15.7) Anesthetist 253(18.7) 153 (9.2) < 0.001 Midwife 177(13.1) 250 (15.1) Health Officer 127(9.4) 257 (15.5) Pharmacist - 254 (15.3) Medical Laboratory - 257 (15.5) Highest educational qualification Postgraduate (specialty or MSc+) 68(5.0) 60 (3.6) Undergraduate (BSc or MD) 676(49.8) 1141 (68.9) < 0.001 Diploma/certificate 612 (45.2) 454 (27.4) Marital status Single 784(57.8) 680 (41.1) < 0.001 Married 572(42.2) 975 (58.9) Residential House Own 129(9.5) 223 (13.5) Rent 740(54.6) 1129 (68.2) < 0.001 Provided by health facility 418(30.8) 197 (11.9) Live with parents 69(5.1) 106 (6.4) Birthplace Urban 721(53.2) 1114 (67.3) Rural 635(46.8) 541 (32.7) < 0.001 Health facility type Health Center 660(48.7) 522 (31.5) Primary Hospital 225(16.6) 567 (34.3) < 0.001 General Hospital 278(20.5) 364 (22.0) Specialized Hospital 193(14.2) 202 (12.2) Improvements in job satisfaction levels Job satisfaction increased by 16 percentage points from 50.8% in 2014 to 66.8% in 2022 (95% CI of the change: 12.5%, 19.5%, P < 0.001). Satisfaction among female workers increased by 12%, while satisfaction among male workers rose by 19%. Notable gains were observed in anesthetists (25.7%), health officers (20.1%), postgraduates (23.6%), and workers in Amhara (18.0%), Oromia (16.1%), and SNNP (15.0%) between 2014 and 2022 (Table 3). Table 3 Job satisfaction levels by characteristics of the study participants and study period Characteristics 2014 2022 Difference in job satisfaction rate (95% C.I) P value N = 1356 N = 1655 N (%) N (%) (a) (b) (b-a) Overall, Job satisfaction level 689 (50.8) 1105 (66.8) 16 [12.5, 19.5] < 0.001 Sex Female 315 (58.3) 364 (70.7) 12.4 Male 376 (46.1) 741 (65.0) 18.9 Age in years 20–29 482 (49.1) 517(66.3) 17.2 30–39 128 (51.2) 513(67.2) 16 40+ 81 (65.3) 75 (67.0) 1.7 Type of profession Medical doctor 147 (39.2) 118 (52.7) 13.5 Nurse 260 (61.3) 179 (68.8) 7.5 Midwife 114 (64.4) 105 (68.6) 4.2 Anesthetists 108 (42.7) 171 (68.4) 25.7 Health officer 62 (48.8) 177 (68.9) 20.1 Medical laboratory - 175 (68.1) - - Pharmacist - 180 (70.9) - - Qualification Postgraduate (MSc+) 27(39.7) 38 (63.3) 23.6 Undergraduate (BSc) 297 (43.9) 718 (62.9) 19 Diploma/certificate 367 (60) 349 (76.9) 16.9 Birthplace Urban 341(47.3) 750 (67.3) 20 Rural 350 (55.1) 355 (65.6) 10.5 Type of working health facilities Primary Hospital 93 (41.3) 370 (65.3) 24 General Hospital 125 (45) 238 (65.4) 20.4 Referral Hospital 75 (38.9) 114 (56.4) 17.5 Health Center 398 (60.3) 383 (73.4) 13.1 Region Amhara 186 (60.4) 247 (78.4) 18 Oromia 177 (39.7) 207 (55.8) 16.1 SNNP 136 (51.3) 169 (67.1) 15.8 Addis Ababa 36 (39.6) 95 (50.8) 11.2 Others** 156 (63.4) 387 (73.0) 9.6 ** includes Harari, Dire Dawa, Somali, Afar, Benishangul Gumuz, and Sidama Improvements in Motivational Factors Job satisfaction among healthcare professionals showed notable improvements in several key areas between 2014 and 2022. Satisfaction with salary and benefits increased significantly, with a mean score difference of 0.5 (95% CI [0.44, 0.56], p < 0.001), indicating better compensation packages. Professional and career development opportunities also increased substantially, with a mean score difference of 0.4 (95% CI [0.03, 0.33], p < 0.001). However, moral satisfaction slightly declined, with a mean score difference of -0.1 (95% CI [-0.15, -0.05], p = 0.001). Overall, the composite mean score of job satisfaction rose from 3.2 to 3.4, with a mean score difference of 0.2 (95% CI [0.16, 0.23], p < 0.001), reflecting cumulative positive changes across various motivational factors (Table 4). Table 4 Improvements in health professionals’ motivational factors between the 2014 and 2022 study periods. Characteristics Number of items 2014 2022 Mean score difference (95% C.I) P value (n = 1356) (n = 1655) Mean score (SD) (maximum mean score = 5) Mean score (SD) (maximum mean score = 5) Salary & benefits 3 2.1(0.85) 2.6 (0.79) 0.5 [0.44, 0.56] < 0.001 Professional and career development 2 2.8(0.99) 3.2 (0.80) 0.4 [0.03,0.43] < 0.001 Job 3 3.4(0.89) 3.4(0.70) 0 [-0.06, 0.06] 1 HRH Management 7 3.3(0.92) 3.4(0.68) 0.1 [0.04, 0.16] 0.009 Moral satisfaction 3 4.1(0.75) 4.0 (0.57) -0.1 [-0.15, -0.05] 0.001 Working conditions 10 3.0(0.64) 3.1(0.54) 0.1 [0.06, 0.14] < 0.001 Living conditions 4 2.8(0.80) 2.9(0.73) 0.1[ 0.45, 0.16] 0.004 Workload 2 3.5(0.94) 3.7(0.73) 0.2 [0.14, 0.26] < 0.001 Job security 1 3.9(1.22) 3.9(0.97) 0 [-0.08, 0.08] 1 Composite Mean Score - 3.2 (0.54) 3.4(0.41) 0.2 [0.16, 0.23] < 0.001 Total Items 35 Self-Perceived Improvement in Benefits and Working Conditions Between 2014 and 2022, healthcare professionals in Ethiopia reported notable improvements in job satisfaction across several key areas. Statistically significant gains were observed in the availability of essential supplies, with 43.8% of respondents reporting positive changes, particularly in health centers (44.6%), compared with hospitals (32.7%) (p = 0.011). Salary improvements were reported by 38.9% of the respondents. Additionally, the availability of working equipment improved significantly, especially in hospitals (44.3%), compared with health centers (24.8%) (p < 0.001). Access to higher or postgraduate education also improved, with 13.4% of professionals reporting better opportunities overall. Hospital staff reported significantly greater access (23.8%) than did health centers (12.7%) (p = 0.001) (Table 5). Table 5 Health professionals’ perceived improvements in benefits and working conditions over the past eight years (before the study period of 2022) Areas of improvement Percent of respondents who reported perceived improvement Health center (%) Hospital (%) P value Total (%) Availability of supplies to do your job, such as drugs, gloves, needles, bandages, sutures, disinfectants 44.6 32.7 0.011 43.8 Salary 39.4 33.4 0.197 38.9 Duty allowance 35.8 34.9 0.872 35.7 Supportive supervision, coaching, and feedback 31.9 41.2 0.071 32.7 Availability of working equipment to do your job well, such as ultrasound, X-ray, and lab machines 24.8 44.3 < 0.001 26.2 Opportunities for in-service training or continuing professional development 24.9 23.3 0.659 24.8 Opportunities for promotion or growth 23.6 22.6 0.859 23.6 Access to higher or postgraduate education 12.7 23.8 0.001 13.4 Other benefits, such as housing allowance or free housing, free medical care, transportation allowance 11.2 6.8 0.141 10.9 Risk allowance 10.3 9.7 0.784 10.3 Factors Contributing to Job Satisfaction Improvements Human Resources for Health (HRH) management was the strongest driver of job satisfaction, with a point-biserial correlation coefficient of r = 0.42 (17.6% effect size) in 2014 and r = 0.33 (10.9% effect size) in 2022. Salary and benefits also played a key role, with r = 0.34 (11.6% effect size) in 2014 and r = 0.30 (9% effect size) in 2022. Professional and career development, with r = 0.33 (10.9% effect size) in 2014 and r = 0.25 (6.3% effect size) in 2022. Additionally, the impact of workload on job satisfaction weakened, with r = 0.22 (4.8% effect size) in 2014 and r = 0.16 (2.6% effect size) in 2022. Job security had the weakest effect, dropping from r = 0.17 (2.9% effect size) in 2014 to r = 0.04 (0.2% effect size) in 2022 (Table 6). Findings from Key Informant and In-depth Interviews The findings from qualitative interviews with health managers and senior health professionals were categorized into six key themes: salary and financial incentives, performance evaluation and career development, professional development, amenities and supplies, leadership, governance and management, and non-financial incentives. Salary and Financial Incentives Health professionals and human resource managers reported meaningful improvements over the past six years in salaries and financial incentives including duty pay, risk, hardship, and positional allowances. These changes were generally welcomed as positive steps forward. However, many expressed ongoing frustration with the overall salary structure, feeling it fails to fairly reflect the level of effort and responsibility their roles require. This concern has been further intensified by the rising cost of living, which continues to erode the real value of their earnings and fuels a persistent sense of dissatisfaction. "How can we manage to cover our expenses with 7,000 Ethiopian Birr salaries during this period of high inflation, especially when necessities such as 5 liters of oil cost 1,000 Birr, house rent is 2,000 Birr, and a bar of soap costs 35 Birr?" — A health professional. Health professionals noted that the establishment of private wings within hospitals allowed them to work outside regular hours, resulting in additional income and increased motivation. "One positive change that has brought satisfaction is the creation of private clinics/wings in hospitals. These allow professionals to work outside normal hours and receive extra compensation. However, improvements are still limited, as these wings lack inpatient services and essential resources, although they provide some motivation,” a medical director from the hospital. Performance Evaluation and Career Development Health professionals and HR managers reported improvements in performance evaluation over the past six years. Performance evaluations are now conducted regularly every six months and are linked to educational and career development opportunities. "There are positive changes in performance evaluation. For example, performance evaluation was only conducted when there was career development or competition for educational opportunities. Now, for the past two years, assessments are done every six months," a health professional from the Regional Health Bureau. An HR manager from the Regional Health Bureau elaborated: "Our organization conducts performance evaluations continuously every quarter, with results summarized and documented twice a year. For example, the performance result of an organization was 86% over the last six months. "If an individual's performance is rated at 86.5%, I will not approve it unless strong evidence is provided showing that their performance exceeds that of the hospital or unless evidence is presented to demonstrate that they stand out from the rest of the team." However, some health professionals reported that performance evaluations were not always conducted according to guidelines, with concerns over evaluators, standardization of evaluation methods, and transparency. "Efficiency in performance evaluation has been a source of conflict. Performance evaluations are conducted without our awareness. No one is informed about the evaluation process, as it is performed invisibly by a committee of department heads. They neither share the evaluation criteria with us nor inform us when our performance is being assessed. The committee members receive marks above 90%, while the rest of us are rated in the 70–80% range, even though we do most of the actual work." — Health professional. The participants also reported improvements in career development processes, which increased their motivation. However, some health professionals disagreed with the policy requiring education or study leave to be undertaken on weekends to count toward career development. "Career advancement is possible until the staff reaches the peak career level. However, if a staff member pursues further education, the years spent on education will not be counted for career development unless it is done on weekends. Additionally, the staff must maintain an efficiency rating of 65 and above for six consecutive performance evaluations." — Human resource manager from the Regional Health Bureau. Professional development There has been a shared concern among health professionals and HR managers regarding the limitation of educational opportunities in recent years. However, some participants from the Addis Ababa, SNNP, Oromia, and Afar regions noted that sufficient educational opportunities for general practitioners to pursue specialty programs still exist, which has improved motivation and satisfaction among medical doctors. Nevertheless, opportunities for other health professional staff have significantly decreased. "In the past two to three years, we have maintained a commendable record of sending staff for further education. For instance, this year, 11 newly employed physicians received educational opportunities." — Human resource manager from the Regional Health Bureau. Amenities and Supplies Several participants reported improvements in the availability of electricity, water, medical supplies, and equipment during the 2022 study period. However, issues such as frequent power outages and inadequate water supply, particularly in rural areas, persist. Increased budget allocation for medications and healthcare financing reforms, which allow facilities to use their funds to address supply gaps, have contributed to these improvements. Additionally, the drug request system has enhanced supply management. However, drug shortages continue to be a significant issue, often requiring patients to purchase medications from external pharmacies. "We spent approximately 900,000 Birr on drugs purchased this year. This amount is insufficient, given the increasing number of patients, particularly with the increase in community-based health insurance. Even with the increased budget for medications, it still falls short owing to the growing influx of patients." — Health professional from a health center. Leadership and Governance Management Most participants noted improvements in accountability. Whereas decisions were previously made solely by individual managers, they are now made collaboratively, with official approvals involving two or more officials. Many health professionals and HR managers have observed improvements in regular supportive supervision at the individual, unit, and institutional levels. Supportive supervision is conducted using a standardized checklist, and constructive feedback is provided to help professionals enhance their service delivery. However, some participants reported a lack of uniform supervision practices. While some managers conduct regular supervision and provide feedback, others do not, and the issues identified during supervision are not always addressed. "They ask us about the problems we are facing, but they don't address our concerns even when we bring them up frequently. We don't even get a blood pressure apparatus. All our concerns are 'received' by managers who do not act." — Health professional. Nonfinancial incentives Participants identified additional incentives such as housing, health insurance, and access to subsidized food items. However, the majority noted no significant improvements in the availability of residential housing or housing allowances. An exception was noted by some participants from the Oromia and Amhara regions, who reported receiving a monthly housing allowance of 1,000 Birr specifically for specialists and medical doctors. However, the houses provided lacked basic infrastructure and utilities such as electricity and water, making them unsuitable for living. "The facility provides houses, but they are difficult to live in as there is no water, electricity, kitchen, or recreational areas. The location of the houses is also inconvenient, situated in open fields with nothing nearby to refresh oneself." — Health professional. Most participants reported improvements in the availability of groceries, as health facilities now offer household items such as edible oil, teff, and sugar at subsidized prices through cooperative shops. "We know other workers are given various food items such as edible oil, flour, and other materials at affordable prices via their cooperative shops, supported by the government. Thus, we also need similar distributions for various items." — Hospital HR Manager. Discussion Despite progress in health professionals' job satisfaction and human resource management, Ethiopia continues to face challenges related to low health worker performance primarily driven by low motivation, job dissatisfaction, and poor working conditions (18, 21). Efforts to address these issues have been guided by the Health Sector Transformation Plan (HSTP) and Human Resources for Health (HRH) Strategy, which concentrates on structural reforms (22, 29). This study provides a temporal analysis of health sector reforms by examining trends in job satisfaction among health professionals from 2014 to 2022, using a repeated cross-sectional study design. The study identified a notable rise in job satisfaction among health professionals in Ethiopia, showing a 16-percentage-point increase between 2014 and 2022. The findings of this study are harmonious with studies conducted in Ethiopia and other African countries, demonstrating a consistent trend toward achieving job satisfaction among healthcare professionals (30–33). The findings of this study reveal significant differences in job satisfaction enhancement among health professionals, pressing both areas of progress and those that demand further attention. These differences are evident across various demographic and professional characteristics, such as gender, age, geographic location, type of health facility, and specific health profession, as detailed below. Compared to their male counterparts, female professionals experienced less enhancement in job satisfaction; still, a gender gap remains. This gap may stem from factors such as work-life balance challenges and variations in professional tasks and prospects. Addressing gender-specific dynamics within healthcare systems is essential for achieving equal improvements in job satisfaction. Younger health professionals, particularly those aged 20–39, reported the greatest improvements in job satisfaction. In contrast, older professionals experienced minimal change, suggesting the presence of systemic barriers that may disproportionately impact on more experienced staff. Geographically, job satisfaction changes were most notable in the Amhara, Oromia, and SNNP regions, whereas professionals in resource-limited regions endured more limited changes. These differences may be driven by factors such as limited capital, weaker leadership, and a lower capacity to apply customized motivational strategies in resource-limited regions. The type and condition of the health facility where professionals work significantly influence their level of job satisfaction. Health professionals working in health centers reported the greatest improvements in job satisfaction, indicating notable advancements in their work environment and support systems. In contrast, health professionals working at hospitals showed more modest enhancements, probably due to ongoing challenges such as overcrowding and high caseloads, which may continue to impact staff morale and limit further progress. These patterns align with findings from South Africa, Uganda, and Ethiopia, where gender, age, health facility type, and geographic differences have been shown to impact job satisfaction (34–38). This highlights the need for targeted strategies to address the unique challenges faced by different aspects of health professionals' job satisfaction, including inadequate advancements across all regions and health facility types. Health professionals who attain advanced educational qualifications consistently report greater job satisfaction. This underscores the transformative power of education and career development in cultivating a motivated, empowered, and deeply fulfilled healthcare workforce (39). Between 2014 and 2022, Ethiopia made substantial advancements in the job satisfaction of health professionals, largely due to targeted interventions aimed at expanding payment and other benefits, improving working conditions, enhancing professional development opportunities, and strengthening support systems for health professionals. These findings align with research from low- and middle-income countries, including those in Sub-Saharan Africa, where improved working conditions and opportunities for career advancement have been linked to higher levels of job satisfaction among professionals (12, 30). Our study also revealed that payment-related factors are predictors of job satisfaction among Ethiopian health professionals. This finding is consistent with previous research conducted in Ethiopia and other international contexts, which consistently identifies fair and competitive compensation as a key determinant of job satisfaction and motivation among health professionals (1, 12, 40). Encouragingly, the study also highlights significant progress in access to professional development opportunities and career advancement factors long recognized for their role in enhancing motivation and improving retention among health workers. Similar results have been found in South Africa and India, where creating better career development opportunities has helped reduce staff turnover and improve the performance of health professionals. The findings underscore the pivotal role of career development in fostering a resilient, motivated, and high-performing health workforce an essential foundation for sustainable health systems (41, 42). Improving satisfaction with workload reflects a growing global emphasis on preventing work-related stress. Increasingly, international literature highlights the importance of maintaining balanced workloads to promote long-term employee engagement and overall well-being (43). HRH operation practices have also served as central contributors to job satisfaction. Strong links were observed between satisfaction and effective HRH operation systems, including the use of clear human resource procedures and guidelines, regular performance appraisals, and structured work plans. These results align with earlier findings in Ethiopia and other low-income countries, reaffirming the importance of strategic human resource operations in building motivated and productive health professionals (40, 44, 45). Despite ongoing efforts to enhance working conditions for health professionals in Ethiopia, significant gaps persist in critical motivational drivers. Job-related factors such as clear job descriptions, alignment of roles with skills, providing sufficient training, and job security have shown minimal enhancement. These findings emphasize the significance of addressing job-related rudiments and job security to enhance health professionals' job satisfaction and motivation. These findings align with studies conducted in Ethiopia, which linked analogous challenges in terms of job satisfaction and motivation (40, 46, 47). Health facility differences also stood out. Hospitals generally reported stronger human resource operational practices, better supervision, and more access to professional development. These findings are consistent with WHO reports on African health systems, which suggest hospitals frequently benefit from more investment in setup and labor force development (49). Nevertheless, health centers have demonstrated noteworthy progress in the availability of essential medical supplies, indicating advancements in logistics and procurement systems, another crucial determinant of job satisfaction, particularly in resource-constrained settings (40, 49). The qualitative data supported these patterns, revealing persistent concerns among health professionals in rural health centers about limited access to educational opportunities for nonphysician staff. While medical doctors often benefit from specialized training programs, other health workers continue to face significant barriers to professional development. These findings call for an additional inclusive approach to professional development that ensures equal access to learning opportunities across all settings and regions. Finally, despite some improvements in financial benefits, many professionals, especially those in lower-level facilities, expressed dissatisfaction with current compensation levels. This dissatisfaction, exacerbated by rising living costs and perceived disparities in the performance evaluation process, highlights the need for fair, transparent, and standardized human resource policies. Strengthening these systems could help foster trust, boost morale, and improve retention and service delivery in Ethiopia's health sector. Limitations of the study The study did not use a cohort design to assess changes in job satisfaction and motivational factors over time among the same participants. The differences between the two study groups may have introduced bias regarding their comparability. Furthermore, perceived improvements may not align perfectly with actual improvements. As a remedial measure, we conducted qualitative interviews with health professionals and HR managers to gain deeper insights and help mitigate any potential bias that could have arisen during the quantitative interviews. Conclusion Job satisfaction among health professionals in Ethiopia improved significantly between 2014 and 2022, driven by enhanced financial incentives, strengthened HR management practices, improved workload management, and expanded professional and career development opportunities. Despite notable progress, significant challenges remain including disparities related to gender, age, and geographic location, as well as limited resources, inadequate educational opportunities, and inconsistent performance evaluation systems. Ethiopia's proactive efforts to address these HRH issues underscore the importance of integrating both financial and non-financial incentives to sustain workforce motivation. For long-term impact, policymakers should embed workforce development into the national agenda, conceding recent achievements with targeted actions to close persistent gaps. Tailored, evidence-based interventions adapted to local contexts will help maintain these gains and advance Ethiopia's health sector transformation. Declarations Ethics approval and consent to participate Ethical approval was obtained from the Ethiopian Public Health Institute Institutional Review Board (IRB) with the number EPHI-IRB-417-2021 and the Johns Hopkins School of Public Health Institutional Review Board (JHSPH IRB number 00000287. Written informed consent was obtained from all participants before data collection. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the Cooperative Agreement number: 72066320CA00008. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government. USAID provided support in the form of salaries for authors. The funders had no role in the design, data collection, analysis, interpretation, or writing of the manuscript. Authors' contributions ZA developed the study design, conducted the data analysis, interpreted the data, addressed ethical considerations, and wrote the manuscript. JM, FA, TG, and SS were involved in developing the study design, protocol development, data analysis, data interpretation, and drafting the manuscript. FA contributed to the conceptualization and drafting of the methods section. JS contributed to data interpretation and played a key role in critically reviewing and writing the manuscript. AD and MG contributed to data collection and manuscript review. All authors critically reviewed the manuscript and approved the final version. Acknowledgments We extend our sincere gratitude to the Ministry of Health of Ethiopia for reviewing the study design, issuing a support letter to the regional health bureaus, and granting permission to carry out this research. We are also grateful to the regional health bureaus and health facilities for their collaboration and support throughout the study. We gratefully acknowledge the United States Agency for International Development (USAID) for providing financial support. Finally, we extend our appreciation to the study participants, as well as the data collectors and supervisors, whose contributions were essential to the success of this study. References Cantarelli P, Vainieri M, Seghieri C. The management of healthcare employees’ job satisfaction: optimization analyses from a series of large-scale surveys. BMC Health Serv Res. 2023; 23:428. Hilo AA, McPeak J. 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Job motivation and associated factors among healthcare professionals serving in primary hospitals in the Central Gondar Zone, Northwest Ethiopia: a mixed-methods approach. Front Public Health. 2025; 13:1494447. World Health Organization. The African Regional Health Report: The Health of the People. Geneva: WHO; 2014. Assefa T, Haile Mariam D. Essential drug availability and affordability in Ethiopia: implications for universal health coverage. J Pharm Policy Pract . 2020; 13:23. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7150387","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":487761443,"identity":"29c1bb3a-dde4-49aa-a161-fc7708e8ed6c","order_by":0,"name":"Zeine Abosse Anore","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYFACxgYgcQDMegBlEK+F2YBILWAAVskmQZQW+fbmtgcfau7IyfcfPlbNA2TwMzA/fHQDn7N6DrYbzjj2zNjgRlrabR4gQ7KBzdg4B48WZonENmketsOJGyR4zG6DGQd42KTxaWGTf9gm/eff4cT5/ee/FfP8I0ILjwRjmzRj2+HEhgM5bMy8bURokeBJbJPs7QP7xVhybt9hY8lmAn6Rbz/+TOLHN3CIPfzw5tthOX725oeP8WlBAUw8IJKZWOUgwPiDFNWjYBSMglEwYgAAJfdQpE1JHGQAAAAASUVORK5CYII=","orcid":"","institution":"University Medical Center Groningen","correspondingAuthor":true,"prefix":"","firstName":"Zeine","middleName":"Abosse","lastName":"Anore","suffix":""},{"id":487761444,"identity":"fee19b43-72bd-43fd-9d61-a7bcc6f0fd44","order_by":1,"name":"Jemal Mohammed Ali","email":"","orcid":"","institution":"University Medical Center Groningen","correspondingAuthor":false,"prefix":"","firstName":"Jemal","middleName":"Mohammed","lastName":"Ali","suffix":""},{"id":487761449,"identity":"7ce44191-8335-4221-8170-9456a9d8d675","order_by":2,"name":"Tegbar Yigzaw Sendekie","email":"","orcid":"","institution":"Jhpiego","correspondingAuthor":false,"prefix":"","firstName":"Tegbar","middleName":"Yigzaw","lastName":"Sendekie","suffix":""},{"id":487761451,"identity":"670dbcdc-f6ec-4efe-9274-4dfa668cd585","order_by":3,"name":"Firew Ayalew","email":"","orcid":"","institution":"Jhpiego","correspondingAuthor":false,"prefix":"","firstName":"Firew","middleName":"","lastName":"Ayalew","suffix":""},{"id":487761452,"identity":"96902876-f4e1-4825-8f49-6a5d3f73a6ae","order_by":4,"name":"Shelemo Shawula","email":"","orcid":"","institution":"USAID","correspondingAuthor":false,"prefix":"","firstName":"Shelemo","middleName":"","lastName":"Shawula","suffix":""},{"id":487761453,"identity":"7e5cd956-be72-4108-be94-4edb89312210","order_by":5,"name":"Asfaw Demissie","email":"","orcid":"","institution":"Jhpiego","correspondingAuthor":false,"prefix":"","firstName":"Asfaw","middleName":"","lastName":"Demissie","suffix":""},{"id":487761454,"identity":"26fdaa1a-1f47-43df-b014-9c0c616ccb28","order_by":6,"name":"Mesfin Goji","email":"","orcid":"","institution":"Jhpiego","correspondingAuthor":false,"prefix":"","firstName":"Mesfin","middleName":"","lastName":"Goji","suffix":""},{"id":487761455,"identity":"a88fb8c3-cb8a-4b3c-885d-c70d5b0bce88","order_by":7,"name":"Jelle Stekelenburg","email":"","orcid":"","institution":"University Medical Center Groningen","correspondingAuthor":false,"prefix":"","firstName":"Jelle","middleName":"","lastName":"Stekelenburg","suffix":""}],"badges":[],"createdAt":"2025-07-17 15:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7150387/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7150387/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87216438,"identity":"30151542-1362-4e96-ab88-65714aef3c13","added_by":"auto","created_at":"2025-07-21 15:31:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1395875,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7150387/v1/90933ba4-1157-41e9-a391-082c91c29677.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Improving Job Satisfaction and Motivation Among Health Professionals in the Public Health Sectors in Ethiopia: Evidence from a Repeated Cross-Sectional Study","fulltext":[{"header":"Background","content":"\u003cp\u003eHealth professionals are the foundation of the healthcare system [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Health systems perform well in delivering standard health services only when they have sufficient, competent, motivated, and equitably distributed health professionals [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, the health sector continues to grapple with critical challenges, including shortages of health professionals and their uneven distribution across regions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The problem is significant and serious in low- and middle-income countries, including Africa. Africa's health professional crisis is driven by multiple factors including insufficient training capacity, rapid population growth, weak leadership and management of health professionals, and ineffective retention strategies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Ethiopia is one of the low-income countries listed by the World Health Organization as facing health professional challenges [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEmployees spend a significant portion of their time at work, so if their job does not provide adequate satisfaction or worse, leads to dissatisfaction they may feel unhappy or unfulfilled for much of the workday [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eJob satisfaction refers to a positive or enjoyable emotional response that arises from evaluating one's job or work-related experiences [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It can also be described as the degree to which health professionals are satisfied or dissatisfied with their jobs based on their assessment of the work or job along a continuum from favorable to unfavorable, including everyone's work experiences, feelings about their job, and various aspects of their job [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEmployee satisfaction is crucial, as it can significantly influence the behavior of healthcare workers, affecting both their well-being and the performance of the organizations [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Job dissatisfaction may harm an organization by increasing absenteeism, turnover, and inefficiency, potentially reducing productivity and performance [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In contrast, high levels of job satisfaction among employees can enhance organizational productivity and effectiveness [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHealthcare organizations continue to face challenges in sustaining high levels of employee satisfaction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Studies show that job satisfaction levels among health professionals in low- and middle-income countries differ significantly. A systematic review revealed that 32% of physicians and dentists in middle-income countries experienced burnout levels exceeding the high-risk threshold, while 60% expressed overall satisfaction with their jobs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Ethiopia, many health professionals report dissatisfaction with their jobs and existing incentive structures, which is consistent with findings from other low-income countries [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Moreover, recent studies and systematic reviews in Ethiopia revealed notable variability in job satisfaction across regions, professional categories, and public and private healthcare settings [\u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Specifically, healthcare professionals working in primary and general hospitals in Ethiopia report higher job satisfaction than their counterparts in tertiary hospitals [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAnalyzing the determinants of job satisfaction and motivation is crucial to fostering optimal work environments, as it contributes to increased productivity, reduced stress and employee turnover, and improved standards of patient care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Studies in sub-Saharan African countries have identified various factors influencing the job satisfaction of health professionals, including age, job category, years of service, perceived preparedness, communication and recognition from managers, high stress levels and burnout, the work environment, and the number of hours worked each week [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Ethiopia, employee satisfaction has been positively influenced by factors such as effective supervision, a conducive work environment, and access to professional growth opportunities. Additionally, the security of the working environment, coworker relationships, good relationships between supervisors and staff, and opportunities for further education play significant roles in improving healthcare workers' job satisfaction. Adequate supportive supervision and rewards such as recognition have been documented as key drivers of health professionals' job satisfaction [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOver the past eight years, the Ministry of Health in Ethiopia, in collaboration with stakeholders, has implemented human resource for health management interventions aimed at enhancing job satisfaction, motivation, performance, and productivity of health professionals. The key interventions included the development of tailored financial and nonfinancial incentives, creating a supportive work environment, improving availability and access to professional development opportunities, and reviewing career structures. These comprehensive interventions were designed and implemented to create a robust, well-supported, and highly motivated workforce capable of meeting Ethiopia's growing healthcare needs and contributing to the overarching goal of achieving universal health coverage (UHC) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Despite ongoing efforts to improve working conditions for the health workforce in Ethiopia, there is limited evaluative evidence on whether these interventions effectively enhance job satisfaction and motivational drivers among health professionals.\u003c/p\u003e\u003cp\u003eTherefore, we conducted a study to assess improvements in job satisfaction among health professionals and to identify the motivational drivers influencing job satisfaction over time. Our goal was to generate insights that could inform the design and implementation of the next iteration of the Human resources for health (HRH) strategy. Using healthcare management frameworks, we analyzed changes in job satisfaction and the key factors contributing to it among health professionals in the public sector. By comparing our findings with baseline data from 2014, we offer a comprehensive view of the evolving dynamics within the health workforce.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy Design and Setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study employed a repeated cross-sectional design to assess and compare improvements in job satisfaction among health professionals in 2022 with findings from 2014.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Population and Sampling\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn both the 2014 and 2022 studies, the study populations included medical doctors, nurses, midwives, anesthetists, and health officers. In addition, the 2022 study included pharmacists’ pharmacy technicians, and medical laboratory professionals and technicians upon recommendation by the Ministry of Health.\u003c/p\u003e\u003cp\u003eIn 2014, the estimated population of targeted health professionals consisted of 1,544 medical doctors, 38,916 nurses, 5,203 midwives, 417 anesthetists, and 4,782 health officers across 3,465 public health facilities [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In 2022, these numbers significantly increased to 17,665 medical doctors, 103,107 nurses, 23,333 midwives, 1,879 anesthetists, 33,172 health officers, 20,673 medical laboratory professionals/technicians, and 32,374 pharmacists/pharmacy technicians operating in 4,207 public health facilities (health centers and hospitals) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWorkplace distributions indicated that medical doctors and anesthetists predominantly worked in hospitals, whereas nurses, midwives, health officers, pharmacists, and medical laboratory professionals were deployed in hospitals and health centers.\u003c/p\u003e\u003cp\u003eThe study employed a two-stage cluster sampling design in both study periods. In the first stage, health facilities were selected, followed by the selection of health workers within those facilities. Nationally representative sample sizes for health professionals were calculated separately for each study period. The sample sizes were determined based on a 95% confidence level, a 5% margin of error, a design effect of 1.2, and a 10% nonresponse rate [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the absence of prior national-level estimates on job satisfaction, a sample size of 1,356 health professionals was determined in 2014. The calculation was based on an assumed job satisfaction prevalence of 50%, which is a standard approach when no reliable baseline data are available. For the 2022 study, the sample size was adjusted to 1,655 health workers, considering the job satisfaction levels from the 2014 study, which were 41.6% at the hospital level and 60.2% at the health center level [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA total of 224 health facilities comprising 107 hospitals and 117 health centers were randomly selected for the 2014 study. In 2022, a new sample of 165 facilities, including 85 hospitals and 80 health centers, was used to assess progress and changes over time. The list of facilities was provided to the data collectors, who randomly chose individual health workers to participate in the study. In 2014, 16 health professionals (four from each profession) were randomly selected from each facility. In the 2022 study, 12 health professionals (two from each profession) were sampled from each hospital, and six health professionals (one from each profession) sampled from each health center. Owing to the limited number of anesthetists, all available anesthetists working in the hospitals on the day of data collection were included in both study periods.\u003c/p\u003e\u003cp\u003eIn 2022, 24 human resources managers and 18 senior health professionals from 32 health facilities, the Ministry of Health, and eight regional health bureaus were invited to participate as key informants in in-depth interviews. The objective of these interviews was to gather qualitative insights into the changes in motivational factors following the implementation of the human resources management intervention over the last six-year period.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection tools and procedures\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe 2022 study employed a validated job satisfaction tool created by Management Science for Health (MSH) and previously used in the 2014 study [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The tool consists of 35 questions that address various job-related attributes, including salary, benefits, professional development, human resources for health (HRH) management, working and living conditions, workload, and job security (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Responses were captured via a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).\u003c/p\u003e\u003cp\u003eOverall job satisfaction was assessed via a global job satisfaction scale developed by Warr, Cook, and Wall [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] that evaluates overall job satisfaction with the following statement: \"Considering everything, I am satisfied with my job,\" rated on a scale from 1 (strongly disagree) to 5 (strongly agree).\u003c/p\u003e\u003cp\u003eAdditionally, key informants and in-depth interview guides were developed and employed to gather insights from human resources managers and health workers regarding their perceptions of improvements in both financial and non-financial incentives since the implementation of the National Human Resources for Health (HRH) strategic plan (2016–2025).\u003c/p\u003e\u003cp\u003eAll questionnaires were translated into local languages to ensure that the participants understood the questions. Electronic data collection was conducted from May to June 2014 and again from June to July 2022 via the Kobo Toolbox. Qualitative data were collected in addition to quantitative data. Data collectors received training on how to administer the tools and adhere to research ethics. They explained the study's objectives to participants and provided written consent forms. Face-to-face interviews were conducted in private settings to ensure secrecy. Qualitative interviews (KIIs) were audio-recorded and supplemented with field notes. The research team monitored the data collection procedures daily to maintain quality.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe 35 items of job satisfaction grouped across nine domains\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"1\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSatisfaction domain and items\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSalary and benefits (3 items)\u003c/p\u003e\u003cp\u003e- My salary package is fair\u003c/p\u003e\u003cp\u003e- My salary is fair compared to other staff with the same level of responsibility\u003c/p\u003e\u003cp\u003e- My benefits are fair compared with other staff at my level\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional and career development (2 items)\u003c/p\u003e\u003cp\u003e- I feel there are sufficient opportunities for promotion with my employer\u003c/p\u003e\u003cp\u003e- I have access to coaching and mentoring when needed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJob (3 items)\u003c/p\u003e\u003cp\u003e- The job is a good match for my skills and experience\u003c/p\u003e\u003cp\u003e- My job description is clear and up to date\u003c/p\u003e\u003cp\u003e- I have been given the training that I need to succeed in my position\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHRH management (7 items)\u003c/p\u003e\u003cp\u003e- I receive recognition for doing good work\u003c/p\u003e\u003cp\u003e- My supervisor applies personnel policies and practices fairly to me\u003c/p\u003e\u003cp\u003e- I have a current work plan developed with my supervisor\u003c/p\u003e\u003cp\u003e- My annual performance appraisal is based on my work plan\u003c/p\u003e\u003cp\u003e- I feel that the organization values my work\u003c/p\u003e\u003cp\u003e- My supervisor is available when I need support\u003c/p\u003e\u003cp\u003e- The head of this health facility is competent and committed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMoral satisfaction (3 Items)\u003c/p\u003e\u003cp\u003e- I would encourage my friends and family to seek care here\u003c/p\u003e\u003cp\u003e- I consider myself a part of the local community that I am serving as a health worker\u003c/p\u003e\u003cp\u003e- I feel that the community values my work\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorking conditions (10 Items)\u003c/p\u003e\u003cp\u003e- The facility takes specific measures to protect me against HIV/AIDS and other occupational hazards\u003c/p\u003e\u003cp\u003e- I have a good relationship with my coworkers.\u003c/p\u003e\u003cp\u003e- Overall, the morale level in my team or work group is good\u003c/p\u003e\u003cp\u003e- I have the working equipment I need to do my job well and efficiently, such as ultrasound, X-ray, and blood pressure cuffs\u003c/p\u003e\u003cp\u003e- This facility has good access to drugs and medications\u003c/p\u003e\u003cp\u003e- My workspace is clean\u003c/p\u003e\u003cp\u003e- At work, I have access to safe, clean water\u003c/p\u003e\u003cp\u003e- At work, I have good access to electricity\u003c/p\u003e\u003cp\u003e- At work, I have good internet connectivity\u003c/p\u003e\u003cp\u003e- Safe and efficient transportation to work\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving conditions (4 Items)\u003c/p\u003e\u003cp\u003e- At home, I have access to safe, clean water\u003c/p\u003e\u003cp\u003e- At home, I have good access to electricity\u003c/p\u003e\u003cp\u003e- I have access to good schooling for my children\u003c/p\u003e\u003cp\u003e- The community where I live has good shopping and entertainment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorkload (2 Item)\u003c/p\u003e\u003cp\u003e- My workload is reasonable\u003c/p\u003e\u003cp\u003e- I can take time to eat lunch every day\u003c/p\u003e\u003cp\u003eJob security (1 Item)\u003c/p\u003e\u003cp\u003e- I am not worried about losing my job\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003cb\u003eData Management and Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe data were exported from the Kobo Toolbox to SPSS to conduct both descriptive and inferential statistical analyses. Means, percentages, and standard deviations were calculated to ensure the consistency and completeness of the data.\u003c/p\u003e\u003cp\u003eThe outcome variable \"overall job satisfaction\" was categorized into \"satisfied\" (combining \"strongly agree\" and \"agree\") and \"not satisfied\" (combining \"strongly disagree,\" \"disagree,\" and \"neutral\").\u003c/p\u003e\u003cp\u003eThe motivational factors were organized into nine subscale categories: salary and benefits (3 items), professional and career development (2 items), job (3 items), HRH management (7 items), moral satisfaction (3 items), working conditions (10 items), living conditions (4 items), workload (2 items), and job security (1 item) (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Composite mean scores for each subscale were calculated, with scores ranging from 1 to 5.\u003c/p\u003e\u003cp\u003eDescriptive and inferential statistical analyses were performed, and an independent samples t-test was used to compare the proportions of job satisfaction and composite mean scores of the motivational factors across the two study periods.\u003c/p\u003e\u003cp\u003eThe point-biserial correlation coefficient (r pb) was calculated to assess the relationship between job satisfaction level (a dichotomous variable) and the composite mean scores of motivational factors (continuous variables). This analysis aimed to determine the contributions of human resource management interventions (motivational factors) to improving job satisfaction levels across the two study periods. Following Cohen's guidelines for assessing effect size, we computed the coefficient of determination (CD = r²) to quantify the proportion of variance in job satisfaction explained by variation in motivational factors. This proportion ranges from 0 (indicating no shared variance) to 100% (indicating complete shared variance), which helps to identify key contributors to job satisfaction improvement. We used Cohen's effect size benchmarks for correlation coefficients (r-family) to interpret the results:\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eA correlation coefficient of less than 0.1 (C D \u0026lt; 1%) has no effect.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e0.1 \u0026lt; = r \u0026lt; 0.3 (1%\u0026lt;=CD \u0026lt; = 9%) has a small effect.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e0.3 \u0026lt; = r \u0026lt; 0.5 (9%\u0026lt;=CD \u0026lt; 25%) has a medium effect.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003er \u0026gt; = 0.5 (CD \u0026gt; = 25%) has a large effect [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003eP values \u0026lt; 0.05 and 95% confidence intervals were also used for making statistically significant decisions.\u003c/p\u003e\u003cp\u003eWe utilized NVivo 12 software for qualitative data analysis, employing thematic approaches to examine, code, display, and interpret the interviews. To ensure trustworthiness, methodological integrity, and comprehensive documentation while avoiding reductionism, we meticulously documented each step of our process. We selected health professionals and human resource directors for their rich experiences and diverse insights into job satisfaction among health professionals. The qualitative interview questions were designed to ensure that the findings apply to both groups. Verbatim quotations and detailed narratives were incorporated to represent participants lived experiences and ensure the credibility of the qualitative findings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical considerations\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Ethical clearance was obtained from the Institutional Review Boards of both the Ethiopian Public Health Institute (EPHI) and Johns Hopkins University. Support letters from the Ministry of Health were sent to the Regional Health Bureaus and the participating health facilities to facilitate effective communication between the data collectors and facility managers. Before participation, eligible individuals were provided with comprehensive information about the study, including its potential benefits and risks, and were informed that participation was entirely voluntary. Confidentiality and privacy were rigorously maintained throughout the study. The data collectors adopted a nonjudgmental and empathetic approach, ensuring that the participants fully understood their rights, including the freedom to decline participation or withdraw from the study at any time without consequence.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eCharacteristics of Study Participants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn the 2014 study, a total of 1,356 health workers from 222 health facilities participated, whereas in the 2022 study, 1,655 health workers from 165 facilities were included. The response rate was 100% in 2014 and 94.4% in 2022. In both studies, more than half of the participants were male: 60.2% in 2014 and 68.9% in 2022. The proportion of young adults aged 20\u0026ndash;29 years was 72.4% in 2014, whereas it was 47.1% in 2022. Most participants held undergraduate qualifications in both years, with 95% in 2014 and 96% in 2022 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of the study participants by study period\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;1356\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;1655\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value (Chi-square)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e540 (39.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e515 (31.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e816 (60.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1140 (68.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eAge in years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e982 (72.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e780 (47.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e250 (18.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e763 (46.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e124 (9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e112 (6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eProfession\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical Doctor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e375 (27.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e224 (13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e424(31.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e260 (15.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnesthetist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e253(18.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e153 (9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMidwife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e177(13.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e250 (15.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth Officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e127(9.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e257 (15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e254 (15.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical Laboratory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e257 (15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eHighest educational qualification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostgraduate (specialty or MSc+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68(5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60 (3.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUndergraduate (BSc or MD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e676(49.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1141 (68.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiploma/certificate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e612 (45.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e454 (27.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e784(57.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e680 (41.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e572(42.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e975 (58.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eResidential House\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOwn\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e129(9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e223 (13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e740(54.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1129 (68.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProvided by health facility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e418(30.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e197 (11.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLive with parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69(5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e106 (6.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirthplace\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e721(53.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1114 (67.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e635(46.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e541 (32.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth facility type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth Center\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e660(48.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e522 (31.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e225(16.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e567 (34.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneral Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e278(20.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e364 (22.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpecialized Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e193(14.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e202 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eImprovements in job satisfaction levels\u003c/b\u003e\u003c/p\u003e\u003cp\u003eJob satisfaction increased by 16 percentage points from 50.8% in 2014 to 66.8% in 2022 (95% CI of the change: 12.5%, 19.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Satisfaction among female workers increased by 12%, while satisfaction among male workers rose by 19%. Notable gains were observed in anesthetists (25.7%), health officers (20.1%), postgraduates (23.6%), and workers in Amhara (18.0%), Oromia (16.1%), and SNNP (15.0%) between 2014 and 2022 (Table\u0026nbsp;3).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eJob satisfaction levels by characteristics of the study participants and study period\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\" rowspan=\"3\"\u003e\n \u003cp\u003eDifference in job satisfaction rate (95% C.I)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1356\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1655\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e(a)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e(b)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e(b-a)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOverall, Job satisfaction level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e689 (50.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1105 (66.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e16 [12.5, 19.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e315 (58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e364 (70.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e376 (46.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e741 (65.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e18.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003eAge in years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e482 (49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e517(66.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e17.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e128 (51.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e513(67.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e81 (65.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (67.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of profession\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e147 (39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118 (52.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e260 (61.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e179 (68.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e114 (64.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e105 (68.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnesthetists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e108 (42.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e171 (68.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e25.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth officer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e62 (48.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e177 (68.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical laboratory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e175 (68.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePharmacist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e180 (70.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQualification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostgraduate (MSc+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e27(39.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (63.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e23.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUndergraduate (BSc)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e297 (43.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e718 (62.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiploma/certificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e367 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e349 (76.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e16.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBirthplace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e341(47.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e750 (67.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e350 (55.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e355 (65.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of working health facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e93 (41.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e370 (65.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGeneral Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e125 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e238 (65.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReferral Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e75 (38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e114 (56.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e398 (60.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e383 (73.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e186 (60.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e247 (78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOromia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e177 (39.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e207 (55.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSNNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e136 (51.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e169 (67.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAddis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (39.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e95 (50.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOthers**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e156 (63.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e387 (73.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e** includes Harari, Dire Dawa, Somali, Afar, Benishangul Gumuz, and Sidama\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImprovements in Motivational Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJob satisfaction among healthcare professionals showed notable improvements in several key areas between 2014 and 2022. Satisfaction with salary and benefits increased significantly, with a mean score difference of 0.5 (95% CI [0.44, 0.56], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating better compensation packages. Professional and career development opportunities also increased substantially, with a mean score difference of 0.4 (95% CI [0.03, 0.33], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, moral satisfaction slightly declined, with a mean score difference of -0.1 (95% CI [-0.15, -0.05], p\u0026thinsp;=\u0026thinsp;0.001). Overall, the composite mean score of job satisfaction rose from 3.2 to 3.4, with a mean score difference of 0.2 (95% CI [0.16, 0.23], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), reflecting cumulative positive changes across various motivational factors (Table\u0026nbsp;4).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eImprovements in health professionals\u0026rsquo; motivational factors between the 2014 and 2022 study periods.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eNumber of items\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eMean score difference (95% C.I)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1356)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1655)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean score (SD) (maximum mean score\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean score (SD) (maximum mean score\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSalary \u0026amp; benefits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.1(0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.6 (0.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5 [0.44, 0.56]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProfessional and career development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8(0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.2 (0.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4 [0.03,0.43]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJob\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.4(0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.4(0.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [-0.06, 0.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHRH Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3(0.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.4(0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1 [0.04, 0.16]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMoral satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.1(0.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0 (0.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.1 [-0.15, -0.05]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorking conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.0(0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.1(0.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1 [0.06, 0.14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLiving conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8(0.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.9(0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1[ 0.45, 0.16]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorkload\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.5(0.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.7(0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2 [0.14, 0.26]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJob security\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.9(1.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.9(0.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [-0.08, 0.08]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComposite Mean Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.2 (0.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.4(0.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2 [0.16, 0.23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal Items\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-Perceived Improvement in Benefits and Working Conditions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween 2014 and 2022, healthcare professionals in Ethiopia reported notable improvements in job satisfaction across several key areas. Statistically significant gains were observed in the availability of essential supplies, with 43.8% of respondents reporting positive changes, particularly in health centers (44.6%), compared with hospitals (32.7%) (p\u0026thinsp;=\u0026thinsp;0.011). Salary improvements were reported by 38.9% of the respondents. Additionally, the availability of working equipment improved significantly, especially in hospitals (44.3%), compared with health centers (24.8%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Access to higher or postgraduate education also improved, with 13.4% of professionals reporting better opportunities overall. Hospital staff reported significantly greater access (23.8%) than did health centers (12.7%) (p\u0026thinsp;=\u0026thinsp;0.001) (Table\u0026nbsp;5).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eHealth professionals\u0026rsquo; perceived improvements in benefits and working conditions over the past eight years (before the study period of 2022)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eAreas of improvement\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003ePercent of respondents who reported perceived improvement\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHealth center (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHospital (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAvailability of supplies to do your job, such as drugs, gloves, needles, bandages, sutures, disinfectants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSalary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDuty allowance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.872\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSupportive supervision, coaching, and feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAvailability of working equipment to do your job well, such as ultrasound, X-ray, and lab machines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOpportunities for in-service training or continuing professional development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.659\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOpportunities for promotion or growth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.859\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAccess to higher or postgraduate education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther benefits, such as housing allowance or free housing, free medical care, transportation allowance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRisk allowance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.784\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors Contributing to Job Satisfaction Improvements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHuman Resources for Health (HRH) management was the strongest driver of job satisfaction, with a point-biserial correlation coefficient of r\u0026thinsp;=\u0026thinsp;0.42 (17.6% effect size) in 2014 and r\u0026thinsp;=\u0026thinsp;0.33 (10.9% effect size) in 2022. Salary and benefits also played a key role, with r\u0026thinsp;=\u0026thinsp;0.34 (11.6% effect size) in 2014 and r\u0026thinsp;=\u0026thinsp;0.30 (9% effect size) in 2022. Professional and career development, with r\u0026thinsp;=\u0026thinsp;0.33 (10.9% effect size) in 2014 and r\u0026thinsp;=\u0026thinsp;0.25 (6.3% effect size) in 2022. Additionally, the impact of workload on job satisfaction weakened, with r\u0026thinsp;=\u0026thinsp;0.22 (4.8% effect size) in 2014 and r\u0026thinsp;=\u0026thinsp;0.16 (2.6% effect size) in 2022. Job security had the weakest effect, dropping from r\u0026thinsp;=\u0026thinsp;0.17 (2.9% effect size) in 2014 to r\u0026thinsp;=\u0026thinsp;0.04 (0.2% effect size) in 2022 (Table\u0026nbsp;6).\u003c/p\u003e\n\u003cdiv\u003e\n \u003cdiv align=\"left\"\u003e\u003cstrong\u003eFindings from Key Informant and In-depth Interviews\u003c/strong\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eThe findings from qualitative interviews with health managers and senior health professionals were categorized into six key themes: salary and financial incentives, performance evaluation and career development, professional development, amenities and supplies, leadership, governance and management, and non-financial incentives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSalary and Financial Incentives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth professionals and human resource managers reported meaningful improvements over the past six years in salaries and financial incentives including duty pay, risk, hardship, and positional allowances. These changes were generally welcomed as positive steps forward. However, many expressed ongoing frustration with the overall salary structure, feeling it fails to fairly reflect the level of effort and responsibility their roles require. This concern has been further intensified by the rising cost of living, which continues to erode the real value of their earnings and fuels a persistent sense of dissatisfaction.\u003c/p\u003e\n\u003cp\u003e\u0026quot;How can we manage to cover our expenses with 7,000 Ethiopian Birr salaries during this period of high inflation, especially when necessities such as 5 liters of oil cost 1,000 Birr, house rent is 2,000 Birr, and a bar of soap costs 35 Birr?\u0026quot; \u0026mdash; A health professional.\u003c/p\u003e\n\u003cp\u003eHealth professionals noted that the establishment of private wings within hospitals allowed them to work outside regular hours, resulting in additional income and increased motivation.\u003c/p\u003e\n\u003cp\u003e\u0026quot;One positive change that has brought satisfaction is the creation of private clinics/wings in hospitals. These allow professionals to work outside normal hours and receive extra compensation. However, improvements are still limited, as these wings lack inpatient services and essential resources, although they provide some motivation,\u0026rdquo; a medical director from the hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerformance Evaluation and Career Development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth professionals and HR managers reported improvements in performance evaluation over the past six years. Performance evaluations are now conducted regularly every six months and are linked to educational and career development opportunities.\u003c/p\u003e\n\u003cp\u003e\u0026quot;There are positive changes in performance evaluation. For example, performance evaluation was only conducted when there was career development or competition for educational opportunities. Now, for the past two years, assessments are done every six months,\u0026quot; a health professional from the Regional Health Bureau.\u003c/p\u003e\n\u003cp\u003eAn HR manager from the Regional Health Bureau elaborated:\u003c/p\u003e\n\u003cp\u003e\u0026quot;Our organization conducts performance evaluations continuously every quarter, with results summarized and documented twice a year. For example, the performance result of an organization was 86% over the last six months. \u0026quot;If an individual\u0026apos;s performance is rated at 86.5%, I will not approve it unless strong evidence is provided showing that their performance exceeds that of the hospital or unless evidence is presented to demonstrate that they stand out from the rest of the team.\u0026quot;\u003c/p\u003e\n\u003cp\u003eHowever, some health professionals reported that performance evaluations were not always conducted according to guidelines, with concerns over evaluators, standardization of evaluation methods, and transparency.\u003c/p\u003e\n\u003cp\u003e\u0026quot;Efficiency in performance evaluation has been a source of conflict. Performance evaluations are conducted without our awareness. No one is informed about the evaluation process, as it is performed invisibly by a committee of department heads. They neither share the evaluation criteria with us nor inform us when our performance is being assessed. The committee members receive marks above 90%, while the rest of us are rated in the 70\u0026ndash;80% range, even though we do most of the actual work.\u0026quot; \u0026mdash; Health professional.\u003c/p\u003e\n\u003cp\u003eThe participants also reported improvements in career development processes, which increased their motivation. However, some health professionals disagreed with the policy requiring education or study leave to be undertaken on weekends to count toward career development.\u003c/p\u003e\n\u003cp\u003e\u0026quot;Career advancement is possible until the staff reaches the peak career level. However, if a staff member pursues further education, the years spent on education will not be counted for career development unless it is done on weekends. Additionally, the staff must maintain an efficiency rating of 65 and above for six consecutive performance evaluations.\u0026quot; \u0026mdash; Human resource manager from the Regional Health Bureau.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProfessional development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere has been a shared concern among health professionals and HR managers regarding the limitation of educational opportunities in recent years. However, some participants from the Addis Ababa, SNNP, Oromia, and Afar regions noted that sufficient educational opportunities for general practitioners to pursue specialty programs still exist, which has improved motivation and satisfaction among medical doctors. Nevertheless, opportunities for other health professional staff have significantly decreased.\u003c/p\u003e\n\u003cp\u003e\u0026quot;In the past two to three years, we have maintained a commendable record of sending staff for further education. For instance, this year, 11 newly employed physicians received educational opportunities.\u0026quot; \u0026mdash; Human resource manager from the Regional Health Bureau.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAmenities and Supplies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral participants reported improvements in the availability of electricity, water, medical supplies, and equipment during the 2022 study period. However, issues such as frequent power outages and inadequate water supply, particularly in rural areas, persist. Increased budget allocation for medications and healthcare financing reforms, which allow facilities to use their funds to address supply gaps, have contributed to these improvements. Additionally, the drug request system has enhanced supply management. However, drug shortages continue to be a significant issue, often requiring patients to purchase medications from external pharmacies.\u003c/p\u003e\n\u003cp\u003e\u0026quot;We spent approximately 900,000 Birr on drugs purchased this year. This amount is insufficient, given the increasing number of patients, particularly with the increase in community-based health insurance. Even with the increased budget for medications, it still falls short owing to the growing influx of patients.\u0026quot; \u0026mdash; Health professional from a health center.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLeadership and Governance Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost participants noted improvements in accountability. Whereas decisions were previously made solely by individual managers, they are now made collaboratively, with official approvals involving two or more officials.\u003c/p\u003e\n\u003cp\u003eMany health professionals and HR managers have observed improvements in regular supportive supervision at the individual, unit, and institutional levels. Supportive supervision is conducted using a standardized checklist, and constructive feedback is provided to help professionals enhance their service delivery. However, some participants reported a lack of uniform supervision practices. While some managers conduct regular supervision and provide feedback, others do not, and the issues identified during supervision are not always addressed.\u003c/p\u003e\n\u003cp\u003e\u0026quot;They ask us about the problems we are facing, but they don\u0026apos;t address our concerns even when we bring them up frequently. We don\u0026apos;t even get a blood pressure apparatus. All our concerns are \u0026apos;received\u0026apos; by managers who do not act.\u0026quot; \u0026mdash; Health professional.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNonfinancial incentives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants identified additional incentives such as housing, health insurance, and access to subsidized food items. However, the majority noted no significant improvements in the availability of residential housing or housing allowances. An exception was noted by some participants from the Oromia and Amhara regions, who reported receiving a monthly housing allowance of 1,000 Birr specifically for specialists and medical doctors. However, the houses provided lacked basic infrastructure and utilities such as electricity and water, making them unsuitable for living.\u003c/p\u003e\n\u003cp\u003e\u0026quot;The facility provides houses, but they are difficult to live in as there is no water, electricity, kitchen, or recreational areas. The location of the houses is also inconvenient, situated in open fields with nothing nearby to refresh oneself.\u0026quot; \u0026mdash; Health professional.\u003c/p\u003e\n\u003cp\u003eMost participants reported improvements in the availability of groceries, as health facilities now offer household items such as edible oil, teff, and sugar at subsidized prices through cooperative shops.\u003c/p\u003e\n\u003cp\u003e\u0026quot;We know other workers are given various food items such as edible oil, flour, and other materials at affordable prices via their cooperative shops, supported by the government. Thus, we also need similar distributions for various items.\u0026quot; \u0026mdash; Hospital HR Manager.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite progress in health professionals' job satisfaction and human resource management, Ethiopia continues to face challenges related to low health worker performance primarily driven by low motivation, job dissatisfaction, and poor working conditions (18, 21). Efforts to address these issues have been guided by the Health Sector Transformation Plan (HSTP) and Human Resources for Health (HRH) Strategy, which concentrates on structural reforms (22, 29). This study provides a temporal analysis of health sector reforms by examining trends in job satisfaction among health professionals from 2014 to 2022, using a repeated cross-sectional study design.\u003c/p\u003e\u003cp\u003eThe study identified a notable rise in job satisfaction among health professionals in Ethiopia, showing a 16-percentage-point increase between 2014 and 2022. The findings of this study are harmonious with studies conducted in Ethiopia and other African countries, demonstrating a consistent trend toward achieving job satisfaction among healthcare professionals (30\u0026ndash;33).\u003c/p\u003e\u003cp\u003eThe findings of this study reveal significant differences in job satisfaction enhancement among health professionals, pressing both areas of progress and those that demand further attention. These differences are evident across various demographic and professional characteristics, such as gender, age, geographic location, type of health facility, and specific health profession, as detailed below.\u003c/p\u003e\u003cp\u003eCompared to their male counterparts, female professionals experienced less enhancement in job satisfaction; still, a gender gap remains. This gap may stem from factors such as work-life balance challenges and variations in professional tasks and prospects. Addressing gender-specific dynamics within healthcare systems is essential for achieving equal improvements in job satisfaction. Younger health professionals, particularly those aged 20\u0026ndash;39, reported the greatest improvements in job satisfaction. In contrast, older professionals experienced minimal change, suggesting the presence of systemic barriers that may disproportionately impact on more experienced staff.\u003c/p\u003e\u003cp\u003eGeographically, job satisfaction changes were most notable in the Amhara, Oromia, and SNNP regions, whereas professionals in resource-limited regions endured more limited changes. These differences may be driven by factors such as limited capital, weaker leadership, and a lower capacity to apply customized motivational strategies in resource-limited regions. The type and condition of the health facility where professionals work significantly influence their level of job satisfaction. Health professionals working in health centers reported the greatest improvements in job satisfaction, indicating notable advancements in their work environment and support systems. In contrast, health professionals working at hospitals showed more modest enhancements, probably due to ongoing challenges such as overcrowding and high caseloads, which may continue to impact staff morale and limit further progress. These patterns align with findings from South Africa, Uganda, and Ethiopia, where gender, age, health facility type, and geographic differences have been shown to impact job satisfaction (34\u0026ndash;38). This highlights the need for targeted strategies to address the unique challenges faced by different aspects of health professionals' job satisfaction, including inadequate advancements across all regions and health facility types. Health professionals who attain advanced educational qualifications consistently report greater job satisfaction. This underscores the transformative power of education and career development in cultivating a motivated, empowered, and deeply fulfilled healthcare workforce (39).\u003c/p\u003e\u003cp\u003eBetween 2014 and 2022, Ethiopia made substantial advancements in the job satisfaction of health professionals, largely due to targeted interventions aimed at expanding payment and other benefits, improving working conditions, enhancing professional development opportunities, and strengthening support systems for health professionals. These findings align with research from low- and middle-income countries, including those in Sub-Saharan Africa, where improved working conditions and opportunities for career advancement have been linked to higher levels of job satisfaction among professionals (12, 30). Our study also revealed that payment-related factors are predictors of job satisfaction among Ethiopian health professionals. This finding is consistent with previous research conducted in Ethiopia and other international contexts, which consistently identifies fair and competitive compensation as a key determinant of job satisfaction and motivation among health professionals (1, 12, 40).\u003c/p\u003e\u003cp\u003eEncouragingly, the study also highlights significant progress in access to professional development opportunities and career advancement factors long recognized for their role in enhancing motivation and improving retention among health workers. Similar results have been found in South Africa and India, where creating better career development opportunities has helped reduce staff turnover and improve the performance of health professionals. The findings underscore the pivotal role of career development in fostering a resilient, motivated, and high-performing health workforce an essential foundation for sustainable health systems (41, 42). Improving satisfaction with workload reflects a growing global emphasis on preventing work-related stress. Increasingly, international literature highlights the importance of maintaining balanced workloads to promote long-term employee engagement and overall well-being (43).\u003c/p\u003e\u003cp\u003eHRH operation practices have also served as central contributors to job satisfaction. Strong links were observed between satisfaction and effective HRH operation systems, including the use of clear human resource procedures and guidelines, regular performance appraisals, and structured work plans. These results align with earlier findings in Ethiopia and other low-income countries, reaffirming the importance of strategic human resource operations in building motivated and productive health professionals (40, 44, 45).\u003c/p\u003e\u003cp\u003eDespite ongoing efforts to enhance working conditions for health professionals in Ethiopia, significant gaps persist in critical motivational drivers. Job-related factors such as clear job descriptions, alignment of roles with skills, providing sufficient training, and job security have shown minimal enhancement. These findings emphasize the significance of addressing job-related rudiments and job security to enhance health professionals' job satisfaction and motivation. These findings align with studies conducted in Ethiopia, which linked analogous challenges in terms of job satisfaction and motivation (40, 46, 47).\u003c/p\u003e\u003cp\u003eHealth facility differences also stood out. Hospitals generally reported stronger human resource operational practices, better supervision, and more access to professional development. These findings are consistent with WHO reports on African health systems, which suggest hospitals frequently benefit from more investment in setup and labor force development (49). Nevertheless, health centers have demonstrated noteworthy progress in the availability of essential medical supplies, indicating advancements in logistics and procurement systems, another crucial determinant of job satisfaction, particularly in resource-constrained settings (40, 49).\u003c/p\u003e\u003cp\u003eThe qualitative data supported these patterns, revealing persistent concerns among health professionals in rural health centers about limited access to educational opportunities for nonphysician staff. While medical doctors often benefit from specialized training programs, other health workers continue to face significant barriers to professional development. These findings call for an additional inclusive approach to professional development that ensures equal access to learning opportunities across all settings and regions.\u003c/p\u003e\u003cp\u003eFinally, despite some improvements in financial benefits, many professionals, especially those in lower-level facilities, expressed dissatisfaction with current compensation levels. This dissatisfaction, exacerbated by rising living costs and perceived disparities in the performance evaluation process, highlights the need for fair, transparent, and standardized human resource policies. Strengthening these systems could help foster trust, boost morale, and improve retention and service delivery in Ethiopia's health sector.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations of the study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study did not use a cohort design to assess changes in job satisfaction and motivational factors over time among the same participants. The differences between the two study groups may have introduced bias regarding their comparability. Furthermore, perceived improvements may not align perfectly with actual improvements. As a remedial measure, we conducted qualitative interviews with health professionals and HR managers to gain deeper insights and help mitigate any potential bias that could have arisen during the quantitative interviews.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eJob satisfaction among health professionals in Ethiopia improved significantly between 2014 and 2022, driven by enhanced financial incentives, strengthened HR management practices, improved workload management, and expanded professional and career development opportunities. Despite notable progress, significant challenges remain including disparities related to gender, age, and geographic location, as well as limited resources, inadequate educational opportunities, and inconsistent performance evaluation systems. Ethiopia's proactive efforts to address these HRH issues underscore the importance of integrating both financial and non-financial incentives to sustain workforce motivation. For long-term impact, policymakers should embed workforce development into the national agenda, conceding recent achievements with targeted actions to close persistent gaps. Tailored, evidence-based interventions adapted to local contexts will help maintain these gains and advance Ethiopia's health sector transformation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethiopian Public Health Institute Institutional Review Board (IRB) with the number EPHI-IRB-417-2021 and the Johns Hopkins School of Public Health Institutional Review Board (JHSPH IRB number 00000287. Written informed consent was obtained from all participants before data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the Cooperative Agreement number: 72066320CA00008. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government. USAID provided support in the form of salaries for authors. The funders had no role in the design, data collection, analysis, interpretation, or writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZA developed the study design, conducted the data analysis, interpreted the data, addressed ethical considerations, and wrote the manuscript. JM, FA, TG, and SS were involved in developing the study design, protocol development, data analysis, data interpretation, and drafting the manuscript. FA contributed to the conceptualization and drafting of the methods section. JS contributed to data interpretation and played a key role in critically reviewing and writing the manuscript. AD and MG contributed to data collection and manuscript review. All authors critically reviewed the manuscript and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to the Ministry of Health of Ethiopia for reviewing the study design, issuing a support letter to the regional health bureaus, and granting permission to carry out this research. We are also grateful to the regional health bureaus and health facilities for their collaboration and support throughout the study. We gratefully acknowledge the United States Agency for International Development (USAID) for providing financial support. Finally, we extend our appreciation to the study participants, as well as the data collectors and supervisors, whose contributions were essential to the success of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCantarelli P, Vainieri M, Seghieri C. 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The African Regional Health Report: The Health of the People. Geneva: WHO; 2014.\u003c/li\u003e\n\u003cli\u003eAssefa T, Haile Mariam D. Essential drug availability and affordability in Ethiopia: implications for universal health coverage. \u003cem\u003eJ Pharm Policy Pract\u003c/em\u003e. 2020; 13:23.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health professionals, Job satisfaction, Health facility, HRM intervention, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-7150387/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7150387/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Healthcare professional satisfaction is a critical component of effective health service delivery. However, many low-income countries face persistent challenges in maintaining high levels of job satisfaction among their health workforces. This study aims to assess changes in job satisfaction and motivational factors among health professionals in Ethiopia by comparing data collected in 2022 with baseline data from 2014.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A repeated cross-sectional study design was employed to compare job satisfaction and motivational factors among health professionals in 2014 (n = 1,356) and 2022 (n = 1,655). Data was collected using a validated 35-item job satisfaction tool and key informant interviews. Quantitative data were analyzed using descriptive statistics, t-tests, and point-biserial correlation coefficients. Qualitative data were analyzed using thematic approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Overall job satisfaction increased significantly by 16 percentage points (50.8% in 2014, 66.8% in 2022, p\u0026lt;0.001). Significant improvements were observed in salary and benefits (mean score 0.5, 95% CI [0.44, 0.56], p \u0026lt; 0.001), professional and career development (mean score 0.4, 95% CI [0.03, 0.33], p \u0026lt; 0.001), workload (mean score 0.2, 95% CI [0.14, 0.26], p \u0026lt; 0.001), Human Resources for health management (mean score=0.1, 95% CI [0.04, 0.16], p = 0.009), and working conditions (mean score 0.1, 95% CI [0.06, 0.14], p \u0026lt; 0.001). Qualitative findings also revealed perceived improvements in salary, financial incentives, and performance evaluations but highlighted persistent dissatisfaction with salary levels and inconsistencies in the performance evaluation process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Ethiopia has made notable progress in enhancing job satisfaction among health professionals by strengthening human resources for health (HRH) management, increasing financial incentives, and expanding opportunities for career development. Despite this progress, challenges remain, including gender, age, and regional disparities, low salary levels, and inadequate education opportunities. Addressing these issues with targeted interventions and integrating comprehensive incentive schemes into the broader developmental agenda will be crucial for fostering a resilient and motivated health workforce, ultimately enhancing health service delivery and contributing to the country's health sector transformation.\u003c/p\u003e","manuscriptTitle":"Improving Job Satisfaction and Motivation Among Health Professionals in the Public Health Sectors in Ethiopia: Evidence from a Repeated Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-21 11:00:11","doi":"10.21203/rs.3.rs-7150387/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d0333b36-40a0-4202-b1e4-99bac1e2e515","owner":[],"postedDate":"July 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-29T20:53:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-21 11:00:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7150387","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7150387","identity":"rs-7150387","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}