Job satisfaction among local-level health workers following decentralization in Nepal

Job satisfaction among local-level health workers following decentralization in Nepal | 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 Job satisfaction among local-level health workers following decentralization in Nepal Ramesh Kunwar, Prakash Adhikari, Vishnu Khanal, Kamal Ranabhat, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6503971/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: The impact of federalization on health workforce satisfaction remains inconclusive. There is paucity of literature on how decentralization affects health personnel’s motivation and performance. Nepal’s transition to federalism has been ongoing for a decade, yet only few studies have examined its impact on health workers. It is essential to understand factors that affect satisfaction of health workforce in order to ensure seamless delivery of health care. Therefore, this study aimed at assessing the level of job satisfaction among local-level health workers in Sudurpashchim (Far western) province of Nepal. Methods: A cross-sectional study was conducted among 444 health workers in Sudurpashchim Province. Job satisfaction was measured using a five-point Likert scale which has 31 items across three domains: working environment; employment adjustment process and policy; and local governance. The association between job satisfaction and independent variables were examined using Chi-squared test followed by multiple logistic regression. Results: The overall job satisfaction rate was 14.9%, with 34.7% satisfied with the working environment, 16.2% with local governance, and only 4.3% with the employee adjustment process and policy. The Gazetted Officers were less likely to be satisfied (adjusted odds ratio (AOR): 0.48; 95% confidence interval (CI): 0.27, 0.86) compared to their non-gazetted counterparts such as assistants and clerks. Similarly, those with a master's or higher degree (AOR: 0.38; 95% CI: 0.16, 0.89) were less likely to be satisfied with the working environment. Employees from the mountainous regions were less likely to be satisfied with local governance (AOR: 0.38; 95% CI: 0.15, 0.99) compared to their counterparts from hilly/Terai regions. Conversely, health workers serving in the health sections of municipalities were more satisfied than those working in peripheral health facilities (AOR: 2.03; 95% CI: 1.12, 3.65). Conclusion: Overall job satisfaction among the health workers was notably low, particularly in relation to the policies and procedures surrounding employee adjustment following Nepal’s federalization. This phenomenon necessitates rigorous inquiry into poor satisfaction and identifying their underlying causes. Concurrently, it is imperative that the state governments proactively engage with and address the discontent expressed by health workers regarding the adjustment mechanisms, while also prioritizing the strategic expansion of professional advancement opportunities, particularly in geographically marginalized, resource-constrained, and difficult regions such as the Himalayan areas. Decentralization federalization job satisfaction health personnel health governance health workforce Figures Figure 1 Background Decentralization of health systems, with transfer of authority and responsibility for health services from central to elected authorities at the subnational level (provincial governments, municipalities, etc.), with some degree of autonomy has been common globally, with varying implementation timelines across different regions (1–4). European countries underwent decentralization after the second world war, while a few of them recentralized some functions of their national health care systems (5). Numerous countries in Africa and Asia had limited the responsibility of local-level governments, following independence from colonialism. However, in the 1960s and 1970s, they adopted decentralized governance, with corresponding changes in health care systems (3). While the evidence regarding the benefits of health service decentralization is mixed, some studies suggest positive outcomes. For example, research from 20 member countries of the Organization for Economic Cooperation and Development (OECD) indicated a significant reduction in infant mortality, particularly with the local government’s financial autonomy (6). Switzerland, with its highly decentralized system, has positive outcomes such as high life expectancy and universal health coverage, although it also faces challenges such as high out-of-pocket expenses (7). However, in low-income countries, the results are less consistent. While some studies report improvements in mortality and service delivery, challenges related to resource availability and accountability persist (8,9). Decentralization has increased access to healthcare in India and strengthened local ownership in Indonesia (10). However, it has also raised concerns about equity in Pakistan (11), resource allocation in the Philippines (12), and regional disparities in Indonesia (9). The success of decentralization initiatives largely depends on contextual factors, and its overall impact remains a subject of debate in the literature. Despite the common adoption of decentralized health systems, research on its impact on human resources for health (HRH) is less common. The WHO identifies HRH as a crucial building block of a health system (13), and its performance is essential for service accessibility and quality (14,15). Job satisfaction among health workers is a vital component of HRH, influencing service quality, efficiency, and equity (14,16,17). It also impacts absenteeism and turnover (18,19). It is also a major factor that helps staff retention and motivation, which ultimately affect the quality of service. Therefore, maximizing the potential of the health workforce is crucial for achieving positive health outcomes and optimum health system functioning (20). Nepal underwent significant health system reforms following federalization in 2015, transferring basic health service responsibilities to local governments (21). Following the endorsement of the Employment Adjustment Act in 2018, the redistribution of health employees led to 82.9% of the health workforce being deployed at the local level (22). However, this transition has faced enormous challenges, including deployment issues and salary delays, as evidenced by numerous complaints to the Ministry of Health and Population (MoHP) and the Ministry of Federal Affairs and General Administration (MoFAGA) (23–26). Some Nepalese studies have shown the lowest level of job satisfaction among employees adjusted at the local level compared with the provincial and federal levels (27). While some studies have examined job satisfaction before federalization (28), others have focused on specific professions, institutions (29) or limited geographic regions (30). However, there remains a substantial gap in the literature concerning the effects of health system decentralization on the motivation and performance of health workers in Nepal.This study aims to assess job satisfaction and its associated factors among local-level health workers in Sudurpashchim Province, with a particular focus on how the devolution of responsibilities to municipal and provincial governments under federalization has influenced their experiences. Methods Context of the study The 2015 Nepalese Constitution established a three-tiered government: federal, provincial, and local, replacing the previous monarchy system, with each level led by elected representatives (21). This restructuring of governments also demanded decentralized health governance, reallocating health workers from the central, regional, and district levels to newly formed federal, provincial, and municipal structures. Health workers were invited to submit an expression of interest indicating their placement preferences in the new government structure (31). On the basis of the criteria outlined in Section 8 of the Employee Adjustment Act (2018) and available vacancies, health workers were assigned to positions at each level of government. This process was complex, as the MoHP had 26,612 staff members at various levels, often with conflicting responsibilities (22). The government was ill-prepared to address existing complexities, and the enormous task of adjustment put pressure on the existing workforce. Study design and setting A cross-sectional study was carried out from January 11, 2023 to February 6, 2023. The participants were either adjusted by the Federal Government or recruited by the Public Service Commission after the adjustment and were registered as health workers under the Public Health Service Act 2075 (32). Sudurpashchim was chosen as the study setting because of its remoteness, resource-limited context and diverse ecological terrain spanning the Himalayan, hilly (mountainous) and Terai (plain) regions. Its diverse terrain challenges healthcare access, making it crucial for assessing decentralization's impact on service delivery and workforce satisfaction. Additionally, strong internet penetration in health offices, health sections and health facilities ensured the feasibility of an online study. Participants and data collection Data were collected using purposively drawn samples, selected on the basis of health workers’ background characteristics and employment situations, through an online, self-administered questionnaire. A contact person was identified in each district health office, who was familiar with all health professionals within the district. They shared the study information and an online questionnaire (Google form) through the health professionals’ ‘ District Health Worker Messenger Group , which was universally used by health workers in each district. The focal persons followed up participants by sending reminder messages and making phone calls, also providing additional information and guidelines to help them complete the questionnaires accurately and thoroughly. Consenting health workers serving in the health sections of municipalities or in peripheral health facilities administered by the provincial government or municipal offices were included. However, health workers on secondments, temporary contracts, those recruited by the Hospital Development Committees (as they did not constitute employees adjusted/transferred after the federalization process under permanent governmental contracts), those available while on study leave and with less one years of experience were excluded. This structured and carefully selected approach facilitated systematic data collection across all districts, uniformly, from eligible health workers. (Figure 1) The questionnaire was developed based on literature (19,20,33–36). Consultations with subject experts at Tribhuvan University’s Public Health Department and Government’s Health System experts, ensured that the questionnaire was adequately customized for the Nepalese context. The draft questionnaire was pilot tested with ten public health professionals. Based on the feedback received, it was refined to ensure the use of appropriate terminology and descriptors, improve linguistic accuracy following translation into Nepali, and enhance the overall flow and coherence of the questions. Thus, final questionnaire demonstrated strong internal consistency, with a Cronbach’s alpha of 0.88. Variables Outcome variable Job satisfaction was assessed using a 31-item five-point Likert scale questionnaire across the three domains of working environment (15 items), employee adjustment policy and procedures (9 items), and local governance (7 items). The participants rated their satisfaction levels on a scale ranging from ‘ strongly disagree ’ to ‘ strongly agree ’. A score from -2 (strongly disagree) to 2 (strongly agree) was assigned for the positively worded questions, and a score from 2 (strongly disagree) to -2 (strongly agree) was assigned for negatively worded questions, with a score of 0 for neutral responses. The mean item score was used to categorize levels of job satisfaction, following methodologies outlined in previous studies. (35,36): Less than -1 to -2 (highly dissatisfied), 0 to -1 (moderately dissatisfied), More than 0 to 1 (moderately satisfied) and More than 1 (highly satisfied) For logistic regression analysis, individuals with mean scores greater than 0 were categorized as ‘ satisfied=1’ , and those with scores ranging from 0 to -2 were categorized as ‘ dissatisfied =0’. ‘Satisfaction’ was measured as the three domains of job satisfaction and summed as ‘overall satisfaction’: (i) Working environment: Daily support and pressures from local leaders, supervisor support, involvement in planning, proper use of skills, knowledge and experience by the local government and work‒life balance; (ii) Employee adjustment process and policy: Fairness of federalization staff changes, training access, and equity of opportunities compared with health workers of other tiers; and (iii) Local governance: Local government healthcare management, resource use, service delivery capacity, and reward and grievances management. Finally, ‘overall satisfaction’ was obtained by using the sum of the scores. Independent variables Background characteristics of the participants included age, which was initially collected in four groups (≤30, 31–40, 41–50, and 51–60 years) and later categorized as ≤30 and >30 years. Sex was recorded as male or female. Workplace geography was initially classified as Himalayan, hills, and Terai but was later grouped into Himalayan (the most remote region) and Terai/hilly. The place of work was categorized as rural or urban, whereas local residence was recorded as yes or no. Education level was collected as a technical school-leaving certificate, proficiency certificate level, bachelor's level, and master's level or above, which was later condensed into the bachelor's level and master’s level or above. Work site classification included health sections, primary health care centers/basic hospitals, health posts, basic health service centers, community health units, and urban health clinics, which were later categorized into health section of municipalities and peripheral health institutes (37). Designations were recorded as auxiliary health workers, staff nurses/auxiliary nurse midwives, health assistants, and others and were later recategorized into health assistants and other health professionals (32). The employee level was collected at the fourth, fifth, sixth, seventh and eighth levels and subsequently categorized into non-gazetted (fourth and fifth levels) and gazetted officers (sixth and above levels) (38). The service duration was initially recorded as 25 years and was later grouped into ≤15 years and >15 years. Data management and statistical analysis The data collected via Google Forms were downloaded in the form of a spreadsheet, and completeness and duplications of the data were checked. The data were cleaned for completeness. Descriptive analysis was performed by calculating the frequency and percentage of categorical variables. The Chi-squared test followed by multiple logistic regression was used to determine the associations between categorical independent and dependent variables. The variables with a p-value less than 0.1 during Chi-squared analysis were entered into the multiple logistic regression analysis (39). The adjusted odds ratios (AORs) and corresponding 95% confidence intervals (CIs) were reported to demonstrate the associations. A p-value <0.05 was considered as statistical significance. Data analysis was performed via the Statistical Package for Social Science (Version 25). Results Characteristics of the participants Table 1 shows the characteristics of the participants. A total of 444 responses were included in the final analysis, with 63.1% aged 30 years or above and 74.8% male. Six out of the seven (85.4%) employees were from the hill/Terai region, and 52.3% worked in urban areas. Nearly two-thirds (62.4%) were local residents. The majority held bachelor’s degrees (90.5%) and served peripheral health institutions (82.0%) with designations such as auxiliary health workers (41.0%) and health assistants (38.5%). Two out of five of the respondents (41.2%) were at the officer level, and 56.5% had 6 to 15 years of work experience. Table 1 Characteristics of the participating health workers (n=444) Variable Categories Number (%) Age ≤30 years 164 (36.9) >30 years 280 (63.1) Gender Male 332 (74.8) Female 112 (25.2) Workplace geography Hill/Terai 379 (85.4) Himalayan 65 (14.6) Place of work Urban 232 (52.3) Rural 212 (47.7) Local residence Yes 277 (62.4) No 167 (37.6) Educational qualification Up to bachelor’s degree 402 (90.5) Master’s and above 42 (9.5) Worksite Peripheral health institutes 364 (82.0) Health section of municipalities 80 (18.0) Designation Other health professionals 273 (61.5) Health Assistant 171 (38.5) Employee level Non-gazetted 261 (58.8) Gazetted 183 (41.2) Service duration Up to 15 years 368 (82.9) More than 15 years 76 (17.1) Job satisfaction Only small proportion of the seven participants (14.9%) expressed overall job satisfaction [mean satisfaction score: -0.52 (SD: 0.50)]. Similarly, 69.4% were moderately dissatisfied, and 15.8% were highly dissatisfied. Among the three domains, the highest level of satisfaction was observed with the domain working environment, i.e., 34.7% [mean satisfaction score: -0.20 (SD: 0.54)], followed by local governance, i.e., 16.2% [mean satisfaction score: -0.66 (SD: 0.74)], and the employee adjustment process and policy, i.e., 4.7% [mean satisfaction score: -0.95 (SD: 0.57)] (Table 2). Table 2 Level of job satisfaction (n=444) Domains of job satisfaction Categories Number (%) Overall satisfaction Mean (SD.): -0.52 (0.50) Highly satisfied 0 (0.0) Moderately satisfied 66 (14.9) Moderately dissatisfied 308 (69.4) Highly dissatisfied 70 (15.8) Working environment Mean (S.D.): -0.20 (0.54) Highly satisfied 1 (0.2) Moderately satisfied 153 (34.5) Moderately dissatisfied 261 (58.8) Highly dissatisfied 29 (6.5) Employee adjustment process and policy Mean (SD): -0.95 (0.57) Highly satisfied 0 (0.0) Moderately satisfied 19 (4.3) Moderately dissatisfied 244 (54.9) Highly dissatisfied 181 (40.8) Local governance Mean (SD.): -0.66 (0.74) Highly satisfied 3 (0.7) Moderately satisfied 69 (15.5) Moderately dissatisfied 246 (55.4) Highly dissatisfied 126 (28.4) SD: Standard deviation Factors associated with job satisfaction Employee level was significantly associated with overall job satisfaction, with officer-level employees being less likely to be satisfied (AOR: 0.48; 95% CI: 0.27, 0.86). Health workers with a master’s degree or above were less likely to be satisfied (AOR: 0.38; 95% CI: 0.16, 0.89) with the working environment. Likewise, health workers working in the health sector were more likely to be satisfied (AOR: 2.03; 95% CI: 1.12, 3.65) with local governance. In contrast, health workers working in Himalayan regions were less likely to be satisfied (AOR: 0.38; 95% CI: 0.15, 0.99) with local governance (Table 3). Table 3 Factors associated with job satisfaction Variable Categories AOR (95% CI) p value Overall satisfaction 1 Employee level Non-gazetted 1.00 0.01 Gazetted 0.48 (0.27, 0.86) Working environment 2 Education level Below Masters 1.00 0.03 Masters and above 0.38 (0.16, 0.89) Local governance 3 Workplace Peripheral health institutes 1.00 0.02 Health section 2.03 (1.12, 3.65) Geography Hill/Terai 1.00 < 0.049 Himalayan 0.38 (0.15, 0.99) Variables entered in the models: Model 1: Employee level; Model 2: Age, Educational level and Employee level; Model 3: Workplace, geography. Owing to having fewer than 5 cells in one cell, employee adjustment was not included in the multiple logistic regression. AOR: adjusted odds ratio. CI: Confidence interval Discussion This study evaluated job satisfaction among local-level health workers in Sudurpashchim Province. Overall, only a small proportion (14.9%) of health workers reported being satisfied with their jobs following their deployment to local health facilities or municipal health sections as part of Nepal’s ongoing health sector federalization process. The proportion of health workers satisfied with the employee adjustment policy and processes was even lower, at just 4.3%. These findings, along with anecdotal evidence, suggest that the adjustment procedures may not have been implemented in a fair or transparent manner. However, this warrants further investigation. The health workers included in our study were less likely to be satisfied than that reported by previous studies in Nepal and their peers in other low- and middle-income countries ( 28 , 30 , 40 ). For example, a previous study in Banke district of Nepal reported a 24% higher rate of overall satisfaction ( 30 ). Likewise, job satisfaction ranged between 55% and 76.2% in studies conducted in Jhapa, Siraha, Bardiya, and Doti of Nepal ( 28 , 40 ). Similarly, studies among general employees have reported that the satisfaction level is lower among local health workers than among federal/provincial employees ( 27 ). Whereas in India, Pakistan and Ethiopia, 27.7–54% of health workers were satisfied with their jobs ( 41 – 44 ). Job dissatisfaction among Nepali health workers was related with several reasons, including ill-equipped organizational transition ( 30 ), lack of readiness ( 45 ) and inadequate time allowed in preparation for and execution of the transition in the midst of change in the political leadership ( 46 ). Studies from other LMICs suggest that stable employment, job security ( 42 ), and recognition ( 19 ) enhance satisfaction, whereas inadequate stipends ( 10 ), unclear career paths ( 42 ), and poor work‒life balance ( 47 ) diminish it. Although previous studies also report significant job dissatisfaction, as observed in our study, differences in how outcomes were measured mean that the results should be compared with caution. Employee level was a key determinant of overall job satisfaction among local-level health employees. Dissatisfaction possibly stemmed from aspirations for higher positions, such as health section chiefs or health posts in charge. Additionally, tensions between Sr. AHW officers and public health inspectors, driven by unclear seniority, further contributed to dissatisfaction ( 28 , 48 ). The lack of opportunities and authority for employees promoted to officer positions likely worsened the issue, highlighting the need to address hierarchical ambiguities and expand roles and responsibilities at the officer level (gazetted health workers). Employees with a master’s degree or higher were more dissatisfied with the working environment. Similarly, a negative relationship between job satisfaction and education level was observed among community health workers in China ( 49 ). This dissatisfaction likely stems from unmet expectations and underutilized skills due to limited opportunities at the local level ( 50 ). Thus, integrating them into decision-making and granting education-related authorities can increase job satisfaction. Geographical location of workplace and the adjustment policies were also significantly associated with satisfaction, with all employees in the Himalayan region reporting dissatisfaction. As Nepal’s most remote and challenging terrain, this region offers limited resources and career growth opportunities, leading to stagnation and fear in terms of career development prospects and contributing to heightened levels of dissatisfaction. Similarly, study from Pakistan suggests that the inadequacy of health logistics decreases job satisfaction among health workers ( 51 ). Job satisfaction was less common among health workers serving in peripheral health facilities governed by the municipalities than those working in the health sections of municipalities, where they enjoyed greater power and career-related opportunities. This may be because health section employees are directly involved in decision-making, increasing their influence. In contrast, peripheral health workers frequently cited grievances related to inadequate supplies such as medicines and equipment, which decreases motivation and increases dissatisfaction ( 28 ). Additionally, studies suggest that good management, supportive supervision and a good working environment motivate health workers ( 19 , 30 ). The health section oversees peripheral health facilities, but conflicts among senior employees competing for leadership, along with political interference in appointing section chiefs, often lead to turnover and unstable leadership. This instability disrupts the chain of command and weakens governance. Thus, appointing qualified section chiefs through hierarchical policies and ensuring that health facilities meet minimum service standards are crucial for improving governance-related job satisfaction and overall employee satisfaction. Health worker satisfaction with local governance varies by region, with higher levels in the Terai and hilly areas than in the Himalayas. Himalayan health workers face resource scarcity, poor infrastructure, limited governance engagement, and weak supervision due to geographic isolation ( 52 ). This disconnection hampers communication, grievance resolution, and service delivery, lowering satisfaction. This study has several notable strengths, as it focuses on three key domains of job satisfaction work environment, employee adjustment processes and policies, and local governance each of which is highly relevant to the local context. It is also among the first to assess satisfaction related to employee adjustment. However, limitations include potential response bias from self-administered questionnaires and selection bias, as health workers without internet access could not participate. Deteriorating occurrence of job satisfaction among health workers as indicated by the comparison with previous studies from Nepal, needs to be ascertained by further studies such that a conclusive analysis of trends is possible. Moreover, conducting additional studies that would examine the causes, for example by using qualitative methods, are essential to comprehensively grasp the perceptions of local employees regarding the working environment, local governance, and grievances associated with the employee adjustment process and policy. Meanwhile, it is necessary to address health worker’s dissatisfaction related to the adjustment policy and processes, ambiguities about hierarchies and reporting lines, authorities and power, and career opportunities. Conclusion Our study highlighted that only a small proportion of health workers were satisfied after they were adjusted to new roles and governance structure, as part of the federalization in Nepal’s health system. Particular attention must be given to fairness and transparency during the adjustment processes, discrepancies in power and authorities among the employees adjusted in different workplaces and roles, and the availability of career related opportunities. Simultaneously, it is important to address the health workers’ grievances related to the adjustment processes, as this would assist in the implementation of ongoing federalization of the health system. Career related opportunities should be provided to health workers serving in deprived locations and workplaces, such as peripheral health facilities and those located in Himalayan region, in the spirit closing equity gaps. Action research aimed at co-designing, implementing, and evaluating these initiatives could contribute to improved job satisfaction among health professionals. Abbreviations AHW: Auxiliary Health Worker AOR: Adjusted Odds Ratio CI: Confidence Interval HRH: Human Resources for Health MoFAGA: Ministry of Federal Affairs and General Administration MoHP: Ministry of Health and Popoulation OECD: Organization for Economic Cooperation and Development SD: Standard Deviation WHO: World Health Organization Declarations Ethics approval and consent to participate Ethical approval was obtained from the Institutional Review Board of the Institute of Medicine, Tribhuvan University (Reference number: 255(6-11) F2/079/080). Administrative approval to conduct the study was obtained from the Health Directorate, Sudurpashchim Province (Ref 2079/80/301). Consent for publication Not Applicable Availability of data and materials The data will be made available on a reasonable request from the corresponding author. Competing interests The authors declare no competing interests Funding None Author contributions RK with AB conceptualized the study. RK conducted the survey. PA performed the data cleaning and formal analysis with technical input from VK. PA and AB wrote the first draft. AB and BPC supervised the study and provided critical comments throughout the study and preparation of manuscript. VK, AKJ and KR critically reviewed and contributed to the writing of the final manuscript. All the authors have read, reviewed and endorsed the final version of the manuscript. Acknowledgements The authors would like to extend their gratitude to the Ministry of Social Development and all the Health Office Chiefs of Sudurpashchim Province, Nepal, for their support and coordination during the data collection period. References OECD. Making decentralisation work: A handbook for policy-makers [Internet]. 2019. 135–187 p. Available from: https://www.oecd.org/en/publications/making-decentralisation-work_g2g9faa7-en.html Robalino DA, Picazo O, Voetberg A. Does Fiscal Decentralization Improve Health Outcomes? Evidence from a Cross-Country Analysis. Policy Research Working Paper 2565. Washington DC: World Bank. 2001 [cited 2025 Mar 22]. Available from: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=632632 Mills A, Vaughan JP, Smith DL, Tabibzadeh I. Health system decentralization: concepts, issues and country experience [Internet]. World Health Organisation. 1990. p. 151. Available from: https://books.google.co.uk/books?id=efpfQgAACAAJ Saltman RB, Bankauskaite V, Vrangbaek K. Decentalization in Health Care. Brussels European Observatory on Health Syststem and Policies; 2007. Saltman RB. Decentralization, re-centralization and future European health policy: Decentralization as a strategic cornerstone. European Journal of Public Health. 2008;18:2. Jiménez-Rubio D. The impact of fiscal decentralization on infant mortality rates: Evidence from OECD countries. Soc Sci Med. 2011 Nov 1;73:9. De Pietro C, Camenzind Isabelle Sturny P, Crivelli Suzanne Edwards-Garavoglia Anne Spranger L, Wittenbecher Wilm Quentin F. Health Systems in Transition: Switzerland Vol 17 No 4 2015. Switz Heal Syst Rev. 2015;17:4. Cobos Muñoz D, Merino Amador P, Monzon Llamas L, Martinez Hernandez D, Santos Sancho JM. Decentralization of health systems in low and middle income countries: a systematic review. International Journal of Public Health [Internet]. 2017 [cited 2024 Sep 20];62:2. Available from: https://link.springer.com/article/10.1007/s00038-016-0872-2 Dwicaksono A, Fox AM. Does Decentralization Improve Health System Performance and Outcomes in Low- and Middle-Income Countries? A Systematic Review of Evidence From Quantitative Studies. Milbank Q [Internet]. 2018 Jun 1 [cited 2024 Sep 20];96:2. Available from: https://pubmed.ncbi.nlm.nih.gov/29870116/ Ghuman BS, Singh R. Decentralization and delivery of public services in Asia. Policy Soc [Internet]. 2013 Mar 1 [cited 2025 Mar 30];32:1. Available from: https://dx.doi.org/10.1016/j.polsoc.2013.02.001 Herzberg F. One More Time How Do You Motivate Employees? [Internet]. 2002. Available from: www.hbrreprints.org Brennan E, Abimbola S. The impact of decentralisation on health systems in fragile and post-conflict countries: a narrative synthesis of six case studies in the Indo-Pacific. Confl Health [Internet]. 2023 Dec 1 [cited 2025 Mar 30];17:1:31. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10280898/ WHO. Monitoring the Building Blocks of Health Systems : a Handbook of Indicators and. 2010;110. Dieleman M, Toonen J, Touré H, Martineau T. The match between motivation and performance management of health sector workers in Mali. Hum Resour Health. 2006 Feb 9;4. Guilbert JJ. The World Health Report 2006: Working together for health [1]. Educ Heal Chang Learn Pract. 2006;19:3. Dieleman M, Harnmeijer JW. 1174_Improving-health-worker-performance_Dieleman_Harnmeijer. Evid Inf Policy, Dep Hum Resour Heal Geneva. 2006;1:1. Babatunde Jimoh A, Modinat Oyewunmi A, Zaheed Oladimeji A. Relationships Between Job Satisfaction and the Quality of Healthcare Delivery in Ogun State Hospital Management Board, Nigeria. Int J Sci Acad Res [Internet]. 2022;03(November):4680–6. Available from: http://www.scienceijsar.com Kanchanachitra C, Lindelow M, Johnston T, Hanvoravongchai P, Lorenzo FM, Huong NL, et al. Human resources for health in southeast Asia: Shortages, distributional challenges, and international trade in health services. Lancet [Internet]. 2011;377:9767. Available from: http://dx.doi.org/10.1016/S0140-6736(10)62035-1 Daneshkohan A, Zarei E, Mansouri T, Maajani K, Ghasemi MS iyaha., Rezaeian M. Factors affecting job motivation among health workers: a study from Iran. Glob J Health Sci. 2015;7:3:. Bhatnagar K, Srivastava K. Job satisfaction in health-care organizations. Ind Psychiatry J [Internet]. 2012 [cited 2024 Mar 25];21(1):75. Available from: /pmc/articles/PMC3678186/ The Constitution of Nepal 2015 [Internet]. Government of Nepal; 2016. Available from: https://lawcommission.gov.np/np/?cat=87 Progress of the Health and Population Sector , 2019 / 20. 2021; The Himalayanayan Times [Internet]. 2019 [cited 2024 Sep 29]. Thousands of health workers file complaint against their adjustment - The Himalayan Times - Nepal’s No.1 English Daily Newspaper | Nepal News, Latest Politics, Business, World, Sports, Entertainment, Travel, Life Style News. Available from: https://thehimalayantimes.com/nepal/thousands-of-health-workers-file-complaint-against-their-adjustment The Kathmandu Post [Internet]. 2022 [cited 2024 Dec 23]. Staff adjustment leads to personnel mismanagement at health facilities. Available from: https://kathmandupost.com/health/2022/03/16/staff-adjustment-leads-to-personnel-mismanagement-at-health-facilities Republica [Internet]. 2023 [cited 2024 Dec 23]. Health workers in Surkhet without salaries for eight months, authorities say ‘No budget’ - myRepublica - The New York Times Partner, Latest news of Nepal in English, Latest News Articles | Republica. Available from: https://www.myrepublica.nagariknetwork.com/news/health-workers-in-surkhet-without-salaries-for-eight-months-authorities-say-no-budget The Kathmandu Post [Internet]. 2023 [cited 2024 Mar 25]. Dhangadi Sub-metropolis health workers protest demanding due salary. Available from: https://kathmandupost.com/sudurpaschim-province/2023/03/26/dhangadi-sub-metropolis-health-workers-protest-demanding-due-salary Dahal AK, Mishra AK, Chaudhary MK, Aithal PS. Job Satisfaction in Federal Structure - A Case of Bhojpur, Nepal. Int J Appl Eng Manag Lett. 2021;1. Khanal P. Work motivation and job satisfaction among health workers of primary health facilities: a mixed-methods study from Nepal. (Version 2) available Res Sq. 2020;1–21. Singh A, Chakradhar R, Joshi N. Job Satisfaction among Nurses Working in a Tertiary Level Government Hospital. Med J Shree Birendra Hosp [Internet]. 2021 Feb 2 [cited 2025 Mar 23];20:1. Available from: https://nepjol.info/index.php/MJSBH/article/view/28777 Rana K. Job Satisfaction and Change Readiness of Public Health Workers in Context of Federal Health System of Nepal at Local Level: A Cross-Sectional Study in Banke District. SSRN Electron J. 2020; Employment Adjustment Act 2075 [Internet]. Ministry of Home Affairs. 2018. 1–28 p. Available from: https://lawcommission.gov.np/np/wp-content/uploads/2021/01 The Public Health Service Act, 2075 (2018). Nepal Law Commission Internet]. 2019;2075:11. Available from: https://www.lawcommission.gov.np/en/wp-content/uploads/2019/07/The-Public-Health-Service-Act-2075-2018.pdf Thapa R, Bam K, Tiwari P, Sinha TK, Dahal S. Implementing federalism in the health system of Nepal: Opportunities and challenges. Int J Heal Policy Manag [Internet]. 2019;8:4. Available from: https://doi.org/10.15171/ijhpm.2018.121 Office SS. Employee Satisfaction Survey. Repub Maced State Stat Off [Internet]. 2009;3–5. Available from: https://www.academia.edu/35314643/EMPLOYEE_SATISFACTION_SURVEY_2009_Basic_survey_information_REPUBLIC_OF_MACEDONIA_STATE_STATISTICAL_OFFICE Chen AH, Jaafar SN, Noor ARM. Comparison of job satisfaction among eight health care professions in private (non-government) settings. Malaysian J Med Sci. 2012;19:2. Khamlub S, Harun-Or-Rashid M, Sarker MAB, Hirosawa T, Outavong P, Sakamoto J. Job satisfaction of health-care workers at health centers in Vientiane capital and Bolikhamsai province, Lao pdr. Nagoya J Med Sci. 2013;75:3–4. Local Government Operation Act, 2017, Ministry of Federal Affairs and General Administration [Internet]. 2017 [cited 2025 Apr 17].. Available from: https://mofaga.gov.np/detail/1697 Nepal Health Service Rules 2055. Government of Nepal [Internet]. 2005;2055(1999). Available from: https://www.dda.gov.np/download/health-service-rules-2055-1999.pdf Robins RW, Hendin HM TK. Purposeful selection of variables in logistic regression. Source Code Biol Med [Internet]. 2008;3:1–8. Available from: https://scfbm.biomedcentral.com/articles/10.1186/1751-0473-3-17 Ghimire J, Gupta RP, Kumal AB, Mahato RK, Bhandari RM, Thapa N. Factors associated with the motivation and de-motivation of health workforce in Nepal. J Nepal Health Res Counc. 2013;11:24. Girma B, Nigussie J, Molla A, Mareg M. Health professional’s job satisfaction and its determinants in Ethiopia: a systematic review and meta-analysis. Arch Public Heal [Internet]. 2021 Dec 1 [cited 2025 Mar 30];79:1. Available from: https://archpublichealth.biomedcentral.com/articles/10.1186/s13690-021-00664-7 Ejigu Y, Abera N, Haileselassie W, Berhanu N, Haile BT, Nigatu F, et al. Motivation and job satisfaction of community health workers in Ethiopia: a mixed-methods approach. Hum Resour Health [Internet]. 2023 Dec 1 [cited 2025 Mar 30];21(1):1–10. Available from: https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-023-00818-4 Singh T, Kaur M, Verma M, Kumar R. Job satisfaction among health care providers: A cross-sectional study in public health facilities of Punjab, India. J Fam Med Prim Care [Internet]. 2019 [cited 2025 Mar 30];8(10):3268. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6857391/ Kumar R, Ahmed J, Shaikh BT, Hafeez R, Hafeez A. Job satisfaction among public health professionals working in public sector: A cross sectional study from Pakistan. Hum Resour Health. 2013;11:1. Gupta S, Singla A. Organizational change and job satisfaction: An analysis of mediating effect of organizational trust. Indian J Commer Manag Stud [Internet]. 2016;7(3):7–13. Available from: http://www.scholarshub.net Tabvuma V, Bui HTM, Homberg F. Adaptation to externally driven change: The impact of political change on job satisfaction in the public sector. Public Adm Rev. 2014;74:3. Olaniran A, Madaj B, Bar-Zeev S, Banke-Thomas A, van den Broek N. Factors influencing motivation and job satisfaction of community health workers in Africa and Asia-A multi-country study. Int J Health Plann Manage [Internet]. 2022 Jan 1 [cited 2025 Mar 30];37:1. Available from: https://pubmed.ncbi.nlm.nih.gov/34476842/ The Kathmandu Post [Internet]. 2019 [cited 2024 Apr 6]. Staff adjustment proposal worries health assistants across country. Available from: https://kathmandupost.com/national/2019/02/12/staff-adjustment-proposal-worries-health-assistants-across-country Ge C, Fu J, Chang Y, Wang L. Factors associated with job satisfaction among Chinese community health workers: A cross-sectional study. BMC Public Health. 2011;11. Robinson S, Murrells T, Clinton M, College K. Highly qualified and highly ambitious: implications for workforce retention of realising the career expectations of graduate nurses in England. Hum Resour Mangagemnt J. 2006;16:3. Haq Z, Iqbal Z, Rahman A. Job stress among community health workers: A multi-method study from Pakistan. Int J Ment Health Syst [Internet]. 2008 [cited 2025 Mar 30];2;1: Available from: https://ijmhs.biomedcentral.com/articles/10.1186/1752-4458-2-15 Cao WR, Shakya P, Karmacharya B, Xu DR, Hao YT, Lai YS. Equity of geographical access to public health facilities in Nepal. BMJ Glob Heal [Internet]. 2021 Oct 27 [cited 2025 Mar 23];6(10):6786. Available from: https://gh.bmj.com/content/6/10/e006786 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 25 Apr, 2025 Editor assigned by journal 22 Apr, 2025 Submission checks completed at journal 22 Apr, 2025 First submitted to journal 22 Apr, 2025 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. 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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-6503971","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":446577401,"identity":"d3a45373-a8a8-4555-a9b0-9baa4f431597","order_by":0,"name":"Ramesh Kunwar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYLACxgYGAwjLgE0ORB14QLyWCj5jsJYE4rWckUtsANH4tJi3n058+HMHg7HB7R7Dz5VtZunzww4/BNpiJ6fbgF2LzJnczca8ZxjMDO6cMZY825aWu/F2mgFQS7Kx2QHsWiQYcrdJM7Yx2BjcyN0g2dh2LHfj7ASQlgOJ23Bp4X+7/edPiJbNPxvb/qcbzk7/gF+LRO42Bt42oMNu5G6TbDjDliAvnUPAFom3m6V52ySMJW/kf7NsqGAz3CCdU3AgwQCPX/hzN3782WZj2HcjLflmgwGbvPzs9M0fPlTYyeHSAg8FODAAqzTAqxwNyDeQonoUjIJRMApGAgAA+dpjPueVwoYAAAAASUVORK5CYII=","orcid":"","institution":"Health Office, Kailali","correspondingAuthor":true,"prefix":"","firstName":"Ramesh","middleName":"","lastName":"Kunwar","suffix":""},{"id":446577404,"identity":"1b52892a-e864-4f1f-9384-191e012241ea","order_by":1,"name":"Prakash Adhikari","email":"","orcid":"","institution":"Health Service Office Dailekh, Ministry of Social Development","correspondingAuthor":false,"prefix":"","firstName":"Prakash","middleName":"","lastName":"Adhikari","suffix":""},{"id":446577407,"identity":"1e0caf74-b28e-47ac-b12d-655cf42ee888","order_by":2,"name":"Vishnu Khanal","email":"","orcid":"","institution":"Charles Darwin University","correspondingAuthor":false,"prefix":"","firstName":"Vishnu","middleName":"","lastName":"Khanal","suffix":""},{"id":446577409,"identity":"3801ad9a-3a00-4b1d-8d2c-940db5f53776","order_by":3,"name":"Kamal Ranabhat","email":"","orcid":"","institution":"Central Department of Public Health, Institute of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kamal","middleName":"","lastName":"Ranabhat","suffix":""},{"id":446577410,"identity":"7d7a1d5c-b220-41c7-be83-e235d938ac1e","order_by":4,"name":"Arun Kumar Joshi","email":"","orcid":"","institution":"Tribhuvan University","correspondingAuthor":false,"prefix":"","firstName":"Arun","middleName":"Kumar","lastName":"Joshi","suffix":""},{"id":446577411,"identity":"2d372421-9b58-4f61-8c05-dbc07b58f68f","order_by":5,"name":"Bishnu Prasad Choulagai","email":"","orcid":"","institution":"Central Department of Public Health, Institute of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Bishnu","middleName":"Prasad","lastName":"Choulagai","suffix":""},{"id":446577412,"identity":"740f5fe2-8e29-480a-be14-6f1748b14e41","order_by":6,"name":"Ashok Bhurtyal","email":"","orcid":"","institution":"Central Department of Public Health, Institute of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ashok","middleName":"","lastName":"Bhurtyal","suffix":""}],"badges":[],"createdAt":"2025-04-22 11:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6503971/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6503971/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81178821,"identity":"ca098743-1a10-4a36-bf14-8fa6ffbe8681","added_by":"auto","created_at":"2025-04-23 06:56:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":28552,"visible":true,"origin":"","legend":"\u003cp\u003eSampling process\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6503971/v1/1fd30ff6dd947bfca88cba85.png"},{"id":81180004,"identity":"c45542df-e55a-4779-b37d-de65cc46d184","added_by":"auto","created_at":"2025-04-23 07:12:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":798387,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6503971/v1/c08cc314-1928-44a9-aa27-fcea7acc515d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Job satisfaction among local-level health workers following decentralization in Nepal","fulltext":[{"header":"Background","content":"\u003cp\u003eDecentralization of health systems, with transfer of authority and responsibility for health services from central to elected authorities at the subnational level (provincial governments, municipalities, etc.), with some degree of autonomy has been common globally, with varying implementation timelines across different regions (1\u0026ndash;4). European countries underwent decentralization after the second world war, while a few of them recentralized some functions of their national health care systems (5). Numerous countries in Africa and Asia had limited the responsibility of local-level governments, following independence from colonialism. However, in the 1960s and 1970s, they adopted decentralized governance, with corresponding changes in health care systems (3).\u003c/p\u003e\n\u003cp\u003eWhile the evidence regarding the benefits of health service decentralization is mixed, some studies suggest positive outcomes. For example, research from 20 member countries of the Organization for Economic Cooperation and Development (OECD) indicated a significant reduction in infant mortality, particularly with the local government\u0026rsquo;s financial autonomy (6). Switzerland, with its highly decentralized system, has positive outcomes such as high life expectancy and universal health coverage, although it also faces challenges such as high out-of-pocket expenses (7). However, in low-income countries, the results are less consistent. While some studies report improvements in mortality and service delivery, challenges related to resource availability and accountability persist (8,9). Decentralization has increased access to healthcare in India and strengthened local ownership in Indonesia (10). However, it has also raised concerns about equity in Pakistan (11), resource allocation in the Philippines (12), and regional disparities in Indonesia (9). The success of decentralization initiatives largely depends on contextual factors, and its overall impact remains a subject of debate in the literature.\u003c/p\u003e\n\u003cp\u003eDespite the common adoption of decentralized health systems, research on its impact on human resources for health (HRH) is less common. The WHO identifies HRH as a crucial building block of a health system\u0026nbsp;(13), and its performance is essential for service accessibility and quality\u0026nbsp;(14,15). Job satisfaction among health workers is a vital component of HRH, influencing service quality, efficiency, and equity (14,16,17). It also impacts absenteeism and turnover\u0026nbsp;(18,19).\u0026nbsp;It is also a major factor that helps staff retention and motivation, which ultimately affect the quality of service. Therefore, maximizing the potential of the health workforce is crucial for achieving positive health outcomes and optimum health system functioning\u0026nbsp;(20).\u003c/p\u003e\n\u003cp\u003eNepal underwent significant health system reforms following federalization in 2015, transferring basic health service responsibilities to local governments (21). Following the endorsement of the Employment Adjustment Act in 2018, the redistribution of health employees led to 82.9% of the health workforce being deployed at the local level (22). However, this transition has faced enormous challenges, including deployment issues and salary delays, as evidenced by numerous complaints to the Ministry of Health and Population (MoHP) and the Ministry of Federal Affairs and General Administration (MoFAGA) (23\u0026ndash;26). Some Nepalese studies have shown the lowest level of job satisfaction among employees adjusted at the local level compared with the provincial and federal levels (27). While some studies have examined job satisfaction before federalization (28), others have focused on specific professions, institutions (29) or limited geographic regions (30). However, there remains a substantial gap in the literature concerning the effects of health system decentralization on the motivation and performance of health workers in Nepal.This study aims to assess job satisfaction and its associated factors among local-level health workers in Sudurpashchim Province, with a particular focus on how the devolution of responsibilities to municipal and provincial governments under federalization has influenced their experiences.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eContext of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 2015 Nepalese Constitution established a three-tiered government: federal, provincial, and local, replacing the previous monarchy system, with each level led by elected representatives (21). This restructuring of governments also demanded decentralized health governance, reallocating health workers from the central, regional, and district levels to newly formed federal, provincial, and municipal structures. Health workers were invited to submit an expression of interest indicating their placement preferences in the new government structure (31). On the basis of the criteria outlined in Section 8 of the Employee Adjustment Act (2018) and available vacancies, health workers were assigned to positions at each level of government. This process was complex, as the MoHP had 26,612 staff members at various levels, often with conflicting responsibilities (22). The government was ill-prepared to address existing complexities, and the enormous task of adjustment put pressure on the existing workforce.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was carried out from January 11, 2023 to February 6, 2023. The participants were either adjusted by the Federal Government or recruited by the Public Service Commission after the adjustment and were registered as health workers under the Public Health Service Act 2075 (32).\u003c/p\u003e\n\u003cp\u003eSudurpashchim was chosen as the study setting because of its remoteness, resource-limited context and diverse ecological terrain spanning the Himalayan, hilly (mountainous) and Terai (plain) regions. Its diverse terrain challenges healthcare access, making it crucial for assessing decentralization\u0026apos;s impact on service delivery and workforce satisfaction. Additionally, strong internet penetration in health offices, health sections and health facilities ensured the feasibility of an online study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using purposively drawn samples, selected on the basis of health workers\u0026rsquo; background characteristics and employment situations, through an online, self-administered questionnaire. A contact person was identified in each district health office, who was familiar with all health professionals within the district. They shared the study information and an online questionnaire (Google form) through the health professionals\u0026rsquo; \u0026lsquo;\u003cem\u003eDistrict Health Worker Messenger Group\u003c/em\u003e, which was universally used by health workers in each district. The focal persons followed up participants by sending reminder messages and making phone calls, also providing additional information and guidelines to help them complete the questionnaires accurately and thoroughly. Consenting health workers serving in the health sections of municipalities or in peripheral health facilities administered by the provincial government or municipal offices were included. However, health workers on secondments, temporary contracts, those recruited by the \u003cem\u003eHospital Development Committees\u0026nbsp;\u003c/em\u003e(as they did not constitute employees adjusted/transferred after the federalization process under permanent governmental contracts), those available while on study leave and with less one years of experience were excluded. This structured and carefully selected approach facilitated systematic data collection across all districts, uniformly, from eligible health workers. (Figure 1)\u003c/p\u003e\n\u003cp\u003eThe questionnaire was developed based on literature \u0026nbsp; (19,20,33\u0026ndash;36). Consultations with subject experts at Tribhuvan University\u0026rsquo;s Public Health Department and Government\u0026rsquo;s Health System experts, ensured that the questionnaire was adequately customized for the Nepalese context. The draft questionnaire was pilot tested with ten public health professionals. Based on the feedback received, it was refined to ensure the use of appropriate terminology and descriptors, improve linguistic accuracy following translation into Nepali, and enhance the overall flow and coherence of the questions. Thus, final questionnaire demonstrated strong internal consistency, with a Cronbach\u0026rsquo;s alpha of 0.88. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome variable\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJob satisfaction was assessed using a 31-item five-point Likert scale questionnaire across the three domains of working environment (15 items), employee adjustment policy and procedures\u0026nbsp;(9 items), and local governance (7 items). The participants rated their satisfaction levels on a scale ranging from \u0026lsquo;\u003cem\u003estrongly disagree\u003c/em\u003e\u0026rsquo; to \u0026lsquo;\u003cem\u003estrongly agree\u003c/em\u003e\u0026rsquo;. A score from -2 (strongly disagree) to 2 (strongly agree) was assigned for the positively worded questions, and a score from 2 (strongly disagree) to -2 (strongly agree) was assigned for negatively worded questions, with a score of 0 for neutral responses. The mean item score was used to categorize levels of job satisfaction, following methodologies outlined in previous studies.\u0026nbsp;(35,36):\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eLess than -1 to -2 (highly dissatisfied),\u003c/li\u003e\n \u003cli\u003e0 to -1 (moderately dissatisfied),\u003c/li\u003e\n \u003cli\u003eMore than 0 to 1 (moderately satisfied) and\u003c/li\u003e\n \u003cli\u003eMore than 1 (highly satisfied)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFor logistic regression analysis, individuals with mean scores greater than 0 were categorized as \u0026lsquo;\u003cem\u003esatisfied=1\u0026rsquo;\u003c/em\u003e, and those with scores ranging from 0 to -2 were categorized as \u0026lsquo;\u003cem\u003edissatisfied\u003c/em\u003e=0\u0026rsquo;. \u0026lsquo;Satisfaction\u0026rsquo; was measured as the three domains of job satisfaction and summed as \u0026lsquo;overall satisfaction\u0026rsquo;: (i) Working environment: Daily support and pressures from local leaders, supervisor support, involvement in planning, proper use of skills, knowledge and experience by the local government and work‒life balance; (ii) Employee adjustment process and policy: Fairness of federalization staff changes, training access, and equity of opportunities compared with health workers of other tiers; and (iii) Local governance: Local government healthcare management, resource use, service delivery capacity, and reward and grievances management. Finally, \u0026lsquo;overall satisfaction\u0026rsquo; was obtained by using the sum of the scores. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndependent variables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBackground characteristics of the participants included age, which was initially collected in four groups (\u0026le;30, 31\u0026ndash;40, 41\u0026ndash;50, and 51\u0026ndash;60 years) and later categorized as \u0026le;30 and \u0026gt;30 years. Sex was recorded as male or female. Workplace geography was initially classified as Himalayan, hills, and Terai but was later grouped into Himalayan (the most remote region) and Terai/hilly. The place of work was categorized as rural or urban, whereas local residence was recorded as yes or no. Education level was collected as a technical school-leaving certificate, proficiency certificate level, bachelor\u0026apos;s level, and master\u0026apos;s level or above, which was later condensed into the bachelor\u0026apos;s level and master\u0026rsquo;s level or above. Work site classification included health sections, primary health care centers/basic hospitals, health posts, basic health service centers, community health units, and urban health clinics, which were later categorized into health section of municipalities and peripheral health institutes (37). Designations were recorded as auxiliary health workers, staff nurses/auxiliary nurse midwives, health assistants, and others and were later recategorized into health assistants and other health professionals (32). The employee level was collected at the fourth, fifth, sixth, seventh and eighth levels and subsequently categorized into non-gazetted (fourth and fifth levels) and gazetted officers (sixth and above levels) (38). The service duration was initially recorded as \u0026lt;5 years, 6\u0026ndash;15 years, 16\u0026ndash;25 years, and \u0026gt;25 years and was later grouped into \u0026le;15 years and \u0026gt;15 years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData management and statistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collected via Google Forms were downloaded in the form of a spreadsheet, and completeness and duplications of the data were checked. The data were cleaned for completeness. Descriptive analysis was performed by calculating the frequency and percentage of categorical variables. The Chi-squared test followed by multiple logistic regression was used to determine the associations between categorical independent and dependent variables. The variables with a p-value less than 0.1 during Chi-squared analysis were entered into the multiple logistic regression analysis (39). The adjusted odds ratios (AORs) and corresponding 95% confidence intervals (CIs) were reported to demonstrate the associations. A p-value \u0026lt;0.05 was considered as statistical significance. Data analysis was performed via the Statistical Package for Social Science (Version 25).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eCharacteristics of the participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 shows the characteristics of the participants. A total of 444 responses were included in the final analysis, with 63.1% aged 30 years or above and 74.8% male. Six out of the seven (85.4%) employees were from the hill/Terai region, and 52.3% worked in urban areas. Nearly two-thirds (62.4%) were local residents. The majority held bachelor\u0026rsquo;s degrees (90.5%) and served peripheral health institutions (82.0%) with designations such as auxiliary health workers (41.0%) and health assistants (38.5%). Two out of five of the respondents (41.2%) were at the officer level, and 56.5% had 6 to 15 years of work experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Characteristics of the participating health workers (n=444)\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u0026le;30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e164 (36.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u0026gt;30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e280 (63.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e332 (74.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e112 (25.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003eWorkplace geography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eHill/Terai\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e379 (85.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eHimalayan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e65 (14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003ePlace of work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e232 (52.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e212 (47.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003eLocal residence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e277 (62.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e167 (37.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003eEducational qualification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eUp to bachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e402 (90.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eMaster\u0026rsquo;s and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e42 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003eWorksite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003ePeripheral health institutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e364 (82.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eHealth section of municipalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e80 (18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003eDesignation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eOther health professionals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e273 (61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eHealth Assistant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e171 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003eEmployee level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eNon-gazetted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e261 (58.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003eGazetted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e183 (41.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003eService duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eUp to 15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e368 (82.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eMore than 15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e76 (17.1)\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\u003cstrong\u003eJob satisfaction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly small proportion of the seven participants (14.9%) expressed overall job satisfaction [mean satisfaction score: -0.52 (SD: 0.50)]. Similarly, 69.4% were moderately dissatisfied, and 15.8% were highly dissatisfied. Among the three domains, the highest level of satisfaction was observed with the domain working environment, i.e., 34.7% [mean satisfaction score: -0.20 (SD: 0.54)], followed by local governance, i.e., 16.2% [mean satisfaction score: -0.66 (SD: 0.74)], and the employee adjustment process and policy, i.e., 4.7% [mean satisfaction score: -0.95 (SD: 0.57)] (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Level of job satisfaction (n=444)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomains of job satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003eOverall satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eMean (SD.): -0.52 (0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHighly satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eModerately satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e66 (14.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eModerately dissatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e308 (69.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHighly dissatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e70 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003eWorking environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eMean (S.D.): -0.20 (0.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHighly satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eModerately satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e153 (34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eModerately dissatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e261 (58.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHighly dissatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e29 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003eEmployee adjustment process and policy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eMean (SD): -0.95 (0.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHighly satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eModerately satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e19 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eModerately dissatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e244 (54.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHighly dissatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e181 (40.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003eLocal governance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eMean (SD.): -0.66 (0.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHighly satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e3 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eModerately satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e69 (15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eModerately dissatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e246 (55.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eHighly dissatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e126 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: Standard deviation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors associated with job satisfaction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEmployee level was significantly associated with overall job satisfaction, with officer-level employees being less likely to be satisfied (AOR: 0.48; 95% CI: 0.27, 0.86). Health workers with a master\u0026rsquo;s degree or above were less likely to be satisfied (AOR: 0.38; 95% CI: 0.16, 0.89) with the working environment. Likewise, health workers working in the health sector were more likely to be satisfied (AOR: 2.03; 95% CI: 1.12, 3.65) with local governance. In contrast, health workers working in Himalayan regions were less likely to be satisfied (AOR: 0.38; 95% CI: 0.15, 0.99) with local governance (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 Factors associated with job satisfaction\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;AOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall satisfaction\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eEmployee level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003eNon-gazetted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003eGazetted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0.48 (0.27, 0.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorking environment\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 23px;\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003eBelow Masters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003eMasters and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0.38 (0.16, 0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocal governance \u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 23px;\"\u003e\n \u003cp\u003eWorkplace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003ePeripheral health institutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003eHealth section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e2.03 (1.12, 3.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 23px;\"\u003e\n \u003cp\u003eGeography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003eHill/Terai\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026lt; 0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003eHimalayan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e0.38 (0.15, 0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eVariables entered in the models: Model 1: Employee level; Model 2: Age, Educational level and Employee level; Model 3: Workplace, geography. Owing to having fewer than 5 cells in one cell, employee adjustment was not included in the multiple logistic regression. AOR: adjusted odds ratio. CI: Confidence interval\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated job satisfaction among local-level health workers in Sudurpashchim Province. Overall, only a small proportion (14.9%) of health workers reported being satisfied with their jobs following their deployment to local health facilities or municipal health sections as part of Nepal\u0026rsquo;s ongoing health sector federalization process. The proportion of health workers satisfied with the employee adjustment policy and processes was even lower, at just 4.3%. These findings, along with anecdotal evidence, suggest that the adjustment procedures may not have been implemented in a fair or transparent manner. However, this warrants further investigation.\u003c/p\u003e \u003cp\u003eThe health workers included in our study were less likely to be satisfied than that reported by previous studies in Nepal and their peers in other low- and middle-income countries (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). For example, a previous study in Banke district of Nepal reported a 24% higher rate of overall satisfaction (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Likewise, job satisfaction ranged between 55% and 76.2% in studies conducted in Jhapa, Siraha, Bardiya, and Doti of Nepal (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Similarly, studies among general employees have reported that the satisfaction level is lower among local health workers than among federal/provincial employees (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Whereas in India, Pakistan and Ethiopia, 27.7\u0026ndash;54% of health workers were satisfied with their jobs (\u003cspan additionalcitationids=\"CR42 CR43\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eJob dissatisfaction among Nepali health workers was related with several reasons, including ill-equipped organizational transition (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), lack of readiness (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) and inadequate time allowed in preparation for and execution of the transition in the midst of change in the political leadership (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Studies from other LMICs suggest that stable employment, job security (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), and recognition (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) enhance satisfaction, whereas inadequate stipends (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), unclear career paths (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), and poor work‒life balance (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) diminish it. Although previous studies also report significant job dissatisfaction, as observed in our study, differences in how outcomes were measured mean that the results should be compared with caution. Employee level was a key determinant of overall job satisfaction among local-level health employees. Dissatisfaction possibly stemmed from aspirations for higher positions, such as health section chiefs or health posts in charge. Additionally, tensions between Sr. AHW officers and public health inspectors, driven by unclear seniority, further contributed to dissatisfaction (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). The lack of opportunities and authority for employees promoted to officer positions likely worsened the issue, highlighting the need to address hierarchical ambiguities and expand roles and responsibilities at the officer level (gazetted health workers).\u003c/p\u003e \u003cp\u003eEmployees with a master\u0026rsquo;s degree or higher were more dissatisfied with the working environment. Similarly, a negative relationship between job satisfaction and education level was observed among community health workers in China (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). This dissatisfaction likely stems from unmet expectations and underutilized skills due to limited opportunities at the local level (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Thus, integrating them into decision-making and granting education-related authorities can increase job satisfaction.\u003c/p\u003e \u003cp\u003eGeographical location of workplace and the adjustment policies were also significantly associated with satisfaction, with all employees in the Himalayan region reporting dissatisfaction. As Nepal\u0026rsquo;s most remote and challenging terrain, this region offers limited resources and career growth opportunities, leading to stagnation and fear in terms of career development prospects and contributing to heightened levels of dissatisfaction. Similarly, study from Pakistan suggests that the inadequacy of health logistics decreases job satisfaction among health workers (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eJob satisfaction was less common among health workers serving in peripheral health facilities governed by the municipalities than those working in the health sections of municipalities, where they enjoyed greater power and career-related opportunities. This may be because health section employees are directly involved in decision-making, increasing their influence. In contrast, peripheral health workers frequently cited grievances related to inadequate supplies such as medicines and equipment, which decreases motivation and increases dissatisfaction (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Additionally, studies suggest that good management, supportive supervision and a good working environment motivate health workers (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The health section oversees peripheral health facilities, but conflicts among senior employees competing for leadership, along with political interference in appointing section chiefs, often lead to turnover and unstable leadership. This instability disrupts the chain of command and weakens governance. Thus, appointing qualified section chiefs through hierarchical policies and ensuring that health facilities meet minimum service standards are crucial for improving governance-related job satisfaction and overall employee satisfaction.\u003c/p\u003e \u003cp\u003eHealth worker satisfaction with local governance varies by region, with higher levels in the Terai and hilly areas than in the Himalayas. Himalayan health workers face resource scarcity, poor infrastructure, limited governance engagement, and weak supervision due to geographic isolation (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). This disconnection hampers communication, grievance resolution, and service delivery, lowering satisfaction.\u003c/p\u003e \u003cp\u003eThis study has several notable strengths, as it focuses on three key domains of job satisfaction work environment, employee adjustment processes and policies, and local governance each of which is highly relevant to the local context. It is also among the first to assess satisfaction related to employee adjustment. However, limitations include potential response bias from self-administered questionnaires and selection bias, as health workers without internet access could not participate. Deteriorating occurrence of job satisfaction among health workers as indicated by the comparison with previous studies from Nepal, needs to be ascertained by further studies such that a conclusive analysis of trends is possible. Moreover, conducting additional studies that would examine the causes, for example by using qualitative methods, are essential to comprehensively grasp the perceptions of local employees regarding the working environment, local governance, and grievances associated with the employee adjustment process and policy. Meanwhile, it is necessary to address health worker\u0026rsquo;s dissatisfaction related to the adjustment policy and processes, ambiguities about hierarchies and reporting lines, authorities and power, and career opportunities.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study highlighted that only a small proportion of health workers were satisfied after they were adjusted to new roles and governance structure, as part of the federalization in Nepal\u0026rsquo;s health system. Particular attention must be given to fairness and transparency during the adjustment processes, discrepancies in power and authorities among the employees adjusted in different workplaces and roles, and the availability of career related opportunities. Simultaneously, it is important to address the health workers\u0026rsquo; grievances related to the adjustment processes, as this would assist in the implementation of ongoing federalization of the health system. Career related opportunities should be provided to health workers serving in deprived locations and workplaces, such as peripheral health facilities and those located in Himalayan region, in the spirit closing equity gaps. Action research aimed at co-designing, implementing, and evaluating these initiatives could contribute to improved job satisfaction among health professionals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAHW: Auxiliary Health Worker\u003c/p\u003e\n\u003cp\u003eAOR: Adjusted Odds Ratio\u003c/p\u003e\n\u003cp\u003eCI: Confidence Interval\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHRH: Human Resources for Health\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoFAGA: Ministry of Federal Affairs and General Administration\u003c/p\u003e\n\u003cp\u003eMoHP: Ministry of Health and Popoulation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOECD: Organization for Economic Cooperation and Development\u003c/p\u003e\n\u003cp\u003eSD: Standard Deviation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Review Board of the Institute of Medicine, Tribhuvan University (Reference number: 255(6-11) F2/079/080). Administrative approval to conduct the study was obtained from the Health Directorate, Sudurpashchim Province (Ref 2079/80/301). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data will be made available on a reasonable request from the corresponding author. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRK with AB conceptualized the study. RK conducted the survey. PA performed the data cleaning and formal analysis with technical input from VK. PA and AB wrote the first draft. AB and BPC supervised the study and provided critical comments throughout the study and preparation of manuscript. VK, AKJ and KR critically reviewed and contributed to the writing of the final manuscript. All the authors have read, reviewed and endorsed the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to extend their gratitude to the Ministry of Social Development and all the Health Office Chiefs of Sudurpashchim Province, Nepal, for their support and coordination during the data collection period.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOECD. Making decentralisation work: A handbook for policy-makers [Internet]. 2019. 135\u0026ndash;187 p. Available from: https://www.oecd.org/en/publications/making-decentralisation-work_g2g9faa7-en.html\u003c/li\u003e\n\u003cli\u003eRobalino DA, Picazo O, Voetberg A. Does Fiscal Decentralization Improve Health Outcomes? Evidence from a Cross-Country Analysis. Policy Research Working Paper 2565. Washington DC: World Bank. 2001 [cited 2025 Mar 22]. Available from: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=632632\u003c/li\u003e\n\u003cli\u003eMills A, Vaughan JP, Smith DL, Tabibzadeh I. Health system decentralization: concepts, issues and country experience [Internet]. World Health Organisation. 1990. p. 151. Available from: https://books.google.co.uk/books?id=efpfQgAACAAJ\u003c/li\u003e\n\u003cli\u003eSaltman RB, Bankauskaite V, Vrangbaek K. Decentalization in Health Care. Brussels European Observatory on Health Syststem and Policies; 2007.\u003c/li\u003e\n\u003cli\u003eSaltman RB. Decentralization, re-centralization and future European health policy: Decentralization as a strategic cornerstone. European Journal of Public Health. 2008;18:2. \u003c/li\u003e\n\u003cli\u003eJim\u0026eacute;nez-Rubio D. The impact of fiscal decentralization on infant mortality rates: Evidence from OECD countries. Soc Sci Med. 2011 Nov 1;73:9. \u003c/li\u003e\n\u003cli\u003eDe Pietro C, Camenzind Isabelle Sturny P, Crivelli Suzanne Edwards-Garavoglia Anne Spranger L, Wittenbecher Wilm Quentin F. Health Systems in Transition: Switzerland Vol 17 No 4 2015. Switz Heal Syst Rev. 2015;17:4. \u003c/li\u003e\n\u003cli\u003eCobos Mu\u0026ntilde;oz D, Merino Amador P, Monzon Llamas L, Martinez Hernandez D, Santos Sancho JM. Decentralization of health systems in low and middle income countries: a systematic review. International Journal of Public Health [Internet]. 2017 [cited 2024 Sep 20];62:2. Available from: https://link.springer.com/article/10.1007/s00038-016-0872-2\u003c/li\u003e\n\u003cli\u003eDwicaksono A, Fox AM. Does Decentralization Improve Health System Performance and Outcomes in Low- and Middle-Income Countries? A Systematic Review of Evidence From Quantitative Studies. Milbank Q [Internet]. 2018 Jun 1 [cited 2024 Sep 20];96:2. Available from: https://pubmed.ncbi.nlm.nih.gov/29870116/\u003c/li\u003e\n\u003cli\u003eGhuman BS, Singh R. Decentralization and delivery of public services in Asia. Policy Soc [Internet]. 2013 Mar 1 [cited 2025 Mar 30];32:1. Available from: https://dx.doi.org/10.1016/j.polsoc.2013.02.001\u003c/li\u003e\n\u003cli\u003eHerzberg F. One More Time How Do You Motivate Employees? [Internet]. 2002. Available from: www.hbrreprints.org\u003c/li\u003e\n\u003cli\u003eBrennan E, Abimbola S. The impact of decentralisation on health systems in fragile and post-conflict countries: a narrative synthesis of six case studies in the Indo-Pacific. Confl Health [Internet]. 2023 Dec 1 [cited 2025 Mar 30];17:1:31. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10280898/\u003c/li\u003e\n\u003cli\u003eWHO. Monitoring the Building Blocks of Health Systems : a Handbook of Indicators and. 2010;110. \u003c/li\u003e\n\u003cli\u003eDieleman M, Toonen J, Tour\u0026eacute; H, Martineau T. The match between motivation and performance management of health sector workers in Mali. Hum Resour Health. 2006 Feb 9;4. \u003c/li\u003e\n\u003cli\u003eGuilbert JJ. The World Health Report 2006: Working together for health [1]. Educ Heal Chang Learn Pract. 2006;19:3. \u003c/li\u003e\n\u003cli\u003eDieleman M, Harnmeijer JW. 1174_Improving-health-worker-performance_Dieleman_Harnmeijer. Evid Inf Policy, Dep Hum Resour Heal Geneva. 2006;1:1. \u003c/li\u003e\n\u003cli\u003eBabatunde Jimoh A, Modinat Oyewunmi A, Zaheed Oladimeji A. Relationships Between Job Satisfaction and the Quality of Healthcare Delivery in Ogun State Hospital Management Board, Nigeria. Int J Sci Acad Res [Internet]. 2022;03(November):4680\u0026ndash;6. Available from: http://www.scienceijsar.com\u003c/li\u003e\n\u003cli\u003eKanchanachitra C, Lindelow M, Johnston T, Hanvoravongchai P, Lorenzo FM, Huong NL, et al. Human resources for health in southeast Asia: Shortages, distributional challenges, and international trade in health services. Lancet [Internet]. 2011;377:9767. Available from: http://dx.doi.org/10.1016/S0140-6736(10)62035-1\u003c/li\u003e\n\u003cli\u003eDaneshkohan A, Zarei E, Mansouri T, Maajani K, Ghasemi MS iyaha., Rezaeian M. Factors affecting job motivation among health workers: a study from Iran. Glob J Health Sci. 2015;7:3:. \u003c/li\u003e\n\u003cli\u003eBhatnagar K, Srivastava K. Job satisfaction in health-care organizations. Ind Psychiatry J [Internet]. 2012 [cited 2024 Mar 25];21(1):75. Available from: /pmc/articles/PMC3678186/\u003c/li\u003e\n\u003cli\u003eThe Constitution of Nepal 2015 [Internet]. Government of Nepal; 2016. Available from: https://lawcommission.gov.np/np/?cat=87\u003c/li\u003e\n\u003cli\u003eProgress of the Health and Population Sector , 2019 / 20. 2021; \u003c/li\u003e\n\u003cli\u003eThe Himalayanayan Times [Internet]. 2019 [cited 2024 Sep 29]. Thousands of health workers file complaint against their adjustment - The Himalayan Times - Nepal\u0026rsquo;s No.1 English Daily Newspaper | Nepal News, Latest Politics, Business, World, Sports, Entertainment, Travel, Life Style News. Available from: https://thehimalayantimes.com/nepal/thousands-of-health-workers-file-complaint-against-their-adjustment\u003c/li\u003e\n\u003cli\u003eThe Kathmandu Post [Internet]. 2022 [cited 2024 Dec 23]. Staff adjustment leads to personnel mismanagement at health facilities. Available from: https://kathmandupost.com/health/2022/03/16/staff-adjustment-leads-to-personnel-mismanagement-at-health-facilities\u003c/li\u003e\n\u003cli\u003eRepublica [Internet]. 2023 [cited 2024 Dec 23]. Health workers in Surkhet without salaries for eight months, authorities say \u0026lsquo;No budget\u0026rsquo; - myRepublica - The New York Times Partner, Latest news of Nepal in English, Latest News Articles | Republica. Available from: https://www.myrepublica.nagariknetwork.com/news/health-workers-in-surkhet-without-salaries-for-eight-months-authorities-say-no-budget\u003c/li\u003e\n\u003cli\u003eThe Kathmandu Post [Internet]. 2023 [cited 2024 Mar 25]. Dhangadi Sub-metropolis health workers protest demanding due salary. Available from: https://kathmandupost.com/sudurpaschim-province/2023/03/26/dhangadi-sub-metropolis-health-workers-protest-demanding-due-salary\u003c/li\u003e\n\u003cli\u003eDahal AK, Mishra AK, Chaudhary MK, Aithal PS. Job Satisfaction in Federal Structure - A Case of Bhojpur, Nepal. Int J Appl Eng Manag Lett. 2021;1. \u003c/li\u003e\n\u003cli\u003eKhanal P. Work motivation and job satisfaction among health workers of primary health facilities: a mixed-methods study from Nepal. (Version 2) available Res Sq. 2020;1\u0026ndash;21. \u003c/li\u003e\n\u003cli\u003eSingh A, Chakradhar R, Joshi N. Job Satisfaction among Nurses Working in a Tertiary Level Government Hospital. Med J Shree Birendra Hosp [Internet]. 2021 Feb 2 [cited 2025 Mar 23];20:1. Available from: https://nepjol.info/index.php/MJSBH/article/view/28777\u003c/li\u003e\n\u003cli\u003eRana K. Job Satisfaction and Change Readiness of Public Health Workers in Context of Federal Health System of Nepal at Local Level: A Cross-Sectional Study in Banke District. SSRN Electron J. 2020; \u003c/li\u003e\n\u003cli\u003eEmployment Adjustment Act 2075 [Internet]. Ministry of Home Affairs. 2018. 1\u0026ndash;28 p. Available from: https://lawcommission.gov.np/np/wp-content/uploads/2021/01\u003c/li\u003e\n\u003cli\u003eThe Public Health Service Act, 2075 (2018). Nepal Law Commission Internet]. 2019;2075:11. Available from: https://www.lawcommission.gov.np/en/wp-content/uploads/2019/07/The-Public-Health-Service-Act-2075-2018.pdf\u003c/li\u003e\n\u003cli\u003eThapa R, Bam K, Tiwari P, Sinha TK, Dahal S. Implementing federalism in the health system of Nepal: Opportunities and challenges. Int J Heal Policy Manag [Internet]. 2019;8:4. Available from: https://doi.org/10.15171/ijhpm.2018.121\u003c/li\u003e\n\u003cli\u003eOffice SS. Employee Satisfaction Survey. Repub Maced State Stat Off [Internet]. 2009;3\u0026ndash;5. Available from: https://www.academia.edu/35314643/EMPLOYEE_SATISFACTION_SURVEY_2009_Basic_survey_information_REPUBLIC_OF_MACEDONIA_STATE_STATISTICAL_OFFICE\u003c/li\u003e\n\u003cli\u003eChen AH, Jaafar SN, Noor ARM. Comparison of job satisfaction among eight health care professions in private (non-government) settings. Malaysian J Med Sci. 2012;19:2. \u003c/li\u003e\n\u003cli\u003eKhamlub S, Harun-Or-Rashid M, Sarker MAB, Hirosawa T, Outavong P, Sakamoto J. Job satisfaction of health-care workers at health centers in Vientiane capital and Bolikhamsai province, Lao pdr. Nagoya J Med Sci. 2013;75:3\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eLocal Government Operation Act, 2017, Ministry of Federal Affairs and General Administration [Internet]. 2017 [cited 2025 Apr 17].. Available from: https://mofaga.gov.np/detail/1697\u003c/li\u003e\n\u003cli\u003eNepal Health Service Rules 2055. Government of Nepal [Internet]. 2005;2055(1999). Available from: https://www.dda.gov.np/download/health-service-rules-2055-1999.pdf\u003c/li\u003e\n\u003cli\u003eRobins RW, Hendin HM TK. Purposeful selection of variables in logistic regression. Source Code Biol Med [Internet]. 2008;3:1\u0026ndash;8. Available from: https://scfbm.biomedcentral.com/articles/10.1186/1751-0473-3-17\u003c/li\u003e\n\u003cli\u003eGhimire J, Gupta RP, Kumal AB, Mahato RK, Bhandari RM, Thapa N. Factors associated with the motivation and de-motivation of health workforce in Nepal. J Nepal Health Res Counc. 2013;11:24. \u003c/li\u003e\n\u003cli\u003eGirma B, Nigussie J, Molla A, Mareg M. Health professional\u0026rsquo;s job satisfaction and its determinants in Ethiopia: a systematic review and meta-analysis. Arch Public Heal [Internet]. 2021 Dec 1 [cited 2025 Mar 30];79:1. Available from: https://archpublichealth.biomedcentral.com/articles/10.1186/s13690-021-00664-7\u003c/li\u003e\n\u003cli\u003eEjigu Y, Abera N, Haileselassie W, Berhanu N, Haile BT, Nigatu F, et al. Motivation and job satisfaction of community health workers in Ethiopia: a mixed-methods approach. Hum Resour Health [Internet]. 2023 Dec 1 [cited 2025 Mar 30];21(1):1\u0026ndash;10. Available from: https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-023-00818-4\u003c/li\u003e\n\u003cli\u003eSingh T, Kaur M, Verma M, Kumar R. Job satisfaction among health care providers: A cross-sectional study in public health facilities of Punjab, India. J Fam Med Prim Care [Internet]. 2019 [cited 2025 Mar 30];8(10):3268. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6857391/\u003c/li\u003e\n\u003cli\u003eKumar R, Ahmed J, Shaikh BT, Hafeez R, Hafeez A. Job satisfaction among public health professionals working in public sector: A cross sectional study from Pakistan. Hum Resour Health. 2013;11:1. \u003c/li\u003e\n\u003cli\u003eGupta S, Singla A. Organizational change and job satisfaction: An analysis of mediating effect of organizational trust. Indian J Commer Manag Stud [Internet]. 2016;7(3):7\u0026ndash;13. Available from: http://www.scholarshub.net\u003c/li\u003e\n\u003cli\u003eTabvuma V, Bui HTM, Homberg F. Adaptation to externally driven change: The impact of political change on job satisfaction in the public sector. Public Adm Rev. 2014;74:3. \u003c/li\u003e\n\u003cli\u003eOlaniran A, Madaj B, Bar-Zeev S, Banke-Thomas A, van den Broek N. Factors influencing motivation and job satisfaction of community health workers in Africa and Asia-A multi-country study. Int J Health Plann Manage [Internet]. 2022 Jan 1 [cited 2025 Mar 30];37:1. Available from: https://pubmed.ncbi.nlm.nih.gov/34476842/\u003c/li\u003e\n\u003cli\u003eThe Kathmandu Post [Internet]. 2019 [cited 2024 Apr 6]. Staff adjustment proposal worries health assistants across country. Available from: https://kathmandupost.com/national/2019/02/12/staff-adjustment-proposal-worries-health-assistants-across-country\u003c/li\u003e\n\u003cli\u003eGe C, Fu J, Chang Y, Wang L. Factors associated with job satisfaction among Chinese community health workers: A cross-sectional study. BMC Public Health. 2011;11. \u003c/li\u003e\n\u003cli\u003eRobinson S, Murrells T, Clinton M, College K. Highly qualified and highly ambitious: implications for workforce retention of realising the career expectations of graduate nurses in England. Hum Resour Mangagemnt J. 2006;16:3. \u003c/li\u003e\n\u003cli\u003eHaq Z, Iqbal Z, Rahman A. Job stress among community health workers: A multi-method study from Pakistan. Int J Ment Health Syst [Internet]. 2008 [cited 2025 Mar 30];2;1: Available from: https://ijmhs.biomedcentral.com/articles/10.1186/1752-4458-2-15\u003c/li\u003e\n\u003cli\u003eCao WR, Shakya P, Karmacharya B, Xu DR, Hao YT, Lai YS. Equity of geographical access to public health facilities in Nepal. BMJ Glob Heal [Internet]. 2021 Oct 27 [cited 2025 Mar 23];6(10):6786. Available from: https://gh.bmj.com/content/6/10/e006786\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"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":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Decentralization, federalization, job satisfaction, health personnel, health governance, health workforce","lastPublishedDoi":"10.21203/rs.3.rs-6503971/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6503971/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The impact of federalization on health workforce satisfaction remains inconclusive. There is paucity of literature on how decentralization affects health personnel’s motivation and performance. Nepal’s transition to federalism has been ongoing for a decade, yet only few studies have examined its impact on health workers. It is essential to understand factors that affect satisfaction of health workforce in order to ensure seamless delivery of health care. Therefore, this study aimed at assessing the level of job satisfaction among local-level health workers in Sudurpashchim (Far western) province of Nepal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eA cross-sectional study was conducted among 444 health workers in Sudurpashchim Province. Job satisfaction was measured using a five-point Likert scale which has 31 items across three domains: working environment; employment adjustment process and policy; and local governance. The association between job satisfaction and independent variables were examined using Chi-squared test followed by multiple logistic regression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe overall job satisfaction rate was 14.9%, with 34.7% satisfied with the working environment, 16.2% with local governance, and only 4.3% with the employee adjustment process and policy. The Gazetted Officers were less likely to be satisfied (adjusted odds ratio (AOR): 0.48; 95% confidence interval (CI): 0.27, 0.86) compared to their non-gazetted counterparts such as assistants and clerks. Similarly, those with a master's or higher degree (AOR: 0.38; 95% CI: 0.16, 0.89) were less likely to be satisfied with the working environment. Employees from the mountainous regions were less likely to be satisfied with local governance (AOR: 0.38; 95% CI: 0.15, 0.99) compared to their counterparts from hilly/Terai regions. Conversely, health workers serving in the health sections of municipalities were more satisfied than those working in peripheral health facilities (AOR: 2.03; 95% CI: 1.12, 3.65).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eOverall job satisfaction among the health workers was notably low, particularly in relation to the policies and procedures surrounding employee adjustment following Nepal’s federalization. This phenomenon necessitates rigorous inquiry into poor satisfaction and identifying their underlying causes. Concurrently, it is imperative that the state governments proactively engage with and address the discontent expressed by health workers regarding the adjustment mechanisms, while also prioritizing the strategic expansion of professional advancement opportunities, particularly in geographically marginalized, resource-constrained, and difficult regions such as the Himalayan areas.\u003c/p\u003e","manuscriptTitle":"Job satisfaction among local-level health workers following decentralization in Nepal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-23 06:56:31","doi":"10.21203/rs.3.rs-6503971/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-25T06:39:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-23T02:35:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-23T02:33:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-04-22T11:40:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff7c31fb-2936-40e8-8ac2-49e6b78e1e0b","owner":[],"postedDate":"April 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-22T15:38:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-23 06:56:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6503971","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6503971","identity":"rs-6503971","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}