Job satisfaction among local-level health workers following decentralization in Nepal Authors: Ramesh Kunwar, Prakash Adhikari, Vishnu Khanal, Kamal Ranabhat, Arun Kumar Joshi, Bishnu Prasad Choulagai, Ashok Bhurtyal Published: 2026 ABSTRACT AbstractBackgroundThe impact of federalization on health workforce satisfaction remains inconclusive. Paucity of literature on how decentralization affects health personnel’s motivation and performance, critically limits making policies and implementing actions toward optimal performance of health care systems. 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.MethodsA cross-sectional study was conducted among 444 health workers in Sudurpashchim Province. Job satisfaction was measured using a five-point Likert scale which had 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.ResultsThe overall job satisfaction was 14.9%. Domain specific satisfaction was highest for the working environment (34.7%) and local governance (16.2%), but very low for employee adjustment processes and policies (4.3%). The Gazetted Officers were less likely to be satisfied (AOR: 0.48; 95% CI: 0.27, 0.86). Similarly, those with a master’s or higher degree (AOR: 0.38; 95% CI: 0.16, 0.89) and employees from the Himalayan region (AOR: 0.38; 95% CI: 0.15, 0.99) were less likely to be satisfied with the working environment and local governance respectively. In contrast, municipal health section staff (AOR: 2.03; 95% CI: 1.12, 3.65) were more satisfied with local governance.ConclusionJob satisfaction among health workers was low (14.9%), with the lowest satisfaction reported regarding the employee adjustment process following Nepal’s federalization. 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 professional advancement opportunities, particularly in geographically marginalized, resource-constrained, and difficult regions such as the Himalayan areas.Keywords: Decentralization, Federalization, Job satisfaction, Health personnel, Health governance, Health workforce, Health system Background Decentralization of health systems is defined as the transfer of authority and responsibility for health services from central governments to elected subnational authorities with a degree of autonomy [1–4]. It has become a common global trend, however its implementation timelines vary across regions [1–4]. European countries underwent decentralization after the second world war [5]. Likewise, numerous countries in Africa and Asia had undergone decentralization following independence from colonialism. However, a few of them recentralized some functions of their national health care systems [5]. Evidence on the benefits of health service decentralization is mixed. Some studies report positive outcomes, including reduced infant mortality in Organization for Economic Co-operation and Development countries [6], and high life expectancy and improved health coverage in Switzerland [7]. Decentralization has also increased access to healthcare in India and strengthened local ownership in Indonesia [8]. Similarly, in low-income countries, some studies report improvements in mortality and service delivery, although challenges related to resources and accountability persist [9, 10]. Likewise, issues such as high out-of-pocket costs remain in Switzerland. It has also raised concerns regarding equity in Pakistan [11], resource allocation in the Philippines [12], and regional disparities in Indonesia [10]. Overall, the success of decentralization largely depends on contextual factors, and its impact remains debated 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]. Job satisfaction is also major factor that determines staff retention and motivation [20]. Prior to federalization, Nepal’s health workforce was centrally managed under the Ministry of Health and Population (MoHP). Policies and budgeting were determined at the central level and implemented through a top-down approach [21]. Although the Local Self-Governance Act and Regulations 1999 assigned Village Development Committees and municipalities responsibility for managing local health facilities, autonomy at the regional and local levels remained limited [22]. Inequities in workforce distribution, especially in rural and remote areas also persisted [21]. To address these challenges, Nepal adopted a federal structure in 2015. Health system responsibilities were devolved to three tiers: federal, provincial and local governments, with local governments taking primary responsibility for basic health service delivery [23]. Following federalization, Nepal’s health workers were reassigned across the three tiers of government under the Employment Adjustment Act 2018. This redistribution resulted in 82.9% of the health workforce being deployed at the local level [24]. However, this transition was not prepared and managed well, and has faced enormous challenges, including deployment issues and salary delays, as evidenced by numerous complaints to the MoHP and the Ministry of Federal Affairs and General Administration (MoFAGA) [25–28]. 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 [29]. While some studies have examined job satisfaction before federalization [30], others have focused on specific professions, institutions [31] or limited geographic regions [32]. However, there remains a substantial gap in the literature concerning the effects of health system decentralization on the motivation and satisfaction of health workers in Nepal. This study aimed 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. The findings can serve as a credible resource for the formulation of the Local Service Act and human resources for health policies. 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 [23]. 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 [33]. 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 [24]. The government was ill-prepared to address existing complexities, and the enormous task of adjustment put pressure on the workforce. Study design and setting It was a cross-sectional study. The data was collected from January 2023 to February 2023. The participants were either adjusted within 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 [34]. 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 online study. Participants and data collection Data were collected from 444 participants 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, either the office chief or section chief familiar with all health professionals within the district was identified in each district health office. The Google Form, including an informed e-consent section, was disseminated through the ‘District Health Worker Messenger Group’, comprising health workers who were the target study population. These groups included most, but not necessarily all, eligible participants. The form was shared through designated contact persons; however, no other dissemination channels (e.g., email) were used. The contact 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. Information about the study was shared via the same channel where it was clearly indicated that participation was voluntary; and non-participation would not affect their relationship with the contact person or others in the health office. Consenting health workers serving in the health sections of municipalities or in peripheral health facilities administered by the 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 on study leave and with less one year of experience were excluded. This structured and carefully selected approach facilitated systematic data collection across all districts, uniformly from eligible health workers. (Fig. 1) Sampling process The questionnaire was developed through a structured review of relevant literature on health workforce motivation, decentralization, and job satisfaction [19, 35–37]. The final questionnaire comprised three major domains: (i) working environment (15 items), (ii) employee adjustment process and policy (9 items), and (iii) local governance (7 items). The working environment domain consisted of political environment, administrative leadership and support, participation and decision-making, human resource utilization and professional value, and work–life balance and workload [19]. The employment adjustment process and policy consisted of governance and policy implementation, human resource development and compensation and incentives [35]. The local governance included system capacity and readiness, human resource management, and governance and accountability mechanisms [35, 37]. All three domains were combined to generate an overall job satisfaction score. To ensure contextual relevance, the draft questionnaire was reviewed through consultations with subject experts from the Central Department of Public Health Department of Tribhuvan University and health system experts from government institutions. The tool was then adapted to reflect administrative structure, terminology, and practical realities of Nepal’s federal health system. 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. 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 questionnaire based on a five-point Likert scale. The participants rated their satisfaction levels on a scale ranging from ‘strongly disagree’ to ‘strongly agree’. The cut-off values were determined based on the properties of the 5-point Likert scale used in this study, where item scores ranged from −2 to +2. The categorization reflects both the direction (positive/negative) and intensity of satisfaction. Specifically, 0 represents a neutral response, while ±1 and ±2 represent increasing levels of agreement or disagreement. Therefore, the thresholds were defined to distinguish between moderate and strong levels of satisfaction or dissatisfaction: scores between 0 and ±1 indicate moderate levels, whereas scores ±2 indicate stronger levels. The categories were defined as follows: Less than −1 to −2 (highly dissatisfied), Less than −1 to −2 (highly dissatisfied), 0 to −1 (moderately dissatisfied), 0 to −1 (moderately dissatisfied), More than 0 to 1 (moderately satisfied) and More than 0 to 1 (moderately satisfied) and More than 1 (highly satisfied) More than 1 (highly satisfied) Finally, overall satisfaction was obtained by using the sum of the scores. This approach is similar with previously published studies [36, 37]. 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’. 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 [38]. Sex was recorded as male or female. Workplace geography was initially classified as Himalayan, Hilly, 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 upto 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 [39]. 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 [34]. 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) [40]. The service duration was initially recorded as <5 years, 6–15 years, 16–25 years, and >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-square 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-square analysis were entered into the multiple logistic regression analysis [41]. 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 the Social Sciences (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 Hilly/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 38.5% of health workers being health assistants. Two out of five of the respondents (41.2%) were at the officer level, and 82.9% had up to 15 years of work experience. Table 1Characteristics of the participating health workers (n = 444)VariableCategoriesNumber (%)Age≤30 years164 (36.9)>30 years280 (63.1)GenderMale332 (74.8)Female112 (25.2)Workplace geographyHilly/Terai379 (85.4)Himalayan65 (14.6)Place of workUrban232 (52.3)Rural212 (47.7)Local residenceYes277 (62.4)No167 (37.6)Educational qualificationUp to bachelor’s degree402 (90.5)Master’s and above42 (9.5)WorksitePeripheral health institutes364 (82.0)Health section of municipalities80 (18.0)DesignationOther health professionals273 (61.5)Health Assistant171 (38.5)Employee levelNon-gazetted261 (58.8)Gazetted183 (41.2)Service durationUp to 15 years368 (82.9)More than 15 years76 (17.1) Characteristics of the participating health workers (n = 444) Job satisfaction Only 14.9% of the study participants expressed overall job satisfaction. 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% followed by local governance, i.e., 16.2%, and the employee adjustment process and policy, i.e., 4.3% (Table 2). Table 2Level of job satisfaction (n = 444)Domains of job satisfactionCategoriesNumber (%)Overall satisfactionHighly satisfied0 (0.0)Moderately satisfied66 (14.9)Moderately dissatisfied308 (69.4)Highly dissatisfied70 (15.8)Working environmentHighly satisfied1 (0.2)Moderately satisfied153 (34.5)Moderately dissatisfied261 (58.8)Highly dissatisfied29 (6.5)Employee adjustment process and policyHighly satisfied0 (0.0)Moderately satisfied19 (4.3)Moderately dissatisfied244 (54.9)Highly dissatisfied181 (40.8)Local governanceHighly satisfied3 (0.7)Moderately satisfied69 (15.5)Moderately dissatisfied246 (55.4)Highly dissatisfied126 (28.4) Level of job satisfaction (n = 444) 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 municipal health section 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 3Factors associated with job satisfactionVariableCategoriesAOR (95% CI)p valueOverall satisfaction1Employee levelNon-gazetted1.000.01Gazetted0.48 (0.27, 0.86)Working environment2Education levelBelow Masters1.000.03Masters and above0.38 (0.16, 0.89)Local governance3WorkplacePeripheral health institutes1.000.02Health section2.03 (1.12, 3.65)GeographyHill/Terai1.00<0.049Himalayan0.38 (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 Factors associated with job satisfaction 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 assessed 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 process and policy was even lower, at just 4.3%. These findings, together with anecdotal evidence, highlight possible concerns regarding the fairness and transparency of the adjustment procedures. However, given the cross-sectional nature of the study, no causal inferences can be drawn. Our findings suggest that only small proportion of the participants in our study were satisfied compared to the findings from earlier studies in Nepal and in other low- and middle-income countries [30, 32, 42]. For example, a previous study in Banke district of Nepal reported a 24% higher rate of overall satisfaction [32]. Likewise, job satisfaction ranged between 55% and 76.2% in studies conducted in Jhapa, Siraha, Bardiya, and Doti districts of Nepal [30, 42]. Whereas in India, Pakistan and Ethiopia, 27.7–54% of health workers were satisfied with their jobs which is higher that reported in our study [43–46]. The comparatively low level of satisfaction in Nepal may reflect the country’s unique structural, political, and fiscal challenges associated with the federal transition, issues that were not prominent in the settings of the studies mentioned above [32, 43–46]. Unlike Ethiopia and India, where health workforce governance has remained relatively stable within established administrative systems, Nepal experienced a rapid and largely unprepared devolution of health service management to newly formed local governments following the 2015 constitution. This inadequately managed organizational transition [32], characterized by limited institutional readiness [47], insufficient preparation time, and frequent shifts in political leadership [48], likely created systemic disruptions that adversely affected health worker morale more severely than in the comparator countries. In addition, limited opportunities at the local level for highly educated and gazetted health professionals, along with weak political support, may have contributed to greater job dissatisfaction. Moreover, the absence of strict transfer policies for local-level health workers, lack of seniority-based appointments for health facility in-charges and municipal health section chiefs [49], and delays in salary disbursement may have further reduced job satisfaction [28]. Employee level was associated with overall job satisfaction, showing that gazetted health professionals were less satisfied. The 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 [30, 50]. Such tensions have persisted since earlier health service reforms, and repeated court verdicts have further complicated seniority-related issues. For example, in one rural municipality, a Senior. AHW (5th level) was appointed as health section chief instead of a Public Health Inspector (6th level), reportedly due to political influence and personal connections [51]. Moreover, limited opportunities and authority even after promotion may have contributed to lower job satisfaction among officer-level employees. This highlights the need to address hierarchical ambiguities and expand the roles and responsibilities of officer-level (gazetted) health workers. Employees’ educational attainment was associated with job satisfaction, with those holding a master’s degree or higher reporting lower satisfaction with their working environment. A similar pattern has been observed among health workers in China [52]. These findings suggest that highly educated professionals may have greater expectations regarding participation in decision-making, utilization of their competencies, and professional recognition. At the local level, such expectations are often unmet because of limited administrative capacity. Furthermore, anecdotal evidence also suggests that local-level decisions are frequently influenced by personal interests of local leaders rather than evidence-based approaches. This may further reduce satisfaction among highly educated health professionals. Moreover, limited opportunities for career advancement may contribute to lower satisfaction in this group [53]. Geographical location of workplace was also significantly associated with satisfaction, with all employees in the Himalayan region reporting dissatisfaction. As the Himalayan region is Nepal’s most remote and challenging terrain, it offers limited resources and career growth opportunities. The staff repeatedly verbalize the fear of career stagnation when they are in the most remote area of the country, which may have contributed to heightened levels of dissatisfaction. Similarly, a study from Pakistan suggests that the inadequacy of health resources decreased job satisfaction among health workers [54]. 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 [55]. This disconnection hampers communication, grievance resolution, and service delivery, lowering satisfaction. Workplace was significantly associated with satisfaction related to local governance, with health workers at peripheral health facilities reporting lower satisfaction. This may be due to limited involvement in decision-making, fewer career advancement opportunities, and weak local health governance. Peripheral health workers also often face limited resources, including inadequate medicines and equipment, poor reward and grievance management, and political influence in health facility leadership, which may weaken the chain of command and reduce job satisfaction [30]. Furthermore, previous studies have also shown that good management, supportive supervision, and a positive working environment improve health worker motivation and satisfaction [19, 32]. Therefore, appointing qualified section chiefs through clear hierarchical policies and ensuring minimum service standards in health facilities may help improve governance-related and overall job satisfaction. This study has several notable strengths, as it focuses on three key domains of job satisfaction: working environment, employee adjustment process 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. Conversely, key limitation of the study includes potential response bias from self-administered questionnaires and selection bias, as this approach may have limited participation to those active on Messenger, potentially excluding eligible individuals not engaged on the platform. Future qualitative studies are needed to better understand employees’ views on strategies to improve the work environment, governance, and issues related to the adjustment process and policies. Conclusion Only a small proportion of health workers were satisfied after they were adjusted in a new governance structure, as part of federalization in Nepal’s health system. Many of them were not happy with the adjustment process, indicating unfair treatment rather than on the basis of their merit, skills or needs of the health facilities and communities they were assigned to serve. A large number of health workers lamented of the whimsical governance styles of the municipal mayors and other key leaders therein, which included assigning health workers of roles and positions at their discretion. Others described the lack of opportunities for in-service training and career mobility upwards and laterally. Attention must be given to fairness and transparency during adjustment processes, and the new local governance system must ensure the availability and opportunities for career progression. Career opportunities should be prioritized for health workers, especially those serving in remote locations. Action research aimed at co-designing, implementing, and evaluating these initiatives could help identify suitable strategies to improve job satisfaction among health professionals. 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. Many sincere thanks to the reviewers of data collection tools and the participants. Abbreviations Auxiliary Health Worker Adjusted Odds Ratio Confidence Interval Human Resources for Health Ministry of Federal Affairs and General Administration Ministry of Health and Population Organization for Economic Cooperation and Development Standard Deviation World Health Organization Author contributions RK with AB conceptualized the study. RK conducted the survey. AB trained RK and PA and put the study in the perspective of ongoing federalization process. 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 guided the methodological aspects of doing and writing the research. 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. RK and PA are equally contributing authors. Funding None. Data availability The data will be made available on a reasonable request from the corresponding author. Declarations Ethics approval and consent to participate The study was adhered to Declaration of Helsinki. 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). Informed e-consent to participate was obtained from all of the participants in the study. Consent for publication Not applicable Competing interests The authors declare no competing interests. Footnotes Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Ramesh Kunwar and Prakash Adhikari contributed equally to this work. References Associated Data Data Availability Statement The data will be made available on a reasonable request from the corresponding author.