Determinants of Job Satisfaction amongst Medical Officers of Primary Health Centre in Anand District, Gujarat, India

Since, the inception of Alma Ata declaration, the concept of primary healthcare has gathered real momentum as a tool to attain ‘Health for All’ by the year 2000 (WHO 1978) [1]. Each PHC is staffed with two doctors (one allopathic and one AYUSH). Despite their critical importance, there has been an ever present dearth of qualified doctors willing to provide their services as primary care doctors to the underserved rural community [2]. Rao K et al., in their study mentioned about geographic maldistribution of the health workforce in India as a cause of concern [3]. They mentioned that there are several factors which drive health outcomes, but having few health workers influences the ability of the health systems profoundly to deliver preventive and curative services. They stressed on the fact that the large disparity in workforce density between urban and rural areas is alarming. Mainstreaming of AYUSH providers has been identified as a strategy under National Rural Health Mission (NRHM) to fill in the gaps created by unavailability of allopathic doctors [4].

However, there has been considerable discontent among primary care physicians and AYUSH providers regarding their job. In Chhattisgarh, moderate level of satisfaction was observed among PHC MO and AYUSH providers [4]. Job satisfaction has been defined as a pleasurable emotional state resulting from the appraisal of one’s job, an affective reaction to one’s job and an attitude towards one’s job [5]. Dissatisfaction with job is invariably linked with decreased output/work performance and enhanced absenteeism [6]. As there are many individual differences, job satisfaction has become a diverse issue. To have a better understanding, all the facets of job satisfaction have to be understood and considered for sustaining people [7]. So, the current study was undertaken with the objective of finding job satisfaction and its different epidemiological correlates amongst PHC doctors in Anand, Gujarat, India.

The present cross-sectional analytical study was conducted amongst 50 PHC MO (MBBS and AYUSH). All those present on the scheduled meeting date for MO of the district were included as study participants in the study. No further attempt was made for completion of the absent MO during that day; however, majority of PHC MO attended the official meeting and filled the questionnaire. All the MO present in the meeting and who had filled in the questionnaire were the participants. Therefore, 50 MO were considered for the study.

On the scheduled meeting date for MO, as suggested by Chief District Health Officer (CDHO), the investigators reached the meeting place, gave introduction and a brief background for research and distributed the questionnaire to the MO. They were asked to fill the questionnaire without their name; however, they were told to mention their qualification as it was required. Verbal informed consent was taken and everyone present consented and was ready to fill the questionnaire. The MO were asked about any confusion related to the process. There was no hesitation seen among the participants as seen by their gestures and no questions were put forth. Self-administered questionnaire method was used to get the responses from the participants. The CDHO’s permission was taken for the study and anonymity was maintained. Questions were also read out aloud and in case of any confusion, the same was solved. The questionnaire was administered to the participants and the comfortability of the participants was ensured, so that the responses were accurate and as per the individual’s feeling for the job. The MO were given full time to answer the questionnaire. Total number of PHCs in Anand is 45. Job satisfaction was seen in four different heads like “Workload” (WL), “Relationships with Staff” (RS), “Personal Difficulties” (PD) and “Availability of Infrastructure” (AI). In WL, three questions were included for MBBS doctors and two questions were there for AYUSH doctors. These were: i) Administrative workload; ii) Clinical workload; iii) MLC workload. Total scoring in WL head was from 3-12. In scoring for Clinical work, highly overloaded and very less were given same score as 1. Overloaded and less was scored same as 2 and the maximum score was given to average as 3. So, the scoring was 1-2-3-2-1 for highly overloaded, overloaded, average, less and very less respectively. In Administrative workload, highly overloaded was given a score of 1, overloaded as 2, less and very less were same as 3 and average was given a score of 4. In MLC workload, the likert scale ranged from 1-5 from highly overloaded to very less in increasing fashion. In MLC workload, BHMS and BAMS MO have been given 5 for nil work. In “Relationships with staff”, five questions were included. These were: i) Relationship with subordinates; ii) Relationship with higher officials; iii) Conflicts with field staff; iv) Political pressure/Unnecessary interference; v) No powers in execution of work, felt helpless. Total scoring in “Relationships with staff” head was from 3-16. In scoring for “Relationship with subordinates/higher officials” scoring was from 1-5 for the options very poor to very good in increasing order. In question “No powers in execution of work, felt helpless”, the scoring was from 1-4 for all the times to never in increasing order. The other two questions were dichotomous. In “Personal difficulties” five questions were included, these were: i) Commuting/ Residing in quarters; ii) Working in a difficult terrain; iii) Problems of providing education to children because of poor resources like school; iv) Working at PHC is by force or by choice; v) Being called as a doctor of PHC in the medical fraternity brings disgrace. All the questions were dichotomous. Total scoring in “Personal difficulties” head was from 0-5. In “Availability of infrastructure” three questions were included. These were: i) Lack of infrastructure to work in; ii) Improper facilities at PHC; iii) Inappropriate support services like laboratory facilities. All the questions were dichotomous. Total scoring in “Availability of infrastructure” head was from 0-3. Total there were 16 questions for the overall scoring. Six questions were in Likert scale {2 questions (clinical workload and administrative workload) were having scores based on weightage, so the uniform pattern of either increasing and decreasing scores was not seen for these two questions which have been elaborated above} and 10 were of dichotomous type. In dichotomous type, all “No” were scored as 1 except one question on choice for PHC MO, where if a doctor is working by choice then 1 was given. All “Yes” were scored as 0, except as mentioned.

All the individual heads were summated to get a final score. Total scoring was summation of all the individual heads. Job Satisfaction Score=Σ (WL score+RS score+PD score+AI score). Here WL score ranged from 3-12. RS score ranged from 3-16, PD score ranged from 0-5 and AI score 0-3. So, total scores ranged from 6-36. More the score, more was job satisfaction.

For the subcomponent scores and composite scores, Mann Whitney U test was applied. Categorical analysis of all the individual variables under four different heads of job satisfaction was also done. Considering outcome as in numerical ordinal scale and exposure variable (MBBS/AYUSH) as dichotomous, Mann-Whitney U test was applied. For the factors where the outcome variable was measured in dichotomous scale and exposure variable (MBBS/AYUSH) was dichotomous, chi-square was applied. Fisher’s-exact test was also applied. A p-value less than 0.05 was taken as significant. Face validity, consensual validity, content validity of the questionnaire was checked. The data entry was done in excel and analysed by using SPSS 15.0 version. The study was approved by IEC committee of the institute.

Total 50 MO participated in the study, 33 (66.0%) were MBBS doctors and 17 (34.0%) were AYUSH doctors, 14 (28.0%) were female and the rest were male [Table/Fig-1].

A total of 47 (94.0%) MO told that they were overloaded with administrative work, 33 (66.0%) mentioned that they had average clinical work [Table/Fig-2].

A total of 41 (82.0%) MO reported that they have good relationship with subordinates and 40 (80.0%) told that they have good relationship with seniors. About 18 (36.0%) MO reflected that many a times they feel that they do not have powers for execution of work, whereas 16 (32.0%) felt it sometimes.

A total of 36 (72.0%) MO felt that there was external pressure, whereas 29 (58.0%) said that they have had conflict with the field staff [Table/Fig-2].

A total of 29 (58.0%) MO told that they commute to their work place, 26 (52.0%) worked in difficult terrain, 21 (45.65%) faced difficulty in providing education to children [Table/Fig-2].

A total of 31 (62.0%) MO told that they do not have good infrastructure to work in, 32 (64.0%) mentioned that they don’t have good facilities to work.

Differences were significant for overall scores (z=-2.081 and p=0.037) and workload scores (z=-2.663 and p=0.008), else no significant differences were found for other sub component scores [Table/Fig-3].

There were none in highly satisfied, whereas 29 (58.0%) MO were satisfied, 13 (26.0%) were not satisfied with their job [Table/Fig-4].

A total of 12 (24.0%) MO joined the workforce as per their choice. If given an alternative job, 37 (74.0%) MO would like to join the alternative [Table/Fig-5].

MO statements about their liking for this job, these were the comments: Adequate salary, good clinical work, job security, service to poor people, improve living standards of community, independent work, many programmes for Below Poverty Line (BPL) families and poor people, no alternative, preventive and promotive service to community, stability, lot of respect from people.

MO statements about their disliking for this job, these were the comments: Administrative work overload, to be at head quarter, poor facilities, lack of well qualified staff, contractual appointment, less salary, limited resources, lot of programmes in PHC, no motivation and appreciation, no promotion, status not maintained, educational problem of children, interference of people, lack of medicine, no bright future for self and family.

Total 47 (94.0%) MO in the present study told that they were overloaded with administrative work, 33 (66.0%) told that they have average clinical work to do. Poor utilisation of skills was identified as a factor contributing towards job dissatisfaction [8]. In PHCs, as the clinical workload was less; MO lose interest in treating the patients. Relationship with subordinates and seniors was again seen as an important tenet in job satisfaction. In the current study, 41 (82.0%) MO reported that they have a good relationship with their subordinates while 40 (80.0%) said that they have a good relationship with their seniors. Freedom to work and have a complete control over the affairs in the PHC, had much to do with the job satisfaction. In the present study, 18 (36.0%) MO reflected that many a times they felt that they do not have powers in execution of work, whereas 16 (32.0%) MO felt the same sometimes. External pressure at work lessens the job satisfaction. One study carried out by Health, Nutrition and Population Unit (HNP) [9], Human Development Network mentioned in their report that the frustration among rural health workers often stems from the feeling of being exasperated by local political interference. In the present study, 36 (72.0%) MO felt that there was an external pressure, whereas 29 (58.0%) said that they had conflicts with the field staff. During conflicts, field staff were not supportive. According to HNP report [9], frustration among rural health workers also stems from the lack of supporting staff.

Not living at the work place and commuting from an outer town in difficult conditions can waste a lot of time. Travelling also creates stress, if it is done on a day to day basis to reach out for duty hours. We found that 29 (58.0%) MO commute daily to their work place, 26 (52.0%) worked in difficult terrain and 21 (45.65%) faced difficulty in providing education to children. PHCs are present in villages with poor infrastructure and lack of facilities, support services, quarters etc., and this is another important factor in deciding for job satisfaction. HNP report also mentioned that medical students often regarded the housing provided to rural health workers to have poor conditions [9]. They thought that basic facilities like 24-hour water and electricity, good sanitation, and clean surroundings were rarities in rural areas. A total of 31 (62.0%) MO told that they do not have a good infrastructure to work in, 32 (64.0%) reported that they do not have good facilities to work while 43 (86.0%) MO felt that there was a lack of appropriate support services. According to HNP report [9], frustration among rural health workers often stems from the lack of infrastructure. In a study by Kumar P et al., they have mentioned that healthcare providers in their study population were dissatisfied with the material and means of working in the dispensary, facilities of water supply, condition of the toilets and seating spaces [10]. Not being appreciated by the service providers was an important factor. They also mentioned that interpersonal relations have an important effect on the overall job satisfaction of providers. In their study, majority of providers were not satisfied working with co-workers.

In a study conducted in West Ethiopia by Deriba BK et al., did not find any significant association between job satisfaction and working environment or relationship with management [11]. These findings were similar to the findings of the current study.

In categorical analysis for the overall impression of job satisfaction, none of the MO were highly satisfied, whereas 29 (58.0%) MO were satisfied, 13 (26.0%) were not satisfied with their job and 8 (16.0%) were highly unsatisfied. Chopra G and Singh G studied the job satisfaction of 46 Employee State Insurance (ESI) doctors by an interview method. None of the subjects found their job greatly satisfying. They mentioned that only one doctor found his job very satisfying. The percentages of doctors who were moderately satisfied, just satisfied and not at all satisfied were 12 (30%), 16 (40%) and 11 (27.5%) respectively [8]. In a study conducted by Kumar P et al., overall satisfaction score was relatively low in their study population [12]. Study conducted in Gujarat by Central Bureau of Health Intelligence (CBHI), MoHFW also highlighted dissatisfaction in Gujarat by medical staff. It was mentioned in the study that most of the state health personnel were concerned with the parity in salary within their cadre and other comparable cadre in the state. This implies that delay in increments and disparity due to late regularisation etc., was a cause of concern and demotivation [13].

Normally, MBBS doctors opt for postgraduation, so this question was asked in the questionnaire, whether they had joined the service by choice or by force. A total of 12 (24.0%) MO reported that the job was their choice. When a PHC MO joins a post, there is always a pressure that they have not done post graduation and so this might bring disgrace and when we asked about this, 35 (70.0%) mentioned in negative. As per the HNP report [9], rural doctors have a low standing among medical students. Their perception is that rural postings were taken up by those who are left with no other option, i.e., to specialise further or work in an urban area. In the present study, 23 (46.0%) MO mentioned that being called as PHC MO brings disgrace to their name. According to the HNP [9] report, a primary care job commands respect. A total of 37 (82.22%) MO did not encourage new people to join as MO in a PHC, whereas 8 (17.77%) said that they should join a PHC. We also had qualitative data, where the respondents gave their opinion. The respondents replying in favour of working as PHC MO discussed that the perks of a good salary (90%), job security (65%) and clinical work (80%) are required for job satisfaction. In a study conducted by Azam A, on 50 Fiji doctors, in the summary report of World Health Organisation Western Pacific region, mentioned that 55% doctors emphasised the low salary as the primary source of dissatisfaction, followed by poor work conditions (41%) and the lack of postgraduate training (27%) [14]. Chipeta JB stated in his article that factors like implementation of a clear performance management system, recognition awards and others are deemed motivational. [15].

All the AYUSH MO were contractually appointed, whereas some MBBS doctors were permanent in the current study. Job security was quoted as a factor for enhancing job satisfaction. Higher the degree of skill utilisation, higher would be the level of satisfaction, since self-actualisation need is satisfied [16]. The study by Bach S, highlights the optimistic views of policy makers; however, implementation of the same may not meet their expectations. Simple measures based on sound evidence base that critically appraises both recent successes and failures, strengthen human resource capacity in health sector [17].

Since, different factors related to the job play a vital role, it is very difficult to rule out a solo factor as the determinant of satisfaction or dissatisfaction with the job. The dynamics of the relations between these factors is considered more important than any one factor in isolation [18-20]. So, it can be concluded that job satisfaction is seen as a diversified phenomenon having multiple facets.

The sample size could have been larger. Detailed qualitative study like Focussed Group Discussion (FGD) should have been conducted to get the details not revealed in quantitative study. Due to limitations of manpower and time, such ideas were not implemented by the authors; however, they can be planned in future for such similar studies.

Overall job satisfaction scores were poor amongst PHC doctors. Job satisfaction of PHC medical officers is important as they cater to the health needs of rural people which form a very big proportion. If they are satisfied in terms of good job prospects, it can be hoped that their services towards rural people will be better and with a good commitment.

[1].  Geneva: WHO 1978   [Google Scholar]

[2]. Dairo MD, Oke AO, Olowu AO, Adebimpe WO, Adekunle BJ, A descriptive job analysis of doctors as primary health care coordinators in south western Nigeria Annals of Ibadan Postgraduate Medicine 2006 4:42-46.10.4314/aipm.v4i1.39059  [Google Scholar]  [CrossRef]

[3]. Rao K, Bhatnagar A, Berman P, So many, yet few: human reis for health in India Human Reis for Health 2012 88:10-19.10.1186/1478-4491-10-1922888906  [Google Scholar]  [CrossRef]  [PubMed]

[4]. Rao K, Bhatnagar A, Kumra N, Khanna S, Berman P, Reddy S, et al. Which doctor for primary health care? an assessment of primary health care providers in Chhattisgarh, India: a report June 2010. Public Health Foundation of India (PHFI) and National Rural Health Mission (NRHM). Available at: http://www.shsrc.org/webupload/PUBLICATION/HUMAN_RESOURSES_IN_HEALTH/AN_ASSESSMENT_OF_PRIMARY_HEALTH_CARE_PROVIDERS_IN_CHHATTISGARH.pdf  [Google Scholar]

[5]. Weiss HM, Deconstructing job satisfaction: Separating evaluations, beliefs and affective experiences Hum Resour Manage Rev 2002 12:173-94.10.1016/S1053-4822(02)00045-1  [Google Scholar]  [CrossRef]

[6]. Sharaf E, Madan N, Sharaf A, Physician job satisfaction in primary care Bahrain Medical Bulletin 2008 30(1):02-07.  [Google Scholar]

[7]. Molla MIH, Ensuring job satisfaction for managing people at work Global Disclosure of Economics and Business 2015 41(2):155-66.  [Google Scholar]

[8]. Chopra G, Singh G, A study of job satisfaction among doctors in ESI Corporation, Delhi Hospital Administration 1992 29:30-36.  [Google Scholar]

[9]. Rao KD, Ramani S, Murthy S, Hazarika I, Khandpur N, Chokshi M, HNP Discussion Paper, Results from Qualitative Research. Health, Nutrition and Population Unit, Human Development Network, The World Bank, 2010. Available at: http://sitereis.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Reis/281627-1095698140167/HealthWorkerAttitudesTowardRuralServiceinIndia.pdf  [Google Scholar]

[10]. Kumar P, Khan AM, Inder D, Sharma N, Job satisfaction of primary health-care providers (public sector) in urban setting J Family Med Prim Care 2013 2(3):227-33.10.4103/2249-4863.12071824479088  [Google Scholar]  [CrossRef]  [PubMed]

[11]. Deriba BK, Sinke SO, Ereso BM, Badacho AS, Health professionals’ job satisfaction and associated factors at public health centers in West Ethiopia Human Reis for Health 2017 15:3610.1186/s12960-017-0206-328558840  [Google Scholar]  [CrossRef]  [PubMed]

[12]. Kumar P, Khan AM, Inder D, Mehra A, A comparative study of job satisfaction among regular and staff on contract in the primary health care system in Delhi, India J Family Community Med 2014 21(2):112-18.10.4103/2230-8229.13476824987280  [Google Scholar]  [CrossRef]  [PubMed]

[13]. Managing human reis for health in India- A case study of Madhya Pradesh and Gujarat. Central Bureau of Health Intelligence, Directorate General of Health services, Ministry of Health & Family Welfare, New Delhi. In collaboration with WHO- India Country Office 2007   [Google Scholar]

[14]. Azam A, Motivation of Doctors within the Fiji Civil Service [MBA dissertation]. Suva, University of the South Pacific. In: “The Migration of Skilled Health Personnel in the Pacific Region: A Summary Report” WHO Regional Office for the Western Pacific; 2004. World Health Organization. [Available from] http://www.wpro.who.int/publications/docs/Migration_Skilled_Health.pdf  [Google Scholar]

[15]. Chipeta JB, Factors that affect staff morale in tertiary hospitals in Malawi: a case study of Kamuzu Central Hospital Journal of Human Rei and Sustainability Studies 2014 2:230-38.10.4236/jhrss.2014.24024  [Google Scholar]  [CrossRef]

[16]. Chaudhury S, Bannerjee A, Correlates of job satisfaction in medical officers MJAFI 2004 60(1):329-32.10.1016/S0377-1237(04)80004-2  [Google Scholar]  [CrossRef]

[17]. Bach S, HR and new approaches to public sector management: Improving HRM Capacity. Prepared for the Global Health Workforce Strategy Group. Geneva: World Health Organization; 2001. Available from: http://www.who.int/hrh/en/Improving_hrm_capacity.pdf  [Google Scholar]

[18]. Bhandari P, Bagga R, Nandan D, Level of job satisfaction among health care providers in CGHS dispensaries J Health Manage 2010 12:403-22.10.1177/097206341001200401  [Google Scholar]  [CrossRef]

[19]. Bodur S, Job satisfaction of health care staff employed at health centres in Turkey Occup Med (Lond) 2002 52:35310.1093/occmed/52.6.35312361997  [Google Scholar]  [CrossRef]  [PubMed]

[20]. Huby G, Gerry M, McKinstry B, Porter M, Shaw J, Wrate R, Morale among general practitioners: qualitative study exploring relations between partnership arrangements, personal style, and work load BMJ 2002 325:14010.1136/bmj.325.7356.14012130611  [Google Scholar]  [CrossRef]  [PubMed]