In early 2009, the Government of China (GOC) launched a new health care system reforms. The goal of this program is to establish a basic medical and health system covering both urban and rural residents, to provide safe, effective, convenient, and inexpensive medical health services for all [1]. For the last decade, China has been working to achieve universal health coverage as defined by the World Health Organization [2,3,4]. China’s medical and health care system has a dual structure in urban and rural areas, and there are large gaps in medical care in both areas. By the end of 2017, there were 576 million people living in rural areas while there were 4.28 medical and technical personnel per 1000 population in those areas, compared to 10.87 in urban areas. The key aspects of and difficulties with Chinese health care reforms lie in rural areas and PHCFs.
The service capacity of PHCFs needs to be enhanced and the system of primary medical and health care needs to be improved. In recent years, the GOC has emphasized that medical reform should begin at the local level and it has implemented a series of policies, such as enhancing the establishment of local basic medical and health service networks and urban community health service centres, implementing a national essential medicine system, promoting the reform of county hospitals, accelerating the training of general practitioners, advancing hierarchical diagnosis and treatment, and so on. Furthermore, the GOC provided 12 kinds of basic public health services to all residents free of charge. The national subsidy per person for basic public health services increased from 15 Chinese Yuan (CNY) in 2009 to 55 CNY in 2017. The financial subsidy per person for resident medical insurance increased from 120 CNY in 2010 to 450 CNY in 2017. In addition, the proportion of personal health expenditures to total health expenditures has dropped to less than 30% in 2017.
Despite numerous efforts, however, primary health care has not been significantly improved as expected. PHCFs have not served as a gate-keeper in terms of disease prevention and control [1, 5]. Many rural residents preferred to see a doctor in an urban hospital or tertiary hospital directly rather than in a local PHCF. Therefore, the number of outpatients and inpatients in PHCFs have not increased significantly. The “drug-dependent” medical system has not fundamentally changed, and the unbalanced distribution of medical resources is still a major concern [6]. Although expansion of health insurance coverage has led to increase in insurance reimbursements, it has not reduced the financial burden of illness borne by households, nor has it improved the quality of care [1, 7, 8]. According to statistics, personal health expenditures increased from 657.1 billion CNY in 2009 to 1513.3 billion CNY in 2017. The two popular Chinese phrases “kan bing nan” and “kan bing gui” could reflect the current reality.
Talent is the key component to developing PHCFs, and certified physicians are the most valuable resources. To solve medical difficulties for local residents, they need to receive appropriate medical care from physicians. To gain insight into possible problems, the job satisfaction of certified primary care physicians needs to be studied. Job satisfaction is not only closely related to physicians’ feelings towards a job and to the quality and efficiency of their services but is also an important indicator in evaluating retention, motivation, and work performance. Job dissatisfaction could lead to other negative consequences, such as poor communication between doctors and patients, poor quality of care, and even medical disputes [9]. In turn, it may affect the successful implementation of new health system reforms [10,11,12]. A previous study found a correlation between doctors’ job satisfaction and patients’ satisfaction with the quality of health care [13]. Good job satisfaction will enable patients to spend less and achieve better results [14]. Physicians with higher job satisfaction were likely to provide more satisfactory care and more effective treatment than those with lower job satisfaction [14, 15]. The existing challenge is how to create conditions to improve job satisfaction so that physicians are willing to stay in local PHCFs.
The aim of the current study was to evaluate the job satisfaction of physicians in rural Shandong Province following recent health system reforms and to identify the factors affecting their job satisfaction. This study also considered what the Government should do to help PHCFs retain talented personnel.
Review of literature on job satisfaction of physicians
Job satisfaction is a measure of people’s contentedness with their job and an assessment of their work experience [16]. It can be measured using cognitive, affective, and behavioural components. Many researchers have provided definitions of job satisfaction. One of the most widely used is job satisfaciton defined as “a pleasurable or positive emotional state resulting from one’s work or work experiences” [17], while Motowidlo (1996) suggested that it is a perception of the “favourableness of the working environment” [18]. Attempting to combine both approaches, Brief (1998) defined job satisfaction as “an internal state that was expressed by affectively or cognitively evaluating an experienced job with some degree of favour or disfavour” [19]. Other researchers simply defined it as an individual’s satisfaction with one’s job, indicating whether or not he or she likes the job [16]. Numerous studies have revealed the importance of employee satisfaction. A study by Schneider and Bowen indicated that customer satisfaction was largely influenced by the attitudes and behaviours of service employees, while employee satisfaction was positively related to service quality [20]. Consequently, motivating and retaining qualified employees are crucial to the further success of service organizations [21]. To enhance customers’ perceptions of the quality of service, several studies have suggested that managers must increase employees’ self-efficacy and job satisfaction and reduce their role conflict and ambiguity [22, 23].
Several studies have examined the job satisfaction of physicians. A survey conducted by the American Physical Therapy Association in 1989 indicated that physicians were satisfied with their work [24]. The highest job satisfaction was the result of “autonomy,” whereas the lowest was the result of “reward”. This finding was consistent with the results of one study of doctors in Utah and another of doctors in Texas [25, 26]. Moreover, these two studies also revealed that the key factors contributing to physicians’ willingness to leave were heavy clinical workload, high patient expectations, and the clerical aspects of work. A study in New Zealand indicated that general practitioners had a rather high level of job satisfaction [27]. However, health care reforms, long working hours, too much bureaucracy and too many restrictions made them feel stressed and dissatisfied. Similar results were reported in a study of Pakistani public health professionals [28]. Working conditions, job description, and time pressures were the major reasons for dissatisfaction. Other factors influencing the level of job satisfaction were a low salary, lack of training opportunities, inadequate supervision, and insufficient financial incentives [28, 29].
According to an Australian study, lower job satisfaction was associated with poor health, training outside of Australia, fewer professional development opportunities, and longer working hours [10]. Meanwhile, lower job satisfaciton was also associated with a desire to reduce one’s working hours and an intention to leave medical profession. In contrast, a study in Lithuania found that doctors working in PHCFs had a relatively low level of overall job satisfaction [30]. The key factors influencing their dissatisfaction were compensation, social status, and workload.
The job satisfaction of physicians has garnered increasing attention among Chinese researchers. Numerous studies have discussed the factors infulencing job satisfaction and turnover intention. In Xinjiang and Anhui Provinces, Liu et al. (2010) conducted a quantitative study among township health centre (THC) employees in poor rural China. That study indicated that employees in THCs had a moderate level of job satisfaction. They were more satisfied with job significance, job competency, and teamwork than job rewards and working conditions [14]. In Hubei Province, more than a third (36.8%) of village doctors considered leaving their current positions voluntarily [31]. According to that study, income satisfaction, organizational policy implementation, wages and workload, career development opportunities, and working conditions were significant factors that contributed to the intention to quit among village doctors. This fingding was consistent with the results of a study of general practitioners in Hebei Province [32]. In Guangdong Province, the intention to quit among physicians was directly and negatively related to job satisfaction, and it was positively related to work stress and work–family conflict [33]. Thus, reducing working hours, increasing salaries, providing more opportunities for career development and training, and encouragement of senior managers may contribute to a reduction in their intention to quit. In Chongqing, a study found that 42.3% of primary care doctors intended to quit [34]. Findings suggested that the Government should increase its financial input to PHCFs, especially those in less-developed areas, and reform incentives to improve the job satisfaction among primary care physicians. A study in Liaoning indicated that Chinese community health workers enjoyed a moderate level of job satisfaction [35]. That study corroborated the evidence that stress and burnout are important predictors of intrinsic and extrinsic job satisfaction. Studies have examined the job satisfaction among rural village doctors, THC employees, community health workers, and physicians in urban state-owned medical facilities in other provinces of China [14, 36]. Their conclusions indicated that the respondents also enjoyed a moderate level of job satisfaction and that they were increasingly quitting or intending to quit because of job dissatisfaction.
Few investigations have been conducted to ascertain the job satisfaction of certified physicians in PHCFs in Shandong province following China’s recent health system reforms. Accordingly, the current study has been conducted in order to help policymakers to improve strategies designed to enhance physicians’ job satisfaction.
