Introduction
Cadre | Salary costs in the public sector | Other benefits |
---|---|---|
Medical officer interns | Ksh 145,000 / USD 1,200 per month | Extraneous allowance, housing allowances, risk allowances (roughly Ksh 40,000, ~ USD 330) and specifically for MOs also emergency call allowances (Ksh 30,000, ~ USD 250) |
Medical officer | Ksh 250,000 / USD 2,100 per month | |
Registered clinical officer | Ksh 100,000 / USD 840 per month | |
Enrolled/registered nurse | Ksh 94,000 to 100,000 / USD 790 to 840 per month |
Year | Events and implications |
---|---|
2010–2018 | Expansion of medical schools as only 2 medical school before 2010 and an increase to 11 in 2018, meanwhile number of annual outputs increased from 287 in 2006 to 628 in 2019 |
2010–2013 | New constitution in 2010, new government formed after general election in 2013 and devolution of the healthcare system, leading to the national government became responsible for planning and regulation for health and medical education and establishing norms and standards, while 47 devolved county governments are responsible for workforce planning and recruitment |
2013 | Collective bargaining agreement (CBA) drafted by the doctors’ union and the Ministry of Health on 300% pay-rise for doctors, review of job groups, recruitment, deployment and promotions of doctors; though county governments were not signatories to the agreement |
2014 | Ministry of Health published Human Resources for Health Norms and Standards Guidelines for the Health Sector, which required each Level 3 health centre to have at least two MOs and each Level 4 primary hospital to have 17 |
Materials and methods
Study design and framework
Data collection
Respondents | Sampling | Respondent characteristics | Data collection approach | Interview focus |
---|---|---|---|---|
30 junior medical officers who finished internship within 3 years | Snowballing approach through facilitated introductions or referral by an interviewee; individuals were selected also considering different internship hospitals and current occupation | ⦁ Undergraduate training: 29 respondents trained in public universities, 1 trained in private universities ⦁ Internship hospital type: 25 interned in public hospitals, 3 in mission hospitals, 1 in private hospital, and 1 in military hospital ⦁ Internship hospital level: 14 interned in level 5 hospitals and 16 in level 4 hospitals ⦁ Current occupation: 26 currently work as medical officers, 2 work as researchers, 1 work as resident, and 1 work in business | ⦁ Semi-structured interviews ⦁ In-person or online in English between June and Sept 2021 | ⦁ Wellbeing, educational and work environment during the internship, ⦁ Experiences of applying and securing post-internship jobs |
10 consultants with experience supervising interns | Snowballing approach through facilitated introductions or referral by an interviewee; individuals were selected considering different specialty | ⦁ Internship hospital type: 8 respondents work in public hospitals, 1 work in mission hospital, 1 work in private hospital ⦁ Internship hospital level: 3 work in level 6 hospitals, 4 work in level 5 hospitals, 3 in level 4 hospitals ⦁ Specialty: 2 work in surgery, 2 work in internal medicine, 5 work in paediatric, 1 work in obstetrics and gynaecology | ⦁ Semi-structured interviews ⦁ In-person or online in English between June and Sept 2021 | ⦁ Observations of interns’ experiences during internship and employment |
51 county-level and subcounty-level managers | Two counties were purposively selected based on their HRH density and geographic locations; individuals were selected purposefully covering different departments and affiliations | ⦁ County: 14 respondents come from county A, 37 from county B ⦁ Affiliation: 11 respondents work as county health department officials, 2 work as county public service board officials, 2 work as county other department officials, 17 work as subcounty health department officials, 19 work as public facility managers | ⦁ Semi-structured individual or group interviews (22 individual interviews, 8 group interviews involving 29 participants) ⦁ In-person in English between Sept 2021 and March 2022 | ⦁ Respondents’ role as HRH managers ⦁ Counties’ HRH interventions ⦁ How medical officers, clinical officers and nurses are recruited and deployed in counties |
Data analysis
Reflexivity
Results
Recruitment process and stakeholders
“It's a bit complex, because we really do not know what happens, sometimes you just bump into an advert in the media and then after that you will find new people being posted to the hospital. You will not know when the interviews were conducted, who conducted interviews and under what terms these people have come, you don't know, you’ll just be told these people have come to work here.” (Consultant, C10 – L4 Public – Internal medicine)
“I'm sorry to say this. You find that, you know, employment is a political tool. If, if today I am the governor, I want to reward my, my people. Most likely you, you reward them through, through employment.” (County B, B20)“Another thing is that they employ based from tribe. If, like somebody like me coming from Western Kenya and I wanted to be employed around this area [County B] or something is very difficult.” (Medical officer, M10 – L5 Public – Private MO)
Supply of medical officers
“Medical officers are finding it harder because first of all almost every other university is offering medicine nowadays. So the number of medical officers out here is quite high. So if the supply is high, and the demand is constant, the demand by the medical facilities is constant, then that means that means that the people will not be employed as much as they used to be previously.” (Medical officer, M23 – L4 Public – Public MO)
“We all wish as doctors especially myself to work where my job security is good. Working with a private facility in Kenya as a doctor, your job security is not guaranteed. You can wake up in the morning you go, you find- they fire employees. So it‘s not a place that I wish to be.” (Medical officer, M10 – L5 Public – Private MO)
Demand for medical officers in the public sector
“I think overriding reason is finances. We keep on hearing from our county and other county governments about the wage bill, wage bill...the main reason for not employing is not that they’re not there, they are there, they’re qualified they’re jobless, but there isn't enough money to employ to employ all, adequate numbers. That is the main reason.” (County B, B34)
“The issue of counties is finances that is one because unless they are given, what they received is a package, yeah. And unless the salaries are factored in for those doctors from the national government, the county cannot absorb. They will always squeeze if they can, maybe one has retired or one has left the service, that’s when they can absorb at least one or two. The vacancies are there, it's not that they are not there. They are there. But that package does not allow additional employment.” (County A, A05-08)
“When you want to employ a new medical officer, we first do a needs assessment for our county, whether we require just a plain medical officer or specialised medical officers. and then from there we give our views that we require, this is the number we require whether it is medical officers, specialised officers. And then I think the rest, when we give our review as a committee, now the rest is from there up to the County Public Service Board” (County B, B01-05)
“I agree with you but what I am feeling is that the Public Service Board should actually be capacity built to understand what is Human Resources in Health and who is supposed to be employed? …if we are crying that we have a shortage and the Public Service Board does not understand what we need then they need to be upgraded and understand what is happening.” (County B, B13-17)
“I think it's cheaper to have clinical officers, let me start there. And they usually look for medical officers where, in the facilities where there are actual operating theatres because of C sections and all those procedures they think medical officers should do, and consultants. So if you have like or very large county without facilities that have an operating theater, they will tend to take on to clinical officers and nurses.” (Medical officer, M12 – L4 Public – Private MO)
Recruitment outcomes: employment, terms and wages
“But many people in fact, I have very many colleagues right now who are at home without work…So you find someone having, in fact, most of the interns, post internship, many people have like one year to two years job gaps, you can imagine, they have never taken back to hospital, not because they don't want, there are no opportunities.” (Medical officer, M01 – L5 Public - Research)
“And again you see when you employee somebody on contract then the next time you are not renewing the contract, how do you want to manage that person? Even you personally, how do you arrange your life? You are on contract, you are earning today, then tomorrow you are not earning, you are looking for a job elsewhere.” (County B, B01-05)
“And if you apply for a job somewhere. You find these private facilities that will offer you say half of what you are getting [during] your internship, and they are already qualified doctors with a registration number...” (Medical officer, M03 – L4 Mission – Public MO)
“Most of the private hospitals are giving doctors, you just work per working hours and it's not guaranteed. This is depending on the patient flow. So you find this month you might be called for locum, then suddenly next month you're being told, ‘okay, it’s Covid. There are very few patients, so you're going to be on a pay cut’.” (Medical officer, M01 – L5 Public - Research)