Background
Methods
Conceptual framework
Study design
Study setting
Study population and data collection
In-depth interviews
County A | County B | |
---|---|---|
Health Facility Managers | 5 | 2 |
Health Care Providers | 3 | 6 |
Sub-County Managers | 5 | 3 |
County Officials | 6 | 4 |
Union Officials | 0 | 1 |
Total per County | 19 | 16 |
Total both Counties | 35 | |
National Level | 11 | |
Total Interviews | 46 |
Review of documents and secondary data
Data Sources | |
---|---|
Information Systems (Ihris, rhris) | County Public Service Human Resources Manual 2013 |
MoH policy and Strategy documents (Kenya Health Policy 2013–2030, MOH, HRH Norms and Standards Guidelines 2014–2018, The Kenya Health Strategic and Investment Plan, 2014 – 2018) | County Strategic and development plans and reports (Annual Work Plans, County Health Sector Investments Plans, County Integrated Development Plans, Budget reports etc.) |
PFM Act 2012; 2015 | SRC reports and directives |
Collective Bargaining Agreements (CBAs) | Civil Service Code of Regulations |
Data management and analysis
Qualitative data
Quantitative data
Results
County A | County B | |
---|---|---|
HRH Funding | • Inadequate HRH funding • Delays in salaries reported | • Inadequate HRH funding • No delays in salaries reported |
HRH Numbers | • Staffing shortages experienced for all cadres except general clinical officers | • Staffing shortages experienced for all cadres except general clinical officers |
HRH Skill-Mix | • Inadequate skill-mix with specialist shortages | • Inadequate skill-mix with specialist shortages |
HRH Distribution | • Mal-distribution of workers skewed towards hospitals | • Maldistribution health of workers towards hospitals |
HRH Contractual arrangements | • Incoming health workers employed on Permanent and Pensionable (P & P) basis | • Incoming health workers employed on fixed term contracts |
HRH Incentives and motivation | • Inter-cadre disparities in training opportunities reported • Risk allowance for non-service delivery staff eg HR managers, accountants etc • Absenteeism was reported | • Rural staff had differential opportunities for transfers • Risk allowance for non-service delivery staff eg HR managers, accountants etc • Absenteeism was reported |
HRH processes mapping under devolution in Kenya
Funding for human resources for health
HRH funding in the study counties was inadequate
“We are constrained by the limited budget lines. If we could have adequate funds, then we would be able to employ according to the requirements of the norms and meet our objectives in a smooth manner.” (HR Manager, County A)“In the previous budgetary cycles, the health department would not factor in sufficient money for HRH recruitment and promotions. So, when it suddenly arose, we did not know how to help them because once it is not in the budget, it cannot be done. We have since sensitized them and now I think it is being done correctly.” (Senior Economist—Finance Department, County A)
“We don't sponsor their tuition, but we offer them paid study leave. It saves us costs on one hand but again, it might be the reason the attrition number is high. The staff who pay for [their own training costs] themselves are not bonded like those who might have had their tuition paid. So, when they finish training it is easy for them to move to other areas and we have to recruit new health workers” (Medical Superintendent, County A)
Health workers in county A experienced delay in payment of salaries
“Disbursement delays are an issue out of our own hands at the county level. The delays are as a result of delays from the national treasury. Once the funds are available every person gets his/her salary” (Senior Economist, County A)“In some counties, disbursements may have been done but they move this money to build roads. Then they wait for other development projects funds so that they can pay salaries. The workers are paid late and their motivation is affected. It also leads to frequent strikes.” (Professional body 2 Respondent)
“In our county, we have negotiated with a local leading bank. They pay our health workers’ salaries promptly. We are able to pay our workers their net salaries on time and they are able to continue discharging their duties with minimal disruptions.” (Payroll Manager, County B)
HRH Number, Skill-Mix, and Distribution
HRH staffing shortages were reported in both study counties
“If you pick one health indicator such as skilled birth attendance and look at your catchment populace, you'll realize that there's a percentage of women whose deliveries are not being conducted by a skilled birth attendant. This is mostly due to having only one or few nurses at facilities since the health center cannot operate 24 h and on weekends.” (Medical Superintendent, County B)
Staff Cadre | County A | County B | |||||
---|---|---|---|---|---|---|---|
Employed | Required according to staffing norms | % as per norms met | Employed | Norms & Standards | % as per norms met | ||
1 | Medical officers | 32 | 200 | 16.0 | 63 | 76 | 82.9 |
2 | Medical specialists | 7 | - | - | 21 | - | - |
3 | Clinical officers (specialists) | 24 | 160 | 15.0 | 10 | 62 | 16.1 |
4 | Clinical Officers (general) | 155 | 130 | 119.23 | 64 | 50 | 128 |
5 | Nurses (registered) | 499 | 860 | 58.0 | 188 | 340 | 55.3 |
6 | Nurses (Enrolled) | 149 | 1640 | 9.0 | 231 | 656 | 35.2 |
7 | Total | 950 | 4303 | 22.1 | 805 | 1683 | 47.8 |
8 | Health Workforce Density | 8.5 | 44.5 | 19.1 | 15.52 | 44.5 | 34.9 |
“Donor programs have provided resources to hire additional health workers such as clinical officers and nurses which have boosted our HRH numbers and relieved our overall HRH shortages” (Medical superintendent, County B)
Health workers skill-mix
Case study counties had inadequate skill mix characterized by scarcity of specialists
“One of our biggest health concerns in this area is non- communicable diseases. We have very many patients with hypertension and diabetes. Even asthma and COPD due to perennial use of firewood. But we don’t have enough doctors to deal with the cases” (Medical Superintendent, County B)
“The citizens may not get quality services. For example, my boss was complaining that she had been advised to wear plaster for a whole week, only to later find a specialist who found out that she had been mis-managed because she had been attended at our general hospital by someone who is not a specialist” (Payroll Manager, County B)“We require the specialists here because sometimes we are forced to risk. For example, one may refer a pregnant mother who has a previous scar, but she may refuse to go and just come at night and the nurse is forced to risk. The nurse attends to them while praying that nothing goes wrong.” (Nurse, County B)
“It is cheaper for this county when we engage external specialists from other counties because the image is still taken at the same cost and the county does not pay this specialist a salary. For example, from the amount the patients pay, we have an agreed amount that we pay to the radiologist who is interpret the image. It is quite economical.” (Deputy Medical Superintendent, County A)“Occasionally, the experts move to where the staff are and mentor them on what they are meant to do. This helps us fill the gap that is there in terms of skill mix. For example, we had just one renal nurse at the time and the rest of the nurses who joined the team were trained on the job.” (Deputy Medical Superintendent, County A)
Both study counties were characterized by the maldistribution of health workers
“Shortages of staff in the lower level facilities affect our performance because of a lot of unnecessary referrals to the hospitals. Most cases that we feel ought to have been handled at that level end up here. This delays interventions for the patients.” (Deputy Medical Superintendent, County A)“We also have some gaps in documentation due to the rush to attend to the other patient when you have only one staff in a facility.” (Nursing Officer L3, County A)
Health worker employment arrangements
Varied contractual arrangements within similar skill-sets performing similar duties were reported in both counties
“As a health worker on contract basis myself, we achieve more because we are given targets. We have to achieve those targets to remain in that contract which is a positive thing because our colleagues who are on permanent terms are a little bit relaxed in their outputs.” (Health Worker, County B)“P an P employees perform better. Contract employees especially towards the end of the contract, spend most of their time trying to secure their future by looking for other jobs. They are not settled at work during this time and their motivation is low.” (Medical Superintendent, County A)
“Those on permanent and pensionable terms have more benefits such as access to long-term mortgages and car loans, pension, long-term training opportunities and comprehensive medical covers.” (Union Official)
“I don’t think there is anything particularly wrong with contracts, they only need to be fair compensation to the worker…The counties should also look at sustainability and continuity. If you hire an obstetrician for 3 years, they disappear then you must train another one and hire them for 3 years, where is the continuity of services in that?” (Professional body 2)“The problem is that donor/partner programs hire and train staff who are later not absorbed into the system after the project ends because there are no direct policy guidelines for that. When the board hires other people other than these people, human capital is lost.” (Director Public Health, County A)
The informal part-time working arrangements for specialists, who also engaged in dual practice was thought to be inefficient
“Doctors work very few hours in the hospital and then they leave for other commitments. I do not think that they are giving us the maximum value, because it is very difficult to find a doctor working for 8 h in the government facility, yet they are paid a lot.” (Hospital Administrator, County A)
Health Worker Incentive and motivation
Financial incentives | Non-Financial incentives |
---|---|
A mid-range entry level basic pay in hardship areas that is higher than the normal areas for new entrants to the service with bonding to ensure it serves the attraction and retention expectation | Provision of comprehensive health care services for health workforce and immediate family |
A higher house allowance than the normal working areas if housing is not provided | Opportunities for continuous professional development, such as a prioritized post-graduate training after serving a certain number of years |
A hardship allowance paid to members of staff who are stationed in the designated hardship areas | Improved human resources management (HRM) including; reduced workloads, supportive supervision, decentralization of human resources activities, deployment on areas of choice or having fixed term in hardship areas, clear roles and responsibilities within their job description and performance appraisals |
A higher non-practicing allowance (to compensate health workers for not engaging in dual practice) paid to doctor and dentists who are not practicing than normal areas | Access to house, education or car loans at lower negotiated market rates (for highly skilled public sector workers) |
An additional responsibility/duty allowance paid to officers who are required to handle tasks beyond their job descriptions, such as acting as head of a department, nurses who act as professional counselors in facilities and members of sub County Health Management Teams (SCHMTs) | Establishment of social amenities within vicinity of the facility such as staff canteen, gym facility, recreational centers |
Study respondents reported disparities in incentive structures across counties, cadres, contract type, levels of care, and geographical regions
“Some counties are offering car loans and mortgages for their health workers as an incentive in addition to other incentives which has a demotivation aspect to other workers because some counties do not implement such.” (Union Official)“A clinical officer like me will be in one job group in one county and a higher job group in another county. There's a lot of discrepancies that have been created. These people compare notes and it creates a lot of disharmony, unrest and attrition.” (Union Official 2)
“One example is the short courses at Kenya School of Government. Sponsoring should not only be limited to the CHMT members, but it should be across all staff based on job groups and the requirements so that the knowledge gap is not too wide across the staff.” (SCMOH, County A)
“A serious challenge we face is that non-health service workers such as accountants, human resource officers, administrative officers are not paid risk allowance, yet they interact widely with patients and the health workers. It is risky for them too. Training and development for these staff is never taken seriously too yet they are also part of the system.” (HR Manager, County A)
“We feel like we are often overlooked here in the rural facilities. It is difficult to get a transfer. Some staffs have worked in this rural area for many years, but they don’t get transfers. This has demotivated some staff.” (Health Worker, County B)
Absenteeism by health workers was also reported
“Somebody may be absent because this person is sick, this person is, is indisposed…So there is a mechanism under which some of these cases are heard and determined. In other facilities, like for example, if you go to a dispensary, maybe you have three officers or two, they could make their own local arrangement so that there's always one nurse on duty, the other one is always absent. And yet the principal is both of them must be on duty.” (County Manager 4, County A)
“Occasionally, you get one or two members of staff in patterns of absenteeism. Part of the reason why they disappear is because we, as the supervisors are not near that facility. When you get funding for supervisory visits, you find this staff is not there. And maybe this might just be your first time to find him absent. It’s only after you have visited severally that you realize, oh kumbe (so) there is a pattern, he’s never there.” (County Manager 1, County B)
“…there are those ones as I told you, the ones I called ghost workers. You see that is high level because people are put on payroll. For example, they say there are 1000 nurses but the ones we manage are 800. So already 200, you have never seen them… It is only when you have access to the payroll that you realise that there are more people than you thought there are” (County Manager 2, County 1)
“Generally, clients will suffer (due to absenteeism), and it might lead to increased mortality in our facilities. You find that probably when there's an emergency somewhere, and the health care worker is not there. You see that client might succumb.” (County Manager 9, County 1)“Of course, now, when you’re absent it means the service delivery is affected wherever you are. So, if you're a doctor, your clients will not get the services, if you’re a nurse the same. The children maybe they came for immunization they will not find you. So it ends up creating a situation whereby you are spending but the outputs are not coming forth. Just spending but the outputs expected” (County Manager 1, County 2)
“Some of the health workers they have godfathers in the counties. And they have that feeling that the immediate supervisors or any other supervisor, doesn’t have power over them… and sometimes it(absenteeism) becomes infectious to the other personnel. If you don't take action against one who’s doing that (absenteeism) then it will bring another staff becoming absent from his work.” (County Manager 1, County 2)