AMSA-IUA: Conference Proceedings_Jan 2013: 9. Kenya

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International University of Africa

Faculty of Medicine and Health Sciences

African Medical Students Association

Health Problems in Africa: Is there any hope left?

10 – 11 January 2013 AD/ 28 -29 Safar 1434 AH Khartoum - Sudan

Major Health Problems in East Africa

Kenya

Prepared by:

Ahmed Nassir Ahmed, Ahmed Akasha Alsayed;

Khadija Said; Ismail Atako Luta

(MBBS Level 3, Faculty of Medicine – IUA)

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COUNTRY BACKGROUND Republic of Kenya is a country in East Africa that lies on the equator.

With the Indian Ocean to its south-east, it is bordered by Tanzania to the

south, Uganda to the west, South Sudan to the north-west,Ethiopia to the north

and Somalia to the north-east. Kenya has a land area of 580,000 km2 and a

population of a little over 43 million residents.The country is named

after Mount Kenya, a significant landmark and second among Africa's highest

mountain peaks. Its capital and largest city is Nairobi.

Climate

Kenya has a warm and humid climate along its coastline on the

Indian Ocean, which changes to wildlife-rich savannah grasslands moving

inland towards the capital. Nairobi has a cool climate that gets colder

approaching Mount Kenya, which has three permanently snow-capped

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peaks. The warm and humid tropical climate reappears further inland

towards lake Victoria, before giving way to temperate forested and hilly

areas in the western region. The North Eastern regions along the border

with Somalia and Ethiopia are arid and semi-arid areas with near-

desert landscapes. Lake Victoria, is situated to the southwest and is shared

with Uganda and Tanzania.

MAJOR HEALTH PROBLEMS

Malaria

Background

The epidemiology of malaria in Kenya is quite varied

geographically, with high levels of transmission on the coast and around

Lake Victoria but little or no transmission in the highlands above 1,500–

2,000 meters altitude. The Government of Kenya tailors its malaria control

efforts according to malaria risk to achieve maximum impact. Recent

household surveys show significant progress is being made against

malaria in Kenya, with improvements in coverage with malaria prevention

and treatment measures and reductions in malaria parasitemia and illness.

Malaria in Kenya at a glance

Malaria is the leading cause of morbidity and mortality in Kenya .

25 million out of a population of 43 million Kenyans are at risk of

malaria. It accounts for 30-50% of all outpatient attendance and 20% of

all admissions to health facilities. Malaria is also estimated to cause 20%

of all deaths in children under five. The most vulnerable group to malaria

infections are pregnant women and children under 5 years of age. In

collaboration with partners, the government has developed the 10-year

Kenyan National Malaria Strategy (KNMS) 2009-2017 (link) which was

launched 4th November 2009. The goal of the National Malaria Strategy

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is to reduce morbidity and mortality associated with malaria by 30% by

2009 and to maintain it to 2017.

SHORTAGE OF HEALTH WORKFORCE IN

KENYA

Introduction

There is increasing evidence of a strong correlation between the

density of human resources for health (HRH) in a country and population

health outcomes. But many countries lack the right numbers of health

workers in the right places to deliver essential health interventions, such as

immunization and skilled attendance at delivery.

The causes of these shortages and imbalances are manifold. They

include limited production capacity as a result of years of poor planning

and underinvestment in health education and training institutions,

especially in many developing countries. Often, training outputs are

poorly aligned with the health needs of the population. There are also

"push" and "pull" factors that affect workforce retention and may

encourage health service providers to leave their workplaces, including

those related to unsatisfactory working conditions, poor remuneration and

career opportunities, and other labour market pressures. In particular, the

international migration of large numbers of health workers further

weakens the already fragile health systems in many low and middle

income countries. Underlying all this is the reason of many nations, Kenya

being one of them, lack the ability to provide an appropriate amount of

health workforce.

Gaining insight into the confluence of factors that causes health

workforce shortages is critical in designing effective solutions. Rather

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than a single cause, there are multiple complex causes that combine to

produce a global shortage of 4.3 million workers in 57 of the world's

poorest countries. Some of these causes are cross-cutting and seen in all

countries experiencing health worker shortages. Other causal factors affect

a particular country or a region of a country, or have a special potency in

one situation and not another.

Numerous studies have explored the link between an adequate

supply and deployment of HRH and health services delivery. The Joint

Learning Initiative, comprised of global health experts, found that a

density of 2.3 health care workers per 1,000 population was associated

with 80% coverage in skilled birth attendance and measles vaccination

(2004). Anand also found a relationship between the density of the health

workforce and mortality rates for mothers, infants and children under five

(Anand, and Barnighausen 2004). However, thirty-six sub-Saharan

African countries, including Kenya, are facing a critical shortage of heath

care workers (2006).

To address the shortage of health care workers, Kenya has employed

various strategies, two of which included an Emergency Hire Plan (EHP)

and a computer-based distance education program (2008). Kenya’s

emergency hire plan included several donor partners, and facilitated the

rapid recruitment and deployment of health workers. Data from the

KHWIS indicated that the EHP accounted for the hiring of 1,836 nurses

increasing the public sector nursing workforce by 12%. Some EHP nurses

were deployed to closed or new health facilities, increasing functional

health facilities by 9% (Gross et al. 2010). Additionally, a computer-based

distance education program, developed through a partnership between the

African Medical and Research Foundation and Kenya’s ministries of

health, enhanced nurses’ education through distance learning, which

contributed to a 31% increase in the number of registered nurses, as 5,887

upgraded from enrolled to registered (data from KHWIS).

Enhancing the supply and availability of registered health professionals

will only translate into improved workforce to population densities if

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fiscal space is created to hire and deploy new workers. Economic policies

implemented by international finance institutions have created workforce

imbalances in many low-income countries, including Kenya, whereby the

unemployment of licensed health professionals persisted amidst national

health workforce shortages, due to public sector hiring ceilings (2004;

Kingma 2006). While financing the health workforce scale up remains a

challenge, streamlining the deployment process is also a vital component

of health systems strengthening. Kenya’s emergency hire plan consisted of

a fast track recruitment and deployment strategy, addressing inefficiencies

in the personnel management process (Adano 2008). Investments in

strengthening personnel management systems will ensure that new

workers are recruited, hired, and deployed in a timely manner.

HEALTH CARE SYSTEM Kenya’s health care system is structured in a step-wise manner so

that complicated cases are referred to a higher level. Gaps in the system

are filled by private and church run units. The structure thus consists:

Health units Dispensaries The government runs dispensaries across

the country and is the lowest point of contact with the public. These are

run and managed by enrolled and registered nurses who are supervised by

the nursing officer at the respective health centre. They provide outpatient

services for simple ailments such as common cold and flu, uncomplicated

malaria and skin conditions. Those patients who cannot be managed by

the nurse are referred to the health centres.

Private clinics

Most private clinics in the community are run by nurses. In 2011

there were 65,000 nurses on their council's register. A smaller number of

private clinics, mostly in the urban areas, are run by clinical officers and

doctors who numbered 8,600 and 7,100 respectively in 2011. These

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figures include those who have died or left the profession hence the actual

number of workers is lower.

Health centers

These are medium sized units which cater for a population of about

80,000 people. A few are owned by mission hospitals. They are managed

and run by Clinical officers who are the team leaders. A typical health

centre is staffed by:

At least one Clinical officer

Nurses

Health administration officer

Medical technologist

Pharmaceutical technologist

Health information officer

Public health officer

Nutritionist

Driver

Housekeeper

Supporting staff

EDUCATION AND TRAINING

Medical Doctors and Dentists

In Kenya, there are four medical training institutions for doctors—

Nairobi, Moi, Kenyatta and Egerton Universities. Nairobi University is the

sole training school for dentists. In Kenya, all medical and dental students

must earn a degree. Medical degrees require six years of academic education,

plus a one-year internship; while, dental degrees include five years of

educational training, plus a one-year internship. Nairobi University trains

90% of Kenyan trained medical doctors, while Moi University trains the

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remaining 10%. The medical programs at Kenyatta and Egerton Universities

are new and the Kenya Medical Practitioners and Dentists Board (KMPDB)

does not yet capture student data from these institutions. Nairobi University

has 31 professors and 56 lecturers for medical professional students. Moi

University, in Rift Valley Province, has 80 tutors for medical training with a

tutor to student ratio of 1:14.

Clinical Officers

In Kenya, there are 24 training institutions registered with the Kenya

Clinical Officers Council (KCOC) to train clinical officers. Medical

Training Colleges (MTCs), which are government sponsored, represent 17

of the 24 institutions, accounting for 71% of clinical officer training

institutions in Kenya. For the remaining clinical officer training

institutions, two are government sponsored universities (Egerton

University and Kenyatta University), two are private (Lake Institute of

Tropical Medicine and Mt. Kenya University), and three are faith-based

(Kenya Methodist University, St. Mary’s Mumias and Presbyterian

University of East Africa). Currently, all clinical officers are trained at the

diploma level, which requires three years of school, plus one year of

internship. Following their internship, clinical officers can specialize in a

variety of areas, including anesthesia, ophthalmology, pediatrics,

orthopedics, reproductive health, mental health, and ear/nose/throat

(ENT). In 2010, Mt. Kenya University began offering the first Bachelor of

Clinical Medicine program for clinical officers, which includes four years

of academics, followed by a one-year internship.

The distribution of training institutions and newly trained clinical

officers differs provincially. From 2006-2009, Central Province, which

has 6 (25%) of Kenya’s clinical officer training institutions, trained 22%

of new officers. Nyanza Province, with five institutions, trained over

25% of new clinical officers, followed by Rift Valley, with four

institutions and 16% of new officers. Coast Province, with only 2

institutions, trained 13% of new officers. Currently, North Eastern

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Province is the only province that does not train clinical officers. As

mentioned, the KHWIS is in the process of establishing an electronic

database for the KCOC; thus, information on the number of COCs in the

country was estimated based on key informant interviews with the

Registrar. The KCOC estimates there are 8,300 registered clinical

officers (personal communication, Registrar, KCOC). As a result of the

anticipation of the KHWIS, the KCOC is strengthening it licensure

renewal policy, which will assist in ―cleaning‖ the official registry for

clinical officers. Since the KCOC does not currently track workforce

retention, deployment data provides an estimation of the active clinical

officer workforce. The KCOC estimates that approximately 3,800

officers (46%) are deployed in the public sector and 2,500 (30%) in the

private sector (personal communication, Registrar, KCOC).

STATISTICS While the KMPDB has registered 6,306 medical doctors and 780

dentists over the past 32 years, only 75% of these medical professionals

are currently considered ―active‖ in the workforce, having renewed their

medical license within the past five years. According to retention

information from the KMPDB, there are 4,756 active medical doctors and

590 active dentists, which comprise Kenya’s medical and dental

workforce. Eleven percent of active medical doctors are 61 years of age or

older and an additional 17% are 51-60 years of age. While the public

sector retirement age is 60, many doctors continue contributing to the

medical workforce well beyond the age of 60. For active dentists, 5% are

61-70 years of age and 18% are 51-60 years of age. Thirty percent of

active medical doctors and 40% of dentists are female with the remaining

70% of doctors and 60% of dentists being male.

MIGRATION AND RETENTION BRAIN DRAIN

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The total cost of educating a single medical doctor from primary

school to university is 65,997 US dollars; and for every doctor who

emigrates, a country loses about 517,931 US dollars worth of returns from

investment. The total cost of educating one nurse from primary school to

college of health sciences is 43,180 US dollars; and for every nurse that

emigrates, a country loses about 338,868 US dollars worth of returns from

investment.

Developed countries continue to deprive Kenya of millions of

dollars worth of investments embodied in her human resources for health.

If the current trend of poaching of scarce human resources for health (and

other professionals) from Kenya is not curtailed, the chances of achieving

the Millennium Development Goals would remain bleak. Such continued

plunder of investments embodied in human resources contributes to

further underdevelopment of Kenya and to keeping a majority of her

people in the vicious circle of ill-health and poverty. Therefore, both

developed and developing countries need to urgently develop and

implement strategies for addressing the health human resource crisis.

WORKFORCE SHORTAGE AND MAL-

DISTRIBUTION Kenya has bold plans for scaling up priority interventions

nationwide, but faces major human resource challenges, with a lack of

skilled workers especially in the most disadvantaged rural areas.In a

research carried out in the country the authors concluded:

The issue of workforce shortage and mal-distribution is complex and not

unique to the nursing cadre or to Kenya. Poor infrastructure, limited

training opportunities, high workloads, inadequate supplies and

supervision, undisclosed job locations for public sector jobs, and most

recently political instability all continue to be barriers to successful rural

recruitment and retention. Interestingly we found no suggestion that those

born in or with experience working in rural areas are more willing to seek

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rural employment. While donor funded short-term contracts have

increased recruitment in recent years, it is possible that their impact will

be compromised by their unpopularity among nurses due to their lack of

pension plans and job security. The most popular proposed policy

intervention among respondents was the provision of additional financial

incentives for rural posting, though these may be more effective if

implemented as part of a multi-dimensional package. Such a package

would require collaboration between economic and health policy-makers

to earmark funding to not only secure salaries but also improve working

conditions. It should also be accompanied by investment in information

systems capable of monitoring its impact with rigor.

ATTRITION In a research carried out in the country on attrition the researchers noted

that. In hospitals, doctors had much higher rates of attrition, compared to

clinical officers, although resignation was the predominant reason for

attrition in both cadres. This finding may reflect a recent trend for doctors,

who may be moving completely away from public service rather than

staying on with the dual employment opportunity (often referred to as

"moonlighting") that has been on the books for years. The differential

rates of attrition between doctors and clinical officers may thus reflect that

doctors are more likely to emigrate for work in health facilities abroad or

to go completely into private practice or employment in the NGO sector in

the home country (which are not opportunities as readily available to

clinical officers).

Attrition among registered nurses in provincial hospitals was, on average,

twice as high as the rate of attrition of enrolled nurses. While resignation

accounted for about half of attrition among registered nurses at this level,

the loss of enrolled nurses was nearly all due to retirement. By contrast, at

lower facility levels, registered and enrolled nurses had similar rates of

attrition, mostly explained by retirement. This may reflect the higher

international mobility and more numerous alternative employment

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opportunities available to registered nurses (in comparison with enrolled

nurses), particularly in urban areas where the provincial hospitals are

located.

Push Factors

Studies as to why health workers resign have found that the main reasons

are

1. Low pay

2. Poor working and living conditions at the sites where they are

posted

3. Reasons related to the HIV/AIDS epidemic, such as fear of

becoming infected on the job and overwhelming workload and

stress induced by caring for, and seeing high death rates among,

HIV/AIDS patients. For health workers in rural areas, an additional

problem is inadequate quality of housing,

4. Inadequate quality transport

inadequate quality schools for their children.

Pull Factors

Better pay and opportunities available in other occupations or health

facilities abroad.

RECOMMENDATIONS

Key recommendations to parliament and government

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Increase the number, and strengthen the role of community health

workers, including by providing them with basic supplies,

transportation where needed, and compensation for their services.

Strengthen the referral system, for example by providing transport

between health care facilities.

Prioritize the completion and implementation of the National

Social Health Insurance Fund to improve access to maternal and

child health care.

Assess the feasibility of exempting fees for maternal health care in

all health facilities beyond the current exemption for childbirth in

dispensaries and health centres.

With regards to palliative care, allocate a separate budget line for

palliative care, including for new palliative care units that the

government has announced, and implement a program of home-

based palliative care with pediatric expertise.

As a minimum, ensure that the percentage of the health budget

does not decrease.

With regards to obstetric care, increase the number of health

facilities that offer emergency obstetric care, increase the number

of midwives, and develop guidelines on the management of

obstructed labor. Also subsidize routine obstetric fistula repairs in

provincial and district hospitals, and provide free fistula surgeries

for poor patients.