HUMAN RESOURCES FOR HEALTH (HRH) ASSESSMENT REPORT … REPORTS/Final merged NK HRH R… · Teacher...

May 2013

“This document is made possible by the generous support of the American people through the United States Agency

for International Development (USAID). The contents are the responsibility of IntraHealth International and do not

necessarily reflect the views of USAID or the United States Government.”

HUMAN RESOURCES FOR HEALTH (HRH)

ASSESSMENT REPORT FOR NORTHERN

KENYA:

Overview of Health Workforce Distribution

across 10 Counties

i

Kenya Ministry of State for the Development of Northern Kenya and other Arid Lands (MONDKAL) and

IntraHealth International. 2012. Human Resources for Health (HRH) Assessment in Northern Kenya:

An overview of health workforce distribution across 10 counties. Nairobi, Kenya: MONDKAL.

ii

TABLE OF CONTENTS

Abbreviations .............................................................................................................................................. v

Executive Summary ................................................................................................................................... 1

1.0 INTRODUCTION ................................................................................................................................................ 8

1.1 Overview of Human Resources for Health .......................................................................................... 8

1.1.1 Human Resources for Health in Kenya ........................................................................................ 8

1.1.2 The Human Resources for Health Situation in Northern Kenya ......................................... 9

1.1.4 Policy Perspectives on Human Resources for Health .......................................................... 11

1.1.5 Government of Kenya Health Workforce Establishment .................................................... 12

1.1.6 Health Workforce in Kenya ............................................................................................................ 15

1.1.7 Strategies to Improve Health Workforce Retention and Service Delivery ................... 16

1.2 Statement of the Problem and Justification .................................................................................... 17

1.3 Study Objectives ........................................................................................................................................ 18

2.0 METHODS ......................................................................................................................................................... 19

2.1 Study Design ............................................................................................................................................... 19

2.2 Study Sites.................................................................................................................................................... 19

2.3 Sampling Procedures ............................................................................................................................... 20

2.3.1 Secondary Data Sources (institutions) for the Quantitative Aspect ............................... 20

2.3.2 Qualitative Aspects ........................................................................................................................... 20

2.4 Data Collection ........................................................................................................................................... 21

2.4.1 Quantitative Data Extraction and Collation ............................................................................. 21

2.4.2 Qualitative Data ................................................................................................................................. 21

2.5 Data Analysis .......................................................................................................................................... 23

2.5.1 Quantitative Data Analysis ............................................................................................................. 23

2.5.2 Qualitative Data Analysis ................................................................................................................ 24

2.6 Ethical Considerations ............................................................................................................................. 24

2.7 Study Limitations ....................................................................................................................................... 25

3.0 RESULTS ............................................................................................................................................................. 27

3.1 Healthcare Workforce Distribution in Northern Kenya ............................................................... 27

3.1.1 Distribution of Professional Cadres ............................................................................................ 27

3.1.2 Gender Characteristics of Existing Cadres ............................................................................... 28

3.1.3 Health Workforce Distribution by KEPH level ........................................................................ 30

3.1.4 Health Workers’ Views on Drivers of Distribution of the Workforce ............................. 31

3.2 Current Staffing Levels and Vacancies .............................................................................................. 34

3.2.1 Staffing Levels and Vacancy Rates by Professional Cadre ................................................. 34

3.2.2 Budgeted HRH.................................................................................................................................... 37

3.3 Assessment of Adequacy of Staffing ................................................................................................. 42

3.3.1: Rates of Staffing across Northern Kenya................................................................................. 42

3.3.2: Health Worker Migration Between Counties in Northern Kenya ................................... 42

3.3.3 Views on Current Staffing in the Northern Kenya in the Light of National

Staffing Norms .............................................................................................................................................. 43

3.4 HRH Reporting in Northern Kenya ..................................................................................................... 52

3.4.1 (a) HRH Reporting in All KEPH Levels (2-5) in Northern Kenya ....................................... 52

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3.4.2 Influences on Staff Recruitment in Northern Kenya ............................................................ 54

3.4.3 Influences on Staff Re-Deployment in Northern Kenya ..................................................... 57

3.5 Pre-Service Training in Northern Kenya ........................................................................................... 61

3.5.1 Students in Pre-Service Training Institutions .......................................................................... 61

3.5.2. Pre-Service Students from Northern Kenya and Other Counties .................................. 62

3.6 Proportion of Trainees/Admission in Pre-Service Mid-Level Training Institutions .......... 63

3.6.1 Views on Uptake and Training of Health Workers .................................................................... 66

3.7 Staff Turnover Rates Across Northern Kenya ................................................................................. 70

3.7.1 Health Worker Retention ............................................................................................................... 71

3.7.2 Strategies to Improve Recruitment And Retention of Health Workers in Kenya ...... 72

3.7.3 Views on Retention of the Health Workforce in Northern Kenya ................................... 72

4.0 DISCUSSION..................................................................................................................................................... 78

5.0 CONCLUSION AND RECOMMENDATIONS ......................................................................................... 80

5.1 Conclusions.................................................................................................................................................. 80

5.2 Recommendations .................................................................................................................................... 81

6.0 REFERENCES ..................................................................................................................................................... 84

7.0 APPENDIXES ..................................................................................................................................................... 86

List of Boxes, Figures and Tables

Boxes

Box 1: KEPH Staffing Norms by Level ............................................................................................................... 14

Figures

Fig 1: Staffing by KEPH Level ................................................................................................................................ 13

Fig 2: Geographic Coverage of Northern Kenya....................................................................................... 19

Fig 3: Pre-Service Students (Nurses) Home County in Northern Kenya in KMTC, CHAK

and KEC .......................................................................................................................................................... 61

Fig 4: Pre-Service Students’ County of Origin ................................................................................................ 63

Fig 5: Growth in the Number of Students who Qualified to Enroll for Nursing Diploma

in the 10 Counties (2007-2011) ............................................................................................................ 64

Fig 6: Trend Analysis of Male and Female Students Qualified to Enroll for Nursing

Diploma Program ....................................................................................................................................... 65

Fig 7: Average Years of Service for MOMS/MOPHS Staff .......................................................................... 71

Fig 8: Average Years of Service for Select MOMS/MOPHS Cadres in NorthEastern ....................... 72

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Tables

Table 1: Provincial Distribution of Selected MOMS and MOPHS Personnel as a Share of

National Population (2010) ............................................................................................................... 16

Table 2: Study Objectives and Data Sources .................................................................................................. 23

Table 3: County Distribution of Healthcare Professionals in Northern Kenya ................................... 27

Table 4: Gender Distribution by County of Professional Cadres in Northern Kenya ....................... 29

Table 5: Percent Distribution of Professional Cadre by KEPH Level ...................................................... 30

Table 6: Current Professional Cadre Distribution (per 100,000 population Kenya

average) in Northern Kenya Using the 2011 Population Projections ............................... 31

Table 7a: Vacancy levels by County in Northern Kenya - Establishment ............................................. 35

Table 7b: Vacancy Levels by Cadre and County in Northern Kenya ...................................................... 36

Table 7c: Vacancy Levels by County in Northern Kenya – WHO Recommendations ...................... 37

Table 8a: Levels of Vacancy per WHO 100,000 Population Recommendations (Financial

Year 2010/2011) by KEPH Level (2) by Cadre ............................................................................ 38

Table 8b: Levels of Vacancy per WHO 100,000 Population Recommendations (Financial


Table 8c: Levels of Vacancy per WHO 100,000 Population Recommendations (Financial


Table 8d: Levels of vacancy per WHO 100,000 population recommendations (Financial

Year 2010/2011) by KEPH level (5) and cadre for the 10 counties .................................... 41

Table 9: Internal Migration of Nurses from County to County Within Northern Kenya

(All KEPH levels 2-5) ............................................................................................................................ 42

Table 10: Number of Nurses (KEPH Levels 2 – 5) Who Completed Secondary Schooling

Elsewhere but Work in Northern Kenya....................................................................................... 53

Table 11: Proportion of Student Nurses Who Enrolled And Completed Their Studies At

KMTC, CHAK and KEC PST Institutions (2007-2011) ............... .............................................. 62

v

FOREWORD

The Human Resources for Health (HRH) Assessment report for Northern Kenya is intended to

guide the region in identifying its HRH gaps and prioritize its focus in subsequent National

HRH plans in line with devolution as outlined in the new Constitution of Kenya 2010. This

report is a product of extensive field assessment work, collaboration, and comprehensive

feedback from our internal and external stakeholders. Its significance stems from the fact

that HRH is a core building block for an efficient health system in the region.

While HRH issues have continuously affected health systems delivery countrywide,

service coverage across Northern Kenya (comprising of Turkana, Samburu, Marsabit, Isiolo,

Mandera, Wajir, Garissa, Tana River, West Pokot, and Lamu counties) has notably been

worse than all other counties, with the lowest percentage distribution of health professional

cadres with the number of Doctors, Nurses, and Clinical Officers being 2%, 2%, and 5% of

the national total respectively. The health worker to population ratio in these counties has

been worsened by unique geographical challenges. The region is mainly rural, with low

population density and mostly nomadic. Poor telecommunication, infrastructure, and

security also contribute to poor health care access and quality. These conditions further

discourage recruitment, attraction, and retention of potential and existing health workers.

Although, the HRH evaluation of the situation in Northern Kenya will provide

recommendations for corrective actions to be undertaken in order to address this situation.

We acknowledge the significant contribution from the Government of Kenya and all partners,

with specific attention to the Ministry of Medical Services (MOMS) and the Ministry of Public

Health and Sanitation (MOPHS); especially, their Human Resources Departments for their

invaluable contribution to the production of this report. We are also deeply grateful to the

role played by the United States Agency for International Development (USAID) through the

Capacity Kenya Project during the conceptualization, fieldwork support, data analysis, and

the stakeholder evaluation process that yielded this report.

I am convinced that through such teamwork, the Ministry will move forward to ensuring

adequate HRH in the northern region in order to fully realize the goal of providing quality

health care services to all Kenyans as outlined in the Kenya Vision 2030.

vi

ACKNOWLEDGEMENTS

The study report of the HRH Assessment in Northern Kenya: An overview of the health workforce

distribution across 10 counties involved active and ongoing engagement with a wide variety of

stakeholders. The Ministry of State for the Development of Northern Kenya and Other Arid Lands

(MONDKAL) wish to acknowledge the United States Agency for International Development (USAID)

and IntraHealth International Capacity Kenya project in particular, for funding and providing technical

support in this study.

We are especially grateful to the technical team from the MDONKAL- Mr David Siele and Dr. Florence

Bett; and, Capacity Kenya Team - Mr Meshack Ndolo, Ms. Kethi Mullei, Mr Michael Ochieng and Mr

Achim Chiaji for their significant efforts in framing and articulating research questions as well as

providing oversight at every stage of the study; the consulting firms Precise Research Trends (PRT) and

Ipsos Synovate in conducting the study, performing data analysis and report writing; and Mr Jotham

Chacha for administrative support and liaising with field teams during the data collection process. We

would also like to thank the following individuals for their contributions to this report: Dr. Pamela A.

McQuide, Ms Caroline Blair, Ms Katia Peterson and Mr Chris Penders.

We further acknowledge the support provided to the study team from the following institutions in the

data collection process:

Kenya Medical Training College (KMTC)

Nursing Council of Kenya (NCK)

Ministry of Medical Services (MoMS)

Ministry of Public Health & Sanitation (MoPHS)

Kenya Episcopal Conference (KEC)

Christian Health Association of Kenya (CHAK)

Kenya National Examinations Council (KNEC)

Joint Admissions Board (JAB)

Kenya National Bureau of Statistics (KNBS)

Teacher Services Commission (TSC)

Last but not least, the MDONKAL recognize the invaluable contributions of all HRH Stakeholders

(individuals and organizations) who directly or indirectly contributed to the Northern Kenya

assessment.

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ABBREVIATIONS

AMREF African Medical and Research Foundation

CBHW Community Based Health Workers

CHAK Christian Health Association of Kenya

CHE Commission of Higher Education

CHEW Community Health Extension Worker

CHW Community Health Worker

COC Clinical Officers Council

CPD Continuing Professional Development

DANIDA Danish International Development Agency

DMO District Medical Officer

ECN Enrolled Community Nurse

EQUINET Regional Network for Equity in Health in East and Southern Africa

ESP Economic Stimulus Program

FBO Faith Based Organizations

FGD Focus Group Discussions

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria

GOK Government of Kenya

HCW Health Care Workers

HMIS Health Management Information Systems

HR Human Resources

HRD Human Resources Development

HRH Human Resource for Health

HRIS Human Resources Information System

HRM Human Resources Management

ICT Information & Communication Technology

IMF International Monetary Fund

IOM International Organization for Migration

IPPD Integrated Personnel Payroll Database

JAB Joint Admission Board

JICA Japan International Cooperation Agency

KEC Kenya Episcopal Conference

KEPH Kenya Essential Package for Health

KII Key Informant Interviews

KMTC Kenya Medical Training College

KNBS Kenya National Bureau of Statistics

KNEC Kenya National Examination Council

KNHRHSP Kenya National Human Resources for Health Strategic Plan

KRCHN Kenya Registered Community Health Nurse

KRN Kenya Registered Nurse

LMICs Low & Middle Income Countries

MMR Maternal Mortality Rate

MOE Ministry of Education

MDONKAL Ministry for the Development of Northern Kenya and Other Arid Lands

MDG Millennium Development Goal

MOH Ministry of Health

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MOMS Ministry of Medical Services

MOPHS Ministry of Public Health & Sanitation

MPDB Medical Practitioners and Dentists Board

MSH Management Sciences for Health

MSRA Market and Social Research Association

NACONEK National Commission on Nomadic Education in Kenya

NCK Nursing Council of Kenya

NGO Non-governmental Organization

NHSSP National Health Sector Strategic Plan

NKAL Northern Kenya & Other Arid Lands

PHC Primary Health Care

PHSP Public Health Sanitation Program

PLAID People Living with AIDS

PLHIV People Living with HIV

PSC Public Service Commission

RCMRD Regional Centre for Mapping of Resources for Development

RCO Registered Clinical Officer

RN Registered Nurse

RRI Rapid Result Initiative

SOW Scope of Work

TRG Training Resources Group, Inc

TSC Teachers Service Commission

UNICEF United Nations Children's Fund

USAID United States Agency for International Development

VHW Volunteer Health Worker

WHO World Health Organization

1

EXECUTIVE SUMMARY

The delivery of public health interventions requires skilled and adequately supported health

personnel. The term Human Resources for Health (HRH), according to the World Health

Organization (WHO), refers to all people engaged in actions whose primary intent is to

enhance health. These people include care givers (doctors, nurses, clinical officers,

pharmacists, etc) to laboratory technicians, managerial personnel and other staff (cleaners,

medical records officers, health economists) who do not deliver any services to patients

directly but are vital to health system functioning. The importance of HRH is based on the

fact that delivering health services is what health workers do, supported by evidence of a

strong correlation between the density and quality of HRH in a country and population

health outcomes. HRH is one of the core building blocks of a health system and has two

essential components; Human Resources Development (HRD) and Human Resources

Management (HRM). These two components manage the life of a health worker from

training to employment and exit from the health workforce. How well these two components

are managed determines whether a country has numerically adequate and motivated HRH.

For example, the shortage of HRH in many countries could be attributed to limited HRH

production capacity as a result of poor planning and underinvestment in health education

and training institutions (core issues for HRD). These, coupled with unsatisfactory working

conditions, poor remuneration and career opportunities, and other labor market pressures

(core issues for HRM), have resulted in HRH shortages.

The global shortage of health workers has created a challenge in constraining many

countries, particularly those in Sub-Saharan Africa from being able to achieve health equity

and meet population health needs. For example, World Health Organization (WHO) has

estimated that though sub-Saharan Africa has 25% of the world's diseases burden, it

possesses only 1.3% of the trained health workforce. Kenya has an average of 19 doctors and

166 nurses per 100,000 populations, compared to WHO recommended minimum staffing

levels of 36 and 356 doctors and nurses respectively per 100,000 populations. Northern

Kenya1 suffers from inequities in health worker distribution, making the HRH crisis even

worse in these areas. North Eastern Province with a population of 2.3 million representing 6.4

% of the Kenyan population has only 2.3% and 1.9% of the total number of doctors and

nurses working in the country stationed within the province. In comparison, Nairobi

province has a population of 8.2 million (22.1% of the population) and has 25% and 6.6% of

doctors and nurses, respectively.

A number of push and pull factors influence the availability and distribution of health

workers in Northern Kenya. These factors include poor working conditions, poor

remuneration, harsh environmental conditions, and unsafe working environment among

other factors within the study sites that ‘pushed’ health workers away to other sites that

‘pulled’ health workers with factors such as better remuneration, availability of equipment

and supplies and better environmental conditions, among others. These are issues that

Kenya’s two health Ministries – Ministry of Medical Services (MOMS) and the Ministry of

Public Health and Sanitation (MOPHS as well as the Ministry for the Development of

Northern Kenya and Other Arid Lands (MDONKAL) are aware of and a number of policy

initiatives are being developed to address the issue.

1 Northern Kenya is defined as including the areas in the Counties of Turkana, Samburu, Marsabit, Isiolo,

Mandera, Wajir, Garissa, Tana River, West Pokot, and Lamu.

2

However, there is need for comprehensive information on the HRH situation in Northern

Kenya, with increased focus on the following areas of interest: pre-service training,

recruitment, deployment and retention of healthcare workers (HW) in the counties of

Northern Kenya. This study sought to provide empirical evidence to inform policy making

and development of programs that will address the severity of the HRH shortage.

A mixed methods explanatory study design was used. The design allows the use of

quantitative data collection followed by qualitative data collection. Thus the study was done

in two phases with phase 1 focusing on quantitative data exploration. Phase 2 drew on

analyses from phase 1 and undertook primary data collection using qualitative methods. The

objectives of phase 1 were:

1. To describe the current distribution of health workforce personnel in Northern Kenya

disaggregated by cadre, gender, county and level2 of service

2. To describe the current staffing levels and vacancies in Northern Kenya;

disaggregated by level of service and cadre

3. To describe the extent to which staffing vacancies can be improved by (re)

distribution of existing health workers within Northern Kenya

4. To assess whether health workers whose home districts are within Northern Kenya

are more likely to report to health facilities in the region

5. To describe the extent to which the needs of the 10 counties can be met through the

pool of available students in pre-service training in Northern Kenya, with specific

emphasis on nursing students

6. To establish the number of secondary school students from Northern Kenya who are

eligible for pre-service education in nursing

7. To assess the rate of turnover across the 10 counties of Northern Kenya between

2008 to 2010

Objectives of phase 2 were:

To document perceptions on health workforce distribution and adequacy in Northern

Kenya vis a vis other regions

To determine the extent to which staffing vacancies can be improved by (re)


To establish factors (positive/negative) that influence health worker recruitment and

retention in Northern Kenya

To explore determinants of uptake and completion of pre-service mid-level health

training for individuals whose home districts are in Northern Kenya vis a vis those

from other regions

Quantitative data was extracted from databases of various institutions that had information

on HRH in Northern Kenya and also reviewed documents from the two Ministries of Health

and peer reviewed journal articles. The qualitative study component used methods such as

Focus Group Discussions (FGD) with health care workers and trainees and Key Informant

Interviews (KII) with district medical officers and administrators of health training

institutes. Informants were selected using screening criteria that sought to include a wide

2 Level of service refers to the position of the health facility in the Kenya Essential Package of health facility

hierarchy. For example, district hospitals function as Level 4 facilities while national referral hospitals function as

Level 6 facilities.

3

variety of respondents (health workers, students in medical training institutions, health

managers, etc) from different health facilities and training institutions in the ten counties

of Northern Kenya. Results from the two phases have been merged to produce this report

and follow the objectives of the quantitative study.

Health Worker Distribution in Northern Kenya

Data shows that Northern Kenya has the lowest percentage distribution of health

professional cadres with the number of doctors, nurses and clinical officers being 2%, 2%

and 5% respectively. Examining the national picture, Northern Kenya had 3% of the total

national number of medical cadres to serve a population of 6% while Nairobi province had a

9% of all medical cadres with a population of 8%. Variations in number of health workers to

population ratios were seen in the ten counties of Northern Kenya. For example, Mandera

County only had 6% of the workforce to serve 22% population while Garissa County had 18%

healthcare personnel to serve a lower population proportion of 13%. In terms of gender,

there were more male (63%) than female (35%) health workers compared with a population

that has 53% male and 47% female. However, there were more female (52%) than male

(48%) nurses that differed greatly with that of doctors (75% male and 25% female) and

clinical officers (84% male and 16% female). Thus, while there is an acute shortage of health

personnel in Northen Kenya, care needs to be taken when redeploying workers there so that

Counties with pronounced shortages are given priority over others with better health worker

figures. Also issues of gender distribution needs to be considered.

Qualitative data reiterated these findings painting a picture of a hardship area

characterized by poor infrastructure and difficult environmental issues such as poor road

networks and hot conditions. This coupled with the strong ethnic culture amongst those who

originate from the region makes Northern Kenya uniquely different from the rest of Kenya.

What is interesting is that residents of Northern Kenya were not willing to work in that area,

with respondents citing factors such as undesirable climatic conditions (i.e. extremely hot

and dry), poor local infrastructure and working conditions at health facilities especially at

lower level facilities such as health centers and dispensaries. Informant’s reports suggest that

local residents had negative perceptions toward health workers originating from other

regions based on the understanding that most health workers from regions outside

Northern Kenya are thought to only accept work in the region in order to secure future

employment elsewhere, with little or no intention of staying to serve local communities.

Respondents perceived that the turnover of administrative staff was high, offering reasons

such as seeking improved working conditions to explain their migration. Turnover of staff

from Faith-Based Hospitals (FBH) is reportedly low driven by reasons such as motivation to

serve others in line with their religious beliefs. Despite this, there were reports of health

workers seeking to work and stay in Northern Kenya driven by familial (maintain family

bonds), altruistic reasons (want to help their own people), and familiarity with local

conditions and culture. Other young health workers sought to work in Northern Kenya as it

offered them a sense of adventure.

Staffing Levels and Vacancies

Current establishment shows that there is a wide disparity between staff in post3 (35,714)

against established posts4 (118,954). The vacancy rate5 across both MOMS and MOPHS

3 Staff in ‘post’ means employees currently employed by the two health ministries.

4 ‘Established posts’ refers to approved job positions in the two health ministries.

4

facilities is 24%. Using the 2009 population census figures, the overall health worker vacancy

rate in the 10 counties is 79%. With regards to counties, Mandera had the highest health

worker vacancy rate (94%) followed by Turkana (88%) and Wajir (87%). At health worker

level, the vacancy rates for staff were 82% (doctors), 59% (clinical officers), 30% (enrolled

nurses), 52% (laboratory staff) and 60% for pharmacy staff in the 10 Northern Kenya

counties.

The study did try to get figures for budgeted staff. It was however realized that the ministries

of health distributed staff based on County vacancy needs assessment. Thus the (WHO,

2012) recommended staffing requirements for the five cadres studied in Northern Kenya

were used based on the 2009 population census and the ratio of cadres distribution by the

Kenya Essential Package for Health (KEPH) levels (2-5). The analyses reveal the need for a

high number of required HRH for all Counties. Using this approach, Further be Mandera

(94%) and Turkana (88%) counties have the highest vacancy levels in Northern Kenya using

the current staff in post and WHO (2012) HRH staffing levels per 100,000 population.

Staffing Adequacy

Staffing adequacy was assessed by examining the staffing frequency in Northern Kenya

across the 10 counties that were found to fall below the national average workforce-to-

population ratios and could not match the 3% annual population growth rate. Variations in

vacancy rates between counties were reported. This could be attributed to inter-county

migration of health workers. For example, Garissa and Mandera were seen to have several

attractions that include location of international humanitarian agencies, lower insecurity, and

better local infrastructure.

Interview data also supported these findings with respondents stating that interior regions of

counties had less staff compared with sites closer to county headquarters. Reasons for health

worker shortages in Northern Kenya were varied and included poor remuneration coupled

with high cost of living, poor medical equipment and supplies, the attractive packages

offered by international NGOs, or better salaries offered in South Sudan. Also, sites perceived

to be more secure were preferred over those that were not. These issues were reported not

only by frontline health workers but also by their administrators and managers. Some health

worker’s coping mechanisms were seeking better remunerated jobs or getting involved in

running businesses that meant less attention to their work.

Other issues affecting adequacy of staffing included lack of clear procedures as regards

deployment and re-deployment. Varying responses were seen where some managers

thought that deployment was done in Nairobi while others felt that it was done at local level.

In terms of re-deployment, staff was allocated on basis of workload where sites with high

workloads generally had higher numbers of health workers. Low workloads in some sites

were attributed to poor uptake of health services.

Influences over Staff Recruitment in Northern Kenya

Staff recruitment in Northern Kenya were examined through exploration of nursing data that

described schools, counties of origin and rates of reporting to work in health facilities

located in Northern Kenya. The data shows that while 54% of Nurses studied and completed

5 Vacancy rate is the percent difference between job positions that are filled (i.e., have staff) and those that are

unfilled.

5

secondary school in Northern Kenya, 46% were currently deployed and in Northern Kenya.

Interview data revealed issues elaborating influences on recruitment of health workers to

Northern Kenya. Job opportunities in the public service are advertised in major news papers

to avail the opportunity to a wide range of health workers. These advertisements attract staff

from faith-based facilities perhaps drawn by better terms of work. Those that are employed

are then deployed to northern Kenyan or other sites in the country. There is however low

interest in working in Northern Kenya with a number of new staff declining the postings

offered. The district health management team (DHMT) is responsible for staff transfers in a

district and staff are transferred depending on applicant’s reasons for requesting a transfer

and health worker proportions. For example, some managers preferred keeping local staff

where they were as they understood the local conditions and were accepted by their

communities. However, some respondents felt that the process could be abused where some

staff could be transferred for frivolous reasons.

Other issues affecting recruitment was the low acceptability of certificate courses as they

were perceived to have minimal value or that some courses such as nursing were only for

female persons. This resulted in a small pool of qualified medical staff to draw from who in

turn might also not be interested to work in Northern Kenya. Issues affecting recruitment

were staff with perverse incentives who took up employment in Northern Kenya then

transferred to other areas. To address this, some senior ministry officials sought to recruit

health workers who had served in northern Kenya for more than five years arguing that they

were more likely to stay there for longer than young recruits. They however did not involve

managers based at the County level leading to disparities in deployment. While they have

local knowledge that could make a difference in a successful uptake of a post, they are rarely

utilized.

Pre-Service Training in Northern Kenya

Increasing HRH numbers in Northern Kenya is perceived as being dependent on the ability

of training institutions in that region to produce an adequate number of health workers

drawn from the region. This view is largely a reflection of the view that if there were larger

numbers of health workers whose home districts were in Northern Kenya, they would be

more likely to accept working in the region as they would be more accustomed to the

hardships that are frequently cited as reasons why there is poor job uptake. These comprise

of KMTC colleges as well as CHAK and KEC training institutions. Data from these institutions

shows that the number of students from outside the region is higher in both male and

female students. Though policies have been developed that seek to increase the number of

training institutions, existing infrastructure at mid-level health training institutions in Kenya is

inadequate to take on the increased numbers of eligible applicants. In Northern Kenya,

though the average pass rate for students was lower than the national average, it however

increased by 17% annually between 2008 and 2011. Despite this, the number joining medical

training institutions from this region is still low. From a gender perspective, more male

students (13%) qualified for admission to medical training colleges than their female

counterparts (9%) between 2007 and 2011.

Interview data suggests that students perceive the Northern Kenya community has little

interest in pursuing clinical careers. While uptake of medical training programs was at times

limited by lack of school fees, it was also negatively influenced by misconceptions about

diploma and certificate level courses and high illiteracy levels. Respondents suggested that

6

as alternative (parallel) health training programs were expensive, perhaps more chances

should be allocated to students from Northern Kenya in the much cheaper regular admission

courses. Further, Northern Kenya has few mid-level and tertiary institutions which at times

forces those seeking additional training to seek transfers to towns that have such colleges.

Staff Turnover and Retention Across Northern Kenya

The average length of stay in Northern Kenya before exiting was approximately 13 years,

which was 29% below national average of 18.2 years. The average length of stay in North

Eastern province for pharmacists, doctors and dentists was 5, 10 and 11 years respectively.

To be verified Those exiting from service include approximately 200 doctors and 600 nurses

indicate period for reasons such as deaths, transfers to other careers, resignations, and

dismissals. Resignations constitute the highest percentile of attrition. Other factors affect

staff turnover in subtle ways and include poor disciplinary processes and absenteeism at

times attributed to dual practice. Exit of health workers from health service is often driven

attributed to the need for career development, career advancement, better work

environment, and improved terms and conditions of service, among others. These issues are

exemplified in many ways in Northern due to its numerous ‘push’ factors.

Strategies to improve retention include replacing and increasing the number of new health

worker recruits into the health system. Through the Economic Stimulus Program, 3,254

nurses were nationally recruited through this program representing an increase of

approximately 77%. However, Northern Kenya had an acceptance rate (number of health

workers who have accepted a job position in Northern Kenya) of approximately 28%

compared with that of Central province at 99%. This suggests that a number of interventions

that are needed to address retention of health workers in the Northern Kenya. Interview data

reveals these to include improving remuneration of health workers in Northern Kenya,

providing allowances to cope with the high cost of living, increasing in-service training

opportunities, improving health facilities, increasingly consider health workers serving in

these regions for promotion and other interventions.

Conclusion

Results from this assessment have shown that Northern Kenya suffers from acute HRH

shortage, fueled by recruitment (attraction) and retention challenges. Qualitative findings

which sought to capture views of health professionals at both county and national level have

shown that most respondents are in agreement that there is need to find a way to address

the number of health workers in the region. In summary, here are the key issues facing

Northern Kenya with regards to HRH:

Northern Kenya is a hardship area which in turn influences the number of health

workers willing to work in that region. Health workers recruited to work here are

perhaps join on the basis that after a while, they will transfer to other areas. There is

need to address issues related to health worker recruitment and retention, perhaps

by offering incentives that can only be accessed by health workers serving in

Northern Kenya.

The low illiteracy levels and lack of interest in admission to medical training

institutions means that low numbers of health workers who can possibly work in that

region are not produced.

Further, there distribution of health workers in the 10 counties is disproportionate to

population ratios and KEPH Levels which is characterized by low workforce-to-

population ratio compared to other counties in Kenya and also well below the

7

recommended population to health worker ratio by the WHO. Also the vacancy rates

in Northern Kenya are below the minimum 24% for both MOMS and MOPHS.

The survey also revealed that there is a low number of students from Northern Kenya

who qualify to enroll in Nursing diploma program

Recommendations

Recommendations to address these issues are made in three major areas.

a) In order to increase the number and retain health workers particularly from the region,

there is need to:

Establish more Medical Training Colleges in the region

Recruit a minimum number of new health workers each year and replace those that

have been transferred out of the region or lost to attrition.

Increase in-service training of health workers.

Use innovative advertising methods to publicize vacancies for example by advertising

them through regional radio stations.

Develop an incentive programme to attract and retain health workers in the region.

Improvement of training infrastructure in the region that is likely to spur growth and

open up the region.

Improve water and sanitation infrastructure.

Build and maintain decent accommodation facilities for health workers in the region.

Address the high levels of insecurity in the region

There is need to fully implement the transfer and re-deployment policies

Strengthen health managers’ leadership and management skills.

b) Vision 2030 strategy for Northern Kenya notes that innovation is a key challenge for

health delivery systems that must meet the needs of a mobile population dispersed over

a large area with poor infrastructure. There is thus need to:

Adoption of new technologies such as telemedicine will improve access to highly

skilled advice from senior medical personnel.

Invest in health extension through community health workers that may also

improve access to health services

Improve empirical evidence by improving HR Information Systems.

c) The third major recommendation is to closely collaborate with other agencies, ministries

and development partners first to create interest in and source finances for developing

the region. The needs of Northern Kenya are multifaceted and need integrated

approaches to address the issue. MDONKAL is well placed to offer leadership in this

aspect and needs to be supported.

8

1.0 INTRODUCTION

1.1 Overview of Human Resources for Health The delivery of public health interventions, whether in the form of preventive or curative

packages targeted at individual or population levels, requires skilled and adequately

supported human resources [1]. While the workforce goal as stated by the WHO is to get

the right workers with the right skills in the right place doing the right things [2], it is clear

that getting workable solutions to accomplish this goal has not been easy. For example,

many low-income countries (including Kenya) continue to face a number of human resource

challenges attributed to a number of factors clustered as either “push” factors or “pull”

factors [2], [3], [4], [5].‘Push’ factors are issues that make health workers leave the profession

or location of employment to another and include poor working conditions, poor

remuneration, fear of HIV infection, low motivation, unemployment [2], [3],[5]. ‘Pull factors

are issues that attract health workers to an organization or location and include better

working conditions, better remuneration, and a safe work environment [2] [6]. Push factors

create an uneven distribution of health workers which especially affects rural areas [7].

As seen in other parts of the world, Sub-Saharan Africa faces human resources for health

(HRH) crisis. WHO has estimated that although sub-Saharan Africa has 25% of the world's

diseases burden, it possesses only 1.3% of the trained health workforce [8]. Today, health

service providers account for 67% of all health workers globally, though only 57% in the

Americas [2]. The availability of health personnel in Africa is considerably worse compared

with other regions of the world, a situation characterized by health care worker shortage and

distribution between urban and rural areas in such settings [9]. This makes it to be one of the

major stumbling blocks to the delivery of adequate healthcare [2]. For example, some

countries have less than 50% of the required staff available to serve rural populations; while

at times care is provided by non-qualified staff [2] [10]. Further, a recent study showed that

life expectancies in sub-Saharan Africa have dropped in 35% (17 out of 48) of sub-Saharan

African countries [11]. This impedes implementation and scale-up of much needed health

service interventions [12], especially in remote and rural areas where health worker shortages

are most evident resulting in poor health outcomes [13]. In light of this, it is possible that

the health-related Millennium Development Goals (MDGs) will be difficult to be achieved

[14] [15].

1.1.1 Human Resources for Health in Kenya

Recent trends in the Kenyan public health workforce suggest that the country is

experiencing a crisis in human resource service coverage, like many other countries in

the sub-Saharan Africa region [16] [5]. This is attributed to attrition (among other factors)

that is reported to be the leading cause of diminishing numbers of health care workers in key

cadres, particularly among enrolled and registered nurses [5], [17]. A variety of reasons,

including retirement, voluntary resignation, death, emigration to the private sector and

emigration to other countries have been identified as common reasons for staff attrition in

the public health system [15] [5] [17]. Poor remuneration, inequalities in the distribution of

key skilled personal and sub-optimal work environments have further exacerbated HRH

attrition rates [18] [19]. This situation is defined by a public-sector hiring freeze that began

in 1994 which has resulted in a shrinking health workforce that limits the government's

ability to respond to increased demand for health services [16] . Even though an emergency

9

health worker hiring program supported by the US Agency for International Development in

consultation with the Ministry of Health (MOH) has worked to reduce the HRH burden, there

is still need for health workers to join the public health workforce [16] [17]. The impact of

the shortage of HRH dampens health outcomes, systems and service delivery if measures to

abate the crisis are not implemented. The crisis calls for investment in incentives to recruit

and retain personnel in poorer, rural areas to service communities that need them most [15].

Kenya has two ministries of health. The Ministry of Medical Services (MOMS) focuses on

curative aspects of health in Kenya being responsible for all hospitals above level 4 (see fig 1

below) and several parastatal bodies such as the Kenya Medical Supply Agency, the Kenya

Medical Training College, the two national referral hospitals, and the National Hospital

Insurance Fund. The Ministry of Public Health and Sanitation (MOPHS) is in charge of all

preventative aspects of health in Kenya and is responsible for the Kenya Medical Research

Institute (KEMRI) as well as the Radiation Protection Board. Historically, the number of health

care personnel employed by the two health ministries for all key cadres declined significantly

between 2004 and 2008 in spite of the lifting of employment freeze in the public sector. Yet

during the same period the national population increased by 7%, implying a serious decline

in human resource service coverage. The most striking change was the noticeable reduction

in the number of nurses currently in post. Enrolled nurses (certificate level) declined by 5%

while registered nurses (diploma level) declined by 17%. The impact of the high attrition is

likely to be severe, especially in remote, rural and hard-to-reach-areas, which

disproportionally have the highest attrition rate of health care workers [19]. The overall effect

of these factors is negative, thus affecting the health sector’s ability to fully utilize the

existing healthcare workforce and provide quality services. Access to comprehensive HIV and

AIDS related services, especially in rural areas continues to remain inadequate as a result

[20]. However, it is important to note that despite these reports, the health workforce

situation in Kenya may improve if key interventions and strategies as outlined in the national,

sector-wide HRH Strategic Plan are implemented [21].

1.1.2 The Human Resources for Health Situation in Northern Kenya6

While the staff shortages have affected the health system countrywide, the status of

human resource service coverage across Northern Kenya (Turkana, Samburu, Marsabit, Isiolo,

Mandera, Wajir, Garissa, Tana River, West Pokot, and Lamu counties) has notably been

worse than in any of the other seven provinces, with a health worker to population ratio that

has been largely inadequate and inequitable when compared to other regions. [19].The

healthcare worker to population ratio in all of Northern Kenya counties has been worsened

by the geographical spread mostly rural, low population density, and the nomadic lifestyle of

many of its people. Poor telecommunication, infrastructure, and security (perennial inter-

tribal/clan conflicts) contribute further to poor health care access and quality [22]. Northern

Kenya has been marginalized for a very long time and has very low capacity in all areas

including health, education, and other key professions who are able to put the region in the

acceleration lane of development with the rest of the country.

This is attributed to a sense of exclusion of Northern Kenya from the rest of the country

attributed to its separation from the rest of the country, which manifests itself in both

6 This section draws heavily from Kenya (2011): Vision 2030 Development Strategy for Northern Kenya and other

Arid Lands. Nairobi: Government Printer.

10

physical and psychological ways [23]. Northern Kenya displays many of the

characteristics of remote rural areas caught in chronic poverty traps, which face multiple

and interlocking forms of disadvantage. These features are described hereafter.

High levels of Insecurity

Conflict in pastoral areas is attributed to factors such as long-standing inter-communal

tensions, competition over and commercialization of resources, the proliferation of small

arms, and the limited presence of the Government on the ground including weak

enforcement of the law. As a result, conflict continues to undermine socio-economic

development by deterring investment and service delivery and by increasing the

vulnerability of pastoralists to external shocks.

Poor Physical Infrastructure

Poor and inadequate physical infrastructure in Northern Kenya is a key challenge that

needs to be addressed. For example, the road network is rudimentary and in some

places non-existent. The few roads constructed decades ago are in poor condition.

Telecommunications are still restricted to major towns and along highways. Very few

districts in Northern Kenya receive adequate radio and television coverage even after

the recent liberalization of the airwaves. The region has limited access to electricity that

in turn restricts the scope for investment. The lack of adequate infrastructure is a major

reason that explains why the region has attracted less investment compared with other

parts of the country, despite its abundant and diverse natural resource base.

Access to Basic Services

The nature and quality of service provision is a critical factor determining the low levels

of human development evident in Northern Kenya. Proper provision of educational

services was for a long time impeded by myths that pastoralists were uninterested in

educating their children. This situation is now changing as seen, for example, in the

proposal by the Ministry of Education to constitute a National Commission on Nomadic

Education and to pursue service delivery strategies which take account of nomadic

lifestyles and the values of pastoralist parents and children. However, access to

education in the north is still undermined by inappropriate teaching materials, poor

infrastructure, inadequate allocation of high-quality teachers and difficulties in retaining

them. Cultural factors, such as early marriage and a preference for educating boys, as

well as the heavy reproductive demands placed on girls, create significant gender

differentials in educational outcomes. In Mandera, for example, approximately one-third

of men are literate compared with only six percent of women. Similar physical and

human infrastructure constraints characterize health service delivery. An additional

concern is the lack of quality data, and specifically the lack of baseline information

against which progress towards key health goals can be monitored.

Access to Basic Primary Health Services

The average distance to a health facility in Northern Kenya is 52 kilometers, ten times further

than the national target of 5 kilometers [23] However, there are variations in radius of access

to health facilities in different parts of the country with the worst areas being Northern Kenya

whose biggest population are nomadic-pastoralist. For the purposes of this report, we are

going to focus on accessibility in Northern Kenya region, which is mostly rural with the worst

areas in Kenya where, across all 10 counties (i.e. Marsabit, Isiolo, Wajir, West Pokot, Garissa,

Turkana, Samburu, Mandera, Lamu and Tana River) with most health facilities located at a 5

11

kilometer radius to majority of its inhabitants. In this region, shortage of health personnel is

further compounded by mal-distribution, with a predominant urban bias where majority of

health workers are concentrated. In terms of health service provision, on average, 50% of the

equipment in public health facilities and laboratories are obsolete or unserviceable [24]. This

situation complicates the services that can possibly be delivered and their quality in Northern

Kenya.

Pastoralism

Northern Kenya is dominated by mobile pastoralism, while in the better-watered and

better-serviced semi-arid areas a more mixed economy prevails, including rain-fed and

irrigated agriculture, agro-pastoralism, and small-scale businesses in areas such as Lamu.

Due to the community’s long practice of pastoralism, this posed a challenge to the

health workers in that they have to follow the pastoralists where they settle. This also

becomes another challenge when collecting data, because while the health workers

follow up the locals, it becomes difficult to single them out as a target sample

Other factors such as geographical spread, low population density, nomadic lifestyle of

inhabiting communities, insecurity, poor communication and infrastructure have worsened

human resource service coverage and limited access to health care. Despite the challenge of

limited human resource for health in Northern Kenya, few studies have explored the

magnitude of the problem. This situation is now being remedied in part through the

development of an interim strategic plan 2008-2012 to avert HRH challenges in Northern

Kenya by the Ministry of State for Development of Northern Kenya and other Arid Lands

(MODNKAL).

1.1.4 Policy Perspectives on Human Resources for Health

The importance of human resources for health can be seen in major policy documents

outlining Kenya’s development imperatives. Kenya Vision 2030 is the long-term development

blueprint for the country that came after the successful implementation of the Economic

Recovery Strategy for Wealth and Employment Creation (ERS) [25]. The aim of the Vision is

to create “a globally competitive and prosperous country with a high quality of life by the

year 2030”. It envisages transforming Kenya from a developing country to a newly

industrialized middle-income country by the year 2030. The goal of Kenya’s Vision 2030 for

the health sector as a whole is to: “provide equitable and affordable health care at the highest

affordable standards to her citizens” [25]. Good health is a pre-requisite for enhanced

economic growth and poverty reduction and a precursor to realization of the Vision’s social

goals and the Millennium Development Goals [19] [26]. Furthermore, the Constitution under

the Bill of Rights, access to equitable healthcare is a right to every Kenyan. In light of this,

both Ministries of Health are re-aligning their priorities to ensure that planned and current

activities are responsive to expectations of Kenyans through improved health care

infrastructure and service delivery systems [27].

The Second National Health Sector Strategic Plan 2005-2010 (NHSSP II) outlines specific

targets for the health sector. Its aim is to reverse the downward trends in the health status of

Kenyans as observed during the implementation of the first strategic plan (NHSSP I: 1999-

2004) [28]. The aim of NHSSP II was to contribute to the accomplishment of Kenya’s

Economic Recovery Strategy and the achievement of the Millennium Development Goals

[28]. The accomplishment of these goals was premised on the implementation of the Kenya

Essential Package for Health (described below). At the launch of the Second National Health

12

Sector Strategic Plan (NHSSP II), about 106,000 professional health workers (doctors, nurses,

midwives, and laboratory and pharmacy staff) were needed to deliver Kenya Essential

Package for Health (KEPH) as outlined in the strategy. Out of these only about a half (62,000)

were employed and serving [22].

In 2005, the HRH Rapid Results Initiative (RRI) team was established and began developing a

3-year national HRH Strategic Plan for the health sector [24]. The RRI approach aimed at

focusing attention on one specific goal and ensuring that improvements were seen within

100 days and subsequently maintained or improved. The HRH RRI Team comprised of

members from the public and private sectors, faith based organizations, training institutions,

regulatory bodies and professional associations. The team identified engaged in strategy

discussions around HRH issues across the health sector (public, private and faith-based), and

found that besides staff shortages, the inequitable distribution of staff and interestingly,

poor performance of front-line health care workers were cited as important concerns [24].

Based on the available evidence and data, broad strategies and activities were developed to

address the planning, management and development of health personnel over the next 3

years. However, little progress has been made in addressing the HRH crisis due to constraints

such as wide inequalities in distribution of HRH by region and within regions, imbalances by

cadre and gender, the unsustainable nature of the current system of community volunteer

deployment, a suboptimal work environment, and poor remuneration [19].

Ministry of State for the Development of Northern Kenya and Other Arid Lands

This Ministry created in 2008 deserves special mention as one policy initiative instituted to

address the perennial human resources for health and other development problems facing

Northern Kenya as well as other arid areas. A basic issue that the Ministry is seeking to deal

with is poverty whose causes are similar to those identified in Vision 2030: infrastructure,

security, land tenure, education, employment and drought management.

With regards to health, the Ministry acknowledges the poor health indicators in Northern

Kenya, characterized by high maternal, infant and child mortality, high levels of acute

malnutrition, and low immunization coverage [23]. The health service infrastructure is poor,

with few and scattered health facilities staffed by inadequate numbers of personnel.

Distances to referral facilities may be much longer, on poorer roads, than in other parts of

the country. However, the situation in Northern Kenya has been evaluated and corrective

action is ongoing or in preparation to avert this situation and put region at par with the rest

of the country [23]. Strategies specific to improving health including HRH in the region are:

a) Improve access to health care for all the population

b) Increase the number and retention of health and nutrition professionals, particularly

from Northern Kenya

c) Promote health education

d) Address issues that disproportionately affect the health, nutritional and social status

of women and vulnerable groups

e) Strengthen fleet management for upward/downward referral and transportation of

medical supplies and equipment in the region

f) Improve public health in urban areas

1.1.5 Government of Kenya Health Workforce Establishment

The Government’s health workforce establishment is premised on the requirements to

implement the Kenya Essential Package of Health (KEPH) and staffing norms outlined in the

13

Norms and Standards for Health Services Delivery [24]. KEPH outlines a combination of

integrated services to be offered to Kenyan based on life-cycle cohorts needs and

rationalized service delivery from level (basic preventative services) to level 6 (national

tertiary hospitals offering highly specialized curative services) as shown in figure 1 [24]. The

pyramid (fig. 1) outlines services offered by type of facility both public as well as church

aided or private run facilities.

Fig 1: Staffing by KEPH Level

MO1 – Medical Officer or Physician, CO2 – Clinical Officer

Church-aided or otherwise known as faith-based organizations (FBOs)/ mission hospitals are

well-distributed across the country. Most have general practitioners with a few being staffed

by resident general surgeons or gynecologists with a few offering highly specialized services.

Likewise, private medical facilities also provide basic to referral type health care services in

Kenya and are represented at each of the KEPH levels of the health system. Most of them are

found in urban areas. Private facilities in the cities offer specialized services and are run with

qualified medical specialists in private practice with additional support from part-timers from

the government. This setting improves working conditions, increases the self-esteem of

health workers in urban areas and also opens up career opportunities for them [26].

The public sector remains the largest employer of healthcare workers followed by private

sector hospitals and faith-based organizations’ health facilities [19]. However, a large

Admin: Nurse

No. of staff: several trained

Community Health Workers

(CHWs)

Admin: MO1, 1-4 Specialists

Staff: COs2,MO

1, Registered

Nurse

Teaching Hospital, Specialized

medical professionals for

specialized services

Admin: MO1

No. of staff: 1–4 Cos2, 1-4MO

1

Admin: Registered Nurse

No. of staff: 1 – 3 Cos, 1 MO1

Admin: Enrolled Nurse

No. of staff: 1 - 3

14

proportion of health personnel work outside the public sector and are spread out across

many employers with a few being self-employed. The bulk of the public sector services are

provided through the MOPHS and MOMS. Levels 1-3 facilities are under MOPHS and focus

on provision of preventive services while level 4-6 facilities are under MOMS and focus on

curative services (see Fig. 1). The Kenyan Government has begun building primary health care

(PHC) facilities to improve access to health care in remote and rural populations under the

KEPH concept. KEPH defines health care services to be offered at each level depending on

the needs of the specific life-cycle cohort seeking services from a facility [24]. Box 1 outlines

the staffing norms for each level.

Box 1: KEPH Staffing Norms by Level

Based on these staffing needs, the two ministries have a proposed optimal staff

establishment of 72,234 but only 47,247 have so far been approved. Further, about 38,000

approved establishment positions are filled with roughly 9,000 positions remaining vacant.

Annual recruitment has not drastically altered the numbers because of the high level of

attrition [27].Combined, the two health ministries’ had a vacancy rate of 70 percent based

on the new establishment approved in 2010 and 24 percent, based on the previous one [21].

This has been affected by unequal staff distribution in the public sector at the various access

points (health facilities) [28].

Community-based health services (level 1): These services are the most basic health

services offered in Kenya. They are critical for the re-introduction and sustenance of the new

concepts of primary health care. Service providers are Community Based Health Workers

(CBHWs) supported and supervised by Community Health Extension Workers (CHEWs). Level

1 provides preventive and promotive primary healthcare, strengthening timely referral. It

requires 7,600 community health units and 15,200 nurses and 380,000 CHWs to be fully

established throughout the country.

Dispensaries or Clinics (level 2): staffing at this level is by enrolled community nurses

(ECNs), with each centre having a maximum of 3 staff.

Health centers, maternity centers & nursing homes (level 3); these facilities are staffed by

Kenya registered nurses (KRNs). Some centers have one to (a maximum of) 3 registered

clinical officers (RCOs), while some in urban locations have a general practitioner. The

administrator of each facility is a KRN.

Sub-district hospitals (primary) and other hospitals (level 4): These facilities are located

in rural and semi-urban and urban locations. Health services offered are mainly provided by

RCOs and general practitioners are few (a maximum of 4 in highly populated location). The

administrator in most of these facilities is usually a general practitioner.

District hospitals (level 4): These are larger facilities than sub-district hospitals and they

tend to be located in medium-sized towns (district headquarters), have health facilities

staffed by general practitioners and registered clinical officers, and a few now have a resident

physician, pediatrician, general surgeon and gynecologist.

Provincial (Secondary) hospitals (level 5): located in bigger towns especially provincial

headquarters, all have at least one resident physician, pediatrician, general surgeon,

psychiatrist and gynecologist and are able to offer specialized services.

National (Tertiary) hospitals (level 6): have many specialized medical professionals

offering specialized services. These hospitals are also used as teaching institutions.

15

1.1.6 Health Workforce in Kenya

Front-line healthcare workers present in Kenya include Doctors, Nurses (enrolled and

registered), Clinical Officers, Laboratory staff, and Pharmacy staff, among others. Clinical

Officers are commonly found in rural areas than doctors, an issue exemplified in North

Eastern province where the Clinical Officer proportion is higher than that of Doctors or

Nurses. Clinical Officers are middle level health personnel who offer a wide range of medical

services (curative, preventive, promotive and rehabilitative) in all parts of Kenya and in other

sub-Saharan African countries [29]. They supplement the work of Doctors at all levels of

healthcare, from health centers where they are in charge to district and provincial hospitals

to referral teaching hospitals.

Health workers are employed in the public sector, faith-based organizations (FBOs), non-

governmental organizations (NGOs) and the for-profit private sector [22]. The age profile of

healthcare workforce in Kenya shows that 58% of all healthcare workers are aged 41 years

and over, suggesting an aging health workforce [22]. This could be the reason for the

increased the mandatory retirement age of civil servants from 55 years to 60 years that the

Kenya Government implemented in 2009 [17].

Health Worker-to-Population Ratio in Kenya

Kenya currently has an average of 19 doctors, 25 clinical officers, 8 pharmacists, 6

pharmaceutical technologist, and 173 nurses per 100,000 persons compared to WHO

recommended minimum staffing levels of 36 and 356 doctors and nurses respectively per

100,000 persons. Kenya has a total of 146 health care workers per 100,000 population which

is far much below compared to WHO threshold of 250 health care workers per 100,000

population [22] [30].

Past studies provide evidence of inadequate ratios of personnel to population for key skilled

health personnel as well as a striking mal-distribution of personnel along three different

axes; between public and private heath sectors, urban and rural areas, tertiary and primary

levels of the health system. In 2009, there were 6,897 doctors and 31,917 nurses registered

(Table 1). Kenya’s physician density was 14 per 100,000 population compared to a regional

average of 23 per 100,000; the nursing density was 118 per 100,000 compared to the

regional average of 109 per 100,000 [31]. These densities (even though higher than the

regional average for nurses) are far below the WHO recommended densities and much lower

than their European counterparts. The United Kingdom for example has a physician density

of 274 per 100,000 population compared to its regional average of 333 per 100,000, and a

nursing density of 1030 per 100,000, quite above the regional average of 747 per 100,000

population [31]. Central province has 84 healthcare workers per 100,000 people, while North

Eastern has only 33.

Healthcare Workforce Mal-Distribution in Kenya

Northern Kenya suffers disproportionately with regards to inequities in national healthcare

worker distribution, making the HRH crisis particularly worse in this region. To illustrate this,

North Eastern province with a population of 2.3 million, representing 6.4 percent of the

Kenyan population, has only 2.3% (doctors), 5% (clinical officers), 2% (pharmacists),5%

(pharmaceutical technologists) and 1.9% (nurses)health workers working in the country

stationed within the province. In comparison, Nairobi province has a population of 8.2

16

million (8% of the country population) and has 32% (doctors), 7% (clinical officers), 30%

(pharmacists), 15% (pharmaceutical technologists), and, 10% (nurses) respectively [21] as

shown in Table 1 below and Appendix 1. This mal-distribution characterizes the preference

of doctors to be situated in Nairobi, the capital city and the challenges of retention in rural

areas of doctors and other cadres.

Table 1: Provincial Distribution of Selected MOMS and MOPHS Personnel as a Share of National

Population (2010)

Nairobi Nyanza Rift

Valley

North

Eastern

Coast Central Western Eastern

Share of National Total %

National

Population

8 14 26 6 9 11 11 15

Clinical Officer 7 14 27 5 11 12 11 15

Dental

Specialists

25 8 18 1 13 17 6 12

Enrolled

Nurses

5 14 25 3 9 16 11 18

Doctors 32 9 18 2 8 14 6 11

Nurses 10 14 23 2 11 16 8 15

Pharm Tech 15 10 26 5 10 9 9 17

Pharmacist 30 10 16 2 9 11 7 14

Total Medical

cadres

9 13 25 3 9 15 10 16

Source: MOMS/MOPHS HRIS, July 2010 and 2009 Kenya Population and Housing Census

1.1.7 Strategies to Improve Health Workforce Retention and Service Delivery

In response to the HRH crisis, the Government has attempted to develop new standards to

improve working conditions in the health sector and retain staff by offering review and

increase in salaries, offering hardship allowances, providing them with opportunities to

engage in private practice and giving them opportunities for further training in short courses

(internal, external and management courses) especially in donor supported programs though

the data is scanty on the courses offered and the number of people trained also in long

courses (nursing both up-grading and post-basic, doctors at masters level, clinical officers,

physiotherapists, etc). Many healthcare workers fund their own training and information on

such training is not available except in cases where staff request paid or unpaid leave.

Though many medical regulatory agencies (MPDB, NCK, PPB and COC) have issued

continuous professional development (CPD) guidelines, most of these are yet to be enforced.

This is largely due to the limited capacity of these regulatory agencies to enforce the

guidelines [21].

Despite these incentives, there is a continued loss of many qualified HRH professionals to

other occupations, international migration, all of which are driven by ‘push’ factors such as

poor remuneration, limited career growth (or unclear career progression) etc as well as

concerns about safety and security. Complicating this situation is the high level of

unemployment among healthcare workers in the country, which is one of the factors that is

unique about HRH challenges in Kenya; more than 50% of nurses in Kenya are unemployed

due to hiring and/or wage ceilings [32] [22]. The country finds itself in a paradox where

many nurses and clinical officers are unemployed due to persistent financial constraints (i.e.

due to historical hiring freezes issued by the Government thus it finances budgeted positions

only). Meanwhile, the Government continues to periodically freeze newly vacant positions,

17

though this has to an extent been averted through aggressive recruitment of healthcare

personnel under the Economic Stimulus Program (ESP). While these efforts do improve

health worker shortage in the public healthcare sector, there is need to increase staff in the

already seriously understaffed especially in the remote, rural and hard-to-reach areas of

Northern Kenya [21].

Out of 7,395 health facilities in the health sector, the Government owns and operates 48%

(273 hospitals, 579 Health centres and 2,716 dispensaries) of all facilities in the sector. Private

and FBO health facilities complement the provision of health care through the remaining

46% (accounting for 1,044 FBOs and 2,352 private) of health facilities (Appendix 2). In view of

the low investment in infrastructure, most of the public health facilities are old and

dilapidated with 50% of the equipment in public medical facilities and research laboratories

are obsolete or unserviceable. Given the increases in population at 3% per annum and the

increase in demand for services, these facilities do not conform to current infrastructure

norms and standards.

1.2 Statement of the Problem and Justification Research has shown that higher worker density generates better health outcomes, lower

burnout, better morale, and greater job satisfaction [33]. Given that the public sector is a

major provider of health services in many developing countries and one of the major

employers of health workers, their availability and adequacy becomes particularly important

in the public health service [33] [2]. Further, the availability of well-trained and appropriately

skilled health workers has the potential to influence the attainment of health goals including

health related MDGs [33]. For instance, maternal mortality rate (MMR) was one such

indicator that was cited as being directly linked to availability of trained service providers

that have specialized training in maternal health [33].

Northern Kenya historically has experienced the challenge of recruiting and retaining

healthcare workers. This has been attributed to low numbers of trained healthcare workers

and those in training (“pipeline”) whose homes are within Northern Kenya. This region has

been politically and historically marginalized resulting in a lack of economical, social,

professional opportunities thus exacerbating the healthcare workforce challenges in this part

of the country [24]. Moreover, insecurity (mostly perennial inter-tribal/clan conflicts) in this

region is a major deterrent that also influences perceptions of the region. As a result, there is

a steady exodus of healthcare personnel from Northern Kenya to other regions [26]. Also,

since Kenya’s Defense Forces incursion in Somalia in 2011 which was occasioned by frequent

Al-Shabaab militant attacks and abduction of tourists along the Kenyan coast which is

considered as a big tourist attraction and thereafter followed with frequent attacks or

abductions to Kenyan healthcare and aid workers, many healthcare workers might have fled

the region especially those coming from outside Northern Kenya. The Government and

external stakeholders are aware that in order to improve recruitment and increase retention

of healthcare personnel in Northern Kenya, and elsewhere, there is need to invest in

incentives specifically targeting healthcare workers posted to work in remote, poorer, hard to

reach rural areas, enabling them to serve communities that need them most.

This study was done to address this gap in knowledge by conducting an intensive

assessment of the current human resource for health situation in Northern Kenya. To

understand these issues, the study was conducted in two phases. Phase I sought to

collate, analyze and present largely quantitative data. This was complimented by the

18

successful completion of Phase II that contextualized phase I findings through use of

qualitative approaches. This approach was chosen to enable a comprehensive assessment of

issues around HRH in Northern Kenya.

1.3 Study Objectives The study was undertaken in two phases, each having its separate requirements. Objectives

for phase 1 focused on undertaking a comprehensive quantitative assessment of HRH of all

counties in Northern Kenya based on secondary data collection as follows:

a) To describe the current distribution of health workforce personnel in each of the 10

counties of Northern Kenya; disaggregated by professional cadre, gender, length

level of service and length of stay.

b) To describe the current staffing levels and vacancies in Northern Kenya;

disaggregated by level of service and cadre

c) To describe the extent to which staffing vacancies can be improved by (re)


d) To assess whether health workers whose home districts are within Northern Kenya

are more likely to report to health facilities in the region

e) To describe the extent to which the needs of the 10 counties can be met through the

pool of available students in pre-service training in Northern Kenya, with specific

emphasis on nursing students

f) To establish the number of secondary school students from Northern Kenya who are

eligible for pre-service education in nursing

g) To assess the rate of turnover across the 10 counties of Northern Kenya between

2008 to 2010

Study objectives for phase 2 that focused on using qualitative approaches to collect data

were:

a) To document perceptions on health workforce distribution and adequacy in Northern

Kenya vis a vis other regions

b) To determine the extent to which staffing vacancies can be improved by (re)


c) To establish factors (positive/negative) that influence health worker recruitment and

retention in Northern Kenya

d) To explore determinants of uptake and completion of pre-service mid-level health

training for individuals whose home districts are in Northern Kenya vis a vis those

from other regions

19

Figure 2: Geographic Coverage of Northern

Kenya

The area in red indicates the coverage of Northern

Kenya

2.0 METHODS

This section describes the methods used to collect and analyze the data reported in this

study. Both quantitative and qualitative methods were used and are described in each of the

sections below.

2.1 Study Design

The mixed methods sequential explanatory study design was adopted to assess HRH in

northern Kenya [34] [35] . This approach combines elements of qualitative and quantitative

research approaches (e.g., use of qualitative and quantitative viewpoints, data collection,

analysis, inference techniques) for the purposes of breadth and depth of understanding and

corroboration [34].The study approach involved first exploring quantitative aspects of HRH

in Northern Kenya then use qualitative approaches to amplify and also understand these

issues based on results of the quantitative analyses. This approach puts more emphasis to

quantitative results where qualitative results are seen to help explain quantitative results. The

advantage of using such an approach is that the study is based on the strength of both

quantitative and qualitative research methods [35]. Further, such an approach allows a

complete picture of the research problem to be built. For example, qualitative data will help

provide detailed descriptions of individual perceptions and experiences thereby enhance

quantitative measures of phenomena [36]. This method allows for separate collection and

data analysis as well as combined reporting for improved clarity and breadth of explanation

[34], [35].

2.2 Study Sites

Data sources for this study were sourced from

ten counties that fall under the Ministry for

the Development of Northern Kenya and

Other Arid Lands. The ten counties comprised

Turkana, Samburu, Marsabit, Isiolo, Mandera,

Wajir, Garissa, Tana River, West Pokot and

Lamu (Figure 2).

20

2.3 Sampling Procedures

2.3.1 Secondary Data Sources (institutions) for the Quantitative Aspect

Secondary data was used to provide data for quantitative analyses and was sourced from the

following institutions: health ministries (MOMS and MOPHS); the Kenya National Bureau of

Statistics (KNBS); Kenya Medical Training College (KMTC) headquarters; Kenya National

Examinations Council (KNEC); Christian Health Associations of Kenya (CHAK); and Kenya

Episcopal Conference (KEC). These were approached to provide information on health

workforce that they employed in the health facilities that they managed in Northern Kenya.

2.3.2 Qualitative Aspects

All counties selected for this study have urban and rural areas. Areas defined as ‘urban’

were locations anywhere within 0-15 kilometer range of the centre of the county capital

while those defined as ‘rural’ were those locations that were anywhere beyond 30km from

town centre. From these areas, study participants were drawn and represented the

following groups in the ten counties:

Health care workers currently working in a public, private or faith-based facility in

urban and rural locations. Key cadres of interest were enrolled and registered nurses;

clinical officers; lab technicians; pharmaceutical technologists; and medical doctors.

Students currently enrolled in a pre-service mid-level training institution.

Directors of health training institutions (i.e. Kenya Medical Training College and

others under KEC or CHAK).

District Medical Officers (DMOs) as well as provincial medical officers (PMOs) where

possible and other experts/key informants.

Healthcare workers were eligible to participate if they met the following criteria:

Currently work in a health facility in one of the 10 study counties,

Had not participated in a focus group discussion or interview within the last 6

months of the study reported here,

Met the required quota specifications in terms of gender, cadre, origin, duration of

deployment and facility type, and,

Maximum one other staff from the same facility participates in the group.

Students were eligible to participate if they were currently enrolled in the selected pre-

training institution, originally came from one of the 10 counties of Northern Kenya, and

had not participated in a focus group discussion or interview within the last 6 months.

District Medical Officers were eligible for interviews if they had worked for at least 12

months in one of the 10 counties in Northern Kenya. Training Directors were eligible for

interviews if they had worked for at least 12 months in the institution or if less, had worked

in a similar duration in one of the institutions based in Northern Kenya.

Sampling Procedures

Purposive sampling was used to ensure that participants recruited into the study not only

satisfied the inclusion criteria as defined in the target populations but also achieved gender

balance and good representation of individuals from both urban and rural settings. Focus

group discussions (FGDs) were conducted drawn from Counties (3 focus groups each) and

training institutions (3 additional focus groups).

21

For the key informant interviews (KIIs), a combination of both purposive sampling and

snow ball sampling approaches were applied. Snow ball sampling was used to identify

other informants seen to be valuable sources of information during data collection.

Participants who worked in senior level positions at training institutions, health facilities

and MOH offices were also recruited for interview. Authorization by the facility supervisor

was sought for staff participating in group discussions. KIIs with DMOs were booked by

telephone and subsequently carried out face-to-face in the same time period when focus

groups were conducted in a county. A total of 35 in-depth interviews were done.

2.4 Data Collection

2.4.1 Quantitative Data Extraction and Collation

This section provides an overview of the various sources that were identified and

subsequently accessed to provide quantitative data for assessment. The tools or table shells

that were used to extract data from institutional databases or literature are appended to this

report.

Desk Review

A thorough desk review of the status of HRH as well as an overview of the health system in

Kenya was the first activity conducted by the research team, drawing mostly from gray

literature. This included review of MOH policy and strategy documents, MOH reports, as well

as peer-reviewed articles. Additional institutional reports shared with the research team

provided retrospective data to highlight any trends.

Alignment and Development of Tools (“table shells”)

The identified institutions participating in the study were engaged prior to data collection by

the research team to ensure that data for the study was available and readily accessible.

Point-persons from each of the institutions were identified to work closely with the team. In

addition, the team used this period to revise draft tools for data extraction (table shells) to

ensure that they were adequately aligned to capture data within a range of institutional

databases (i.e. electronic or manual records).

2.4.2 Qualitative Data

Prior to the commencement of field work, a research team was recruited that

comprised of residents originating from Northern Kenya. Particular attention was paid

to ensure that research assistants working on the study came from the counties where

the study was being done. This enabled the research team to overcome issues such as

language barriers and local knowledge of study area. The research assistants were

trained over a period of three days to inform them of the study objectives and

procedures.

Following the training, a pre-test was done to examine whether the interview tools

(FGD and KII) were able to capture data of interest and also whether the research

assistants were capable of conducting interviews well. Transcripts of the pre-test were

shared with Capacity Kenya, followed by an interactive de-brief where the study instruments

were jointly revised and finalized for the study locations. Research assistants were then

sent out after training to facilitate the recruitment process.

22

Health facilities in each county were either visited physically or contacted telephonically to

recruit focus group participants with a screener questionnaire based on the study’s eligibility

criteria. Screening ensured that the following characteristics were preserved among FGD

respondents:

Both male and female participants

Long-serving participants and those who arrived in Northern Kenya less than a

year ago

Employees of public, private and faith-based facilities

Participants originally from Northern Kenya and participants from elsewhere

Participants from two different levels of healthcare

Data Collection Procedures

Field work was carried out following a travel schedule developed to cover sites to be

visited (counties) and the specific journey sequence to be adopted. Two field teams were

deemed adequate and were allocated to the study sites as follows:

Team 1: Garissa, Wajir, Mandera, Tana River and Lamu

Team 2: Isiolo, Marsabit, Samburu, West Pokot and Turkana

The distribution of counties per team and the time schedule were largely guided by

condition of roads, information on general insecurity, road infrastructure (i.e. those

known to be impassable during wet season, etc.) and length of distance between sites.

The FGDs consisted of 6-10 participants. A trained moderator conducted the FGD using a

naturally flowing conversational manner using the pre-tested discussion guide. A local note-

taker accompanied the moderator to each focus group to take notes. FGDs were held in

Swahili language. The research team also developed a short form for use by note-takers to

capture contextual and non-verbal features of the interviews and FGDs. The note taker

captured some of the elements of the form as the discussion proceeded and later completed

it after a de-briefing session with the moderator. The data was captured alongside

transcripts. The group discussion took place in a central location like a hotel, school or social

hall. The research team covered transportation costs of respondents to the venues to enable

participants to turn up for the discussions.

In-depth interviews took place in the office of the respondents. Where not possible,

interviews were conducted over a telephone and audio-recorded. At the time when calls were

made to make appointments, the purpose and content of the study was explained briefly to the

respondents and confidentiality assured. The interviews themselves were conducted in the

style of a structured conversation; the order of the questions varied in some cases to

guarantee a natural flow of the interviews. The audio files were transferred to Nairobi via

internet, where they were transcribed in parallel with ongoing fieldwork.

An in-house team was assigned to the two teams in the regions who counterchecked on all

target respondents recruited prior to conducting interviews and focus group discussion. This

ensured that all protocols were followed during recruitment and respondent met the required

criteria.

23

2.5 Data Analysis

2.5.1 Quantitative Data Analysis

Quantitative data analysis was done in light of the study objectives as shown in Table 2. The

table presents the data type (literature or document) and the institution where data was

collected and links this to the specific objectives.

Table 2: Study Objectives and Data Sources

Objective No. Name of Institution

1. To describe the current distribution of health workforce

personnel in each of the 10 counties of Northern Kenya

MOMS; MOPHS (iHRIS database) &

National HRH, 2010

2. To describe the current staffing levels and vacancies in

Northern Kenya; disaggregated by level of service and cadre

MOMS; MOPHS (iHRIS database)

3. To describe the extent to which staffing vacancies can be

improved by (re)-distribution of existing health workers within

Northern Kenya

MOMS; MOPHS (iHRIS database;

WHO

4. To assess whether health workers whose home districts are

within Northern Kenya are more likely to report to health

facilities in the region

MOMS; MOPHS (iHRIS database –

IPPD); NCK

5. To describe the extent to which the needs of the 10 counties

can be met through the pool of available students in pre-service

training in Northern Kenya, with specific emphasis on nursing

students

KMTC; NCK; CHAK; KEC

6. To establish the number of secondary school students from

Northern Kenya who are eligible for pre-service education in

nursing

KNEC; KNBS; MONDKAL

7. To assess the rate of turnover across the 10 counties of

Northern Kenya between 2008 to 2010

MOMS; MOPHS (iHRIS database -

IPPD)

SAS 9.2 software was used to run both descriptive and inferential analyses based on each

objective of the study. Objective No. 1 required data extraction from the health ministries’

iHRIS database to provide a comprehensive description of the current HRH state in Kenya,

with comparison to the situation in Northern Kenya. Likewise, data on staff levels (objectives

No. 2), vacancies (objective No. 3) and turnover (objective No. 7), was also collected using

the same data source.

Objective No. 4 was also addressed by accessing iHRIS. However, the team also accessed

data from the Nursing Council of Kenya (NCK) database as it is considered to be fairly robust

and is updated on a monthly basis as part of regulatory activities. To assess whether there

were differences for health care workers accepting positing and reporting in Northern Kenya,

means testing was done to see whether there are differences for health workers (levels 2-5,

all cadres) and whose home county is in Northern Kenya.

Objective No. 5 focused primarily on mid-level trainees (with emphasis on nurses), those

already in the pipeline and who are most likely going to look to enter the job market in the

coming year or so. Therefore, mid-level training institutional data was collated and analyzed

in two parts – through quick descriptive analyses and through means testing.

Objective No. 6 required collecting data from the Kenya National Examination Council

(KNEC). KNEC is the governing body that maintains a comprehensive database on all

secondary school students who have sat for the final exams. Using the KNECs score system

24

to inform the minimal “pass” mark, descriptive analyses and means testing were done to

determine eligibility to take up formal employment as a nurse. This was done retrospectively

to assess trends (if any) over the past 5 years (2007 -2011).

Objective No. 7 was addressed by accessing data from the two ministries of health – MOPHS

and MOMS (iHRIS databases and IPPD). However, the team requested for records from the

counties to corroborate with the iHRIS and IPPD data. This was done to assess the rate of

staff turnover across the 10 counties of Northern Kenya and also compare with the national

average county turnover.

2.5.2 Qualitative Data Analysis

Qualitative data analysis used a combination of secondary data analysis and qualitative

research. Relevant secondary data was incorporated into the report to corroborate

findings from the qualitative research component comprising FGD with health care

workers and trainees and with KII with district medical officers and administrators of

health training institutes.

A data analysis plan was developed after completion of the pre-test. It mapped sections of

the data collection instrument to finding, and described the process of analyzing transcripts.

A draft coding framework was developed after the pre-tests based on the template of the

final report. The coding framework was refined prior to initiation of coding which was

approved by Capacity Kenya. All transcripts were proofread by moderators while checking

against the original recording to ensure that they captured the discussion verbatim.

Transcripts coding was carried out using NVivo 10 coding software. Content analysis was

used to detect patterns, similarities and differences between groups and different types of

participants. Emerging typical themes and discourse were identified. Notes taken during the

focus groups were treated as additional data and taken into consideration for the data

analysis. Where possible, findings were compared to existing hypotheses and secondary

data with a focus on training, recruitment, deployment and retention of health workers.

Analysis was carried out by one experienced qualitative researcher. The findings were finally

discussed with the moderators and team involved as well as an independent researcher to

check alignment of the findings with what was captured during the discussions.

2.6 Ethical Considerations The secondary data acquired for the study was de-identified prior to analysis. As such, there

was little chance of identifying individuals from the human resources for health data.

In collecting qualitative data, each participant was informed of the study procedures and

requested for their consent to participant in the study. All participants were informed about

the purpose of the study, what their participation meant, the risks and benefits before their

written consent was obtained. All researchers in the study had completed research ethics

training based on the Family Health International (FHI) Ethics curriculum. A refresher-

training of the ethics curriculum was done as part of the training.

Contact information of principal investigators and alternative contacts were shared with

study participants for any additional information about the exercise. All raw data – audio

recordings, transcripts, field notes - were stored safely and in password protected files or

folders adhering to IntraHealth policy on human research participant protection.

25

2.7 Study Limitations Though both phases of the study faced a number of limitations that are described below,

data collected went well.

Study Limitations for Phase 1

A major limitation related to the difficulty of getting quantitative data from a well managed,

easily accessible and transferable database (i.e. data paper forms vs electronic). For example,

manual data did not correspond to what was available in the central HRIS database at the

health ministries in some of the counties in Northern Kenya. A possible reason for this was

the delay in uploading or updating the data from the county level to provincial and

subsequently central HRIS database desk. In some cases, data captured at the different KEPH

levels did not clearly specify professional cadres or gender of health workers. This was

common in all of the 10 counties making it difficult to properly quantify staffing levels by

cadre, gender and levels. Another issue related to the lack of up-to-date list of students

enrolled in the nursing courses from all the satellite colleges in Kenya and had a lot of

information stored as hard copies at training institutions such as the Kenya Medical Training

College (KMTC). In addition, initial reporting in the Health Sector was based on district

statistics, formerly the provincial administrative structure in Kenya, rather than county

reporting, this then called for amalgamating the data into county statistics.

Actual staffing levels and the budgeted staff from the two health ministries so as to assess

the current vacancies as per the KEPH levels (2-5). The central Integrated Human resources

Information system (iHRIS) database provided the current staffing by KEPH levels and the

Department of Human Resources (HR) at the MOMS provided the budgeted staff for the

financial year 2010/2011. Where data on staffing per KEPH level from the iHRIS database did

give expected figures by cadre, data was requested from the Counties in the region.

However, the department did not have the budgeted staff requirements since they only use

estimates based on what they believe the Government is able to add in the payroll (Appendix

13). It was noted that the Department of Human Resources at MOMS calculations are not

based on workforce-to-population ratio method which is commonly used by WHO but rather

on financial availability by the Government. Hence it was not possible to get the budgeted

staff requirements for the financial year 2010/2011 from the HR department in the MOMS.

Instead, estimates as per WHO recommended workforce-to-population ratios for Doctors,

Clinical Officers, Nurses, Laboratory staff and Pharmacy staff were used [31].

To compare consistencies in registered cadres of medicine, pharmacy and registered nurses,

data was requested and received from the Joint Admissions Board (JAB) on the number of

enrolled students into each program.

Study Limitations for Phase 2

Access to rural health facilities located far in the interior of some counties was a

challenge. It was planned that some rural facilities will be sampled during fieldwork but

it turned out that the facilities were too far with no reliable means of transport of getting

there. As a result, recruitment of participants had to be limited to a distance of not

farther than fifty (50) kilometers from the major county headquarters as informants were

able to convene there with ease. Even so, informants had to be ferried from their

facilities to the venue of the interview sessions and back.

26

It was anticipated that each health facility had a good number of staff from which to

select participants. However, some health rural facilities were found to have few staff

limiting selection as the facility could not be left un-attended or stop offering services as

a member of has been selected to participate in a group discussion. To overcome this

challenge, only health facilities whose services could not be severely be disrupted were

sampled. In addition, staff who were off duty on the day of interview were considered

for participation. This was coordinated with health administrators to provide details of

those on off-duty.

Insecurity also affected fieldwork. Armed security personnel were hired throughout the

duration of the study to assure security of fieldworkers as interviews took place.

27

3.0 RESULTS

The data reported here was obtained in two phases. First, secondary data on HRH in

Northern Kenya was obtained and analyzed. Next, qualitative data was obtained through

undertaking fieldwork in northern Kenya based on issues arising from quantitative data

assessments. The two pieces of data are merged in this report following the dictates of the

study design. Where there is congruence between phase 1 and 2 objectives, data is

combined to provide more nuance to the results. Where the objectives differ, the data is

reported separately.

3.1 Healthcare Workforce Distribution in Northern Kenya Data providing information on health worker distribution in Northern Kenya is drawn from

secondary data (from NCK, MOMS, MOPHS, KEC and CHAK) as well as primary data

(qualitative).

3.1.1 Distribution of Professional Cadres

The 2010 National HRH report shows that Northern Kenya has the lowest percentage

distribution of all healthcare professional cadres (Table 1) with 2% doctors, 2% nurses and

5% clinical officers [22].

Table 3: County Distribution of Healthcare Professionals in Northern Kenya

ALL LEVELS

SHARE OF THE 10 COUNTIES

Medical

Officers

Clinical

Officers Nurses

Laboratory

staff

Pharmacy

Staff

Other

(Clinical7) Total Population

Garissa 34% 22% 17% 14% 14% 19% 18%

13%

Isiolo 8% 7% 11% 10% 10% 9% 10%

3%

Lamu 5% 7% 6% 9% 10% 7% 6%

2%

Mandera 2% 9% 5% 6% 8% 6% 6%

22%

Marsabit 13% 7% 11% 11% 13% 12% 11% 6%

Samburu 3% 6% 11% 8% 8% 8% 9% 5%

Tana River 3% 8% 7% 8% 7% 9% 8% 5%

Turkana 11% 9% 10% 7% 12% 11% 10% 18%

Wajir 8% 12% 8% 9% 10% 8% 9% 14%

West Pokot 11% 12% 14% 18% 8% 12% 13% 11%

Source: MOPHS/MOMS HRIS 2012, (*) Data obtained at County Office

The 2010 National Human Resources for Health annual report supports these findings [22].

The report shows Northern Kenya to have the lowest percentage distribution of all medical

cadres. For example it had 3% of the total national number of medical cadres to serve a

7Other clinical staff includes Community oral health officer, Dental officer/technologist/Intern, Health

administrative officer, Health records and information officer/Technologist, Nutrition officer, public health

officer/technician, Inspector of drugs and Radiographer.

28

population of 6% while Nairobi province had a 9% of all medical cadres with a population of

8%. This depicts a striking inequitable distribution of health personnel in Northern Kenya.

Table 3 shows the current staff distribution per county and aggregated by cadre.

The table shows that Mandera County has the highest population (22%)of all the Northern

Kenya counties but only has 2% (1/61) doctors, 9% (31/361) clinical officers and 5%

(307/1,782) nurses. Garissa County has 18% healthcare personnel but has a lower population

proportion at 13%. Mandera County has a healthcare workforce proportion of 6% and a

population of 22%.

The data shows that the Northern Kenya healthcare workforce staffing distribution needs to

improve to reach a reasonable staffing level per population ratio thus alleviate the serious

HRH challenges facing the region. The table also suggests that more needs to be done to

reduce staffing gaps and increase local healthcare professional cadres in the region, perhaps

by exploring additional ways to address this issue.

3.1.2 Gender Characteristics of Existing Cadres

A review of the existing staffing levels by KEPH level (2-5) was done to assess gender balance

in all the five key cadres studied in this report. The assessment found that the distribution of

each gender in the five healthcare professional cadres was not balanced. For instance, some

cadres such as doctors, clinical officers and pharmacists were predominantly male while

cadres like, nurses and lab technologists were largely female (Table 4). Broadly, males

account for 45% of all HRH personnel in the MOMS and MOPHS while females were 55% in

comparison [22].

The majority of health workers in Northern Kenya were male 63% (2,037/3,153) while female

staff were 35% (1,116/3,153) across all cadres. These proportions indicate disparity in staffing

by gender within the population in the region when compared with the proportion of male

53% and female population (47%) in Northern Kenya. In addition, Nurses had a different

gender distribution in the region with females being 52% while male were 48% (Table 4). This

differed greatly from the gender distribution of doctor where 75% were males and 25%

females while the proportion of male and female clinical officers was 84% and 16%

respectively. The gender disparity seen in the five cadres needs to be addressed.

29

Table 4: Gender Distribution by County of Professional Cadres in Northern Kenya

All Levels

Share of the 10 Counties

County

Medical Officer

Clinical Officer

Nurses

Laboratory staff

Pharmacy Staff

Other(Clinical)

Total

Population

Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female

Garissa 57% 43% 89% 11% 45% 55% 96% 4% 83% 17% 83% 17% 63% 37% 54% 46%

Isiolo 60% 40% 74% 26% 31% 69% 94% 6% 63% 38% 77% 23% 49% 51% 51% 49%

Lamu 67% 33% 63% 37% 51% 49% 93% 7% 88% 13% 92% 8% 67% 33% 52% 48%

Mandera 100% 0% 90% 10% 74% 26% 91% 9% 100% 0% 100% 0% 85% 15% 55% 45%

Marsabit 100% 0% 81% 19% 48% 52% 83% 17% 91% 9% 95% 5% 67% 33% 52% 48%

Samburu* 100% 0% 95% 5% 44% 56% 100% 0% 86% 14% 93% 7% 61% 39% 50% 50%

Tana River 50% 50% 87% 13% 54% 46% 92% 8% 100% 0% 92% 8% 71% 29% 50% 50%

Turkana* 86% 14% 94% 6% 53% 47% 75% 25% 100% 0% 84% 16% 67% 33% 52% 48%

Wajir 100% 0% 95% 5% 57% 43% 88% 13% 75% 25% 85% 15% 71% 29% 55% 45%

West

Pokot* 86% 14% 70% 30% 42% 58% 90% 10% 100% 0% 87% 13% 59% 41% 50% 50%

Total 75% 25% 84% 16% 48% 52% 91% 9% 88% 12% 88% 12% 65% 35% 53% 47%

Source: MOPHS/MOMS HRIS, * Data obtained from the County Office

1Other Clinical staff: Community oral health officer, Dental officer/technologist/Intern, Health administrative officer, Health records and information

officer/Technologist, Nutrition officer, public health officer/technician, Inspector of drugs and Radiographer.

30

3.1.3 Health Workforce Distribution by KEPH level

Healthcare workforce in Northern Kenya was aggregated to examine its influence on delivery

of KEPH interventions in levels 2 – 5. This was done to necessitate analysis by professional

cadre. Most of the healthcare professional cadres are employed at level 4 (67%, 1,969/2,942)

while level 2 and 3 had the least number of the health professional cadres, that is 11%,

(327/2,942) and 12% (350/2,942) respectively (Table 5). This distribution is clearly at odds

with the intent of the NHSSP II. It should be noted that Doctors are only found from KEPH

levels 3 and above with the highest percentage being in KEPH level 4. All healthcare

professional cadres are highly concentrated in Garissa County while Marsabit had the lowest

across all levels in Northern Kenya (Appendix 11 and 12).

Table 5: Percent Distribution of Professional Cadre by KEPH Level

Cadre

KEPH Level

Level 2 Level 3 Level 4 Level 5

Medical Officer 0% 6%(3/54) 70%(38/54) 24%(13/54)

Clinical Officer 3%(10/347) 9%(30/347) 77%(268/347) 11%(39/347)

Nurses 17%(280/1,688) 13%(213/1,688) 62%(1048/1,688) 9%(147/1,688)

Laboratory Staff 3%(5/162) 15%(25/162) 73%(119/162) 8%(13/162)

Pharmacy Staff 0% 5%(4/84) 89%(75/84) 6%(5/84)

Other(Clinical) 5%(32/607) 12%(75/607) 69%(421/607) 13%(79/607)

The Northern Kenya HRH data depicted in Table 5 is not enough to determine whether the

region suffers from serious staffing challenges. Thus a comparison of the current health

workers to 100,000 population ratio for all the 10 counties of Northern Kenya was done and

is shown in Table 6. Of importance is the serious staffing gap for healthcare workforce (for

example, doctors and nurses in Garissa are 3 doctors and 49 nurses per 100,000 population

which is far below national ratios of 19 doctors and 173 nurses respectively per 100,000

population). In comparison, Mandera county with the highest population (22%) of all

Counties in Northern Kenya had almost zero (0) doctors and 9 nurses per 100,000 population

respectively which is far below national ratios of 19 and 173 doctors and nurses per 100,000

population respectively. Also, all the healthcare workers to population ratios in the region all

fall far below the national ratios and WHO recommended health worker to population ratios.

It would have been much more helpful to have the entire 47 county healthcare professional

cadres summaries done to give a tacit view for comparison with Northern Kenya. Therefore,

using the population census of 2009, it is noted that there is a disproportionate healthcare

worker-to-population ratio distribution for HRH within the 10 counties in Northern Kenya

(Appendix 3) as per the WHO HRH guidelines and recommendations.

31

Table 6: Current Professional Cadre Distribution (per 100,000 population Kenya average) in

Northern Kenya Using the 2011 Population Projections

County Medical Officer Clinical Officer Nurses Lab Staff Pharmacy Staff

Current

Per

100,0

00 Current

Per

100,0

00 Current

Per

100,0

00 Current

Per

100,0

00 Current

Per

100,0

00

Garissa 21 3 80 12 307 46 24 4 12 2

Isiolo 5 3 27 18 194 128 17 11 8 5

Lamu 3 3 27 25 102 95 15 14 8 7

Mandera 1 0 31 3 94 9 11 1 7 1

Marsabit 8 3 27 9 190 62 18 6 11 4

Samburu 2 1 22 9 150 63 13 5 7 3

Tana

River 2 1 30 12 128 50 13 5 6 2

Turkana 7 1 31 3 147 16 12 1 10 1

Wajir 5 1 42 6 151 22 16 2 8 1

West

Pokot 7 1 44 8 229 42 31 6 7 1

Source: MOPHS, MOMS IPPD 2012

3.1.4 Health Workers’ Views on Drivers of Distribution of the Workforce

These views draw on the FGDs and KIIs done in Northern Kenya. Respondents generally felt

that the distribution of health work force in Northern Kenya was inadequate compared with

other regions in the country. According to Public Service Commission (PSC) policy, health

personnel can work anywhere in Kenya. Most health workers interviewed in the study whose

home district was outside Northern Kenya expressed less willingness to work in the region. In

addition, only a few health workers from Northern Kenya accepted to work in the region as

most disliked the prospect of working in that region. Reasons provided for such preference

were varied but predominantly focused on perceived negative attitudes toward the region.

Reasons mentioned include undesirable climatic conditions (i.e. extremely hot and dry), poor

local infrastructure and working conditions at health facilities especially at lower level

facilities such as health centers and dispensaries. The following quotes illustrate these issues.

“Most Somalis don’t want to work here in North Eastern (Kenya), they want to work in

other parts of the country.“ (Health Worker, Garissa County)

“I think it is because when they are normally taken to these areas of Northern Kenya,

people feel that this place is harsh. It is horrible to work in this area because of the sun-

it is hostile.” (Health Worker, Isiolo County)

“We lack medicine and protective gadgets, for example, you run short of gloves, you are

there with another, you want to assist, the patient is bleeding, so you cannot, because

of infection prevention, you cannot do something to that patient. Though sometimes

they experience that us health workers undergo is poor conditions that we work on. You

find that although you have that heart, maybe you are working, but because you do

not have enough protection, you can’t work to your satisfaction”. (Health Worker,

Pokot County)

32

Similarly, HRH administrative staff, managers and students accepted that Northern Kenya

had a shortage of health workers. A review of grey literature and discussions with

respondents indicate that there are striking differences in the distribution of the health work

force between sectors. A health manager expressed the view that some health workers were

known to leave public and private sectors in Northern Kenya to work outside the region due

to the working environment as shown by this quote.

“Majority of them [health administrators working in Northern Kenya] are people from

here and they have that mechanism because they are adapted to this atmosphere thus

why they are working here. Some who come from outside they won’t, they will work for

two to three months and make arrangements how to go back to their places”. (Health

Manager, Marsabit County)

Findings also reveal that several administrative staff respondents perceive that there is high

turn-over of administrative staff, particularly in the private sector among across all ten (10)

counties. An explanation for this was that administrative staff were constantly in search of

improved working conditions in terms of terms of employment and often targeted NGOs.

“They (health administrators) run away from one NGO to the other. For example, here

you are been paid let us give an example of ten shillings, and then you hear there is an

NGO somewhere that is paying 15 shillings. Definitely in the morning you will find me

there.” (Health Administrator, Garissa County)

Interestingly, although literature indicates that there is migration from FBOs to GOK posts,

the general consensus among the respondents interviewed was that migration from faith-

based facilities to GOK facilities was not very common. It is thought that health workers at

FBOs are less likely to leave as their motivation to work is deeply embedded in shared

religious beliefs or faith.

Despite the negative picture painted by the preceding illustrations, this was not the case

across all sites and across all health workers. For example, some health workers in Garissa,

Pokot and Turkana counties preferred to work in their counties for the following reasons.

“This is where we were born, this is where we were brought up and we would like to

work for our people.” (Health Worker, Garissa County).

“When I was posted to this place, it was an opportunity for me to serve my people. It

was only me who stayed there longer [after deployment] because I come from the

locality.” (Health Worker, Pokot County).

“I saw many cases of malnutrition when in college and decided I was going to serve

those people. When we were filling where to go, my first choice was Turkana. I just

wanted to come to Turkana”. (Health Worker, Turkana County).

Similarly, administrative staff originally from Northern Kenya also reported that staff

migration within and across counties in Northern Kenya is most likely to occur if health

workers were keen on working near their homes. A benefit of this is the advantage of being

familiar with the area. In some instances, staff were posted to work in areas that were known

33

to be insecure in terms of periodic violence such as Turkana, West Pokot and Mandera

counties as illustrated below.

“It’s there for some because some people are working here and they are from Garsen,

so one would prefer where they come from, home area, because home is home, even if

its Moyale…” (Health Administrator, Lamu County)

“What I mean by security, actually even moving at night here, it’s not safe, there are

some places which you cannot even… when you want to collect a patient at night, it's

not possible”. (Health Administrator, Isiolo County)

Some health workers and health administrators preferred to work in the region stating that

working in there allowed them to live with their families. Such locations also enabled them to

serve their own people and provided them with a stronger sense of belonging to their

communities. Further, working at places of birth enabled them to live close with family

members thus minimize expenses and get opportunities to invest in business as shown by

the following quotes.

“…. everybody would like to work where you sleep at your home and then you go to

work in the morning, you stay with your children and the wife and parents” (Health

Worker, Garissa County)

“I would prefer to work where I have my relatives here but at least closer to home,

either Kilifi , Malindi , Voi but near Mombasa, anywhere near Mombasa.” (Health

Worker, Lamu County)

“It was my dream because when I was in secondary school in Lamu Secondary. I was

dreaming to help my community and my dream came true and is very happy because

Lamu is my homeland.” (Health Administrator, Lamu County)

“Everybody would want to work where they were born because their family is there so a

person from Nairobi will want to stay in Nairobi and if I am from here I will want to

stay here, all those challenges you will live with them.” (Health Administrator, Lamu

County)

“When you are working in an environment where you were brought up, you can do

some investments here and there and so if you even lose your job then you are secure

and you will be happy because you have your community there and you giveback what

they deserve and when you serve the community you feel good.”(Health

Administrator, Lamu County)

Familiarity with the region, culture and practices amongst health workers from Northern

Kenya was another factor that contributed to their preference to work in the region. Another

added advantage noted by respondents was that this is thought to enhance communication

between service providers and clients leading to better provision of services. Discussions

with health workers suggested that health workers from regions outside Northern Kenya

faced greater challenges as they had to orient themselves with the local culture and

language they were to successfully provide health services a highlighted by these quotes.

34

“In terms of [Isiolo] it is my home, now the experience is not that bad. I am used to

staying in Isiolo. And working with the community I normally understand them. But

when a new person comes and tries to see how people communicate with this people, it

might be quiet different but I am used to these people in the community.” (Health

Worker, Isiolo County)

“You see each and every community has its own norms and because you don’t

understand their norms you must be affected because to get used to their way of life

you have to change. Now changing you is what affects you”. (Health Worker, Lamu

County)

Interestingly, there were some differences in the choice of seeking employment in Northern

Kenya amongst women. Despite preference of some male health workers to work in the

region, some female health workers preferred to work away from home when still single in

search of adventure, as illustrated by the following quotes.

“Me I would like to work away from home, maybe you are not married, for example like

me, I work away from home”. (Health Worker, Garissa County)

“For me I think it (working away from home) will be a new experience and interacting

and meeting new people. At least I will go there stay like a year or two, see the people

the community if it is something I cannot bear then I will decide whether to stay or go.

But initially I think it will be good to, have a new experience and meeting new people”.

(Health Worker, Lamu County)

3.2 Current Staffing Levels and Vacancies

3.2.1 Staffing Levels and Vacancy Rates by Professional Cadre

The staffing levels in Northern Kenya are presented in Appendix 12. Current establishment

as computed by the MOMS and MOPHS as reported in the National HRH Report (2010)

stands at 118,954 against 35,714 staff in post [22]. The vacancy rate for both MOMS and

MOPHS is 24%. Using the above statistics and assuming that the establishment of 118,954

was to be normally distributed to counties as per the population figures of 2009 census, then

the overall vacancy rate in the 10 counties is 79%. This implies that the total health workers

in the 10 Counties should be 14,957 compared to 3,153 in post currently.

Using the above approach and again assuming that the establishment for the 10 counties is

to be proportional to the 2009 population census figures in each county, the vacancy rates

(Establishment less in post/Establishment) has been reported in tables 7a and 7b. As shown

in Table 7a, Mandera has a vacancy rate of 94%, mostly contributed by a high vacancy rate of

Doctors (99%), nurses (83%), Clinical officers (84%), and Laboratory staff (86%). Other

counties with high vacancy rates include Turkana (88%), Wajir (87%). On overall, the vacancy

rate for doctors, clinical officers, enrolled nurses, laboratory staff and pharmacy staff for the

10 Counties has been shown to be 82%, 59%, 30%, 52% and 60% respectively.

35

Table 7a: Vacancy levels by County in Northern Kenya - Establishment

County In post Establishment Vacancy Rate

Garissa 574 1,992 71%

Isiolo 316 458 31%

Lamu 204 325 37%

Mandera 188 3279 94%

Marsabit 334 931 64%

Samburu 287 716 60%

Tana River 239 767 69%

Turkana 315 2,734 88%

Wajir 275 2,116 87%

West Pokot 421 1,639 74%

Total 3,153 14,957 79%

36

Table 7b: Vacancy Levels by Cadre and County in Northern Kenya

County

Medical Officer Clinical Officer Nurses Laboratory staff Pharmacy Staff Other(Clinical) Total

A B C A B C A B C A B C A B C A B C A B C

Garissa 21 45 53% 80 118 32% 307 336 9% 24 47 49% 12 28 58% 130 1415 91% 574 1989 71%

Isiolo 5 10 52% 27 28 2% 194 78 -147% 17 11 -56% 8 7 -22% 65 330 80% 316 464 32%

Lamu 3 7 60% 27 20 -38% 102 56 -83% 15 8 -94% 8 5 -71% 49 234 79% 204 329 38%

Mandera 1 74 99% 31 195 84% 94 554 83% 11 77 86% 7 47 85% 44 2329 98% 188 3276 94%

Marsabit 8 21 62% 27 55 51% 190 157 -21% 18 22 17% 11 13 16% 80 659 88% 334 927 64%

Samburu 2 16 88% 22 43 48% 189 121 -56% 13 17 23% 7 10 31% 54 511 89% 287 718 60%

Tana River 2 17 88% 30 45 34% 128 129 1% 13 18 27% 6 11 45% 60 542 89% 239 763 69%

Turkana 7 62 89% 31 163 81% 179 463 61% 12 64 81% 10 39 74% 76 1947 96% 315 2737 88%

Wajir 5 48 90% 42 125 66% 151 357 58% 16 50 68% 8 30 73% 53 1500 96% 275 2109 87%

West

Pokot 7 37 81% 44 98 55% 248 278 11% 31 39 20% 7 23 70% 84 1170 93% 421 1645 74%

Total 61 339 82% 361 889 59% 1782 2529 30% 170 351 52% 84 212 60% 695 1063

7 93% 3153 1495

7 79%

Key

A – In Post

B – Establishment

C – Vacancy Rate

37

Table 7c: Vacancy Levels by County in Northern Kenya – WHO Recommendations

County Population

Health Workers

In Post

Recommended Number (assuming WHO

250 H/W per 100,000 population)

Vacancy

rate

Garissa 623,060 574 1,558 63%

Isiolo 143,294 316 358 12%

Lamu 101,539 204 254 20%

Mandera 1,025,756 188 2,564 93%

Marsabit 291,166 334 728 54%

Samburu 223,947 287 560 49%

Tana River 240,075 239 600 60%

Turkana 855,399 315 2,138 85%

Wajir 661,941 275 1,655 83%

West Pokot 512,690 421 1,282 67%

Total 4,678,867 3153 11,697 73%

3.2.2 Budgeted HRH

The advantage of understanding budgeted staff requirements (obtained using the

workforce-to-population ratio approach for HRH benchmarking) is that the approach is quick

and simple to apply. Also, it may be used for comparative analyses across regions, countries

and over time. It is also easy to be understood by a wide range of audiences including those

who might not be familiar with more advanced statistical modeling techniques. However,

this approach does not take into account any other variables, aside from population size,

which are known to play a part in determining the impact of health workforce performance

on health outcomes in a given context. These other variables include population structure,

epidemiology and burden of disease, patterns of service and provider utilization;

organizational efficiency; health policies, regulations and standards; technological capacity;

distribution of the health workforce by occupation, place of work and socio-demographic

characteristics; individual provider performance; public demand and expectations; and,

availability and means of financing. Approaches to HRH benchmarking that take into account

any or all of these factors are much more demanding in terms of data requirements and

model specification. These calls for a better approach in getting HRH staff requirements in

any region or country and this shall be a step in obtaining vacancy rates.

During the process of data collection, data for budgeted staff for Northern Kenya was

sourced from the two ministries of health for the financial year 2010/2011. However, it was

not possible to get these numbers because the officials in the Department of Human

Resources at the MOMS (Appendix 16) informed us that additional staffing requirements in

the MOPHS and MOMS are just based on agreed staffing numbers as discussed by senior

officials in the two ministries. Once this number is approved, the two health ministries decide

on staff distribution depending on the County vacancy needs assessment. To be able to

address this question, we used recommended staffing requirements for the five cadres

studied in Northern Kenya using the 2009 population census and the ratio of cadres

distribution by KEPH levels (2-5) [31].

The vacancy levels as presented in Tables 8a to 8d show that a high number of HRH is

required across all the counties in Northern Kenya using the WHO recommended HRH

staffing levels per 100,000 population across all KEPH levels (2-5) [31]. Also it can be seen

that Isiolo and Lamu counties have got the highest vacancy levels in Northern Kenya using

the current staff in post and WHO HRH staffing levels per 100,000 populations [31].

38

Table 8a: Levels of Vacancy per WHO 100,000 Population Recommendations (Financial Year 2010/2011) by KEPH Level (2) by Cadre

Doctors Clinical Officers Nurses Laboratory Staff Pharmacy Staff

Counties

WHO

per

100,000

Pop. Actual

Vacancie

s

WHO

per

100,00

0 Pop. Actual

Vacancie

s

WHO

per

100,00

0 Pop.

Actua

l Vacancies

WHO

per

100,00

0 Pop. Actual

Vacancie

s

WHO

per

100,000

Pop.

Actua

l

Vacancie

s

Garissa 0 0 0 33 1 32 2298 26 2272 10 0 10 0 0 0

Isiolo 0 0 0 8 2 6 6313 27 6286 2 0 2 0 0 0

Lamu 0 0 0 5 2 3 4684 14 4670 2 1 1 0 0 0

Mandera 0 0 0 55 0 55 427 4 423 16 0 16 0 0 0

Marsabit 0 0 0 16 1 15 3043 50 2993 5 0 5 0 0 0

Samburu* 0 0 0 12 0 12 3123 41 3082 4 2 2 0 0 0

Tana River 0 0 0 13 1 12 2486 21 2465 4 0 4 0 0 0

Turkana* 0 0 0 46 1 45 801 21 780 14 0 14 0 0 0

Wajir 0 0 0 35 0 35 1064 11 1053 11 0 11 0 0 0

West Pokot* 0 0 0 27 2 25 2083 48 2035 8 2 6 0 0 0

39

Table 8b: Levels of Vacancy per WHO 100,000 Population Recommendations (Financial Year 2010/2011) by KEPH Level (3) by Cadre


Counties

WHO

per

100,00

0 Pop.

Actu

al Vacancies

WHO

per

100,000

Pop. Actual Vacancies

WHO

per

100,000


WHO

per

100,000


WHO

per

100,000


Garissa 56 0 56 100 3 97 1757 17 1740 50 1 49 13 0 13

Isiolo 13 0 13 23 2 21 4828 15 4813 11 3 8 3 0 3

Lamu 9 1 8 16 3 13 3582 10 3572 8 2 6 2 0 2

Mandera 93 0 93 165 2 163 327 10 317 82 0 82 22 0 22

Marsabit 26 0 26 47 1 46 2327 13 2314 23 0 23 6 0 6

Samburu* 20 1 19 36 3 33 2388 23 2365 18 3 15 5 0 5

Tana River 22 0 22 39 6 33 1901 21 1880 19 5 14 5 0 5

Turkana* 77 1 76 137 0 137 613 9 604 68 0 68 18 0 18

Wajir 60 0 60 106 1 105 813 7 806 53 0 53 14 0 14

West

Pokot* 46 0 46 82 9 73 1593 49 1544 41 11 30 11 4 7

40

Table 8c: Levels of Vacancy per WHO 100,000 Population Recommendations (Financial Year 2010/2011) by KEPH Level (4) by Cadre


Counties

WHO

per

100,00

0 Pop. Actual

Vacancie

s

WHO

per

100,000

Pop.

Actua

l

Vacancie

s

WHO

per

100,000

Pop. Actual

Vacancie

s

WHO

per

100,000

Pop. Actual

Vacancie

s

WHO

per

100,000

Pop.

Actua

l Vacancies

Garissa 657 5 652 855 24 831 8380 54 8326 241 4 237 235 4 231

Isiolo 151 5 146 197 23 174 23024 144 22880 55 14 41 54 8 46

Lamu 107 2 105 139 22 117 17084 76 17008 39 11 28 38 8 30

Mandera 1082 1 1081 1408 27 1381 1558 77 1481 397 11 386 387 7 380

Marsabit 307 6 301 400 22 378 11097 111 10986 113 18 95 110 11 99

Samburu* 236 1 235 307 19 288 11391 86 11305 87 8 79 85 7 78

Tana River 253 2 251 329 22 307 9067 85 8982 93 8 85 91 6 85

Turkana* 902 4 898 1174 27 1147 2923 104 2819 331 12 319 323 10 313

Wajir 698 5 693 908 41 867 3879 132 3747 256 16 240 250 8 242

West

Pokot* 541 7 534 704 31 673 7596 127 7469 199 16 183 194 3 191

41

Table 8d: Levels of vacancy per WHO 100,000 population recommendations (Financial Year 2010/2011) by KEPH level (5) and cadre for the 10 counties


Counties

WHO

per

100,0

00

Pop. Actual

Vacancie

s

WHO

per

100,000

Pop. Actual

Vacancie

s

WHO

per

100,000

Pop. Actual

Vacancie

s

WHO

per

100,000

Pop. Actual

Vacancie

s

WHO

per

100,000

Pop. Actual

Vacancie

s

Garissa 225 13 212 122 39 83 1216 147 1069 26 13 13 16 5 11

Isiolo 0 0 0 0 0 0 0 0 0 0

Lamu 0 0 0 0 0 0 0 0 0 0

Mandera 0 0 0 0 0 0 0 0 0 0

Marsabit 0 0 0 0 0 0 0 0 0 0

Samburu* 0 0 0 0 0 0 0 0 0 0

Tana River 0 0 0 0 0 0 0 0 0 0

Turkana* 0 0 0 0 0 0 0 0 0 0

Wajir 0 0 0 0 0 0 0 0 0 0

West

Pokot* 0 0 0 0 0 0 0 0 0 0

Source for Tables 8a – 8d: Actual – MOPHS/MOMS HRIS 2012 and (*) actual staff data obtained from County offices

42

3.3 Assessment of Adequacy of Staffing

HRH adequacy in Kenya and especially in Northern Kenya needs to be assessed and

addressed with urgency. This is to ensure the equitable allocation of Government resources

to reduce disparities in health status especially in Northern Kenya which has been

marginalized for a long span of time. HRH staffing in Northern Kenya has been a challenge

for the GOK and addressing these issues is a key priority in the helping in achievement of

health-related MDGs and Kenya’s Vision 2030.

3.3.1: Rates of Staffing across Northern Kenya

To be able to assess the staffing frequency in Northern Kenya, we accessed and studied the

staffing levels in Northern Kenya under the KEPH concept. The rate of staffing across the

region is not adequately distributed with respect to the population estimates of 2011 based

on the 2009 population census and as per the annual population growth rate of 3%. Table 6

gives the current number of doctors, clinical officers, nurses, laboratory staff and pharmacy

staff per 100,000 populations in Northern Kenya. The current staff ratio in all counties falls

below the national average workforce-to-population ratios. The vacancy rates in the 10

counties are disproportionate in the sense that some counties have got very high vacancy

rates in the region (Table 7a, b & c). This further complicates the situation in the ground

calling for an urgent and speedy action by both the GOK and other healthcare stakeholders

so that the region may not lag so much behind in the achievement of the health-related

MDGs and Kenya Vision 2030.

3.3.2: Health Worker Migration Between Counties in Northern Kenya

HRH migration within and between Northern Kenya Counties complicates the HRH

challenges facing the region as a whole. Migration of health workers in Northern Kenya was

further examined using staffing and vacancy rates as shown in Table 9.

Table 9: Internal Migration of Nurses from County to County Within Northern Kenya (All KEPH

levels 2-5)

FROM

TO

Garissa

Isiol

o

Lam

u Mandera Marsabit Samburu

Tana

River Turkana

Waji

r

West

Pokot

Los

s

Differen

ce

(Gain)

Garissa - 8 13 21 28

Isiolo 1 - 1 2 -2

Lamu - 1 1 -1

Mandera 9 - 6 15 3

Marsabit - 0 0

Samburu - 0 0

Tana

River - 0 0

Turkana - 0 1

Wajir 39 9 - 48 -28

West

Pokot 1 - 1 -1

Gain 49 0 0 18 0 0 0 1 20 0 0

Source: Provincial Doctors in North Eastern, Eastern, Rift Valley and Coast Provinces, Data not obtained for these

counties

43

Table 9 shows that Garissa County has greatly benefited from the migration of HRH from

other counties. Though there is little documentation of reasons as to why most staff moves

to Garissa County, most probable reasons are good local infrastructure, security among

others. Mandera seems to have some ‘pull’ factors that include few reported cases of

insecurity, improved social amenities which may be attributed to many establishments by

international humanitarian agencies in the regions’ counties. Also ‘push’ factors in Isiolo,

Mandera, Wajir and West Pokot need to be examined and include lack of security, poor

remuneration, an environment of abject poverty and poor infrastructure [2], [37].

3.3.3 Views on Current Staffing in the Northern Kenya in the Light of National Staffing

Norms

Perception of Health Workforce on Staffing Levels in Northern Kenya: Inter-and-Intra

County Variations

Health workers from all counties observed that variations exist in the distribution of

workforce in Northern Kenya compared with other places in the country. Intra country

variations in staffing were also reported with some counties being hard hit with inadequate

staff than others. Such a scenario results to high workload among the health staff in

Northern Kenya:

“The more you go to the interior, the worst [staffing variations] it become. It [staffing] is

not fairly distributed.” (Health Provider, Wajir County)

“I think the problem is in this hospital because when I went to Thika, the staff were so

many. We were even running for our clients instead of clients coming to us. So there are so

many there while we are very few here. And also some hospitals have students to assist

them unlike our hospital. Here we have a lot of challenges. Those dispensaries are in the

interior. It’s a big problem because the dispensary cannot be able to keep that class.”

(Health Provider, Samburu County)

When asked about staffing gaps, a health worker in Garissa posted to work in level 4 type of

heath facility mentioned that they only had 35 staff present whereas the staffing expectation

for the facility is 60.

“Right now we are four but two are on contracts which are ending this month now we

are going to remain with two and the work load is very hard you see.” (Health

Worker, Garissa County)

Reasons for Health Worker Shortages in Northern Kenya

Health workers reported a number of challenges that drive the shortage of health care

workers in Northern Kenya. Findings indicate that health care providers in all counties were

uncomfortable with the low remuneration paid to the work force in the public sector.

Consequently, some are unable to cope with the high cost of life since they are expected to

cater for basic needs of their families. This diminishes the morale of most health staff who

feel less compensated for the heavy work they perform in the health sector. Instead, the

majority seek for jobs in NGOs that pay better than the public sector:

44

“… The salaries are very low, so they [health workers] prefer even going to work for

locals in town than working here [at a public health facility]. So they [health providers]

get employment then they disappear.” (Health Worker, Marsabit County)

“The salary is less, there is a lot of work, house rent, and I work day and night. Am

alone. If it’s an NGO and they are paying me good, I cannot mind [quitting]. I can work

in Dadaab.”(Health Worker, Marsabit County)

Results show that better employment opportunities in Northern Kenya exists in sectors that

offer attractive packages to the health staff. For example, international NGOs that operate in

places like Lamu, Garissa and Mandera offer better pay compared to the ones offered in the

Public sector. When health workers get such opportunities in either Northern Kenya or

Southern Sudan, they quit their work stations immediately thereby creating shortage of staff

in health institutions in Northern Kenya:

“If I get another good opportunity I shift, and that is not a secret, I quit

immediately.”(Health Worker - Private, Lamu County)

“So therefore now people are going to southern Sudan. Myself even in three months am

going to south Sudan, I got posted there. You see, the Kenyan system is one of the

widely accepted; you can work anywhere, any part of the world.”(Health Worker-

Private, Garissa County)

Health workers in private health facilities from Isiolo and Samburu counties expressed

concerns over insecurity in their areas that makes many health workers to prefer working in

more secure areas outside Northern Kenya. The health workers fear for their lives and a

desire to remain safe hinders many from taking up their posts when posted to volatile

counties like Isiolo and Samburu:

“You see like the issue of insecurity. Like where I come from, I have never been to Isiolo

before. And we are watching the news how the people are been killed, they are fighting,

so if you would hear that you are coming to Isiolo, it is better that work stays.” (Health

Worker- Private, Isiolo County)

“The insecurity is the cause of lack of filling of the posts. When I tell them I’ve come

from Samburu the first thing they would say is wow! That insecure place where people

are shooting each other. So when you hear you are posted to Samburu and you are

from that area, the stigma first sets in, the way you think about the guns being here.”

(Health Worker- Private, Samburu County)

It was established that insecurity in the Isiolo and Tana River counties hinders many health

workers from taking up their posts in the area. Managers from these areas emphasized that

many workers fear being robbed and killed for no apparent reason, that sometimes happens

even when offering health services during out-reach missions. For these reasons, many

health workers decline to work in these two counties:

“There are so many problems [in Northern Kenya] one of them is insecurity. They

[bandits] stop you, rob you and then beat you up.” (Health Manager, Isiolo County)

45

Results also indicate that many counties like Marsabit and Isiolo lack adequate medical

facilities to enable health providers offer quality services to patients. In the absence of basic

commodities such as drugs, some health providers become disillusioned and either seek

transfers or resign from their posts leading to shortages of staff:

“…There are a lot of challenges in working in these areas, even for those of us who are

coming from around. You are prepared to come and work, you are equipped at the

training level, so when you come to the facility, there are a lot of challenges, like what

he said. You are in a facility, where there are no delivery services; there are emergencies

you need to attend to, like when there is a mother who is bleeding, you start now

looking for transport to a hospital which is some distance away, you know. Also there is

no even communication, maybe even network for calling; you end up struggling with

this mother, maybe even losing her. Even there are no equipments, so I think there are

a lot of challenges in working and as pertaining the staff, the staff show their different

colors.” (Health Worker- Private, Marsabit County)

Service providers in most counties stated that they lacked infrastructure such as supply of

electricity and medical commodities to enhance provision of high quality services. This issue

was more prevalent in Tana River and Mandera Counties. This makes health workers to feel

marginalized and lack motivation to serve the needy as expected by their profession. Some

service providers utilize their own cash to facilitate provision of services. For instance, some

hire means of transport using their own cash in order to deliver important commodities like

drugs to health centers:

“... there’s no water in the dispensary, or there’s no electricity I think it’s harder; and also

there are no roads; the doctors always hire motorbikes to carry drugs; out of his

pocket.” (Health Worker- Private, Tana River County)

Health administrators, unlike health providers and managers, did not perceive low

remuneration as a very big challenge to them. This could be because the majority merely

posses certificate courses that do not require too much payment. Only few health

administrators pointed out the challenge of low remuneration:

“At the end of the day, you find that if you get hold of your salary, you are left with

nothing. You distribute back home, you pay school fees for the kids and then you are

left with the rent which you pay. You start applying for a salary advance. So, when you

get an opportunity you will run away.” (Health Administrator, Garissa County)

“That person is not used to that environment [of Northern Kenya] since he was born, so

it’s like when he comes he starts to develop…..He starts to adapt to the new

environment. It depends on the way he will take up the environment. Some of them

take it negatively (and leave…).” (Health Manager, Turkana County)

Health administrators complained about the hardships in counties like Tana River and Pokot

that discourage them from working in the region. In Tana River, for example, there is limited

fresh water. Yet the use of contaminated water could affect the health of health staff

negatively. In Pokot County, health administrators complained about the harsh climatic

conditions that make it unbearable to work in the region:

46

“When you use contaminated water; it has some parasites that will penetrate and form

a clog in your blood.” (Health Administrator, Tana River County)

“On my side first I can say it’s a hardship area compared to where I was in Bungoma;

the population side, it’s not too large and then also the facilities are scattered; then also

the climatic conditions are not favorable.” (Health Administrator, Pokot County)

“… Hardship area; if you go to a place like Kacheliba, life there is so hard; you don’t get

drinks or food; the people there think that every place is like that.” (Health

Administrator, Pokot County)

Limited funding that hindered staff from accessing transport when it was needed was seen

to be de-motivating. The available vehicles were old and kept breaking down such that they

could not be relied upon in emergency cases. This endangered lives of people who may

require urgent medical attention in cases of cattle rustling or any other emergencies:

“The funding is not enough, comparing actually with other ministries which are not in

the ministry of health, so at times, we are not even getting vehicles, we are not able to

pay allowances for the staff when there is even a referral, getting vehicles is an issue,

the vehicles we operate are 10 years old, if you compare with other departments like…

there is a place in Northern Kenya, those guy push vehicles, like now the hospital here, I

think our vehicles are junks, they go breaking all the time on the road.” (Health

Administrator, Isiolo County)

Perceptions of Health Administrators on Staffing Levels in Northern Kenya - Inter and

Intra County Variations

Health administrators, just like other cadres interviewed, felt that staffing levels were

inadequate compared to other regions in Kenya. The few health workers are made to

shoulder very heavy burdens because of the imbalance between health providers and

patients. In Isiolo District, lower cadres like nurses are forced to perform duties of higher

cadres such as those of doctors and clinical officers:

“I am on leave but previously I have really experienced a lot of shortages of staff in this

facility. Like, for example, you are supposed to man a whole ward which is supposed to

be having more than fifty patients in a day. So that is already a shortage. One nurse

covering actually a whole ward for a whole day. A ward that has around fifty patients,.

so there is a lot of shortage in that side”. (Health Administrator, Isiolo County)

“ Even in the health centers, we don’t have clerical officers there, so the work which is

supposed to be done by clerical officers there, it is done by nurses.” (Health


In Marsabit and Pokot counties, health administrators stated that insecurity due to cattle

rustling in the region kept workers in-doors as early as 6.00pm. It was established that cattle

rustlers could kill anyone they met irrespective of the importance of the individual in the

community. The fear of losing lives to cattle rustlers hinder many health workers from

working in Marsabit and Pokot counties:

47

“I don’t go beyond 6p.m. these people with red clothes like Red Indians, they won’t say

you are so and so, they kill anyone. Many people have been killed on this road to Isiolo

even students.” (Health Administrator, Marsabit County)

“We’ve been hearing of the Northern part of Kenya about the cattle rustling ad all; so

when he/she comes, they first want their life to be secure.” (Health Administrator,

Pokot County)

Perception of Managers on Staffing Levels in Northern Kenya

Managers in all counties maintained that staffing levels in Northern Kenya were markedly

lower than in other parts of the country. In terms of variations in staffing levels between

counties, these were noted as well, with one respondent stating that staffing in Garissa was

better than in Wajir:

“In Garissa there is a medical training facility and college that even assists them in staff

by getting students but in our situation even we don’t have facility here and Garissa is

far much better when it comes to staffing.” (Health Manager, Wajir County)

“There’s no specialty; like if you are a lab technician you cannot work in a lab only; if

you see in another department the work load is high you have to go and assist.”

(Health Manager, Turkana County)

Variations in Staffing Levels:

There are very distinct variations with regards to Health workers staffing in Northern Kenya.

These are described by country hereafter.

Garissa:

This county is perceived to have more staff across different cadres and KEPH levels as

compared to other counties of Northern Kenya. Garissa compared to districts like Wajir and

Mandera, is perceived to have better road and telecommunication infrastructures as well as

key social amenities. Most of the health workers we talked to preferred settling in Garissa as

opposed to Wajir Mandera and Tana River. The key factor was ease of access to other

regions outside Northern Kenya mainly Nairobi as well as proximity to the Dadaab refugee

camps. This was key for the health workers looking for work with NGOs. Most of the NGOs

stationed at Dadaab refugee camp preferred to employ health workers from Garissa and

especially Nurses. At facility level, the Provincial Hospital (Level 4) is perceived to be well

equipped and serves the whole of Garissa and neighboring counties such as Mandera and

Wajir where it acts as a referral hospital for North Eastern region.

Wajir/Mandera:

Due to banditry and perceived harsh weather conditions, health workers rarely have an

interest to work in Wajir or Mandera. The road networks are poor which makes it impossible

to access these two towns during the rainy season. Health workers mention that they

attribute the lack of proper facilities and instruments to work, with issues of accessibility of

these two towns. Most of the health workers interviewed mention that, they work through

partnership programs from NGOs such as Capacity Kenya, which provides better

remuneration terms as compared to public sector.

48

Tana River:

The health workers in Tana River cited that, their biggest issue was lack of interest from the

community in accessing health facilities. Most of the locals prefer consulting witchcraft and

prefer home based delivery. This essentially means that the facilities are underutilized.

Lamu:

There were no striking issues of understaffing in Lamu compared to the other Northern

Kenya regions. However, it was reported that there was lack of opportunities for staff to

further their careers since Lamu is landlocked and does not have any college or institutions.

Due to lack of institutions where staff can take extra courses as they continue working makes

it less ideal for working as compared to Garissa.

West Pokot/Isiolo/Turkana:

Similar to Wajir and Mandera, West Pokot and Turkana are perceived to hardship area due to

high insecurity, poor road network to the rural parts of the counties, harsh weather that

drives cost of food high as well as lack of water during dry season. In addition, it was pointed

out that inadequate health equipment makes it difficult for the health workers to perform

their duties effectively.

Managers in all counties expressed concern over the low remuneration in the public health

sector. Most managers possess higher education and professional qualifications than the rest

of the health workforce. Some are graduates and post-graduates that perhaps pushed them

to seek better remunerated jobs. In order to cope with low remuneration, some managers

ran businesses to supplement their salaries that in turn could result in poor quality health

services:

“Working at this place [Mandera]….(is not attractive). The government pays very little,

so we also balance and while I was with the ministry of health I opened a small

chemist, I was running it after my work so I would just come here to do my records then

later on I found out it was better to work in the private sector than sticking to the

government. if it’s an NGO and they are paying me good I cannot mind. I can work in

Dadaab.” (Health Manager, Mandera County)

Results show that managers, despite having seniority, are paid very minimal incentives to

retain them in Northern Kenya. In order to cope with minimal financial returns, most

managers prefer to work in urban contexts with plenty of opportunities for additional

income generation compared with working in rural areas:

“The incentives that we [managers] are given compared to someone who is working in

a different place [are very low]. Look at something like house allowance, actually house

allowance is much lower than someone in a town. The assumption being maybe that

the rents are low, this is not true. Also if you look at something like the hardship

allowance, it’s not worth keeping you in some of those areas, and in towns there are

opportunities of getting more work and also income generating activities, so there are

more opportunities than some of those areas.” (Health Manager, Lamu County)

Managers in Turkana and Mandera counties felt that international NGOs attract most health

staff because of better remuneration. This enables health workers to meet basic needs of

their families and feel well compensated for the services they provide to the community:

49

“I think it’s attributed to the presence of NGOs; international organizations; because I

remember we have UNHCR and others; so what happens those are internationals and

can take you across the border; then if you are given something good, why stay? So the

turnover is high.” (Health Manager, Turkana County)

“Some [health staff] might resign because there are many NGOs in this region. Because

of the poor pay most of the staff might resign.” (Health Manager, Mandera County)

Managers from Tana River, Turkana and Mandera counties perceived their areas as hardship

regions in terms of climate, poor infrastructure, lack of medical commodities and basic

necessities. In view of the limited hardship allowance, most health workers feel hesitant to

work in such environments with minimal returns. Some seek transfers to better regions in the

country leading to staff shortages in Northern Kenya. The situation could be reversed by

increasing the hardship allowance provided to health workers in these areas:

“That person is not used to that environment [of Northern Kenya] since he was born, so

it’s like when he comes he starts to develop. “ (Health Manager, Tana River County)

“There’s only something called hardship allowance which is 1,800, very little. I think the

salary should be higher ….higher than that of staff working in other good parts of

Kenya. If the roads were good; they’d go home see their people and then come back;

and of cause even these vegetables and fruits would come to these sides more and

maybe they’d be cheaper…another problem I’m seeing is…housing issues. …in the

market, there are no houses to rent; and then the other thing is maybe sponsorship; if I

wanted to go for a course in nursing… many people could be given sponsorship or

scholarship as a motivation…” (Health Manager, Turkana County)

“Generally its mainly high staff turnover, more staff resigning for greener pastures

especially in NGOs and maybe low motivation of staff sometimes you are posted to a

rural place, you don’t get the supplies most people don’t want to work in hardship

areas, so they will seek their own ways to go to the national level, maybe using

influential people to get out of the place.” (Health Manager, Mandera County)

Managers further stated that there is a general lack of medical equipment, drugs and other

necessary commodities in health facilities in Northern Kenya. The issue is more critical in

Lamu, Pokot and Mandera counties where by the available x-ray machines keep on breaking

down due to poor maintenance. Health providers are left without equipment to support

them in delivery of high quality medical care to patients. This makes health workers to loss

morale of working in these areas and could seek for transfers. The morale of health workers

could be boosted through provision of a budget to health facilities for maintenance of

equipment and regular supply of medical commodities:

“The other challenges are on terms of maybe breaking down of our machines like X-

ray, like laundry machine, like measuring machines. We have been facing those

challenges.” (Health Manager, Lamu County)

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“The equipments are not there. We don’t get our supplies on time.” (Health Manager,

Pokot County)

“It’s not only the salary that motivates you because you when you get a patient and

you can’t help that patient in your rural place it is frustrating you might even lead to

resignation because there is nothing you are doing for the community, so I think that

itself is de-motivating. Also there is the other issue of high staff turnover.” (Health

Manager, Mandera County)

Managers in Tana River complained about poor road networks and state of roads while

those in Mandera were more concerned about communication challenges that hinder them

from accessing basic needs like food. The absence of basic supportive infrastructure has over

time led to a sense of marginalization amongst the health work force and inhabitants of

Northern Kenya. For health workers, this only increases the desire to work elsewhere which

has resulted in high turnover in Northern Kenya:

“Poor infrastructure in terms of roads and housing are major to us.” (Health Manager,

Tana River County)

“There is no accessibility of communication, you can be posted in a remote area where

there is no communication network, and then there is a challenge of getting food in some

places”. (Health Manager, Mandera County)

Health Manager’s Views on Levels of Deployment and Re-Deployment

Differences were seen when views regarding the level at which deployment is undertaken in

Northern Kenya were given. Whereas managers in Marsabit and Isiolo counties stated that

deployments are done at a centralized location in Nairobi, managers in Lamu, Pokot and

Tana River counties said that deployment is done at the local level. When deployment is

done at Nairobi, managers complained of low-uptake of posts due to reluctance of health

workers to venture into harsh working environment of Northern Kenya.

“The local one [recruitment] was done only once through the courtesy of ESP

programmes. Otherwise recruitments are done at the headquarters level. Thus we

[health managers] are getting problems of people coming here [or low up-take of

employment offers in the health sector]”. (Health Manager, Marsabit County)

“The recruitment you know is done centrally, the only time we have recruited is this

time of the ESP but recruitment is done centrally by the government and the Ministry

and then people are posted.” (Health Manager, Isiolo County)

“The posting for coast region, it is done at the provincial level. The posting at the county

level is done at the district level. …. Ours is not a posting. Ours is just a movement. We

are moved from this ward to the other ward. Ours is just a movement.” (Health

Manager, Lamu County)

Workload as a Determinant of Re-Deployment

Managers in Tana River and Marsabit counties observed that the work load often determines

whether or not deployment and re-deployment takes place in Northern Kenya. Some areas

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51

in Northern Kenya have low uptake of medical services. Such areas do not need many health

workers as opposed to areas that are busy such as towns. To this end, managers post staff

depending on demand for medical services in Northern Kenya:

“You are posting people but based on work load, if you compare this hospital with

another hospital, like compare this, this is a district hospital, compare it with Malindi

hospital, work load, will you post a person here, Ngao here, you will say if I post

somebody in Ngao, there is no work, he will just go to sleep because those who are here

already are saying there is no work. ..The community, they are not utilizing the facility

due to long distance… the community doesn’t have the potential for money, you know

you look at the community in terms of business, in this areas the business is not good,

transport if bad”. (Health Manager, Tana River County)

“Yes, we sit down as the DHMT and identify the needs; we look at the workload, how

busy is the faculty and the distance of that facility from the town, looking at the

distance and the service need, the volume of work we post people and if the facility is

busy we tend to give more staff. If the facility is far we give more workers reasons being

if the facility service is far from the town. In the rural there is basically nothing in those

places, they are no shops and no gardens to plant things to survive on, so what we do

we tend to send more people so that they get time so that they come and do their

shopping the other two are working. But if there is only one worker in that facility,

when that person comes to Marsabit town to shop the facility is closed. Definitely, you

cannot prevent that person from shopping since that is how he survives.” (Health


Despite the workload determining deployment, managers in Tana River County lamented

that some politicians and senior staff at the headquarters influence the process and ignore

the laid down policy regulating the process. When this happens, health managers are left

helpless because they lack power to influence the process with a view to retaining health

staff in Northern Kenya as per the demands. In cases when Northern Kenya is used to recruit

staff, the newly employed staff seek transfers immediately and leave Northern Kenya with

perennial shortage of medical staff:

“The normal procedure is, posts are being given from top [influential people at the

ministry] then they are posted to these places but they are not recruited or posted within

these places.” (Health Manager, Tana River County)

“…Many people were coming from outside the county and after sometime maybe

somebody works for one year and then they go for transfers and we saw it was a sort of

tribal sort of a thing, those who were recruited knew those who were recruiting so

somebody comes with maybe around ten people and says am employing this number in

this facility or in this county but after sometime because they are not from within they go

and they leave.” (Health Manager, Pokot County)

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3.4 HRH Reporting in Northern Kenya

3.4.1 (a) HRH Reporting in All KEPH Levels (2-5) in Northern Kenya

Regional HRH acceptance and reporting rate were examined to understand the rates at

which trained HRH from Northern Kenya report to their posts and work at health facilities in

the region. This was done with a focus on nurses through data received from the two health

ministries that described current staffing levels and by county of birth for all cadres in all

KEPH levels (2-5) in Northern Kenya Counties.

The Nurses Council of Kenya (NCK) is the body which registers all trained and qualified

Nurses in Kenya and maintains an updated database. Updated data on nurses’ district of

birth, County schooled, whether they are qualified and currently working in Northern Kenya

was obtained from NCK. Table 10 below represents the nurses reporting across all the 10

counties in Northern Kenya. From Table 10 below we find that the 54% (935/1,735) of Nurses

who studied and completed secondary school in other parts of Kenya while 46% (800/1,735)

of Nurses were currently deployed who had completed secondary school in Northern Kenya.

Although there is a slight difference between the two groups, we must note that this may

also suggest the need to increase the number of nurses currently working in Northern Kenay

whose home districts are within the region. Benefits in targeted recruitment of nurses from

Northern Kenya will also help in improved health service delivery through better

communication (familiarity with local culture and language) and ultimately contribute

towards achieving MDGs and vision 2030.

53

Table 10: Number of Nurses (KEPH Levels 2 – 5) Who Completed Secondary Schooling Elsewhere but Work in Northern Kenya

LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

COUNTIES

Completed

school in NK

Completed

school

elsewhere

Completed

school in NK

Completed

school

elsewhere

Completed

school in NK

Completed

school

elsewhere

Completed

school in NK

Completed

school

elsewhere

Marsabit 19 31 14 15 61 50 0 0

Isiolo 17 10 9 14 59 85 0 0

Wajir 7 4 3 5 32 53 0 0

West Pokot 35 18 33 22 59 81 0 0

Garissa 15 11 31 26 42 35 87 60

Turkana 7 16 9 23 52 72 0 0

Samburu 20 31 25 8 30 75 0 0

Mandera 5 2 6 4 29 48 0 0

Lamu 9 5 7 5 31 46 0 0

Tana River 13 8 8 13 26 59 0 0

Source: NCK Database 2012

54

3.4.2 Influences on Staff Recruitment in Northern Kenya

Health Worker Views on Recruitment Process

Health workers in all counties of study maintained that job opportunities are advertised in

local newspapers. This approach is employed to provide all potential employees with equal

chances of participation since newspapers circulate in all counties in Kenya. Candidates then

apply for varied posts and are invited for interviews to establish their suitability in taking up

the posts:

“There was an advertisement, then we applied and later we were called for an interview

and luckily I secured a chance. The government advertises through the newspapers

mostly, and then after you apply for the relevant post, then you do an interview. The

interview can be done within the provincial level of the district level, when you go there

you may get your post if you are not many, sometimes they don’t even fill up because

of the shortage. We got an advert from a news paper, I applied, I was shortlisted for an

interview, after some time we were shortlisted as successful candidates and we went to

pick our letters from the headquarters and I found myself in Samburu.” (Private

Health Provider, Samburu County)

“Like in the public service it’s just advertised on paper that there’s this job and then the

people apply; like us we applied for vacancies we were shortlisted and went to the

public service commission in Nairobi and did an interview and then we were offered the

appointment.” (Private Health Provider, Tana River County)

Deployment is done by the Ministry of Health. Changing from one post to another is subject

to availability of staff that are willing to work in Northern Kenya. However, due to the harsh

environment and the infrastructure challenges, there is low interest across all cadres of to be

transferred to Northern Kenya health facilities. At the district level, the Hospital Management

Team (DHMT) is responsible for transfers. The DHMT personnel get applications from

interested staff who seek transfers and they are the ones who either approve/disapprove the

transfer request.

Willingness to Take Up Posts

Private health providers in Turkana County observed that few workers are willing to take up

their posts due to the harsh environment in Northern Kenya. The situation is worse when

recruits are posted to the interior of the county. Many of them decline the postings offered:

“In February when we advertised for nurses to take up the rural areas, out of the 20,

those who came were just only 8 from outside; and again when they were told that

they were going to go to the interior they declined the offer and they went back, so we

were still missing 8 chances for nursing department to work in the rural area; they’ve

not been found.” (Private Health Provider, Turkana County)

Although health workers in Marsabit County supported re-deployment of health workers,

they cautioned that the policy could be abused if not well managed. They feared that some

senior staff could misuse the policy to re-deploy staff they do not get along well with. To this

end, measures should be put in place to safeguard health workers from unnecessary

transfers to other stations within Northern Kenya:

55

“Some participants were afraid of an abuse of the deployment policy. In participants’’

own words, “...[at we have to give our technical inputs because sometimes they might

even be re deploying somebody who has been very hard working but maybe somebody

wants him out of that position.” (Private Health Provider, Marsabit County)

Faith based organizations had a different approach to deployment of staff to work in

Northern Kenya. While health workers in public health facilities get re-deployed from the

headquarters, the faith based deployment and re-deployment is subject to sponsorship from

the faith institution. The church institution decided on where to post a health worker which

happened upon request from the health worker:

“No this is determined by the institution by itself, so like here, we are under this

institution and it is us… you cannot transfer somebody from here to another place

unless he himself likes it and you will not call it a transfer…. because you do not have

that capacity to take somebody from this facility to another facility.” (Private Health

Provider, Wajir County)

With regards to the retention of staff, it was observed that most of the faith based staff opt

for government jobs due to perceived “better remuneration”:

“Well, yeah, like you know at the facility there is a time we got some whom they had

been pushed here, they came here through Faith Based, to work with the Faith Based

organization but then when the government announced recruitment of staff, they

jumped over the other side because their terms were good. A number of them have left

me here.” (Private Health Provider, Wajir County)

These statements suggest that some FBOs perhaps offer a less attractive package when

compared with public health institutions. The parallels drawn here are that health workers in

both faith-based and public health institutions are subject to the same kind of challenges

that Northern Kenya provides and also the expectations are almost similar as opposed to the

notion that institutions outside the public sector are better off.

Health Administrator’s Views on Recruitment Process

Health administrators just like service providers’ concurred that job opportunities had been

advertised in the local newspapers. Qualified candidates applied and were invited for

interviews by the Public Service Commission:

“Through an advertisement in the newspaper then we applied. Recruitment was done

[through interviews conducted] by the Public Service Commission and the Ministry of

Health posted successful candidates. The Permanent Secretary and staff know which

facilities require staff.” (Health Administrator, Samburu County)

Influence of Ethnicity and Place of Birth on recruitment

Managers from Pokot, Marsabit and Samburu counties prefer to deploy staff from Northern

Kenya because they are likely to accept the posting and stay longer than health staff from

outside the province. They assume that local people already understand the hardships in the

region and may be willing to bear with them unlike people from other parts of the county

56

who often decline to take posts in Northern Kenya. Managers in Marsabit County stated that

they prefer local staff to enhance acceptability of medical interventions:

“…if you have somebody with minimum requirements and skills, I have to be biased to

choose somebody from the local a tribe which exists there.” (Health Manager,

Turkana County)

“It [deployment] falls [is influenced by] on a tribal line, you see those people who are

recruiting maybe coming from different communities and especially the communities

that are small like these ones of Northern Kenya like the Pokot now, maybe they don’t

have a representative there so during recruitment they are left behind, they are given

less chances so I think that is just our issue”. (Health Manager, Pokot County)

‘You cannot post a Samburu to go and work in a Borana territory. Even if you have

many Samburus they will not agree to work in a Borana territory they will be killed and

vice versa. Samburu and Turkana cannot be taken to Borana or Somali territory

because of the conflict that is ongoing. It is viewed like it is a tribal conflict even if I

know it is a few people within the tribes.” (Health Manager, Samburu County)

Over and above the place of birth being a factor in deciding deployment, there is another

element of “qualification bias” of the certificate courses from the eastern part of Northern

Kenya. It was observed that the community doesn’t see certificate courses as of value to

them. This misconception is due to the fact that nursing was the only course offered at the

Garissa KMTC. The perception is that nursing courses were predominantly the preserve for

the female gender. This being the case, nursing is still regarded to be a feminine profession

with only a few males showing interest. This is compounded by poor uptake of girl child

education in the region. All these emerge as some of the many barriers that happen to have

an impact on the recruitment of health workers in Northern Kenya.

Managers from Marsabit and Isiolo indicated that they have staff drawn from varied parts of

Kenya through to shortage of people from those areas to be absorbed into the medical field.

Whereas the Government of Kenya (GOK) is interested in encouraging people to work in

their counties through the Economic Stimulus Program (ESP), the situation was different in

Northern Kenya due to shortage of a pool of qualified medical workers to draw from:

‘I will compare [deployment] in the recent economic stimulus program, it was actually

targeting the locals from those particular areas, but now in the absence and we

couldn’t raise then, we had to get people from outside… Because if you came to say

that you want to recruit the nomads, people from nomadic communities and you end

up not finding them in adequate numbers and they also need the services, they will

have to be served by people from other areas.” (Health Manager, Lamu County)

‘You know here, we have a mixture of Meru, Turkana, Samburu, Borana, and Somali.

Those are the major tribes so we usually make sure each of the groups at least when

we are recruiting has got somebody as long as they are qualified.” (Health Manager,

Isiolo County)

Managers in Marsabit County stated that some health workers take up posts in order to

obtain permanent and pensionable jobs in the Government. A training manager at Ortum

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Medical Training College said that some staff join the college as a conduit to work at other

places. Soon after they report to their stations, they seek transfers and leave the institution

without adequate staff:

“Most of them [fresh recruits] want to go into government institutions to get permanent

jobs, and after some time they go back to their preferred areas. They just come here

[Marsabit] get chances of being employed by the government because there is scarcity

[of health human resource]. Whenever they come here, they are most likely to get jobs.

After that they get transfers and go back to their home areas.” (Health Manager,

Marsabit County)

“The challenges that have come there will be things like the remoteness of the place

and in regard to this you find that there is a high turnover of staff in terms of both the

tutors and in the clinical and worse in the clinical areas. People want to come because

of the name of the place but to get it as a stepping stone to move on. They say they are

working in Ortum but once they get admitted as a staff they start looking for greener

pastures. So it has been one of the biggest challenge, we are not also able to pay them

like the government would because this is a nonprofit organization. We charge the

students as other schools and we only increased the fees in March this year.” (Health

Training Officer, Pokot County)

3.4.3 Influences on Staff Re-Deployment in Northern Kenya

Deployment Policies

According to senior managers at the ministry, the recruitment of health workers follows

Government procedures. The older and more experienced health workers are perceived to

be better workers than fresh graduates from university. These issues are not guided by the

civil servants recruitment policy, rather are seen to be a good way to getting staff that are

likely to stay in the job longer. This essentially compounds the argument of understaffing of

health workers.

“What we have done in recruiting, we have been recruiting the nurses and the clinical

officers on piece meal. I have seen here and even public service commission’s trying to

pick the older you are, the earlier you come in. It is a good method because if you have

remained for five years and you want to come to the government, it means you have

seen what is outside, and you are going to be a better worker than a young person,

who has just left school, who has not suffered and after five years you make your mind.

Will I go to government or should I remain too private? They will make a decision

where…although it has not been put in black and white, I have seen it happening.”

(Health Administrator, Nairobi)

Furthermore, managers in all counties acknowledged the existence of policies to guide

recruitment of health workers in the MOH. These ensured that an employee could work

anywhere in the health service. Though the policy was seen to have good intentions, many

managers felt that these policies were rarely adhered to during deployment of health

workers.

“It will depend with the government because when you are in the college, as you come

out, you sign that you can work anywhere. So for me to be here, I do not take it as an

offence”. (Health manager, Isiolo County)

58

“…someone must get a replacement prior to being released from the current work

station. However, this policy is often overlooked especially when an influential person is

interested in the transfer of a health staff from Northern Kenya to another part of the

country”. (Health Manager, Tana River District)

When posted to Northern Kenya, health personnel prefer to be posted in urban areas as

opposed to rural areas. Managers from Isiolo County observed that health workers who are

posted to the interior are those from outside the province:

“You see now, they [health workers] don’t like the harshness of that area. The harsh

climate, they don’t…[like]. Not majority like… all of them they are here in the district

[headquarters]. They don’t like going beyond there. And in any case people from down

country are the one who are pushed [to the] interior”. (Health Manager, Isiolo

County)

Health administrators in Pokot had limited options with regard to where to work since the

policy of the Government requires health workforce to be deployed anywhere in the country:

“Of course we are in Kenya all of us; If your work in a Government institution you

cannot choose where to work.” (Health Administrator, Pokot County)

Results show that students did not have an idea of how the distribution of health staff was

done. They referred instead to the information their colleagues shared with them.

“We are expected to work anywhere in the country. “ (Student, Turkana County)

Limited Participation in Deployment by Health Managers

Some managers across all 10 counties of the study cited that deployment of health workers

rarely involves engagement of district/county level managers and decision-makers but is

effected at the central level. Such a scenario creates gaps in the deployment process because

managers at the county levels are better knowledgeable of health staff requirements than

staff at the Central level at Nairobi. When recruitment is done at the central level, there are

higher chances of low uptake of posts because of perceived attitude of insecurity in

Northern Kenya:

“Deployment is done at Nairobi by staff at the headquarters. Qualified staff are issued

with letters to report to their respective work stations. In many cases, recruits decline to

report when posted to the interior of the county”. (Health Manager, Tana River

County)

Managers observed that inter-county migration was common but only among the lower

cadres of health workers. Nurses in particular migrated from one region to another with

ease. However, this trend is uncommon among specialized doctors who offer skilled services

in specific areas. Furthermore, managers observed that internal migrations occur in search of

better places with infrastructure within Northern Kenya. This implies that extremely

marginalized regions remain with limited staff:

“Some (staff) come from Marsabit especially nurses. Nurses you know they are posted

59

from the province some Moyale, Isiolo like that. I have seen more with the nurses. I

have not seen a doctor who has moved from Marsabit, Moyale to here. The other day in

fact somebody was posted from Marsabit (doctor) to Isiolo and he refused. “(Health

Manager, Isiolo County)

There are areas that are more marginalized than others even in those marginalized

areas.” (Health Manager, Lamu County)

Role of Deployment Policies:

Managers in all counties lamented over the poor uptake of posts in Northern Kenya due to

poor infrastructure and insecurity. Again, it was established that technical skills are

sometimes misused because medical doctors are frequently posted to Northern Kenya as

administrators:

“[It is because of the] harsh working environment and that is why they do fear. Again, it

is a matter of hardship area and we get our facilities in places which are

underdeveloped. There is no water, no food sometimes; there is drought, no network

communication, so there are some of the things hindering people to come and work at

the grassroots level” (Health Manager, Wajir County)

“You need 2 vehicles of police escort; when we need to go there we go to Baringo,

Elemmian; and is in Turkana; so services becomes a challenge. But now that’s one is in

another periphery of security issues, now it’s affecting all of them. It’s not only private

that are affected, government facilities are also affected; because those facilities you

cannot access meaningful health services cannot be rendered the way it was supposed

to be”.(Public Health Officer, Turkana County)

Another issue raised by managers was limited HR personnel to manage staffing issues or

HRM issues in Northern Kenya. The managers pointed out that technical staff, without skills

in HRM, often work in this capacity. This could help to explain the notable gaps in human

resource distribution since the staff who are tasked to determine staffing gaps often lack the

required skills to identify areas that require more health workers and determine when such

work force is required:

“There are few people in Northern Kenya who are skilled to handle issues of human

resource. In the absence of such a need, any staff available at public health facility is

assigned responsibilities of human resource management.” (Health Manager, Pokot

County)

Managers expressed differing views regarding how influential ‘place of birth’ could be in

determining the likelihood to work in Northern Kenya as well as inclination to take up work

in certain areas. Most managers in eight (8) counties felt that working at one’s place of birth

provided opportunities for health workers to live with their families. Consequently, financial

management of a family becomes less expensive as less cash is spent on housing, food and

transport to and from the place of work. A manager from Mandera felt that it was important

to serve his own people while others were more inclined to work in their home districts to

support their communities:

“You see some of them come from Isiolo and their children have been brought up here.

../../../../Omanya/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.IE5/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/womanya/Documents/IntraHealthBackup/AppData/Local/AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Conny/Documents/2012/Synovate%20work%20250712/HRH%20REPORT/7175d97c-33a5-4c56-b8cf-4e6a22cd441f

60

So I think there is no reason for them to want to move.” (Health manager, Isiolo

County)

“Everybody wants to stay in their social set-ups, and lifestyle, you are used to staying in.

like now when I am saying I am very comfortable staying in Marsabit, colleagues in

Nairobi are wondering, what’s so good in Marsabit. so it is the social lifestyle and the

way, the communal and staying in the families around and also some of these people

have dependence and the living standard of your home area will be lower than if you

are staying in other towns and in the process you can help even your dependants and

the families.” (Health manager, Marsabit County)

“I refused and said I want to come to Mandera because I had that urge of serving my

community in Mandera. But those people who are not from this side don’t like coming

to this side here are people from down Kenya not necessarily north eastern native and

their stay here is always short.” (Health manager, Mandera)

Health managers generally held the view that health workers whose home districts were in

Northern Kenya were more likely to work in the region. Other health workers are thought to

be more willing to work in Northern Kenya but prefer towns where they can easily access

basic amenities such as piped water, better housing, transport and electricity to rural areas:

“I think if somebody is from this background supposed the background is here

somebody will be willing to come because that somebody is from here but when you

take somebody from another part to come to Marsabit they [health workers] just see

Marsabit as a North Eastern hardship area.” (Health Manager, Marsabit County)

“They usually say I was brought up here; you want me to go back to the same

manyatta. What is the use of going to school? They also want to; if they have to come

they work at the district hospital. Maybe they prefer it like that because they say they

have been brought up here.” (Health Manager, Isiolo County)

Managers from all counties felt that the cost of living in Northern Kenya was high compared

with other regions in the country. The explanations given for this include that increase in

paying for basic amenities like water, electricity and food, among others, as these are not

easily or readily accessible in some counties – such as Wajir, Tana River and Turkana:

“Like life here is very expensive as you compare to other parts of the country and you see

when you are here, you have to eat, you need to clothe yourself and so you find that

what you are earning is almost equivalent to what you have been using on a daily basis

in terms of food.” (Health Manager, Wajir County)

“It is challenging because of cost implications so by the time you get things is very

expensive and then the cost of the operations becomes high; you know like now the rate

we charge I think go high even for the patients you feel not everybody is able to afford

the care they get; like they almost comparing with private hospitals in Nairobi).” (Health

Manager, Turkana County)

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3.5 Pre-Service Training in Northern Kenya

3.5.1 Students in Pre-Service Training Institutions

Mid-level health training institutions especially KMTC, CHAK and KEC in Northern Kenya

were examined to find ways of improving the training of pre-service students. These mid-

level training institutions can be useful as they provide Northern Kenya with health personnel

of interest, particularly Nurses, Clinical Officers, Medical Laboratory Technologists and

Pharmaceutical Technologists who can reduce the HRH challenges facing the region. It was

essential to know the number of pre-service students in the three training institutions. We

obtained data from 2007 to 2011 focusing on the number of nursing, clinical officer, medical

laboratory and pharmaceutical technologists students from KMTC colleges as well as CHAK

and KEC training institutions within the region. The data from KMTC, CHAK and KEC is

illustrated in Fig. 3 and Table 11 below which shows and increasing trend for both genders

for all pre-service students for the nurse cadre.

Fig. 3: Pre-Service Students (Nurses) Home County in Northern Kenya in KMTC, CHAK and KEC

Source: KMTC, CHAK and KEC, 2012

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Table 11: Proportion of Student Nurses Who Enrolled And Completed Their Studies At KMTC,

CHAK and KEC PST Institutions (2007-2011)

Institution

Year

Enrolled Completed

NK Proportion Outside NK Proportion NK Proportion Outside NK Proportion

KMTC

2007 28 24% 88 76% 25 23% 85 77%

2008 35 22% 126 78% 27 17% 133 83%

2009 41 23% 136 77% 41 23% 139 77%

2010 54 26% 151 74% 34 19% 141 81%

2011 65 27% 179 73% 37 20% 150 80%

CHAK

2007 18 38% 29 62% 7 20% 28 80%

2008 20 31% 45 69% 14 22% 51 78%

2009 27 32% 58 68% 20 26% 58 74%

2010 31 38% 50 62% 22 28% 58 73%

2011 45 35% 82 65% 35 31% 79 69%

KEC

2007 3 4% 68 96% 3 4% 75 96%

2008 1 2% 61 98% 1 1% 70 99%

2009 2 4% 43 96% 1 3% 31 97%

2010 3 13% 21 88% 1 7% 13 93%

2011 7 50% 7 50% 0

0

Total

380 25% 1144 75% 268 19% 1111 81%

Table 11 shows that while the number of students enrolled in medical training institutions

from northern Kenya has been increasing between 2007 and 2011, it was still significantly

lower than that of students admitted from other regions of Kenya. A similar picture is

presented when the number of students completing medical training courses is considered.

For example, while only 19% of students enrolled in medical training institutions from

Northern Kenya completed their training, about 81% of students from other Kenyan regions

completed their studies.

3.5.2. Pre-Service Students from Northern Kenya and Other Counties

There was need to assess whether there are differences in the number of pre-service

students in KMTC, CHAK and KEC training institutions, whose home counties are from within

and outside Northern Kenya. This was to examine whether home mid-level training

institutions in Northern Kenya are helping in addressing the needs of increased HRH

challenges in the region. If data available, comparison of number of students enrolled in

other KMTC campuses outside NK will inform on status of implementation of the quota

system of enrollment Figure 4 shows that the number of pre-service students whose home

county is outside NK is higher across males and females. This implies that there needs to be

an effort to increase the number of students in pre-service whose home county is in NK. The

GOK and health development partners needs to address this challenge so that gains in HRH

training of locals from NK who qualify to enroll in mid-level training institutions are given

high priority to up HRH training in the region.

63

Fig. 4: Pre-Service Students’ County of Origin

Source: KMTC, CHAK and KEC, 2012

3.6 Proportion of Trainees/Admission in Pre-Service Mid-Level

Training Institutions

Health training institutions in Kenya are either public, private (for profit) or faith-based (FB).

Most of these institutions are accredited, and provide health training in 16 subject areas. In

terms of the types of cadres produced from these institutions, there are variations depending

on the types of courses offered. For instance, Kenya Medical Training College (KMTC) – a

mid-level training institution - provides training for cadres such as diploma nursing, clinical

medicine and surgery, medical laboratory, pharmaceutical technologist, etc, (Appendix 8).

Likewise, KEC and CHAK, both mid-level faith-based health training institutions, offer training

for the following cadres: Nurses, Clinical Officers, Pharmaceutical technologists, and

Laboratory technologists. Tertiary level institutions that are known to provide post-basic

health training for health trainees, offering degree courses such as, Bachelor of Science in

Nursing, Dentistry, and Pharmacy. Tertiary level institutions in Kenya which currently offer

health training include: Kenyatta University, University of Nairobi, Moi University, Aga Khan

University Hospital and Kenya Methodist University.

Policies have been developed to regulate licensing of mid-level training institutions,

institutional accreditation, academic standards for admission into health professional

training, types/level and duration of courses offered, internship requirements, curriculum

development and review, continuing professional development and specialization by the

GOK in collaboration with key cadre professional bodies or authorities (KMA, PPB, COC,

NCK). Changes instituted in the training of health professionals include:

Easing restrictions on private sector participation;

64

Permitting local institutions to partner and be accredited to foreign training

institutions/universities;

Opening up of training in anesthetics for nurses;

Introduction of degree courses for clinical officers, nurses personnel and other health

professions; and

Parallel systems of training and e-learning.

Anecdotal evidence suggests that existing infrastructure at mid-level health training

institutions in Kenya is inadequate for taking on the increased numbers of eligible applicants

seeking training in health related professions. As a result, the number of health trainees in

training are still below WHO recommendations of health worker–to-population ratios

required to deliver equitable and quality health care to Kenyans. To address this shortfall, the

MOH has devised a strategy to have more health training institutions approved, accredited

and started in the country, leading to the spike in the number of trainees enrolled in

medicine and nursing programs. Currently, the number of health trainees has more than

doubled over the past few years, with fewer intakes accepted in to courses than the number

of applicants.

Moreover, for those who are enrolled at mid-level colleges, many experience difficulties

completing their courses as students must attend their “practicum” which tends to be in the

form of an attachment to a health facility. With limited practicum placements due to low

number of available sites to work from, a sub-optimal learning environment is created,

characterized with overcrowding in both classrooms and hospitals (health facilities).

To be able to establish the proportion of trainees/in-takes in pre-service mid-level training

institutions in Northern Kenya, information pertaining to the number of KCSE students from

the region (whose home district is in Northern Kenya) who qualified to be enrolled into an

accredited health training institution that offers recognized health professional courses in

Kenya was sought. A review of the proportion of in-takes and trainees from 2007 to 2011 at

selected pre-service mid-level health training institutions which included Kenya Medical

Training Colleges (KMTC) satellites, and those under Christian Health Association of Kenya

(CHAK) and Kenya Episcopal Conference (KEC). Appendix 9 outlines the number of students

whose home district is in Northern Kenya who sat for their KCSE examinations from 2007 to

2011 (5 years) and attained a mean grade of at least C- (C minus). From the table, we note a

marked increase in the number of students who qualified for enrolment from 2008 to 2011

for both males and females in the 10 counties in Northern Kenya. However, it is important to

note that the average pass rate for these students still fell way under the national average, at

2.67%, over the 5 year period.

A comparison was also conducted to assess any potential variations in the number of

students who did and did not qualify within the 5 year period by county, some data missing-

figure 5 should have 2 sets of data presented in Figure 5. Although there was a slight decline

of 5% (202/4,198) in the number of students who qualified for the period 2008 compared to

2007, an average growth rate of 17% was realized for the period between 2008 and 2011.

This is a clear indication that the number of students who qualified to enroll for nursing

diploma has been in the rise.

Fig. 5: Growth in the Number of Students who Qualified to Enroll for Nursing Diploma in the 10

Counties (2007-2011)

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Source: KNEC 2012

Gender mainstreaming was examined by comparing the number of students within the 10

counties who qualified for entrance into a basic (enrolled) nursing diploma program over the

past 5 years by gender (see Appendix 10). To compare male and female students, an analysis

of recruitment of male and female students was done to establish a trend over time. Figure

6 shows the growth rate of the number of male and female students who qualified to join for

a nursing diploma programme. The average computed growth rate in the number of those

qualified for male and female has been computed as 13% and 9% respectively. These

statistics indicate that the growth of the number of male students has been growing at a rate

of 5% more compared to their female counter parts.

Fig. 6: Trend Analysis of Male and Female Students Qualified to Enroll for Nursing Diploma

Program

2,408 2,3042,655

3,274

3,842

1,790 1,692 1,8962,151

2,513

0

1,000

2,000

3,000

4,000

5,000

2007 2008 2009 2010 2011

Chart Title

Male Female

Source: KNEC 2012

66

From appendix 9 and 10, a decrease in the number of students who qualified for enrolment

between 2007 and 2008 for both males and females is noted while we observe an increase in

the number of students who did qualify for entrance into a basic (enrolled) nursing degree

program over the 4 years (2008 - 2011) for both males and females in the Northern Kenya

counties.

In an effort to determine future workforce requirements, the MOMS strategic plan 2009/012

intends to:

Carryout a HRH Manpower survey;

Preparation of a Manpower development Plan;

Develop and implement a National HRH Training Policy;

Determine current and projected output for both pre-service and in-service training;

Develop and set training quality standards and institutional output projections for

both pre-service and in-service training;

Promote phase institutional capacity building and infrastructure development; and

Establish a HRH training fund.

3.6.1 Views on Uptake and Training of Health Workers

Students’ Views on Uptake of Medical Training College

It appears that there was a general consensus amongst student respondents that the

community has little interest in pursuing or appreciating clinical medicine. This was

attributed to high poverty levels within communities making it difficult for many to afford

school fees for post-secondary education. However, it is still important to note that the

community has some misperceptions or poor understanding of some health courses, with

some not seeing the value of certificate courses:

“Many students in this area do not take medical courses. The majority do not qualify for

the courses. Some who qualify lack school fees and some people are prefer diploma

courses to certificates.” (Student, Garissa County)

In terms of understanding the appropriate prerequisite courses to take in order to pursue

health training, many respondents held the view that community members were largely

unaware of what subjects were needed in order to get into medical training institutions and

to eventually provide health services. For instance, a student in Marsabit County who trained

in human resource management regretted having chosen that course. Instead, she felt that

a course in malnutrition could have benefited her community more as this is a pertinent

issue in Northern Kenya and requires trained personnel to mitigate its impacts especially

among the under 5 year olds and the elderly:

“… in our area, Marsabit County, the rate of malnutrition is very high. So taking a

course like Human Resource [that l am taking may not have been well thought out]

when the rate of malnutrition is very high…I can say that if I could have done nutrition

I think I would have helped the society.” (Student, Turkana County)

The issue of certain communities being perceived to not hold a lot of value for mid-level

certificate health training also came out in the discussions. In one instance, some health

administrators were of the opinion that people of Somali origin foster negative attitudes

towards certificate courses. For this reason, they are unwilling to join mid-level medical

67

training institutions in Northern Kenya:

“A Somali…, if you finish high school, you will not dare join this training college

because he will tell you it is a certificate”. (Health Administrator, Garissa County)

Some of the students that we interviewed in Nairobi and Machakos made two observations.

One, when it came to student enrollment the system was more flexible to the “Parallel”

students as opposed to “regular” students recruited through the Admission Board. Secondly

the “parallel students” get to choose where they want to go for their training as opposed to

the “regular students”. The system seems to be an unclear on the procedures of recruitment

of students to Kenya medical training colleges or even if the system is clear, it is not well

understood by applicants.

“The advantage the parallel student has, a parallel student can select a college he

wants to go to, for instance if I am applying maybe to go to Kisumu, I will get that

college automatically, if I have applied for a parallel while if you are a regular student,

they will select for you the college to go to.” (Student, Nairobi County)

“But at times in the case of regular, you could be in regular, but you still want

somewhere else, so you find that the letter could be forcing you to be in a college you

don’t like.” (Student, Nairobi County)

“Also when you apply, there are two categories, regular and parallel. When you apply

using a parallel method, you start where you want to be deposited. If it’s regular, you

are deposited anywhere in the country.” (Student, Machakos County)

Administrators Views on Health Training

Administrative staff working in Northern Kenya reported having inadequate

education/training especially within the private sector. This is because the majority scored

low scores on the national exams denying them admission to local universities to undertake

medical training. However, many times individuals who were unable to meet the minimum

grade requirements to enter into tertiary level training institutions are able to apply for

admission into middle-level medical training colleges – for example, Kenya Medical Training

College (KMTC). This institution offers them the health training and at a standard that is still

widely accepted and allows them to practice clinical medicine through obtaining a diploma

or certificate in a wide range of training courses:

“I have done a diploma in health care management. I have also been trained in senior

health manager’s course and then I am also in training in leadership development.”

(Health Administrator, Garissa County)

As is often the case in health facilities that are short-staffed, administrators are at times

expected to carry out medical tasks involving patients. This has proven to be difficult as

many health administrators do not have the required skills to carry out the tasks set before

them through formal training. For the few that manage to get into health training courses,

they are at times forced to drop out due to financial constraints. This was the experience of

one administrator in Isiolo:

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“Sometimes it was difficult because you were needed to do what you don’t know. But by

and by, we are now conversant… the year 2005, I applied to go for training at GTI, that

is Government Training Institute, and I was there for about 6 months. I trained in

Accounts although I did not make it through because of funds.” (Health


To further exacerbate challenges related to seeking further training, Northern Kenya has very

few mid-level and tertiary level training institutions. As a result, few health administrators

expressed the view that limited training opportunities in Northern Kenya forces them to seek

employment in towns and cities like Nairobi where there are a wider range of training

opportunities. Apart from training to acquire new knowledge, most health staff believes that

with the additional training and skills they will be more likely to receive a job promotion:

“Even the locals want to work in Nairobi and can advance in your education and even

attain a degree but here you can’t continue with your education. There is no college,

everything it is down. Everyone wants to go and work in Nairobi because of the low

comes and even continue with education to pursue his/her degree but here no.

everything is down.” (Health Administrator, Marsabit County)

Health Worker Views on Training of Health Workers

Majority of front-line health workers in Northern Kenya are perceived to be nurses. One of

the reasons cited was because the entry level requirements to get into mid-level (certificate

or diploma) nursing or tertiary (bachelors degree) nursing is perceived to be far lower than

what is expected for other clinical cadres, like medical officers. However, many health

workers who complete mid-level training are known to pursue tertiary level training to

advance their careers as seen in the excerpt below:

“…medical training college (MTC)…then I did my Diploma in Community Nutrition,

Kenya Medical Training College and later I did my in-service training, Egerton

University, Bachelor of Science Food Nutrition and Diabetics.” (Health Worker,

Marsabit County)

Students from low income families were also thought to face difficulties when trying to gain

entry into an alternative or ‘parallel’ health training programs. In some instances, it was

thought that some colleges offered two types of training to students – one termed “regular”

requires just under sixty thousand shillings (i.e. Kshs 58,000) while the parallel program

requires nearly twenty thousand shillings more (i.e. Kshs 77,000). In discussion, it was

suggested that majority of Northern Kenyans should be given a chance to apply, on more

than one occasion to parallel programs so as to increase the likelihood of entry, given that

majority of individuals born and raised in the region come from low income households:

“MTC should open more chances to regular categories because we have the regular

category and parallel. So you find like the regular category is paying like Ksh.58000

and parallel is paying Ksh.77000. so you see getting the regular category is very hard.

They can even give the chances to two students from Samburu. So they should open a

bit more chances for regular category.” (Health Provider, Samburu County)

It was found that limited opportunities exist in most counties such as Lamu for both pre- and

continuing professional training. This denies potential students from pursuing medical

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training thereby limiting the pool from which employees can be drawn from:

“There are no colleges, and if you want to study you really have to pay a lot of money,

traversing to Mombasa or Nairobi, especially if its long distance, but you know if you

are in Mombasa you can access many educational colleges.” (Health Worker, Lamu

County)

Managers Views on Training of Health Workers

Managers stated that most students from Northern Kenya fail to meet required grades for

enrolling in medical courses. This is attributed to the high levels of illiteracy in Northern

Kenya. The situation is worse among girls because most families prefer to educate boys

when faced with financial constraints.

“I must say, we give priority to them [students from Northern Kenya], in the past we

have had one or two that may have not met these requirements, but that was years

back and you have to go and plead on their behalf because it’s a remote area and they

would be given concession, but that is no more. Also maybe this is good, let them take

their place in the Kenyan society because most of them if well educated, they are bright

young people, so if the minimal requirement is this lets assist them to reach that so

that if they come in, they can follow what is being taught.” (District Training

Manager, Pokot County)

Managers from most counties such as Turkana, were expressed a concern over limited

opportunities for training in Northern Kenya. This applies to both pre-training and

continuing professional medical training that is required in order to cope with the new

expectations and challenges in the medical fraternity.

“The thing lacking here [is an array of] training opportunities for continuity; because if

you are in Lodwar you can’t access a training institution maybe to progress in a certain

career; and other people who are working for example in Nairobi can enroll into

evening classes; but this one has been improved this year because we have had Mt.

Kenya University coming into Turkana; so I think maybe with emergence of that we

may have some improvement on such kind of things.”. (Health Manager, Turkana

District)

Factors that Influence Application to Pre-Service Health Training

Students in counties maintained that Kenya Medical Training College and other mid-level

health training institutions serve as a back plan for students who fail to gain entry to tertiary

level health training institutions. The requirements for admission for a medical training at the

University require a minimum grade of A. Yet the majority of students from Northern Kenya

don’t score such grades. Despite lack of admission to pursue medical courses, such students

with interest in medicine join mid-level courses:

“I started by obtaining a certificate in public health. Then I joined the Kenya Medical

College to take a diploma in nursing and mid-wifely”. (Student, Marsabit County)

“I did not qualify for the medical school at local universities; but was admitted at a

Medical Training College at Nyeri. Thereafter, l was posted to Northern Kenya.”

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(Student, Tana River County)

Results show that parents can influence children to pursue medical courses through

malnourished state of parents. Such students aspire to take medical courses in order to help

mitigate the medical challenge facing their parents. Again, some parents persuade their

children to drop preferred courses in preference for medical courses as per the formers’

advice.

“(The reason) why I chose to do nutrition was because I had a personal experience from

my parent who was suffering and actually when he went to the facility [for admission].”

(Student, Turkana County)

“[It was] pressure from parents. For my case, I really did not like nursing but from the

start I wanted to do something different apart from medicine. I wanted to do something

like Arts or Music but since my parents all of them were … in the medicine side

(profession), they were like (insisted that) you should do medicine; this is what you are

supposed to do. So I had no choice, but with time, I have come to understand the value

of medicine.” (Student, Turkana County)

Students mentioned that some members of their families in the medical sector served as role

models for them to take their courses. This trend was noted, among nurses and clinical

officers whose relatives influenced their preference for medical courses:

“I was influenced by my aunt who was a nurse at a local hospital. I admired her work

and opted to pursue a similar profession.” (Student, Marsabit County)

“My uncle is a clinical officer. He likes his work and serves many people in the

community. I took medical training to emulate him.” (Student, Turkana County)

3.7 Staff Turnover Rates Across Northern Kenya

Each year, about 200 doctors and 600 nurses exit the national health service due to death,

transfer out, resignation, dismissal, poor remuneration, retirement and working environment

amongst others [31]. Resignations constitute the highest percentile of attrition. Improving

disciplinary control is still a challenge due to the poor leadership and management standards

especially given that supervisors are themselves guilty of flouting ethical standards and

engaging in of unprofessional conduct. Absenteeism has been noted occasioned by dual

practice among doctors, part-time employment of HWs on locum basis in private facilities

and unauthorized private practice. Appendix 11 illustrates the main causes of attrition over

the last five years. High staff attrition has a negative impact on the health service delivery.

The exit from the service of productive workers is often driven by issues such as career

development; career advancement; work environment; terms and conditions of service;

personal needs – marital and family considerations; economic needs – better remuneration;

and social needs – better standards of living. However, Northern Kenya may have a high

attrition of HRH due to its numerous ‘push’ factors. In comparison to the national attrition

rate, all the 10 counties in Northern Kenya suffer from high health worker staff attrition of

the. Also, one or a combination of the above factors contributes to the internal migration

(public service/private sector/NGOs and rural/urban migration) or external migration

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(abroad) of skilled and productive personnel [WHO, 2006]. Although there is no accurate

data on the factors contributing to the high turnover of health personnel, it is noteworthy

that the majority of affected key cadres are doctors, nurses, laboratory personnel and public

health personnel. The grounds for leaving the service include: resignation; desertion;

abscondment; transfer of service; none resumption of duty after study leave or secondment

[19].

3.7.1 Health Worker Retention

Retention of health personnel was examined by capturing data on staff turnover (attrition) in

Northern Kenya. As quantitative data was not available by County, data for the North Eastern

Province was used as a proxy for staff turnover. Staff turnover is defined as the rate at which

an employer gains and losses employees. This information was collected from the centralized

HRIS database. The average length of stay at each of the 8 provinces in Kenya was calculated

to determine the national average and to enable comparisons across provinces to be made.

For NEP, the average length of stay (see Figure 7 below) was found to be approximately 13

years, which was not only the lowest number of years spent in employment but was found to

be roughly 29% below national average of 18.2 years. This suggests that the rate of attrition

in this province is markedly higher than other regions in the country. Data for County level

length of stay in service was not readily available for all cadres however we obtained the data

for Nurses only for the MOMS, MOPHS and NCK.

Figure 7: Average Years of Service for MOMS/MOPHS Staff

Source: MOMS/MOPHS HRIS

As seen in Figure 8, there is poor retention of the following cadres: pharmacists, doctors and

dentists, with an average length of stay in North eastern province ranging from 5, 10 and 11

years, respectively. Cadres with less attrition in comparison to the aforementioned group of

cadres includes public health officer (PHO), enrolled nurses, laboratory technologists, and

health records information Officers (HRIOs) who have average length of stay in the region

from 19, 19, 22 and 21 years, respectively. The average length of stay in Northern Kenya with

a medium attrition rate for Nurses is 14 years, Pharmaceutical Technologists 14 years and

Clinical Officers 17 years.

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Figure 8: Average Years of Service for Select MOMS/MOPHS Cadres in North Eastern

3.7.2 Strategies to Improve Recruitment And Retention of Health Workers in Kenya

In the past few years, Kenya has made significant progress in the recruitment of health

professionals. In some instances, this has been done in through a collaborative effort with

development partners such as the United States Agency for International Development

(USAID), Danish International Development Agency (DANIDA) and the Global Fund to Fight

AIDS, Tuberculosis and Malaria (GFATM) who have funded the recruitment of health workers

on short-term contracts for both public and faith-based organizations. Through the ESP in

2009, the GOK aimed to recruit 4,200 nursing positions [27]. Each of the 210 constituencies

in Kenya had to recruit approximately 20 nurses to serve within the respective regions – with

particular focus of hiring health personnel to work in underserved, remote/ rural areas. Since

then, 3,254 nurses have been recruited through this program. This represents a staff increase

of approximately 77% [22].

However, the 2009 ESP recorded the lowest application, selection and acceptance rate of the

200 funded nurse positions across the 10 constituencies in North Eastern province, which has

an acceptance rate of approximately 28%. In comparison, Central province had a 99%

acceptance rate. Further analysis of the ESP recruitment in North Eastern province revealed

that the majority of applicants were from outside the province (15% from North Eastern and

85% from elsewhere). This suggests that the pool of health workers whose home district is in

Northern Kenya is quite small relative to health workers from other regions of the country

[22]. Also very low literacy levels coupled, poor local economy and high levels of insecurity in

the region have lead to the poor retention rates, not unique to the health workforce, in the

region. Currently, over 80% of the health workforces are from areas outside of Northern

Kenya.

3.7.3 Views on Retention of the Health Workforce in Northern Kenya

Findings from the study indicate that there are a number of interventions that are needed to

address retention of health workers in the Northern Kenya. These are discussed hereafter.

Poor health worker remuneration in Northern Kenya

Perceptions of the current remuneration (salary and allowances) for staff to stay in the region

is that it is not enough as allowances are perceived not to be lower than the cost of living in

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the region which is high. In addition, lack of travel allowance that matches the travel cost in

the region is perceived to be a hindrance for health workers continued stay in Northern

Kenya.

“… The salaries are very low, so they [health workers] prefer even going to work for

locals in town than working here [at a public health facility]. So they [health workers]

get employment then they disappear.” (Health worker, Marsabit County)

Health workers opt to work in NGOs where the remuneration is far much better than the

public sector. With a better pay, they are willing to even work in the harshest areas.

“The salary is less, there is a lot of work, house rent, and I work day and night. I am

alone. If it’s an NGO and they are paying me good, I cannot mind [quitting]. I can work

in Dadaab.” (Health Worker, Marsabit County)

“If I get another good opportunity I shift, and that is not a secret, I’ll quit immediately.”

(Health Worker - Private, Lamu County)

High Cost of Living

Perceived harsh conditions in Northern Kenya have not made it easier. The cost of living is

high as access to basic foodstuffs is at inflated prices yet health workers in the region get the

same pay with health workers outside Northern Kenya. Health workers and administrators

alike cite that hardships in counties within Northern Kenya discourage them from working in

the region. In Tana River, for example, there is limited fresh water. Yet the use of

contaminated water they say could affect the health of health staff negatively. In Pokot

County, health administrators complained about the harsh climatic conditions that make it

unbearable to work in the region. Provision of basic commodities such as water and ease of

access to quality food is likely to change health workers perceptions of the region and

enhance their retention in Northern Kenya:

“When you use contaminated water; it has some parasites that will penetrate and form

a clog in your blood.” (Health Administrator, Tana River County)

“On my side first I can say it’s a hardship area compared to where I was in Bungoma;

the population side, it’s not too large and then also the facilities are scattered; then also

the climatic conditions are not favorable.” (Health Administrator, Pokot County)

“… Hardship area; if you go to a place like Kacheliba, life there is so hard; you don’t get

drinks or food; the people there think that every place is like that.” (Health

Administrator, Pokot County)

Limited In-Service Training Opportunities

Due to limited number of training institutions that offer basic and in-service health training

located in Northern Kenya, health workers based in the region feel disadvantaged working in

Northern Kenya. Health workers are unable to pursue higher education or grow their career

through continuous professional development (CPD) as there are almost no institutions of

higher learning. This is perceived to be a barrier for retention of health staff who want to

grow their career.

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Poorly Equipped Health Facilities

This lack of adequate medical facilities to enable health providers offer quality services to

patients. The poorly equipped health facilities are described to be found in public health

facilities where health workers mentioned that they affect their morale in giving due

attention on health delivery. In the absence of basic commodities such as drugs, some health

providers become disillusioned and either seek transfers or resign from their posts leading to

shortages of staff:

“…There are a lot of challenges in working in these areas, even for those of us who are

coming from around. You are prepared to come and work, you are equipped at the

training level, so when you come to the facility, there are a lot of challenges, like what

he said. You are in a facility, where there are no delivery services; there are emergencies

you need to attend to, like when there is a mother who is bleeding, you start now

looking for transport to a hospital which is some distance away, you know. Also there is

no even communication, maybe even network for calling; you end up struggling with

this mother, maybe even losing her. Even there are no equipments, so I think there are

a lot of challenges in working and as pertaining the staff, the staff show their different

colors.” (Health Worker- Private, Marsabit County)

In addition, poor infrastructure such as supply of electricity and medical commodities are

mentioned as challenges that hamper provision of high quality services. The issue was

mentioned to be prevalent in Tana River and Mandera Counties. This makes health workers

to feel lack motivation to serve the needy as expected by their profession. Instances where

health managers utilize their own cash to facilitate provision of services came up where

some mentioned they go to the extent of hiring means of transport using their own cash in

order to deliver important commodities like drugs to health centers.

In the absence of basic commodities such as drugs, some health workers become

disillusioned and either seek transfers or resign from their posts leading to shortages of staff.

To enhance retention of health workers in Northern Kenya, there is need make provision of

adequate supplies in the health facilities which will most likely raise the morale of health

workers.

“... there’s no water in the dispensary, or there’s no electricity I think it’s harder; and

also there are no roads; the doctors always hire motorbikes to carry drugs; out of his

pocket.” (Health Manager, Tana River County)

Insecurity

Insecurity in Northern Kenya counties is mentioned as hindering many health workers from

taking up their posts in the area. Health managers from these areas emphasized that many

workers fear for their life even when offering health services during out-reach missions. For

these reasons, many health workers decline to work in these two counties. In addition, some

parts of Northern Kenya, particularly those with common inter-clan and tribal conflict force

health workers to stay away from their work stations. Most of the health workers opt to stay

in the urban centers where it is safe for them to stay and commute to their designated

health facilities.

“The insecurity is the cause of lack of filling of the posts. When I tell them I’ve come

from Samburu the first thing they would say is “wow! That insecure place where people

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are shooting each other?” So when you hear you are posted to Samburu and you are

from that area, the stigma first sets in, the way you think about the guns being here.”

(Health Worker- Private, Samburu County)

Absence of Social Amenities

Health workers reported that most parts of Northern Kenya lack basic social amenities where

they can relax and unwind. It is felt that the government should provide social amenities

(such as a club house and sports facilities) at the health facilities to cater for health workers

needs on the social aspects.

Poor Physical Infrastructure

Health workers in the region reported that the distance from one town/urban center to the

other is on average 400 kilometers of poorly managed /weather road was de-motivating. As

a result, transport is very expensive and at times, the roads are impassable depending on the

time of year (like during rainy reasons), limiting access to some health facilities located in

extremely rural settings. This is further compounded by high transportation cost which is not

factored in the hardship allowance provided. As such, health workers in some of the far off

regions have to meet the own cost of travel. This aspect does not auger well with health

workers who feel that it should have been catered for by the employer instead of them

having to dig into their personal finances.

Lack of Consideration on Promotions

Health workers cite that working in Northern Kenya puts them at a disadvantaged position

when they compare themselves with other health workers in regions outside Northern

Kenya. There is a perception that health workers rarely get opportunities to be promoted as

there are few opportunities for training that are provided to them. This is likely to be a key

barrier for retention of health workers in the region.

Transfers and Redeployment

GOK policy allows health staff to work for three years at one station prior to seeking transfer

to another station. The staff leaving is expected to provide a replacement as a pre-requisite

for the transfer. Despite this policy, managers in Marsabit and Garissa counties lamented that

transfers are done without observation of proper procedures. Health officers who request for

transfers are expected to provide replacements but this condition is hardly adhered to.

Consequently, many health workers are transferred without replacements leading to

shortages of medical staff in most counties in Northern Kenya. In other cases, some people

who have served in the region for long find it difficult to transfer because they lack

replacements for their posts. Many people are reluctant to move to Northern Kenya unlike to

other parts of the country. In order to improve the situation, a need arises to enforce this

requirement so as to limit the number of transfers from Northern Kenya that end up not

being replaced:

“There was a time, the administration really even wanted to put a sanction, once a staff

is recruited here, he should only go back to where he wants or he transfers on a

condition that there is a replacement of the same staff, but it never worked.” (Health


“It’s the government regulations; they indicate that after 3 years you will be transferred

but now when it comes time for you to go, they say there is shortage, and they will

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need a replacement, and nobody actually can agree to come here so that we do an

exchange.” (Health Manager, Garissa County)

Managers felt that re-deployment after 2 years could help in retaining staff in Northern

Kenya. The current policy expects workers to serve for three years before re-deployment.

Some managers felt that the duration should be reduced to two years; especially in hardship

counties like Tana River, Mandera, Garissa and Marsabit:

“It’s the government regulations; they indicate that after 3 years you will be transferred

but now when it comes time for you to go, they say there is shortage, and they will

need a replacement, and nobody actually can agree to come here so that we do an

exchange.” (Health Manager, Garissa County)

“Redeployment is a fair way of now dealing with this kind of staff motivation because

within the district there are more hardship and less hardship areas, you find maybe

some places have infrastructure, water and electricity.” (Health Manager, Mandera

County)

Further to the above, most of the health managers and especially the ones coming from rural

facilities, stated that due to the lack of capacity within the facilities, they have been left to

duplicate roles i.e. a health center that is supposed to have 15 staff members, you will find

that there are only 2 or 3 health workers who have to double up as nurses, clinical officers,

pharmacists and also perform administrative chores, like filling reports to on a monthly basis.

Managers in Turkana County felt that is it important to discuss deployment with health

workers prior to transferring them. Otherwise, failure to do so could lead to massive

resignations of people re-deployed to stations they may not prefer. This will further

complicate the fragile situation of limited staff in Northern Kenya:

“I believe it will not (be a solution to staffing shortages in Northern Kenya); reason is

we have first to make things right here, because remember we have had people being

transferred here and some of them resign and some of them do not even report; so we

first have to correct some of the things that maybe discouraging these people to come,

and once we have done that I think anyone will be willing to work anywhere else in

Kenya.” (Health Manager, Turkana County)

Managers in Turkana County observed that the needs of health workers should be addressed

as a way of retaining them in Northern Kenya. Otherwise, very few workers will be attracted

to the region unless underlying challenges like poor infrastructure, lack of medical

commodities and equipment, among others are addressed:

“I believe it will not [be a solution to staffing shortages in Northern Kenya]; reason is

we have first to make things right here, because remember we have had people being

transferred here and some of them resign and some of them do not even report; so we

first have to correct some of the things that maybe discouraging these people to come,

and once we have done that I think anyone will be willing to work anywhere else in

Kenya.” (Health Manager, Turkana County)

Poor Supportive Supervision

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Findings from the study indicate that health workers staff retention is affected when there is

no support coming from the seniors in terms of supervision and visit at the health facilities.

This drives down their morale when they are infrequent visits by their seniors which send the

message that they do not pay much attention to their needs. This is felt that it can easily

affect the drive of a health worker continued working in the region when senior personnel

(DMO, PMO and Directors) at the ministry level fail to pay them a visit to experience the

challenges they go through. Regular visits by the said personnel will most likely boost their

morale of working in the region.

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4.0 DISCUSSION

The objective of this study was to assess the HRH situation in Northern Kenya; with particular

focus on gathering information related to current staffing, training, attraction and retention

as well as documenting county specific HRH needs. This was done through a review and

analysis of secondary data that provided quantitative information then followed by primary

data collection on qualitative aspects of HRH in Northern Kenya.

The study found that though the Kenyan Government and her development partners had

implemented actions to address staffing gaps, it still remains a challenge. For example, North

Eastern Province was only able to fill 28% of the funded 420 nurse posts under the ESP

program in 2009/10. Further between June 2009 and July 2010, the two health ministries

increased their staff numbers by 2,793 people. Despite the increased funding available, the

health sector has struggled to recruit the required staff especially in the hard-to-reach areas.

Thus the current staffing for Northern Kenya as shown in Table 3 were far much below both

national and WHO recommended workforce-to-population ratios and did not meet the

requirements to implement the KEPH approach to health service delivery. This means that an

immediate solution would be to redistribute HRH from counties with high numbers of health

workers to those with acute shortages to have at least key and essential medical staff in post

as other long term solutions are being found. This action needs to consider the fact that

most health workforce working in that region is drawn outside Northern Kenya. Health

workers from Northern Kenya were reported to be unwilling to work there due to factors

such as infrastructure gaps, lack of commodities and equipment in health facilities and the

harsh climatic conditions of the region.

Even though the Government is attempting to employ many local people to increase the

numbers of health workers from that region, there perhaps is need to consider the low levels

of illiteracy in Northern Kenya. For instance, during recruitment of health staff in all counties

through the Economic Stimulus Program (ESP), there was a limited pool of qualified health

personnel that recruiters could draw from in Northern Kenya. The situation is worse in cases

of girls because most communities prefer to educate the boy child when faced with limited

resources. There is also limited interest among local students to enroll in medical courses

due to stereo-types about certificate courses. For example, the Somali were reported to be

reluctant to enroll for certificate courses yet they do not always obtain high grades that are

required in order to pursue medical training at higher institutions of learning. The high

illiteracy levels deny the youth from Northern Kenya to pursue medical courses that can

enable them to be posted to serve their own communities and contribute to the socio-

economic development of their counties. There is need for awareness creation among

residents of Northern Kenya on the value of education to enable them benefit from

improved health services offered increasingly by Northern Kenya residents as well as

increased income from participation in other economic activities.

Supporting the preceding argument is the fact that most students in pre-service colleges

based in northern Kenya came from counties outside that region. Even though some

students from northern Kenya did join medical training colleges, lack of school fees due to

high poverty levels in the region prohibited them from completing their courses. This

suggests that there is need to engage with other development partners and Government

bodies to approach the problem of low admissions to medical training colleges holistically. It

79

might mean improving the quality of primary and secondary schooling in the region in

addition to offering scholarships to students qualifying for medical courses.

HRH distribution in Northern Kenya was found to not only be highly unequal by county, but

also by varied by cadre of health workers. For example, the number of doctors in the ten

counties surveyed was much lower than that of nurses or clinical officers. Indeed, analyses of

vacancy rates in the 10 counties (Table 7a and 7b) assuming that the establishment of

118,954 was to be normally distributed to counties as per the population figures of 2009

census, then the overall vacancy rate in the 10 counties was 79%, implying that the total

health workers in the 10 Counties should be 14,957 compared to 3,153 in post currently.

Using this approach and assuming that the establishment for the 10 counties is to be

proportional to the 2009 population census figures in each county, the vacancy rate

computed using WHO recommendations for the 10 counties is 73%. The vacancy rates

computed are way above the 24% rate computed for Kenya hence a clear confirmation that

there is a very huge shortage of Health Workers in Northern Kenya.

Respondent interviews suggest that inter-regional migration between Northern Kenya

counties has implications on health workforce distribution. The majority of health workers

reportedly preferred working in urban centers, especially the headquarters of the counties,

where they could easily access basic facilities, opportunities for education and business. Staff

posted to the interior were less likely to take up their appointments due to lack of housing,

poor roads and insecurity. Other health staff transferred to areas they considered friendly

especially when they were employed by international NGOs that offer better remuneration

than the public sector. Despite this, study findings also indicate that some health workers

chose to live and work in Northern Kenya for reasons such as altruism (serving their own

communities), maintaining family bonds by living closer to them or because of business

interests. While there is need to mobilize resources to address the factors that ‘push’ health

workers out of the region, perhaps in the short term, actions that build on reason why some

health workers stay in northern Kenya need to be enhanced.

These issues were supported by interview data that shows the need for Government run

facilities to improve incentives for its health workers. For example, poor remuneration in

public facilities compared to NGOs that offer better packages, the attraction of lighter

workloads in private health facilities that have access to basic equipment and commodities

unlike their counterparts in the public sector are major ‘pull’ factors. These factors result in

migration from one institution to another in search of better employment sites.

Organizations such as FBOs that are not as well funded as public and private facilities offer

other incentives such as faith that results in retention of health workers who are attracted by

such incentives.

Although policy exists to guide deployment of staff, variations in views regarding what

number and type of staff are recruited existed. Some managers stated that recruitment was

done at Nairobi while service providers said that it was done at the local levels. The

recruitment of health workers is done through advertising the posts through newspapers

and conducting interviews through the Public Service Commission. However, interview data

revealed that there is some interference by some influential politicians and staff at Nairobi.

The result is recruited staff to work in Northern Kenya soon seek transfers after deployment.

The scenario perpetuates the cycle of shortage of staff in Northern Kenya. There is need

correct these issues to ensure that staff posted to Northern Kenya are retained in the region.

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5.0 CONCLUSION AND RECOMMENDATIONS

5.1 Conclusions

Northern Kenya has been economically, socially and politically marginalized for a very long

time. Respondents generally agreed that Northern Kenya is a hardship area and needs some

incentives for health deployed in the region that will enhance deployment and retention of

workers in the region. This will help redress the acute shortage of health workers seen in the

region that is additionally hampered by low health worker recruitment and retention of

healthcare workers, migration of health workers, human resource interventions and decisions

not informed by quality data, weak structures for HRH leadership and management at all

KEPH levels and high attrition rates among healthcare workers especially in hard to reach

areas.

The study found that recruiting students for health related courses did not improve the

staffing levels in the health facilities. This was mainly due to reports of low literacy levels, low

rates of student admissions from Northern Kenya to medical training colleges and poor

perceptions of certificate courses that can offer a pathway to more advanced medical

courses. Thus, Northern Kenya has become a fertile ground for securing a permanent job for

health workers whose origin is outside Northern Kenya when vacancies emerge and are not

fully taken up by residents from Northern Kenya.

Lack of qualified health personnel in the region is complemented by volunteer health

workers who work in most of the remote health facilities. These volunteer health workers

have basic health training (mainly facilitated by NGOs in the region) on public health but are

called upon to provide assistance in providing medical services in rural health facilities. The

volunteer health workers have a clear understanding of the culture and social issues within

their communities and are better placed to work with the communities in the interior health

facilities. There is also goodwill from the community when they see that it’s someone they

can easily relate to. There is thus need to enhance training of volunteer health workers as

they have become critical in provision of health services in rural Northern Kenya and do not

have the required skills to provide the services.

There is need to increase the numbers of pre-service mid-level health training colleges.

However in the short term, offering scholarships to qualified students who have completed

their KCSE to study medical courses shall in the long term develop the much needed HRH in

the region. Scaling up of education of the disadvantaged or marginalized groups (women

and girls) from primary to college is going to help reduce the high illiteracy levels of the girl

child. Also an education system which is adaptive to the nomadic pastoralism in the region

shall greatly reduce illiteracy levels.

In summary, the study concludes that:

Distribution of Health workers in the 10 counties is disproportionate to population

ratios and KEPH Levels. This is characterized by low workforce-to-population ratio

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compared to other counties in Kenya and also well below the recommended

population to health worker ratio by WHO.

The vacancy rates in Northern Kenya is lower than 24% minimum vacancy

requirement for both MOMS and MOPHS.

The survey also revealed that there is a low number of students from Northern Kenya

who qualify to enroll in Nursing diploma program

It is evident from the study that there exists poor retention of Health Workers in

Northern Kenya

5.2 Recommendations

HRH situation in Northern Kenya has since the creation of the Ministry of the Development

of Northern Kenya and Arid Lands (MODNKAL) been highlighted as an important factor to

the achievement of health-related MDGs and Kenya’s Vision 2030 through the Interim

Strategic Plan 2008 – 2012. The MODNKAL is addressing HRH challenges by involving all the

line ministries and development partners. In line with Vision 2030 development strategy for

Northern Kenya, there is need for the government to address the concerns raised in this

study at 2 different levels that address both ‘push’ and ‘pull’ factors. Three major

recommendations are made:

I. In order to increase the number and retain health workers particularly from the region,

there is need to:

Establish more Medical Training Colleges in the region. With reference to enrolment of

students in Middle level Medical training colleges, the number of students enrolled

could be enhanced if the quota system is done in a way that interested students from

ASAL regions are considered at lower grades than their counter parts elsewhere. This

could be through affirmative action as it is entrenched in the Constitution of Kenya

2010. In addition, establishing more training colleges will provide opportunities for

further training of health workers based in the region as well providing opportunities

for students to learn at an environment similar to where they will eventually work.

Recruit a minimum number of new health workers each year and replace those that

have been transferred out of the region or lost to attrition. This needs to be based on

workforce-to-population ratios. Further, it will be important to re-distribute health

workers in Northern Kenya based on the population figures in each county.

Increase in-service training of health workers. A better approach to in-service training

for health workers needs to be implemented where health workers whose origin is

outside Northern Kenya stand an equal chance for training with those whose origin is

in Northern Kenya. This will help retain health workers from outside Northern Kenya.

Use innovative advertising methods to publicize vacancies. There is need to change the

approach vacancies on notice boards at the health centers and newspapers as they

are not easily accessible to would be recruits and instead use radio. Regional radio

stations have a wider reach and are mostly likely to have a wider reach than

newspaper and notices at the health facilities.

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Develop an incentive programme to attract and retain health workers in the region.

An Increase of hardship allowance to levels above the current rate will most likely

help meet high cost of living experienced in the region and motivate health workers

to move to the region. The hardship allowance should be good enough to meet

travel cost to and from the region (for health workers whose origin is outside

Northern Kenya) as well as meet cost of consumables.

Improvement of training infrastructure in the region is likely to spur growth and open

up the region. This will provide opportunities for higher institutions to open up

institution where health workers can advance their careers as they continue working

in the region and not feel disadvantaged from their colleagues in other regions

outside of Northern Kenya. In addition, provision of housing would a key motivator

for health workers to work in a certain institution.

Improve water and sanitation infrastructure. This can be done by first carrying out

assessments in appropriate locations and considering economic, environmental and

cultural factors that might influence its use. There is also need to build partnerships

with intergovernmental bodies to develop water harvesting and irrigation

infrastructure.

Build and maintain decent accommodation facilities for health workers in the region.

Better housing needs to be provided to ensure that once a staff is posted, he or she

will find it easier to adapt to the environment when housing is catered for. A

suggested floated by a key administrator at the Ministry of Medical Services is that

the government needs to provide furnished houses or guest houses in the region

with all social amenities such as water and food to ensure that health workers do not

find it inconveniencing to get a decent house to live in.

Insecurity was a major concern raised by health workers. There is need to consider

enhancing security in the region to make it suitable for staff both from Northern

Kenya and outside the region. In addition, there might be need to integrate peace

building and conflict management in student’s curriculum, reinforcing community-

supported efforts to reduce insecurity incidences, and, improving access to the youth

and women fund and perhaps require beneficiaries to use part of the funds to

promote peace.

Full implementation of both transfer and re-deployment policies. Care should be taken

when re-deployment is undertaken to prevent an abuse of the process and mass

resignations of some health workers who may be opposed to the practice. This will

not negatively influence staff who are comfortable and willing to continue working at

their current stations.

Strengthen health managers’ leadership and management skills. Strengthening the

leadership and management skills of health managers in the Kenyan health system is

now acknowledged as a vital component of health systems strengthening [38] [39]

[40] . Indeed, many of the reasons related to motivation, remuneration and attrition

can be said to emanate from weak leadership and management skills. Supporting this

are assessments of health managers’ leadership and management skills which were

83

found to be weak [38] [39] [40]. In addition, many medical training institutions

(diploma and degree) did not prepare their students for leadership and management,

instead focusing on clinical skill acquisition [40]. As outlined in the HRH transition

work plan [41], it is vital to urgently improve the leadership and management skills

of health managers based in Northern Kenya. This will not only serve to reduce the

out migration of health workers from the region, but also improve their motivation.

II. The Vision 2030 strategy for Northern Kenya notes that innovation is a key challenge

for health delivery systems that must meet the needs of a mobile population

dispersed over a large area with poor infrastructure. There is thus need to:

Adoption of new technologies such as telemedicine will improve access to highly

skilled advice from senior medical personnel. AMREF is running a pilot project in

East Africa, which links hospitals in Mandera and Turkana and remote parts of

Tanzania with its clinical services in Nairobi. There are experiences elsewhere in

Africa from which to learn that include West Africa, South Africa, and the US

Pentagon’s Africa Command, which provide consultation, diagnostic and training

services at a distance.

Investing in health extension through community health workers may also

improve access to health services as mobile health workers deliver basic

preventive and curative care. The work of traditional health providers and their

rich store of indigenous knowledge will also remain important, and an

opportunity to integrate culturally specific knowledge about health and disease

into health care systemsi.

Improve empirical evidence by improving HR Information Systems. An ongoing

challenge in determining retention of health workers in Kenya is the absence of

good HR information systems especially in the public, private and FBO sub-

sectors [MOMS, MOPHS & Capacity Kenya, 2009]. There is thus need to establish

and maintain good HR information systems to provide accurate HR data as

needed.

III. The third major recommendation is to closely collaborate with other agencies,

ministries and development partners first to create interest in and source finances for

developing the region. The needs of Northern Kenya are multifaceted and need

integrated approaches to address the issue. MDONKAL is well placed to offer

leadership in this aspect and needs to be supported.

84

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11. Sanders, D. and A. Haines, Implementation Research Is Needed to Achieve

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12. Naicker, S., et al., Shortage of healthcare workers in sub-Saharan Africa: a

Nephrological perspective. Clinical Nephrology, 2010. 74(S1): p. 129-133.

13. Sridhar, D. and A. Gostin, Innovations in Global Health in the New Political Era. Global

Health Governance, 2009. 2(2).

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Challenges. Health Services Research, 2007. 42(3 Pt 2): p. 1373-1388.

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Kenya: An assessment of current practice, in EQUINET Discussion Paper Series 62. 2008,

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18. Mullei, K., et al., Attracting and retaining health workers in rural areas: investigating

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21. MOMS and MOPHS, National Human Resources for Health (HRH) Annual Report:

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M.o.P.a.N.D.a.t.N.E.a.S. Council, Editor. 2007, Government Printer Nairobi.

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Newsletter. 2010, Kenya Medical Training College: Nairobi.

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Unpublished Report of the Africa Working Group of the Joint Learning Initiative on

Human Resources. 2006, WHO, World Bank & Rockefeller Foundation.

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SAGE Handbook for Research in Education: Pursuing Ideas as the Keystone of

Exemplary Inquiry, C. Conrad and R. Serlin, Editors. 2011, SAGE Publications, Inc

Thousand Oaks. p. 147-182.

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Design: From Theory to Practice. Field Methods, 2006. 18(1): p. 3-20.

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Contributions to Outcomes Research. Circulation, 2009. 119: p. 1442-1452.

37. Liese, B. and G. Dussault, The State of The Health Workforce in Sub-Saharan Africa:

Evidence of Crisis and Analysis of Contributing Factors, in Africa Region Human

Development Working Paper Series. 2004, World Bank: Washington.

38. Cheruiyot, J. and R. Njoroge, Report On Public Health Sector Human Resource

Performance Needs Analysis at The Sub-National Level. 2012, Capacity Kenya: Nairobi.

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86

7.0 APPENDIXES Appendix 1: Provincial Distribution of Selected MOMS and MOPHS Cadres

(Share of National Total %)

Appendix 2: Number of health facilities by type and ownership (2010)

Controlling Agency Hospitals

Health

Centres

Dispensar

ies

Maternity &

Nursing Homes Clinics

Sub-

Total

Ministries of Health 273 579 2,716 1 1 3,570

FBO& Other NGOs 80 174 691 21 78 1,044

Other Public

Institutions

11

47

336 35

429

Private 108 47 167 160 1,870 2,352

Total 472 847 3,910 182 1,984 7,395

Source: Health Management Information Systems (HMIS), 2010

Appendix 3: County Population Distribution by gender and year (last available

year and 10 year earlier if possible)

County Male Female Total

Tana River 119,853 120,222 240,075

Lamu 53,045 48,494 101,539

Garissa 334,939 288,121 623,060

Wajir 363,766 298,175 661,941

Mandera 559,943 465,813 1,025,756

Marsabit 151,112 140,054 291,166

Isiolo 73,694 69,600 143,294

Turkana 445,069 410,330 855,399

West Pokot 254,827 257,863 512,690

Samburu 112,007 111,940 223,947 Source: KNBS 2009 census

87

Appendix 4: Geographical map of Kenya with County boundaries

Source: County Boundaries

88

Appendix 5: Percent Change In The Number of MOH Staff, 2004-2008”,

Category Staff in post

2004 2008 % Change

Enrolled Nurses 12884 12066 -5

Public health officers 4268 4027 -5

Registered Nurses 3482 2803 -17

Clinical officers 2188 2118 -3

Doctors 1203 1716 43

Total 23784 22818 -4

Source: MOH, HR Mapping and Verification Study 2004, IPPD, 2008

Appendix 6: Provincial Community Health Workers Data (2010)

Appendix 7: Change in MOMS/MOPHS staffing levels for key cadres: 2010 Vs

2009

89

Appendix 8: Courses offered by KMTC

90

Appendix 9: Number of students within the 10 counties who did and did not

qualify for entrance into a basic (enrolled) nursing diploma program over the

past 5 years.

2007 2008 2009 2010 2011

County Qu

ali

fied

Did

n

ot

qu

ali

fy

Qu

ali

fied

Did

n

ot

qu

ali

fy

Qu

ali

fied

Did

n

ot

qu

ali

fy

Qu

ali

fied

Did

n

ot

qu

ali

fy

Qu

ali

fied

Did

n

ot

qu

ali

fy

Turkana 461 335 439 422 500 516 596 577 698 742

Samburu 364 265 347 333 395 408 470 456 551 586

Marsabit 267 194 254 244 289 299 345 334 404 430

Isiolo 388 282 370 355 421 435 502 486 588 625

Mandera 461 335 439 422 500 516 596 577 698 742

Wajir 413 300 393 378 447 462 533 516 624 664

Garissa 510 370 485 467 552 571 659 638 771 820

Tana River 243 176 231 222 263 272 314 304 367 391

West Pokot 825 600 785 755 894 924 1,066 1,033 1,249 1,328

Lamu 267 194 254 244 289 299 345 334 404 430

Total 4,198 3,051 3,997 3,844 4,551 4,700 5,425 5,256 6,355 6,757

Data Source: Ministry of Education, Economic Survey 2011

**Minimum entry points into basic Nursing Course

Aggregate: C Minus Subjects: Languages (C-), Biology(C-), Mathematics/physics/chemistry (D+)

91

Appendix 10: Number of students within the 10 counties who did qualify for

entrance into a basic (enrolled) nursing Diploma program over the past 5 years

by gender.

2007 2008 2009 2010 2011

County M

ale

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Turkana 264 197 253 186 292 208 360 236 422 276

Samburu 209 155 200 147 230 164 284 186 333 218

Marsabit 153 114 147 108 169 121 208 137 244 160

Isiolo 223 166 213 157 246 175 303 199 355 232

Mandera 264 197 253 186 292 208 360 236 422 276

Wajir 237 176 226 166 261 186 322 211 378 247

Garissa 292 217 280 205 322 230 397 261 466 305

Tana River 139 103 133 98 153 110 189 124 222 145

West Pokot 473 352 453 333 522 373 644 423 755 494

Lamu 153 114 147 108 169 121 208 137 244 160

Total 2,408 1,790 2,304 1,692 2,655 1,896 3,274 2,151 3,842 2,513

Source: KNEC 2012

Appendix 11: Current distribution of health workers and other HRH personnel

in Northern Kenya by KEPH level and cadre

Appendix 11. a-1 LEVEL 2

Medical

Officer

Clinical

Officer Nurses

Laboratory

staff

Pharmacy

Staff

Other

(Clinical)

County Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Garissa 0 0 0 1 16 10 0 0 0 0 1 0

Isiolo 0 0 1 1 13 14 0 0 0 0 3 0

Lamu 0 0 2 0 9 5 1 0 0 0 3 0

Mandera 0 0 4 0 0 0 0 0 0 0

Marsabit 0 0 1 0 24 26 0 0 0 0 5 0

Samburu 0 0 28 13 2 0 0 0 6 0

Tana River 0 0 0 1 15 6 0 0 0 0 4 0

Turkana 0 0 1 0 17 4 0 0 0 0 5 1

Wajir 0 0 3 8 0 0 0 0 0 0

West Pokot 0 0 2 0 29 19 2 0 0 0 4 0

92


Medical Officer Clinical Officer Nurses

Laboratory

staff

Pharmacy

Staff

Other

(Clinical)

County Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Garissa 0 0 3 0 14 3 1 0 0 0 2 0

Isiolo 0 0 1 1 7 8 3 0 0 0 3 2

Lamu 0 1 3 0 9 1 2 0 0 0 6 0

Mandera 0 0 1 1 9 1 0 0 0 0 1 0

Marsabit 0 0 1 0 2 11 0 0 0 0 8 0

Samburu 1 0 2 1 8 15 3 0 0 0 8 0

Tana River 0 0 6 0 11 10 4 1 0 0 9 1

Turkana 1 0 6 3 0 0 0 0 6 0

Wajir 0 0 1 0 7 0 0 0 0 0 0 0

West Pokot 0 0 3 6 28 21 11 0 4 0 28 1


Medical

Officer

Clinical

Officer Nurses

Laboratory

staff

Pharmacy

Staff

Other

(Clinical)

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Garissa 4 1 24 0 27 27 4 0 3 1 17 1

Isiolo 3 2 18 5 36 108 13 1 8 3 37 13

Lamu 2 0 12 10 32 44 10 1 7 1 36 4

Mandera 1 0 25 2 57 20 10 1 7 0 29 2

Marsabit 6 0 25 3 55 56 16 3 10 1 51 3

Samburu 1 0 19 0 27 59 8 0 6 1 36 4

Tana River 1 1 20 3 42 43 8 0 6 0 36 4

Turkana 4 0 26 2 53 51 9 3 10 0 43 9

Wajir 5 0 40 2 76 56 14 2 6 2 44 8

West Pokot 6 1 26 6 38 89 13 3 3 0 35 9

93

Appendix 11.

a-4 LEVEL 5

Medical

Officer

Clinical

Officer Nurses

Laboratory

staff

Pharmacy

Staff Other(Clinical)

County Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Garissa 6 7 34 5 47 100 12 1 4 1 64 15

Isiolo 0 0 0 0 0 0 0 0 0 0 0 0

Lamu 0 0 0 0 0 0 0 0 0 0 0 0

Mandera 0 0 0 0 0 0 0 0 0 0 0 0

Marsabit 0 0 0 0 0 0 0 0 0 0 0 0

Samburu 0 0 0 0 0 0 0 0 0 0 0 0

Tana River 0 0 0 0 0 0 0 0 0 0 0 0

Turkana 0 0 0 0 0 0 0 0 0 0 0 0

Wajir 0 0 0 0 0 0 0 0 0 0 0 0

West Pokot 0 0 0 0 0 0 0 0 0 0 0 0

Appendix 12: Total number of health workers and other HRH personnel in the 10

counties by cadre

All Levels

Medical

Officer

Clinical

Officer Nurses

Laboratory

staff

Pharmacy

Staff Other(Clinical) Total

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Male

Fem

ale

Garissa 12 9 71 9 137 170 23 1 10 2 108 22 361 213

Isiolo 3 2 20 7 60 134 16 1 5 3 50 15 154 162

Lamu 2 1 17 10 52 50 14 1 7 1 45 4 137 67

Mandera 1 0 28 3 70 24 10 1 7 0 44 0 160 28

Marsabit 8 0 22 5 92 98 15 3 10 1 76 4 223 111

Samburu 2 0 21 1 83 106 13 0 6 1 50 4 175 112

Tana River 1 1 26 4 69 59 12 1 6 0 55 5 169 70

Turkana 6 1 29 2 94 85 9 3 10 0 64 12 212 103

Wajir 5 0 40 2 86 65 14 2 6 2 45 8 196 79

West Pokot 6 1 31 13 105 143 28 3 7 0 73 11 250 171

Total 46 15 305 56 848 934 154 16 74 10 610 85 2037 1116

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Appendix 13: Attrition in Kenya

Appendix 14: Workers by age group and cadre

95

Appendix 15: Computed Health Worker vacancy Level 2010/2011

Kenya 10 Counties Surveyed

CADRE Staff - In Post Established Positions % Vacancies Staff -

In

Established ( 12.1%

assuming normal

distribution to

Population census

data

Vacancy rate

Enrolled Nurse 11,429 20,902 45 1782 2529 30%

Nursing Officer 4724 16,900 72 2045 100%

Medical Officer Intern 728 503 -45 61 100%

Doctors 1,138 2,799 59 61 339 82%

Clinical Officer 2,615 7,345 64 361 889 59%

Community oral health officer 105 586 82 71 100%

Dental specialist 331 432 23 52 100%

Dental Technologist 368 100 45 100%

Health administration officer 217 1,268 83 153 100%

Health records & information

officer

41 637 94 77 100%

Health records & information

technician

568 664 14 80 100%

Medical Eng. technician 287 468 39 57 100%

Medical engineering technologist 40 478 92 58 100%

Medical Lab Technician 602 1,245 52 151 100%

Medical Lab Technologist 167 1,658 90 201 100%

Laboratory staff 769 2903 142 170 351 52%

Nutrition Officer 423 3,260 87 394 100%

Occupational therapist 286 685 58 83 100%

Orthopaedic technologist/plaster

technician

236 354 33 43 100%

Pharmaceutical technologist 308 1,548 80 187 100%

Pharmacist 579 207 -180 25 100%

Pharmacy staff 887 1,755 84 212 60%

Physiotherapist 466 875 47 106 100%

Public Health Officer/technician 4,053 11,643 65 1409 100%

Radiographer/Radiologist 306 547 44 66 100%

Social Welfare Officer 42 1291 97 156 100%

Others 4,814 42,291 89 695 5117 86%

Total 35,714 118,954 70 3153 14957 79%

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