UNDERSTANDING THE LABOUR MARKET OF

HUMAN RESOURCES FOR HEALTH IN KENYA

Working Paper, November 2013

Harrison Kiambati1, Caroline Kiio

1, John Toweett

1

1 Technical Planning and Coordination, Ministry of Medical Services, Nairobi, Kenya

This paper represents the opinions of individual authors and is the product of professional research. It is not meant to represent the

position or opinions of the WHO or its Members, nor the official position of any staff members. Any errors are the fault of the authors.

The World Health Organization does not warrant that the information contained in this health information product is complete and

correct and shall not be liable for any damages incurred as a result of its use.

Abstract

Universal health coverage depends on having the necessary human resources to deliver health care

services. Kenya is among the African countries currently experiencing a crisis in the area of human

resources for health (HRH). The major causes of the crisis include inadequate and inequitable

distribution of health workers; high staff turnover; weak development, planning and management of

the health workforce; deficient information systems; high migration and high vacancy rates;

insufficient education capacity to supply the desired levels of health workers needed by the market;

inadequate wages and working conditions to attract and retain people into health work, particularly

in rural underserved areas. This shortage affects most of the available health worker categories. This

document provides an overview of the HRH labour market in Kenya, highlighting the importance of a

comprehensive approach to understanding the driving forces that affect the supply and demand for

health workers, in order to provide a basis for developing effective HRH polices that can contribute

to progress towards universal health coverage.

Acknowledgements

Angelica Sousa and Jennifer Nyoni made helpful comments on drafts of this paper. All remaining

errors are the authors' responsibility. The country analysis was based on a protocol written by

Richard Scheffler in consultation with WHO, aimed at understanding the health labour dynamics and

productivity in low- and middle-income countries. Financial support for the publication was

provided by the European Commission and the United States Agency for International

Development. This document has been developed as the first phase of the Health Labour Market

Study forming part of the WHO and the European Commission programme on strengthening health

workforce development and tackling the critical shortage of health workers. Together with the WHO

Regional Offices for Africa and the Eastern Mediterranean, it was put forward with the WHO

Collaborating Centre for Health Workforce Economics Research at the School of Public Health,

University of California, Berkeley for building knowledge and skills on the analysis of health labour

market and productivity in four selected countries: Cameroon, Kenya, Zambia and Sudan. Thanks are

due to Giuditta Rusconi for research assistance. The report was edited by David Breuer. Advice was

kindly provided by Humphrey Cyprian Karamagi. Special thanks to the support accorded by the

WHO Kenyan office, the Director of Medical services Dr. Francis Kimani and the facilities that

participated in the assessment.

Contents

1. Introduction .................................................................................................................................... 1

2. Country profile ................................................................................................................................ 2

2.1 Health system......................................................................................................................... 3

3. Health labour market framework ................................................................................................... 5

4. Data ................................................................................................................................................. 6

5. Health labour market analysis ........................................................................................................ 7

5.1 Production ............................................................................................................................... 7

5.2 Registered health workers .................................................................................................... 10

5.3 Health workers by category .................................................................................................. 10

5.4 Health workforce by age ....................................................................................................... 11

5.5 Health workforce by sex ....................................................................................................... 12

5.6 Geographical distribution of the health workforce .............................................................. 14

5.7 Health workforce by sector ................................................................................................... 15

• Informal economy ..................................................................................................................... 15

5.8 Migration and turnover ........................................................................................................ 15

5.9 Wages .................................................................................................................................... 17

5.10 Health workers shortages and surpluses .............................................................................. 19

• Vacancies .................................................................................................................................. 19

• Needs-based shortages ............................................................................................................. 19

6. Conclusion ..................................................................................................................................... 21

7. Lessons learned ............................................................................................................................. 22

8. Recommendations ........................................................................................................................ 22

References ............................................................................................................................................ 24

Annex .................................................................................................................................................... 26

1

1. Introduction

Universal health coverage is defined as ensuring that all people can use the promotive, preventive,

curative, rehabilitative and palliative health services they need, of sufficient quality to be effective,

while also ensuring that the use of these services does not expose the user to financial hardship

(WHO, 2010). Three major goals of universal health coverage have been clearly outlined: (1) equity

in access to health services – those who need the services should get them, not only those who can

pay for them, (2) that the quality of health services is good enough to improve the health of those

receiving services, and (3) financial-risk protection – ensuring that the cost of using care does not put

people at risk of financial hardship. An integral part of universal health coverage, however, remains

the human resources for health that deliver health care services, without whom its success cannot

be guaranteed (Sousa et. al., 2013). Human resources for health (HRH) include public and private

sector doctors, nurses, midwives, pharmacists, technicians and other paraprofessional personnel, as

well as untrained and informal-sector health workers, such as practitioners of traditional medicine,

community health workers, and volunteers (WHO, 2006).

Kenya remains committed to making significant improvements in its human resources for health

situation. However, the country will not achieve the ambitious health milestones set, including

achieving the Millennium Development Goals, without improving the quality, quantity and

distribution of the health workforce. Skilled providers, physicians, nurses and midwives, assist in only

44% of births, and there are great inequalities in access to health services across provinces (Kenya

National Bureau of statistics & ICF Macro, 2010). Generally speaking, the Central Province and

Nairobi are deemed to have the best facilities, whereas the North-Eastern Province is the most

underdeveloped and therefore has the fewest health facilities. Poor people in rural areas who are ill

and choose to seek care usually only have the option of treatment at primary care facilities. These

facilities are often understaffed and underequipped and have limited drugs and other medical

supplies.

Several factors inhibit Kenya’s ability to provide adequate health care for its citizens. The most

important is underfunding of the health sector. Thus, health care services in Kenya partly depend on

donors. In 2002, more than 16% of the total expenditure on health care originated from donors. This

high dependence has caused the government to redefine a health insurance initiative included in the

Vision 2030 to create and implement a mandatory national health insurance scheme as a means of

funding curative services (Ministry of State for Planning, National Development and Vision 2030,

2007). It is believed that this will come in handy to support the Health Sector Service Fund, which

involves channelling funds directly to public health facilities. Other factors also inhibit Kenya’s ability

to provide adequate health care for its citizens, including inefficient utilization of resources, the

increasing burden of diseases and rapid population growth.

In Kenya, 80% of government spending in health is personnel compensation. The health sector is

labour-intensive and dependent on its workforce for the precise application of the knowledge and

technical skills in providing health care services. Human resources in the sector represent both

strategic capital and a critical resource for the performance of the health system. The country has

made significant progress, including scaling up the recruitment of additional health workers,

reviewing health worker salaries and benefits and strengthening human resource policies and

2

practices. Nevertheless, despite the progress, there are still several health workforce challenges such

as: inadequate and inequitable distribution of health workers; high staff turnover; weak

development, planning and management of the health workforce; deficient information systems;

high migration; and an inadequate performance management framework at all levels.

This case study on Kenya aims to highlight the importance of adopting a comprehensive approach to

understanding the driving forces that affect the supply and demand of health workers to provide a

basis for developing effective human resources for health policies that can facilitate the success of

universal health coverage.

2. Country profile

Kenya has a population of about 41 million (2011), with 51% females and 49% males. The proportion

of children fully immunized against communicable diseases is 83% (2010). Life expectancy is 59 years

(2009) for both men and women. The country has witnessed significant progress in health indicators,

with reduction of mortality of children younger than five years from 115 per 1000 live births in 2003

to 74 per 1000 live births in 2008–2009 and infant mortality from 77 per 1000 live births to 52 per

1000 live births (Fig. 1). This level and distribution of health in the country has been affected by the

following contextual factors. The population growth rate has remained high (2.4% annual growth

rate), with a high young and dependent population. The period showed improvements in gross

domestic product (GDP) and reduction in the population living in absolute poverty, although more in

urban areas, and absolute poverty levels still remained very high (46%). Literacy levels remained

high at 84%, although inequities in age and geographical distribution persist (World Bank, 2013).

Table 1. Countries indicators – Kenya

Indicators Kenya

Population 41 609 700

Adult literacy rate (aged 15 years and older) 87%

GDP per capita in PPP terms 865

Expenditure on health as a percentage of GDP 4.5

Prevalence of HIV infection

6.3

Main causes of death HIV, tuberculosis

and malaria

Sources: World Bank (2013), World Health Organization (2013) and Kenya National Bureau of

Statistics (KNBS) and ICF Macro (2010).

3

Fig. 1. Mortality rates in Kenya, 1993–2008

UMR: under five mortality rate

IMR: infant mortality rate

NMR: neonatal mortality rate

MMR: maternal mortality rate

Source: Kenya National Bureau of statistics (KNBS) and ICF Macro (2010)

Gender disparities are significant, although showing improvement, particularly after 2003, a

reflection of better opportunities for women. However, disparities exist and persist, with the

gender-related development index ranging from 0.63 (Central province) to 0.40 (North Eastern

province). Finally, security concerns still persist in some areas of the country, making it difficult for

the communities to access and use existing services. Gender-related crime is also reported in urban

areas, particularly in the informal settlements.

2.1 Health system

The general public assessment indicates that the poverty index for most of the population strongly

contributes to the delayed health care seeking in health care centres. This financial constraint

manifests negatively and leads to increased morbidity and mortality. Among ill Kenyans who did not

choose to seek care, 44% were hindered by cost. Another 18% were hindered by the long distance to

the nearest health facility.

Basic primary care is provided at primary health care centres and dispensaries. Dispensaries are run

and managed by enrolled and registered nurses who are supervised by the nursing officer. They

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

malaria and skin conditions. The patients who cannot be managed by the nurse are referred to the

health centres.

Subdistrict, district and provincial hospitals provide secondary care: integrated curative and

rehabilitative care. Subdistrict hospitals are similar to health centres with the addition of a surgery

unit for Caesarean sections and other procedures. District hospitals usually have the resources to

provide comprehensive medical and surgical services, whereas the provincial hospitals are regional

centres that provide specialized care including intensive care, life support and specialist

consultations.

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Fourth-level care is provided at the national referral hospitals Moi and Kenyatta, which provide very

comprehensive specialized care including intensive care, life support and specialist consultations.

These two facilities are located in Eldoret and Nairobi respectively. Gaps, which regularly appear in

the system, are filled by private and church-run facilities.

The Kenya Vision 2030 goal for the health sector focuses on providing equitable and affordable

quality health services to all Kenyans since good health and nutrition boosts the human capacity to

be productive, thus enhancing economic growth and reducing poverty.

Towards this goal, the Government’s First Medium-Term Plan 2008–2012 aims at restructuring

Kenya’s health care delivery system to shift emphasis from curative to promotive and preventive

health care, which includes efforts to control environmental threats to health and improving

nutritional status and research that targets the health needs of communities. The strategy thus

focuses on decentralizing health care funding and the responsibility for delivering health services to

district hospitals, health centres and dispensaries. Further, more appropriately, it recognizes that

health care delivery and ultimately health outcomes are being hampered by the inadequate and

inequitable distribution of human resources for health.

The Second National Health Sector Strategic Plan (NHSSP II) (2005–2010, extended to 2012) outlines

the strategic objectives of focus to achieve the health sector policy priorities stressed in the Kenya

Health Policy Framework 1994–2010:

• to increase equitable access to health services;

• to improve the quality and responsiveness of services in the sector;

• to improve the efficiency and effectiveness of service delivery;

• to enhance the regulatory capacity of the Ministry of Health;

• to foster partnerships in improving health and delivery services; and

• to improve the funding of the health sector.

The overall human resources for health goal for NHSSP II is for employment of optimal levels of

human resources and the development of capacity in accordance with the health needs of the

population in alignment with the Kenya Essential Package for Health (KEPH) priorities to improve the

provision of high-quality health care services (Ministry of Health, 2005).

NHSSP II thus aims to, among other issues, address human resources for health shortages by

increasing numbers, rationalizing deployment and improving the quality and mix of the workforce.

Accordingly, the plan aims to reduce the extent and impact of health worker shortages and the

lopsided distribution of available health workers across the country.

In 2006, the ministry and stakeholders developed Norms and Standards for Health Service Delivery

through a consultative process to provide a rational framework to guide investment in health sector

(Ministry of Health, 2006). The Norms and Standards refer to the minimum and appropriate mix of

human resources and infrastructure required to serve populations at different levels of the health

service delivery system. It defines the health system structure, expected service standards, minimum

human resources and infrastructure at different levels and the process and expectations of

supervision and monitoring. The Norms and Standards is a guide to the efficient, effective and

5

sustainable delivery of the KEPH defined as the common service delivery package under NHSSP II.

The 2008–2012 strategic plans for both health ministries provide for developing strategies that

facilitate the employment of optimal levels of human resources and the development of appropriate

capacity. This is in accordance with the KEPH priorities of improving the provision of high-quality

health care services to meet the health care needs of the population.

The specific goals aimed at addressing current human resources for health challenges to be achieved

by 2012 are (Ministry of Public Health and Sanitation, 2007; Ministry of Medical Services, 2007):

• institutionalizing a planning and policy framework human resources for health;

• provision of adequate numbers of equitably distributed health workers;

• improving human resource capacity to meet the health needs of the population;

• improving the retention of health workers at all levels,

• institutionalizing performance management systems; and

• improving human resource management systems and practices.

The Constitution of Kenya and Kenya health policy 2011–2030 shift the focus to address the

following:

• improving the production of health workers (numbers and quality) by aligning curricula and

training with needs and competencies, promoting multi-skilling and multitasking and enhancing

the skills, knowledge and attitudes of the health workforce required to deliver health goals;

• reviewing and applying evidence-informed health workforce norms and standards for the

different tiers of services;

• ensuring the appropriate and equitable distribution of health workers in facilities;

• improving attraction and retention packages and incentives for health workers;

• strengthening human resources development and systems and practices; and

• improving institutional and health worker productivity and performance.

3. Health labour market framework

This section summarizes Scheffler, Bruckner & Spetz (2012) to understand the dynamics of the

health labour market.

Assessing the health labour market requires to study both the demand and the supply sides, and

how to match them in order to determine shortages (or surpluses) of health workers.

The supply of health workers includes the number of qualified health workers willing to work at a

given wage rate in the health care sector (physicians, nurses and other care providers). Thus, training

is a key determinant of this part of the labour market. The number of trained health workers

depends on that of training institutions, the number of years of training, the education level, the

cost of training, the individual interest in working in that field, the expected probability of getting a

job after training, etc. It is linked to the market for training health workers.

6

The demand for health workers, which is linked to the demand for health care, is measured by the

hiring of human resources for health by public and private institutions. Each of these institutions

competes, with varying wage rates, budgets, provider payment practices, labour regulations and

rules that determine hiring and wage decisions.

In general, the higher the wage, the larger the number of available health workers willing to work for

the health sector. Additional considerations, including better working conditions, safety and career

opportunities, also determine the decision to work in that sector or rather to work in another sector

or to migrate.

The interaction between the supply and demand for health workers determines the wages and other

compensation, the number of health workers employed, the number of hours they work, the

geographical location and their employment settings.

4. Data

Scheffler, Bruckner & Spetz (2012) suggested a preliminary list of indicators for conducting studies.

These indicators included the number of health workers and the hours they work (by health

occupation, by sector, by facility, by sex, by age, by location, etc.), wages paid (by government, by

the private sector, etc.) and other non-wage compensation and vacancy data. Available data on

these variables were collected for 2005–2010. Besides, since graduates of health workforce schools

(such as medical schools and nursing schools) and net migration are important factors, the study also

sought to determine the attractiveness of the health professions in Kenya by identifying spaces

available and applications to medical, nursing and other training programmes.

Further, hiring of human resources for health by the government, nongovernmental and private

sectors and the size and structure of compensation schemes are considered. The earnings and

compensation benefits offered to human resources for health were measured by the wages paid by

government and private sector. Data on non-wage compensation (health benefits, housing, moving

expenses, pension and job security) were also gathered.

Data on wages, non-wage compensation and employment levels in government was obtained from

the Ministry of Health payroll data, the Ministry of Health’s facilities listing and the draft human

resource strategic plan. Data on wages, non-wage compensation and employment levels in the

private and NGO sectors was obtained from the umbrella bodies that govern the management of

private and NGO facilities such as the Christian Health Association of Kenya (CHAK), Kenya Episcopal

Conference (KEC) and Health NGOs for Health (HENNET).

Trends overtime were analysed and key shortage problems were identified. Since shortages result

when the demand for human resources for health exceeds the supply, vacancy data were provided

and analysed wherever available.

7

5. Health labour market analysis

5.1 Production

In general, the education sector in Kenya is fragmented, with several ministries and government

departments taking different roles and responsibilities. The greatest challenge has been the lack of

coordination among the various training agencies, resulting in inefficiency, duplication of effort and

wastage of resources (Ministries of medical services and public health and sanitation, 2009). This

therefore prompts the need to streamline the coordination and unified structured institutional and

legal framework governing national health education and training in Kenya.

The Kenya Medical Training College produces the largest number of health workers in Kenya (Table

2). The number of graduating physicians, nurses and laboratory technicians increased between 2005

and 2011. The number of graduating physicians increased three-fold, while laboratory technicians

increased by only 46%. Although the number of graduating nurses increased by 123% in the period

analysed, the number of graduating nurses declined by 81 between 2010 and 2011.

Table 2. Graduation statistics for selected categories from Kenya Medical Training College

Category 2005 2006 2007 2008 2009 2010 2011

Percentage

change

2005- 2011

Nurses -

specialized 985 1077 1408 1485 2186 2280 2199 123.25%

Medical lab

sciences -

specialized

254 277 221 206 245 354 370 45.67%

Clinical

medicine and

surgery -

specialized

354 535 583 625 911 963 1328 275.14%

Total 1593 1889 2212 2316 3342 3597 3897 144.63%

Source: Database of the Kenya Medical Training College, Nairobi, Kenya (2011)

Table 3 depicts the capacity of the institutions and the training output for physicians, pharmacists,

dentists and nurses for the main medical institutions (except Kenya Medical Training College). The

number of graduates increased between 2002 and 2005. However, the output of 2005 exceeds the

stated capacity for all types of health workers except for the number of physicians graduating at Moi

University.

8

Table 3. Training Outputs of medical institutions (except medical training college)

Institution Cadre Capacity

Output:

2002

Output:

2005

University of Nairobi Doctors 100 98 199

Pharmacists 40 42 64

Dentists 33 32 36

Nurses 40 40 52

Moi University Doctors 50 41 36

Nurses 20 19 34

Aga Khan University Nurses 40 63

CHAK training institutions

(nine institutions) Nurses 240 380 460

KEC/CS (12 institutions) Nurses 454 399 429

Nairobi Hospital Nurses 180 150 -

Source: Ministries of medical services and public health and sanitation (2009)

The financial constraints facing public training institutions have lead to an incommensurate number

of trainees to cater for the country’s demand, thus leading to a near crisis in human resources at

work stations. Even though the Ministry of Health established a norm of 1 teacher per 10 students,

the actual teacher-to-student ratio is 1 per 21 students. The excess of the capacity and the high

student–teacher ratio underscores the limited capacity of the health training institutions to train

new graduates.

The number of potential health workers qualified but not enrolled for training in Kenya Medical

Training College increased between 2008 and 2011 (Table 4). The demand for health training courses

is quite high in the country, with limited training opportunities available. Applicants for medical

training have increased by 50%. Although the percentage of qualified applicants that are not

enrolled has decreased from 81% to 75%, many qualified applicants are still not enrolled, showing

that the demand for training slots is high but capacity is insufficient.

Table 4. Training Gaps in the Kenya Medical Training College

Year 2008 2009 2010 2011

Qualified applicants 21 617 20 000 18 294 24 574

Enrolled 4 080 4 623 5 418 6 125

Qualified but not enrolled 17 537 15 347 12 876 18 449

Source: Database of the Kenya Medical Training College, Nairobi, Kenya (2011)

Table 5 shows the number of students that were in training during 2008/2009 and 2009/2010. In

general, the number of health workers in training has decreased by 17%. Physicians in training

decreased by 23% and clinical officers by 29%, whereas public health officers declined by 52% and

pharmaceutical technologists by 59%. In contrast, more future dentists and nurses were in training.

9

Table 5. Number of health workers in training

Type of personnel 2008/09

Number

2009/10

Number

Percentage change

2008 - 2010

Doctors 3172 2437 -23.17%

Dentists 152 199 30.92%

Pharmacists 339 349 2.95%

Pharmaceutical technologists 509 207 -59.33%

BSc in nursing 731 818 11.90%

Registered nurses 1847 1989 7.69%

Clinical officers 1509 1076 -28.69%

Public health officers 666 322 -51.65%

Doctors 3172 2437 -23.17%

Dentists 152 199 30.92%

Total 8925 7397 -17.12%

Source: Ministry of Public Health and Sanitation (2010)

Table 6 shows the total number of people graduating in nursing between 2005 and 2010. The

number of graduates peaked in 2009, more than doubled from 2005. From 2009 to 2010, however,

the number of graduates decreased by 24%. The public and mission-sponsored institutions train the

largest number of nurses. The proportion of the public sector increased from 60% in 2005 to 75% in

2009. On average, the public trains about 70%, whereas the missions train about 20%. This implies

that most of the nurse training relies on public sector resources.

Table 6. Data from nursing council

Year of

registration

Total

graduates

Public

institutions

Private

institutions

Institutions

outside

Kenya

Mission

institutions

Other

institutions

2005 1676 60.0% 4.9% 0.8% 30.2% 4.1%

2006 2333 66.4% 4.8% 0.5% 26.0% 2.3%

2007 2514 65.1% 5.9% 0.2% 27.0% 1.8%

2008 2792 70.3% 4.2% 0.3% 23.9% 1.4%

2009 3879 75.8% 3.9% 0.5% 16.6% 3.1%

2010 2940 73.4% 4.1% 0.5% 19.1% 2.9%

Other institutions include: Moi forces and local government council.

Source: Annual report of the Nursing Council, (2010)

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5.2 Registered health workers

The total number of registered health workers increased by 4.7% between 2008 and 2009: from

76 883 in 2008 to 80 464 in 2009 (Table 7). Except for enrolled nurses and public health technicians,

the number of registered health personnel increased in all categories. This increase in the total

number of registered health workers does not imply, however, that there are more health workers

available to provide health care services. There are concerns about the accuracy of the registry

information, since it is not updated in time to account for retirement, deaths and outward migration.

Table 7. Number of registered health care personnel, 2008 and 2009

Registered medical personnel

Type of personnel 2008 2009

Number Number per

1000 pop Number

Number per

1000 pop

Doctors 6623 0.017 6897 0.017

Dentists 974 0.003 1004 0.003

Pharmacists 2860 0.007 2921 0.007

Pharmaceutical

technologists 1815 0.005 1950 0.005

BSc in nursing 657 0.002 778 0.002

Registered nurses 14073 0.037 15948 0.04

Enrolled nurses 31917 0.083 31917 0.081

Clinical officers 5035 0.013 5888 0.015

Public health officers 6960 0.018 7192 0.018

Public health

technicians 5969 0.016 5969 0.015

Total 76883 0.203 80464 0.204

Source: Ministries of medical services and public health and sanitation (2011 b)

5.3 Health workers by category

Table 8 shows the number of health workers in the public sector in 2013, thereby taking into

account the different categories, the skill mix and the density per 1000 people. The total density of

health workers in the public sector is 0.74 per 1000 people. Of 31 060 people working for the

Ministry of Health and Ministry of Public Health and Sanitation in the national health system in 2013,

nearly 60% are nurses or the equivalent (Table 8). In order of importance, they are followed by

registered clinical officers (10.4%) and laboratory technicians (9.8%). Medical officers account for

only 4.6%. This implies that nurses deliver most health services.

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Table 8: Health workers distribution by cadre category, 2013

Cadre category

Number of

HW

% of total

HW Density per

1000 people

Medical officers 1 424 4.58% 0.0342

Pharmacists 413 1.33% 0.0099

Pharmaceutical technologists 732 2.36% 0.0176

Laboratory technologists and technicians 3 032 9.76% 0.0729

Health records and information officers

and technicians

558 1.80% 0.0134

Nutritionists 364 1.17% 0.0087

Registered clinical officers 3 236 10.42% 0.0778

Physiotherapists 296 0.95% 0.0071

BSc in nursing 537 1.73% 0.0129

Kenya registered community health

nurses

18 212 58.63% 0.4377

Dentists and dental technologists 270 0.87% 0.0065

Public health officers and technicians 1 652 5.32% 0.0397

Radiographers 222 0.71% 0.0053

Community oral health officers 112 0.36% 0.0027

Total 31 060 100% 0.7465

Source: Ministries of medical services and public health and sanitation (2013)

The trend over time for the different health worker categories gives a mixed picture. The number of

nurses declined sharply from 2003 to 2011 reaching a minimum in 2010. Physicians and pharmacists,

however, followed a positive trend in the period analysed (Table 1 in the Annex).

5.4 Health workforce by age

The age distribution of the workforce is very important for any organization and even more so in the

health sector. Since attaining skills is an expensive undertaking that takes a while in the health

sector. The average age of the various types of health workers varies substantially, and this appears

to reflect retention and recruitment patterns (Fig. 2). This suggests that the two health ministries

have an ageing health workforce, especially laboratory and dental technicians compared with

medical officers and pharmacists. This is mainly as a result of the many years Kenya had a civil

service employment freeze. Of the enrolled nurses, 40% are aged 41 years and older and 20% are

older than 50 years. The enrolled nurses are older because this type of health worker is being

phased out, and very few are being produced from pre-service training institutions or joining

employment. In contrast, more than half the physicians working for the Ministry of Health are

younger than 36 years of age. This reflects the high turnover of physicians in the Ministry of Health.

12

Figure 2: Age distribution of key cadres

In 2009, the retirement age of civil servants was increased from 55 to 60 years. This, coupled with

rising recruitment among younger health workers, is expected to result in a change in the age profile

of public sector health workers. In Fig. 2, 56 years old is the cut-off point in the analysis, since that is

the age of the oldest health worker in regular employment in the Ministry of Health as of July 2010.

5.5 Health workforce by sex

Most health care workers in the public market in Kenya are women (Table 9). In 2013, for instance,

of the 31 060 health care workers in the public sector, women represent nearly 60% of all personnel

in the national health system. This preponderance is the result of the significant weight of the nurse

categories, which are traditionally women-oriented occupations in Kenya. Incidentally, more than

73% of all Kenya registered community health nurses in the public market in Kenya and 62% of all

BSc nurses are women.

The feminization of the health workforce implies challenges in terms of managing human resources,

especially reconciling the maternity constraints and administrative provisions such as family

reunification with the requirements of providing services. Measures such as task shifting and the use

of temporary personnel should be carefully explored in an attempt to overcome this constraint.

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Table 9: Public health workforce by gender

Cadre category

Number of

males

Number of

females

% of Males in

cadre category

% Females

in cadre

category

Total

Medical officers 998 426 70.08% 29.92% 1 424

Pharmacists 238 175 57.63% 42.37% 413

Pharmaceutical

technologists 368 364 50.27% 49.73% 732

Laboratory

technologists and

technicians

1 668 1 364 55.01% 44.99% 3 032

Health records

and information

officers and

technicians

273 285 48.92% 51.08% 558

Nutritionists 140 224 38.46% 61.54% 364

Registered

clinical officers 1 959 1 277 60.54% 39.46% 3 236

Physiotherapists 200 96 67.57% 32.43% 296

BSc in nursing 202 335 37.62% 62.38% 537

Kenya registered

community

health nurses

4 886 13 326 26.83% 73.17% 18 212

Dentists and

dental

technologists

163 107 60.37% 39.63% 270

Public health

officers and

technicians

1 163 489 70.40% 29.60% 1 652

Radiographers 168 54 75.68% 24.32% 222

Community oral

health officers 53 59 47.32% 52.68% 112

Total 12 479 18 581 40.18% 59.82% 31 060

Source: Ministries of medical services and public health and sanitation (2013)

For other health care worker categories, however, men are in the majority. As depicted in Table 9,

Kenya has 426 women physicians versus 998 men (70% men). In other categories such as registered

clinical officers, physiotherapists, dentist and dental technologists, public health officers and

technicians and radiographers, men represent more than 60% of each specific workforce.

14

5.6 Geographical distribution of the health workforce

Although the number of health workers has increased in recent years, health workers are very

unequally distributed across provinces (Table 10). Central province has twice as many health

workers per 1000 population as the North Eastern province, which is the poorest province with the

highest rates of mortality among children younger than five years. Nairobi has the highest density of

physicians, dental specialists and pharmacists among the provinces. Nurses are more concentrated

in the coast and central regions.

Table 10 : Density of health workers by province in Kenya

Province Density of health workers per

1000 population

Central 1.81

Western 1.62

Coast 1.57

Nairobi 1.48

Rift valley 1.38

Nyanza 1.23

Eastern 1.18

North Eastern 0.84

An emergency hiring programme was implemented in 2006 to provide a three-year contract for

health workers working in underserved areas. It used strategies to recruit local health workers and

provided hardship allowances, housing grants and paid leave. Introduction of hardship allowances

and available data on health worker mobility and retention are intended to curb the outward

migration of health workers within and outside the country.

The Government of Kenya has also undertaken measures to improve working conditions (since

2009). This is by ensuring that the hospitals have the necessary infrastructure. In implementing the

constitution, the country has embarked on improved institutional and health worker productivity

and a performance structure that is appropriate in delivering health care and ensures an equitable

distribution of health workers in facilities.

A national electronic database for nurses has also been developed to better match nurses in the

underserved areas. In addition to improving the retention of health workers in underserved areas,

the government has established norms and standards to improve productivity and health

performance, such as changing the job description of the health workers.

15

5.7 Health workforce by sector

The public sector has become the single largest employer of health workers in the country in the

past three years because of expanding and opening new facilities and upgrading existing ones. The

number of health workers in the public sector was 31 060 in 2013. Before 2007, a long-standing

employment freeze for civil servants (except for selected health workers such as physicians) resulted

in a long-term decline in the number of civil servants, including health workers; this is now being

reversed. The employment freeze was largely a result of the Structural Adjustment Program

advocated by the World Bank. Development partners employed 3422 health workers in 2008 (Table

2 in the Annex).

• Informal economy

The informal sector in Kenya includes traditional medicine practitioners and traditional birth

attendants. These are unregulated, but the implementation of the new health law will change this.

5.8 Migration and turnover

The information on the migration of health workers is very scanty, and yet the general trends

indicate considerable movement either internally or externally.

Table 11 displays the total number of health workers recruited by the Ministry of Health and the

turnover of this recruited staff during 2005–2009. The last column indicates the number of recently

recruited staff members the Ministry of Health still employed in 2009. Notably, more than 50% of

physicians and an alarming 81% of enrolled community nurses left the health workforce. Laboratory

technologists and technicians had 49% turnover. Turnover includes normal attrition, resignation and

internal and external migration.

Table 11: Staff establishment and exits of the public sector

a

The share of staff recruited between 2005 – 2009 that exited the public sector due to

normal attrition, resignation and internal and external migration. b Total recruited staff minus share of total recruited staff that exited the public sector.

Source: Ministry of Health (2009)

MOH staffing trends 2005–2009

Designation Recruitment Exitsa Differenceb

Medical officers 1678 972 706

Clinical officers 845 356 489

Enrolled Nurse 2406 1964 442

Nursing Officer 1101 461 640

Medical Lab Technologist / Technicians 381 185 196

16

Data on outward migration from the Nursing Council of Kenya show that the number of nurses

verified to work outside Kenya continues to decline. The United States of America remains the single

largest destination for Kenyan nurses. In 2009, 336 nurses were verified (these are nurses whose

certificates of qualifications were verified as valid by the Nursing Council of Kenya at the request of

foreign employers) to work outside of Kenya. This number represents just over 10% of the number

of nurses graduating from nursing schools each year. (Note: the fact that a nurse’s certificate has

been verified is not proof that the nurse has left or will leave the country for a foreign-based

employer.) During the past four years, the number of health workers seeking new job opportunities

has declined because of improved working condition and remuneration in Kenya in both the public

and private sectors.

Table 12: Nurses external migration 2008 and 2009

Destination country 2008 2009

Italy 1

Ghana 1

Uganda 6 2

South Africa 4 2

Dubai 3

Tanzania 4 5

Botswana 7 5

England 158 6

Ireland 6 7

New Zealand 9 8

Namibia 16

Canada 6 40

Australia 36 40

U.S.A. 255 200

Total 491 336

Source: Annual Report of Nursing Council of Kenya (2009)

Some of the reasons or factors identified for turnover or migration of health workers include:

• better career prospects affect movement from faith-based organizations and the private sector;

• poor working conditions related to commodities, equipment and other infrastructure;

• family and personal – common among people newly employed and those approaching

retirement;

• better pay;

• training and professional development; and

• devolution and establishment of a county system has triggered a transfer request.

17

5.9 Wages

Personnel compensation takes a substantial amount of government spending on health: 80%. The

private hospitals pay relatively higher basic salaries than the government-owned hospitals. Table 13

shows the average monthly salaries for various health worker categories in the public sector. Nurses

and technicians earn less than half the highest wage, which is earned by medical officers and

specialists, dentists and radiologists. Although the medical officers earn the highest salary, this

remains very low compared with international salaries, showing the poor competitiveness of Kenya

on the international health labour market.

Table 13: The Description of wages by occupation public health workers

Cadres Monthly wages -USD Basic highest Annual

Salaries USD

Medical officers 1 222 14 667

Medical specialists 1 222 14 667

Registered clinical officers – specialists 768 9 217

Registered clinical officers 768 9 217

Nursing degree holders 656 7 883

Kenya registered community health nurses 539 6 477

Enrolled community nurses 489 5 871

Health information officers 539 6 477

Health information technicians 489 5 871

Orthopaedic technologists 539 6 477

Laboratory technicians 489 5 871

Laboratory technologists 539 6 477

Pharmaceutical technologists 489 5 871

Pharmacists 768 9 217

Dentists 1 222 14 667

Dental technologists 539 6 477

Medical engineering technicians 489 5 871

Plaster technicians 489 5 871

Radiographers 539 6 477

Radiologists 1 222 14 667

Community oral health 539 6 477

Physiotherapists 539 6 477

Occupational therapists 539 6 477

Community Health Extension Workers 489 5 871

Social workers 768 9 217

Public health officers 539 6 477

Public health technicians 489 5 871

Medical engineering technologists 539 6 477

Source: Ministry of Health, Integrated Payroll and Personnel Database

18

Table 14 shows the minimum and maximum wages for the government-owned facilities, faith-based

facilities and mission hospitals. A comparison of the remuneration of the health personnel in the civil

service and the private sector shows that the health personnel in the private sector are remunerated

better than those in the civil service. Nevertheless, nurses earn the least in mission hospitals.

However, the government pays a better package to health personnel than the mission hospitals (see

Table 15). The government health workers are entitled to more non-wage allowances than workers

in the other sector, and this has resulted in the migration of health workers from other sectors to

the public sector.

Table 14: Salary by ownership in USD

Private hospitals Mission hospitals Government-owned

hospitals

Designation Monthly salary Salary

p.m.

Monthly salary Salary

p.m.

Consolidated pay

scales

Min Max Mini Max Min Max

Specialist

consultants 2435 5353 4118 1753 2906

Medical

officers 1024 2259 1412 1765 2353 1118 1129 2224

Dentists 1471 3235 1765 2353 1129 2224

Pharmacists 1024 2259 882 1765 2353 1118 1129 2224

Nursing

officers 482 976 365 188 376 212 363 775

Enrolled

nurses 365 647 247 71 188 118 292 692

Clinical

officers 494 247 753 259 353 765

Source: HRH strategic plan review report (2010-2011)

Table 15: Allowances

Allowances Range (USD)

(depending on job group)

Non- practice 145.74 - 757.84

Extraneous 58.30 - 349.77

Risk 23.32 - 58.30

Responsibility/ administrative 46.64 - 104.93

Hardship 58.30

Commuter 23.32 - 186.55

House allowance 40.81 - 699.55

Source: Ministry of Health, Integrated Payroll and Personnel Database

19

Other non-wage compensation includes:

• health insurance covering outpatient, inpatient and bereavement;

• housing for the critical hospital staff with a concerted interministerial effort to improve social

facilities such as schools, housing, electricity, water and communication in hard-to-reach areas;

• a transfer or transport allowance for movement based on baggage and distance; and

• pension processing is part of the performance contracts designed by the permanent secretary.

5.10 Health workers shortages and surpluses

The most common measure for identifying whether there are economic shortages or surplus of

health workers in a health labour market is the vacancy rate, which is defined as the ratio of the

number of unfilled vacancies to the number of funded health care posts. This allows the gap

between the demand and the supply of health workers to be identified.

• Vacancies

As shown in Table 16, in the public sector, the vacancy rate for medical and clinical officer is highest,

ranging 35%. Regarding the position as nursing officer in the public sector, there are 23.3% unfilled

positions. Faith based organization show much higher vacancy rates than the public sector, being

above 50% for all displayed cadre categories. The total number of available posts in faith based

facilities is however smaller than the total number in the public sector. Consequently, the overall

vacancy rates are closer to the values for the public sector, than the faith-based sector.

Table 16: Health workers vacancy rate of government-owned facilities (GOK) and Faith-based

organizations (FBO), 2010

Cadre GOK

Vacancy rate

FBO

Vacancy rate

GOK / FBO

Vacancy rate

Medical officers 34.2% 64.3% 38.0%

Clinical officers 35.4% 62.9% 40.3%

Nursing officers 23.2% 61.6% 32.7%

Medical laboratory technologists

and technicians 6.8% 53.4% 19.2%

Pharmaceutical technologists N.A. 53.9% 53.9%

Source: Ministry of Health, Integrated Payroll and Personnel Database (2010)

• Needs-based shortages

To estimate the deficiency of the health system to cover the needs of the population, the needs

based shortage is estimated to identify the gap between the available health workforce and the

health workforce required to meet the needs of the population. Table 17 depicts the number of in-

post positions for various health categories working in the public sector as well as the estimated

positions that would be required according to the needs of the population in 2010. Overall, the in-

post positions cover only 30% of the estimated needed positions. For all health worker categories

20

except medical officer interns and pharmacists, the number of in-post staff members does not reach

the estimated needed staff members. Even though nurses already represent the largest share of

health workers, their number has to be increased substantially. To meet the needs of the

population, there is a shortage of 72%, as shown by the gap of 9473 enrolled nurses and a shortage

of 45% nursing officers (with a gap of 12 176). Medical officers and clinical officers face a similar

situation, as their current number covers only respectively 41% and 36% of the estimated needs-

based positions.

Table 17: Staff Establishments (2010)

Cadre Staff in-post

Required

Positions

Needs-based

shortage (%)

Enrolled nurses 11 429 20 902 45

Nursing officers 4 724 16 900 72

Medical officer interns 728 503 - 45

Medical officers 1 138 2 799 59

Clinical officers 2 615 7 345 64

Community oral health officers 105 586 82

Dental specialists 331 432 23

Dental technologists 368 100

Health administration officers 217 1 268 83

Health records and information officers 41 637 94

Health records and information technicians

Medical engineering technicians 287 468 39

Medical engineering technologists 40 478 92

Medical laboratory technicians 602 1 245 52

Medical laboratory technologists 167 1 658 90

Nutrition officers 423 3 260 87

Occupational therapists 286 685 58

Orthopaedic technologists and plaster

technicians

Pharmaceutical technologists 308 1 548 80

Pharmacists 579 207 -180

Physiotherapists 466 875 47

Public health officers and technicians 4 053 11 643 65

Radiographers and radiologists 306 547 44

Social welfare officers 42 1291 97

Others 4 814 42 291 89

Total 35 714 118 954 70

Source: Ministries of medical services and public health and sanitation, HRIS and New Establishment

(2010)

21

6. Conclusion

Providing high-quality health care services for all Kenyans as stated in the constitution remains a

challenge largely because of economic, social, political and other factors that have resulted in an

imbalance between the demand and supply of health services and the limited human resources for

health. Inadequate numbers of skilled human resources have had a particularly negative effect on

efforts to expand access and improve the quality of health services.

Kenya’s health sector recognizes that human resources constraints are a critical ingredient

hampering Kenya’s health outcomes. There has been a concerted effort by all actors to address

health workforce management issues as sector challenges affecting all the health subsectors (public,

private and faith based).

Kenya’s constitution, the Vision 2030, the health policy 2011–2030 and strategic plan for human

resources have specifically in one way or another addressed the challenges of human resources for

health. It is hoped that implementing a devolved system by establishing human resource

management at the county level will address two key challenges: mainly access to and equity of the

health workforce and thus health care.

The health sector is labour-intensive, with 80% of government expenditure allocated to personnel

compensation, leaving only 20% for other equally important input areas such as commodities,

infrastructure, information management and governance. Despite this level of expenditure, human

resources are still a great challenge in service delivery.

Kenya’s 2010 constitution and Kenya’s health policy are geared to addressing key issues on

workforce distribution as the country devolves services while increasing funding to the sector. Over

the years, human resources planning has been sidelined, and this widening production gap has

contributed to inconsistency in addressing the increase in population and disease burden, leading to

deterioration in health indicators. The country also needs to rethink its health workforce

performance and production capacity given the ageing workforce among some types of workers that

were employed in large numbers after independence and are about to leave the labour force.

The number of personnel in the Ministry of Health remained constant between 2003 and 2011 for

most types of workers apart from physicians, which grew by 54%, and pharmacists by 280%. Of

particular concern is the decline in the number of nurses between 2003 and 2011. The vacancy rates

of medical officers and pharmacists clearly show that they have utilized all their established

positions.

The marked degree of both internal and external migration is likely to affect service delivery. Internal

and external movement can be attributed to various factors, with the key being remuneration and

career prospects. In addition, the remuneration packages seem to vary between governments, faith-

based organizations and the private sector, and health workers strongly attribute the internal

movement to this variation.

22

7. Lessons learned

A deeper examination of the health labour market has revealed that the uneven geographical

distribution of the health workforce as well as an overall shortage of health workers stems from

various labour market and governance factors, including an exodus of trained health workers to

other countries in Africa and overseas, an equally complicated internal brain drain and a poorly

funded and limited medical-training infrastructure. There is limited education capacity to supply the

desired levels of health workers needed by the market, inadequate wages and working conditions to

attract and retain people into health work, particularly in underserved areas and low funding in

health facilities, resulting in demand that is too low and other market imbalances. Future strategies

to increase the availability of health workers will need to be designed taking into account the labour

market dynamics to be effective in increasing the available supply of health workers to the entire

population.

8. Recommendations

Previous policy frameworks and strategic plans have deliberately strived to identify and address the

human resource issues with minimum effect. This is because of a lack of a holistic approach to

human resources for health challenges, with a lot of focus on personnel management instead of

looking entirely at the production, absorption, retention and motivation and turnover of the health

workforce within the country and in the global arena. Thus, Kenya suffers from both shortages and

poor distribution of health workers largely because the approach to human resources for health

planning and programming is not informed by a good analysis of the health labour market. Resolving

the challenge of shortage and poor distribution of health workers and thus achieving universal

coverage will therefore depend largely on how Kenya succeeds in undertaking an in-depth analysis

of the health labour market and understand the driving forces that affect the supply and demand of

the health workforce, both in Kenya and at the global level.

Currently the country’s focus on distribution is based on reviewed and evidence-informed health

workforce norms and standards for the different tiers of services and strengthened systems and

practices in human resources development. Based on the findings and analysis in this report, the

following specific recommendations are made.

• The available vacancies need to be filled, especially in the poor areas, through incentives and

promotion policies for deployment.

• The current health workforce needs to be used more efficiently by increasing the

productivity and performance of the health workforce to improve the quality of services

offered.

• To address retention, migration and the geographical imbalance of the health workforce, a

concerted effort needs to be made to improve the working conditions and incentives for

health workers, particularly in rural and remote areas of the country, to attract and retain

more health care workers to rural health facilities.

• The budgetary allocation to health needs to be increases to adequately cater for other

health inputs given that human resources is taking nearly 80% of the budget.

23

• Access to training for students from rural and remote areas should be improved.

• The health workforce remuneration should be harmonized across the subsectors and in

government to stem internal migration and improve service delivery.

• The coordination between the ministries responsible for health, education, labour and

finance should be strengthened to match the health workforce production to the country’s

need and to ensure absorption into the labour market to address population growth and the

increased disease burden.

• The regulation of the private sector needs to be improved to manage dual practice, to

improve the quality of training and to enhance service delivery.

24

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26

Annex

Table 1. Staff in-position (Ministry of Health), 2003–2011

Category 2003 2004 2005 2006 2007 2008 2009 2010 2011

Physicians 1 380 1 496 1 501 1 553 1 763 1 985 1 559 1 783 2 129

Pharmacists 160 171 130 109 119 233 202 522 621

Dentists 281 284 400 382 409 505 427 211 256

Nurses 15

581 16 123 15 899 15 082 15 981 14 586 10 958 10 735 11 610

Clinical officers 2 019 2 145 2 143 1 908 2 165 2 193 1 620 1 414 2 149

Public health

officers 2 019 2 145 2 143 3 908 4 115 NA NA NA NA

Laboratory

technicians 1 508 1 611 1 630 1 699 1 748 1 378 1 465 1 423 1 553

Nutritionists 353 348 394 405 417 NA NA NA NA

Physiotherapists 420 411 440 450 453 461 301 457 459

Radiographers 263 278 205 248 267 297 261 284 291

Source: Ministries of medical services and public health and sanitation (2011)

Table 2. Number of contract personnel employed by development partners, 2008

Development partner Cadre Total

Nurses

Clinical

officers

Lab

techs

Nutrition

officers

Pharm

techs Others

William J. Clinton

Foundation 1 186 134 88 1 408

United States Agency for

International Development

(Capacity Project)

618 86 90 36 830

Malaria programme (Global

Fund to Fight AIDS,

Tuberculosis and Malaria)

431 69 500

NASCOP (Global Fund to

Fight AIDS, Tuberculosis and

Malaria)

116 82 48 47 24 77 394

United States President’s

Emergency Plan for AIDS

Relief

10 20

170 200

GAVI Alliance 90 90

Total 2 451 322 295 47 60 247 3 422

Source: Ministries of medical services and public health and sanitation (2009)