View
12
Download
1
Tags:
Embed Size (px)
DESCRIPTION
Research paper from Kenya, presented during the conference by Ismael Atako , IUA Medicine.
Citation preview
-101-
International University of Africa
Faculty of Medicine and Health Sciences
African Medical Students Association
Health Problems in Africa: Is there any hope left?
10 – 11 January 2013 AD/ 28 -29 Safar 1434 AH Khartoum - Sudan
Major Health Problems in East Africa
Kenya
Prepared by:
Ahmed Nassir Ahmed, Ahmed Akasha Alsayed;
Khadija Said; Ismail Atako Luta
(MBBS Level 3, Faculty of Medicine – IUA)
-102-
COUNTRY BACKGROUND Republic of Kenya is a country in East Africa that lies on the equator.
With the Indian Ocean to its south-east, it is bordered by Tanzania to the
south, Uganda to the west, South Sudan to the north-west,Ethiopia to the north
and Somalia to the north-east. Kenya has a land area of 580,000 km2 and a
population of a little over 43 million residents.The country is named
after Mount Kenya, a significant landmark and second among Africa's highest
mountain peaks. Its capital and largest city is Nairobi.
Climate
Kenya has a warm and humid climate along its coastline on the
Indian Ocean, which changes to wildlife-rich savannah grasslands moving
inland towards the capital. Nairobi has a cool climate that gets colder
approaching Mount Kenya, which has three permanently snow-capped
-103-
peaks. The warm and humid tropical climate reappears further inland
towards lake Victoria, before giving way to temperate forested and hilly
areas in the western region. The North Eastern regions along the border
with Somalia and Ethiopia are arid and semi-arid areas with near-
desert landscapes. Lake Victoria, is situated to the southwest and is shared
with Uganda and Tanzania.
MAJOR HEALTH PROBLEMS
Malaria
Background
The epidemiology of malaria in Kenya is quite varied
geographically, with high levels of transmission on the coast and around
Lake Victoria but little or no transmission in the highlands above 1,500–
2,000 meters altitude. The Government of Kenya tailors its malaria control
efforts according to malaria risk to achieve maximum impact. Recent
household surveys show significant progress is being made against
malaria in Kenya, with improvements in coverage with malaria prevention
and treatment measures and reductions in malaria parasitemia and illness.
Malaria in Kenya at a glance
Malaria is the leading cause of morbidity and mortality in Kenya .
25 million out of a population of 43 million Kenyans are at risk of
malaria. It accounts for 30-50% of all outpatient attendance and 20% of
all admissions to health facilities. Malaria is also estimated to cause 20%
of all deaths in children under five. The most vulnerable group to malaria
infections are pregnant women and children under 5 years of age. In
collaboration with partners, the government has developed the 10-year
Kenyan National Malaria Strategy (KNMS) 2009-2017 (link) which was
launched 4th November 2009. The goal of the National Malaria Strategy
-104-
is to reduce morbidity and mortality associated with malaria by 30% by
2009 and to maintain it to 2017.
SHORTAGE OF HEALTH WORKFORCE IN
KENYA
Introduction
There is increasing evidence of a strong correlation between the
density of human resources for health (HRH) in a country and population
health outcomes. But many countries lack the right numbers of health
workers in the right places to deliver essential health interventions, such as
immunization and skilled attendance at delivery.
The causes of these shortages and imbalances are manifold. They
include limited production capacity as a result of years of poor planning
and underinvestment in health education and training institutions,
especially in many developing countries. Often, training outputs are
poorly aligned with the health needs of the population. There are also
"push" and "pull" factors that affect workforce retention and may
encourage health service providers to leave their workplaces, including
those related to unsatisfactory working conditions, poor remuneration and
career opportunities, and other labour market pressures. In particular, the
international migration of large numbers of health workers further
weakens the already fragile health systems in many low and middle
income countries. Underlying all this is the reason of many nations, Kenya
being one of them, lack the ability to provide an appropriate amount of
health workforce.
Gaining insight into the confluence of factors that causes health
workforce shortages is critical in designing effective solutions. Rather
-105-
than a single cause, there are multiple complex causes that combine to
produce a global shortage of 4.3 million workers in 57 of the world's
poorest countries. Some of these causes are cross-cutting and seen in all
countries experiencing health worker shortages. Other causal factors affect
a particular country or a region of a country, or have a special potency in
one situation and not another.
Numerous studies have explored the link between an adequate
supply and deployment of HRH and health services delivery. The Joint
Learning Initiative, comprised of global health experts, found that a
density of 2.3 health care workers per 1,000 population was associated
with 80% coverage in skilled birth attendance and measles vaccination
(2004). Anand also found a relationship between the density of the health
workforce and mortality rates for mothers, infants and children under five
(Anand, and Barnighausen 2004). However, thirty-six sub-Saharan
African countries, including Kenya, are facing a critical shortage of heath
care workers (2006).
To address the shortage of health care workers, Kenya has employed
various strategies, two of which included an Emergency Hire Plan (EHP)
and a computer-based distance education program (2008). Kenya’s
emergency hire plan included several donor partners, and facilitated the
rapid recruitment and deployment of health workers. Data from the
KHWIS indicated that the EHP accounted for the hiring of 1,836 nurses
increasing the public sector nursing workforce by 12%. Some EHP nurses
were deployed to closed or new health facilities, increasing functional
health facilities by 9% (Gross et al. 2010). Additionally, a computer-based
distance education program, developed through a partnership between the
African Medical and Research Foundation and Kenya’s ministries of
health, enhanced nurses’ education through distance learning, which
contributed to a 31% increase in the number of registered nurses, as 5,887
upgraded from enrolled to registered (data from KHWIS).
Enhancing the supply and availability of registered health professionals
will only translate into improved workforce to population densities if
-106-
fiscal space is created to hire and deploy new workers. Economic policies
implemented by international finance institutions have created workforce
imbalances in many low-income countries, including Kenya, whereby the
unemployment of licensed health professionals persisted amidst national
health workforce shortages, due to public sector hiring ceilings (2004;
Kingma 2006). While financing the health workforce scale up remains a
challenge, streamlining the deployment process is also a vital component
of health systems strengthening. Kenya’s emergency hire plan consisted of
a fast track recruitment and deployment strategy, addressing inefficiencies
in the personnel management process (Adano 2008). Investments in
strengthening personnel management systems will ensure that new
workers are recruited, hired, and deployed in a timely manner.
HEALTH CARE SYSTEM Kenya’s health care system is structured in a step-wise manner so
that complicated cases are referred to a higher level. Gaps in the system
are filled by private and church run units. The structure thus consists:
Health units Dispensaries The government runs dispensaries across
the country and is the lowest point of contact with the public. These are
run and managed by enrolled and registered nurses who are supervised by
the nursing officer at the respective health centre. They provide outpatient
services for simple ailments such as common cold and flu, uncomplicated
malaria and skin conditions. Those patients who cannot be managed by
the nurse are referred to the health centres.
Private clinics
Most private clinics in the community are run by nurses. In 2011
there were 65,000 nurses on their council's register. A smaller number of
private clinics, mostly in the urban areas, are run by clinical officers and
doctors who numbered 8,600 and 7,100 respectively in 2011. These
-107-
figures include those who have died or left the profession hence the actual
number of workers is lower.
Health centers
These are medium sized units which cater for a population of about
80,000 people. A few are owned by mission hospitals. They are managed
and run by Clinical officers who are the team leaders. A typical health
centre is staffed by:
At least one Clinical officer
Nurses
Health administration officer
Medical technologist
Pharmaceutical technologist
Health information officer
Public health officer
Nutritionist
Driver
Housekeeper
Supporting staff
EDUCATION AND TRAINING
Medical Doctors and Dentists
In Kenya, there are four medical training institutions for doctors—
Nairobi, Moi, Kenyatta and Egerton Universities. Nairobi University is the
sole training school for dentists. In Kenya, all medical and dental students
must earn a degree. Medical degrees require six years of academic education,
plus a one-year internship; while, dental degrees include five years of
educational training, plus a one-year internship. Nairobi University trains
90% of Kenyan trained medical doctors, while Moi University trains the
-108-
remaining 10%. The medical programs at Kenyatta and Egerton Universities
are new and the Kenya Medical Practitioners and Dentists Board (KMPDB)
does not yet capture student data from these institutions. Nairobi University
has 31 professors and 56 lecturers for medical professional students. Moi
University, in Rift Valley Province, has 80 tutors for medical training with a
tutor to student ratio of 1:14.
Clinical Officers
In Kenya, there are 24 training institutions registered with the Kenya
Clinical Officers Council (KCOC) to train clinical officers. Medical
Training Colleges (MTCs), which are government sponsored, represent 17
of the 24 institutions, accounting for 71% of clinical officer training
institutions in Kenya. For the remaining clinical officer training
institutions, two are government sponsored universities (Egerton
University and Kenyatta University), two are private (Lake Institute of
Tropical Medicine and Mt. Kenya University), and three are faith-based
(Kenya Methodist University, St. Mary’s Mumias and Presbyterian
University of East Africa). Currently, all clinical officers are trained at the
diploma level, which requires three years of school, plus one year of
internship. Following their internship, clinical officers can specialize in a
variety of areas, including anesthesia, ophthalmology, pediatrics,
orthopedics, reproductive health, mental health, and ear/nose/throat
(ENT). In 2010, Mt. Kenya University began offering the first Bachelor of
Clinical Medicine program for clinical officers, which includes four years
of academics, followed by a one-year internship.
The distribution of training institutions and newly trained clinical
officers differs provincially. From 2006-2009, Central Province, which
has 6 (25%) of Kenya’s clinical officer training institutions, trained 22%
of new officers. Nyanza Province, with five institutions, trained over
25% of new clinical officers, followed by Rift Valley, with four
institutions and 16% of new officers. Coast Province, with only 2
institutions, trained 13% of new officers. Currently, North Eastern
-109-
Province is the only province that does not train clinical officers. As
mentioned, the KHWIS is in the process of establishing an electronic
database for the KCOC; thus, information on the number of COCs in the
country was estimated based on key informant interviews with the
Registrar. The KCOC estimates there are 8,300 registered clinical
officers (personal communication, Registrar, KCOC). As a result of the
anticipation of the KHWIS, the KCOC is strengthening it licensure
renewal policy, which will assist in ―cleaning‖ the official registry for
clinical officers. Since the KCOC does not currently track workforce
retention, deployment data provides an estimation of the active clinical
officer workforce. The KCOC estimates that approximately 3,800
officers (46%) are deployed in the public sector and 2,500 (30%) in the
private sector (personal communication, Registrar, KCOC).
STATISTICS While the KMPDB has registered 6,306 medical doctors and 780
dentists over the past 32 years, only 75% of these medical professionals
are currently considered ―active‖ in the workforce, having renewed their
medical license within the past five years. According to retention
information from the KMPDB, there are 4,756 active medical doctors and
590 active dentists, which comprise Kenya’s medical and dental
workforce. Eleven percent of active medical doctors are 61 years of age or
older and an additional 17% are 51-60 years of age. While the public
sector retirement age is 60, many doctors continue contributing to the
medical workforce well beyond the age of 60. For active dentists, 5% are
61-70 years of age and 18% are 51-60 years of age. Thirty percent of
active medical doctors and 40% of dentists are female with the remaining
70% of doctors and 60% of dentists being male.
MIGRATION AND RETENTION BRAIN DRAIN
-110-
The total cost of educating a single medical doctor from primary
school to university is 65,997 US dollars; and for every doctor who
emigrates, a country loses about 517,931 US dollars worth of returns from
investment. The total cost of educating one nurse from primary school to
college of health sciences is 43,180 US dollars; and for every nurse that
emigrates, a country loses about 338,868 US dollars worth of returns from
investment.
Developed countries continue to deprive Kenya of millions of
dollars worth of investments embodied in her human resources for health.
If the current trend of poaching of scarce human resources for health (and
other professionals) from Kenya is not curtailed, the chances of achieving
the Millennium Development Goals would remain bleak. Such continued
plunder of investments embodied in human resources contributes to
further underdevelopment of Kenya and to keeping a majority of her
people in the vicious circle of ill-health and poverty. Therefore, both
developed and developing countries need to urgently develop and
implement strategies for addressing the health human resource crisis.
WORKFORCE SHORTAGE AND MAL-
DISTRIBUTION Kenya has bold plans for scaling up priority interventions
nationwide, but faces major human resource challenges, with a lack of
skilled workers especially in the most disadvantaged rural areas.In a
research carried out in the country the authors concluded:
The issue of workforce shortage and mal-distribution is complex and not
unique to the nursing cadre or to Kenya. Poor infrastructure, limited
training opportunities, high workloads, inadequate supplies and
supervision, undisclosed job locations for public sector jobs, and most
recently political instability all continue to be barriers to successful rural
recruitment and retention. Interestingly we found no suggestion that those
born in or with experience working in rural areas are more willing to seek
-111-
rural employment. While donor funded short-term contracts have
increased recruitment in recent years, it is possible that their impact will
be compromised by their unpopularity among nurses due to their lack of
pension plans and job security. The most popular proposed policy
intervention among respondents was the provision of additional financial
incentives for rural posting, though these may be more effective if
implemented as part of a multi-dimensional package. Such a package
would require collaboration between economic and health policy-makers
to earmark funding to not only secure salaries but also improve working
conditions. It should also be accompanied by investment in information
systems capable of monitoring its impact with rigor.
ATTRITION In a research carried out in the country on attrition the researchers noted
that. In hospitals, doctors had much higher rates of attrition, compared to
clinical officers, although resignation was the predominant reason for
attrition in both cadres. This finding may reflect a recent trend for doctors,
who may be moving completely away from public service rather than
staying on with the dual employment opportunity (often referred to as
"moonlighting") that has been on the books for years. The differential
rates of attrition between doctors and clinical officers may thus reflect that
doctors are more likely to emigrate for work in health facilities abroad or
to go completely into private practice or employment in the NGO sector in
the home country (which are not opportunities as readily available to
clinical officers).
Attrition among registered nurses in provincial hospitals was, on average,
twice as high as the rate of attrition of enrolled nurses. While resignation
accounted for about half of attrition among registered nurses at this level,
the loss of enrolled nurses was nearly all due to retirement. By contrast, at
lower facility levels, registered and enrolled nurses had similar rates of
attrition, mostly explained by retirement. This may reflect the higher
international mobility and more numerous alternative employment
-112-
opportunities available to registered nurses (in comparison with enrolled
nurses), particularly in urban areas where the provincial hospitals are
located.
Push Factors
Studies as to why health workers resign have found that the main reasons
are
1. Low pay
2. Poor working and living conditions at the sites where they are
posted
3. Reasons related to the HIV/AIDS epidemic, such as fear of
becoming infected on the job and overwhelming workload and
stress induced by caring for, and seeing high death rates among,
HIV/AIDS patients. For health workers in rural areas, an additional
problem is inadequate quality of housing,
4. Inadequate quality transport
inadequate quality schools for their children.
Pull Factors
Better pay and opportunities available in other occupations or health
facilities abroad.
RECOMMENDATIONS
Key recommendations to parliament and government
-113-
Increase the number, and strengthen the role of community health
workers, including by providing them with basic supplies,
transportation where needed, and compensation for their services.
Strengthen the referral system, for example by providing transport
between health care facilities.
Prioritize the completion and implementation of the National
Social Health Insurance Fund to improve access to maternal and
child health care.
Assess the feasibility of exempting fees for maternal health care in
all health facilities beyond the current exemption for childbirth in
dispensaries and health centres.
With regards to palliative care, allocate a separate budget line for
palliative care, including for new palliative care units that the
government has announced, and implement a program of home-
based palliative care with pediatric expertise.
As a minimum, ensure that the percentage of the health budget
does not decrease.
With regards to obstetric care, increase the number of health
facilities that offer emergency obstetric care, increase the number
of midwives, and develop guidelines on the management of
obstructed labor. Also subsidize routine obstetric fistula repairs in
provincial and district hospitals, and provide free fistula surgeries
for poor patients.