International University of Africa

Faculty of Medicine and Health Sciences

African Medical Students Association

Health Problems in Africa: Is there any hope left?
10 11 January 2013 AD/ 28 -29 Safar 1434 AH Khartoum - Sudan

Major Health Problems in East Africa

Kenya

Prepared by:

Ahmed Nassir Ahmed, Ahmed Akasha Alsayed; Khadija Said; Ismail Atako Luta (MBBS Level 3, Faculty of Medicine IUA)
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COUNTRY BACKGROUND
Republic of Kenya is a country in East Africa that lies on the equator. With the Indian Ocean to its south-east, it is bordered by Tanzania to the south, Uganda to the west, South Sudan to the north-west,Ethiopia to the north and Somalia to the north-east. Kenya has a land area of 580,000 km2 and a population of a little over 43 million residents.The country is named after Mount Kenya, a significant landmark and second among Africa's highest mountain peaks. Its capital and largest city is Nairobi.

Climate
Kenya has a warm and humid climate along its coastline on the Indian Ocean, which changes to wildlife-rich savannah grasslands moving inland towards the capital. Nairobi has a cool climate that gets colder approaching Mount Kenya, which has three permanently snow-capped

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peaks. The warm and humid tropical climate reappears further inland towards lake Victoria, before giving way to temperate forested and hilly areas in the western region. The North Eastern regions along the border with Somalia and Ethiopia are arid and semi-arid areas with neardesert landscapes. Lake Victoria, is situated to the southwest and is shared with Uganda and Tanzania.

MAJOR HEALTH PROBLEMS

Malaria Background
The epidemiology of malaria in Kenya is quite varied geographically, with high levels of transmission on the coast and around Lake Victoria but little or no transmission in the highlands above 1,500 2,000 meters altitude. The Government of Kenya tailors its malaria control efforts according to malaria risk to achieve maximum impact. Recent household surveys show significant progress is being made against malaria in Kenya, with improvements in coverage with malaria prevention and treatment measures and reductions in malaria parasitemia and illness.

Malaria in Kenya at a glance

Malaria is the leading cause of morbidity and mortality in Kenya . 25 million out of a population of 43 million Kenyans are at risk of malaria. It accounts for 30-50% of all outpatient attendance and 20% of all admissions to health facilities. Malaria is also estimated to cause 20% of all deaths in children under five. The most vulnerable group to malaria infections are pregnant women and children under 5 years of age. In collaboration with partners, the government has developed the 10-year Kenyan National Malaria Strategy (KNMS) 2009-2017 (link) which was launched 4th November 2009. The goal of the National Malaria Strategy

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is to reduce morbidity and mortality associated with malaria by 30% by 2009 and to maintain it to 2017.

SHORTAGE OF HEALTH WORKFORCE IN KENYA

Introduction
There is increasing evidence of a strong correlation between the density of human resources for health (HRH) in a country and population health outcomes. But many countries lack the right numbers of health workers in the right places to deliver essential health interventions, such as immunization and skilled attendance at delivery. The causes of these shortages and imbalances are manifold. They include limited production capacity as a result of years of poor planning and underinvestment in health education and training institutions, especially in many developing countries. Often, training outputs are poorly aligned with the health needs of the population. There are also "push" and "pull" factors that affect workforce retention and may encourage health service providers to leave their workplaces, including those related to unsatisfactory working conditions, poor remuneration and career opportunities, and other labour market pressures. In particular, the international migration of large numbers of health workers further weakens the already fragile health systems in many low and middle income countries. Underlying all this is the reason of many nations, Kenya being one of them, lack the ability to provide an appropriate amount of health workforce. Gaining insight into the confluence of factors that causes health workforce shortages is critical in designing effective solutions. Rather

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than a single cause, there are multiple complex causes that combine to produce a global shortage of 4.3 million workers in 57 of the world's poorest countries. Some of these causes are cross-cutting and seen in all countries experiencing health worker shortages. Other causal factors affect a particular country or a region of a country, or have a special potency in one situation and not another. Numerous studies have explored the link between an adequate supply and deployment of HRH and health services delivery. The Joint Learning Initiative, comprised of global health experts, found that a density of 2.3 health care workers per 1,000 population was associated with 80% coverage in skilled birth attendance and measles vaccination (2004). Anand also found a relationship between the density of the health workforce and mortality rates for mothers, infants and children under five (Anand, and Barnighausen 2004). However, thirty-six sub-Saharan African countries, including Kenya, are facing a critical shortage of heath care workers (2006). To address the shortage of health care workers, Kenya has employed various strategies, two of which included an Emergency Hire Plan (EHP) and a computer-based distance education program (2008). Kenyas 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 Kenyas ministries of health, enhanced nurses education through distance learning, which contributed to a 31% increase in the number of registered nurses, as 5,887 upgraded from enrolled to registered (data from KHWIS). Enhancing the supply and availability of registered health professionals will only translate into improved workforce to population densities if

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fiscal space is created to hire and deploy new workers. Economic policies implemented by international finance institutions have created workforce imbalances in many low-income countries, including Kenya, whereby the unemployment of licensed health professionals persisted amidst national health workforce shortages, due to public sector hiring ceilings (2004; Kingma 2006). While financing the health workforce scale up remains a challenge, streamlining the deployment process is also a vital component of health systems strengthening. Kenyas 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

Kenyas health care system is structured in a step-wise manner so that complicated cases are referred to a higher level. Gaps in the system are filled by private and church run units. The structure thus consists: Health units Dispensaries The government runs dispensaries across the country and is the lowest point of contact with the public. These are run and managed by enrolled and registered nurses who are supervised by the nursing officer at the respective health centre. They provide outpatient services for simple ailments such as common cold and flu, uncomplicated malaria and skin conditions. Those patients who cannot be managed by the nurse are referred to the health centres.

Private clinics
Most private clinics in the community are run by nurses. In 2011 there were 65,000 nurses on their council's register. A smaller number of private clinics, mostly in the urban areas, are run by clinical officers and doctors who numbered 8,600 and 7,100 respectively in 2011. These

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figures include those who have died or left the profession hence the actual number of workers is lower.

Health centers
These are medium sized units which cater for a population of about 80,000 people. A few are owned by mission hospitals. They are managed and run by Clinical officers who are the team leaders. A typical health centre is staffed by: At least one Clinical officer Nurses Health administration officer Medical technologist Pharmaceutical technologist Health information officer Public health officer Nutritionist Driver Housekeeper Supporting staff

EDUCATION AND TRAINING

Medical Doctors and Dentists
In Kenya, there are four medical training institutions for doctors Nairobi, Moi, Kenyatta and Egerton Universities. Nairobi University is the sole training school for dentists. In Kenya, all medical and dental students must earn a degree. Medical degrees require six years of academic education, plus a one-year internship; while, dental degrees include five years of educational training, plus a one-year internship. Nairobi University trains 90% of Kenyan trained medical doctors, while Moi University trains the

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remaining 10%. The medical programs at Kenyatta and Egerton Universities are new and the Kenya Medical Practitioners and Dentists Board (KMPDB) does not yet capture student data from these institutions. Nairobi University has 31 professors and 56 lecturers for medical professional students. Moi University, in Rift Valley Province, has 80 tutors for medical training with a tutor to student ratio of 1:14.

Clinical Officers
In Kenya, there are 24 training institutions registered with the Kenya Clinical Officers Council (KCOC) to train clinical officers. Medical Training Colleges (MTCs), which are government sponsored, represent 17 of the 24 institutions, accounting for 71% of clinical officer training institutions in Kenya. For the remaining clinical officer training institutions, two are government sponsored universities (Egerton University and Kenyatta University), two are private (Lake Institute of Tropical Medicine and Mt. Kenya University), and three are faith-based (Kenya Methodist University, St. Marys 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 Kenyas clinical off icer training institutions, trained 22% of new officers. Nyanza Province, with five institutions, trained over 25% of new clinical officers, followed by Rift Valley, with four institutions and 16% of new officers. Coast Province, with only 2 institutions, trained 13% of new officers. Currently, North Eastern

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Province is the only province that does not train clinical officers. As mentioned, the KHWIS is in the process of establishing an electronic database for the KCOC; thus, information on the number of COCs in the country was estimated based on key informant interviews with the Registrar. The KCOC estimates there are 8,300 registered clinical officers (personal communication, Registrar, KCOC). As a result of the anticipation of the KHWIS, the KCOC is strengthening it licensure renewal policy, which will assist in cleaning the official registry for clinical officers. Since the KCOC does not currently track workforce retention, deployment data provides an estimation of the active clinical officer workforce. The KCOC estimates that approximately 3,800 officers (46%) are deployed in the public sector and 2,500 (30%) in the private sector (personal communication, Registrar, KCOC).

STATISTICS
While the KMPDB has registered 6,306 medical doctors and 780 dentists over the past 32 years, only 75% of these medical professionals are currently considered active in the workforce, having renewed their medical license within the past five years. According to retention information from the KMPDB, there are 4,756 active medical doctors and 590 active dentists, which comprise Kenyas medical and dental workforce. Eleven percent of active medical doctors are 61 years of age or older and an additional 17% are 51-60 years of age. While the public sector retirement age is 60, many doctors continue contributing to the medical workforce well beyond the age of 60. For active dentists, 5% are 61-70 years of age and 18% are 51-60 years of age. Thirty percent of active medical doctors and 40% of dentists are female with the remaining 70% of doctors and 60% of dentists being male.

MIGRATION AND RETENTION BRAIN DRAIN

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The total cost of educating a single medical doctor from primary school to university is 65,997 US dollars; and for every doctor who emigrates, a country loses about 517,931 US dollars worth of returns from investment. The total cost of educating one nurse from primary school to college of health sciences is 43,180 US dollars; and for every nurse that emigrates, a country loses about 338,868 US dollars worth of returns from investment. Developed countries continue to deprive Kenya of millions of dollars worth of investments embodied in her human resources for health. If the current trend of poaching of scarce human resources for health (and other professionals) from Kenya is not curtailed, the chances of achieving the Millennium Development Goals would remain bleak. Such continued plunder of investments embodied in human resources contributes to further underdevelopment of Kenya and to keeping a majority of her people in the vicious circle of ill-health and poverty. Therefore, both developed and developing countries need to urgently develop and implement strategies for addressing the health human resource crisis.

WORKFORCE DISTRIBUTION

SHORTAGE

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Kenya has bold plans for scaling up priority interventions nationwide, but faces major human resource challenges, with a lack of skilled workers especially in the most disadvantaged rural areas.In a research carried out in the country the authors concluded: The issue of workforce shortage and mal-distribution is complex and not unique to the nursing cadre or to Kenya. Poor infrastructure, limited training opportunities, high workloads, inadequate supplies and supervision, undisclosed job locations for public sector jobs, and most recently political instability all continue to be barriers to successful rural recruitment and retention. Interestingly we found no suggestion that those born in or with experience working in rural areas are more willing to seek

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rural employment. While donor funded short-term contracts have increased recruitment in recent years, it is possible that their impact will be compromised by their unpopularity among nurses due to their lack of pension plans and job security. The most popular proposed policy intervention among respondents was the provision of additional financial incentives for rural posting, though these may be more effective if implemented as part of a multi-dimensional package. Such a package would require collaboration between economic and health policy-makers to earmark funding to not only secure salaries but also improve working conditions. It should also be accompanied by investment in information systems capable of monitoring its impact with rigor.

ATTRITION
In a research carried out in the country on attrition the researchers noted that. In hospitals, doctors had much higher rates of attrition, compared to clinical officers, although resignation was the predominant reason for attrition in both cadres. This finding may reflect a recent trend for doctors, who may be moving completely away from public service rather than staying on with the dual employment opportunity (often referred to as "moonlighting") that has been on the books for years. The differential rates of attrition between doctors and clinical officers may thus reflect that doctors are more likely to emigrate for work in health facilities abroad or to go completely into private practice or employment in the NGO sector in the home country (which are not opportunities as readily available to clinical officers). Attrition among registered nurses in provincial hospitals was, on average, twice as high as the rate of attrition of enrolled nurses. While resignation accounted for about half of attrition among registered nurses at this level, the loss of enrolled nurses was nearly all due to retirement. By contrast, at lower facility levels, registered and enrolled nurses had similar rates of attrition, mostly explained by retirement. This may reflect the higher international mobility and more numerous alternative employment

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opportunities available to registered nurses (in comparison with enrolled nurses), particularly in urban areas where the provincial hospitals are located.

Push Factors
Studies as to why health workers resign have found that the main reasons are 1. Low pay 2. Poor working and living conditions at the sites where they are posted 3. Reasons related to the HIV/AIDS epidemic, such as fear of becoming infected on the job and overwhelming workload and stress induced by caring for, and seeing high death rates among, HIV/AIDS patients. For health workers in rural areas, an additional problem is inadequate quality of housing, 4. Inadequate quality transport inadequate quality schools for their children.

Pull Factors
Better pay and opportunities available in other occupations or health facilities abroad.

RECOMMENDATIONS
Key recommendations to parliament and government

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Increase the number, and strengthen the role of community health workers, including by providing them with basic supplies, transportation where needed, and compensation for their services. Strengthen the referral system, for example by providing transport between health care facilities. Prioritize the completion and implementation of the National Social Health Insurance Fund to improve access to maternal and child health care. Assess the feasibility of exempting fees for maternal health care in all health facilities beyond the current exemption for childbirth in dispensaries and health centres. With regards to palliative care, allocate a separate budget line for palliative care, including for new palliative care units that the government has announced, and implement a program of homebased 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.

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