HAF Application in North Eastern Province, Kenya
Context and Health Workforce Challenge
In November 2007, USAID and the Ministry of Health (MOH) in Kenya requested a health workforce assessment in the North Eastern Province (NEP) of Kenya in anticipation of a large scale up of HIV/AIDS and other health services. With a population of 1.3 million and a land mass that comprises 20% of the country, the province is sparsely populated. The main economic activities are pastoralism and livestock production. Households have an average of 8 family members, and 44% of the population lives on less than $1.00 per person per day.
The Kenya Demographic and Health Survey 2003 and other recent data show health indicators for the province well below the national average. Despite a maternal mortality of 1,000/100,000 (nationally 414/100,000), there is only 1 obstetrician in the entire province in addition to 1 physician and 2 surgeons. Health services are mainly delivered by clinical officers, nurses and public health officers, but these are few and dispersed over a huge area, leaving many areas uncovered. For example, only 30% of the established positions in Madera District are filled. Overall, 32% of the health facilities are closed due to lack of health staff. As an emergency measure, donors are supporting the placement of 44% of the existing health staff.
HAF Application: Methodology and Process:
The goal of the HRH Action Framework (HAF) application was to identify strategies that would lead to adequate numbers of skilled and motivated health workers, equitably distributed. The process followed four phases: (1) In-country leadership agreement, (2) Work preparation, (3) Situational Analysis & Planning, and (4) Implementation.
A preparatory meeting was held (phase 2) to identify key stakeholders, gather existing health workforce data, agree on the scope of work and its objectives, and plan for the initial stakeholder meeting. Rich information was obtained on Human Resources (HR) strategies already being tried, what works and what doesn’t, and what the stakeholders viewed as the health workforce priorities.
Situational Analysis was carried out by a team of two international HR consultants and 3 local health managers who brought valuable local knowledge and who supported the implementation of the action plan resulting from the analysis. The team identified the following key challenges in the six HAF Action Fields:
Management Systems: 70% of the health staff are from outside the province
Policy: lack of a decentralized recruitment and deployment policy
Finance: high donor dependency for health staff
Education: limited local capacity to train health workers
Partnership: weak linkages among communities, partners and government
Leadership: dependence on young, largely inexperienced health managers due to high staff turnover
Based on these findings eight interventions were recommended for immediate action:
1. establish functional Human Resource Management (HRM) units at provincial and district levels;
2. institute a leadership development program at all levels;
3. recruit locally and introduce a realistic hardship package;
4. lobby MOH and partners to hire additional staff;
5. invest in housing and related amenities;
6. increase the intake of local students to training institutions;
7. ensure obstetric capability at facilities linked to nomadic clinics;
8. mobilize resources to support HRH programs and initiatives.
A stakeholder subgroup was identified to develop the action plan with assistance from the HR consultant team.
The support of the HR Director of the MOH in Nairobi proved to be essential for key outcomes such as the policy reform needed to decentralize staff recruitment and deployment to the NEP. Unfortunately, following elections later that year in Kenya, she was transferred, so the policy reform slowed. Nonetheless, the NEP action plan is now incorporated into the national HR strategy and the leadership group in NEP continues to champion the implementation plan. The strong presence of the AIDS, Population and Health Integrated Assistance (APHIA II) Project in the province to support this leadership group and to advocate for follow-up is crucial. To date (July 2009) a leadership development program has been implemented for 50 health managers, and USAID support has been requested to fill 100 critical staff positions through the Emergency Hiring Program. Under this program, staff members are initially sponsored by a donor organization, but transfer after three years to the MOH personnel payroll to become established government health workers.