The impact of out-migration on the nursing workforce in Kenya

A qualitative inquiry of access to and quality of primary healthcare in seven communities in East and West Africa (SevenCEWA): perspectives of stakeholders, healthcare providers and users

BACKGROUND

Universal health coverage is one of the Sustainable Development Goal targets known to improve population health and reduce financial burden. There is little qualitative data on access to and quality of primary healthcare in East and West Africa. The aim of this study was to describe the viewpoints of healthcare users, healthcare providers and other stakeholders on health-seeking behaviour, access to and quality of healthcare in seven communities in East and West Africa.

METHODS

A qualitative study was conducted in four communities in Nigeria and one community each in Kenya, Uganda and Tanzania in 2018. Purposive sampling was used to recruit: 155 respondents (mostly healthcare users) for 24 focus group discussions, 25 healthcare users, healthcare providers and stakeholders for in-depth interviews and 11 healthcare providers and stakeholders for key informant interviews. The conceptual framework in this study combined elements of the Health Belief Model, Health Care Utilisation Model, four 'As' of access to care, and pathway model to better understand the a priori themes on access to and quality of primary healthcare as well as health-seeking behaviours of the study respondents. A content analysis of the data was done using MAXQDA 2018 qualitative software to identify these a priori themes and emerging themes.

RESULTS

Access to primary healthcare in the seven communities was limited, especially use of health insurance. Quality of care was perceived to be unacceptable in public facilities whereas cost of care was unaffordable in private facilities. Health providers and users as well as stakeholders highlighted shortage of equipment, frequent drug stock-outs and long waiting times as major issues, but had varying opinions on satisfaction with care. Use of herbal medicines and other traditional treatments delayed or deterred seeking modern healthcare in the Nigerian sites.

CONCLUSIONS

There was a substantial gap in primary healthcare coverage and quality in the selected communities in rural and urban East and West Africa. Alternative models of healthcare delivery that address social and health inequities, through affordable health insurance, can be used to fill this gap and facilitate achieving universal health coverage.

Health workforce metrics pre- and post-2015: a stimulus to public policy and planning

BACKGROUND

Evidence-based health workforce policies are essential to ensure the provision of high-quality health services and to support the attainment of universal health coverage (UHC). This paper describes the main characteristics of available health workforce data for 74 of the 75 countries identified under the 'Countdown to 2015' initiative as accounting for more than 95% of the world's maternal, newborn and child deaths. It also discusses best practices in the development of health workforce metrics post-2015.

METHODS

Using available health workforce data from the Global Health Workforce Statistics database from the Global Health Observatory, we generated descriptive statistics to explore the current status, recent trends in the number of skilled health professionals (SHPs: physicians, nurses, midwives) per 10 000 population, and future requirements to achieve adequate levels of health care in the 74 countries. A rapid literature review was conducted to obtain an overview of the types of methods and the types of data sources used in human resources for health (HRH) studies.

RESULTS

There are large intercountry and interregional differences in the density of SHPs to progress towards UHC in Countdown countries: a median of 10.2 per 10 000 population with range 1.6 to 142 per 10 000. Substantial efforts have been made in some countries to increase the availability of SHPs as shown by a positive average exponential growth rate (AEGR) in SHPs in 51% of Countdown countries for which there are data. Many of these countries will require large investments to achieve levels of workforce availability commensurate with UHC and the health-related sustainable development goals (SDGs). The availability, quality and comparability of global health workforce metrics remain limited. Most published workforce studies are descriptive, but more sophisticated needs-based workforce planning methods are being developed.

CONCLUSIONS

There is a need for high-quality, comprehensive, interoperable sources of HRH data to support all policies towards UHC and the health-related SDGs. The recent WHO-led initiative of supporting countries in the development of National Health Workforce Accounts is a very promising move towards purposive health workforce metrics post-2015. Such data will allow more countries to apply the latest methods for health workforce planning.

Working Atmosphere and Job Satisfaction of Health Care Staff in Kenya: An Exploratory Study

BACKGROUND

Job satisfaction and working atmosphere are important for optimal health care delivery. The study aimed to document working atmosphere and job satisfaction of health care professionals in Kenya and to explore associations between job satisfaction, staff characteristics, and working atmosphere.

METHODS

Data from the integrated quality management system (IQMS) for the health sector in Kenya were used. Job satisfaction was measured with 10 items and with additional 5 items adapted to job situation in Kenya. Working atmosphere was measured with 13 item questionnaire. A stepwise linear regression analysis was performed with overall job satisfaction and working atmosphere, aspects of job satisfaction, and individual characteristics.

RESULTS

Out of 832 questionnaires handed out, 435 questionnaires were completed (response rate: 52.3%). Health care staff indicated high commitment to provide quality services and low levels regarding the adequacy and functionality of equipment at their work station. The aspect "support of the ministry of health" (β = 0.577) showed the highest score of explained variance (32.9%) regarding overall job satisfaction.

CONCLUSIONS

IQMS which also evaluates job satisfaction and working atmosphere of health care staff provides a good opportunity for strengthening the recruitment and retention of health care staff as well as improving the provision of good quality of care.

Migration Experiences of Foreign Educated Nurses

Purpose: Global nurse migration has a recognized impact on host and source countries, but the lived experience of foreign educated nurses is an important aspect of the success of this migration. A systematic review of the literature was conducted to understand the lived migration and acculturation experiences of foreign educated nurses. Design: A systematic review of the literature, based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was conducted. Primary research articles or secondary analyses were selected based on keyword and citation-based searches ( n = 44). Findings: Nurses’ experiences included migration and licensing barriers, difficulty with communication, racism and discrimination, skill underutilization, acculturation, and the role of the family. Conclusions: Barriers encountered in host countries may impede acculturation and successful nursing practice, resulting in circular migration and poor patient safety outcomes. Implications for Practice: Social support systems and cultural orientation programs can mitigate the impacts of social isolation and racism. Addressing common barriers can help minimize deskilling and allow safe and effective transitions to host countries.

Exploring the potential for advanced nursing practice role development in Kenya: a qualitative study

Background

Definitions of advanced nursing practice abound, yet little has been published concerning the context for advanced nursing in sub-Saharan Africa. This study set out to explore the existence of, and potential for, advanced nursing practice in Kenya.

Methods

Ten nurses were invited to participate in semi-structured qualitative interviews. Participants were purposively selected to provide insight into the practice of experienced nurses in urban, rural, community, hospital, public and private health care settings. Interview narratives were recorded, transcribed and subsequently analysed using a thematic approach.

Results

All participants reported that they were engaged in the delivery of expert, evidence-based care. The majority also undertook administrative activities, teaching in the practice area and policy and practice advocacy. However, only the two private practice nurses interviewed during the study were working with the level of autonomy that might be expected of advanced nurse practitioners.

Conclusions

While participants were undertaking many of the activities associated with advanced nursing roles, advanced nursing practice as widely understood in the (largely western derived) international literature was not identified. The nurses practicing with the greatest autonomy were generally those with the lowest educational qualifications rather than the highest. Highly qualified nurses and midwives tend to move into management and education, and see little opportunity for advancement while remaining in clinical practice. It is notable that, although a growing number of universities offer master’s level education, no African countries have yet regulated an advanced level of practice. The existence of the physician substitute ‘clinical officer’ cadre in Kenya, as in other Sub-Saharan African countries, suggests that the development of the advanced nurse practitioner role is unlikely at present. However, there is a pressing need for advanced nurses and midwives who can implement evidence-based practice and exercise clinical leadership in the drive to attain the Millennium Development Goals and their post-2015 successors.

Informing the scale-up of Kenya's nursing workforce: a mixed methods study of factors affecting pre-service training capacity and production

BACKGROUND

Given the global nursing shortage and investments to scale-up the workforce, this study evaluated trends in annual student nurse enrolment, pre-service attrition between enrolment and registration, and factors that influence nurse production in Kenya.

METHODS

This study used a mixed methods approach with data from the Regulatory Human Resources Information System (tracks initial student enrolment through registration) and the Kenya Health Workforce Information System (tracks deployment and demographic information on licensed nurses) for the quantitative analyses and qualitative data from key informant interviews with nurse training institution educators and/or administrators. Trends in annual student nurse enrolment from 1999 to 2010 were analyzed using regulatory and demographic data. To assess pre-service attrition between training enrolment and registration with the nursing council, data for a cohort that enrolled in training from 1999 to 2004 and completed training by 2010 was analyzed. Multivariate logistic regression was used to test for factors that significantly affected attrition. To assess the capacity of nurse training institutions for scale-up, qualitative data was obtained through key informant interviews.

RESULTS

From 1999 to 2010, 23,350 students enrolled in nurse training in Kenya. While annual new student enrolment doubled between 1999 (1,493) and 2010 (3,030), training institutions reported challenges in their capacity to accommodate the increased numbers. Key factors identified by the nursing faculty included congestion at clinical placement sites, limited clinical mentorship by qualified nurses, challenges with faculty recruitment and retention, and inadequate student housing, transportation and classroom space. Pre-service attrition among the cohort that enrolled between 1999 and 2004 and completed training by 2010 was found to be low (6%).

CONCLUSION

To scale-up the nursing workforce in Kenya, concurrent investments in expanding the number of student nurse clinical placement sites, utilizing alternate forms of skills training, hiring more faculty and clinical instructors, and expanding the dormitory and classroom space to accommodate new students are needed to ensure that increases in student enrolment are not at the cost of quality nursing education. Student attrition does not appear to be a concern in Kenya compared to other African countries (10 to 40%).

Physician tracking in sub-Saharan Africa: current initiatives and opportunities

BACKGROUND

Physician tracking systems are critical for health workforce planning as well as for activities to ensure quality health care - such as physician regulation, education, and emergency response. However, information on current systems for physician tracking in sub-Saharan Africa is limited. The objective of this study is to provide information on the current state of physician tracking systems in the region, highlighting emerging themes and innovative practices.

METHODS

This study included a review of the literature, an online search for physician licensing systems, and a document review of publicly available physician registration forms for sub-Saharan African countries. Primary data on physician tracking activities was collected as part of the Medical Education Partnership Initiative (MEPI) - through two rounds over two years of annual surveys to 13 medical schools in 12 sub-Saharan countries. Two innovations were identified during two MEPI school site visits in Uganda and Ghana.

RESULTS

Out of twelve countries, nine had existing frameworks for physician tracking through licensing requirements. Most countries collected basic demographic information: name, address, date of birth, nationality/citizenship, and training institution. Practice information was less frequently collected. The most frequently collected practice fields were specialty/degree and current title/position. Location of employment and name and sector of current employer were less frequently collected. Many medical schools are taking steps to implement graduate tracking systems. We also highlight two innovative practices: mobile technology access to physician registries in Uganda and MDNet, a public-private partnership providing free mobile-to-mobile voice and text messages to all doctors registered with the Ghana Medical Association.

CONCLUSION

While physician tracking systems vary widely between countries and a number of challenges remain, there appears to be increasing interest in developing these systems and many innovative developments in the area. Opportunities exist to expand these systems in a more coordinated manner that will ultimately lead to better workforce planning, implementation of the workforce, and better health.

The public sector nursing workforce in Kenya: a county-level analysis

BACKGROUND

Kenya's human resources for health shortage is well documented, yet in line with the new constitution, responsibility for health service delivery will be devolved to 47 new county administrations. This work describes the public sector nursing workforce likely to be inherited by the counties, and examines the relationships between nursing workforce density and key indicators.

METHODS

National nursing deployment data linked to nursing supply data were used and analyzed using statistical and geographical analysis software. Data on nurses deployed in national referral hospitals and on nurses deployed in non-public sector facilities were excluded from main analyses. The densities and characteristics of the public sector nurses across the counties were obtained and examined against an index of county remoteness, and the nursing densities were correlated with five key indicators.

RESULTS

Of the 16,371 nurses in the public non-tertiary sector, 76% are women and 53% are registered nurses, with 35% of the nurses aged 40 to 49 years. The nursing densities across counties range from 1.2 to 0.08 per 1,000 population. There are statistically significant associations of the nursing densities with a measure of health spending per capita (P value = 0.0028) and immunization rates (P value = 0.0018). A higher county remoteness index is associated with explaining lower female to male ratio of public sector nurses across counties (P value <0.0001).

CONCLUSIONS

An overall shortage of nurses (range of 1.2 to 0.08 per 1,000) in the public sector countrywide is complicated by mal-distribution and varying workforce characteristics (for example, age profile) across counties. All stakeholders should support improvements in human resources information systems and help address personnel shortages and mal-distribution if equitable, quality health-care delivery in the counties is to be achieved.

Kenya's health workforce information system: a model of impact on strategic human resources policy, planning and management

OBJECTIVE

Countries worldwide are challenged by health worker shortages, skill mix imbalances, and maldistribution. Human resources information systems (HRIS) are used to monitor and address these health workforce issues, but global understanding of such systems is minimal and baseline information regarding their scope and capability is practically non-existent. The Kenya Health Workforce Information System (KHWIS) has been identified as a promising example of a functioning HRIS. The objective of this paper is to document the impact of KHWIS data on human resources policy, planning and management.

METHODS

Sources for this study included semi-structured interviews with senior officials at Kenya's Ministry of Medical Services (MOMS), Ministry of Public Health and Sanitation (MOPHS), the Department of Nursing within MOMS, the Nursing Council of Kenya, Kenya Medical Practitioners and Dentists Board, Kenya's Clinical Officers Council, and Kenya Medical Laboratory Technicians and Technologists Board. Additionally, quantitative data were extracted from KHWIS databases to supplement the interviews. Health sector policy documents were retrieved from MOMS and MOPHS websites, and reviewed to assess whether they documented any changes to policy and practice as having been impacted by KHWIS data.

RESULTS

Interviews with Kenyan government and regulatory officials cited health workforce data provided by KHWIS influenced policy, regulation, and management. Policy changes include extension of Kenya's age of mandatory civil service retirement from 55 to 60 years. Data retrieved from KHWIS document increased relicensing of professional nurses, midwives, medical practitioners and dentists, and interviewees reported this improved compliance raised professional regulatory body revenues. The review of Government records revealed few references to KHWIS; however, documentation specifically cited the KHWIS as having improved the availability of human resources for health information regarding workforce planning, management, and development.

CONCLUSION

KHWIS data have impacted a range of improvements in health worker regulation, human resources management, and workforce policy and planning at Kenya's ministries of health.

Internationally educated nurses in the United States: Their origins and roles

Despite the importance of the internationally educated nurse (IEN) workforce, there has been little research on the employment settings of IENs and other aspects of their employment. We analyzed data from the 2008 National Sample Survey of Registered Nurses to characterize IENs in the United States using descriptive statistics and multivariate ordinary least squares regression. We find notable differences in the decade of immigration, current age, and highest nursing education across the countries in which IENs were educated. IENs are more likely to be employed in nursing and to work full-time. They receive higher total annual earnings and earn higher average hourly wages. However, when demographic, human capital, and employment characteristics are held constant, IENs from every country except Canada earn no more than U.S.-educated nurses. Future research should seek to identify the causes of these employment and earnings differences to understand the role and impact of the IEN workforce.

Modernising the regulation of medical migration: moving from national monopolies to international markets

BACKGROUND

Traditional top-down national regulation of internationally mobile doctors and nurses is fast being rendered obsolete by the speed of globalisation and digitisation. Here we propose a bottom-up system in which responsibility for hiring and accrediting overseas staff begins to be shared by medical employers, managers, and insurers.

DISCUSSION

In this model, professional Boards would retain authority for disciplinary proceedings in response to local complaints, but would lose their present power of veto over foreign practitioners recruited by employers who have independently evaluated and approved such candidates' ability. Evaluations of this kind could be facilitated by globally accessible National Registers of professional work and conduct. A decentralised system of this kind could also dispense with time-consuming national oversight of continuing professional education and license revalidation, which tasks could be replaced over time by tighter institutional audit supported by stronger powers to terminate underperforming employees.

SUMMARY

Market forces based on the reputation (and, hence, financial and political viability) of employers and institutions could continue to ensure patient safety in the future, while at the same time improving both national system efficiency and international professional mobility.