Tracking health sector priority setting processes and outcomes for human resources for health, five-years after political devolution: a county-level case study in Kenya

Abstract

Background Health sector priority setting in Low and Middle-Income Countries (LMICs) entails balancing between a high demand and low supply of scarce resources. Human Resources for Health (HRH) consume the largest allocation of health sector resources in LMICs. Health sector decentralization continues to be promoted for its perceived ability to improve efficiency, relevance and participation in health sector priority setting. Following the 2013 devolution in Kenya, both health service delivery and human resource management were decentralized to county level. Little is known about priority setting practices and outcomes of HRH within decentralized health systems in LMICs. Our study sought to examine if and how the Kenyan devolution has improved health sector priority setting practices and outcomes for HRH. Methods We used a mixed methods case study design to examine health sector priority setting practices and outcomes at county level in Kenya. We used three sources of data. First, we reviewed all relevant national and county level policy and guidelines documents relating to HRH management. We then accessed and reviewed county records of HRH recruitment and distribution between 2013 and 2018. We finally conducted eight key informant interviews with various stakeholder involved in HRH priority setting within our study county. Results We found that HRH numbers in the county increased by almost two-fold since devolution. The county had two forms of HRH recruitment: one led by the County Public Services Board as outlined by policy and guidelines and a parallel, politically-driven recruitment done directly by the County Department of Health. Though there were clear guidelines on HRH recruitment, there were no similar guidelines on allocation and distribution of HRH. Since devolution, the county has preferentially staffed higher level hospitals over primary care facilities. Additionally, there has been local county level innovations to address some HRH management challenges, including recruiting doctors and other highly specialized staff on fixed term contract as opposed to permanent basis; and implementation of local incentives to attract and retain HRH to remote areas within the county. Conclusion Devolution has significantly increased county level decision-space for HRH priority setting in Kenya. However, HRH management and accountability challenges still exist at the county level. There is need for interventions to strengthen county level HRH management capacity and accountability mechanisms beyond additional resources allocation. This will boost the realization of the country’s efforts for promoting service delivery equity as a key goal – both for the devolution and the country’s quest towards Universal Health Coverage (UHC).

Trends in inpatient and post-discharge mortality among young infants admitted to Kilifi County Hospital, Kenya: a retrospective cohort study

“…Conversely, the number of admitted children older than 60 days decreased alongside a reduction in local malaria transmission, 22 introduction of routine childhood pneumococcal conjugate and rotavirus immunisation 23 and expansion in numbers of health facilities in Kilifi County. 24 Variation in annual admissions over the years was due to multiple health workers’ strikes. 13 During these periods, the general paediatric ward was closed and only the sickest children were admitted to the paediatric HDU due to limited staffing and bed capacity.…”

Management of human resources for health: implications for health systems efficiency in Kenya

“…For example, in a crosscountry study a higher health workforce density was associated with decreases in maternal and infant mortality rates [30,31], and decrease the total burden of disease [32]. Many studies have highlighted the difficulty by health systems in achieving optimal HRH numbers [29,[33][34][35][36][37]. While donor support was highlighted in Kenya as a potential path to increasing funding to hire and train health workers, experiences from elsewhere shows that the reliance on external funding for HRH scale-up needs to be carefully considered in view of sustainability [38].…”

Examining the absorption of post-internship medical officers into the public sector at county-level in devolved Kenya: a qualitative case study

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