USAID | PEPFAR | IntraHealth
Human Resources for Health Kenya Mechanism
Terms of Reference
Consultancy for Development of a More Cost Effective and Equitable Framework for the Training of Medical Specialists in Kenya
1.1 HRH Kenya Mechanism
The Human Resources for Health (HRH) Kenya is a Mechanism funded by the Presidents Emergency Fund for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID).
Implemented by IntraHealth International Inc. and its partners AMREF Health Africa and Strathmore University Business School (SBS), the mandate of HRH/Kenya is to strengthen health workforce management to achieve improved health outcomes.
It is anticipated that by the end of the five-year Mechanism (Sept. 27, 2016 –Sept. 26, 2021):
1) Health workers training colleges will have increased numbers of market ready graduates who are responsive to Kenya’s disease burden;
2) National and County leadership will have efficient HRH management systems to address workforce challenges including reduction of staff shortages; and,
3) National and County Governments will make HRH decisions based on market – driven data and disease epidemiology to improve health outcomes.
HRH Kenya mechanism serves to build on the successes and lessons learned from HRH Capacity Bridge & FUNZOKenya Projects.
As part of its mandate to strengthen pre-service and specialist medical education in Kenya the mechanism has been requested by the Ministry of Health (MOH) specifically, the office of the Chief Administrative Secretary (CAS) health to support the ministry to develop a suitable framework for the training of medical specialists in Kenya.
1.2 Background to consultancy
Kenya requires improved access to well-trained, knowledgeable, well-distributed/deployed and culturally-sensitive health workers to deliver on the Universal Health Coverage (UHC) agenda that focuses on meeting the health demands of the fast-growing population.
Even then, there is a critical shortage of human resources for health (HRH), with the country ranking among the 57 HRH-crisis countries in the world, with 1.5 HWs per 1,000 populations, against the recommendation of 2.3/1,000.
The situation is worse for the medical specialists who constitute about 37% of the number of active and retained medics in the public sector. This is not to forget the anticipated increase in demand for specialist health workers in such areas as renal, radiology and intensive care units (ICU) services following launch of the Managed Equipment’s Services (MES) in the country.
To address the shortage and, the increasing demand for training of more specialists in the country, we need to pay keen attention to several hey areas.
To start with, in as much as there is general awareness that, there is a shortage of medical specialists especially at the county level, there lacks updated data to succinctly quantify the gaps by category of specialization (e.g. Internal Medicine, Paediatrics, Surgery, Obstetrics and Gynaecology, radiology, pathology), county and, national needs, for the next few years.
Further, the medical specialists/registrars, on qualification, occasionally fail return to previous work stations (especially at the counties) where the bulk (80%) of the population live, not even for those who are bonded.
This development has been attributed to, among others, availability of a more conducive work environment at the health facilities and, environs to effectively execute their work—among others, better opportunities for locum or, private practice, better social welfare including quality schools for their young children, accommodation, power, water, security, functional support infrastructure: diagnostic facilities, consultation facilities, functional effective referral systems in urban areas compared to rural areas.
Still, concerns have been raised (especially for the government sponsored staff) regarding the quality of the training of the medical specialists/registrars receive, whether, such trainings are responsive to national and, individual county needs.
In as much as there are drastic changes in how medical education is being delivered globally for effective service delivery, especially through embracing interprofessional education (Stevenson, Noyes, Peyre& Berk, 2015)1, specialists training in Kenya has not been in line with training needs, going by the illustrative example of; anaesthetists, surgeons, specialists in internal medicine, clinical officer and nurse specialists among others (MOH Training Needs Assessment report, 2015). Similarly lacking is a specialists sector-wide training needs assessment to determine training priorities.
Again, it has been found that, many counties take deliberate efforts to sponsor their own staff to specialist trainings and, with the availability of national government/donor sponsorships, released staff to attend the trainings, while maintaining such staff on county payroll.
This move has been in the hope that, such staff return to their work stations to support the counties. Unfortunately, most of this staff occasionally don’t go back, the area of speciality may not be required in the county of initial work stations, replacements are hardly ever made, and counties never compensated for the salary cost while staff is in training.
This calls for the need to determine the most cost-effective and sustainable financing model for the specialist trainings – whether such costs should (i) be met by individual staff, national government, donors, county government or, a combination of these sources and, more, whether the Registrars should be self-sponsored or, offered scholarships / grants or, loans.
In the determination, it will be critical to examine ways of reducing the Intra-county, to private sector, externally within the region or to the western world-CANADA, Australia UK USA migration of the specialists that has proved to be a challenge, denying the counties, much-required human resource to spearhead UHC and speciality service provision in Kenya.
Kenya has traditionally relied on the classroom-based approach in the training of specialists, more often, away from the duty stations and, in the urban areas. Alternative innovative specialist learning models that include residency, collegiate and telemedicine (Turner & Barajaz, 2016) are yet to be fully tested yet institutions such as the College of Surgeons of East, Central and Southern Africa (COSECSA) with commendable results.
The East Central and Southern Africa College of Obstetrics and Gynaecology is also following suit with the Council is in place, the curriculum updated and, reviewed and, Medical Boards accreditation processes ongoing in the member countries. It would be a good opportunity to learn from these initiatives to guide the country on areas of innovations required in specialists training.
Another area that merits attention is, obtaining effective coordination and implementation in specialist training. Training is a national mandate, implemented by both levels of government, through the Ministerial Human Resource Management and Advisory Committee (MHRMAC) at the National level and the County Public Service Boards (CPSB) through the County Human Resource Advisory Committees (CHRAC) and County Departmental Training Committees in the health department (MOH HRD Procedure Guidelines, 2015), it is not clear how these actors coordinate.
This is especially in such aspects as nomination, aligning training specialists’ areas with employer (county & national) needs, bonding, tracking trained specialists’ post-graduation. Inability to effectively manage these actors can lead to many coordination and implementation challenges adversely affecting the production of specialists.
Against the above background, this consultancy is intended to gather information to help the government, primarily the national MOH to reorganize and transform the training and, deployment of specialists with a focus on three areas.
(i) Human resource development (HRD) including financing of specialists’ training,
(ii) Human resources management (HRM) including attraction, deployment and retention,
(iii) Human resource information systems and data for specialist training.
The overall aim of the consultancy is to develop an equitable and sustainable framework for training of medical specialist in Kenya for the MOH consideration, approval and subsequent implementation.
2.0 Training Specialist Framework
Review the current practices in the training and, deployment of medical specialists and, develop a more cost effective and, equitable framework focusing on the key domains of HRH as provided below.
2.1 Human resource development (HRD) including financing of specialists’ training
- What are the specialist training needs by cadre and, county?
- What is the effectiveness of the specialist’s trainee nomination and selection processes especially in meeting individual, national and, county levels needs?
- What is the effectiveness of the traditional training approaches/models for the training of medical specialists vis-à-vis emerging innovative approaches such as collegiate, residency, Residency sandwiches, among others? What are recommendations on the respective trainings in the future.
- What are illustrative examples of Medical Training Institutions (MTIs), hospitals, professional organizations that have adequate implementing the innovative learning approaches (e.g. Tenwek Mission Hospital, AIC Kijabe Hospital, the College of Surgeons of East, Central and Southern Africa (COSECSA). And, what can we learn from them?
- What are the costs of implementing the proposed innovative learning approaches? What innovative financing approaches should the country apply to meet the specialist training costs? What are the lessons that can be learned from these approaches to improve on any innovative programmes?
- What revisions are required to faculty capacity and, curriculum to improve specialists training for the key cadres and, what are the areas in need of improvement to attain high quality standards. Consider, among others, faculty/ clinical instructors, regulations, curricula and infrastructure, post-graduation surveys of alumni and the employer feedback and, effectiveness of the certification processes for the specialists.
- In what areas do the counties and national government collaborate in the training of specialists? Is this adequate to meet the needs of sponsors?
- What is the total annual investments in scholarships and grants on specialist training in Kenya (county & National) and, implications of a shift to such innovative financing approaches as the AEF?
2.2: Human resource management
- What are the best practices in paying salaries to the specialists whilst on training to reduce the current high burden to county governments?
- What are the staffing and service delivery challenges for the counties that arise from the current specialist training model at facility level and, what are the resolutions?
- What are the challenges encountered when deploying specialists and, retaining specialists at the county level facilities?
- What are the HRM policy gaps and obstacles hindering specialists training? What institutional opportunities/gaps exists among emerging new institutions on HR in the Health Act such as; Inter Governmental Relations Technical Committee(IGRTC), Public Service Commission (PSC)/County Public Service Boards(CPSBs), Council of Governors(COG),Salaries and Renumeration Commission (SRC) and the ministry of labor and remedies or alignment needed to be incorporated to implement a robust training of medical specialists
- How effective is the specialist bonding mechanism?
- If specialist on training were to be taken over by the national government, what policy and institutional mechanisms should be in place to realize this goal?
- What are the current practices in trained specialists posting and how effective are they and what can be done to improve them (cross sharing of specialists)?
- What are illustrative examples of most effective human resources management policies being used by the faith based and private hospitals (e.g. Aga Khan, Gertrude’s, Mater Hospital, CHAK, KCCB & SUPKEM affiliated hospitals.) in the training of specialists and, how can these policies be replicated in the public sector?
2.3: Medical specialist Data
- Based on iHRIS, what is the current inventory of specialists in service delivery and, projections for the next three years?
- How can specialists training be more effectively tracked through iHRIS and, what enhancements are required in iHRIS to improve tracking?
- What is the ideal ratio between the cadres for specialists’ training to create an ideal specialty team for provision of specialty services at national and county government health facilities e.g. a physician to other health specialists such as nurses etc.
- What are the returns on investment on specialist training in the health sector?
- What data systems exists for specialists and linkages with GOK and regulatory boards systems?
3.0 Consultancy methodology
The methodology of the consultancy is as outlined below in addition to other approaches;
- A desk review of available literature and practice of specialists training in Kenya and the region.
- Conduct key informant interviews (KII) with stakeholders that include; National and county MOH. This will include- Director of Medical services (DMS),heads of departments, County Directors of Health and CHMTs, health professional regulatory boards and council, health sector trade unions, Commission for University Education (CUE), TVETA, deans/ principals of medical training institutions both public, private and FBOs of colleges of health sciences, academic directors CEO and departmental heads of major hospitals – public, private and FBO (KNH, Aga Khan MTRH etc.) and hospitals implementing innovative learning for specialists (Tenwek, Kijabe, Coast General etc.) .
- Assessments questionnaire(s)to answer the afore mentioned questions.
- A workshop for pre-dissemination/validation of the findings followed by finalization of a report.
4.0 Consultancy deliverables
The following are the deliverables for this consultancy;
- Inception report of understanding of task/assignment process and approach in executing the assignment.
- Situational analysis report of specialist training in Kenya and region
- Assessment tools-questionnaire & KII guide
- Draft report on framework for specialist training in Kenya with key findings and recommendations & concise PowerPoint slides for high level dissemination.
- Lead and facilitate a workshop to validate the findings and recommendations with stakeholders
- Final report with feedback incorporated from pre-dissemination workshop
- Distill and develop 2 pager briefs for senior leadership at MOH
5.0 Institutional Framework and team contacts
The consultants/ consultancy team will report to the office of the Chief Administrative Secretary (CAS) for Health at MOH and work in closely with HRH Kenya Mechanism specifically the following officers; Team Lead Health Workforce Training, HRH Coordination Manager and the Deputy Chief of Party/Technical Director.
This consultancy is a 25 days assignment that will be undertaken during the month of April to June 2019.
7.0 Location and travel of assignment:
Nairobi or other locations in Kenya. The assignment may require travel within/without Nairobi and the HRH Kenya Mechanism will facilitate accordingly as per policy.
8.0 Consultants profile
This assignment requires two consultants who will complement each other in execution. Therefore;
- A medical educationists at Ph.D. or master’s level with over 10 years’ experience in health education and or service delivery.
- A human resource management (HRM) or organizational development specialists with 10 years’ experience and good grasp of the health sector and devolution.
- Good report writing skills
- Team player with good interpersonal, communication and presentation skills.
9.0 Daily rate
The consultancy is estimated to be completed in 25 working days at an agreed daily rate.
Qualified Consultants should submit technical and financial proposal stating a daily rate for the number of days proposed, to firstname.lastname@example.org by 12 noon, 23rd April 2019
11.0 Gantt Chart of deliverables and timelines