1. P RESENTED AT THE AMREF I NTERNATIONAL C ONFERENCE 25 TH N OVEMBER 2014 B Y R ICHARD G ICHUKI, P ROJECT O FFICER RABD-AMREF K ENYA FACTORS AFFECTING MOTIVATION AND RETENTION OF PRIMARY HEALTH CARE WORKERS IN THREE DISPARATE REGIONS IN KENYA:

2. PRESENTER DISCLOSURES Richard Gichuki No relationships to disclose 2

3. Background Study objectives Methodology Results Discussion Conclusion and recommendations OUTLINE

4. Human resources for health (HRH) is one of the six building blocks of the health systems –WHO Report published in 2004 estimated 1m additional HWs in sub-Sahara Africa. Attracting and retaining HWs in Kenyan Health system has been a challenge. Baseline study conducted in 2011 and published in HRH journal (http://www.human-resources- health.com/content/12/1/33/abstract )http://www.human-resources- health.com/content/12/1/33/abstract BACKGROUND

5. BACKGROUND_CONCEPTUAL FRAMEWORK “Push and pull factors” that determine movement of personnel (Padarath A, et all; 2003) 5 Push Factors-leavePull Factors-Attract Low remuneration and salariesLevels of morale Lack of Job satisfactionRewards and Incentives Work associated risksSocial values Lack of further education and career development opportunities Barriers to migration Lack of education opportunities for children Low quality of life and high levels of crime

6. Main objective –Investigate whether factors related to the motivation and retention of HWs differ across the three different settings in Kenya Specific objectives –To investigate whether socio-demographic characteristics of the respondents varies across the disparate setting. –To determine whether work environment factors differ across the three settings –To determine whether factors related to job satisfaction differ across the three settings. STUDY OBJECTIVES

7. Cross sectional mixed methods design utilizing quantitative and qualitative methods Sampling technique: –Cluster sampling used to select 81 facilities where 361 HWs were drawn –Purposive sampling: FGDs (7) and In-depth interviews (30) Study Population and sites –HWs mainly from primary level fac’ –3 counties visited -Turkana North, Machakos County, Kibera in Nairobi County METHODOLOGY

8. DATA COLLECTION AND ANALYSIS Data analyzed through: −Content analysis of qualitative information −Descriptive statistics −Proportions −Bi-variate analysis −Chi-square test −0.05 level of significance used. 8

9. Ownership of Facilities by Region 9

10. Type of Service Provider NairobiMachakosTurkanaTotal (n=101)(n=143)(n=102)(n=346) %% Administrator2.03.01.02.0 CHEW1.02.13.92.3 CHW10.93.514.79.0 Clinical Officer9.97.79.89.0 Lab Technician11.911.24.99.5 Lay Counsellor3.01.45.93.2 MO2.04.91.02.9 Nutritionist7.92.85.95.2 Parmacists5.02.14.93.8 Registered Nurse33.744.832.437.9 Support Staff5.09.82.96.4 Allied Professional7.96.312.78.7 Total100.0 SERVICE PROVIDER BY REGION

11. CharacteristicCategory NairobiMachaksTurkana P-value (n=101)(n=143)(n=102) SexMale38%33%55%0.001 Female62%67%45% Age<3563%52%77%0.004 >3537%48%23% Post Sec Educ Yes89%79%78% 0.001 No11%21%22% Alternative Yes38%42%35% 0.373 Sources of IncomeNo62%58%65% RESULTS: BACKGROUND CHARACTERISTICS OF RESPONDENTS

12. Characteristic Category NairobiMachaksTurkana (n=100)(n=136)(n=98)P-value Attended Upgrading Course Yes45%35%34%0.096 No55%65%66% Highest level of upgrading course attended Diploma22%40%27%0.01 Masters16%2%0% Other 1 62%57%73% RESULTS: TRAINING CHARACTERISTICS OF PROFESSIONAL HEALTH WORKERS “The other thing apart from money for their own pockets there are also money for trainings like if you have a certificate in nursing the county health team should give you money to go and train in that way you will attract more people” FGD-Turkana

13. % of respondents reporting MachakosNairobiTurkanaP-Value Satisfied with their job35.343.643.20.563 Job good match for skills63.078.268.20.334 Recognition for doing work52.155.465.90.246 Training have been provided to succeed in their work61.374.353.40.034* Morale level at depart’ is good42.058.460.20.046* Feels protected from comm’ diseases (HIV)56.373.369.30.045* RESULTS: JOB SATISFACTION

14. % of respondents MachakosNairobiTurkanaP-value Workload is manageable37.271.664.0<0.001 Good access to drugs37.271.664.0<0.001 Equip’s to do their job19.830.433.70.264 Efficient transp’ to work33.154.031.40.001 Job allwd relx dur’ Lunch43.077.577.9<0.001 Good schooling for child’46.046.136.00.193 Good access to water47.170.662.8<0.001 RESULTS: ASSESSMENT OF WORK ENVIRONMENT

15. “I think that one of the challenges that people experience is the means of transport whereby in case you have some emergency and you want to report to the work-station you cannot get there in good time so transport is a major challenge” FGD-Turkana “Water is not available for 24 hours because we are using a bore hole that is using a generator, I mean source of power. So when there is mechanical problems the patients go without water” FGD-providers Machakos. 15

16. RESULTS: RENUMERATION PACKAGE Enough promotion opport’= 40% Enough Training opport’= 32% While 18% felt that their salary is fair 16

17. RESULTS: RENUMERATION PACKAGE “By increasing the hardship allowance and for example if you are working in Kenyatta and you are being paid 100,000 if you go to Kitui and the pay is made at 200,000 then they will come” FGD-Providers-Machakos “Enhanced allowances like house allowance a fellow on Kitale receives more than a person in Lodwar and when it comes to hardship when you are not married you get Kshs. 600. What does that mean? Is it standard? There are a lot of things that de-motivate one from working here especially when it comes to the issue of allowances” FGD-Providers –Turkana 17

18. Provider working in Nairobi county twice more likely to have undergone at least one training since post basic training compared to other counties OR: 2.1 (1.2, 4.22). Provider working in Turkana county 90% more likely to be younger(<35yrs) than other counties OR: 1.9 (1.1, 3.7). Turkana county had the highest proportion of male respondents (54%) compared to Machakos (32%) and Nairobi (35%). DISCUSSION

19. Retaining HWs at their places of work hinges on several issues: remuneration including allowances, as well as good infrastructure. County Governments though still new in their functions, have an unprecedented opportunity to offer incentives that could encourage HWs to remain in the rural and remote areas Attracting HWs to rural and remote areas will require creative approaches Workers already employed in the rural and remote regions face a number of constraints that curtail their ability to offer health care to patients CONCLUSION

20. Attracting HWs to rural areas –Engage county governments to improve infrastructure in counties –Engage potential HWs to work in rural and remote areas Retaining HWs in rural areas –Address HWs remuneration package –Improve working environment in HFs –Make the HWs comfortable especially those in rural and remote areas –Focus on health managers as an important variable in health worker motivation Need for further analysis of the data for more results RECOMMENDATIONS

21. European Union for Funding World Vision Kenya as prime Partner County Health management Teams for facilitating the survey HCWs AMREF ESRC for ethical approval Research team ACKNOWLEDMENT

22. Thank you