By Dr. Steve Adudans
The shortage of manpower Kenya’s health sector has generated a lot of concern as it significantly contributes to the poor service delivery in the areas of preventive and curative interventions.
Over the years, the country has been faced with many challenges in the health care system; a majority which can be solved by adequate skilled personnel at the various health institutions. For instance, the shortage of anesthetists in the nation’s health sector and a framework of operations in the same area has caused challenges in the process of surgery.
An anesthetist is a specialist who administers an anesthetic (a drug that causes temporary loss of bodily sensation) to a patient before treatment, while anesthesia is a specialty of medicine that deals with reversible, controllable and predictable methods of pain relief for operative surgery, with or without loss of consciousness.
Kenya has three cadres of anesthesia providers namely: physician anesthesiologists, clinical officer anesthetists (RCOA) and nurse anesthetists (KRNA).
A Workforce survey published in 2017 by the World Federation of Societies of Anesthesiologists found that Kenya had less than 200 registered nurse anesthetists. With all three cadres combined the ratio of anesthesia providers to population stands at about1.7 per 100,000. This is significantly below the recommended world standards of 5 physician anesthesiologists to 100,000.
The workforce shortage means that the patients cannot access safe surgery anesthetists, which increases the burden on the patients. In counties such as Taita Taveta, patients have to seek surgery services in the neighboring Tanzania while a county like Mandera, whose surface area is larger than Denmark has only two qualified anesthetists serving patients.
The importance of anesthesia in healthcare delivery cannot be overemphasized, as it addresses not just pain management and intensive care, but also for pregnant women in labor billed for cesarean session as well as for injuries sustained during accidents.
Other areas where anesthesia is required include, care of patients with infections, chronic conditions like heart and kidney problems among others.
Although, problems identified as fueling the shortage of manpower in anesthesia include, lack of training institutions, ill-equipped medical schools, lack of theaters and anesthetic equipment for surgery procedures, which is evident in the upsurge in medical tourism, the number of registered anesthetists in the country has grown steadily over the past five years.
Currently, the country boasts of 187 licensed practitioners up from 57 five years ago. Many more are expected to graduate in the coming months.
With the growing number of licensed nurse anesthetists in the country, the need to formally recognize this cadre of nurses into the organizational structure of the health workforce became clear. The government in consultation with the private sector players has developed a scope of practice that defines the roles and responsibilities of the nurse anesthetists.
This process started in 2017 and involved comprehensive stakeholder engagement to ensure that all parties that work with nurse anesthetists had input in developing this resource document. The scope of practice describes the procedures, and actions the KRNA is permitted to perform in line with their professional license.
The Kenya Registered Nurse Anesthetist program started as an in house training program at Kijabe Hospital. With accreditation from the Nursing Council of Kenya, Kijabe College of Health Sciences (then Kijabe School of Nursing) instituted a formal 18 months training program for diploma level nurses in 2007. Given the need for hands on training, the class size was kept small leading to a modest growth of the KRNA graduates over time.
In 2014, seven years after the formal training program started, there were only 57 licensed nurse anesthetists practicing in mission and rural facilities. In the same year, Kijabe Hospital and Center for Public Healthand Development together with Vanderbilt University Medical Center became a beneficiary of a grant from the General Electric Foundation. The program dubbed ImPACT Africa-Improving Perioperative Care and Training in Africa- was mandated with building capacity for the training of nurse anesthetists in Kenya.
The program supported the development and delivery of the second training site for KRNAs through the Kenya Medical Training College (KMTC), Kisumu campus. With support from additional partners (Clinton Global Initiative and Elma Philanthropies) who have joined to support the program-there are now three training sites for nurse anesthetists. In addition to Kijabe and KMTC Kisumu, the KMTC Kisii campus has also been accredited by the Nursing Council of Kenya to provide the KRNA program.
These KRNAs serve in primarily rural facilities. There are now nurse anesthetists in about 39 of the 47 counties in Kenya. In addition to this, the programs implemented have supported the training of trainers building a network of more than 30 tutors for the KRNA program. The tutors are part of the teams at the primary training sites as well as select sites used by the KRNA program for external rotation for the trainees.
The funding provided also supported establishment of two simulation centers (at Kijabe Hospital and Jaramogi Odinga Oginga Teaching and Referral Hospital) equipped with high fidelity mannequins that mimic real patients.
Set up to simulate a real theater/intensive care unit space-the simulation center gives anesthesia providers the chance to acquire skills before caring for live patients. This has ensured that quality of training has improved with a focus on patient safety. A third simulation site will be established at Kisii Teaching and Referral Hospital.
The partnership with KMTC has seen improvement in the numbers of those trained from under-served regions. A direct result of the collaboration with KMTC has been the first licensed nurse anesthetists from counties like Mandera, Wajir, Taita Taveta, and Garissa. Support has been given to KMTC to support the training including donation of books to supplement the library material resources.
With the World Health Organization (WHO) recognition of emergency and essential surgery and anesthesia as vital components to Universal Health Coverage, their is need for increased investment in strengthening both access to and quality of surgery and anesthesia care. Quality training of health workers to support the surgical system is a sustainable investment that will provide long term returns on investment.
Dr Adudans is the Executive Director, Center for Public Health and Development (CPHD)