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We explain social and organisational processes influencing health professionals in a Kenyan clinical network to implement a form of quality improvement (QI) into clinical practice, using the concept of 'pastoral practices'. Our qualitative empirical case study, conducted in 2015–16, shows the way practices constructing and linking local evidence-based guidelines and data collection processes provided a foundation for QI. Participation in these constructive practices gave network leaders pastoral status to then inscribe use of evidence and data into routine care, through championing, demonstrating, supporting and mentoring, with the support of a constellation of local champions. By arranging network meetings, in which the professional community discussed evidence, data, QI and professionalism, network leaders also facilitated the reconstruction of network members' collective professional identity. This consequently strengthened top-down and lateral accountability and inspection practices, disciplining evidence and audit-based QI in local hospitals. By explaining pastoral practices in this way and setting, we contribute to theory about governmentality in health care and extend Foucauldian analysis of QI, clinical networks and governance into low and middle income health care contexts.

This commentary article addresses a critical issue facing Kenya and other Low- and Middle-Income Countries (LMIC): how to remedy deficits in hospitals' nursing workforce. Would employing health care assistants (HCAs) provide a partial solution? This article first gives a brief introduction to the Kenyan context and then explores the development of workforce roles to support nurses in Europe to highlight the diversity of these roles. Our introduction pinpoints that pressures to maintain or restrict costs have led to a wide variety of formal and informal task shifting from nurses to some form of HCA in the EU with differences noted in issues of appropriate skill mix, training, accountability, and regulation of HCA. Next, we draw from a suite of recent studies in hospitals in Kenya which illustrate nursing practices in a highly pressurized context. The studies took place in neo-natal wards in Kenyan hospitals between 2015 and 2018 and in a system with no legal or regulatory basis for task shifting to HCAs. We proffer data on why and how nurses informally delegate tasks to others in the public sector and the decision-making processes of nurses and frame this evidence in the specific contextual conditions. In the conclusion, the paper aims to deepen the debates on developing human resources for health. We argue that despite the urgent pressures to address glaring workforce deficits in Kenya and other LMIC, caution needs to be exercised in implementing changes to nursing practices through the introduction of HCAs. The evidence from EU suggests that the rapid growth in the employment of HCA has created crucial issues which need addressing. These include clearly defining the scope of practice and developing the appropriate skill mix between nurses and HCAs to match the specific health system context. Moreover, we suggest efforts to develop and implement such roles should be carefully designed and rigorously evaluated to inform continuing policy development.

This commentary article addresses a critical issue facing Kenya and other Low- and Middle-Income Countries (LMIC): how to remedy deficits in hospitals' nursing workforce. Would employing health care assistants (HCAs) provide a partial solution? This article first gives a brief introduction to the Kenyan context and then explores the development of workforce roles to support nurses in Europe to highlight the diversity of these roles. Our introduction pinpoints that pressures to maintain or restrict costs have led to a wide variety of formal and informal task shifting from nurses to some form of HCA in the EU with differences noted in issues of appropriate skill mix, training, accountability, and regulation of HCA. Next, we draw from a suite of recent studies in hospitals in Kenya which illustrate nursing practices in a highly pressurized context. The studies took place in neo-natal wards in Kenyan hospitals between 2015 and 2018 and in a system with no legal or regulatory basis for task shifting to HCAs. We proffer data on why and how nurses informally delegate tasks to others in the public sector and the decision-making processes of nurses and frame this evidence in the specific contextual conditions. In the conclusion, the paper aims to deepen the debates on developing human resources for health. We argue that despite the urgent pressures to address glaring workforce deficits in Kenya and other LMIC, caution needs to be exercised in implementing changes to nursing practices through the introduction of HCAs. The evidence from EU suggests that the rapid growth in the employment of HCA has created crucial issues which need addressing. These include clearly defining the scope of practice and developing the appropriate skill mix between nurses and HCAs to match the specific health system context. Moreover, we suggest efforts to develop and implement such roles should be carefully designed and rigorously evaluated to inform continuing policy development.

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 ...

The huge strategic response to COVID-19 is, put simply, the globe's single largest and most concentrated health service redesign effort. To counter the effects of the pandemic in Low Resource Settings (LRS) the World Bank has promised to invest $160 billion into Africa over the next 15 months with bilateral donors also pledging large sums to support COVID-19 responses (e.g. USAID $775 million, UK-AID £200 million). Over 60 LRS governments had applied for World Bank funding by 19th June 2020 with plans to spend huge sums on health system strengthening at unprecedented speed [1]. UN agencies and a multitude of technical assistance organisations are reorienting their work to support countries in areas spanning guideline dissemination, training, improving information systems and equipment and consumable production, procurement and supply chain management amongst others. Some LRS governments are planning emergency recruitment to address critical workforce deficits. It is imperative, therefore, that we use the COVID-19 moment to optimise learning about how to transform health service delivery to benefit population health.

Health systems are faced with a wide variety of challenges. As complex adaptive systems, they respond differently and sometimes in unexpected ways to these challenges. We set out to examine the challenges experienced by the health system at a sub-national level in Kenya, a country that has recently undergone rapid devolution, using an 'everyday resilience' lens. We focussed on chronic stressors, rather than acute shocks in examining the responses and organizational capacities underpinning those responses, with a view to contributing to the understanding of health system resilience. We drew on learning and experiences gained through working with managers using a learning site approach over the years. We also collected in-depth qualitative data through informal observations, reflective meetings and in-depth interviews with middle-level managers (sub-county and hospital) and peripheral facility managers (n = 29). We analysed the data using a framework approach. Health managers reported a wide range of health system stressors related to resource scarcity, lack of clarity in roles and political interference, reduced autonomy and human resource management. The health managers adopted absorptive, adaptive and transformative strategies but with mixed effects on system functioning. Everyday resilience seemed to emerge from strategies enacted by managers drawing on a varying combination of organizational capacities depending on the stressor and context.

Abstract Background While health worker strikes are experienced globally, the effects can be worst in countries with infrastructural and resource challenges, weak institutional arrangements, underdeveloped organizational ethics codes, and unaffordable alternative options for the poor. In Kenya, there have been a series of public health worker strikes in the post devolution period. We explored the perceptions and experiences of frontline health managers and community members of the 2017 prolonged health workers' strikes. Methods We employed an embedded research approach in one county in the Kenyan Coast. We collected in-depth qualitative data through informal observations, reflective meetings, individual and group interviews and document reviews (n = 5), and analysed the data using a thematic approach. Individual interviews were held with frontline health managers (n = 26), and group interviews with community representatives (4 health facility committee member groups, and 4 broader community representative groups). Interviews were held during and immediately after the nurses' strike. Findings In the face of major health facility and service closures and disruptions, frontline health managers enacted a range of strategies to keep key services open, but many strategies were piecemeal, inconsistent and difficult to sustain. Interviewees reported huge negative health and financial strike impacts on local communities, and especially the poor. There is limited evidence of improved health system preparedness to cope with any future strikes. Conclusion Strikes cannot be seen in isolation of the prevailing policy and health systems context. The 2017 prolonged strikes highlight the underlying and longer-term frustration amongst public sector health workers in Kenya. The health system exhibited properties of complex adaptive systems that are interdependent and interactive. Reactive responses within the public system and the use of private healthcare led to limited continued activity through the strike, but were not sufficient to confer resilience to the shock of the prolonged strikes. To minimise the negative effects of strikes when they occur, careful monitoring and advanced planning is needed. Planning should aim to ensure that emergency and other essential services are maintained, threats between staff are minimized, health worker demands are reasonable, and that governments respect and honor agreements.