Table 4 Illustrative quotes on strategies to improve human resources and work environment

Training

‘The ‘life saving skills’ was the first technical programme that was run in the country …. they conducted a number of trainings [to] update the skills of midwives and doctors’ (Officer, Autonomous Organisation).

‘Initially the clinical officers did not have a strong obstetrics midwifery component in their curriculum, and this had to be addressed … ..The current discussion and action [is] to review the midwifery curriculum and update it … to ensure that we produce competent midwives’ (Officer, Multinational partner).

‘United Nations Population Fund has also [been] supporting midwives to go to school and then they bond them in those districts’ (Officer, Professional Organisation).

‘Some time back government took a strategy of comprehensive nurses but different people hold different views regarding that. The idea was to have one skilled person in nursing, midwifery and a bit clinical. I think that did not work. I think the general concern is that many of those comprehensive nurses do not have sufficient skills in midwifery’ (Officer, Multinational partner).

‘The number of midwives has been dwindling because between 2008 and 2010 there were no government schools training midwives. All government schools shifted to training comprehensive nurses both enrolled and registered. That was a disaster. So when we tried to recruit there were no midwives. The only schools that continued training midwives were [four] Private not for profit hospitals’ (Officer, Autonomous Organisation).

Recruitment and deployment

‘Many midwives have been trained but government is not employing them because government is following outdated staffing norms. You may have 5000 midwives trained, but if staffing norms say recruit 300, only 300 will be recruited’ (Officer, Autonomous Organisation).

‘You see recruitment depends on the wage bill when the wage bill is limited then the district cannot recruit … Also xxx (an NGO) has also supported us in recruitment of midwives mean while we are waiting for the general government recruitment’ (District Officer).

‘I think government has tried to give us more money for recruitment of the right cadres, improvement of infrastructure to house those recruited’ (Officer, MOH).

‘You find those who are trained are actually not recruited because of the markup that government has placed on its ability to pay for the civil service number of personnel. So you find that although the training of cadres of doctors and midwives somehow increased, the recruitment has been literally very static’ (Officer, Professional Organisation).

‘For us xxx (institution) we would have loved to have 100% recruitment but then government would say it doesn’t have the money for salaries and other things. …. We have agreed that we continuously advocate to ensure that the gaps in staffing are filled up’ (Officer, Interest Group).

Attraction and retention

‘Yes that was mainly done for doctors, salary was increased and they posted to Level IV Health centres. Midwives will also have an increment …. there is an increment of 18% for registered nurse and 13–14% for enrolled midwife. But in terms of money, this is very little, I don’t think it will offer a lot of attraction, when you put it in real money terms it is very little’ (Officer, Civil society organisation).

‘Some people have tried performance improvement strategies like recognition of best performers but that is in a few isolated districts …. Other project-based incentives in districts involve sponsoring those who want to be midwives and after training you tie [bond] them to the district for some time’ (Officer, MOH).

‘Unfortunately, we did not have a strategy deliberately to retain midwives in health centre level II and III throughout the country. We paid them like any other health worker, we made them struggle to look for accommodation like any other health worker. So invariably, we failed to attract and retain midwives in remote areas’ (Officer, Autonomous Organisation).

Infrastructure

‘It is difficult to know what has actually happened. I think there has been a lot of effort put in by government. The whole concept of level III to IV health centres … refurbishing maternity or units in this country, has been premised on the need to improve access of emergency obstetric care … But … every time people do assessments on emergency obstetric care, the gaps are still there’ (Officer, Multinational partner).

‘Yes a lot has been done in terms of renovation, re-modelling of many health facilities and some hospitals. There has been procurement of ambulances, construction of delivery wards at every sub county where we have level III health centres the government and partners have also procured delivery equipment. … There has been some provision of staff accommodation’ (Officer, MOH).

[When asked if the plan was to continue expanding the infrastructure]: ‘I think we want to consolidate by getting the right staffing’ (Officer, MOH).

‘The way to go is to equip level III health centres, improve on the supplies especially [the] delivery equipment [up to] Health centre level II where there are midwives’ (District Officer).

‘Majority of people go to level II health centers because it is again the nearest to the population. So possibly that is what we should be emphasizing … if obstetric services [are available at] 50 miles, and there is a place of 5 miles where I can get a midwife, most people will go [to the nearest unit]’ (Officer, Professional Organisation).

Medicines and supplies

‘This has improved a lot. We used to have many stock-outs even for the basics like fansidar for pregnant mothers but these days level II and III health centres are given predetermined basic kits every 2 months. This is more regular than it was. We revise contents regularly and it may not fit everybody but I think it has improved things. Then level IV health centres and hospitals are supposed to estimate what they want and use their budgets. There are still some challenges but I think is now much better’ (Officer, MOH).

‘If you go to many of the facilities they have drugs. So in terms of resources I think that is okay. In terms of clearly defining what drugs are needed and ordering them on time, I think there is still a challenge there because these drugs are supplied within a certain framework of time. So if they get finished it is difficult to replenish because you have to wait for the next supply to come through. So to me, the flexibility is the challenge’ (Officer, MOH).

‘There are many arguments, when you talk to the districts they seem to have [some] problems with it. When you talk to National Medical Stores, they say they are delivering enough. …. for accountability purposes I think it is much better, they have decreased a lot of pilferage of resources, but it also has its limitations, at times it was not supplying enough supplies for a unit’ (Officer, Professional Organisation).

‘Some of (the challenges) is poor communication but also the way the districts make the priority list. When they are making the list, they have little money and they do not include [some items]. The way they make the list sometimes is not informed by the needs, other times it is not just a priority for them. I think it is a gender issue. Also they would rather have antibiotics and panadol and let the mothers find what to do. That is part of it but I think secondly, the money the districts get is not enough’. (Officer, Civil society organisation).