HRH priority setting in theory
From the review of policy and legal documents accessed, devolved HRH recruitment should be a joint responsibility of the County Public Services Board (CPSB) and the County Department of Health (CDoH). The recruitment process should begin with identification of staffing gaps by respective heads of divisions within the CDoH and respective health facility managers [22]. These gaps are to be drawn based on the organizational structure of the CDoH, health facility staffing norms, the schemes of service of various HRH cadres, and health worker career progression guidelines [23]. The Chief Officer of Health and the Human Resource Manager at the CDoH (who is seconded from the County Department of Public Service but based in the CDoH) then consult the CPSB for approval of the HRH vacancies identified to be filled [12, 22]. To approve the declared vacancies, the CPSB would seek to verify the number of vacancies identified, when they occurred and whether the vacancies are within the authorized establishment for the CDoH. The CPSB further consults with County Treasury to ascertain that the CDoH has the necessary required budgetary allocation to fill up the identified vacancies [22].
The CPSB then advertises the declared and approved vacancies for a period of at least 3 weeks via various media outlets and in the communities through administrative channels so that the marginalized communities are reached as well. All interested applicants have to fill a prescribed application forms and submit to the CPSB [22].
The CPSB in liaison with the Chief Officer of Health develop a short-listing criterion as guided by relevant legal and policy requirements for the positions to be filled. The CPSB is then required to counter check with relevant professional bodies to ensure that the shortlisted HRH candidates are all duly and appropriately registered. Short-listed candidates are then invited for interviews through the media outlets [22].
Candidates for the different positions should be selected based on merit, fair competition and representativeness of the diversity of the county [12]. The board coordinates and monitors the recruitment process to ensure equity and transparency [22].
Final candidates for the respective positions are rationalized and approved by the CPSB. The CDoH’s Human Resource Manager then prepares appointment letters with terms of service, which are then signed by an authorized officer, who can be from the CPSB or to whom the CPSB has delegated its authority. The CDoH’s Human Resource Manager should then communicate with the appointed candidates to pick their appointment letters [22].
The recruited staff can accept or reject the offer in fourteen (14) days. After 14 days, the Human Resource Manager should advise on how to fill the resulting vacancies in case any of the new recruits rejects the job offer. Officers that have accepted their appointment should be put on probation for 6 months, after which if their performance be satisfactory, they should be confirmed and admitted in to the permanent and pensionable establishment by the public service board [22] unless they are employed on contract terms.
Fixed-term contract employments are either medium-term or short-term. Medium term contracts run for a maximum of 5 years and are subject to one renewal whereas short-term contracts cannot be engaged for more than 3 months. Casuals workers can be engaged on urgent, short-term contracts by the CDoH, with approval of the CPSB [22].
HRH recruited by the donor contractors should also be informed by the CDoH HRH needs and the workers paid as per government guidelines. If there is an agreement between the donor and government, the donor workers get absorbed at the end of the contract as per the agreement [22].
From the review of policy and legal documents, it is not clear which institution of office within the county government has the ultimate responsibility for distribution and deployment of health workers.
Devolved HRH recruitment in practice and its influences
Since its establishment in 2013, our study county had been recruiting health workers through two parallel mechanisms. One of them is led by the CPSB as per the existing policy and legal requirements. However, there has existed another process where health workers dubbed ‘casual workers’ are recruited directly by the CDoH on short-term contract without the involvement or participation of the CPSB.
At the end of each financial year, sub-county health management teams and hospital management teams do submit their HRH requirements to the County Health Management Team (CHMT), which is the senior management organ of the CDoH. At the same time, the CDoH human resource unit establishes transitions that have occurred in that particular year i.e., deaths, transfers, resignations and retirements.
CM002: “In anything, you must start from the user. So the user can be in most cases be it the hospital or be it us a sub-county. So we make these requests through the {CDoH} as a team or as respective {cadre or sub-county or hospital}. … so the different needs from different hospitals and sub-counties are submitted to the county.”
At the CDoH, a human resource advisory council was established consisting of the County Director of health, CEC Member for Health, Chief Officer of Health, representatives of core cadres such as the doctors, nurses and clinical officers; and the Human Resource Manager. This council does sit to look at human resource issues raised more holistically; it looks at the raised requests against available HRH finances and deliberates whether the submitted requests could be fulfilled. The advisory council then advises the CHMT based on their findings, after which the CDoH submits their HRH request to the CPSB.
Upon receiving the request, the CPSB also looks into the laws that guide the recruitment process and engages Chief Officer of Finance to ascertain the budgetary allocation of the CDoH and affordability of the requested new recruits by the department.
After approving the recruitment request from the CDoH, the CPSB undertakes the hiring process on behalf of the CDoH. The CDoH Human Resource Manager undertakes a technical role in the recruitment process - including taking part in the shortlisting and interviewing activities led by the CPSB. Once the new staff are hired, have received appointment letters and reported to the Human Resource Manager, the posting and deployment of these new staff is undertaken by the Chief Officer of Health.
From the interviews, the key influencing factors for health worker recruitment at the county are largely (i) push and demands from local politicians to create jobs for “their people,” (ii) service need owing to opening of new health facilities, and (iii) budgetary limits set to the CDoH over HRH expenditure.
Interviewees reported that local politicians have over the time used their influence to have “their people” employed by the CDoH, including those without necessary qualification. It was however reported that the CDoH human resource unit and the CPSB had been resisting to recruit workers that do not meet minimum qualification as per the scheme of service. The politicians then began circumventing the process of recruitment through the CPSB and compelled the CDoH to create a parallel recruitment for HRH as short-term casual employees. These “casual workers” (largely proposed by local politicians) also included health professionals who would be hired on short-term contract and managed by the CDoH without involvement of the CPSB as required by legal and policy provisions. Unlike the CPSB formal employment, no advertisements were made for these casual workers.
CM004: “Like now, here {one of the local dispensaries} … , when they wanted staff, the MCA {local Member of County Assembly} brought 7 casuals to go there … and in a dispensary, we are not supposed to have more than 3 casuals, i.e. a gardener, a cleaner and a watchman”
Due to the political and emotive nature of the casual workers, their recruitment and deployment was thus handled directly by the senior managers of the CDoH. At some point, the CDoH made a request to have the contracted ‘casuals’ absorbed in to permanent employment by the CPSB. The CPSB declined to employ them as they could not obtain a justification for their employment. However, politicians continued to pile pressure on the CPSB, pushing it to absorb these ‘casuals’ that had been recruited without their involvement. The CPSB eventually absorbed the ‘casuals’ who had the requisite qualifications in to the permanent and pensionable scheme. However, most of the casual workers who had been informally recruited did not meet minimum qualifications and thus could not be absorbed.
CM004: “we wrote a memo, we have to go through their papers. So, we went and applied and we verified their things. We took 24, and the rest … they were told in advance that after 3 months, you’re no longer going to, you have to reapply.”
In the early days of devolution, there was a political push to open new health facilities. The CDoH would then use these new facilities as a basis for obtaining political goodwill from the MCAs to hire more health workers. The corresponding increase in HRH and facility numbers, however, did not help address existing chronic health worker shortage in the county.
CM002: “We’ll tell the MCA, okay, we’ve opened {the facilities}. I know you want services for your people, but look at this. We now have one person seeing this population. (S) he has no replacement/substitute. If the person falls sick today, who will come?”
The CDoH had a budgetary ceiling of 30% of its budgetary allocation to salaries and other remunerations and some managers acknowledged that the county was currently at the ceiling of its HRH recruitment budget. It thus had capacity to replace HRH but not to employ more, unless the ceiling was lifted, or more funds were allocated for HRH salaries and remuneration.
County level HRH deployment in practice, and its influences
From the interviews, it was reported that the county does not have set guidelines on distribution of HRH. Given the scarcity of HRH in the county, the distribution of employed staff has been guided by the concept of bare minimum in distributing health workers in the county i.e., the minimum number that each facility is supposed to have. The staff postings are usually done by the Chief Officer at the CDoH after consultation with key managers.
CM001: “Right now we are one thousand, five hundred and fifty-one {1551} health workers and that number is still very low. In fact, it is the bare minimum number in every place. And it’s like half of the population of the county.”
Whenever the CDoH got new staff, top managers would sit down and deliberate on what they had. The managers consider factors such as HRH requests made and workloads of health facilities. Heads of respective HRH cadres had a big influence over the distribution of the respective cadres given that they were responsible for the services provided by those particular cadres. Deployment from the county level would be done to the county hospitals and sub-county health management units. The sub-county health management units would then determine factors such as current staff numbers and workloads in the respective PHC facilities, then subsequently distribute the HRH they receive to their PHC facilities.
It was reported that occasionally, some staff would be deployed/re-deployed for disciplinary reasons i.e., staff considered to be undisciplined would be transferred from rural facilities and closer to where managers are based for easier monitoring of their conduct.
Table 2 summarizes the county-level health sector recruitment and deployment roles both in theory and in practice.