Our analysis on the readiness and capacity of Kenya internship training hospitals suggested that in 2018 the overall staffing, equipment and service availability was inadequate when compared with the regulator’s requirements. Level 4/district, smaller hospitals (23 of the 61 assessed) were more likely to have fewer human resources, equipment and specialty services, and less likely to meet quality and safety indicators. The implication is that hospitals with lower capacity may either have to improvise to offer core services or refer patients to other facilities. This could significantly influence the quality of training as interns might not be able to fully consolidate their knowledge and skills.
Over half of the internship training hospitals did not have five or more specialists as required by the regulator, the medical council, which suggests inadequate training and supervision of medical officer interns. Internal medicine specialists and anaesthesiologists were most often lacking suggesting that in many centres non-specialist but licensed general medical or specialist clinical officers fill these roles. Even in these larger Kenyan hospitals such personnel will also likely therefore be leading provision of care for severe COVID-19. Where medical officers are themselves also scarce, medical officer interns may become the only “in-house” doctor on call and be forced to take on full responsibility for patient care potentially threatening patient safety if interns are forced to care for serious, acute medical and surgical conditions without appropriate supervision (8, 14, 15). The likely challenges to provision of high quality safe care are further suggested by poor scores of all but tertiary hospitals against organisational indicators of quality and safety practice. In fact guidelines or instruction for quality and safety were rarely present and there seemed very limited evidence that quality and safety indicators are monitored, reviewed, reported and acted upon. These findings are consistent with reports highlighting challenges with patient safety in low- and middle-income country (LMIC) hospitals (16).
Internship hospitals appear most able to provide appropriate essential resources and capacities in the major disciplines of surgery and OBGYN. Challenges were especially noted in the disciplines of internal medicine and paediatrics and neonatology. Many facilities lack ECG machines, CT scans, defibrillators, equipment used for peritoneal or hemo-dialysis, and lumbar puncture kits. More specific to neonatal and child health were lack of capacity in ability to provide exchange transfusion, neonatal CPAP and intraosseous access. Capacity to offer mental health and neurological care, only listed as internship requirements in 2020, was especially low most particularly in Level 4 small hospitals. Kenya has a severe shortage of psychiatrists and neurologists as well as psychiatric nurses (17). For facilities without capacity in the major disciplines now including mental health and neurology services it is likely that hospitals are forced to refer patients elsewhere or improvise approaches to care in order to serve patients. Interns’ training experience is therefore likely to be very varied and more attention may therefore need to be paid to planning how interns can be provided with adequate training in all specialties if this is a key long-term aim.
Kenya has dramatically increased its medical training volume hoping to produce 9,000 new graduate medical physicians by 2030 to narrow its staffing gap (5). More hospitals especially at county-level (district hospitals) are accredited as internship training centres. These hospitals are usually smaller in size and more likely to be distant from the well-established university tertiary hospitals in major cities that scored much higher across domians in our analysis. Rural rotations and residencies have been recommended by the WHO to increase health worker retention (18). Students or interns in these settings may also be more likely to learn hands-on clinical procedures and be actively engaged in patient care (19) as opposed to tertiary hospitals where the presence of more specialists and general medical officers may result in interns undertaking more administrative work. However, the prerequisite of good internship training is that the hospitals are adequately staffed and equipped and ready to deliver teaching and training. Our data suggested that this is not always the case and are consistent with previous qualitative research suggesting that district hospitals provided limited learning with limited suitability as internship sites (8).
The potential consequences of poor training and supervision during internship are therefore worth consideration. As well as failing to consolidate knowledge and skills in major specialties interns may also develop burnout and stress-related psychological problems more rapidly (8). These stresses and being forced to take significant clinical responsibility in poorly-resourced hospitals may push medical officer interns to leave the profession or the public sector which is often most resource constrained as soon as they are licensed/registered (20). This will likely worsen the internal and external brain-drain undermining universal health coverage and equity and limiting any benefits from public investment in medical education (20). Inadequate support and supervision also threatens patient safety by creating the conditions for significant medical errors to occur. Even in settings without a ‘blame culture’ such errors can have profound effects on the health workers as well as the patients further exacerbating workers’ psychological distress (21, 22). We must also remember that todays’ medical officer interns will become tomorrows general medical officers who are often then responsible for the training of the next cohorts of interns and other health worker cadres (23). Therefore, poor internship training for medical officers continuously compromises the quality of training and skills that are passed on and this may be a particular challenge to patient safety and healthcare quality that rely so heavily on effectively functioning teams (24).
Our analyses have clear implications for Kenya policy-makers. The regulator requires internship hospitals to maintain the minimum requirement of staff and be able to offer a core set of quality services with self-report against such requirements at least once a quarter. Our data would suggest many internship hospitals in Kenya might not continuously achieve these minimum requirements. Should this prevent interns from being licensed or should interns be reallocated to centres meeting regulatory requirements? While more stringent and regular audit and re-accreditation of internship training centres might be conducted by the regulatory council to ensure that only the hospitals that meet the minimum requirements are allowed to receive and train interns, adequate mitigation measures need to be in place so that interns themselves are not disadvantaged further. More widely, our findings point to the need to carefully consider the potential consequences of rapidly expanding medical training and of appropriate planning and financing for new internship centres, especially in rural areas.
Several limitations should be noted for the current analysis. To start with, our analysis was only limited to the 61 internship training hospitals sampled by KHFA, mostly public hospitals. A total of 13 hospitals were not sampled in KHFA and are either private hospitals or mission hospitals, therefore comparison by hospital ownership was not feasible. Second, aside from the KHFA’s own limitation on data missing, we noted data inaccuracy and inconsistency in KHFA data we retrieved. We made efforts to clean these data especially on human resources through correspondence input though we were unable to validate all the number from the KHFA survey. Third, to assess the readiness and capacity of internship training hospitals we selected 166 signal indicators from the 3000 questions from KHFA survey. Our criteria were to ensure that the indicators selected are the minimum requirement and should be achievable (i.e. should be “1” for all indicators). Our selection was guided by the national guidelines and agreed by four authors, three of whom have experience supervising interns. However, we acknowledge that this process is somewhat subjective. Fourth, we only focused on the structural and organizational features of internship training hospitals. We did not include indicators on process or outcome indicators due to limited data availability. Ideally these should be considered while evaluating internship training hospitals. Last but not least, the KHFA data was collected in a snapshot in 2018 prior to Covid-19. The appointment and posting of specialists may fluctuate from time to time but Covid-19 specifically could have led to the government investing in hospital infrastructure, equipment and emergency hiring to improve their response capacity to Covid. Therefore it is possible that the readiness and capacity of Kenyan internship training centres has improved since 2018 (25). Despite these limitations our data do suggest important shortcomings in internship training centres in Kenya. We suggest other LMICs that are rapidly expanding their medical training should also evaluate their internship training sites to explore the generalisability of our findings.