Insight into the remuneration of health workers in the public service

In Kenya, health is guaranteed by the Constitution of Kenya, 2010, which places emphasis on a universal healthcare system. According to Vision2030, the country aims to offer equitable and affordable healthcare to all citizens by strengthening the healthcare system.

The constitution devolved the provision of healthcare to county governments. The national government provides overall policy guidelines and plays an oversight role.

Prior to the establishment of the Salaries and Remuneration Commission (SRC), remuneration and benefits payable to public officers were set through ad hoc committees and commissions. Owing to the limited mandate of the foregoing commissions and committees, they only addressed remuneration and benefits in selected sectors and subsectors of the public service.

The absence of a holistic approach led to substantial differences in salaries, allowances, benefits and grading, and resulted in discontentment, low morale, and inefficiencies in the public service.

Further, the absence of clear and comprehensive policy guidelines to facilitate the effective management and administration of allowances in the public service led to the proliferation of allowances, distortions in remuneration, unfairness in pay, lack of transparency, accountability, and inequity.

SRC was established under the constitution and SRC Act, 2011, to address these shortcomings. Section 12(1) of SRC Act establishes equal remuneration to persons for work of equal value as a principle in determining remuneration and benefits in the public service.

Remuneration in the public service consists of basic salary, and remunerative and facilitative allowances, which are paid depending on the nature of work, designation, and locality.

Health workers are mainly employed in the Ministry of Health (MOH), national and county hospitals, Kenya Medical Training College, universities and select State corporations.

The health sector includes the following units: hospitals, clinics, nursing, home cares, medical and dental practices, ambulance transportation, complementary medicine, and other health activities, such as medical laboratories and scientific and research services.

The healthcare sector provides goods and services to treat patients with curative, preventive, rehabilitative, and palliative care.

The health worker cadres in Kenya include: doctors, pharmacists, dentists, nurses, clinical officers, lab technicians and other paramedics (physiotherapist, radiographers, occupational therapists, nutrition and dietetics officer, entomologists, chemist, technologists and technicians, public health officers, health record officers, medical social workers, community oral health officers, parasitologist, biochemists, anaesthetists, mortuary attendants, orthopaedics, radiation protection officers, and biomedical engineers).

Wage Bill

The public health subsector is the second largest consumer of the public wage bill, after the teaching service. The subsector share in the total public wage bill is about 12.5 per cent, equivalent to around Ksh 120 billion.

As at 2018, the number of health workers in the public service, excluding health workers at the Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH), was about 67,740. Further, there was an increase in the number of registered health professionals for all cadres in 2022.

The wage bill for the health subsector is majorly influenced by the number of health workers in the public service and collective negotiation agreements (CBAs). For example, between 2013 and 2018, the wage bill spiked by nearly three-fold from approximately Ksh 38 billion in 2013 to Ksh 108 billion in 2018.

This is due to the expansion of the public service following the implementation of the constitution, which created two levels of government that led to an increment in the stock of health workers in the public service.

The wage bill spike was compounded by salary increments for health workers over the years under review following the implementation of CBAs between the government and health workers’ trade unions.

The Economic Survey 2023 reported that the national government expenditure on health services is expected to increase by 33.1 per cent from Ksh 88.2 billion in 2021/22 to Ksh 117.4 billion in 2022/23.

Recurrent expenditure on health services is expected to increase by 23.4 per cent from Ksh 40.2 billion in 2021/22 to Ksh 49.6 billion in 2022/23. Development expenditure is expected to increase by 41.3 per cent from Ksh 48 billion in 2021/22 to Ksh 67.8 billion in 2022/23.

In addition, the total county government expenditure on health services declined marginally from Ksh 108.8 billion in 2020/21 to Ksh 108.3 billion 2021/22. This is expected to rise by 1.4 per cent to Ksh 109.8 billion in 2022/23.

On the other hand, the recurrent expenditure on health services by county governments rose by 1.3 per cent to Ksh 91.8 billion in 2021/22, and projected to decline by 0.9 per cent to Ksh 91 billion in 2022/23.

In 2021/22, development expenditure on health services by county governments declined by 9.8 per cent to Ksh 16.5 billion, and expected to increase to Ksh 18.8 billion in 2022/23.

Healthcare in county governments

The health sector in county governments is provided for in the Fourth Schedule of the constitution as a devolved function, except the national referral and teaching hospitals.

Devolution of the health sector to the counties has resulted in varied placement of county health workers in different pay groups with varied remuneration and benefits.

This is outlined below:

1. Health workers devolved from the national government: The devolved health workers moved with the remuneration and benefits structures that was obtaining at the national government. This cadre is paid all the requisite allowances unique to health workers.
2. Health workers inherited from defunct local authorities: The remuneration and benefits for this cadre was determined through CBAs, prior to the creation of SRC.
3. Health workers hired by the County Public Service Boards (CPSB): The designations and terms of engagement for this cadre is determined by CPSBs.
4. Health workers hired under the Economic Stimulus Programme (ESP): These are health workers formerly employed on contract by MoH under ESP. MOH adopted a policy for their absorption by counties upon the expiry of contracts.

Some counties may not have all the above categories within their respective health sectors.

Allowances payable to healthcare workers in the public service

1. Non-Practicing Allowance: Meant to attract and retain scarce, rare and critical professional skills in the public service and is specific to doctors (medical, dental and pharmacists), and legal professionals in specific public service institutions.
2. Extraneous Allowance: For staff who work long hours on a continuous basis and may include extra responsibilities. It is payable to officers whose duties expose them to excess physical and mental stress and extended undefined long working hours.
3. Doctors Allowance: For doctors, pharmacists, and dentists deployed in the hospital whose nature of work involves frequent calls for service delivery.
4. Health Risk Allowance: For employees engaged in hazardous duties or whose work will have a deleterious effect on health over a period of time. It is paid to health workers whose salaries have not been consolidated to include the risk factor.
5. Health Workers Service Allowance: For health workers by virtue of their nature of work in heightened exposure.
6. Nursing Services Allowances: For nursing staff by the nature of their work in heightened exposure.
7. Emergency Call Allowance: For officers on call in case a need arises for them to be present at the duty station. It is paid to health workers in the hospital to cushion them for frequent calls to offer services beyond normal working hours i.e. nights.