In Kenya we face an acute shortage of medical specialists. Patients often face long queues and wait times—sometimes months—to consult with a specialist for urgent conditions like maternal health issues, cancer, or childhood illnesses. Advanced practice nurses (APNs), new in Kenya, can play a crucial role in managing some of these conditions under the supervision of specialist physicians, thereby reducing delays and improving health care delivery. 

Patients often face long wait times—sometimes months—to consult with a specialist. 

APNs are registered nurses with advanced education and clinical practice requirements to provide specialized care. Despite their potential, the APN role is often not well understood within the nursing field or the larger health sector, including how APNs can also support primary health care (PHC) and referral services at the community level and lower-level facilities. Through our Global Health Workforce Programme (GHWP) project, IntraHealth partnered with the Nursing Council of Kenya to conduct an APN readiness assessment across seven counties (Bomet, Kakamega, Kiambu, Machakos, Murang’a, Nairobi, and Uasin Gishu). 

Between July and September, we conducted key informant interviews and surveys to explore the readiness of national and subnational institutions to support both the training and practice of APNs. At the national level, we assessed readiness in policy, legal and regulatory frameworks, career progression, and employment, while at the subnational level we focused on counties’ readiness to integrate APNs within their health services. We also assessed the readiness of training institutions’ curricula, educators, infrastructure, and clinical practicum sites.

• Meet Janet Muriuki and Peter Shikuku in Nairobi at the Global Health Practitioners Conference.

Preliminary readiness findings

We found that in Kenya there’s confusion around the role of APNs. According to the International Council of Nurses, an APN has two pathways: a nurse practitioner, often working in PHC and community settings, or a clinical nurse specialist, often deployed in specialized hospital departments, academic health centers, and government health agencies. In Kenya there are no clear guidelines of practice for these two APN categories.

Within the larger health sector there’s confusion about how the clinical responsibilities of APNs correspond with the responsibilities of Kenya’s clinical and medical officers. The national-level agencies at the Ministry of Health and the county governments that employ the public health workforce also lack clarity on APNs. The counties and faith-based facilities do not see the value of employing an APN if the job at their facilities could be done by a diploma nurse. 

There is a need for standardized training for APNs. The Nursing Council of Kenya provides guidance on core curricula for nurses, and this should include guidance on core competencies for APN training. Standardized training should also include guidance on faculty, infrastructure, libraries, laboratories, and practicum sites for the APN cadre. There also is an apparent shortage of clinical mentors to support the practicum training of APNs.

The absence of a clear career progression pathway for APNs affects integration of APNs into employment. The APNs lack a career progression guideline that would facilitate their integration into the heath workforce through the government’s Public Service Commission and the Salaries and Remuneration Commission. 

Despite these challenges, some public and private hospitals in Kenya have demonstrated successful APN integration with clear roles and responsibilities. At Moi Teaching and Referral Hospital in Eldoret, Uasin Gishu, APNs have been integrated into health service delivery and are working alongside physicians and consultants in managing patients. This is also the case at Gertrude’s Garden Children’s Hospital in Nairobi.

The way forward for APNs in Kenya

The APN cadre has been implemented successfully in some countries in the West with a well-established structure for both training and practice. These examples provide valuable insights for deriving best practices that can be adopted across Kenya.

APNs can be instrumental in reducing delays and improving patient outcomes.

In countries where APNs have been well integrated into the health system, the majority work at the PHC level. The Government of Kenya is advancing universal health coverage (UHC) through primary health care networks at the county level. APNs could potentially work within these networks as a member of the multi-disciplinary team to enhance health outcomes of the population. Within the context of the hub-spoke model, when APNs are stationed in the hub (a sub-county hospital) they can provide the much-needed mentorship and clinical support to other nurses at dispensaries and health centers. This would help to improve access to quality PHC and reduce referrals to the higher-level facilities. At the county and national referral hospitals, APNs can be instrumental in working with specialized doctors in reducing delays and improving patient outcomes.

To accelerate APN integration in Kenya, the following recommendations are essential:

1. Clearly define the APN role in the health sector and develop an advocacy and communications strategy to inform key stakeholders and the public on the benefits of the role in enhancing health outcomes.
2. Develop regulatory, employment, and professional development tools for the APN role.
3. Develop core curricula for APNs with prescribed core competencies to provide guidance to training institutions and standardize APN training.
4. Integrate the APN role in primary health care to support attainment of UHC.
5. Integrate the APN role within specialist medical services to ease long queues for consultants and enhance service delivery 
6. Train APN clinical instructors and mentors to support practicums for APNs.

Call to action

The integration of APNs in Kenya is still in its early stages, with significant opportunities for improvement. By addressing the gaps and leveraging the opportunities, Kenya can scale up the APN cadre and benefit from enhanced health care delivery and improved patient outcomes. It is vital that all stakeholders support these efforts to scale up APN training and practice in Kenya.

The project is producing a report with recommendations, a plan, and a strategy for the cadre’s expansion in Kenya, and will disseminate it to Kenya’s health leaders.

Let's meet! 

The authors will participate in the Global Health Practitioners Conference in Nairobi, Kenya, on October 28 - 31, 2024. If you will also attend, introduce yourself to Janet Muriuki and Peter Shikuku at our Expo Table in Jambo Hall Foyer. Janet Muriuki will moderate a session, "Drought, Disaster and Hope: Addressing the Impacts of Climate Change on East Africa’s Pastoralist Communities," on October 29, 4-5:30 pm EAT. Learn more about our participation in the conference here. 

The Developing Capacity to Establish Specialist and Advanced Practice Nursing Roles in Kenya project is a Global Health Workforce Programme project awarded by the Tropical Health and Education Fund and funded by the UK Department of Health and Social Care (DHSC). Led by IntraHealth International in collaboration with the Nursing Council of Kenya, the Nursing and Midwifery Council of Ghana, and Ideal Health Organization, this 12-month project supports implementation of Kenya’s Primary Healthcare Strategy by expanding the roles for specialist and advanced practice nurses so they are empowered to deliver quality health services at all levels.