Concerning Professional Regulation, the Public Health Council must heed to Key Stakeholders’ concerns

By Chrispory Juma and Camlus Odhus

Public Health as a profession has been existence for a long time. Some authors have dated the founding age of public health to around 400 BC when the Hippocrates published his book titled Airs, Waters and Places. Since then, Public Health Officers have been involved in disease control, health promotion, epidemic preparedness and investigation, and health education. In Kenya, Public Health Officers and Technicians are tasked with safeguarding the health of the public, including ensuring food safety, promoting basic sanitation and hygiene, educating the public on various health risks, planning diverse population health interventions, and enforcing a vast array of public health laws. To do this, health officers must adopt multidisciplinary and collaborative approaches, work with integrity and professionalism, and emphasize equity and prevention for a healthy population.

Thus in 2013, the Ministry of Health saw through a law known as the Public Health Officers (Training, Registration and Licensing) Act, which made provision for the professionalization, training, registration and licensing of Public Health Officers (PHOs) and Public Health Technicians (PHTs) in Kenya. The Act established the Public Health Officers and Technicians Council (PHOTC), whose purpose is to exercise general supervision and control over the training, practice and employment of public health officers and technicians in Kenya, and to advice the government and Ministry of Health on matters of public health governance. Over the past two years, the Council has done its level best to put its house in order, including setting up training regulations and curriculum for Kenyan institutions that train the Public Health workforce including Universities and other colleges; putting up measures for internship and registration of graduates; setting up an online information portal, among other achievements.

In line with its mandate to ensuring that all public health professionals within its jurisdiction meet an acceptable level of competence before they begin to practice, the PHOTC has gazette a raft of guidelines. This level of competence is measured by assessing the applicant’s knowledge, skills and professionalism. It is in this regard that the Council has decided on annual examinations, where graduates who have successfully completed their internships undergo written and oral interviews before being issued with a License to Practice. The Council set registration examination fees at Kshs. 20,000 and Kshs. 15,000 for degree and diploma graduates, respectively. The seemingly high fees have created a raging controversy among the graduate fraternity with them calling for the fees to be revised to reasonable levels, and streamlined with other professional bodies’ fees. Others have called for the scheduled exams to be called off all together until the grievances are addressed, in line with sound stakeholder engagement mechanisms.

Graduate PHOs go through a mandatory one-year unpaid internships without any allowances or benefits, at times even without any supportive supervision from the national government. As if that is not enough, interns are expected to pay Kshs. 1000 for the internship. Even after this, their absorption into the Public Service is not guaranteed, at both the County and National levels even as the Higher Education Loans Board expect many of these graduates to start repaying university loans, amidst the tough economic times. The graduates are, therefore, asking where the council expects them to get the exorbitant Kshs. 20,000 to pay up for the examinations. They would also like to know the criteria which used to arrive at the figures, yet other profession’s examinations are much affordable. Doctors undergo paid internships and for those in public service, have to part with Ksh. 8,000 for Board registration. Nurses pay up less than Kshs. 5,000 for their professional examinations to the Nursing Council. While PHOTC have a mandate to set fees among other regulatory roles, the decision processes need to be open, fair, objective, participative and reasonable.

Public health professionals across Kenya have also questioned the list of graduates who have already been lined up for the test. Core to this discussion is the question regarding how holistic a professional’s training should be. While board examinations have been used the world over as filters, societies are increasingly weary of prohibitions, and regulators should instead adopt facilitative processes in for holistic development of any profession. Needless to say, Kenyans will pass exams through hook or crook but passing a first-past-the-post exam is neither indicative of a qualified professional nor should it assure members of the public regarding integrity and professionalism. The PHOTC is well advices to enlarge its focus beyond exams and unreasonable fees, and to train their lenses on institutions that are non-compliant with admission and training standards.

Until a proper system is put in place to monitor and enforce training standards, administering entry exams does not assure the public that quacks and half-baked officers will not be the ones tasked with promoting and safeguarding their health. And in a country that suffers from gross inequality, questions must be asked regarding whether profession of Public Health is now on sale to the highest bidder? We must guard against a culture that dishes out opportunities to those that can afford irrespective of their competence and qualifications, at the expense of many that could be deserving, yet cannot afford. Are the right candidates selected to join the right institutions? What is the quality of training at the respective institutions? Is there enough effective oversight on the training of health officers? What procedures are in place to go beyond an exam-based filter to a competency-based professional grounding?   How is PHOTC going to systematize continuing professional development, given that public health has one of the largest specialization options of any career? Employers, although not specifically about public health, have continued to note the poor quality and employability of job-seekers from local institutions of higher learning, despite such applicants holding impressive academic qualifications. The challenge is for PHOTC to find a balance between evolving employers’ needs, the country’s health aspirations, and current socio-economic realities, and to feed these back into the training standards and ongoing initiatives for professional development.  

These are weighty issues that many do not expect the regulator to have sorted out in its brief existence. But public health professionals are watching to see that a solid foundation is set for the sustainable development of the profession in the country. Most importantly, and as anticipated by the Constitution, what public consultative mechanisms have PHOTC put in place to ensure effective stakeholder engagement? It would be important for the regulator to put in place effective stakeholder engagement strategies, backed by a sound communications plan to ensure ongoing exchange of information in a non-confrontational manner. Sadly, on this facet, the regulator is found wanting. Although backed up by an Act of Parliament and having the benefit of a fully constituted board, PHOTC should seek to gain the confidence of her stakeholders, and work collaboratively with genuine member-driven associations rather than wave statutes at the slightest interrogation. Unless the regulator has a thousand-strong secretariat and adequate finances to police the profession, it is well advised to forge cooperative alliances while remaining above board. As we have witnessed with other regulators, laws are not enough to maintain sanity, and public participation and support for policy actions are key ingredients for success. We want the Council to succeed wildly, for we, the members of the public health profession and the public - whose health we are here to safeguard - will be the ultimate beneficiaries of such a success, but we are also ready to scrutinize how it conducts business because we have a legitimate right to do so, both as citizens and as corporate members.

A strong council would need all PHOs and PHTs of all calibers to move along with it, regardless of their stature in the society. It would be in naïve, in bad faith, unjust and arrogant to go ahead with the planned examinations without properly responding to concerns raised. We expect it to have a special sitting to deliberate on the exorbitant examination charges, because if this is not done, professionals will need a rethink. The Council must be fully supported in its efforts to restore integrity in the Public Health sector, but that support can only be effective with participatory decision making on its governance roles. Kenya needs strong institutions to move towards national, regional and global development goals, including the new Sustainable Development Goals related to public health, and PHOTC must not disappoint.

Disclaimer: The writers are Kenyan Public Health Practitioners. Views in this article do not necessarily reflect those of their affiliate organizations. Chrispory Juma is a MPH Student and Community Mobilization Expert (chrispory.juma@gmail.com); Camlus Odhus is a post-graduate Commonwealth Public Health Scholar (codhus20@gmail.com)