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Suggested citation: Kenya Ministry of Health (MOH) and IntraHealth International, 2012. Report of the Rapid Baseline Survey of the National Trainining Mechanism in Kenya. Nairobi, Kenya: MOH.

Rapid Baseline Survey of the National Training Mechanism in Kenya iii

Table of Contents LIST OF ACRONYMS ..................................................................................................... viii EXECUTIVE SUMMARY .................................................................................................. 10 INTRODUCTION ............................................................................................................ 12 PURPOSE OF THE ASSESSMENT .................................................................................... 12 METHODOLOGY ........................................................................................................... 13

Assessment questions ......................................................................................................................... 13 Assessment design and overview by result area ........................................................................... 13 IR 1: Supporting increased number of new health workers ......................................................... 13 IR 2: Training Needs Assessment ...................................................................................................... 13 IR 3: Strengthening the capacity of training institutions ............................................................... 14 IR 4: Strengthening regulatory bodies to enhance training demand ........................................ 14 Assessment sites ................................................................................................................................... 14 Target population and assessment sample .................................................................................... 15 Data collection methods ................................................................................................................... 15 Data collection .................................................................................................................................... 16 Data quality assurance ...................................................................................................................... 16 Data Analysis ........................................................................................................................................ 16 Survey Limitations ................................................................................................................................ 17 Sample Size ........................................................................................................................................ 17 No Response ..................................................................................................................................... 17 Unavailability of data ....................................................................................................................... 17 Ethical considerations and human subject protection ................................................................. 17 Privacy for research participants ...................................................................................................... 17 Confidentiality ..................................................................................................................................... 17 Compensation ..................................................................................................................................... 18

RESULTS ......................................................................................................................... 18 Demographic information about study sample ............................................................................ 18

Intermediate Result 1 .................................................................................................. 18 Forecasting training needs ................................................................................................................ 18 Creating an enabling environment for training fees access ....................................................... 19 Funding of student fees ................................................................................................................... 19 Average total annual fees for in-service training ......................................................................... 19 Increasing capacity of training institutions ...................................................................................... 19 Number of health workers graduating by region ......................................................................... 21 Number of student allowed to enrol by regulatory bodies ......................................................... 21 Training institutions’ output performance ...................................................................................... 22 Barriers to increasing training capacity ......................................................................................... 23

Intermediate Result 2 .................................................................................................. 23 The survey collected data from the training institutions on existing provision of in-service training, coordination of training in the regions, database processes used to track in-service training for health workers in the institution and linkages to MOH and regulatory bodies. ................................................ 23 Facilitating training .............................................................................................................................. 23 In-service training for health workers .............................................................................................. 23 Coordination of in-service training at surveyed institutions ......................................................... 23 Tracking training through training database and data linkages ............................................... 24 Recommendations for linking database to MOH and Regulatory bodies ............................... 24 Capacity of training institutions to offer continuous professional development (CPD) training ............................................................................................................................................................ 25

Rapid Baseline Survey of the National Training Mechanism in Kenya iv

CPD/CME Courses ............................................................................................................................................ 25 CPD/CME policy, guidelines and calendar ................................................................................................... 26 Documentation of in-service training, CPD/CME .......................................................................................... 26 Business management tool .............................................................................................................................. 27 Funds for in-service CPD/CME training ........................................................................................................... 27 Learning approaches and CPD/CME Calendar ........................................................................................... 27 Acceptance of learning approaches for CPD/CME .................................................................................... 27 Evaluating performance .................................................................................................................... 28 Barriers to meeting and increasing training demand .................................................................. 28

Intermediate Result 3 .................................................................................................. 28 Developing content and courses to support curricula ................................................................. 28 Improving the capacity of faculty and clinical mentorship ........................................................ 29 Induction training for preceptors/mentors .................................................................................... 29 Pooling mentorship programs and resources ............................................................................... 32 Framework for assessing preceptor/clinical instructors ................................................................ 32 Capacity to deliver training through innovative approaches ................................................... 33 Upgrading training facility management systems and infrastructure ........................................ 34 Clinical placement sites ................................................................................................................... 34 Existing infrastructure for adopting new technologies to train health workers for CPD and accreditation .................................................................................................................................... 35

Intermediate Result 4 .................................................................................................. 35 Guidelines for curriculum development and implementation ................................................... 35 Capacity existing in the regulatory bodies to coordinate and regulate licensure and accreditation of training institutions and CPD .............................................................................. 36 CPD/CME accreditation, review and curriculum guidelines ....................................................................... 36 Linkages to MOH and training institutions ...................................................................................... 36 Lessons learned from training accreditation programs ............................................................... 37 Training regulatory framework ........................................................................................................ 37

Discussion .................................................................................................................... 38 Current state of forecasting for new health workers ..................................................................... 38 Current state in addressing health workers training demands .................................................... 38 Capacity of training institutions to offer continuous professional development (CPD) training................................................................................................................................................................ 39 Existing models and gaps in models used to assess and update training needs in the training institutions ............................................................................................................................................. 39

Conclusion and Recommendations ......................................................................... 41 Current state of forecasting for the health workers ....................................................................... 41 Capacity of training institutions to offer continuous professional development (CPD) training................................................................................................................................................................ 42 Existing models and gaps in models used to assess and update training needs in the training institutions ............................................................................................................................................. 42 Existing infrastructure for adopting new methodologies to train health workers for CPD and accreditation ....................................................................................................................................... 42 Capacity existing in the regulatory bodies to coordinate and regulate licensure and accreditation of training institutions and CPD. .............................................................................. 42

APPENDIX A: List of Participating Institutions............................................................. 44 APPENDIX B: Introduction and Consent .................................................................... 45 APPENDIX B: Approval Letter from MOH ................................................................... 57

Rapid Baseline Survey of the National Training Mechanism in Kenya v

List of Tables and Figures Table 1: Target Survey Respondents by Region ...................................................................................... 15 Table 2: Target Survey Respondents ......................................................................................................... 15 Table 3: Numbers of Health Workers Graduating by Type of Institution ............................................. 21 Table 4 : Perceived rates for acceptance of e-learning, mobile and distance learning ............... 28 Table 5: Existence of joint meetings by type of training institutions ..................................................... 29 Figure 1 - Respondents by Ownership of Institution ................................................................................ 18 Figure 2 - Funding Sources for Student Fees at Surveyed Institutions .................................................. 19 Figure 3 - Comparison of Pre-service Enrollment and Graduation by Number of Health Workers

and Cadre ........................................................................................................................................... 20 Figure 4 - Actual Enrollment Compared to That Allowed by Regulatory Bodies .............................. 22 Figure 5 - Training Institutions' Performance against Maximum Output Capacity ............................ 22 Figure 6 - Barriers to increasing training capacity .................................................................................. 23 Figure 7 – Training Institutions’ Performance on Tracking Training through Databases ................... 24 Figure 8 - Training Institutions' Suggestions for Improving Stakeholder Linkages ............................... 25 Figure 9 - Existence of CPD/CME calendar ............................................................................................. 26 Figure 10 –Barriers to meeting current demand ..................................................................................... 28 Figure 11 - Preceptors/mentors completed induction training ............................................................ 30 Figure 12 - Channels used for sharing clinical knowledge .................................................................... 31 Figure 13 - Frequency of Preceptor/Mentor Engagement in Self-Directed Learning as Reported

by Training Institutions ......................................................................................................................... 32 Figure 14 - Recommended Areas to Pool Mentorship Programs with Other Training Institutions ... 32 Figure 15- Resource Support Available for Mentorship by Number of Training Institutions .............. 33 Figure 16 – Capacity of competency for the mentors to Convert Curricula to Distance, e-

Learning and m-Learning Formats ................................................................................................... 34 Figure 17 - Number of Clinical Placement Sites by Region ................................................................... 34 Figure 18 - Capacity Gaps for Implementing Alternative Training Approaches by Number of

Training Institutions .............................................................................................................................. 35 Figure 19 - Frequency of Evaluating CPD/CME Programs by Regulatory Bodies ............................. 36 Figure 20- Strength of Regulatory Bodies’ Linkages with MOH and Training Institutions .................. 37

Rapid Baseline Survey of the National Training Mechanism in Kenya vi

ACKNOWLEDGEMENTS This baseline survey involved a wide variety of stakeholders. We wish to acknowledge and thank the Permanent Secretaries of both Ministry of Medical Services (Ms Mary W. Ngari, CBS) and Public Health and Sanitation (Mr. Mark K. Bor , CBS) for giving us an opportunity to carry out this important assessment. Special thanks to the Heads of Departments of Human Resource and Development of the two ministries, Mr. David Njoroge and M/s Grace Odwako who facilitated the approval processes and guiding the survey. We also acknowledge United States Agency for International Development (USAID) and IntraHealth-Chapel Hill for financing and giving technical advice. The survey could not have been successful without training institutions, regulatory bodies and professional associations. We are grateful to Dr. Perle Combary, Dr. Leigh Shamblin, Dr. James Mwanzia, Dr. Norbert Rakiro, Prof. Steve Okeyo, Peter Milo, David Maingi, Martin Kinyua, Nobert Boruett, Allan Oginga, Isaac Munene, Mohamed Ibrahim, Emily Mungai and Joelle Mumley for the role they played for the success of this survey such as development and review of the questionnaire, data collection, data analysis. Special thanks to Wanjiru Kangara and Dr. Hazel Mumbo for the editorial role. We acknowledge the authors; Joyce Kinaro, Assistant Director – Monitoring and Evaluation (M & E) and Joseph Murage, M&E Officer both of FUNZOKenya Project, IntraHealth International.

Rapid Baseline Survey of the National Training Mechanism in Kenya vii

Rapid Baseline Survey of the National Training Mechanism in Kenya viii

LIST OF ACRONYMS CPD Continuing Professional Development CME Continuous Medication Education FBO Faith Based Organization HRD Human Resources for Health ICT Information Communication Technology IR Intermediate Result IT Information Technology KII Key informant interview KMTC Kenya Medical Training College MCH Maternal Child Health M & E Monitoring and Evaluation MOH Ministry of Health NEP North Eastern Province PHO Public Health Officers PNA Performance Needs Assessment TNA Training Needs Assessment USG United States Government USAID United States Agency for International Development

FOREWORD The Ministry of Medical Services and the Ministry of Public Health and Sanitation are committed to improving access to affordable health care services in order to accelerate the achievement of national health targets, Millennium Development Goals and Vision 2030. To provide quality health care to all Kenyans, there is a need to have adequate qualified health workforce that can address current and emerging health needs in the country. This can be achieved through training of new health workers, addressing current in-service training needs, strengthening training institutions to increase their admission capacity and lastly to support the regulatory bodies to improve professionalism among the health worker force. The Ministries of Health are undertaking reforms that have the potential to promote greater efficiency, accountability and decentralization of health training mechanism in the health sector. In this rapidly changing environment, the Government of Kenya supported by FUNZOKenya carried out a rapid survey to identify the areas of needs of the health workforce to ensure that adequate numbers of well-trained health workers are available to provide quality services throughout the country. This report identifies key issues in the training institutions that can be used for forecasting of the health force. It addresses health workers training demands and their capacity to offer Continuous Professional Development (CPD) training. In addition, the survey gives useful insights on the gaps in the existing models used to assess and update training needs in the training institutions. Further, the survey indicates strengths and weakness of the existing infrastructure in adopting new methodologies to train health workers for CPD as well as the capacity of the regulatory bodies to regulate licensure and accreditation of training institutions. We are pleased that the recommendations in this study provide the Ministries of Health and training institutions with an opportunity to make evidence based decisions in their bid to strengthen training mechanisms for the health workers. Together with the Faith Based Organisations, private sector and development partners, the Ministries are ready to support interventions that can transform health workforce training.

Dr. Francis M. Kimani, MB.ChB, MMed Dr. S.K Sharif, MBS, MBChB, MMed., MSc. DIRECTOR OF MEDICAL SERVICES DIRECTOR OF PUBLIC HEALTH AND SANITATION

Rapid Baseline Survey of the National Training Mechanism in Kenya 9

EXECUTIVE SUMMARY

Introduction The Government of Kenya (GOK) is determined to improve access and equity of essential health care services to accelerate the achievement of national health targets, Millennium Development Goals and Vision 2030. To achieve this, a well-managed heath workforce with appropriate skills equitably distributed across the country is essential. This survey set out to identify gaps that can be addressed by the Ministries of Health (MOH) in collaboration with FUNZOKenya project to streamline training mechanism. The respondents were selected training institutions, regulatory bodies and professional associations. Gaps identified in the survey include inadequate mechanism to coordinate training data, weak linkages between training institutions, Ministries of Health and Regulatory bodies. The survey shows that there are opportunities for the training institutions to expand their admission capacity through improvement of infrastructure, adapting delivery of courses through innovations and diversification of funding resources. Existing gaps in Continuous Professional Development (CPD) can be addressed by strengthening policy and guidelines. There is also need to improve mentorship program, through strengthening clinical placement and skills development of the preceptors. Establishing a mechanism in regulatory bodies to evaluate accreditation is critical, development of training regulatory framework and development of a CPD database linked to training institutions, regulatory bodies and Ministries of Health (MOH). Findings Finding of this survey show that about 57% of the training institutions do not have a mechanism to forecast training needs and only 21% indicated they had a follow-up committee for updating the forecast. Although majority of training institutions (71%) run in-service training courses, less than half (43%) of them had in-service database of staff who had undertaken training. In addition, half of the training institutions have documentation for CPD/CME (Continuous Medical education), with only 21% having their database linked to MOH and regulatory bodies. The results also show that majority of the students accessing training were either fully self or self/partly public funded, a negative implication for access to health training for students from poor and marginalized areas who cannot afford the high fee charged for training but also training institutions could capitalize on this opportunity by increasing admission capacity for paying students. In relation to CPD/CME, only 29% of institutions indicated they run regularized courses for in-service (CPD/CME) and half of them do not have a training calendar. The findings show that traditional face-to-face remains as the most used method of training delivery with distance learning being more preferred alternative method than mobile learning. Lastly, that most training institutions lack Information Technology (IT) infrastructure and faculty lack skills to convert curriculum content for new training delivery approaches. About 67% of the regulatory bodies indicated that they did not have a mechanism to regularize accreditation. In addition, half of the regulatory bodies do not have written guidelines for curriculum review.


Conclusion The Government of Kenya is persuaded that the identified gaps in this survey are critical to the health sector and need to be addressed in order to achieve national health targets, Millennium Development Goals and Vision 2030. With the support of our development partners, the Government of Kenya is confident that strategies to seal these gaps are in place and should be properly implemented to enable us move towards achieving our overall objective to improve access and equity of essential health care services.


David Njoroge, Ms. Grace Odwako Assistant Director Director, Human Resource Development- MOPHS Human Resource Development-MOMS

INTRODUCTION

Training is one of the key inputs into the performance of health workers and delivery of health services in any country. A Performance Needs Assessment (PNA) of the Kenya national health training systems that which was conducted in 2010/2011 revealed several areas of concerns and opportunities to include:

• Linkages between stakeholders in the system are weak, which affects system efficiencies as well as the quality of training and service delivery.

• Resources currently provided to support health care and health care training systems are insufficient, especially in the areas of staff, health care facilities, supplies and ICT. This affects both the quantity and quality of health care provision and health care training.

• Curricula for health care training, while strong in many aspects, are not optimized and are not necessarily structured or standardized to deliver on national priorities.

• Clinical placements need to be strengthened in order to provide more practical and relevant experience for students.

• Faculty and clinical preceptors need more support in terms of supervision and training in order to perform their roles more effectively.

• Gender inequalities exist in the health training system. This has been observed to impact on system effectiveness and need to be addressed.

The PNA recommended the establishment of a national health training policy and advisory board to create a mechanism to coordinate the health care training mechanism in order to strengthen linkages, increase standardization and efficiency as well as other interventions designed to close performance gaps in the health training system.

In view of the foregoing, the Government of Kenya in collaboration with the United States Agency for International Development (USAID) came up with a strategy to address these key issues. This bore a USAID funded project FUNZOKenya, a 5-yr (2012-2017) initiative designed to improve health training in Kenya. FUNZOKenya is working closely with Kenya’s Ministries of Health, USG-funded health programs, leading health training institutions in Kenya, the National Health HRD Working Group, and at least eight regional training hubs to strengthen training capacity, address the quality and accessibility of training for current health workers, and support training facilities and regulatory bodies.

PURPOSE OF THE ASSESSMENT The purpose of this assessment was to establish baseline data and information against which the effect of Ministries of health interventions could be assessed, specifically identifying:

• The current state of forecasting for health workers • The current state in addressing health workers training demands • The capacity of training institutions to offer continuous professional development (CPD)

training • Existing models and gaps in models used to assess and update training needs in the

training institutions


• Existing infrastructure for adopting new methodologies to train health workers for CPD and accreditation

• The capacity existing in the regulatory bodies to coordinate and regulate licensure and accreditation of training institutions and CPD.

METHODOLOGY

This rapid assessment was a cross sectional descriptive survey using quantitative and qualitative methods. Assessment questions Assessment questions identified included: • What is the current capacity of the health worker training system to admit, graduate, and

train pre-service and in-service health workers? • What is the current state of institutional resources available for training pre-service and in-

service health workers in Kenya? • To what extent do regulatory bodies meet their mandates to:

o Coordinate licensure and accreditation of training institutions and CPD? o Assess performance gaps and determine needs for continuing professional development

for health workers? o Enforce current standards for re licensure of health workers? o Assess current status of data generation and sharing as it relates to training information?

Assessment design and overview by result area IR 1: Supporting increased number of new health workers The assessment sought to understand training institutions’ capacity to train more new health workers, especially in specialty areas; the availability and adequacy of clinical placement sites; methods used to forecast the number of new trainees to meet established forecasting targets; plans to increase number of health workers by cadre; and existing opportunities for health workers to access financial support for their training. Data was also collected on the number of trained faculty, including their qualifications, computer skills, and e-learning skills; existing faculty/student ratios and requirements for extra space should institutions wish to expand classroom space for new students or include new technology (computers); and respondent recommendations for areas of the curriculum content to review and update. The assessment was also designed to help document existing local and international linkages with other training institutions and benefits accrued from those linkages. IR 2: Training Needs Assessment In conjunction with the Training Needs Assessment (TNA) that the Ministries of health in collaboration with FUNZOKenya conducted in the summer 2012, this assessment sought information from faculty and health service providers of different professions and cadres (public health officers, clinical officers, nurses, pharmacists, lab technicians) on: existing provision of in-service training, database processes used to track in-service training for health workers in the


institution, levels of staff retention; existing opportunities for professional development, felt needs for update training, existing staff members’ computer skills, processes used to validate health professional skills, challenges faced when seeking in-service training, opportunities and felt knowledge gaps that hinder provision of quality health care services. The assessment also reviewed existing mentorship methods used in the training institution and challenges existing in the mentorship process. IR 3: Strengthening the capacity of training institutions In relation to capacity of the institutions, the baseline assessment sought information to document opportunities for integrating e-Learning, m-Learning, d-Learning and offering evening/weekend classes for both pre-service and in-service training as well as to understand opportunities for health workforce and faculty to use self-learning via Internet and mobile phones. Questions were also asked about current curricula used and their adequacy to meet expected quality of services and national health priorities, challenges experienced, opportunities for curriculum reviews and content areas recommended for improvement for each cadre as well as opportunities for innovations in delivery of training outside the current traditional approaches, and necessary infrastructure/technology needed to successfully implement the new approaches. Finally, the assessment also sought to documented tools used to track performance of learners as well as existing mentorship methods used in the training institution and challenges and recommendations for improved mentorship and preceptorship in clinical instruction. An inventory of available clinical placement sites and existing staff skills of faculty in relation to adult learning methodologies within the regional catchment areas would be documented. IR 4: Strengthening regulatory bodies to enhance training demand Under strengthening of regulatory bodies to enhance training, the assessment focused on training standards, practice standards, functional databases, registration and licensing and effective management systems. This was in order to improve their abilities to optimize training and practice regulation. Assessment sites The study was carried out in a select number of training institutions throughout Kenya. Public, Faith Based Organizations (FBOs) and private institutions accredited to train health workers were included in the sample. Regulatory and professional bodies were also assessed. Table 1 below shows the distribution of institutions by regions.


Table 1: Target Survey Respondents by Region

Nairobi Central South Rift North Rift Western Coast NEP Total Public 2 2 1 2 2 2 1 12 Private 1 1 2 FBO 1 1 2 Regulatory Body 6 6 Professional Association 6 6 Total 14 2 1 3 4 2 2 28

Target population and assessment sample The survey used a purposive convenience sample of training institutions and regulatory bodies. The target group of training institutions identified included institutions with a national focus, institutions in marginalized areas, public, private and FBOs and training regulatory bodies (see APPENDIX A: List of Participating Institutions). The survey planned to interview representatives from 15 health training institutions (including nine tertiary institutions, three mid-level institutions from marginalized areas, Kenya Medical training Institute (KMTC) headquarter, one private institutions and two mid-level FBOs), 6 regulatory bodies and 6 health professional associations participated. Professional associations conduct in-service training/CMEs and therefore an important group to participate. Respondents from each institution included training faculty, clinical instructors/preceptors and secretaries or Chairmen of regulatory bodies and professional associations.

Table 2: Target Survey Respondents

Respondent category Faculty Preceptors Total KMTC Headquarter 1 1 2 MTC in marginalized areas 3 3 6 FBOs 2 2 4 Private midlevel training institution 1 1 2 Tertiary 9 9 18 Regulatory bodies 6 (Chairman/Secretary) 6 Professional associations 6 (Chairman/Secretary) 6 Total 28 16 44

Data collection methods Data collection methods employed to generate information were key informant interviews (KII) of stakeholders, self-assessment questionnaires (see APPENDIX B: Introduction and Consent) and use of secondary data. Documents reviewed were identified purposively to generate maximum data and information needs. Specifically, the project used information from the Report on the Performance Needs Assessment of the Kenya Health Training System1 and the Rapid Training Needs Assessment Report2 to generate tools and identify issues for probing during KIIs. Data was collected from targeted public, private and faith-based organization (FBOs) training institutions together with regulatory bodies and professional associations.

1 Kenya Ministry of Health (MOH) and IntraHealth International, 2011. Report of the Performance Needs Assessment of the Kenya Health Training System. Nairobi, Kenya: MOH. 2 FUNZOKenya Project Report, October 2011.


Data collection Qualitative and quantitative data collection was carried out from July 16th – July 27th 2012. Open ended questions generated qualitative data.Ten surveyors collected data under the supervision of the M&E Team lead. Training was conducted for the surveyors before data collection, where the tool was discussed to clarify any issues regarding the question. The questionnaire was further reviewed by the M&E team to include all the comments during training and pre-testing and forwarded to Chapel Hill for final approval. Surveyors were divided into five teams to cover Nairobi, Mombasa region and NEP and Western region and Rift Valley. A supervisor was selected to lead each assessment team. Data quality assurance Pre-testing was conducted by the research team members who were also involved in development of the questionnaire and understood the data collection goals in all the result areas. Each questionnaire was given a reference number to avoid double entries and to enhance accuracy. During data collection, each questionnaire was systematically checked by the supervisor, to ensure data was correctly recorded and that the information received was plausible. Where necessary, the supervisor discussed with the surveyor to clarify information on individual questionnaires. All supervisors regularly reported on data collection progress (number and type of targets reached compared to the plan and type of questionnaires collected, major events and constraints). After completion of data collection, the survey principal team leader checked whether the questionnaires were correctly filled out. Where data was missing or not accurate, a repeat of data collection from the particular respondent either face-to-face, e-mail or by telephone was carried out. After the principal team leader was satisfied with data quality, questionnaires were handed over to the M&E officer for data entry and analysis. Data entry and analysis was conducted using SPSS. SPSS screens were developed with the principal team leader rechecking coding of all variables. To ensure data quality, the M&E team proceeded as follows:

• Each questionnaire was adapted as case in SPSS format. • Entry of all data, by questionnaire, was done by maintaining quality check criteria on

labelling and coding. After the initial entry was completed, the M&E team lead checked data quality by entering over 13% of the same questionnaires data to check for errors and ensure accuracy.

• After analysis, results were checked for coding errors, completeness and uniformity. Data Analysis Quantitative analysis involved creation of dummy tables. Dummy tables indicated how information would be analysed and presented during report writing. The dummy tables had columns with variables while the rows contained results by their percentages and total number of cases. Descriptive statistical analysis was used to compute frequencies, recoding of variables and running of cross tabulations. Basic descriptive statistics on frequencies were computed to assess the quality of data and to assist with recoding of categorical variables or grouping variables. Frequencies were used to identify missing cases or few cases. After running


frequencies and recoding, cross tabulation was carried out. Cross tabulation was used to compare for example, variables/responses on number of students graduating by region and cadre. Cross tabulation would therefore help to identify and assess disparities in training needs and capacities to conduct training across the regional hubs. Data output was organized according to each question and by each category of respondents. This facilitated the M& E Team to write the survey report. During the process of writing the report, further analysis was carried out as needed. Tables, graphs and pie charts were used to present results. Qualitative analysis was undertaken by coding open ended questions with common themes or issues grouped together for analysis quantitatively. Responses with suggested recommendations were also analyzed and presented in the report. Survey Limitations Sample Size This was a rapid assessment that used a purposive sample of 15 health training institutions, 6 regulatory bodies and 6 professional associations. This is not a representative sample for the entire training system; hence the conclusions may not be generalized for the entire system. However the study identified gaps that can be used by the project as baseline indicators. No Response Participants were asked to provide information on a voluntary basis. As a result, responses to some questions on some questionnaires were left blank and some questionnaires were not returned at all. The effect of this was to reduce the size of the sample. Unavailability of data Some data was unavailable from respondents especially with questions that requested data for cadre disaggregated into sex and regions. Ethical considerations and human subject protection The survey was approved by the Ministry of Health (MOH) under whose mandate the program is anchored. The survey was also approved by IntraHealth Ethical committee. Written consent was obtained from all respondents before conducting interviews. The consent form described the respondent rights and confidentiality of the information given. During the preparation of the survey, M&E Team and staff who were supervising for data collection undertook online human subjects and protection training. Privacy for research participants Respondents who participated in the survey were assured that data collected from their institutions will be private without access to unauthorized people. Confidentiality The respondents were explained about the survey and how the results would be used and about their rights to give information or refuse. The respondents were assured that their names would not be used in the report and all responses will be aggregated in one report.


Compensation Respondents were to give information voluntarily and no nature of compensation was provided as inducement to respond.

RESULTS

Demographic information about study sample A total of 35 questionnaires out of 44 in the sample size were received which included 14 from faculties (11 public, two private and one FBO), 13 from preceptors (10 public, one private and two FBOs), eight regulatory/professional bodies (6 regulatory and two professional associations). There were fewer respondents because in some areas like Western and NEP regions some institutions were sharing the same placement clinical preceptors while there were some regulatory bodies that have same role of professional body.

Figure 1 - Respondents by Ownership of Institution

11

21

14

10

12

13

6

2

0

2

4

6

8

10

12

14

16

Public Private FBO Total

Faculty Preceptors Regulatory bodies Professional associations

The results below are organized by objectives of the study.

Intermediate Result 1 The survey collected data from training institutions on their capacity to train more new health workers, mechanisms or guidelines to forecast training needs and establishment of targets, access to training by students and barriers that hinder increased admission capacity for the training institutions. Forecasting training needs The survey results showed that eight out of 14 (57%) training institutions had no mechanism or guideline to forecast training needs compared to 6 (43%) institutions with a mechanism. This


data is supported by other on- going health workforce forecasting which indicates that that health worker forecasting models have gaps that need to be addressed in Kenya. On updating of forecasting training needs, five institutions with a mechanism responded to this question and three of them updated their forecast within one to two years while two had a forecast after more than two years. On existence of a committee or a mechanism to follow-up or update forecasting training needs in the institutions, three out of 14 institutions have such a committee or mechanism, 4 had no such a mechanism while the remaining seven institutions did not respond. Creating an enabling environment for training fees access Funding of student fees Figure 2 below shows that training institutions utilized several options to fund student fees. Through a multiple response question, majority of the institutions have students that pay for pre-service training through fully self/family support and partly self & partly public.

Figure 2 - Funding Sources for Student Fees at Surveyed Institutions

56

8

10

12

Partly Self & Partly Privately

Fully Private Fully Public Partly Self & Partly Public

Fully Self/Family

0

2

4

6

8

10

12

14

Average total annual fees for in-service training The average annual fee for in-service course is in the range of Ksh 100,000 to Ksh 200,000. It should be noted that the high in-service cost in universities is when health workers are upgrading into degree courses. Other data collected by the project through a desk review of training institutions has also established that the average annual cost to disburse for pre-service students is as follows: Public = 101; 148; FBO = 154,271; Private = 130,588. These costs are inclusive of the Ksh 30,000 to cover costs such as book allowance, personal effects and transport. Increasing capacity of training institutions Data collected from 14 institutions (11 public, two private and one FBO) show that in the last academic year, there were 8,561 health workers who enrolled in surveyed institutions and 5,597 health workers who graduated in the same period. Figure 3 below presents a comparison of


total students enrolled and those graduating by cadre. As shown below, surveyed institutions are enrolling more nurses than any other cadre, followed by laboratory technologists/technicians and clinical officers. The highest number of health workers who graduated from pre-service training in the last academic year was in the nurse cadre, followed by clinical officers, public health officers (PHOs), and nutritionists. Results also indicate that all the institutions surveyed except two train nurses, six institutions train nutritionists, and four institutions train clinical officers. There are considerably more nurses, laboratory technologists, medical records officers, PHOs, pharmacists, and medical doctors enrolling than graduating. This suggests that either the capacity to train in these cadres has recently increased or the attrition rates among these cadres while in pre-service training are high.

Figure 3 - Comparison of Pre-service Enrollment and Graduation by Number of Health Workers and Cadre

15239

511 586 608933

1232 1278

3159

0 108 244 252 535 252

1322

405

2188

0

500

1000

1500

2000

2500

3000

3500

Entered pre‐service education in last year Graduated pre‐service education in last year

Public training institutions remain the key trainers of health workers in all cadres. Table 3 below shows that common courses offered by private institutions and FBOs include Nursing, Clinical Officers, Public Health Officers and Nutritionists.


Table 3: Numbers of Health Workers Graduating by Type of Institution

Number of Health Worker

Medical

doctors

Dentists

Lab tech.

Nurses

Clinical officers

Pharmacists

PHO

s

Nutritionists

Medical

records Off.

Total

Public 108 405 2,157 1,295 244 395 519 252 5,375 Private 31 148 16 195 FBO 27 27 Total 108 405 2,188 1,322 244 543 534 252 5,596

Number of health workers graduating by region The survey sought information on the number of health workers who graduated distributed by regions. Only two institutions responded to this question, an indication that there are gaps in student management information system in training institutions. One private institution had had all the graduates from the same region while the other FBO institution had 22 out of 27 (81%) graduates from the same region, as the institution. Number of student allowed to enrol by regulatory bodies Figure 4 below shows a comparison between the numbers of health workers enrolled in the pre-service training institutions surveyed and the number of students that the institutions are allowed to enroll per the regulatory bodies associated with each cadre. Results indicate that, with the exception of clinical officers, training institutions are enrolling more new students than they are technically allowed to enroll by regulatory bodies. One institution did not respond to this question. This data, when combined with comparison data on enrollment vs. graduation, suggests that training institutions may be increasing their capacity to train new health workers faster than regulatory bodies are expanding enrollment restrictions. This is a potential area of intervention for the Ministry through the FUNZOKenya project.


Figure 4 - Actual Enrollment Comppared to Thatt Allowed by Regulatory Bodies

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Barriers to increasing training capacity Training institutions were also asked to identify barriers to increasing training capacity. As shown in figure 6 below, expert teaching faculty and accommodation are the most common current barriers to increased training capacity in the institutions surveyed followed by content development and clinical instruction.

Figure 6 - Barriers to increasing training capacity

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Intermediate Result 2 The survey collected data from the training institutions on existing provision of in-service training, coordination of training in the regions, database processes used to track in-service training for health workers in the institution and linkages to MOH and regulatory bodies. Facilitating training In-service training for health workers The results show that the majority of training institutions (10 out of the 14, 71%: 9 Public and 1 Private) conduct in-service training courses while the rest (29%) do not have such courses. In addition, on existence of in-service database 12 institutions responded, with 6 (43%) institutions indicated they have database of health workers who have undertaken in-service training, 6 (43%) institutions had no database while two (14%) institutions did not respond. Further, for the training institutions that have in-service training database undertaken by health workers, five institutions had updated the database within less than one year while one institution had their database updated between one to two years. For the 6 institutions with in-service database, five institutions had a linked database while remaining one institution was not linked. Two institutions were linked to professional association, two institutions linked to Nairobi KMTC, one institution linked to MOH while another one was linked to regulatory body. Coordination of in-service training at surveyed institutions The assessment showed that in three training institutions in Nairobi, North Eastern province (NEP) and Coast regions, there is a committee that coordinates in-service training while the rest


of the institutions in Central, South Rift, Western and North Rift regions have no such committee. The committee coordinates training on part time basis in the region giving guidance to students and liaises with KMTC for information. Tracking training through training database and data linkages Training institutions were asked to rate how well they tracked training through databases. The results as indicated in figure 7 below show that only one out of 14 (7%) institutions rated their performance on training database and data linkages by institution as excellent, five out of 14 (36%) institutions rated good performance, two out of 14 (14%) institutions rated fair, four out of 14 (29%) institutions rated poor while the remaining 2, (15%) institutions did not respond to the question.

Figure 7 – Training Institutions’ Performance on Tracking Training through Databases

Excellent7%

Good36%

Fair14%

Poor29%

No Response14%

Recommendations for linking database to MOH and Regulatory bodies As indicated in figure 8 below, areas recommended by training institutions for improving linkages with MOH and regulatory bodies were holding stakeholders meetings, developing linkages, establishing training institutions as CPD/CME providers and having a standardized database in training institutions with harmonized curriculum.


Figure 8 - Trraining Instittutions' Sugggestions for IImproving Stakeholder LLinkages

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CPD/CME policy, guidelines and calendar Results show that six out of 14 (43%) institutions had a policy for practice guidelines on registration/accreditation that is linked to in-service training/CME/CPD compared to eight out of 14 (57%) institutions without such a policy. In addition six out of 14 (43%) of the training institutions rated their level of compliance on accreditation regulations as satisfactory, one (7%) institution rated their level of compliance as unsatisfactory, while the remaining seven (50%) of the institutions did not respond to the question. As shown in figure 9 below regarding the training/teaching calendar for CPD/CME, 9 out of 14 (64%) institutions do not have a calendar for CPD/CME, two out of 14 (14%) have a calendar while the remaining three out of 14 (22%) institutions did not respond to the question.

Figure 9 - Existence of CPD/CME calendar

Yes14%

No64%

None Response22%

The results further show that the two institutions with such calendar for CPD/CME had a good compliance to CPD. On existence of guidelines for CPD/CME four out 14 (29%) institutions indicated existence of guidelines for CPD/CME while the rest (71%) of the institutions did not respond to the question. Documentation of in-service training, CPD/CME The results from the survey show that half (7 out of 14) institutions have a documented in-service training CPD/CME compared to the rest of the institutions who do not have documentation or did not respond to the question. In addition for the seven training institutions with a documented in-service CPD/CME training, all had a regularized/systematic process except one institution. Furthermore, for the seven training institutions with a documented in-service CME/CPD training three had their in-service CPD/CME linked to MOH/regulatory bodies while the rest of the institutions had not linked their database.


Business management tool Regarding business management tool, results show that seven out of 14 (50%) of institutions had tools while the rest of the institutions did not have such tools. In addition 8 out of 14 (57%) institutions indicated the need for additional management tools, one out of 14 (7%) of institutions did not need additional tool while the remaining five out of 14 (43%) institutions did not respond to the question. Funds for in-service CPD/CME training The survey on funds for in-service CPD/CME training showed that 6 out of 14 (43%) institutions received their support through donor support while 3 out of 14 (21%) indicated government as another source. In addition, ten out 14 (71%) of the training institutions indicated that there are opportunities to raise alternative funding for in-service CME/CPD compared to 29% of the institutions without alternative funding. Further, training institutions indicated donors and fees as other alternative funding for in-service/CME/CPD. 6 institutions responded to the question about making profit after raising resources for in-service/CPD/CME with 2 institutions indicating they make profit while the remaining four did not make profit. One institution indicated that they use the profits to improve training resources/materials/supplies. Existing models and their gaps used to assess and update training needs in the training institutions Learning approaches and CPD/CME Calendar Most institutions indicated they use classroom/face-to-face as learning approaches to deliver courses, two used e-learning while three used distance learning approach. The results show that seven out of 14 (50%) institutions had appropriate rate for the acceptance on e-learning, two out of 14 (14%) institutions had fairly appropriate rate on e-learning while the rest (36%) institutions did not respond to the question. For mobile learning, four out of 14 (29%) institutions had appropriate rate for acceptance, three out of 14 (21%) institutions had fairly appropriate rate, and two out of 14 (14%) institutions indicated it was unacceptable while the rest of the institutions did not respond to the question. For distance learning, eight out of 14 (57%) institutions had appropriate rate for acceptance, 1 (7%) institution had fairly appropriate rate for acceptance while the rest of the institutions did not respond to the question. This is illustrated in table 4 M-learning appears to be the learning approach which received the lowest rating among the three approaches. Acceptance of learning approaches for CPD/CME Training institutions were asked to rate e-learning, m-learning, and distance learning approaches as being appropriate for learners, fairly appropriate, or unacceptable for learners. Table 4 shows responses.


Table 4: Perceived rates for acceptance of e-learning, mobile and distance learning

Appropriate Fairly appropriate Unacceptable No Response Total e-Learning 7 2 5 14 M-learning 4 3 2 5 14 D-learning 8 1 5 14

Evaluating performance Training institutions were asked to evaluate their performance by addressing health training demands to increasing training capacity. Barriers to meeting and increasing training demand Training institutions were asked through a multiple response question to identify barriers to meet training demand. As Figure 10 below shows the multiple responses, lack of expert teaching faculty and sufficient equipment and materials were most frequently mentioned as barriers.

Figure 10 –Barriers to meeting current demand

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Intermediate Result 3

The baseline survey collected data from the training institutions on joint technical/curriculum meetings, capacity of clinical mentorship, sharing of clinical experiences and their capacity to deliver training through innovative approaches. Developing content and courses to support curricula The results show that 6 out of 14 (43%) institutions have a training needs assessment tool to guide curriculum reviews as compared to eight out of 14 (57%) institutions without such a tool. Joint technical/curriculum meetings


The results show that 9 out of 14 (64%) training institutions hold joint technical/curriculum meetings between classroom, teachers and clinical placement site instructors to support quality instruction, compared to 36% who do not have such meetings. Table five shows that 3 out of 14 (21%) institutions without joint curriculum meetings were universities.

Table 5: Existence of joint meetings by type of training institutions

Existence of joint meetings YES NO Total

Universities 4 3 7 Middle Level 3 1 4 Private 2 2 FBO 1 1 Total 9 5 14

Of the training institutions that have joint meetings, 36% meet on quarterly basis, 21% meet bi-annually, Forty-three percent of training institutions were not sure or did not respond on this question. Improving the capacity of faculty and clinical mentorship Training institutions were surveyed regarding a regularized system of mentorship program for preceptors/mentors, how they rated their mentorship program, recommended areas that need strengthening and if preceptors/mentors have undergone induction training. The survey also requested information on how regular the mentors spend time on self-directed learning, opportunities to pool mentorship program with other training institutions and recommended areas to pool mentorship. Induction training for preceptors/mentors The results in figure 11 show that preceptors/mentors in six out of 14 (43%) training institutions surveyed had undergone induction training to prepare them for a preceptor/mentor role, while four out of 14 (28.5%) institutions had not conducted training for their preceptors/mentors. The remaining four (28.5%) institutions did not respond to the question.


Figure 11 - Preceptors/mentors completed induction training

Yes43%

No28.5%

None Response28.5%

Sharing of clinical experiences The results show that nine out 14 (64%) training institutions had mechanism for regular sharing of clinical experiences; four out of 14 (29%) institution had no such mechanism while one (7%) institution did not respond to the question. Further results show that of the training institutions with a sharing mechanism, six institutions rated their mechanism as good while three institutions rated their mechanism as poor. On the channels used for sharing knowledge, as shown in figure 12 below, most common channels used in the training institutions are meetings, presentations at clinical areas and exchange visits.


Figure 12 - CChannels useed for sharingg clinical knoowledge

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Pooling mentorship programs and resources Results show that 11 out of 14 (79%) institutions had opportunities to collaborate on mentorship programs with other training institutions while one institution had no opportunities and two did not respond to the question. As shown in figure 14 below, most training institutions suggested teaching and learning and clinical areas as areas of opportunity for collaboration.

Figure 14 - Recommended Areas to Pool Mentorship Programs with Other Training Institutions

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Framework for assessing preceptor/clinical instructors Results indicate that 8 out of 14 (57%) institutions have a framework/policy for assessing knowledge, skills and competencies of faculty and preceptor/clinical instructors while the rest (43%) institutions do not have such a framework. On other preceptor tools in the institution, three institutions indicated they have checklist and written exams, two institutions use staff appraisals while one institution uses logbooks & checklist. For the training institutions with a


framework policy, seven indicated to have a policy implementation committee while 1 institution did not have. Capacity to deliver training through innovative approaches The results indicate that in 10 out of 14 (71%) institutions faculty and mentors have competencies to deliver training using the innovative training approaches as compared to 29% institutions without competencies. Regarding access to resources, figure 15 shows that physical library and anatomical models are the most available support for mentorship. Further the survey established that only two out of 14 (14%) institutions had an excellent rate of access to resources, nine out of 14 (64%) institutions had a fair rate of access while 22% institutions did not respond to the question.

Figure 15- Resource Support Available for Mentorship by Number of Training Institutions

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As shown in figure 16, 8 out of 14 (57%) of the respondents indicated that their institutions had a fair capacity of competency for the mentors to convert current curriculum to distant learning, e-learning and mobile phone learning, five out of 14 (36%) of the institutions had no competencies while 1 out 14 (7%) institutions had good competency.


Figure 16 – Capacity of competency for the mentors to Convert Curricula to Distance, e-Learning and m-Learning Formats

Good Competency

7%

Fair Competency57%

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Upgrading training facility management systems and infrastructure The survey collected data on opportunities for innovations in delivery of training outside, the current traditional approaches and necessary infrastructure/technology needed to successfully implement the new approaches. Clinical placement sites The training institutions were asked to indicate the number of clinical placement sites they used for their trainees across the regions in the country. Most training institutions who respondent to the question indicated a fair distribution of sites by regions as indicated in figure 17. Coast region had the highest, 25 clinical placement sites while NEP region had 8, as the lowest number of sites.

Figure 17 - Number of Clinical Placement Sites by Region

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Existing infrastructure for adopting new technologies to train health workers for CPD and accreditation As shown in figure 18 most training institutions mentioned IT infrastructure and students & lecturers computer skills as the capacity gaps for alternative approaches in delivery of training.

Figure 18 - Capacity Gaps for Implementing Alternative Training Approaches by Number of Training Institutions

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Intermediate Result 4

Strengthening performance gaps identification The survey collected data from the regulatory bodies and professional association on existence of coordination mechanism for CME/CPD accreditation, existence guidelines for curriculum development, existence of training standards and linkages with the training institutions and Ministry of Health. Strengthening regulation of curriculum review, development and implementation Guidelines for curriculum development and implementation On guidelines for curriculum development, implementation and review, results show that 6 out of 8 regulatory/professional bodies had guidelines for curriculum development, while the rest did not. In addition 4 out of 8 bodies had written guidelines for curriculum review while the rest did not have. The results also showed that three out of eight regulator/professional bodies reviewed their curriculum within three to five years while the remaining five did not respond to the question or not sure when review was conducted. It was also observed that 6 out of eight regulatory/professional bodies had application of guidelines to accreditation and licensure while the rest did not have.


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Excellent37.5%

Fair37.5%

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Lessons learned from training accreditation programs Lessons learnt and challenges derived from the training accreditation program by regulatory/professional bodies include awarding CPD points manually leading to delays of updating health workers database and knowledge sharing among regulatory & professional bodies and stakeholders. Supporting a database system to capture training and regulatory information Regulatory bodies were asked if they had a system in place to document in-service training, CPD/CME. They were also asked to disclose whether or not any database they had for tracking training was linked to the MOH and/or other regulatory bodies. The results from the survey show that half of the training institutions, (50%) have a documented in-service training CPD/CME compared to the rest of the institutions who do not have documentation or did not respond to the question. Further, for the 7 training institutions with a documented in-service CPD/CME training, all had a regularized/systematic process except one institution. The results also showed that only 3 out 14 (21%) institutions had their in-service CPD/CME database linked to MOH/regulatory bodies. Supporting standardization and quality assurance of training and health worker performance The survey collected data from the regulatory bodies and professional associations on existence of regulatory framework or standards and how often the framework/standards are updated. A previous PNA report conducted through Capacity project indicates that one of the emerging issues on standardization is harmonization of curriculum across training institutions. Training regulatory framework Regarding training regulatory framework or standard, results show that five out of eight regulatory/professional bodies had a training regulatory framework while the rest of the bodies


did not have such a framework. Furthermore, the five regulatory/professional bodies with a training framework, three bodies updated the framework regularly, one body rarely updated the framework while the other body was not sure when the framework was updated.

Discussion The survey has provided information on current capacity of the health worker training system to admit, graduate and train pre-service and in-service health workers, status of data generation and sharing as it relates to training information, state of institutional resources available for training pre-service and in-service health workers, coordination licensure and accreditation of training institutions and CPD. Current state of forecasting for new health workers The results of the baseline survey show major gaps in data base and linkages to regulatory bodies and MOH. About 57% of the training institutions did not have a mechanism to forecast training needs and only 21% indicated they had a follow-up committee for updating the forecast. This result has implications on the management of resources required for training health workers including required faculty, preceptors, placement sites, supplies and other utilities. Although majority of training institutions (71%) run in-service training courses, less than half (43%) of them had in-service database of staff who had undertaken training. In addition, half of the training institutions have documentation for CPD/CME, with only 21% having their database linked to MOH and regulatory bodies. Lack of a database can contribute to none recognition or missed opportunity for promotion of health workers which can affect their service delivery. Less than half (43%) of the training institutions indicated that their rate of performance on training database and data linkages was excellent and therefore acceptable. The results imply that majority of training institutions have inadequate capacity to manage training data on health workforce. This finding raises important issues related to forecasting and decision making when institutions do not provide accurate information on the trained health workers. It is therefore important to establish a mechanism to coordinate training data and to build capacity of institutions to link data with the regulatory bodies and MOH for purposes of having an updated database to guide decision making on the national health worker needs. Current state in addressing health workers training demands The results show that majority of the students accessing training were either fully self or self/partly public funded. The annual cost for in-service was in the range of Ksh 100,000 to Ksh 200,000 with those upgrading to degree courses paying even higher. This finding has negative implications for access to health training for students from poor and marginalized areas who cannot afford the high fee charged for training. On the other hand, the finding provides an indication that there are students willing to pay and therefore training institutions could capitalize on this opportunity by increasing admission capacity for paying student. In addition,


financial intuitions could use this indication to develop products that attract loans for paying student and faculty. The results also show that only three regions out of seven existing regional hubs in the project indicated having a committee that coordinates in-service training in the regions. This finding brings to focus the need for organized in-service training to increase access to training that is performance based for the regions and therefore enhancing identification of regions requiring support. Accommodation was found to be a critical bottleneck affecting capacity of training institutions to address demand. There is therefore a need to explore strategies to address trainee accommodation for example, through admitting more day scholars. However, there were institutions found to admit more students than what the regulatory bodies allow. This occurrence of admitting students could have negative implication of compromising quality of training. However, it could be an opportunity for expansion of the training institutions to admit more students. Supporting institutions with skills to forecast the student load could enhance the same institutions to identify resources for the expanded capacity. Capacity of training institutions to offer continuous professional development (CPD) training The results show that only 29% of institutions indicated they run regularized courses for in-service (CPD/CME) and half of them do not have a training calendar. Further, half of the training institutions indicated the possibility of offering core cutting courses across cadres. In addition, majority (57%) of the training institutions did not have a CPD/CME policy and guidelines. This finding has implication on the capacity of training institution to plan, coordinate and attract health workers to improve their skills. The respondents indicated that donors and government are the main sources of funds for CPD/CME training although training institutions also indicated that they have opportunities to raise alternative funding. Depending on donors and government alone for in-service training brings up issues for sustaining the program hence the need for supporting capacity of training institutions to diversify funding sources through use of market oriented management tools. Existing models and gaps in models used to assess and update training needs in the training institutions The findings show that traditional face-to-face remains as the most used method of training delivery. The results also show that distance learning was the most preferred alternative method and mobile learning was the least preferred. In addition, only 1 institution indicated that their mentors have good competency to convert current curriculum to distant learning, e-learning and mobile phone learning. To increase their admission capacity, training institutions could adapt delivery of courses through innovations in training. This entails upgrading the knowledge and skills of faculty to improve and develop curriculum content. Training institutions still use traditional methods of sharing clinical experiences such as meetings and presentations that need resources such as space and time while adopting methods such as online clinical sharing can be more cost effective. However, alternative methods of training delivery require modern


information technology (IT) infrastructure. Consistent with other studies such as PNA, IT infrastructure, students & lecturers computers skills remain capacity gaps for adopting alternative approaches. Consistent with the PNA report (2011), the survey showed gaps in clinical placement. Half of the training institutions did not have a regularized system for mentorship program for preceptors while less than half (43%) of the institutions had not inducted their preceptors. In addition, 57% of those who responded to the question indicated that they had limited time spent on self-directed learning. Majority (79%) of the institutions recommended opportunities to pool mentorship program with other training institutions such as in teaching & learning, clinical areas and research & documentation. The findings of this survey highlight gaps in clinical placement models and inadequate capacities for providing quality clinical teaching and therefore the need to build capacity of faculty and clinical preceptors. In addition, there is need to strengthen clinical placement sites for health workers’ skills development. Further, there is need to identify and update training needs in the institutions of learning. Results show that 43% of training institutions did not have a framework for assessing skills of preceptors/clinical instructors’ competencies while more than half (57%) of the institutions did not have a training needs assessment tool to guide curriculum reviews, with only two public universities, KMTC related campuses and 1 private college having a training assessment tool. This may be an indication that clinical placement sites that have regularized system mentorship program and trained preceptors are more likely to receive more requests than they can handle thereby over stretching resources in the clinical sites as noted during one of the project monitoring visits in Western Kenya. Existing infrastructure for adopting new methodologies to train health workers for CPD and accreditation The results of the assessment show that most training institutions lack IT infrastructure. Both faculty and trainees lack adequate skills and access to computer services and Internet. Faculty lack skills to convert curriculum content for new training delivery approaches. The findings have implication for adopting new methodologies for delivering training for health workers effectively. There is need therefore to support IT infrastructure and skills for faculty to convert curriculum for adoption of new methodologies. Capacity existing in the regulatory bodies to coordinate and regulate licensure and accreditation of training institutions and CPD. The baseline survey conducted interviews from all six existing regulatory bodies and two professional associations. About 67% of the regulatory bodies indicated that they did not have a mechanism to regularize accreditation. In addition, half of the regulatory bodies do not have written guidelines for curriculum review. This finding has implications on the capacity of the regulatory bodies to guide and monitor activities of the training institutions in the development and review of curriculums as well as monitoring of accredited and accreditation of health training institutions. Inadequate monitoring of training institutions has the potential of having mushrooming of training institutions offering low quality training.


About 67% of the regulatory bodies are not linked to a central database for CPD/CME accreditation. It was also noted that CPD points are awarded manually leading to delays in updating of health workers database. Although CPD/CME is a legal requirement, some regulatory bodies are not aware. This finding has implication on the seriousness of providing CPD/CME when the regulatory body is not aware that it is a legal requirement thereby reducing opportunities for upgrading skills of health workers. About 33% of the regulatory bodies do not have training regulatory framework. A similar % of regulatory bodies reviewed their curriculum within 3-5 years. However, there is no legal interval indicated for the period to review the curriculums. Lack of guidelines on the curriculum review has implications on using outdated content of training health workers with consequences of producing health workers with inadequate skills to address emerging health challenges. There is need therefore, to support the regulatory bodies to develop guidelines for curriculum review.

Conclusion and Recommendations

The survey identified gaps that can be addressed by the Ministries with support from FUNZOKenya project to streamlining national training mechanism through the following recommendations. Current state of forecasting for the health workers

• Establish a mechanism to coordinate training data and to build capacity of institutions to link data with the regulatory bodies and MOH for purposes of having an updated database to guide decision making on the national health workers' needs.

Current state in addressing health workers training demands

• Work with MOH, regulatory bodies and stakeholders to identify cadres of health workers that can be supported by project scholarship and loans

• Establish a loan mechanism to support more students on self/family support and partly self and partly public for pre-service and in-service courses

• Need for organized in-service training to increase access to training that is performance based for the regions and therefore enhance identification of regions requiring support.

• Explore strategies to address trainee accommodation for example, through admitting more day scholars

• Work with regulatory bodies and training institution with expansion opportunities in order to maximize their admission capacity without compromising the quality of training

• Support training institution to increase their admission capacity by adapting delivery of courses through innovations in training by upgrading the knowledge and skills of faculty to improve and develop curriculum content


Capacity of training institutions to offer continuous professional development (CPD) training

• Support institutions with skills to forecast the student load through identification of resources for the expanded capacity by using market oriented management tools

Existing models and gaps in models used to assess and update training needs in the training institutions

• Support training institution to strengthen clinical placement sites for health workers’ skills development

• Work with MOH and training institutions to regularize mentorship program and strengthen selected clinical placement sites

• Support training institutions to develop a framework or policy for assessing knowledge, skills and competencies of faculty & preceptor instructors

• Support training institutions to develop training needs assessment tool to guide curriculum review

• Support training institutions to establish joint meetings on curriculum between classroom, teachers and clinical placement site instructors

• Work with MOH, regulatory bodies, training institutions and other stakeholders to establish a committee in the region that coordinates trainings. Through establishing coordination at the region and County levels, a community of good practice could be expected to emerge and be used to share knowledge, practices, models that are working, synergies in the regions and providing feedback on the training mechanism

• Support training institutions to adopt cost effective sharing of clinical experience such as on-line and tele-conferencing

• Support MOH, regulatory bodies, training institutions to review and adopt existing CPD/CME policy and guidelines as standard policy in training institutions

Existing infrastructure for adopting new methodologies to train health workers for CPD and accreditation

• Support training institution on IT infrastructure and skills for faculty to convert curriculum for adoption of new methodologies

• Support selected training institutions to improve teaching faculty, equipment/materials, content development and infrastructure to increase their capacity and meet training demands which provides an opportunity for the institutions to work with the financial agencies for loans

• Facilitate MOH, regulatory bodies and other stakeholders to establish training institutions as CPD/CME providers and having a standardized database in training institutions with harmonized curriculum

Capacity existing in the regulatory bodies to coordinate and regulate licensure and accreditation of training institutions and CPD.

• Work with MOH, regulatory bodies and other stakeholders to establish a mechanism to evaluate accreditation


• Support regulatory bodies to computerize the process of awarding CPD points in a central database accessible to MOH, regulatory bodies and training institutions

• Support regulatory/professional bodies in developing training regulatory framework



APPENDIX A: List of Participating Institutions Name of Institution Region

1 Maseno University Western 2 Great Lakes University of Kisumu Western 3 Masinde Muliro University of Science & Technology Western 4 St. Mary School of Clinical Medicine - Mumias Western 5 Moi University North Rift 6 Lodwar MTC College North Rift 7 North Eastern Province College of health Science North Eastern 8 Garissa MTC College North Eastern

9 Egerton University South Rift 10 Pwani University Coast 11 Kilifi Medical Training Centre Coast 12 Nairobi Medical Training Centre Nairobi 13 Kenyatta University Central 14 Jomo Kenyatta University of Agriculture Technology Central

Name of Regulatory Body 1 Nursing Council of Kenya Nairobi 2 Clinical Officers Council Nairobi 3 Kenya Medical Practitioners & Dentist Board Nairobi 4 Pharmacy & Poison Board Nairobi

5 Kenya Medical Laboratory Technician and Technologist Board (KMLTTB) Nairobi

6 Kenya Nutritionists and Dietarian Institute (KNDI) Nairobi

Name of Professional Association 1 National Nurses Association of Kenya Nairobi

2 Pharmaceutical Society of Kenya Nairobi

APPENDIX B: Introduction and Consent Hello, my name is ------------------and we are conducting this baseline survey from IntraHealth FUNZOKenya project on behalf of the Ministries of Health (MOH)-MOMS and MOPHS. The goal of the FUNZOKenya project is to improve access to and quality of health workforce training by supporting an increased number of new health workers trained; supporting current health worker training needs; strengthening the capacity of training institutions; and strengthening Regulatory Bodies to enhance training demand. The baseline survey seeks to establish baseline data and information against which the effect of interventions can be assessed. I would like to ask you some questions about your/ institution/department/regulatory body in regard to infrastructure capacity to provide pre-service/ in-service health workforce training/enhancing training demand, documentation and accreditation. The interview will take about 20-25 minutes to complete. Your participation in giving us information is voluntary and there is no penalty for refusing to take part. If you are uncomfortable during the interview you may stop the interview at any time or refuse to answer any questions. The information you provide is confidential, and will not be linked to you directly, and will be collated in a summary report without mention of your identity. Whatever information you provide will be used solely to build capacity of training institutions and to improve access to training opportunities. We will not record any identifying information such as your name, age, and address on the questionnaire form on which your responses are recorded or in publications. We hereby thus request your consent to continue with the interview by signing or putting a mark below. Do you have any questions about the baseline survey?

Consent to participate in the baseline survey I have read/listened and understood the information above describing the procedures, benefits and risks of participating in this baseline survey. I agree to participate as an informant in this survey. _______________ ________________________________________________ Date Signature or Mark of Respondent _______________ ________________________________________________ Date Signature of Person Obtaining Consent


BASELINE SURVEY: FACULTY, REGULATORY BODIES AND PROFESSIONAL ASSOCIATIONS Name of Interviewer___________________________ Date______________________ Name of Institution__________________

Type of Institution_______________________Public_________Private__________

FBO______________________________

Regulatory Body_____________________

Professional Association______________________

(Circle your responses against the number indicated. If a response requires to give a figure, indicate so against the dotted lines)

NB: Insert the responses on the right hand column of the questionnaire

NO

SECTIONS: QUESTIONS AND FILTER

CODING CATEGORIES

SECTION 1: TRAINING INSTITUTIONS (Pre and in-service)

101

a) How many students enrolled for pre-service training in the last academic year? b) How many health workers graduated from pre-service program in the last full academic year?

a) Health workers who entered the training in the last academic year

Medical Officers……………………………...........….….......1 Dentists.................................................................................2 Lab Technologists/technicians..................................3 Nurses...................................................................................4 Clinical Officers..................................................................5 Pharmacists.........................................................................6 Public Health Officers.....................................................7 Nutritionist and related cadre……..…………..……..8 Health records Information officers……….….…..9 b) health workers who graduated in last academic year Medical Officers……………………………..........……....... 1 Dentists................................................................................2 Lab Technologists/technicians..................................3 Nurses...................................................................................4 Clinical Officers..................................................................5 Pharmacists..........................................................................6 Public Health Officers......................................................7


Nutritionist and related cadre…………………..……..8 Health records Information officers….........….…...9

102 Of the total number who graduated, how many were males and how many were females

Males.....................................................................................1 Females............................………………….………...…….…..2

103

Of the number that graduated, how were they distributed by region?

Central Kenya.....................................................................1 Coast......................................................................................2 Eastern..................................................................................3 NEP........................................................................................4 Nyanza..................................................................................5 Rift Valley.............................................................................6 Western................................................................................7 Nairobi.................................................................................8

104

How many students has the regulatory body allowed the institution to take annually by cadre?

Medical Officers………...…………………...........…….......1 Dentists................................................................................2 Lab Technologists.............................................................3 Nurses...................................................................................4 Clinical Officers..................................................................5 Pharmacists.........................................................................6 Public Health Officers.....................................................7 Nutritionist and related cadre………………….….….8 Health records Information officers…….….….…..9

105 According to your assessment, what is the performance (output) against the maximum prescribed capacity?

Below 80 %..……………….............….……….....…........…. 1 80 -89 % …………………………………………………......... 2 90-100 %...........………………………….……………..….......3 Above 100 %……….…………………………….……...…....4

106 a)Does the institution have a mechanism/guideline for forecasting training needs? b) If yes, state frequency of forecasting c) Is there a mechanism for supporting follow-up/ updating of forecasting training needs?

a)Yes………………………………………… …………............. 1 No…………………………………………… ……...…...….........2 b) If yes what is the regularity of forecasting?

State the frequency in years___________________

c) Presence of a mechanism to support follow-ups Yes.................................................................................1 No..................................................................................2

107 In your opinion, what are the current gaps to ensure that the institution meets

Teaching faculty……………………………………...…....1 Equipments/Materials…………………...………....…..2 Management....................................................................3


its training demand? Other (Specify)................................................................96

108 a)Does the institution run ain-service training courses b) If yes, does the institution have a database of in-service training undertaken? c) If the institution has a data base, when was it last updated?

a) Yes..…………….…………………...……................…..........1 No..........................……………...………......……...…........2 a) Yes..…………….…………………...……................…..........1 No...................................................................................2

c) If yes, specify duration since it was updated <1 year ago........................................................................1 1-2 years ago.....................................................................2 >2 years ago......................................................................3

109

a)If a training database exists, is it linked to any other database? b)If your database is linked to any other training data base, can you specify the linkages

a)Data base exists Yes........................................................................................1 No.........................................................................................2 b) Specify the linkages Regulatory body……………………..……..…….......…. 1 Professional Association.....…………….……........... 2 MOH………………………..………………….....………….... 3 Min of Education…………………………….......….…...4 Other training institution Specify ___ ............. 96

110

How is/are students’ fee generated

a) Fully self/Family sponsored................................1 Partly self and partly privately sponsored........................................................................2 Partly self and partly public funded...................3 Fully privately sponsored...........................................4 Fully public funded.......................................................5

111 What is the average total annual fee for in-service training

Specify amount _______________________

112 In your opinion, what are the current bottlenecks to increased training capacity?

Expertise in content development..........................1 Expertise in Teaching faculty.....................................2 Clinical instruction..........................................................3 Accommodation.............................................................4 Other (Specify)................................................................96

113 How many clinical placement sites are available for your health trainees disaggregated by region for the training

State names of placement sites by region Central Kenya....................................................................1 Coast....................................................................................2 Eastern.................................................................................3 NEP.......................................................................................4


institution (State names in each region where institution has placement sites)

Nyanza................................................................................5 Rift Valley...........................................................................6 Western............................................................................7 Nairobi..............................................................................8

114

a) Does your institution have a joint technical/curriculum meetings between classroom, teachers and clinical placement site instructors? b) If your response is yes, how often are the meetings?

a) Existence of joint meetings Yes.....................................................................................1 No......................................................................................2 b) Regularity of meetings Quarterly.........................................................................1 Bi-annually......................................................................2 Annually...........................................................................3 Every 2 years..................................................................4 More than 2 years.......................................................5 Not sure when last held..........................................98

115 Does your institution have a regularized/system of mentorship program for preceptors/clinic instructors/mentors

Yes......................................................................................1 No.......................................................................................2 If yes give summary description

116 a) If you have a mentorship system in your institution, how can you rate its functional strength? b) If fair or poor, in which areas would you recommend strengthening?

a) Strength of mentorship program Very functional................................................................1 Fair/half..............................................................................2 Poorly functional............................................................3 b) If not strong, specify areas that need strengthening Open ended__________________________

117 Have the preceptor/mentors undergone an induction training

Yes.....................................................................................1 No......................................................................................2

118 If you have mentorship system, how regular do the mentors spend time on self-directed learning?

Very regularly, at least daily or most days.......................1 Occasionally/Non in some months.....................................2 Irregular/at least some days in a month..........................3 Very limited/once in a while...................................................4 None at all......................................................................................5


119 a) In your opinion, are there opportunities you have to pool mentorship program with other training institutions? b) If yes, which areas would you recommend? Please explain

a)Mentorship pooling opportunities Yes....................................................................................................1 No....................................................................................................2 b) List of recommended areas to pool mentorship (open ended)

120 a) Does the institution have a framework/policy for assessing knowledge, skills and competencies of faculty& preceptor/clinical instructors/ b) If the answer is yes, are there other preceptor tools the institution uses? c) Is this assessment mechanism supported by a committee?

a) Yes.........................................................................................1 No...............................................................................................2 b) Other preceptor tools (Specify) c) Existence of policy implementation committee Yes............................................................................................1 No.............................................................................................2

121 Does the institution have a training needs assessment tool to guide curriculum review?

Presence of a training assessment tool Yes............................................................................................1 No.............................................................................................2

122 What is the level of competencies for the mentors to convert current curriculum to distant learning, e-learning and mobile phone learning

Good........................................................................................1 Fair............................................................................................2 No competencies................................................................3

123 Does the institution have competences to deliver training using the innovative training approaches mentioned above?

Yes............................................................................................1 No.............................................................................................2

124 a) What resource support is availability for mentorship (Circle all that apply)

a) Resources available Physical library......................................................................1 Electronic database.............................................................2 Journals...................................................................................3 Anatomical models............................................................4 Network for mentors.........................................................5


b) If the resources are available, how can you rate their access?

Other (Specify)...................................................................96 None......................................................................................98 b) Rate of access Excellent.................................................................................1 Fair...........................................................................................2 Poor.........................................................................................3

B: SECTION 2: DATABASE ON TRAINING AND COORDINATION

201

In a scale of four, 1 being excellent, 2 good, 3 fair and 4 poor, how can you rate the performance of training database and data linkages of your institution?

Rate of performance of database Excellent................................................................................1 Good......................................................................................2 Fair..........................................................................................3 Poor........................................................................................4

202 According to your knowledge, is there a committee that coordinates in-service training in the region?

Yes..........................................................................................1 No..........................................................................................2 If yes, please specify the mandate of the of the committee.....................................

SECTION 3: STRENGTHENING THE CAPACITY OF TRAINING INSTITUTIONS

301

Does your institution run a regularized courses for in-service, CPD/CME?

Yes………………..…………………......………..………...........1 No…………....…………………………......……..……….….... 2

302 If your institution offers CPD courses, who are the target learners? (Circle all that apply)

Medical Officers………………………..…...........……......1 Dentists..............................................................................2 Lab Technologists...........................................................3 Nurses..................................................................................4 Clinical Officers.................................................................5 Pharmacists........................................................................6 Public Health Officers....................................................7 Nutritionist and related cadre…..…………….……..8 Health records Information officers…...….……...9 Other____________________________________..............96 (Specify)

303 a) Does the institution offer cross-cutting CPD

a)Presence of cross-cutting CPD courses in the institution


courses? b) In your opinion, are there core cross cutting courses/Topics that can be taught across several medical/ health cadres to improve clinical care. c)If yes, give a list of those courses/topics

Yes......................................................................................1 No........................................................................................2 b) Possibility of offering core cross cutting courses across cadres Yes.......................................................................................1 No........................................................................................2 c)List of topics that can be offered across cadres__________

304 From the list of cross cutting courses you listed above, indicate 3 most popular/accessed cross cutting courses

List most popular courses.

305 Which learning approaches do you use to deliver the courses (Circle all that apply)

Learning approaches Classroom/face-to-face ................................................1 e-learning……………………………........................……......2 Mobile learning…..............……………..………….……... 3 Distance learning...............................................................4 Any other method (Specify)….....………………...…...96

306 If you were to introduce alternative methods of learning approaches (e-learning, mobile etc) what do you consider as the current capacity gaps that would hinder success?

Open ended

307 (Referring to learning approaches) How would you rate the acceptance of the learning approaches you listed above for CPD/ CME?

a) E-learning Appropriate........................................................................1 Fairly appropriate.............................................................2 Unacceptable.....................................................................3 b) Mobile learning Appropriate........................................................................1 Fairly appropriate.............................................................2 Unacceptable.....................................................................3 b) Distance learning Appropriate........................................................................1 Fairly appropriate.............................................................2


Unacceptable.....................................................................3 308 a) Does your institution

have a training/teaching calendar for CPD/CME? b) If you have a schedule for CPD/CME calendar, what is the compliance level by the health workers? c) If the institution has a training calendar, is there a guideline for CPD/CME?

a)Schedule/Guidelines exist Yes.........................................................................................1 No..........................................................................................2 b) Compliance to CPD Good..............................................................................1 Poor................................................................................2 c) Existence of guidelines Yes....................................................................................1 No.....................................................................................2

309 a) Currently, is there a mechanism for regular sharing of clinical experiences? b) If the answer is yes, how effective is the mechanism? c) List the channels used for sharing knowledge (Tick/Circle all that apply)

a) Existence of knowledge sharing mechanism Yes....................................................................................1 No.....................................................................................2 b) Effectiveness of knowledge sharing mechanism Good..................................................................................1 Poor....................................................................................2 c) Channels of knowledge sharing

Meetings....................................................................1 Exchange visits.........................................................2 Presentations at the clinical areas................3 On-line........................................................................4 Teleconferencing...................................................5

310 a) In your institution, is/are there a business management tool/instrument to manage pre-service and in-service training programs? b) If the response of above question is yes, is there a need for additional management tools?

a) Existence of a management tool Yes......................................................................................1 No.......................................................................................2 b) A need for additional management tools Yes......................................................................................1 No.......................................................................................2

311 a) Does the institution have a policy of and practice guidelines for

a) Existence of policy and registration linked to in-service Yes.....................................................................................1


registration/accreditation that is linked to in-service training/CME/CPD b) If the response is yes, what is the level of compliance?

No......................................................................................2 b) Level of compliance to the accreditation regulations Satisfactory......................................................................1 Unsatisfactory.................................................................2

312 How does the institution raise funds for in-service/ CME/CPD training health workers?

Sources of resources Workers self sponsored...............................................1 Donor support.................................................................2 Government.....................................................................3 Other (specify)...............................................................96

313 Are there opportunities of raising alternative funding for in-service/CME/CPD?

Yes......................................................................................1 No......................................................................................2 If yes, specify the source...........................................96

314 a)When the institution raises resources for in-service/CME/CPD, do you make any profits? b)If the institution makes a profit, how is this profit used?

a)Raising of resources Yes......................................................................................1 No.......................................................................................2 Just break even.............................................................3 b) Use of profits made To improve training resources/ materials/supplies............................................................1 Does other work (Specify)...........................................98

315 a) Is there a process of documenting in-service training, CME/CPD? b) If the process exist, is documentation regularized/systematic c) If the documentation is regularized/systematic, is the database linked to MOH/other regulatory bodies?

a) Existence of documentation process Yes..........................................................................................1 No..........................................................................................2 b) Documentation process regularized/systematic Yes.........................................................................................1 No..........................................................................................2 c)Linkages of in-service/CME/CPD to MOH/regulatory bodies Yes..................................................................................,.....1 No.........................................................................................2

316 What recommendations for improving linkages with MOH and regulatory bodies would you give?

Open ended


SECTION 4: REGULATORY BODIES, MOH-HRD &PROFESSIONAL ASSOCIATIONS

401 a) Does the regulatory body have a coordinating mechanism for CME/CPD accreditation? b) If yes, is the mechanism regularized?

a) Existence of a mechanism to evaluate accreditation Yes...................................…….................……......…........... 1 No..........................................…......................................... 2 b) Accreditation mechanism regularized Yes…………………….....……………….............................. 1 No..............…………………………………..….…............... 2

402 How often are CME/CPD program evaluated/reviewed?

Annually.…………………………… ……………….............1 Every 2 years..................................................................2 Within 3-5 years...........................................................3 More than5 years.........................................................4 Not sure..........................................................................98

403

When was the last time CME/CPD program was evaluated/reviewed?

Specify dates or year________________________________ Can’t remember………………………..……….…….... 98 No response………………………………………........... 99

404 What are the experiences derived from the training accreditation program?

Open ended (Lessons, challenges, best practices, gaps in performance etc)

405 a) Does the regulatory body have written guidelines for curriculum development and implementation b) Does the regulatory body have written guidelines for reviewing curricula?

c)If yes, how often are your curricula reviewed

a) Existence of guidelines for curriculum development and implementation Yes...............,,......................................................................1 No........................................................................................2 b) Existence of guidelines for curriculum review Yes......................................................................................1 No.......................................................................................2 c)If yes, frequency of curriculum reviews Annually.………………………………..…………….............. 1 Every 2 years.....................................................................2 Within 3-5 years..............................................................3 More than5 years............................................................4 Not sure............................................................................98


d) If the guidelines exist, are they applied to the continued accreditation of training institution and licensure of graduates from those institutions?

d) Application of guidelines to accreditation and licensure Yes......................................................................................1 No.......................................................................................2

406 What is the level of linkages between related regulators and the ministries of health and training institutions?

Excellent...............................................................................1 Fair..........................................................................................2 Poor.....................................................................................3 Not sure...........................................................................98

407 a)What is the status of linkage to a central database for CME/CPD and training institutions? b) If the response is yes, what are the types of elements of linkages?

a)Presence of linkages Strong..................................................................................1 Weak....................................................................................2 Does not exist..................................................................3 b) Elements of linkages Sharing of curriculum....................................................1 Sharing mentorship........................................................2 Sharing policies dialogue............................................3 Sharing database.............................................................4 Other (Specify).................................................................96

408 a) Does the regulatory body have a training regulatory framework or standard? b) If the trainings framework/standards exist, how often is it/are they updated?

a) Existence of a training regulatory framework/standards Yes........................................................................................1 No.........................................................................................2 Not sure............................................................................98 b) Updated of the training regulatory framework Regularly.............................................................................1 Rarely Updated ................................................................2 Not sure..............................................................................98

Thank you for participating. Is there any other information you would want to add which you have not already mentioned? Please feel free to mention.


APPENDIX B: Approval Letter from MOH


kenya national training mechanism baseline survey report

Documents

kenya survey o

training needs assessment

assessment design

assessment sample

assessment questions

assessment sites

rapid baseline survey

survey limitations