Nursing on the edge: Inside Kenya's fragile health workforce

Universal Health workers protesting outside Parliament Building, demanding better remuneration terms on May 27, 2024. [Kanyiri Wahito, Standard] The 2025 World Nursing Report outlines an unsettling picture in many public hospitals across Kenya, where a single nurse serves between 30 and 40 patients in one shift. This falls significantly below the World Health Organisation's (WHO) recommended nurse-to-patient ratio. The report also highlights Kenya's improving but still inadequate nurse-to-population ratio. While the ratio has increased from 8.3 to 22.7 per 10,000, it's still below the WHO's recommended 25 per 10,000. The report warns of potential workforce attrition due to low pay and poor working conditions, which could lead to significant losses to high-income countries by 2030. Thousands of trained nurses remain unemployed, not because they lack skills, but because they're waiting endlessly for delayed hiring and proper absorption into the public health system. Meanwhile, the few working within it stretch themselves across wards, often compromising the quality of care just to keep patients alive. Perhaps more frustrating is the underutilisation of Advanced Practice Nursing (APN) roles. While other countries are empowering nurses to take up more autonomous positions and bridge physician gaps, Kenya continues to restrict their scope, despite ample evidence that APNs improve outcomes in underserved areas. In Kenya's rural clinics and dispensaries, nurses often run the entire operation, prescribing, managing emergencies, and handling deliveries. Yet many lack career growth opportunities and fair remuneration. Yet behind these statistics are deeply human stories. Christabel Wesonga, a nurse director at Aga Khan University Hospital, leans over a newborn, checking vitals, cleaning tiny skin, and recording every detail. The infant is just days old, yet the cycle of care she receives is the result of years of experience, system gaps, and relentless dedication. "We are there 24 hours," says Christabel, who oversees maternal and child health. "You can't disconnect emotionally, especially when a baby you've nurtured for a year finally takes their first step. It's these small wins that keep us going." This year's International Nurses Day theme: 'Our Nurses. Our Future. The Economic Power of Care resonated deeply in Kenya, where nurses carry the weight of a health system often stretched too thin. From nurturing new life to guiding young professionals, these frontline workers are more than caregivers. They are crisis responders, educators, and, often, the last thread of hope. Professor Eunice Ndirangu, chairperson of the Nursing Council of Kenya (NCK) and dean of the Aga Khan University School of Nursing, has spent nearly two decades shaping the future of nursing in East Africa. "Our curriculum is no longer static," she explains. "We incorporate AI, simulation-based learning, and case-based training that mirrors our realities." Still, the disconnect between training and practice is hard to ignore. While the Kenyan government rolls out universal health coverage (UHC) through the Primary Healthcare Fund, the glaring shortfall in nurse absorption undermines the system. The Ministry of Health's 2025 strategy outlines a Sh48 billion funding gap for primary health, where nurses are the backbone. "Nurses form the majority of the healthcare workforce, yet they are missing from decision-making spaces," Eunice notes. "We need policy inclusion, better pay, and room to lead." Anthony Ichahuria Mwangi has been a nurse for seven years, five of them in oncology. "Unlike general care, where patients disappear after a few days, in oncology, you see them for years. You build bonds," he says. "Sometimes, I'm their only constant." But being a male nurse comes with a complex set of challenges, especially cultural ones. "I've been rejected by patients simply for being male. Especially in communities where women are not allowed to be touched by men," he recalls. "You're stuck between wanting to help and respecting beliefs. It's tough." Yet Anthony persists. "Care is embedded in me. I started helping my great-grandfather when I was a child. That empathy has only grown," he says. "Yes, nursing is seen as a woman's job, but I believe empathy doesn't have a gender." In his oncology unit, Anthony often trains doctors on cannulation, a testament to the depth of skill nurses bring. "We've developed skills so advanced that doctors call us for help. That's power. That's respect earned on the ground." Christabel oversees some of the busiest units at Aga Khan University Hospital: maternity, child health, accident and emergency. "There are days you don't even get a sip of water. Days when you're holding a baby who didn't make it. Then, the next shift starts," she says. She recalls a baby abandoned in Nairobi's City Park Forest. Christabel and her team cleaned, fed, and advocated for her. "When a nun came to take the baby to a new home, she said, 'You've been so passionate. We'll name her Christabel.' That moment, I'll never forget." Christabel has also seen a mother abandon a sick child at the hospital after a year of treatment. "She left a note. Said she couldn't handle it. But we did. That child is now in a loving home, growing. We all chipped in, nurses, doctors, social workers." But such stories also come with an emotional cost. "Yes, I've been to therapy," Christabel admits. "I prefer group sessions. When your whole team cries together, reflects, and lets go, it heals in ways individual therapy can't." All three nurses agree Kenya's nursing system needs structural support. "I would change how we view advanced nursing roles," Eunice says. "With UHC and a population that largely sees nurses before any doctor, we must train and compensate them for expanded scopes." Anthony adds that many male nurses struggle with mental health, often self-medicating with alcohol. "We were never taught how to grieve," he says. "Some go into nursing unaware they'll lose patients. That shock breaks many." Eunice says that's changing. "Now, we incorporate grief and mental resilience into our curriculum. Because burnout is real, and it costs lives." Many public hospitals remain ill-equipped. Anthony recalls working in a maternity unit with just five nurses attending to over 60 women in labour. "You focus on safety. There's no time for politeness. The public judges us, but they don't see what's on our backs." The Kenya Health Sector Strategic Plan 2025-2029 outlines a roadmap toward UHC. But massive funding gaps threaten its success. For instance, the Primary Health Care Fund needs Sh61 billion, yet only Sh13 billion has been allocated. The Emergency and Critical Illness Fund is similarly underfunded. Despite these odds, Kenya's nurses return to work every day. They cradle life, mentor the next generation, and carry the invisible weight of a broken system. "Nurses are great people," Christabel says. "They have a special heart." Anthony echoes that sentiment: "If you know your destination, you won't get lost in the system. But the system must also meet us halfway." From policy halls to bedside battles, Kenya's nurses are doing more with less every day. They hold hands through grief, spark joy in healing, and educate tomorrow's lifesavers, all while working within a fragile system. SIDEBAR What the World Nursing Report says about Kenya The 2025 World Nursing Report, released by the International Council of Nurses (ICN) and the World Health Organization (WHO), shows that the world's nursing workforce is under increasing strain. The world continues to face a severe shortfall of nurses, with a current global deficit of 5.8 million. Although the total number of nurses has grown from 27.9 million in 2018 to 29.8 million in 2023, the growth is not fast enough to meet rising healthcare demands. The report warns that many health systems are nearing a breaking point, and immediate action is needed to protect both the delivery of care and those who provide it. Nurses globally still contend with low wages, long working hours, unsafe environments, and limited representation in decision-making roles. The aftermath of COVID-19 revealed the fragility of healthcare systems and highlighted just how critical, yet underappreciated, nurses are during times of crisis. The ICN underscores the importance of targeted investment in education, employment, and leadership, urging governments to act swiftly to retain the existing workforce and attract new professionals into the field. Kenya's situation reflects many of these international concerns. While there has been commendable progress, the nurse-to-population ratio has improved from 8.3 to 22.7 per 10,000; it still falls short of the WHO's recommended 25 per 10,000 and is far below the 60 per 10,000 needed to achieve Universal Health Coverage (UHC). As of 2023, Kenya had 40.2 nurses per 10,000 people, but disparities remain stark across counties. In underserved areas like Turkana, Garissa, or Migori, nurses are burdened with high patient loads, erratic pay, and even threats of violence. Thousands of trained nurses remain unemployed due to delayed recruitment and underfunded county health budgets, despite the evident need. The report cautions that unless salaries, safety, and work conditions improve, Kenya risks losing a significant share of its workforce to emigration by 2030. Professor Eunice Ndirangu, Chair of the Nursing Council of Kenya (NCK), affirms, "We're educating more nurses, but the system is not absorbing them fast enough. And those inside are often overworked and left out of leadership spaces." The report makes one thing clear: to protect healthcare, countries must protect their nurses first.

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