“Addressing Recruitment and Retention Challenges of Qualified Health Workers in Rural Ghana: Establishing the problem from evidence Institute of People Centred Health Care Management, University of Stirling, (Inverness Campus) Scotland James Antwi, Ghana 28 th April 2010

Introduction and structure Ghana faced HRH crisis (out migration and distribution) Policy measures to address the crisis... Approach without evidence and involvement of HW and communities Ghana /structure of health services Out-migration/ what has been done? Evidence of mal-distribution (effects) What has been done to address it? (Results?) What needs to be done to address it?

The Regional Map of Ghana  Area of 238,537 sq.km.  Population of over 22 million  55% of the people live in rural areas  Agriculture accounts for 41% of GDP and employs 60% of the workforce  GDP per capita US$ 2,130 in (2002)  10 administrative regions  Decentralised local government structures  Located on the west cost of Africa

Ghana’s Key Economic and Social Sector Indicators Indicators (2006/2007)GhanaSub Sahara Africa Population, mid-year (millions)(2007) Population growth (%) (2007) Real GDP growth (%) Life expectancy at birth (years) 5747 Infant mortality (per 1,000 live births) 6896 Child malnutrition (% of children under 5) 2229

Maternal Mortality Rates (per 100,00 live births) (2006) 540 Adult literacy, male (% of ages 15 and older) 7369 Adult literacy, female (% of ages 15 and older) 5550 Gross primary enrollment, male (% of age group) 9498 Gross primary enrollment, female (% of age group) 9386

Organisation of Ghana’s Health Care System Health policy serves as the engine for wealth creation Three tier levels operating on preventive and curative models of health care - Primary care (CHPS, Health centres, clinics, maternity homes) - Secondary care ( districts, metro, municipal, regions) - Tertiary (teaching hospitals, research Inst.) MOH- policy, resource mobilisation, coordination Training & Research- HTI, Universities, Research Institutions Service Delivery- GHS, TH’s Mission, Quasi, Private, Ghana Ambulance Service, TAMP Regulation - MDC, PC,NMC,FDB, PHMBH,TAMPC Financing - NHIA, GOG, Partners

The size of public health workforce 39,000 in 2003 to 46,000 in 2009

What we know about out migration and rural practice Continuing Demands on Health Workers from Developed Countries -effects of Globalization -large unmet HRH needs of developed countries. -attractive pay regimes The Push Factors -years of under-investment in human resource, (production & dev’t) - poor conditions of service - restrictive employment policies - poor working environment (lack of equipment, etc) Effect of HIV/AIDS on HRH - rising employee attrition, - increasing absenteeism, - low productivity Effect of out migration on rural practice – Highly skilled health workers move to urban areas to fill vacancies as a result of relatively attractive conditions in urban areas. (social, environmental, facility, equipment, education)

HRH Policy to address ‘out migration’ HRH Education, Training and Development : - focus on the training of middle level health workers - increase intake into Training Institutions & skill mix - encourage the private sector participation in training HRH Establishment of Ghana College of Surgeons and Physicians: - localized postgraduate training - Enhanced professional and career development, through fellowships Strengthening systems and structures -accreditation and regulation - Infrastructure development Salary rationalisation (2006) Incentives (car loans, housing schemes, tax exemptions) MIDA/GHANA health project ( ‘brain gain’ through short term exchanges) Ghana Health Workforce Observatory

HRH policy on training focuses on the production of middle level health workers. HRH policies have been structured to increase training and recruitment of more clinical health workers as against support staff

“Trends in HRH attrition”

Today, HRH challenges remain - progress in modern medicine - production of new drugs and new ways of medical investigations - new devices and new ways of using them - new skills and competencies in the use of complex tools and equipment - personnel trained in narrow fields - patients seeing variety of health care providers - Increasing demand on health care

The problem with HRH in rural Ghana In Ghana, the effect of global HRH challenges affected equitable distribution of qualified health workers. lack of appropriate skills to perform the needed tasks The distribution of qualified health workers are skewed highly in favour of the urban areas. Those areas therefore depend mostly on auxiliary staff for service delivery.

Measures adopted in the past to retain health workers in rural areas.... Deprived area incentives (25% of basic salaries) Compulsory posting Fast track promotions Decentralisation of HRH Fellowships However, these measures failed/not properly implemented to address the challenges

Now let us pause, reflect and look for the evidence! “We were not sent into this World to do anything into which we cannot put our hearts” …….John Ruskin ( ) A famous English author, Poet and Social Critic

Public Health workers by region: Mid (2008 payroll figures)

Regional distribution of qualified health workers

Health professionals per population 2008

Density of Doctors, Nurses and Midwives: WHO recommends 2.43 of clinical health workers like Nurses, Midwives and Doctors for countries to attain 80% coverage of deliveries

Outpatient attendance and HRH implications In 2001, the out-patient attendance per doctor: - in a typical teaching hospital was in a regional hospital was During the same period, the out-patient attendance per nurse: -in a teaching hospital was in a regional hospital was 963

Varied Staffing ratios Average doctor; bed ratio =0.05 Average nurse; bed ratio = 0.64 Varied staffing ratios; Doctors ranges from 0.20 in urban areas to 0.01 in rural areas; Nurses ranges from 1.36 in urban areas to 0.21 in rural areas

A Health Worker in rural or underserved area in Ghana

Health workers and rural practice Rural practice of qualified health workers has historic and global dimensions Chris Ham (1982) from Butler et al (1973) indicated that in Britain, ‘areas which are currently facing most serious shortages seem to have a fairly long history of manpower difficulties ’ ( Butler, Bevan and Taylor,1973, p 42)

Engaging the workers/communities Establishing The problem From evidence Show impact of Problem on Health outcomes By engaging Workers, communities Identify factors Affecting R&R Rural areas; What are the Factors that Can improve situation Change old factors not working (adopt realistic Ones) Org. Structure Policy Social environment H/Reforms HR systems HR management Motivation Economic models Labour market Demand/supply Contribute to improvements in health outcomes Addressing R&R in Rural areas

What the literature says? Internationally, there is evidence that higher density of HRH is a significant factor in improving maternal, infant and under- five mortality rates (Anand et al, 2004) There is ecological evidence of positive correlation between pop density of HRH and cost effective health interventions (Speybroeck et al 2006) HRH play a critical role in improving health outcomes - adequate health care depends on the availability of health workforce (WHO, World Bank reports, 2006) In all countries shortage of qualified health professionals is more critical in rural or underserved areas (Dussault, G and Franceschini, M, 2006) Geographical mal distribution of qualified health workers exacerbates the existing inequalities and contributes to lower health outcomes in rural areas (Hayes et al 2005)

Methods/Techniques/analysis Action research to diagnose the problem A randomized sample size of 42health workers making 5.5% of workers in those districts (MD’s, Nurses, Pharmacists, Allied Health professionals) and 8 (students, heads of Training Institutions, policy makers and community leaders) from 6 rural districts Smaller groups of 8 formed for focus group workshops to solicit views about the scope of the problem and consequent health impact Smaller groups analysed the views and prioritised them

Doctor density and Health outcomes by regions

Health workforce shortage in rural areas is critical than previously estimated While most of the urban areas are operating at a maximum HRH capacity, there are gaps in HRH ratios in rural areas There are no significant differences in medical doctor density and three health outcomes between government classified deprived regions and the other regions Health care delivery is a team work and requires effective skill mix

Findings Increased workload, stress, low productivity Existing policies on recruitment and retention were formulated without the involvement of workers and communities Involving stakeholders in problem diagnosis ensures greater sense of awareness Impact of problem is greatly felt if methods employed involve the people Communities are willing to support interventions if involved in problem diagnosis

Policy implications Since previous attempts to equitably distribute have proved unsuccessful, there is the need to explore obstacles and barriers to improvement Realising the impact on health outcomes, there is the need to identify what constitute realistic incentive package in underserved areas What policy steps are needed to support change Critical need to explore means of attracting and retaining qualified health workers to rural or underserved areas in Ghana in order to effect significant change in health outcomes.

What we need to do to shape existing policies Engaging Engage service providers and community members Learning from existing projects partnerships & exchanges Designing Design interventions for change considering the ideal and work towards the ideal situation in phases Realizing Realize the ideal situation and show contribution to improvement in health outcomes (MDG’s and GPRS)

“Together, we train and deploy forces to combat the disease burden and disabilities in our society today”………….. That is our health workers, motivated and retained at all levels! Thank you