The Effect of Nurse Migration on the Provision of Health Services in Ghana

GUJHS. 2008 Apr; Vol. 5, No. 1.

Matthew Crommett
Georgetown University
Dodowa Health Research Centre, Ghana

Introduction
The World Health Organization’s 2006 World Health Report found that Africa is responsible for 24% of the global burden of disease but only 3% of the world’s healthcare workforce to manage it (1). The loss of skilled labor from poorer to richer countries has raised global concern and has been labeled “brain drain” (2).  The WHO lists malaria, tuberculosis, and HIV/AIDS as the major health issues in Ghana (3). The burden of these diseases is incredible; over 350,000 people are living with HIV/AIDS in Ghana, there are over 79,000 people living with tuberculosis, and over 3.5 million new cases of Malaria occur annually (4). With a population of slightly over 22 million, these health problems plague Ghanaians in alarming number. For proper treatment, these diseases require continual attention from health professionals (1). However, the human resources available to deal with these health issues are severely depleted, causing many cases to be dealt with at home (5). Similarly, service outputs in public and private health centers have declined due to lack of trained staff (2).

In Ghana, the drastic internal and international migration by trained nurses has a huge impact on the provision of healthcare. One example lies in the survival of infants; the WHO recognizes a correlation between a low infant mortality rate (IMR) and a high health worker density (6).  In Ghana, the IMR decreased between 1983 and 1998, but from 1999 to 2003 when the vacancy levels of registered nurses increased from 25.5% to 57%, the IMR also increased (2).

Many factors contribute to the low 2006 population to nurse ratio reported by the Ghana Health Service (GHS) of 1,537:1, but few match the impact of nurse migration (7).  The Ministry of Health (MOH) calculates that in 2006 the number of nurses (including professional nurses, community health nurses, enrolled nurses, and midwives) at 16,316, a shortage of 30,999 nurses in accordance with the “workable” number of 47,315 (8). With disease prevalence high, the migration of nurses exasperates the health system and affects the way care is administered.

The National Health System of Ghana
The provision of healthcare in Ghana is not an easy task, as services must combat illnesses associated with poverty and lack of education. Ghana’s growing population coupled with inadequate funding and low numbers of resources – both human and material – causes much stress on the healthcare system. The nurse attrition in Ghana inhibits progress towards the health sector’s key indicators of quality, access, efficiency (geographical and financial), partnership collaboration and judicious use of finances and resources (2).

The MOH has relationships with various sectors and organizations in Ghana. They have a working relationship with other sectors of the government, such as the Ministries of Education, Food and Agriculture, Works and Housing, Local Government and Rural Development, and Environment, Science and Technology (9).  As far as health related sectors, the MOH works with public, private, and traditional health organizations throughout the country. The Minister of Health sits atop the hierarchy of the Ghana health system while the primary actor in the administering of healthcare is the GHS. The MOH creates policies about health related outcomes, but relies of the GHS, the private sector, and traditional medicine to provide health care to the people of the country. Also under direct supervision of the MOH, along with the Ministry of Education and university officials, are teaching hospitals. Teaching hospitals are at the forefront in providing care while also teaching and training health workers (10).

The GHS is the public sector service provider and it contains eight directorates within its national auspices. The eight segments that comprise the national service are: public health; institutional care; policy, planning and monitoring; human resources development; health administration and support services; internal audit; supplies, stores and drug management; and finance.

The system is further separated into regional, district, and sub-district services.  At the regional level, the District Health Management Team (DHMT) delivers public health services along with the public health division of the regional hospital. The Regional Health Administration (RHA) provides support to the districts and sub-districts within each region through supervision and management. The regional hospital also delivers curative services. These hospitals have the capacity to provide specialized care not available at district hospitals. Generally, they provide care to a geographically well-defined population of 1.2 million people (10).
The DHMT also provides public health services at the district level, with district hospitals providing additional public health support and all curative services. District hospitals serve a population averaging between 100,000 and 200,000 and they are the clinical care facilities available at the district level. The District Health Administration (DHA) manages and supervises the sub-districts (10).

The sub-district level provides preventive, curative, and outreach services through health centers. Traditionally, the health center is the first point of contact between patients and the health delivery system.  Minor surgical services can be performed at these centers, while anything complicated or severe will be referred to a hospital. Health centers serve populations of about 20,000. Community-based Health Planning and Services (CHPS) augment the work of a health center and provide community and household care for minor ailments. Traditional birth attendants and healers also receive national recognition as part of the public health sector (10).

The government of Ghana realizes the importance of collaboration to provide the best healthcare possible, and exemplifies this notion with their work with the private sector. In keeping with the decentralization of the health care system, they have put effort into continued partnerships with members of the private sector. Using government funds, the GHS awards contracts to Non-Governmental Organizations (NGOs) for specialized services. The GHS provides training to the NGOs’ staff before collaborating with them to ensure that all health programs are held to the same standards and protocols (10). Agencies, banks and organizations such as the World Bank, the United States Agency for International Development (USAID), Danish International Development Assistance (Danida), the African Development Bank (AfDB), and the U.K. Department for International Development (DFID) provide financial assistance for facilities, resources and health interventions (11).

In order to improve access and quality of basic healthcare services in Ghana, the government passed the National Health Insurance Act in 2003. This act mandated district-level MHOs or district wide insurance schemes (12).In a typical two-parent family with three children, the entire family would be covered for 14.4 Ghana Cedis (16 USD) per year. The benefit package, which is intended to cover basic health care services, includes everything from outpatient consultations to essential drugs to maternity, emergency and dental care. Certain public health services historically provided for free, such as family planning and immunizations, are also covered.

Nurses play a large role in nearly every segment of the healthcare system. Every nurse requires training from the training institutions, support from internationally and domestically financed programs, and knowledge on important health care legislation such as the Health Insurance Act. This is why the drop in number of trained professional nurses from 1,728 to 1,537 between the years 2001 and 2006 while the population increased is devastating to the healthcare system (13). Most nurses work in the public sector, but the shortage affects both the public and private health institutions within Ghana (2).

The Picture of Nurse Migration
The migration of nurses in Ghana comes in two forms: internal and international. Internally, the trend is for nurses to move from rural to urban areas. Internationally, nurses are leaving Ghana to work, primarily, in developed countries. Both occurrences happen due to a variety of factors, none of which are mutually exclusive.

Internal migration occurs from rural areas to urban areas due to the challenges of living in a remote setting (14). In Ghana, the geographical distribution of nurses favors the more urban Greater Accra Region; which has 18.5% of the country’s population and 30.9% of the country’s registered nurses14. Meanwhile, the three more rural, northern regions comprise 18.3% of Ghana’s population but contain only 15.6% of the registered nurses (14). It is generally more desirable to work in a urban setting that comes with easier transportation, more educational options for children, greater career opportunities, generally improved housing, and less social isolation (14). This internal migration further exacerbates the healthcare sector by making the jobs of workforce planners increasingly difficult (15). Keeping job satisfaction high is difficult when a nurse’s personal freedom of choice in geographic location is challenged (6).
International migration is even more detrimental because it involves nurses leaving the country altogether. The WHO totals the number of Ghanaian nurses and midwives working in Ghana at 17,322, and the total number working in OECD countries at 2,267, meaning that 13% of the home country workforce is working in OECD nations (6).  Nurses emigrate due to the difficult circumstances that come with working in Ghana and the bright potential associated with working in developed countries.

Overall, Ghanaians seem to have the tendency to want to migrate; 40% of Ghanaians, and 62% of Ghanaian health professionals, expressed their intentions to emigrate in a 2001 study. Research shows that not only do thousands of trained nurses migrate internationally; they plan to do so before they are even certified. A study targeting 400 trainee nurses at 7 training institutions (5 public and 2 private) saw that 55.5% of nursing trainees intended on emigrating. An overwhelming majority of 88% stated that waiting to complete training was the primary reason that they were refraining from emigrating immediately (16).

The reasons for migrating vary, but all follow along the line of seeking greener pastures. Only 4% of the trainees responded, “helping to prevent the staff shortage” as the reason that they wanted to become a nurse in a survey studying their intentions. 85% of the other reasons were also honorable, however made no declaration of helping the Ghanaian staff shortages. Only 4.5% named their initial intention as traveling abroad, leaving many other reasons why the other 51% wish to migrate. The students listed further training (37.6%), conducive working environments (28.4%), realistic remuneration (18.4%), and better healthcare systems (15.6%) as the main reasons they planned on migrating (16).

Another study focusing on which Ghanaian trainees are more prone to leave adds being male, living in the Greater Accra Region, and having a relative in the health profession outside Ghana to the list of reasons (17). The Human Resources for Health Report published in 2007 by the MOH suggests that poor working conditions, the opportunity for promotion, the procurement of further accommodation, and low salaries account for the international migration (8). However, wages are not the primary reason for moving. Wage differentials between the host countries to which nurses migrate have little to no effect on the desire of a nurse to migrate there (18). The WHO echoes these reasons and adds globalization to the long list of contributing factors (19).

The major nations acquiring these migrating nurses do not comprise as long a list. A case can be made that every nation employs a Ghanaian nurse, but the two major players in the Ghanaian nurse migration are the United States and the United Kingdom (18). These countries’ nursing wages per month, USD $3,056 and $2,576 respectfully, tower over Ghana’s monthly wage of $206 (18). Even with these wage discrepancies, the primary reasons for migrating have to do with the working conditions in Ghana (18). The outflow of Ghanaian nurses to the United Kingdom, for example increased from 40 in 1998/99 to 154 in 2005/06 (20).

Liese et al. reported in 2003 on an internal document of the MOH that showed a decrease from 15,046 nurses in 1998 to 11,325 nurses in 2002 in Ghana (21).   However, in the years since this report was published, the number of nurses in Ghana has improved. The Ministry of Health reports an increase in nurses since 2002, with the 2006 total standing at 14,507 (7). These numbers do not necessarily mean that less nurses are emigrating; the number of nurses going through training has increased, as has the distortion of nurses in urban settings in comparison to rural settings.

Plans, Policies, and Interventions
The health sector has implemented a number of interventions aimed at tackling the issue of nurse migration (22). To inhibit the rural to urban migration and to attract trainees to the remote areas, a Deprived Area Posting Allowance was created by the MOH in 2004 (16). Also created with the goal of motivating nurses to stay was the Additional Duty Hours Allowance (ADHA), implemented in 1998 (1). The distribution and usage of vehicles at health centers now includes nurses, sending a message of appreciation. Administratively, regions began re-organizing human resource filing systems in 2006 (22).

However, these plans have not all arrived to universal acceptance and admiration. The deprived area incentive boosted take-home pay above the civil service norms; however, this plan ended up decreasing staff motivation when the allowances were disseminated in a non-discriminatory nature (14). Likewise, problems with the ADHA infuriated nurses to the point of possibly encouraging emigration (6). Some sector leaders also speculate that the ADHA has partially caused some nurses to move from the public sector to the private sector (1). They received lower allowances than doctors and the program was reconstructed before the nurses had any impact on changing it (1).

In 2006, the Human Resource for Health Development department of the MOH took it upon themselves to look into the priority areas and strategies for action in improving human resources within the health system (8). A number of the priority areas involved strategies that would improve the working conditions and retain nurses. The new human resource filing re-organization has allowed for updated staff databases and easier human resource tracking and analysis, a key step in examining how much of the nurse population is lost due to migration (22).

In 2006, the department created the Human Resources for Health (HRH) Task Team, consisting of a group of experts in HRH development, planning and management from both the public and private sectors. The team’s goal is to build the capacity to be able to analyze HRH data within Ghana. They were able to use existing data to draft a policy and strategy schedule for the next five years. This was considered a success, yet the group lacked members from the Ministries of Finance and Education and will have to confront this inadequacy in the future (8).

The ADHA scheme was formerly the motivation tool in the effort to increase nurses’ wages. Inconsistencies of the scheme caused its abolishment along with the deprived area incentives scheme in 2006 and a new system has been introduced (8). The new system is based on a reformed salary structure and has been met with concern and, again, disparities, causing the construction of an appellate body that constantly deals with concerns and revises with salary structure (8). Despite concerns, the HRH department attributes decreased attrition in the past year to the coupling of the new salary system and the strict implementation of the bonding scheme (8).  To make up for the destruction of the deprived area monetary incentives, the team has decided to implement non-monetary incentive schemes in the remote regions (8). Nevertheless, nurses still refuse postings in deprived areas (22).

The department also implemented three levels of initiatives to improve the human resources performance management, the third of which applies to nurses. The focus of the third initiative is to provide educational support and professional development for all staff. To foster this initiative, the department had the goal to increase local fellowships by 60% over the number awarded in 2005. A massive shift away from foreign fellowship and toward local fellowship ensued and the department saw a 77% increase in accepted local fellowships. Another goal of the department was to undertake a needs assessment of health workers, this goal was accomplished and now there is more information on numbers, locations and types of health workers in Ghana (8).

The health system in Ghana also introduced middle level cadre training in 2006 (8). Delanyo Dovlo explained the renewed interest in mid-level cadres, or “substitute workers,” in Sub Saharan Africa (23). He states that “…due in part to increased migration of health professionals…the nature of “substitutes” makes them very specific to a country and thus not involved in international labor market dynamics” (23).  Ghana decided to introduce and train these workers to, “ensure adequate skill mix, reduce the wage bill and increase productivity as well as getting people to work in hard to reach places…” (8).

The Ministry of Health opened seven new training schools and the private sector opened three. Also, a Medical Assistant school opened in one site in Ghana. These new schools will bring 610 workers into the health system to lessen the burden on the rest of the health workers, especially the nurses. The MOH hopes that more workers will lessen workloads and improve working environments (8).

To further increase the output of trained Ghanaian nurses, the MOH has continually taken more students into training institutions since 2004. Including all public and private nurse training institutions, 4815 new students were enrolled in 2006 (8). This number is more than double the number of new students in 2004 (2,085) and a notable improvement over the 4,166 new students in 2005 (8). There is also a bonding scheme in place, with nurses required to spend a specified time in Ghana after completion of training (15). However this has been ill enforced and there have been stories of buying out of the bond, especially when posted in remote areas (15).

The HRH department has identified bold strategies in enhancing the working environments of its health personnel. As the majority of nurses work in the public health sector, methods derived by the HRH will affect most nurses providing care in Ghana. It will be a true challenge to successfully implement these strategies, but if done, the retention of trained nurses will improve.

Challenges
The effort to retain trained nurses and provide the highest quality of care possible remains a challenge for the health system in Ghana. The recruitment of nurses from developed countries, a continued shortage of faculty at training institutions, the state of the Ghanaian economy and the pursuit for outside funding all loom while leaders try to increase the occupation’s appeal.
The top two host countries, the U.S. and the U.K., pose separate but equal challenges in the attempt to slow international recruitment of Ghanaian nurses. A comprehensive international treaty regulating international migration does not exist, so inadequate international agreements serve as the components of international migration’s legal framework (24). The U.S., in part due to a lack of a national health system, has no code or regulation in the international recruitment of nurses. The American Public Health Association and the World Federation of Public Health Associations have urged the U.S. to impose restrictions on international recruitment of nurses, but the country has taken no major steps (25). The U.S. has become more and more reliant on foreign nurses, now taking in more annually than it educates on its own soil (25).  The other major country involved in recruiting from Ghana, the U.K., has shown signs of updated regulation in recruitment. The U.K. adopted a new Code of Practice in 2004, prohibiting the National Health Service (NHS) in recruiting from developing countries (26). However, evidence suggests that this Code is ineffective as nurses can apply for employment on their own and private recruitment agencies are not under the Code’s auspices (27). The Code has good intentions, but all it has done is cause nurses in Ghana to personally send in applications, or to migrate through private recruiting agencies and then apply to NHS hospitals once in the U.K. (26).

Despite the increase in intake at all training institutions in Ghana in the past few years, one problem continually surfaces: there are not enough faculty members to accommodate the rise in students (22). Academic health professionals migrate in a similar fashion to nurses and are also depleted in number (28). It will be a challenge for the Ghana Ministries of Health, Education, and Finance to solve the problem of training staff shortages.

Commonly considered a marker for health sector improvements, the economy of Ghana has improved in recent years (29). Despite improvements, Ghana’s economy is still not on track to reach the Millennium Development Goal of middle-income status by 2015 (29). Thus, providing higher salaries and monetary incentives will continue to be a challenge for the health sector.
Ghana depends on international donors and banks to finance many of the projects and infrastructure of the health system. Ensuring continued support from outside funding agencies is a constant challenge. One such agency, the African Development Bank (AfDB), asserted in its 2005 evaluation of assistance to the health sector that the poor performance of projects in Ghana can be attributed to mismanagement and poor economic conditions. The bank goes on to say that the brain drain of health workers, such as nurses, is also spawned by the poor economic conditions.  Ghana faces the challenge of improving economic conditions because the conditions force nurses out, interrupt management of projects, and create distrust among funding agencies. Also, Ghana’s “general lack of human resources” hampers projects funded by outside sources at the operational level. DFID and the World Bank are the primary outside contributors to Ghana’s health sector, and although the health system is well coordinated by the Government, the lack of nurses and other human resources lessens opportunities for health development projects (11).

Recommendations
The continued decentralization of the health system is a crucial step in the attempt to retain nurses (30). Decentralization empowers local nurses and shows them that local issues matter (30). The Ghana Health Service must employ a number a strategies within this decentralized framework in order to ensure success in retention and improvement in quality of care.

It is imperative that Ghana continues to craft creative initiatives to improve their supply of nurses. One instance of creativity paying off is that Ghana has made a call to reappoint retired nurses and two-thirds of those eligible have applied (31). The adoption of mid-level cadre training has attacked the nurse supply shortage from a different angle, and their training that is only useful on the national (and not international) level will hinder the brain drain. In this regard, adjusting all training to regional and national demands in the district training centers will be crucial in generating nurses who have skills pertinent to Ghana (6).

The best method to combat international recruitment is through increased regulation. Sound migration policies need to be made in Ghana and also in the developed nations receiving nurses (24). Nurses have the freedom to work wherever they choose due to The 1948 Universal Declaration for Human Rights. Thus, to hinder the flow of nurses to developed nations, specifically the U.S. and the U.K., the host countries must create effective laws. Ghana also needs to regulate, through bilateral or multilateral agreements, the emigration of nurses trained on its soil (24).

Although the number of nurses migrating to the U.K. peaked at 354 in 2003/04, this number has decreased to 154 in 2005/06 largely due to the Code of Practice (20). However, private recruitment agencies should be covered in the Code to further stem to outflow of nurses from developing countries (26). Similarly, all nurse employers in the U.S. should voluntarily adopt codes of ethics that inhibit international recruitment in countries with nursing shortages (25). The U.S. and the U.K. governments should provide assistance in enlarging training classes of nurses in their own countries to aid their internal nursing shortages (25). Also, the developed nations should provide compensation for the negative effects that they have had on health systems in developing countries, including Ghana, to make up for the loss of nurses (260.

Leaders in Ghana’s health sector need to continue to heed to recommendations of international organizations that also strive to improve health. The International Council of Nurses has mentioned fellowships as a way to attract trainee nurses to deprived areas and to the country as a whole (14). Ghana is already employing this technique and made large strides in 2006 with their effort to increase local fellowships. The 2005 evaluation by the African Development Bank stressed that the Government of Ghana should do two things related to nurse migration to improve collaboration with outside funding agencies: step up accommodation and incentives for health workers and initiate the capacity to better understand the brain drain (11). In the past two years, the Ministry has revised their incentive scheme and has instituted databases to better understand the migration. Although these are steps in the right direction, Ghana must recommend to outside agencies that they direct funding towards initiatives aimed at halting the brain drain. More programs that lessen the loss of skilled workers will increase the number of human resources and the performance of all funded programs will improve.

A strategy of training even more nurses to account for the losses in external attrition needs to be established through multi-sector reform (2). To ensure that trainees have enough teachers to train them, interest must be generated in the teaching profession. Strategies involving the continual education of nurses, increases in teaching salaries, or even the chance to providing feedback on curricula all could enhance the appeal of becoming an academic health professional in Ghana.

The problem of working in rural areas must be solved. With the abolition of the Deprived Area Posting Allowances in 2006, Ghana needs to create new schemes to attract nurses to deprived areas. Bonding schemes are an option, but they require nurses with the least experience to be working under the hardest remote conditions and have been known to turn nurses to emigration when the services in rural areas are insufficient (31). Thus, housing or housing allowance incentives, fast tracking promotion, and career development all constitute safer options.

Also, a push in improvement in occupational safety and equipment will improve the atmosphere of working in Ghanaian health clinics and hospitals across the country.
Non-monetary incentives are crucial in improving on-site conditions and staff morale (21). The International Council of Nurses notes non-monetary incentives such as “opportunities for professional development and continued education” as more motivating than financial incentives “which are met with indifference” (14). All policies need to be supported by the Registered Nurse Council of Ghana so that incentive programs are not rendered ineffective in short amounts of time (30).

To better the working environment of nurses in Ghana, the salaries proposed in 2006 must be effective. Competitive salaries accommodating a living wage must be offered to staff to prevent them from seeking employment elsewhere in country or abroad (21). With increased wages and more retained nurses, the operational capacity of the health sector will improve and provide more areas for international agencies to provide funds.

Conclusion
Many strategies must be employed by the Ghanaian health sector to retain nurses because the demand from developed countries is increasing, working in rural areas is still wholly undesirable, and the trend of desired migration among trainees persists. Factors outside of the health sector also have direct and harmful effects on the provision of care in Ghana. Despite the improvements made by the Ghanaian health sector, with the economy improving at too slow of a rate to provide appropriate and effective monetary incentives and English-speaking nurses continuing to be in high demand, there are still many challenges to face. Not to be undervalued is the impact of the HIV/AIDS epidemic. A disease that requires as much treatment as AIDS will only make the loss of nurses due to migration that much more poignant. Increased intake of trainee nurses to teaching institutions, the development of mid-level cadres, increased remuneration, better working conditions, and reduction in demand from the U.S. and the U.K. all could alleviate the loss of nurses to migration.

Nurses migrate at a faster rate than other health professionals, causing a lack of staff and a poor skill-mix of the residual staff, leading to low staff performance and poor service output (2). However, the health sector’s acute awareness of the problem, the recent improvements in retention, and the creation of new human resource strategies in 2006 provide hope for the health system and the health of all Ghanaians.

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