US embassy cable - 04ACCRA1303

UNCLAS SECTION 01 OF 03 ACCRA 001303 
 
SIPDIS 
 
E.O. 12958: N/A 
TAGS: ECON, ELAB, GH 
SUBJECT: GHANA: BRAIN DRAIN IN HEALTH CARE TAKING ITS TOLL 
 
 
 1. Ghana,s shortage of medical personnel is impacting 
patient care, burdening the economy and threatening to 
cripple the health care system. Ghana graduates 150 doctors 
and 600 nurses per year, but loses an average of 72 doctors 
and 216 nurses a year to migration, according to the WHO; 
other statistics show the losses are much higher.  The 
&brain drain8 is also a factor in education and the 
military, but in light of the investment that international 
donors have made to Ghana,s health sector and the more 
immediate impact of insufficient medical staff, this report 
will focus on the health care sector. 
 
The extent of the problem 
------------------------- 
2. GOG statistics indicate that 31 percent of health 
professionals trained in Ghana between 1993 and 2002 have 
left--an exodus of 3,100 people, including 600 doctors. 
Ghana,s nurse shortage is also severe; MOH estimates the 
number has dropped from 15,000 to 11,000 since the late 
1980,s. 
 
3. The brain drain is not a new phenomenon in developing 
countries, including Ghana. However, the pace in Ghana has 
quickened. The Human Resources Director for the Ghana Health 
Service (GHS), Dr. Ken Sagoe, says Ghana was losing about 
half of each year,s graduating doctors within 5 years of 
graduation in 1980. The incidence has risen to two thirds of 
each class leaving within two years, he reports. 
 
4. Ghana produced 2000-3000 doctors since 1969, yet has about 
the same number of doctors now--1600, including foreign 
doctors--as it did then. Accordingly, the doctor to 
population ratio has worsened, while World Bank data show 
this contrasts Niger, Malawi, Ethiopia and Burkina Faso where 
the ratio improved substantially as the number of doctors 
kept up with population growth. 
 
5. The ratio is most alarming in Ghana,s less developed 
northern regions where there is one doctor for every 66,000 
people. In October 2003, the Ghana Medical Association (GMA) 
reported that in the northern two thirds of Ghana, there were 
5 dentists, 3 surgeons, one obstetrician, and no 
pediatricians. Dr. Sagoe reports that northern medical 
centers experience staffing shortages of 70 percent, compared 
to 50 percent in Accra. MOH estimates suggest that by 2006, 
Ghana will face shortfalls of 1800 doctors, 6700 nurses, 6600 
midwives and 1400 pharmacists. 
 
6. The burden on Ghana,s health care system will worsen. 
Ghana recently launched a National Health Insurance Scheme 
(NHIS), which will offer free and subsidized health care to 
expand coverage. Dr. Adu-Gyamfi, GMA President, says that 
now, about 30 percent of people who should seek hospital 
treatment do, and the NHIS could cause this number to double. 
Dr. Sagoe reports that other developing countries that 
instituted similar schemes show a three to fourfold jump in 
the use of health facilities. NHIS is expected to cost Ghana 
USD 13 million annually, according to the MOH. The GOG plans 
to finance the scheme by raising the VAT by 2.5 percent. 
 
Why are they leaving? 
--------------------- 
7. Poor remuneration and working conditions, especially in 
the public sector, are a major deterrent for medical staff. 
The average doctor in Ghana earns about USD 250 per month, 
and a senior nurse earns about USD 150. There is little 
provision for a livable pension or retirement benefits. 
 
8. In 1999, Ghana (the GoG? MOH?)the GOG introduced an 
additional duty allowance scheme that allows doctors to earn 
USD 400-500 per month in overtime pay. Nurses are limited to 
USD 150 and perceive the discrepancy as unfair, providing 
another incentive to leave the system, says Dr. Sagoe. 
Allowances go only to clinicians; professors of non-clinical 
subjects or administrators are ineligible. The allowances 
also caused problems with the IMF. The Ministry of Finance 
reports that unbudgeted wage increases to health workers was 
a key factor preventing Ghana from meeting IMF targets in 
2002 and caused the World Bank and IMF to withhold USD 147 
million in funds. 
 
9. Ghana,s pay is low even with overtime. The Gambia 
reportedly pays doctors USD 1500-2000 per month, and Nigeria 
pays USD 1000-1200. Ghana hosted dozens of Nigerian doctors 
until 2000, according to Dr. Sagoe, when Nigeria increased 
salaries and 60 Nigerian doctors left Ghana for home. 
 
10. Doctors also emigrate because of Ghana,s limited career 
development opportunities. Doctors seek modern equipment and 
facilities and good post-graduate training opportunities to 
stay current, but Ghana,s health institutions face acute 
shortages of tools, equipment and instructors. Though Ghana 
inaugurated a Post Graduate College in 2003 to provide 
specialist training, Dr. Adu-Gyamfi says that it needs to be 
continually updated or else it will fail to attract people. 
There is even speculation that it could contribute to the 
problem if candidates seek specializations attractive in 
developed countries. 
 
11. Doctors are also deterred by delays in promotions and 
salary, inefficient bureaucracy, a rigid seniority system, 
and political and governance reasons. Nurses often go on 
study-leave abroad and do not return. It is particularly 
difficult for Ghana to entice people to serve in more remote 
areas where there is limited support, infrastructure, 
recreation, schools and services for families. 
 
Where are they going? 
--------------------- 
12. A 1999 study showed that nearly 55 percent of migrating 
medical personnel went to the UK, with 35 percent to the US 
and others to South Africa, Canada and Saudi Arabia. About 
1000 Ghanaian doctors live in the US, with 600 in New York 
alone. 
 
13. EU expansion and the likely migration of Eastern European 
doctors to the UK may give immigrating Ghanaian doctors 
competition. However, aging populations and domestic 
shortages will sustain developed country demands for health 
workers. A 2003 report by a Ghanaian consultant, &The Brain 
Drain and Retention of Health Professionals in Africa8 
conjectured that the UK could need 25,000 more doctors in 
2008 than in 1997. The UK,s Royal College of Nursing 
reported in 2003 that 42,000 nurses in the UK--1 in 12--were 
foreign. 
 
14. In April 2004, the UK and Ghana announced a protocol to 
stem the flow of Ghanaian nurses to the UK. Britain, 
recognizing the serious implications of Ghana,s nurse 
exodus, will seek surplus nurses first from Europe. The 
MOH,s Chief Nursing Office told Econoff that since, 
officially, there is no recruiting by the UK, it is not 
apparent how nurse migration might be prevented. 
 
Impact of the Exodus 
-------------------- 
15. Ghana is not harnessing its substantial investment in 
medical education. MOH 2002 estimates say brain drain costs, 
in terms of lost training costs and costs to hire foreign 
replacements, could be USD 9 million a year over the next few 
years. The costs from doctor emigration alone could be USD 4 
million. The brain drain also means lost contributions to GDP 
and taxes, the costs of illness aggravated by staff shortages 
and costs arising from substituting less qualified staff. 
 
16. The cost to support a Ghanaian medical student is about 
USD 10,000 per year for 6 years. Ghana formerly paid tuition 
for qualified Ghanaians, but in 1998 instituted a 
cost-sharing program where students pay 1.5 million cedis 
(USD 168) per year. Foreign students pay full tuition, and 
Ghanaians who do not qualify academically pay 24 million 
cedis (about USD 2700), but Ghana is still paying most costs 
for Ghanaians. 
 
17. Local media reports frequently on the repercussions of 
health worker shortages. In May 2004, the Tema General 
Hospital labor ward temporarily closed due to lack of 
doctors, forcing women in labor to trek 16 miles to Accra or 
to expensive private facilities. The Accra Psychiatric 
Hospital reports it has 3-4 nurses for 195 patients at any 
given time. In May 2003, the University of Ghana Medical 
School reported that it only had 10 lecturers--with most due 
for retirement within 6 years--instead of the minimum of 30. 
In January 2003, the new Brong-Ahafo regional hospital 
reported it was short 168 health workers out of a required 
workforce of 482. A June 2004 press report attributed poor 
rural health to the lack of health professionals in rural 
areas. 
 
18. With the escalating burden on medical staff, there is 
real concern about burnout, errors, increased staff absences 
and frustration, and reduced productivity. Dismal conditions 
and morale will compound the problem by encouraging early 
retirement or emigration. The head of the Ghana Registered 
Nurses Association (GRNA) fears that overworked nurses will 
cause poor patient care and a possible public outcry; closing 
health facilities may be the only way to avoid such 
confrontation. Faced with a daunting staffing imbalance, it 
is not at all clear that Ghana will be able to achieve its 
Millennium Development health goals of improving maternal 
health, reducing child mortality and combating disease. 
 
19. Since 1990, Ghana has employed Cuban doctors and 
currently hosts 188. Ghana pays each USD 100 per month, and 
likely pays an equal amount to the Cuban government, per Dr. 
Sagoe. Host hospitals add a monthly stipend of USD 50. The 
Cuban Medical Brigade reported in May 2004 that it had 
handled 3.6 million outpatient cases in the last two years in 
Ghana, in addition to 34,000 surgeries and 25,000 births. 
There is some concern about miscommunication since many of 
the Cuban doctors do not speak English. 
 
What Is Ghana Doing About Brain Drain 
------------------------------------- 
20. Ghana cannot compete with developed world salaries but 
needs to find a formula that will entice health workers to 
stay and serve, particularly in rural and deprived areas. Dr. 
Sagoe informally polled doctors and thinks the MOH could 
attract them with a salary of USD 1,000-2,000 per month. But 
Ghanaians also want long-term financial security, something 
that Ghana is only approaching on a piecemeal basis without 
an appealing comprehensive incentives package. 
21. Ghana,s struggle to offer incentives has been challenged 
by stalled negotiations, inefficiency, and lack of resources. 
GHS has been negotiating an appropriate pay structure for 2.5 
years. Car distribution programs--to aid doctors in remote 
areas--have misappropriated cars to non-doctors, GMA 
executives, and political supporters. In 2003, however, 40 
cars did go to deprived areas, and Dr. Sagoe believes that 
420 more will be distributed fairly. Current incentive 
packages (TV, housing, radios, bikes) to deprived area health 
workers cost USD 3.4 million per year. 
 
22. Doctors want the security of owning a home and have 
appealed to the GOG to facilitate home financing assistance. 
Dr. Sagoe told Econoff that the MOH had been in talks with a 
local bank, but current salaries cannot support long-term 
loans and talks collapsed. Dr. Adu-Gyampfi advocates creating 
a fund for housing, pensions, children,s education, or even 
a 10-year bonus, to tie doctors to Ghana. 
 
23. Another strategy to retain higher numbers is to train 
more people (although the potential downside is that more 
money is spent on more graduates who leave). MOH policy is to 
double the annual nurse graduates to 1200 per year, and GOG, 
aided by development partner funding, is expanding training 
centers, capacity. The Head of the GRNA suggests that 
developed countries that poach nurses should help fund 
efforts to increase the graduate pool. GHS is trying to 
increase the doctor pool with a program to guide outstanding 
medical assistants to medical school. The University of Ghana 
Medical School announced in May 2004 that it would increase 
its admission next year from 111 to 135 students to try to 
meet Ghana,s demand for doctors. 
 
24. Though Ghana pays the bulk of medical school costs, it 
has no enforceable mechanism to compel doctors to repay with 
service. After one year of postgraduate training, required 
for registration as a doctor, there is little to hold doctors 
in Ghana. Dr. Sagoe told Econoff that 30 years ago there was 
an unwritten obligation for new doctors to serve 5 years, but 
that is not the case today, and many doctors feel little 
sense of duty. Dr. Adu-Gyampfi said it is easy to skip out on 
any bonding agreement or to simply pay the fine. Generally, 
Ghana can only appeal to patriotism in an effort to encourage 
doctors and nurses to stay. 
 
25. Government efforts at least have been able to forestall 
strikes by health care workers. Dr. Sagoe says that strikes 
occurred every 3 months in the late 1980,s, and every six 
months in the mid 90,s. Since President Kufuor took power in 
2000, his government demonstrated a willingness to listen and 
act, and medical professionals are responding by giving him 
time to implement change. 
 
26. Drs. Sagoe and Adu-Gyampfi believe that using HIPC funds 
to offer higher salaries and incentives would be a boost for 
the efforts to retain doctors and nurses. World Bank and 
donor funds may not be used for salaries, however, but Dr. 
Sagoe maintains that without salary assistance, there may be 
no health system left to salvage in the long run. It is in 
the donors, interest to support Ghana,s efforts to retain 
its medical workforce, since donors have spent millions on 
health care and facilities in Ghana.  A critical factor in 
ensuring that these investments are sustainable is to 
guarantee that there will also be an adequate supply of 
trained health care professionals. 
Yates