Ghana: What to do when local doctors emigrate or stick to the capital

Filling the Gap…

Von Tom Pulse & Tanja Zangger

Although overall doctor density in Ghana has not grown over the past twenty years, eighteen out of twenty Dutch doctors were able to be gradually phased out in favour of an increasing number of local colleagues.

Health care in the Brong Ahafo province in Ghana in the mid-1980s seemed to be stuck in a cycle of dependency. How to get Ghanaian doctors to work and stay in the districts of the province of 1.2 million inhabitants? Brong Ahafo was “blessed” with a mere twenty local doctors, mainly attached to the provincial state hospital. Twenty expatriate doctors worked in seven district hospitals in the province. In comparison: the Korte Bu teaching hospital in the capital, Accra, had three hundred doctors on its payroll. Only young doctors who were fulfilling their obligatory two years of rural service could be assigned to work in the districts. However, as soon as their time was over, they would move back to the city. Expatriate staff seemed indispensable, indefinitely.

To try and break the circle of lack of local staff and gap-filling through expats, several solutions were tried. One of the most far-reaching attempts was the donation of a car plus the topping-up of salaries in hard currency to convince local doctors to sign up. However, even this did not convince many of them to work in the rural districts. Only a few accepted and even less were inclined to commit themselves for a long term. In some cases, the arrangement increased the brain drain from Ghana as a whole. Doctors saved their hard currency, sold the car and used the money to pay for a ticket and an initial stay in the US or in the UK, while trying to find a job.

Research was done into the motives behind the reluctance amongst Ghanaian doctors to sign up for district hospitals. Many of them feared being too far away from the centres of gravity, both professionally and personally.

Some wondered where to do their shopping, or even asked how to find a suitable partner to marry. The lack of acceptable housing kept others away from the district hospitals. Worries abound about the quality of drinking water, or the availability of electricity and about retirement! In the professional field, doctors felt that a posting in a district hospital would be too far away from the relevant networks. How to make a career if no one in the capital knows you exist? How to keep up with advances in knowledge and expertise far from relevant libraries and professors?

It was crystal clear what was needed. Higher salaries per se would not attract more doctors to district hospitals. To commit themselves, doctors were in need of services; not money. In co-operation with the hospitals, a long-term programme of investment was embarked upon. Postings would have to become more attractive. If services were seen as missing, these services had to be improved or implemented. Extra staff housing was built according to standards attractive enough for city dwellers. More means of transport were put in place so the sense of isolation could be broken. Supporting and improving local primary schools could make them more suitable for the children of highly educated intellectuals. To lessen the professional constraints, district hospitals were advised to set up libraries. Internet connections could guarantee a link to the ‘outside’ world. Through a bursary fund doctors would get access to up-grading courses. An initial system to help accumulate retirement benefits was set up.

To further enhance the recruitment and retention of young Ghanaian doctors a training programme for General Practitioners has been created in 2002 in Brong Ahafo and a specialist course, adjusted to local circumstances, is now up and running as well.

*The case story was first published in: “Health care and technical assistance: a pertinent question.”(Cordaid 2003). Reproduced with the kind permission of Cordaid, the Dutch member of Medicus Mundi International. Contact: Monique Lagro,