Assessing Policies and Strategies to Reduce the Impact of Health Worker Shortages in Primary Health Care Facilities in Ghana

Author: Eunice Okyere

Okyere, Eunice, 2018 Assessing Policies and Strategies to Reduce the Impact of Health Worker Shortages in Primary Health Care Facilities in Ghana, Flinders University, College of Medicine and Public Health

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The shortage of health workers in rural areas is a global challenge although its impact is greatest in low- and middle-income countries. In attempts to address this problem, interventions and strategies have been suggested and implemented but very little has been established or documented on the effectiveness and sustainability of these interventions in attracting health workers to stay in rural areas. In Ghana, despite policy interventions put in place to reduce the impact of rural health worker shortages and increase their retention in Primary Health Care (PHC) facilities for quality health care delivery, such facilities continue to lack adequate numbers of skilled health workers. This research was therefore designed to assess the effectiveness and level of implementation of interventions including task-shifting practice, incentive packages, and policies on recruitment, postings and finance, and to examine the push and pull factors that affect health workers’ movements. The study in the Upper East region of Ghana was designed to achieve the following objectives: to explore policies and strategies (incentives) put in place to retain health workers; to explore the extent to which these policies and strategies worked; to examine the extent of task-shifting in management of inadequate numbers of health workers; and to explore the push and pull factors that affect health worker retention.

The study was conducted in 10 of the 13 districts in the Upper East region of Ghana. The districts were selected purposively to obtain a mix of health centres situated in typically rural, peri-rural and urban settings to improve the study area diversity. An interpretive phenomenology research design was used to understand the meaning and importance of health workers’ and managers’ perceptions and experiences of task-shifting, incentives and other policies regulating health workers in the study area. Qualitative methods and a realist evaluation framework approach were used, with data collected through field interviews and review of relevant policy documents. In total, 68 in-depth interviews were conducted with health workers in PHC facilities (health centres) and four in-depth interviews with key persons involved in staff management. The data were analysed using thematic analysis with inductive and deductive approaches.

The findings revealed that task-shifting was a common practice across health facilities to help reduce the impact of insufficient numbers of health workers. Generally, health workers had comprehensive training that supported the organisation of task-shifting. However, they were sometimes engaged in tasks above their level of training and beyond their job descriptions. Adequate training was not usually provided before additional tasks were assigned. While some staff perceived the additional tasks they performed as an opportunity to learn new skills and become multipurpose, others described this as stressful, work overload or unsafe because of the tendency to complicate the health status of patients.

Different incentive packages, fiscal and non-fiscal, had been instituted to motivate health workers working in rural health facilities in the region. Generally, awareness levels about incentives varied among different cadres of health workers, with most of them unaware of their full incentives package. Health workers had different preferences for incentives and did not regard some as attractive enough to motivate them. Different cadres of health workers involved in the study had different perceptions on recruitment and posting policies and described the processes as unfair and employment contracts unclear. Push and pull factors that affected health worker retention in rural areas included distance from spouses and other family members, fear that unmarried workers would not find suitable partners in rural areas, poor infrastructure development, inadequate equipment, lack of ambulances to aid referrals, poor/inadequate social amenities and lack of safety.

The findings suggest that the impact of health worker shortages in the Upper East region of Ghana can be improved if task-shifting is systematically organised with adequate training and supervision put in place. Health workers should be made aware of all incentives and appropriate distribution mechanisms should be put in place to ensure that all workers benefit from incentives. Some incentive packages need modification, along with reinstatement of previous incentives and introduction of new ones to achieve the intended purpose of motivating health workers to work in rural areas. Health workers should be involved in formulation of their incentive packages so that their preferences can be considered. Policies on recruitment, posting and finance need modification so that health workers build trust in the health sector. Adequate social amenities and infrastructure development are required, and this shows the need for comprehensive programs rather than stand-alone interventions in rural areas.

Keywords: Task-shifting, incentive packages, health workers, health policies, rural areas, staff retention

Subject: Public Health thesis, Primary Health Care thesis

Thesis type: Doctor of Philosophy
Completed: 2018
School: College of Medicine and Public Health
Supervisor: Associate Professor Lillian Mwanri