When the numbers confront the rhetoric in Ghana’s management of nurses

“Simple can be harder than complex: You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there, you can move mountains.” Steve Jobs

This week, the Deputy Minister of Health Tina Mensah announced that the five-year bonding of nurses trained in public health institutions had been scrapped. This decision comes on the back of government struggling to employ nurses though Ghana has a nursing deficit. Bonding of nurses was introduced by the government of J.A. Kufuor in 2005 as a means of curbing nursing and midwife brain drain that was impacting negatively on healthcare delivery. At that time, most nurses were promptly absorbed into our health system following graduation, a situation that does not exist today. Therefore, on the surface, this decision must be welcomed as it allows these nurses to seek employment elsewhere. However, it still opens up the debate on our health strategy and policy planning.

To start with, Ghana’s healthcare expenditure is under considerable strain. According to data from the Ministry of Health, Ghana’s health expenditure per capita (the average amount spent by the government on each citizen in the area of health) is $68, having peaked in 2013 at $111. Of this close to 60% is spent on the payment of salaries of health sector human resources. Meaning government has very little room to manoeuvre when it comes to increasing human resource numbers. With other countries clamouring for our nurses’ thanks to degree equivalence especially in Commonwealth countries, it is only sensible that these nurses are freed so they can earn a living.

The irony, however, is that though they are being allowed to leverage their qualifications elsewhere, the government has been silent on the allowances we pay to these nurses. It should not take a rocket scientist to work out that unless a means is found to recoup value from these nurses wherever they find themselves this stipend would soon become an unnecessary drain on the already stretched finances of the health sector. It could even be argued that we may by default be funding the health systems of countries otherwise wealthier than we are. I will seek to explain.

Take the United Kingdom as an example, data from the think tank King’s Fund, suggests there more than 30,000 extra nurses are required currently with the number expected to increase to 70,000 within five years. With the cost of £70,000 to train a nurse from scratch, it is now widely accepted that the country cannot meet its training requirements in the short to medium term. Even then and with the shortage of nurses estimated to have cost the National Health Service (NHS) about £2.4 billion in 2018, trainee nurses are still expected to pay fees. Though they are eligible to apply for a bursary from the NHS, a reduced maintenance loan from Student Finance England and a £1000 grant, these funds are based on an eligibility criterion that relies on household income. This can be your income, your parents’ income, or that of your partner, spouse or civil partner.

With this in mind, a nurse trained in Ghana with state handouts who migrate to the UK is at a considerable advantage as they are devoid of any student loans. Will this advantage not lead to a situation where Ghana becomes a training ground for nurses who simply need to pass an English language exam and prove equivalence based on a computer-based test and practical skills assessment? If that is the case then by extension will Ghanaian public funds not simply be paying for better healthcare in England?

It even looks more diabolical when one realises that the United Kingdom has a health expenditure per capita of $3,958 (approximately sixty times that of Ghana) and a current nurse to population ratio of 8.3 to 1000 with Ghana having 1.2 to 1000 population (a difference of seven nurses for every 1000 citizens).

I understand the political ramifications of any conversations around trainee nursing allowances. However, I struggle to make sense out of how as a people we can continue to fund this in the light of our inability to employ this vital health human resource. My views on Ghana’s nursing deficit and how we seem clueless about managing it are well known. However, I believe that the time has come for us to peel off our political cloaks to have an honest conversation. A conversation that looks holistically at our current nursing numbers, what our nursing requirements are going to be in the next decade, whether we genuinely want to bridge our nursing deficit and as to whether politics rather than technocratic planning should dictate our nursing recruitment and training strategy.

It even looks more diabolical when one realises that the United Kingdom has a health expenditure per capita of $3958 (approximately sixty times that of Ghana) and a current nurse to population ratio of 8.3 to 1000 with Ghana having 1.2 to 1000 population (a difference of seven nurses for every 1000 citizens).

It is not surprising that the government gave no reasons for its decision to moving away from the bonding of nurses. On the contrary, I am surprised that the announcement did not receive any scrutiny but passed more or less with a whimper. I am because by all indications, nurses are the face of healthcare provision in Ghana and the health professionals many of us come into routine contact with when we experience episodes of ill health.

We often complain when in our view the level of care they provide is below par. Yet, seem indifferent when decisions that affect their numbers and resourcing are taken. The truth is we cannot be this apathetic at best and extremely partisan at worst in these matters and expect improvement in the quality of healthcare we receive or our health outcomes. Our nurse to population ratio has been dropping since 2013 when it was 1.59 nurses to 1000 citizens to our current 1.2 to 1000. Yet, we are told that more nurses have been employed in the last two years than in any other year in recent times. How we have failed to peruse the numbers and challenge these assertions defies me.

The irony is that the government may be right on their nursing recruitment claim but that may just be a smokescreen. This is because, with a population growth rate of 2.2 per cent annually, approximately 3.8 million people have been added to Ghana’s population of 26,607,642 since 2013 meaning just to account for population growth 3,800 extra nurses (634 annually) would have had to be recruited just to keep our nurse to population ratio at 2013 levels. Considering that we even failed to maintain annual recruitment at 2013 levels and are just playing catch up, is there any wonder we are recruiting more but our nursing deficit is widening?

I will end with these words of caution; we can choose to bury our heads in the sand and play ostrich with bulk numbers. The reality is for as long as we are a member state of the World Health Organisation and continue to report our health data, we would only be fooling ourselves locally whilst exposing our naivety globally.

By Kwame Sarpong Asiedu

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