Health Sector Reform and Deployment, Training and Motivation of Human Resources towards Equity in Health Care : Issues and Concerns in Ghana. Dr Delanyo Dovlo Director, Human Resources Development Division, Ministry of Health, P.O. Box M44, Accra, Republic of Ghana. Abstract Ghana, a low income developing country, is undergoing health sector reforms aimed at achieving greater equity of access to services, improved efficiencies in resource utilization, development of wider linkages with communities and other partners, as well as improved quality of health services. These reforms have strong influences on, and are influenced by, issues of human resources development, deployment and motivation. Some of the human resources issues debated under the reforms include issues of distribution of personnel, reprofiling of staff types and skill mixes including delegation of some essential skills. Issues of gender influence on staff distribution, as well as social and geographical factors, affect human resources deployment to meet the health sector reform goals. Health workers in Ghana have severe distribution differentials in terms of geography as well as between tertiary and primary care sites. Efforts at redress include developing multi-purpose health workers, delegation of certain life saving skills to midwives, schemes to improve personnel administration systems and provision of new incentive mechanisms. Keywords : Health Sector Reform, Human Resources Development, Equity, Access, Reprofiling of Human Resources. Introduction. Ghana, originally known as the Gold Coast, was a British colony for approximately one hundred years before independence in 1957. British rule brought modern or western health systems into the country. The country’s health systems at the time are described as focusing on hospital based clinical care; initially served expatriate Civil Servants and merchants and most facilities were concentrated in port towns and areas with commercial activities; and focus on sanitation activities in towns and cities(1). The health sector, after the immediate post-independence period, started addressing issues of equity in health care by expanding the availability of hospitals and health centres to cover much more of the countryside. However these facilities were still not equitably distributed(1). This action also coincided with the introduction of new cadres of health care workers such as Medical Assistants (or Health Centre Superintendents), Technical Officers and Field Technicians for Diseases Control and Surveillance. By the mid 1980s, like other sub-Saharan African countries, frequent coups d’etat and changes in government and economic decline had contributed to severe reductions in the resources available for health care. This, it is noted by the World Bank, resulted in poor service conditions for health workers and a rapid decline in morale(2). Primary Health Care Policy and Strategy papers were produced in 1979. It moved towards developing district health teams and district based health service systems in order to refocus priorities towards basic clinical and prevention oriented services(1). In 1985, the government of Ghana introduced user fees into the health services marking a significant shift in health policy towards cost recovery, decentralization of management and rationalization of services. A report in a World Bank publication(2) indicated an estimated 50,000 surplus staff in the Ghana Public Sector. In the government 2 health sector, it was estimated that out of a total of 38,000 staff in 1987, some 22,000 were non-technical or unskilled staff and 8,000 of these were redundant labour(3). A number of mainly unskilled staff were redeployed with the aim of improving the proportion of trained health workers providing services. Staffing levels in the health services were reduced from approximately 38,000 to 27,000 over a five year period. In the early 1990s Ghana began taking a series of actions towards restructuring its health sector, including developing a Basic Minimum Package of Services; refocusing the emphasis on PHC including Reproductive Health; decentralizing greater management and financial responsibility to Districts; de-linking of Health Service Delivery from the Civil Service; and reviewing the MOH’s organisational structure to reflect a shift from vertically systems to a more functional horizontal system. In 1995 the President of Ghana unveiled a policy document for taking Ghana into a “Middle Income Country” bracket. This document is called “Ghana: Vision 2020"(4). The Health Sector produced a five year medium term Health Policy and Strategies(5) derived from “Ghana: Vision 2020" that outlined the following objectives: 1) Efficient utilization of all resources allocated for health. 2) Access and equity are key factors in this policy. 3) Improve the standards and quality of services and personnel who deliver them. 4) Increase the empowerment of people and their communities. 5) New and improved organizational and institutional arrangements including increased decentralized authority for health service delivery to an executing agency outside the Civil Service. In 1996, a detailed programme of work(6) was produced aimed at implementing the medium term health strategies. The development of human resources management strategies formed an important component of the strategic framework and programme of work. In October 1996, Parliament passed into law the “Ghana Health Services and Teaching Hospitals (1996) Act”-Act 525(7). This law provided legal backing to the underlying institutional changes in the reforms. This paper attempts to answer the following questions: 1) What is the distribution of staff in terms of gross numbers, of trained qualified personnel, e.g., doctors, nurses. 2) Does the distribution of health staff enhance equity, accessibility and affordability? 3) How does the current health reform process and its human resources policies and strategies address issues of access, equity, and affordability of health services? Methods and Sources of Information This paper is a descriptive review and analysis, using data collected from annual “manpower budget hearings” and data from the Ghana Civil Service “Integrated Personnel and Payroll Database”. Various human resources and health reform policy discussion documents prepared to support implementation of the Health Sector medium term strategy were also reviewed. The “manpower hearings” are conducted annually in each region and involve determining for each Budget and Management Centre (BMC)a the following information: 1) The number of staff in the various staff categories currently at post. 2) The number of staff on the payroll of the BMCb. 3 3) New staff requirements for [a] new facilities or extensions to existing facilities, [b] changes in workload, [c] staff loss from retirements, etc. 4) Staff who exceed service requirements and establishment levels. The Integrated Personnel and Payroll Database (IPPD) is the national database on all public sector staff. It provides some of the gross staff location summaries. The analysis were performed using data on staff employed in the Government Sector only. The data excludes the NGO/Christian and “Private for profit” health sector which has approximately another 5,000 personnel. The “Private for Profit” and Industrial health services are rather smaller numbers and are restricted largely to the three main urban centres which contain approximately 90% of all private medical practice(1). Results and Discussion 1. General Situation Ghana is a low income developing country located in sub-Saharan Africa. It had a population estimated at 16 million in 1993 with an annual growth rate of 3.0%(8). GDP was estimated at US$400 per capita in 1991(8). It was only in the late 1980s that positive GDP growth rates were again recorded, ranging from 3% to 5% per annum(9). Infant mortality rate (IMR), which was 133 per 1000 live births at independence in 1957, was more recently estimated at 66 per 1000 live births. Maternal Mortality Rate is estimated at between 250 - 400 per 100,000 live births. Per capita expenditure on health was estimated at $6.4 in 1996, but is expected to grow to about US$9 per annum by 2001(9). Studies show that these health and economic indicators vary widely within the country(1). It is a fact that the four northernmost regions and rural areas in general, have worse health indicators than the south and the citiesc. The Ghana Government Health Sector had a total of 29,645 staff of various professions and categories on payroll(10) as of April 1996 (Tables 1 and 2). Ghana’s current health sector reform objectives were predicated on the summation of the country’s health services situation as follows: 1) Health facilities are mal-distributed with more access toward the south of the country, and in the cities. On average, some 40% of Ghanaians live more than 15 kilometres away from even the most basic health services(5). 2) The budget for health was distributed toward tertiary clinical care (25% of recurrent expenditures went to 2 teaching hospitals 35% went to the districts and primary care, whilst the national levels retained about 40%). a The BMC is the basic management unit in the health services with a single manager and budget, currently the MOH has approximately 220 BMC. bSometimes the payroll does not match the number of staff at post due to transfers, study leaves, seconded staff and improper placement of names. CIn spite of a growing urban and peri-urban slums 4 Table 1. Ministry of Health’s workers by categories, April 1996 Number by Average Estimated Payroll Total Salary Salary Male Female (GH C) (GH C) Medical Doctors 879 178 1,057 3,939,511 4,164,062,935 Medical Assistants 195 147 342 2,890,154 988,432,668 (Sub Total) (1,074) (325) (1,399) Dentists 25 17 42 3,927,503 164,955,126 Other trained Oral Health 5 4 9 1,514,418 13,629,762 Personnel (Sub Total) (30) (21) (51) Pharmacist 143 49 192 3,134,236 601,773,312 Dispensing Technician 175 16 191 2,951,174 563,674,234 (Sub Total) (318) (65) (383) General Nurses & 726 5,002 5,728 2,646,072 15,156,700,416 Midwives Enrolled Nurses 451 4,131 4,582 1,436,756 6,583,215,992 Comm.