Aggregate Human Resources for Health (HRH) Gaps by Region
Based on the minimum staffing requirement of the health sector staffing norms, the gap analysis revealed that, in aggregate, 105,440 health workers were needed to meet the minimum staffing needs of the GHS as at May 2018. However, a total of 61,756 were accounted for by the various districts and health facilities as their health workforce at post. This meant a staffing Gap or vacancies of 47,758 were unfilled at GHS. Thus, as at the end of May 2018, GHS had only 59% of its aggregate staffing requirement leaving a vacancy rate of 41%. These aggregate figures, however, varied widely across various categories of staff and geographical locations. Table 2 provides details on the aggregate HRH requirements and Gaps for all Regions.
On average, staff availability ratio for administrative and support staff was 54% as compared to 28% for allied health staff and 49% for clinical staff. See supplementary Table 1 for details of the cadre-by-cadre requirements and gaps.
Table 2: Aggregate HRH Requirements and Gaps by Region (All Staff Categories)
Region
|
Total Staff Required (a)
|
Total at Post
(b)
|
Absolute HR Gaps
(c = a-b)
|
Staff Availability Ratio (SAR = b/a)
|
Ashanti
|
13,730
|
7,854
|
6,209
|
57%
|
Brong Ahafo
|
10,510
|
5,009
|
5,777
|
48%
|
Central
|
8,283
|
5,366
|
3,245
|
65%
|
Eastern
|
14,627
|
6,390
|
8,579
|
44%
|
Greater Accra
|
9,317
|
8,497
|
1,041
|
91%
|
Northern
|
12,716
|
9,335
|
4,233
|
73%
|
Upper East
|
6,643
|
4,011
|
3,038
|
60%
|
Upper West
|
7,606
|
3,169
|
4,757
|
42%
|
Volta
|
10,800
|
5,738
|
5,490
|
53%
|
Western
|
11,208
|
6,387
|
5,389
|
57%
|
National
|
105,440
|
61,756
|
47,758
|
59%
|
Crude Equity Index (Highest /Lowest)
|
2.17
|
The results depicted in Table 2 show Greater Accra region as having the highest Staff Availability Ratio (SAR) of 91% followed by the Northern region with SAR of 73% and the Upper West Region with the lowest SAR of 42%. Of note, the crude equity index showed that in aggregate, the best-staffed region (Greater Accra) was 2.17 times (or 217%) better off than the worst staffed region (Upper West).
Descriptive Analysis of Staff Availability Across Levels of Health Facilities
As shown in Table 3, the total number of staff required at the CHPS zones and compounds was about 14,670 (13.9% of the overall staffing requirements), while those currently at post were 10,082 representing SAR of 68.7%. Thus, about 7,141 additional staff were required to fill the staffing gaps or vacancies at the CHPS level. About 827 out of 3,584 (23.1%) CHPS included in the analysis met the minimum staffing requirement of at least one (1) midwife at post while 3.2% (n=113) of CHPS had the maximum staffing requirement of two (2) midwives as per the national policy. Approximately 74% of the CHPS Zones and Compounds failed to meet the minimum staffing requirement of at least one (1) midwife.
Furthermore, against a staffing standard of a minimum of two (2) and a maximum of four (4), about 44% (1,572 out of 3,581) of CHPS had only one (1) Community Health Nurse (CHN) assigned to the zone while additional 46% of CHPS had at least two (2) CHNs. Overall, 3,350 representing 93.5% of the number of CHPS included in this analysis had at least one (1) CHN. Of the 11,627 CHNs accounted for in this analysis, 6,150 (53%) were deployed at CHPS while 3,763 (32%) were placed at Health Centres with responsibilities for outreach services.
Table 3: HRH Requirements and Gaps for Various Levels of Service Delivery
Type of Health Facility
|
Total Staff Required (a)
|
Total at Post
(b)
|
Total HR Gaps
(c = a-b)
|
Staff Availability Ratio (SAR = b/a)
|
CHPS
|
14,670
|
10,082
|
7,141
|
68.7%
|
Health Centre
|
29,521
|
15,357
|
14,419
|
52.0%
|
Polyclinic
|
4,211
|
3,333
|
879
|
79.1%
|
Primary Hospital
|
45,068
|
24,817
|
21,094
|
55.1%
|
Regional Hospital
|
7,050
|
5,505
|
1,679
|
78.1%
|
District Health Directorate*
|
3,390
|
1,456
|
2,048
|
42.9%
|
Municipal Health Directorate*
|
1,371
|
701
|
744
|
51.1%
|
Metropolitan Health Directorate*
|
162
|
70
|
93
|
43.2%
|
National
|
105,443
|
61,321
|
48,097
|
58.2%
|
*These are management and administrative structures overseeing the operations of health facilities and other public health interventions within their jurisdictions. Staff in these structures were included for the comprehensiveness of the analysis
Also, Health Centres required a total of 29,521 staff (28.0% of the overall staffing requirements) as compared to the current state where only 15,357 staff were available at post (52.9% SAR). Consequently, about 14 419 additional staff are required at Health Centres for optimal service delivery at this level. Particularly, only 47.1% (415 out of 882) of health centres had at least one (1) Physician Assistant, and even more critically, just 5.8% (n=51) of health centres had up to two (2) Physician Assistants. However, 90.8% of all Health Centres had at least one (1) midwife at post, leaving 9.2% of health centres without midwives.
While about 4,211 staff were required at Polyclinics, some 3,333 staff were at post at the time of the gap analysis (representing SAR of 79.1%), leaving a staffing deficit of 879. Similarly, Primary Hospitals required about 45,068 staff (which representing 42.7% of the overall staffing requirements) as compared to 24,817 that were at post (SAR of 55.1%). Finally, Regional Hospitals needed a total of 7,050 compared with 5,505 that were at post depicting SAR of 78.1%, and a staffing gap of 1,679 across all the Regional Hospitals.
All primary (district) hospitals had at least one General Practitioner (Medical Officer). This means that the so-called ‘no man stations’ or ‘hospitals with no doctor’ had been eliminated by 2018. However, 16 hospitals (12.6%) were still ‘one-man stations” and only 59.1% of the hospitals, mostly in urban areas, had 3 or more General Practitioners. Also, 87.5% of the primary hospitals had at least 10 midwives at post whereas 92.2% of the hospitals recorded 15 or more General Nurses at post. However, just 61.7% of the hospitals had up to 35 or more General Nurses. Also, a paltry 36 out of 127 Primary Hospitals (28.3%) had Obstetrician & Gynaecologist at post.
Each Regional Hospital had at least two (2) Obstetricians & Gynaecologists at post although only 3 Regional Hospitals had 3 or more Obstetrics & Gynaecology specialists. Similarly, fewer than a quarter of the primary hospitals (24.4%, n=31) had specialist surgeons while 18.1% of Primary hospitals and 90% of Regional Hospitals had Paediatricians at post. There was no primary or secondary hospital with a Dermatologist while only one (1) Regional Hospital had a Psychiatrist.
Regarding Critical Care Nurses (CCNs), less than a third of primary hospitals (27.3%, n=35) were found to have at least one Critical Care Nurse at post. Thus, Critical Care Nurses were completely unavailable in over 70% of primary hospitals. Similarly, two (2) Regional Hospitals also lacked Critical Care Nurses. Also, 43.3% (n=55) of primary hospitals had qualified Peri-Operative Nurses. As low as 22% (n= 28) of primary hospitals and 60% (n =6) of Regional Hospitals had trained Emergency Nurses. However, only 13 primary hospitals (10%) had up to two (2) trained Emergency Nurses.\
Aggregate HRH Cost Estimates: Requirements, Deficits and Distributional Inefficiencies
Using the Ministry of Health (MOH) and Ghana Health Service (GHS) perspective, the estimated cost (which included salaries, market premium and other allowances paid from the consolidated fund), of meeting the minimum staffing requirements was estimated to be about GH¢2,358,346,472 which is equivalent to US$521,758,069 (using December 2017 Interbank Exchange Rate of US$1: GH¢4.52) while the current cost of the staff at post was estimated at GH¢1,424,331,400 (US$315,117,566). The GHS, therefore, required an additional budget of GH¢1,335,069,404 (US$295,369,337) to meet the minimum requirement of staffing for the various levels of service delivery (see Table 4). This represented about 57% additional budgetary requirement to fill vacant posts to meet the minimum nationally agreed staffing norms.
However, in some health facilities, mostly in urban areas, it was observed that they had been staffed beyond the stipulated numbers in the staffing norms and could theoretically be deemed as inequitably distributed. The cost of this prevailing staff maldistribution across regions, districts and facilities (inefficient distribution of staff) was estimated at GH¢401,054,332 (US$88,728,835) annually. This represented 28.2% of the government’s expenditure on the wage bill. It was observed that the prevailing cost of inefficient staff distribution in the Greater Accra Region was about GH¢79,539,377 (US$17,597,207.30) which was the highest among all the regions. The region’s staffing cost based on numbers at post was estimated to be GH¢211,487,566 ($46,789,285) compared with the expected staffing cost (based on the staffing norms) of GH¢216,834,126 ($3,724,364), leaving inefficient staff distribution cost in the region of about 39% of its wage bill. Therefore, the potential efficiency savings from staff redistribution could offset the minimal staffing deficit if re-deployment of staff was pursued from areas of excess to areas of need in the region.
Also, the Northern and Ashanti regions were plagued with similar patterns of the high cost of inefficient staff distribution. For instance, while the Northern region was usually considered to be grossly understaffed, the analysis revealed that 36% of current staffing cost in the region was attributable to inefficient distribution which conservatively costs the government some GH¢78,038,383 ($17,265,129) annually. In the same vein, 29% of the prevailing staffing cost in the Ashanti region was attributable to inefficient distribution which amounted to potential efficiency savings of GH¢53,274,031 ($11,786,290.04) annually if redistribution was pursued in the region.
It is noteworthy, however, that the Eastern Region had the lowest cost of inefficient staff distribution of GH¢23,017,244 ($5,092,310.62) per annum which translated into 16% of the prevailing staffing cost. The region was, however, confronted with a significant shortage of health workforce which required a net investment of GH¢198,814,906 ($43,985,598.67) over 5 years after the re-deployment of excess staff to meet their minimum staff requirement. See Table 4 for details of the expected staffing cost compared with the current cost and the potential efficiency savings that could accrue from staff redistribution across all regions.
It is worth noting, however, that the aforesaid costs varied significantly across different categories of health workers as presented in a national summary in the supplementary Table 1.
Table 4: Cost of Aggregate HRH Requirements, Gaps and inefficient distribution in Ghana by Regions.
Region
|
Total Expected Cost
|
Total Current Cost
|
Cost of Inefficient Staff Distribution
|
Total Cost of Shortage
|
Proportion of Inefficiency to Current Cost
|
(GH¢)
|
US$
|
(GH¢)
|
US$
|
(GH¢)
|
US$
|
(GH¢)
|
US$
|
Ashanti
|
307,673,077
|
68,069,265
|
184,695,059
|
40,861,739
|
53,274,031
|
11,786,290
|
176,252,049
|
38,993,816
|
29%
|
Brong Ahafo
|
232,105,773
|
51,350,835
|
114,796,453
|
25,397,445
|
23,396,508
|
5,176,219
|
140,705,828
|
31,129,608
|
20%
|
Central
|
182,776,572
|
40,437,295
|
116,987,137
|
25,882,110
|
31,458,889
|
6,959,931
|
97,248,323
|
21,515,116
|
27%
|
Eastern
|
322,420,490
|
71,331,967
|
146,622,828
|
32,438,679
|
23,017,244
|
5,092,311
|
198,814,906
|
43,985,599
|
16%
|
Greater Accra
|
216,834,126
|
47,972,152
|
211,487,566
|
46,789,285
|
79,539,377
|
17,597,207
|
84,885,937
|
18,780,075
|
38%
|
Northern
|
290,656,714
|
64,304,583
|
217,152,425
|
48,042,572
|
78,038,383
|
17,265,129
|
151,542,672
|
33,527,140
|
36%
|
Upper East
|
148,811,404
|
32,922,877
|
92,074,647
|
20,370,497
|
24,167,133
|
5,346,711
|
80,903,890
|
17,899,091
|
26%
|
Upper West
|
171,496,126
|
37,941,621
|
69,139,832
|
15,296,423
|
18,871,455
|
4,175,101
|
121,227,749
|
26,820,298
|
27%
|
Volta
|
235,851,965
|
52,179,638
|
127,988,154
|
28,315,963
|
29,751,003
|
6,582,080
|
137,614,814
|
30,445,755
|
23%
|
Western
|
249,720,225
|
55,247,837
|
143,387,300
|
31,722,854
|
39,540,309
|
8,747,856
|
145,873,235
|
32,272,840
|
28%
|
National
|
2,358,346,472
|
521,758,069
|
1,424,331,400
|
315,117,566
|
401,054,332
|
88,728,835
|
1,335,069,404
|
295,369,337
|
28%
|
Cost Estimates of Staffing Requirements, Gaps and Inefficient Distribution at Various Levels of Service Delivery
The analysis revealed significant health workforce expenditure gaps and inefficiencies for the various levels of healthcare delivery within the GHS (see Table 5). In particular, the expected annual staffing cost for CHPS was estimated at GH¢231,823,176 (US$51,288,313) as against prevailing expenditure of GH¢191,693,352 ($42,410,033) – 21% less than optimal wage bill related expenditure at the community level. However, despite this apparent workforce expenditure deficit, the total cost of inefficient staff distribution within CHPS was estimated to be GH¢95,147,366 ($21,050,302.21) annually. Thus, almost 50% of prevailing staffing cost at CHPS could be optimised via possible staff redistribution especially for Community Health Nurses of which about 2,992 could be redistributed to cover 77% of the existing gaps for Community Health Nurses.
For Health Centres, the annual expected cost of staffing based on the staffing norms was estimated at GH¢570,040,243 (US$126,115,098) while the prevailing cost was estimated to be GH¢320,121,782 (US$70,823,403), but the prevailing cost also contained inefficient staff distribution which was roughly GH¢100,744,215 (US$22,288,543), representing 31% of the prevailing staffing expenditure. Therefore, the total cost of staff shortage could be ameliorated by about 29% if staff rationalisation is undertaken.
Furthermore, the annual expected cost of staffing Polyclinics was about GH¢98,443,018 (US$21,779,429) compared with a prevailing expenditure of GH¢80,600,579 ($17,831,987). However, maldistribution of staff amongst Polyclinics costs the taxpayer GH¢30,218,681($6,685,549) per annum, representing 37% of prevailing staffing cost. For Primary Hospitals, the total expected cost of staffing was estimated at GH¢1,163,063,130 (US$257,314,852) per annum whereas the prevailing cost of staffing was about GH¢634,088,004 (US$140,284,956.64) of which GH¢120,239,721($26,601,708.19) or 19% was attributed to inefficient staff distribution.
Similarly, Regional Hospitals required an overall staffing cost of GH¢197,989,928 (US$43,803,081) compared to the prevailing expenditure of GH¢149,837,220 (US$33,149,827). About 27% (GH¢40,162,967 or $8,885,612) of the current cost was, however, attributable to inequitable distribution of staff which could offset nearly half of the additional staffing expenditure (GH¢88,315,674 or $19,538,866) needed across all the Regional Hospitals.
From the foregoing, it was apparent that while current staffing expenditure is generally below expected levels, an average of 22% (range: 14-50%) of existing staffing cost across the levels of primary and secondary healthcare could be better optimised using staff rationalisation.
Table 5: Cost estimates for staffing requirements, gaps and inefficient distribution by type of health facility
Type of Facility
|
Total Expected Cost
|
Total Current Cost
|
Total Cost of Inefficient Distribution
|
Total Cost of Shortage
|
% of Inefficiency to Current Cost
|
GHc
|
US$
|
GHc
|
US$
|
GHc
|
US$
|
GHc
|
US$
|
CHPS
|
231,823,176
|
51,288,313
|
191,693,352
|
42,410,034
|
95,147,366
|
21,050,302
|
135,277,190
|
29,928,582
|
50%
|
Health Centres
|
570,040,243
|
126,115,098
|
320,121,782
|
70,823,403
|
100,744,215
|
22,288,543
|
350,662,676
|
77,580,238
|
31%
|
Polyclinics
|
98,443,018
|
21,779,429
|
80,600,579
|
17,831,987
|
30,218,681
|
6,685,549
|
48,061,119
|
10,632,991
|
37%
|
Primary Hospitals
|
1,163,063,130
|
257,314,852
|
634,088,004
|
140,284,957
|
120,239,721
|
26,601,708
|
649,214,847
|
143,631,603
|
19%
|
Regional Hospitals
|
197,989,928
|
43,803,081
|
149,837,220
|
33,149,827
|
40,162,967
|
8,885,612
|
88,315,674
|
19,538,866
|
27%
|
District Health Directorates
|
71,349,138
|
15,785,208
|
27,744,496
|
6,138,163
|
3,901,849
|
863,241
|
47,506,490
|
10,510,285
|
14%
|
Municipal Health Directorates
|
28,256,462
|
6,251,430
|
13,683,188
|
3,027,254
|
3,027,632
|
669,830
|
17,600,906
|
3,894,006
|
22%
|
Metropolitan Health Directorates
|
3,417,796
|
756,150
|
1,592,694
|
352,366
|
336,300
|
74,403
|
2,161,401
|
478,186
|
22%
|
National
|
2,364,382,891
|
523,093,560
|
1,419,361,317
|
314,017,990
|
393,778,730
|
87,119,188
|
1,338,800,304
|
296,194,758
|
28%
|