Health workforce retention situation and effect on service delivery in three highly deprived districts in Ghana: a mixed methods design

Background Health systems in low- and middle-income countries are experiencing numerous challenges, including a health workforce crisis, primarily in retaining health workers in rural, deprived areas. This paper explores stakeholders’ perspectives about the health workforce retention situation in deprived settings and how this affects health service delivery. Methods The study was conducted in three deprived, hard-to-reach districts of the Eastern region of Ghana, namely Kwahu Afram Plains North (KAPN), Kwahu Afram Plains South (KAPS), and Kwahu East (KE). The study followed a mixed methods approach, analysis of existing human resource (HR) data, and 21 in-depth interviews (IDIs) with key stakeholders and nine focus group discussions (FGDs) with community health committees to understand how attrition affects health services provision in deprived settings. The qualitative data were analyzed thematically, and the HR quantitative data were descriptively analysed. Results Across the districts, there is very high staff turnover. For example, KAPS exhibited the most volatility, with turnover rates from 0% in 2019 to a peak of 5.16% in 2023. District and sub-district health managers described the staff turnover situation in two dimensions. First, they discussed the phenomenon of health workers being posted to these settings but rejecting postings despite being officially posted by the Ghana Health Service. Managers also reported scenarios where postings were accepted and staff reported, only to stay for a short period before vacating. Another key feature was the high vacancy rates, with 46%, 38%, and 31% in 2023 in KAPS, KAPN, and KE, respectively. The health worker density in the three districts is very low, falling below the World Health Organization's (WHO) recommended threshold of 44.5 health workers per 10,000 population. The health workforce retention situation had serious ramifications for the provision of healthcare in these contexts. Across the three districts, participants reported a) poor quality of care, b) disrupted service delivery, c) poor health outcomes, and d) overwork of existing staff. However, evidence showed that such staff shortages presented excellent capacity-building opportunities that otherwise would not have existed for these non-expert, lower cadre staff. Conclusions The findings provide evidence about the health workforce retention situation in hard-to-reach areas in Ghana and how it impacts healthcare delivery. This study has also provided substantial depth and breadth of evidence to support the formulation of well-informed, evidence-based policies to tackle current retention problems in hard-to-reach communities.