Clinton, Yvette PhD; Anderson, Frank W. MD, MPH; Kwawukume, E. Y. MB ChB, FWACS
The retention of trained health care providers in developing countries is a key component to improving health and achieving the United Nations' Millennium Development Goals, which aim to decrease maternal and child mortality.1 The migration of health workers from developing to developed countries has resulted in a health care workforce crisis that threatens progress in global health.2 According to the Ghana Ministry of Health, approximately 60% of physicians trained in Ghana in the 1980s have left the country.3 As of 2002, 30% of physicians trained in Ghana were practicing in the United States or Canada,4 and in 2003, the United Kingdom approved 850 work permits for Ghanaian health and medical personnel (including physicians and nurses).3
Researchers have not fully explored the role of postgraduate training for specialists in developing countries as a possible intervention to improve public health and to reduce brain drain and migration. Although a number of published articles have addressed the process of establishing postgraduate training programs in some specialties,5–8 most of these studies have not examined the impact of postgraduate training on the retention of physicians in country. Recently, one of these studies—examining an internal medicine postgraduate training program established in 2001 in Laos—showed that the majority of the first graduating class (five of six residents) remained in country.6 An objective assessment of why physicians matriculate into these postgraduate programs and remain in country after graduating may be useful to encourage and develop such programs for sustainable human resource capacity and public health improvement. Understanding how programs retain physicians could provide a theoretical basis for why and how postgraduate training programs can change global health care policy and trends.
A previous study of certified specialists who had completed an academic university-based postgraduate training program in obstetrics–gynecology (ob/gyn), at both the Korle-Bu Teaching Hospital (Accra, Ghana) and the Komfo Anokye Teaching Hospital (Kumasi, Ghana), demonstrated that 29 out of 30 had stayed in the country.9 This high retention was mainly due to the actual availability and presence of a viable training program in Ghana; social and economic factors also played a significant role in graduates' decisions to stay in Ghana. Graduates of the training program wanted and were able to practice as faculty at universities, to provide service for the Ministry of Health, and/or to go into private practice in Ghana.9 In the current study, to complement our previous findings of graduates from the training program, we interviewed current residents enrolled in the ob/gyn postgraduate training program at the Korle-Bu Teaching Hospital to determine the extent to which these factors play a part in a resident physician's decision to stay in Ghana.
The Ghana Postgraduate Training Program (GPTP) was established in 1989 to correct the low repatriation rate of physicians sent abroad to train. Ghanaian obstetricians and gynecologists developed a five-year curriculum, with assistance from the Royal College of Obstetricians and Gynecologists, from the American College of Obstetricians and Gynecologists, and from university ob/gyn departments in both the United Kingdom and the United States. A grant from the Carnegie Foundation of New York helped fund the GPTP. Two teaching hospitals in Ghana—the Korle-Bu Teaching Hospital in Accra and the Komfo Anokye Teaching Hospital in Kumasi—implemented the GPTP. The curriculum incorporated elements from both the British and U.S. systems adapting them to the Ghanaian context. The curriculum included management and team leadership skills, a six-month exposure to ob/gyn in an in-country rural district hospital, and a three-month externship in ob/gyn in either the United Kingdom or the United States in year five.9–11
The University of Michigan institutional review board and the Korle-Bu Teaching Hospital ethics review committee approved the study. As of July 2006, 32 residents were enrolled in the ob/gyn GPTP at the Korle-Bu Teaching Hospital in Accra, Ghana. The departmental secretary provided phone numbers for 29 of these residents. One of us (first author, Y.C.) attempted to contact all of these residents to invite them to participate, but could not make contact with three of the residents. An additional three residents were either on leave or on rotation outside of the study city, two more did not participate because of scheduling conflicts, and one was no longer part of the GPTP. All 20 remaining residents agreed to participate and provided written consent. We provided no incentives for participating.
We developed a 52-item questionnaire in English; we based the items on the three retention factors we identified in our previous research.9 This questionnaire comprised 11 demographic questions, 4 background/education questions, and 37 items to assess aspects of training and how social and economic factors relate to decisions to stay and practice (or not) in Ghana. Residents indicated on a five-point Likert scale the extent to which they agreed or disagreed with the items (5 = strongly agree, 1 = strongly disagree). The residents took about 20 minutes to complete the paper-based questionnaire. We entered the responses into SPSS (version 11, Chicago, Illinois) and calculated frequencies for individual items.
Social scientists often use semistructured interviews as a qualitative methodology to obtain a more in-depth understanding of their study participants' lives; for example, researchers evaluating an internal medicine postgraduate training program in Laos used semistructured interviews to better understand participants' experiences in the program.6 We recognized that interviews would allow us to achieve a more holistic understanding of why Ghanaian residents decided to stay in Ghana for postgraduate training and why they intend to stay (or leave) upon graduating from the GPTP.
One of us (Y.C.) conducted audiotaped, face-to-face, semistructured interviews with a convenience sample of nine participants who had completed the survey. Y.C. conducted the interviews in English, asking the residents open-ended questions about how training (including program availability), economic, and social factors related to their decisions to stay in Ghana (e.g., “What would you say is the biggest reason you're going to stay in Ghana?” “In what ways would you say that either the needs of the people of Ghana or your commitment to serve the people of Ghana influence your decision to stay in Ghana?”). Each interview lasted between 20 and 40 minutes. A professional transcriber transcribed the interviews verbatim, and one of us (Y.C.) rechecked the transcripts for accuracy. One of the tapes was inaudible and was therefore not transcribed. One of us (Y.C.) reviewed the transcripts, making notes in the margins to identify key themes to help fine-tune the code list.12 Y.C. then coded the transcripts in NVivo (Doncaster, Victoria, Australia) for themes related to training (including program availability), economic, and social factors. Y.C. created a cross-case display matrix for each factor to analyze the data. In the matrix, each participant represented a row, and each column represented a variable. Researchers often use cross-case displays to enhance generalizability and to deepen their understanding and provide further explanation of qualitative data.13 Y.C. extracted dominant themes for each a priori identified factor (i.e., training, economic, and social) and identified characteristic quotes to illustrate the themes. We (F.A. and Y.K.) verified that the themes and quotations accurately reflected the responses in context. Then, we reviewed the original transcripts in light of the findings to ensure accurate portrayal of the residents' reported experiences.
Table 1 shows the demographic information of all the survey participants as well as the data for the subset of residents who participated in the semistructured interviews.
Eighty-five percent (n = 17) of the residents self-reported that they were certain they would stay in Ghana after they completed the GPTP. Both our qualitative findings (the results of our interviews) and our quantitative findings (Tables 2-4) show that the retention of residents in Ghana can be attributed to three main factors: (1) training (i.e., the presence of a postgraduate training program in ob/gyn in Ghana), (2) social (e.g., a commitment to serve the people of Ghana), and (3) economic (e.g., the feeling that one can “make it” in Ghana).
The importance of specializing and the presence of a program.
Specializing in ob/gyn was extremely important to the residents and is one of the major reasons these physicians decided to stay in training. One resident stated, “My father was a specialist. You see, I had always been brought up to believe that I should always improve myself.” Another resident realized over time that he wanted to specialize:
At a certain stage you are in … medical school your first dream is to become a doctor. When you become a doctor, you finish your “housemanship,” start working … then you begin to realize that it's not just enough probably—you have to become a specialist.
We asked participants what they would have done if no postgraduate training programs had been available in Ghana. One stated, “Oh, I would have left [Ghana] … because I really wanted to … have postgraduate training. I would have moved out.” Similarly, another resident expressed, “I would have gone outside … because graduate training was … paramount to me.” Specialization was so important to the residents that 95% of them (n = 19) reported they would have left Ghana if the country had no postgraduate training programs (Table 2).
Whereas a few of the interviewed residents reported that they would have been interested in a postgraduate training program in internal medicine, pediatrics, or surgery, most expressed that they really wanted to specialize in ob/gyn (Table 2). One resident stated,
Once I had decided that I wanted to do obstetrics and gyny, wherever the training program was, even if it had been on the moon [laughter], I would have gone.
A few residents reported that they had considered leaving or had actually left Ghana to find a specialization program elsewhere. These physicians reported that getting into an ob/gyn residency program outside of Ghana was difficult, so in the end they had decided to stay in Ghana and specialize in ob/gyn instead of specializing in internal medicine or pediatrics in the United States. One resident stated, “My goal at that time … wasn't just to leave the country. But my goal was to do obstetrics and gynecology,” and another resident explained, “I was only interested in certain key subspecialties.… My understanding was that it wasn't easy to get [a residency position] outside, especially if you are black…. And I wasn't prepared to just accept anything at all.”
The presence of the GPTP allowed those individuals who really wanted to specialize in ob/gyn an opportunity to stay in Ghana.
Trained to practice in Ghana.
In addition to the presence of the program, the Ghanaian focus of the program was an important reason to remain in Ghana. The majority of the residents interviewed (75%; n = 15) indicated that the program had trained them to practice specifically in Ghana. When we asked one resident, “What aspects of the training program would you say have influenced you to continue to want to stay and practice in Ghana?” he replied,
I think the program in Ghana trains one to practice in Ghana. And that's probably the strong point of the program for me, because I don't plan to practice anywhere else. I plan to practice in Ghana. So the fact that it's tailored towards what we do in Ghana makes me comfortable to work in Ghana. I think that's probably the strongest point.
Another resident expressed,
I think our study here is very practical. And there's a lot of hands-on experience. You have opportunity to see a very wide range of cases … you won't stay in a labor ward here for more than a week without encountering cases like eclampsia, the ruptured uterus, or obstructed labor…. And therefore you see a lot of them, and you learn to manage them.
While not all residents explicitly linked being trained to practice in Ghana as a reason for staying in country, most agreed that the program did train them to practice in Ghana.
The dominant themes related to social factors that emerged from the resident interviews included (1) residents' commitment to serve the people of Ghana, (2) their social ties to family members and friends in Ghana, and (3) their connection to the larger Ghanaian culture and way of life (Table 3).
Commitment to serve the people of Ghana.
The residents interviewed and surveyed have a very strong commitment to serving the people of Ghana. Most of the residents interviewed explicitly stated that one of the factors contributing to their decision to stay in Ghana was their recognition that people in Ghana needed them. The residents recognized their own desire to help out.
When we asked one resident the main reason he stayed in Ghana, he replied, “I think people need you. The services are needed here.” He also expressed the importance of being able to provide specialized services, “And now I'm a specialist.… So why are you going to leave…?” Similarly, another resident reported that his “desire to serve the people is high.” This same resident also stated, “Well, I think that … [the] only reason why I'm staying in Ghana now is that I feel that my patients, for now, need me.” A third resident discussed the influence of her experience working in the district (a rural area in Ghana):
[I] got to realize that poverty is a real problem and there are people who need my help. And I guess that is also one of the things that keeps me staying, because I realize that if everybody goes, what will happen to the people who cannot afford … going outside for treatment.
Social ties to family and friends.
Other social aspects of Ghana that were important to the residents included the presence of family and friends and feeling that Ghana is home. Although these factors were important to them, the extent to which these factors played a role in their decisions to stay in Ghana varied. For some, family and friends were quite important. As one resident described,
[In] Ghana, we tend to have this extended family system where you are not alone at any point in time. Your cousins are … your family, your brothers are there, your parents are there, and you still live together, closely knit. And friends from school and friends at work still see each other as brothers and sisters[….] That bonding for me, it's very important, but you don't find this outside Ghana. For instance, you can live in the flats [apartments] for a year and not know who is next door. And the only time you probably meet is in the garage when you are both driving off…. But in Ghana it is not like that, you can visit friends, you can see them, you can chat…. And for me that is very satisfying and for which reason … I would still on this day stay in Ghana.
Although many of the residents mention that they liked Ghanaian culture, not all residents explicitly linked this with why they wanted to stay in Ghana. However, a few residents did acknowledge that this was a factor impacting their decision to stay in Ghana. For example, one resident, when asked about the factors that have kept him in Ghana, stated,
I love Ghana…. We have our own … unique things. It's silly sometimes, but you still enjoy it, you understand it. If you grew up here all your life, it's kind of difficult to imagine that you would just leave.
Even though family, friends, and familiarity with Ghanaian culture are important to the residents, the results from the survey and interviews demonstrate that the commitment to serve was a stronger factor in keeping the residents in Ghana (Table 3). One resident expressed that his family needed him, yet when asked if his family influenced him to stay and do the GPTP, he stated, “Well, they didn't really influence me in staying. But now everybody's happy I'm around.”
The residents felt that jobs in Ghana would be available to them after they completed the GPTP. The majority of residents considered salary to be important; however, they also expressed that it was not the most important factor in their decision to stay in Ghana. Although many of the residents believed that the salaries in Ghana are adequate, a couple expressed frustration with the pay and felt that the salaries needed to be improved.
Residents expressed that finding a job when they completed the program should be relatively easy. One resident stated, “Specialists are needed […] so there's always jobs available.” Another resident said,
I think [there are] a lot of job opportunities here…. The opportunities for O & G [are] there. In Ghana … look at our population. It's physically a very young population.
While most of the residents thought that finding a job when they completed the program would be easy, a few felt that finding the ideal job may be a little harder. One resident said, “It's easy to get the job … the problem is getting a job where I want it.”
Having jobs available for graduates is important, as most of the residents expressed that they would leave Ghana if job opportunities were poor. When we asked one resident what he would do if job opportunities were not good, he replied, “If I thought the job opportunities were not [good … ], I will go where I have to get [a job], because I can't be educated and just stay without working.”
Many of the residents also expressed that finding a “good-paying job” on completion of the program is important (Table 4). As one resident conveyed,
[Salary]'s quite important[….] I'm not working just because of the work. It's my occupation [laughs], and I have to earn my livelihood by it. And therefore, it should be able to support me to stay. I expect that from the job I'm doing, I'll be able to earn a decent living.
Although residents consider salary important, it is not usually the most important factor in their decision to remain in Ghana (Table 4). One resident expressed that the satisfaction is not just in making money but also in gaining recognition for his work. He stated,
I was brought up with very little…. Of course I expect to be paid. I would love to have good money. But that is not the primary reason for deciding to specialize. It's just to get the recognition to serve at the higher level. I mean, for me that is all there is to it: maybe just [feeling] prestigious to be a specialist. For me … economics [are] not so crucial.
The vast majority of residents acknowledged that they will not be paid as much as doctors outside of Ghana, yet they felt that their salaries were adequate by Ghanaian standards.
One resident stated, “So the money might not be [what I] guess [it is] in America but … it will at least give you a decent living, and fine, we will take it.” Another resident, when asked if he was worried about the economic situation, answered,
Oh, no! I'm not worried at all. I mean, as I'm healthy, I'm strong, I have the skill, I know I can earn a living. That's not a problem [laughs]. And I didn't think that I needed to travel outside to succeed.
Another resident discussed how—before he started the GPTP—he thought that in order to “make it,” a physician would have to leave Ghana, but now he realizes that physicians can afford to live in Ghana:
And now I've seen that you can stay … after finishing the program … I know you can make it here. Yes. The idea that you have to leave the country before you can make it … personally, I don't have that idea now.
Overall, the residents believed that jobs would be available to them when they completed the program and that they would be able to earn enough money to make it in Ghana.
Economic and social interactions
Two residents felt that the current salaries in Ghana are a major factor pushing them out of the country. Yet, these two also discussed social factors that tend to pull them toward remaining in Ghana. One resident stated, “Financially, I think we get a very bad deal. [Low pay is] … a strong push out of the country”; however, when we asked him why he remains in Ghana, he replied,
Well, mainly because I've stayed in Ghana for so long after medical school. And I have a lot of things going in Ghana. My family's in Ghana, my wife and kids. And I think moving would be such a major change, which would probably be very difficult … and … the size of the change … is one of the factors that is keeping me here.
Another resident who has also been frustrated with the salaries has considered leaving Ghana, but he is torn by the social factors. This resident initially had planned to stay in Ghana, but now he is not sure. He expressed that economic factors are pushing him out of Ghana:
There are so many times the doctors have to go on strike. Before you are paid, and even when you're paid, it's … it's like nothing. I mean … the amount of money that we are on strike for is really nothing to write to home about, but we have to go on strike several times before [getting] paid. And it's as soon as you finish one fight, it's another fight.
Similar to other residents, he does not expect to be paid like doctors outside and would be okay if he could have a decent living in Ghana. While the economic factors are pushing him away from Ghana, the social factors are keeping him here. This resident expressed that he really loves Ghana:
I have friends, and you grow up with people and you really feel comfortable here. So that kind of tends to pull you down [to stay in Ghana]. You wonder if … I move out, will I still be happy the way you are here…. Those are the things that kind of still attract me here, but I'm not sure how long it will keep on attracting me.
Discussion and Conclusions
Three main factors—training (including presence of program), social, and economic—seem to be interacting with one another to create a climate for retention. Residents repeatedly stated that the social factors are a significant reason they stay in Ghana; however, 95% of the residents reported that they would have left the country for specialized training elsewhere, had postgraduate training programs not been present in Ghana. Economic factors and social factors are interacting so that the strong social commitment counteracts the less-than-optimal economic factors. The end result is that 85% of the residents plan on staying in Ghana when they complete the training program.
We found that the combination of the desire to specialize and the presence of the postgraduate ob/gyn program in Ghana was imperative for retaining physicians in Ghana. Training residents to practice ob/gyn specifically in Ghana may also contribute to the retention of in-country physicians. Most of the physicians considered specialization important and indicated that if there were no specialization programs in Ghana they would have left the country to obtain postgraduate training. Furthermore, the interest in ob/gyn among the residents was high. Given that obtaining ob/gyn training in the United States is highly competitive for foreign-trained doctors, the postgraduate training program in ob/gyn in Ghana gave residents a viable option for this specialized training.14
The residents in the GPTP clearly recognize that their services are needed to improve health care in Ghana. Their strong commitment to serve the people of their country is an important reason they have decided to stay in the country. Although the GPTP uses only academic criteria for admission to the program and does not evaluate applicants' commitment to stay in Ghana, the program seems to have selected people with a strong commitment to stay in the country.
Economic factors alone do not drive retention. Some residents express dissatisfaction with economic conditions in Ghana, but the ability to receive specialist training and the rich social opportunities of being in their home country seem to make the economic situation acceptable to them.
One of the limitations of the study is that we did not interview residents at both teaching hospitals in Ghana. The residents at the postgraduate training program in Kumasi, Ghana, may differ in their views about specialization and the impact of social and economic factors in their decision to stay in Ghana.
The current study implies that this group of resident obstetricians and gynecologists will continue the trend of remaining in Ghana. This study and our previous study9 are the only published reports that identify and explore factors related to the retention of ob/gyn physicians in a developing country. The training of obstetricians in Ghana is not only important for solutions in health care worker retention but will also have a significant positive effect on access to emergency obstetric care, which will contribute to meeting the Millennium Development Goal of reducing maternal mortality by three-quarters by 2015.1 Reducing maternal mortality requires access to emergency obstetric care,15 and increasing the number of obstetricians and gynecologists in country may help to reduce barriers to care. Further, graduates of the program can train a significant number of health workers, and their leadership both improves the capacity to provide needed services at facilities and influences local, regional, and national health policy pertaining to maternal mortality.6 To better understand the public health impact of training obstetricians, we are documenting the location and scope of practice of all graduates and examining the facility and health care impact when placed in rural district facilities.
Providing postgraduate training in developing countries is a significant component in improving the global health care workforce crisis. Residents and graduates not only provide health care services but also provide health policy leadership and constitute a sustainable supply of physician and other health care personnel trainers.6 The GPTP in ob/gyn, in which participants of this study were involved, resulted from a collaboration of university ob/gyn departments in the United States, the United Kingdom, and Ghana.10,11 Faculty and students at many academic health centers have expressed great interest in global health programs. The response of those with established and well-functioning educational systems should include considering long-term partnerships with academic health centers in developing countries. Efforts to share expertise and to jointly create high-quality and sustainable training programs would contribute to the missions of each institution and sustainably enhance the long-term effort to increase the number of health workers globally.
Funding for this project was through the Department of Obstetrics and Gynecology, University of Michigan (Ann Arbor, Michigan).
The University of Michigan institutional review board and the Korle-Bu Teaching Hospital ethics review committee approved this study.
Portions of the data from this manuscript have been presented at the University of Michigan Department of Obstetrics and Gynecology Grand Rounds, March 11, 2010.