Remote, deprived districts in Ghana are experiencing an ongoing health workforce retention crisis, with high vacancy rates and health workers rarely completing their three-year postings, due to challenging conditions. Consequently, these districts are experiencing poor health outcomes. The THET funded project, led by the University of Ghana School of Public Health and the Liverpool School of Tropical Medicine, is addressing this challenge through a participatory action research project which will support the design and implementation of community-based interventions to improve health workforce retention.
We recently completed a three-day intervention development workshop in Afram Plains North with key stakeholders from the three most deprived districts in Ghana. To capture the experience of adapting to life living and working in Kwahu East, we spoke with Betty.
Betty is a midwife from Accra; she attended school in the central region, originally training as a community nurse, before being posted to Kwahu East as a midwife ten years ago. When she was informed of the posting, her feelings were mixed – whilst she was eager to get to know somewhere new, she was also “very, very disappointed” and apprehensive for the stark shift from city to rural life, admitting that when she first arrived “looking at the living conditions there, I was wondering if I could stay there even three months”.
“Though it has so many disadvantages, there are so many advantages.. you get to do things on your own, you build yourself to become a better person, you are able to do things within and outside your scope.”
Despite her initial concerns, Betty feels that the posting has been a largely positive experience, which is making herself and her colleagues “better people” through remaining focused and determined. One of the main advantages is that district postings empower you to “become independent”, presenting you with tasks which might be referred to seniors or deemed “outside your scope of work” at large hospitals. This exposure “keeps you on your toes”, equipping health workers with a broader skill set and experience than they would achieve working at urban facilities, something she noted whilst interacting with other midwives at training courses. Additionally, the experience has built her self-confidence “as a human being and as a woman”, since you “have no other choice than to be confident in what you’re doing” and do not encounter the pronounced hierarchies present in other settings. Betty also finds deep satisfaction in the close relationship she’s built with the community, explaining that through one-to-one engagement, health workers become truly integrated and gain community trust. Consequently, members readily approach her with issues and concerns, which they might refrain from doing at hospitals where they might feel intimidated. Finally, she has been lucky enough to start a family with her husband, who she met in Kwahu East.
“You meet people one on one in communities you are able to engage with whatever you are doing, so you become part and parcel with the community […] being here, wow, it’s really building relationships.”
Whilst Betty described numerous advantages of her posting, it has not been without its challenges. Healthcare workers in deprived districts are forced to function with very limited resources, which staff must overcome through constant improvisation e.g., cutting up IV fluid giving sets into smaller portions and using them to locate veins instead of using tourniquets, which are less available. Additionally, current policy does not account for the broad responsibilities of health workers in remote districts, meaning that conducting tasks outside your scope remains a legal offense.
Outside of the medical setting, health workers are confronted with basic living conditions, including lower quality water sources and housing, interrupted power supplies and limited access to high quality education for their children. Due to the long distance and poor network condition, postings in remote districts also put significant strain on relationships and family life, with Betty noting that she and many other colleagues have had romantic relationships and friendships fail because of the posting. Aside from the poor road conditions, health workers in these remote districts must cross over the Afram river, either by small boats or by ferry. Betty explains that some Ghanaians are “aquaphobic” and might not realise until they find themselves crossing the river. River crossings can also be particularly problematic for women who are menstruating, as Ghanaian culture considers menstruating women to be “unclean” and advises them against crossing the river on smaller boats, limiting opportunities to visit home or attend training and workshops in neighbouring districts. Betty feels that this is because, depending on their flow, menstruating women might experience headaches or feel dizzy and weak, potentially increasing the chance of falling into the water. Finally, she described how remote districts are typically associated with higher rates of sexual violence, having heard numerous accounts from friends and colleagues, though she notes that the frequency of accounts have been declining.
“As a woman mostly when you are in your menstrual cycle, you are not expected to cross the river […] it’s all about culture, even though we are in the 21st century we hold on to our culture […] woman is considered unclean”
Betty’s advice to other health workers facing remote postings is simple: “it’s all good – it’s all about communication, it’s about communication.. wherever you find yourself, try! Life is not always in the cities […] you are going to be a better person when you live in the smaller communities, trust me”. Currently, Betty has no plans to leave Kwahu East, though she notes that she may relocate in the future, to find better schools for her child.
“Initially I was really disappointed to come to Kwahu east, but I’ve realised that it has done me more good than harm”
Written by India Hotopf, Research Assistant at the Liverpool School of Tropical Medicine