Ghana: To export nurses or not?

This week was one of those weeks where I had struggled to make my mind up regarding what to share with readers. I struggled because there was so much happening on the health front. At the beginning of the week, there was talk about nurse skill transfer by way of export. Midweek, I found myself grappling with why Ghana seemed to have a booming funeral economy but tanking health economy. In the meantime, other issues of relevance in the news. It was difficult to pick one story and research effectively without feeling that deliberate neglect of other important matters was taking place. However, one particular issue kept my focus and that was the commitment of our President to export help human resource to the Caribbean.I guess it did because not too long ago I had written a piece on Ghana’s nursing deficit and suggested ways by which it could be bridged. Secondly, all the other issues were indicative of a struggling health delivery system that relied heavily on the adequacy of nursing services.

That there is a drastic shortage of nurses across the world is a known fact. A number of reasons have been given for this phenomenon including, an ageing population in the developed world, increased life expectancy overall in most countries due to decrease infant mortality, better management of many chronic diseases mostly in the developing world, advancements in the fight against cancer through new frontiers of individualised gene therapy and a decrease in the number of infectious diseases that lead to mortality especially in the developing world. Ironically, though the developed world has more sophisticated healthcare, nursing is one profession where as a result of their ageing population they seem to require more numbers. In the UK, for example, it is estimated the 51,000 nurses will be required by 2021 to plug the National Health Service nursing deficit. According to the World Health Organization (WHO), the situation is no different across the G20 with 77% of developed countries facing a nursing staff shortage. Realising that local training cannot plug these gaps, nearly all of these countries relying on nurses from abroad to ease this situation. This development has mixed consequences for emerging economies, especially in the lower middle-income bracket.

As countries of emerging economies have seen considerable social mobility, their requirements for nurses has appreciated too. Thus, though Barbados has a nurse to population ratio of 1 nurse to 227 citizens compared with Ghana with a ratio of 1 nurse to 839 citizens, with a Gross Domestic Product (GDP) of $15,206 (approximately four times that of Ghana), I was not surprised they required more health human resources. A look at the life expectancy data for the two countries makes interesting reading. Whilst Barbados has an average life expectancy of 77.05 years (1.85 years higher than their populations predicted life expectancy at birth of 75.2 years and 5.05 years higher than the world average of 72 years), Ghana’s life expectancy is 65.5 years (3.5 years less than our predicted life expectancy at birth of 69 years and 6.5 years less than the world’s average life expectancy).

The implications of this are that many in Barbados are living longer than expected and having to cope with chronic diseases which require more nursing care. Whereas with a 27.4% increase in Ghana’s midlife death rate, many between the ages of 25 years and 54 years are dying much earlier before their requirement for old age nursing becomes a societal burden. This coupled with the fact that the government has little money to absorb all trained nurses in Ghana into employment implies that our country has about 10,900 trained and qualified nurses sitting at home. I have always said this is sacrilegious to our educational system and an indictment on the intellect of these unfortunate nurses and our country as a whole.
With this in mind, is the best option exporting our artificial excess capacity? I will want to answer this question from two fronts. Firstly, from the personal benefit of the individual nurses. Truth is, most of these nurses have skills that are required worldwide. In recent times, the United Kingdom has rolled out the red carpet to these nurses on condition that they are able to pass an English competency test. Sadly, most who have attempted this have not made the mark, with those who have made the mark promptly getting jobs that pay them wages they could have only dreamt about had they stayed in Ghana. The option to work in the Caribbean where an English proficiency test is not a requirement and salaries are much higher thus becomes an attractive alternative. My checks indicate that a registered nurse in that country will earn a starting salary of $15,373 per annum (GH82,759 per year or approximately GHS6,896 at current exchange rate).

Also, the career prospects and professionalism that surrounds their work in the developed world and these new emerging economies ensure that they thrive. A check with many UK NHS Trust will point to the fact that most of the nurses originate from the Philippines (currently the largest source of migrant nurses worldwide), the Caribbean, South Africa, Ghana, Nigeria and India. These nurses are known to send significant remittances back home helping their families and boosting the local economy. Others have engaged in skills transfer as a means of helping to upskill their local counterparts.

For the country as a whole, this sort of migration cannot be seen as having a positive impact on our quest for health improvement. To start with if we want to seriously tackle the chronic disease creep and to decrease the ascending death rate of our active working population, we would require citizens to increase the average number of times they attend outpatient appointments to ensure that they stay healthy; and have diseases like diabetes, asthma and cardiovascular conditions like hypertension under control. At the current outpatient per capita of 0.97, even a doubling of this figure will have a significant impact on chronic disease management as citizens on average will see a health professional once every six months but will also require more nursing hands.

This is because such chronic disease monitoring these days are carried out worldwide by nurses with specialities in these specific areas who can afford the skill, knowledge and time for patients in a manner that time constraints on doctors prevent them from. Thus, we would require an upskilling of many of our current crop of general nurses to specialist and backfill from the pool of unemployed and newly trained nurses, if we have any plans of ensuring our productive workforce live past age 65.

Many will go back to the financial question and ask how we through government would pay for this. Reality is we cannot expect the government to foot this bill on its own. Our health economy as it stands will require considerable private investment backed by a willingness from the government to create an enabling environment if we are serious about remodelling it. Many entrepreneurs can opt out of the over-concentration on the funeral economy to focus on health. A serious country invests in the health of its citizenry rather than monetize their death. It would also require regulators of the health profession ensuring that private players employ qualified nurses only. If we did this many would be surprised at the number of these unemployed nurses who would find themselves in jobs. I have argued in the past that the quality of health staff could become a declaration that all health facilities would have to make when submitting claims to the National Health Insurance Scheme, for example, and non-compliance could result in withholding of payments.

In summary, I would conclude by saying the arguments that the export of nurses as proposed by Mr President is a silver bullet that could help fix the problem of unemployed nurses is a huge smoke screen. No single solution in isolation without taking all the underpinnings of our nursing requirements into consideration will solve the problem and improve the quality of nursing care we receive as people at the same time. All that will be achieved with this approach will be to create winners and losers whilst doing little to improve our quality of life or the proportion of our population that lives beyond 65 years which currently stands at 3.38% compared with 11.81% for Barbados. I welcome any debate on this subject encouraging readers to pitch their truth against mine as Marcus Aurelius always insisted.

By Kwame Sarpong Asiedu