The challenge triangle of the Ghanaian Nurse

“I have lived and slept in the same bed with English Countesses and Prussian Farm Women…no Woman has excited Passions among Women than I have.”

The above quote is credited to Florence Nightingale, widely regarded as the Founder of Modern Nursing; a Selfless and God-fearing fellow who left a life of luxury to care for the Sick and Dying, during the Crimean War.

In 1974,the International Community honoured the memory of Miss Nightingale, by declaring May 12 as the International Nurses Day, in memory of her Birth Anniversary.

As we celebrate Nurses today, I join hands with many others across the world to congratulate all Nurses the world over, on their tireless efforts in patient care.

I empathize with nurses, in their struggles as they brave the odds to take care of their patients; and take cognizance of the fact that, sometimes, the tough times that they go through may make them forget why they chose Nursing, as a career in the first place.

But then there are people who always zap them back to reality and inspire them to stick to the fight; and that includes their Mother, Florence Nightingale, as espoused in her quote above.

The Ghanaian Nurse, today, is challenged by a Triad of 1) Difficulty in obtaining admission into nursing school, 2) More Difficulty in successfully completing nursing training once admitted, and 3) Extreme Difficulty in finding work employment after a successful post-training internship rotation.

This was not the case, a few years gone by, when there was an ‘Affirmative Action’ to get the nursing profession in Ghana populated to make up for the widening gap in the Nurse-Patient Ratio.

In the late 70’s, entry into nursing training was facilitated with relatively average post-basic grades, and juicy trainee allowance. This seemed to have worked, until another challenge reared its ugly head; the problem of Out-Migration of ‘already made quality’ GH Nurses into more developed economies of the west and Europe. This challenge took a spike over the decade period of 1995 to 2005; after which the Ministry of Health(MOH) put in an intervention Policy of holding Government-funded nursing graduates to a 5-year Bond, to serve in a Public Health facility, following which the graduate was free to move into the Private Sector or travel abroad.

Understandably, Public Sector Nursing Training Institutions became the envy of many a prospective nurse, as gaining entry meant ‘automatic’ access to Nursing Trainee Allowance and ready Public Sector job, after completion.

As Private Sector participation in nursing training increased, the advantages in Public Sector nursing training became more apparent; and consequently admission demand outstripped training post availability supply in the public nursing colleges, with its attendant alleged Bribery and Corruption; College Principals being principally accused.

This strategy of Bonding and Posting trained nurses to Government Hospitals, Clinics, Health Centres, and Community-based Health Planning and Services(CHPS) compounds, had also been achieving its end, until about a decade ago when yet, another challenge surfaced. Successive Governments had been struggling with a ballooning Public Sector Wage Bill, amid poor management of the National Economy.

This basically made it difficult for the MOH and Government of Ghana (GOG) to find Financial Clearance with the Finance Ministry, and make timely postings of bonded nurses, leaving in its trail, a backlog of over 30,000 bonded but un-posted nurses and midwives.

At the tail end of the John A. Kufour administration, the Health Ministry gave a hint of cancelling the ‘Bonding Policy’. This idea was also entertained by Prof JEA Mills(of blessed memory) when he won power from the Kufour regime; but the Mahama-led administration that took over from the Mills government, was forced to cancel the trainee nurse allowance, under an Extended Credit Facility(ECF) with the International Monetary Fund(IMF). The Mahama administration was also accused of turning a blind eye to fulfilling its part of the contractual agreement of posting bonded nurse graduates, heaving a pile of Bonded but Un-posted Nurses and Midwives, since the year 2011.

The state of affairs currently; well we are told by the new Government of President Nana Addo Dankwa Akufo-Addo (Prez NADAA), that some 21,000 nurses and midwives have been posted within the quarter of their first budget. However, this, if wholly true, has not come easy; as the new political leadership of the MOH has recently been inundated with picketing of nurses, midwives, and other allied bonded but un-posted health graduates.

It is evident that the MOH dreads the fate of many other nurses, soon to graduate…especially from the backdrop of the Akufo-Addo government restoring the trainee allowance policy, and having given indication of extending the credit facility arrangement with the IMF.

It comes therefore as no surprise that, Kwaku Agyemang Manu, the Honourable Minister of health, and his deputy, Tina Mensah(MP), have separately been quoted on Starrfmonline, indicating government’s intention of cancelling the 5-year trainee bonding policy.

The way I see the Health Ministry’s intended shift in paradigm; I say a Reaction instead of a Response to the continued need to produce more nursing staff, to continuously improve the Nurse to Population Ratio. Ghana is yet to meet the recommended International Nurse-Citizen Ratio of 1:1,000, or 10:10,000, also expressed as 100 nurses to 100,000 citizens.

At the turn of the year 2013, the Ghana MOH reported that its nurse to population ratio had seen a 20% improvement over the 2012 figure, although it fell short of the 2013 programme of work target of 1 nurse to 800 citizens; and the MOH took liberties to pat itself on the shoulder by concluding that the Ministry nearly met the World Health Organization(WHO) target of 1(one) nurse to 1,000(one thousand) citizens.

This so called ‘great achievement’ pales up when compared with Germany’s ratio of 11.5:1,000 in the same year under review on the world bank OECD workforce scale.

It becomes even more pale when compared with 1990 world bank figures of Zimbabwe (1.4:1,000), Ecuador(1.6:1,000), Oman(2.2:1,000), Cyprus (3.6:1,000), Japan(6.4:1,000), and San Marino (25.5:1,000).

We do need more nurses, especially with our 2014 National Unemployment Rate at 5.2%, an annual population growth tottering under 3%, and with an Economy showing signs of recovery and potential positive growth.

Sometimes, I get the feeling that the Government/ MOH forget that Healthcare is an Essential Service. Health as an Essential Service has 2 implicit values, that, it is so crucial to the consuming public 1) that it cannot be sold at commercial rate, and 2) that it should not ordinarily be withheld from consumers. It is therefore imperative, as a developing economy, that, Government continues to lead the way in providing Public Sector Healthcare in order to insure Cost Subsidy to the public.

Also, the Prez NADAA Government should remind itself that it has recently fulfilled a campaign promise of Restoring the Nurse Trainee Allowance Policy in its 2017 Appropriation Act; a major delineation factor between Public and Private Sector Nursing Training Institutions.

Government’s consideration to embark on a wholesale cancellation of the nurse bonding policy, therefore, is probably not a well thought through Response to the current problem; rather a Reaction out of frustration. Going forward, the MOH may consider the following:

Bonding some nurses/midwives on need basis, in accordance with its 5-year programme of work outlook. The selected bonding should also be done at the postgraduate and specialized nursing/midwifery training levels. The Ministry may also give bonding quotas to District and Regional Health Directorates based upon their own projected needs. This will enable the MOH plan well with the Finance Ministry for Financial Clearance and prompt posting of staff to fulfill their bonds.

The Nurse Trainee Allowance should be maintained, but merely in nomenclature. Beneficiaries will pay back into a Revolving Fund, once they get employed after school, through monthly deductions over a 36 to 60-month period. The payment should be without interest, but the principal base of the fund should be invested strategically to yield some decent and relatively risk-free returns. Further payment of trainee allowance may subsequently be made from this Revolving Pool. Un-bonded beneficiaries may redeem their payment in bulk or installments before clearance to travel abroad; or they can pay through deductions at source from their private employers in an arrangement with the MOH.

Central Government should take steps to support the Private Sector in Healthcare participation. Start-up credit facilities may be advanced to Syndicated Large Group Practices, while these may be given Tax Incentives once they reach an agreed nurse employment carrying capacity. These private facilities may also enjoy import duty rebates on Equipment and Instruments. Government may then be in a good position, to negotiate reasonable ‘control prices’ for patients with these private facilities, thereby enabling affordable care access to the consuming public.

The MOH and Ghana Health Service(GHS) should strongly consider high skilled training of Nursing/Midwifery Staff, in Sub-Specialty care to provide Medical Tourism to our Neighbouring West Africa, Europe and the West; especially in Assisted Fertility and Reproductive Health care. These have the potential to increase the Internally Generated Fund(IGF) base of the Health Service.

Hopefully the above suggestions may give Government something to wrap its thought around, as it moves to make the Health Sector more efficient and productive.

And to our ‘over-burdened’ and probably ‘under-compensated’ nurses; as you celebrate your day, today, let me remind you that, it is easy to get lost in your struggles and forget about your mission as Modern Nurses…to Care, to Heal, to Serve Humanity.

Let the Florence Nightingale Legacy remain Heartfelt. Happy Nurses Day!

Author: E.K.P. Kwarko (MD, MPH), is an Obstetrician Gynaecologist, a Public Health Practitioner, and a Public Interest Advocate.