Postings And Transfers In The Ghanaian Health System: A Study Of Health Workforce Governance

The Ghana Health Service (GHS) is the public sector service delivery agency of the Ministry of Health (MOH). The GHS was established by the Ghana Health Service and Teaching Hospitals Act (525) of 1996, which created an agency model for the MOH. The GHS is administratively decentralised down national, regional, district and sub-district lines. In terms of human resources management, the MOH has a Human Resources Directorate with overall responsibility for the nation’s health workforce planning, administration and development across its different agencies (which apart from the GHS includes regulatory, purchaser and training agencies). Within the GHS itself, a Human Resources Directorate at national-level headquarters is responsible for training, planning and management functions of the public sector health service delivery workforce it controls. Professional nurses make up the greatest proportion of health workforce in Ghana (i.e., 26.8%); this is followed by enrolled nurses (25.4%), community health nurses (18.4%), and midwives (12.8%). Though the Greater Accra Region is the second most populous region in the country, being the capital city region, it attracts the greatest numbers of staff, and has the highest proportion of professional nurses, midwives and community nurses in the country.

A health workforce which is appropriately deployed and well-motivated is crucial to supporting health service delivery. Postings and transfers – that is the decision making and negotiation regarding where health providers work, and their geographic mobility within the health system – is an under-researched aspect of health workforce governance. How and why the health workforce is deployed across geographic settings is foundational to the delivery of public services because it affects attainment of health goals like universal health coverage through issues of maldistribution, absenteeism, poor morale, decreased efficiencies, and lowered health system accountability. The limited evidence to date shows that postings and transfers are mediated by a variety of complex factors, such as public administration standards, labour market forces, political dynamics, professional power, human resource management systems and accountability mechanisms.

There is much literature from Ghana and other low- and middle-income countries identifying factors which influence staff preferences to take up or stay in posts, such as remuneration, career progression opportunities, facility infrastructure and social amenities (e.g., schools for children, employment for spouses, road networks, and accommodation). However, much of this work has focused on broader issues of attraction, motivation and retention, with very minimal attention paid to understanding the actual dynamics of the posting and transfer process itself. What is missing in our understanding of postings and transfers is the complexity of negotiations between the one posting or transferring and the one being posted or transferred. These negotiations themselves are complex because they magnify issues of governance: they reflect potential flashpoints between individual and organisational goals which are embedded in broader policy contexts, health system organisation, and power dynamics. The content of the concept of health systems governance has evolved over time from regulation and stewardship to greater acknowledgment of the importance of leadership. While the concept of governance in health continues to emerge, the literature remains lean and primarily normative, that is, there is little empirical evidence from real-life systems on ‘what is’ governance, rather than idealised statements of ‘what should governance be’. The objective of this article is to explore the formal and informal policies and processes which underpin posting and transfer practices at district-level.

Formal rules for decision-making authority for postings and transfers are cascaded down MOH and GHS lines. Each level, from MOH headquarters to GHS headquarters, to regional, district and facility levels has a different scope of decision-making authority regarding the posting and transfer of employees, generally related to the mandate of that level. Thus, MOH as the coordinating body for the entire health sector determines agency staff allocations, and post staff to its agencies (such as the GHS). MOH has no formal posting and transfer powers within the agencies themselves. GHS headquarters determines staff quotas at regional level and posts to regions, but has no posting and transfer powers to specific districts. GHS-HQ must, however, be informed of the final postings and transfers within-region as part of its monitoring of staff distribution. If staff want to move from one region to another, they have to seek release from their region of work to GHS-HQ, and GHS-HQ confirms that there is a vacancy in the region the staff desires to move into prior to posting them. A region can refuse to release or accept staff. Similarly, the region posts to districts and is not supposed to interfere with facility posting within-district. Again, the district can refuse to release or accept staff. Inter-regional postings are identified on regional needs and are the responsibility of either the director-general, director of human resources, or regional directors of health services, depending on the category of staff. Postings across districts are the responsibility of regional directors. Postings within districts are the responsibility of district directors. Therefore, it appears that the bulk of posting and transfer powers exists somewhere between the region and district. Staff distribution is meant to be done on the basis of need, geographical access and equity, and the principle underlying posting is that staff are to be distributed solely on a basis of vacancies, and they are to “be done with fairness and transparency”.

It is generally understood that while the rules are generally adhered to, there are informal lobbying mechanisms by which people get around the rules based on ‘who you know’ at which level, and also that the strongly hierarchical nature of the health system makes authority at lower levels hesitant to confront authorities at higher levels. There are three themes : 1) differential negotiation-spaces at regional and district level surrounding postings and transfers; 2) lack of clarity of staff on conditions of service for transfer or study leave eligibility; and 3) a sense of unfairness in the posting and transfer system from the perspective of district managers and staff alike. In practice, staff reach the district in a variety of ways. There are two negotiation-spaces during the posting process. The first occurs at the region-level interview. First, staff are given a GHS posting form to fill and submit. They are then called for interview. Staff largely reported that they are posted to the region where they were trained. However, there were several cases where the regions were “full”, i.e., had reached their quotas for staff of particular cadres. In those cases, staff were able to choose another region, or were assigned a region directly. About half of staff reported that during the regional interview they were given the option of choosing three districts of their preference.

If a staff is married they can provide their marriage certificate to support their request. However, choices are not met in every case. Others reported being assigned a district directly, without option. Of those interviewed staff who were given options, the single-most important factor in their choice of district was accommodation availability, particularly in rural areas where staff are less likely to have relations or friends. Other factors which influenced their choice of district were varied and ranged from marital issues (desiring to be near spouses), parental/familial issues (desiring to stay near ailing parents or extended family, or desiring to move away from family to gain independence – this was especially important for younger staff in their first post), and greater exposure to work tasks in a rural setting. Staff also heavily relied on their informal networks (colleagues and extended family) to advise on the particularities of a district to inform their choice. Still others believed that it simply was not allowed to refuse a posting, or that refusal will lead to unemployment, partly because they have observed this happen to other colleagues. Our findings reflect the fact that the majority of interviewed staff did not feel empowered to refuse the district to which they were assigned. When staff did feel emboldened to refuse postings, a key reasons was when they had observed other colleagues having had the ability to change their postings. These changes were possible regardless of whether the health worker had someone to lobby on their behalf or not.

The second negotiation-space occurs when staff report to the DHA. Districts receive new staff via two means. The first is that the DHA scans the needs of the district and then lobbies the region for them to assign staff, and are successful. The second is when the region sends staff that they have received to the district, often straight from the training institutions. Staff are to appear at the DHA they have chosen or have been assigned to with their posting letters. Once at the DHA, staff are interviewed by the district director and deputy director of nursing services. Staff are then assigned to sub-districts; certain cadres, such as community health nurses which are numerous, ballot for placement, which involves placing their names on pieces of paper for random selection for the sub-district facility they will be posted to.

District managers largely concur that in their posting decisions the needs of the district took priority over posted staff’s personal factors. While the DHA did try to accommodate staff by balancing factors of staff qualifications, marital status, language and housing accommodation, district managers indicate that these do not override the needs of the district. Where there appears to be even less negotiation space is around transfers (all-types within and across districts and regions). There exists a perception that transfer was most often employed more punitively than as reward. Both district managers and staff share this view. Transfers often come unexpectedly, are disruptive, and staff would simply be informed by the DHA that they were being transferred with minimal consultation. Many staff who have been transferred complain that they are given little time to move (in one case, just 1 week), and in a context of limited accommodations, especially when rents are paid 1–2 years advance without refund, this was particularly challenging.

In practice, staff are eligible to apply for transfer after 5 years. If they are able to find someone to swap with them then they can go sooner, however the administrative procedures mean this can take several months.

One of the main issues for staff postings and transfers is related to study leave. Study leave with pay is dependent on staff attending an approved list of training institutions, as well as an approved list of training programmes. The procedure for study leave is that staff submit a letter of intent 1 year in advance of when they would like to go on study leave. The lack of policy communication, and thus staff clarity surrounding conditions of service results in a sense of unfairness in the system from staff and district managers alike. However, because of the greater negotiation-space (in the case of postings) at regional-level as compared to district-level, interviewed staff appear to trust the region more, viewing them as more favourable to their preferences.

Conclusions In a context of ambiguous conditions of service, frontline staff rely on information gathered through informal networks to make sense of the postings and transfers system. Staff do not necessarily refuse rural postings, but seek legitimate exit routes through study leave. Insufficient communication surrounding changes in postings and transfers policy, and the limited negotiation space at district-level as compared to regional-level exacerbates staff perceptions of an unfair system. There is great need for policy consistency and clarified information to better align staff and system goals.

LYDIA ANSU
PHYSICIAN ASSISTANT STUDENT
LEVEL 200
UCC