Migration of Health Professionals from Ghana ...

...in the Context of Social Justice.

An incomplex definition of social justices means equitable access to resources and the benefits derived from them; a system that recognizes inalienable rights and adheres to what is fair, honest, and moral. For my analysis, my inclination to cadge for the application of David G. Gil?s three related levels of social justice: individual human relations; social institutions and values; and human global relations, is overwhelmingly stupendous in the analysis of health worker migration in the context of social justice for its aptness.

In his celebrated thesis, Gil at the first level conceptualized social justice in the most pithy manner, expounding individual human relations based on the ?l-Thou? treatment of all mankind, as foreshadowed in Biblical, Quranic and other gospel credos, and illustrated in maxims such as ?love thy neighbour as thyself? and ?do not do onto others what you do not want done to thyself?. In his view, it is when individuals practice the ?I-Thou? relation that people everywhere would have equal social, economic and political rights, responsibilities, and opportunities and no one would be dominated and exploited by others.

Viewing the brain drain of health professionals from Ghana in light of the above principles unclothes a concatenation of impairments that depraves what is considered just, fair and honest, at the first level of his conceptualization of social justice.

Clearly, the educational sector in Ghana receives the greatest budgetary allocation (Government recurrent expenditure on education more than doubled from 17% in 1981 to 41% in 1994 whilst the sector?s share of the GDP equally more than doubled from 1.5 in 1984 to 3.8 in 1998) which is now augmented by the GETFund, which is sourced from a 2.5% deduction from the Valued Added Tax (an indirect tax which is paid by the ultimate consumer; and for that matter all Ghanaians). The essential point here is that the continuous financial resources to the educational sector in Ghana, from which medical professionals are trained, emanates mainly from a social capital in the form of taxes, loans, inflows from benevolent institutions termed as the donor community, and not disregarding the immense contributions by the individual beneficiaries of higher education in the form of cost-sharing.

Budgetary allocation to the health sector in Ghana which currently stands 11% and projected to increase to 15% is another investment that affects directly or indirectly our spending on education and training of health professionals especially clinical and other important aspects of their training. The implication is that a super-colossal quantum of Ghana?s national budget is allocated to the education and health sectors from which health professionals benefit year in year out.

The training of a medical doctor in Ghana is pegged at $10 000 annually and estimated to cost $70 000 for the seven-year training period. These are no small investments for an economy which is going through difficult times, and it is by reason of this that even the loss of a handful of our medical professionals have dire socio-economy consequences for the Ghanaian economy.

From the on-going analysis, it is abundantly clear that the individual Ghanaian contributes in diverse ways towards funding of these two important sectors of the economy from which the health professionals are churned out, and have every right to enjoy an appreciable level of health care services, which is commensurate to this levels of investment, as a direct outcome of his/her investments.

However, contrary to the above expectation, the health worker who is a vital agent in health care delivery abnegates his/her post for the attractions of the West. As a corollary, the capacity of the health sector to provide adequate care for the tax payer (most of who live under $1 per day) is disenabled, exposing the most vulnerable to unwarranted lack of health care and protection from the detrimental effects of ill health.

Some argue that remittance from Ghanaians abroad has sky-rocketed over the years becoming one of the main sources of foreign exchange supply apart from cocoa and gold. This assertion definitively endorses the out-migration of all kinds of skills especially skilled health professionals from Ghana in search of the British Pound and the American Dollar. Migratory trends however point to the fact that it is easier for the professionals to migrate than it is for the unskilled. In this scenario, migration is not even an option for the poor and the unskilled to consider in the light of the heavy investment and the level of skill required, though there may be exceptions.

I argue therefore that even though remittance from abroad has become an important part of our economy, it mostly benefit the upper-middle-class and the upper-class in the Ghanaian society. I posit my premise on the fact that if about half the population of Ghana lives under $1 per day, then many are those who cannot afford to see their children through university for the acquisition of such skills as medicine and others which are necessary for up-ward social mobility.

Deducing from the above, it is clear that whilst the upper-middle-class and the upper class are able to afford higher education for their children through their own investment and the social investment of corporate Ghana, the lower-class are economically incapacitated from doing so. The implications are that whereas those from the upper-middle-class and the upper class families are able to berth a reasonable position on the social ladder, including the opportunity to emigrate and all the benefits that emanate thereof to them as individuals and to their families, it is as a matter-of-fact infeasible for those in the lower-class bracket.

The overall picture is that whilst the mainstay of the health sector in Ghana is from the ineluctable and de rigueur contributions of all Ghanaians, a majority of who are poor, they are indirectly robbed of these investments through the out-migration of the professionals, aided by international recruitment agencies. Consequentially, whereas the lower-class hardly benefits from the so-called remittance from abroad, they are indeed denied access to health care to which they made inescapable contributions. This gambit, in fact, defies the first level of social justice as identified from the fore-going.

The realization of social justice at the second level requires that social institutions, policies and values must encourage equal rights, responsibilities, opportunities concerning key dimensions of social life, i.e., organization of work, management of productive resources, socialization and social control among others, all in the institutional context of society.

The urgency of the above proposition, based on the dynamics of social life, which is in constant flux, requires ?the collective will of the people? to change social policies and values which are outmoded as a result of changes in social circumstances in order to achieve desirable outcomes. It should be noted that people have struggle for, and achieved, such changes throughout history, in spite of fierce resistance from social classes interested in preserving the status quo.

It is in the light of the above that we need to revisit our social values, policies and institutions to see what has gone wrong and how we can collectively initiate a change for our own benefit. By now I am sure there is no doubt in anybody?s mind that migration has become a value that is well cherished and encouraged in our society. It is fascinating how heroes are made out of the so-called ?being theres? or ?Burgers? in our society regardless of the person?s achievement in life.

Returning to the issue of health worker migration and our social policies and institutions, the ?Medium Term Health Strategic Framework 1997-2002? identified the high rate of attrition among health workers in Ghana as one of the major problems facing the sector as a result of massive out-migration. Key factors identified as responsible for this included, importantly, poor remuneration for health workers in Ghana vis-?-vis attractive service conditions in the advanced countries, among others. It is in view of this that the Additional Duty Hour Allowance (ADHA) was introduced to entice or motivate our dear health workers to stay but this could not save the situation.

The birth of the ?Human Resource and Strategic Policy 2002-2006?, which I consider the most laudable and pragmatic, in its outlook, in comparison with previous health policies, due its attempt to compensate health through other motivational packages apart from the ADHA, e.g., attachment of vehicles to deprived stations; payment of rural allowances (30% and 50% of basic salary to doctors and other staff respectively); provision of viable housing ownership schemes for health workers; award of fellowships to health workers to study abroad; educational allowances for those who need to enrol their children in boarding schools outside their stations; among others, have equally been ineffectual or not implemented at all.

It is by reason of the above that I disagree with the position of the guest speaker at the 4th congregation and swearing-in ceremony of the College of Health Sciences, Dr Charles Mensa, who likened the demand for health workers to products in economics with demand and supply determining their price. He should understand that what he is calling for is the wanton over commercialization of the health sector to the disadvantage of the poor and the vulnerable who will have to pay the price.

We should all appreciate the fact the current ADHA bill, as intimidated by the health minister (72 billion cedis) is already astronomical but has not curbed the menace though it might have helped in retaining some staff who might have left. We must also appreciate the fact that there are areas of the economy which are equally competing for scarce national resources and any extravagant increments and bonuses to health workers may spark off similar demands from other interest groups, e.g., lecturers, teachers etc. We should also be cognizance of the fact that there is no way we can meet, even half-way, the monetary gains this professionals may make as individuals abroad by the extravagant increase in wages and bonuses for them locally.

I however concur with Dr Mensa (similar calls for attitudinal change from Mr. Kwame Pianim and Mr. Kobina Okyere, Deputy Director of National Development Planning Commission) that our professionals need to stay to work for change in policy as they are young and energetic. I will also like to add my voice to this clarion call, as research has shown that it is the middle-class, of which doctor and other health professionals belong, which is able to pressurize governments towards reforms in many countries. It therefore behoves our health workers to stay and work towards policy change, if the system does not inspire confidence. It is only by doing this that we are able to create policy systems conducive to meeting our development needs as a nation.

From the fore-going, readers will agree with me that systems of social policies are always results of human choice just as values, as guiding principles, are also products of human choice. Hand in hand these values and policies shape our institutions and vice-versa. Whence, if the institutional requirements of social justice, based on our social policies and values, are not conducive to meeting our aggregate or corporate intrinsic needs such as health needs, as the case is, then there is the need for re-examination of our values, policies and social institutions for our own advancement. Anything unlike this will not work for the achievement of such desirable goals as social justice. I therefore on this note call for a national debate on the issue.

Broadening social justice progressively from the local levels to the global levels requires that we extend the ?I-Thou? relations to all the world?s people and elongating it to the institutional context of social justice from local and national to global levels. It is only by doing this that we are able to prevent all forms of domination and exploitation.

The disclosure that 600 Ghanaian trained doctors live and work in New York Area alone; about 20% of its requirement, 50% of Ghanaian trained nurses practices in the UK and a host of others scattered in the West is a clear manifestation of exploitation of the Ghanaian health human resources. Statistic has shown that the average spending on health per head in Ghana is currently ?7 as compared to ?900 in the UK. This may be even more in the United States. This implies that the both the United Kingdom and the United States, for instance, are more financially resourceful to make more investments in their health service, especially the training of health personnel than Ghana. However, in spite of this financial endowment, they prefer to ravish the health services of poor countries for their own benefits. This gambit of robbing the vital health human resource of poor countries like Ghana to redeem or sustain that of the rich is unacceptable and breaches the principles of social justice any how we may look at it. It is for this reason that London and Washington need to do more than they are doing currently to stem the tide.

Turning to institutions at the global level with the necessary leverage and responsibility to work to minimize the trend, it is abundantly clear that the modus operandi of international employers and prospective health workers seeking opportunities in advanced countries have become too complex for these institutions.

Dr Kwaku Afriyie, the former Ghana?s Minister for Health, and his predecessor in the past three or so years had launched initiatives to address some of the external factors which were probably overlooked in the past in minimizing the attrition rates. They had been very instrumental in the development of the Commonwealth Code of Practice for the international recruitment of health professionals which was adopted at the Pre-World Health Assembly meeting of Commonwealth Health Ministers on the 18th of May, 2003. Although not a legal document, it is to promote some form of fairness, transparency, and most of all some mutuality of benefit for the countries that recruit and the countries that lose their manpower in the process.

Further to this, at the recent meetings of the 57th World Health Assembly and the 114th Executive Board of the World Health Organization and the Commonwealth Health Ministers, the issue of brain drain of health professionals from Third World Countries attracted the attention of participants when Ghana?s Health Minister, Dr Kwaku Afriyie, raised the issue as part of the agenda for discussion. This led to a resolution in which the World Health Assembly charged member states to use government-government agreements to set up health personnel exchange programmes to check the exodus of health professionals from their respective countries.

Although seen as an international effort, doubts about its feasibility or viability were expressed univocally by Nyonator, Dovlo and Sagoe (all doctors with the Ghana Health Service) since its inception. They noted that, ?whilst the programme has worked between developing countries, for instance, Ghana and Jamaica, and South Africa and SADC countries, it has not received any interest with rich industrial countries?. Moreover, since it is by no means a legal instrument, benefiting countries continue to recruit from the poor countries.

The insufficiency of the Commonwealth recruitment Code was re-echoed by Mr James Johnson, the Chairman of the British Medical Association, at the opening of the ?Joint 20th Triennial Consultation/Conference of Commonwealth Medical Association (CMA) and the 46th Annual General Conference of the Ghana Medical Association (GMA), at Cape Coast, in Ghana.

It is therefore cloudless that mutualism, cooperation, fairness, honesty, equality among others, which are hallmarks of social justice with moral connotations are depraved even in international agreements leaving many moral and ethical issues unanswered.It is for the above reasons that a national debate will be necessary to engender broad-base ideas and suggestions in tackling the problem.

Clearly, health outcomes are already on the nosedive. This has already translated in low Gross Domestic product (GDP), low income investments that could never raise productivity and incomes, largely because of low health status of the people, as intimated by the sector minister a couple of days ago.

It is on this note that I add my voice to that of Mr. sam Okudjeto, chairman of the council for college of Health Sciences and others, for government to demand reparation from countries which have been benefiting from the exodus of Ghanaian medical professionals. That is the right thing to do.

Insights into the dynamics of social justice however require significant changes in values, without which there can never be any meaningful changes in our social institutions and policies. We must identify some of the culture-base obstacles in our values, the political structures, among others, that are impeding the realization of the necessary transformations in our values towards changes in our social policies and institutions towards our development.

If systems of social policies are choices in any generation and tend to be influenced and constrained by traditions and beliefs that reflect choices of prior generations, then we must agree that the questions are boldly written on the wall and posterity will put them to us for not acting quickly enough to prevent a the disaster that is unfolding in the health sector.

From the foregoing, it is clear that there is social injustice from all the three levels within which this issue has been examined, there is therefore the urgent need for us to put our acts together to expedite action on the issues involved, now or never.