Career Destinations of University of Ghana Medical School Graduates of Various Year Groups

Summary

Background

To report on the current career destination of the University of Ghana Medical School (UGMS) qualified doctors in the year groups, 1998, 2000, 2003, 2005 and 2008.

Design

Interview of doctors from each year group currently working at the Korle-Bu Teaching Hospital corroborated by phone calls to the doctors.

Subjects

All Ghanaian doctors from each graduating year group.

Main Outcome Measures

1. Current location of employment in Ghana or abroad, 2. Gender ratios of the doctors retained in Ghana

Results

Three hundred and seventy-two (372) UGMS doctors consisting of 353 Ghanaians and 19 foreign students graduated over the five year groups. Of the 353 Ghanaians, 113 emigrated, while all but one of the 240 living in Ghana, practice medicine. The retention rate improved from 54.2% in 1998 to 86.3% in 2008. The overall retention rate however is 68.0% while the retention rates for the male and female doctors were 69.3% and 64.6% respectively. Of the 177 doctors practicing in Ghana from the first 4 year-groups (i.e. 1998, 2000, 2003 and 2005,) 139 (i.e. 31, 31, 34 and 43 from the respective year groups) have either completed postgraduate training or are in the residency training programme. Thus 78.5% of these doctors working in Ghana have opted for postgraduate training.

Conclusion

The establishment of the GCPS and to a lesser extent the introduction of the ADHA before it appear to have slowed down the medical brain drain as more and more doctors avail themselves of the local opportunities. The GCPS therefore needs supporting effectively in order to continue to be a strong incentive for the retention of doctors in Ghana, apart from helping to staff district general hospitals with specialists.

Introduction

Medical emigration from Ghana and other developing countries to Europe and North America has been of great concern to Ghanaian policy makers since the 1970 and 80s when there was a serious downturn in the economy and western industrialized countries revised their immigration policies to focus on highly trained professionals.¹ Economic considerations as well as the availability of local opportunities for postgraduate training are thought to have ranked high in the decision to emigrate.² Meanwhile the country has continued to experience a shortage of doctors to the extent that about 13% of public hospitals are without even a single doctor.³ This unfortunate situation is due not only to a shortage of doctors but also their inequitable distribution, resulting in most doctors being located in the southern half of the country and in the urban areas compared to the northern half and the rural areas.^3,4 Meanwhile Ghana has been graduating an average of 230 doctors a year over the last few years⁵ and one wonders where all these doctors are located.

Following the introduction of the Carnegie Postgraduate Training Programme in obstetrics and gynaecology in 1985 and the policy of regional postgraduate training via the West African Colleges of Medicine and Surgeons, there has been a slowing down in the emigration rate of Ghanaian doctors attracted to the specialty of obstetrics and gynaecology.⁵ The number of doctors specializing in this specialty rose and led to an impressive increase in the number of obstetricians practicing in Ghana.^6,7,8

In the late 1990s, the health care delivery system in Ghana suffered a number of strikes by doctors spearheaded by the Junior Doctors' Association demanding better pay and conditions of service. These culminated in a negotiated settlement between the Ghana Medical Association, (GMA), the Ministry of Employment and Social Welfare and the Ministry of Health (MOH) in two documents (MOUs) signed on 30/9/1999 and an addendum on 27/11/2000.

These documents established the payment of “Additional Duty Allowance” (ADHA) which delivered better emoluments.⁹ These were thought to have encouraged young doctors to stay in Ghana. Since then there has been a growing interest on the career destinations of young doctors graduating from 1998, through the start of the new millennium (Year 2000) and thereafter, with respect to their retention rate in the country.

Another significant development in the area of healthcare delivery and training is the establishment of the Ghana College of Physicians and Surgeons in December 2003 as the legal institution to conduct postgraduate training, award fellowships as well as conduct continuing professional development (CPD) programmes in all specialties of medicine, surgery and dentistry.¹⁰ The two interventions being studied therefore are the ADHA and the establishment of the Ghana College of Physicians and Surgeons (GCPS).

Methods

The main and supplementary pass lists of the UGMS year groups of graduating doctors for the years 1998, 1999/2000, 2003, 2005 and 2008 were collected from the UGMS administration and the total numbers of graduating doctors tallied. Using the lists, doctors at the KBTH from the 5 year-groups were personally contacted by the authors regarding the current career locations of members of their year groups. These were corroborated by information from 3 other members of each year group depending on the certainty of the classmates' recall. In case of doubt, mobile phone calls were made to the individual doctors and /or their classmates in Ghana to confirm their current locations or those of their classmates.

Assumptions

It is assumed that many of these graduates plan and emigrate within the first few years after graduation.¹¹ It is also assumed that members of each year group behave similarly when it comes to remuneration and seeking opportunities for postgraduate training and career progression. The year groups were chosen based on the following:

• The 1998 year group was chosen to represent the pre-intervention year-group, i.e. the pre-ADHA era.

• The 1999/2000 (new millennium) year-group was chosen to represent the “start of the intervention” year group.

• The 2003 year-group depicts the initial effects of the ADHA on the aspirations and plans of the graduating students, over 3 years following the introduction of the ADHA. It also importantly marks the official launching of the GCPS in December 2003.

• The 2005 year-group is thought to be influenced by both the ADHA, (over 5 years since its introduction) and the establishment of the GCPS.

• The 2008 year-group is thought to embrace the year group that graduated 8 years after the introduction of the ADHA, but 11 years as at the time of the study in July 2011. It also represents 8 years since the establishment of the GCPS (i.e. 2003-2011). It is thought that it is too soon to fully assess the 2008 year group. Studies by Dovlo and Nyonator¹¹ indicate that about 50% and 75% of each batch of graduates (from 1985 to 1994) emigrate or are in the process of doing so, within 4.5 and 9.5 years respectively.

Exclusion

All foreign students who graduated in the year groups were excluded from the analysis. Two of the foreign UGMS graduates of the 2008 year group, however, are living and practicing in Ghana.

Results

There were 373 UGMS medical graduates over the 5 year-groups, consisting of 354 Ghanaians and 19 foreign students. Following the death of one resident in urology in a road traffic accident in 2006, the career destinations of the remaining 353 Ghanaians were located. One hundred and thirteen (113) of them have emigrated while 240 live and practice medicine in Ghana. One Ghanaian doctor is a full time pastor.

Tables 1–5 detail the career locations of each year group while Tables 6 and 7 look at the yearly retention rates and the gender distribution of the graduates in Ghana as a percentage of their number at the time of graduation. There is no significant difference between the male and female doctors with respect to their retention rates i.e. 69.3% of males versus 64.6% of the females.

Table 1.

Career Location of the 1998 UGMS Graduating Doctors living in Ghana (As at July 2011).

FACILITY	N	%
Teaching Hospitals	20	51.3
Regional Hospitals	-	-
District Government Hospitals	4	10.3
Public Health	5	12.8
Private Practice	4	10.3
Non-Governmental Organisation	-	-
Parastatal	6	15.4
Total	39	100

^*One resident in urology training died in a road traffic accident in 2006.

Table 5.

Career locations of the UGMS Doctors of the Year 2008 in Ghana (As at July 2011).

FACILITY	N	%
Teaching Hospitals	11	17.5
Regional Hospitals	9	14.2
District General Hospitals	31	49.2
Public Health	1	1.6
Private Practice	8	12.7
Non-Governmental Organisation	2	3.2
Parastatal	1	1.6
TOTAL	63	100

^*There were 15 foreign students in the 2008 year group.

Table 6.

Retention Rates in Ghana of UGMS Doctors of the 5-Year Groups

Year	No. Of Doctors In Ghana and (Total No. At Graduation)	Percentage Of Year Group
1998	39 (Out Of 72)	54.2%
2000	36 (Out Of 72)	50%
2003	44 (Out Of 67)	65.7%
2005	58 (Out Of 69)	84.1%
2008	63 (Out Of 73)	86.3%
Average	240 (Out Of 353)	68.0%

Table 7.

Gender distribution of the 5 UGMS Year-Groups Living in Ghana

Year	Total Male	Males In Ghana (%)	Total Female	Females In Ghana (%)
1998	54	29	18	10
2000	52	26	20	12
2003	48	34	19	9
2005	46	38	23	19
2008	54	49	19	14
Total (%)	254	176 (69.3%)	99	64 (64.6%)

Table 2.

Career Location of the UGMS Doctors of the Millennium (2000) Batch in Ghana. (As at July 2011)

FACILITY	N	%
Teaching Hospitals	12	33.3
Regional Hospitals	5	13.9
District Government Hospitals	4	11.1
Public Health	7	19.4
Private Practice	5	13.9
Non-Governmental Organisation	2	5.6
Parastatal	1	2.8
TOTAL	36	100

Table 3.

Career Location of the UGMS Doctors in Ghana who graduated in 2003, (As at July 2011).

FACILITY	N	%
Teaching Hospitals	26	59.1
Regional Hospitals	1	2.3
District Government Hospital	11	25.0
PublicHealth/Health Administrators	3	6.8
Private Practice	-	-
Non-Governmental Organisation	1	2.3
Psychiatry	1	2.3
Parastatal	-	-
Pastor	1	2.3
Total	44	100

Table 4.

Career locations of UGMS Doctors working in Ghana who graduated in 2005 (As at July 2011).

FACILITY	N	%
Teaching Hospital	36 – 34 PGs/2 MO	62.1
Regional Hospital	4 - 3 PGs/1 MO	6.9
District General Hospital	11 - 8 PGs /3 MDs	19.0
Public Health	-	-
Private Practice	6	10.3
Non-Governmental Organisation	-	-
Parastatal	1	1.7
Total	58	100

^*There were 4 foreign students

Out of 73 who graduated in 2005, there were 4 foreigners and 69 Ghanaians, 58 of whom are working in Ghana.

It is also significant that of the 177 practicing doctors from 4 year-groups (i.e. 1998, 2000, 2003 and 2005, which groups may be thought to have had enough time to decide on postgraduate training) 139 (i.e. 31, 31, 34 and 43 from the respective year groups out of 177) have either completed postgraduate training or are in the residency training programme. Thus about 78.5% of those working in Ghana have opted for postgraduate training.

The 2008 year-group consisted of 63 Ghanaians living and working in Ghana and 15 foreigners who are excluded from the analysis. By July 2011 when the study was undertaken, this 2008 year-group had completed their 2-year housemanship for just about a year and 10 had emigrated.

Altogether the percentage of male doctors working in Ghana as at July 2011 is 69.3% while that for the female doctors is 64.6%. Of the 39 doctors who graduated in 1998 and are resident in Ghana, 32 have either completed postgraduate training or are in the training programme. Corresponding figures for the years 2000, 2003 and 2005 are 31 out of 36, 34 out of 44 and 43 out of 58 respectively.

The numbers for the year group 2008, i.e. 4 out of 63 are not meaningful as they are not comparable to the earlier groups that had enough time to decide on what specialization to do if at all.

Thus 140 out of the 177 doctors (79.1%), from the 4 year-groups (1998, 2000, 2003 and 2005) have either completed or are currently in the postgraduate training programme.

Discussion

The first graduates of the GCPS were admitted to the College in December 2006. The establishment of the GCPS in 2003 and the payment of ADHA since year 2000 has significantly and progressively slowed down the brain drain of UGMS trained graduates over the 5-year groups. This is supported by the high percentage (79.1%) of the retained doctors from the year groups 1998, 2000, 2003 and 2005 being in postgraduate practice or training. In the 1998 year-group, (that is in the pre-ADHA era) and as at July 2011, 45.8% of the doctors had emigrated compared to 50% of the 2000-group, 34.5% of the 2003-group, 16.0% of the 2005-group and so far, 13.7% of the 2008 year-group. Thus on a positive note, the retention rates of the doctors improved from 54.2% in 1998 to 86.3% in 2008. The group that graduated 5 years following the inception of the GCPS i.e. the 2008 year group would be presumed to be fully aware of the benefits, emerging status, life style gains as well as improvement in the quality of life (if any), of the graduates of the GCPS as 3 batches of members have been admitted to the GCPS around their time of graduation with MB Ch B. It is believed that this consideration is important in encouraging the graduating young doctors to stay and aim for postgraduate training here in their homeland Ghana. This appears to be the experience in other parts of the world.¹

The medical retention rate improved from 54.2% in the 1998 year-group through to 86.3% in 2008 although the figure for 2008 is not that reliable. These effects have been occasioned by multi-factorial issues i.e. ‘the push and pull factors; the increasing difficulty with immigration requirements, decreasing job and postgraduate training opportunities in the UK¹² and the USA, but above all, better conditions of service and better opportunities for postgraduate training at home have all contributed to the improved retention rate of the doctors.

The high percentage of the retained doctor (78.5%) who have either completed or are in the postgraduate training programme does suggest that post-graduate training is perhaps a dominant consideration in deciding to leave the country to countries with better postgraduate opportunities such as the USA or UK, the two favoured destinations.¹³ This is similar to the experience published from Libya and Fiji.^14,15 It must also be said that with the tightening of immigration rules and their stricter enforcement seen lately in Europe and the USA, the expansion of the European Union with the resultant immigration of doctors from newly admitted countries from central and eastern Europe to the UK and other wealthier European countries, training opportunities for graduates from Africa have dwindled.¹² This might also have discouraged some of our graduates from emigrating.

The rise in “Private Practice” from 6.9% to 11.0% of retained graduates over the period is striking. This is in line with the WHO reported internal country movement of health workers from the public to the private sector particularly if there are considerable differences in income levels.¹⁶

Although the ADHA is an important consideration in deciding to stay and work in Ghana, the establishment of the GCPS seems to have the more dominant effect on the retention rate of the young doctors studied. The GCPS therefore needs supporting effectively in order to continue to be a strong incentive for the retention of doctors in Ghana. This additionally has led to the increasing staffing of the district general hospitals with specialist doctors, a most welcome outcome of the training programmes of the GCPS.

Conclusion

The establishment of the GCPS and to a lesser extent the introduction of the ADHA before it, appear to have slowed down the medical brain drain in Ghana, as more and more doctors avail themselves of the local opportunities. The GCPS therefore needs supporting effectively in order to continue to be a strong incentive for the retention of doctors in Ghana, apart from helping to staff our district general hospitals with specialists.