Article Text

Cost analysis of health workforce investments for COVID-19 response in Ghana
1. James Avoka Asamani1,
2. Hamza Ismaila2,
3. Sunny C. Okoroafor1,
5. Ebenezer Oduro-Mensah4,
6. Margaret Chebere5,
8. Juliet Nabyonga-Orem6,
9. Christmal Dela Christmals7,
10. Jennifer Nyoni1,
11. Patrick Kuma-Aboagye8
1. 1Health Workforce Unit, Universal Health Coverage Life - Course Cluster, World Health Organization Regional Office for Africa, Brazzaville, Congo
2. 2Office of the Director-General, Ghana Health Service - Headquarters, Accra, Ghana
3. 3Health Financing and Investment, World Health Organization Regional Office for Africa, Accra, Ghana
4. 4Ga East Hospital, Ghana Health Service, Accra, Ghana
5. 5Human Resources Division, Ghana Health Service, Accra, Ghana
6. 6Health Financing and Investment Unit, Universal Health Coverage - Life Course, World Health Organization Regional Office for Africa, Brazzaville, Congo
7. 7Centre for Health Professions Education, North-West Unversity, Potchefstroom, North West, South Africa
8. 8Office of Director-General, Ghana Health Service, Accra, Ghana
1. Correspondence to Dr James Avoka Asamani; Asamanij{at}who.int

## Abstract

The COVID-19 pandemic had multiple adverse impacts on the health workforce that constrained their capacity to contain and combat the disease. To mitigate the impact of the pandemic on the Ghanaian health workforce, the government implemented a strategy to recruit qualified but unemployed health workers to fill staffing gaps and incentivise all public sector health workers. This paper estimated the cost of the new recruitments and incentives given to health workers and presented lessons for health workforce planning in future health emergencies towards health systems resilience. Between March and November 2020, 45 107 health workers were recruited, representing a 35% boost in the public sector health workforce capacity, and an increase in the recurrent public health sector wage bill by about GHS103 229 420 (US$17 798 176) per month, and about GHS1.24 billion (US$213.58 million) per annum. To incentivise the health workforce, the government announced a waiver of personal income taxes for all health workers in the public sector from April to December 2020 and offered a 50% additional allowance to some health workers. We estimate that the Government of Ghana spent about GH¢16.93 million (equivalent to US$2.92 million) monthly as COVID-19 response incentives, which translates into US$35 million by the end of 2020. Ghana invested considerably in health workforce recruitment and incentives to respond to the COVID-19 pandemic, resulting in an almost 37% increase in the public sector wage bill. Strengthening investments in decent employment, protection and safety for the health workforce using the various resources are helpful in addressing future pandemics.

• Health economics
• Health systems
• Health policy
• Public Health
• COVID-19

## Data availability statement

All data relevant to the study are included in the article.

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### Summary box

• The COVID-19 pandemic had multiple adverse impacts on the health workforce, including infections and mortalities, violence and harassment, discrimination, burn-out and mental disorders, which have contributed to reducing the availability of the health workforce and the weakening of the health systems’ capacity to respond to the pandemic.

• Lessons from Ghana show that responding to the COVID-19 pandemic requires a tailored investment in the health workforce to ensure the availability of skilled and motivated health workers.

• Ghana’s example highlights that providing incentives to health workers can play an essential role in mobilising the health workforce needed for public health emergency response.

• There is a need for health workforce planners and policy-makers to heighten advocacy for strengthening investments in decent employment, protection and safety for the health workforce as a means to achieving health systems resilience.

## Introduction

The COVID-19 pandemic has had multiple impacts on the health workforce (HWF), including infections and mortalities, violence and harassment, discrimination, burn-out, and mental disorders.1 These impacts reduced the available stock of health workers in many countries, contributing to the weakening of the health systems’ capacity to respond to the pandemic.1 2 It also increased the workload and psychosocial stress, which adversely impacted the well-being of health workers.3 All these further constrained the capacity of the HWF to contain and combat the disease.

The economic shock imposed by the pandemic and the resultant response measures adopted by countries also constrained both the public and private sectors’ ability to mobilise resources and expand fiscal and financial space to recruit newly trained health workers.4 This exacerbated the unemployment of health workers in a situation that otherwise required more health workers. Finally, owing to the resultant strain the pandemic imposed on global health systems, developed countries resorted to heightened reliance on international recruitments to fill staffing gaps, which, in turn, fuelled excessive out-migration from the Africa region in recent months.5–8 For example, a report by the Organisation for Economic Co-operation and Development (OECD) noted that in the context of COVID-19, ‘many OECD countries have recognised migrant health workers as key assets and introduced policies to help their arrival and the recognition of their qualifications’.8

Before the pandemic, Ghana had increased its public sector employed HWF density from 10.7 doctors, nurses and midwives per 10 000 in 2005 to 26.5 by 2018.9 However, using a more comprehensive and updated dataset that covers the public and private sectors, including those unemployed, in 2021, Ghana had an estimated 6173 doctors and 125 024 (both professionals nurses and associate/enrolled/community nurses) and 12 786 midwives.10 These estimates translate into a density of 45.37 doctors, nurses and midwives per 10 000 population as compared with the global threshold of 44.5 needed to make progress towards the tracer indicators of the sustainable development goal three.11 Nonetheless, the country is faced with HWF challenges with an estimated 20 000–30 000 health workers, especially nurses and midwives, potentially unemployed,12 and inequitable distribution, which was costing the Government an equivalence of 28% of its wage bill in 2018.13 In Ghana, COVID-19 HWF infections mimicked the global HWF infection trend. A total of 3656 health worker infections, representing about 7.6% of the total number of reported infections (ie, 48 643) and 2.7% of the total number of public sector HWF (ie, 133 746), as recorded at the end of October 2020 (GHS, 2020). As the pandemic unfolded, there were guidelines14 15 and calls16 to adequately prepare the HWF to respond to the health emergency. Suggested approaches for achieving this included tackling existing shortages of health workers, updating the knowledge and skills of health workers, ensuring timely payments of salaries and allowances to avoid industrial strike actions, and improving health worker safety and protection.14

To mitigate the impact of the pandemic on the Ghanaian HWF, the Government of Ghana, on 5 April 2020, announced a strategy to rapidly recruit qualified but unemployed health workers to fill staffing gaps, and incentivise all public sector health workers by waiving income taxes on their salaries. The government also committed to paying an additional 50% base salary bonus to front-line health workers, as well as ensuring health worker protection through the provision of personal protective equipment (PPEs), training on infection prevention and control and a life insurance cover of up to GHS350 000 (approximately US$60 345) per front-line health worker against COVID-19 infection and death.17 To quantify these HWF investments in the context of the COVID-19 pandemic response, this paper estimates the overall cost of the new recruitments and incentives given to front-line health workers. This paper also presents lessons that would guide HWF planning in future health emergencies and inform country efforts in building health systems resilience. As part of a larger work on the impact of COVID-19 on the HWF in Ghana, we reviewed relevant health policy/strategic documents to gain contextual insights. We also sought clarifications from the National Response Coordination and Case Management Authority for COVID-19 in Ghana, Heads of the Human Resources for Health Directorates of the Ministry of Health and Ghana Health Service, Heads of Case Management Facilities and HWF planners at the Ghana Health Service on the official data regarding the unit cost of the announced benefit and number of health workers that were involved or affected. Data on the additional recruitments for COVID-19 response were obtained from the online recruitment portal used by the Ministry of Health and Ghana Health Service, which was corroborated with documents of the recruitment approval from the Ministry of Finance (financial clearance). The summary from these sources was validated by the Directors of Human Resources and the Director-General of the Ghana Health Service, who jointly coordinated and oversaw the recruitment and deployment processes. We calculated the annual cost of remuneration of the additional recruitment as a sum-product of the new recruitments, their corresponding basic salary and market premium (allowances paid to the health workers) (table 1). We also estimated the cost of the financial incentives as the sum of the product of the number that benefited from the incentive(s) and the monetary value of the incentive(s) (see table 2). Table 1 Summary of additional recruitment by category, number and cost, March–November 2020 Table 2 Financial incentives for front-line health workers for COVID-19 response, April–December 2020 ## Additional HWF recruitments and the associated annual cost of remuneration Data available from the Ministry of Health recruitment portal,18 the Ministry of Finance statements19 and Ghana Health Service reports show that up to the end of June 2020, the public sector recruited a total of 34 382 permanent staff of various categories. These included 24 285 health professionals between March and June 2020 and an additional 10 097 graduate unemployed nurses and midwives (both public and privately trained) in June 2020. Additionally, there were 1000 temporary recruitments of Contact Tracers between April and June 2020. Furthermore, between July and November 2020, an additional 9725 health workers of various categories were recruited, bringing the total permanent recruitment into the public health sector to 44 107 and the overall recruitment to 45 107, as shown in table 1.18 20 Compared with a total of 127 101 public sector health workers in 2019,21 the aforementioned additional recruitment represented a 35% boost in the public sector HWF capacity to respond to the COVID-19 pandemic. About 80% of the permanent recruitments were the nursing and midwifery cadres (40% nurse associates, 30% professional nurses and 6% midwives). Medical and pathological laboratory technicians (biomedical scientists, laboratory technicians and assistants) were nearly 3% of the total recruitments (n=1236) while general medical practitioners (medical officers) were 2% (n=967) and physician assistants were 1.34% (n=606). As only aggregate was made available for this analysis, we had a limitation of not being able to disaggregate by gender and geographical distribution of their deployment. Table 1 summarises the public sector recruitments from March to November 2020 by type, category, numbers and cost implications. As shown in table 1, we conservatively estimate that the additional public sector recruitments increased the recurrent public health sector wage bill by about GHS103 229 420 (US$17 798 176) per month, translating into almost GHS1.24 billion (US$213.58 million) per annum. These costs, however, exclude other government HWF incentives such as the income tax waiver and 50% front-line health worker salary allowance (see next section), cost of PPE and COVID-19-related pieces of training for health workers. ## Estimated cost of financial incentives given to health workers To incentivise the HWF, the government announced a waiver of personal income taxes for all health workers in the public sector from April to December 2020 and offered a 50% additional allowance to some 10 001 front-line health workers.22 Due to difficulties in ascertaining the exact number of persons who benefited from the income tax waivers, we undertook a conservative estimation by limiting our analysis to the cost of tax waivers and the additional 50% basic salary given to only front-line health workers for which data were readily available. For the purpose of administering the COVID-19 response incentives, the Ministry of Health defined front-line health workers as ‘any health worker(s) directly involved in triaging, isolation, laboratory testing, ambulance service, holding centres, treatment centres, surveillance and contact tracing for COVID-19’.23 With this definition, the ministry vetted health workers’ claims, and by the end of December 2020, the Ministry of Health indicated that 10 001 health workers qualified and were receiving the 50% top-up allowance. Professional nurses and nurse associates (enrolled nurses and community health nurses) cumulatively made up almost 46% of the front-line health workers, while the environmental and occupational health and hygiene professionals comprised some 14%, and general medical practitioners and specialist medical practitioners together composed 3.15%. As demonstrated in table 2, we estimate that the Government of Ghana spent about GH 16.93 million (equivalent to US$2.92 million) monthly as COVID-19 response incentives to the defined 10 001 front-line health workers, which translates into some US$35 million by the end of 2020. ## Summary cost estimates of Ghana’s HWF recruitments and incentives Conservatively, Ghana spent at least US$213.6 million within the first year of the COVID-19 pandemic on HWF recruitment and incentives (table 3). This estimate, however, excludes expenditures on PPEs and training of health workers on case management and public health response measures to the pandemic. The new recruitments are estimated to have increased the health sector wage bill by 32% compared with the 2019 wage bill. However, the much publicised and talked about incentives granted to health workers, particularly those defined as front-line health workers, represented only 5.2% of the additional cost compared with the 2019 wage bill. Reports from the Ministry of Finance show that 47% of the sector budget came from Government of Ghana (GoG) sources, while the remaining 53% were sourced from internally generated funds of health facilities (24%) and 29% from development partners and donors.19 20

Table 3

Cost of COVID-19 HWF recruitments and incentives compared with the 2019 health sector wage bill

## Lessons for HWF planning in future health emergencies

Ghana invested considerably in HWF recruitment and incentives to respond to the COVID-19 pandemic, resulting in an almost 37% increase in the public sector wage bill. A recent study suggests that Ghanaian health workers felt more satisfied and appreciated compared with their Kenyan counterparts.24 Although the level of satisfaction of the Ghanaian health workers has not been empirically linked to the incentives given to fight the COVID-19 pandemic, it could be one of the hypotheses for further research. Also, while the impact of the incentives granted the Ghanaian health workers on the overall success or otherwise of the pandemic response in the country is yet to be ascertained, an important takeaway for the global health community is that incentives can play an essential part in mobilising the HWF for emergency response.

Furthermore, Ghana significantly increased its public sector HWF capacity by recruiting 45 107 health workers (including 10 000 temporary contact tracers), which represents an increase of 35.5% of the overall public sector HWF at prepandemic levels. Although this appears commendable, it also underlines the magnitude of the pre-pandemic levels of HWF unemployment in the country, a phenomenon that is well documented.10 25 26 From a HWF perspective, although the pandemic posed the most significant challenge in several decades, it also provided public sector employment opportunities for health workers who would have otherwise remained unemployed for a while. This observation is not limited to Ghana; similar recruitment of more than 45 000 volunteers, retirees and unemployed health workers was reported in Ethiopia.27 Thus, HWF planners and policy-makers should heighten advocacy for strengthening investments in decent employment, protection and safety for the HWF using the various resources being availed to the health sector to fight COVID-19, which the lessons could be helpful for addressing future pandemics.

## Conclusion

Responding to the COVID-19 pandemic, as well as other public health emergencies, requires a tailored investment in the HWF to ensure the availability of skilled and motivated health workers. Strategies need to be developed and implemented towards improving health systems’ resilience rather than short-term measures to mitigate the impact of the emergencies. In this Ghana’s instance, investments were tailored to holistically improve health systems performance and resilience by recruiting qualified health workers who were previously unemployed. Additionally, incentives were provided to the health workers to motivate the health workers. Incentives do play an essential role in mobilising the HWF needed for public health emergency response. Obtaining and sustaining investment in the HWF requires sustained advocacy by HWF planners and policymakers. The advocacy should focus on the need for decent employment and protection and safety for the HWF as a means of achieving health systems resilience.

## Data availability statement

All data relevant to the study are included in the article.

## Footnotes

• JAA and HI are joint first authors.

• Handling editor Seye Abimbola