Modelling the Wage Bill and Budget Space for Health Workforce in Ghana: Implications for Sustainable Health Professions Education Policy

Abstract

Global discussions on health systems strengthening have lately tilted towards increasing investments in human resources for health to address health workforce challenges, especially shortages and employment. Countries have, as a result, increased investments in the health workforce by expanding the production and recruitment of the needed health workforce, with the resultant effects of increasing health workforce budget space and the unending clamour by health policy actors for further increases. Despite these calls, there has been no wage bill affordability and budget space analysis to rationalise the sustainable production of and demand for health workers, which is the thrust of Ghana’s current health workforce policy and strategy. Using an adapted approach (the Asamani approach), the study modelled the supply of some essential health workers and their associated cost of employment, compared it with the modelled budget space for health workforce employment and then drew conclusions on the wage bill sustainability for policy consideration. Of the seven cadres considered in the study (doctors, professional nurses, midwives, enrolled nurses, community health nurses, pharmacists and biomedical scientists), who constitute about 97% of the wage bill, the study found the baseline stock to be 129 378 in 2022, which was estimated to increase to 199 715 by 2027 and 254 466 by 2032 with corresponding wage bills of US$869.4 million and US$ 1.1 billion, respectively, holding routine salary increases constant. The budget space for health was, meanwhile, projected to be US$899.3 million and US$1.1 billion in 2022 and 2032 respectively, out of a projected overall government fiscal space of US$7 billion per year. This study concludes that, given current levels and mix of production, Ghana was estimated to expend an average of 88% of its health budget space as wage bill cost. This was 54.4% over the global median and 95.6% over the African Region’s median, making the current regime unsustainable.

Keywords

Human resources for health health workforce fiscal space budget space production demand recruitment training sustainability

Key Messages

Ghana has been on a transformational agenda to address health workforce shortages.

The transformation agenda, mostly expansionary in nature with increased intake into health training institutions and enhanced remuneration, has, however, been without any wage bill affordability and budget space analysis to inform sustainability.

Given the current level and mix of production, the study found that Ghana approximately expended an average of 88% of its health budget space as wage bill cost, some 1.5 folds far in excess of the global median and 1.95 folds of the African Region’s median.

The current trajectory is unsustainable in light of fiscal realities, calling for the streamlining of health workforce production and employment to engender sustainability.

Introduction

Human Resources for Health (HRH) is a core component of any health system.^1,2 Due to this critical role of the HRH, the Sustainable Development Goal (SDG) three target 3c recommends, among other things, strengthening the recruitment, development, training, and retention of the health workforce, especially in low-and middle-income countries (LMICs), to ensure healthy lives and promote well-being,³ given the evidence that investments in the health workforce provide significant value to health systems.⁴

However, most African countries face chronic shortages of the needed health workforce due to inadequate investments and funding for health workforce needs.⁵ For example, Ghana in the late 1990s and early 2000s experienced severe shortages of health workers and the out-migration of health professionals, mainly nurses and doctors, with about 62% of its total health workforce, at the time, intending to migrate abroad. The shortage of nurses and doctors became much more pronounced following the introduction of a social health insurance scheme in 2005 and the expansion in access to primary health care through the Community-based Health Planning and Services (CHPS) initiative,^6,7 which led to increased access to health care and workloads.

To reposition the health workforce to engender a functional global health system, there have been calls for adequate funding from domestic and international sources to make appropriate HRH investments.⁸ Ghana heeded these calls by identifying low enrolment rates into health training institutions, inadequate remuneration, lack of career development opportunities and deplorable working conditions as some of the shortages confronting its health workforce, and taking steps to address these challenges.⁹

Asamani et al¹⁰ and Antwi and Phillips¹¹ report that following improvements in remuneration of health workers and enrolments into health training institutions, nursing and medicine throughput increased dramatically and almost spontaneously, while retention improved through reduced out-migration. On the improved retention, Antwi and Phillips,¹¹ following an analysis of the effect of wage increases in Ghana, concluded that a 10% increase in wages decreased annual attrition from the public payroll to 1.8% from a mean of 8% among the 20 to 40-year-old health workers from professions that had the propensity to migrate.

On the production side, the analysis also found that enrolment of medical students, which hitherto averaged 261 per annum between 2003 and 2005 and 465 per annum between 2007and 2009, surpassed 1000 per year since 2014 as a result of a major wage increase in 2010, prompting expansion in the number of medical schools. For nurses and midwives, the major jumps in enrolments started in 2009, while those of pathology and medical laboratory technicians (biomedical scientists) started in 2012.

As a result, the health workforce density doubled between 2005 and 2016 while the public health sector wage bill ballooned from US$536.2 million in 2010 to US$727.95 million in 2020,¹⁰ consuming more than 70% of the entire health budget of the government in 2011 and 2012, which was blamed on the knock-on effects of the 2010 salary enhancements.

The ensuing collateral effect was wage-related cost containment measures starting from 2014, in which there was a net freeze in employment from 2015 to 2017 which resulted in large numbers of trained health workers remaining unemployed for 2 to 4 years.¹⁰ In 2018, an evidence-based health workforce gap analysis was used to justify additional recruitments. This led to increases in budgetary allocations and the employment of thousands of unemployed health workers.^12,13

Nonetheless, as the country continues to produce more than 25,000 health workers annually (from both public and private sectors), the production rate is outpacing the rate of increase in the compensation budget allocation to the Ministry of Health.

An independent review of the health sector noted that ‘given the high personal emoluments proportion of the recurrent budget and continuing expansion of the workforce, there is a need for detailed analysis of the fiscal space for absorbing the new workforce ’¹⁴(p. 48). Similarly, a World Bank assessment of the health sector called for a re-examination of the sustainability of the trajectory of training,¹⁵ which call only adds up to several others made in the health sector’s administrative reports.^13,16-18

Despite these calls, there has been no wage bill affordability and budget space analysis to rationalise the production of health workers, which is the thrust of the current health workforce policy and strategy.¹⁹

Against this background, this paper presents an analytical framework for assessing the potential budget space with the application for the health workforce in Ghana to examine the sustainability of wage bill levels given the current rate of production and/or supply of key health professionals against the potential budget space for the health workforce.

Methodology

We undertook a modelling of the supply of health workers and its associated cost of employment and compared it with the modelled budget space for health workforce employment. We then concluded on the wage bill sustainability for policy consideration.

Approach to modelling the supply of health workers and the cost of their employment

The supply of health workers represents the number of health workers who are available and willing to work in healthcare settings at a particular compensation level.²⁰ Supply can be estimated as ‘Headcount’ or ‘Full-Time Equivalent (FTE)’ to account for adjustments in capacity for work and productivity or the number of hours that health workers devote to the provision of health services.²¹

Three methods for forecasting the supply of health workers have been widely described in the literature – linear projections, the stock and flow method and the cohort analysis approach^22-25 – and the study adopted the Asamani et al²⁶ approach (a stock and flow method), developed and applied in many African contexts.^27-32

Using this approach, as illustrated in the framework in Figure 1, we considered the expected outflows from the current stock due to various reasons (such as retirements, illness, deaths and career change) and the expected inflows (based on the training capacity and immigration rates of health professionals),^22,26 and then adjusted according to the labour participation rate,³³ using the arithmetic formulae for the supply forecast and estimation of the resulting wage bill, outlined in Box 1.

Figure 1.

Framework for supply forecasting for health workers.

Box 1.

Supply-side estimation formulae.

S_{n, t}

[T_{n, t - 1} \times (1 - a_{n}) + I_{n}]

. . . (1)
Where:
• S_n,t is the effective supply of health workers of category n , at time t .
• T_n,t is the aggregate or effective stock of health workers of category n at time t.
• a_n represents the attrition rate (a proportion of the stock, T_n,t-1 that died, retired, could not work due to ill health, migrated out or changed careers outside the health sector).
• I_n is the inflows of health workers of category n trained domestically or immigrating from another country.

W a g e B i l l = S_{n, t}

x W_n,t . . . (2)
Where:
• W_n,t is the wages or income level the health worker of category n , at time t .

Source: Adapted from Asamani et al.^26,27

Approach to modelling the public sector budget space for health workforce employment

Building on recent conceptual discussions on budget space analysis,^34-36 and empirical applications for health workforce,^28,37 we used a three-step process to make guided estimates of the budget space for health workforce in Ghana:

Step 1: Estimating the overall government fiscal space

As a first step, we sought to determine the overall fiscal space for the country, bearing in mind factors such as the size and growth of the economy, the size of public debt and revenue, and the possibility of capital financing,^38,39 as well as the recently updated International Monetary Fund’s list of factors that affect the overall fiscal space of a government.⁴⁰ Leaning on the macro-fiscal factors espoused by the IMF and the estimation process suggested by Barroy and Gupta,³⁴ we conceived the overall fiscal space to be a function of (a) Gross Domestic Product, (b) tax to GDP ratio, (c) level of borrowing, (d) Debt service or re-payments of principals and interests and (e) Statutory Payments; the nature of which relationship is illustrated in equation (3) in Box 2.

Box 2.

Government fiscal space estimation formulae.

Gov’t Fiscal Space = [(GDP × TxGR) +B +ODA] – (DebtP + StatP) . . . (3)
Where:
• GDP represents the Gross Domestic Product,
• TxGR is tax to GDP ratio,
• B represents borrowing,
• ODA is Foreign aid from official donors
• DebtP is Debt servicing and repayments, and
• StatP and Statutory Payments

Step 2: Estimating the Public Expenditure Envelope for Health (PEEH)/Budget space for health

Following the determination of the overall government fiscal space, we then determined the budgetary space for health spending, which represents the portion of public expenditure allocated to the health sector as informed by the decisions made by the legislature and budget negotiations between the Ministry of Finance and the different ministries. This is illustrated in equation (4) in Box 3.

Box 3.

Public health expenditure envelope for health formulae.

• PEEH = Government fiscal space × Pt . . . (4)
Where PEEH represents the Public Expenditure Envelope for Health, while Pt is the proportion of the annual public expenditure envelope dedicated to the health sector

As argued by Asamani et al,³⁷ the proportion of the government budget space allocated to health reflects the policy intent and the level of prioritisation of health within public service spending. Although there is no consensus on the proportion of government budget space that must be allocated to the health sector, African governments made the Abuja declaration to dedicate 15% of general government spending.^41,42

Step 3: Estimating the health workforce budget space

The public expenditure envelope for health (PEEH) – often termed as General Government Health Expenditure (GGHE) – is variously allocated to different investment areas and functions of the public health sector, including health workforce, infrastructure, medicines and technologies, information systems, management, and service delivery systems. Therefore, we determined the amount of budget space allocated to the health workforce (and any other investment area) to ‘. . . depend not only on the size of GGHE but also on the level of prioritisation given to the HWF employment within the GGHE’³⁷(p. 3) and legislative guidance and restrictions on allocative proportions,^43,44 albeit there is no normative standard on the proportion of the health budget or spending vis-à-vis the global average of 57%⁴⁵ and the African Region’s average 45%,³⁷ as shown in equation (5) and Table 1 in Box 4:

Table 1.

Summary of the variables that were used in projecting the budget space for health workforce.

Category	Indicator (Variable)	Source	Assumptions/Scenarios
Conducive macroeconomic environment
National income and price levels	Projected GDP growth (GDP growth per year, Projected revenue generation.	IMF	Variations in GDP growth rates
National income and price levels	Trends in government health expenditure as % of GDP.
Size and effectiveness of government	Government revenue, excluding grants (% of GDP) (REV/GDP).	IMF	Variations in revenue commitments.
Borrowing
Propensity to borrow	Gross debt to GDP ratio (DEBT/GDP)	IMF	TBD
Reprioritisation
Prioritisation of health	Historical trends in Government health expenditure (% total government expenditure) (GHE/GE).	WHO	General government health expenditure as a proportion of total government expenditure is equal to its average value in the GHED during the period.
	Health budget as % of total government budget trends.		2018-2020.
			Total government expenditure as a proportion of GDP is equal to its average value in the GHED during the period 2018-2020.
Prioritisation of HRH	HRH spending (% of Government health expenditure) (HRH/GHE)	WHO.	Variation in contributions.
	Historical trends in allocation to wage bill (absolute and as % of health spending).	Workforce expenditure data.	Variations in UHC and SDG targets.
	Capacity of training institutions to produced HRH and absorption into public sector.	MOH documents.	Variation in contributions from government revenue and health sector budgets, earmarked taxes, and foreign aid.
	Changes in wages and compensation package	MTERs.
	Plans and targets for pre-service and in-service training.

Box 4.

Health workforce budget space (HBS) formulae.³⁷

HBS = PEEH × Qt +E . . .(5)Where PEEH = Public Expenditure Envelope for Health (or equivalently the general government health expenditure, GGHE),Qt = the proportion of the Public Expenditure Envelope for Health dedicated to paying for salary and benefits to employees and retaining health workers. Qr may be the aggregate for all health workers or specified for cadres of interest to estimate potential budget space for those cadres and E = anticipated efficiency gains that can be made from re-prioritisation and streamlining of existing spending

Table 1 provides a summary of the indicators and data sources used in estimating the health workforce budget space for Ghana based on the steps and formulae explained above.

Findings

Projected supply and its wage bill cost

Supply of health workers and the projected wage bill requirements

Based on data availability and impact on the wage bill, the supply projection considered cadres of selected health workers in the public sector such as Doctors, Professional Nurses, Midwives, Enrolled Nurses, Community Health Nurses, Pharmacists and Biomedical Scientists. These cadres together account for 96% of all clinical health professionals in the public health sector of Ghana⁴⁶ and are core to the monitoring of the sustainable development goal three target 3c, which is monitored through the National Health Workforce Accounts (NHWA).⁴⁷ The relevant indicators to enable a stock and flow analysis were triangulated from a previous study,²⁶ government payroll data and databases of the regulatory bodies (see Table 2).

Table 2.

Data sources for the supply forecasting.

Variable/Value	Doctors	Professional nurses	Midwives	Enrolled nurses	Community health nurses	Pharmacists	Biomedical scientists	Data sources
Current stock	4136	45 163	23 316	36 201	17 471	992	2099	CAGD December 2022 Payroll
Average Enrolments	1566	7353	4827	8379	4184	343	396	MDC, NMC, PC & AHPC
Duration of training	6	3	3	2	2	6	4	MDC, NMC, PC & AHPC
Graduation rates	70.0%	73.0%	79.0%	86.0%	92.0%	81.6%	93.0%	MDC, NMC, PC & AHPC
Attrition rates	7.1%	3.2%	7.9%	5.5%	4.7%	0.9%	2.0%	Administrative data from GHS
Cost of training per annum	4495.6	2430.1	2430.1	1620.1	1620.1	4142.2	2941.5	Respective Training Institutions
Median income (Salary and other monetary benefits)	9025.0	5257.6	5257.6	2815.3	2815.3	6566.0	7816.3	CAGD Payroll Data

As illustrated in Figure 2, across the seven cadres considered in this analysis (Doctors, Professional Nurses, Midwives, Enrolled Nurses, Community Health Nurses, Pharmacists and Biomedical Scientists), the baseline stock of 129 378 in 2022 was estimated to increase at an average annual rate of 6% (ranging from 3% to 12%). At this rate, the aggregate stock was expected to increase by 54.3% to 199 715 by 2027 and then further increase by 27% from 2027 to reach 254 466 by 2032. Correspondingly, the baseline estimate of US$571.386 million wage bill for the seven cadres was expected to increase significantly to US$869.346 million by 2027 and balloon to US$ 1.102 billion by 2032, even without considering routine salary increases resulting from labour negotiations.

Figure 2.

Projected supply of health workers (in headcount), 2022to 2032.

Specifically, the number of doctors in the public sector was projected to more than double from 4136 in 2022 to 10 027 by 2032, representing about a 142% increase over 10 years, and occasioned by an average enrolment of 1556 (from local and foreign training) with a graduation rate of at least 70%.

At baseline, meanwhile, there were 98 835 nurses of all kinds in 2022, made up of 45.7% (N = 45 168) professional nurses, 36.6% (N = 36 174) enrolled nurses, and the rest (N = 17 494) being community health nurses. Given the current trajectory of production, the number of nurses was likely to increase by at least 56% to 154 374 by 2027 and 198 449 by 2032. It was further projected that by 2032, the mix of nurses was likely to be made up of 40% professionals, 39% enrolled nurses and 21% community health nurses.

The number of midwives was, however, projected to increase by 36.1% from 23 316 in 2022 to 31 734 in 2027, and further increase by 17.5% to 37 312 by 2032, growing at an average of 4.8% per annum (range: 2.5%-8.5%).

Finally, it was anticipated that with the expanded intake of pharmacists and biomedical scientists, their stock would increase from 992 and 2099 in 2022 to 3594 and 5083, respectively by 2032.

Projected budget space for health and health workforce

Descriptive summary of macroeconomic indicators

From 2012 to 2022, Ghana’s Gross Domestic Product (GDP) in Current USD grew moderately, around an average of 5% per annum, with a minimum of 0.5% recorded in 2015 and a maximum of 9.3% in 2012. The GDP growth rate, however, retained an unsteady trend, moving up and down, with an overall downward trend.

Similarly, the revenue to GDP ratio (TxGR) (%) evolved unevenly (with a peak of 14.6% in 2015 and a bottom in 2013 of 12.5%), while the maximum revenue to GDP the Government collected hovered around 14.6% in 2015, with an all-time minimum of 12.5% in 2013 and an average of 13.6% over the period.

From one period to the other, government’s annual borrowings either increased or decreased, averaging at US$ 5.4 billion, with the lowest borrowing of US$ 2.0 billion recorded in 2015, coinciding with the highest revenue-to-GDP ratio of 14.6% (See Table 3). Debt servicing or repayments, another important factor in assessing government’s fiscal space and resultant budgetary space for health and health workforce, tremendously increased over the period at a pace of 511.1%, leading to an average of US$ 5.9 billion of debt payments per year over the period. Throughout the period (2012-2022), General Government’s total expenditures evolved at a fits-and-starts pace.

Table 3.

Summary of macroeconomic indicators, 2012to 2021.

Measure	Gross domestic product (GDP) − Current USD	GDP growth rate (%)	Revenue to GDP ratio (TxGR) (%)	Annual borrowings (B) − USD	Annual debt payments (DebtP) in USD	General government total expenditure (USD)
Average	63 780 000 000	5.0	13.6	5 385 359 241	5 878 692 389	14 090 800 563
Median	63 702 000 000	5.4	13.6	4 734 801 120	6 071 271 859	13 736 699 280
Minimum	49 437 000 000	0.5	12.4	1 980 940 590	1 704 211 870	9 206 652 510
Maximum	79 157 000 000	9.3	14.6	10 704 223 200	10 414 230 368	20 328 309 170

The trend of prioritisation of health and health workforce government expenditure

As shown in Figure 3, since 2000, the health sector received its highest level of prioritisation in 2009, when it was allocated about 12.4% of the general government spending. Between 2005 and 2015, the health budget constituted about 9.9% of the general government spending; however, declining significantly to an average of 6.4% since 2016.

Figure 3.

The trend of prioritisation of health within general government expenditure.

Data from the Medium Expenditure Framework for various years showed that HWF spending as a share of health expenditure averaged 58% (2010-2020) (see Figure 4), retaining a fluctuating trend, however, in response to macroeconomic conditions and socio-political dynamics, and remaining above 60% since 2019.

Figure 4.

The trend in prioritising the health workforce within health expenditure.

Projected budget space for health and the health workforce

Under the assumptions described in the Methodology section, the overall government of Ghana’s fiscal space was estimated to hover around US$7.022 billion per year (range: US$5-US$7.9 billion per year), representing approximately 8.2% of GDP (ranging: from 7.2% to 9.6% between 2022 and 2032) as shown in Table 4. From this projected overall Government of Ghana’s fiscal space and given the observed levels of prioritisation of health sector spending from the public sector expenditure envelope, it was estimated that an average of 13.4% of the overall fiscal space, translating into US$899.3 million budget space in 2022 and US$1.1 billion by 2032, could be spent on health (ranging from 12.3% to 14.4%).

Table 4.

Projected budget space for health and health workforce.

Estimated variable	Government fiscal space (GFS)	Public expenditure envelope for health (PEEH)	HWF budget space (HFS)	Projected government overall fiscal Space as percent of GDP	Projected budget space for health as percent of GDP	Percent of GDP spent on HWF	Percent of health budget prioritised for HWF
2017	4 545 618 841.04	536 383 023.24	295 628 599.47	7.53	0.89	0.49	55.1
2018	6 177 465 668.70	728 940 948.91	591 513 711.81	9.18	1.08	0.88	81.1
2019	7 756 250 312.41	915 237 536.86	608 221 840.99	11.35	1.34	0.89	66.5
2020	11 416 061 272.56	1 347 095 230.16	933 407 994.83	16.31	1.92	1.33	69.3
2021	10 860 154 292.49	1 281 498 206.51	816 781 743.87	13.72	1.62	1.03	63.7
2022	7 304 996 991.98	899 333 133.41	573 203 209.57	9.61	1.18	0.75	63.7
2023	5 040 605 327.03	635 650 607.31	392 558 344.55	7.19	0.91	0.56	61.8
2024	5 603 077 854.62	715 232 741.76	441 782 188.54	7.68	0.98	0.61	61.8
2025	6 164 368 704.83	800 287 777.73	514 278 271.40	8.01	1.04	0.67	64.3
2026	7 251 629 759.11	952 375 083.30	609 091 098.27	8.87	1.16	0.75	64.0
2027	7 735 231 299.83	1 029 128 456.84	670 190 915.76	8.83	1.18	0.77	65.1
2028	7 936 246 347.34	1 071 443 397.68	708 469 239.98	8.80	1.19	0.79	66.1
2029	7 540 304 198.03	1 033 954 624.12	668 146 325.36	8.10	1.11	0.72	64.6
2030	7 486 652 186.14	1 046 245 851.86	674 169 519.58	7.79	1.09	0.70	64.4
2031	7 546 614 422.75	1 070 581 496.26	684 654 703.02	7.60	1.08	0.69	64.0
2032	7 639 215 024.29	1 098 809 917.54	702 943 706.20	7.46	1.07	0.69	64.0
Average	7 022 631 101.45	941 185 735.25	603 589 774.75	8.18	1.09	0.70	63.97
Median	7 486 652 186.14	1 029 128 456.84	668 146 325.36	8.01	1.09	0.70	63.97
Minimum	5 040 605 327.03	635 650 607.31	392 558 344.55	7.19	0.91	0.56	61.76
Maximum	7 936 246 347.34	1 098 809 917.54	708 469 239.98	9.61	1.19	0.79	66.12
Standard deviation	963 995 328.36	158 766 768.39	109 851 400.14	0.75	0.09	0.07	1.28

This anticipated budget space for health represented an average of 1.1% of GDP between 2022 and 2032, ranging from 0.9% to 1.2%, out of which the health workforce budget space was projected to start at US$573.2 million in 2022 and increase by US$129.7 million (23%) to US$702.9 million by 2032. Overall, an estimated 0.7% of GDP was likely to be spent on the health workforce, fluctuating between 0.6% and 0.8%. Compared with the anticipated budget space for health, the health workforce budget space represented about 64.0% (range: 61.8%-66.1%) of the anticipated budget space for health of 8.5% (range: 7.8%-9.2%) of the expected overall fiscal space of government.

Comparison between projected budget space and anticipated Wage Bill

With an estimated total health workforce budget of US$573.2 million in 2022, the accompanying health workforce wage bill (ie, US$571.4 million) was projected to account for almost 100% of the HWF budget, however, varying significantly between US$571.4 million in 2022 and US$869.4 million in 2026. The proportion of affordable wage bill given the estimated health workforce budget space was, meanwhile, estimated to range between 62% and 100%, averaging at 74% by 2030.

However, if the current level and mix of production continued, approximately 88% (ranging between 64% and 100%) of the health budget space would be expended as wage bill cost, far in excess of the global median of 57% and the Africa Region’s median of 45%. Therefore, the reprioritisation of the mix and scale of the health workforce is deemed inevitable, as the current trajectory would no longer be sustainable in the light of fiscal realities and does not seem to be linked to a clear plan to make it sustainable. See Figure 5 and Table 5 for details.

Figure 5.

Comparison between the projected budget space for the health workforce and the estimated wage bill requirements.

Table 5.

Projected budget space compared with projected wage bill given the current rate of HWF production.

Estimated variable	Public expenditure envelope for health (PEEH)	HWF budget space (HBS)	Estimated wage bill (EWB)	Proportion of wage bill affordable given budget space (C/B) (%)	Proportion of Health Budget to be taken by HWF if production is not streamlined (C/A) (%)
2022	$ 899 333 133.41	$ 573 203 209.57	$ 571 386 102.48	100	64
2023	$ 635 650 607.31	$ 392 558 344.55	$ 637 152 606.31	62	100
2024	$ 715 232 741.76	$ 441 782 188.54	$ 699 650 945.75	63	98
2025	$ 800 287 777.73	$ 514 278 271.40	$ 759 067 843.61	68	95
2026	$ 952 375 083.30	$ 609 091 098.27	$ 815 578 294.98	75	86
2027	$ 1 029 128 456.84	$ 670 190 915.76	$ 869 346 352.98	77	84
2028	$ 1 071 443 397.68	$ 708 469 239.98	$ 920 525 859.53	77	86
2029	$ 1 033 954 624.12	$ 668 146 325.36	$ 969 261 125.01	69	94
2030	$ 1 046 245 851.86	$ 674 169 519.58	$ 1 015 687 560.66	66	97
2031	$ 1 070 581 496.26	$ 684 654 703.02	$ 1 059 932 266.93	65	99
2032	$ 1 098 809 917.54	$ 702 943 706.20	$ 1 102 114 581.08	64	100
Average	$ 894 651 158.73	$ 586 059 810.82	$ 725 363 691.02	74	88
Median	$ 899 333 133.41	$ 591 513 711.81	$ 729 359 394.68	71	90
Minimum	$ 536 383 023.24	$ 295 628 599.47	$ 571 386 102.48	62	64
Maximum	$ 1 347 095 230.16	$ 933 407 994.83	$ 869 346 352.98	100	100
Standard deviation	$ 253 023 877.01	$ 181 642 444.06	$ 111 496 269.10	14	13

Discussion

Although it is widely acknowledged that health workforce investment is a critical part of health and inclusive of economic development, there have been limited applications of the principles of fiscal space and budget space analyses to assess the affordability and feasibility of health workforce wage bills. This study applied recent and evolving conceptual thinking regarding health workforce budget space^34,40 and advanced previous attempts³⁷ to quantify the budget space that can shape employment and demand for education for the health professions. In Ghana’s context, it represents the first attempt at exploring the budget impact of health workforce production and demand since the expansionary health workforce production of the early 2000s.⁴⁸

The analysis reveals that the production rate of health workers is very high, at least 25 000 per year. This finding is consistent with the policy disposition of the government since 2007 when it started prioritising the expansion and liberalisation of training of mid-level carders of health workers. The finding also corroborates previous research on the supply of health workers in Ghana; in particular, Asamani et al²⁷ predicted a looming surplus of midwives and auxiliary nurses, which warranted streamlining. Indeed, the unemployment situation of nurses and midwives is well documented,^10,49-51 which, according to labour economics, is a signal that the labour market is getting saturated with their supply.^20,52 The Human Resources for Health policy proposed streamlining the production of the health workforce in line with the country’s needs. This study provides clear evidence on the supply which, when taken with other evidence generated previously, will guide policy implementation.

Furthermore, the study finds that given the current trajectory of workforce production, the public sector wage bill is ballooning, and is becoming no longer sustainable to employ all those who are being trained amidst several warnings that the compensation budget of the public health sector had reached unsustainable levels.^15,53,54 For example, an independent review of the health sector’s 5-year programme of work in 2007¹⁴(p. 48) made the following profound findings and recommendations:

‘As to HR supplies in general, the team feels that the health sector must be careful not to use a “shotgun” approach and specific targets should be set for the new cadres needed taking into consideration limitations of current personnel emolument levels and the comparative economic advantage of different cadre types [. . .]. Given the high personal emoluments proportion of the recurrent budget and continuing expansion of the workforce, there is a need for detailed analysis of the fiscal space for absorbing the new workforce ’ (p. 48).

Despite these warnings and recommendations, subsequent health workforce policies and strategies have failed to rationalise the production of health workers in line with need and financial affordability.

Efficiency in health workforce spending in Ghana has been a topic of considerable policy and public discourse for some time,^15,53,55 where an estimated 28% of the wage bill is said to be wasted due to the maldistribution of thousands of health workers.¹³ It has been argued that increased government spending on health and other social services is unsustainable if the resources are not efficiently used.^36,56

Limitations

It is important to point out that the scope and data limitations must be considered when interpreting the findings of this study. First, while it is preferable to use actual historical expenditure data on the proportion of general government health expenditures that are allocated to the health workforce (wage bill as a proportion of GGHE), there were no such publicly available expenditure data for some years. Hence, we used budget estimates, which reflect the policy intent, to extrapolate the proportions.

Second, the supply and wage bill projections made in this paper covered only seven cadres of health workers in the public health sector of Ghana, mainly due to data availability and logistical challenges. Nonetheless, these cadres constitute the largest share (96%) of the clinical health workforce and consume more than 70% of the health workforce budget.

Third, given the positive relationship between the credibility of the study’s results and the quality of the data used, it would have been essential to conduct sensitivity analyses to explore the effect of other forgone or alternative assumptions such as efficiency gains occasioned by equitable HRH distribution, task sharing or job enlargement vis-à-vis new recruitments, boosting efficiency in government expenditure, pursuing sound macroeconomic policies on the findings. Possibly, the effect of the sensitivity analysis on the study findings would be significant and worthy of future research.

Conclusion

Given the limited budget space in the short term and the debt distress the economy is undergoing,⁵⁷ there are no clear opportunities to expand the health workforce budget space through government budget reprioritisation. However, there is scope for Ghana’s budget space for the health workforce to be improved when issues of public spending and management inefficiencies are addressed to free up resources for increased investments in HRH. Improving budget processes, from planning to execution, and health workforce reforms that potentially deal with inappropriate staff mixes will improve the efficiency of public health workforce spending.

Policy Recommendation

From the foregoing, it is imperative for government to undertake a comprehensive health labour market analysis and use the evidence to develop an HRH sustainability plan, learning from the Rwandan experience.⁵⁸ This should include a review of the health training programmes to streamline them and bring about operational and budget efficiency that would improve the health workforce budget space and enhance the implementation of the health sector HRH policy and strategy.

Footnotes

Appendix

Annex 1.

Estimated cost of wage bill for seven cadres of health workers under prevailing levels of production, 2022 to 2032.

Cadre	2022	2023	2024	2025	2026	2027	2028	2029	2030	2031	2032
Physician	37 327 381.20.20	44 570 337.15.15	51 299 043.23.23	57 550 011.18.18	63 357 160.40.40	68 752 002.03.03	73 763 809.90.90	78 419 779.42.42	82 745 175.10.10	86 763 467.68.68	90 496 461.49.49
Nurses	237 451 123.78.78	258 074 108.51.51	278 037 157.72.72	297 361 389.37.37	316 067 245.60.60	334 174 514.43.43	351 702 350.65.65	368 669 296.12.12	385 093 299.34.34	400 991 734.45	416 381 419.63
Midwives	122 587 303.81	132 952 050.88	142 497 982.94	151 289 786.36	159 387 037.31	166 844 605.44	173 713 025.68	180 038 840.73	185 864 916.39	191 230 732.07	196 172 648.31
Pharmacist	6 513 487.33	8 292 614.88	10 055 730.28	11 802 977.64	13 534 499.77	15 250 438.21	16 950 933.20	18 636 123.73	20 306 147.55	21 961 141.16	23 601 239.82
Biomedical Scientist	16 406 415.61	18 956 874.59	21 456 324.40	23 905 785.21	26 306 256.81	28 658 718.97	30 964 131.89	33 223 436.55	35 437 555.12	37 607 391.31	39 733 830.79
Enrolled Nurse	101 915 062.71	116 596 296.15	130 470 061.75	143 580 770.25	155 970 389.77	167 678 580.23	178 742 820.20	189 198 526.98	199 079 169.89	208 416 377.43	217 240 038.57
Community Health Nurse	49 185 328.05	57 710 324.14	65 834 645.43	73 577 123.61	80 955 705.31	87 987 493.68	94 688 787.99	101 075 121.47	107 161 297.28	112 961 422.82	118 488 942.47
Total	571 386 102.48	637 152 606.31	699 650 945.75	759 067 843.61	815 578 294.98	869 346 352.98	920 525 859.53	969 261 125.01	1 015 687 560.66	1 059 932 266.93	1 102 114 581.08

Acknowledgements

The authors are grateful to Prof. James Avoka Asamani, Health Workforce Team Lead of the World Health Organization Africa Regional Office (WHO AFRO), for his guidance on the model development.

Funding:

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests:

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions

Conception or design of the work – HI & CDC. Data collection – HI & YH. Data analysis and interpretation – HI, CDC & JNO. Drafting the article – HI. Critical revision of the article – CDC, JNO & YH. Final approval of the submitted version – HI, CDC, JNO & YH.

Reflexivity Statement

The authors are a mix of senior academics, experienced researchers and a senior national government and international consultant on budget space analysis with multidisciplinary backgrounds in teaching and learning, nursing education, health financing and investment, health system and policy research. All authors are from the Global South.

Ethical Approval

The study, part of a larger doctoral study, has been granted full ethics approval by the Health Research Ethics Committee of the North-West University (Approval No. NWU-00122-22-A1) and the Ghana Health Service Ethics Review Committee (Approval No. GHS-ERC:018/08/22).

Data Availability Statement

Data related to the study are available in respective worksheets of the Health Workforce Budget Space and Sustainability Model published alongside the paper.

ORCID iD

Christmal Dela Christmals

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