The Ghanaian health system faces a number of major challenges in the recruitment, deployment and retention of health care workers (HCWs). Significant among these is the decision by many young, newly trained professionals to migrate due to a number of reasons, including seeking more attractive work and living conditions abroad. Migration patterns of HCWs over recent years show that Ghana has a relatively high migration rate compared to other African countries, particularly among doctors and nurses. Sixty percent of doctors from the country’s main medical school emigrated between 1986 and 1995. Requests for verification of nurses’ qualifications to work abroad showed annual figures almost double the replacement rates from training institutions. Human resources for health are also poorly distributed, being one of the ingredients of an increasing inequality among the country’s regions and between urban and rural settings. For those HCWs who stay, the incentives for higher productivity and location in remote areas are also low. In 1998, partly in response to these factors as well as industrial agitation from the Ghana Medical Association (GMA) and health worker unions, the Government of Ghana (GOG) introduced the Additional Duty Hours Allowance (ADHA). The original purpose of the ADHA scheme was to compensate doctors for hours worked beyond the standard 40 hours per week or 160 hours per month.

Initially the allowance was only paid to doctors. In 1999 the Nurses Association agitated for and was included in the ADHA. Even though the ADHA scheme arose from industrial action between the GOG and HCW unions, the significant increases to income levels that resulted would seem a powerful intervention to positively affect HCW recruitment, deployment and retention. To explore this question and examine the consequences of the scheme, the Capacity Project partnered with the Ghana Health Service (GHS) to undertake a comprehensive study of the ADHA scheme. The study investigated how the scheme impacted a number of human resources (HR) factors associated with health worker recruitment, deployment, retention and performance—specifically, how the significantly higher income levels resulting from the ADHA scheme influenced job satisfaction, motivation, workplace climate and the relationship between clinical and administrative staff, as well as productivity. The study provides a detailed chronology of the ADHA scheme and explores lessons learned from the way in which the GOG implemented and administered the scheme.