Health workforce retention situation and effect on service delivery in three highly deprived districts in Ghana: a mixed methods design

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This paper explores stakeholders’ perspectives about the health workforce retention situation in deprived settings and how this affects health service delivery. Methods The study was conducted in three deprived, hard-to-reach districts of the Eastern region of Ghana, namely Kwahu Afram Plains North (KAPN), Kwahu Afram Plains South (KAPS), and Kwahu East (KE). The study followed a mixed methods approach, analysis of existing human resource (HR) data, and 21 in-depth interviews (IDIs) with key stakeholders and nine focus group discussions (FGDs) with community health committees to understand how attrition affects health services provision in deprived settings. The qualitative data were analyzed thematically, and the HR quantitative data were descriptively analysed. Results Across the districts, there is very high staff turnover. For example, KAPS exhibited the most volatility, with turnover rates from 0% in 2019 to a peak of 5.16% in 2023. District and sub-district health managers described the staff turnover situation in two dimensions. First, they discussed the phenomenon of health workers being posted to these settings but rejecting postings despite being officially posted by the Ghana Health Service. Managers also reported scenarios where postings were accepted and staff reported, only to stay for a short period before vacating. Another key feature was the high vacancy rates, with 46%, 38%, and 31% in 2023 in KAPS, KAPN, and KE, respectively. The health worker density in the three districts is very low, falling below the World Health Organization's (WHO) recommended threshold of 44.5 health workers per 10,000 population. The health workforce retention situation had serious ramifications for the provision of healthcare in these contexts. Across the three districts, participants reported a) poor quality of care, b) disrupted service delivery, c) poor health outcomes, and d) overwork of existing staff. However, evidence showed that such staff shortages presented excellent capacity-building opportunities that otherwise would not have existed for these non-expert, lower cadre staff. Conclusions The findings provide evidence about the health workforce retention situation in hard-to-reach areas in Ghana and how it impacts healthcare delivery. This study has also provided substantial depth and breadth of evidence to support the formulation of well-informed, evidence-based policies to tackle current retention problems in hard-to-reach communities. health workforce retention healthcare rural primary health care Ghana Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background There is a global recognition that without a well-trained, equitably distributed, and well-motivated health workforce, efforts to achieve universal health coverage (UHC) and the Sustainable Development Goals (SDGs) by 2030 will be impeded [ 1 – 4 ]. As a result, numerous policies and initiatives have been implemented internationally to tackle health workforce challenges in both high-income countries (HICs) and low- and middle-income countries (LMICs) [ 5 , 6 ]. Yet, these problems remain pervasive and create inequitable access to quality healthcare in deprived, hard-to-reach areas. There is also increasing population demand for better quality healthcare amid unplanned urbanization, underfunded health systems, high disease burden, and recent global health security threats from outbreaks [ 7 – 11 ]. A major health system constraint exacerbating the human resources (HR) crisis is the retention of health workers in rural, deprived areas in LMICs. In these settings, healthcare needs are greater, resources are limited, and such locations are often less attractive for health workers. The challenges of attracting and retaining health workers impede the capacity of health systems to deliver quality care. Studies have consistently shown that such inequities and disparities often leave deprived and rural settings with a limited, skilled, and experienced health workforce to deliver standard care [ 12 – 14 ]. Similar to most LMIC contexts, Ghana is facing a health workforce crisis, with the mass exodus of experienced health workers and persistent challenges in attracting and retaining health workers in deprived and hard-to-reach areas. The WHO African region reported that the health workforce density in Ghana was less than 2.22 per 1,000 population in 2018 [ 15 ]. This implies that most health facilities in deprived areas are without the required health workforce. Studies have shown that such shortages and inequities in distribution impact the delivery of quality healthcare [ 16 – 18 ], health workforce motivation and the number of qualified staff in critical managerial and clinical roles, as well as increasing the workload and burnout for staff who remain at remote facilities [ 19 , 20 ]. These developments have far-reaching ramifications for health systems, including potential negative impacts on equity, quality of care, and mortality rates [21,22]. In Ghana, the Ministry of Health and its agencies launched measures and policies to address retention challenges, with limited success. Over the past two decades, there have been ad hoc policy recommendations and key decisions by the Ghana Health Service (GHS) that have been implemented partially or poorly. Key policies and initiatives include introducing the deprived area incentive allowance, recruitment and deployment of Cuban doctors to deprived districts, and opportunities for promotions and study leave for rural service (promotion out of term), among others [23–25]. In addition to centralized policies, anecdotal evidence suggests district and sub-national managers have rolled out innovations such as provision of accommodation, community mobilization of resources to support health workers, and addressing social and welfare needs of staff. Despite these interventions, retention issues remain high, and solutions are unclear. It is also unclear what the views of health managers in these settings are on how the retention crisis potentially impacts healthcare delivery. This study aims to explore and characterize the health workforce retention situation and stakeholders’ perspectives on the effects on health service delivery in Ghana. Methods Study design This cross-sectional mixed-methods study was conducted in three deprived districts of the Eastern Region of Ghana: Kwahu Afram Plains North (KAPN), Kwahu Afram Plains South (KAPS), and Kwahu East (KE). We combined analysis of existing human resources (HR) administrative data with qualitative data from in-depth interviews (IDIs) and focus group discussions (FGDs) to characterise health workforce retention and explore perceived effects on service delivery in deprived settings. Study setting The study was conducted in three deprived and hard-to-reach districts of the Eastern region of Ghana, namely KAPN, KAPS, and KE. The three districts (KAPN, KAPS, KE) are classified as hard-to-reach with persistent human resources challenges and suboptimal service delivery outcomes. Many facilities operate with unfilled positions and rely heavily on lower-cadre staff, including community health workers supporting Community-based Health Planning and Services (CHPS). Many health workers in these districts are lower cadres, including community health workers working in the Community-Based Health Planning and Services. Doctor-to-patient ratios are very low; for example, in Kwahu Afram Plains North, there is one doctor per 70,000 population. The district has 86% rural and 14% urban population distribution. Approximately, three-quarters of the communities are located on Islands within water bodies (Volta Lake, River Afram and Obosom River). Regarding health services infrastructure, the district has one hospital at Donkorkrom and thirteen Community-based Health Planning Services (CHPS). According to the Kwahu Afram Plains North District Planning Coordinating Unit (DPCU) 2018 report, most of the inhabitants in other settlement communities take between 25 and 35 minutes of walking to access the main district hospital at Donkorkrom. About 59.9% of the population patronize health facilities outside the settlement where they live. Study participants Two qualitative participant groups were included. Key informants for IDIs : District Directors of Health Services, Human Resource Officers, Health Service Administrators, District Public Health Nurses, facility managers/in-charges, and representatives of Community Health Management Committees (CHMCs). FGD participants : CHMC members, assembly members, traditional leaders (chiefs and elders), youth leaders, women’s group representatives, religious leaders, community health volunteers, older persons’ representatives, and unit committee members. Sampling procedure Purposive sampling was used to recruit participants based on their roles in service delivery and knowledge of the district health workforce situation. Given the gendered dimensions of health workforce issues, gender balance was considered in sampling. In total, 28 facility heads, 15 District Health Management Team (DHMT) members and 7 hospital staff participated in IDIs. A purposive sampling technique was also adopted to recruit participants for the FGDs. In all, 3 FGDs were conducted in each of the districts among CHMCs (Community Health Management Committee) members. Across districts, 9 FGDs were conducted (3 functional CHMCs, 3 non-functional CHMCs, and 3 CHMCs close to the district capital), yielding 66 participants (16 females, 50 males). Recruitment of participants Potential participants were engaged through existing project contacts established during community engagement and via formal communication with national, regional, district, and sub-district leadership. The study team provided information sheets outlining eligibility and study details prior to scheduling interviews and FGDs. Data collection Data collection tools were developed for this work and pre-tested before actual field data collection. The data collection involves the extraction of human resource for health data, staff satisfaction survey, and community views on health workforce retention. Refer to Supplementary File 1 for the data collection tools that aided the data collection process. Human resources for health data We compiled HR administrative data for 2019–2023 on: number posted, vacancies available, number posted and reported, number posted but did not report, number reported but refused to stay, and number who left the district. In-depth interviews To understand the health workforce situation and the potential effects on service delivery and quality of care, the managers were interviewed during the project launch and inception meeting. The interviews were conducted using a pre-tested topic guide with content developed based on the review of relevant literature and the expertise of the research team. Generally, the guide explored their views on the health workforce situation and the impact on potential health service delivery and outcomes. The interviews were conducted by five members of the research team. The interviews were conducted in English, as all participants were health managers, health workers, or community leaders who were literate and spoke English. The interviews lasted no longer than 1 hour and took place in a private area during the project inception meeting. Refreshments and reimbursement for travel costs were provided following the completion of the interviews. Participants were not privy to any arrangements for reimbursement or refreshments before the interview to avoid any potential bias in their participation and responses. All interviews were recorded following the consent of the participants using digital recorders. In addition, the researchers took detailed notes to ensure non-verbal cues and gestures that had potential relevance and implications for the study were all captured. Focus group discussions The FGDs were facilitated by the FGD guide (developed based on relevant literature and the research team’s expertise on the topic), which explored community stakeholders’ views on the health workforce retention situation and their views on how this tends to affect service delivery and overall health outcomes. The guide specifically explored issues around availability, accessibility and quality of health care service and infrastructure, leadership and management of facilities and how HR availability and retention improve or worsen. The FGDs were facilitated by three members of the research team. All the FGDs were audio recorded after obtaining informed consent from the participants. Overall, the FGDs lasted for approximately 1 hour and 15 minutes. Data analysis Qualitative data (IDIs and FGDs) were managed using NVivo software version 12 and analyzed using the thematic analysis approach. Data were transcribed verbatim. Based on the review and coding of 6-7 transcripts and guided by the topic guides and research objectives, a coding framework was developed. We then applied this coding framework to all the transcripts. We then reviewed the coded data, looking for emergent themes and refining them through discussion amongst the authors. We then developed narratives for each theme, which were transcribed verbatim and managed in NVivo (version 12). Following review and coding of an initial subset of transcripts, a coding framework was developed deductively from the guides and inductively from emerging data. The framework was applied to all transcripts; themes were refined through team discussion and thematic narratives were developed. HR administrative data were analysed descriptively to summarise posting, reporting, refusal to stay, attrition, and vacancies across districts and years (2019–2023). We computed the following operational measures: Turnover rate = number of health workers who left the district ÷ total number of health workers posted (per year). Non-reporting rate = number posted who did not report ÷ total number posted (per year). Refusal-to-stay rate = number who reported but refused to stay ÷ total number posted (per year). Vacancy rate = number of vacant positions ÷ total approved positions. Health worker density = number of health workers per 10,000 population. Rigour and trustworthiness To improve the quality and rigour of the findings from the qualitative data, several measures were adopted. First, the team ensured the accurate translation of tools and transcripts/notes during the data collection period. Second, we undertook training and debriefing sessions held for the research team on all the study tools before fieldwork. All recorded interviews were recorded, whilst the notes and transcripts throughout the fieldwork suggested ways to improve quality, including revision of topic guides and development of further probing questions, addressing any gaps and errors on the spot. Results The results are divided into two sections. First, we present results on the nature and characteristics of the health workforce retention situation using secondary health workforce records, IDIs with key stakeholders, and FGDs with CHMCs to describe a) staff turnover, b) vacancy rate, and c) health worker density rates. The second section describes how the retention issues affect health services provision in deprived settings, drawing on in-depth interviews with key stakeholders and focus group discussions with community health committees. Health workforce retention situation Staff turnover HR records indicated high staff turnover across all three districts (Figure 1). In KAPN, turnover decreased from 5% in 2019 to 2% in 2021, then rose to 4% in 2023. KAPS showed the most volatility, rising from 0% in 2019 to 5.16% in 2023. KE remained relatively stable at around 2% from 2019 to 2022, increasing to 4% in 2023. Insert Figure 1 here District and sub-district managers described two recurrent patterns: health workers posted to these districts who do not report, and those who report but leave after a short period. As one participant noted: “ I know that it is one of the districts that, from time immemorial, has been facing health personnel deficits… a lot of the health personnel that are posted to their districts do not accept postings… those perceptions are sometimes the reality ” (KAPN, community member, male, IDI). Another manager observed: “ They are posting maybe about 30, 40. By the end, you get even less than half of the number reporting to post” (KAPN, manager, male, IDI). Posted but did not report Between 2019 and 2023, the incidence of posting but not reporting for work revealed significant disparities in compliance with deployment directives. KAPN emerged as the most consistently affected district, with the non-reporting rate rising from 14% in 2019 to a peak of 24% in 2020—the highest recorded incidence during the five years. Although the rate declined slightly in subsequent years, it remained notably high, registering 19% in 2021, 15% in 2022, and marginally increasing to 16% in 2023 (Figure 2). In contrast, KAPS maintained full compliance in 2019, 2020, 2022, and 2023, reporting zero cases in each of those years. However, 2021 witnessed a sudden and unexplained spike to 17%, representing a marked deviation from the district’s otherwise consistent trend. Meanwhile, KE consistently recorded 0% non-reporting throughout the entire period, indicating sustained adherence to reporting obligations. Insert Figure 2 here. Overall, the data present a clear contrast among the districts. While KAPS and KE demonstrate strong or recovering compliance, KAPN stands out as a district facing persistent and systemic challenges. These findings underscore the need for targeted investigation and context-specific interventions to address underlying factors contributing to non-reporting in the most affected areas. District and sub-district health managers described the staff turnover situation in two dimensions. First, they discussed the phenomenon of health workers being posted to these settings but refusing to post. “I know that it is one of the districts that, from time immemorial, has been facing health personnel deficits. When I refer to health personnel deficits, I mean that many of the health personnel posted to their districts do not accept postings due to some of the challenges they think they may face when they take up their duties. And I must say that those ideas or those perceptions are sometimes the reality” (KAPN, community member, male, IDI). Health facility managers in KAPN admitted that the district often received significant allocation of postings, but only a few took up the posts, whilst the majority refused postings to the district. “So first, I will say that, yes, sometimes you see them posting letters. They are posting maybe about 30, 40. By the end, you get even less than half of the number reporting to post” (KAPN, manager, male, IDI). Additionally, newly posted staff commonly reject postings to this district despite being officially posted by the Ghana Health Service. According to the managers, this has been one of the major challenges affecting the health workforce situation in the district. “So, we realize that most of the people who are posted, I mean the health workers who are posted to such communities, tend to go for review of postings. And so, day in and day out, they will receive letters that we are going to receive some staff, but at the end of the day, they do not report to post. And so, that is the situation ” (KE, manager, male, IDI) Reported but refused to stay KAPN experienced a gradual yet consistent rise in refusal-to-stay rates, increasing from 6% in 2019 to 13% in 2023, indicating a growing retention challenge. On the other hand, KAPS recorded sharp, short-term spikes, with refusal rates surging to 20% in 2020 and peaking at 40% in 2021, before dropping back to 0% in the following years. KE’s trend has been more unpredictable, with refusal rates fluctuating over the years and a significant peak of 25% in 2022. These variations highlight the need for tailored approaches to address retention issues in each district. Insert Figure 3 Stakeholders reported that although some accept postings, after a short period, they leave the district. Many attributed this to having to cross water via canoe or ferry, which people fear. “ First of all, people don't know the area. The only perception they have is that it is a very deprived and very difficult area. And the mere fact that you have to cross the water to be there scares people. And so, people would do anything to either change their postings or whatever. Those who also accept to be there, for reasons best known to them, after two, three, or four years, all want to leave the place ” (KAPN, Sub-district Male Manager). Another KE manager asserted the following: “For the districts, retention of health workers is a bit challenging. From where I'm coming from, I have several health workers who have left posts for various reasons, and some did not report to post at all.” (KE, manager, male, IDI) Vacancy rate Another key feature of the health workforce retention in these deprived districts is high vacancy rates, with 46%, 38% and 31% in 2023 in KAPS, KAPN, and KE, respectively (see Figure 4). In KAPN, the vacancy rate has remained relatively stable since 2019. However, both KAPS and KE witnessed reductions: KAPS saw a significant decrease in vacancy rates from 67% in 2019 to 46% in 2023; and KE experienced a downward trend in vacancy rates, starting at 58% in 2019 and decreasing to 38% in 2023. Insert Figure 4 Here Managers reported acute shortages of health workers in many of their facilities. In some cases, there was only one health worker who had to deal with all the patients and their healthcare needs. “One of the things you will find going round the district is seeing facilities manned by one or two staff. This has become the norm, so the communities just make do with what they have. I appreciate the situation of distance and depravity, which often discourages healthcare workers from accepting postings or are not willing to stay” (KAPN, manager, male, IDI) Another had this to say “So based on the vast nature of our district, the healthcare workers are also few. Sometimes you can go to a healthcare facility, and you have just two or three nurses available doing all the work of maybe four or five people. So, there are a few of them available at the district” (KAPS, manager, male, IDI) Health worker density As shown in Figure 5, the health worker density in the three districts was very low, falling below the WHO’s recommended threshold of 44.5 health workers per 10,000 population. This benchmark is crucial for adequate healthcare services and UHC. KAPN has the highest density at 37.3 health workers per 10,000 population, yet it still fell short of the WHO benchmark. KAPS had the lowest density, with only 20.6 health workers per 10,000, less than half of the recommended level. KE had a density of 27.6 health workers per 10,000, which, while better than KAPS, remains significantly below the optimal standard. Insert Figure 5 Here Use of volunteers Due to the staff shortages in all the districts, managers were compelled to use community health volunteers to augment the staffing strength to ensure continuity of care. These volunteers have supported in making referrals, facilitating community outreach activities, and providing other auxiliary services at the health facilities. “As for their work in terms of service delivery, it is good, because whenever someone who is sick comes to call some of us the promoters (volunteers) we then call the nurse and they come and render the services to the person based on issue reported, and anytime you call on them they are there to work, so with this I will say that it is good, because they are helping us, health-wise in the community” (KE, community member, male, FGD) Perceived effects of poor retention on service delivery Participants also shared their observations of how the current retention challenges potentially impact healthcare delivery in these deprived settings. Overall, four key areas were noted, namely a ) poor health outcomes, b) quality of care, c) burnout of existing staff, d) disrupted service delivery and e) staff gaining useful experience Poor health outcomes Several managers reported that a lack of staff affected the health outcomes. One manager gave an example of high numbers of stillbirths and neonatal deaths in the district due to a lack of skilled staff: “The talk surrounding stillbirths and neonatal deaths is high. You can observe these phenomena as reflections of certain deficiencies in the skilled personnel responsible for identifying and guiding pregnant women to appropriate delivery locations. Therefore, it is evident that the absence of staff is impacting several of our indicators. When examining district indicators, the gaps become apparent. Although our ANC coverages and family planning initiatives may have improved, challenges persist, such as instances of stillbirths and related issues.” (KAPN, manager, male, IDI) Managers reported that they are unable to reach the targets for coverage of services such as child immunization and other outreach work. “…. it’s the outreaches, the immunization programs, that have been affected, because we don't meet our targets every year, any set objectives, because of the staff strength, we can't meet our targets. So, our objectives are not always fully achieved” (KAPS, manager, male, IDI) Several managers reported that service delivery and achieving district health targets are hindered when staff leave the district. They emphasized the loss of staff who are experienced and know the community well, also highlighting the burden of training, coaching and supporting new staff to perform well, which takes time and effort from the managers, impeding general performance. One manager in KAPN specifically spoke about difficulties in record-keeping faced by new staff: “It affects the service delivery and the performance greatly because when you look at an experienced staff leaving the district or leaving the facility because of one reason or the other, and looking at how great their whole work is based on that individual and the person leave, you are now going to coach somebody who is going there to also go and replace the person, which will take time for the person to pick up from where that person left before you can get your indicators. So, somehow, all the indicators will come down, and the image of the facility will come down” (KAPN, manager, male, IDI) Poor quality of care Managers across the districts reported that when there are few staff in the facility, they work long hours providing services during the day and night, affecting the quality of care. Clients also complained about the quality of services. Managers also reported that when there are few staff, they leave the facility unattended when they take a break, meaning clients come to the facility to find no staff available and make complaints. As one manager explained: “They do not run shifts, these two people work for 24 hours and so intermittently, they go on breaks. When community members come to seek care at the facility during their break periods, these complaints arise. And also, because the work is stressful, the output is affected when they get overwhelmed”. (KAPS, manager, male, IDI) X respondents in x highlighted that when there are few staff, they have to take on multiple roles, causing stress and increasing waiting times, potentially preventing some patients from seeking health care in future. “…we lack staff there, maybe one person has to take care of you, take your records, issue you a card, and take your temperature before you go and see a doctor. But if we have more staff there, as I'm doing one thing, somebody will do another thing. But since it's always and often one person, that person can spend one hour on one client, whilst other clients are waiting to be attended to. So, if that were the case, the client would not prefer coming to the hospital at all, or the OPD.”. (KAPN, manager, male, IDI) In some district health facilities, staff are reportedly inexperienced or lack the specialist skills needed. They sometimes take on tasks they are not skilled in, which is risky for their patients as well as themselves. “There are instances, probably somebody is not a physician assistant, or somebody is not a midwife, the person has to conduct an emergency delivery or has to cater for a condition that the person may not be well-abreast with. In that case, if you decide to go your own way and then handle it as you are, you may put yourself in danger and put the client also at risk.” (KAPS, manager, male, IDI) Burnout of existing staff Views from most of the health care providers, especially health facility managers, noted that due to the shortages of health workers, the few workers that remain have increased workloads, thus experiencing burnout. This arose from the available staff playing multiple roles in providing healthcare services and working for extended periods, with little to no breaks. “Because looking at my facility, for example, it's a health center, but staffing is a challenge, so you have to play multiple roles. There are days that I'll go out and do all sorts of roles, and by the time I get home, it will be around 7 pm, 8 pm. And with that, you have been on the bike for a whole day. Your body feels the impact. By the end of it all, you have to repeat it the following day, which you have no choice but to do. And some of our communities are very, very tough to get to, even during the dry season, as well as the rainy season; some of them, you can't even attempt to go.” (KAPS, manager, male, IDI) Several managers and community members across all the districts described how the existing staff were overworked as they cover all shifts and must be available to manage any emergencies during the day and night. This resulted in the staff being exhausted and stressed. “Because of the number of midwives, you cannot get four midwives for the morning, four midwives for the afternoon, and four midwives for the night shift… So, the two midwives will be running up and down until daybreak. And so, they can easily break down; they easily break down” (KAPN, manager, male, IDI) Disrupted service delivery Managers reported that in some instances, when a health worker leaves, then the service is suspended. For example, when a midwife leaves, a replacement may not be immediately available, and delivery services are suspended. Consequently, women often travel further for delivery care. A female facility manager in KAPS had this to say: “When the person in charge of a service leaves, an immediate replacement might not be available. This could result in the service being temporarily unavailable, or you might have to until new staff are hired and posted before the service can be resumed.” (KAPS, manager, female, IDI) Capacity-building opportunities One manager reported that he often talks with staff about the advantages of working in a deprived area. He explained that staff must manage many situations, gaining valuable and transferable skills and knowledge, which they might not gain in other settings “So, it builds your capacity, and your experience, and your techniques too. So, we do talk to them about this advantage that they can get in this deprived area. They shouldn't think about anything else, but they should just think about the working experience that they'll get.” (KAPS, manager, male, IDI) Discussion Summary of key findings This study set out to explore stakeholders’ perspectives about the health workforce retention situation in deprived settings and the extent to which this affects healthcare delivery. We found that across districts, there is very high staff turnover. For example, KAPS exhibited the most volatility, with turnover rates from 0% in 2019 to a peak of 5.16% in 2023. Respondents highlighted two trends: health workers being posted to these settings, but rejecting postings and staff accepting postings, but leaving shortly thereafter. Another key feature is high vacancy rates, with 46%, 38%, and 31% in 2023 in KAPS, KAPN, and KE, respectively. Managers reported acute shortages of health workers in many of their facilities, with only one health worker per facility in some cases. Consequently, managers are compelled to use community health volunteers, who support making referrals to facilities and overall community mobilization drives for immunization and other health promotion activities. The health worker density across districts is low, falling below the WHO’s threshold. Several managers reported that a lack of staff affected health outcomes such as high numbers of stillbirths and neonatal deaths, as well as the ability to reach service coverage targets such as child immunization. Due to the shortages of health workers, the few workers that remain have increased workloads, thus experiencing burnout. Disrupted service delivery is often associated with these staff shortages and high turnover. Managers reported that in some instances, when a health worker leaves, the service is suspended. However, through taking on a high level of responsibility and variable tasks, staff gain valuable and transferable skills and knowledge, which they might not gain in other settings. Findings compared with previous literature In most resource-poor settings in LMICs such as Ghana, health workforce challenges are often enormous and characterized by high staff turnover and high vacancy rates, and particularly in rural and remote areas. The global health workforce strategy has highlighted these issues as major challenges confronting health systems of LMICs [ 1 ]. For example, rural and deprived regions of Kenya[ 2 ] and Nigeria [ 3 , 4 ] face health workforce retention challenges, with many staff remaining in or moving to urban areas to work. A notable finding in this study was the common use of community health volunteers to overcome health workforce shortages. The recognition of their roles in this study is also reflected in the global landscape, where this cadre of health workers has played central roles in providing care to cut-off and hard-to-reach areas [ 5 , 6 ]. As a result of these shortages, task shifting to community health workers or volunteers remains a common practice[ 2 , 5 ]. The WHO has recognised the role of these volunteers and called on stakeholders and policy makers to improve their conditions of service, build their capacity and provide them with better incentives as they provide care in the remotest of places, help mobilise community members to access and utilise care, or cooperate and better engage with the formal health systems[ 7 , 8 ]. In other regions in Ghana, community health workers and volunteers are also widely used to augment the health workforce shortage [ 9 ]. Countries in SSA and other LMICs have also evidenced community health volunteers or workers in key roles in filling staff shortages [ 5 , 7 , 8 , 10 , 11 ]. Although studies have reported the role of community health volunteers globally, their roles as a stop-gap measure to temporarily fix staff shortages in deprived and rural settings have been inadequately reported in Ghana. In our study, the density of health workers fell below the WHO-recommended density. This aligns with the situation in most parts of SSA, where health worker density is often low and accounts for poor health outcomes [ 12 , 13 ]. Low health worker density has been demonstrated to impact overall mortality, life expectancy at birth, infant mortality, under-5 mortality, and maternal mortality [ 13 , 14 ]. It is anticipated that Africa and other LMICs will experience further health workforce shortages of about six million by 2030 [ 1 ]. However, these shortages often culminate in high staff density, as seen in the present study. As observed in this study, a common feature of the health workforce situation in the deprived districts is the high turnover or attrition rates. This contributes to the huge staff shortages as reported across the three districts. This situation is not uncommon, as evidence shows that staff attrition is a predominant characteristic of most health systems in LMICs [ 15 – 17 ]. In Ethiopia, studies have shown evidence of high attrition, with some expressing intention to leave, with dire consequences for the health system [ 16 ]. Further, it has been reported that high staff turnover will potentially affect the quality of healthcare, patient outcomes and service utilization [ 18 ]. Staff turnover and attrition are common shortfalls associated with health systems in Ghana and other countries. This study found that this situation often impacts critical health outcomes, disruption of healthcare but also has a positive side of offering capacity building for staff through the gaining of valuable experience by leading or being exposed to diverse opportunities to directly provide care with or without supervision. Burnout and excessive workload are key features of staff health systems with retention challenges. The findings of huge burnout and workload associated with staff turnover in these studies are common features reported in other studies [ 19 ]. This often occurs as the few remaining staff take on extra responsibilities and duties, with longer shifts at the various facilities. The challenges in retaining health workers in deprived communities have far-reaching ramifications on health outcomes and the overall health systems. Stakeholders perceived that health workforce retention challenges often result in low immunization coverage, poor health outcomes, and the inability of the health system to meet certain outcomes and immunization targets. This is consistent with evidence from the USA, where evidence also highlights a situation where the health workforce shortages at the sub-national level may be associated with higher maternal mortality [ 20 ]. A similar situation was also observed in Zimbabwe, where the country is also experiencing critical shortages of key health cadres, and this has led to affected healthcare availability and quality of healthcare for pregnant women and children[ 14 ]. Implications for policy and practice Findings underscore the need to strengthen implementation of existing national retention policies and to evaluate why previous measures have had limited traction. Options include refining incentive packages for hard-to-reach postings, improving living and working conditions (e.g., accommodation, transport across water bodies), ensuring timely replacement for critical cadres (e.g., midwives), and supporting locally led innovations by district managers. In light of this, it remains imperative that existing policies such as the Ghana Health Service (GHS) Policy and Guidelines on promotions, GHS Study leave Policy, Guidelines for selecting staff for study leave with pay and the Staffing Norms for the Health Sector. Reviewing and enforcing the implementation of these policies and plans will help tackle several of the above challenges in these deprived districts. As seen in this study, community health volunteers were a stop-gap measure to fill current health workforce gaps. Given this is common practice, we call for further support, technically and financially, to ensure these volunteers continue to support healthcare delivery in these settings with high staff turnover. This might include more research into the role of community health volunteers and how their capacity can be effectively strengthened. Retooling them with capacity-building opportunities and credentialing their roles with some form of remuneration and career pathway would ensure retention and more gains from their contributions. Further, roll out of structured support—training, supervision, supplies, and modest incentives— for volunteers could enhance effectiveness and sustainability, while recognising the scope of practice. Strengthened HRH information systems would enable closer monitoring of posting, reporting, attrition and vacancies to inform rapid corrective action. Strengths and limitations There are several strengths and limitations to this study. The findings are based on a sample of health managers and community members from three of the several deprived, rural districts in Ghana. As a result, views from participants about the retention situation and effect on service delivery cannot reflect or represent the picture nationally or across the entire deprived districts and communities facing a similar situation. However, we did include the perspectives of managers, health workers and community members to enable a holistic picture of the health workforce situation. We did not include service delivery or health outcome data but instead relied upon views of managers, health workers, and community members on the effects of the health workforce shortages on service delivery. The study integrates multiple data sources (HR administrative data, IDIs, FGDs) and perspectives (managers, health workers, community stakeholders), offering a rich picture of retention challenges in three deprived districts. However, the qualitative sample and geographic scope limit generalisability. We did not analyse service coverage or health outcomes quantitatively; perceived effects were reported by participants. HR data gaps may have affected the completeness of counts, although repeated validation and triangulation with qualitative insights bolster credibility. Conclusions Retention of the health workforce in deprived, hard-to-reach communities is a major imperative for the attainment of the UHC goal. The findings report several fundamental challenges that undermine this effort, such as staff shortages, burnout, high turnover, and poorly motivated staff. These challenges have critical implications for equitable access to quality care that people in remote, hard-to-reach, and deprived areas so urgently need. Whilst recommending the enforcement and implementation of existing strategies and policies that can address several of these challenges, we also advocate for the need for locally driven, low-cost interventions to address issues of retention and overall health workforce challenges. Abbreviations CHMCs: Community Health Management Committees CHPS: Community-based Health Planning and Services DHMT: District Health Management Team FGD(s): Focus group discussion(s) GHS: Ghana Health Service HIC(s): High-income country(ies) HR: Human resources HRH: Human resources for health IDI(s): In-depth interview(s) KAPN: Kwahu Afram Plains North KAPS: Kwahu Afram Plains South KE: Kwahu East LMIC(s): Low- and middle-income country(ies) SDGs: Sustainable Development Goals UHC: Universal health coverage WHO: World Health Organization Declarations Ethics approval and consent to participate This research was conducted according to the Helsinki Declaration for Medical Research. Ethical approval was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC:007/02/24) and the Liverpool School of Tropical Medicine Research Ethics Committee (24-002). All participants provided informed consent prior to data collection. Confidentiality and data security procedures were followed throughout the study. Written informed consent was sought from participants before the data collection. Data were reported in an aggregated form to enhance the confidentiality and anonymity of the respondents Consent for publication Not applicable. Availability of data and materials De-identified qualitative data are not publicly available due to confidentiality commitments to participants. Aggregated human resources administrative data supporting the findings may be available from the corresponding author on reasonable request and with permission from the relevant district and regional health authorities. Competing interests The authors declare that they have no competing interests. Funding This work was supported by Global Health Partnerships (grant number: GHWP LG.07). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors’ contributions LB and PA conceived the study. LB, PA, SKM, SA, KB, MA, WA and JR designed the methodology. LB, SKM, SA, KB and WA coordinated data collection. LB, SKM, WA, IH, SA, PA, JR curated the data. LB and SKM conducted the formal analysis with input from JR and PA. LB drafted the first version of the manuscript. IH, JR, MA, and PA provided critical review and editing. JR and PA provided overall supervision. All authors read and approved the final manuscript. (Initials used: LB = Leonard Baatiema; SKM = Sedzro Kojo Mensah; SA = Sam Amon; IH = India Hotopf; KB = Kassim Basit; MA=Moses Aikins; WA = William Akatoti; JR = Joanna Raven; PA = Patricia Akweongo.) Acknowledgements We thank the Eastern Region Health Directorate, the District Health Management Teams of KAPN, KAPS and KE, facility managers, CHMC members and all participants for their time and insights. We are grateful to the field researchers for their contributions to data collection and transcription. References Global strategy on human resources for health: Workforce 2030. Muia D, Kamau A, Kibe L. Community Health Workers Volunteerism and Task-Shifting: Lessons from Malaria Control and Prevention Implementation Research in Malindi, Kenya. American Journal of Sociological Research [Internet]. 2019;2019:1–8. Available from: http://journal.sapub.org/sociology Abimbola S, Olanipekun T, Igbokwe U, Negin J, Jan S, Martiniuk A, et al. How decentralisation influences the retention of primary health care workers in rural Nigeria. Glob Health Action. 2015;8. Okoroafor SC, Ongom M, Mohammed B, Salihu D, Ahmat A, Osubor M, et al. Perspectives of policymakers and health care managers on the retention of health workers in rural and remote settings in Nigeria. Journal of Public Health (United Kingdom). 2021;43:I12–9. Woldie M, Feyissa GT, Admasu B, Hassen K, Mitchell K, Mayhew S, et al. Community health volunteers could help improve access to and use of essential health services by communities in LMICs: An umbrella review. Health Policy Plan. Oxford University Press; 2018. p. 1128–43. Angwenyi V, Aantjes C, Kondowe K, Mutchiyeni JZ, Kajumi M, Criel B, et al. Moving to a strong(er) community health system: Analysing the role of community health volunteers in the new national community health strategy in Malawi. BMJ Glob Health. 2018;3. Vareilles G, Pommier J, Marchal B, Kane S. Understanding the performance of community health volunteers involved in the delivery of health programmes in underserved areas: A realist synthesis. Implementation Science. BioMed Central Ltd.; 2017. 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Soc Indic Res. 2022;163:609–32. Rosser JI, Aluri KZ, Kempinsky A, Richardson S, Bendavid E. The Effect of Healthcare Worker Density on Maternal Health Service Utilization in Sub-Saharan Africa. American Journal of Tropical Medicine and Hygiene. 2022;106:939–44. Haley CA, Vermund SH, Moyo P, Kipp AM, Madzima B, Kanyowa T, et al. Impact of a critical health workforce shortage on child health in Zimbabwe: A country case study on progress in child survival, 2000-2013. Health Policy Plan. 2017;32:613–24. Riehm KE, Latimer E, Quesnel-Valle A, Stevens GWJM, Garipy G, Elgar FJ. Does the density of the health workforce predict adolescent health? A cross-sectional, multilevel study of 38 countries. Journal of Public Health (United Kingdom). 2019;41:E35–43. Michael YH/, Jira C, Girma B, Tushune K. HEALTH WORKFORCE DEPLOYMENT, ATTRITION AND DENSITY IN EAST WOLLEGA ZONE, WESTERN ETHIOPIA. Castro Lopes S, Guerra-Arias M, Buchan J, Pozo-Martin F, Nove A. A rapid review of the rate of attrition from the health workforce. Hum Resour Health. BioMed Central Ltd.; 2017. Assefa T, Haile Mariam D, Mekonnen W, Derbew M, Enbiale W. Physician distribution and attrition in the public health sector of Ethiopia. Risk Manag Healthc Policy. 2016;9:285–95. Willard-Grace R, Knox M, Huang B, Hammer H, Kivlahan C, Grumbach K. Burnout and health care workforce turnover. Ann Fam Med. 2019;17:36–41. Snyder JE, Stahl AL, Streeter RA, Washko MM. Regional Variations in Maternal Mortality and Health Workforce Availability in the United States. Ann Intern Med. 2020;173:S45–54. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":131019,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStaff turnover rate by district (2019–2023)\u003c/strong\u003e\u2028Turnover (%) by year for KAPN, KAPS and KE, showing volatility in KAPS and increases in 2023 in KAPN and KE.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7685937/v1/b7473ce29f501f26e4695062.png"},{"id":93729494,"identity":"d1a0b9b1-f8cc-4953-922a-b51ca906cd1a","added_by":"auto","created_at":"2025-10-17 02:15:15","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":230220,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrends in non-reporting among posted staff (2019–2023)\u003c/strong\u003e Percentage of staff posted who did not report to post, highlighting persistently higher rates in KAPN and a spike in KAPS in 2021.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7685937/v1/a41e2d00126ec3e33d7131bc.jpeg"},{"id":93727218,"identity":"13ce75bf-49a2-4192-852f-3bd27931dcc6","added_by":"auto","created_at":"2025-10-17 02:07:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":160284,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRefusal-to-stay among staff who reported (2019–2023)\u003c/strong\u003e Percentage of staff who reported but later refused to stay, with peaks in KAPS (2020–2021) and KE (2022), and a gradual rise in KAPN.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7685937/v1/efe72f07138aad3f66b18455.png"},{"id":93727209,"identity":"de729c99-e643-475f-8136-42e74b3f3dbc","added_by":"auto","created_at":"2025-10-17 02:07:15","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":120982,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStaff vacancy rate by district (2019–2023)\u003c/strong\u003e Vacancy (%) over time, with reductions in KAPS and KE since 2019 but overall high vacancies across districts in 2023.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7685937/v1/efadad5305041412c55fd087.png"},{"id":93727213,"identity":"a40f2c75-1f19-467f-98c7-53671a219788","added_by":"auto","created_at":"2025-10-17 02:07:15","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":97056,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHealth worker density per 10,000 population\u003c/strong\u003e District-level density estimates (per 10,000 population) for KAPN, KAPS and KE, each below the WHO threshold of 44.5.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7685937/v1/822fdf29d13611abe685ef54.png"},{"id":93731157,"identity":"a9263adb-672c-4397-9cde-7fe720a32898","added_by":"auto","created_at":"2025-10-17 02:23:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1859296,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7685937/v1/d3f7de44-3ae2-428c-b5b4-44f1a0d9e945.pdf"},{"id":93727202,"identity":"17235605-2370-4d77-9a02-dc2faee8a40f","added_by":"auto","created_at":"2025-10-17 02:07:14","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":54416,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1Datacollectiontools.docx","url":"https://assets-eu.researchsquare.com/files/rs-7685937/v1/ac903a750fd923f9e5f79696.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health workforce retention situation and effect on service delivery in three highly deprived districts in Ghana: a mixed methods design","fulltext":[{"header":"Background","content":"\u003cp\u003eThere is a global recognition that without a well-trained, equitably distributed, and well-motivated health workforce, efforts to achieve universal health coverage (UHC) and the Sustainable Development Goals (SDGs) by 2030 will be impeded [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As a result, numerous policies and initiatives have been implemented internationally to tackle health workforce challenges in both high-income countries (HICs) and low- and middle-income countries (LMICs) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Yet, these problems remain pervasive and create inequitable access to quality healthcare in deprived, hard-to-reach areas. There is also increasing population demand for better quality healthcare amid unplanned urbanization, underfunded health systems, high disease burden, and recent global health security threats from outbreaks [\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA major health system constraint exacerbating the human resources (HR) crisis is the retention of health workers in rural, deprived areas in LMICs. In these settings, healthcare needs are greater, resources are limited, and such locations are often less attractive for health workers. The challenges of attracting and retaining health workers impede the capacity of health systems to deliver quality care. Studies have consistently shown that such inequities and disparities often leave deprived and rural settings with a limited, skilled, and experienced health workforce to deliver standard care [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSimilar to most LMIC contexts, Ghana is facing a health workforce crisis, with the mass exodus of experienced health workers and persistent challenges in attracting and retaining health workers in deprived and hard-to-reach areas. The WHO African region reported that the health workforce density in Ghana was less than 2.22 per 1,000 population in 2018 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This implies that most health facilities in deprived areas are without the required health workforce. Studies have shown that such shortages and inequities in distribution impact the delivery of quality healthcare [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], health workforce motivation and the number of qualified staff in critical managerial and clinical roles, as well as increasing the workload and burnout for staff who remain at remote facilities [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These developments have far-reaching ramifications for health systems, including potential negative impacts on equity, quality of care, and mortality rates [21,22].\u003c/p\u003e\u003cp\u003eIn Ghana, the Ministry of Health and its agencies launched measures and policies to address retention challenges, with limited success. Over the past two decades, there have been ad hoc policy recommendations and key decisions by the Ghana Health Service (GHS) that have been implemented partially or poorly. Key policies and initiatives include introducing the deprived area incentive allowance, recruitment and deployment of Cuban doctors to deprived districts, and opportunities for promotions and study leave for rural service (promotion out of term), among others [23\u0026ndash;25]. In addition to centralized policies, anecdotal evidence suggests district and sub-national managers have rolled out innovations such as provision of accommodation, community mobilization of resources to support health workers, and addressing social and welfare needs of staff.\u003c/p\u003e\u003cp\u003eDespite these interventions, retention issues remain high, and solutions are unclear. It is also unclear what the views of health managers in these settings are on how the retention crisis potentially impacts healthcare delivery. This study aims to explore and characterize the health workforce retention situation and stakeholders\u0026rsquo; perspectives on the effects on health service delivery in Ghana.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This cross-sectional mixed-methods study was conducted in three deprived districts of the Eastern Region of Ghana: Kwahu Afram Plains North (KAPN), Kwahu Afram Plains South (KAPS), and Kwahu East (KE). We combined analysis of existing human resources (HR) administrative data with qualitative data from in-depth interviews (IDIs) and focus group discussions (FGDs) to characterise health workforce retention and explore perceived effects on service delivery in deprived settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in three deprived and hard-to-reach districts of the Eastern region of Ghana, namely KAPN, KAPS, and KE. The three districts (KAPN, KAPS, KE) are classified as hard-to-reach with persistent human resources challenges and suboptimal service delivery outcomes. Many facilities operate with unfilled positions and rely heavily on lower-cadre staff, including community health workers supporting Community-based Health Planning and Services (CHPS). Many health workers in these districts are lower cadres, including community health workers working in the Community-Based Health Planning and Services. Doctor-to-patient ratios are very low; for example, in Kwahu Afram Plains North, there is one doctor per 70,000 population. The district has 86% rural and 14% urban population distribution. Approximately, three-quarters of the communities are located on Islands within water bodies (Volta Lake, River Afram and Obosom River). Regarding health services infrastructure, the district has one hospital at Donkorkrom and thirteen Community-based Health Planning Services (CHPS). According to the Kwahu Afram Plains North District Planning Coordinating Unit (DPCU) 2018 report, most of the inhabitants in other settlement communities take between 25 and 35 minutes of walking to access the main district hospital at Donkorkrom. About 59.9% of the population patronize health facilities outside the settlement where they live.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy participants\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Two qualitative participant groups were included.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eKey informants for IDIs\u003c/strong\u003e: District Directors of Health Services, Human Resource Officers, Health Service Administrators, District Public Health Nurses, facility managers/in-charges, and representatives of Community Health Management Committees (CHMCs).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFGD participants\u003c/strong\u003e: CHMC members, assembly members, traditional leaders (chiefs and elders), youth leaders, women\u0026rsquo;s group representatives, religious leaders, community health volunteers, older persons\u0026rsquo; representatives, and unit committee members.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eSampling procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to recruit participants based on their roles in service delivery and knowledge of the district health workforce situation. Given the gendered dimensions of health workforce issues, gender balance was considered in sampling. In total, 28 facility heads, 15 District Health Management Team (DHMT) members and 7 hospital staff participated in IDIs. A purposive sampling technique was also adopted to recruit participants for the FGDs. In all, 3 FGDs were conducted in each of the districts among CHMCs (Community Health Management Committee) members. Across districts, 9 FGDs were conducted (3 functional CHMCs, 3 non-functional CHMCs, and 3 CHMCs close to the district capital), yielding 66 participants (16 females, 50 males).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment of participants\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Potential participants were engaged through existing project contacts established during community engagement and via formal communication with national, regional, district, and sub-district leadership. The study team provided information sheets outlining eligibility and study details prior to scheduling interviews and FGDs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tools were developed for this work and pre-tested before actual field data collection. The data collection involves the extraction of human resource for health data, staff satisfaction survey, and community views on health workforce retention. Refer to Supplementary File 1 for the data collection tools that aided the data collection process.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman resources for health data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;We compiled HR administrative data for 2019\u0026ndash;2023 on: number posted, vacancies available, number posted and reported, number posted but did not report, number reported but refused to stay, and number who left the district.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn-depth interviews\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;To understand the health workforce situation and the potential effects on service delivery and quality of care, the managers were interviewed during the project launch and inception meeting. The interviews were conducted using a pre-tested topic guide with content developed based on the review of relevant literature and the expertise of the research team. Generally, the guide explored their views on the health workforce situation and the impact on potential health service delivery and outcomes. The interviews were conducted by five members of the research team. The interviews were conducted in English, as all participants were health managers, health workers, or community leaders who were literate and spoke English. The interviews lasted no longer than 1 hour and took place in a private area during the project inception meeting. Refreshments and reimbursement for travel costs were provided following the completion of the interviews. Participants were not privy to any arrangements for reimbursement or refreshments before the interview to avoid any potential bias in their participation and responses. All interviews were recorded following the consent of the participants using digital recorders. In addition, the researchers took detailed notes to ensure non-verbal cues and gestures that had potential relevance and implications for the study were all captured.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFocus group discussions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe FGDs were facilitated by the FGD guide (developed based on relevant literature and the research team\u0026rsquo;s expertise on the topic), which explored community stakeholders\u0026rsquo; views on the health workforce retention situation and their views on how this tends to affect service delivery and overall health outcomes. The guide specifically explored issues around availability, accessibility and quality of health care service and infrastructure, leadership and management of facilities and how HR availability and retention improve or worsen. The FGDs were facilitated by three members of the research team. All the FGDs were audio recorded after obtaining informed consent from the participants. Overall, the FGDs lasted for approximately 1 hour and 15 minutes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative data (IDIs and FGDs) were managed using NVivo software version 12 and analyzed using the thematic analysis approach. Data were transcribed verbatim. Based on the review and coding of 6-7 transcripts and guided by the topic guides and research objectives, a coding framework was developed. We then applied this coding framework to all the transcripts. We then reviewed the coded data, looking for emergent themes and refining them through discussion amongst the authors. We then developed narratives for each theme, which were transcribed verbatim and managed in NVivo (version 12). Following review and coding of an initial subset of transcripts, a coding framework was developed deductively from the guides and inductively from emerging data. The framework was applied to all transcripts; themes were refined through team discussion and thematic narratives were developed.\u003c/p\u003e\n\u003cp\u003eHR administrative data were analysed descriptively to summarise posting, reporting, refusal to stay, attrition, and vacancies across districts and years (2019\u0026ndash;2023). We computed the following operational measures:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eTurnover rate\u003c/strong\u003e = number of health workers who left the district \u0026divide; total number of health workers posted (per year).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNon-reporting rate\u003c/strong\u003e = number posted who did not report \u0026divide; total number posted (per year).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRefusal-to-stay rate\u003c/strong\u003e = number who reported but refused to stay \u0026divide; total number posted (per year).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVacancy rate\u003c/strong\u003e = number of vacant positions \u0026divide; total approved positions.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHealth worker density\u003c/strong\u003e = number of health workers per 10,000 population.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eRigour and trustworthiness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo improve the quality and rigour of the findings from the qualitative data, several measures were adopted. First, the team ensured the accurate translation of tools and transcripts/notes during the data collection period. Second, we undertook training and debriefing sessions held for the research team on all the study tools before fieldwork. \u0026nbsp;All recorded interviews were recorded, whilst the notes and transcripts throughout the fieldwork suggested ways to improve quality, including revision of topic guides and development of further probing questions, addressing any gaps and errors on the spot.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe results are divided into two sections. First, we present results on the nature and characteristics of the health workforce retention situation using secondary health workforce records, IDIs with key stakeholders, and FGDs with CHMCs to describe a) staff turnover, b) vacancy rate, and c) health worker density rates. The second section describes how the retention issues affect health services provision in deprived settings, drawing on in-depth interviews with key stakeholders and focus group discussions with community health committees.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth workforce retention situation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStaff turnover\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHR records indicated high staff turnover across all three districts (Figure 1). In KAPN, turnover decreased from 5% in 2019 to 2% in 2021, then rose to 4% in 2023. KAPS showed the most volatility, rising from 0% in 2019 to 5.16% in 2023. KE remained relatively stable at around 2% from 2019 to 2022, increasing to 4% in 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Figure 1 here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDistrict and sub-district managers described two recurrent patterns: health workers posted to these districts who do not report, and those who report but leave after a short period. As one participant noted:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI know that it is one of the districts that, from time immemorial, has been facing health personnel deficits\u0026hellip; a lot of the health personnel that are posted to their districts do not accept postings\u0026hellip; those perceptions are sometimes the reality\u003c/em\u003e\u0026rdquo; (KAPN, community member, male, IDI).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother manager observed:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThey are posting maybe about 30, 40. By the end, you get even less than half of the number reporting to post\u0026rdquo;\u003c/em\u003e (KAPN, manager, male, IDI).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePosted but did not report\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween 2019 and 2023, the incidence of posting but not reporting for work revealed significant disparities in compliance with deployment directives. KAPN emerged as the most consistently affected district, with the non-reporting rate rising from 14% in 2019 to a peak of 24% in 2020\u0026mdash;the highest recorded incidence during the five years. Although the rate declined slightly in subsequent years, it remained notably high, registering 19% in 2021, 15% in 2022, and marginally increasing to 16% in 2023 (Figure 2). In contrast, KAPS maintained full compliance in 2019, 2020, 2022, and 2023, reporting zero cases in each of those years. However, 2021 witnessed a sudden and unexplained spike to 17%, representing a marked deviation from the district\u0026rsquo;s otherwise consistent trend. Meanwhile, KE consistently recorded 0% non-reporting throughout the entire period, indicating sustained adherence to reporting obligations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Figure 2 here.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, the data present a clear contrast among the districts. While KAPS and KE demonstrate strong or recovering compliance, KAPN stands out as a district facing persistent and systemic challenges. These findings underscore the need for targeted investigation and context-specific interventions to address underlying factors contributing to non-reporting in the most affected areas.\u003c/p\u003e\n\u003cp\u003eDistrict and sub-district health managers described the staff turnover situation in two dimensions. First, they discussed the phenomenon of health workers being posted to these settings but refusing to post.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I know that it is one of the districts that, from time immemorial, has been facing health personnel deficits. When I refer to health personnel deficits, I mean that many of the health personnel posted to their districts do not accept postings due to some of the challenges they think they may face when they take up their duties.\u003c/em\u003e\u003cem\u003e\u0026nbsp;And I must say that those ideas or those perceptions are sometimes the reality\u0026rdquo; (KAPN, community member, male, IDI).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealth facility managers in KAPN admitted that the district often received significant allocation of postings, but only a few took up the posts, whilst the majority refused postings to the district.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So first, I will say that, yes, sometimes you see them posting letters. They are posting maybe about 30, 40. By the end, you get even less than half of the number reporting to post\u0026rdquo;\u003c/em\u003e (KAPN, manager, male, IDI).\u003c/p\u003e\n\u003cp\u003eAdditionally, newly posted staff commonly reject postings to this district despite being officially posted by the Ghana Health Service. According to the managers, this has been one of the major challenges affecting the health workforce situation in the district.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So, we realize that most of the people who are posted, I mean the health workers who are posted to such communities, tend to go for review of postings. And so, day in and day out, they will receive letters that we are going to receive some staff, but at the end of the day, they do not report to post. And so, that is the situation\u003c/em\u003e\u0026rdquo; (KE, manager, male, IDI)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReported but refused to stay\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;KAPN experienced a gradual yet consistent rise in refusal-to-stay rates, increasing from 6% in 2019 to 13% in 2023, indicating a growing retention challenge. On the other hand, KAPS recorded sharp, short-term spikes, with refusal rates surging to 20% in 2020 and peaking at 40% in 2021, before dropping back to 0% in the following years. KE\u0026rsquo;s trend has been more unpredictable, with refusal rates fluctuating over the years and a significant peak of 25% in 2022. These variations highlight the need for tailored approaches to address retention issues in each district.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Figure 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStakeholders reported that although some accept postings, after a short period, they leave the district. Many attributed this to having to cross water via canoe or ferry, which people fear.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eFirst of all, people don\u0026apos;t know the area. The only perception they have is that it is a very deprived and very difficult area. And the mere fact that you have to cross the water to be there scares people. And so, people would do anything to either change their postings or whatever. Those who also accept to be there, for reasons best known to them, after two, three, or four years, all want to leave the place\u003c/em\u003e\u0026rdquo; (KAPN, Sub-district Male Manager).\u003c/p\u003e\n\u003cp\u003eAnother KE manager asserted the following:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For the districts, retention of health workers is a bit challenging. From where I\u0026apos;m coming from, I have several health workers who have left posts for various reasons, and some did not report to post at all.\u0026rdquo;\u003c/em\u003e\u0026nbsp; (KE, manager, male, IDI)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVacancy rate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnother key feature of the health workforce retention in these deprived districts is high vacancy rates, with 46%, 38% and 31% in 2023 in KAPS, KAPN, and KE, respectively (see Figure 4). In KAPN, the vacancy rate has remained relatively stable since 2019. However, both KAPS and KE witnessed reductions: \u0026nbsp;KAPS saw a significant decrease in vacancy rates from 67% in 2019 to 46% in 2023; and KE experienced a downward trend in vacancy rates, starting at 58% in 2019 and decreasing to 38% in 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Figure 4 Here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eManagers reported acute shortages of health workers in many of their facilities. In some cases, there was only one health worker who had to deal with all the patients and their healthcare needs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;One of the things you will find going round the district is seeing facilities manned by one or two staff. This has become the norm, so the communities just make do with what they have. I appreciate the situation of distance and depravity, which often discourages healthcare workers from accepting postings or are not willing to stay\u0026rdquo;\u003c/em\u003e (KAPN, manager, male, IDI)\u003c/p\u003e\n\u003cp\u003eAnother had this to say\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So based on the vast nature of our district, the healthcare workers are also few. Sometimes you can go to a healthcare facility, and you have just two or three nurses available doing all the work of maybe four or five people. So, there are a few of them available at the district\u0026rdquo;\u003c/em\u003e (KAPS, manager, male, IDI)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth worker density\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Figure 5, the health worker density in the three districts was very low, falling below the WHO\u0026rsquo;s recommended threshold of 44.5 health workers per 10,000 population. This benchmark is crucial for adequate healthcare services and UHC. KAPN has the highest density at 37.3 health workers per 10,000 population, yet it still fell short of the WHO benchmark. KAPS had the lowest density, with only 20.6 health workers per 10,000, less than half of the recommended level. KE had a density of 27.6 health workers per 10,000, which, while better than KAPS, remains significantly below the optimal standard.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Figure 5 Here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUse of volunteers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the staff shortages in all the districts, managers were compelled to use community health volunteers to augment the staffing strength to ensure continuity of care. These volunteers have supported in making referrals, facilitating community outreach activities, and providing other auxiliary services at the health facilities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;As for their work in terms of service delivery, it is good, because whenever someone who is sick comes to call some of us the promoters (volunteers) we then call the nurse and they come and render the services to the person based on issue reported, and anytime you call on them they are there to work, so with this I will say that it is good, because they are helping us, health-wise in the community\u0026rdquo;\u003c/em\u003e (KE, community member, male, FGD)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived effects of poor retention on service delivery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants also shared their observations of how the current retention challenges potentially impact healthcare delivery in these deprived settings. Overall, four key areas were noted, namely a\u003cstrong\u003e)\u0026nbsp;\u003c/strong\u003epoor health outcomes, b) quality of care, c) burnout of existing staff, d) disrupted service delivery and e) staff gaining useful experience\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePoor health outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral managers reported that a lack of staff affected the health outcomes. One manager gave an example of high numbers of stillbirths and neonatal deaths in the district due to a lack of skilled staff:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The talk surrounding stillbirths and neonatal deaths is high. You can observe these phenomena as reflections of certain deficiencies in the skilled personnel responsible for identifying and guiding pregnant women to appropriate delivery locations. Therefore, it is evident that the absence of staff is impacting several of our indicators. When examining district indicators, the gaps become apparent. Although our ANC coverages and family planning initiatives may have improved, challenges persist, such as instances of stillbirths and related issues.\u0026rdquo; (KAPN, manager, male, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eManagers reported that they are unable to reach the targets for coverage of services such as child immunization and other outreach work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;\u0026hellip;. it\u0026rsquo;s the outreaches, the immunization programs, that have been affected, because we don\u0026apos;t meet our targets every year, any set objectives, because of the staff strength, we can\u0026apos;t meet our targets. So, our objectives are not always fully achieved\u0026rdquo; (KAPS, manager, male, IDI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral managers reported that service delivery and achieving district health targets are hindered when staff leave the district. They emphasized the loss of staff who are experienced and know the community well, also highlighting the burden of training, coaching and supporting new staff to perform well, which takes time and effort from the managers, impeding general performance. One manager in KAPN specifically spoke about difficulties in record-keeping faced by new staff:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It affects the service delivery and the performance greatly because when you look at an experienced staff leaving the district or leaving the facility because of one reason or the other, and looking at how great their whole work is based on that individual and the person leave, you are now going to coach somebody who is going there to also go and replace the person, which will take time for the person to pick up from where that person left before you can get your indicators. So, somehow, all the indicators will come down, and the image of the facility will come down\u0026rdquo;\u0026nbsp;\u003c/em\u003e(KAPN, manager, male, IDI)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePoor quality of care\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eManagers across the districts reported that when there are few staff in the facility, they work long hours providing services during the day and night, affecting the quality of care. Clients also complained about the quality of services. Managers also reported that when there are few staff, they leave the facility unattended when they take a break, meaning clients come to the facility to find no staff available and make complaints. As one manager explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They do not run shifts, these two people work for 24 hours and so intermittently, they go on breaks. When community members come to seek care at the facility during their break periods, these complaints arise. And also, because the work is stressful, the output is affected when they get overwhelmed\u0026rdquo;.\u0026nbsp;\u003c/em\u003e(KAPS, manager, male, IDI)\u003c/p\u003e\n\u003cp\u003eX respondents in x highlighted that when there are few staff, they have to take on multiple roles, causing stress and increasing waiting times, potentially preventing some patients from seeking health care in future. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;we lack staff there, maybe one person has to take care of you, take your records, issue you a card, and take your temperature before you go and see a doctor. But if we have more staff there, as I\u0026apos;m doing one thing, somebody will do another thing. But since it\u0026apos;s always and often one person, that person can spend one hour on one client, whilst other clients are waiting to be attended to. So, if that were the case, the client would not prefer coming to the hospital at all, or the OPD.\u0026rdquo;.\u0026nbsp;\u003c/em\u003e(KAPN, manager, male, IDI)\u003c/p\u003e\n\u003cp\u003eIn some district health facilities, staff are reportedly inexperienced or lack the specialist skills needed. They sometimes take on tasks they are not skilled in, which is risky for their patients as well as themselves.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There are instances, probably somebody is not a physician assistant, or somebody is not a midwife, the person has to conduct an emergency delivery or has to cater for a condition that the person may not be well-abreast with. In that case, if you decide to go your own way and then handle it as you are, you may put yourself in danger and put the client also at risk.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(KAPS, manager, male, IDI)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBurnout of existing staff\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eViews from most of the health care providers, especially health facility managers, noted that due to the shortages of health workers, the few workers that remain have increased workloads, thus experiencing burnout. This arose from the available staff playing multiple roles in providing healthcare services and working for extended periods, with little to no breaks.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Because looking at my facility, for example, it\u0026apos;s a health center, but staffing is a challenge, so you have to play multiple roles. There are days that I\u0026apos;ll go out and do all sorts of roles, and by the time I get home, it will be around 7 pm, 8 pm. And with that, you have been on the bike for a whole day. Your body feels the impact. By the end of it all, you have to repeat it the following day, which you have no choice but to do. And some of our communities are very, very tough to get to, even during the dry season, as well as the rainy season; some of them, you can\u0026apos;t even attempt to go.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(KAPS, manager, male, IDI)\u003c/p\u003e\n\u003cp\u003eSeveral managers and community members across all the districts described how the existing staff were overworked as they cover all shifts and must be available to manage any emergencies during the day and night. \u0026nbsp; This resulted in the staff being exhausted and stressed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Because of the number of midwives, you cannot get four midwives for the morning, four midwives for the afternoon, and four midwives for the night shift\u0026hellip; So, the two midwives will be running up and down until daybreak. And so, they can easily break down; they easily break down\u0026rdquo;\u0026nbsp;\u003c/em\u003e(KAPN, manager, male, IDI)\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDisrupted service delivery\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eManagers reported that in some instances, when a health worker leaves, then the service is suspended. For example, when a midwife leaves, a replacement may not be immediately available, and delivery services are suspended. Consequently, women often travel further for delivery care. A female facility manager in KAPS had this to say:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;When the person in charge of a service leaves, an immediate replacement might not be available. This could result in the service being temporarily unavailable, or you might have to until new staff are hired and posted before the service can be resumed.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(KAPS, manager, female, IDI)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCapacity-building opportunities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne manager reported that he often talks with staff about the advantages of working in a deprived area. He explained that staff must manage many situations, gaining valuable and transferable skills and knowledge, which they might not gain in other settings\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So, it builds your capacity, and your experience, and your techniques too. So, we do talk to them about this advantage that they can get in this deprived area. They shouldn\u0026apos;t think about anything else, but they should just think about the working experience that they\u0026apos;ll get.\u0026rdquo;\u003c/em\u003e (KAPS, manager, male, IDI)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\u003ch2\u003eSummary of key findings\u003c/h2\u003e\u003cp\u003eThis study set out to explore stakeholders\u0026rsquo; perspectives about the health workforce retention situation in deprived settings and the extent to which this affects healthcare delivery. We found that across districts, there is very high staff turnover. For example, KAPS exhibited the most volatility, with turnover rates from 0% in 2019 to a peak of 5.16% in 2023. Respondents highlighted two trends: health workers being posted to these settings, but rejecting postings and staff accepting postings, but leaving shortly thereafter. Another key feature is high vacancy rates, with 46%, 38%, and 31% in 2023 in KAPS, KAPN, and KE, respectively. Managers reported acute shortages of health workers in many of their facilities, with only one health worker per facility in some cases. Consequently, managers are compelled to use community health volunteers, who support making referrals to facilities and overall community mobilization drives for immunization and other health promotion activities. The health worker density across districts is low, falling below the WHO\u0026rsquo;s threshold. Several managers reported that a lack of staff affected health outcomes such as high numbers of stillbirths and neonatal deaths, as well as the ability to reach service coverage targets such as child immunization. Due to the shortages of health workers, the few workers that remain have increased workloads, thus experiencing burnout. Disrupted service delivery is often associated with these staff shortages and high turnover. Managers reported that in some instances, when a health worker leaves, the service is suspended. However, through taking on a high level of responsibility and variable tasks, staff gain valuable and transferable skills and knowledge, which they might not gain in other settings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eFindings compared with previous literature\u003c/h2\u003e\u003cp\u003eIn most resource-poor settings in LMICs such as Ghana, health workforce challenges are often enormous and characterized by high staff turnover and high vacancy rates, and particularly in rural and remote areas. The global health workforce strategy has highlighted these issues as major challenges confronting health systems of LMICs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. For example, rural and deprived regions of Kenya[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and Nigeria [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] face health workforce retention challenges, with many staff remaining in or moving to urban areas to work.\u003c/p\u003e\u003cp\u003eA notable finding in this study was the common use of community health volunteers to overcome health workforce shortages. The recognition of their roles in this study is also reflected in the global landscape, where this cadre of health workers has played central roles in providing care to cut-off and hard-to-reach areas [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As a result of these shortages, task shifting to community health workers or volunteers remains a common practice[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The WHO has recognised the role of these volunteers and called on stakeholders and policy makers to improve their conditions of service, build their capacity and provide them with better incentives as they provide care in the remotest of places, help mobilise community members to access and utilise care, or cooperate and better engage with the formal health systems[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In other regions in Ghana, community health workers and volunteers are also widely used to augment the health workforce shortage [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Countries in SSA and other LMICs have also evidenced community health volunteers or workers in key roles in filling staff shortages [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Although studies have reported the role of community health volunteers globally, their roles as a stop-gap measure to temporarily fix staff shortages in deprived and rural settings have been inadequately reported in Ghana.\u003c/p\u003e\u003cp\u003eIn our study, the density of health workers fell below the WHO-recommended density. This aligns with the situation in most parts of SSA, where health worker density is often low and accounts for poor health outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Low health worker density has been demonstrated to impact overall mortality, life expectancy at birth, infant mortality, under-5 mortality, and maternal mortality [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It is anticipated that Africa and other LMICs will experience further health workforce shortages of about six million by 2030 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, these shortages often culminate in high staff density, as seen in the present study.\u003c/p\u003e\u003cp\u003eAs observed in this study, a common feature of the health workforce situation in the deprived districts is the high turnover or attrition rates. This contributes to the huge staff shortages as reported across the three districts. This situation is not uncommon, as evidence shows that staff attrition is a predominant characteristic of most health systems in LMICs [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In Ethiopia, studies have shown evidence of high attrition, with some expressing intention to leave, with dire consequences for the health system [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Further, it has been reported that high staff turnover will potentially affect the quality of healthcare, patient outcomes and service utilization [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Staff turnover and attrition are common shortfalls associated with health systems in Ghana and other countries. This study found that this situation often impacts critical health outcomes, disruption of healthcare but also has a positive side of offering capacity building for staff through the gaining of valuable experience by leading or being exposed to diverse opportunities to directly provide care with or without supervision. Burnout and excessive workload are key features of staff health systems with retention challenges. The findings of huge burnout and workload associated with staff turnover in these studies are common features reported in other studies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This often occurs as the few remaining staff take on extra responsibilities and duties, with longer shifts at the various facilities.\u003c/p\u003e\u003cp\u003eThe challenges in retaining health workers in deprived communities have far-reaching ramifications on health outcomes and the overall health systems. Stakeholders perceived that health workforce retention challenges often result in low immunization coverage, poor health outcomes, and the inability of the health system to meet certain outcomes and immunization targets. This is consistent with evidence from the USA, where evidence also highlights a situation where the health workforce shortages at the sub-national level may be associated with higher maternal mortality [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A similar situation was also observed in Zimbabwe, where the country is also experiencing critical shortages of key health cadres, and this has led to affected healthcare availability and quality of healthcare for pregnant women and children[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eImplications for policy and practice\u003c/h2\u003e\u003cp\u003eFindings underscore the need to strengthen implementation of existing national retention policies and to evaluate why previous measures have had limited traction. Options include refining incentive packages for hard-to-reach postings, improving living and working conditions (e.g., accommodation, transport across water bodies), ensuring timely replacement for critical cadres (e.g., midwives), and supporting locally led innovations by district managers. In light of this, it remains imperative that existing policies such as the Ghana Health Service (GHS) Policy and Guidelines on promotions, GHS Study leave Policy, Guidelines for selecting staff for study leave with pay and the Staffing Norms for the Health Sector. Reviewing and enforcing the implementation of these policies and plans will help tackle several of the above challenges in these deprived districts.\u003c/p\u003e\u003cp\u003eAs seen in this study, community health volunteers were a stop-gap measure to fill current health workforce gaps. Given this is common practice, we call for further support, technically and financially, to ensure these volunteers continue to support healthcare delivery in these settings with high staff turnover. This might include more research into the role of community health volunteers and how their capacity can be effectively strengthened. Retooling them with capacity-building opportunities and credentialing their roles with some form of remuneration and career pathway would ensure retention and more gains from their contributions. Further, roll out of structured support\u0026mdash;training, supervision, supplies, and modest incentives\u0026mdash; for volunteers could enhance effectiveness and sustainability, while recognising the scope of practice. Strengthened HRH information systems would enable closer monitoring of posting, reporting, attrition and vacancies to inform rapid corrective action.\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThere are several strengths and limitations to this study. The findings are based on a sample of health managers and community members from three of the several deprived, rural districts in Ghana. As a result, views from participants about the retention situation and effect on service delivery cannot reflect or represent the picture nationally or across the entire deprived districts and communities facing a similar situation. However, we did include the perspectives of managers, health workers and community members to enable a holistic picture of the health workforce situation. We did not include service delivery or health outcome data but instead relied upon views of managers, health workers, and community members on the effects of the health workforce shortages on service delivery.\u003c/p\u003e\u003cp\u003eThe study integrates multiple data sources (HR administrative data, IDIs, FGDs) and perspectives (managers, health workers, community stakeholders), offering a rich picture of retention challenges in three deprived districts. However, the qualitative sample and geographic scope limit generalisability. We did not analyse service coverage or health outcomes quantitatively; perceived effects were reported by participants. HR data gaps may have affected the completeness of counts, although repeated validation and triangulation with qualitative insights bolster credibility.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eRetention of the health workforce in deprived, hard-to-reach communities is a major imperative for the attainment of the UHC goal. The findings report several fundamental challenges that undermine this effort, such as staff shortages, burnout, high turnover, and poorly motivated staff. These challenges have critical implications for equitable access to quality care that people in remote, hard-to-reach, and deprived areas so urgently need. Whilst recommending the enforcement and implementation of existing strategies and policies that can address several of these challenges, we also advocate for the need for locally driven, low-cost interventions to address issues of retention and overall health workforce challenges.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHMCs: Community Health Management Committees\u003c/p\u003e\n\u003cp\u003eCHPS: Community-based Health Planning and Services\u003c/p\u003e\n\u003cp\u003eDHMT: District Health Management Team\u003c/p\u003e\n\u003cp\u003eFGD(s): Focus group discussion(s)\u003c/p\u003e\n\u003cp\u003eGHS: Ghana Health Service\u003c/p\u003e\n\u003cp\u003eHIC(s): High-income country(ies)\u003c/p\u003e\n\u003cp\u003eHR: Human resources\u003c/p\u003e\n\u003cp\u003eHRH: Human resources for health\u003c/p\u003e\n\u003cp\u003eIDI(s): In-depth interview(s)\u003c/p\u003e\n\u003cp\u003eKAPN: Kwahu Afram Plains North\u003c/p\u003e\n\u003cp\u003eKAPS: Kwahu Afram Plains South\u003c/p\u003e\n\u003cp\u003eKE: Kwahu East\u003c/p\u003e\n\u003cp\u003eLMIC(s): Low- and middle-income country(ies)\u003c/p\u003e\n\u003cp\u003eSDGs: Sustainable Development Goals\u003c/p\u003e\n\u003cp\u003eUHC: Universal health coverage\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This research was conducted according to the Helsinki Declaration for Medical Research. Ethical approval was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC:007/02/24) and the Liverpool School of Tropical Medicine Research Ethics Committee (24-002). All participants provided informed consent prior to data collection. Confidentiality and data security procedures were followed throughout the study. Written informed consent was sought from participants before the data collection. Data were reported in an aggregated form to enhance the confidentiality and anonymity of the respondents\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;De-identified qualitative data are not publicly available due to confidentiality commitments to participants. Aggregated human resources administrative data supporting the findings may be available from the corresponding author on reasonable request and with permission from the relevant district and regional health authorities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This work was supported by Global Health Partnerships (grant number: GHWP LG.07). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;LB and PA conceived the study. LB, PA, SKM, SA, KB, MA, WA and JR designed the methodology. LB, SKM, SA, KB and WA coordinated data collection. LB, SKM, WA, IH, SA, PA, JR curated the data. LB and SKM conducted the formal analysis with input from JR and PA. LB drafted the first version of the manuscript. IH, JR, MA, and PA provided critical review and editing. JR and PA provided overall supervision. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(Initials used: LB = Leonard Baatiema; SKM = Sedzro Kojo Mensah; SA = Sam Amon; IH = India Hotopf; KB = Kassim Basit; MA=Moses Aikins; WA = William Akatoti; JR = Joanna Raven; PA = Patricia Akweongo.)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;We thank the Eastern Region Health Directorate, the District Health Management Teams of KAPN, KAPS and KE, facility managers, CHMC members and all participants for their time and insights. We are grateful to the field researchers for their contributions to data collection and transcription.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal strategy on human resources for health: Workforce 2030. \u003c/li\u003e\n\u003cli\u003eMuia D, Kamau A, Kibe L. Community Health Workers Volunteerism and Task-Shifting: Lessons from Malaria Control and Prevention Implementation Research in Malindi, Kenya. American Journal of Sociological Research [Internet]. 2019;2019:1\u0026ndash;8. Available from: http://journal.sapub.org/sociology\u003c/li\u003e\n\u003cli\u003eAbimbola S, Olanipekun T, Igbokwe U, Negin J, Jan S, Martiniuk A, et al. How decentralisation influences the retention of primary health care workers in rural Nigeria. Glob Health Action. 2015;8. \u003c/li\u003e\n\u003cli\u003eOkoroafor SC, Ongom M, Mohammed B, Salihu D, Ahmat A, Osubor M, et al. Perspectives of policymakers and health care managers on the retention of health workers in rural and remote settings in Nigeria. Journal of Public Health (United Kingdom). 2021;43:I12\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eWoldie M, Feyissa GT, Admasu B, Hassen K, Mitchell K, Mayhew S, et al. Community health volunteers could help improve access to and use of essential health services by communities in LMICs: An umbrella review. Health Policy Plan. Oxford University Press; 2018. p. 1128\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eAngwenyi V, Aantjes C, Kondowe K, Mutchiyeni JZ, Kajumi M, Criel B, et al. Moving to a strong(er) community health system: Analysing the role of community health volunteers in the new national community health strategy in Malawi. BMJ Glob Health. 2018;3. \u003c/li\u003e\n\u003cli\u003eVareilles G, Pommier J, Marchal B, Kane S. Understanding the performance of community health volunteers involved in the delivery of health programmes in underserved areas: A realist synthesis. Implementation Science. BioMed Central Ltd.; 2017. \u003c/li\u003e\n\u003cli\u003eLeon N, Sanders D, Van Damme W, Besada D, Daviaud E, Oliphant NP, et al. The role of \u0026ldquo;hidden\u0026rdquo; community volunteers in community-based health service delivery platforms: Examples from sub-Saharan Africa. Glob Health Action. 2015;8. \u003c/li\u003e\n\u003cli\u003eBaatiema L, Sumah AM, Tang PN, Ganle JK. Community health workers in Ghana: the need for greater policy attention. Available from: https://gh.bmj.com\u003c/li\u003e\n\u003cli\u003eScott K, Beckham SW, Gross M, Pariyo G, Rao KD, Cometto G, et al. What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. Hum Resour Health. BioMed Central Ltd.; 2018. \u003c/li\u003e\n\u003cli\u003eCometto G, Ford N, Pfaffman-Zambruni J, Akl EA, Lehmann U, McPake B, et al. Health policy and system support to optimise community health worker programmes: an abridged WHO guideline. Lancet Glob Health. Elsevier Ltd; 2018. p. e1397\u0026ndash;404. \u003c/li\u003e\n\u003cli\u003eLiu J, Eggleston K. The Association between Health Workforce and Health Outcomes: A Cross-Country Econometric Study. Soc Indic Res. 2022;163:609\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eRosser JI, Aluri KZ, Kempinsky A, Richardson S, Bendavid E. The Effect of Healthcare Worker Density on Maternal Health Service Utilization in Sub-Saharan Africa. American Journal of Tropical Medicine and Hygiene. 2022;106:939\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eHaley CA, Vermund SH, Moyo P, Kipp AM, Madzima B, Kanyowa T, et al. Impact of a critical health workforce shortage on child health in Zimbabwe: A country case study on progress in child survival, 2000-2013. Health Policy Plan. 2017;32:613\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eRiehm KE, Latimer E, Quesnel-Valle A, Stevens GWJM, Garipy G, Elgar FJ. Does the density of the health workforce predict adolescent health? A cross-sectional, multilevel study of 38 countries. Journal of Public Health (United Kingdom). 2019;41:E35\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eMichael YH/, Jira C, Girma B, Tushune K. HEALTH WORKFORCE DEPLOYMENT, ATTRITION AND DENSITY IN EAST WOLLEGA ZONE, WESTERN ETHIOPIA. \u003c/li\u003e\n\u003cli\u003eCastro Lopes S, Guerra-Arias M, Buchan J, Pozo-Martin F, Nove A. A rapid review of the rate of attrition from the health workforce. Hum Resour Health. BioMed Central Ltd.; 2017. \u003c/li\u003e\n\u003cli\u003eAssefa T, Haile Mariam D, Mekonnen W, Derbew M, Enbiale W. Physician distribution and attrition in the public health sector of Ethiopia. Risk Manag Healthc Policy. 2016;9:285\u0026ndash;95. \u003c/li\u003e\n\u003cli\u003eWillard-Grace R, Knox M, Huang B, Hammer H, Kivlahan C, Grumbach K. Burnout and health care workforce turnover. Ann Fam Med. 2019;17:36\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eSnyder JE, Stahl AL, Streeter RA, Washko MM. Regional Variations in Maternal Mortality and Health Workforce Availability in the United States. Ann Intern Med. 2020;173:S45\u0026ndash;54. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"health workforce, retention, healthcare, rural, primary health care, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-7685937/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7685937/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eHealth systems in low- and middle-income countries are experiencing numerous challenges, including a health workforce crisis, primarily in retaining health workers in rural, deprived areas. This paper explores stakeholders\u0026rsquo; perspectives about the health workforce retention situation in deprived settings and how this affects health service delivery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe study was conducted in three deprived, hard-to-reach districts of the Eastern region of Ghana, namely Kwahu Afram Plains North (KAPN), Kwahu Afram Plains South (KAPS), and Kwahu East (KE). The study followed a mixed methods approach, analysis of existing human resource (HR) data, and 21 in-depth interviews (IDIs) with key stakeholders and nine focus group discussions (FGDs) with community health committees to understand how attrition affects health services provision in deprived settings. The qualitative data were analyzed thematically, and the HR quantitative data were descriptively analysed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAcross the districts, there is very high staff turnover. For example, KAPS exhibited the most volatility, with turnover rates from 0% in 2019 to a peak of 5.16% in 2023. District and sub-district health managers described the staff turnover situation in two dimensions. First, they discussed the phenomenon of health workers being posted to these settings but rejecting postings despite being officially posted by the Ghana Health Service. Managers also reported scenarios where postings were accepted and staff reported, only to stay for a short period before vacating. Another key feature was the high vacancy rates, with 46%, 38%, and 31% in 2023 in KAPS, KAPN, and KE, respectively. The health worker density in the three districts is very low, falling below the World Health Organization's (WHO) recommended threshold of 44.5 health workers per 10,000 population. The health workforce retention situation had serious ramifications for the provision of healthcare in these contexts. Across the three districts, participants reported a) poor quality of care, b) disrupted service delivery, c) poor health outcomes, and d) overwork of existing staff. However, evidence showed that such staff shortages presented excellent capacity-building opportunities that otherwise would not have existed for these non-expert, lower cadre staff.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe findings provide evidence about the health workforce retention situation in hard-to-reach areas in Ghana and how it impacts healthcare delivery. This study has also provided substantial depth and breadth of evidence to support the formulation of well-informed, evidence-based policies to tackle current retention problems in hard-to-reach communities.\u003c/p\u003e","manuscriptTitle":"Health workforce retention situation and effect on service delivery in three highly deprived districts in Ghana: a mixed methods design","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 02:07:09","doi":"10.21203/rs.3.rs-7685937/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-31T14:48:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222991887564212498177181016375717506849","date":"2026-03-25T00:07:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-19T10:19:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230441276914332229636215320841509307829","date":"2025-10-03T08:27:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-03T08:15:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-03T08:03:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-03T04:49:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-01T15:54:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-10-01T13:52:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5b1ea846-b86c-4e4a-b88d-cbc566f225c5","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-17T02:07:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 02:07:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7685937","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7685937","identity":"rs-7685937","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}