Incentive package for doctors in Ghana

Abstract

Background Ghana continues to face persistent maldistribution of doctors between rural and urban areas. This thesis evaluates the Early Study Leave with Pay policy, introduced in August 2016 to incentivise rural service through earlier access to study leave with continued salary, and examines the broader drivers and barriers influencing doctors’ decisions to work in rural and urban settings. Methods A mixed-methods design combined a systematic review, Interrupted Time Series analysis, and a three-round Delphi study. Caesarean section (CS) activity was used as a proxy for doctor presence. Analyses covered national, regional, district and hospital levels from 2011 to 2022, using segmented regression with Newey-West standard errors. The Delphi study involved doctors and regional health directors and assessed consensus on factors influencing rural and urban working. Results The systematic review identified limited Ghana-specific evidence on incentive schemes and persistent gaps in economic evaluation. Nationally, the intervention was associated with a 228.2% immediate increase in CS cases and a 217.9% reduction in the post-intervention growth rate (p < 0.001). Effects varied substantially across regions and districts. Delphi participants reached consensus on 40 descriptors, 37 of which were considered important. Four themes emerged: financial factors, professional development and career advancement, work-life balance, and community lifestyle factors. The Early Study Leave with Pay scheme itself was not perceived as a key facilitator. Conclusion The policy contributed to measurable but uneven redistribution of healthcare workers. Financial and educational incentives alone are insufficient to resolve rural-urban disparities; sustainable workforce policy should combine them with career progression, family support and hospital-level capacity strengthening. The findings support context-sensitive health workforce strategies in Ghana and comparable low- and middle-income countries.