--Responding to Dr. Atsu Amegashie's views.

I find much encouragement in Dr. Amegashie's invitation for a debate on the above subject. I think there is the need for both intelligent and common sense debate on the issue. I find that the writer has great ideas on the subject which are informed by his expertise. Thus, I don't intend to argue with him on the intellectual strengths of his ideas. I hope to inject some element of pragmatism into the debate. I must also state that, in the main, I do agree with Dr. Amegashie's analysis so this contribution is not meant to refute his ideas. I want to add to them and if for any reason we disagree, I do so in recognition of the fact there could be other competing ideas on any subject.

How does Ghana achieve competitive remuneration packages for those of its citizens with good "outside option" and achieve pay equity in the public sector where the doctors find themselves? Do we have a good assessment of the different "outside options" available to all the different categories of public sector employees? Whose responsibility would it be to assess and pay public sector worker based on their "greener pastures option?" Is it the worker, the union or the government (employer)?

Understandably, the exit of doctors is much felt than any other professional because of their gravely inadequate numbers, and also because we overly depend on doctors for health delivery in Ghana. If any Ghanaian believes than less than 2000 professional can carry the health of Ghanaians on their shoulders then such an individual is in for big trouble. That is why a professional association of less than 2000 members wields so much power (both real and perceived) than any other professional grouping in Ghana.

Are doctors adequately paid in Ghana? NO. Can we do anything about it? YES, we can and should.

What I have not been able to grasp is the comparison between minister's salary and that of the doctor. Can't we arrive at what a good and attractive salary should be for a doctor in concert with other allied health professionals? In the first place, I don't personally know and no one has supplied what the minister's salary is at the moment. That would make a good analysis, at least. We cannot assume that we can make savings from 88 people if we are not sure of how much they are receiving! I submit that doctors? salaries should be computed based on realistic inputs--demands on them, economic costs of their work, perks (based on our perceived and actual need for them), expertise, etc. I do believe that as a country we can pay the doctors whatever we agree to pay to them. I would, however, recommend that such inputs as minister's remuneration and their "outside option" be dropped from the debate.

One reason for dropping the two considerations above is that the minister as political office holder has limited number of years to serve and there is a huge uncertainty (risks, different from those of doctors) associated with the job. Also, in some respects, especially in terms of citizenship rules, the minister may be indispensable. You cannot employ non-Ghanaians to the minister's position as it could be possible with doctors. Moreover, it is not convincing enough to compare the "flight risks" between doctors and ministers. No professional politician can cross the national borders to continue their career in another country. Here, I am not talking of such a minister using his/her other skills. I don't agree with the "outside option" argument because we are talking about the gap between First World and Third World countries. Financially, it would almost always appear lucrative "out there" than "in here." Even in the case of Botswana, their economy is far advanced (per capita: US$3430 [2003]) than Ghana's (per capita: US$320 [2003]). For now, take these figures as given. Remuneration wise, there is very little that the Government can do just to appease doctors to stay, not even if doctors are paid the unknown minister's salary.

I also don't subscribe to the idea that the doctor has to stay and work in Ghana. If there is free mobility of labour, why not doctors? Are they the only ones educated at the expense of the tax payer? Dr. Amegashie and I were educated at the same tax payer's expense but we have made individual choices to live in Canada (damn Ghana:)! I would rather posit that any doctor who wants to leave should leave! Because it is his/her right. Probably, when things get worse, they would get better! Of course, we should also not try to conclude that people are making movements only based on economic considerations. Not all doctors would leave Ghana even if they would be flown in private jets. And some of them are also "been tos" so there is nothing attractive for them "out there."

Dr. Amegashie has offered some beautiful suggestions about the way out and those are good ideas worth serious consideration.

My complimentary ideas include:

1) District assemblies should set aside funds to retain doctors in their communities. These should be measures that go beyond what the central government does for the doctors. The assemblies may target perks that are community specific, and geared toward enhancing the job of the doctor. I don't want to be too prescriptive here.

2) Health institutions should cut internal corruption and free up resources to enhance working conditions, mainly workplace enhancement and in the case of Teaching Hospitals, financial and in-kind outlays. Charity should begin at home. And also the petty extortions from poor patients by some medical professionals before certain necessary procedures are carried out should stop so that we can all sympathize with the cause of the doctors.

3) Encouraging the restrictive use of the few doctors on hand (mostly in referral systems). This would discourage the over-reliance on doctors in the medical system. We need to use doctors where their value added is greater. It would also free the doctors of unnecessary workload demands. For example, if we have specialized clinics or professionals for malaria control, doctors could offload most consultations associated with malaria (#1 killer overall in Ghana, kills 25% of kids under 5, 44% of outpatient time, leading cause of all hospital admissions in Ghana---by 2002 Ghana Health Service figures). So, for Malaria alone, we are killing our doctors. Anyone who knows malaria knows that you do not need such highly skilled health professionals--doctors--to deal with them.

4) Training more doctors and bonding them. There are different things that we can experiment. Dr Amegashie has already discussed a good part of it. What I want to add to Dr. Amegashie's ideas is that we need to make a point that if we find that we have a competitive advantage in producing doctors for the international market then let's go for it...why wait? There are hundreds of brilliant minds that we are not able to admit into medical schools each year. We have to expand! Train more! Retain more! Export more! Reap more returns! Re-invest more! On the other hand, we can focus on the training of other medical professionals who are equipped as first contact health person instead of the doctor. This is already in place but we need to prioritize it. Why! According WHO the disease that kill developing countries are in order of severity: 1)Lower respiratory infections, pneumonia and other diseases of the lungs; 2) HIV/AIDS; 3) Malaria; 4) Diarrhoea; 5) Tuberculosis; 6) Measles; 7) Whooping cough, or pertussis; 8) Tetanus; 9) Meningitis; 10) Syphilis

So, how many of these killers can we not treat with the help of other professionals other than doctors? Of course, there are more public health concerns than concerns about curative medical services.

5) May be others can throw more light how we can also repatriate Ghanaian doctors abroad. They may not need financial rewards. They may be looking for challenge, new opportunities to give back, etc.

Of course, doctors should be paid well but we need to develop a sensible, pragmatic and cost effective health delivery system based on the health needs of Ghanaians.