The Impact of Local Capacity Building on “Brain Drain” and Maternal Mortality in Ghana

By Melissa A. Elafros, MA and Frank J. Anderson, MD, MPH

The United Nations Millennium Development Goals (MDGs), conceived in 2000, are intended to spur the advancement of 7 economic and social areas in developing countries by 2015. MDG 5 calls for a 75% reduction in the 1990 maternal mortality rate. Maternal mortality rate, defined as the number of deaths per 100,000 women of reproductive age, is unevenly distributed across the globe.3 In 2000, women of child-bearing age in sub-Saharan Africa were 50 times more likely to die than women in industrialized countries.3 Although maternal mortality is clustered around labor, delivery, and the immediate post-partum period, indirect causes of death, such as HIV/AIDS, often elevate the risk of maternal death in developing countries.3

The MDGs, including MDG 5, have been repeatedly criticized as overly ambitious criteria that doom developing countries to failure.1,2 Recent data suggests that only 25 of 118 developing countries are on track to achieve MDG 5 by 2015.4 However, there is no doubt that international initiatives like the MDGs have prompted international improvements in the availability of and access to adequate health care. The Ghana Post-Graduate Training Program (GPTP) is an example of how initiative-spurred international cooperation can create lasting change in a developing country.

Ghana is a nation of 18 million people, roughly the size of the state of Minnesota in sub-Saharan Africa. At 540 deaths per 100,000 women, Ghana’s maternal mortality rate is one of the highest in the world.5 This alarming rate is a product of the nation’s dearth of quality medical care resulting from historically high rates of ‘brain drain’. Nearly 60% of the general practitioners trained in Ghana during the 1980’s left the country primarily to practice in the United Kingdom or the United States. In addition, of the physicians that left the country to seek post-graduate training in obstetrics-gynecology during this time, 90% of them did not return to Ghana after completion of their program.6

To counteract this health crisis, Ghanaian medical leaders collaborated with the Royal College of Obstetricians and Gynecologists (RCOG), the American College of Obstetricians and Gynecologists (ACOG), and university departments of Obstetrics and Gynecology in both the U.K. and U.S., to develop the GPTP in 1989.7 A grant provided by the Carnegie Institute in New York provided initial funding for the program.6 Based off the British and American medical training programs but adapted for Ghanaian culture, the 5-year training program includes medical knowledge and skills as well as management and leadership training, instruction in community-based research, and, in the final year, a 3-month externship to the U.K. or U.S.7 In addition, the program includes a 6-month rural health posting in which residents live and practice in underserved areas of Ghana. The program is administered at Ghana’s two teaching hospitals: the Korle-Bu Teaching Hospital in Accra, affiliated with the University of Ghana Medical School, and the Komfo-Anokye Teaching Hospital in Kumasi, affiliated with the Kwame Nkrumah University of Science and Technology School of Medical Sciences.7 Relationships with university departments in the U.K. and U.S. have permitted visiting faculty members to assist with in-country faculty development. The opportunity to earn board certification from the West African College of Surgeons adds world-class credibility to the GPTP.6,7

The GPTP has become a competitive specialty training program in Ghana with a high physician retention rate.6 Of the programs 85 graduates thus far, 83 have remained in country (1 has immigrated to the U.S., 1 is deceased).8 GPTP graduates practice in 30 different locations across the country.8 More than 15% were the first physicians with obstetrics-gynecology training in their area and have helped decrease the referral load to the nation’s teaching hospitals.8 Although it cannot be causally linked, improved access to obstetrics-gynecological care from GPTP graduates has undoubtedly contributed to the continuing decline in the nation’s maternal mortality rate.6 In addition, more than 25% of GPTP graduates serve in leadership positions with the ability to affect future maternal health policy, including the Director of Family Planning, the Chairpersons of Ghana’s two teaching hospitals, and the Minister of Health.6,8

The GPTP has decreased ‘brain drain’, improved provider proficiency, and contributed to Ghana’s decreasing maternal mortality rate. Persuaded by the program’s vast impact, the Ghanaian Ministry of Health now serves as the GPTP’s primary funding source. In order to accomplish initiatives like MDG 5, the health care community must devote more resources to capacity-building projects like the GPTP. We enthusiastically encourage international medical collaborations so that successful aspects of the GPTP can be implemented around the globe to benefit patients.

Melissa Elafros is an MD/PhD student at the Michigan State University College of Human Medicine and a Global Pulse Journal editor.

Works Cited

1 Easterly W. How the Millennium Development Goals are Unfair to Africa. World Development. 2009;37(1):26-35.
2 Stifel D, Sahn D. Progress Toward the Millennium Development Goals in Africa World Development. 2002;31(1):23-52.
3 Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. Lancet. 2006 Sep 30;368(9542):1189-200.
4 Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet. 2011 Sep 24;378(9797):1139-65.
5 Biritwum R. Promoting and monitoring safe motherhood in ghana. Ghana Med J. 2006 Sep;40(3):78-9.
6 Klufio CA, Kwawukume EY, Danso KA, Sciarra JJ, Johnson TR. Ghana postgraduate obstetrics/gynecology collaborative residency training program: Success story and model for Africa. Am J Obstet Gynecol. 2003;189:692-6.
7 Anderson FW, Mutchnick I, Kwawukume EY, Danso KA, Klufio CA, Clinton Y, et al. Who will be there when women deliver? Assuring retention of obstetric providers. Obstet Gynecol. 2007 Nov;110(5):1012-6.
8 Boothman E. Assessing the Public Health Impact of Training Obstatricians in Ghana Ann Arbor: University of Michigan Health System; 2011.