Two neighbors, two paths: What Ghana and Nigeria teach us about achieving Universal Health Coverage through health workforce reform

This blog is based on findings from the article: “Addressing health workforce shortages as a precursor to attaining universal health coverage: A comparative policy analysis of Nigeria and Ghana,” published in Social Science & Medicine (2024). https://doi.org/10.1016/j.socscimed.2024.117095

The workforce crisis at the heart of health systems

No health system can function without its workforce. Doctors, nurses, pharmacists, and other professionals are the foundation of service delivery, and their availability is critical to achieving universal health coverage (UHC). Yet, the world faces a projected shortfall of 15 million health workers by 2030, with sub-Saharan Africa among the most severely affected regions.

Two West African neighbors, Nigeria and Ghana, provide an interesting contrast. Both countries share similar histories, burdens of disease, and health system structures. Yet, while Ghana has made important strides in strengthening its workforce, Nigeria has lagged behind. A recent comparative study offers insights into why their paths have diverged, and what this means for the broader quest for UHC.

Diverging approaches to a shared problem

Achieving meaningful progress in addressing health workforce shortages requires aligning interests, ideas, and institutions toward a common goal. In Ghana, the government’s idea that workforce strengthening was essential for UHC aligned with the interests of health professionals seeking fair pay and career growth, and with institutions such as training colleges and unions that supported reform. In Nigeria, however, conflicting interests, most notably physician dominance over other health cadres, combined with government’s idea that existing workforce numbers were sufficient and institutions that reinforced the status quo, have contributed to policy stagnation and worsening shortages.

In 2006, both Nigeria and Ghana were grappling with severe shortages of health professionals. But while Ghana moved towards bold reforms, Nigeria’s policy response stagnated.

Ghana invested in expanding training capacity, creating new professional colleges for physicians, nurses, and pharmacists, while also upgrading existing institutions. The government introduced a single spine salary structure to reduce disparities across professions and adopted transparent, performance-based rewards to motivate staff. These measures reduced migration of skilled workers and increased the health workforce by more than 300% in less than two decades.

In contrast, Nigeria’s workforce crisis deepened. The federal government has often denied the scale of shortages, citing costs as prohibitive. Political dominance by physicians and longstanding rivalries with other health professionals have slowed reform. Universities have faced repeated closures due to strikes, limiting training capacity. Meanwhile, brain drain continues at alarming rates, with thousands of Nigerian doctors and nurses leaving each year for Europe, North America, and beyond.

What explains these differences?

Two key factors stand out:

1. Political will and inclusiveness: Ghana’s Ministry of Health took the lead, engaging stakeholders across professions in policy design and implementation. This collaborative approach ensured buy-in and reduced tensions between professional groups. Nigeria’s policymaking, by contrast, has been marked by denial of shortages, fragmented interests, and professional dominance.
2. Financing and prioritization: Ghana backed its commitments with investment, funding new institutions, mass recruitment, and welfare improvements. Nigeria has underfunded health workforce development, with most of its health budget consumed by salaries rather than training or infrastructure.

Four critical lessons for addressing shortages

The study highlights four areas that any country must consider when tackling health workforce shortages:

• General approach: Ghana adopted a bottom-up, stakeholder-driven process; Nigeria has lacked coordinated engagement.
• Welfare and remuneration: Transparent, equitable pay structures in Ghana contrast with Nigeria’s physician-dominated system.
• Autonomy and career progression: Ghana created pathways for all cadres to reach senior professional status, while Nigeria limits top roles to physicians.
• Financing: Ghana invested in training and recruitment; Nigeria has taken little action to expand its workforce base.

Why this matters for UHC

The health workforce is a core component of the health system, without which, no health system would even exist. Without motivated and well-distributed health professionals, universal health coverage will remain out of reach. Ghana’s example shows that progress is possible when there is political will, inclusive policymaking, and investment. Nigeria’s struggles remind us that denial, underfunding, and professional rivalries can stall even the most urgent reforms.

Moving forward

The global community must recognize that health workforce shortages are a political problem as much as a technical one. Policies must move beyond rhetoric to genuine investment in people, fair systems of remuneration, and career pathways that value all cadres of professionals.

For countries in Africa and beyond, the lesson is clear: building a strong health workforce requires aligning interests, ideas, and institutions towards a common goal. Only then can we move towards making UHC a reality rather than an aspiration.