‘Let me move to another level’: career advancement desires and opportunities for community health nurses in Ghana

Abstract

Career advancement and continued education are critical components of health worker motivation and retention. Continuous advancement also builds health system capacity by ensuring that leaders are those with experience and strong performance records. To understand more about the satisfaction, desires, and career opportunities available to community health nurses (CHNs) in Ghana, we conducted 29 in-depth interviews and four focus group discussions across five predominantly rural districts. Interview transcripts and summary notes were coded in NVivo based on pre-defined and emergent codes using thematic content analysis. Frustration with existing opportunities for career advancement and continued education emerged as key themes. Overall, the CHNs desired greater opportunities for career development, as most aspired to return to school to pursue higher-level health positions. While workshops were available to improve CHNs knowledge and skills, they were infrequent and irregular. CHNs wanted greater recognition for their work experience in the form of respect from leaders within the Ghana Health System and credit towards future degree programs. CHNs are part of a rapidly expanding cadre of salaried community-based workers in sub-Saharan Africa, and information about their experiences and needs can be used to shape future health policy and program planning.

Keywords

community health career advancement health workforce Ghana professional opportunities nurses

Introduction

Many countries in sub-Saharan Africa face a shortage of health workers, which threatens the sustainability of health systems and ability to achieve sustainable development goals (SDGs). In 2015, the physician to patient ratio in Sub-Saharan Africa was 2.3 per 10,000 (1) and the projected shortfall of doctors, nurses, and midwives totaled 800,000 (2). Rural areas face an even greater deficiency, as trained health workers are concentrated in urban centers. For instance, in Ghana, only 32% of physicians and nurses work in rural districts where over half of the population resides (3). In this context, volunteer and paid community-based health staff play a critical role in the delivery of health education, disease prevention, and reproductive and child health services. In response, a number of studies have explored factors affecting the retention and motivation of community health workers (CHWs) (4). Through this research, career advancement has emerged as an important component of satisfaction.

Career advancement is frequently mentioned as a factor compelling unpaid CHWs to volunteer. A study of CHWs in South Africa found that ‘career benefits’ was one of the two most frequently mentioned motivators (5), while another reported that many unpaid CHWs remained in their posts to increase their chances of being hired as paid nurses (6). Through their work as CHWs, they hoped to acquire the skills needed to take on more demanding jobs in the health sector while gaining access to social capital and resources. In addition, in a systematic review of CHW motivation, not having clear opportunities for career advancement was reported as a disincentive to remain in one’s post (4).

Career advancement is also a source of motivation for paid health workers (7). While salary is a primary drive for many paid health staff, career advancement opportunities are nevertheless essential for job satisfaction, particularly among low-level health staff and those working in challenging or rural regions (7). In a systematic review of health worker motivation in 17 low- and middle-income countries in Africa and Asia, career development (the ability to specialize or get a promotion) and continuing education (the ability to attend seminars or classes while employed) were identified as priorities for paid health workers. Career development was mentioned as a motivator in 85% of the studies, surpassed only by financial incentives, mentioned in 90% (7).

In addition to enhancing health worker motivation, career advancement is a form of capacity building and means of ensuring that leaders within a health system have experience and a strong performance record. Establishing career ladder systems for nurses, which allow for continuing education, certification, and promotion, has been shown to increase clinical competence, improve collaboration between providers at different levels, and decrease the cost of care (8). Therefore, career advancement is an important policy aim, particularly as countries work to institutionalize their community-based health workforces.

Many CHW programs in sub-Saharan Africa emerged in an ad hoc fashion in response to pressing health crises, such as HIV and tuberculosis, and have relied heavily on community members’ volunteer labor (9). Yet, as these programs mature, many governments are working to formalize the role of CHWs within the health system (10). For instance, the Ethiopian government employs a team of salaried health extension workers who are selected from the communities where they will work and receive a year of training to deliver disease prevention, reproductive health, hygiene, and health education services, while Malawi employs health surveillance assistants who receive 3 months of training, reside in their catchment areas, and perform health promotion and prevention activities (11). This trend is likely to continue as the most recent World Health Organization guidelines for CHW programs recommend paying CHWs for their work with a financial package commensurate with their job demands and training (12). As more countries establish salaried community health roles, it will be important to understand the factors that motivate existing cadres of paid community-based workers, such as community health nurses (CHNs) in Ghana.

Study context

In Ghana, primary health care is delivered through an integrated three-tiered system (13). Level C operates at the District Hospital and District Health Administration, where management works with local government to plan, supervise, and monitor health service delivery. Level B works at the sub-district level to plan, develop, and assess the implementation of community-based service delivery. This level includes health facilities where registered nurses, midwives, and other clinical staff may supervise CHNs. CHNs work at the community level, Level A, alongside unpaid community health volunteers (CHVs) to bring healthcare services directly to residents through house visits (13). This paper focuses on the experiences of CHNs working at the sub-district and community levels.

In order to become a CHN, senior high school (SHS) graduates may apply for and complete a 2-year CHN training school certificate or a 3-year CHN training school diploma, after which they can be posted to a community (14). After 3 years of service, CHNs may be promoted to senior CHN positions and are eligible for partial or full sponsorship to pursue higher degree programs. However, evidence suggests that these incentives have not been consistently applied (15). CHNs may complete an additional 3–6 months of training focused on community engagement, outreach, community health planning, and midwifery to become community health officers (CHOs), who hold the additional responsibility of managing CHVs (16).

Previous studies of paid health workers in Ghana, including doctors, nurses, midwives, and CHNs, have found that lack of career development opportunities is a major disincentive to accepting positions in rural areas (17 –19). In a qualitative study exploring nurse motivation to accept rural postings, two of the nurses’ most pressing concerns were professional development/continued education and career advancement (18). The nurses noted that in rural locations there are few workshops or opportunities for in-service training, and thus it was more challenging to take the steps necessary to return to school to pursue a midwifery or medical degree. However, these studies did not specifically address the career advancement desires of CHNs, who start from a different place on the career trajectory.

In this qualitative study, we explore the factors that motivated respondents to become CHNs, satisfaction with existing opportunities for career advancement, and desires for continuing education. These results can inform program planning for salaried health workers, both at health facilities and in the community.

Methods

This study was conducted as part of the Innovations for Maternal, Newborn, and Child Health Community Care Hub project. Participants were selected randomly from a list of active CHNs working in five primarily rural districts in Ghana: Ningo Prampram, Ada East, Ada West, South Dayi, and South Tongu. Results from Ada East and Ada West were combined, as they had been one administrative district that was divided shortly before data collection. Selected CHNs were contacted in their districts and asked to participate voluntarily.

From May to June 2014, the research team conducted 29 in-depth interviews with CHNs and 4 focus group discussions with 23 individual participants. The topics raised included work challenges, job satisfaction, and relationships with peers and supervisors. Qualitative data were collected by trained, local staff using topic guides piloted during a training session and revised to fit the local context. Interviews and focus group discussions were typically held in a centrally located rented office space in each district, providing privacy and independence from health centers or community demands. They ranged from 40 min to 2 h, and participants received compensation of 20 Cedis (about $3.50 USD) to cover their travel costs. Respondents gave written informed consent to participate and be audio-recorded; they were assured that their supervisors and employers would not be made aware that they had chosen to participate. Names and identifying information were redacted from the written transcripts and the audio files were stored on a password-protected computer.

Interview transcripts and summary notes were coded in NVivo (version 10) by the research team based on pre-defined codes; additional codes were added which emerged during review of transcripts. Data were analyzed using thematic content analysis. The research staff met to check interrater reliability and consistency using randomly selected transcripts and agreement was reached through consensus.

The broader Care Community Hub project baseline assessment also involved 11 in-depth interviews with CHN supervisors, a CHN knowledge assessment tool, and a quantitative survey on CHN job satisfaction, motivation, communication with supervisors, career goals, and workplace challenges, the results of which are presented in Sacks et al. (20) and Bellerose et al. (21). The survey instruments and baseline results for the full study are available in a Care Community Hub report by Alva et al. (22). The findings were used to develop a mobile health application called ‘CHN on the Go’, which contained networking tools and training modules for CHNs, and were shared with Ghana Health Service and other partners working to improve CHN performance.

This study was approved by the Institutional Review Board at John Snow Inc. and the Ethical Review Committee at Ghana Health Service (GHS-ERC: 07/09/13).

Results

Among the 52 CHNs who participated in interviews and focus group discussions, the average age was 29 years (range 22–56 years), and 87% were female. The CHNs were distributed evenly across the five districts (with Ada East and West combined), and ranged in years of experience from 1 to 34, with a median of 2.5 years of experience. The main themes that emerged were: original motivation for becoming a CHN, overall satisfaction with role, respect and integration within the health system, desire for career advancement, and satisfaction with opportunities for career advancement and continued education.

Original motivation for becoming a CHN

Many CHNs noted that they always wanted to become a nurse and serve their communities. They described feeling passionate about increasing access to lifesaving healthcare and improving community members’ health literacy.

I want to be a community health nurse because those in the typical community, because of where they are, don’t have access to health care, so I want to work as a community health nurse so that I can render the health care services to them. (Female, age 27, 1.5 years as a CHN)

I particularly have the desire of taking care of people and especially the children. And community health nurses, the majority of their work is on the babies side – that is why I choose community health nursing, so that I can help children who are more vulnerable to be able to grow and develop well both mentally and physically. (Female, age 28, 2 years as a CHN)

However, others chose to become CHNs because they did not have the grades to pursue a higher-level degree, and community health nursing offered an alternative with a lower entry requirement.

I studied science at the SS [SHS] level and my aim was to become a medical doctor but the grade I had then couldn’t permit me to go straight. So, I went into community health nursing. (Female, age 25, 2.5 years as a CHN)

Satisfaction with CHN role

CHNs largely expressed that, for someone with their skill set, they had a desirable job with a reasonable salary; however, they named specific areas of dissatisfaction. These included little respect and recognition, limited opportunities for career advancement, and insufficient training sessions to continuously improve their clinical skills and knowledge.

At the end of the day and looking at the things I have done, most of times I feel fulfilled that I have done something. I have impacted life. I have spoken to someone, and I have changed someone’s way of thinking. Though the salary is there, our needs are many. No matter what you are needing, still you will need more. (Female, age 45, 14 years as a CHN)

Respect and integration within the health system

The majority of CHNs reported maintaining cordial relationships with other health workers at their facilities. Yet, a few CHNs noted that tensions exist between nurses of different levels.

There is a kind of division between we the health workers, especially community health nurses, registered health nurses, and then midwives, which is a challenge to our work. (Male, age 28, 2 years as a CHN)

In the health aspect, they all discriminate. So, if you see sometimes you will hear something and you will feel very bad. You cannot commit yourself to the work as such. (Female, age 25, 3 years as a CHN)

In addition, CHNs noted that they do not always feel respected within Ghana Health Service due to their lower status role.

Nowadays it has been like a crime that we have committed to become a community health nurse. I am saying this because you are trying to kill yourself for the job. You try everything. You are working hard. There is no way the top people will recognize your work. There is no single day they will praise you, always fault finding... You are at the grassroot level. They don’t respect us. (Female, age 35, 2 years as a CHN)

Desire for career advancement

When asked where they hoped to be in 5 years, most CHNs expressed wanting to return to school to pursue a higher degree that would enable them to move into a Level B role as a public health nurse, midwife, or medical assistant.

I want to be a midwife... It’s like when I entered into nursing, ..., I was enjoying the course very much, so now that I’m in, I said let me move to another level. (Female, age 35, 5 years as a CHN)

In 5 years’ time, I am planning to go back to school, so maybe from there I will be a public health nurse. (Female, age 24, 1.5 years as a CHN)

Next year, god willing, I will be going to school. . . I want to do midwifery. Then after that will go to the University... I want to pursue public health. (Female, age 25, 4 years as a CHN)

I would like to continue with my education. Now they say there is a top up [subsidy] for us in the university. So, if am able to get the admission, then I will continue and if I will be able to do the diploma and I can go to the university, I will continue. (Male, age 35, 6 years as a CHN)

Satisfaction with current opportunities for career advancement

Many CHNs were frustrated with existing opportunities for career advancement and the little recognition given for their work experience in healthcare when pursuing other degrees. In order to become a midwife or public health nurse with more responsibility and prestige, CHNs needed to return to school to pursue a different degree and could not count their hours as a CHN toward that goal. Furthermore, going to school required funding and additional training that was sometimes unavailable to CHNs.

We community health nurses, if you want to maybe further your education, . . . you have to go back and write WASSCE [exams], maybe you will go better your core math or whatever the mark is you have to better. Meanwhile, maybe you’ve been working in the field for maybe 4 years, you have working experience... so that thing is difficult. (Female, age 25, 2 years as a CHN)

Right now, if you want to advance, it’s either you leave community health nursing, or maybe I’m a diploma holder, and I want to go further, I can’t go and do the degree... I have to divert. (Female, age 25, 2 years as a CHN)

We are restricted as to how to progress educationally. As we’ve completed the community health nursing... the chances for us to progress is very limited. (Female, age 26, 2 years as a CHN)

Respondents also mentioned that this system disadvantages older CHNs.

Some of our colleagues are old in the system. They cannot go to any school or advance in any education again. So, what I would like them, our in charges, to do is to find some ways to upgrade them so that they can also be happy. (Female age 25, 2.5 years as a CHN)

If that facility sponsors me, fine, I can come and work up to a time and go. And, if it did not and I sponsor myself, there is no way I will come back [to school]. (Female, age 35, 2 years as a CHN)

Is just that there are no avenues for us to go to school quickly. (Female, age 25, 3 years as a CHN)

Opportunities for continued education

Workshops were available for CHNs to attend to improve their skills and knowledge; however, they were infrequent and irregular. Typically, not all CHNs were allowed to attend each workshop; rather, a few CHNs would attend and then teach their colleagues the information. CHNs asked for more refresher courses and suggested that online workshops be used when possible.

Ever since I started [as a CHN], I think there’s only been one or two [workshops]... it’s not that regular. It just happens once in a while. (Male, age 25, 2 years as a CHN)

Anytime there is changes in the system, new things are coming. So, I think immediately when there is something new, they have to call us and educate us. (Female, age 25, 1.5 years as a CHN)

The more you go through that training, the more new ideas you get because health is dynamic each day, each time. Things are changing. The way of treatment is changing. New medicines are coming out. (Female, age 45, 14 years as a CHN)

Although nearly all CHNs expressed confidence in their clinical abilities, CHNs noted that most of their confidence came from years of learning from other CHNs and honing their skills on-the-job while delivering care to their communities, rather than formal training opportunities.

We don’t do [the] clinical aspect in the training college; it is on the field that you learn it. So, for my 3 years, I have been here, I have learned a lot to the extent that if my in-charge [supervisor] is not around, I can treat malaria, diarrhea... (Male, age 35, 6 years as a CHN)

Discussion

Overall, this study suggests that CHNs desire greater opportunities for career advancement and continued education, as many aspire to occupy higher-level health positions. As most CHNs planned to return to school for an advanced degree within 5 years of the interview, the lack of opportunities to pursue higher positions in the course of their work emerged as a clear source of frustration and demotivation. While some training workshops were available for CHNs to improve their skills, they were infrequent and offered inconsistently throughout the year. In addition, although subsidies for further education are listed as an incentive available to CHNs in national guidelines (15), study participants were unaware of this benefit or unsure that they would receive it. These results indicate that some career advancement opportunities were available for CHNs willing to seek them out, but needed to be better incorporated into CHN degree programs and communicated to current CHNs and supervisors.

CHNs multi-year training represents a considerable investment, yet our findings highlight that most CHNs see their position as a stepping-stone and do not intend to remain in it for more than a few years. While previous analyses have highlighted additional resources needed to improve CHN retention in their roles, such as stronger supervision and transportation to conduct home visits (20), resources are also needed to improve CHN retention within Ghana Health Service, including policies to ensure that CHNs can move up to higher levels within the system. When these resources are not in place, CHNs may become disgruntled or leave the Ghana Health Service.

Dissatisfaction may be greater for CHNs who do not feel respected by higher level clinical staff or the Ghana Health Service. Disrespectful relationships between community-based workers and facility health staff are a missed opportunity for the newest members of a health system to learn about others’ roles and network with senior members.

Despite our expectation that younger CHNs would desire greater opportunities for career advancement and continued education, we found few major differences across age groups. While CHNs in their mid-20s with 1–3 years of work experience mentioned wanting to return to school to pursue higher degrees most often, there were multiple CHNs between age 30 and 40 years who also shared that aim. In addition, CHNs of all ages and experience levels desired opportunities to improve their clinical skills while in their current roles.

When asked about job satisfaction and challenges, salary was mentioned infrequently and never as CHNs most pressing concern. This finding aligns with research demonstrating that receiving a competitive salary can validate the work of community-based health staff, but is often not sufficient for retention, as staff greatly want to be recognized for their hard work, especially when they feel their jobs are challenging (17). Studies exploring the determinants of turnover intention among paid health workers in Ghana revealed that while there was low satisfaction with compensation, it was not the primary driver of turnover intent or employment abroad (17, 23).

A limitation of this study is that some CHNs included held the additional designation of CHO, but were not identified as such within the qualitative data. The CHO role includes an additional 3–6 months of training and greater responsibility. It therefore may be viewed by CHNs as an important career advancement step. In addition, since 2014, when these data were collected, small changes have been made to strengthen the CHN advancement structure. CHNs can now use their certifications to complete a top-level university course, and upon passing, can be enrolled in a midwifery or public health degree program (24). In addition, newly qualified nurses, nursing assistants, and midwives from accredited universities now receive a PIN or AIN, a professional identification that must be renewed yearly. As part of the renewal process, CHNs must complete a small number of continued professional development activities organized by the Nursing and Midwifery Council of Ghana (24). More research is needed to understand whether these career development programs are accessible to CHNs across Ghana and if they have been successful in improving clinical skills and motivation.

Our results highlight the importance of continuing to strengthen the career advancement pathways available to community-based health staff in Ghana and other contexts. These opportunities for advancement should be equitable and affordable. They should also be sustained over time, rather than delivered one-off, to avoid ‘expectation-gaps’ (25). Potential policy solutions include (a) providing educational subsidies to CHNs pursing higher education during the course of their work, commensurate with number of years of service; (b) allowing CHNs to receive credit toward future degree completion for each year of service; (c) assuring that existing mentorship programs for CHNs are being implemented consistently and in accordance with national policies; (d) increasing opportunities for CHNs to receive coaching from others in the healthcare field, including midwives, nurses, physicians, and public health professionals; and (e) ensuring mechanisms are in place for CHNs to offer ongoing feedback on career advancement pathways to policy-makers. Mobile applications, such as CHN on the Go and WhatsApp, are commonly used by CHNs to exchange information and could be formally integrated into national professional development approaches to increase access to technical information, coursework, mentorship, and feedback mechanisms.

When designing policies to promote CHN career advancement, it is important to consider their potential impact on staff turnover. As CHNs leave their posts to pursue additional degrees, strong recruitment, training, and retention practices must be in place to ensure that enough clinically skilled CHNs remain available to meet community needs. CHNs wanted to gain credit toward higher-level health positions or complete their studies during the course of their work as CHNs, which could potentially keep posts filled while CHNs pursue their educational goals. It may also improve recruitment outcomes if SHS students know that becoming a CHN could provide an advantage when pursuing a higher-level health career.

Strengthening career advancement opportunities for health staff is a worthwhile policy aim. An abundance of research, including evidence from this study, suggests that providing clear, achievable opportunities for career advancement and development will improve CHN motivation and retention (7). This may occur directly by increasing external motivation or indirectly by boosting organizational commitment (26). Providing strong opportunities for career advancement and development will also build workforce capacity by ensuring that high-level positions are occupied by qualified staff who have progressed through a pipeline.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

This study was approved by the Institutional Review Board at John Snow Inc. and the Ethical Review Committee at Ghana Health Service (GHS-ERC: 07/09/13).

ORCID iD

Meghan Bellerose

References

World Bank. Physicians (per 1,000 people) – sub-Saharan Africa [Internet]. World Bank, 2017 [cited 2020 Aug 24]. Available from: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=ZG

Scheffler

Mahoney

Fulton

Dal Poz

Preker

. Estimates of health care professional shortages in sub-Saharan Africa by 2015: critical shortages of health workers are projected in 2015 throughout Sub-Saharan Africa, and the projected cost to eliminate them approaches $20 billion. Health Affairs. 2009; 28(Suppl. 1): w849–w862.

Alhassan

Spieker

van Ostenberg

Ogink

Nketiah-Amponsah

de Wit

TFR

. Association between health worker motivation and healthcare quality efforts in Ghana. Human Resour Health. 2013; 11: 37.

Kok

Dieleman

Taegtmeyer

Broerse

Kane

Ormel

, et al. Which intervention design factors influence performance of community health workers in low-and middle-income countries? A systematic review. Health Policy Plan. 2015; 30: 1207–1227.

Akintola

What motivates people to volunteer? The case of volunteer AIDS caregivers in faith-based organizations in KwaZulu-Natal, South Africa. Health Policy Plan. 2011; 26: 53–62.

Dageid

Akintola

Sæberg

Sustaining motivation among community health workers in aids care in Kwazulu-natal, South Africa: challenges and prospects. J Community Psychol. 2016; 44(5): 569–585.

Willis-Shattuck

Bidwell

Thomas

Wyness

Blaauw

Ditlopo

Motivation and retention of health workers in developing countries: a systematic review. BMC Health Serv Res. 2008; 8: 247.

Buchan

Evaluating the benefits of a clinical ladder for nursing staff: an international review. Int J Nurs Stud. 1999; 36: 137–144.

Swartz

Colvin

CJ.

‘It’s in our veins’: caring natures and material motivations of community health workers in contexts of economic marginalisation. Crit Public Health. 2015; 25: 139–152.

10.

Zachariah

Ford

Philips

Lynch

Massaquoi

Janssens

, et al. Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa. Trans R Soc Trop Med Hyg. 2009; 103: 549–558.

11.

Kok

Ormel

Broerse

Kane

Namakhoma

Otiso

, et al. Optimising the benefits of community health workers’ unique position between communities and the health sector: a comparative analysis of factors shaping relationships in four countries. Glob Public Health. 2017; 12: 1404–1432.

12.

World Health Organization. WHO Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes. Geneva: World Health Organization; 2018.

13.

Republic of Ghana Ministry of Health. National Communtiy-Based Health Planning and Services (CHPS) Policy: accelerating attainment of universal health coverage and bridging the access inequity gap [Internet]. 2016 [2020 Aug 23]. Available from: https://www.moh.gov.gh/wp-content/uploads/2016/02/CHPS-policy-final-working-draft-for-validation.pdf

14.

Nyonator

Awoonor-Williams

Phillips

Jones

Miller

RA.

The Ghana community-based health planning and services initiative for scaling up service delivery innovation. Health Policy Plan. 2005; 20: 25–34.

15.

Acquah

Frelick

Matikanya

. Providing doorstep services to underserved rural populations: Community health officers in Ghana [Internet]. Capacity Project US AID Global Health/HIV/AIDS and the Africa Bureau Office of Sustainable Development. 2006 [2020 Aug 23]. Available from: https://www.hrhresourcecenter.org/node/1292.html

16.

Schwarz

Kim

J-H

Ratcliffe

Bell

Awoonor-Williams

Nimako

, et al. The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey. Gates Open Res. 2019; 3: 1468.

17.

Bonenberger

Aikins

Akweongo

Wyss

The effects of health worker motivation and job satisfaction on turnover intention in Ghana: a cross-sectional study. Human Resour Health. 2014; 12: 43.

18.

Lori

Rominski

Gyakobo

Muriu

Kweku

Agyei-Baffour

Perceived barriers and motivating factors influencing student midwives’ acceptance of rural postings in Ghana. Human Resour Health. 2012; 10: 17.

19.

Snow

Asabir

Mutumba

Koomson

Gyan

Dzodzomenyo

, et al. Key factors leading to reduced recruitment and retention of health professionals in remote areas of Ghana: a qualitative study and proposed policy solutions. Human Resour Health. 2011; 9: 13.

20.

Sacks

Alva

Magalona

Vesel

Examining domains of community health nurse satisfaction and motivation: results from a mixed-methods baseline evaluation in rural Ghana. Human Resour Health. 2015; 13: 81.

21.

Bellerose

Alva

Magalona

Awoonor-Williams

Sacks

Supervision of community health nurses in Ghana: a mixed-methods study on experiences and mentorship needs. Health Policy Plan. 2021; 36: 720–727.

22.

Alva

Magalona

Sacks

Care community hub: baseline report [Internet]. JSI Research & Training Institute, Inc.; 2015 [cited 2020 Aug 24]. Available from: https://www.jsi.com/resource/care-community-hub-baseline-report/

23.

Antwi

Phillips

DC.

Wages and health worker retention: evidence from public sector wage reforms in Ghana. J Dev Econ. 2013; 102: 101–115.

24.

Nursing and Midwifery Council of Ghana. Examination & Licensing [Internet]. 2020 [cited 2020 Aug 24]. Available from: https://www.nmc.gov.gh/web/examination-licensing/content/92-official

25.

Ormel

Kok

Kane

Ahmed

Chikaphupha

Rashid

, et al. Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation. Human Resour Health. 2019; 17: 59.

26.

Vallières

Kok

Mahmud

Sarker

Jeacocke

Karuga

, et al. Measuring motivation among close-to-community health workers: developing the CTC Provider Motivational Indicator Scale across six countries. Human Resour Health. 2020; 18: 1–12.