In order to tackle the workforce challenges specific to an organization, one must first understand the exact nature of those challenges. Across the entire economic spectrum, and especially in low- and middle-income countries (LAMICs) including Ghana, public sector resource allocation for mental health is disproportionately low [
1], and this is from a health expenditure pie that is already much too small [
2]. Close to a third of countries have no specified mental health budget, and of the 101 countries that have a mental health budget, most spend less than 1% of their total health budgets on mental healthcare [
1]. Ghana’s mental health sector is funded primarily by the government and is supplemented by internally generated funds and donations. Total annual health expenditure is 7.8% of GDP (2011), per capita expenditure is US$ 114 and mental health funding receives just about 3% of the healthcare expenditure [
3]. The low funding for mental health, among other factors, affects recruitment and retention of mental health professionals, and the scarcity of mental health professionals places specialist psychiatric care out of the reach of most people in LAMIC [
4,
5], particularly in the lowest income countries and in rural/low-income regions within countries [
6]. Several other factors account for the relative lack of mental health professionals in LAMICs including insufficient training opportunities, deteriorating health of the workforce, brain drain and rural/urban imbalance [
7]. The lack of education and training opportunities in mental healthcare severely handicaps LAMICs, as they have no means to make up for the scarcity of mental health professionals from an internal source [
8]. The most common factors that force health workers away from jobs in rural areas are the lack of incentives and amenities, as well as limited opportunities for career progression [
9]. The remote and underdeveloped areas with poor or no social amenities are always difficult to post staff to, without innovative incentives [
10]. In an in-depth survey of nursing leaders and in-practice nurses in both rural and urban Ghana on potential incentives to promote recruitment and retention in rural service, many respondents reported low satisfaction with rural practice influenced by the high workload and difficult working conditions, perception of being “forgotten” in rural areas by the Ministry of Health, lack of professional advancement and the lack of formal learning or structured mentoring [
11]. The issue of stigma and low prestige associated with mental health has also contributed to the relative lack of trained mental health professionals in LAMICs. For example, a study of Ghanaian medical students showed the students thought psychiatry had little prestige and was less lucrative than other specialties, and the majority felt uncomfortable interacting with patients with mental illness [
12].
Brain-drain issues also contribute greatly to the mental health capacity problem in LAMICs. Migration of professionals from low- and middle-income countries to richer countries is a large-scale phenomenon [
14-
17], and in 2000, it was estimated that there were 1.5 million professionals from LAMICs working in industrialized countries [
18]. Like all other health professionals in these countries, mental health providers often migrate to areas with higher incomes [
8].
To address the human resource gap within Ghana’s mental health delivery system, in November 2007, Ghana’s Ministry of Health decided to create two new community-based mental health posts and develop curricula to support these. The two posts were the clinical psychiatry officer (CPO) and the community mental health officer (CMHO). CPOs are trained for 2 years and are expected to diagnose and treat a limited number of mental health conditions whilst CMHOs are trained for 1 year and are only expected to be involved in case detection for referral to CPOs and psychiatrists, health promotion and monitoring with treatments initiated by CPOs and psychiatrists [
19]. Currently, due to the limited numbers of psychiatrists who practice mainly in three big cities in Ghana, community mental healthcare is provided predominantly by community mental health workers (CMHWs) comprising CPOs, CMHOs and community psychiatric nurses (CPNs). Whilst there have been several studies exploring retention in health workers, little is known about health workers engaged in the provision of mental health services and the factors that affect their career choices and retention [
20]. Thus, we seek to examine the views of the CMHWs, psychiatrists and health policy directors around these issues and to make recommendations to improve the recruitment and retention of these mental health cadres. The two research questions were the following:
1.
What factors influence CMHWs to choose careers in mental health?
2.
What factors influence the retention of CMHWs in Ghana?