Who gets posted where? Power, politics and maldistribution of doctors in Ghana

Power and politics considerably shape health workforce distribution in many ways, often leading to deficient supply in deprived environments, yet this remains overlooked empirically. Drawing on power and politics theories, we explored the intricacies of how political patronage and power dynamics shape posting and transfer of doctors, contributing to maldistribution and compromising access to care quality in northern Ghana. We collected qualitative data from in-depth interviews with doctors, regional and district health managers, and document synthesis on how power and politics playout in doctors’ posting and transfer process. The findings showed that doctors’ deficit in the north is framed as a political issue driven by weak political will, and poor institutional and resource commitment to addressing the problem. This is amplified by power practices flowing from multiple directions circumventing posting and transfer of doctors to the deprived north. Political actors exercised authoritative power over, and control of the bureaucracy to bend rules, by giving directives for doctors to be reposted or transferred out of the north to their preferred locations. Doctors on the other hand deployed expert power over district health managers and power with family and social networks in securing reposting or transfer out of the northern regions. District health managers, meanwhile, worked with limited power within and simply complied with directives without resistance in order to keep their jobs. Transparent and accountable posting and transfer processes backed by empowerment of district and regional health managers with authoritative power to enforce local retention measures can ensure equitable doctors’ distribution.