Vol:.(1234567890) Chinese Journal of Academic Radiology (2023) 6:188–195 https://doi.org/10.1007/s42058-023-00130-z 1 3 ORIGINAL ARTICLE Density and regional distribution of radiologists in a low‑income country: the Ghana situation Benjamin Dabo Sarkodie1 · Benard Ohene‑Botwe2  · Yaw B. Mensah1 · Edmund Tagoe4 · Bashiru Babatunde Jimah3 · Edmund Kwakye Brakohiapa1 · Klenam Dzefi‑Tettey4 Received: 20 May 2023 / Revised: 19 November 2023 / Accepted: 23 November 2023 / Published online: 2 December 2023 © The Author(s) 2023 Abstract Background This study assessed the density and distribution of radiologists across all 16 regions in Ghana to generate ref- erence information for planning and policy formulation to encourage radiology specialization and in designing systems to improve the dissemination of radiological services across all the regions in Ghana. Method A cross-sectional design was used to collect secondary data on all radiologists (n = 93) registered with the Medical and Dental Council of Ghana (MDCG) as of December 2022. This information collected on the records of the MDCG was confirmed with records from the Ghana Association of Radiologists. Population and land area data were also collected from the National Statistical Service of Ghana for each region in the country. The Stata statistical software version 15 was used to analyze the data collected. Results There were 93 radiologists in the country. The majority were male (n = 60, 65%) and about one-third of the radiolo- gists were female. The national density of radiologists was 1.9 radiologists per 5000 km2. Only 3 of the 16 regions in the country had a better distribution of radiologists per 5000 km2. There were three radiologists per million people in Ghana with a skewed regional distribution. Seven out of the 16 regions lacked radiologists. The proportion of female radiologists stationed within the Greater Accra and Ashanti regions was 87.9% (29/33). The Bono, Eastern, Northern, and Western regions had one female radiologist each. Conclusions Actions are needed to improve the shortage and skewed distribution of radiologists. The outcome will help to improve radiological services across all the regions in Ghana. Keywords Radiologists · Ghana · Radiology human resources · Low-income country · Imaging Abbreviations CHPS Compound Community-based health planning and services MRI Magnetic resonance imaging CT Computed tomography Introduction Radiologists play an unmatched role in healthcare institu- tions across the world. They provide valuable input in policy formulation, screening, diagnosis, treatment, and follow-up * Benard Ohene-Botwe benard.ohene-botwe@city.ac.uk; sirbenard13@gmail.com Benjamin Dabo Sarkodie Ghana_neo@yahoo.com Yaw B. Mensah ybmensah@yahoo.com Edmund Tagoe edtagoe2006@gmail.com Bashiru Babatunde Jimah jimah@uccsms.edu.gh Edmund Kwakye Brakohiapa ebrakohiapa2000@yahoo.com Klenam Dzefi-Tettey k.dzefitettey@kbth.gov.gh 1 Department of Radiology, University of Ghana School Medicine and Dentistry, Accra, Ghana 2 Department of Midwifery & Radiography, School of Health Sciences & Psychological Sciences, City, University of London, London, UK 3 Department of Medical Imaging, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana 4 Department of Radiology, Korle-Bu Teaching Hospital, Accra, Ghana http://crossmark.crossref.org/dialog/?doi=10.1007/s42058-023-00130-z&domain=pdf http://orcid.org/0000-0002-0477-640X 189Chinese Journal of Academic Radiology (2023) 6:188–195 1 3 of patients with new diseases as well as existing ones across almost all subspecialties of medicine [1]. The contribution of imaging departments to health care delivery has grown proportionately with the fast-paced advancement seen in health-related technology. Improving knowledge through sub-specialization and attempts to incorporate machine learning and artificial intelligence models in routine radi- ology practice hold a lot of promise for the future of the specialty with respect to providing evidence-based care for clients [2, 3]. Despite these global developments, most African coun- tries including Ghana are yet to catch up fully with the current imaging trends, though they have seen significant growth and increased relevance in patient management over the last decade [4]. This deficiency is observed with respect to the availability of human resources and radiologi- cal equipment [5]. According to international guidelines reviewed, an esti- mate of 100–120 radiologists is acceptable for a million pop- ulation. Countries such as Germany and the United States of America have enough radiologists to meet this requirement [6]. On the contrary, most African countries are far from reaching this goal. This shortage is intense in Ghana and was estimated by Edzie et al. from data collected in 2019 to be less than two radiologists for every million Ghanaians which is at least 50 times worse than the recommended num- bers [6]. Moreover, there are insufficient subspecialists in interventional radiology, pediatric radiology, female imag- ing, and neuroradiology. Nigeria has a worse situation as 250–300 radiologists were reported to serve a population of over 174 million people [7]. The cause of this relatively low number of radiologists in Ghana is multifactorial and includes issues relating to government policy, medical education system, and socio- economic factors. Interventions of the government of Ghana and the Ministry of health are skewed toward attaining uni- versal primary health care and preventive medicine with less focus on specialized and curative care [8]. Even in special- ized care, priority is given to specialties such as obstetrics and gynecology as well as child health, because these areas align directly with the country’s goals of reducing infant and maternal mortality. However, it has to be mentioned that radiological services even form the backbone for providing adequate maternal and child health services, since radiolo- gists are vital in the monitoring of both early and late dis- eases including pregnancy complications as well as neonatal illnesses associated with prematurity, intrauterine growth restriction and congenital anomalies. Thus, sufficient radio- logic monitoring of pregnant women and their unborn babies at all levels of health care also contributes to a reduction of infant and maternal mortality and brings countries closer to achieving sustainable development goals. Moreover, radiolo- gists provide immense support for screening and diagnostic services in almost every clinical discipline to improve the health and well-being of people. Currently, training to become a radiologist in Ghana involves enrolling in a 4-year residency program which a doctor qualifies for after meeting all requirements such as a 2-year mandatory housemanship after medical school and 2–3 years of work in a district, regional or teaching hospital as a medical officer. Most doctors after this long route of medical training may opt for a shorter residency program even if they decide to specialize at all. Radiology has informally been reported in Ghana as a specialty with a few entrants but a relatively high attrition rate. Though this claim needs further investigation to bring clarity, the structure of the residency program is such that candidates who fail one of the many examinations are delayed thus, further prolonging the 4-year program. Most of the remain- ing specialties conduct a final exit exam which is at the end of a 3-year residency program and many doctors find this arrangement more convenient. There are three accredited radiology training centers in the country. These include the Korle-Bu Teaching Hospital, 37 Military Hospital, and Komfo Anokye Teaching Hospital. Two of these centers are located in the Greater Accra Region (the capital city), whereas the Komfo Anokye Teaching Hos- pital is sited in the Ashanti region. The limited number of training sites coupled with few specialists account for the low intake and subsequent low output seen in the field. The rural areas in Ghana are disadvantaged in terms of health outcomes mostly because of a lack of adequate health infrastructure and human resources [9]. This human resource challenge is seen among all cadres of health workers [10, 11]. The scarcity of radiologists in Ghana may affect rural dwellers disproportionately, because it compounds their existing socio-economic and infrastructural challenges. Although attempts are being made to improve the number of radiologists in Ghana, there is a lack of data on the density and regional distribution of radiologists in Ghana for plan- ning. Consequently, this study was undertaken to assess the density and distribution of radiologists across all 16 regions in Ghana to generate reference information for planning and policy formulation to encourage radiology specialization and in designing systems to improve the dissemination of radio- logical services across all the regions in Ghana. Methods Study design A cross-sectional design was chosen for this study and data were conveniently sampled from the register of the Medical and Dental Council of Ghana. 190 Chinese Journal of Academic Radiology (2023) 6:188–195 1 3 Study setting The study was conducted in Ghana, a low-middle income country in West Africa with a total population of about 31 million according to the 2021 population and housing cen- sus. There are 16 regions, 6 of which are newly created from the previous 10 regions in the country. The country boasts of 1 quaternary hospital, 5 teaching hospitals, and a regional hospital in each of the previous 10 regional capitals. There are also several district and community hospitals as well as private facilities and Community-Based Health Planning and Services (CHPS Compound) facilities. Study participants and size The study gathered data on the distribution of radiologists across all regions in Ghana. Here, secondary data on all radi- ologists registered with the Medical and Dental Council of Ghana (MDCG) as of December 2022 were collected. The MDCG is the legal body that regulates medical doctors’ practice in Ghana. Hence, the professional records of all radiologists, totalling, 93 on the register were reviewed. This information was confirmed with records from the Ghana Association of Radiologists, which is the society radiolo- gists in Ghana belong to. The population and land area data were also collected from the National Statistical Service of Ghana for each of the regions in the country. Study variables The variables assessed in the study were the density and distribution of radiologists across all 16 regions in Ghana to generate reference information for planning and policy formulation to encourage radiology specialization and in designing systems to improve the dissemination of radio- logical services across all the regions in Ghana. In particular, the study accessed data on gender, staff distribution, age, location, the number of people radiologists were serving, and the number of radiologists per 5000 square kilometers. Data from the registers were entered into Microsoft Excel version 23 for management and scrutiny. After ensuring that the current data were appropriately entered, they were then transferred to the Stata statistical software version 15 for analysis. Data analysis The Stata statistical software version 15 was used to process and analyze the data collected using descriptive statistics. The number of radiologists per 1,000,000 population as well as the number of radiologists per 5000 square kilometers (km2) of land area was computed for all 16 regions to further explain the distribution and how it affected access. Radiologists sampled were categorized by sex and plotted on a map to give more detail on the distribution of radiolo- gists by sex in the country. The presence of a radiologist in a region may not translate directly into improved accessibility of the basic radiological services as this also depends on the availability of functioning equipment, work output of radiologists, affordability of services, and the peculiar health needs of a population. This is a limitation which requires further investigation in subsequent studies. Ethical approval for this study was waived by the Eura- care Ethics and Research Protocol Committee (Ref Number EADHC 1010/20–21). Results There were 93 radiologists in the country. The majority of radiologists in Ghana were male and they formed 65% (60/93) of all the radiologists in the country. Approximately one-third (n = 33, 35%) of the radiologists were female. Figure 1 shows the uneven distribution of the few radiolo- gists in the country. The Northern half of the country is least served. There were 3 radiologists in the Northern region. There were 2 radiologists stationed in Ho, the capital town of the Volta region. The Eastern region had 4 radiologists. The Western and Central regions had one and five radiol- ogists, respectively, and their services could extend to cover the remaining regions where there was no radiologist. The Bono East, Bono, and Ashanti regions are located in the central parts of Ghana and had 2, 3, and 19 radiologists, respectively. The Ashanti region which is the second most populous region had a relatively better share of the nation’s radiologists. The Greater Accra region which is the small- est region had the highest number of radiologists. These 54 radiologists served the most populous region in the country. There were more radiologists in the Greater Accra region than in the rest of the 15 regions in the country. There was no radiologist in 7 out of the 16 regions in the country and these regions included Ahafo, North East, Oti, Savannah, Upper East, Upper West, and the Western North regions. The proportion of female radiologists stationed within the Greater Accra and Ashanti regions was 87.9% (29/33). The Bono, Eastern, Northern, and Western regions had one female radiologist each. The regional distribution of female radiologists in Ghana is also presented in Fig. 2. The frequency of radiologists and population in the 16 regions in Ghana can be found in Table 1, while the distri- bution of radiologists per 1,000,000 population in the 16 regions in Ghana is presented in Fig. 3. The Greater Accra, Ashanti and Bono regions had 9.9, 3.5, and 2.5 radiologists per 1,000,000 population, respec- tively. Eight regions had less than one (1) radiologist per 1,000,000 population. In the Western region, there was 1 191Chinese Journal of Academic Radiology (2023) 6:188–195 1 3 radiologist serving a population of over 2 million people (6.7% of the national population). Using the national figures in the evaluation showed that there were 3 radiologists per million people in Ghana. There were only five radiologists with a sub-specialty (Fig. 4) at the time of writing this article. These included one neurointerventional radiologist, one diagnostic neuroradiolo- gist, two interventional radiologists, and one pediatric radi- ologist. Only the pediatric radiologist was female. Moreover, all the radiologists with sub-specialty were located in the capital, Accra, except the two interventional radiologists; one was in the Ashanti region, and the other was in the cen- tral region of Ghana. Estimation of the regional density of radiologists per 5000 square kilometers indicated that the Greater Accra region again had the best density with 83.2 radiologists. The Ashanti region which is eight times as large as the Greater Accra region had 3.9 radiologists per 5000 square kilometers. The Central region with a total land area of 9826 square kilometers had 2.5 radiologists per 5000 square kilo- meters. The remaining regions had from 0 to 2 radiologists per 5000 square kilometers. The national density of radiolo- gists revealed that there were 1.9 radiologists per 5000 km2 in Ghana. Only 3 of the 16 regions in the country had better distribution of radiologists per 5000 km2. The distribution of radiologists per 5000 square kilometers in the 16 regions of Ghana is presented in Table 2. Discussion The northern, upper east, and upper west regions of Ghana are among the most deprived areas in the country [12, 13]. The Ghana Poverty Mapping (GPM) report used the poverty line ofGH₵1314 to categorize people living in poverty. With a population of 2,445,061, northern region has 44.2% of the people living below the poverty line. This is followed by the upper east region which has 46% of the population (1,034,688) living below the poverty line. Out of 688,328 people in the upper west region, 69.4% live below the pov- erty line (Ghana Statistical Service, 2015). There is often a lack of medical equipment including radiological machines in these deprived communities, as the priority of policymak- ers remains the provision of basic amenities, such as safe drinking water, roads, schools, and basic health care and not the provision of sophisticated and specialized equipment such as those required for the day-to-day work of a radiolo- gist. There is a consequent lack of appetite for radiologists to move to such areas. Without basic medical care in rural communities, radiological services may never become well established. This, however, does not remove the need for such services, since the occurrence of diseases is independ- ent of the availability of medical specialists. To improve radiological services in these deprived areas, other specialties must be enhanced and equipped with ade- quate specialists, since radiologists depend on requests from colleague doctors in these other fields [3]. These non-radi- ology specialists are required to make initial diagnoses and request radiological procedures to confirm or rule out their suspicions. Similar to the northern parts of Ghana, the Oti region which has comparable demographic characteristics suffer the same shortage. People in these deprived and poor areas may not be able to afford sophisticated investigations such as magnetic resonance imaging (MRI) and computed tomogra- phy (CT) scans as can their urban counterparts. Empowering the people economically is as crucial as making available radiological services. Most of the country’s development is around the central and southern parts. This somehow compares with the dis- tribution of radiologists in this study. The Eastern, Ashanti, Bono, and Bono East regions are better off economically compared to the northern regions and have more devel- opment in terms of social amenities available to them in Fig. 1 Regional distribution of radiologists in Ghana (December 2022) 192 Chinese Journal of Academic Radiology (2023) 6:188–195 1 3 addition to a higher number of radiologists. Most of the radiologists serve the population from the regional capitals which commonly hold the regional hospitals. The Ashanti region is economically empowered and has seen a good share of social development. The Greater Accra region is the most developed region in Ghana and has the highest number of radiologists. Apart from two interventional radiologists stationed outside this region, the other three radiologists with subspecialties, such as neurointerventional radiologists, diagnostic neu- roradiologist, interventional radiologists, and a pediatric radiologist, are all within the capital, which also has at least three (3) medical schools. This finding demonstrates that sub-specialty radiology services in the country are also not evenly distributed. Many factors could account for this, but radiologists, like most doctors, are attracted to developed areas of the country where social amenities are not chal- lenging to come by. In such developed regions, radiologists have access to private practice to support the low income provided to them by the government. Most of the technology required to adequately practice radiology exists in devel- oped regions.1 Radiologists may select stations that are well equipped to support the improvement of the skills they acquired during training. Male radiologists were more than female radiologists in Ghana by a ratio of approximately 2:1. There was also Fig. 2 Regional distribution of female radiologists in Ghana (December 2022) 23 6 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 5 10 15 20 25 G re at er A cc ra A sh an ti Bo no Ea ste rn N or th er n W es te rn A ha fo Bo no E as t Ce nt ra l N or th Ea st O ti Sa va nn ah U pp er Ea st U pp er W es t W es te rn N or th V ol ta Number (n) of female radiologists Re gi on s 193Chinese Journal of Academic Radiology (2023) 6:188–195 1 3 only female radiologist with sub-specialty, within the area of pediatric radiology. This low number in female radiologists could be because of the relatively long train- ing period but must be separately investigated. Women have a biological clock and cater for the home in ways most Ghanaian men do not and these may contribute to their relatively low numbers in a field as demanding as radiology. To improve the rural number of radiologists, however, training more females, unfortunately, may not cause drastic change, since this study has indicated that the female radiologists in the country are based in and around the developed cities. This claim is supported by Bowman et al. who found that female health workers prefer to work in urban centers [9, 14]. The Greater Accra region took over from the Ashanti region as the most populous region according to the latest population census. Though more than half of the coun- try’s radiologists are located in the Greater Accra Region, they are still inadequate for the size of the population as only ten radiologists were matched to approximately 1 mil- lion population. In the Ashanti region, approximately four radiologists catered for a million population. These two regions have tertiary facilities that require them to extend services to nearby regions. Considering standards set by high-income countries, the Greater Accra and Ashanti regions need at least ten times more radiologists to adequately serve their population. The remaining 14 regions had less than three radiologists per million population. A thoughtful policy is required to improve the situation. Heavy workload posed by the short- age of radiologists could lead to delayed diagnosis, increased reporting errors, and reduced work output due to exhaustion and radiologist burnout. Screening and emergency facili- ties may also be severely affected by the unavailability of radiologists. Advancement in radiology-related research might stagnate due to the inadequate number of radiologists, because patient care must be prioritized. Table 1 Frequency of radiologists and population in the 16 regions in Ghana (December 2022) Regions Number of radiologists Population of region Frequency % Frequency % National median 1.5  Ahafo 0 0 564,536 1.8  Ashanti 19 20.4 5,432,485 17.6  Bono East 2 2.2 1,203,306 3.9  Bono 3 3.2 1,208,965 3.9  Central 5 5.4 2,859,821 9.3  Eastern 4 4.3 2,917,039 9.5  Greater Accra 54 58.1 5,446,237 17.7  North East 0 0 658,903 2.1  Northern 3 3.2 2,310,943 7.5  Oti 0 0 747,227 2.4  Savannah 0 0 649,627 2.1  Upper East 0 0 1,301,221 4.2  Upper West 0 0 904,695 2.9  Western 1 1.1 2,057,225 6.7  Western North 0 0 880,855 2.9  Volta 2 2.2 1,649,523 5.4  Total (n) 93 100 30,792,608 100 Fig. 3 Regional distribution radiologists per 1,000,000 population in the 16 regions in Ghana 0 3.5 1.7 2.5 1.7 1.4 9.9 0 1.3 0 0 0 0 0.5 0 1.2 Different regional distribu�on radiologists per 1000000 popula�on in the 16 regions in Ghana Ahafo Ashan� Bono East Bono Central Eastern Greater Accra North East Northern O� Savannah Upper East 194 Chinese Journal of Academic Radiology (2023) 6:188–195 1 3 Approximately two radiologists served a 5000 km2 area in Ghana. This generally implies that many Ghanaians do not readily have access to a radiologist in a nearby town and have to travel tens of kilometers to receive care from radiolo- gists within their zone. The inhabitants of the Greater Accra region travel a rel- atively shorter distance to access radiological services as there were approximately eighty-four radiologists covering a zone of 5000 km2. The populace of the Ashanti region has roughly four radiologists per 5000 km2 which are only marginally higher than the average national figures. People in the northern parts of the country have it worse because of the large land size, poor infrastructural development, and scarcity of radiologists. The long distances traveled coupled with poor road infrastructure could affect health outcomes gravely. While this work provides crucial information, a limitation is that it did not obtain more demographic information about these radiologists, such as age, professional background, and educational qualifications for analysis. The study also did not consider the ratio of radiologists to equipment as a factor due to a lack of data on the number of imaging equipment in the country. Conclusions There is a shortage of radiologists at all levels of the health care system in Ghana. The northern half of the country is worst affected by this shortage. This means that the avail- able ones may be overworked as a small number caters for millions of Ghanaians. Actions are needed to address the situation to improve the accessibility of radiological medi- cal resources and good health outcomes in different prov- inces. The government can achieve this by encouraging the training of more radiologists, with a focus on attracting candidates from rural areas. It can also develop policies to incentivize radiologists to work in underserved regions, pos- sibly through financial or career advancement incentives. Moreover, addressing the gender disparity in radiology by promoting inclusivity and investigating factors discouraging female doctors from choosing radiology, and encouraging policies that promote gender diversity in medical specialties, will help increase the number of female radiologists in the country. There is also a need to conduct more research to uncover factors influencing the unattractiveness of radiology residency for some doctor. Acknowledgements The authors thank all who contributed to the suc- cess of this work. Authors’ contributions BDS was involved in conceptualization; data curation; formal analysis; funding acquisition; investigation; methodol- ogy; project administration; resources; software; supervision; valida- tion; visualization; roles/writing—original draft; writing—review & editing. BOB was involved in: formal analysis; methodology; software; supervision; validation; visualization; roles/writing—original draft; writing—review & editing. YBM was involved in: project administra- tion; resources; software; supervision; validation; visualization; roles/ writing—original draft; writing—review & editing. ET was involved in: methodology; validation; roles/writing—original draft; writing— review & editing. BBJ was involved in methodology; validation; roles/writing—original draft; writing—review & editing. EKB was involved in: validation; roles/writing—original draft; writing—review 1(Male) 1(Male|) 2(Male) 1(Female) Sub-specialty radiologists in Ghana Neurointerven�onal radiologist Diagnos�c neuroradiologist Interven�onal radiologist Paediatric radiologist Fig. 4 Sub-specialty radiologists in Ghana Table 2 Radiologists per 5000 square kilometer in the 16 regions of Ghana (December 2022) Regions Land size Number of radiologists Radiologists per 5000 km2 km2 % Ahafo 5196 2.2 0 0 Ashanti 24,389 10.2 19 3.9 Bono East 23,248 9.7 2 0.4 Bono 11,113 4.7 3 1.3 Central 9826 4.1 5 2.5 Eastern 19,323 8.1 4 1.0 Greater Accra 3245 1.4 54 83.2 North East 9070 3.8 0 0 Northern 26,524 11.1 3 0.6 Oti 11,066 4.6 0 0 Savannah 34,790 14.6 0 0 Upper East 8842 3.7 0 0 Upper West 18,476 7.7 0 0 Western 13,842 5.8 1 0.4 Western North 10,079 4.2 0 0 Volta 9504 4.0 2 1.1 Total 238,533 100 93 1.9 195Chinese Journal of Academic Radiology (2023) 6:188–195 1 3 & editing. KD-T was also involved in: methodology; validation; roles/ writing—original draft; writing—review & editing. All authors read and approved the final manuscript. Funding None. Availability of data and materials All data generated or analyzed during this study are included in this published article. Declarations Conflict of interest The authors declare that they have no competing interests. Ethical approval and consent to participate Ethical approval for this study was waived by the Euracare Ethics and Research Protocol Com- mittee (Ref Number EADHC 1010/20–21). Consent for publication This article does not contain any individual person’s data in any form. Consent for publication was included in the ethical approval (Ref Number EADHC 1010/20–21). 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