Kelly Askew, Director, African Studies Center, University of Michigan
Anne Pitcher, Coordinator, African Social Research Initiative, University of Michigan
International Collaboration and Research Capacity Strengthening: Exploring Integrated Solutions for the US and Africa
Clement Ahiadeke, Institute of Statistical, Social, and Economic Research (ISSER); University of Ghana
Youth: Education, Health, and Economic Livelihoods
Chair: Kofi Awusabo-Asare, University of Cape Coast
The Association between Stunting and Early Childhood Development in Children of Preschool Age: A Study Using the South African Birth to 20 Data
Daniela Casale, University of Kwazulu-Natal
A growing literature in developing countries finds a strong association between stunting in early childhood (measured by low height-for-age) and educational attainment or cognitive outcomes in children. Much of this work focuses on outcomes in children of school-going age, however. We contribute to this literature by exploring the links between linear growth retardation and early development in children of preschool age, using a very rich longitudinal dataset on children born in 1990 in urban South Africa – the Birth to Twenty Cohort Study. In particular, we analyse the impact of stunting at age two on children’s scores on the Vineland Social Maturity Scale (VSMS) at age four, a measure of social competence or ‘daily living skills’, and the Revised-Denver Prescreening Developmental Questionnaire (R-DPDQ) at age five, a measure which places greater emphasis on capturing children’s cognitive functioning. To attenuate the problem of confounding relationships between child and family-specific variables and stunting, we control for a variety of factors including biological characteristics, socio-economic status, home environment, parenting quality and child characteristics. We find no significant impact of stunting on children’s performance on the VSMS, but a large and significant impact on the R-DPDQ. A disaggregated analysis of the various components of the scores suggest that children with low height-for age at age two do not necessarily fall behind in terms of daily living skills and social maturity, but do substantially worse on measures capturing fine motor skills and higher order cognitive functioning.
Basic Education and Issues of Cost, Access, and Equity: Evidence from Ghana (1991-2006)
Louis Boakye-Yiadom, University of Ghana
The importance of basic education to the improvement in well-being has been acknowledged worldwide. It is in recognition of this, that the Millennium Development Goals (MDGs) prominently include the achievement of universal primary education by 2015. In Ghana, educational policies and reforms have underscored the importance attached to the realisation of universal basic education. Apart from their likely effects on households’ educational costs and access to basic schooling, these policies and reforms have the potential for altering the distribution of well-being. In order to provide insight into these issues, this paper highlights the links between costs incurred (by households) on basic education and access to basic education. Using data from the 1991/92, 1998/99, and 2005/06 Ghana Living Standards Surveys (GLSS) and a combination of descriptive statistics and econometric techniques, the study highlights the links between household expenditure (on basic education) and schooling participation rates. We also explore the links between fee-free educational policies and household expenditure on basic education. Our findings suggest that while Ghana’s capitation grant scheme and the school feeding programme may be having considerable favourable effects, the direct costs of basic education are not trivial. Our analyses show that many households are characterised by the presence of schooling-deprived children and that the poor are more likely to suffer this predicament. It is therefore recommended that the capitation grant scheme and the school feeding programme be enhanced to ensure that the direct costs of schooling do not deprive any child of basic education. The paper’s findings have significant implications for the formulation and implementation of educational policy in developing countries. Keywords: Education; costs; access; equity; and wellbeing.
Illuminating the Fertility Aspirations, Gender Ideals, Values, and Attitudes of the “Lost Generation”: A Case Study of HIV-infected Adolescents in Uganda
Massy Mutumba, Gary Harper, and Rachel C. Snow, University of Michigan
Planned and unplanned macro-social changes show powerful effects on the structures and processes of society (House, Umberson and Landis, 1988). Worldwide, unprecedented access to cell phones and internet connectivity has spurred informal exchanges of knowledge and values regarding sexual, gender and family ideals worldwide. Demographic and health data from Africa suggest that changes are underway in the attitudes of young people towards women’s rights, family planning, marriage and divorce, sexuality, new forms of family configurations, and gender ideals. However, these changes have not been well documented. It is also not clear how young people’s values and attitudes structure their health behaviors and ultimate health and wellbeing, particularly on issues related to sexual risk-taking, family planning, and mental health.
HIV-infected adolescents represent an expanding population in sub-Saharan Africa; a “lost population” whose socialization has been greatly compromised by the disruption and/or erosion of kinship networks following massive AIDS-related deaths in the region. To date, little is known about the life goals and aspirations as well as values of this population. Data on how gender roles, identity and attitudes may differ between HIV-infected and HIV-uninfected adolescents in Uganda, or even their counterparts in the region are extant. And the impact of macro-social factors such as gendered norms, values and attitudes on these young people’s behavior, health and wellbeing is also unknown.
This paper capitalizes on on-going cohort study among 500 HIV-infected youth (12 – 19 years) at the Joint Clinical Research Center, Kampala to: (1) explore gender ideals, fertility aspirations and attitudes towards marriage, cohabitation, non-marital childbearing, and domestic violence among HIV-infected adolescents in Uganda; (2) enable comparison of gender and fertility attitudes between HIV-infected and HIV-uninfected adolescents in Uganda (using data from Uganda demographic health surveys) and other countries (Demographic Health surveys, World Values Survey); and (3) and assess the impact of gendered values and attitudes on health seeking behavior and mental health of HIV-infected adolescents in Uganda. Key words: Adolescents, Gender, Health, Africa
Youth Vulnerability in Detroit: Residential Instability, Livelihoods, and Sexual Health
Louis Graham, Detroit Youth Project and University of Massachusetts Amherst
Detroit Youth Passages (DYP) is a four-year Ford Foundation funded project that seeks to examine and positively transform structural conditions that contribute to sexual vulnerabilities. DYP is a partnership between the University of Michigan School of Public Health, Detroit Hispanic Development Corporation, Ruth Ellis Center, and Alternatives For Girls. DYP’s research centers on the relationships between residential instability, unemployment, and transactional sex, forced sex, and intimate partner violence. Phase one of the project included hundreds of hours of participant observation and shadowing, 80 semi-structured interviews, 30 life-histories, a venue-based survey of 275 young people, a photovoice project on violence prevention, and a power mapping exercise. Phase two includes communication, dissemination, and translation activities focused on service provision improvement, policy advocacy efforts, and media engagement. This presentation will give an overview of the DYP project, preliminary findings, and current project activities. Constant comparison, grounded theory, and narrative techniques were used in the analysis of qualitative data. Emergent themes highlight the contextual, historical, and institutional aspects of the ways in which: 1) low formal education attainment along with racial and transphobic hiring discrimination contribute to unemployment in the formal economy; 2) low incomes, joblessness, and lack of social support add to homelessness, couch surfing, and housing insecurity; and 3) economic desperation and residential instability limit control over one’s own body that can lead to survival sexwork and mental disorders such as post-traumatic stress disorder and suicidality. Descriptive and bivariate analysis of survey data furthers this line of inquiry in characterizing: 1) how young women and men whose bodies are commodified, participate in sexual commerce by selling sex on the street and dancing in clubs and afterhours spaces; 2) difficulties faced by young people to develop healthy sexualities in contexts of violence, discrimination, and harassment related to stigma, sexism, racism, homonegativity, and transphobia; and 3) the resilience and courage of young people across the city.
Determinants of the Wage of the First Job for Youth
Cecil Mlatsheni, University of Cape Town
The labour market is a central consideration in the transition from youth to adulthood. Work signifies a step closer to economic independence for youth, which in turn is a strong measure of a successful transition to adulthood. While it is quite well known that youth experience higher unemployment rates than adults, not much is known about the nature of the first engagement of youth with the labour market in the context of South Africa. This paper explores the determinants of the income that a youth receives from his/her first job using the Cape Area Panel Study (CAPS) survey. The analysis is restricted to the experiences of only two race groups, namely Africans and Coloureds. This restriction offers interesting insights as these population groups are closest to each other than other race groups in terms of socio-economic status yet labour market outcomes tend to be different. The CAPS data set is ideal for this exercise in that we can control for variables such as age at the time of the first job and time taken to find the first job. We also extend the analysis to control for selection. We find that race and gender are important determinants of the wage of the first job. The significance of variables such as education and test scores depends on the specification.
The Post 2014 Agenda for Population and Development: A Focus on Africa
Rachel C. Snow, Population Studies, Public Health, University of Michigan; Lead Author, Beyond ICPD Global Review, UNFPA
Electoral Politics and Democratic Accountability
Chair: David Howell, University of Michigan
The Democratic Quality of Local Elections in Mozambique
Carlos Shenga, University of Cape Town
This study systematically assesses and compares the democratic quality of local elections so far conducted in Mozambique. It aims to assess political participation in local elections including voter turnout and whether opposition parties contested or boycotted elections. It aims to examine the political competition of local elections including levels of competitiveness such as the share of the winners vote and whether the election produced alternation of power. Finally it aims to evaluate the legitimacy of local elections including the extent to which losers accept defeat, whether the election process was peaceful and democratic regime survival. Based on these findings this study ends by suggesting areas of further research for Mozambican electoral scholars and highlighting trends that may be of interest to internal and external democratic practitioners’ whose aim is to strengthen Mozambican electoral policy and democracy.
This study will employ a local election dataset on turnout and competitiveness. The data has been gathered by the author and it is based on objective official information from the Constitutional Council of Mozambique – which is the judiciary body that validates election results, the National Electoral Commission — the institution that administers and supervises elections, and other secondary documents. Data on other indicators of democratic quality of elections has been gathered from many secondary sources, including national media.
Transition without Transformation: The Political Economy of Two Decades of Multiparty Elections in Malawi
Blessings Chinsinga, University of Malawi
This paper examines the political economy of two decades of multiparty elections in Malawi based on a critical review of election observation mission reports for four elections since May 1994 using historical institutionalism. All the four elections have been declared free but not necessarily fair and almost a similar set of problems has been observed in each election and among various election observation missions. The underlying assumption is that institutions in nascent democracies will improve with passage of time as voters, candidates and administrators gain experience to deal with the demands, values and practices of democratic dispensation. The argument of this paper is that Malawi has not been able to achieve free and fair elections due to the perverse interaction between formal and informal institutions that has undermined efforts to reform electoral processes on the basis of the electoral observation mission reports. This demonstrates that processes of change are often heavily contested by diverse interests with different forms and degrees of power, influence and authority, creating winners and losers in the process. The losers are keen on changing the status quo while the winners are intent on defending the status quo. Since incumbents are always winners from persistence of the deficiencies in the electoral processes, the momentum for electoral reforms is hardly existent.
Marginalization in Kenya: Redressing Historical Injustices through Affirmative Action and Devolution
Adams Oloo, University of Nairobi
The concept of marginalization is an emotive subject in Kenya even as its precise meaning remains contentious. In Kenya, the concept can be used to include exclusion, underdevelopment or alienation of certain ethnic groups or social cleavages. Against this background, the marginalized in Kenya include Women, the Youth, persons living with disabilities as well as ethnic and racial minorities. The aforementioned have been marginalized by successive governments since the colonial era in what has been categorized in Kenya as “historical injustices”. The Constitution of Kenya 2010 seeks to redress these injustices specifically through devolution of political power and economic resources to the devolved units and likewise through affirmative action for the marginalized by guaranteeing the representation of their interests.. This paper will analyze the relevance of the provisions of the Constitution of Kenya 2010 in redressing the plight of those who have been characterized as marginalized as well as tease out the policies that need to be implemented so as to ensure that inclusive and equitable programs are adopted both at the national and county levels as a measure of redressing past “historical injustices.”
Disciplining the Electorate? The International Criminal Court in Kenya’s
Gilbert Khadiagala, University of Witwatersrand
Transnational actors have played prominent roles in Africa’s democratization since the early 1990s, mobilizing resources and pressures that propelled change. Comparative studies of external promotion of democracy in Africa have emphasized the duality of these interventions: on one hand, they have, in most cases, empowered domestic constituencies for change while in others they have engendered recalcitrance from parties that decry excessive intrusion on sovereignty. Understanding distinctive outcomes of these interventions has often entailed probing the power of the major players and their strategies, but equally significant, the ability of target states to comply or resist external entreaties. This study examines the recent Kenyan elections from the perspective of the coalescence of normative pressures exerted on the Kenyan electorate in the choice of the president. Like the 2007 elections that occasioned polarization and profound violence, the 2013 elections were held in the convulsive shadows of the ICC’s indictment of Uhuru Kenyatta and his running mate, William Ruto. The ICC galvanized diverse voices around a transnational discourse on electability and responsibility which had an impact on the electoral outcome. Assessing the ICC’s discourse and countervailing debates is instructive in illuminating the limits of international action in elections in deeply-divided societies.
Gender, Poverty, and Inequality
Chair: Clement Ahiadeke, University of Ghana
How Has Economic Growth Affected Poverty and Inequality in Ghana and South Africa?
Samuel Kobina Annim, University of Cape Coast; David Lam, University of Michigan; and Murray Leibbrandt, University of Cape Town
Inequality Traps and Human Capital in South Africa
Vimal Ranchhod, University of Cape Town
South Africa is persistently ranked as one of the most unequal societies in the world. We investigate whether there is empirical evidence consistent with the ‘inequality traps’ theories, along the dimensions of education. We show that the returns to tertiary education are very high, but few people manage to attain such qualifications. A major reason for not studying further is due to financial constraints. In addition, students from the top third of the income distribution perform better on a scholastic aptitude test than those from the middle and bottom third, and their performances seem to diverge as the cohorts get older. We conclude that there is compelling evidence of an economics based inequality trap in education, and suggestive evidence of a social externalities based inequality trap in education. We conclude with a discussion of possible policy responses.
Home Ownership in Ghana: A Gender Analysis
Abena Oduro, University of Ghana
Using data from a survey that collected individual-level asset ownership data in 2010, we investigate the factors associated with the ownership of the place of residence by women and men in Ghana. Most adults in Ghana aspire to own their home. Initial analysis of the 2010 survey found that less than 25 percent of persons aged 18 years and above own the place of residence and the incidence of homeownership is lower among women than it is among men. Logistic regressions will be employed to find out the correlates of home ownership (for example, age, marital status, education, employment and wealth) and whether these are the same for women and men. In Ghana, the concept of ownership has several dimensions. Persons identified as owners of an asset do not always have the rights associated with being an owner, i.e. the right to sell, bequeath or use the asset as collateral. The second part of this paper will investigate the correlates of the right to sell among owners of the place of residence. Separate logistic regressions will be run for women and men. The dependent variable in most previous studies on the determinants of home ownership including an early study on Ghana is the household, i.e. whether the household resides in owned or rented accommodation. The novelty of this study is that the focus is on individuals and the likelihood that an individual will be a homeowner.
Measured as Poor versus Feeling Poor: Comparing Objective and
Subjective Poverty Rates in South Africa
Dorrit Posel, University of KwaZulu-Natal
We compare subjective and objectives measures of poverty in South Africa using data collected in the 2008/2009 Living Conditions Survey (LCS). In addition to detailed questions on income and expenditure, the LCS asked respondents to provide an assessment of the economic status of their household, ranging from ‘very poor’ to ‘wealthy’. Although we find considerable overlap in subjective and objective poverty status among households, we also identify a number of significant characteristics which distinguish households where poverty measures are not consistent. These characteristics highlight both the low dimensionality in the measurement of objective economic welfare, and the possible underestimation of objective economic resources in the household. This underestimation may arise partly because per capita measures do not recognize scale economies in the household and also because the value of economic activity can be difficult to measure, as in the case of subsistence farming. We consider the implications of our findings for the measurement of objective poverty in post-apartheid South Africa. Key words: income poverty; subjective poverty; economies of scale; adult equivalence
Distributive Politics across Regime Types: The Provision of Goods and Services
Chair: Brian Min, University of Michigan
Why Some African Countries are Governed Better than Others
Alecia Ndlovu and Rod Alence, University of Witwatersrand
“Bad governance” is often invoked as a blanket explanation for sub-Saharan Africa’s disappointing record of development. Yet since the end of the Cold War, governance structures and outcomes have varied widely within the region. This paper seeks to explain why some African countries are better governed than others. It focuses on how natural resources and democratic institutions affect governance quality. We break with sweeping portrayals of Africa as an invariably unfavorable environment for effective governance. Instead we identify the wide diversity of natural endowments and political institutions within the region, then analyze the impact of this diversity on governance quality. We find that abundant natural resources have not hindered the emergence of democratic institutions. And where democratic institutions have emerged, they have had a positive effect on the state’s performance as an agent of development. The presence of lucrative mineral and fuel resources magnifies democracy’s contribution governance quality.
Housing Provision and Finance in Developing Economies: State Policies, Interventions, and Results. Ghanaian Experience since 1957
Jonathan Ayitey, Kwame Nkrumah University of Science and Technology
This paper examines the history of housing provision and finance in Ghana since independence. It discusses various state interventions in the form of subsidy programs, fiscal measures and land use controls and decisions over the years. We evaluate the effectiveness or otherwise of state policy in providing decent accommodation over the years. The paper also surveys the strategies that poor households have adopted to survive and the implications of these strategies on the housing stock.
Primary and secondary sources of data were used in the study. We obtained data from purposively selected key informants using semi-structured interviews, documentary analysis, informal discussions and observations. The fieldwork was conducted in four ministries and their subsidiary boards and agencies (i.e. Ministry of: Water Resources, Works and Housing, Local Government and rural Development, Land and Natural Resources and Finance and Economic Planning). From the Ministries, Departments and Agencies (MDA’s), 25 informants were interviewed.
The study claims that to attain an appreciable degree of housing accessibility, policy makers need to tailor specific programs to address particular target groups who have been marginalized by privatization and liberalization with the associated price mechanism which do not really address the needs of the poor in society. A coordinated and dynamic system for housing policy is required if the current housing situation is to be improved. Keywords: Ghana, Government policy, Housing policy, Housing finance, Housing affordability
Politics, Policy, and Housing Provision in Luanda, Angola
Sylvia Croese, Stellenbosch University; and Anne Pitcher, University of Michigan
This paper assesses the changing spatial structure of Luanda, the capital of Angola, following the adoption of a number of policies on urban planning, property rights, residential housing and commercial development since the end of the civil war in 2002. Owing to civil conflict, rural to urban migration, and natural population growth, the population of Luanda has swelled from approximately 500,000 residents before independence in 1975 to around 7 million inhabitants in 2013. Over the last decade, government subsidized housing to public servants, the provision of social housing, forced resettlement, and voluntary relocation have spatially reconfigured residential patterns and practices in the greater Luanda area. The core of the city is increasingly the preserve of the city’s wealthiest inhabitants whereas the city’s poorest residents increasingly occupy the urban periphery. The paper will compare the demographic, social, and physical characteristics of a social housing project, Zango, with a government subsidized neighborhood for the middle class, Nova Vida to identify the complex ways in which distributive politics and policies have both constrained and facilitated housing delivery and the growth of a housing market in the last ten years. Moreover, it will highlight the role that social agency plays in undermining or modifying the efforts of public officials to socially engineer urban transformation in one of Africa’s most expensive cities.
Planning, Participation, and Power: The Struggle for the Soul of Detroit
Amy Krings, Gregory B. Markus, Brock Grosso, and Sophia Karnovsky, University of Michigan
This paper provides an overview of the “Detroit Works Project”, a planning process intended to come to terms with the city’s chronic population loss, ailing local economy, declining municipal revenues, and crippled public services. In particular, we evaluate public participation during the planning process (2010 – 2012) as well as the substance of the final report titled “Detroit Future City” which was released in January, 2013. We conclude—as do many Detroiters, in media reports and in our conversations with them—that despite insistent claims to the contrary and perhaps good intentions on the part of its leaders, the project to date has offered a largely symbolic, limited, and ineffective role for residents in the struggle for the future of their city. We also conclude that the narrative articulated by planners and public officials, and echoed by the local media, is misguided and misleading in some important respects. As a consequence: (1) the planning has failed to benefit from key insights that Detroit residents could have offered had they been engaged more collaboratively; (2) many residents remain deeply suspicious and even fearful of the plan’s implementation; and (3) little public capacity and few mutually trusting relationships have been developed to date to support ongoing planning and assessment of early results of implementation. We offer some observations on how public participation can be made more authentic and effective, to the advantage of the citizens of Detroit and the future of their city.
The UN-HABITAT Global Housing Strategy: A Paradigm Shift towards Adequate Housing for All
Mohamed El Sioufi, Coordinator, Housing and Slum Upgrading Branch, UN-HABITAT
Maternal and Newborn Health
Chair: Cheryl Moyer, University of Michigan
“If It Is Dead, I Remove It”: Operations of Traditional Practitioners Involved in the Management of Obstetric Complications in the Kassena-Nankana District in Northern Ghana
Raymond Aborigo, Navrongo Health Research Centre
Introduction: In 2002, WHO launched the first global strategy on traditional and alternative medicines. Central to the strategy is the operations of traditional practitioners whose role, especially in maternal health, has not been well defined. We explored the activities of traditional providers who manage obstetric complications in the Kassena-Nankana district, Northern Ghana, with the aim of drawing the attention of health authorities to the exclusion of a critical stakeholder in maternal health at the community level.
Methods: A descriptive qualitative research design was employed. About 20 focus group discussions were conducted with traditional birth attendants and 19 in-depth interviews with traditional healers with expertise in managing pregnancy complications. A list of TBAs was obtained from community key informants for the focus group discussions while traditional healers were identified through the snowballing technique. All interviews were conducted in Kasem or Nankani, the local languages in the district, audio recorded, transcribed into English and imported into NVivo 10 for thematic analysis.
Results: Traditional healers manage maternal complications at the community level and their services are used by a diverse group of people. These include families that refuse to use allopathic providers, women whose complications are not traditionally recognized as complications requiring hospital care, and complications that are believed to be caused by witchcraft or other culturally defined syndromes. Due to increasing campaigns for women to use health facilities, some of the healers are have limited client base while others remain popular with clients extending beyond local community boundaries. Some claim to have handled complications that could not be managed by hospitals and none reported ever losing a woman during treatment.
Conclusions: Traditional healers are involved in the management of pregnancy complications and the health system needs to recognize and examine the potential dangers that their activities may be posing to the health of women.
Perception of Cervical Cancer Risk and Actual Risk in Women in Northern Ghana
Constance Opoku, Tamale Teaching Hospital
Objective: This study assessed the perception of risk of cervical cancer and existence of risk factors for cervical cancer among women accessing antenatal or child welfare clinics in the Tamale Teaching Hospital.
Methods: A convenience sample of 300 women were selected and interviewed using a semi-structured questionnaire to inquire about demographics, knowledge of cervical cancer, risk factors and perception of risk of cervical cancer.
Results: Based on preliminary data from 275/300 women interviewed to date.
184 (67%) respondents had never heard about cervical cancer. Only 9(3%) respondents had been screened before. 165 (60%) respondents didn’t think they had any risk for cervical cancer. 10 respondents admitted to having sex at age 15 or less and of those, 7(70%) didn’t think they were at risk. 76 respondents were in polygamous relationships and of those, 41 (54%) didn’t think they were at risk. 2 respondents admitted to having ≥ 5 sexual partners and both (100%) didn’t think they were at risk. 15 respondents had 2 or more risk factors for cervical cancer and all 15(100%) said they had no risk.
Conclusion: There is an unmet need for cervical cancer screening among women in the Northern region of Ghana and a lack of knowledge of the risk factors. There is a strong potential to improve screening uptake if screening is made available and women are educated on personal risk.
National Health Insurance, Social Influence, and Antenatal Care Use: A Village-Level Spatial Analysis of Women’s Maternal Health Care Utilization in Ghana
Nkechi Owoo, University of Ghana
The study explores the importance of social influence and the availability of health insurance on maternal care utilization in Ghana through the use of antenatal care services. A number of studies have found that access to health insurance plays a critical role in women’s decision to utilize antenatal care services. However, little is known about the role that social forces play in this decision. This study uses village-level data from the 2008 Ghana Demographic and Health Survey to investigate the effects of health insurance and social influences on the intensity of antenatal care utilization by Ghanaian women. Using GIS information at the village level, we employ a spatial lag regression model in this study. Results indicate that controlling for a number of socioeconomic and geographic factors, women who have health insurance appear to use more antenatal services than women who do not. In addition, the intensity of antenatal visits appears to be spatially correlated among the survey villages, implying that there may be some social influences that affect a woman’s decision to utilize antenatal care. A reason for this may be that women who benefit from antenatal care through positive pregnancy outcomes may pass this information along to their peers who also increase their use of these services in response. In addition, as more women utilize these maternal care services, other women may also do same in the interest of conformity. These findings suggest that campaigns and outreach programs to promote utilization of antenatal care services should pay attention to women’s social networking groups. Public health officials may also explore the possibility of disseminating information relating to maternal care services via the mass media. Keywords: Antenatal care, health insurance, social influence, Child and maternal health, maternal mortality, spatial analysis
Progress Gaps in Maternal and Child Health in Ghana: Addressing Inequalities through Policy
Phyllis Dako-Gyeke, University of Ghana
Background: Utilization of Maternal and Child Health (MCH) interventions among several African sub-populations remain a key challenge. In Ghana, the socio-economic and geographical circumstances constrain fair and equitable delivery of health services, creating a disadvantage for some sub-populations across the country. Unequal distribution of income, assets and health services within the country has contributed to low levels of basic health care utilization and limited access to health services amongst certain social groups. Consequently, attention to the influence of these contextual factors on utilization of MCH interventions in Ghana is essential for effective development of programs and policies.
Study Objectives: This study measured inequalities in MCH using the PROGRESS categories adopted by the MASCOT* Consortium to monitor progress and policies dedicated to MCH in Ghana. It aimed to establish status of MCH inequalities, analyse influence of social determinants of health (PROGRESS) on MCH inequality gaps and identify existing policies implemented to reduce MCH inequality gaps.
Methods: The Multiple Indicator Cluster Survey (MICS) of 2006 was used to measure access to contraceptive use, skilled delivery, ANC, PNC, DPT3, exclusive breastfeeding, and stunting by place of residence(P), ethnicity or race(R), occupation(O), gender(G), religion(R), education(E), socio-economic status(S) and social capital(S). 3545 households and 1723 women were included in the analysis. Seventy-one percent of households were rural. The study also reviewed 6 policies and 4 programmes and strategies on MCH in Ghana.
Results: Our results showed wide rural-urban differences in skilled birthing with less than half of rural women as urban women delivering with a skilled attendant. Under-five children in urban areas had a better chance of surviving childhood than in rural areas. Most post-secondary and tertiary educated women with professional or semi-professional jobs were 2.5 times more likely to use contraception to avoid pregnancy, 15.5 times more likely to access antenatal care while 94% of urban women delivered with a skilled attendant. Children of tertiary educated women were at an advantage as they were more likely to be vaccinated (61.5%) and less likely to be stunted (3.6%). Women belonging to traditional and no religious groups were less likely to attend ANC and deliver with a skilled birth attendant.
Conclusion and Policy Implications: Maternal and Child health inequalities in Ghana are influenced by social determinants including place of residence; ethnicity; occupation; gender; religion; education; and social capital (PROGRESS). From our analysis higher education, high-income occupation or wealth significantly lower the probability of adolescent pregnancy and increases the probabilities of contraception use and skilled birth attendance. The Community-based Health and Planning Services (CHPS) policy and the National Health Insurance Scheme were identified to directly target inequality in geographical and financial access to health care.
How do we pursue integrated solutions to challenges in education, health, employment, and governance and among different social categories such as youth and the elderly?