1. Eradicate extreme poverty and hunger
1.8 Prevalence of underweight children under age 5 10.6 11.6 11.0
2. Achieve universal primary education
2.1 Net attendance ratio in primary education1 70.8 70.5 70.6 2.3 Literacy rate of 15 to 24-year-olds2 89.3a 80.9 85.1b
3. Promote gender equality and empower women
3.1 Ratio of girls to boys in primary, secondary, and tertiary education
3.1a Ratio of girls to boys in primary education3 na na 1.0 3.1b Ratio of girls to boys in secondary education3 na na 1.0 3.1c Ratio of girls to boys in tertiary education3 na na 1.0
4. Reduce child mortality
4.1 Under-5 mortality rate4 78 62 60
4.2 Infant mortality rate4 52 43 41
4.3 Proportion of 1-year-old children immunized against one dose of measles 88.2 90.3 89.3
5. Improve maternal health
5.2 Percentage of births attended by skilled health personnel5 na na 73.7 5.3 Contraceptive prevalence rate6 na 26.7 na
6. Combat HIV/AIDS, malaria, and other diseases
6.1 HIV prevalence among the population age 15-24 0.2 1.5 0.8 6.2 Condom use at last high-risk sex10 39.3 19.2 29.3 6.3 Percentage of the population age 15-24 with comprehensive correct knowledge of
HIV/AIDS11 27.2 19.9 23.6
6.4 Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 0.97 0.92 0.94 6.7 Percentage of children under 5 sleeping under insecticide-treated bed nets 47.5 45.6 46.6 6.8 Percentage of children under 5 with fever who are treated with appropriate antimalarial
drugs12 46.8 50.6 48.5
Urban Rural Total 7. Ensure environmental sustainability
7.8 Percentage of population using an improved drinking water source13 57.0 71.4 64.2
7.9 Percentage of population with access to improved sanitation14 20.5 9.6 15.0 na = Not applicable
1 The ratio is based on reported attendance, not enrollment, in primary education among primary school age children (6-11 years). The rate also includes children of primary school age enrolled in secondary education. This is a proxy for MDG indicator 2.1, Net enrollment ratio.
2 Refers to respondents who attended secondary school or higher or who could read a whole sentence or part of a sentence
3 Based on reported net attendance, not gross enrollment, among 6-11-year-olds for primary, 12-17-year-olds for secondary, and 18-24-year-olds for tertiary education
4 Expressed in terms of deaths per 1,000 live births. Mortality by sex refers to a 10-year reference period preceding the survey. Mortality rates for males and females combined refer to the five-year period preceding the survey.
5 Among births in the five years preceding the survey
6 Percentage of currently married women age 15-49 using any method of contraception
7 Equivalent to the age-specific fertility rate for women age 15-19 for the three years preceding the survey, expressed in terms of births per 1,000 women age 15-19
8 With a skilled provider
9 With any health care provider
10 High-risk sex refers to sexual intercourse with a non-marital, non-cohabitating partner. Expressed as a percentage of men and women age 15-24 who had higher-risk sex in the past 12 months.
11 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about transmission or prevention of the AIDS virus.
12 Measured as the percentage of children age 0-59 months who were ill with a fever in the two weeks preceding the interview and who received any antimalarial drug
13 Percentage of de jure population whose main source of drinking water is a household connection (piped), public tap or standpipe, tubewell or borehole, protected dug well, protected spring, or rainwater collection.
14 Percentage of de jure population whose household has a flush toilet, ventilated improved pit latrine, pit latrine with a slab, or composting toilet and does not share its facility with other households
a Restricted to men in a subsample of households selected for the male interview
b The total calculated as the simple arithmetic mean of the percentages in the columns for male and females
Introduction • 1
INTRODUCTION 1
1.1 G
EOGRAPHY, H
ISTORY,
ANDE
CONOMY 1.1.1 Geographyhe Republic of Ghana is centrally located on the West African coast. It has a total land area of 238,537 square kilometres, and it is bordered by three French-speaking countries: Togo on the east, Burkina Faso on the north and northwest, and Côte d’Ivoire on the west. The Gulf of Guinea lies to the south and stretches across the 560-kilometre coastline.
Ghana is a lowland country except for a range of highlands on the eastern border. The highest elevation is Mt. Afadjato, 884 metres above sea level, found in the Akuapem-Togo ranges, west of the Volta River. Ghana can be divided into three ecological zones: the low, sandy coastal plains, with several rivers and streams; the middle and western parts of the country, characterised by a heavy canopy of semi-deciduous rainforests, with many streams and rivers; and a northern savannah, which is drained by the Black and White Volta Rivers. The Volta Lake, created by the hydroelectric dam in the East, is one of the largest artificial lakes in the world.
Ghana has a tropical climate with temperatures and rainfall patterns that vary according to distance from the coast and elevation. The eastern coastal area is comparatively dry, the southwestern corner is hot and humid, and the north of the country is hot and dry. The average annual temperature is about 26ºC (79ºF). There are two distinct rainy seasons in the southern and middle parts of the country, from April to June and September to November. The North is, however, characterised by one rainfall season that begins in May, peaks in August, and lasts until September. Annual rainfall ranges from about 1,015 millimetres (40 inches) in the North to about 2,030 millimetres (80 inches) in the Southwest. The harmattan, a dry dusty desert wind, blows from the northeast and covers much of the country between December and March, lowering the humidity and visibility, and also creates very warm days and cool nights in the North. In the South, the effects of the harmattan are felt mainly in January.
1.1.2 History
Ghana gained independence from British colonial rule on 6 March 1957, and became a republic in the British Commonwealth of Nations on 1 July 1960 with Accra as its administrative and political capital.
Ghana operates a multi-party democracy with an executive president who is elected for a term of four years with a maximum of two terms. There is a parliament elected every four years, an independent judiciary, and a vibrant media.
There are 10 administrative regions in Ghana: Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Northern, Upper East, and Upper West. Ghana’s population was estimated at 27 million in 2014 (GSS 2013a). The Ashanti, Eastern, and Greater Accra regions together constitute about 50 percent of the country’s population. Upper East is the least populated region, accounting for 2 percent of the total population of Ghana. The regions are subdivided into 216 districts to ensure equitable resource allocation and efficient, effective administration at the local level (GSS 2013b).
The Ghanaian population is made up of several ethnic groups, with the Akans constituting the largest group (48 percent), followed by the Mole-Dagbani (17 percent), Ewe (14 percent), Ga-Dangme (7 percent), and others (GSS 2013b).
T
1.1.3 Economy
The structure of the Ghanaian economy has seen minimal changes over the past two decades. The agriculture sector, previously the largest contributor to the Ghanaian economy, has been overtaken by the service and industry sectors. By 2014, the service sector was the fastest growing sector of the economy, contributing 52 percent of the gross domestic product (GDP), followed by the industry sector, at 27 percent, and the agriculture sector, at 22 percent. In 2014, the service sector recorded its highest growth, of 6 percent, followed by the agricultural sector with 5 percent growth, and the industry sector with 1 percent growth (GSS 2015).
Overall, the 2014 real annual GDP grew by 4 percent compared with 7 percent growth recorded in 2013 (GSS 2015).
About 45 percent of the economically active population are engaged in agriculture, and 41 percent provide services. A high proportion of the employed population of Ghana works in the informal sector, the majority being self-employed (GSS 2014).
The leading export commodities of Ghana are cocoa, gold, and timber. Recently, the economy has diversified to the export of non-traditional commodities such as pineapples, bananas, yams, and cashew nuts. The tourism industry contributes substantially to the country's economy, as a key driver of economic growth. The industry is currently the third largest foreign exchange earner after merchandise exports and remittances from abroad and has become one of the most important and fastest growing sectors of the Ghanaian economy (BOG 2007).
Over the past decade, the government of Ghana has embarked on various economic and poverty-reduction programmes designed to improve the living conditions of its citizenry. The Livelihood Empowerment Against Poverty (LEAP) programme was introduced in 2007 and, in 2008, the poor began to receive cash support on a monthly basis.
Many changes have occurred in the education sector over the past 15 years. Pre-school education has officially been incorporated into the basic education as a part of primary and junior high school. All primary schools are required to have nurseries or kindergartens. In the 2005-2006 academic year, the government absorbed school fees for all pupils enrolled in basic public schools, resulting in free education (Darko et al. 2009). During the same period, a school feeding programme was introduced on a pilot basis and has since been extended to all basic schools. While the programme aims at improving the nutritional status of school pupils, a secondary effect has been to increase enrolment.
At the secondary level, the senior high school was introduced in the 2007-2008 academic year, expanding the system from three to four years, but this policy was reversed in 2009.
The introduction of the Ghana Education Trust Fund (GETFUND), a public trust set up by an Act of Parliament in the year 2000, has brought many improvements to the education system. The fund provides educational infrastructure such as buildings to support the country’s tertiary institutions and, as a result, has improved teaching and learning within these institutions.
1.2 D
EMOGRAPHICP
ROFILESources of demographic information about the Ghanaian population include censuses, surveys, and administrative data. Population censuses provide more comprehensive demographic information than other sources. Ghana has completed five censuses since gaining independence in 1957. The first one was conducted in 1960 and reported a population of 6.7 million. The 1970 census recorded 8.6 million people, and the 1984 census, 12.3 million. In 2000, the Population and Housing Census (PHC) recorded 18.9 million, while in the 2010 PHC, 24.7 million were recorded. The average annual growth rate between 2000 and 2010 was 2.5 percent. The growth rates over individual periods were 2.4 percent, 2.6 percent, 2.7
Introduction • 3 percent, and 25 percent during 1960-1970, 1970-1984, 1984-2000, and 2000-2010, respectively (Table 1.1).
The population density has increased over the years from 29 persons per square kilometre (persons/km2) in 1960 to 103 persons/km2 in 2010. The proportion of the population living in urban areas has more than doubled in the last five decades, expanding from 23 percent in 1960 to 51 percent in 2010.
The sex ratio of 102.2 males per 100 females recorded in 1960 has declined to 95.2 males per 100 females in 2010. The proportion of the population under age 15 has also decreased from 45 percent in 1960 to 38 percent in 2010 (Table 1.1), while the proportion of the population age 65 years and older increased from 3 percent to 5 percent over the same period (data not shown separately). Over the last five decades, life expectancy at birth has increased from 38 years to 60 years among males and from 43 years to 63 years among females (GSS 1979, 1985, 2002, and 2013b).
Table 1.1 Basic demographic indicators
Indicators Pop census
1960 Pop census
1970 Pop census
1984 Pop & housing
census 2000 Pop & housing census 2010
Population (millions) 6.7 8.6 12.3 18.9 24.7
Annual growth rate (percent) na 2.4 (1960-1970)
2.6 (1970-1984)
2.7 (1984-2000)
2.5 (2000-2010)
Density (population/km2) 29 36 52 79 103
Percent urban 23 29 32 44 51
Sex Ratio 102.2 98.5 97.3 97.9 95.2
Population under 15 years 45 48 46 42 40
Life expectancy (years)
Male 38 45 50 55 60
Female 43 48 54 60 63
na= Not applicable
Sources: Ghana Statistical Service (GSS), 1979, 1985, 2002, and 2013b
Population and housing censuses are resource intensive, expensive to implement, and generally take place at 10-year intervals. Sample surveys are, therefore, important for informing demographic profiles during inter-censal periods. They are conducted to collect a wide range of data to complement the census data. Sample surveys are cheaper and can be implemented more frequently and at regular intervals.
The Ghana Demographic and Health Survey (GDHS), which is a household survey, is an example of a sample survey data collection tool.
Another important but often neglected data source in Ghana is the administrative data. These data are generated as a by-product of events and processes, and they provide relatively up-to-date information to fill gaps in both censuses and surveys. Vital registration systems (birth and death registration), health systems (immunisations), and education data (enrolment) are examples of administrative data.
1.3 P
OPULATIONP
OLICY ANDR
EPRODUCTIVEH
EALTHP
ROGRAMMESThe National Population Policy of Ghana was formulated in 1969 in recognition of the simultaneous high growth of population and fertility. The policy was revised in 1994 because of its modest impact after 25 years of implementation. The revision took into account emerging issues such as HIV/AIDS, population and the environment, and concerns about the elderly and children. It developed new strategies that would ensure the achievement of its goals and objectives. The revision of the population policy also entailed concerted effort to systematically integrate population variables in all areas of national development and programme planning (NPC 1994).
Some selected targets of the revised population policy included the following:
• Reduce the total fertility rate (TFR) from 5.5 in 1993 to 5.0 by 2000, 4.0 by 2010, and 3.0 by 2020
• Achieve a contraceptive prevalence rate (CPR) with modern methods of 15 percent by the year 2000, 28 percent by 2010, and 50 percent by the year 2020
• Reduce the population growth rate from about 3 percent per annum to 1.5 percent per annum by the year 2020
• Increase life expectancy to age 70 years by the year 2020 (NPC 1994)
The attainment of these population targets is recognised as an integral component of the national strategy to accelerate economic development, eradicate poverty, and enhance the quality of life of all Ghanaians.
In collaboration with the United Nations Population Fund (UNFPA), the United States Agency for International Development (USAID), the World Bank, and other development partners, Ghana has implemented several projects aimed at reducing reproductive health problems among its population.
Support from these agencies has targeted policy coordination, implementation, and service delivery.
The government is committed to improving access and equity of access to essential health care services. The priority areas identified include HIV/AIDS and other sexually transmitted infections (STIs), malaria, tuberculosis, guinea worm disease, poliomyelitis, reproductive health, maternal and child health, accidents and emergencies, noncommunicable diseases, oral health and eye care, and specialised services.
Emphasis is also being placed on regenerative health and preventive as well as community-based health care services. This has necessitated the introduction of the Community-based Health Planning and Services (CHPS) programme in which trained nurses are stationed in selected communities to provide health care services to members of the communities.
In response to the HIV/AIDS epidemic, the government of Ghana set up the National AIDS Commission to oversee the implementation of HIV/AIDS programmes using a multi-sectoral approach and to ensure that HIV/AIDS prevention education, treatment, care, and support reach every corner of the country. The Ghana Health Service (GHS) also set up the National AIDS Control Programme (NACP) to offer HIV/AIDS prevention and education services. The combined efforts of all stakeholders ensured the implementation of the Ghana HIV/AIDS Strategic Framework: 2001-2005 (World Bank 2003). These collaborative efforts have had a positive impact. In 2013, only 1.3 percent of Ghanaian adults were HIV positive (GHS 2014).
The Roll Back Malaria, tuberculosis (TB-DOTS), and integrated management of childhood illnesses (IMCI) are also priority areas under the country’s health care system. Other health interventions instituted as part of the government’s efforts to make health care accessible and affordable to all include the introduction of the National Health Insurance Scheme (NHIS) and a free maternal care programme (United Nations 2008).
Sustainable accessibility and availability of improved water and sanitation are essential to the health of a population. Therefore, extensive efforts are being made in Ghana to ensure universal access to safe drinking water and improved sanitation facilities by the year 2025 (MWRWH 2009). The Ghana WASH Project, under the auspices of the Ministry of Local Government and Rural Development, is a USAID-funded initiative. The goal of the project is to improve water and sanitation facilities and to increase hygiene education among rural and peri-urban communities to prevent the spread of diseases like diarrhoea, dysentery, cholera, and, recently, Ebola. The Ghana WASH Project is supported by a number of
Introduction • 5 agencies, including Relief International, the Adventist Development Relief Agency, and Winrock International.
1.4 O
BJECTIVES ANDO
RGANISATION OF THES
URVEYThe primary objective of the 2014 GDHS was to generate recent reliable information on fertility, family planning, infant and child mortality, maternal and child health, and nutrition. In addition, the survey collected specialised data on malaria treatment, prevention, and prevalence among children age 6-59 months; blood pressure among adults; anaemia among women and children; and HIV prevalence among adults. This information is essential for making informed policy decisions and for planning, monitoring, and evaluating programmes related to health in general, and reproductive health in particular, at both the national and regional levels. Analysis of data collected in the 2014 GDHS provides updated estimates of basic demographic and health indicators covered in the earlier rounds of the 1988, 1993, 1998, 2003, and 2008 surveys.
The GDHS will assist policymakers and programme managers in evaluating and designing programmes and strategies for improving the health of Ghana’s population. The 2014 GDHS also provides comparable data for long-term trend analysis in Ghana, since the surveys were implemented by the same organisation, using similar data collection procedures. Furthermore, the survey adds to the international database on demographic and health–related information for research purposes.
The survey was implemented by the Ghana Statistical Service (GSS), the Ghana Health Service (GHS), and the National Public Health Reference Laboratory (NPHRL) of the GHS. The Noguchi Memorial Institute for Medical Research (NMIMR) performed the external quality assurance testing for the malaria and HIV testing component of the 2014 Ghana DHS survey. Financial support for the survey was provided by the United States Agency for International Development (USAID), the Global Fund through the Ghana AIDS Commission (GAC) and the National Malaria Control Programme (NMCP), the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the International Labour Organization (ILO), the Danish International Development Agency (DANIDA), and the Government of Ghana. ICF International provided technical assistance through The DHS Program, a USAID-funded project offering support and technical assistance in the implementation of population and health surveys in countries worldwide.
In addition to the main survey, a follow up study on family planning was conducted by a different team on a subsample of households selected for the GDHS survey. The main goal of this study was to better understand the underlying factors behind observed variations in unmet need and to strengthen assessments of the demand for family planning. The research team re-interviewed a subsample of the selected GDHS original female respondents in 13 clusters who consented to be re-interviewed. Women age 15-44 who were not currently using family planning or who reported not wanting their current pregnancy or their most recent live birth were eligible for the follow-up survey. Additionally, a randomly selected 10 percent of current female users of family planning age 15-44 in those clusters also were eligible for the study. Results of the follow up study on unmet need for family planning are not discussed in this report and will be published in a separate report.
1.5 S
AMPLED
ESIGNThe sampling frame used for the 2014 GDHS is an updated frame from the 2010 Ghana Population and Housing Census provided by the Ghana Statistical Service (GSS 2013b). The sampling frame excluded nomadic and institutional populations such as persons in hotels, barracks, and prisons.
The sampling frame used for the 2014 GDHS is an updated frame from the 2010 Ghana Population and Housing Census provided by the Ghana Statistical Service (GSS 2013b). The sampling frame excluded nomadic and institutional populations such as persons in hotels, barracks, and prisons.