Demographic and Health Survey Ghana2014

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Ghana

2014

Ghana 2014 Demographic and Health Survey Demographic and

Health Survey

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Ghana

Demographic and Health Survey 2014

Ghana Statistical Service Accra, Ghana

Ghana Health Service Accra, Ghana

The DHS Program ICF International Rockville, Maryland, USA

October 2015

International Labour Organization

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This report summarises the findings of the 2014 Ghana Demographic and Health Survey (2014 GDHS), implemented by the Ghana Statistical Service (GSS), the Ghana Health Service (GHS), and the National Public Health Reference Laboratory (NPHRL) of the GHS. Financial support for the survey was provided by the United States Agency for International Development (USAID), the Global Fund to fight AIDS, Tuberculosis, and Malaria 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.

Additional information about the 2014 GDHS may be obtained from the Ghana Statistical Service, Head Office, P.O. Box GP 1098, Accra, Ghana; Telephone: 233-302-682-661/233-302-663-578; Fax: 233-302-664-301;

E-mail: info@statsghana.gov.gh.

Information about The DHS Program may be obtained from ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; Telephone: +1-301-407-6500; Fax: +1-301-407-6501; E-mail:

info@DHSprogram.com; Internet: www.DHSprogram.com.

Suggested citation:

Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International. 2015. Ghana Demographic and Health Survey 2014. Rockville, Maryland, USA: GSS, GHS, and ICF International.

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Contents • iii

TABLES AND FIGURES

1 INTRODUCTION ... 1

Table 1.1 Basic demographic indicators ... 3

Table 1.2 Results of the household and individual interviews ... 10

2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION ... 11

Table 2.1 Household drinking water ... 13

Table 2.2 Household sanitation facilities ... 14

Table 2.3 Household characteristics ... 15

Table 2.4 Household possessions ... 17

Table 2.5 Wealth quintiles ... 18

Table 2.6 Hand washing ... 19

Table 2.7 Household population by age, sex, and residence ... 20

Table 2.8 Household composition ... 21

Table 2.9 Birth registration of children under age 5 ... 22

Table 2.10 Children’s living arrangements and orphanhood ... 23

Table 2.11 School attendance by survivorship of parents ... 25

Table 2.12.1 Educational attainment of the female household population ... 26

Table 2.12.2 Educational attainment of the male household population ... 27

Table 2.13 School attendance ratios ... 29

Figure 2.1 Population pyramid ... 20

Figure 2.2 Children under age 18 living away from home: Place or person with whom they currently live ... 24

Figure 2.3 Age-specific attendance rates of the de-facto population 5 to 24 years ... 30

3 CHARACTERISTICS OF RESPONDENTS ... 31

Table 3.1 Background characteristics of respondents ... 32

Table 3.2.1 Educational attainment: Women ... 34

Table 3.2.2 Educational attainment: Men ... 35

Table 3.3.1 School attendance: Women 15-24 ... 36

Table 3.3.2 School attendance: Men 15-24 ... 37

Table 3.4.1 Literacy: Women ... 38

Table 3.4.2 Literacy: Men ... 39

Table 3.5.1 Exposure to mass media: Women ... 40

Table 3.5.2 Exposure to mass media: Men ... 41

Table 3.6.1 Employment status: Women ... 43

Table 3.6.2 Employment status: Men ... 44

Table 3.7.1 Occupation: Women ... 45

Table 3.7.2 Occupation: Men ... 46

Table 3.8 Type of employment: Women ... 47

Figure 3.1 Women’s employment status in the past 12 months ... 42

4 MARRIAGE AND SEXUAL ACTIVITY ... 49

Table 4.1 Current marital status ... 50

Table 4.2.1 Number of women’s co-wives ... 51

Table 4.2.2 Number of men’s wives ... 52

Table 4.3 Age at first marriage ... 53

Table 4.4 Median age at first marriage by background characteristics ... 54

Table 4.5 Age at first sexual intercourse ... 55

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Table 4.6 Median age at first sexual intercourse by background characteristics ... 56

Table 4.7.1 Recent sexual activity: Women ... 57

Table 4.7.2 Recent sexual activity: Men ... 58

5 FERTILITY ... 59

Table 5.1 Current fertility ... 60

Table 5.2 Fertility by background characteristics... 62

Table 5.3.1 Trends in age-specific fertility rates ... 63

Table 5.3.2 Trends in age-specific and total fertility rates ... 63

Table 5.4 Children ever born and living ... 64

Table 5.5 Birth intervals ... 66

Table 5.6 Postpartum amenorrhoea, abstinence, and insusceptibility ... 67

Table 5.7 Median duration of amenorrhoea, postpartum abstinence, and postpartum insusceptibility ... 68

Table 5.8 Menopause ... 68

Table 5.9 Age at first birth ... 69

Table 5.10 Median age at first birth ... 69

Table 5.11 Teenage pregnancy and motherhood ... 70

Figure 5.1 Total fertility rates, selected Sub-Saharan African countries ... 61

Figure 5.2 Trends in age-specific fertility rates ... 63

6 FERTILITY PREFERENCES ... 71

Table 6.1 Fertility preferences by number of living children ... 72

Table 6.2.1 Desire to limit childbearing: Women ... 73

Table 6.2.2 Desire to limit childbearing: Men ... 74

Table 6.3 Ideal number of children by number of living children ... 75

Table 6.4 Mean ideal number of children ... 76

Table 6.5 Fertility planning status ... 77

Table 6.6 Wanted fertility rates ... 78

7 FAMILY PLANNING ... 79

Table 7.1 Knowledge of contraceptive methods ... 80

Table 7.2 Knowledge of contraceptive methods by background characteristics ... 81

Table 7.3 Current use of contraception by age ... 83

Table 7.4.1 Current use of contraception by background characteristics ... 85

Table 7.4.2 Trends in the current use of contraception ... 86

Table 7.5 Source of modern contraception methods ... 88

Table 7.6 Informed choice ... 89

Table 7.7 Twelve-month contraceptive discontinuation rates ... 90

Table 7.8 Reasons for discontinuation ... 90

Table 7.9 Knowledge of fertile period ... 91

Table 7.10 Need and demand for family planning among currently married women ... 92

Table 7.11 Future use of contraception ... 94

Table 7.12 Exposure to family planning messages ... 95

Table 7.13 Contact of nonusers with family planning providers ... 96

Figure 7.1 Trends in current use of contraceptive methods, Ghana 1988-2014 ... 87

Figure 7.2 Trends in unmet need and percentage of demand satisfied with modern methods, Ghana 1993-2014 ... 93

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Tables and Figures • xi

8 INFANT AND CHILD MORTALITY ... 99

Table 8.1 Early childhood mortality rates ... 102

Table 8.2 Early childhood mortality rates by socioeconomic characteristics ... 104

Table 8.3 Early childhood mortality rates by demographic characteristics ... 105

Table 8.4 Perinatal mortality ... 106

Table 8.5 High-risk fertility behaviour ... 107

Figure 8.1 Mortality trends, Ghana 1988-2014 ... 103

9 MATERNAL HEALTH ... 109

Table 9.1 Antenatal care ... 110

Table 9.2 Number of antenatal care visits and timing of first visit... 111

Table 9.3 Components of antenatal care ... 112

Table 9.4 Tetanus toxoid injections ... 113

Table 9.5 Place of delivery ... 115

Table 9.6 Assistance during delivery ... 116

Table 9.7 Timing of first postnatal checkup for the mother ... 119

Table 9.8 Type of provider of first postnatal checkup for the mother ... 120

Table 9.9 Timing of first postnatal checkup for the newborn ... 121

Table 9.10 Type of provider of first postnatal checkup for the newborn ... 122

Table 9.11 Problems in accessing health care ... 123

Figure 9.1 Mother’s duration of stay in the health facility after giving birth ... 117

Figure 9.2 Trends in maternal health care, 1988-2014 ... 118

10 CHILD HEALTH AND EARLY DEVELOPMENT ... 125

Table 10.1 Child’s size and weight at birth ... 127

Table 10.2.1 Vaccinations by source of information: Children age 12-23 months ... 129

Table 10.2.2 Vaccinations by source of information: Children 24-35 months ... 129

Table 10.3.1 Vaccinations by background characteristics: Children 12-23 months ... 130

Table 10.3.2 Vaccinations by background characteristics: Children 24-35 months ... 131

Table 10.4 Vaccinations in first year of life ... 132

Table 10.5 Prevalence and treatment of symptoms of ARI ... 134

Table 10.6 Prevalence and treatment of fever ... 136

Table 10.7 Prevalence of diarrhoea ... 137

Table 10.8 Diarrhoea treatment ... 139

Table 10.9 Feeding practices during diarrhoea ... 141

Table 10.10 Knowledge of ORS packets ... 142

Table 10.11 Disposal of children’s stools ... 143

Table 10.12 Activities that promote learning ... 145

Table 10.13 Reading and book ownership ... 147

Table 10.14 Textbooks and reading materials ... 148

Table 10.15 Language for education ... 149

Table 10.16 Travel to school ... 151

Figure 10.1 Trends in basic vaccination coverage among children 12-23 months, Ghana 1988-2014 ... 133

11 NUTRITION OF CHILDREN AND WOMEN ... 153

Table 11.1 Nutritional status of children ... 156

Table 11.2 Initial breastfeeding ... 159

Table 11.3 Breastfeeding status by age ... 161

Table 11.4 Median duration of breastfeeding ... 163

Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview ... 164

Table 11.6 Infant and young child feeding (IYCF) practices ... 166

Table 11.7 Prevalence of anaemia in children ... 168

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Table 11.8 Micronutrient intake among children ... 171

Table 11.9 Presence of iodised salt in household ... 172

Table 11.10.1 Nutritional status of women ... 174

Table 11.10.2 Nutritional status of men ... 176

Table 11.11 Prevalence of anaemia in women ... 177

Table 11.12 Micronutrient intake among mothers ... 180

Figure 11.1 Nutritional status of children by age ... 157

Figure 11.2 Trends in nutritional status of children under age 5, Ghana 2003-2014 ... 158

Figure 11.3 Infant feeding practices by age ... 161

Figure 11.4 IYCF indicators on breastfeeding status ... 162

Figure 11.5 IYCF indicators on minimum acceptable diet ... 167

Figure 11.6 Trends in anaemia status among children age 6-59 months, Ghana 2003 2014 ... 169

Figure 11.7 Trends in nutritional status among women age 15-49, Ghana 2003-2014 ... 175

Figure 11.8 Trends in anaemia status among women age 15-49, Ghana 2003-2014 ... 178

12 MALARIA ... 181

Table 12.1 Household possession of mosquito nets ... 183

Table 12.2 Access to an insecticide-treated net (ITN) ... 184

Table 12.3 Use of mosquito nets by persons in the household ... 186

Table 12.4 Use of existing ITNs ... 187

Table 12.5 Use of mosquito nets by children ... 189

Table 12.6 Use of mosquito nets by pregnant women ... 190

Table 12.7 Source and cost of nets ... 192

Table 12.8 Household disposal of mosquito nets ... 193

Table 12.9 Mosquito net disposal ... 193

Table 12.10 Indoor residual spraying against mosquitoes ... 195

Table 12.11 Use of intermittent preventive treatment (IPTp) by women during pregnancy ... 196

Table 12.12 Prevalence, diagnosis, and prompt treatment of children with fever ... 198

Table 12.13 Source of advice or treatment for children with fever ... 199

Table 12.14 Haemoglobin <8.0 g/dl in children ... 200

Table 12.15 Prevalence of malaria in children ... 201

Table 12.16 Exposure to messages on malaria by media source ... 202

Table 12.17 Exposure to specific messages on malaria ... 203

Figure 12.1 Percentage of the de facto population with access to an ITN in the household ... 185

Figure 12.2 Ownership of, access to, and use of ITNs ... 187

Figure 12.3 Trends in ITN use ... 191

13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR ... 205

Table 13.1 Knowledge of AIDS ... 207

Table 13.2 Knowledge of HIV prevention methods ... 209

Table 13.3.1 Comprehensive knowledge about AIDS: Women ... 211

Table 13.3.2 Comprehensive knowledge about AIDS: Men ... 212

Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV... 213

Table 13.5.1 Accepting attitudes towards those living with HIV/AIDS: Women ... 215

Table 13.5.2 Accepting attitudes towards those living with HIV/AIDS: Men ... 216

Table 13.6 Attitudes towards negotiating safer sexual relations with husband ... 217

Table 13.7 Adult support of education about condom use to prevent AIDS ... 218

Table 13.8.1 Multiple sexual partners: Women ... 220

Table 13.8.2 Multiple sexual partners: Men ... 221

Table 13.9 Point prevalence and cumulative prevalence of concurrent sexual partners ... 222

Table 13.10 Payment for sexual intercourse and condom use at last paid sexual intercourse ... 223

Table 13.11.1 Coverage of prior HIV testing: Women ... 225

Table 13.11.2 Coverage of prior HIV testing: Men ... 226

Table 13.12 Pregnant women counselled and tested for HIV ... 227

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Tables and Figures • xiii

Table 13.13 Male circumcision ... 228

Table 13.14 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms ... 229

Table 13.15 Prevalence of medical injections ... 231

Table 13.16 Comprehensive knowledge about AIDS and of a source of condoms among youth ... 233

Table 13.17 Age at first sexual intercourse among young people ... 234

Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth ... 236

Table 13.19.1 Multiple sexual partners in the past 12 months among young people: Women ... 237

Table 13.19.2 Multiple sexual partners in the past 12 months among young people: Men... 237

Table 13.20 Age-mixing in sexual relationships among women age 15-19 ... 238

Table 13.21 Recent HIV tests among young people ... 239

Figure 13.1 Women and men seeking treatment for STIs ... 230

Figure 13.2 Trends in age of first sexual intercourse ... 235

14 HIV PREVALENCE ... 241

Table 14.1 Coverage of HIV testing by residence and region ... 243

Table 14.2 Coverage of HIV testing by selected background characteristics ... 244

Table 14.3 HIV prevalence by age ... 245

Table 14.4 HIV prevalence by socio-economic characteristics ... 247

Table 14.5 HIV prevalence by demographic characteristics ... 248

Table 14.6 HIV prevalence by sexual behaviour ... 250

Table 14.7 HIV prevalence among young people by background characteristics ... 252

Table 14.8 HIV prevalence among young people by sexual behaviour ... 253

Table 14.9 HIV prevalence by other characteristics ... 253

Table 14.10 Prior HIV testing according to current HIV status ... 254

Table 14.11 HIV prevalence among couples... 255

Figure 14.1 HIV prevalence among all adults age 15-49 by sex, Ghana 2003 and 2014 ... 246

15 ADULT HEALTH AND LIFESTYLE ... 257

Table 15.1 History of hypertension ... 259

Table 15.2 History of hypertension and actions taken to lower blood pressure ... 260

Table 15.3 Coverage of blood pressure measurement among women and men ... 260

Table 15.4.1 Blood pressure status: Women ... 262

Table 15.4.2 Blood pressure status: Men ... 263

Table 15.5 Consumption of fruit and vegetables ... 265

Table 15.6 Household use of salty foods ... 266

Table 15.7 Knowledge of iodised salt and perceived benefits of using iodised salt ... 267

Table 15.8 Knowledge and attitude concerning tuberculosis ... 269

Table 15.9.1 Use of tobacco: Women ... 271

Table 15.9.2 Use of tobacco: Men ... 272

Table 15.10.1 Health insurance coverage: Women ... 273

Table 15.10.2 Health insurance coverage: Men ... 274

Table 15.11 Registration with N/DHIS ... 275

Table 15.12.1 Payment for N/DHIS coverage: Women ... 276

Table 15.12.2 Payment for N/DHIS coverage: Men ... 277

Table 15.13 Possession of a valid N/DHIS card ... 278

Table 15.14 Out-of-pocket payment for medicines and services by respondents covered by N/DHIS ... 279

Table 15.15 Need for health services not covered by N/DHIS ... 280

Table 15.16 N/DHIS card holders’ perceived quality of services received ... 281

Table 15.17 Client satisfaction among respondents covered by N/DHIS ... 283

Table 15.18 Treatment seeking behaviour among all respondents ... 284

Table 15.19 Type of health services received among all respondents ... 285

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Table 15.20 Awareness of health services for children and pregnant women ... 286

Table 15.21 Satisfaction with health services among all respondents ... 287

Figure 15.1 Awareness of high blood pressure and treatment status among women and men age 15-49 with high blood pressure ... 264

16 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES ... 289

Table 16.1 Employment and cash earnings of currently married women and men ... 290

Table 16.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings ... 292

Table 16.2.2 Control over men’s cash earnings ... 294

Table 16.3 Women’s control over their own earnings and over those of their husbands ... 295

Table 16.4.1 Ownership of assets: Women ... 296

Table 16.4.2 Ownership of assets: Men ... 297

Table 16.5 Participation in decision making ... 298

Table 16.6.1 Women’s participation in decision making by background characteristics ... 298

Table 16.6.2 Men’s participation in decision making by background characteristics ... 300

Table 16.7.1 Attitude towards wife beating: Women ... 301

Table 16.7.2 Attitude towards wife beating: Men ... 302

Table 16.8 Indicators of women’s empowerment ... 303

Table 16.9 Current use of contraception by women’s empowerment ... 304

Table 16.10 Ideal number of children and unmet need for family planning by women’s empowerment ... 305

Table 16.11 Reproductive health care by women’s empowerment ... 306

Table 16.12 Early childhood mortality rates by women’s status ... 307

Table 16.13 Entitlement to maternity leave ... 308

Table 16.14 Maternity leave ... 309

Table 16.15 Median number of weeks women do not work before and after birth ... 310

Table 16.16 Bridewealth negotiation ... 311

Figure 16.1 Number of decisions in which currently married women participate ... 299

APPENDIX A SAMPLE DESIGN ... 317

Table A.1 Households ... 318

Table A.2 Enumeration areas and enumeration area size ... 318

Table A.3 Sample allocation of clusters and households ... 319

Table A.4 Sample allocation of completed interviews with women and men... 319

Table A.5 Sample implementation: Women ... 321

Table A.6 Sample implementation: Men ... 322

Table A.7 Coverage of HIV testing by social and demographic characteristics: Women ... 323

Table A.8 Coverage of HIV testing by social and demographic characteristics: Men ... 324

Table A.9 Coverage of HIV testing by sexual behaviour characteristics: Women ... 325

Table A.10 Coverage of HIV testing by sexual behaviour characteristics: Men ... 326

APPENDIX B ESTIMATES OF SAMPLING ERRORS ... 327

Table B.1 List of variables for sampling errors, Ghana DHS 2014 ... 329

Table B.2 Sampling errors for the national sample, Ghana 2014 ... 330

Table B.3 Sampling errors for the urban sample, Ghana 2014 ... 331

Table B.4 Sampling errors for the rural sample, Ghana 2014 ... 332

Table B.5 Sampling errors for the Western region sample, Ghana 2014 ... 333

Table B.6 Sampling errors for the Central region sample, Ghana 2014 ... 334

Table B.7 Sampling errors for the Greater Accra region sample, Ghana 2014 ... 335

Table B.8 Sampling errors for the Volta region sample, Ghana 2014 ... 336

Table B.9 Sampling errors for the Eastern region sample, Ghana 2014 ... 337

Table B.10 Sampling errors for the Ashanti region sample, Ghana 2014 ... 338

Table B.11 Sampling errors for the Brong Ahafo region sample, Ghana 2014 ... 339

Table B.12 Sampling errors for the Northern region sample, Ghana 2014 ... 340

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Tables and Figures • xv

Table B.13 Sampling errors for the Upper East region sample, Ghana 2014 ... 341

Table B.14 Sampling errors for the Upper West region sample, Ghana 2014 ... 342

APPENDIX C DATA QUALITY TABLES ... 343

Table C.1 Household age distribution ... 343

Table C.2.1 Age distribution of eligible and interviewed women ... 344

Table C.2.2 Age distribution of eligible and interviewed men ... 344

Table C.3 Completeness of reporting ... 345

Table C.4 Births by calendar years ... 345

Table C.5 Reporting of age at death in days ... 346

Table C.6 Reporting of age at death in months ... 346

Table C.7 Nutritional status of children based on the NCHS/CDC/WHO International Reference Population ... 347

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Foreword • xvii

FOREWORD

his report presents findings from the 2014 Ghana Demographic and Health Survey (GDHS), a nationally representative survey of 9,396 women age 15-49 and 4,388 men age 15-59 from 11,835 interviewed households. The primary purpose of the GDHS was to generate recent and reliable information on fertility, family planning, infant and child mortality, maternal and child health, and nutrition. In addition, the survey collected information 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.

The 2014 GDHS is the sixth in a series of population and health surveys conducted in Ghana as part of the global Demographic and Health Surveys (DHS) Program. 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. 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.

Dr. Philomena Efua Nyarko

Government Statistician Ghana Statistical Service

T

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Acronyms • xix

ACRONYMS

ACT artemisinin-based combination therapy AIDS acquired immunodeficiency syndrome

ANC antenatal care

ARI acute respiratory infection ASFR age-specific fertility rate

BCG Bacille Calmette-Guerin

BMI body mass index

BOG Bank of Ghana

CAFE computer assisted field editing CBR crude birth rate

CDC Centers for Disease Control and Prevention CDD Control of Diarrhoeal Diseases

CEDAW Convention on the Elimination of All Forms of Discrimination against Women CHPS community-based health planning and services

CSPro Census and Survey Processing System CPR contraceptive prevalence rate DANIDA Danish International Development Agency DBS dried blood spot

DFID Department for International Development DOTS directly observed treatment, short-course

EA enumeration area

ELISA enzyme-linked immunosorbent assay EQA external quality assurance

GAR gross attendance ratio

GAC Ghana AIDS Commission

GDHS Ghana Demographic and Health Survey GDP gross domestic product

GETFUND Ghana Education Trust Fund GFR general fertility rate

GHS Ghana Health Service

GPI gender party index

GPS Global Positioning System GSS Ghana Statistical Office HCT HIV counselling and testing

HepB hepatitis B

HIV human immunodeficiency virus

IFSS Internet File Streaming System

ILO International Labour Organization IMCI integrated management of childhood illnesses IPTp intermittent preventive treatment

IRS indoor residual spraying

ITN insecticide-treated net

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IUD intrauterine device IYCF Infant and Young Child Feeding LAM lactational amenorrhoea method LEAP livelihood empowerment against poverty LPG liquid petroleum gas

LLIN long-lasting insecticidal net MDG Millenium Development Goal MoH Ministry of Health

MWRWH Ministry of Water Resource Works and Housing NACP National AIDS/STI Control Programme

NAR net attendance ratio

NDPC National Development Planning Commission NGO nongovernmental organisation NHIS National Health Insurance Scheme NMCP National Malaria Control Programme

NMIMR Noguchi Memorial Institute for Medical Research NPHRL National Public Health and Reference Laboratory ORS oral rehydration salt

ORT oral rehydration therapy PAHO Pan American Health Organization PHC population and housing census PLHIV people living with HIV/AIDS PMI President’s Malaria Initiative

PMTCT prevention of mother-to-child transmission RDT rapid diagnostic test

RHF recommended home fluid RTI reproductive tract infection

SHS secondhand smoke

STI sexually transmitted infection TB tuberculosis TFR total fertility rate

UNDP United Nations Development Programme UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development VAD vitamin A deficiency

WASH water, sanitation and hygiene WHO World Health Organization

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Millennium Development Goal Indicators • xxi

MILLENNIUM DEVELOPMENT GOAL INDICATORS

Millennium Development Goal Indicators Ghana 2014

Sex

Total

Indicator Male Female

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 89.3^a 80.9 85.1^b

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

5.4 Adolescent birth rate⁷ na 76.3 na

5.5a Antenatal care coverage: at least one visit⁸ na 97.0 na 5.5b Antenatal care coverage: four or more visits⁹ na 87.3 na

5.6 Unmet need for family planning na 29.9 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

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Introduction • 1

INTRODUCTION 1

1.1 G

EOGRAPHY

, H

ISTORY

,

AND

E

CONOMY 1.1.1 Geography

he 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

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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

EMOGRAPHIC

P

ROFILE

Sources 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

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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

OPULATION

P

OLICY AND

R

EPRODUCTIVE

H

EALTH

P

ROGRAMMES

The 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).

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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

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Introduction • 5 agencies, including Relief International, the Adventist Development Relief Agency, and Winrock International.

1.4 O

BJECTIVES AND

O

RGANISATION OF THE

S

URVEY

The 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

AMPLE

D

ESIGN

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.

The 2014 GDHS followed a two-stage sample design and was intended to allow estimates of key indicators at the national level as well as for urban and rural areas and each of Ghana’s 10 administrative regions. The first stage involved selecting sample points (clusters) consisting of enumeration areas (EAs)

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delineated for the 2010 PHC. A total of 427 clusters were selected, 216 in urban areas and 211 in rural areas.

The second stage involved the systematic sampling of households. A household listing operation was undertaken in all the selected EAs in January-March 2014, and households to be included in the survey were randomly selected from the list. About 30 households were selected from each cluster to constitute the total sample size of 12,831 households. Because of the approximately equal sample sizes in each region, the sample is not self-weighting at the national level, and weighting factors have been added to the data file so that the results will be proportional at the national level.

All women age 15-49 who were either permanent residents of the selected households or visitors who stayed in the household the night before the survey were eligible to be interviewed and have their blood pressure measured.

In half of the households, all men age 15-59 who were either permanent residents of the selected households or visitors who stayed in the households the night before the survey were eligible to be interviewed. In addition, in the subsample of households selected for the male survey:

• blood pressure measurements were performed among eligible men who consented to being tested;

• children age 6-59 months were tested for anaemia and malaria with the parent’s or guardian’s consent;

• eligible women who consented were tested for anaemia;

• blood samples were collected for laboratory testing of HIV from eligible women and men who consented; and

• height and weight information was collected from eligible women, men, and children age 0- 59 months.

1.6 Q

UESTIONNAIRES

Three questionnaires were used for the 2014 GDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. These questionnaires, which were based on standard Demographic and Health Survey (DHS) questionnaires, were adapted to reflect the population and health issues relevant to Ghana. Comments on the questionnaires were solicited from various stakeholders representing government ministries and agencies, nongovernmental organisations, and international donors. The definitive questionnaires were first prepared in English; they were then translated into the major local languages, namely Akan, Ga, and Ewe.

The Household Questionnaire was used to list all the members of and visitors to the selected households. Basic demographic information was collected on the characteristics of each person listed, including his or her age, sex, marital status, education, and relationship to the head of the household. For children under age 18, parents’ survival status was determined. The data on age and sex of household members obtained in the Household Questionnaire were used to identify women and men who were eligible for individual interviews. The Household Questionnaire also included questions on child education as well as the characteristics of the household’s dwelling unit, such as source of water, type of toilet facilities, materials used for the floor of the dwelling unit, and ownership of various durable goods.

The Woman’s Questionnaire was used to collect information from all eligible women age 15-49.

These women were asked questions on the following topics:

Demographic and Health Survey Ghana2014

Ghana

2014

Ghana 2014 Demographic and Health Survey Demographic and

Health Survey

Ghana

Demographic and Health Survey 2014

Ghana Statistical Service Accra, Ghana

Ghana Health Service Accra, Ghana

The DHS Program ICF International Rockville, Maryland, USA

CONTENTS

TABLES AND FIGURES

FOREWORD

T

ACRONYMS

MILLENNIUM DEVELOPMENT GOAL INDICATORS

INTRODUCTION 1

1.1 G

, H

,

E

T

1.2 D

P

1.3 P

P

R

H

P

1.4 O

O

S

1.5 S

D

1.6 Q