Opportunities and challenges of community-based rural drinking water supplies: An analysis of water and sanitation committees in Ghana

Providing safe drinking water in rural areas is a major challenge because it is not easy to establish institutional arrangements that will ensure that drinking water facilities are provided, maintained, and managed in an efficient, equitable, and sustainable way. Like many other countries, Ghana has adopted a community-based approach to meet this challenge. Community-based water and sanitation committees (WATSANs) are in charge of managing drinking water facilities at the local level. They are supported by water and sanitation teams of each district administration and by the Community Water and Sanitation Agency, an independent agency that has been created to facilitate the community-based approach. This paper is based on the analysis of two survey datasets of WATSANs and households in rural Ghana. The paper confirms some findings of the earlier literature on this topic. For example, communities that have a higher level of existing community groups are more likely to have functioning WATSANs, while ethnically diverse communities are less likely to have these organizations. The paper also indicates that WATSANs have a positive effect on the mobilization of payment for water services. Using empirical data on local leaders, the paper shows that leadership also matters for the provision of safe drinking water. In particular, the paper suggests that female leaders seem to be effective in this respect.Community-based resource management, Decentralization, drinking water supply, Participation, Sustainable development,

Decentralization and local public services in Ghana: Do geography and ethnic diversity matter?

"This paper explores disparities in local public service provision between decentralized districts in Ghana using district- and household-level data. The empirical results show that districts' geographic locations play a major role in shaping disparities in access to local public services in Ghana. Most importantly, the findings suggest that ethnic diversity has significant negative impact in determining access to local public services, including drinking water. This negative impact is significantly higher in rural areas. However, the negative impact of ethnic diversity in access to local public services (drinking water) decreases as average literacy level increases. The paper relates the results to literature and discusses policy implications of main findings." from authors' abstractDecentralization, Access to public services, Ethnic diversity, Geography, Development strategies,

Information flow and acquisition of knowledge in water governance in the Upper East Region of Ghana:

"This paper provides an assessment of information flows and the acquisition of knowledge in water governance of the Upper East Region, Ghana. These flows are patchy, often parallel, disconnected or slow. In many cases a great deal of information is gathered but for a number of reasons not transferred into knowledge that impacts on decision making and action. An analysis of knowledge flows can serve as guidance for research projects and capacity building endeavours to allow tackling the gap between data collection and knowledge for action." from authors' abstractWater governance, Irrigation, drinking water, information flow,

Climate change and variability in Ghana: Stocktaking

This paper provides a holistic literature review of climate change and variability in Ghana by examining the impact and projections of climate change and variability in various sectors (agricultural, health and energy) and its implication on ecology, land use, poverty and welfare. The findings suggest that there is a projected high temperature and low rainfall in the years 2020, 2050 and 2080, and desertification is estimated to be proceeding at a rate of 20,000 hectares per annum. Sea-surface temperatures will increase in Ghana’s waters and this will have drastic effects on fishery. There will be a reduction in the suitability of weather within the current cocoa-growing areas in Ghana by 2050 and an increase evapotranspiration of the cocoa trees. Furthermore, rice and rooted crops (especially cassava) production are expected to be low. Hydropower generation is also at risk and there will be an increase in the incidence rate of measles, diarrheal cases, guinea worm infestation, malaria, cholera, cerebro-spinal meningitis and other water related diseases due to the current climate projections and variability. These negative impacts of climate change and variability worsens the plight of the poor, who are mostly women and children

Stone Quarrying and Livelihood Transformation in Peri-Urban Kumasi

Stone quarrying is one of the key extractive economic activities in the Ashanti Region, supplying the bulk of stone of varying aggregates to the construction industry within the region and beyond. Yet the resource-rich communities have seen little socio-economic improvements. The paper draws on experiences from Nkukua Buoho and Ntiri Buoho in the Afigya Kwabre District of Ghana. It examines the peoples’ livelihood transformation where quarrying, both small and large-scale is a dominant economic activity. With a sample size of 110 respondents, data was collected by means of questionnaires and in-depth interviews. The paper observed that while quarrying is a major economic activity, its effects in socio-economic and environmental terms are unsatisfactory. It is the view of this paper that effective collaboration involving all the stakeholders would make the industry socio-economically beneficial to the communities and environmentally sustainable. Keywords: Stone Quarrying, Livelihood transformation, Sustainability, Peri-urban, Buoh

The linkages between agriculture and malaria: Issues for policy, research, and capacity strengthening

"Malaria afflicts many people in the developing world, and due to its direct and indirect costs it has widespread impacts on growth and development. The global impact of malaria on human health, productivity, and general well-being is profound. Human activity, including agriculture, has been recognized as one of the reasons for the increased intensity of malaria around the world, because it supports the breeding of mosquitoes that carry the malaria parasite. Malaria can cause illness (morbidity), disability, or death; and all three effects have direct and indirect costs that can affect productivity. Since agriculture is the main activity of rural people in many endemic areas, it has been suggested that effective malaria control measures can be devised if attention was paid to the two-way effects of agriculture and malaria. There is the need to compute the direct costs of malaria treatment and control and the impacts of those costs on the ability of farm households to adopt new agricultural technology and improved practices, and keep farm and household assets. It is equally important to know the indirect costs of seeking health care and taking care of children and others who are afflicted by malaria and the relationship of the indirect costs to the farm labor supply and productivity. On the other hand, many agricultural activities like irrigation projects, water-harvesting and storage, land and soil management techniques, and farm work sequencing can lead to increase in mosquito populations and therefore increase the incidence of malaria in agricultural regions. This paper has raised issues on the two-way effects of agriculture and malaria and recommended areas that require policy actions and further research. The research findings can then be used in devising effective policies for controlling malaria in endemic areas of the world and assist in preparing a tool kit for capacity development on agriculture and malaria." from authors' abstractMalaria, Agriculture, Development, technology, Impact, Research, Policy, Capacity strengthening, Innovation, Institutional change, Science and technology,

Pulled in or pushed out : understanding the complexities of motivation for alternative therapies use in Ghana

The impact of strong cultural beliefs on specific reasons for traditional medicine (TRM) use among individuals and populations has long been advanced in health care and spatio-medical literature. Yet, little has been done in Ghana and the Ashanti Region in particular to bring out the precise “pull” and “push” relative influences on TRM utilization. With a qualitative research approach involving rural and urban character, the study explored health beliefs and motivations for TRM use in Kumasi Metropolis and Sekyere South District, Ghana. The study draws on data from 36 in-depth interviews with adults, selected through theoretical sampling. We used the a posteriori inductive reduction model to derive broad themes and subthemes. The “pull factors”—perceived benefits in TRM use vis-à-vis the “push factors”—perceived poor services of the biomedical treatments contributed to the growing trends in TRM use. The result however indicates that the “pull factors,” viz.—personal health beliefs, desire to take control of one’s health, perceived efficacy, and safety of various modalities of TRM—were stronger in shaping TRM use. Poor access to conventional medicine accounted for the differences in TRM use between rural and urban areas. Understanding the treatment and health-seeking behaviour of a cultural-related group is critical for developing and sustaining traditional therapy in Ghana

Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem?

BACKGROUND: Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources. METHODS: The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified. RESULTS: Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS. CONCLUSION: Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage

Does the National Health Insurance Scheme provide financial protection to households in Ghana?

BACKGROUND: Excessive healthcare payments can impede access to health services and also disrupt the welfare of households with no financial protection. Health insurance is expected to offer financial protection against health shocks. Ghana began the implementation of its National Health Insurance Scheme (NHIS) in 2004. The NHIS is aimed at removing the financial barrier to healthcare by limiting direct out-of-pocket health expenditures (OOPHE). The study examines the effect of the NHIS on OOPHE and how it protects households against catastrophic health expenditures. METHODS: Data was obtained from a cross-sectional representative household survey involving 2,430 households from three districts across Ghana. All OOPHE associated with treatment seeking for reported illness in the household in the last 4 weeks preceding the survey were analysed and compared between insured and uninsured persons. The incidence and intensity of catastrophic health expenditures (CHE) among households were measured by the catastrophic health payment method. The relative effect of NHIS on the incidence of CHE in the household was estimated by multiple logistic regression analysis. RESULTS: About 36% of households reported at least one illness during the 4 weeks period. Insured patients had significantly lower direct OOPHE for out-patient and in-patient care compared to the uninsured. On financial protection, the incidence of CHE was lower among insured households (2.9%) compared to the partially insured (3.7%) and the uninsured (4.0%) at the 40% threshold. The incidence of CHE was however significantly lower among fully insured households (6.0%) which sought healthcare from NHIS accredited health facilities compared to the partially insured (10.1%) and the uninsured households (23.2%). The likelihood of a household incurring CHE was 4.2 times less likely for fully insured and 2.9 times less likely for partially insured households relative to being uninsured. The NHIS has however not completely eliminated OOPHE for the insured and their households. CONCLUSION: The NHIS has significant effect in reducing OOPHE and offers financial protection against CHE for insured individuals and their households though they still made some out-of-pocket payments. Efforts should aim at eliminating OOPHE for the insured if the objective for establishing the NHIS is to be achieved

A narrative synthesis of illustrative evidence on effects of capitation payment for primary care: lessons for Ghana and other low/middle-income countries

Objective: To analyse and synthesize available international experiences and information on the motivation for, and effects of using capitation as provider payment method in country health systems and lessons and implications for low/middle-income countries.Methods: We did narrative review and synthesis of the literature on the effects of capitation payment on primary care.Results: Eleven articles were reviewed. Capitation payment encourages efficiency: drives down cost, serves as critical source of income for providers, promotes adherence to guidelines and policies, encourages providers to work better and give health education to patients. It, however, induces reduction in the quantity and quality of care providedand encourages skimming on inputs, underserving of patients in bad state of health, “dumping” of high risk patients and negatively affect patient-provider relationship.Conclusion: The illustrative evidence adduced from the review demonstrates that capitation payment in primary care can create positive incentives but could also elicit un-intended effects. However, due to differences in country context, policy makers in Ghana and other low/middle-income countries may only be guided by the illustrative evidencein their design of a context-specific capitation payment for primary care.Funding: Netherlands Fellowship Programme (NFP), Fellowship number: NFP-PhD.12/352Keywords: Capitation payment, primary care, cost-containment, national health insurance, Ghan