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Testimonies from Kigali, Lessons for Ghana

BY: Godfred Bonnah Nkansah

Between the 9th-15th of November 2018, my organization, Marie Stopes Ghana supported me to participate in the 5th International Conference on Family Planning (ICFP) in Rwanda. 

As was my first ICFP, I made it a point to listen keenly and take copious notes of key concepts and good practices I could learn from and replicate in our Ghana Country Programme to support our Family Planning interventions in the private and public sectors.

I thought I could share a few of these lessons below.

a) Family Planning as a Development Goal

My first observation was the fact that, as a country we had not positioned a fundamental need and right like FP in the appropriate context. Because of that we have for years not given FP the recognition and support it needs. Here in Ghana, we have positioned FP as a health issue.

But you see, FP goes beyond health; it is a fundamental development issue. In the opening preamble of our 1994 National Population Policy, the country’s population is described as the instrument and objective of development.

The Policy identifies population management, especially through fertility management as a major strategy to improving the quality of our human capital.

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FP is positioned as a fundamental development need in the policy, but the practice thereof has been very different. From our leadership as a country to the ordinary citizen in my hometown, FP is seen as a women’s issue; it is one of those services a woman receives when she goes to the health facility; it is a medicalized service, and in many ways an over-medicalised one, and that to me is where the problem is. So what is the way forward? We need to situate FP as a development goal.

I am yet to come across a single evidence of a country which has developed over the past 70years which did not prioritize fertility management through family planning as part of its development goals. The reason for development is the people; they are also the instruments for development.

At any point in time, you must have a strategy to ensure that the numbers you have are by choice, not chance. You should be able to determine how many people you want and can adequately provide for.

This decision is taken in leadership, and heavily promoted in the home, where all the beautiful policies receive interpretation in the bedroom. The first point of consideration in development planning should therefore be the people; the number of people we are planning for.

It is following this determination that we can begin to make plans for quality health, education, jobs, infrastructure and security for these same people. As a regular conference convener, the first question my team and I have always asked at the start of every project has been ‘how many people are we expecting?’.

That informs all other decisions – the budget, the venue, feeding, sanitation, security etc. Meanwhile, it seems that is the last question we always ask as a people. We are so eager to implement social policies such as free education and healthcare without pausing to ask how many people can be supported by such interventions in the most sustainable manner over the long term.

This is our bane; the most important question has become the least considered in our development discourse.

Quite recently, the Executive Director of the National Population Council, Dr. Leticia Adelaide Appiah granted an interview on the overpopulation crises of Nigeria and made some very staggering revelations I think are worth re-iterating here as lessons for Ghana. Dr. Appiah shared that by 1960, Nigeria had a population of 45.1million whilst the United Kingdom had a population of 52.2million. By 2017, however, Nigeria’s population had increased to 191million, whilst that of the UK, was 66.2million.

Thus although the UK was more populated than Nigeria at her independence from the UK, Nigeria today has three times the population of the UK.

The impact of population growth on the two countries are clear for all to see. Whereas the UK is well able to provide all the essential social services and welfare packages for its citizens, and also takes care of millions of immigrants, Nigeria is struggling to supply the most basic social services for its people.

Dr. Appiah shared further that some economists have posited that, at one percent population growth rate, there must be a corresponding 6.5 -7% growth in GDP in order to maintain the same quality of life for the citizenry. At our current 2.2-2.5% annual population growth rate, we can all estimate the level of annual GDP growth rate we need to even maintain the current quality of life for our people.

Meanwhile, FP can easily help us avoid this undue stress on ourselves and our development agenda as a people, by helping to prevent unintended pregnancies, and ensuring that every birth is wanted. It is open secret that nearly 45 per cent of all pregnancies in a given year here in Ghana are unintended: the women did not want the children. If FP is not such an important development issue, then I do not know what else is.

b) Ghana is Lagging Behind in Family Planning

My second observation from the ICFP was the fact that Ghana is seriously lagging behind in improving the use of Modern Contraception. Our rate of utilization of FP services is low. With our current modern Contraceptive Prevalence Rate (mCPR) at 25% as reported in our 2017 Maternal Health Survey, Ghana has only improved by 3% since 2014.

We therefore improve by one percent (1%) every year from 2014 when we reported 22% mCPR. Mathematically then, we will need another 25years to reach mCPR of 50%. But can we wait for that long? I think the answer is a big no! We need to quadruple efforts at promoting voluntary contraception among our sexually active adolescents and young people, and government must show stronger commitment to FP than we are seeing now.

At the Conference, I got to know that in 13years, Rwanda had improved its mCPR from 10% in 2005 to 50% in 2018. By 2024, they aim to be at 60% mCPR. They have grown in their FP usage by 3% every year. Then came the story of Burkina Faso: by 2014, Burkina’s mCPR was 20%, two percentage points behind Ghana. Only three years afterwards, Burkina has chalked a 30% mCPR, growing at 3% per annum, whilst Ghana grows at 1% per annum.

As I listened to the Prime Minister of Rwanda, and the Minister of Health of Burkina Faso on what had accounted for their quantum leaps into success, I understood why Ghana had been such a slow player. Both Governments have committed to investing heavily in health, especially FP and have also positioned FP as a major development goal.

They really want to bring down fertility rates amongst their women, and ensure that they have family sizes they can adequately cater for, whilst also protecting the lives of their women.

The story is, however, not so for Ghana. We have not and are not investing enough in this important service. Ghana is economically more endowed than these two countries we are talking about here, yet they have found it needful to commit very significant proportions of their resources to improving the health of their people, by among others, increasing their access to choice as far as their reproductive health is concerned. But for us, the least said, the better. A bigger chunk of budget for FP commodities is still funded by donors such as UNFPA and USAID. Our FP programmes are almost totally donor funded.

c) Ghana is Behind in Investment in Health and Family Planning

My third observation was also the fact that, Ghana is very much behind in terms of investment in health. I have observed with much sadness the ever decreasing budgetary allocation by successive governments to health since the Abuja Declaration of 2001, at which Ghana committed to allocating at least 15% of its annual budget to health.

Today, Rwanda commits 20% of its annual budget to health. A significant part of these resources go into the provision of sexual and reproductive health services including FP and HIV and AIDS. Burkina Faso has also been increasing its budgetary allocation to health every year since the incumbent government took office, and is very close to achieving the minimum 15% Abuja threshold.

Again a significant proportion of these resources go into sexual and reproductive health. In both countries, there is a very strong Presidential support for FP: both Presidents are key advocates for FP services. Clearly, there is an opportunity for Ghana to learn from these examples of top level support for an essential service such as FP. Since 2006, Ghana’s investment in health, as a proportion of annual national budget has been declining. I thought I should insert this simple table to help us appreciate how low we have sunk as a nation.

Percentage of annual national budget allocated to health

2006          2007           2008            2009           2010           2011       2012    
16.24%      14.57%      14.87%        14.27%        11.04%      12.46%   13.3%  

2013         2014         2015         2016       2017        2018
11.08%     9.26%       6.97%      7.78%     7.77%      7.23%

We are currently not meeting even half the Abuja commitment, and that is a huge challenge for us as a people. This has always been my argument as one trained in Practising Sustainable Development. True development starts with the people; it starts with the health of the people, because it is only when the people are healthy that they can be educated and also take advantage of economic opportunities.

And so in that order, human capital development starts with investments in firstly the health of the people, and then education, and then job creation, and then infrastructure, and then security and all the other issues. Within the health domain, child health and sexual and reproductive health must receive very great attention. Those two are among the cornerstones of a robust health system. But you see, we cannot say this for our Ghanaian situation.

We do not invest in Public Health; we invest millions to build curative health centres such as hospitals and depend on a donor to fund our preventive health interventions. This is a great paradox to me. I thought we would rather invest to prevent the sickness, than to invest to cure it, because prevention is better than cure?

The Table above is reflective of budgetary allocations to the health sector in general, a large proportion of which goes into remuneration and not capital investment and services. When I tried gathering data for investments in family planning and sexual and reproductive health in general, the findings were too depressing to share. If we really want to improve the use of modern contraception, then it is vital that government increases investment into the sector. The sexual and reproductive health needs of our adolescents and young people must be paramount in our public health intervention programming and investments.

I would not formally conclude my article because it is the first of a series I aim to share with our leadership as a country and our people. In my next episode of Testimonies from Kigali, Lessons for Ghana, I will tell you about how we have been playing with the future of our adolescent girls with our lip services on teenage pregnancies. I am an optimist, and believe in our ability to rise up as a people and solve our problems; that is the Ghanaian spirit I was introduced to as a child. We can do it if we decide to; it is just about re-aligning our priorities, and putting the right people in charge of our public health interventions at all levels.

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The writer is the Advocacy Manager and Adolescent Focal Person for Marie Stopes International Ghana, an international NGO headquartered in the UK, and with presence in 37 countries, specialised in the provision of sexual and reproductive health services.