83 * PSPDiscussion Paper Series Public Disclosure Authorized

19705 November 1995

Poverty Assessment in Ghana Using Qualitative and Participatory Research Public Disclosure Authorized Methods

Andy Norton Ellen Bortei-Doku Aryeetey Public Disclosure Authorized David Korboe D.K. Tony Dogbe

November 1995

Public Disclosure Authorized Poverty and Social Policy Department Human Capital Development and Operations Policy The World Bank Abstracts

This Booklet of Abstracts contains short summaries of recent PSP Discussion Papers; copies of specific papers may be requested from Patricia G. Sanchez via All-in-One. The views expressed in the papers are those of the authors and do not necessarily represent the official policy of the Bank. Rather, the papers reflect work in progress. They are intended to make lessons emerging from the current work program available to operational staff quickly and easily, as well as to stimulate discussion and comment. They also serve as the building blocks for subsequent policy and best practice papers. Preface

This paper is one of a series undertakenas part of the ExtendedPoverty Study in Ghana. A synthesisof this work is available in Ghana: Poverty Past, Present and Future (Report No. 140504-GH.Population and HumanResources Division, West CentralAfrica Department, World Bank, WashingtonD.C., June 29, 1995). Four of the backgroundpapers are appearing in the Povertyand Social PolicyDiscussion Paper Series:

Harold Coulombeand Andrew McKay, 'An Assessmentof Trends in Poverty in Ghana, 1988-92.' Poverty and Social Policy DiscussionPaper No. 81, World Bank, WashingtonD.C. (November1995)

Lionel Demery, Shiyan Chao, Rene Bernierand Kalpana Mehra, 'The Incidenceof Social Spendingin Ghana.' Povertyand Social PolicyDiscussion Paper No. 82, World Bank,Washington D.C. (November1995)

Andy Norton, David Korboe, Ellen Bortei-Dorkuand D.K. Tony Dogbe, 'Poverty Assessmentin Ghana using Qualitativeand ParticipatoryResearch Methods.' Poverty and Social Policy DiscussionPaper No. 83, World Bank, Washington D.C. (November1995)

ChristineJones and Ye Xiao, 'Accountingfor the Reductionin Rural Poverty in Ghana, 1988-1992.'Poverty and Social PolicyDiscussion Paper No. 84, World Bank, WashingtonD.C. (November1995)

The papers draw upon the work of many. The contributionsof the Ghana Statistical Service, Ministryof Health, and Ministryof Educationin the Governmentof Ghana, and of UNICEFand the CanadianIntemational Development Agency (CIDA), are gratefullyacknowledged. The views expressedare those of the authors. They shouldnot be attributedto the World Bank, its Board of Directors,its managementor any of its membercountries.

Acknowledgments

This overview report has been compiledby Andrew Norton, drawing heavily on inputs from the other authors. Fieldwork for this study has been carried out over three phases, with inputs of support from ODA (field costs phase I & 2) GTZ (support to costs of training, phase 1) and UNICEF (support to phase 3).

Acknowledgments are due to: the field teams (members listed below) for their enthusiasmand commitment;the two Task Managers who have been involved in the Extended Poverty Study for the World Bank, Lionel Demery and Tom Stephens, for their firm support; the administrativeand logistical staff of CEDEP (the NGO who coordinatedthe study) for their efficiency and hard work; and above all the membersof poor rural and urban communitieswho gave their time to share their analysesof poverty with us.

Team members:

Phase 1.

ResearchSupervisor - Dr. AndrewNorton Lead Researcher-Dr. Ellen Bortei-DokuAryeetey TeamLeaders - Dr. Felix Fiadjoe - Mr.Dan Inkoom - M. Wim Alberts Members - Mrs.MargaretDoku - Ms. MargaretAssan - Ms. JudithThompson - Mr.Samuel Dodoo - Mr.Martin Dery - Mr.Dominic B. Kanyoke - Mr. ThomasKuby - Mr. D.K. (Tony)Dogbe - Mr. Ben Arthur AdministrativeOfficer Mrs. SalomeAhenkora ResearchManager - Mr. D.K. (Tony)Dogbe Phase 2 Research Supervisor - Dr. Andrew Norton Lead Researcher - Dr. Ellen Bortei-Doku Aryeetey Team Leaders - Mr. Wim Alberts - Mr. D.K. (Tony) Dogbe Members - Dr. Felix Fiadjoe - Rev. Fr. Anyomi - Mr. Robert Kuwornu - Mr. Robert Agarku - Mrs. Salome Ahenkora - Mr. Charles Owusu - Mr. Dan Amuah - Mr. Martin Dery - Mr. Samuel Dodoo - Mr. Dominic B. Kanyoke - Mr. Paa Kwesi Afari Administrative Officer Ms. Celia Marshall Research Manager - Mr. D.K. (Tony) Dogbe

Travelling Secretariat - - Mr. Kwaku Ahenkora - Mr. Kwame Apiagyei

Phase 3 Research Supervisors - Mr D.K. Tony Dogbe - Dr Andrew Norton Lead Researcher - Dr David Korboe Team Leaders - Mr. Kweku Ahenkora - Mr. D.K. Tony Dogbe - Dr. David Korboe Members - Mr. Dela Afenyadu - Ms. Vida Affum - Mrs.Doris Amoyaw - Ms. Mercy Anim - Ms. Theresa Baffoe - Mr. Robert de Graft Agyarko - Mr. Samuel Duodu - Mr. Dominic Kanyoke - Mr. Kwaine Manhyia - Mr. Kojo Mbir - Mr. Kojo Mensah-Abrampa - Mr. Kwame Opoku - Ms. Dora Owusu - Ms. Petrina Owusu Yeboah Administrative Officer - Mrs Salome Ahenkora * Abstract

The Ghana Participatory Poverty Assessment was conducted over three phases in fifteen communities by mixed teams of academic researchers, government staff and personnel of NGOs. Key findings on the local experience of poverty included the following: the main elements in defining the poorest members of communities were disability, age combined with the lack of adult children, widowhood and childlessness; the incidence and depth of poverty is greatest in the rural north; assets at the community level (such as access to water for domestic and productive use, access to services and natural resources) are seen as more important to rural communities than urban; gender dimensions are critical to understanding poverty - this emerged primarily through the finding that there are substantial elements of separation to men's and women's livelihood in much of urban and rural Ghana.

The concept of vulnerability captures many dimension of the experience of deprivation in rural Ghana. Seasonal vulnerability is particularly strong in the rural north (especially the Upper Regions), manifested in chronic food insecurity often affecting whole communities. Views of long-term trends in rural communities focused on environmental issues such as declining access and quality of water, declining soil fertility and declining common property resources for the vulnerable to fall back on in times of crisis. Key long-term trends identified by the urban poor related to the evolution of policy frameworks in the era of adjustment. While a considerable improvement is seen as having occurred in the early phase of economic reform (1983 to 1988) there is a general perception that opportunities for the urban poor have been becoming more constrained in the last six to seven years.

The investigation of the conmunities' own assessment of their priority needs was a consistent theme in the research. The strongest elements emerging from the priority rankings in the rural north were food security, water (both for domestic and productive use), access to health care, and education. The picture that emerged from priority rankings in the rural south was more diverse. Again, access to curative healthcare emerged as a strong and consistent priority, while improvements in transport infrastructure (roads and bridges) was also a strong theme - reflecting problems in accessing both markets and services. Other common themes included access to credit, off-farm employment and water for domestic use. The most consistent concerns in priority rankings in urban communities were with inadequate employment opportunities and the supply of small-enterprise credit. The condition of the urban infrastructure was also a major issue - with supply of water again a strong theme.

Investigation of the barriers the poor face in accessing healthcare services highlighted the following issues: cost barriers are a major issue in accessing formal healthcare, both in terms of overall cost and the lack of flexibility in rescheduling treatments. Furthermore, provisions for exempting the poor from user charges are not working. In education, the major concern of most community members and teachers canvassed was with issues of quality rather than of basic access. Major concerns included: poor quality of teaching and facilities; lack of supervision of teachers; lack of clear feedback to parents on childrens' performance; the policy of retrenchment of untrained teachers leading to shortages of teachers in isolated rural communities.

CONTENTS

Executive Summary and Key Policy Findings

1. Introduction

1.1 Background of the Study 1.2 Methodology 1.3 Field Sites

2. Main Findings

2.1 Local Conceptions of Poverty 2.2 Priorities of the Poor in Poverty Reduction 2.2.1 Strategies for Moving out of Poverty 2.3 Vulnerability: Dynamic Dimensions of Poverty 2.3.1 Seasonal Dimensions of Poverty 2.3.2 Long-Term Trends in Poverty 2.4 Survival Strategies and 'Safety Nets' 2.4.1 Survival and Coping Strategies 2.4.2 Formal and Informal Safety Nets 2.5 Perceptions of Service Quality and Access in the Health Sector 2.6 Perceptions of Service Quality and Access in the Education Sector 2.6.1 Access and Utilization 2.6.2 Local Views of Education Quality 2.6.3 Perceived Relevance of Education 2.7 Domestic Water and Sanitation

ExecutiveSummary and Key Policy Messages

The Ghana ParticipatoryPoverty Assessmentwas conducted over three phases, and a total of fifteen communitieswere involved, selected to give a representativepicture of the living conditionsof the poor in Ghana. In particular, care was taken to represent adequatelythe rural and urban dimensionsof poverty, as well as the different regions, major livelihood groups and agro-ecological zones in the country. The overall objective of the study was to contribute to social policy formulation in Ghana through expanding understanding of the processes that produce and reproduce poverty in different environmentsand among different social groups. Special emphasiswas given in the third phase of the study to understanding the poor's experience and understandingof the constraintsthey face in terms of access and quality of delivery of key social services. The main conclusionsof the study are as follows.

T'heexperience and understanding of poven'y

The nature of poverty in Ghana. In all communities the local experience and understanding of poverty and vulnerability was examined. In broad terms our conclusionssupport those of the quantitativeanalysis of the GLSS within the Extended Poverty Study by emphasizingthat the incidenceand depth of poverty is greatest in the rural north. This emerged through both the extent to which poverty was judged to be prevalent throughout the whole of communities(even in local terms) and the criteria which were used to define that poverty. In the rural north the predominant feature of poverty was a general crisis of livelihoods in terms of the lack of remotely adequate basic foodstuffs to feed the household for all or part of the year. A summary of the local conceptionsof poverty and vulnerabilityleads to the followingkey messages:

In all sites there were consistent elements in defining 'the poorest of the poor', which focused on the intersection of a variety of conditions which lead to households which have no labor resources, and individuals who have no control over labor resources of any kind. The key elements were disability, age combined with the lack of adult children, widowhoodand childlessness. Female household headship was more likely to appear as an indicator of poverty in the rural north than the rural south or urban contexts. While female headship as such is not related in a simple sense to poverty the combinationfor women of age, widowhood and lack of adult children was frequently seen as associatedwith chronic vulnerability.

* Assets at the communitylevel were seen as more important to rural communities than urban - these included access to water for domestic and productive use, access to public services, access to an abundant natural resource base in terms of fertile farmland and common property resources, and access to transport infrastructure, markets and extension services.

i * The view of poverty as being a dynamic condition impacting on entire communities was particularly strong in the northern rural areas, vulnerable to drought and to the 'hungry season' prior to the single main annual harvest of bulk foodstuffs. The material collected supports the view that the experience of depth of poverty and vulnerability in the rural north is greater than in other areas through the fact that access to food predominates in local views of poverty, and that in some communities serious food insecurity prevails for at least part of the year for virtually every community member. Nonetheless the material is suggestive of some variation - with highly populated areas in the Upper East (Bawku and Bongo Districts) suffering the worst conditions.

* In urban areas poverty tends to be seen more as an individual condition - with key elements in defining well-being including access to stable employment, the ability to acquire marketable skills and access to seed capital (as well as the fundamental asset of physical health and strength).

* As well as physical assets (livestock, capital etc.) and human assets (health, skills) an individual's social network, and membership of social institutions forms a key dimension of well-being and livelihood security. Access to land often comes through community membership rather than the market, and the accessibility of a supportive kin network is critical at times of personal crisis (urgent need for money to pay hospital bills, etc.).

* Gender dimensions emerged primarily through stressing the fact that there are substantial elements of separation to men's and women's livelihoods in many sections of the rural and urban poor in Ghana. In ranking exercises in rural areas there was a tendency for men to rank men and women to rank women, rather than seeing households as unified entities. Men and women thus also stressed different elements to the experience of poverty in some communities.

The results of the priority rankings. The issue of the communities' own assessment of their priority needs was a consistent theme in our research. Where possible these views were solicited through focus groups which reflected the diversity of the communities under study in terms, at least, of gender and generational issues. The major findings can be grouped into three broad regional 'blocks': the rural north (the Upper Regions and the Northern Region), the rural south (including the transition zone, forest zone and the coastal savannah - for our purposes communities in Brong Ahafo, Volta, Western and Central Regions) and urban communities (including intermediate rural towns in the Volta and Central Regions, and communities within the major urban centers of Accra, Tamale and Techiman).

Priority rankings in the rural north. The strongest themes emerging from the priority ranking exercises in the rural north are food security, water (both for productive and domestic use), access to health care, and education. A particular nexus of conditions

ii affects extremely resource-poor communities in the Upper Regions (especially very densely populated areas such as Bongo and Bawku) which finds expression in the constant emphasis on the provision of dry-season water for productive as well as domestic purposes. In essence rainfed agricultureof a traditional kind has become so unproductive that the provision of a dry-season income is now essential to anything approachinga viable level of livelihoods. Dry season water supply, through wells and dams, provides for vegetable gardening which can be a highly significant support to incomes, and for pasturing animals in the vicinity of the village so that manure resources - invaluable for farming land depleted by decades of continual farming without fallow - can be utilized to a far greater extent than is possible if animals have to move to a distant dry-seasontranshumance site. Emphasis on domestic water supply is also strong in communitiesthat have not benefited from external programs such as the CIDA and NORRIP communitywater projects. The other consistent emphasisis on healthcareprovision - reflecting both poor conditionsin terms of access, and the value of physical health and strength which is a consistenttheme in the local views of poverty reflected from all areas.

Priority rankings in the rural south. The picture emerging from priority rankings in the rural south is more diverse - reflecting the greater diversity in terms of livelihood systems and environmentin this zone, as well as the tendency towards greater social stratification, and therefore intra-communitydiversity. In some communities, such as Butre in Western Region, food security was not a major concern even for the poor - although this was not true of all the sites (food supply was very insecure for the poorer community members in Afrangua, in Central Region). Again access to curative healthcareemerged as a strong and consistent theme - in only one communitywas this not listed as a priority need. Improvements in transport infrastructure (roads and bridges) emerged as a major priority in three of the five southern rural communities. This reflects to some extent the ecological conditions of much of southern Ghana, where heavier and more persistent rainfall can in extreme cases lead to communities becoming totally isolated for periods of the year. In addition to denying access to services, poor quality access roads are frequently seen as impacting negatively on the economic opportunities available. Difficulties of road access are a major disadvantage in relation to highly perishableproducts such as tomatoes. Access to water for domestic use again emerged as a major theme, especially in the village of Butre in Western Region. In communitieswhere water did not feature as a priority in ranking exercises this could often be traced to an interventionby an outside agency.

Other common themes included access to off-farm employmentand credit for farming (predominantlymen) and trading activities (predominantlywomen). Better sanitation and drainage emerged as themes in three of the five communities. In general the emphasis on education was lower than in the north - though in large measure this is probably because the situation in terms of provision was better (all of these communitieshad at least one primary school, and two - Derma and Dekpor Horme, also had Junior Secondary Schools). For those communitieswhich did not have Junior

iii SecondarySchools, the distancesto travel to such facilities were usually less than in the north.

Priority rankings in the urban communities. In the six urban communities differentiationin perceived needs was marked - even in some cases between different sections of the town which experienceddifferent kinds of problems in relation to urban services. The most consistent concerns, reflecting the nature of urban livelihoods were with inadequate employment opportunities and the supply of small-enterprise credit. Although these elements were very consistently scored they were rarely the first priority. An exception was Sekondi - which has seen the almost total disappearanceof a once-active labor-market associated with the port and associated services. Priority rankings seemed to reflect to a large degree the condition of the local urban infrastructure. In particular it was interesting to note that three of our five communities had major problems of supply of potable water. Other issues of urban infrastructure that received emphasis in some communities were sanitation (especially in the Techiman Zongo where facilities were almost non-existent)and urban roads. The latter was only mentioned once, but in an interesting context. East Maamobi has had access roads since 1987 (provided under the World Bank Urban 1 Project). The Maamobi field team stressed that this is usually one of the first things that the participants mentionedin terms of new senrices that have come into the area. The roads are said to have brought much improvementto the area for diverse reasons. These included greatly improved physical security making journeys at night (a particularly important benefit for women) and ease of access to health facilities.

Strategies for moving out of poverty. There was no uniform perception of how individuals might move out of a condition of poverty. In urban areas there was widespread despondency about the future. Informants noted that recruitment to unskilled wage-labor in government service had virtually dried up with structural adjustment policies - and unskilled wage-labor was disliked for the reasons outlined above. Therefore increasinglywell-being is seen as tied to the capacityto acquire skills which can be used in a self-employed context (predominantly within the informal sector). This is said to be leading to increasedcompetition for apprenticeshippositions, and thereby increasing costs to individuals of gaining access to such training. In rural areas where there are substantialopportunities in terms of cash crop production (much of southern Ghana) access to capital for farming enterprises is continuallyraised as the most significant 'blockage' to individual progress. In the poorer communities of northern Ghana, the constraintsat the level of the Region or communityare continually raised as more significant than those at the level of the household or individual. The individual strategy most commonly used to cope with, or move out of, poverty is labor migration. The paradox here is that in migrating substantial numbers of residents of poor communities end up by severing their ties with the sender community, thus eventuallyending transfers to ltheirkin group. In northern Ghana the accumulationof livestock was often seen as an important strategy for moving out of poverty. Apart from the inherent productive value of livestock rearing, the manure provided for the

iv farm is critical to households' farm production (especially under conditions of land scarcity).

Rural communitiessaw far more opportunitiesfor action at the level of the community to increase livelihood security than their counterparts in the urban sector. In urban communitiesonly the occupationalassociations to which many in the informal sector belong were mentioned in this context. Although local leadershipsexist in urban areas they seem to be commonly viewed as distant from the concerns of the poor. Rural communitiesshowed considerableenthusiasm for mobilizationto support the provision of social and economic infrastructure, taking the form of assistance with construction and maintenance of facilities such as schools and clinics, as well as more unusual initiativessuch as a desire to establisha grain bank in a food-insecurecommunity in the Upper East Region. It is notable that, although northern communities had much the same analysis of the importanceof social infrastructuretheir ability to provide cash to support such constructionprojects was very highly constrained - while contributions in terms of labor could be mobilized at the same level as the south. Service provision systemsthat rely to a substantialextent on the capacityof local communitiesto generate cash will thus lead to equity problems in terms of access.

The views of appropriate action to support poverty reductioninitiatives which could be taken by governmentand NGOs reflected to a large degree the priorities listed above. In the rural south and in urban areas provision of improved employment opportunities was seen as a major priority for government action - although the sense of specific details of what actions this might involve were not clear. Similarly credit emerged as a major concern both for farming and small-scaletrading activities (the latter particularly for women). This is seen as an area for both government and NGO intervention. Improved access to water and quality of water supply were major issues in some of the urban communities, as was improved sanitation. To a greater degree than in rural communities, urban communities tend to see domestic water and sanitation as appropriate areas for governmentintervention. In rural areas of the south there was a strong concern in some communitieswith the conditionof the road infrastructure . The improvement of road infrastructure was generally seen as an area suitable for collaborationbetween communitylevel institutions (mobilizinglabor and maintenance funds) and outside agencies, particularly local government (provision of capital, equipment and possibly food-for-work incentives). Partnerships with government ministries were seen as the appropriate means for increasing access to basic health and education services. There is still a tendency to see the community's role in terms of contributing labour (and sometimes materials) to the constructionand maintenance of physical infrastructure. In the rural north the view of appropriatesupport from outside agencies reflected the issues of water supply, food security and service delivery outlined above. In some cases there was a distinction between the kinds of assistance that government and NGOs should best provide (with NGOs seen as having an advantage generally where extensive capacity building support to local institutions is required, e.g. managinga cereal bank).

v Vulnerability. Poor peoples' conceptionsof poverty often correspond closely to the notion of vulnerability - a dynamic notion which captures the sense of threat posed by the negative effects of various forms of change over time, whether in the form of seasonal variation, long-termtrends, or various kinds of shock.

Seasonalityand poverty. Seasonalfluctuations were a major aspect of well-being in all research sites. In addition to the well-documentedphenomena of stress points in the agricultural cycle, which takes its most severe form in the 'hungry season' problems of many savannah communities,there are significant seasonalcycles in urban occupations related to factors such as weather (impact on building), the cycle of social activity and key festivals, and market flows related to the agricultural year. As has been noted above the major seasonal foodisecurity issue in Ghana is the extreme 'hunger season' experienced by many communities in the north - especially those where intense population pressure has led to declining soil fertility (for example, Komaka, Beo Tanko and Sombo in our sample). These communitiesexperience major problems of basic food supply even in a normal year - and the impact of drought years can be extreme. As a general rule, the more diverse the farming system, in terms of the mix of basic staplesand crops grown to generate income, the less was the degree of vulnerabilityto seasonal food scarcity. On top of that cassava, as a crop which can be available for harvestingall year round, often plays a special role in mitigating vulnerability.

Where there are marked seasonal changes such as in the north, seasonal patterns of illness have been observed. Ill-health is said to be most prevalent at the peak of the dry season in February and March, by which time the food situation has started to worsen. Fevers, stomach disorders and respiratory diseases were described as the most common at this time. By experience the most dangerous time to fall sick is during the rainy season when there is very limited food supply, and no money to go to the hospital. It is also the time when people need their energy most to work on their farms. Worse still, increased poverty during the lean season makes it difficult for the family to respond adequatelywhen someonefalls sick at this time. In the middle and coastal belt double maxima rainfall areas of communitiessuch as Butre, Kpando Gabi, Derma and Dekpor Horme, there is apparently little differentiationin the seasonal occurrence of sickness. Cholera and diarrhoea seem to peak during the 'time of mangoes' in the minor rainy season, but other diseases occur all-year round.

Long-term trends. Views of trends in rural communities tend to focus on environmental issues such as declining access and quality of water, declining soil fertility and declining common property resources for the vulnerable to fall back on in times of crisis. The view of the urban poor relates in more detail to the evolution of policy frameworks in the era of adjustment. While a considerable improvement is appreciated to have occurred in the early phase of economic reform (from 1983 to 1988) there is a general perception that opportunities for the urban poor have been becoming more constrainedin the period since the last six to seven years. In part this is attributed to increased 'crowding' of the informal sector due to both low levels of demand and increasing numbers of people trying to survive in this sector. The increase

vi is variously attributed to retrenchees searching for new livelihoods and Ghanaians returning to the country from other parts of West Africa as a result, in part, of improvementsin the general climate in Ghana, and varying kinds of problems affecting other countries (recession, conflict). In all communitiesthere is some concern over what is perceived to be a very poor situation in relation to assistance with credit for trading and productive activities. In the urban areas this is perceived as a declining trend whereas in some rural areas this seems to be perceived more as a continuationof an unsatisfactorysituation.

The list of aspectsof decline in environmentalconditions in rural areas included: water access (declininglevels of the water table, decreasing quantity, quality and duration of stream flow); availability and quality (fertility) of farm land and pasture for animals; access to a range of products from common property areas, for both own consumption and sale for income (including fuelwood, medicines, foraged foodstuffs such as snails, fruits, mushrooms, bushmeat, and other non-timber forest produce). In the northern savannah communitiesthe key elements of environmentalchange were perceived to be declining soil fertility due to decreasing fallow periods, declining water resources as outlined above and a shorteningof the rainy season, combined with less predictability. In the relativelymore agriculturallyabundant communities of the middleand coastal belt, importantchanges have takenplace in crop mixesin responseto environmentaldegradation, as well as marketdemands. The droughtand accompanyingbush-fires of 1983 were noted in many communitiesas a 'watershed'point followingwhich there were long-termchanges in the local ecology.

Another long-term trend which was highlighted in some areas was a tendency to weakening of the bonds of local social institutions of kinship and community. In Nyingare in the Northern Region, for example, focus groups among women revealed a perception that ten years ago there was strong social cohesionin the village. Communal labor institutions were still strong (and acting as a safety net for households experiencing problems in terms of labor due to sickness or disability), respect and authoritywas still given to the chief and his elders, communitysolidarity was still expressed through mutual support and assistance for one another. Decline in the traditional institutionalframework for such reciprocalarrangements was a fear expressedin other sites in the north associatedwith increasinglevels of temporaryand long-termlabour migration. Such changes clearly create increased vulnerability for the poorer sections of such communities,by weakening their 'social assets' in terms of networks of kinship and communitythrough which they could mobilise claims on food and labour from their neighbours. In one urban site - which had been affectedby the recent ethnicconflict in the north - fear was expressed that Ghana's evolving democraticsystem could also foment socialdisintegration.

Survival and Coping Strategies. The coping strategieswe recorded in the course of the three phases were very diverse. Some of the more commonelements included:

vii * For the rural north: Out-migration in search of employment; sending children to stay with kin in times of stress; using 'famine foods' gathered from the bush.

* For the rural south: Reducing expenditures (taking children out of school); changes in conjugal patterns (contracting informal unions due to inability of young men to make bridewealth payments).

* For the urban south: Reducing expenditures, including relying increasingly on cooked food sellers, withdrawing children from school; diversifying income sources

An important point to note on coping strategies, is that different coping strategies at the individual level are not available equally to all categories of the population. For example, market-based fallback mechanisms such as migration from the rural north are more readily available to young men than to many women, children or the elderly (although there is evidence of increasing female migration). The removal of the young man may even have negative effects for the livelihoods of those left behind (depending on the level of transfers received). Where a common 'fallback' mechanism appears to have negative consequences for more vulnerable sections of the population consideration needs to be given to possible alternatives. For example, over the last fifteen years some areas of the Upper East Region have diversified with considerable success into vegetable farming as a dry-season activity, providing an alternative source of income which may firstly, reduce male out-migration, and secondly, provide income on a broader basis within the community. Provision of dry-season water sources to support this kind of activity was the main priority need emerging from the rural communities in the Upper Regions. Assistance of this kind may strengthen community- based fallback mechanisms (local 'safety-nets') through encouraging community solidarity and cohesion.

By all accounts many of the long-standing coping strategies that are known in resource- poor communities are becoming less accessible for combating stress periods. This is explained by the fact that most of these strategies are themselves under threat because of worsening ecological conditions and the escalating cost of living. The situation appears to be more grave in northern Ghana, where in communities such as Beo Tanko the consumption of wild foods forms a regular part of strategies of dry-season survival, though one should not under-estimate the looming deprivation in other parts of the country.

Fonnal and infonnal 'safety nets". The capacity to help disadvantaged kin or community members was frequently listed as an attribute of the non-poor in our study. At the same time there was a general sense in many communities that community or kin-based systems of mutual aid were becoming weaker (as descnbed under trends in social cohesion above). One area where assistance from kdn was consistently cited as critical was in accessing social services - particularly emergency healthcare. External sources provided valuable but relatively rare assistance in many of the field sites. Best placed were those communities

Vi. with an ongoing NGO program. Governmental safety nets were not mentioned by any informantsas being in any way relevant for the poorest members of these communities.

Perceptionsof access and qualit in healthcare

Many small rural communities in Ghana have very low levels of access to modern health facilities. Despite the already low level of coverage, there are situationsin which health services have been closed down or withdrawn in the case of mobile services. Where mobile services exist their effectivenessis frequently undermined by problems of lack of punctuality, and the charging of informal, extra-legal fees. As a result people in the rural communities rely extensively on traditional health providers such as traditional birth attendants (TBAs), herbalist/bone-setters,fetish priests drug peddlers and spiritualists. Close proximity to modern health facilities in the urban centres has considerablyreduced dependence on these informal sources, though there are certain categories of illness that people prefer to take to a traditional healer. Examples were given of situations in which relatives had withdrawn their patients from hospital to be taken to traditionalhealers.

Everywhere the selectionof a health care provider is contingentupon many factors, and as a result visits to a health facility tend to follow a sequence. A visit normally starts with the most accessible and the least expensiveof the facilities available, though other considerationssuch as type of illness rather than cost and convenience may influence the sequence. Sequencing of visits to the health care facility commonly takes the following form. Many people depend on home remedies or visits to the herbalist as the first step in the treatmentof illness. When it becomes critical they will proceed to the doctor or the spiritualist / fetish priest, depending on the local classification of the illness.

Under current conditionsof hunger, the willingnessand ability of poor people to spend on amenities such as orthodox healthcareis low. In all three regions studied, high user costs are resulting in the exclusion of the poor from utilization of hospital services. The public medical system -- laden with accessibilityconstraints, extralegalcharges and often requiring high financial outlays for transport -- is widely perceived as expensive. Predictably, hospital consultationsfall significantly in the "lean season", even though disease tends to be more endemic then, especially among children. In some of the government hospitals (one in particular) there appeared to be a situation of complete chaos in relation to charges for healthcare. Official staff appeared unable to give consistent figures for charges for the most basic services. Furthermore, unofficial rents were charged for a wide range of small services.

There were generally positive perceptions of all healthcare providers who lived in the community. Servicesprovided from healthcarepersonnel outside of their official roles (as friends, neighbors, kin or community members) were in cases more appreciated than the official facilities they worked in. In the sites where communityhealth workers had been trained the services was perceived positively. The diagnostic services of drug

ix store chemists were highly valued. Chemists were generally perceived as "doctors" and therefore, implicitly, as giving higher status and more reliable advice and treatment than nurses - perceptions which contribute to the dangers of self medication.

Provisions for cost exemption for the poor generally do not work. Exemption provisions were found to be much more effective when executed by ailment rather than by direct means testing (i.e. for the poor). Indeed, the latter is proving costly in administrative resources -- money as well as staff time. Only in the mission and charity hospitals is exemption by means found to be working reasonablywell; but even then, with high hidden costs. Sometimes, the assistance of the Department of Social Welfare has to be solicited, and transport facilities provided to enable applicants' circumstancesto be investigated. This system is slow and bureaucratic - furthermore, once someonehas been identified as poor they generally still do not get treated as there is no provision for resources to assist them.

In terms of barriers to access to formal healthcare it was noted in all our northern communitiesthat even the wealthy do not generally store their resources in the form of cash. Therefore finding funding for an emergency treatment is not just a problem for the poor - it applies to everyone in such communities. Generally speaking it takes some days to arrange for the sale of an animal (generally the means by which cash is raised). Under these conditions, it is not surprising thatflexibility in accepting deferred payment was often more valued as an attribute of a service provider than the simple level of cost.

The main groups affected by retrenchmentin the health sector have been the less skilled personnel -- drivers, cleaners, orderlies and similar categories. The most obvious consequence of their retrenchment has been the adverse impact on hospital cleaning services. It must be said, though, that while the situation may have been worsened by the recent retrenchmentof lower status personnel, public hospitalsin Ghana have had a long history of problems with efficient cleaning. Apart from its inimical effect on cleaning operations, another outcome of the policy of retrenching auxiliary nurses has been to entrench pre-existing staff shortages. Throughout the country, relatives of in- patients are having to stay on the wards to help look after their sick kin. Previously, auxiliaries would have been available to perform this function. At one site, where major losses have been incurred through the retrenchment of auxiliary nurses, necessarycuts are having to be made to the size of outreach teams.

Access to outreach services. The mobile health services introduced under the PHC portfolio have' had modest success in reaching remote areas. However, according to our research the achievementsin respect of coverage are somewhat offset by the fact that public outreach teams have tended to be rather unreliable with keeping dates and times. Not uncommonly, they arrive a day or more late, when villagers are not expecting them and have leit for their farms. The principal factor constraining outreach visits to peripheral sites was reported to be financial, in particular budgetary cutbacks resulting in reduced transport allocations and fuel rations. The reduction in

x auxiliary nurse numbers has also imposed strains on the capacity of some health administrationsto release professionallyqualified nurses for outreach work.

On occasion, we found outreach teams levying unofficial charges ostensibly to offset their transport expenses and to purchase necessary consumables for treatment and nutritional demonstrations.These kinds of informal charges are, of course, not subject to any form of exemption for the poor - and consequently essential public health services (such as vaccinations)are being priced in some instances beyond the reach of the poor.

Perceptionsof access and quality in education

Factors impedingaccess to basic educationservices:

* At the communitylevel very poor conditionof school buildings (rural communities); disincentives to continuing education due to lack of Senior Secondary School facilities in rural areas (the cost of boarding fees puts secondary education way beyond the reach of the children of the poor). In urban communitiesparents have a greater range of options and are not constrained to the same degree by the availabilityof schools within the communityarea.

* At the household level lack of resources to purchase equipment and school fees. Costs of schoolingare perceived as having risen rapidly in comparison to capacity to pay. Heavy costs are borne in the first year of JSS due to requirements of householdsto purchase equipment for students (uniform, table and chair, math sets, technical drawing board), and in the last year due to costs of registration for exams. These costs outweigh that of the official school fees. Rising real costs combine with poverty to keep significant numbers of children out of school, often as drop-outs. Cost barriers also remain significant in relation to education for access to primary schooling. A major component of this is rising PTA fees in line with increasing community responsibility for maintenanceof structures etc. The rising costs are more dramaticin relation to the north - as the ending of the policy of free schooling in the early 80s has meant that the rise in costs is steeper there. The bulk of the costs are not composed of formal school fees, however, as with JSS. At all levels in certain householdsthe main perceived cost of educationwas the opportunitycost of losing the child's labor for domestic and productive purposes.

* No evidence was found of any provision for cost exemption for the poor in education. Sympathetic headmasters frequently allow children to attend for some time without paying fees, but headteachersare accountablein the end for collecting fees for all pupils and are not empowered to make exemptions. This runs counter to an assertion the Minister of Education made in a widely broadcast speech that children should not be expelled from school for non-paymentof fees. Some NGOs

xi fund the costs of school fees for the poor (the largest to do this for its project sites is World Vision International).

* Evidence was found (especially in secondary schools) of schools being forced to tolerate increased levels of absenteeism as many children have to earn the money for their school fees.

* The classic pattern of a drop in the ratio of girls to boys between primary and JSS was observed. Some informants felt that the high costs of JSS were a factor in discouragingfemale attendance. Some informants also drew the classic conclusion of low female school attendance contributing to higher incidence of teenage pregnancy, the contracting of socially inappropriateunions and therefore initiating cycles of poverty.

Local perceptions of the quality of education services. The major concern of most community members and teachers canvassed in our study (especially the third phase) was with issues of quality rather than of basic access. The mushrooming of rural schools (through community initiative, particularly under the ongoing reforms) has meant that educational resourceshave had to be spread quite thin. Thus, while schools may be more accessible (in terms of proximity; not costs), rural communitiestend to have so few teachers per school as to render the quality and value of education in such schools questionable. In terms of the quality of education the following main messages emerged from the research:

* Consistent with the findings of the second round of the Ghana Living Standards Survey, the quality of education was found to be perceived as low across the sites studied - in the views of both communitymembers and service providers. Sharing of furniture built for individual pupils is common. Many children are doing pieceworkor helping on their parents farms and pastures after school, leaving them exhausted and with no time for their homework.

* In some sites supervisionof teachers was a major concem - especially with respect to children being made to work on teachers' farms during class hours. Another concem (particularly in urban areas) was that teachers put all their efforts into 'private' lessons for children who stay behind after the formal class is over. The single greatest factor that seemed to determine the efficiency of the system of teacher supervision was the availability of transportation allowances for schools' inspectors.

* Parents complained that under the new (post reforms) system feedback on the performanceof children in class was confusing (this appears to be related to the fact that the overall class position of the child is no longer reported - which is the easiest thing for an illiterate parent to understand). Thus the poor performance of their

xii children at examinationsfrequently comes as a shock - and the parents' help is not enlisted in encouragingthe child to perform better.

The policy of retrenchmentof untrainedteachers is leading to a shortageof teachers in isolated rural communities. Our research suggeststhat trained teachers are often unwilling to take up rural postings, especially in isolated areas. There may also be unfortunateresults in terms of the gender balance of the teacher force - the majority of untrainedteachers are women.

In terms of the perceived relevanceof education the following main messages emerged from the research:

* The criteria by which local communitiesdefined the 'relevance' of the education service were based on two factors: the ability of children to get jobs, the ability of children to read and write in English (so that illiterate parents no longer have to go elsewhere to get letters read and written, compromisingthe privacy of the family, and children can perform basic tasks like identifying the correct hospital card for family members etc.). In only one communitywas literacy mentionedin relation to learning improved techniquesin traditional occupations - in relation to farming in the Mamprusivillage in the Northern Region. In relation to these criteria education (at the level to which it is pursued by the poor - generally no higher than JSS) is perceived to be failing. People consistentlysaid that their children could not read and write at the end of school. In relation to this parents and teachers in some sites argued that the new educational curriculum was too broad - with insufficient time and attention paid to basic literacy.

- Regarding the match between user aspirations and the revised curriculum for first- cycle (ISS) schools, our findings indicate that the reforms are not fulfilling the purpose for which they were designed. In both rural and urban areas, the implementation of the technical training component, king-pin in the educational reform program, is largely perceived as unsatisfactory. In case after case -- in schools, communitiesand in GES offices -- informants alluded to the lack of tools, working materials, workshop buildings and trained teachers. This situation, a serious impediment to effective skills training in the JSSs, has arisen mainly because, in the current cost-sharing framework, communities are not only responsible for financing capital requirements and school furniture, but also for providing tools and other inputs needed for the program. Consistently, therefore, the skills training objective is being underminedby the high incidence of poverty. There is also a clear regional dimensionto this, with our research suggesting that communitiesin the poorer areas of the country (in this case specifically the sites in our sample in northern Ghana) are less able to meet these extra responsibilitiesthan those elsewhere. Lack of skilled craft teachers is also a major constraint in all the rural areas in our study. The technical training component was consistently described as the weakest link in the JSS agenda.

xiii In terms of the functional literacy program the research teams found that the level of availability of materials was very good. The main constraint in most communities (especially rural ones) was the lack of availability of volunteer facilitators. This was generally seen as resulting from the low level of material incentive for people to do this. The majority of participants in all sites were adult women (there was no evidence of the program picking up school-leaverswho had had to abandon their education).

Local perceptions of water and sanitation services

Within the towns and villages studied, the availability of safe water and sanitation is often a function of NGO, or other donor presence. Many poor households rely on streams and uncoveredwells of dubious purity. Except where interventions have been implemented, therefore, water quality tends to be particularly poor during the dry season when natural water sources tend to dry up. In the Northern Region in particular huge amounts of women's labor time during the dry season are expended on fetching water - affecting their potential access to employment and income-generating opportunities. Evidencefrom all three rounds of the PPA indicate that for communities where water supply is problematic this remains the over-ridingpriority - especially for women. In all low-income urban sites, we found a high level of indiscriminate defecation, largely resulting from extremely low levels of provision. Understandably, women are more concernedabout the deficienciesof water and sanitation: it is they and the children who are responsiblefor replenishinghousehold water supplies; and cultural norms prevent them from evacuatingtheir bowels in open spaces.

Obtaining land is a major issue in relation to some kinds of urban services. There is a particular problem with obtainingland for latrines as it lowers the value of surrounding property. It was found that while VIP latrines functioned excellently in rural communitieswhere populationdensity is low they were virtually impossibleto maintain in densely settled urban areas at the concentrationsthey existed in the areas studied. It is therefore recommended that a review should be made of means by which District Assemblies can find ways of making more land available for latrines in poor urban areas - in order to decrease pressure on existing facilities, and thereby set up a virtuous where the presence of a latrine in a neighborhoodis no longer regarded as a health and environmentalhazard.

Summaiy: key policy messages

The following are the key policy issues and recommendationsemerging from our work:

1. Policy implicationsof priorities in poor rural and urban communities. As a result of using a variety of different methods, including needs ranking exercises, and comparing results from a variety of sites the following general messagesemerge from local communities:

xiv * improvedlivelihood securityfor the rural north: People perceive a general crisis of livelihoods, exacerbatedby deterioratingenvironmental conditions. In much of the north the problems of the 'hungry season' dominate local views of poverty. Raising the productivityand improvingthe robustness of farming systemsin fragile environments is not an easy task, but it is nonetheless one that needs revisiting through all means possible, including: provision of dry season water resources to assist livestock rearing and dry-seasongardening initiatives (these are particularly valuablebecause income can be generated in the lean season); agricultural research and extension services which are attuned to the needs of poor farmers; improved 'safety net' provision for the poorest. Our research suggests that the endemic problems of food security in northern Ghana in particular have never received the serious attention they merit. While all communitiessurveyed prefer the prospect of assistanceto develop the productivityand securityof their livelihoodsto 'safety net' kinds of assistance, the severity of problems experienced by the poor in the north suggests a need for a more robust response in terms of an ongoing institutional framework for addressing the worst affected social groups and areas. Northern communitiesalso showed a relatively higher level of emphasis on education as a priority - which may reflect the greater importance of accessing the migrant labor market for these communities.

* improved access and quality in healthcare is a priority: This was the most consistent messagefrom all of the sites, rural and urban. Accessibilitywas seen in terms of both cost and non-cost barriers. The key to improved access and quality lies in a vigorous promotion of a community-basedapproach to both basic curative and preventive services. Detailed recommendations of healthcare are provided below.

* improved transport infrastructure is a priority in rural areas: In many rural communitiesimproving access to markets and to services such as hospital care was seen to a large extent in terms of the unreliability of physical access. This was particularly true of some of the southern communities, where access during the rains was highly restricted.

* access to water for domestic consumption: Was invariably the top priority in communities experiencing particular difficulties with this. These included communitiesin the rural north, south, and some urban communities. This was a particularly strong priority for women, and for children - the groups which have primary responsibility for domestic water provision. Schoolchildren in Tamale listed the time spent fetching water as the single greatest problem they faced in pursuing an education.

xv access to employment opportunities, credit and skills training: Emerged as the most consistent priorities in our urban sites - along with specific concerns related to the conditionof the local urban infrastructure.

It should be noted that apart from the themes outlinedabove, which emerged with some consistency, many other priority needs reflected closely specific social and economic environments. We would recommend, firstly, that donor agencies and government consider the priorities expressedabove as an input in developingpoverty-focused sector programs and projects, and; secondly, that bearing in mind the locally specific nature of many of the constraints which communities perceive in seeking to improve the security and quality of their livelihoods,that the process of strengtheningthe local level capacity to plan and implementprograms in a participatory fashion with communities through a District level planningapproach should be strongly supported.

2. Regional dimensions of poverty. Our research strongly supports the findings of the quantitative Poverty Profile that the depth and extent of poverty is greatest in the rural north. This emerged principally through the consistent stress on food security as the defining feature of poverty and vulnerability in poor northern communities. We also found considerable varialion in the depth of poverty by community - with the poorest being those communitieswhere the natural resource base has become extremely depleted as a result of high population densities. Particular dimensions of poverty which are worth noting include: the strong identification of poverty with community- level factors (access to natural resources, services etc.); the strong seasonaldimensions of poverty related to water supply and food security.

3. Gender, and the intra-household allocation of responsibilities and distribution of resources. Findings of the PPA confirm conclusionsfrom many other studies of Ghana that men and women have substantially different bases for their livelihoods, and that there is a high separation of income streams within the household. They also confirm the common conclusionthat the labor burden of women is generally much greater than that of men, restricting their access to market-basedincome generating opportunities. The high labor burden of women, of course has a range of other implications for their well-being, including health implications. Two main conclusions can be drawn from this:

* if monitoring systems are to provide a comprehensive picture of the impact of economic reform on the poor they need to disaggregate income and consumption trends at a level below the household - trends in terms of gender cannot be 'read off' by looking at the differencebetween female and male-headedhouseholds.

* a very wide range of priorities are suggested for sector policy, and project interventions, including: specific attention across a wide variety of fields to making available to women technologies which can lessen their labor burden (including improved year-round access to domestic water, grinding mills to lessen burdens of

xvi food preparation, improved access to travel and transportation, and technologies which lessen the labor burden of fuel collection); paying specific attention to the access of women to health and education services; paying specific attention to increasing the productivity of economic activities in which women are already involved; paying specificattention to the low level of access to women to credit and productive services (e.g. agricultural extension).

4. Access to services: implications of community roles in the provision of social infrastructure. The research found evidence to support the hypothesis that the differential capacity of communities to contribute to cost-recovery in health and education may lead to regional inequities in the provision of social infrastructure, and hence access to services. At a fundamentallevel, it can be assumed that, given equal population size, the capacity of communitiesin different areas to provide labor for 'community projects' (typically oriented towards the construction of physical structures, e.g.. clinic, schools) will be fairly similar, but the capacity to raise cash is clearly dependenton a range of other considerations,including wealth and the level of monetizationof the local economy. Patterns of settlementalso influence the level of relative effort that is being demanded of communities - with economies of scale for larger settlements in the provision of some social infrastructure. As has been noted above, there is a strong regional dimension to the capacity that different communities have to contribute cash to communityprojects such as the constructionof infrastructure for education and health - broadly following the major 'fault lines' of poverty which are confirmed in Ghana by both quantitativeand qualitativeanalysis.

5. Environmental decline and rural livelihoods. Processes of environmental degradation emerge as a major concern in all rural areas of Ghana. These have a number of different dimensions: declining water access and quality in terms of both undergroundand surface water resources; deteriorating soil fertility in some areas due to reduced fallow periods, increased intensity of land-use; changes in the crop mix due to environmentalas well as economic factors (e.g.. the spread of swollen shoot disease for cocoa, St. Paul's wilt disease for coconut). This emphasizes the fact that the issue of accelerated growth is not necessarily the same as that of sustainable growth, in environmentalor social terms. Given the importance which the predominant areas of agricultural development in recent years have for the economic future of Ghana (predominantlyWestern and Brong-AhafoRegions) there must be a concern that the agricultural productivityof these regions will suffer in the long run as have the central areas of the forest zone over recent years. This will harm incomes for the poor both in the short run (in those areas) and in the long run through declining migration opportunities.

6. Access to education. The research suggests a combination of constraints in access to educationwhich apply at both the level of the household and the level of the community (although provision at the level of the community was seen as less important in poor urban areas). These are summarized above. In terms of specific areas where action could be implementedto improve the situation we recommend:

xvii * a review of the possibility of instituting cost-exemption provisions to those areas of school expenses under the control of schools (regular and special fees, uniform requirements)

* the contributions that communities are making in education through provision and maintenance of infrastructure should be recognized - as should the fact that contributions in labor are easier for poor communities to make than contributions of cash (whether at the level of the community or the individual household through school fees)

* strengthening of systems of school supervision through provision of transport and traveling allowances

* there is a need to develop local institutions to manage scholarship schemes - currently education beyond the JSS level is totally inaccessible to children from poor rural areas - which affects the perceived incentive to send children to school at all levels

* the fact that under the new system (since the education reforms) feedback on pupil performance is complex for illiterate parents to understand should be addressed - parents need information about the progress of their children if their help is to be enlisted in encouraging their children, and not over-burdening them with productive or domestic tasks to the point where they perform ineffectivelyat school

* guidelines should be developed to ensure that the policy of retrenchment of unqualified teachers does not remove teaching staff from poor and isolated rural communities.

7. Access, utilization and quality of healthcare. Until the real costs of consultation are reduced substantially (through improvements in fee exemption facilities and procedures, the elimination of graft and by meaningful improvements to outreach as well as regular out-patient services), poor people will continue to avoid the public medical system or postpone consulting it when ill. Especially necessary in this respect are:

* awareness creation regarding legitimate costs and exemptions

• introduction of clear and transparent systems for levying charges in large health facilities (preferably with a single point for payment within the hospital so it is clear that other charges are unofficial and illicit - a system which has been adopted at some mission hospitals)

* awareness creation regarding the detrimental impact of drug abuse (dangers of short courses of drugs etc.);

xv. * an expansion of (and improvement in) outreach services; including community-based schemes (CHWs etc.)

* the implementation of practicable exemption provisions for the poor, particularly at community level.

* a renewed investigation of the possibility of instituting systems of either deferred payment, or community-based credit, for medical treatment - people in poor communities, especially in the north, often hold wealth in forms other than cash (e.g.. cattle) which means that money for emergency treatment cannot be raised rapidly even if the household has the resources to pay.

In relation to extending the effectiveness of cost-exemption provisions the following actions are recommended for consideration:

* extension of cost exemption provisions applied by ailment to a wider range of diseases which disproportionately affect the poor (or for which the poor are more likely to use public services) as this type of exemption provision is far easier to implement than systems which require the service provider to make a means-based assessment of an individual

* piloting of community-based and managed exemption systems (involving community level institutions)

* and/or an extension of cost-exemption provision by age-group (elderly, children) - again as this is easier to implement than means-tested measures

* and/or the introduction of provisions to waive user fees on a District-wide basis in areas suffering from particular crises (e.g.. civil conflict, drought)

* a comprehensive review of this issue involving both the Ministry of Health and the Department of Social Welfare so that clear instructions can be developed for staff on cost exemption for poor and vulnerable groups

* improved flow of information to communities about their entitlements in relation to cost-exemption

XIX

LINRODUCTION

1.1 Background to the Study

The Ghana Participatory Poverty Assessment forms part of the Extended Poverty Study. The following report covers material from three phases of the research. The first was in May/June 1993, the second in April/May 1994, and the third in November 1994. This exercise forms part of the World Bank's Extended Poverty Study, and has been supportedprimarily by the UK OverseasDevelopment Administration (phases I & 2), and UNICEF (phase 3) with additional funding for the first phase provided by GTZ. In total fifteen communitiesparticipated in the research, six urban and nine rural, and nine of Ghana's ten regions were representedin the sample chosen.

The teams which carried out the research consisted of broadly four categories of participant: academic researchers; personnel of the Ministry of Local Government and Rural Development; personnel from local non-governmental organizations; and personnel from international development agencies. Before each of the three fieldwork exercises a training workshop was held. The training workshops covered a set of research methods commonly known under the title PRA (Participatory Rural Appraisal). In the first phase two experienced international PRA trainers participated - after that training was predominantly handled by research participants. Practical and logistic arrangements for the fieldwork were coordinated by a Ghanaian NGO (CEDEP).

The following report consists of material derived from that fieldwork. The material presented here has gone through a process of synthesis involving the preparation of field site reports for each of the fifteen communities covered by the research as well as two extensive synthesis documents. These reports are: Ghana Participatory Poverty Assessment, Synthesis Report (Rounds 1 & 2), and Extended Poverty Study (PPA Phase 3): Access and Utilization of Basic Social Services by the Poor in Ghana. Preparation of these documents was predominantly carried out by the lead researchers for each phase of the PPA - for the first two exercises, Dr. Ellen Bortei-Doku Aryeetey (ISSER, University of Ghana, Legon) and for the third phase Dr. David Korboe (UST, Kumasi).

A participatoryapproach to carrying out country poverty assessmentshas been found to have considerable benefits for both the content and impact of the study.' The reasons for involving and consulting with a range of stakeholders, including the poor are: to understand better the social, economic and political dynamics which perpetuate poverty in a given country; to ensure that strategies identified for poverty reduction reflect the

1 See AndrewNorton and Tom Stephens, Participationin PovertyAssessments, Technical Paper, ENVSP for a fuller discussionof this (forthcoming,1995)

1 real concerns voiced by the poor; to promote ownership of the proposed solutions by a variety of stakeholders; and to build in-country institutional capacity for ongoing analysis of poverty and formulation of policies to reduce it. The specific objectives of the first two phases of the research were the following: a) to explore local conceptions of poverty, vulnerability and relative well-being in poor urban and rural communities in Ghana. b) to explore what the poor themselves see as the most effective actions for poverty reduction which can be taken by i) individuals or families, ii) communities, iii) government agencies, iv) other institutions c) to investigate what people in poor urban and rural communities see as the main concerns and problems in their lives at present and how these have changed over the last 5-10 years

In effect phases one and two were designed as a discrete research project. In the course of the evolution of the Extencled Poverty Study, however, it was decided to focus in more detail on a specific issue - namely the question of the access and utilization of key public services by the rural and urban poor. A third phase of research was therefore initiated which focused on this specific issue. The objectives for the third phase were as follows: a) to illustrate the ways in which the rural and urban poor perceive service delivery (both governmental and non-governmental) in the fields of health, education and water/sanitation, in terms of: - their level of access to services provided - the relevance of the services provided in terms of the capacity to meet their perceived needs - their level of utilization of services, and the significance of various constraints which impede access and utilization. b) to illustrate the perceptions of service providers within the governmental service provision structures, primarily at the District and sub-District levels concerning: - the specific needs of the poor in relation to service delivery - factors which impede access to services by the poor - ways in which service delivery to the poor might be improved.

The principle change in methodology from the first two phases of research was the fact that participation in the research was extended from the community level to include service providers in the field of health and education (including those in the informal sector, such as traditional healers).

2 1.2 Methodology

The research methods selected for the Ghana PPA were predominantly drawn from a set of techniques commonly known under the rubric of Participatory Rural Appraisal. These include both forms of investigation familiar from other forms of qualitative research, such as focus groups, conversational and semi-structured interviewing, and some other techniques specific to PRA. These involve structured analytical exercises carried out by local people through which they elaborate their own analysis of the major issues they face in their lives. Examples of such exercises include wealth ranking; matrix ranking and scoring to assess priority needs and the performance of service providers; institutional diagramming; seasonality diagramming to assess patterns in livelihoods and; participatory mapping of communities to assess social groups, service provision and natural resource endowments.

1.3 Field Sites

The following comprises a preliminary overview of the findings of the qualitative and participatory research carried out within the Extended Poverty Study in Ghana. The research was carried out in fifteen communities, with some additional material drawn from two sites which were included in the training program for the first phase of the research. The fifteen sites were:

Phases 1 & 2

i. Sombo (Nadowli District) Upper West Region ii. Komaka (Bawku West District) Upper East Region iii. Beo Tankou (BongoDistrict) Upper East Region iv. Derna (Tano District) Brong Ahafo Region v. Butre (Ahanta West District) Western Region vi. Sekondi (Shama Ahanta East District) Western Region vii. East Maamobi (Ayawaso East District) Greater Accra Region viii. Dekpor Horme (Ketu District) Volta Region ix. Kpando Gabi (Kpando District) Volta Region

Phase 3

x. Chagni (Tamale District) Northern Region xi. Nyingare (Mamprusi District) Northern Region xii Techiman (Techiman District) Brong Ahafo Region xiii Koforidua (Sunyani District) Brong Ahafo Region xiv Afrangua (Mfantsiman District) Central Region xv Breman-Asikuma (Breman-Asikuma District ) Central Region

3 Site selection was designed, on the basis of available quantitative and secondary material as well as the extensiveexperience of the research teams, to create a purposive sample which would be illustrative of the living conditions of the poor in Ghana, in terms of the following major criteria:

* rural/urban balance * modes of livelihood (farming, fishing, pastoralism etc.) * agro-ecologicalzones * major ethnic/culturalgroupings (matrilinealvs. patrilineal, etc.) * level of access to services and infrastructure * level of integration with markets.

Another factor which influenced site selectionwas a desire on the part of the teams to work in communitieswhere institutionalmechanisms were present which could take up issues raised in the research with the communitiesconcerned. To some extent this may have created a bias in the sample towards communitieswith access to a development program (whether NGO or governmentsupported). Where this appears to be an issue some allowanceis made in the analyticaltreatment of the material.

2 MAINFINDINGS

The aim of this section is to summarizethe principal conclusionsfrom the three phases of research of the Ghana PPA. Principal policy implicationswill be outlined in the final section of the paper.

2.1 Local Conceptionsof Poverty

Local conceptionsof poverty were investigated in all sites, to elicit local experiences and understandingsof the nature of poverty in Ghana. Poverty at the level of a lived experiencerefers to prevailing cultural values concerning 'needs' - the poor are those who fall below an acceptable standardof livelihood. This has social dimensions - they are people who cannot participate as full members in the daily life of their communities. Sometimesthe social status of a person may determine their economic status - migrant groups may lack access to high quality farmland not only because they lack money, but also because they lack entitlements in respect of the local social institutions which determine land access.2 The values which define poverty vary from one community to another, ancldefining the poor at the national level, for the purposes of public policy, is not the same issue as defining the poor in a local community. There is much to be learned, however, from seeing how poverty is viewed and experienced

2In our study this was illustratedparticularly strongly in the immigrantfarmers from the Upper West Regionwho were a substantialsub-section of the populationof the rural town of Derma in Brong-Ahafo Region.

4 by local communitiesand households,and our findings suggest that there are significant general messagesthat can be drawn from these perspectives.

In looking at local understandings it is important to recognize that poverty has dimensionsthat apply at different levels of social organization. The constraints which act on a household's access to income or services are different at the level of the individual, the household and the community. A child's access to education, for example, may have the following dimensions: at the level of the household, lack of money for fees and other costs and concern about missing the child's productive and domestic labor; at the level of the community lack of facilities such as schools and basic transport infrastructure.

The theme of local views of poverty and well-being was explored through two principal methods: wealth ranking exercises for households, individuals and communities, and semi-structuredinterviews. The major conclusionsemerging from the material gathered in our research on local views of poverty are as follows:

Criteria for assessing poverty and vulnerability at the level of the household and individual. These varied by region, and according to the gender and generation of informants, as is outlined below. To the extent that generalization is possible the following elements can be outlined as consistent elements in local views of the characteristicsof poverty and well-being:

* Physical assets: These can be divided into physical assets for production (extremely diverse - including animals, grinding mills, access to land, fishing equipment etc. in rural areas and diverse assets to support productive, and especially trading activities in urban areas, such as vehicles) and non-productive assets which facilitatea higher standardof livelihoodand social status - particularly the type and condition of housing. Both forms of assets also function as stores of wealth which can assist households to survive lean times and therefore reduce vulnerabilityto temporary crises.

Hunan assets: The key importance of labor as an asset in poor urban and rural communitiesreceived constantemphasis in terms of the emphasison disability, age, health, childlessnessand widowhood in defining the bottom strata of the poor. In this category was placed mentally ill people who could not fend for themselves, handicappedpeople, old people who could no longer work (and lacked networks of kin for support), and generallyweak (sick, not healthy) people. In urban areas the possessionof marketable skills (more than formal education)was frequently cited as a key asset that distinguishedthe poor from the non-poor.

* Social assets: An individual's social status and network is a critical resource. As noted above, in rural areas community membership generally confers access to productive resources such as land, and access to and control over labor is critically

5 affected by an individuals social status (including gender) and position within the kin group. The social network is also critical for support in times of need - so much so that in some urban areas people refused to carry out wealth ranking exercises as they argued that it is only when a person is in crisis (e.g. a sickness in the family) that you can assess their level of access to support from kin - which is a key factor in assessing their security of livelihood. Social marginality through isolation from kin networksis a key element of poverty for many migrant groups.

* Activities: In some rural communitiesthe necessity to engage in casual 'by-day' labor was seen as indicative of the poor; the capacity to assist with community projects, and to help disadvantagedkin was seen as an indicator of wealth in most rural communities.

* Level of conswnption:In respect of consumptionsecure access to income and food predominatedin most sites. In urban areas emphasison the diversity of the diet as well as absolute access to food was frequently an indicator of wealth. The other key element defining poverty at this level (applying mostly in the rural and urban south) was the qualityof clothing of an individual and his or her children.

* Access to services: At the householdlevel this was predominantlyseen in terms of health and education. The capacity to educate children beyond primary level was a frequent indicator of wealth for the urban and rural south. In terms of health access was generally perceived in terms of capacity to pay - in relation to education other factors were also involved (especiallythe opportunity cost of the child's labor for either agricultural production, income generationor domestic labor).

Criteriafor assessingpoverty at the level of the community. Rurl poverty, especiallyin the north, is often seen as communitypoverty, where everybody in the community experienceslow incomes, and lacks basic necessities such as water, roads, clinic and schools.For this reason wholecommunities are often describedas poor - and it is possible to carry out 'ranking' exerciseswhich rank communitiesaccording to the level of well- being of their members,in the same way as is usuallydone with householdsor individuals. The criteria which emergegenerally fall into three maingroups:

* Commandover naturalresources of the comnunity as a whole: Includingin particular access to abundant fertile farmiingland, access to common property resources from which essentialmaterial for livelihoodssuch as fuelwoodand foragedfoodstuffs can be gathered,and mostimportantly of all in the north, accessto water for both domesticand productiveneeds.

* Accessto public services:(education, health - level of provisionwithin the community);

* Access to transportinfrastructure., markets, and ease of mobility: Concernover road transport infrastructure,for example was particularlystrong in many communitiesin

6 the forest zone, where, during the heavy rains, a poor qualityaccess road can lead to whole areas being without any form of access to vital services such as curative healthcare,as wellas marketsfor localproduce.

As a general rule communitypoverty is a more comfortabletopic for general discussion than individual or household level poverty, as it avoids the uncomfortable sense of judgementof individualworth and demeaningconnotations of dependencywhich frequently underliesuch discussions.

Viewsof CommunityPoverty in twoNorthern Communities

Beo Tanko. BongoDistrict, Upper East Region Most of the issuesof dramaticconcern to residentsof Beo Tanko (even the poor) were issues that affected everyone in the community, whatever the level of individual resources they controlled. Of overwhelmingconcern were issues such as the really dramaticproblems associatedwith access to water, and the lack of a school or health post in the community.In seeking to probe the issue of 'community-poverty'and assets held at the communitylevel the team asked a focus group of women to cite examples of 'better-off' communities and what the characteristics of these are. They mentionedAdaboya, Akayonga and Dua becausethey have the following: water -for dry season gardening,human consumption,saving timefor women a market-place-provides incomefrom petty tradingfor women good farmlands- abundanceof good quality landforfarming, goodfields natural resources (common property resources) - abundance of economic trees for income- generationfor women - sheahnut trees, dawadawa. Abundantforage and pasture for livestock, goats, sheep etc. - which in turn meansabundant manurefor 'compoundfarms'.

Komaka, BawkuWest District, Upper East Region Thereare rich and poor villagesin the area. Accordingto the youngmen the rich areashave dawadawa and sheanut trees from which these communitiesmake money. Some rich communitieshave water which enablesthem to make dry seasongardens and with the proceedsthey are able to buy "zinc' to roof their houses.Some places have muddyareas and are thereforeable to plant rice and afterthe rice, they plant onionsin the dry season. In richer communities,because there are schools,there are more educatedpeople who bring 'zinc' to roof their parent's houses.They also have bigger markets from w'oichthey are able to trade. The poorerones lack theseand otherslike medicalfacilities. Examples of richercommunities are Gogoand Zebillaand it's surroundingareas. This is becausethey havewater to makedry seasongardening. Examples of poorercommunities are Agatuse,Komeka and Sapeliga.

The oldmen also identifiedthe followingas the attributesof a richcommunity:. - Thecommunity has a dam for dry seasongardening. - The communityhas a school,maiket and a healthfacility . -Thecommunity has a largenumber of houses -Thecommunity has a grindingmill . source: site reports,field teams

The understanding of stratification in poor urban and rural communities. Investigating the experienceand understandingof poverty, vulnerabilityand well-being in poor rural and urban communities involves not only looking at how people define those conditions, but also how they see the distribution of those categories. There was considerable variation in this - with poorer communities tending towards more homogeneity in the level of livelihood. In general, informants divided society (and in

7 particular, their own communities)into four broad wealth cohorts. At one end of the wealth spectrum are those who are perceived as being definitely well off, those who have stable assets to bequeath to their dependents. To paraphrase from the descriptions presented by our informants, "they feed their children properly; they live in good houses ... which they will pass on to their dependents; and they are able to assist others". These members are simply referred to as the "rich" (very few could be named in the rural communitiesstudied; relatively more in the urban). At the other extreme are the chronically hungry, variously referred to as the "extremely poor", the "perennially needy" and the "pathetic". These were said to comprise two broad groups: firstly "God's poor" - a group in which a variety of factors combine to produce a level of destitution which has no apparent remedies - key factors here include disability, age, widowhood and childlessness (female-headshipof households appeared as an indicator of poverty in the rural north, but less so in urban areas and the rural south); secondly a group vvho were seen as chronically poor without obvious disadvantagesrelated to health, disabilityand age - but who were generally resourceless - without significant other assets or skills. Significant among the resourceless sub- group in the rural south are some immigrant widowers and other landless sojourners, many of whom lack not just economic means, but social assets (e.g., supportive kin networks) as well. In between the two extremes (rich and perennially poor) are the majority -- the cohort of so-called "deprived, but hard-working" members of society -- the "not-so-poor" or "hand-to-mouth"category. In poor rural communities, especially in the north, they may be particularly vulnerable to seasonal fluctuationsin well-being, and their living conditionscan be almost as difficult as those of the perenniallypoor.

Regional dimensionsof the undlerstandingof poveny. Criteria for defining wealth in the northern rural communities were based to a significantly greater degree on food availabilitythan in southern rural communities- reflecting the greater vulnerability and depth of poverty in the rural north. In one of the southern field sites (one of the communities where the workihop research was carried out, Darko) village women actually had difficulty identifying the 'poorest' strata of the village as they felt that should mean people who do not get enough to eat - and they were clear that there was no one in the village who went hungry. By contrast the classificationby women into categories of 'rich', 'medium' and 'poor' in the village of Sombo was predominantly based on criteria of food security. A poor woman was described as follows:

"A woman who cannot afford to buy a bowl of grain. One who has to work for others in order to get a share of the crop and after eating it, has nothing left, and has to fall on wild leaves or berries to survive.n

In the community of Beo Tankou in Bongo District in the Upper East Region villagers distinguishedbetween two categories of the poor: the 'beggar with one bag' who has food which lasts for a few months but has to beg for food in the lean season and for seed to plant, and; the 'beggar with two bags' who has to beg in both seasons (predominantly disabled people, orphans, and the aged without adult children to

8 support them). In a wealth ranking exercise 63 % of the communitywere estimated to be 'beggars with one bag' and 30% to be 'beggars with two bags'. Only 7% were seen as having no problem with security of food stocks. A key factor in the greater vulnerabilityof the northern communitiesin terms of food security is the fact that the single, short, rainy season means that there is only one substantial food harvest per year. The far more diverse food farming patterns of the rural south mean that the livelihood systems are more robust and seasonal dimensions of poverty much less severe.

9 Wealth Ranking at Nyingare

Wealth ranking exercises, where local informants assessed the distribution of the members of their communities according to criteria of wealth and well-being which they themselves defined were carried out in most of the communities in the PPA. An example from Nyingare, a rural community in the Northem Region is reproduced below:

In a group discussionwith fourteen nen. The following Wealth/well being categories were identified:

Bundana: is a rich man. He has money, can support his family, can support others too. He helps poor people to send their sick to hospital, feeds the hungry, makes contributions on behalf of the community for the development of the community. He supports other people in times of need. Moreover he lives in a cement block house and owns property including other buildings, grinding mills, vehicles, cattle, sheep and goats. The number of cattle a bunidanaowns could be as much as three hundred (300).

Wonsua: is an average person who is neither poor nor rich. He has a bullock and two ploughs, a few sheep of about twenty (20), and can feed his fanily adequately. He does not work on other people's farms. He does his own farming. He plants his own seeds. He does not seek alms from other people.

Faradana: is a poor person. 'You know good but you cannot do good." That is such a person knows what should be done but has not got the means. For example, "If you have an in-law somewhere and the person dies, you know what to do but you cannot do anything and things will go wrong." A faradana cannot feed his family and has to suffer for everyday's food because he cannot store food for the following day. He cannot establish his own farm because he has no food to eat to go to farm. He ends up working on other people's farm 'by-day' to earn a little to feed his family and himself.

Nundana: This is seen as the poorer group among the 'faradana'. The people classified as nundana cannot feed their families. They need support always. During functions or even market days, they do not have good clothes to wear. They have to borrow dresses. Some even do not have wives because they cannot afford the dowry. They do not often look cheerful. Widows are classified among the Nundanas. They do not have anybody to care for them 'okangua mariba'. Orphans 'kpimsi' are also classified among nundanas. When an orphan matures and can fend for himself, he is called 'kpinga'.

Tarima: These are blind people and cripples. People give them food to eat because they cannot work. They move from house to house with small boys and/or girls begging for food. Even their dresses have to be given to them by somebody. The blind people do not know the type of food they eat nor the water they drink.

Classification of Households: From the household map of the community a list of households in every house, was compiled. The names of the households were transferred one by one onto single rectangular cards such that each card represented a household. A five-man panel was selected to help in the identification of the wealth group categories of each household, going through each card, one by one. The scores for each category of wealth group was obtained by counting the number of cards in each wealth group category. Before scoring, the cards of the members of the panel, were removed in order to prevent them from having to rank themselves. The outcome was as follows:

Group: no. of hhs Percentage Bundana 2 4% Wonsua 6 13% Faradana 29 62% Nundana 7 15% Tarima 3 6%

10 Differences in perceptions of poverty by gender and generation.In both rural and urban areas the household was generally not the primary unit in men' s or women's perceptions of analyzing welfare. Both were predominantlyconcerned with their own livelihoods and came up with different sets of criteria for analyzing well-being. The material confirms the findings from other studies in Ghana and other parts of West Africa which show a high level of separation of income streams, and other means of sustaining livelihoods, between men and women within the household. Because men tended to define poverty in terms of a 'poor man' and women in terms of a 'poor woman', the forms of income and assets listed were largely gender specific. So in rural areas of the south women listed production of food crops, and did not list ownershipof cocoa farms, a predominantlymale asset. In the northern communitiesthe criteria for men were clearly based around material assets (although economic and social dependency,and food security and clothing provision were also mentioned). By contrast the women's ranking of village women related almost exclusively to food security. Evidence from the first round suggests a more marked distinction in gender perceptions of poverty, wealth and well-beingin rural than in urban contexts.

The following table summarizesthe material from our fieldwork concerning the issue of separate livelihoodsfor men and women.

Separation of Livelihoods of Men and Women in PPA Study

Activity Men Women Social Classification -Men compare themselveswith other -Women compare themselves with men other women -Well-being is determined by -Well-being is determined by ability ownership of productive assets, fixed to provide daily for family, good assets and ability to provide for health, good personal care, good family marriage, and resourceful children

Production -Men focus on food and tree crops, -Women focus on food crops and crafts, wide range of artisanry non-forest products (NFIP), food activities, processing and trading, limited crafts -Concern with the major harvest and artisanry activities -Interest in ecological change and -Depend on diversification iniputs

-Men depend on limited sources -Women depend on multiple sources Income -Men managetheir own income -Manage their own income -Men look to women in the stress -Cash flow is staggered through out periods (lean season) the year -

-Men provide for production inputs, -Women provide for their production Expenditure and clothes for themselves, shelter, food, inputs, food, their clothes, children's Domestic Responsibilities school fees, health, utility bills clothes, educationalcosts (other than school fees), health bills, utility bills, provide water, fuelwood Source: PPA Field work, 1994

11 Urban households at East Maamnobiand Sekondi operate along the same pattems of separate livelihoods between men and vomen. Here husbands not engaged in primary production are expected to give 'chop morney' to add to their wives' efforts. The issue of inadequate 'chop money' remains a serious bone of contention in many urban households. Wives often complain that the chop money is less than half what is required, in which case they are forced to contribute a greater share than the men.

By contrast women in northern Ghana work more directly under the supervision of their husbands or male relatives, though increasingly there are areas in which they maintain independent resources. All over the country the trend is for women to establish their own farms in addition to the family or men's farms. In fieldwork in the two communities in the Upper East Region in 1994 we found that female labour migration is starting to become more acceptable socially. It was also noted that the phenomenon of female headship of households was more common in the south (urban and rural) than the north. The correlation between poverty ancl female headship appeared to apply only to the north to any reliable extent - where the rare female-headed households tend to be genuinely socially marginal under the patrilineal kinship systems which prevail in the north.

By and large, generational differences in the view of poverty appeared to be a feature of rural rather than urban pe:rspectives of poverty, and of men rather than women - with older men stressing a traditional view of wealth relating to assets that defined status under a purely agrarian system of livelihoods, while younger men express a greater concern with cash income and the acquisition of skills which can produce such an income. In the northern community of Sombo, a stark generational difference emerged in the perception of family size. Older people (both male and female) considered the number of household members as a measure of wealth ("they will grow up and support you in old age") young men and women saw this as a cause of poverty, because of the inability of parents to cater for and educate children sufficiently. To some extent these perceptions reflect social change (with an increased emphasis on individual income as opposed to the large family farming unit among the young), and to some extent they reflect the developmental, cycle of the household, as a large number of young children represents a burden to younger parents, while they become an asset in terms of transfers of income and labor as they grow up and the parents age.

12 Gender and Livelihoods in Butre, Western Region

Butre is a small fishing village, with a population of Ahanta and Fanti peoples. The kinship systems of both groups are mnatrilineal.There are strong gender dhmeions in fishing and farming activities. The majority of the canoe owners are older men plus a few young men. A handful of women have acquired their own canoeswhich are operatedby their male relatives. Normally the person who owns the canoe also owns the fihing net and outboard motor where there is one. Invariably in every house where there is a fisherman there is a woman who smokes and markets fish. We did find however that some fish smokers have no male relatives in fishing. Fishsmoking is very important for the women. They tend to combine it with farming, though a few are engaged solely in farming or fish smoking. Farming is far more significant for women than for the men. Land for farming can be obtained from the chief or the family heads, by both men and women. Wives who are not natives of Butre depend more on their husbands for farm land. The women cultivate both the main subsistence crop, cassava, and small quantities of maize, as well as commercial crops like tomatoes and onions. Gender segregation in work is very distinct at Butre. Whereas the men rely on their sons and male relatives to support them in fishing, the women depend on their daughters and female relatives for labour assistance. It appears that men devote all of their labour to their occupational pursuits, while women commit themselves to both their occupations and their domestic responsibilities such as cooking, cleaning, child care. Very often these multiple tasks are performed simultaneouslyduring the day. Child labour is invaluable for women to meet their labour requirementsfor domestic chores; both young boys and girls fetch water, clean and baby-sit alongside their mothers.

The Concept of Household at Butre: A wide variety of demographic composition and management patterns can be found in the compounds in Butre. Whereas many compounds constitute one household by virtue of their common family origins and 'head' and shared feeding arrangements, It is common to find multiple household heads in one compound. In a few instances migrant fishermen and local residents occupy rented rooms. Compounds are not only known by their heads but also by the occupants of the rooms. This was vividly illustrated in the social map prepared by a women's group, in which an attempt was made to represent every room in every compound in Butre! Separate livelihoods based on separately owned and managed resources between men and women, is common of household arrangements at Butre. Spouses and relatives sharing a household / compound do not pool their resources into a common fund for the home, but rather contribute to domestic expenses. Though children are seen as dependents, they are expected to earn their keep as soon as they are able, in the form of unpaid labour service. source: field site report

Differences in the understandingof poverty in rural and urban areas. A comparison of the experiencesand understandingof poverty in rural and urban areas reveals a number of points of differentiation at a general level. The view of poverty as community poverty, where everybodyin the communityexperiences low incomes, and lacks basic necessitiessuch as water, roads, clinic and schools,is considerably stronger in rural than urban areas. This is also the case for the view of poverty as a transient condition affecting whole communities in periods of crisis or seasonal stress. In poor urban communitiesthere is greater differentiationbetween individuals in terms of their personal wealthand their accessto communityresources. Here it is the middlegroup that is seen to be in the majority, though the third group consideredto be the poor appears to be quite large. The idea of communitypoverty does not featureas prominentlyhere as one finds in the runalareas, as socialamenities are generallyavailable. The determiningfactor here is not availabilitybut affordability.

13 In urban areas the degree of long-ternnvulnerability of individuals was often seen as being tied to their level of acquisitionof marketable skills within the informal sector. Unskilled wage work within the private sector was disliked due to a perceived powerlessness of workers in the face of abuses and breaches of (verbal) contracts by their employer. Unskilled self-employed laboring (market truck-pushers, 'loading- boys' etc.) was seen as leaving the individual extremely vulnerable to sickness, disability (temporary or permanent), and infirmity due to aging. While self-employed artisans might not earn more than such laborers, they are envied for having higher social status and much greater long-term security. All groups in the informal sector, however, envied those in formnalsector waged employment (i.e. where the employee has a contract of employment). For those with informal sector skills, access to seed capital was an importantdimension in defining the non-poor.

Summary:key assets of the rural and urbanpoor. A summaryof the local conceptions of poverty and vulnerabilityleads to the followingkey messages:

a In all sites there were consistent elements in defining 'the poorest of the poor', which focused on the intersection of a variety of conditions which lead to households which have no labor resources, and individuals who have no control over labor resources of any kind. The key elements were disability, age combined with the lack of adult children, widowhood and childlessness. Female household headshipwas more likely to appear as an indicatorof poverty in the rural north than the rural south or urban contexts. While female headship as such is not related in a simple sense to poverty the combinationfor women of age, widowhoodand lack of adult children was frequently seen as associatedwith chronic vulnerability.

• Assets at the community level were seen as more important to rural communities than urban - these included access to water for domestic and productive use, access to public services, access to an abundant natural resource base in terms of fertile farmland and commonproperty resources, and access to transport infrastructure and markets.

* The view of poverty as being a dynamic condition impacting on entire communities was particularly strong in the northern rural areas, vulnerable to drought and to the 'hungry season' prior to the single main annual harvest of bulk foodstuffs. The material collected supports the view that the experience of depth of poverty and vulnerability in the rural north is greater than in other areas through the fact that access to food predominates in local views of poverty, and that in some communities serious food insecurity prevails for at least part of the year for virtually every communitymember. Nonethelessthe material is suggestive of some variation - with highly populated areas in the Upper East (Bawku and Bongo Districts) suffering the worst conditions.

14 * In urban areas poverty tends to be seen more as an individual condition - with key elements in defining well-being includingaccess to stable employment, the ability to acquire marketable skills and access to seed capital (as well as the fundamental asset of physical health and strength).

* As well as physical assets (livestock, capital etc.) and human assets (health, skills) an individual's social network, and membershipof social institutions forms a key dimension of well-being and livelihood security. Access to land often comes through communitymembership rather than the market, and the accessibility of a supportivekin network is critical at times of personal crisis (urgent need for money to pay hospitalbills, etc.).

* Gender dimensions emerged primarily through stressing the fact that there are substantial elements of separation to men's and women's livelihoods in many sections of the rural and urban poor in Ghana. In ranking exercises in rural areas there was a tendency for men to rank men and women to rank women, rather than seeing householdsas unified entities. Men and women thus also stressed different elementsto the experienceof poverty in some communities.

2.2 Priorities of the Poor in Poverty Reduction

In all communitiescovered in our study the issue of the priorities of the poor in relation to appropriate action for poverty reduction was examined. While perhaps the most important element to examine in relation to public policy is what the urban and rural poor see as the most important actions for governmentand other outside agencies to take, it was also considered important to explore local views of the roles that individuals, households and communities could take in order to contribute to overcomingthe key constraintsthat they faced. This confirmed that in no instance did the members of poor urban and rural communitiesregard the key issues they faced as ones over which they were completelypowerless and for which outside 'charity' would be the only solution. There was a complete recognition that action by the state and NGOs should be matched by an equivalent effort from poor communities and households.

The results of the priority rankings. The issue of the communities' own assessment of their priority needs was a consistenttheme in our research. Where possible these views were solicited through focus groups which reflected the diversity of the communities under study in terms, at least, of gender and generational issues. The major findings can be grouped into three broad regional 'blocks': the rural north (the Upper Regions and the Northern Region), the rural south (including the transition zone, forest zone and the coastal savannah - for our purposes communities in Brong Ahafo, Volta, Western and Central Regions) and urban communities (including one intermediate rural town in Volta Region, and communitieswithin the major urban centers of Accra, Tamale and Techiman). In examiningthe issue of communitypriorities we have taken

15 care in the interpretation: the fact that a service does not appear as a priority need may be because the communityis satisfiedwith the existing service - rather than that they do not regard it as important. It should be noted that material on health and education is also examinedunder separate headingsin sections 2.6 and 2.7 below.

Priority rankings in the rural north. The strongest themes emerging from the priority ranking exercises in the rural north are food security, water (both for productive and domestic use), access to health care, and education.

In the semi-arid north only one community failed to rank water as a priority need - Nyinagare in the Northern Region - which can be attributed fairly clearly to the fact that the communityhas been provided with a borehole by the NORRIP water program. It is also partly due to the fact that agriculturein the area of Nyingare is suffering less from over-use of limited land resourcesby a dense population that in the communities of the Upper Regions, where, particularly in Bongo and Bawku, rainfed farming is now so unproductivethat resourceswhich can provide dry season income (such as a dam for dry-seasongardening) are becomingincreasingly critical for basic survival.

In Beo Tanko, in Bongo District, Water was consistently evaluated the most pressing need of the community. Among the linkages that were expressedin different contexts were the following: deterioration in the level of water supply has decreased animal holdings in the village, thereby reducing soil fertility by decreasing manure resources available (poor water supply also encourages villagers to pasture cattle elsewhere which has the effect of reducing farn production - a far more serious problem for villages which face land scarcity); poor water supply creates a huge extra burden for village women; lack of dry-season water supply means that the village lacks effective means for dry season income-generation through vegetable gardening, shea nut extraction, processing of dawadawa for sale etc.; the poor quality of the village water supply leads to severe health problems which in turn impact on the productive capacity of the village. The major articulated demand in relation to water in Beo Tanko is the provision of a dam. The villagers say that a hard layer of rock has defeated all efforts to sink boreholes and hand-dug wells. They also want a dam, however, because it is the most convenient source of water for dry-season gardening and livestock.

16 Water in Tanko

The community informed the team that the only source of water in the dry season was a small pond "which resembles a traditional grave". One had to squeeze tight in order to get access to the water which comes in tiny driblets. This information was confirmed by the team leader who took time off to visit the pond. He found out that only one woman could enter the 'hole' at a time and only half a calabash of water could be scooped out at a time. For this reason, women have to wait several hours to fetch water in turns. It was reported that women usually went in two batches. The first batch leaves around 7.00 p.m. (after supper) and returns around mid-night. The second batch leaves around mid-night and returns at dawn or day-break depending on the n umber of women who might be waiting at any one particular time. The same pond provides water for the community in the rainy season. A focus group of village men linked the lack of water with the high illness of disease in the village, citing guinea worm, bilharzia, diarrhea, stomach pains and skin rashes as ailments linked to the bad water that community members drink

source: field team site report

In Komaka, in Bawku, food security was seen as the principle problem facing the community,while, again, a dam was seen as the most practical solution to this problem as it would allow the villagers to increase the fertility of their farms through pasturing animals locally, and would provide dry season income through vegetable farming (currentlythose of the villagers who are able walk six miles to another site to do this). People in Komakamade an explicit link betweenprovision of a dam and the capacityto retain young men in the village and prevent temporary and permanent out-migrationof the youth. In Sombo, in the Upper West Region, people also saw provision of a dam as one of the top two priorities for the community. In Nyingare the emphasis on strengtheningthe productive systemwas still on rainfed farming - with the village men expressing a hope for renovation of the local farmers' service center which used to provide help in promotinganimal traction for farming.

The other consistent messages emerging from the priority rankings carried out in the rural north was that improved access to education and curative healthcare were priorities among most communities and social groups. Improved access to curative healthcare emerged as one of the top four priorities listed in all ranking exercises carried out in the rural north. The need was usually expressedthrough a desire to have a clinic facility within the community, as physical distance and cost of transport were seen as major barriers to access. The emphasisplaced on education as a priority need was variable - with a strong emphasis emerging from Nyinagare in the Northern Region, where improved access to educationwas the first priority, and lower emphasis in other sites, even those like Beo Tanko and Komaka where there is no primary school in the village and children have to walk three miles or more to the nearest facility. In Nyingare there was a primary school but it did not cater for classes four to six - so to complete their schooling the children had to walk a distance of over two miles to and from Gambaga.

17 Access to grinding-mills for processing millet also emerged as a priority for women in two of the sites. Essentially this reduces dramatically the time spent of food processing by women, and thus, along with domestic water supply, is a major issue for them.

In summary, priorities from the rural north focused on basic livelihoods, reflecting the endemic problems of food security experienced in this area, as well as the chronic problems of domestic water supply that affect communities which have not benefited from external aid such as the NORRIP and CIDA programs of village water supply. The emphasis on provision of dry season water for productive purposes is worth highlighting as it reflects two key problems that afflict the communities which are in the most difficult situation in terms of high population densities, land scarcity and declining soil fertility (conditions which are characteristic of the Bongo and Bawku areas). A dry season water source (such as a dam) can provide two key elements which strengthen the local livelihood systems: enabling livestock owned by villagers to pasture in the area for longer periods of the year thus providing manure for chronically under-nourished farming land and; providing for vastly increased dry season income through vegetable gardening to compensate for the decline of productivity in the traditional grain-farming system. The other consistent emphasis is on healthcare provision - reflecting both poor conditions in terms of access, and the value of physical health and strength which is a consistent theme in the local views of poverty reflected from all areas.

Priority Rankings in the Rural South. The picture emerging from priority rankings in the rural south is more diverse - reflecting the greater diversity in terms of livelihood systems and environment in this zone, as well as the tendency towards greater social stratification, and therefore inira-community diversity. In some communities, such as Butre in Western Region, food security was not a major concern even for the poor - although this was not true of all the sites (food supply was very insecure for the poorer community members in Afrangua, in Central Region). Again access to curative healthcare emerged as a strong and consistent theme - in only one community was this not listed as a priority need, which was Derma in Brong-Ahafo Region where a reasonably well-stocked clinic functions, and improved access to healthcare was seen mainly in terms of the condition of the access road, which is impassable for periods in the rains, denying access to hospital care. Improvements in transport infrastructure (roads and bridges) emerged as a major priority in three of the five southern rural communities. This reflects ito some extent the ecological conditions of much of southern Ghana, where heavier and more persistent rainfall tends to lead to communities becoming totally isolated for periods of the year.3 In addition to denying access to services, poor quality access roads are frequently seen as impacting negatively on the economic opportunities available. Derma, for example, has come to specialize

3 Though it is important to note that someareas of northem Ghana also suffer from rainy-season isolation from services and markets. This is especially true of some of the Mamprusi settled areas in the norther part of the NorthernRegion which are known,with a touchof grimhumor, as 'overseas'.

18 in tomato production in recent years. Difficulties of road access are a major disadvantagein relation to highly perishablecrops such as this.

Access to water for domestic use again emerged as a major theme, especially in the village of Butre in Western Region. In a pattern repeated in some other sites, three wells had been dug with local assistance at points over the last twenty years, but not one of them was now functioningreliably. A local spring had become the major water source, but it is muddy, the water has a salty taste, and it is seen by villagers as the source of guinea worm infection. During the dry season women spend long periods in the day and night queuing for water. In communitieswhere water did not feature as a priority in ranking exercises, such as Afrangua in the Central Region, this could often be traced to an interventionby an outside agency (in this case the NGO, World Vision Internationalwho sunk a borehole in 1986).

Other common themes included access to off-farm employmentand credit for farming (predominantlymen) and trading activities (predominantlywomen). Better sanitation and drainage emerged as themes in three of the five communities. In general the emphasis on education was lower than in the north - though in large measure this is probably because the situation in terms of provision was better (all of these communitieshad at least one primary school, and two - Derma and Dekpor Horme, also had Junior SecondarySchools). For those communitieswhich did not have Junior Secondary Schools, the distances to travel to such facilities were usually less than in the north.

Priority Rankings in the Urban Communities. Six urban communities were covered by the study, including intermediate towns in Volta and Central Regions (populations of 10-15,000) where many aspects of livelihoods remained rural in character, and poor communitieswithin four other urban centers: Accra (East Maamobi), Sekondi, Tamale (Chagni) and Techiman (Zongo and Dwemoh). Again, differentiationwas marked - even in some cases between different sections of the town which experienced different kinds of problems in reaction to urban services. The most consistent concerns, reflecting the nature of urban livelihoods were with inadequate employment opportunitiesand the supply of small-enterprisecredit. Although these elements were consistently scored they were rarely the first priority. An exception was Sekondi - which has seen the almost total disappearanceof a once-activelabor-market associated with the port and associated services. As the business steadily disappeareddue to the long-term impact of the construction of ports at Tema and Takoradi the economy of this community became increasingly dependenton fishing, for men, and fish-smoking and trading for women. The stagnanteconomy means that the youth at Sekondi have an over-riding concern with the issue of un- and under-employment.

Priority rankings seemed to reflect to a large degree the condition of the local urban infrastructure. In particular it was interestingto note that three of our five communities had major problems of supply of potable water.

19 Other issues of urban infrastructurethat received emphasis in some communitieswere sanitation(especially in the Techiman Zongo where facilities were almost non-existent) and urban roads. The latter was only mentioned once, but in an interesting context. East Maamobi has had access roads since 1987 (provided under the World Bank Urban 1 Project). The Maamobi fieLdteam stressed that this is usually one of the first things that the participants mentioned in terms of new services that have come into the area. The roads are said to have brought much improvement to the area for diverse reasons. These included ease of access to health facilities. Now sick people can be conveyed much more quickly to hospilaLbecause cars can come close to their homes. Also benefits were perceived in terms of increasedphysical security - there are more people walking around at night so thieves cannot go unnoticed. The large roads provide channels of safe passage at nig;ht- a particularly important benefit for women.

Problems of Water Supply in Poor Urban Conmunities

Chagni, Tamale: "Discussionsrevealed that dunng the dry seasonmany children,especially girls, absentthemselves from schoolor arrive late becausethey and their mothersor auntsstart lookingfor water as early as 1.00 a.m.. They spendmany hours waiting for their turn. They normaUywilU make at leastthree trips. At the end they are too tired to go to school.The water problem sometimes results in quarrelsbetween husbands and wives. Culturally,men do not fetch water. So whenthe taps start runningaround midnight and a man wakes the wife up to fetchwater, it can resultin a quarrel.Nursing mothers, especially, find it difficultto get up and fetchwater at this time. The scarcityof wateralso affectswomen's economic productivity, as it takesaway from the time availableto pursue their main income-generatingactivity, trading. A woman remarked 'withoutwater you cannotsleep'. In Enotherexercise the womenin Unit 3 indicatedthat of the varioussocial services,they spentthe most moneyon water. Waterfrom wellsor privatetaps bad to be paid for. This was supplementedwith water from tanker servicesin the dry season.The only sources of free water were the communitywell, the dam and rain water. In the discussionon male and femalecontribution to household budget it came out that the entireexpenditure on water was bome by the women. As cultwralnorm, men werenot concernedand consideredit as a woman'sresponsibility.

Techisnan,Zongo "Althoughthey livewithin the confinesof an urbancenter, they have no accessto good portablewater, and all their water for domesticuse is from the streamand two shallowsmal wells. Both the streamand the wellsare accessiblebut the qualityis verypoor for humanconsumption. The surroundings of the streamare litteredwith humanexcreta. Duringthe rainy season,the rainwashes the excrementinto the stream.Boiling of waterbefore consumption is not practised,throughout the researchonly a lady informantconfinned doing this. We witnesseda womanbagging the dirty water fromthe Tano into polyethylenebags to be frozenfor sale." In a priority rankingexercise with schoolchildren,the timethey spentfetching water was listedas the mostsignificant problem the childrenfaced in theirschooling.

Kpando-Gabi Water for domesticpurposes was the highest priority of the group "because all human beings needed water to survive". The introduction of pipes had led to the neglect of wells. Now the pipes are broken down and the wells have fallen into disrepair.

Source,field site reports

20 The emphasis on improved access to education was again strongest in the north (Tamale), while in Maamobi and Sekondi a high premium was placed on being able to acquire skills that could be used in a self-employedcontext. Improved access to healthcare services, again received strong and consistentemphasis.

2.2.1 Strategiesfor moving out of poverty

In addition to the material gathered on priority rankings the views of community members on how these issues could be tackdedwere also investigated. The following table, from Komaka in the Upper East Region, illustrates the kinds of responses that were elicited.

"Ways Out of Poverty"-from a group interview with community members, Komaka, Upper East Region Strategy actions by: Govt. Agencies NGO's IndividualMlh Community Livestock -Take care of grazing Provide collective Veterinary Services Loans to buy breeding Rearing -Buy best breed security i.e. guard stock -Fodder etc. against theft etc.

Dam, Wells -Contribution towards Provide cement -Dams for dry season cost gardening to stop -Feeding of workers migration of the youth l______-Digging of wells -Provide cement Grain banks -Individual will sell Community will Establish rural banks Provide working grain to GB after buy/store grain after for saving cash capital harvest harvest. Resell in the lean season at reduced or affordableprice Seed Increase farmlands Form community Provide early l______groups maturing seed Bullock/ Payments in Form groups of 10 to To provide loans for ploughs insalment and in farm bullockslploughs kind Fertiliser -Start dry season Will ensure community To be provided by gardens pays back loan after govemment on credit. -Make maie farms harvest

The following summarizesthe ways in which the participants in our research saw that individuals, households and communities could help themselves to improve their situation - as well as their priorities for outside action.

Individuallhouseholdlevel strategiesfor moving out of poverly

There was no uniform perception of how individuals might move out of a condition of poverty. In urban areas there was widespread despondency about the future.

21 Informants noted that recruitment to unskilled wage-labor in government service had virtually dried up with structural adjustmentpolicies - and unskilled wage-labor was disliked for the reasons outlined above. Therefore increasingly well-being is seen as tied to the capacity to acquire skills which can be used in a self-employed context (predominantlywithin the informal sector). This is said to be leading to increased competition for apprenticeshippositions, and thereby increasing costs to individuals of gaining access to such training.

In rural areas where there are substantialopportunities in terms of cash crop production (much of southern Ghana)access to capital for farming enterprisesis continually raised as the most significant 'blockage' to individualprogress.

In the poorer communitiesof northern Ghana, the constraintsat the level of the Region or communityare continually raised as more significant than those at the level of the household or individual. The individual strategy most commonlyused to cope with, or move out of, poverty is labor migration. The paradox here is that in migrating substantial numbers of residents of poor communitiesend up by severing their ties with the sender community, thus eventually ending transfers to their kin group. Thus although the individual's situation may dramatically improve, long term effects on the communitymay not always be positive (dependingon the balance between the effect of the loss of an active community member as against the level of remittance to the household and extended family). In northern Ghana the accumulationof livestock was often seen as an important strategy for moving out of poverty. Apart from the inherent productive value of livestock rearing, the manure provided for the farm is critical to households' farm production (especiallyunder conditionsof land scarcity).

22 Costs of Apprenticeship

The cost and period of study under apprenticeships vary according to the vocation, and sometimes the aptitude of the student. On the average it takes about three years to go throughan artisanal course. Over the past ten years the training fees involved in apprenticeships have risen considerably, making it difficult for the youth from poorer homes to gain access to this previously accessible institution. The types of charges that are involved include: an initial charge, usually 50-100,000 cedis; cost of tools and equipment (varies from around 15-100,000; the costs of the graduation party (drinks, gifts, sheep, money).

Anane Bokor Fitters Workshop at East Maamobi.. There are 2 masters and 17 apprentices here. The apprenticeshave to pay the following initial costs: ¢50,000, unspecified drinks, tools worth about ¢50,0004150,000. The training takes 4 years, they are given a daily allowance of C100-¢200.

Prince of Peace Hairdressing Salon, East Maainobi... Mad. Ama has 2 apprentices, they have to pay the following initial costs: ¢30,000-¢40,000, 4 towels, 2pkts rollers, set of combs.

Somnelimesapprentices cannot pay the fees...Peter at Sekondi could not continue school after middle 4, because his parents could not afford it. He went into tailoring apprenticeship at the cost of C20,000 (now ¢50,000), a pkt of matches, cigarettes, beer, schnapps.His father could not pay the entire costs so half of it was waived. His graduation fee was one sheep and one bottle of schnapps.

Some of the Fees are More Reasonable... At the coffin maker's workshop in Sekondi apprenticesare required to pay -3,000, a bottle of schnapps, 5 pkts cigarettes, 12 boxes of matches

Although securing access to education for children is clearly a very high priority for householdsit did not emerge as a particularly strong element in peoples' presentationof strategies for moving out of poverty at the household level in rural areas of southern Ghana (althoughit did feature in the rural north). It is of course possible that although education for children is highly valued, local experience suggests that it is not a particularly important strategyfor moving out of poverty for the householdas a whole.

Community-levelstrategies for povery reduction

The mobilization, at the community level, of resources for the provision of transport, social and economic infrastructurehas long been a feature of Ghanaian life. While provision of labor appears to be fairly universal, the capacity of communities to contribute cash varies greatly. One community (Derma, in Brong-AhafoRegion) had put a great deal of effort into the provision of community-levelassets (including an unfinished tomato-processingplant, a clinic, two Junior Secondary Schools, a Rural Bank, and a still unfinished program of rural electrification). While community involvement in the provision of social infrastructure is also widespread, community involvement (as in Derma) in the provision of productive infrastructure tends to be

23 dependent on the identification of specific income-enhancing strategies which can be carried out at the community level.

It is notable that, although northern communities had much the same analysis of the importance of social infrastructure their ability to provide cash to support such construction projects was very highly constrained - while contributions in terms of labor could be mobilized at the same level as the south. As has been noted above, the key resource at the community level in much of northern Ghana is the provision of a dry season water source - both for domestic use and productive activities. Over recent years (since the mid-1970s) dry season farming of a range of crops for market sale (in particular onions) has become a vital survival strategy for many communities and individuals, especially in the Upper East Region. While communities are prepared to make extensive labor inputs to small dam facilities, the cash costs of establishing them tend to be outside their reach.

It was striking that while rural communities had established practices for the support of community-level initiatives, and also innovative ideas for extending these - in urban communities there was little that people felt they could accomplish through collective action at this level4 . In terms of moving out of poverty only the occupational associations to which many in the informal sector belong were mentioned in this context. Although local leaderships exist in urban areas they seem to be commonly viewed as distant from the concerns of the poor.

Local views of priorites for public action for poverty reduction

The local priorities for public action for poverty reduction varied between our sites in line with the differences outlined above. For the rural north the major concerns were with strengthening livelihoods through provision of water for dry season productive activities and domestic use, and with improved service delivery in health and education. A role for outside agencies was perceived in terms of providing assistance with construction of dams and provision of wells. In relation to service provision the poor level of access to both health and education facilities was a major concern. While communities could help in provision of physical infrastructure effective sustainable management of schools and clinics was seen as being a matter for public action. In relation to NGOs, a high level of appreciation was voiced for NGO efforts in health and education provision, and a, recognition of certain areas where NGOs had specialist expertise which could assist in strengthening local livelihoods. In Komaka, for example, the community members were keen to establish a grain bank to create emergency food stocks in the village and thus reduce vulnerability to both drought and the ravages of the 'lean season'. This was seen as an area where NGO assistance was likely to be more appropriate and effective than government assistance.

4. See page 108, Aryeetey,et al. (SynthesisReport, Phase 1 & 2)

24 In the rural south and in urban areas provision of improved employment opportunities was seen as a major priority for government action - although the sense of specific details of what actions this might involve were not clear. Similarly credit emerged as a major concern both for farming and small-scaletrading activities (the latter particularly for women). This is seen as an area for both government and NGO intervention. Improved access to water and quality of water supply were major issues in some of the urban communities, as was improved sanitation. To a greater degree than in rural communities, urban communities tend to see domestic water and sanitation as appropriate areas for government intervention. In rural areas of the south there was a strong concern in some communitieswith the conditionof the road infrastructure . The improvement of road infrastructure was generally seen as an area suitable for collaborationbetween communitylevel institutions (mobilizing labor and maintenance funds) and outside agencies, particularly local government (provision of capital, equipment and possibly food-for work incentives). As in the north partnerships with governmentministries were seen as the appropriatemeans for increasing access to basic health and education services. There is still a tendency to see the community's role in terms of contributingto the constructionand maintenanceof physical infrastructure.

2.3 Vulnerability: DynamicDimensions of Poverty

Frequently local understandingsof people in poor rural and urban communitiesof the key elements in sustaining their livelihoods concur more with the concept of 'vulnerability' than that of poverty. The idea of a secure livelihood is frequently more important than the incentive to maximizeincome. 5 To ensure this security people need more than just access to opportunitiesfor employmentor increasing the productivity of their self-employedor household based activities and access to social services. They also need a structure of stable institutionsat the local level which provide a framework for local cooperationin a variety of critical areas - which may include managing the natural resource base of the community; community based systems for assisting vulnerable groups; systemsof cooperationin farming or other productive activities.

Vulnerabilityis a 'dynamic' concept which refers to the way people experiencechange over time. Such change may have a number of different dimensions:

* seasonal change: Including periods of stress in terms of food supply, the incidence of disease and workloads (especiallyof women) in relation to farming, access to fuel and access to water

* long-term trends: For example declining soil fertility, unfavorable movements in terms of trade, changes in the labor market etc.

* 'shocks': Experiencedeither at the level of the region or community (e.g. drought) or at the level of the individual/household(e.g. illness).

5 See, for example,Robert Chambers,Introduction IDS Bulletin on Vulnerability1989

25 Some of these issues have been coveredunder local conceptionsof poverty above, but a brief summaryof some further issues can provide useful further insights into the nature of poverty and change in Ghana.

2.3.1 Seasonal dimensions of poverty

Seasonal fluctuations were a major aspect of well-being in all research sites. In addition to the well-documentedphenomena of stress points in the agricultural cycle, which takes its most severe form in the 'hungry season' problems of many savannah communities, there are significant seasonal cycles in urban occupations related to factors such as weather (impact on building), the cycle of social activity and key festivals, and market flows related to the agricultural year. The cycle of festivals has a complex effect on urban trades: major festivals, especially Christmas, bring large numbers of out-migrants back from overseas where they may be very high eamers indeed in local terms, causing a reported peak in building activity in one communityas they provided major infusions of cash for house-buildingprojects which are effected over a period of severai years. Festivals also lead to high spending on personal appearance, and peak activity for hairdressers and tailors - while the period of a major festival constitutes a slump in business for cooked food sellers, as people are more inclined to prepare food at home.

As has been noted above the major seasonalfood security issue in Ghana is the extreme 'hunger season' experiencedby many communitiesin the north - especially those where intense population pressure has led to declining soil fertility (for example, Komaka, Beo Tanko and Sombo in our sample). These communitiesexperience major problems of basic food supply even in a normal year - and the impact of drought years can be extreme. As a general rule, the more diverse the farming system, in terms of the mix of basic staples and crops grown to generate income, the less was the degree of vulnerabilityto seasonalfood scarcity. On top of that cassava, as a crop which can be available for harvesting all year round, often plays a special role in mitigating vulnerability.

26 BeoTankou: Food Security Calendar

A group of men prepareda foodavailability calendar at BeoTankou showmig the timesof the year when foodis short supply as follows:

Onne Thereis food: (November-December) milletstores; potatoes; groundnuts; bambara beans; rice; cowpeas. Potatoesand beans are soldfor income.

Sapoulgo Food is availablebut declining: (January/February) haveused some to performfunerals, sacrifices. Start eatingflour water (fula) reducedsales

Dawaiga Inadequatefood resources and watershortage: (March/April) seedsare reservedfor planting. Mostpeople are outof cash. Poor people have no animalsto sell.

Natule Heightof HungerPeriod: (May/June) All grainhas been sown;now dependon frtits.

Saama Improvingfood situation: (July/August) Earlymillet is harvested. Somesales to pay for labour.

Fono Improvingfood situation: (September/October) Groundnutsand bambarabeans harvested. Someof the harvestis sold to pay debtsand to buy animalsfor sacrifices. field site report

Where there are marked seasonal changes such as in the north, seasonal patterns of illness have been observed. Ill-healthis said to be most prevalent at the peak of the dry season (dawalik, Komaka; dawaliga, Beo Tankou) in February and March, by which time the food situation has started to worsen. Fevers, stomach disorders and respiratory diseases were described as the most common at this time. By experience the most dangerous time to fall sick is during the rainy season (seug, Komaka; seng, Beo Tankou) when there is very limited food supply, and no money to go to the hospital. It is also the time when people need their energy most to work on their farms! Some diseases cross over from animals to humans, they include tick attacks, anthrax and to some extent foot rot.

Worse still, increasedpoverty during the lean season makes it difficult for the family to respond adequatelywhen someonefalls sick at this time. At Beo Tankou deaths had recently occurred which according to the participants could have been avoided with hospital care if the people had money to visit the hospital:

"Most of us have no money or food and nothing to sell for money. That is why death is so rampant in this village. Take the death of this small boy this morning for example, the boy died of measles. We all know he

27 could have been cured at the hospital. But the parents had no money and so the boy died a slow and painful death not out of measles but out of povertyl". (A group of men at Beo Tankou, 1994).

In the middle and coastal belt double maxima rainfall areas of communities such as Butre, Kpando Gabi, Derma and Dekpor Horme, there is apparently little differentiationin the seasonal occurrence of sickness. Cholera and diarrhoea seem to peak during the 'time of mangoes' in the minor rainy season, but other diseases occur all-year round.

2.3.2 Long-Term Trends in Poveny

Long-term trends in the rural sites

The predominantfactors in the perceptions of long-term trends of rural populationsare environmental. For poor urban populations they relate to the labor market and the perceivedavailability of work and demandfor informal sector products and services.

The list of aspects of decline in environmentalconditions in rural areas included: water access (declininglevels of the water table, decreasing quantity, quality and duration of stream flow); availability and quality (fertility) of farm land and pasture for animals; access to a range of products from common property areas, for both own consumption and sale for income (including fuelwood, medicines, foraged foodstuffs such as snails, fruits, mushrooms, bushmeat, and other non-timber forest produce). In the northern savannahcommunities the key elements of environmentalchange were perceived to be declining soil fertility due to decreasing fallow periods, declining water resources as outlined above and a shorteningof the rainy season, combinedwith less predictability.

In the relativelymore agriculturallyabundant communities of the middle and coastalbelt, importantchanges have takenplace in crop mixesin responseto environmentaldegradation, as well as market demands. Some of the changes have however been introduced via governmentpolicy, as in the case of rice productionfollowing the Afife dam at Dekpor Horme, and tomatoes at Derma. At Dekpor Horme sugarcane,oil palm, agor trees and bamboohave been replacedin significanceby cassavaas the main reserve or stress period crop, especiallyfor women,after the constructionof the dam led to large scale alienationof village lands. It is importantto note that before the dam the number of significantcash cropswas greater for both men and women. Though the middle belt communitieshave a relativelybetter situationwith regardsto food productionthan we find in northernGhana, increasingproblems with soil fertilitypose a threat to food secunty. At Butre a time line discussionwith a Mad. Sefua oIInatural resources revealed that soil fertility had dropped from a perceivedhigh level to a low point, since the 1940s. She indicatedthe loss of crop varietythat has accompaniedthis processas follows:

28 * 1940s- they could plant plantain, yam, groundnuts, coconut

* 1981- rainfaU had become erratic, but cassava sticks could produce six big tubers compared to a few small ones today.

* 1994- rainfall is unpredictable, cassava variety has changed, because traditional varieties no longer do well.

She attributed poor soils to 'too many farmers', and a drastic reduction in the fallow period from 5 years to 2 years.

Trendsin Liveihood:Nyingare, Norhern Region

About 20 years ago the man sources of livelihood was farming. The farms could produce enough foodstuffs to feed the familythroughout the year. Crops suchas millet, guineacorn, maize,yam, beans, groundnuts, vegetables,okro, etc. were grown. Peopledid not rely on fertilisersalone but used farm manureand the farmscould produce more food. Therewere plentyof trees, suchas sheanut,dawadawa, and mangowhich produceda lot of fruits. Peoplereared a lot of livestockand poultryin the village.

In 1983, bush fires greatly affected almost all the sources of livelihood in Nyingare. A lot of their fiuit trees such as, sheanut and dawadawa got bumt. During the same era, the soils became poorer and their farms could no longer produce much like they used to twenty years ago. Farming became less and less lucrative. Children are no longer keenly interested in farming because it is less rewarding even if they have not been to school. Fire wood cutting and charcoal has rather become more lucrative. They have become the only solution especially to women for meeting their needs. Yam could no longer be cultivated. Maize produce then also gave way and the only crops cultivated were: millet, guinea corn, groundnuts, beans and vegetables. Sheanut trees and dawadawa trees declined in output and were not as rewarding like they were twenty years before.

The long drought and unreliable rains greatly affected crop yields. Farmers could no longer depend on their farm produce throughout the year. Women had to depend on the felling of trees for fuel wood and to bum charcoal to sell in order to purchase grains to supplement their household food requirements. Women at times had to gather some bitter leaves locally known as 'gora' which they would boil and then pound into cake form which was eaten with a small quantity of salt and pepper added to it. At times, when they were able to buy a small quantity of grains after selling fire wood or charcoal they would then grind the grains on stones to make com meal to be eaten with the pounded bitter leaves. It was not easy to come by vegetables or ingredients and groundnut paste to make soup to be eaten with the bitter leaves. Women had to go through a very busy day struggling to look for food or anything to feed the children. Men had to rely more on their wives who struggled to fend for the family. source: group interviews,field site reports

Changes in crop mixes have had mixed consequences on the communities that are affected. This is illustrated by changes at Derma. Over a twenty-year period cocoa has dropped from the position of top ranked crop at Derma to the bottom of the list while tomato and maize have risen to occupy the top positions. The Akomadan Agricultural Project persuaded farners to grow tomatoes at Derma, after declining rainfall and bush fires had made cocoa less profitable. Also between 1981 and 1983 when this shift became widespread chemicals shortages made cocoa vulnerable to black pod disease. Returnees coming back to the area

29 after the expulsionof migrantsfrom Nigeria in 1983 realisedit was more profitable to go into short-termcash crops such as maize and cassavarather than cocoa, which was more difficultto manage.The tablebelow showsthe long-termtrends in crop mixesat Derma as describedby the Assemblyman. The trends in crop mix changesmay be sending a signal that the poor cannot wait for crops like cocoa to turn their lives around because of the relativelylong time to maturityand friition.

Table13: MajorCrops In Orderof Inportanceto VillageProduction, L971-L993

Period Crops - in order of significance in village production 1971-5 Cocoa, maize, plantain, tomato 1975-83 tomatoes, cocoa, maie, plantain 1983-90 tomatoes, mnaiz, cassava plantain, cocoa 1990-93 tomatoes, maize garden-eggs,groundnut cassava,plantain, cocoa Source: Derma Field work - interview with Assembly-man.

It is worth noting that a ccommonfeature in many of the accounts of declining environmentalconditions was a perception of a watershed point in 1983 when severe drought and general systemic collapse of many of Ghana's institutions combined to produce a general environmentalcrisis. An epidemicof bush-fires produced permanent change in many ecological systems up and down the country. Clearly, however, ongoing trends of clearanceof forest and bush fallow made some areas more vulnerable to this than others.

The fact that virtually all rural communitiesperceive an ongoing and systematic decline in the richness of the natural resource base, including many instances where the crop mix has changed profoundly over time (cocoa is scarcely grown in Derma any more, the St. Paul's wilt disease has wiped out coconut plantationsin Butre) has implications that go well beyond the scope of this paper. Over the last thirty years in Ghana the dynamic areas of production in agriculture have been in those areas where extensive resources of bush, forest and fallow land still existed which could be converted for production (Western Region, Brong-AhafoRegion). If history repeats itself we can expect to see export crop production in these areas fall as it did earlier in Ashanti and Eastern Regions, where general environmentalstress has contributed to the widespread abandonmentof cocoa farms due to swollen shoot disease.

30 Another long-term trend which was highlighted in some areas was a tendency to weakening of the bonds of local social institutions of kinship and community. In Nyingare in the Northern Region, for example, focus groups among women revealed a perception that ten years ago there was strong social cohesion in the village. Men organized themselves in groups through communal labor to assist each other to build and roof houses. Women supported each other to do farm work such as sowing, weedingand harvesting. A woman who had recently given birth to a baby was always supportedby older women with firewood and young girls to care for their babies and even to give treatmentto the babies wheneverthey fell sick. The individualfamilies tried to support each other. Women would move in groups in search of food to feed their children. They went to the bush in groups to cut fire wood and to burn charcoalto sell. Respectand authoritywas still given to the chief and his elders. Communitysolidarity was still expressedthrough mutual support and assistancefor one another. Decline in the traditionalinstitutional framework for such reciprocalanrangements was a fear expressedin other sites in the north associatedwith increasinglevels of temporaryand long-termlabour migration. Such changes clearly create increasedvulnerability for the poorer sections of such communities,by weakeningtheir 'social assets' in terms of networksof kinshipand community through which they could mobilise claims on food and labour from their neighbours.

Long-term trends in urban sites

In urban areas, local analysis of long-term trends in livelihoodsindicate that people feel that there has been a continuing downward slide in many types of business, which started around 1988, and their standards of living are falling. This followed on a period of generally perceived improvement and recovery from around 1983 to 1988. The following reasons were offered for this change: low levels of demand for many informal sector products and services; an increase in the numbers of people seeking to sustain livelihoods through urban self-employmentdue to factors such as retrenchment from govemment service, parastatals and the private sector, or large numbers of Ghanaians returning from abroad due to the poor condition of many economies in the region, such as Ivory Coast, Liberia, Togo and Nigeria. Paradoxically some informants perceivedvery substantialincreases in both the amount of activity in many urban trades, and the level of unemployment. This was partly explained by the fact that many categories of urban worker were seen as severely under-employed,and that some categories were not perceived as in employmentat all (for example apprentices) becausethey were working without salaryin order to developskills.

To illustrate these trends, in East Maamobi, Almost all the participantsindicated that there has been a decline in their businesssince 1988, with a sharp drop in 1993. Some womentraders explained that their businessimproved after 1983when the situationwas the worst they could remember. Subsequentlyconditions improved steadily till about 1988,but by 1990 the decline in their business started again. They were unable to give any quantitativeindicators of this pattern,as many of them do not keep written records on their business. Howeverstatements such as 'at first I could sell this basketfulof palmfruitbefore

31 the end of the day, now it may take three days to sell' were very illustrative. Many people attributed the decline to increased poverty, higher prices and too many traders and other operators. On one street the number of hair dressers has increased from 4 to 10 since 1990. Sister Ama prepared a long-terrn trend matrix which showed clearly that business was on the decline, and at the moment is considered to be 'bad'. A tailors' location map drawn by Abdul Azziz Tailors showed that within about a 100 metre radius around them, there were 4 tailors and five seamstresses.

In terms of livelihoods another point worth noting is that many of our urban informants relied on activities to a substantial degree which are thought of as rural in nature. For example, the most common male occupation in Sekondi was fishing, and farming was central to the livelihoods of informants in Tamale and in Kpando-Gabi (which although it is a rural town, would appear as 'urban' in the census, with a population of around 10,000). Thus many of the concerns with decline in farming echoed those of our rural poor communities, Interestin!gly, however, these 'rural/urban' dwellers (or 'urban farmers/fishermen') saw different types of causes for the decline in livelihoods. There was a greater tendency to see the withdrawal of the state from supporting input supply as the main problem in these communities. In Tamale this took the form of reduced access to inputs and, critically, agricultural credit, while in Sekondi the representatives of local artisanal fishing groups particularly bemoaned the recent steep price rises in pre-mix fuel used for outboard motors, due to the rapid withdrawal of a subsidy. There was appreciation that there had been abuse of the subsidy (use of subsidized fuel for other purposes than fishing) but there was also a feeling that the rapid rise in price had not given fishing people time to adapt - many had been put in an impossible position in relation to loans they had taken to buy boats and equipment which they now had no chance to repay. In general, then, members of poor urban communities often have natural resource based components to their livelihoods - they are however far more dependent on monetized inputs to maintain these activities than poor rural dwellers, who have more flexibility in terms of the strategies they can adopt. These may involve recourse to non-motorized fishing craft for fishermen and recourse to crop technologies that do not require monetized inputs such as fertilizer for farmers.

Urban Farmers:Trends in Livelihoodsin Chagni, Tamale Informantsexplained that most of the men of the Changnicomnmunity are fannersby professionbut they are graduallyshifting into tradingbecause of lackof inputse.g. fertiliser.A chief,who was also a memberof the focus group, further explained the linkages between crop farming, poverty, trading and animal husbandry. 'Farmingcomes first becauseno matterwhich activity one is involvedin, one has to eat first. People begin to complainabout poverty when they are hungry. Aftercrop farmershave satisfiedtheir food needs, they sell the surplus food at this point the farmerbecomes a trader. Surplusmoney earned from trading is convertedinto animals. The crop farmer at this stage becomesan animal rearer.' Anotherinformant explained as follows:"Farming in the Northis dying, fertiliser,tractor and other inputs are expensive.The youthare willingto farm but they knowthat withoutfertiliser, yields will be poor, and they might go hungry. A traderwould alwayshave liquid money at hand and will thereforealways eat." source:field site reports

32 In some of the communitiesevidence was found of retrencheeswho had suffered rapid declines in living standards, moving from the local 'rich' category to the mainstream poor. One retrencheeinterviewed in Breman-Asikumanin the Central Region indicated that since she lost her job with the Cocoa Board she had become totally dependent on brewing the local gin (akpeteshie)for income. She was no longer able to afford to buy clothing for herself or her children (rated as her top expenditure item before retrenchment) or pay school fees, and was having difficulty meeting essential medical expenses. She said her colleagues who have been redeployed have either resorted to petty trading or farming, or have traveled outside the area to look for employment. Retrenchmentwas seen as having negative effects at the community level in terms of reduced market opportunities,job avenues for the youth and an increase in the rate of crime such as theft.

Social cohesion again emerged as a concern in the urban north as it had in the rural north. The urban communityin Chagni was the only community in the study which was heavily affected by the ethnic conflict between members of the Konkomba and Dagomba ethnic groups which erupted in northern Ghana in 19936. The box below summarizesthe views from that community. Two points should be noted - this is a viewpoint from one side of the conflict, the Dagombas - it was not possible (in part because of the conflict) for any work to be done involving either side in the eastern parts of the Northern Region where the conflict was severe. The second point that should be noted is that the communityelders' concern with issues of social cohesion is understandablegiven the recent experience of this conflict. People are aware that Ghana is moving into a new phase with the reintroduction of democratic forms of governance which is perceived in poor communities as creating dangers as well as opportunities.

In conclusion, views of trends in rural communitiestend to focus on environmental issues such as declining access and quality of water, declining soil fertility and declining common property resources for the vulnerable to fall back on in times of crisis. The view of the urban poor relates in more detail to the evolution of policy frameworksin the era of adjustment. While a considerableimprovement is appreciated to have occurred in the early phase (from 1983 to 1988) there is a general perception that opportunities for the urban poor have been becoming more constrained in the period since the last six to seven years. In all communitiesthere is some concern over what is perceived to be a very poor situation in relation to assistance with credit for trading and productive activities. In the urban areas this is perceived as a declining trend whereas in some rural areas this seems to be perceived more as a continuation of an unsatisfactorysituation.

6 For those not familiar - this was an extremelyserious conflict set againstthe comparativelypeaceful historywhich Ghana has enjoyed. Estimates of the casualtiesvary widelybut generally cite figures of well over a thousand dead.

33 A view of ethnicity and social cohesion: elders and opinion leaders in Chagni, Tamale

So many different ethnic groups are represented in Changni. They include the Dagombas, who are the indigenous people of the land, Ashantis, Moshies, Ewes, etc. There were two Kokomba houses but these were burnt down during the recent war. According to the group of informants, commumntymembers escorted the two Kokomba failies to the nilitary barracks before their houses were later burned down. This was because the relationship between the community members and their Kokomba neighbours was very good before the war erupted. The informants explained that the war erupted as a result of an attempt by the Konkombas to wipe out the Dagombas from Yendi, take the land and establish a paramount chieftaincy. In an earlier informal discussion with the social welfare staff, it was explained that Yendi is the traditional seat of the Dagombas where their paramount chief resides. Moreover, the Dagombas consider their chief as next to God. The chief is popularly installed through an elaborate process of consultations with various identifiable segments of the Dagomba population. As the group put it:

"Anything that disturbs the peace of the chief disturbs the peace of all Dagombas"

In the view of the group, presently there are no ethnic tensions within the Changni community. Cordial relationships exist between aU the ethnic groups. Cordial relationships also exist between the various religious groupings e.g. Christians and Moslems; though Moslems form the majority. The assemblyman cited himself as an example of the cordiality between the religious groupings. Although he is a Christian, a Roman Catholic, by faith, he was elected as an assemblyman in a predominantly Moslem community. A cordial relationship exists between the chief and the assemblynan. According to the assemblyman, 'if he needs me he sends for me, if I need him I go to him. I have confidence in him and he has confidence in me.'

Both the sub-chief and the assemblymarnagreed that the only tbing which can seriously disturb the peace of the community is 'partv politics'.

The sub-chief explained that 'the youth have never seriously experienced party politics so they do not understand it'. It was also explained that it will be difficult for the parliamentarian of the community to mobilise community members for comraunallabour because those who do not belong to his party will not co- operate with him. Further views were expressedalong these lines:

'In the absence of political parties there is peace'.

'With political parties, it is difficult for people to live in harmony without suspicion'.

'Party politics brings division. It brings a grudge between people. It brings enmity and disunity'. Source: PPA site report

2.4 Survival Strategies and 'Safety Nets'

2.4.1 Survival and coping strategies

A detailed examination of livelihoods of the poor in Ghana clearly reveals that the concept of a 'coping strategy' has potential pitfalls. What to an outsider may appear as a 'coping strategy' for a period of unusual stress, may to poor urban or rural populations appear as a normal part of their strategies for sustaining their livelihoods on a daily basis. For example, while we may see removing a female child from school as

34 a 'coping strategy', to the family concerned it may appear as a fairly routine withdrawal of what was in any case a 'luxury' item of expenditure. Nonetheless, certain defined strategies can be identified which apply to people's attempts to cope with the consequences of negative changes over times (seasonal stress, temporary 'shocks', long-term negative trends). Both the negative impacts, and the strategies that evolve to cope with them may occur at various levels: household, individual or community. For example, the loss of a member of the household labor force during the farming season to illness, with accompanying medical expenses, constitutes a 'shock' at the level of the household's livelihood, with no necessary broader impact. A drought year impacts on a whole community, though the responses it provokes may be organized at various levels, including the household, the wider kin group and the community.

The coping strategieswe recorded in the course of the three phases were very diverse. Some of the more commonelements included:

- For the rural north: Out-migrationin search of employment; sending children to stay with kin in times of stress; using 'famine foods' gathered from the bush.

- For the rural south: Reducingexpenditures (taking children out of school); changes in conjugal patterns (contractinginformal unions due to inability of young men to make bridewealthpayments).

* For the urban south: Reducing expenditures, including relying increasingly on cooked food sellers, withdrawingchildren from school; diversifyingincome sources

An importantpoint to note on coping strategies, is that different coping strategiesat the individual level are not available equally to all categories of the population. For example, market-basedfallback mechanismssuch as migration from the rural north are more available to young men than to many women, children or the elderly.7 The removal of the young man may even have negative effects for the livelihoods of those left behind (dependingon the level of transfers received).8

Where a common 'fallback' mechanism appears to have negative consequences for more vulnerable sections of the population considerationneeds to be given to possible alternatives. For example, over the last fifteen years some areas of the Upper East

7 Although there was a perception in many communities that femnalemigration was increasing. This is backed up by studies carried out of girls, predominantly from the Northern Region, who migrate to Accra to work as market porters, frequently living on the streets. See Bearing the Weight: The Kayayoo, Ghana's Working Girl Child Agarwal, Attah, Apt, Grieco, Kwakye and Turner, paper presented to the Unicef Conference on the Girl Child January, 1994. s For discussions of the effects of differential market access by gender on fallback mechanisms for men and women see Ann Whitehead, "I'm Hungry, Mum: the Politics of Domestic Budgeting"in OfMarriage and the Market ed. Young, Wolkowitz and McCullagh, 1981. Also Whitehead,1987, Distributional Effects of Cash Crop Innovation: The Peripherally Commercialised Farmers of North East Ghana.

35 Region have diversified with considerable success into vegetable farming as a dry- season activity, providing an alternative source of income which may firstly, reduce male out-migration, and secondly, provide income on a broader basis within the community. Provision of dry-seasonwater sources to support this kind of activity was the main priority need emerging from the rural communities in the Upper Regions. Assistance of this kind may strengthencommunity-based fallback mechanisms (local 'safety-nets') through encouragingcommunity solidarity and cohesion.

The adaptations which the urban poor reported included an increasing recourse to cooked food sellers, which prove cheaper than attempting to cook at home. It was also reported that it was easier to limit expenditureon quantityby using cooked food sellers, perhaps an indication that the hospitality norms of traditional Ghanaian cultures make the consumption of regular meals in densely crowded residential spaces socially uncomfortable. An increasing tendency to pay for both goods and services 'by installments' was also reported..

By all accounts many of the long-standingcoping strategiesthat are known in resource poor communitiesare becoming less accessible for combating stress periods. This is explained by the fact that most of these strategiesare themselves under threat because of worsening ecological conditions and the escalating cost of living. The situation appears to be more grave in northern Ghana, where in communitiessuch as Beo Tanko the consumptionof wild foods forms a regular part of strategiesof dry-seasonsurvival, though one should not under--estimatethe looming deprivation in other parts of the country.

Coping strategies in the middle belt and the coastal zones have suffered as a result of environmental degradation. T:ree crops at Butre have lost their significance as 'fall back' resources, with the destruction of coconut trees from Cape St. Paul CoconutWilt disease. Oil palm trees that have been planted in replacementmostly by men, have not started fruiting in the majority of cases. With this disaster women have also lost the opportunity to earn income from coconut oil processing, and all the economic by- products that come with coconut processing; the coconut technologyis likely to be lost to the subsequentgenerations of men and women. In forest zone communitiessuch as Derma the income-generationand nutrition benefits of some gathered items of minor forest produce have become increasinglyless available (for example, snails which were commonly gathered for sale in parts of the year in Derma). This follows a general pattern where degradationof commonproperty or open access resources tends to have a heavy impact on the poor who are disproportionatelydependent on these resources due to lower levels of access to land and labour for farming.

2.4.2 Formal and informal safety nets

In several instances a criteria for identifyingthose who were not poor, wealthy or high status was their capacity to help kdn or 'help the community'. By contrast poverty in some instances (especially one of the workshop sites, Darko) was associated with

36 'dependency' on others for survival. In larger, more ethnically diverse, and complex situations the network of support individuals can mobilize is not in any simple sense linked to 'the community' (viewed as a homogenous social group bound by common norms and carrying out some activities in common). One area where assistance from kin was consistently cited as critical was in accessing social services - especially emergencyhealthcare.

External sources provided valued, but relatively rare assistance in many of the field sites. Best placed were those communities with an ongoing NGO program, such as Afrangua, and Koforidua (World Vision), or Komaka (Action Aid). On a less systematicbasis the Baptist and Catholic churches had provided assistance in two crisis years (1983 and 1992) in the community of Sombo (Upper West Region). Governmentalsafety nets were not mentioned by any informants as being in any way relevant for the poorest members of these communities. Our research suggests that the endemic problems of food security in northern Ghana in particular have never received the serious attention they merit. While all communitiessurveyed prefer the prospect of assistance to develop the productivity and security of their livelihoods to 'safety net' kinds of assistance, the severity of problems experienced by the poor in the north suggests a need for a more robust response in terms of an ongoing institutional frameworkfor addressing the worst affected social groups and areas.

2.5 Local Perceptionsof Service Quality and Access in the Health Sector

Many small rural communities in Ghana have very low levels of access to modern health facilities. Despite the already low level of coverage, there are situations in which health services have been closed down or withdrawn in the case of mobile services.9 As a result people in the rural communities rely extensively on traditional health providers such as traditional birth attendants (TBAs), herbalist/bone-setters, fetish priests drug peddlers and spiritualists.Close proximityto modern health facilities in the urban centres has considerablyreduced dependenceon these informal sources, though there are certain categories of illness that people prefer to take to a traditional healer.'0 Exampleswere given of situationsin which relativeshad withdrawntheir patients from hospital to be taken to traditional healers.

Everywhere the selectionof a health care provider is contingentupon many factors, and as a result visits to a health facility tend to follow a sequence. A visit normally starts with the most accessible or least expensive of the facilities available, though other considerationssuch as type of illness rather than cost and convenience may influence the sequence. Sequencing of visits to the health care facility commonly takes the

9 An ante-natal clinic at Beo Tankou has been terminated

'° . In northern Ghana, for example, fractures are always taken to traditional practitioners - 'bone-setters'. In Central Region epileptics were taken to local spiritualist churches in search of a cure.

37 followingform. Many people depend on home remedies or visits to the herbalist as the first step in the treatmentof illness. When it becomes critical they will proceed to the doctor or the spiritualist / fetish priest, depending on the local classification of the illness.

The following section summariseslocal views on different types of healthcare services:

* Home remedies: For the average person cut off from a clinic or chemist, home remedies are affordable and available. Both men and women learn about medicinal plants from their close relatives; the women are particularly familiar with herbs that cure childhooddiseases, and female reproductivedisorders. Home remedies include the use of herbs, peddled drugs, and good nutritious food. But the knowledge is limited and not effective for very sick people. Home remedies are thus seen more as for first aid and minor ailments.

* Herbalist: The herbalist is always available. Though knowledgeof medicinal trees and other plants is quite extensivein the community, the herbalist is recognised for his/her special skills in maldng them work. Their speciality in the north is bone- setting. But times have changed and some people have become sceptical about herbs, commentingthat "traditional medicines have lost their potency, people have forgotten how to make them work" (Group of men, Beo Tankou, 1994). Threats to the availabilityof herbs were also raised as an issue. Evidence of genetic erosion is growing due to difficulties that have been observed in finding certain varieties of herb plant species. It is widely feared in the rural communities one day that these plants would disappear altogether. Apart from the problems with the natural resource base, there is concern that the herbalist is no longer honest, and reliable. For the sake of profit, he is now prepared to dupe his patients. The excessive commercialisationof the vocation is believed to have reduced the potency of herbs. In the words of an old man at Komaka, Bawku, "At first they used to charge only a fowl. Now they take at least a fowl, guinea fowl, and C2,000."

* Fetish priest/soothsayer: 'They are available in the community or neighbouring communities. They advise on what sacrifices to make in order to get well, or overcome other kinds of misfortune(apart from ill-health).

* Spiritualist: The place of a spiritualist rivals that of the herbalist or fetish priest in many ways. They are more commonly found in the south than in the north of Ghana. Many derive their strength from Christian teaching, though in practice there are overlaps between their spiritualism, occultism and fetish practices. Sickness caused by witchcraft is said to be the speciality of the spiritualist. At Butre the Nakaba Gardens where Maame Osofo casts out demons is highly rated in the sequencing of health care visits. Like the herbalist and fetish, spiritualists are easily accessible and also very flexible in their charges. The women at Butre do acknowledge however that there are diseases that the Nakaba Gardens cannot cure.

38 * Clinic: It is widely appreciated that modem health care facilities such as clinics have powerful treatment for very sick people. All over, women and men acknowledge that child mortality for certain diseases such as measles has reduced. Similarly death in pregnancyand child birth has gone down compared to the past. Illnesses such as hernia can now be cured by surgery. In spite of the high regard for hospital treatment, patients obviously do not always take this route. Some of the reasons that are given are cited below. People are discouraged from going to the clinic because of the high costs involved. In addition one has to pay before treatment. Whether they get well or not, subsequentcharges are not reduced. From the north there were complaints that non-literate and poor patients are shown no sympathy at the clinics: ".. nurses at each point want to take money from you... .It is not first come first served or treated but those who have money get treatment, and those who do not have money die..... The pharmacists at the clinics give patients less quantity of the drug than the doctor has prescribed and sell what they should have given to you." (A group of 13 women at Komaka, 1994). But these experiencesare not necessarilyuniversal in the Ghanaian context. Elsewhere in the south the health staff are described as pleasant and hardworking, though patients have to wait too long to see a doctor.

3 Drug seller/chemists: In the case of minor ailments the drug seller can give medicine for quick relief (e.g. headache). The drug seller is usually a peddler, he has a mobile service and often has no formal knowledgeof drugs or doses, except information he has picked up on the job. He is seen to be good because he sells medicine on credit. But the drug seller can be dishonest about his medical knowledgeand treatment: "There is danger of overdose because they do not explain or inform mothers of the correct dosage ... If you say you have stomach-ache and he has not got the medicine, he will give you one for headache because it is the money he is after." (13 womenat Komaka, 1994).

In the urban centres, chemists or pharmacistsgain a very good reputation if they are kind and understandingabout their patients' problems. Their kindness is expressed in terms of selling prescriptionsto people in small batches, or sometimesallowing people to pay for the full prescriptionby instalment. This raises very serious problems with regards to drug abuse and the complicationsthat arise as a result. When people cannot afford the prescriptionthey may simply abandonit.

With the introduction of the health sector reforms -- comprising the Primary Health Care (PHC) program and the Expanded Program on Immunization (EPI), patients are now expected to share in the costs of health delivery. Drug costs are now being recovered in full (through the cash-and-carry system),1 and patients are required to contribute towards the cost of consultationsas well.

"Indeed, drug prices are frequently marked up in cash-and-carry pharmacies to cover inflation and petty losses.

39 In general, the most accessible health options in the communities studied are those under private control. In urban areas, where they are more widely available, drugstores tend to be the first choice of the sick. In spite of assurances given prior to the introduction of the cash-and-carrysystem, the research teams were consistentlytold that private drugstores tend to be better stocked than hospital pharmacies are. Sometimes referred to as "'doctors"12 by community members, drugstore-keepers typically dispense orthodox rnedication without prescription, parceling out drugs in whatever combinationsand quantitiesthe self-prescribingcustomer requests and is able to afford.13 In the view of local populations the male drug-store keeper is often incorrectly perceived as having a higher level of diagnostic skill than the female clinic nurse. At home, nurses are consulted by local residents for advice and treatment (in some cases their informal assistance in the capacity of community members appeared much more highly appreciated than the services of the formal institutions for which they worked).

In rural communities, particularly in the northern savannah (where poverty is more intense and orthodox/ quasi-conventionalhealthcare is less readily available), herbs tend to be the first option in sickness. Northern communitiesalso rely on remarkably competent "bone-setters" to restore fractured limbs -- we would hasten to add, however, that this is done without the benefit of anesthesia! Common in most rural areas are traditional birth attendants -- or TBAs -- who deliver babies, using indigenous skills. It is also common for the sick to combine treatments from a variety of sources (e.g., exorcism with herbal preparations; or herbs with conventionalmedicines bought from drugstores). Even hospital patients will sometimes combine their doctor's treatmentwith herbal applications.

The least orthodox categories (such as the "spiritual churches" and herbalists) are most patronizedby the ultra-poor and the oldest members of society -- who also tend to have the most traditional lifestyles. The study also revealed that while these groups are the most dominant users, many other rural households use the services of such infornal health delivery agencies during periods of financialhardship. There are several reasons for the higher utilizationof informal healthcare options, including:

the generally superior accessibilityof such healthcare providers (not only do they tend to be locally resident whereas orthodox facilities are only available in the larger towns; bureaucracy and waiting times are negligible compared with public

' 2This may explain why the latest round of the Ghana Living Standards Survey is reporting incredibly high levels of professional consultations. 13The Techiman team reports, from interviews with drugstore managers, that drug abuse is increasing in the area. Common names for popular stimulants include "Mike Tyson" and "Carl Lewis". It is also widely recognized that antibiotics (especially ampicillin), typically purchased from local drugstores in short doses, are used by the public to deal with all manner of health problems, from small cuts to headaches!

40 hospitals, where one often has to queue for three to five hours before being attended to);

* the lower costs involved (in response to a question about comparative costs, we were told by a focus group of men: "spiritual churches charge no fees; one simply gives what one can when one can");

* the flexibility of payment (herbalists, TBAs, "bone-setters"and "spiritual healers" are more likely to accept deferred payments or payments in kind; this is particularly appreciated during periods of extreme hardship, when cash is not easily available); and

* the additional services included in the packages of some alternative healthcare providers; in the north, for example, TBAs are reported to be providing postnatal care -- including bathing the baby and shaping its head! Also in the north, the hostile attitude of public sector nurses and paramedicalpersonnel was mentioned as a barrier to access.

But for a few exceptions (of some state-trainedTBAs and certain northern hospitals which have incorporated the services of bone-setters into the mainstream healthcare delivery system), informal healthcare providers operate in complete isolation of the Ministry of Health. Hospital authorities have frequently reported serious complications arising from erroneous diagnoses, wrong doses and superstitious treatments administeredby informal healthcareproviders.

At the drugstore level, access to credit is normally dependenton one's perceived credit rating. Formal sector workers and people with reasonably comfortable resident relatives have least difficulty accessing such credits. A drugstore manager at Asikuma indicated that as many as three in ten of his customers purchase their drugs on credit. For seriously ill patients, intra-lineage transfers are the principal medium by which medical treatment is financed. The desperatelypoor and those whose families are not perceived as credit-worthy must either fall on the most expensive moneylenders,14 delay seeking orthodox medical help, depend on the largesse of kith and kin, or must utilize the informal healthcare options. The Brong Ahafo and Central Region teams found, from separate reviews of relevant hospital records, that in-patient attendance rates fall significantly in the "hungry season" (February/March - July), when farm labor demands and the incidence of disease are both high. Sadly, antenatal consultationsare not excepted.

'4Monthlyinterest rates can be as high as 50 per cent (as in Asikuma). Acrossthe hinterland,poor people are sometimescompelled to sell economicassets (cattle, planting seed, etc.) on the buyers' terms or to pawn their farms to extortionistmoneylenders. It appears ironical that richer householdsin the public service are often able to obtain loans at sub-inflationinterest rates from workplace sources and from institutions such as the Home Finance Company.

41 Costs of orthodox medical consultationsare perceived as high, though it must be said that hospitals are perceived as more competent in general. In frustration, an old woman told our Koforidua team, "if you don't have money today, your disease will lead you to your grave". Our northern research team was also told, repeatedly and rather pathetically: "we watch our children die because we cannot pay the high hospital bills". Consistently, formal health service authorities -- hospital administrators, District Medical Officers and District Health Management Teams (DHMTs) -- confirmed communities' claims that significant numbers of patients have difficulty paying for orthodox healthcare services. In our matrix ranking interviews also, public hospitals consistentlyscored badly on the cost criterion. With the mark-ups permitted by government, the cash-and-carry system operated by public hospital pharmacies is reported to be providing drugs at no cheaper than can be obtained from the competitive private drugstores. It is important to recognize also that the relatively high cost of hospital treatment comprises not just drug expenditures, but also transportation expenses (which can be disproportionatelyhigh for poor people living in remote rural settlements). In Afrangua and its surroundingvillages, for example, where there is not a single resident motor vehicle, access to emergency medical attention is severely constrained.

.****..*...... AccessCr_rin Health Facility Af Av Ef Cl Qu Ac Va Ti Ex Drugstore 2 4 1 X 3 4 1 4 1 Herbalist 4 4 3 X 4 4 3 3 4 Hospital 1 3 4 X 2 3 4 2 4 Nurse atHome 4 3 1 X 3 4 1 3 2 Matrix ranking of health delivery options by access criteria; free scoring with four seeds by a focus group of 15 men aged 18-60, Changni (Rural site, Northern Region).

Af: affordability of service Av: availability of the service Ef: effectiveness of treatment Cl: cleanness of environment Qu: quality of care provided (including providers' attitudes) Ac: accessibility Va: variety of services Ti: time spent at the facility Ex: expertise

1: Bad; 4: Good

42 lace of Treatment Criterion Clinic Drugstore Herbalist Hospital 12 Apostle Affordability(Af) 2 3 11 1 4 Accessibility(Ac) 2 2 9 2 5 Flexibility of Payment (Fl) 2 2 11 2 3 Expertise(Ex) 4 3 1 9 3 Time Spent at Facility (Ti) 3 3 8 1 5 Matrix rankingof health delivery options by access criteria;free scoring with twenty seeds by a focus group of 10 women, Afrangua.

1: Bad; 20: Good

Payments are not consolidated in the average public hospital: patients must pay at each stage of the consultation process -- at the records office, at the entrance to the consulting room, at the laboratory, at the dispensary, etc. Graft further raises the cost of treatment in government hospitals. At Tamale, the government hospital was described, rather disgracefully, as a "gold mine". Informants told how "the seriously ill must tip the attendant just to be transported in the lift" and how "tips were demanded before a child could receive a life-saving blood transfusion". As few hospitals issue receipts for official payments, patients have no way of telling which of the imyriad of fees are legal and which are not. The result is that patients often spend far more on "service charges" than on the drugs per se.

Provisions for cost exemption for the poor generally do not work. A major issue in access to healthcare under a regime where cost-recovery is seen as an intrinsic part of the strategies adopted to support and finance delivery systems is whether those who are genuinely unable to pay can be effectively identified for exemption from user fees. While formal provision exists to do this in Ghana, our findings indicate that such systems are highly inadequate. In the public sector, the administration of exemption concessions is proving difficult and costly -- in time and, even more seriously, in life also. Even when exemptions are approved, drugs are not always available. 1 5 At Tamale, for instance, the Department of Social Welfare's quarterly budget for facilitating exemptions is only a meager C10,000 (approximately ten dollars)! In response to a question about how well the exemption provisions were working in his area of jurisdiction, the District Medical Officer at Abura Dunkwa replied "the exemptions are cumbersome; how do I determine who is a pauper? Besides, my office is not reimbursed for drugs handed out without charge to paupers ... so we cannot be generous in applying the concessions"." If they attempted to implement the exemption provisions faithfully, therefore, clinics serving the most deprived districts would need to impose exorbitant mark-ups on their drugs in order to be able to restock their pharmacies.

15As noted in a focus group of 15 men at Nyingare, "sometimes the health posts do not have the drugs. They give you a note [meaning prescription]to take to the drugstore, so some patients go the drugstore directly". '6 Similar sentiments were expressed by the administration of the Tamale Hospital.

43 The discretionary nature of curTent exemption guidelines is also reported to be leaving the system susceptible to abuse by staff. In any case, few poor people are meaningfully aware of the existence of the fee exemption provisions. Exceptions to the generally poor effectiveness of existing exemptions are limited to cases of tuberculosis, leprosy, AIDS, cholera and other diseases with serious public health implications; in other words, targeting is only proving successful where it is implemented by ailment rather than through administratively cumbersome means-testing procedures.

NGO and mission hospitals17 tend to operate special needs units and are reporting remarkably greater levels of success in determining patients' financial means and in identifying the poor, but that is mainly on account of significantly higher levels of motivation and commitment, which cannot be taken for granted in the state system. Even then, high costs are sometimes incurred soliciting assistance from the Department of Social Welfare for recovering debts or for investigating patients' backgrounds and the financial circumstances of their kinsfolk. 18 Treatment at NGO and mission hospitals is routinely subsidizeid; the subsidy on drugs can be as high as 90 per cent. Sometimes they offer follow-up services to out-patients who lack social networks; they may also provide home counseling to AIDS sufferers and free rations to malnourished patients.

An important criterion for determining a patient's eligibility for fee-free treatment in mission hospitals such as the Catholic Hospital at Asikuma and the Baptist Medical Center at Nalerigu is the financial standing of the patient's extended family. Thus, a patient's social networks are investigated before a recommendation for free treatment is made. That being so, commLunityclinics have an innate advantage that ought to be explored in the fee exemption debate. The fact that the Nyingare community has successfully implemented a levy-free policy for destitute households using the community standpipe shows that community-based approaches are worthy of some attention.

Where adequate staffing is unavailable (the norm across Ghana), state hospital authorities and social workers who must be jointly consulted in determining a patient's eligibility for exemption often have their offices in different parts of the town. Their different responsibilities to varied clienteles and authorities also means that their work schedules are typically divergent. Even when they coexist in the same hospital, they are not always properly integrated into the hospital system. At the Tamale Hospital, for example, the social workers complained of being ignored in the fonnulation of the hospital's social policy framework.

17Such as the Catholic Hospital at Asikuma,the Holy Family Hospital at Techiman, and the Baptist Medical Center at Nalerigu. In general,mission hospitals receive government support in the form ofbasic staff salaries at levels of finding similarto what state hospitalsreceive, but are permnitteda higher level of autonomyin their operations. "'Source: Catholic Hospital, Breman Asikuina.

44 Tamale GovernmentHospital Four senior officials were interviewed at the Tamale Govermnent Hospital -- two senior nursing officers and two social workers. The informants could not tell how much a patient reporting to the OPD is required to pay. Neither could the informants agree on the official fee payable for a routine consultation. It was confirmedthat if the relative of a patient donates blood to save his/her life, a "processingfee" (for blood group matching, HIV testing, etc.) is charged to the patient, who must also pay for the bag in which the blood is stored. One of the social workers noted that "the cash-and-carrysystem was introduced to ... ensure that drugs are available, yet drugs are never available". In a.damning indictmentof the hospital in which she works, one of the nursing officers stated, "I'm not sure that I like anything about this hospital. It used to be a nice place, but now it is not. Formerly, if there was an emergency, ... you went through the relevant procedures to revive the patient before the doctor's arrival. Now ... you fold your arms and wait for the doctor [because]the materials you need are not available and the patient has to buy them all; ... the things to work with are our main problem". SheikinaHospital, Tamale Sheikina was founded by Dr. David Abdulai and his wife, Doris, in 1991. A charitable facility for the poor, Sheikinastaff have no fixed salaries (the foundingdoctor included). Staff earnings are entirely dependenton what funds are available at the end of each month. The hospital derives its income from freewill donations, cereal farms tilled by the beneficiary communities, and token contributionswhich some patients are able to make. From its crop harvests, the hospitalprovides one free meal a day to the town's destitute. Of its 11 nurses, eight were trained on the job -- one of these from illiterate beginnings. The hospital aims to treat 30 patients a day on a first-come-first-servedbasis. Those who are unable to receive attention must wait for their turn the next day. To this end, each user community has been made to build a hut for its members' use. The poor are identified primarily by the appearanceof their skin (ostensiblyan indication of nutritional status) but also by means of an automaticself-screening mechanism of rudimentary levels of provision in the wards and waiting area -- intended to be commensuratewith the income status of the target beneficiaries. With no beds, patientshave to sleep on the floor, but that is no worse than poor patients endure in the larger public hospitals anyhow. Patients sometimeswait for days to see the doctor, but again the northern poor have few better options. Extracts from interviews on two hospitals in the Tamale area.

Retrenchment in the health sector. Has been restricted mainly to drivers, cleaners, orderlies and other less skilled personnel. The most obvious consequence (as mentioned by medical authorities) has been the adverse impact on hospital cleaning services. At the Tamale hospital, where water is supplied to users by manual labor in the dry season, the availability of water (and by inference, the level of hygiene) has been negatively influenced by the retrenchment policy. It must be said, though, that while the situation may have been worsened by the recent retrenchment of cleaning personnel, public hospitals in Ghana have had a long history of problems with efficient cleaning. It is also clear that cleanliness did not emerge as the main priority of the poor themselves in relation to treatment - these have more to do with an accessible and affordable service. Apart from its intrinsic value in a health facility, cleanliness and

45 improved maintenancewould also obviouslyhave a beneficialimpact on staff morale - so this is an area worth consideringfor improvement19.

Apart from its inimical effect on cleaning operations, the social outcome of the policy of retrenching auxiliary nurses has been to entrench pre-existing staff shortages. Throughout the country, relatives of in-patients are having to stay on the wards to help look after their sick kin. Previously, auxiliaries would have been available to perform this function. Trained on the job, their services augmentedthose of the professionally qualified nurses, freeing the latter to undertake outreach assignments. According to the District Medical Officer at Abura Dunkwa, the size of his outreach team has had to be cut in order to maintain an adequate number of nurses at the health centers. Other research teams did not report similar findings, however.

In those hospitals which have access to non-state funds (e.g., the Techiman Holy Family Hospital, the Asikurna Catholic Hospital and the Saltpond Government Hospital), the problems created by retrenchment (specifically, the reduction in cleanlinessand the decline in ward care) are being redressed by recruiting new hands off the state payroll. In order to maintain a decent level of competent staffing all year round, the Holy Family Hospitalat Techiman is buying back leave days (holiday time) from serving personnel. At the Saltpond Hospital, evidently one of the cleaner governmenthospitals, funds are being raised from a variety of sources -- appealing for support from the town's expatriate citizenry, renting out space and levying extra- statutory charges on services offered (thereby raising further the cost of access for the poor). Across the country, it is common knowledge that government hospitals are facing very real problems tending their grounds and keeping their premises clean.

Based on the limited evidenceavailable (from the GambagaDistrict and Mpeseduadze), it would appear that community-basedclinics are a popular option. Certainly, the concept is much cherished by the villages with whom we spoke (see illustration 6, for example). Even though the Mpeseduadze clinic has now collapsed, the Community Health Assistant (CHA) who had ran the facility during its existence is very well spoken of and is still consulted by large numbers of villagers for diagnoses and prescriptions.20Any gifts which patients are able to present in appreciationfor services rendered are graciously receilved by the CHA, himself a member of the larger community. Owing to misconduct on the part of some CHAs, however, the entire concept of community-basedclinics mannedby state-trainedCHAs has been abandoned defacto -- an action akin to throwing the baby out with the bath water. The extension

19Given the low level of technologyassociated with cleaningfunctions outsideof specializedareas (sterilizationetc.) this would appear to be an area where contractingout this function to people who would have difficultygetting formal sectorjobs (localwomen's' groupsetc.) couldbe investigatedas a low-cost solution. 20Accordingto the Mpeseduadzechief and the local Assemblyman,the limitedassistance which the CHA is able to provide is preferred to the services available at the government hospital located some six kilometers away. An important reason given for the CHA's extreme popularity is his welcoming demeanor. In contrast, nursing staff at governmenthospitals were routinely describedas rude.

46 of the health outreach concept to incorporate necessary supervisory mechanisms and sanctions may well have served the needed backstopping function, enhancing the implementation of relevant controls on CHA activities.

Experiencesfrom communityclinics at Mpeseduadzeand Nalerigu Defunct communityclinic at Mpeseduadze Between 1978 and 1986, World Vision International (WVI) provided active support to the community of Mpeseduadze, a small village in the Central Region. Among the diverse projects developed was a communityclinic manned by a trained community health assistant. By 1984, the clinic had received wide acclaim, attractinga clientele from neighboringvillages and larger towns such as Saltpond and Mankessim,both of which were endowedwith formal healthcare services. The clinic's medicine stock was replenishedthrough a revolving fund. A small mark-up (of the order of 10-15 per cent) on medicine prices ensured that the community health assistant manningthe clinic could be paid, and allowed inflation on recurrent inputs to be offset. Consideringthat local residents no longer needed to pay transport costs or wait in endless queuesat governmenthealth posts elsewhere, the cost of treatment at Mpeseduadzewas generally acceptableto the clientele villages, and patronage dropped at nearby herbal centers and "spiritualchurches". Early in 1986, WVI moved out of Mpeseduadze,under the terms of a pre-plannedwithdrawal. Unfortunately, an indigenous managementcapacity had not been established during the years of WVI presence. Within three months of WVI's departure, it was already difficult to restock the clinic's medicine chest. A well-meaningbut manageriallyinept communityleadership had begun to siphon funds out of the clinic's receipts to finance developmentprojects. By the end of the year, the clinic had ceased to function for lack of drugs. Communityclinics in the Naleriguarea Twenty communitiesaround Nalerigu have been able to maintain their local clinics largely through good management and supervision. Each of the twenty participating communities contributesto establisha C15000 revolving drug fund. With this amount, the community is eligible to obtain a boxful of subsidized "essentialdrugs" (typically first aid needs) from the Baptist Medical Center (BMC) at Nalerigu. In each community, a resident health assistant, chosen from the community, is responsible for administeringfirst aid and accounting for the drugs supplied. Village health committeesoversee the work of the communityhealth worker. Monitoring is performed by BMC extension health workers on a monthly basis, with each extensionworker covering approximately10 clinics.

In terms of barriers to access to formal healthcare it was noted in all our northem communities that even the wealthy do not generally store their resources in the form of cash. Therefore finding funding for an emergency treatment is not just a problem for the poor - it applies to everyone in such communities. Generally speaking it takes some days to arrange for the sale of an animal (generally the means by which cash is raised). Under these conditions, it is not surprising thatflexibility in accepting deferred payment was often more valued as an attribute of a service provider than the simple level of cost.

Access to outreach services

The mobile health services introduced under the PHC portfolio have had modest success in reaching remote areas. However, according to our research the achievements in respect of coverage are somewhat offset by the fact that public

47 outreach teams have tended to be rather unreliable with keeping dates and times. Not uncommonly, they arrive a day or more late, when villagers are not expectingthem and have left for their farms. The principalfactor constrainingoutreach visits to peripheral sites was reported to be financial, in particular budgetary cutbacks resulting in reduced transport allocationsand fuel rations. The reductionin auxiliary nurse numbers has also imposed strains on the capacity of some health administrationsto release professionally qualified nurses for outreach work. These losses may well be a contributing factor to the inability of outreach teams to be punctual in their village rounds.

Discussions with the Acting Medical Officer for the Abura Dunkwa-Kwamankese district, and confirmed through community interviews at Afrangua, revealed that the most reliable outreach teams are succeeding mainly by levying unofficial charges to offset their transport expenses21 and to purchase necessary consumables for treatment and nutritional demonstrations. Supplementaryinterviews conducted in Kumasi and at Abura Dunkwarevealed that it is common for Maternal and Child Health (MCH) teams to run out of growth monitoring and antenatal record cards as well as other medical supplies (syringes, needles, cotton wool, etc.). Sometimes,DHMTs are compelled to seek financial assistance from their District Assemblies. Under the straitened funding conditions, however, District Assembliesare unable to provide much financial support to needy outreach teams.

While the amounts charged at the MCH consultations (for immunizations, weighing and other basic services) may appear small -- of the order of C200 per monthly consultation -- the evidence from this study shows that rural women sometimes have difficulty meeting this cost. The poorest mothers are, thus, sometimes compelled to skip immunizations.22 The reason may be partially explained by the fact that the responsibility for meeting the non-food needs of infants tends to be left to the womenfolk. Of the few women specifically interviewed on the subject, none seemed aware that the bulk of the fees being charged are unofficial.23 This is to be expected since receipts are not being issued for payments madeby the public.

Mobile health services run by the state are generally restricted to the immediate needs of children and expectant/nursing mothers. In practice, this means immunizations, weighing, advice on child spacing and the administrationof oral rehydration salts to children suffering from diarrheal dehydration. In communities such as Afrangua, general consultations and the community health education component of the PHC

21Evidencefrom the education sector (particularlyinterviews with FLP coordinators,teachers and GES personnel)suggests that the timely reirnbursementof legitimatetransport and travel (T&T)claims may be a major incentive in ensuring successfulextension work. In each region, the depressing impact of the slow responsein reimbursingsuch claims was cited as a supervisionproblem. 22Theunreliability of outreachvisits (in terms of keeping dates and times) is another factor that affects the efficiencyof the immunizationprogram. 23The only approved charge, apart from drug costs, is a nominal C50 fee for weight checks. Immunizationand ante-natalservices are meant to be fully exemptfrom charge.

48 program are largely being sidelined owing to inadequate staff numbers. The education componentis intended to address issues such as water purification and storage, personal hygiene and environmentalsanitation. Of particular concern is the fact that relevant anti-malaria information is not reaching the poor, even though malaria remains the main cause of morbidityin all three ecologicalzones (GSS 1993: 23).

In rural areas, where birth rates remain high, family planning advice is bypassing the adolescent femalepopulation. Despite the plannedparenthood campaign being directed at mothers (in its practical implementation),our Brong Ahafo and Central Region teams found several women who would not practice family planning, convinced instead that large numbers of children are an effective cultural strategy for securing their partners' affection. The two teams also report that women who have had multiple marriages tend to have significantly more children. In the face of persisting poverty, and with men routinely defaulting in their traditional obligationof fending for their partners, divorces rates are high and the search for new conjugal unions is common. Not only is the role of an efficient family planning program -- sensitively designed to respond to the dynamics of culture and poverty -- particularly important. It is also plausible that the success of the family planning program may depend, to a significant degree, on the incorporationof fundamentalpoverty-reduction measures.

2.6 Local Perceptionsof Service Quality and Access in the EducationSector

2.6.1 Access and utilization

Owing to public funding constraints and the general shift to what is described as a demand-oriented, community-based approach to provision, communities are now required to contribute substantiallytowards the cost of educating their children. This, in the government's view, is meant to "ensure financial sustainability"of the education policy (ISSER 1993: 15). The costs are not only monetary: communities must also provide relevant labor inputs for structural works. Statistical data from the last two rounds of the Ghana Living Standards Survey (GLSS) confirm a substantial rise in household expenditure on education. Interviews with parents and school authorities indicate that the statutory fees payable to the governmentare only a small fraction of the myriad of hidden costs which parents have to bear under the present educational program (see below).

Primary schools and junior secondary schools (JSSs) are available in most established urban centers, but less so in rural areas. Senior Secondary School (SSSs) are moderatelyavailable in urban areas, but an absolute rarity in rural areas. As a result, rural dwellers tend to regard the JSS as the terminal stage in de facto education opportunities. While the non-availabilityproblem is worst in rural communitiesof the northern savannah (confirmed by data from all three rounds of the GLSS), it is typical for rural pupils (particularly those at JSS level) to walk several kilometers to school -- sometimes crossing rivers in boats or wading through streams en route. Problems of

49 accessibility, and in particular the high transport expenditures necessitated by long commuting distances, were often cited by villagers as a key factor contributing to the significantdrop-out rate at the transitionalstages (viz. primary to JSS; and JSS to SSS). Formal fees payable for SSS educationare perceived to be very high. In the words of an informant at Changni, "some fathers have never counted twenty thousand cedis at any one time in their lives, yet parents are being asked to pay [annual fees of up to] forty-five thousand cedis [at SSS level]".24 During the rainy season, access can be seriously impeded in rural areas by the lack of roads and transport facilities. Yet, according to the government's education blueprint, a central objective of the reform package is to increase the rate of school enrollment (ISSER 1993: 15).

Creches are less well provided but, where provided, the patronage demonstrates a demandfor the service. Female members of the Asikuma Youth Association(generally aged between25 and 40) also identified a crehe as their principal concern. Parents at Asikuma report that, under new governmentregulations, children under five years will no longer be accepted in state--runnurseries. This is likely to lead to a decline in the ability to pay for formal child-mindingservices, which will be available in the private sector only. If this were to happen it is likely that larger numbers of mothers would either be compelledto stay at home or would have to carry their toddlers to work.

Accessto Education:a Child at GambagaJSS Kwame Lambor comes from a family of nineteen children. Each morning, he walks the one- and-a-half-milestretch to his school, the GambagaJSS. His father, a "faralana" (poor man), has no money to buy fertilizers to improve the output of his leached farmland. His annual harvest averages two 50-kilogramsackfuls of maize. In order to feed his household, he seeks work on other people's farms, receiving about C300 (30 US cents) for a full day's hire. Kwame sometimes leaves home for school without eating. During the rainy season, he is sometimesunable to go to school if the river which he has to cross floods its banks. In the dry season also, he has to spend much of his mornings searching for water, which makes schooling difficult.

De facto GES policy, in respect of basic education, is that communities should be responsible for erecting their own schools. In the more established urban areas, pre- existing state-built schools are likely to be available. In any case, GES's liability is currently limited to providing teachers, textbooks and some consumables such as chalk and registers. Even then, our research teams found that in the schools visited in the third phase of the research these conditionswere generallynot fulfilled.

Some District Assemblies are levying supplementary annual charges on parents (C1500 per child for the Cape Coast District) in order to finance necessary structural rehabilitation works. According to GES officials at Asikuma, some of the more deprived rural schools in that district are using children's labor to generate income to supplement meager school budgets. As with the sanctioned costs of MCH services, official school fees do not seem particularly high (reported to be around C1050 per

24Commentmade in a focus group interviewwith 15 men aged 18-60, Changni.

50 annum), but poor parents sometimes find these difficult to pay. This situation is aggravated by the proliferation of other (hidden but quite legal) expenditures: ad hoc levies for structural works, annual parent-teacherassociation levies (C5000 in parts of the north), supplementarysports fees, examinationfees, initial registration fees (C4000 at Changni)and sometimescosts of providing classroomfurniture for individual pupils. School uniforms (at approximately C6000 each), travel costs (where pupils have to travel to school by motorized transport), lunch money and expenses on stationery and consumableinputs for practical crafts lessons are further additions that raise the real cost of education. Also significantin raising household education expendituresis the high birth rate in rural areas

Though the Ministry of Education has issued clear instructionsforbidding the expulsion of pupils on grounds of non-paymentof fees, headteachersoften feel compelled to act to the contrary since they are held directly accountable for the collection of fees. Tuming indebted children away is particularly common in the last months of the academicyear, before the main harvest.25

In some cases, this strategy proves successful in forcing parents to pay up on outstanding fees, but there are also many instances where pupils never return to the classroom once they have been sent away for their fees. At Changni, in the north, drop-out rates are reported to be a high 45 per cent -- typically on account of parents' inability to pay their wards' fees. At the MpeseduadzePrimary School, 15 out of 23 pupils from a neighboringvillage, Asafonna, dropped out in the last academic year on similar grounds. On numerous occasions, and in all three regions, we came across children from poor homes who were compelled to find piecework in order to settle their fees, or to purchase other basic needs such as pencils and school uniforms. Given that the bottom line in the reformed education program is to eradicate illiteracy, the distressing situation described above must beg the critical question of the sustainability of the cost recovery formula being administered. In the rural hinterland especially, cuts in governmentexpenditure have worsenedan already inferior position.

In the severely deprived northern savannah, where education had been free of charge until recently, the financial impact of the new cost recovery approach seems to be particularly harsh. Given the severityof poverty across the savannahbelt (and the high incidence of poverty-induced mortality), the northern communities studied are especially anxious about the future of educationunder the current cost-sharing regime. Informant after informant decried the real cost of education as high, and the financial returns low.

Functional literacy. In respect of the community-basedFunctional Literacy Program (FLP), access is largely dependent on the availability of a volunteer instructor

25Source:focus group discussionwith nine teachersat Mpeseduadze,near Afrangua. The group included two headteachers.

51 (facilitator). FLP officials report serious difficulties in recruiting suitable facilitators.2 6 This is not surprising, as such volunteers are expected to teach classes several times each week without remuneration. Expectedly, motivation and commitment are low among the program's facilitators; they may arrive late or absent themselves without giving notice. It must be said, however, that the situation is somewhat better in rural areas-perhaps, because teaching is a prestigious career in the perception of poor Ghanaians.

Among learners too, enrollment is low and drop-out rates high. Interviews with informants suggest that this situation may be indirectly attributed to poverty. Older adults, the main targets of the program, are often exhausted after working long hours during the day, thereby affecting their ability to participate productively in the evening classes. Attendance rates also tend to drop substantially in the farming season (when labor demands are highest) and during festive periods (when non-natives travel out to celebrate the season in their own home villages). The most common request made by learners was for better lighting. 27 Many complained that the aging process had affected their eyesight, and that they found night reading difficult.

2.6.2 Local views of education quality

The major concern of most community members and teachers canvassed in our study (especially the third phase) was with issues of quality rather than of basic access. The mushrooming of rural schools (through community initiative, particularly under the ongoing reforms) has meant that educational resources have had to be spread quite thin. Thus, while schools may be rnore accessible (in terms of proximity; not costs), rural communities tend to have so few teachers per school as to render the quality and value of education in such schools questionable.

Teachers, officials of the Ghana Education Service (GES), literate parents and older siblings were consistently emphatic that the quality of education has declined substantially over the last decade. The results of the 1994 SSS examinations are a revealing testimony to this oft-repeated assertion. Of some 42000 registered candidates, just over 1000 passed the examination! The sentiments of many parents and teachers are aptly encapsulated in the words of a GES official at Cape Coast who opined that "to reduce the duration of basic education so suddenly and drastically [from 17 years to 12] without adequate preparation is criminal." In the larger cities of Accra and Kumasi, irate parents continue to criticize the reforms, describing them as "an expensive experiment with a whole nation's education" and "an ill-planned program whose implementation is prodcucingnothing but illiterate (sic) school leavers".

26ITheCentral Region research team was fortunate to be accommodatedon a common campus with FLP organizers participating in a review session at the time of our fieldwork. It was, thus, possibleto hold some quite useful discussionsin our Freetime. 27Manypoor homes across the country only own one lantern. This can be a serious problem when one memberof the householdhas to participatein night classes.

52 In general, school-childrenand illiterate parents -- typically lacking an adequate basis for assessing quality -- were rather less aware of the purported erosion in academic standards. Even then, parents in the northern settlement of Changni repeatedly asked our research team "why are our children failing their examinations?" With schools no longer required to provide aggregaterankings of pupils' performance, parents appear to be having difficulty monitoringtheir children's progress under the educationalreforms. In the worst cases, from northern Ghana especially, some parents receive absolutelyno feedback (apparentlydue to non-supervision)and only become aware of their children's performanceafter the first proper (i.e., JSS-to-SSS)examination, when it is too late to correct the situation.

Focus group discussion with nine teachers (seven male, two female) from schools in the Afrangua- MpeseduadzeArea

In the course of the fieldwork in the Central Region, the team leader met with a group of nine teachers from four schools in the Afrangua area (one day nursery, two primary and one junior secondary school). Reproduced below are relevant extracts from the meeting.

On the lack of textbooks, the following information was provided:

School Course Enrollment # of Course Textbooks Mpeseduadze Prim English 1 47 1 Mpeseduadze Prim Maths 1 47 10 Mpeseduadze JSS Ghan. Language 2 37 2 Mpeseduadze JSS Cultural Studies 2 37 35 Mpeseduadze JSS Vocational Skills 1 37 0* Mpeseduadze JSS Vocational Skills 2 37 0* Mpeseduadze JSS Technical Drg/Skills 1 37 0* Mpeseduadze JSS Technical Drg/Skills 2 37 0* Mpeseduadze JSS Technical Drg/Skills 3 29 0* Afrangua Prim English 3 23 8 Afrangua Prim Maths 3 23 23 + Afrangua Prim English 4 11 1 Afrangua Prim Maths 4 11 11+

* Yet, designed to be skills-oriented, the entire JSS concept hinges on successful training in the technical and vocational subjects

Asked how well the JSS concept was working, one informant exclaimed, 'you tell me! What can you expect when there are neither workshops nor equipment, ... when we have no books for Technical Drawing and Vocational Skills, none at all, and nobody to teach the Technical Skills course?"

Regarding their main priorities for improvement, the group agreed the following order:

Factor Rank Additional teachers 1 Additional textbooks/ teaching aids 2 Improved motivation for staff 3 Improved infrastructure 4

Even where schools are immediately available in the community, children of poor and illiterate parents sometimes have to spend their afternoons on the family farms and

53 pastures or helping with other household economicundertakings (such as petty trading) and domestic chores. Ultimatelythey either cannot find the time, or are too exhausted, to do their school homework properly. During festivals and funerals also, parents traveling to their native villages sometimestake their children along, causing losses of up to two weeks in schooling time. The obvious result is a decline in their ability to understand future lessons and to benefit effectively from tuition received. A similar fate befalls those other children who must work in order to financetheir education.

In the basic educationprogram, defacto policy of the GES is to provide one teacher for 35-40 pupils. The enforcement by GES officials of this so-called "enrollment factor" prescriptionhas been particularly inimical to the provision of quality education in rural schools. Classesin such schools are often compelled to share teachers. The result is a reduction in the attention that can be devoted to each class, with a correspondingloss in overall efficiency and quality of instruction in rural areas. Ultimately, government's intention of developing the country's human capital through decent education is bound to be underminedby such dismal conditions.

In contrast to rural schools which tend to be underutilized, urban schoolroomstend to be overpopulated. At Techiman Zongo, 93 students share a standard JSS1 classroom. Under such conditions of overcrowding, we can expect, ceterisparibus, a high risk of cross-infection. Given the twin problems of (non-)affordabilityof healthcare and the routine misuse of antibiotics, overcrowding in classrooms may indeed represent a greater problem than is generally recognized. In the Techiman school under discussion, controlling the students is only achieved with difficulty, and teachers are reported to be having trouble rnoving through non-existentaisles to provide one-to-one tutoring.

It is also common, in deprivecdareas -- both rural and urban -- to find pupils sharing standard classroomfurniture built for individual use. Teachers interviewedwere of the view that approximately one-third of pupils share chairs and desks in the Afrangua area. At the Mpeseduadze Primary School, two children share a chair only 300 centimeterswide, and at Tamale, a standard bench (approximately1.5 meters wide) is shared by five pupils. Equally appalling is the situation at Nyingare, where some teachers lack chairs and some schoolchildrenare compelled to squat or kneel on the screed floor while using their benches as desk space. Evidently, the quality of education cannot be satisfactory under such conditions of learning. Symptomatically, we found numerous examples of JSS children (mainly rural, less so of urban) who could not spell their own surnames correctly. In a focus group discussion with six males (of mixed ages) at Afrangua, it was also affirmed -- and unanimously so -- that many of the village's Class Six pupils cannot read Class Two books satisfactorily. These findings are consistent with those of Oti-Boatenget al (1990: 26) who report that "the appallingly low literacy and numeracy rates ... are only in part accounted for by

2"Respiratorytract infections were often listed among the commonest diseases afflicting poor communities.

54 individualswho have never attended school.... For the majority [of the very poor and rural residents in general], school attendance fails to equip them with the most basic skills."

It is ironical that the most deprived schools also tend to be the ones with the highest staff turnover rates. Such schools, often located in the rural areas, are dependent on national service personnel to fill teaching shortfalls. It is common knowledge, however, that national service postings are typically made in November, a full two months after the academic year has commenced. Problems with finding suitable accommodationfurther delay their reporting for duty.

The new policy of phasing out non-professional teachers. Has contributed further to staff shortages in deprived rural districts. GES officials in the Central Region report that women are disproportionatelyrepresented in the non-professionalgroup (perhaps, because their multiple roles -- especially their childbearing responsibilities -- leave them with little time for pursuing further studies). That non-professionalteachers have been much more willing to accept postings to deprived areas than have professionallytrained teachers is widely acknowledged in Ghana, and is especially important to the understandingof the impact of retrenchmenton the quality of education. The general embargo on new recruitment into the public sector also means that national service personnel, after acquiring relevant teaching skills in their one year of service, cannot easily be retained in the system. In any event, there can be little logic in a policy that seeks to retrench one group of non-professionalteachers while relying on another group of untrained, inexperiencedteachers with high turnover characteristics.

With the low rate of teacher production nationwide, teaching shortfalls have become particularly difficult to fill. For the 1994/95 academic year, for example, the entire district of Asikuma-Odoben-Brakwa(one of 110 in Ghana) received only 13 teachers whereas there were 146 full-time vacancies to be filled. It is altogether counterproductive that these new recruits were not sent to fill any of the existing vacancies but were rather made to replace non-professionalteachers in the district's primary schools.29 The current shortfall for the Northern Region stands at some 2300. Across the country, it is no longer possible to compensate for temporary shortfalls arising from maternity and illness -- which, in earlier decades, were addressed by calling on so-called "supply (reserve) teachers". Interviews with officials of the GES indicate that the shortage of teachers has been caused by two main factors: the conversion, since the late 1970s, of large numbers of teacher training colleges into secondary schools; and the increased demand for teachers arising from the rise in population and school enrollment, and the enlargement of the teaching curricula at primary and JSS levels. Also believed to be significant is the fact that the functional

29This in spite of the fact that some were speciallytrained in key technical subjects for which JSSs are complainingof teacher shortages. In this respect, retrenchmentin the educationsector is also causing an underutilizationof prime manpowerresources.

55 literacy program is relying for its administrativefunctions on teaching staff siphoned from the classrooms.

In separate interviews with teachers and officials of the GES, informants emphasized the lack of textbooks. At Dwemoh in Brong-Ahafo,a class of sixty-odd pupils share three French textbooks between them. At Asikuma, the headteacher of the Catholic Boys School lamented, "there are some subjects for which we have no textbooks at all not even one for the teacher's reference".30 English readers for Class Four pupils have not been printed since 1]990;and according to the Textbooks Officer at Cape Coast, a parent of a Class One pupil would need to spend C18000 if he wished to furnish his child with the necessary textbooks.3 ' In the face of such logistical inadequacies,a bleak manpower situationand real difficultiesin householdfinancing of educational needs, it is not surprising that educational workers are generaLLycynical about the anticipatedrewards of the educationalreform program.

In respect of the factors that make for quality education, teachers interviewedare of the unanimousview that the availabilityof teachers is the most critical. Even the JSS of the CatholicBoys' School at Asikuma, adjudged the best in the district for the 1991/92 academicyear, now has no Mathematicsor TechnicalSkills teacher! Given the general state of inadequate school staffing in the communitiesstudied, there can be little doubt that the problem of quality education is very real, and that the implications are indeed ominous.

If assessed from observations3 of actual classroom tuition, the quality of instruction is not always satisfactory. Particularly in the hinterland, it is not uncommon to find poorly paid teachers treating their teaching assignments as a part-time undertaking. Such teachers may devote prime schooling time to other work (e.g., selling in the market, at Techiman; farming in most of the other sites) as a means of supplementing their incomes. The field teaims received several reports of teacher absenteeism and complaintsof pupils being compelledto spend school hours on teachers' private farms. Sometimes, children are simpLyleft to play throughout the school day -- a complaint repeatedly made by schoolchildrenat Nyingare in the Northern Region. On occasion, the lack of textbooks was attributed partly to headteachers' defaulting in collecting supplies from their district capitals.

Both the GES and teachers interviewed in focus groups admit to the inadequacy of school supervision. A diversity of transport-relatedproblems -- inadequate motorbikes, insufficient fuel supplies and the lack of financial resources for reimbursing transport costs -- were cited as the main reasons for this condition. It was reported in three GES

30A focusgroup of nine teachers(seven mnale; two female)from Mpeseduadze and its surroundingvillages madesimilar observations. 3 1This cost rises significantlyat higherlevels of the educationalladder. 32Wesurreptitiously observed classes in sessionat Afrangua,Mpeseduadze and Asikunia.

56 offices (at Abura Dunkwa, Asikuma and Cape Coast) that this situationhas improved in very recent months following the receipt of special funds provided by GES for reimbursingheadteachers and supervisorsfor approvedtravel expenses.

In areas where school buildingsare old, it is common to find walls that are crumbling, roofs that are either ripped or lealdng,33 classrooms that are damp and murky, and screed floors that are seriously pitted. Structural problems were frequently cited by school authorities and GES officials as posing a risk to school populations.

Fundingdifficulties cause the collapseof a school roof at Gambaga In an example from the state-run Presbyterian JSS at Gambaga (in northern Ghana), serious funding constraints had prevented a sagging roof from being repaired. Under the government's educationalsector reforms, communitiesare entirely responsible for all structural maintenance expenditures. Owing to the dire state of poverty, manifest in a high rate of malnutrition, this community was unable to raise the necessary finance. Eventually, in October 1994, the roof collapsed on a roomful of schoolchildren while their class was in session. Twelve children were injured, with one sufferingfractures in both legs.

Another important factor commonly cited by GES officials, teachers and some literate parents for the noticeable decline in educational quality is the increase in the number of subjects taught in basic schools. Whereas the Middle School system which has been replaced by the JSS taught only four core subjects (English, Mathematics, Geography and History), JSS pupils are now required to study 12 or so subjects. Necessarily, this expansion of the teaching curriculum has resulted in a reduction in the hours allocated to English as a course. Logically, the decline in the ability of pupils to understand the English language has adverse implications for understanding other courses taught in that language.34 Further impairing the appreciation of the English language is the practice of teaching junior classes (up to the Primary 3 level) in native languages.

2.6.3 Perceived relevanceof education

In terms of the perceived relevanceof educationthe following main messages emerged from the research.

The criteria by which local communities defined the 'relevance' of the education service were based on two factors: the ability of children to get jobs, the ability of children to read and write in English (so that illiterate parents no longer have to go elsewhere to get letters read and written, compromisingthe privacy of the family, and children can perform basic tasks like identifying the correct hospital card for family members etc.). In only one community was literacy mentioned in relation to learning improved techniques in traditional occupations - in relation to farming in the Mamprusi

33In the rainy season,such problemscan causeserious disruptions of classes. 34Even "Arabic" (qur'anic) schools, common in Islamic communities in the north and in the migrant zongos, are shiftingvoluntarily to the secularsystem in order to benefit more from English tuition.

57 village in the Northern Region. In relation to these criteria education (at the level to which it is pursued by the poor - generally no higher than JSS) is perceived to be failing. People consistently said that their children could not read and write at the end of school. In relation to this parents in some sites argued that the first-cycle (primary and JSS) curriculum was too broad - with insufficient time and attention paid to basic literacy.

Regarding the match between user aspirations and the revised curriculum for first-cycle schools, our findings indicate that the reforms are not fulfilling the purpose for which they were designed. In both rural and urban areas, the implementation of the technical training component, king-pin in the educational reform program, is largely perceived as unsatisfactory. In case after case -- in schools, communities and in GES offices -- informants alluded to the lack of tools, working materials, workshop buildings and trained teachers. This situation, a serious impediment to effective skills training in the JSSs, has arisen mainly because, in the current cost-sharing framework, communities are not only responsible for financing capital requirements and school furniture, but also for providing tools and other inputs needed for the program. Consistently, therefore, the skills training objective is being undermined by the high incidence of poverty. There is also a clear regional dimension to this, with our research suggesting that communities in the poorer areas of the country (in this case specifically the sites in our sample in northern Ghana) are less able to meet these extra responsibilities than those elsewhere. Lack of skilled craft teachers is also a major constraint in all the rural areas in our study. The technical training component was consistently described as the weakest link in the JSS agenda.

2.7 Domestic Water and Sanitation

Within the towns and villages studied, the availability of safe water and sanitation is often a function of NGO presence. Many poor households rely on streams and uncovered wells of dubious purity. Except where interventions have been implemented, therefore, water quality tends to be particularly poor during the dry season when natural water sou;rcestend to dry up. In the Northern Region in particular huge amounts of women's labor time during the dry season are expended on fetching water - affecting their potential access to employment and income-generating opportunities. Evidence from all three rounds of the PPA indicate that for communities where water supply is problematic this remains the over-riding priority - especially for women. In those communities where water problems had been successfully addressed it was generally the result of either NGO or donor-funded interventions.

In all low-income urban sites, we found a high level of indiscriminate defecation, largely resulting from extremely low levels of provision. Understandably, women are more concerned about the deficiencies of water and sanitation: it is they and the children who are responsible for replenishing household water supplies; and cultural norms prevent them from evacuating their bowels in open spaces.

58 Obtainingland is a major issue in relation to some kinds of urban services. There is a particular problem with obtainingland for latrines as it lowers the value of surrounding property. It was found that while VIP latrines functionedexcellently in rural communitieswhere populationdensity is low they were virtually impossibleto maintain in densely settled urban areas at the concentrationsthey existed in the areas studied. It is therefore recommendedthat a review shouldbe made of means by which District Assembliescan find ways of making more land available for latrines in poor urban areas - in order to decreasepressure on existingfacilities, and thereby set up a virtuous where the presence of a latrine in a neighborhoodis no longer regarded as a health and environmentalhazard.

59 Appendix1

Examplesof PRA VisualsGenerated During the Research

As noted in Section 1.2 considerable use was made during the research of methods which are commorly known under the rubric of PRA (Participatory Rural Appraisal). These methods draw on various traditions of research including applied anthropology, Participatory Action Research, Rapid Rural Appraisal and agro-eco-systems analysis. Although the origins of the methods are predominantly rural, and generally related to participatory planning of natural resource management, they are increasingly used in a wide variety of contexts, including urban research and poverty research. Much of the early development of these approaches took place within a context of participatory community development rather than policy research, and was carried out by NGOs in Africa and South Asia. The methods place emphasis on the following dimensions:

* local people as analysts rather than informants - whether for the purposes of local level planning and action or participatory policy research, a key element of PRA is that research participants play an active role in generating analyses and directions for action, rather than acting as informants who provide information that outsiders will analyse - outsiders act as facilitators in the process - stimulating examination of issues by local research participants, but striving to avoid adopting a dominant mode in behavior or attitudes • group contexts for research, often differentiated according to different social categories (women, men, youth elders etc.) - a process of generating consensus yields information and stimulates examination of key problems facing the community or social group in question * visual sharing of information - a process of generating visual representations (maps, institutional diagrams, causal flow diagrams, seasonality diagrams, matrices) allows for transparency, cross-checking by a number of participants, and enhanced participation in the process of analysis. * Empowering weaker, marginal members of communities to participate in the research process.

The results of some of these exercises have been described above - but these have tended toward description of the non-visual methods, such as wealth-ranking and priority ranking.

Largely for reasons of space the outputs of visual exercises such as participatory mapping have not been included. In the following pages a small sample of the visual PRA outputs generated during the research are presented to illustrate the use of these methods.

60 Visual 1: CompoundHouse, East Maamnobi,Accra

Reproducedbelow is a diagram of a compoundhouse in East Maamobi Accra, together with a 'key' which gives certain key informationby household. Points to note include the following:a single compoundhouse has 30 familiesand 84 people within it; they all share a single latrine and kitchen area; there are eight different ethnic groups; the inhabitantsare predominantlyfrom the north and predominantlyMuslim (all 26 northern families are Muslim); the majority of womenwork, and all the working women are traders.

7e i______l _ _ a _ _ i _ _ ~_ _ _ _ s Kw, _ _I ______I _j~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ _ _ __Y I _ _ _ _ C__ - J.A44O4;~

.I I _ 2IL* WaS,* A** k - _ ; ' I

; ~ ~ _ _ _ '__!_,____K=-

3*4 ' *RwI-__ , r _ _ + _ : _ ' _ 2a o z i Z z1 4 i.~. _ | _2. t . S . iiLfu* i'_ II I 1______-___!_____- i c e

_ l. ItA'F' - + _ j^,(_Z l wZ_ t I , , oEU:c ri _ tr iu^^el z !1 § § l w . i < ,Z r

2j, Si___ ;_ _ _ I , ; ;, laL4_s - u*>b 7).- ni_lM3

i,I f - 4 *bwsA^ 5^,j ______

1: tI li1.W I ".3A 1*4Loss > tgA.'1.6XAhE~;fEiC | _ it j . | ' ' + + [tI 9 Z .: l A < V Al Z I ' - | j C ____4 ,, i AE i1o~ ' 4 N u -s I+ *~~ ~~~~~~~~~~~ H+II ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~i Z i E

_ _ _ _ C^ t44s-1 3fA -.& .. .. j *,,I

tt~~~ ! L- ~ W" F .> ; N - _

61 Visual 2: Social Map of Komaka, UpperEast Region

This social map also contains a wealth ranking exercises, illustrating the distribution of different wealth strata according to the villagers'own classifications of wealth and poverty.

f~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~f - ._ P.,,_s y ,os -

' fowst74~~~~~~~NAP O; bm-` A-

) }{k fiS A'A CW

4:uca 2 _/ ¢;>,' m2 72orr5tele\ - 7 -° --

EI V4aAtA.w C * a!l Ct) * - a I

'7~~~~~~~~~~~~~~~~Z g Oa^< 'e Gs?g *5 _ S {° _ ° ~~~~~~~~~~~~~~0p*

"IQ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~,

XX,\14q-Cma 1? f-o-.47~~~~~~~i~4o

AM

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62 Visuals 3 & 4: Examplesof SeasonalityAnalyses of FoodSecurity in two Rural Communities- Dekpor Horne(Volta Region) and Sombo(Upper East)

The following seasonality charts illustrate seasonal patterns in food availability - in one case for the main staple crop (millet), and in the other case differentiated for the six most important crops (maize, cassava, cowpea, sweet potato, okro and rice).

SOMBO- MEN ONLY PERIODSOF FOOD SHORTAGES

uw FEB MAR APt MAY JN JUL AuG SEPT OCT NOV OEC

-o,A A L 51 V j c 9 i lAVCBAsSYEAR) :

__O___AVA5L3L15 M CKRP,: Md*.°0 CpopS5 _ E____,

*.e . we1 *# e ,eF|**

:T..

4 wjj. . - 3 ¢ - Ae - ' Z-tc

-£ESiL' 9 -0 5 ~*r -s arm-s -t 9 9W* i 1f . .1.{ * f i I 6

63 Visuals 5 & 6: Sources of Income, and a Seasonality Analysis by the Women of Komaka

These two visual diagrams prepared by the women of Komaka, in the Upper East Region, illustrate key dimensions of their livelihoods. A complex seasonality chart indicates seasonal variation (according to the local calendar) in food availability, farm work, cash income and diseases. A pie chart indicates the main sources of money/income for women in this very poor community.

5e4enal;j 5, dCA Ag In f0do40141o.hIF ro c,, nG> cs.iffi -sech;t,. aiaO',, , ~wrkj~o

SAPALut2QFquG IWAUL(-r .Q*4 SEWIJci. r0or Re.Ci- S Tln CeZL ok fo tZr.e f

*** *ae* Is *.e *} i... **.

so ....0 0**O*O.9 * 0411 . -* ** -vi§§* *. ****- **0 on^ z

! *A -I- iSSOCS***,.*X* *,*~ *...... * * *. . *** * ,,...'**.*db.\ I tA/4

8*0*B : :***:* C.r..j

t Ao _ .... . _ _... ;

*.~~~~~~~~~~~~ @440g8 PtdtaF 4^

A fF drIn Mei+O4 Free 4co's.V mqtf4;4^. 5

5Cource; 4œn¢ cQ bt:'|1s

an A )4"1 utq.~ -' Vwqk~A *ive r%k-~o r c 4

64 Visual 7: Institutional Diagram by the men of Butre, Western Region

Institutional diagrams illustrate, through a combination of the size and positioning of the smaller circles the accessibility and importance of a variety of service institutions for the people of the community (the larger circle). In this case there is a high emphasis on the Town Development Committee, the chief and the Traditional Birth Attendant. An unusual feature is the appearance of the Dutch Embassy - this community is the site of an old Dutch fort, and has gained access to small amounts of development assistance through the cultural links that have ensued from this.

65