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Ill Health Unleashed? Cities and Municipal Services in Ghana Franklin Obeng-Odoom∗

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Ill Health Unleashed? Cities and Municipal Services in Ghana Franklin Obeng-Odoom∗ Review of African Political Economy Vol. 38, No. 127, March 2011, 43–60 Ill health unleashed? Cities and municipal services in Ghana Franklin Obeng-Odoom∗ Department of Political Economy, School of Social and Political Sciences, University of Sydney, New South Wales, Australia Increasing urbanisation, wealth and ill health in cities necessitate careful study, especially in African cities whose development is widely regarded as rapid and chaotic. Using Ghanaian cities as a case study, this article analyses some of the important sources of ill health, identifies why they persist, and assesses how they impinge on economic growth, redistribution, and poverty reduction. It argues that, although there is considerable evidence that policy change is urgently needed, the tensions and contradictions between economic and social efficiency, intermeshed with vested political interests, are likely to impede significant changes to the status quo. Keywords: Ghana; Africa; cities; water; sanitation; health Introduction Now that the World Health Organisation (WHO) has put cities at the centre of public health and declared 2010 ‘Urbanisation and Health’ year, it is timely to consider public health and cities, especially in developing countries, where there is rapid and chaotic urbanisation. In fields such as Sociology, Anthropology, Epidemiology, and Urban Planning, the approach has typically been to consider health differentials between rural and urban areas, and between and within cities (Galea et al. 2005). In terms of methodology, such studies are typically written from the standpoint of either public administration or mainstream public health, with the former emphasising administrative efficiency and effectiveness of institutions (for example, Smith 1997, Blore 1999, Olowu 2003), and the latter stressing the relationship between the epidemiological changes that occur with urbanisation and their impacts on health (for example, Yach et al. 1990, McDade and Adair 2001). These existing studies suffer from two main weaknesses. First, they tend to look at the process of urban growth as a homogeneous phenomenon, even though there are various components of the ‘urban experience’, such as urbanicity, urbanisation, and urban environment. Urbanicity connotes the prevalence of factors such as transport congestion and industrial pollution that are more prevalent in cities than in rural areas. ‘Urbanisation’ refers to a process of change with associated socio-economic and politico-cultural trans- formations. ‘Urban environment’ goes beyond ‘urbanicity’ because it embraces physical, social and urban resource infrastructure (Vlahov and Galea 2002, pp. 5–6, Ompad et al., 2008, p. 465). Because the urban experience is not one homogeneous transformation, ∗Email: [email protected] ISSN 0305-6244 print/ISSN 1740-1720 online # 2011 ROAPE Publications Ltd DOI: 10.1080/03056244.2011.552568 http://www.informaworld.com 44 F. Obeng-Odoom studies on urban health need to consider demographic, social, and political economic changes in cities. Second, these frameworks do not typically examine economic development – economic growth, redistribution, and poverty reduction. How development interacts with urban health needs more critical consideration (Blore 1999, Galea et al. 2005). This second analytical weakness was recognised and highlighted in the health-related sessions at the 2010 World Urban Forum in Rio de Janeiro. The forum also stimulated civil society publications which stressed the need for better understanding of health issues in cities (for example, Sugranyes and Mathivet 2010). This article tries to overcome these conceptual and empirical gaps by using a broader political economic framework to examine urban health. It does so by analysing water delivery and waste management. It thereby seeks to explore the challenge of transforming the existing arrangements to achieve the overall goals of improving health and promoting sustainable development (UN-HABITAT 2008, p. 5). Specifically, it examines how water and sanitation services are provided and how the mode and level of service delivery, in turn, impact on urban health and wealth. The geographical focus of the study is Ghana, where two main factors make this study particularly relevant. First, Ghana is one of the most rapidly urbanising countries in Africa. According to the United Nations (UN) Department of Economic and Social Affairs (DESA 2007), Ghana’s population was 47.8% urban as of 2005, a figure which was higher than the average for West Africa (41.7%), sub-Saharan Africa (35.0%) and Africa as a whole (37.9%). The rate of urbanis- ation in Ghana between 2005 and 2010 is estimated at some 3.54% per annum, lower than for West Africa (3.77%) and sub-Saharan Africa, but higher than for all of Africa (3.31%) and the world (1.91%). Second, Ghana is believed to have entered the era of homo urbanus (UN-HABITAT 2009) – Anna Tibaijuka’s shorthand for a situation in which more people live in cities than in rural areas.1 Estimates also suggest that by 2050, the share of the population living in urban areas (75.5%) will be about three times the share of the population living in rural areas (24.4%) in Ghana (DESA 2007). The rest of the article is divided into five sections. The first four sections look at the health conditions of urban citizens, provide an overview of water and sanitation conditions and assess the effectiveness of policies to improve these municipal services, respectively, while section five empirically ascertains the connections which exist between water, sanitation and health. The state of health of urban citizens The health situation in Ghanaian cities must be described as a prelude to the subsequent discussion. The description needs to examine trends in disease, morbidity or mortality. Although the data is not comprehensive, it is evident that there are major health problems in the cities. In 2008 alone, 37.5% of children in urban areas sought treatment for diarrhoea and 59.6% had fever; in the same year, there were 50 deaths per 1000 births (Ghana Statistical Service [GSS] and Ghana Health Service 2009a). The perinatal mortality rate is 34 per 1000. Malaria constitutes 30–40% of all outpatient cases in Ghana, with one in five children under five years old receiving malaria treatment in the two weeks preceding the 2008 demographic and health survey (GSS and Ghana Health Service 2009b). These figures need to be put in a wider context to be meaningful. However, two pro- blems inhibit a detailed comparative analysis with, for example, other African countries. First, obtaining comparable urban figures is difficult because the institutions that compile health data sets do not usually disaggregate these into urban and rural. Second, Review of African Political Economy 45 missing figures make it difficult to compare even national-level figures. In spite of these problems, however, available data suggest that, in comparison with the rest of Africa, the health profile of inhabitants of Ghanaian cities is better than the African average in some sectors and worse in others. For example, from 1990 to 2010, the proportion of the urban population in sub-Saharan Africa living in slums declined from 70 to 62%, while in Ghana the decline was from about 80 to 45% (Economic Commission for Africa and African Development Bank Group 2009, p. 46, UN 2010a, p. 64).2 The limited figures available show that there has been considerable improvement in the health profile of urban citizens. For instance, between 1988 and 2003, the under-five mor- tality rate in urban areas reduced from 131.1 to 93 per 1000 live births. At the same time, the infant mortality rate dropped from 66.9 to 55.0 per 1000 live births. From 2000 to 2004, supervised delivery increased from 50.2% to 53.4%. Around the same time, postnatal care improved from 46.3% to 53.3%, nationally (Ghana Health Service 2005). The national health situation in Ghana, however, does not look so good when compared to continental averages. For instance, between 1990 and 2008, infant mortality in sub- Saharan Africa dropped by 22% (UN 2010b) but in Ghana, the figures for 1988 to 2003 show a reduction of only 13% (Ghana Health Service 2006). Furthermore, malaria is more endemic in Ghana than many other tropical African countries. Ghana is classified as one of 31 ‘high-burden countries’ by the World Health Organisation (WHO). Between 2001 and 2006, for instance, there was no evidence that there was a significant reduction in the number of malaria cases nationally, although between 2006 and 2008, the number of malaria cases declined dramatically from 8.3 million to 3.2 million (WHO 2009, p. 102). Still, malaria, delivery, and diarrhoea diseases are the worst causes of death in the country (Ghana Health Service 2006). Twenty per cent of under-five mortality results from malaria and 50% of outpatient cases relate to malaria (Koram 2008). The health profile of urban citizens is worsened by the nature of the healthcare system. Even though Ghana has switched from a ‘pay as you go’ system of healthcare to health insurance, the scars of for-profit healthcare are present and the current system is limited in its coverage. Generally, about 60% of women and 70% of men are not covered by health insurance (GSS and Ghana Health Service 2009a). Only 10.8% of the urban popu- lation is covered by health insurance. Several reasons, such as inability to pay the premiums or a lack of confidence in the insurance scheme, explain this low coverage (GSS 2008, pp. 30–31). This state of affairs has contributed to low life expectancy in Ghana. From an average of 57.9 years in 2006, life expectancy declined to 56.5 years in 2009 (UNDP 2009), a figure significantly lower than the 64.3 years which was the world average in 2006 (UNDP 2007). What factors might be driving this poor state of health? Among a plethora of reasons, weak growth-centric developmentalist concerns such as low GDP growth, high levels of inflation and their correlates – whose collective effect is to reduce the ability of the country to invest in a pro-poor health system (see, for example, Government of Ghana 2003, Aryeetey and Kanbur 2004) – are some possible explanations.
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