Equity Case Study: Ghana - Leveraging evidence to advocate for a national dialogue on equity
© UNICEF/NYHQ2008-0862/Olivier Asselin
As in many developing countries in Africa, Ghana’s national progress toward meeting the Millennium Development Goals (MDGs) masks regional and socio-economic disparities.
By Abhijit Shanker
28 March 2012 - UNICEF Ghana has taken proactive action to engage national stakeholders in a far-reaching dialogue to address regional and socio-economic disparities that continue to undermine progress toward achievement of the Millennium Development Goals. By raising awareness of these gaps, particularly as they affect women and children, and by promoting action through the provision of technical assistance that draws on hard data and reliable evidence, UNICEF is making a strong and persuasive case for government and development partners to improve their allocation of resources in order to reduce life-limiting inequities.
As in many developing countries in Africa, Ghana’s national progress toward meeting the Millennium Development Goals (MDGs) masks regional and socio-economic disparities. For example, the national mortality rate for children under five years of age has dropped from 111 per 1000 in 2003 to 69 per 1000 in 2009, but it has also risen in one region (DHS 2008). At the same time, the World Bank reports that the poverty rate and the number of poor people has fallen countrywide, while the actual number of poor people has increased by 900,000 in the northern part of the country. UNICEF Ghana seeks to raise the level of attention paid to such disparities - for example in health care, education and employment - by Government, development partners, and civil society, with the aim that greater awareness of inequities will lead to concrete actions to give every child an equal start in life.
Strategy & Implementation
UNICEF has taken a two-pronged approach to persuading the Government of Ghana of the value of addressing socio-economic disparities through more equitable allocation of resources to the country’s most deprived areas and population groups. First, UNICEF sought to raise awareness of the socio-economic disparities - including poverty, deprivation and violence - that are faced by many of Ghana’s women and children, through advocacy to engage government officials, development partners, influential leaders in society, and the general public in a national dialogue. UNICEF devised a strategy for reaching each of these target groups and designed tools to support the campaign.
Second, UNICEF has undertaken cross-cutting efforts to improve outcomes for children by focusing on helping individual government ministries, including the Ministries of Health, Education and Employment and Social Welfare, to implement programmes aimed at reducing inequities. UNICEF has supported the Ministry of Health and the Ghana Health Service to analyze which interventions would make the greatest difference for the poorest Ghanaians - and how improving health outcomes of the poorest citizens would impact achievement of Millennium Development Goals (MDGs) 4, 5, and 6. The Ministry of Education has benefitted from a bottleneck analysis that points out the different status of education outcomes in various regions, coupled with the interventions that would most effectively unclog each blockage. In Social Welfare, extensive effort has been spent to improve the operations of the LEAP cash grant, targeted at the poorest Ghanaians. Because ministries often apply broad, national solutions with generalized appeal to confront recognized challenges, UNICEF made strong use of data and reliable evidence in its advocacy work with decision-makers to convince them to allot a greater share of human and financial resources to address the most marginalized regions and groups through focused actions.
Progress & Results
Evidence-based advocacy. In order to construct a strong evidence base for its advocacy, UNICEF engaged Ghana’s Ministry of Women and Children’s Affairs (MOWAC) in a joint, equity-focused situation analysis (SitAn), whose report was launched to celebrate International Children’s Day on 16 November 2011. The report details the latest data on the economy, health, education, water, sanitation as well as child and social protection. With a strong, pro-equity case built on the SitAn’s findings UNICEF is using the data to inform the media, political leaders and development partners and to foster national dialogue.
Just prior to the launch of the SitAn report, the UNICEF Representative and the Chief Director of the Ministry briefed senior editors of major newspapers, radio and TV stations on the report’s findings, resulting in positive media coverage. The report notes Ghana’s progress in meeting MDGs 1, 2, 4 and 6. However, it points out that most of these advances took place in the southern part of the country, while the northern regions have seen less dramatic improvements. It also indicates services which have become more equitable, such as immunization, as well as those that are benefitting the wealthier portions of society more than the poorest quintile. Finally, the analysis calls for enhanced decentralization and use of data in national and regional planning as means of reducing these inequities.
Anticipating the 2012 presidential election and realizing the opportunity to raise the profile of the equity agenda during the pre-election period, UNICEF has also engaged the heads of the three major political parties in discussions on the subject. In these sessions, the UNICEF Representative has made the case for stronger attention to equity in the parties’ manifestos by highlighting the disparities in services among geographic areas and wealth quintiles and the potential for improved development outcomes to be won by addressing them. UNICEF will host a joint briefing session for the parties in December 2011, to present the findings of the SitAn in detail. UNICEF has also scheduled briefings for members of Parliament, religious groups, and traditional leaders in December 2011 and in January 2012.
In its relationships with development partners, UNICEF has made conscious efforts to leverage its role as an observer to the multi-donor budget support (MDBS) discussions and successfully lobbied for a session on equity and disparities at the 2011 MDBS Annual Performance Review. As a consequence, the MDBS Aide Memoire gave much greater attention to issues of equity and poverty than had previous aides memoire. As a result, current discussions between development partners and Government with respect to the MDBS Performance Assessment Framework (PAF) now include cross-sectoral targets such as poverty reduction and attention to underserved areas. Inserting equity into these discussions represents a critical success for the equity agenda because the Government of Ghana is conscious that around $400 million in annual general budget support depends on achievement of the PAF targets.
Proactive collaboration with national ministries. UNICEF has made determined efforts to raise national ministries’ awareness of equity issues and to promote their action to prioritize the equity agenda.
Equity in health care. In order to support the Ministry of Health’s objective of achieving equity in health care, UNICEF’s health team, along with the Ghana Health Service, in early 2011 undertook a detailed analysis of inequities. That examination demonstrated that the prioritization of equity-focused interventions outlined in the Government’s Health Sector Medium Term Development Plan (HSMTDP) would help the Ministry of Health (MoH) achieve the following objectives:
- Enable Ghana to reach MDG4 in all but the poorest parts of the country, which would achieve close to 70 per cent of their target, representing a substantial acceleration in the rate of achievement;
- Reduce the incidence of malaria by 38-45 per cent, depending on the region
- Reduce neonatal mortality by 30 per cent in the more vulnerable parts of the country and by 19 per cent in the less vulnerable areas;
- Reduce maternal mortality by approximately 14-17 per cent, with the greatest positive impact on the most vulnerable populations.
Most striking was the fact that these gains could be achieved for about USD 1.3 billion, approximately one-quarter of the projected total HSMTDP cost.
After presenting its analysis at the annual Health Summit to the Ministry of Health, Health Service, NGOs and development partners in April 2011, the Ministry started working on the key areas identified for action in the analysis, including a new human resources (HR) policy for the health sector. UNICEF has also begun working with the Ministry to analyze access, bottlenecks, costs and equity (ABCE) with technical support from the Institute for Health Metrics and Evaluation at the University of Washington, USA. The analysis mapped health facilities, investigated costs and constraints of care delivery, and undertook small area estimations to obtain district level data. A planning meeting in November 2011 laid out the steps necessary to gather and analyze this information, which should be available by mid-2012.
Introducing bottleneck analysis in education. The UNICEF Education Section supported Ghana’s Ministry of Education (MoE) in creating a bottleneck analysis tool based on the Marginal Budgeting for Bottlenecks (MBB) tool used in the health sector. The analysis resulted in clear presentations of bottlenecks at national and regional levels (see Table 2) and demonstrated that reported national averages mask significant disparities among regions and districts. It also gave districts the evidence they need to lobby for additional resources.
UNICEF presented the bottleneck analysis results at the annual Education Sector Review meeting. They subsequently provided the basis for a special meeting of the Minister of Education, her senior managers, and key development partners, at which plans for addressing obstacles to improving quality of education in the poorest areas were made. These meetings resulted in valuable commitments by Government, among them the provision of a 20 per cent salary incentive for teachers to work in deprived areas.
A follow-up step in the bottleneck analysis initiative was the development of a cost and impact simulation model, which predicts the impact of various interventions on the six determinants in the bottleneck analysis framework. This model will be used to prepare Ghana’s application for Global Partnership for Education Funds (GPEF, formerly known as Fast Track Initiative), which will total at least $50 million. The GPEF programme currently under development has an explicit focus four key equity components: equitable access; gender equality; quality improvement; and strengthening school management in deprived districts.
In addition to the education bottleneck analysis work, UNICEF and the Ministry of Education commissioned a comprehensive study on out-of-school children in Ghana as one of the 25 countries participating in the Global Initiative on Out-of-School Children. The study conducted a thorough analysis of the profile of out-of-school children and key barriers and bottlenecks that keep them out of school, and outlined effective policies and approaches to address the barriers. The study results will help the government make strategic choices on how to expand educational opportunities for the most disadvantaged and marginalized populations.
Promoting selective cash grants to improve social welfare. UNICEF has also supported the Ministry of Employment and Social Welfare (MESW) to pilot the Livelihood Empowerment Against Poverty (LEAP) cash transfer programme in an effort to provide assistance for the poorest households who are taking care of orphaned and vulnerable children (OVCs), the elderly and the disabled. UNICEF has facilitated a baseline analysis and is planning an impact evaluation that will indicate the impacts that LEAP makes on the lives of destitute families, thereby helping MESW improve its management information system, refine its operational manual, and improve its payment mechanism.
One of the most significant achievements already achieved by the LEAP programme is the adoption of its Common Targeting Mechanism by two other ministries. This mechanism, which includes a streamlined questionnaire for the proxy means test and a community validation component, will be used by the National Health Insurance Authority to provide exemptions to the health insurance premium for LEAP recipients. And, the Ghana Education Service will use the Common Targeting Mechanism to determine which children should receive a free school uniform. UNICEF and the World Bank, with financial support from the UK Department for International Development (DFID), contributed significant technical support to the mechanism’s creation.
The Government of Ghana’s planning documents clearly identify the need to address the poorest and most deprived population groups, but translating this general policy desire into action has proven difficult. Often, ministries lack either the capacity or resources required to identify and extend services to the neediest regions and people. Another obstacle is the limited budget flexibility Government possesses; between 70 per cent and 90 per cent of the social ministries’ budgets are spent on employee wages. There are also situations in which Government is spending money on inefficient programmes that do not prioritize the most vulnerable, and convincing elected officials to discontinue politically popular programmes is not easy.
The culture of data analysis and use to plan and allocate resources is in its early stages and relatively weak. As a result, policy hearings at the Ministry of Finance and Economic Planning (MOFEP) to review ministerial budgets do not yet rely on evidence to determine which programmes to support. However, these hearing present potentially valuable opportunities for engaging ministerial attention and decision-making authority in the future, especially since MOFEP will implement Programme-based Budgeting in 2012.
Understandably from a political perspective, many decision makers prefer to spread the benefits of social programmes across as many districts as possible so that all political players can share credit and popularity. Consequently, while the LEAP programme has spread rapidly to over 80 districts, only a few hundred families in each district have benefited to date. UNICEF and its development partners have been trying to convince MESW to target all families in the districts in which over 80 per cent of the families fall below the poverty line, with limited success to date. Systemic change to target disproportionately more resources to the poorest districts or to ignore comparatively wealthier districts in favor of poorer ones is a singular challenge.
The flip side of targeting resources to the worst performing districts is that this practice inadvertently creates an incentive to continue performing poorly, as has been noted in educational settings. UNICEF and its partners therefore need to find ways to promote and reward good performance, while maintaining financial support for under-performance.
UNICEF can use its seat as an observer at the MDBS table to influence the use of $400 million in general budget support to steer the government toward taking concrete steps to reduce inequities. UNICEF does not allocate funds to general budget support, but our voice is respected as representative of development interests untainted by national agendas.
Simple, straightforward, evidence-based presentations of equity issues are most effective. By way of example, the education bottleneck analysis impressed the Minister of Education because it portrayed key information on a single graph. She used the analysis as the basis for a retreat for her senior managers to discuss how to combat inequity.
The SitAn launched in November 2011 provided a major platform for engagement with government officials, journalists, and other influential authorities. With the finalization of the urban MICS in September 2011, its new findings will be used to demonstrate the variety of living standards in the capital city of Accra.
UNICEF also plans to draft a Manifesto for Children outlining ten methods for improving equitable service delivery. This Manifesto will be shared with the major political parties in an effort to influence their 2012 election manifestos.
The ABCE approach will be rolled out, beginning with the mapping of health facilities, followed by the cost analysis and the small area estimations; these interventions are slated for completion by June 2012 and provide further evidence for developing the health sector medium-term development plan for the next four years with a sharper equity focus.
The education sector group, which is co-chaired by UNICEF and DFID, will monitor the MoE’s actual spending of funds allocated to incentive teachers to work in deprived areas. UNICEF is also supporting an analysis of expenditure patterns at the Ghana Education Service which will investigate why equitable and efficient interventions known to policy makers have not been funded and implemented. This initiative will provide a platform for monitoring whether and how the remote teacher incentives are actually funded. Ultimately, MOE will need to analyze whether having additional teachers in these areas correlates with improved learning outcomes for children in hard-to-reach schools.