DOCUMENT RESUME

02527 - A1852869]

Impact of Population Assistance to an African Country. ID-77-3;B-179421: B-156518. June 2, 977. 45 pp. 9 appeidices (20pp.).

Report to the Congress; by Elmer B. Staats, Comptroller General.

Issue Area: International Economic and Military Programs: U.S.Development Assistance Overseas (603).

Contact: International Div.Budget Function: International Affairs: Foreign Economic and

Financial Assistance (151).Organizate.n Concerned: Department of State; Agency for

International Development.Congressional Relevance: House Committee on International

Relations; Senate Committee on Foreign Relations; Congress.Authority: Foreign Assistance Act of 1961, as amended, sec.

104b.

Rapid population growth combined with poor social andeconomic conditions is hindering development efforts in manycountries. African birthrates are among the highest in theworld, and population growth rates are expected to increase asimproved health care lovers mortality. Ghana is one Africannation that has recognized its population problem. It haspromulgated an official population policy, and has established afamily-planning program. The United States has provided about75% of the $15.9 million of population assistance to Ghana.Ghana's program, however, has reached only a small percentage ofthe population, primarily urban. Recommendations: In planningdevelopment assistance for Ghana and other African nations, GAOrecommends that the Administrator of the Agency forInternational Development, as appropriate: encouragegovernments, and provide support when necessary, to examine therelationships between social and economic change and fertility;help governments to establish population policies whichencourage the types of social and economic developmentidentified as having a maximum impact on fertility; consider theimpact n population growth of planned U.S. development projectsand work to integrate population and development projects; andtake actions to encourage the establishment of an effective,systema-ic coordinating mechanism for population assistance inGhana and in other countries where none exists. (Author/SC)

REPORT TO THE CONGRESS

BY THE COMIPTROLLER (ENERAA LOF' THE UNITEt STATES

Impact Of PopulationAssistance To AnAfrican Country

Department of StateAgency fo, International Development

Rapid population gowth combined with poorsocial and economic conditions is hinderingdevelopment efforts in rmany nations. Africanbirthrates are among the world's highest, andpopulation growth ates are expected to in-crease as improved health care lowers mor-tality. Ghana is one African nation that hasrecconized its population problem, promul-gated an official population policy and estab-lished a family planning program.

The United States has provided about 75 per-cent of the $15.9 million of opulation assis-tance to Ghana. Ghana's program, however,has, reached only a smal' percentage of thepopulation, primarily urba~n. GAO believeszhanges are needed if the population growthrate s to be lowered significantly and recom-mends actions the Agenc,, should take, in-cluding integration of pop lation and devel-opment assistance, to meet this objective.

ID-77-3 JUNE 23, 1977

COMPTROLLER GENERAL OF THE UNITED STATES

WASHINGTON. O.C. 205U

3-179421B-156518

To the President of the Senate and theSpeaker of the House of Representatives

This is the second in a series of reports on worldpopulation growth, its impact on the quality of life, andprograms designed to slow growth rates. This report focuseson an Pirican country--Ghana---and addresses the populationsituation, interrelationships between population growth andsocial and economic development, and the effectiveness ofthe populaticn-related activities of the Agency for Inter-national Development and others. We believe information ofthis type is useful to the Congress in considering populationand development assistance legislation.

We made our review ursuant to the Budget and AccountingAct, 1921 (31 U.S.C. 53), and the Accc.nting and Auditing Actof 1950 (31 U.S.C. 67).

Copies of this eport are being sent to the Director,Office of Management .nd Budget; the Secretary of State; andthe Administrator, Agency for International Development.

Comptroller Generalof the United States

COMPTROLLER GENERAL'S IMPACT OF POPULATION ASSISTANCEREPORT TO THE CONGRESS TO AN AFRICAN COUNTRY

Department of StateAgency for InternationalDevelopment

DIGEST

This report addresses the impact of assistanceby the Agency for International Developmentand others to help restrain population growthin a developing African country--the problems,restraints, and successes experienced.

Africa has a population of about 400 million,with birth rates among the highest in the worldand a 2.6 percent growth rate. This may in-c.ease in coming years as err:ntly high deathrates are lowered by improved health condi-tions. Even at the current growth rate, thepopulation will double in 27 years.

Eighteen of the world's 28 least-developednations are in Africa. Health care is alreadyinadequate, and practical education systemsare lacking. Although about three-quartersof the labor force is engaged in agriculture,food production lags behind population growth.

The Agency provided $860 million in the fis-cal year 1965-1976 period for programs to re-strain population growth in developing coun-tries. Of this total, about $50 million hasgone directly from the United States toAfrican nations.

Although most Asian and many Latin Americannations have established population policiesand family planning programs, less thanQne-fifth of the African governments, as of1976, had done so.

The United States had regular bilateral popu-lation assistance programs in 1976 in nineAfrican countries. GAO selected Ghana as acase study because it has a population growthproblem, an official population policy, anestablished family planning program, and has

TIL mt. Upon removal, the reportcover date should be rted hereon.i ID-77-3

received more direct population-related aidfrom the United States than any other Sub-Saharan country.

Ghana's population jumped from just over2 million in 1921 to over 1G million in 1976.The growth rate is now estimated at about3 percent annually. Many demographers expectthis to increase as expanding health servicesreduce mortality. Even at the current rate,the population is expected to double by theyear 2000. (See pp. 3-5.)

Like many African countries, Ghana is tryingto put an adequate system cf birLh and deathregistration into operation. Nevertheless,available data shows'rapid population growthis an important hinderance to developmentefforts, including improvement in the qual-ity of life. In Ghana:

-- Economic growth has not kept pace withincreases in population, resulting in adeclining per capita real income since1960. (See p. 8.)

--Domestic food production is net keepingpace with the growing demand. The nutri-tional status of the population has notimproved in the last 10-15 years, andcaloric deficiencies are common nationwide.(See pp. 8 and 9.)

--A high percentage of the people are young(under 15), placing a burden on those inthe 15-65 work-age groups. (See pp. 5-7.)

--The number of children enrolled in primaryand middle schools has increased, but be-cause f population growth, the percentagein relation to the total eligible has de-creased. (See p. 11.)

-- Less than 30 percent (by estimate) of thepopulation has access to reasonably ade-quate curative medical services; an evensmaller percentage has access to healthservices to prevent sickness. (See pp. 11-13.)

ii

-- Housing and sanitation problems in urbanareas are compounded by high levels ofmigration from rural areas. (See pp. 12-13.)

The Government of Ghana published a strongpopulation policy statement in 1969 that U.S.officials believe could serve as a model forother African countries. It acknowledged theneed for a population policy as an integralpart of national social and economic planning.(See pp. 16 to 18.)

In January 1970, the government establishedthe Ghana National Family Planning Programin the Ministry of Economic Planning to planand coordinate family planning activities,using governmental and private organizations.Objectives include disseminating family plan-ning information, increasing clinics provid-ing family planning services, and expandingsales of commercial contraceptives. (Seepp. 18 to 23.)

U.S. loans and grants to Ghana thrcugL fiscalyear 1976 totaled about $300 million. U.S.population assistance began in 1968 and hasreached about $9.75 million. Additional U.S.funds were supplied through other organiza-tions. Population assistance from all donors,including Canada, the United Kingdom, theInternational Planned Parenthood Federationand its U.S. affiliate, and the United NationsFund for Population Activities, totaled about$15.9 million by mid-1976. The Governmentof Ghana has been increasing financial sup-port to its population program, for a totalof $2.5 million since 1974. No effectivemechanism exists for coordinating thesesources of population assistance. (Seepp. 24 tc 29.)

Only about 7 percent of Ghana's 2 millionwomen of reproductive age are counted asfamily planning acceptors in clinic records.About three-quarters of the registeredclinics offering family planning are inurban areas. The program has hardly reachedthe rural areas where 70 percent of the

iii

population live. It is not believed thatan appreciable number of couples are usingcontraceptives sold commercially. (SeePo. 32 to 38.)

Agency officials and others believe thatmore people would accept family planning ifservices were provided together with healthca.e. Results of the U.S.-financed Danfaproject in Ghana appear to be supportingthese views. (See pp. 60 and 61.) However,Agency officials in Ghana also believe thatthe greatest acceptance le' 1 would occurin the context of social and economic devel-opment, a point made by a number of Africancountries at tie World Population Conferencein 1974. (See pp. 38-40.')

Because of factors such as government con-straints and coordination problems, 1.ttleeffective integration of population andother development assistance has occurred.Unitil this situation is rectified, Agencyofficials believe it best to continue sup-porting the Ghana National Family PlanningProgram, with its emphasis on clinic and:ommercial distribution systems. (See p. 42.)

Expanding family planning programs will benecessary if such services are to be avail-able to the majority. If such services areto e accepted to the extent required toreduce the population growth rate signifi-cantly, measures that improve social andeconomic environments and help reduce themotivation to have children need to be iden-tified and put into operation. In a recentpolicy statement, the Agency has recognizedthe need for such an approach.

The effectiveness of population assistanceis improved when there is full coordinationof programs by multiple donors. In planningdevelopment assistance for Ghana and otherAfrican nations, GAO recommends that theAdministrator of the Agency, as appropriate:

iv

-- Encourage goverrments, and provide supportwhen necessary, to examine the relation-ships between social and economic changeand fertility.

--Help governments to establish populationpolicies which encourage the types of socialand economic development identified as hav-ing a maximum impact on fertility.

--Consider the impact on population growthof planned U.S. development projects andwork to integrate population and develop-ment projects.

--Take actions to encourage establishmentof an effective, systematic coordinatingmechanism for population assistance inGhana and in other countries whre noneexists. (See p. 44 and 45.)

The Department of State and Agency forInternational Development reviewed thisreport and commented that it accuratelydescribed the population and family plan-ning situation in Ghana and tnat theyagreed with the recommendations. (Seep, 45 and apps. I and II.)

;iAO plans to review the need to integratepopulation and other development prcgramsand the extent to which the Agency has doneso in assistance programs in Asia, LatinAmerica, and Africa.

beaLrS11U1 v

Contents

Page

DIGEST

CHAPTER

1 THE POPULATION OF A DEVELOPING COUnrRY INAFRICA 1Ghana's population situation 2

Population size and growth rate 3Fertility, mortality, nd populationgrowth trends 4

High percentage of dependents 5

2 IMPACT OF POPULATION GROWTH ON THE QUALITY OF 8LIFE IN GHANA

Food production not keeping pace with 8demandPopulation growth and land use patterns 9Impact of high fertility on both food 9supply and demand

Education: an important part of development 10Proportion of children in school 11decreasing

Health care iadequate despite progress 11Urban migration and economic growth 13Factors influencing fertility in Ghana 13

Traditional way of life 14Kinship societies 14Education 15Urbanization 15

3 GHANA'S DEVELOPMENT AND POPULATION POLICIES 16Ghana's porulation p Licy 16Ghana National Family Planning Program 18GNFPP 5-year plan: 1973-1978 19GNFPP activities: room for improvement 22

4 U.S. AND OTHER DONOR ASSISTANCE 24U.S. economic assistance 24Other donors' assistance 25Population assistance to Ghana 25U.S. strategy for population assistance 2uU.S. population projects 27

CHAPTER Page

Other donors' population programs 27International Planned Parenthood 28Federation and Planned ParenthoodAssociation of Ghana

Family Planning International 28Assistance and Christian Council ofGhana

UniteA Nations Fund for Population 29Activities

Need for effective cordination of 29population assistance

5 OBSERVATIONS ON RESULTS OF GHANA'S POPULATION 32PROGRAMS .'ND SUGGETIONS FOR IMPROVEMENTSFamily planning program framework estab-

lished 32Not enough acceptors - a measure of the 32

family planning program's neffectivenessFamily planning services limited 37How to reach more potential acceptors- 38

The Danfa ProjectUrban and rural approaches 39The Mampong Valley approach 39

Need to integrate family planning with 40other development projects

Potential fur family planning combined 40with other development projects

U.S. population assistance plans 41

6 CONCLUSIONS AND RECOMMENDATIONS 43

7 SCOPE OF REVIEW 46

APPENDIX

I Letter dated March 28, 1977, from the Deputy 47Assistant Secretary for Budget and Finance,Department of State

II Letter dated March 31, 1977, from the Auditor 49General, Agency for International Development

III Map of Ghana 52

IV Bureau of Census projectional Impact of 53populatin growth in Ghana

APPENDIX Page

V Support to GNFPP by year and donor 56

VI Assistance to population programs in Ghana 57

VII Population projects in Ghana supported by 58the Agency for International Development

VIII Sample project integrating population and 64development

IX Principal officals responsible for adminis- 66tration of activities discussed in thisreport

ABBREVIATIONS

AID Agency for International Development

CCG Christian Council of Ghana

FPIA Family Planning International Assistance

GAO General Accounting Office

GhRRM Ghana Rural Reconstruction Movement

GNFPP Ghana National Family Planning Program

IPPF Interniational Planned Parenthood Federation

PPAG Planned Parenthood Association of Ghana

UNFPA United Nations Fund for Population Activities

CHAPTER 1

THE POPULATION OF A DEVELOPING COUNTRY IN AFRICA

Africa's estimated population in 1975 was about 400million, about 10 percent of the world's total. Its over-all growth rate, estimated at 2.6 percent in 1975, is amongthe highest in the world. This rate is expected to increaseas currently high death rates are lowered by improved healthconditions. Even at the current growth rate, however, thepopulation will double in 27 years.

Africa's growing population compounds a number of com-mon population problems and undesirable situaticns: (1)15 out of every 100 infants die before their first birthday,(2) life expectancy averages only 43 years, (3) each physicianserves 15,800 people, and (4) food production is not keepingpace with population growth.

Official concern with population increases has been slowto develop in most African countries. Thg World Populationconference in 1974, attended by most african nations, focusedattention on african views. many countries feel that rapideconomic and social development, along with increased foreignassisttance and a more equal distribution of the world's wealthand resources, can create the conditions for reductions inpopulation growth rates. A number of African states recognizethat population problems in some countries are hindering socialand economic development.

The United States directly provided about $0 millionin assistance to governments of African nations for popula-tion projects during the 1965-1976 period. In 1976 the U.S.Agency for Internaticral Development (AID) bad regularbilateral population assistance programs in nine Africancountries--Botswana, Cameroon, Ghana, Kenya, Liberia, Morocco,Nigeria, Tanzania, Tunisia, and Zaire. In addition, theUnited States provides financial support to private andinternational organizations that are involved in family plan-ning and other population-related activities in African na-tions.

We selected Ghana as a case study for this review be-cause it has a population growth problem, an official popu-lation policy, an active program, and has received more popu-lation assistance from the United States than any other Sub-Saheran African country.

1

GHANA'S POPULATION SITUATION

Located on the Gulf of Guinea in West Africa, just afew degrees north of the Equator, the Republic of Ghanahas an area of 92,100 square miles, slightly smaller thanthe State of Oregon. (See app. II.) Ghana's 1976 popu-lation is estimated at 10.1 million and its growth rate atabout 3 percent. Oregon's 1975 population is estimatedat 2.3 million; during the 1970-1975 period its populationgrowth rate averaged about 1.8 percent annually, of whichabout 1.3 percent was due to migrants. At these rates, thepopulation in Ghana will double in just 23 years and in Ore-gon 38 years.

The Ghanaian economy has a comparatively small modernurban sector, with an educated urban elite consisting of notmore than perhaps 3 percent of the country's population.The elite is made up largely of civil servants and militarypebsonnel, with much smaller components of professional andbusiness people. The urban population enjys the major partof government expenditures, even though it comprises lessthan 30 percent of the country's population.

Conditions in the rural areas discourage the young(especially the educated) from pursuing rural and agricul-tural life and increase the drift to the already overcrowdedcities. These same factors deter professionals, more af-fluent business people, and officials from accepting posi-tions in the rural areas, which further deters modernizationand development.

The rural areas, however, are extremely important inGhana. Based on 1970 data, more than 70 percent of thepopulation live in rural areas; almost 60 percent of totalemployment is in agriculture. Agriculture and forestry-related products contributed 70 to 80 percent of foreignexchange earnings during the period 1970 to 1973.

While demographic data adequate to describe the typicalGhanaian family is not available, research done in ruralareas outside the capitol, Accra, suggests that the typicalGhanaian family in these areas that accepts family planninghas five members. The father is a farmer, literate, butwith only 1 to 3 years of primary school. The mother ismarried, illiterate, a Protestant, and a member of the Gatribe. She is 28 and has had four pregnancies. She hasthree living children at the time of acceptance, havinglost one child through miscarriage or infant mortality.

2

If she did not accpt family planning, she would probablybecome pregnant at least four more times and have at leastthree more children. Besides being a housewife, she alsofarms.

Population Size and Growth Rate

We believe population censuses are important not only

for planning and evaluating population programs, but alsofor social and economic planning in all areas. A populationcensus was taken in Ghana every 10 years from 1891 to World

War II. A census was taken in 1948 and again in 1960, andthe most recent one was taken in 1970. Unlike the earlierones, the 1960 census provided much information on the demi-graphic profile of the population. The 1960 census conta.nsthe most complete published data. Much of the informationgathered in the 1970 census had not been analyzed in 1976when we were reviewing the programs in Ghana.

Ghana. as many other developing countries, is trying toimplement a system of vital registration capable of pro-ducing reliable estimates of birth and death rates and popu-lation growth. although the Births and Deaths RegistrationAct of 1965 made it compulsory to register births and deaths,

it has not yet been possible to determine completeness ofregistration.

Ghana's population was just over 2 million in 1921. Itreached 6.7 million by 1960, 8.6 million by 1970, and wasestimated by a government ministry to reach 9.8 millionin 1975. It was estimated to be 10.1 million in 1976.Recognizing the possible under-enumeration of the 1970 cen-sus and the possible over-enumeration of the 1960 census,some government officials believe that the average rate ofgrowth during the 10-year period was 2.6 percent annually.

Estimates of the 1976 growth rate range from 2.7 per-

cent to 3.3 percent. AID officials in Washington hlave of-ficially estimated the population growth rate at 2.7 per-cent, but, agree with USAID/Gh&na and Ghana National FamilyPlanning Program officials that the annual rate is now about

3 percent. A further increase in the growth rate, however,is believed likely as the mortality rate falls during the

next decade. Ghana's goal is to reduce the growth rate to1.75 by the year 2000.

3

Fertility, mortality, andpopulation growth trends

The fertility rate is estimated to be 45 to 5 birthsper 1,000 persons per year. This rate is high, even fortropical Africa, which has fertility rates among th(ihighest in the world. In Ghana, the average number of chil-dren born to women was estimated in a 1969 study t rangefrom 6.5 to 7.3. The graph below shows fertility in Ghanaand some other African countries.

AVERAGE NUMBER OF CHILDREN EVER BORNNUMBER OF CHILDREN

7

56~~~~~~~~~~~~ GHANA

-/ _--'--- ZAIRE

3

2

15 20 25 30 35 40 45 50 55AGE GROUP OF WOMEN

SOURCE: DYNAMICS OF POPULATION GROWTH IN GHANA, S.K. GAISIE

Large families are still favored by most Ghanaians.The table below shows that the Ghanaian ideal family sizeand the proportion of families wanting four or more childrenexceed even developing country ideals.

4

Ideal family Percent wanting 4size or more children

Europe and North America 2.0 - 3.1 4.0 - 49

Asia (excl. Japan), Latin Americaand North Africa 3.2 - 5.0 25 - 80

Ghana rural 7.5 98(female)Tropical Africa-rural 6.0 - 7.5 90 - 98

Tropical Africa-urban elite 4.3 - 6.1 88 - 89

Note: "The Control of Family Size in Tropical Africa,"(1968) Dr. John C. Caldwel].

The mortality rate (deaths per 1,000 persons per year)was estimated by the government to have declined fromn 30 in1960 to 20 in 1970. This compares with the world average.mortality rate of 12 for the 1970-1975 period. With es-timates of the current population growth rate around 3.0percent, the population would double in 23 years. The popu-lation growth rate, however, is expected to increase in thenext few years because of an anticipated decline in the mor-tality rate as health services are expanded, and because anincreasing percentage of the population will be reproductive-age women.

Trends of Ghana's birth, death, and growth rates aredepicted below.

ANNUAL EVENTS PER 1000 POPULATION

BIRTH RATE50

40

POPULATION GROWTH -

30 _,_ RATE 1

20 --- -

10o DEATH RATE

1960 1970 1975

Hiqh percentage of dependents

Ghana's high population growth rate has resulted inan increasing percentage of the population in the dependent

5

age groups. The pecentage of the population under 15 yearsin 1960 was 44 percent, 47 percent in 970, and 48 percentin 1975. By comparison, in the United States, 25 percentof the population is under 15. Since 3 percent of Ghana'spopulation is over age 65, only 49 percent of the popula:ionis in the 15-65 year old economically-active age group.Of this group, 45 percent are women 15-49 years old, andit is estimated that about 16 ercent of them are pregnantat any one time. The graph and age distribution pyramidsbelow illustrate the high proportion of dependents in Ghana.

DEPENDENTS SUPPORTED BY ADULTSIN DEVELOPED COUNTRIFS VERSU GHANA. 1975

DEVELOPED COUNTRIES GHANA

JLI IL " .IL _.

| 55 PERSONS UNDER AGE 15 AND 102 PERSONS UNDER AGE 15 ANDOVER AGE 64 ARE SUPPORTED OVER AGE 64 ARE SUPPORTED BYBY EACH 100 AGED 15 THROUGH EACH 100 AGED 15 THROUGH 64.64.

Source: U.S. Bureau of the Census, based on United Nations data cndGovernment of Ghana Ministry of Economic Planning data.

6

POPULATION PYRAMIDS: 1960 AND 1970DEMONSTRATING PREPONDERANCE OF YOUTH IN GHANA

1960 AGES

Source: Adopted from Office of international 65Health, U.S. Department of Health,Educatlon, and Welfare (from Ghanaian 60-64government publication) 55

50-54

145-4

140-44

35-39'30-34

?25-29

!20-24

115-19

'10-14

'5-9

'0-4

55-59

800 700 600 500 400 300 200 100 0 100 200 300 4~0 500 600 700 800

MALE (IN THOUSANDS) 'FEMALE

1970 AGES

Sourc. Adopred from Ghonaian Mlnlrtry of [ -65+ IEconomic Planning documnt i

50-54

45_49

40-44

:35-39

130-34

25-29

- F 1 ~115-19

'5-9

10-4

800 700 600 500 400 300 200 100 0 100 200 300 400 500 6n0 700 800MALE (IN THOUSANDS) FEMALE

7

CHAPTER 2

IMPACT OF POPULATION GROWTH N THE

QUALITY OF LIFE IN GHANA

Ghana's population was estimated at about 10.1 millionin 1976, up 1.5 million from the 1970 census count. Popula-tion growth is impeding social and economic development ef-forts. The country's gross national product (GNP) in constantdollars grew during the 1960 to 3972 period but per capitaincome, in constant dollars, dec;i. by 7 percent during thesame period. Manifestation of the hiJ-' opulation growthrate include increased food imports, : urdened healthfacilities, and a smaller proportion o .iigible studentsin school.

FOOD PRODUCTION NOT KEEPINGPACE WITH DEMAND

Specialists generally agree that the nutritional status.of Ghana's population has not improved in the last 10 to 15years. Net food availability has not increased much, ifat all, during this period. Caloric deficiencies are commonin all parts of the country, with lowest income children andpregnant and lactating mothers receiving only about 50 per-cent of their requirements. Protein deficiencies are equallycommon. On the average, only about 60 percent of the proteinrequirements of the total population have been met, with themost severe shortfalls occurring among infants and youngchildren.

Agriculture in Ghana is characterized by small scalefarming--30 percent of the farm holdings are less than 2acres, and more than 80 percent are less than 10 acres. Itis estimated that small farmers, cultivating 10 acres orless, produce about 80 percent of the total food cropproduction.

Domestic food production kept pace with demand untilthe late 1950s. Demand was expanding due to populationgrowth and increasing purchasing power. Increases in foodproduction were being ac!._ved mainly through acreage ex-pansion. This continued until about 1958, when domesticproduction no longer kept pace with demand. Since then,Ghana has had to import increasing quantities of food.

8

The agricultural sector has made substantial contributionsto Ghana's foreign exchange earnings, contributing between 70and 80 percent from 1966 to 1973. These earnings resultedalmost entirely from cocoa exports. Imports of food and liveanimals averaged more than 17 percent of Ghana's total merchan-dise imports for the same period, adding to the country's for-eign exchange shortages.

Population growth andland use patterns

To maintain soil fertility, small landholders have devel-oped a complex system of land rotation which requires 6 to 8years of fallow to 1 to 3 years of cropping.

With low population densities and abundance of arableland resources, land rotation and traditional farming prac-tices have done well in maintaining soil fertility and safe-guarding the delicate balance between exploitation and re-generation of Ghana's soils. However, with increasing pop-ulation densities and commercialization, the system of landrotation has in some cases been modified and in other casesused continuously for cropping. For exa ple, in some denselypopulated areas, such as parts of northern Ghana, the systemof land rotation has been replaced by compound Lamming, char-acterized by continuous cropping with manure. There isdoubt whether the use of manure is sufficient to maintainthe present low levels of productivity over a period of time.

According to AID, the following problems have occurredas a result of shortened fallow:

-- Loss of soil fertility.

-- Soil degradation and erosion.

--Persistent weed growth.

---Increasingly poor yields.

Impact of high fertility onboth fo-S2pply and demand

Ghana's high fertility rate is causing an increased fooddemand. To some extent, it also contributes to agriculturalproductivity by increasing labor input. On the other hand,an AID official told us, the rate of fertility has a subtleeffe on the supply side of food production. It is

9

acknowledged that women farmers in Ghana produce more of thefood grown on small farms for domestic consumption than domen. Frequent pregnancies (often with resulting illness andmalnutrition) reduce the time and energy these women candevote to farmLng.

All in all, the two most important challenges of Ghanaianagriculture (according to the USAID Development Assiz:tanceProgram) are the high rates of population growth and urbani-zation. These demographic force have the following implica-tions for agriculture:

-- Large increases in the market-dependent population.

--Possible shifts in preferences of the market-depen-dent population to consumption patterns which may beless easily supported by established cropping patterns.

-- A decline in the size of the potentisal agriculturallabor force (people willing to work in agriculture)but large increases in the size of the total andurban labor force it relation to the employmentopportunities of the Ghanaian economy.

EDUCATION: AN IMPORTANTPART OF DEVELOPMENT

The government sees education as a major factor in thenation's social, cultural, and economic future. It has animportant role in improving the quality of human life andcontributes to a sound economic foundation.

Although education had developed unevenly with thegradual changes in the social system, by 1957 enrollmentin primary (ages 6-12) and middle (ages 12-16) schools wasnearly half a million. In 1961 free compulsory primary andmiddle school education was established. Beginning withthe 1974-75 school yeaz, such schooling consists of 6years of primazy and 3 years of middle school.

One of the major objectives of Ghana's educationalpolicy is to progressively increase the number of .;;!drenin chool so that by 1980 every child has access to atleast a basic formal eduati . To achieve this goal, Ghanarealizes that it must overcome the present shortage ofschool spaces.

10

Proportion of childrenin scool decreasing

Furthermore, although the numoer of children enrolledprimary and middle schools has been increasing, the per-

_-nt of eleigible children enrolled has been decreasing asshown below.

School Enrollment as aPercentage of Population

Enrollment in Percent Childrenprimary and Population children ages 5-14

Year middle schools ages 5-14 in school not in school

1957 571,580 1,529,199 37.4 957,6191965-66 1,404,930 2,045,734 68.7 640,8041970-71 1,389,804 2,452,835 56.7 1,063,0311971-72 1.415,801 2,543,590 55.7 1,127,7891974-75 1,490,667 2,835,477 52.6 1,346,810

Ghana is allocating increasing funds for education. Theper capita education expenditure for 1974 was 40 percent abovethat of 1971. Ghana's 1975-76 budget for education providedfor expanding primary and middle school enrollment by 70,000.But during that same period the number of children aged 5-14was expected to increase by at least 100,000. So, while i.Lremcney is being spent on education, the increase is not keepingpace Fiith the increasing number of primary and middle schoolage children; the proportion of such children in school nasbeen decreasing.

Quantitative projections indicating he impact of therising population on school enrollment were made by the Bureauof the Census' International Statistical Programs Center andare included in appendix IV.

HEALTH CARE INADEQUATEDESPITE PROGRESS

A primary requirement for economic and social develop-ment is acknowledged to be improving the health of the people.Although the number of health personnel and facilities hasincreased markedly over the last 20 years, Ghanaians continueto be malnourished. The rural poor suffer a disproportionateburden of diseases from largely preventable causes, becausethe geographic distribution and allocation of health facili-ties still greatly favors the urban areas. It is estimated

11

that less than 30 percent of the population has access toreasonably adequate curative services and an even smallerpercentage to preventive health services. The problems arebeing compounded by a steady increase in population and theresulting increase of a dependent population less resistantto infectious diseases because of undernutrition and mal-nutrition. According to AID, the following is necessary toimprove health in Ghana.

-- Better management of existing resources.

-- More doctors and paramedical personnel.

--More simple functional health facilities, particularlyin the rural areas.

-- Increased rural water supplies.

-- Educating the public on sanitation and health servicebenefits.

Ghana's rural areas have few doctors and hospital beds.In 1971 (the most recent year for which data is available),the rural Upper Region had an average of 1 doctor for every100,000 people. Even in Greater Accra, where medical facili-ties are most available, the ratio of doctors to people is1 to 6,000. Similarly, hospital beds ranged from 1 bed forabout 1,520 people in the rural Brong-Ahafo Region to 1 for290 people in Greater Accra.

Quantitative projections indicating the impact of risingpopulation growth on needs for health manpower were made bythe Bureau of Census' International Statistical Programs Centerand are included in appendix IV.

Water supply and waste disposal facilities, while almostuniversally deficient, are also more available in urban areas.In 1973 the government estimated that 40 percent of the popu-lation had a piped water supply. According to 1975 estimates,however, rural communities receive only 10 percent of thetotal supply. On a per capita basis, larger city availabilityapproaches that o': developed countries, towns under 20,000have a lesser amount, and villages have scarcely been touched.(Canada is providing assistance in this area.)

Waste disposal facilities are entirely inadequate; themodern sewerage system under construction in Accr. will beGhana's first. There is general agreement that the incidence

12

and prevalence of diseases related to poor environmentalsanitation represents a serious problem. The problem is com-pounded by population growth and rural-urban migration. Ghanais trying to improve health facilities and services, but atthe same time, must also attempt to provide for the 300,000annual population increase.

Ghana's policy paper on population (see p. 17) notesthat high fertility and optimum health are not commonly foundtogether. While high fertility is not the sole cause ofpoor health, the control of fertility does contribute toimproved health.

URBAN MIGRATION AND ECONOMIC GROWTH

Per capita real income has been stagnant in the pastdecade, and migration to urban areas has increased. The1970 census shows over 37 percent of the population wasborn in a region other than where it was counted. Thefigure for 1960 was about 14 percent. The regional growthrates between 1960 and 1970 ranged from 5.6 percent in theGreater Accra to only 1.4 percent in the Eastern and UpperRegions. An important reason for the different growth ratesis migration. Cities are growing faster than rural areas.Available health and social services are strained, andrural-urban migrants often arrive lacking urban skills ac-cording to AID. Much of the urban growth has been in theform of shanty towns, and housing and sanitation is charac-terized as deplorable.

The urban population may surpass the rural population by2000. Based on the United Nations medium population esti-mates and analysis, the Bureau of Census' InternationalStatistical Programs Center (ISPC) projects that the number ofGhanaians living in rural areas will rise from 6.8 millionin 1975 to 9.8 million in 2000, but the number of Ghanaiansin urban areas will advance from 3.2 million in 1975 to10.5 million in 2000.

Foreign immigration is not significant and has largelybeen curtailed since enforcement of the Alien ComplianceOrder of' 1969, which brought about the deportation of a num-ber of aliens.

FACTORS INFLUENCING FERTILITY IN GHANA

Historically, the high birthrate in Ghana has been re-lated to culture and environment--tribal society, attitudes,

13

and practical considerations. Studies have shown that familyfertility decisions are responsive to changes in the family'seconomic and social environment and in personal attitudes.But, the nature of fertility determinants, the changes theyundergo, and their interdependence, is complex and the rela-tive importance of different factors is difficult to assess.Several factors affecting fertility may change simultaneously.

Traditional way of life

In the past, high fertility was considered necessary tooffset high infant and child mortality. There was a culturalpreference for sons to insure survival of the family line.Parents had to depend on grown children for support in theirold age. Under conditions of subsistence agriculture, chil-dren began to contribute at an early age and cost little tosupport. Aspirations were low and expectations of a betterlife were largely absent. The relationship between high fer-tility and poor maternal and child health was not understood.Traditionally, the value of a woman was defined largely interms of her ability to bear children. The weight of com-munity and family pressures encouraged high fertility.

Kinship societies

Traditionally, Ghanaian tribal societies have been or-ganized along matrilineal or patrilineal groupings with severalgenerations living together as extended families. Prope~rtyholding, inheritance, and family decisionmaking are organizedaround those with common blood relationships rather than be-tween husbands and wives.

These corporate kin groups place high value n childrenas a means of perpetuating a man's lineage and az security inold age. A large family has been a mark of restige andhonor to the parents. One tribe honors a mother of 10 in apublic ceremony of congratulations. By contrast, barrenwumen are often regarded with contempt and pity.

Corporate kin groups provide economic and personal sup-port for their members in the bearing and nurturing of chil-dren. Individuals, therefore, have a sense of security inundertaking marriage and parenthood. Children, as members ofthe lineage, are looked after by other members of the kin-group. Furthermore, the economic burden of rearing childrenis shared because a child draws from the general storehouseand not the parents' income alone.

14

Education

Data indicates that completed fertility for Ghanaianwomen, both urban and rural, aged 45 and over, is inverselyrelated to educational status.

Completed Fertility (Average Number ofChildren Ever Born Per Woman Aged 45

and Over) By Educational Status (note a)

Completed fertilityEducationdi status All women Urban Rural

No education 6.2 5.7 6.2Elementary 5.5 5.2 5.9Secondary 2.1 2.5 1.0University 0.4 0.5 ---

a/ Source: "Dynamics of Population Growth in Ghana"S. K. Gaisie.

Research in Ghana has not determined precisely why edu-cation corresponds with reduced fertility. It may lead tomarriage postponement, increased knowledge of contraceptives,changed attitudes toward birth control, and, by providinggreater employment opportunities for women, increase the"opportunity cost" of children.

Whatever the reason(s), it is clear that traditional be-liefs and practices are affected by social and economic chan-ges. The Ghana Rural Reconstruction Movement Mampong Valleyproject may provide some useful data in this area (see app.VIII).

Urbanization

As urbanization increases, one might expect the kinshipinfluence to diminish. There is some indication that inurban areas practical considerations have begun to overtakecultural practices as determinants of fertility.

In Ghana, rural fertility exceeds urban fertility by 15percent, and the urban-rural differences within regions rangefrom 3 percent in the north where urbanization is minimalto 36 percent in Ashanti. Explanations offered by a Ghanaiandemographer for the urban-rural differential included: mar-riage at a later age in urban areas, greater use of ontra-ceptives in larger towns, and different age structures ofurban and rural populations.

15

CHAPTER 3

GHANA'S DEVELOPMENT AND

POPULATION POLICIES

Ghanaian population growth attracted government attentionafter the 1960 census showed a population increase of two-thirds more than the 1948 census. Concern and interest grewduring the decade, resulting in the publication of an officialpopulation policy in 1969. AID officials believe this paper,"Population Planning for National Progress and Prosperity,"could serve as a model for other African countries.

In January 1975, the government published "The Guidelinesfor the Five-Year Development Plan" for 1975-80. This is aqualitative statement of development strategy and outline fora plan whose major goals include economic growth, full employ-ment, equitable income distrihution, national economic inde-pendence, ma' enanca of a ra onable external balance of pay-ments, and r nable price staoility. We believe that rapidpopulation growh will hinder, directly or indirectly, fullachievement of many of these goals.

The guidelines emphasize agricultural and rural develop-ment, pointing out that development efforts in the past havebeen concentrated in the largest urban areas, resulting in aninequitable distribution of social services and facilities.Improvement in the distribution of education and health serv-ices are identified as important objectives.

Although the guidelines for the 1975-80 development planhave been published for some time, when we did this reviewthe plan itself was not published.

AID officials believe, however, that family planningpolicy and programs will be an integral part of the plan.High government officials have shown increased interest ina family planning policy. For example, the governmentsupported a national family planning seminar in January 1976.

GHANA'S POPULATION POLICY

As stated, official concern over the population growthrate developed during the 1960s. The 1963 "Seven-YearDevelopment Plan" warned that the rapid population increasewould impede development and strain the economy. In 1966-67,a multivolume study ("A Study of Contemporary Ghana") pointed

16

out that economic savings could be realized by reducing therate of population growth.

In 1968, the Ghana Manpower Board prepared a statement ofnational population policy. This was published in 1969 asthe official policy paper "Population Planning f :r National Pro-gress and Prosperity." In his preface to the policy statement,the Commissioner for Economic Affairs noted:

"This is the first time in the history of this countrythat the Government has defined its policies onpopulation and has taken a definite stand in the matterof population growth...

The size of our present population does not pose im-mediate problems for us. However, the rate at whichthe population is increasing will very certainlycreate serious social, economic, and politicaldifficulties before the turn of the century. Ifwe want to alter the rate of growth, even arginally,in two decades' time, w must initiate action now."

The statement itself read, in part:

"The population of Ghana is the nation's most valuableresource...

The welfare of the nation is now endangered by a subtle,almost imperceptible demographic change. During vhepast three or four decades the death rate has beenslowly falling, permitting more children to surviveinto adulthood and adding years to the life expectancyof our people. But while the death rate has beenfalling, there has been no noticeable change in thebirth rate...

Unless birth rates can be brought down to parallelfalling death rates, Ghana's population will climbat a rate very dangerous to continuing prosperity,and the children of the next few generations willbe born into a world where their very numbers maycondemn them to life-long poverty...

Ghana is now producing more children than it cancomfortably provide for..."

AID summarized the statement's major policy recommenda-tions as follows:

17

-- Details of the population program were to be developedby participation of national and regional, public andprivate entities.

--Reduction of morbidity and mortality were to bean important part of the program.

--Quantitative goals were to be set on the basis ofreliable demographic data.

-- The government would encourage and provide informationand assistance to persons wishing to space or limitthe size of their families, but this would be donethrough persuasion rather than coercion.

-- Efforts would be made to expand the nondomestic roleof women in the ec6nomy to reduce pro-natalistinfluence.

--Policies would be adopted to regulate internal migra-tion and immigration.

--Agreements with international public and privateorganizations would be developed to benefit fromtheir experience and assistance in population programs.

Considering its promulgation date, we elieve Ghana'sofficial population policy is comprehensive and progressive.U.S. officials believe it could serve as a model for otherAfrican countries. Like the World Population Plan of Action(which resulted from the World Population Conference held inBucharest, Romania, in August 1974), it stressed the inter-relation of social, economic, and cultural development withpopulation goals and policies.

GHANA NATIONAL FAMILYPLANNING PROGRAM

In January 1970, the government authorized the establish-ment of the Ghana National Family Planning Program (GNFPP).Because the population policy and GNFPP were considered inte-gral parts of social and economic development work, the secre-tariat was placed within the Ministry of Economic Planning.The secretariat is responsible for planning and coordinatingthe activities of GNFPP.

GNFPP was designed to utilize existing institutions,facilities, and personnel in both the public and private

18

sectors. Various ministries and agencies were to be involvedin family planning activities.

-- The Ministry of HealtL is primarily responsible forthe provision of contraceptive services, for patienteducation, and for the training of technical person-nel involved in the service program.

--The Ministry of Information and the Ministry of Labor,Social Welfare, and Cooperatives are primarily respon-sible for the information and education components ofthe program. The personnel and facilities of theseministries are utilized for both the mass media andpersonal contact programs.

--Personnel from the Ministries of Education andAgriculture (Extension Services Division) are alsoto contribute to the information and education as-pects of the program.

-- The Planned Parenthood ssociation of Ghana (PPAG)and the Christian Courcil of Ghana (CCG), both inthe private sector, provide contraceptive servicesand play important roles in the training andpublic information activities.

The secretariat has overall responsiblity for planningand coordinating the activities of GNFPP, while the partici-pating agencies are responsible for the operational aspectsof the program.

GNFPP 5-YEAR PLAN: 1973-1978

In 1970, GNFPP developed a 5-year (1973-78) plan of ac-tion which had an overall goal of reducing the populationgrowth rate to 1.75 percent annually by 2000. The plan noted,however, that initially, tne death rate would probably declinemuch faster than the b .rthrate so that not much decline in thegrowth rate should be expected before 1985. GNFPP realizesthat the growth rate in Ghana is anticipated to rise to 3.5percent per year before it declines.

The 5-yeaz plan called for GNFPP not only to expandfamily planning services but also to create an environmentconducive to generating increased demand for such services.Generally, the plan specifies:

19

(1) Increasing the number of amily planning clinicsoffering a full range of services.

(2) Expanding commercial outlets for distributing non-prescription contraceptives.

(3) Establishing satellite clinics at district andvillage levels using motile health and family plan-ning teams.

(4) Staffing family planning clinics with qualifiednurses, auxiliaries, health educators, and fieldworkers.

(5) Recriiting and training traditional village birthattendants (who belp won,-n with their deliveries),physicians, family planning nurses and auxiliaries,community health nrrses, and art-time and full-time field workers.

Most outside financial support for Gi1FPP has come fromthe United States. While other donors have supported popula-tion programs in Ghana, mostly in research and universitytraining, the United States has been the major outside sup-porter of operational family planning services. During fis-cal years 1971-1976, the United States provided about $3.2million to GNFPP. The Ghanaian government began providingfinancial support to GNFPP in 1974 and has been increasingits support each year. Through fiscal year 1976, it hadcommitted about $2.5 million. The sources of GNFPP fundingare shown in appendix V.

20

GNFPP billboard in Accra. One of several displayed in urban areas.

Ministry of Health Maternal and Child Health Clinic in Cape Coast, Central Region. Thisclinic provides family planning on Tuesdays from 2:00 to 4:00 p.m. It had 168 newacceptors in 1975.

21

GNFPP ACTIVITIES: ROOM FOR IMPROVEMENT

GNFP. secretariat was established in the Ministry ofEconomic Planning to plan and coordinate the family planningprogram. GNFPP provides nonclinical contraceptives (foamsand condoms) for the commercial distribution program. Some600 commercial outlets are said to be involved. It also isinvolved in disseminating information, training paramedics,family planning nurses, and field personnel, and coordinatingpopulation programs. GNFPP operates no family planningclinics on its own, but clinics in Ghana register with itand supply data on family planning acceptors.

From 1972 through 1975, the number of family planningclinics registered with GNFPP increased from 140 to 189.We estimate, however, that only about three-fourths of theseclinics are active in family planning and report their acti-vities. Of these active clinics, about 50 percent are oper-ated by the Ministry of Health, and the remainder by PPAG,CCG, and other private organizations. The family planningclinics operated by the Ministry of Health use facilitiesof its health clinics, whereas almost all of those oper-ated by PPAG and CCG offer only family planning services.While Ministry of Health family planning clinics are col-located with health clinics, family planning sessions areseparate from health clinic sessions and often are offeredfor only a few hours per week.

During our discussions, GNFPP, AID, and other officialsexpressed a need for better coordination between the minis-tries and GNFPP. Officials of GNFPP secretariat believe thatthe ministries should be more involved in family planning.For example, hospital and other Ministry of Health facilitiesand staff had not been made available for family pla.ningservices as expected by GNFPP, and trained family planningnurses did not always practice family planning at healthclinics. GNFPP officials also noted difficulty getting theMinistry of Information to distribute GNFPP literature.

Another improvement would be to increase the number ofhours family planning services are available at the Ministryof Health clinics. AID officials want family planning tobecome an integral part of the maternal/child health clinic.

We asked Ghanaian, AID, and other officials how suchsituations can be resolved. Some felt that placing GNFPPsecretariat in the Ministry of Health would provide greatercontinuity of family planning and health care services. One

22

observer noted that the existence of a separate organizationcharged with family planning generally creates conflict.GNFPP officials commented that a strong family planningorganization was necessary in Ghana, at least i the earlyphases of program development, because of the pro-natalistculture within which the program was to operate. Theystated GNFPP was placed within the Ministry of EconomicPlanning because various ministries and private organizationswere supposed to play an active part in the total effort.One of GNFPP's chief concerns has been to convince the rele-vant ministries of the importance of family planning to theirparticular programs. They hope that once this concern andcommitment has mat rialized, the ministries will assume in-creasing respor.siilities for the family planning program,and integrate it more fully within the total developmenteffort.

Recent signs indicate that the family planning programin Ghana may be at a turning point. High government offi-cials have affirmed the importance of family planning inthe context of total development. The Ministry of Healthhas also shown more interest in family planning. It haspointed out the importance of family planning as an integralpart of maternal/child health care and has planned seminarsfor regional health personnel to explain and encourage thatrelationship. AID officials noted, however, that familyplanning has still been offered only in separate sessionsand not as an ongoing function of the maternal/child healthclinic.

23

CHAPTER 4

U.S. AND OTHER DONOR

ASSISTANCE

The United States, multilateral organizations, and othercountries have provided a substantial amount of economicassistance to Ghana since 1946. Assistors and amounts pro-vided include:

AmountCountry or organization (in millions)

United States a/$290.4World Bank (InternationaL Bank for

Reconstruction and Development/International Development Association a/ 162.3

African Development Bank a/ 10.3United Nations programs a/ 35.7Federal Republi- of Germany E/ 128.0United Kingdom b/ 86.1Canada b/ 63.6

Total $776.4

a/ Assistance fiscal years 1946-1975.b/ Assistance calendar years 1960-1974.

Assistance to Ghana has gone through several phases.From 1962-66 assistance from governments and multilateralagencies averaged about $30 million per year. During theperiod 1967-71, the United States and other Western donorsincreased their average annual assistance to $67 million.Assistance slowed, however, in 1972 when a new governmentwas formed. n late 1974 and in early 1975 bilateral-debtrescheduling agreements were signed by all major donors,clearing the wy for major assistance.

U.S. ECONOMIC ASSISTANCE

U.S. economiic assistance from 1962 to 1971 increasedfrom $11.6 million per year in the first 5 years to $31million per year in the second 5 years. Most of the assis-tance from 1967 tc 1971 was directed to balance-of-paymentssupport throiugi loans to finance import of commodities andPublic Law 480 sales of agricultural commodities.

24

U.S. assistance following Ghana's 1972 change ofgovernment was relatively limited. Only AID's populationprogram assistance continued at its pre-1972 level. Begin-ning in 1975, after the debt resettlements, the United Statesplanned significant increases in aid. In fiscal years 1973through 1976, U.S. economic assistance totaling about $60 mil-lion was obligated, including a large loan approved before thechange in government, but withheld until after the debt settle-ments.

In 1961, Ghana became the first country with a PeaceCorps program. S ce that time, more than 1,500 Peace Corpsvolunteers have served in Ghana--two-thirds of these haveserved in the education sector. In 1976, 176 of the 211 volun-teers were working in this field. Peace Corps expenditures inGhana over the last 5 years have averaged about $1.5 millionyearly.

OTHER DONORS' ASSISTANCE

The World Bank Group expects to provide up to $70 millionannually in the next 3 years, concentrating on livestock,agricultural, and rural development. Of particular note isthe proposed $21 million credit from the International Develop-ment Association for an integrated agricultural developmentproject for the Upper Region. (See p. 41.) The Federal Re-public of Germany is concentrating its assistance on a ruraldevelopment scheme centered on rice production in the Northernand Upper Regions and expects to provide about $16 millionper year from 1975 to 1980. The Canadians have a major villagewater supply project in the Upper Region and want to increaseassistance to the rural sector. Canada's commitment is ex-pected to approximate $20 million per year. The United King-dom plans to provide support to the Upper Region agriculturaldevelopment project.

POPULATION ASSISTANCE TO GHANA

Less than 2 percent of all economic assistance from alldonors to Ghana has been for population programs. For fiscalyears 1971-76, population assistance from countries and in-ternational and private organizations has totaled about $15.9million. Approximately 75 percent (about $11.9 million) ofthis assistance has come from the United States, throughvarious channels. (See app. VI.) Donor assistance to popu-lation programs over the next few years is expected to totalabout $10.6 million, with the United States providing almost75 percent of that assistance, directly and indirectly.

25

Officials of two other major countries told us they believedtheir assistance was needed more in agricultural and ruraldevelopment than in population programs.

U.S. STRATEGY FOR POPULATION ASSISTANCE

The United States' assistance to Ghana's population pro-grans has come f m (1) AID's centrally-funded programs,planned and managed by AID's Washington Office of Populationand ission-planned bilateral programs, (2) funding of pri-vate organizations, and (3) support of the United NationsFund for PopFlation Activities.

AID's 5-year strategy for providing population assistanceto Ghana, issued in January 1975, included the followingpoints:

-- Assist in modernizing the planning and managementstructures in GNFPP and the Ministry of Health.

-- Strengthen the integrated family planning sectorapproach within the Ministry of Health.

-- Continue to improve the commercial distribution sectionof Ghana's overall population program.

--Continue working with other donors who support infor-mation, education, and communication efforts in thefamily planning area.

-- Continue support for ongoing research and evaluationprojects.

-- Encourage GNFPP support of the voluntary agency portionof the program.

AID envisions that, if the above strategy is successful,it will have provided a base for the family planning deliverysystem by the end of fiscal year 1980. Major elements will be

--a strengthened management, planning, and support staffof GNFPP,

--an expanded commercial distribution program for contra-ceptives, and

-- two hundred Ministry of Health facilities and anappreciable number of voluntary agency facilitiesoffering integrated family planning services.

26

U.S. POPULATION PROJECTS

Since fiscal year 1971, there have been two AID bilateralpopulation projects and five regional or worldwide projectswhich involve family planning activities in Ghana. (See app.VI.) Each of these projects is briefly described in appendixV and summarized below. An eighth project supports familyplanning in the context of rural development, but funds arenot allotted to AID's population category.

One bilateral projec supports the Chana National FamilyPlanning Program. Over $3.2 million (primarily for commodi-ties, budget support, and training) was granted during the fis-cal year 1971-76 period. AID expects to provide about $3million in the next 3 years. The other major bilateral projectis surport of the Danfa rural health and family planning pro-ject. Implemented through a contract with the University ofCalifornia, this project seeks to test various approachesto delivering health and family planning services and strenlg-thening Ghanaian personnel capability in related areas.

Five regional projects now include activities in Ghana.The university teaching of population dynamics project haspresently been implemented at the University of Ghana. About$1.5 million had been provided by mid-1976. The demographicteaching and research project at the University of Cape Coastinvolves teaching at that school and studying mortality trendsin southwest Ghana. The World Education Incorporated familylife education project has a program in Ghana to integratefamily planning components into the adult education network.The African health training institutions project involvesboth seminars nd work with health schools in Ghana and eightother nations. A project designed to improve commercialcontraceptive distribution in five countries is planned forGhana.

OTHER DONORS' OPULATION PROGRAMS

Private organizations, the United Nations Fund for Popu-lation Activities (UNFPA), and third countries have providedassistance to Ghana's population programs. The U.S. Govetn-ment contributes significant portions of the funds to severalof the private organizations and 1UNFPA. (See app. VI.) Twoprivate organizations, the International Planned ParenthoodFederation and Family Planning International Assistance, aredirectly involved in the provision of family planning serv-ices. A third private organization, the Ford Fourdation,has provided funds to pay the salary of a technical assistant

27

responsible for establishing a research and evaluation unitwithin the GNFPP. The UNFPA is providing funds for researchand improved demographic data gathering. The United Kingdomand Canada have provided small amounts of equipment andfunds to GNFPP. Appendix VI lists population assistance toGhana.

International Planned Parenthood Federation (IPPF) andPlanned Parenthood Association of Ghana

IPPF affiliate in Ghana is the Planned Parenthood Associ-ation of GhanA (PPAG), which staffs and operates about 36family planning clinics. A number of these are open only oneday per week. These clinics are not collocated with facilitieswhich deliver other health services and in the past have pro-vided only family planning services. PPAC officials, however,are expeLimenting with clinics that provide some maternal andchild health services as well. In addition to providing con-traceptives at its clinics, the PPAG also promotes familyplanning through home visits, talks, lectures, group meetings,film shows, and exhibitions by its field workers.

PPAG's involvement began in 1967. IPPF has rovided$2.1 1/ million since 1971, to support PPAG operations. TheUnited States is a major contributor to IPPF. Annual IPPFfunding of PPAG currently is about $400,000. As a majorparticipant in GNFPP's new activities, PPAG will also benefitfrom AID's 1977-1979 population program support project (seepp. 59 and 60).

Family Planning International Assistance andChristian Council of Ghana

Family Planning International Assistance (FPIA) is theoverseas division of the U.S. IPPF affiliate, the PlannedParenthood Federation of America. FPIA supports anotherprivate Ghanaian organization providing family planning serv-ices--CCG. The CCG operates 12 free-standing family plan-ning clinics. While these clinics do not provide any otherform of health service, they do provide marriage and familycounseling. FPIA began supporting CCG in July 1973; priorto that CCG was supported by IPPF. FPIA has provided about$200,000 to CCG. Like PPAG, CCG is to have a role in GNFPP's

1/ This fig re includes IPPF support of Christian Council ofGhana (CC prior to 1973. See comments in FPIA section.

28

new intensive outreach demonstration project, which receivesAID funding. (See p. 55.)

United Nations Fund forPopulation Activities

Current UPA activities in Ghana include the UnitedNations Regional Institute for Population Studies and assis-ting the biths and deaths registry under Ghana's CentralBureau of Statistics.

The Institute seeks to promote and strengthen re:;earchand training in demography and related fields in English-speaking countries of Africa. Housed at the University ofGhana near Accra, the Institute is a joint effort of theUnited Nations and the Ghana Government and offers three pro-grams:

--A 12-month course leading to a graduate diploma inpopulation studies.

--A course lasting at least 9 months for a master of artsdegree in population studies.

--A Ph.D. degree program in population studies.

Other Institute activities include data collection, governmentadvisory services, and seminars and workshops in interestedcountries. The total cost of the project, which began in1972, is expected to be $2.8 million through 1977, with 1975expenditures estimated at $300,000.

The other active UNFPA project is assistance for the ex-pansion of the national registration system for births anddeaths and development of vital statistics. This 7-yearproject aims at establishing a nationwide birth and deathregistration system and capability to use vital statisticaldata in making reliable estimates of the country's popula-tion. The project began in January 176; UNFPA's contribu-tion is expected to be $2.8 million.

NEED FOR EFFECTIVE COORDINATIONOF POPULATION ASSISTANCE

Foreign governments, international organizations, and pri-vate nonprofit organizations are providing population assis-tance to Ghana. The diagram on page 31 illustrates the flowof this aid, often through intermediaries, to recipientorganizations.

29

We observed, however, that there is no systematic,effective coordinating mechanism that seeks to maximizebenefits from limited resources and to make sure that thenature and results of projects are fully disseminated.Specifically, we noted the absence of a reqularly-scheduledmeeting of representatives of donor and recipient organi-zations--both private and governmental--to discuss thepopulation situation and related projects.

Without making a full examination, we did learn ofseveral situations which might have been prevented by suchmeetings. For example:

--A PPAG and a Ministry of Health clinic offeringfamily planning were located closely together, butwe were told that coordination between their fieldworkers was ineffective.

--One GNFPP official pointed out that the U.S. Mission-planned Danfa project (see pp. 60 and 61) and two U.S.centrally-planned projects [university teaching ofpopulation dynamics and demographic teaching andresearch (see p. 62)] were not fully coordinated tothe extent desirable.

-- A professor with the demographic teaching projecttold us he was unaware of social and economic databeing collected by the Danfa project (see pp. 60-62)and was also unaware of research being done bythe U.N.-funded Regional Institute for PopulationStudies Program.

-- A CCC official said he was unaware that his organi-zation had a defined role in AID's 1977-79 supportgrant to GNFPP. (See pp. 58-60.)

We believe effective systematic coordination mechanismsare needed to maximize the impact of population assistancewhen multiple donors and organizations are concerned. Forexample, in Costa Rica, meetings of organizations involvedii population assistance and family planning projezts areheld.

We recommend that AID act to encourage establishmentof effective systematic coordinating mechanisms for popu-lation assistance in Ghana and other African countrieswhere none exist. (See p. 45.)

30

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CHAPTER 5

OBSERVATIONS ON RESULTS OF GHANA'S POPULATION

PROGRAMS AND SUGGESTIONS FOR IMPROVEMENTS

Ghana's population policy was published in 1969, and

cormitments to population programs began soon after. Now,

a framework has been established and the program has made

some progress. However, it has reached only a small pro-

portion of the population, especially in the rural areas

where 70 percent of the population lives. Records indicate

about 93 percent of the approximately 2 million women of

reproductive age are not clinic acceptors of family planning.

FAMILY PLANNING PROGRAM

FRAMEWORK ESTABLISHED

Ghana's 1969 population policy statement is considered

to be probably the best in Africa, and Aid officials believe

it could serve as a model for other African countries. GNFPP,

charged with implementing the policy, attracted attention to

Ghana's population situation and, most recently, has begun

eliciting support from other sections of the government.

Since 1974, Ghana has committed increasing amounts of finan-

cial support to GNFPP--the 1976 commitment was over $1 mil-

lion. About 140 Ministry of Health and other clinics are

registered with GNFPP and dispensing contraceptives. Com-

mercial distribution has also been systemized. This frame-

work for family planning is probably the most important

accomplishment of the overall program to date.

NOT ENOUGH ACCEPTORS - A MEASURE OF THE

FAMILY PLANNING PROGRAM'S INEFFECTIVENESr

Measuring the results of family planning programs is

difficult in developing countries which, like Ghana, lack

good demographic and other data. Although contraceptives

are dispensed through both clinics and commercial outlets,

only clinics keep data on contraceptive acceptors. From

this data, GNFPP compiles the number of new acceptors and

revisits to clinics. AID officials warned us these statis-

tics may not accurately indicate actual contraceptive use

and therefore do not necessarily measure program effective-

ness. Recognizing this limitation, we analyzed the number

of new acceptors and revisits to family planning clinics

since fiscal year 1972. Although this data does not include

the estimated 10,000-12,000 acceptors who use commercial

distribution outlets, their exclusion does not materially

affect the overall results of the program.

32

o o0C ' Ci 4 u o N W E 3

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o Q,@ o *- a 0- 0c I a u t A L Wo qL L W

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to0 C r- -4rOr---N 0 vs; 44J ) P-1 - P utin Eq W7 o E L

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33

The above statistics show the clinic program is averagingabout 13,600 visits a month with a total of about 140,000new acceptors during the period July 1971 to December 1975.*Thus, about 93 percent of the approximately 2,000,000 womenof reproductive age (15-49) are not clinic acceptors. Irnaddition, the data shows that despite the modest increase inthe number of clinics registered, the number of new acceptorshas remained relatively constant and actually decreased duringthe most recent reporting period. The 2 to 3,000 new clinicacceptors per onth has not even kept pace with the monthlyincrease of almost 5,000 women of reproductive age.

Nonclinical contraceptives (foam and condoms) are sup-plied through 600 commercial outlets. Information on thisaspect of 'he program is limited. AID officials know howmany contraceptives are shipped to Ghana for both the clini-cal and commercial distribution portions of the program. Theydo not know and are unable to determine, because of poor data,the stock levels or sales volume through commercial outlets,but have estimated that in 1975, commercial distribution wasreaching 10,000 to 12,000 continuing acceptors.

AID recognizes that the results of GNFPP's program havebeen disappointing and that it has not reached a significantnumber of Ghanaians. The targets established in the 1973-75 GNFPP/AID Population Program Support project have not beenreached. The original target was to reach 96,000 new ac-ceptors annually (8,000 an month) by 1975; in fiscal year1975, there were only about 35,500 new acceptors. By 1972some 5,000 retail outlets were to be selling subsidized con-traceptives, yet in 1975 only 600 such outlets were reportedto be doiny so. AID has included Ghana in a new program toimprove commercial distribuLion. (See p. 60.)

34

PPAG family planning clinic (House No. 88/3) in Cape Coast, Central Region. This clinic isopen daily and had 2,191 new acceptors in 1975--the highest number of any clinic.

! i

PPA ,fAL¥ HEAII MT

AWUTU

PPAG experiment;s clinic in Awutu. This clinic, open only one dday a week, is providingmaternal and child health care as well as family planning services.

35

We agree with AID and GNFPP officials that changes areneeded if a significant reduction in Ghana's population growthrate is to be achieved. Family planning services are general-ly unavailable, and programs that motivate people to acceptfamily planning need to be identified and developed. AID-funded projects in Ghana suggest some approaches.

Family planning services limited

Although about 140 of the targeted 160 clinics were of-fering family planning services in 1975, they were concen-trated in urban areas and had limited hours. For example,one PPAG clinic was only open on Thursdays from 8 a.m. to3 p.m., and one Ministry of Health clinic was open only 2hours per week for family planning services (See photos onpp. 21 nd 36.)

We analyzed acceptors and clinics to determine what areasof the country were being served. In 1975, 77 percent of theclinics were in urban areas, and they accounted for 88 per-cent of the acceptors. Yet, only 30 percent of the Ghanaianpopulation live in urban areas--leaving almost three-quartersof the population to be served by less than one quarter of theclinics.

In fact, over 30 percent of the acceptors were from the2 largest cities, and over 50 percent were from the 6 citieswith a population of over 50,000. Further demonstrationof this urban predominance is shown by the table below, whichindicates a direct relationship between urbanization and theavailability and acceptance of clinic family planning ser-vices. While postulating that an urban clinic may receiveacceptors from surrounding rural areas, clinic personnel saidmost acceptors at such a clinic are from the urban area.

36

Regional Breakdown: Urbanizationand Family Planning Acceptors

Region Percent urban (note a) Percent acceptors (note b)

Greater Accra 85.5 18.0Ashanti 30.0 9.0Central 28.5 6.5Western 27.0 10.0Eastern 24.5 7.0Brong-Ahafd 22.0 4.5Northern 20.5 3.0Volta 16.0 5.0Upper 7.0 1.0

a/ Percent of region's population in towns of over 5,000 in1970.

b/ Total acceptors, July 1970 to December 1975, as a percentof the female population aged 15-49 in 1975.

Unless the family planning program reaches the rural areas,Ghana's high fertility rate is expected to remain substantial-ly unchanged.

How to reach more potentialacceptors--the Danfa project

The Danfa rural health and family planning project, sup-ported by AID, is testing the rlative effectiveness of familyplanning services delivered in conjunction with (1) healtheducation and comprehensive health programs, (2) in conjunc-tion with health education, and (3) by itself in the presentrural Ghanaian setting. Acceptor rates ranged from 14 percentin the first case to only 3.3 percent in the last. (See pp. 60and 61.)

As a result of these findings, officials connected withthe Danfa project have developed a spectrum of potential ac-ceptors for the rural areas studied in that project. Theybelieve about 10 percent of the women would accept familyplanning services without any motivational efforts. Some25 percent more would accept family planning if it were pro-vided with health care at a clinic. Another 15 percent wouldaccept family planning if it were provided with health carein their village. However, Danfa officials say that at thep: esent time 50 percent would not accept family planningusing any of the Danfa approaches.

37

Danfa and AID officials in Ghana believe a similarspectrum could be developed for other sections of Ghana,but note that the percentage of women in each categorywould change, depending on the area's rural or urban char-acteristics. Generally speaking, urban areas would havelarger percentages of people in the first two categoriesand rural areas more isolated than Danfa would have largerpercentages of people in the latter two.

Urban and rural approaches

Danfa officials believe project results to date supportthe following approaches to delivery of family planningservices:

In urban areas: demand for family planning servicesgenerated by amily planning education could be metby government maternal/child health clinics supplementedin high demand areas by special family planning clinicsand private agency clinics. The clinics should bebacked by a well organized commercial distribution net-work for condoms, foam, and pills.

In rural areas: delivery of family planning servicesshould be coordinated with the delivery of healthservices. This would take place through existing healthcenters and posts and should include satellite clinicand mobile family planning teams for the more remoteareas. There should also be commercial distributionthrough existing commercial outlets; major rural mar-kets might provide another outlet.

The Mampon Valley Ap-proach

AID has approved a 3-year support program for the GhanaRural Reconstruction Movement (GhRRM) project in the MpcngValley. This project is based on the premise thdt familyplanning should be an integral part of local-based sccial andeconomic development. Since field operations began n spring1974, project officials have contacted the 20 villages involvedand begun programs to improve agriculture and crafts, pro-mote better nutrition and hygiene, expand literacy, and demon-strate the need for and benefits of community cooperation.They feel it is now appropriate to introduce family planningeducation and services.

Many people we spoke with believed that the approachused in this Mampong Valley project is the best way of

38

delivering family plann`ng assistance. This project shouldprovide a valuable test of that hypothesis if adequate con-trols and data collection are maintained. A description ofthe project is provided in appendix VIII.

NEED TO INTEGRATE FAMILY PLANNINGWITH OTHER DEVELOPMENT PROJECTS

The Danfa research findings to Jate appear to indicatethat many Ghanaians are more likely to accept family plan-ning if it is provided together with health care. It appearsto also indicate, as AID officials in Ghana believe, that be-fore a large percentage of Ghanaians, particularly thoseliving ill rural areas, will accept family planning, theirsocial patterns and economic status must change.

Development, through changes in economic and social sta-tus, is associated with changes in individual attitudes to-ward family size and, consequently, toward family planningaccording to many studies. Data that is accumulating onthe determinants of fertility suggest that different aspectsof development (such as increased female education and reducedinfant mortality) affect motivation to limit family size tovarying degrees. Not enough is yet known about the deter-minants of fertility and the ways that they can be modifiedby development policies and projects.

Development projects may affect the population growthrate directly or indirectly and to varying degrees. Thisimpact should be examined and, to the maximum extent con-sistent with other goals, evelopment projects should bestructured so as to increase otivdtion to limit familysize.

Implementing family planning programs in areas thathave been reached or are being reached by other develop-ment programs could lead to expanded accorLance. Both AIDand Danfa officials believe the country's overall develop-ment program can help gain acceptance of family planning,and that one way to assure that family planning is benefitingfrom other development programs is through integration.

Potential for family planningcJmbined with other developmentproTjects

Most family planning services in Ghana are not providedas an integral part of health services and are not integrated

39

with development projects. AID officials agreed that thereare projects crrently underway or planned such as the twodiscussed below, which could incorporate family planning edu-cation and services.

AID is planning a district planning and rural develop-ment project which aims to improve the quality of life of thepoor in selected rural areas and growth centers of Ghana.Anticipated subprojects include feeder roads, community stor-age facilities, village water systems, land clearing, conser-vation, afforestation, mall scale irrigation, and socialservices. Efforts to develop an economic infrastructure inrural market towns to help develop rural industries are alsoplanned. In discussions during a visit to one site of theproposed project, we noted that AID officials confirmed thatfamily planning services were not available even though,according to health clinic personnel, there was already somedemand for these services. The AID official commented thatfamily planning could be provided with health care in localGhanaian districts where this project would be implemented.He also said project planning should take into account theexpected increase in demand for family planning services.

AID officials also said it is theoretically possibleto incorporate AID family planning projects with other donors'development projects. They cited the International Develop-ment Association's new Upper Region agricultural developmentproject, a 5-year project with the objective of expandingagriculture in the region by developing rmall-scale agricul-ture. Activities are to include: (1) establishing a networkof service centers to provide farm supplies and credit, (2)constructing small health clinics at some of the servicecenters, (3) strengthening veterinary services, (4) estab-lishing 10 group ranches, (5' providing trained extensionservice field assistance, and (6) rehabilitating and con-structing small dams. We discussed including family plan-ning in this project with AID officials. They agreed thatfamily planning could be provided in planned health clinicsand would be a good wa, to expand family planning servicesin the Upper Region. However, they pointed out there wouldbe a problem of coordination since several donors and govern-ment ministries are involved. (See pp. 29 and 30.)

U.S. POPULATION ASSISTANCE PLANS

AID has approved a 3-year extension of its populationprogram support project for GNFPP. (See pp. 53-55.) GNFPPwill continue to concentrate on both family planning clinics

40

and commercial contraceptive distribution systems during this

period, although both components are to be expanded to ruralareas.

The project does not aim at effective integration offamily planning with health care and other development sectors.

AID officials said that while such integration is desirable,currently there are constraints. Government mir,istries, par-

ticularly the Ministry of Health, have had reservations about

including family planning in their programs. Consequently,AID officials are pursuing family planning approaches which

they believe would be as little affected as possible by in-ternal coordination problems. They said that continued sup-

port of family planning in clinics and commercial distribu-tion systems may offer the best chance of success, consideringthese constraints. AID officials told us that for the present,

the family planning program can be expanded by providing con-traceptive information and supplies without promotion by

health education. AID hopes that by 1980, when the new pop-

ulation program support project terminates, a strong familyplanning organization will be in place and coordination prob-lems within the government will be resolved. They hopethat coordination of family planning and health services and

integration of population and development planning could thenbe worked out.

41

CHAPTER 6

CONCLUSIONS AND RECOMMENDATIONS

The interrelationship~ between population growth anddevelopment sectors such as agriculture, education, and healthare complex and critical. Rapid population growth can offsetthe benefits of economic growth and thwart improvements inthe quality of life. The important link between developmentanrt population growth is recognized in Ghana's populationpolicy, which states:

"A national population policy and programme are to bedeveloped as organic parts of social and economicplanning and development activity."

AID and Ghanaian population officials we talked with inGhana fully agreed that population and other development pro-grams should be integrated. The Danfa project seems to bedemonstrating the advantages of integrating family planningand other health programs. The GhRRM Mampong Valley projectpostulates that the demand for family planning will increasewith local-based development in other sectors.

The Congress has stressed coordinating family planningservices with both health programs and programs designed toraise the standard of living of the poor. The section ofthe December 1975 amendment to the Foreign Assistance Actof 1961, Section 104b, on Populaticn Planning and Healthstates in part that:

"Assistance provided under this section shall be usedprimarily for extension of low-cost, integrated deliverysystems to provide health and family planning services,especially to rural areas and to the poorest economicsectorsr using paramedical and auxiliary medical per-sonnel, clinics and health posts, commercial distribu-tion systems, and other modes of community outreach;health programs which emphasize disease prevention,environmental sanitation, and health education; andpopulation planning programs which include educationin responsible parenthood and motivational programs,as well as delivery of family planning services andwhich are coordinated with prcgLams aimed at reducingthe infant mortality rate, prcviding better nutri--tion to pregnant women and infants, and raisingthe standard of living of the poor."

42

The close relationship between population growth anddevelopment was stressed in the World Population Plan of Ac-tion:

"***Policies whose aim is to affect population trendsmust not be considered substitutes for socio-economicdevelopment policies, but as being integrated withthose policies in order to facilitate solution of cer-tain problems facing both developing and developedcountries and to promote a more balanced and rationaldevelopment."

Although AID officials in Ghana have stressed te impor-tance of integrating population projects with other develop-ment projects, we found that little effective integrationhas taken place. While reaching a rural society with familyplanning programs is a common problem in developing countries,we believe AID can nevertheless do more to help by identi-fying factors of development amenable to policy directionthat will create demand for family planning services. TheDanfa project is providing some information of this typeon related aspects of health care (See pp. 60 and 61). Inaddition, AID can and should work with other donors and actas a catalyst in encouraging integration of both socialand economic development projects and projects intended toreduce population growth. In a recent policy statement AIDrecognized the need to support development efforts that en-courage smaller families.

Accordingly, we recommend that the Administrator ofAID, in developing assistance plans for Ghana and otherAfrican countries, as appropriate:

--Encourage governments and provide support when neces-sary to examine the relationships between social andeconomic change and fertility.

-- Help governments to establish population policieswhich encourage the types of social and economicdevelopment identified as having a maximum impacton fertility.

-- Consider the impact on population growth of plannedU.S. development projects and work to integratepopulation and development projects.

43

-- Take actions to encourage establishment of aneffective, systematic coordinating mechanism forpopulation assistance in Ghana and other countrieswhere none exists.

We plan to review the need to integrate population andother development programs and the extent to which AIDhas done so in assistance programs in Asia, Latin America,and Africa.

AGENCY COiMENTS

The Department of State and AID reviewed this reportand commented that it accurately described the population andfamily planning situation in Ghana and that they agreed withthe recommendations. The State Department applauded the re-port's emphasis on the need to integrate population activi-)ties into the whole development-planning process. AID statedthat it was planning to take appropriate actions in line withthe recommendations. State and AID comments are includedin appendices I and II. We also discussed the report withAID officials at the Mission in Ghana. They also agreed withthe report and recommendations and stated that it was usefulto them.

44

CHAPTER 7

SCOPE OF REVIEW

The review was conducted to examine U.S. populationassistance in an African country, Ghana, and past, present,and planned efforts of the Government and donors to reducethe population growth rate. In Ghana we conducted inter-views with and/or reviewed records of organizations including:

U.S. Embal;sy, GhanaUSAID MiFssion, GhanaPeace CorpsWorld Bank GroupUnited Nations Development ProgramWorld Health OrganizationInternational Planned Parenthood FederationFamily Planning International AssistanceWorld Education, Inc.Population CouncilPlanned Parenthood Association of GhanaChristian Council of GhanaGhana Rural Reconstruction MovementCanadian High CommissionBritish High CommissionEmbassy o the Federal Republic of Germany

We also held discussions with several officials fromnational, regional, and district government of Ghana agenciesincluding: the Ghana National Family Planning Program, theMinistry of Health, the Ministry of Economic Planning, and theMinistry of Social Welfare. In Ghana we also visited popula-tion, health, and/or agriculture projects in six of Ghana'snine regions. (See app. III.)

We discussed projects with AID's Office of Populationin Washington and received the data in appendix II from theInternational Statistical Programs Center, Bureau of theCensus.

Data in any developing country is limited and subjectto inaccuracies; Ghana is no exception. Data included inthis report is based on estimates of various researchers.Often there were conflicts between sources. In these caseswe used what we considered to be the most accurate or anaverage of the conflicting data. We believe the data wasadequate for our purposes and permitted us to reach certainconclusions reflected in the report.

45

APPENDIX I APPENDIX I

DEPARTMENT OF STATE

Washnton, DC. 20520

March 28, 1977

Mr. J. K. FasickDirectorInternational DivisionU.S. General Accounting OfficeWashington, D. C. 20548

Dear Mr. Fasick:

I am replying to your letter of December 14, 1976, whichforwarded copies of the draft report: "Population Assistanceto an African Country."

The enclosed comments were prepared by the Director ofthe Office of Population Affairs.

We appreciate having had the opportunity to review andcomment on the dft report. If I may be of furtherassistance, I trust you will let me know.

Sincerely,

D el L. Wiliamson, Jr.Deputy Assistant Secretaryfor Budget and Finance

F:closure: As stated

46

APPENDIX I APPENDIX I

UNCLASSIFIED

GAO DRAFT REPORT: POPULATION ASSISTANCE TO GHANA

The Office of the Coordinator of Population Affairsand the Office of Population Affairs (OES) have reviewedthe GAO report on Population Assistance to Ghana. Wefind it usefully details information about economic andsocial problems resulting from Ghana's high rate of popu-lation growth (3% annually). As it does so, it providesa good basis for understanding the particular populationsituation of Africa. And inasmuch as Ghana has had fora number of years one of the few direct government policiesin Africa to limit population growth, the report is alsouseful in describing an African response to populationproblems. It does so, by summarizing the Ghanaian policyand various programs and projects of interest to us,recognizing a number of deficiencies in the overallGhanaian family planning effort and at the same timesuggesting measures for its improvement. U.S. assistanceefforts, which are also described in so. detail, areconsidered by us to be at an appropriate level andgenerally effective.

We have no major criticism of the report and applaudits emphasis on the need for integrating population acti-vities into the whole developme: effort and for notingthat, particularly in Africa, family planning is mosteffective when delivered as part of general health careservices. Finally we would like to recommend that futureGAO reports include an assessment of whether the Ambassadorand his country team are playing positive roles insupporting Ghanaian population policy and programs as wellas our assistance.

C ord R. NelsonDirector, Office of PopulationAffairs

UNCLASSIFIED

47

APPENDIX II APPENDIX II

AUDITOR GENERAL

Mar 31 1977

Mr. J. K. FasickDirectorInternational DivisionU.S. General Accounting Office441 G Street, N.W.Washington, D.C. 20548

Dear Mr. Fasick:

Thank you for providing the draft report "Population Assistantto an African Country" for AID comment. Agency personnel fam.>with the population program in Ghana found the draft eportgenerally accurate. The Agency is prepared to agree with thethree recommendations contained in the report.

If we can be of further assistance in this matter, please letme know.

Sincerely yours,

i/ IHarry C. Cromer

Attachment: a/s

48

APPENDIX II APPENDIX II

AID COMMENTS ON GAO REPORT: POPULATION ASSISTANCE TO AN AFRICAN COUNTRY

The following represents AID's views on certain issues posed by the GAOdraft report "Population Assistance to an African Country."

We found the report generally an accurate description of the Ghanaianfamily planning program and we are thoroughly in agreement with the intentof the three recommendations. We have organized our comments as responsesto the three recommendations of the draft report first stated on page vand repeated on page 51.

The first recommendation is that AID should encourage the Government ofGhana "to examine relationships between socio-economic change nndfertility... in order to identify the areas where development would havemaximum impact on fertility." AID has financed a variety of researchprojects, including one in Ghana, on this general subject and we are fullyawake to the importance of an understanding of these relationships forsound policy and program development. The draft reports some interestingevidence from Ghana on the effect of education of women on fertility.Other possible relationships are also touched upon, including the causes ofdifferential urban and rural fertility and the possible impact of reducedinfant mortality on the number of children desired. We agree with therecommendation that more attention needs to be paid to socio-economicfactors and we fully intend to examine areas where research might be under-taken. We would then be better able to have a family planning program inGhana which reflects a fuller understanding of the socio-economic determinantsof fertility.

A second recommendation urges AID to be more active in establishing an"effective systematic coordinating mechanism for population assistance inGhana." In support of this recommendation, the draft report notes "theabsence of regularly scheduled meetings of representatives of donor andrecipient organizations", (page 36). The specific examples cited in hereport relate to the lack of coordination between donors and the overnmentof Ghana as well as within the Government of Ghana and within USAID. TheGAO's recommendation has great merit, and is in accord with our general policyon aid coordination.

The third recommendation urges AID to "consider the impact of planned U.S.development projects" and to "integrate population projects and developmentprojects which have a potential for influencing fertility."

AID has become increasingly concerned about the effect of development projectson fertility. We have proposed to Congress that a new section be includedin the authorizing legislation dealing with this particular subject. We will

49

APPENDIX II APPENDIX II

be pursuing this objective in Ghana as in all other AID assisted countries.Consequently this particular recommendation is completely acceptable to us.The sub'jct of "integrating" population and development projects is a bitmore complex. The report looks at this question in two ways: first ofall with respect to the "integration" of family planning into the country'sgeneral health program, and secondly to the "integration" of family planningintc development projects. These have different operational implications.

Most of the specific evidence adduced in the body of the report relates tothe operations of the GNFPP and to the absence of "coordination" betweenGNFPP and the Health Ministry. The draft report mentions this "coordination"problem a number of times. The Danfa motivation study appears to implythat the failure to increase the rate of new family planning acceptorsrelates partly to the absence of adequate "coordination" between GNFPP andthe Health Ministry. Although the GNFPP was placed in the Ministry ofPlannin i order to "integrate" family planning into the total developmenteffort the draft report observes that this has not been accomplished. Thereport notes that the Mission hopes that the "coordination" problem will beresolved by 1980 and integration f family planning and other developmentsectors can then be worked out (page 49).

We call to your attention that other approaches, such as the proposedcommercial and community-based distribution systems, might be as effectiveas "coordination' in achieving a higher family planning acceptor level,and that an improved structure, staffing and bureaucratic relationshipof GNFPP might also raise the effectiveness of the family planning program.

GAO note: Page references in this appendix maynot refer to the final report. Also,recommendation 1 is divided intorecommendations 1 and 2 in the finalreport a.d recommendation 2 is nowrecommendation 4.

50

APPENDIX III APPENDIX III

MAP OF GHANA

UPPER VOLTA '. GNANAADMINISTRATIVE

'' {~~~~~~ ;'a~~~ . DIVISIONS

UPPER 1*OLGATANCA m m eREGION BOUNDARY

O REGION CAPITAL

0 25 SOKILOMETERS

OTAMALE

NORTHERN J COAST · · '

/''.' :.)v, . · i"

BRONG-AHAFO 2 i TOGO'

SUNYANI a ., .,%%.rl~lo L". .:

~.j J ASHANTI

- m EASTERN o D - , v,,C, ,

KOFORIoUA( VOLTA

WESTERN - CENTRAL 9CA

CPE COAST

^ _SKO"DI GULF OF GUINEA

CAPE THREE POINTS

*SITES OF PROJECTS AND FAMILY PLANNING CLINICS VISITED BY GAO TEAM.1. TWO SITES OF THE AGRICULTURE REHABILITATION AND HEALTH PROMOTION PROJECT: OLGATANGA AND

BAWIKU: UPPER REGION.

2. THREE SITES OF THE DISTRICT PLANNING AND RURAL DEVELOPMENT PROGRAM: ATE8USU, fEJI, AND PRANG,

*RONG- AHAFO REGION.

S. TWO FAMILY PLANNING CLINICS IN HO, VOLTA REGION.4. TWO FAMILY PLANNING CLINICS IN KOFORIDUA., EASTERN REGION.

S. SITE OF THE GHANA RURAL RECONSTRUCTION MOVEMENT PROJECT; MAMPONG. EASTERN RE.ION.

6. SITE OF THE DANFA RURAL HEALTH AND FAMILY PLANNING PROJECT: DANFA, ACCRA REGION.

7. THREE FAMILY PLANNING CLINICS AND HEADQUARTERS FOR THE DEMOGRAPHIC ThACHINU '' .SEARCHPROJECT AT THE UNIVERSITY OF CAPE COAST CAPE COAST, CENTRAL REGION.

S, FAMILY PLANNING CLINIC AT SALT POND, CENTRAL REGION.

S. FAMILY PLANNING CLINIC AT EWUTU, CENTRAL REGION.

10. TWO FAMILY PLANNING CLINICS IN ACCRA, ACCRA REGION.

51

APPENDIX IV APPENDIX IV

BUREAU OF THE CENSUSPROJECTIONS: IMPACT OFPOPULATION GROWTH

IN GHANA

The following data was supplied by the Socio-Economic AnalysisStaff, International Statistical Programs Center, U.S. Bureau of theCensus. The Long-Range Planning Model (LRPM-2) developed by thatoffice was used to make these projections. The mediun Census staffprojections are derived, in part, from United Nations medium-populationgrowth estimates.

Projected Population(in millions)

1975 101980 1219,' ~ 131990 151995 182000 20

Projected Life Expectancy at Birth

Period Male Female

1975-1980 44.4 47.61980-1985 46.9 50.21985-1990 49 3 52.71990-1995 51.8 55.31995-2000 54.2 57.8

52

APPENDIX IV APPENDIX IV

Actual and Projected Education Needs(in thousands of students)

Primary Secondary University

1950 270 7.1 0.21975 1,200 120.0 7.62000 3,230 865.0 88.7

Total Education Orations Costsfmilli-,- 1975 U.S. $)r

1950 $ 491975 $1372000 $496

Actual and Projected Health Manpower Needs

1950 1975 2000(

Physicians 210 715 2980Medical Assistants 20 229 2980Dentists 20 43 1990Phdrmacists and Assistants 80 618 1990Midwives 1500 2955 4970Nurses 2000 8412 18880Other 40- 567 1990Sanitation 200 787 1940

Total 4070 14326 37720

Based on achieving World Health Organization minimum goal(for 1985) guidelines for developing countries by the year2000.

53

APPENDIX IV APPENDIX IV

Projected Work ' opulation (15-64)lions)

1975 5.31980 6.11985 7.01990 8.1199.5 9.42000 10.9

Ratio to Population

Year Labor Force Ratio(in thousands)

1975 3870.0 0.391980 4360.0 0.381985 4920.0 0.371990 5580.0 0.361995 6410.0 0.362000 7400.0 0.37

Ratio to Work-age Population (Age 15-64)

Year Labor Force Age 0-14 years 55 & over

1975 0.73 0.85 0.0361980 0.71 0.85 0.041;985 0.7' 0.85 0.0451990 0.69 0.86 0.0501995 0.68 0.84 0.0552000 0.68 0.80 0.061

Based on the United Nations medium population estimates andanalysis, the Bureau of the Census' International Statistical ProgramsCenter (ISPC) projects that the number of Ghanaians living in ruralareas will rise from 6.8 million in 1975 to 9.8 million in 2000 butthe number of Ghanaians in urban areas will advance frrm 3.2 million

ir, 975 to 10.5 million in 2000.

54

APPENDIX V

APPENDIX V

o QI rl- c O

'.1,

02 49

C, I · IO

C C· P CV II r( ~~~00

05r0>41 4!O CV msc ~k Q

tn co cnOz

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a, a a Le L5

APPENDIX Vi APPENDIX VI

ASSISTANCE TO POPULATION

PROGRAMS IN GHANA

Amount

Percent planned forU.S. Total future years

funds fiscal years by all donors

Donor/project (note a) 1971-1976 U.S. funds (note b)

USAID (See p. 27.Population program support - -_

Population program support - 3,214 986

Danfa rural health - 4,354 - 1,771

University teaching ofpopulation dynamics - 1,547 8 B

Demographic teaching andresearch 138102

World Education Inc. -79African health training 61

institutions (note c) . - 177 -

Commercial distribution - 236 -

Total USAID (note d) 100% 9,745 9,745

UNFPA (See p. 29.)Regional In;stitute for

Population Studies 2,473300

Registry of bthsand deaths - 256 -2,136

Others (inactive) - 358 -

Total UNFPA 35.6% 087 1,099 236

IPPF/PPAG (See p. 28.) 38.5% 2,106 811 1,400

FPIA/CCG See pp. 28-29.) 99.0% 231 229 300

Canada - 130 - 150

United Kingdom - 394 - 150

Others - 218 - -

Total external 74.7% 15,911 11,884 10,560

Ghana/GNFPP - 2,487 - 3,498

Total 64.6% 18,398 11,884 $14,058

a/ Estimated U.S percentage of actual organization funding; nationalorigins of country support are not segregate!.

b/ Furds projected for current projects. U.S. totals are given

through fiscal year 1979; most other organization totals

are through completion of current projects or fiscal year1979.

c/ Expenditures are on a regional basis: amounts applicable to Ghana

could not be segregated. Since health schools in nine -ountriesare involved, one-ninth of project funds were arbitrarily al-

located to Ghana or the purposes of this review.

d/ USAID also suppo ts a number of world-wide ano regional projectswhich may benef-t Ghana.

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APPENDIX VII APPENDIX VII

POPULATION PROJEC"S

IN GHANA

SUPPORTED BY U.S.AID

Population program support project

An important bilateral population project in Ghana hasbeen the population program support project which supports theGhana Ndtional Family Planning Program. See pp. 18-20.)From initiation of the project in 1971 through 1976, AID hasgranted more than $3.2 million--about $1.6 million for com-modities, about $300,000 for training and almost $1.2 mil-lion in local currency budget support for GNFPP, and the re-mainder for personnel and other costs. The stated goal ofthe project was to develop the capacity of GNFPP to expandfamily planning services. his was to be accomplished bystrengthening GNFPP support and service network, to include(1) planning and management, (2) inservice training, (3)contraceptive supply, (4) research and evaluation, and (5)intensive service and contraceptive supply outreach in pilotareas.

The $1.6 million provided for commodities during the1971-76 period included almost $1.1 million in contraceptivesupplies. Nonclinical contraceptives (condoms and vaginalfoam) are distributed through the Ghana National TradingCorporation and family plannng clinics, while clinicalcontraceptives (birth control pills, intrauterine devices)are distributed only through the clinics. In addition,GNFPP, supported by AID, has trained 1,266 family planningnurses, fieldworkers, and others.

57

APPENDIX VII APPENDIX VII

People Trained In FamilyPlanning Services

(1970-75) (note a)

Trained byType GNFPP/GOG DANFA PPAG Total

ClinicalNurses 87 9 - 96

Nurse midwives - 8 5 13

Others (note b) 90 78 36 204

Field workersFull-time 148 - 104 252

Part-time 941 - - 941

Total 1,266 95 145 1,506

a/ In addition, 67 participants have been tLained in the UnitedStates in family planning training and demographic research,but are not expected to be directly involved with familyplanning service delivery.

b/ Personnel such as traditional birth attendants, field super-visors, and clinic assistants.

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APPENDIX VII APPENDIX VII

In June 976, AID approved a 3-year extension of itspopulation program support project.

AID has increased the annual funding and continued tosupport GNFPP for basically the same program of familyplanning clinics and a commercial distribution system. Goalsfor numbers of new acceptors and clinics have not been estab-lished. In addition, the project seeks to improve familyplanning programs through:

-- A new intensive demonstration poject in the Easternand Volta Regions to be implemented by the PlannedParenthood Association of Ghana and the ChristianCouncil of Ghana that will demonstrate and expandvarious family planning systems into new areas (throughsatellite clinics and community-based personnel).

-- An intensive rural commercial distribution in theUpper and Northern Regions which will increase theavailability of contraceptives--an information cam-paign will accompany the program.

--A new program of motivational research for selectedstudies in addition to that undertaken by the Danfarural health and family planning project. (SeeDanfa project descLiption below).

--An increased inservice training program for expandedfamily planning training.

During the 1977-79 extension of the grant, AID expectsto directly provide $3 million, while commitments of theGhanaian Government and others to GNFPP are expected tototal $5.9 million.

Danfa rural health andfamily planning project

This important bilateral project seeks to enable Ghanato extend and improve rural health and family planning serv-ices by (1) identifying, testing, and demonstrating practicaland reliable approaches to delivery of health and familyplanning services and (2) strengthening the capability of theGhana Medical School Department of Community Health to trainpersonnel in direct service delivery and operational researchprograms in public health, maternal and child health, andfamily planning. Another purpose is to improve coordinationwith various Ghanaian institutions including the Ministry ofHealth and GNFPP. The project, which began in August 1970,

59

APPENDIX VII APPENDIX VII

is expected to run through 1978. It is implemented througha contract with the University of California, Los Angeles.AID obligations through fiscal year 1976 are estimated at$4.4 million. Total U.S. costs through the planned fiscalyear 1978 completion date are expected to exceed $6 million.

To test various approaches for delivery of health andfamily planning services, four distinct geographical areaswere selected for intensive study. Each area has a popula-tion of 10,000 to 15,000 and is near the village of Danfa,a rural area in the Greater Accra Region. In area I, familyplanning was combined with health education and comprehensivehealth care; area II combined family planning and health edu-cation; and area III added family planning to the existingsituation. Area IV, originally a control area with no newservices, was eliminated from the project. The areas alsoserve as training and research sites.

Comparisons of results in the three areas for July 1972through December 1974 show that area I, which offers familyplanning along with a comprehensive health program, hasthe highest rate of fami3- planning acceptors.

Acceptor Rates by Area (note a)

Area I Area II Area III 7/72-12/74

Population WRA (note b) 2,808 2,285 3,387 8,470Number of female

acceptors (15-44) 394 192 113 699Acceptor rates 14.0% 8.4% 3.3% 8.3%

a/ Data supplied by Danfa project officials.S/ WRA--women of reproductive age (ages 15-44)

Rates of continued use for all contraception methods wereHighest in area I and higher in area II than in area III.Also, a smaller percentage of women acceptors had becomepregnant since acceptance in &rea I as compared to areas IIor III.

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APPENDIX VII APPENDIX VII

University t ching ofpopulation dy, Aics

This regional project, implemented through a contract tothe University of North Carolina, was designed to help selectedAfrican universities introduce interdisciplinary instructionand research on population into their curriculum and researchprograms.

The project, which began in 1972, was originally intendedto encompass universities in several African countries. Al-though the project did fund a seminar on population dynamicsteaching at the University of Monrovia in mid-1976, so far ithas only been implemented at the University of Ghana. A pop-ulation dynamics center has been established in Ghana andassistance has been provided for selected research and fellew-ship support, including students from a number of anglophoneAfrican countries. In addition, a special-purpose library ofpopulation-related texts has been established. The project isexpected to run through fiscal year 1979 and will cost morethan $2.3 million. AID obligations through 1976 total about$1.5 million.

Demographic teaching and researchproject at the University of Cape Coast

The purpose of this regional project is to support (1)demographic teaching at the University of Cape Coast in Ghanaand (2) research on mortality and fertility levels and trendsin southwest Ghana. The project supervisor teaches twocourses in the department of sociology at the university anddirects the research. A baseline census was taken in 1974of the project area, which includes approximately 20,000people in 8 villages. Researzhers hope to analyze the socio-logical data collected to learn how village social structuresand attitudes about the family and community affect fertilitybehavior.

The project, financed by a subgrant of an AID grant tothe Population Council, began in September 1973 and is ex-pected to continue until about 1978 and cost about $240,000.

World Eucation Incorporated:family life education project

The purpose of this worldwide program, which operates inseveral Asian, African, and Latin American countries is coplan and implement an integrated program of adult education.

61

APPENDIX VII APPENDIX VII

In Ghana, World Education emphasizes a relevant educationprocess that will motivate people to think about develop-ment. It expects to include family planning education inadult classes but not distribute contraceptives. The Ghanaproject, which began in 1974, has trained community leadersand has established programs in several areas. Funded by aninterregional grant of $79,200 from AID, the project isexpected to end in late 1976 with an overall evaluation of pro-

ject results.

Family lana n4 courses athealth training institutions

This 5-year regional project helps faculties of Africanhealth training institutions develop and implement familyplanning curricula within-the contexts of family and repro-ductive health curricula. The project, implemented throughan AID contract with th! University of North Carolina, in-volves work with medica. , nursing, midwifery, and other healthtraining institutions in Ghana, Liberia, Cameroon, Nigeria,

Kenya, Tanzania, Ethiopia, Sudan, and Zambia. The projectis developing prototype curricula on family planning andhealth. In addition, seminars have been held for physiciansand nurse and medical educators on family planning in the

context of health care. Total cost is to be $2.1 million,through fiscal year 1978, with estimated obligations throughfiscal year 1976 of $1.6 million. Costs applicable to Ghanacould not be separated.

Commercial distribution

A centrally-funded project to improve commercial distLi-bution of contraceptives in five countries, including Ghana,

has been approved by AID. A 3-year estimated $640,157 costplus fixed-fee contract was signed by AID June 1976, withWestinghouse Electric Corporation to undertake this work in

Ghana. AID officials told us that in March 1977 GNFPP hasapproved this project, although there is still some questionconcerning inclusion of oral contraceptives without prescrip-tion since this is contrary to a regulation of Ghana's PharmacyBoard. Recision of the regulation is under consideration by

the Board. AID officials anticipate that this project willalso contribute to GNFPP's planned commercial distributionproject in the Upper and Northern Regions (see p. 60) oncethis stumbling block in the program is overcome.

62

APPENDIX VIII APPENDIX VIII

SAMPLE PROJECT INTEGRATING

POPULATION AND DEVELOPMENT

In June 1976 AID approved a 3-year support grant under

a regional project for the Ghana Rural Reconstruction Move-ment (GhRRM), a rural community development effort which plans

to include family planning. The project was established inthe Mampong Valley, 40 miles northwest of Accra, to help the

5,000 people in some 20 villages identify practical ways inwhich they can raise their productivity, increase cash in-comes, improve health and nutrition, increase literacy, and

improve the quality of life. This organization, indigenousto Ghana, has operated on a limited budget, most of which(about $30,435 in 1974-75) has come from the private NewYork based international institute of rural reconstructionwith which it is affiliated.

Since project officials believe many of the villagers'problems are interrelated and are compounded by civic inertia,activities are aimed at encouraging group action and thenotion that in working together, individuals can exercise somecontrol over the social and economic factors affecting theirlives. Field operations, which began in April 1974, havebeen small scale because of limited budget. Nevertheless,project workers have contacted all of the villages and haveinitiated a program incorporating the following:

--A demonstration program in improved cropping, animalproduction and care, food processing methods, andtraining in cottage crafts and trade skills.

--Health education programs promoting improved nutri-tion, hygienic practices, and environmental sanitation.

-- Literacy programs and cultural acitivities.

--A demonstration program on the .eed for and benefi:sof cooperative community activities.

We visited the Mampong Valley project and attended thegraduation ceremony of the first class of teachers who willbe working with the villagers. We viewed displays of nutri-tional information on local foods and improved food storage,and also saw a demonstration of water-purification methods.Project workers were enthusiastic and proud of their achieve-ments.

63

APPENDIX VIII APPENDIX VIII

The project's concept paper observes that the quality of

human life is determined by population dynamics (i.e.,

changes over time) and social and economic development. The

central hypothesis is that:

"The provision of community development action pro-

grammes, such as education, health, roads, etc., will

provide for the people the needed release from civic

inertia to propel the community towards self-sustained

development; and that such positive gains will be

safeguarded through the adoption of population pro-

grammes that reflect the increased need to reduce de-

sired and completed family size, which in turn will

generate increased demand for family planning services."

Officials connected with the Mampong Valley project em-

phasize that development and population matters are inter-

related and must be treated together to improve human life.

Project workers believe that, having won the confidence

of the villagers and having shown them how they can help

themselves through local resources, they are now ready to

introduce family planning education and services as another

essential element in the process of improving their lives.

They plan to introduce family planning information and as-

sistance through their 1976-7 health education program.

The Mampong Valley project officials have also applied for

assistance from GNFPP. We were told by GNFPP officials

that they envision providing training for project family

planning nurses and fieldworkers, and supplying contra-

ceptives.

AID's 3-year support program for the project is to

provide $175,000 for staff salaries, vehicle and commodity

procurement, construction, and training. This project is

not being funded under AID's population assistance category.

64

APPENDIX IX APPENDIX IX

PRINCIPAL ID OFFICIALS RESPONSIBLE FOR

ADMINISTRATION OF ACTIVITIES

DISCUSSED IN THIS REPORT

Appointed

ADMINISTRATOR:John J. Gilligan Mar. 1977Daniel Parker Oct. 1973John A. Hannah Mar. 1969

ASSISTANT ADMINISTRATOR: BUREAU FORPOPULATION AND HUMANITARIAN ASSISTANCE:Allen R. Furman (acting) Mar. 1977Fred O. Pinkham Apr. 1976Allen R. Furman (acting) Mar. 1976Henry S. Hendler (acting) Feb. 1976Harriet Crowley (acting) Feb. 1975Jerald A. Kieffer July 1972

DIRECTOR, OFFICE OF POPULATION, B39AU FORPOPULATION AND HUMANITARIAN ASSISTANCE:

R. T. Ravenholt July 1972

MISSION DIRECTOR, GHANA:Irvin Coker May 1976Haven North Nov. 1970

65