Journal of Social Research & Policy, Vol. 5, Issue 1, July 2014

Ghana’s Family Planning Program: A Neglected Policy Initiative? ABDULAI KUYINI MOHAMMED 1 Department of Political Science University of Ghana

Abstract Ghana’s Family Planning Program (FPP), maternal mortality intervention, and HIV/AIDS control program are all health policy priorities, which are supposed to be complementary to achieve desirable reproductive health outcomes. However, it appears disproportionately less attention is being paid to the former compared to the latter two, which are relatively new health policies. This may have implications not only for the effectiveness of the FPP and the other two policies, but more broadly reproductive health outcomes. This study investigates this claim and finds that the FPP has policy merits and that its relegation to the background has led to a very little incentive to space births, and a marginally positive incentive to increase fecund level, with attendant negative developmental consequences. It then concludes that despite the alarming rate of maternal mortality and loss of lives through HIV/AIDS, Ghana’s population is still growing at a dangerous pace, making the FPP as relevant as ever. Keywords: Family Planning Program (FPP); Optimum population size; Development; Maternal health; Free Medical Care for Pregnant Women (FMCPW); Policy synergy.

Introduction The world’s population in 2002 was estimated to be 6.2 billion; expected to be growing by 75 million per annum, with 97 percent of this increase occurring in developing countries (Goldstein & Whitworth, 2005). A disproportionate share of developing countries’ contribution to this rise is accounted for by the faster growth rate in Sub-Saharan African nations. This has raised fears of the inevitability of overpopulation in the sub region with its attendant negative consequences such as scarcity of productive resources, stress and strain on social infrastructure, environmental degradation etc. The concern about population size has also been expressed in Ghana over the years. The country’s population increased from 6 million at independence in 1957 to nearly 18 million in 1996 with a projected estimate of 27 million by 2020 (Arjun, 1996; GMHS, 2007). With the current growth rate of 2.7 percent, the population may reach 32 million by 2040. The past rapid growth of Ghana’s population was an outcome of high fertility, which until recently remained fairly constant, and declining mortality (Arjun, 1996; PPAG, 2009). Even though life expectancy at birth is low at 57.7 years and infant mortality is high at 71 per 1000 births (UNDP, 2007), this has not prevented the population from growing above the annual desirable rate. This has raised fears of an imminent overpopulation, with the government responding by introducing the Family Planning Program (FPP) in 1970. The FPP was strengthened by the launching of the Road Map for Repositioning Family Planning – 2006 to 2010 in 2006 (PPAG, 2009). Despite the fact that the FPP has been running for many years in Ghana it has failed to impact population in a meaningful way. The failure is attributed to factors such as dwindling government commitment in terms of advocacy and resourcing, gap

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Postal Address: University of Ghana, Department of Political Science, P. O. BOX LG 69, Legon, Accra Ghana. Email Address: [email protected], [email protected]

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between knowledge of family planning and use of contraceptives, unpredictability of donor funding, and high unmet need (PPAG, 2009; GMHS, 2007). Meanwhile, a seemingly conflicting initiative to the FPP, an exemptions policy for delivery fees for pregnant women was introduced in 2004 (MoH, 2004). This was gradually phased out and was replaced by health insurance in 2008 (popularly referred to as the Free Medical Care for Pregnant Women - FMCPW). The exemptions policy has an objective of addressing some of the challenges hindering the attainment of one of the Millennium Development Goals (MDG), which focuses on improving maternal health of women by 2015 (Osabutey, 2008). In other words, the policy is meant to curb the high rate of maternal and baby deaths. From the above exposition, it appears the FPP with its emphasis on limiting the number of children per woman, has an anti-natal intent (reducing fertility), while the FMCPW, which focuses on safe delivery, has a pro-natal motive. However, the government has prioritized the unacceptable level of maternal deaths as a national emergency and has diverted much attention and resources to dealing with the problem. The questions that then arise are: Has the prioritizing of the FMCPW left the FPP unattended to? What are the implications of this apparent neglect of the FPP for population growth and development of Ghana? These questions can be answered by providing responses to three further questions: 1. Does Ghana need a Family Planning Program? 2. Will the Family Planning Program reduce fertility? 3. Is the FPP a neglected policy initiative? Methodology Data for the study was obtained from both primary and secondary sources. The primary information was obtained by interviewing 21 key personnel from relevant organizations including the Ghana Health Service, hospitals, and the Planned Parenthood Association of Ghana (PPAG). These respondents were originally identified because of their role connected directly to the development and implementation of the FPP and FMCPW policies. The secondary information was derived from content analysis of published works on both policy initiatives. Theoretical Framework It seems to be the case that, policy-makers in developing countries believe that overconcentration on getting the content and administration of public policies right is most critical in exacting desirable outcomes. In so doing, they totally neglect or pay little attention to ensuring that synergy exists between related public projects and programs that are trying to achieve the same macro level objectives. Yet the literature demonstrates that complementarities of efforts (cooperation, collaboration and coordination as well as mutual reinforcement of related initiatives) of change agents whose separate program of activities ultimately lead to the same endpoint, is extremely crucial in not only achieving the objectives of the individual projects concerned, but also the ends of the bigger whole to which they all contribute their quota (Brislin, 1981; Pressman & Wildavsky, 1984). As Walt & Gilson observe (1994), the traditional focus on the content of policy neglects the other dimensions of process, actors and context which can make the difference between effective and ineffective policy choice and implementation (Walt & Gilson, 1994). Thomas & Gilson (2004) and Cassels (1995) make similar comments in relation to the apparent neglect of these other dimensions of reality of policy making in the Third World. Grindle & Thomas’ (1991) research on the political economy of reform in developing countries has been cited by many scholars. Grindle & Thomas (1991) based their analysis of policy and organizational reform in recent decades from several developing countries to propose a multivariate framework for understanding the emergence, discussion, implementation and sustainability of policy reform in developing countries. They placed premium on the role of policy elites in shaping policy agendas, weighting policy options and

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managing political and bureaucratic challenges of policy reform. They define policy elites as those who have official positions in government and whose responsibilities include making or participating in making and implementing authoritative decisions for society. The main factors in their framework are environmental context of reform, the agenda setting circumstances, and international context, as well as policy characteristics. A fifth factor that also affects policy success or failure, but that has not been mentioned by Grindle & Thomas (1991) is synergy between related public social projects and programs. The first three of their factors together with synergy are adopted here and discussed in turn below. Elements of the environmental context include the individual characteristics of policy elites such as their ideological predispositions, professional expertise and training, experiences of similar policy situations, position and power, political and institutional commitments, loyalties, and personal attributes and goals. It also enfolds the context of policy choice such as societal pressures, historical and economic context. The agenda setting circumstances embrace whether there is a perception of a crisis situation or not. According to Grindle & Thomas (1991), in a perceived crisis situation there is strong pressure for reform and immediate action, the stakes are considered high, change is seen as innovative and high level decision-makers are involved in the reform process. The behavior of policy stakeholders is different in situations that are perceived as non crisis. In non crisis scenarios the agenda setting circumstances are “politics as usual”. Policy makers, without pressure and without extreme limit on their time, select the agenda items. The stakes are seen as low and decisions are often left to middle level decision-makers; incremental change is acceptable and there is flexibility in timing. Decision-making in perceived crisis situations tends to be dominated by concerns about macro political relationships whereas in politics as usual, decision-making tends to be preoccupied by concerns about political and bureaucratic relationships (Grindle & Thomas, 1991, Bridgman & Davis, 2004). The international context or environment refers to the forces that surround and influence the life and development of domestic policies from outside the borders of a country. An increasing body of literature contends that states are increasingly constrained and shaped by global forces (Ohmae, 1995; Falk, 1997). Recognition of the international system’s influences on public policy has opened up an interesting field of studies in the policy discipline. The international system, not only affects policy sectors that are clearly international – examples, trade and defense – but also sectors with no immediately apparent international connection, such as health care. The influence comes from the overall structure of the international system, and a country’s place in it (Howlett & Ramesh, 2003). The influence of the international system is probably not a novel phenomenon, what distinguishes the current movement is that its scope and intensity have greatly increased. This has resulted in what is generally referred to as globalization or, more precisely, internationalization (Hirst & Thomson, 1996). Although originally, internationalization was thought of as a somewhat simple concept, the recent policy literature acknowledges its highly complex nature, the different forms it takes across space and time, and the varying impacts it has on different policy sectors and states (Bernstein & Cashore, 2000; Bennett, 1997; Brenner, 1999). This recognition has prompted scholars to research more curiously into the means, manner, and mechanisms through which domestic policy processes are connected to the international system (Coleman & Perl, 1999; Finnemore & Sikkink, 1998; Bridgman & Davis, 2004). Thus, it could be argued that the domestic healthcare system and policies in Ghana are more international than can be assumed because a proportion of the health budget is funded by donor agencies such as USAID, DANIDA, and the World Bank. These donors dictate health projects and programs that may not fit neatly into the domestic healthcare agenda. Synergy in policy development and implementation Another issue that determines the success or failure of public policies is synergy between related public social projects and programs. According to Brislin (1981), synergy is a behavior of whole systems that cannot be predicted by the behavior of any parts taken separately. In

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order to really understand what is going on, the individual parts should be examined in their relationships to the other components as well as the whole system. In their book entitled “Managing Cultural Synergy”, Moran and Harris reflect that ‘the very differences in the world’s people can lead to mutual growth and accomplishment that is more than the single contribution of each party to the intercultural transaction’ (Moran & Harris, 1981, p. 3). In terms of the FPP and FMCPW, one can infer from Brislin, Moran & Harris’ thoughts on cultural synergy that both policies are part of a system or a bigger whole called reproductive health of women. So in order to improve reproductive health of women we cannot start by working separately on the FPP and FMCPW as this approach will not give us the opportunity to determine their effects on each other and their implications for the broader goal of improving women’s reproductive health. Rather we must act on them as a joint project in order to ensure they are mutually supportive and generate consistent reproductive health outcomes. If they are managed as a joint project it will lead to mutual growth and realization of not only their respective objectives, but also the broader goal of attaining a high standard of reproductive health. I argue that policy synergy, as an approach to designing, implementing and managing the diverse major social policies and programs in developing countries should involve a process in which policy makers and administrators form organizational strategies, structures and practices based on, but not limited to, the workings of individual policies. They need to create linkages between related policies and programs to ensure that their activities are mutually reinforcing. Synergetic policy organizations create new forms of management and transactions that transcend the distinct operations of individual policies to align and harmonize with related initiatives. The harmonization will contribute to the achievement of not only the respective objectives of the individual programs but also the ends of a broader policy domain to which they all belong. This approach recognizes both the similarities and differences between the policies and suggests that we neither ignore, nor minimize the dissimilarities, but that we view them as a resource in designing organizational systems that engender complementarities of efforts across individual policies so that we achieve system-wide objectives. Literature on the technical and political challenges of implementing health policies in developing countries exists and is growing (examples, Carrin, 2003; Carrin & James, 2004; Preker, 2002; Adjei & Agyeapong, 2008). However, work on the challenges of creating synergy between related public social policies and programs, is scanty or non-existent. This article is a modest contribution toward filling this gap in the literature by examining the problem of lack of synergy between the FPP and the FMCPW in Ghana. It also looks at the difficulty of managing the environmental, agenda setting, and international contexts in the development and implementation of the two initiatives. I do this by using some of the elements of Grindle & Thomas’ (1991) framework as well as ideas from Brislin, Moran & Harris’ thoughts on cultural synergy in the analysis. Further, I evaluate the outcomes of the implementation of the FPP based on what some scholars refer to as the six criteria of evaluation (Ayee, 2000; Dunn, 1994; Howlett & Ramesh, 2003). These criteria are efficiency, effectiveness, adequacy, equity, responsiveness and appropriateness. These six criteria of evaluation have been adopted without consenting that they are yardsticks on which all stakeholders in policy making agree. They are criteria from the policy analyst’s perspective rather than those which take into account the various interested individuals and groups who also evaluate public policies and programs. Nevertheless, they provide a useful starting point for examining the facets of policy success and failure. Lessons are then drawn that will be useful for policy reform. Is an FPP policy necessary? A legitimate question to ask about the FPP is: Is it an appropriate policy? Appropriateness refers to the value or worth of a program’s objectives and the tenability of assumptions underlying these objectives (Ayee, 2000; Dunn, 1994). In relation to the FPP, the policy could be justified on the grounds that Ghana’s population is rising rapidly due to high fertility rate and immigration. The fertility rate is said to be rising perhaps at above replacement level and there is a foreseeable chance of Ghana’s population actually increasing. An above replacement fertility means a rising

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population level in Ghana because a natural increase is augmented by the uncontrolled migrant arrivals. Even when we consider the situation with the lowest fertility rate (4.4 in 1998 compared with the current 4.6) and the lowest migration level (75,843 in 1999 compared with the current estimate of 3 million), Ghana’s population will rise by 2020 to 26,516 million because the natural increase will be augmented by an appreciable immigration to Ghana, mostly other Africans who are undocumented (Nigerians, Ivoirians, Burkinabe, etc.), for example, there are an estimated 1 million Malians and 26, 0000 Liberians in Ghana (RIPS, 2009). Granting that there is a foreseeable risk of Ghana’s population overgrowing we must find reasons for FPP policies. Government interference in the private decisions of individuals, and one cannot get more private than the decision to have a child, has to be made on grounds of market failure. In other words, it has to be demonstrated that the private decisions lead to sub-optimal outcomes from the point of view of society. In the context of FPP policy then, the question that easily comes to mind is: What is the optimum population size of Ghana? We might also ask: Are the unfettered choices of parents likely to put us on a path to the optimum population? It certainly is an elusive exercise to search for the optimum population size. Unlike The Hitchhikker’s Guide to the Galaxy where the answer to the ultimate question was revealed as 42 (Guest, 2007), there is no undisputable figure for a country’s optimum population size. There are no certainties and there are many unresolved ethical issues. The Jones Report on Australia’s population carrying capacity put the difficulty this way: ‘they search for a magic figure (for optimum population) or a Rubicon between safety and danger’ (Australian Parliament, 1994, p. 129). In a similar fashion, McDonald & Kippen (1999), contend that it is not sensible to specify particular population targets because of uncertainty about fertility, mortality rates, environmental issues and other circumstances. They posit that in any case our choices of a population target would be very limited due to demographic realities of past fertility rates and achievable future rates, and of a limited range of immigration levels that would be both desirable and achievable. On the basis of the above analysis it will be contentious to state an exact figure for Ghana’s optimum population size. However, what cannot be disputed is that the current high level of population growth rate of 2.7 percent clearly puts the country on an inappropriate demographic path. This argument wins favor from the Planned Parenthood Association of Ghana (PPAG) which estimates that Ghana’s current population growth rate of 2.7 percent is not optimal for the country’s income per capita (PPAG, 2009). It is reasonable to suggest that the optimum rate of growth of Ghana’s population should be below that of Australia, which has almost the same population size as Ghana (24 million), but which boasts of a bigger land size (compare Ghana’s land area of 238,537 sq km to Australia’s 7,617,930 sq km). Moreover, Australia has a bigger per capita income than Ghana ($28,900 as against $584) and is technologically more advanced than Ghana – an advantage which can enable it to better deal with the challenges to higher productivity associated with finite land size. Neville (1990) reveals that the optimum rate of growth of Australia’s population is equal to 1.3 percent per annum but that anywhere in the range of 1.1 percent to 1.6 percent would be close to the optimum that is, it generates close to the optimum growth of income per capita. This implies that Ghana with a smaller per capita income and land area should have an optimum population growth rate far lower than that of Australia, rather than the current alarming rate of 2.7 percent. To further understand the dangerous demographic path Ghana is walking, we need to examine, even if briefly, the merits of a policy aimed at reducing the fertility rate. This area of analysis is known as population economics. The starting point to an economic analysis of optimum population is to understand the principle that optimum population size must balance two dramatically opposed forces: those that bring advantages to size and those that yield disadvantages to size (Guest, 2007; Galor & Zang, 1997). Advantages to scale include those issuing from public goods (such as national defense and public order and safety) where the total cost of the good is not affected by an increase in population up to a point, thereby permitting a higher population to reduce the cost per capita. It is also argued that a larger market can compel innovation in the sense of making it more profitable. A bigger population would also mean greater probability of knowledge breakthroughs which produce multiplier effects on productivity (a process of so-called endogenous growth) (Guest, 2007; PPAG, 2009).

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There are disadvantages to a bigger population size which derive from the exhaustible supply of natural resources (land for example), which lead to congestion and environmental costs and diminishing marginal productivity of labor. A large population size can also mean cheaper labor which can discourage innovation in labor saving technology (Guest, 2007). There is growing evidence that productivity and fertility are negatively correlated, and perhaps in both directions (Becker & Barro, 1998; Galor & Zang, 1997; Gillespie et al., 2009; Guest & Swift, 2006). One of the determinants of this is a situation, where parents with more children spend less on education per child. This suggests that population growth compelled by high fertility may lower productivity. Weighing the advantages against the disadvantages of bigger populations in order to ascertain the net effect is an indeterminate or unresolved issue, both in theory and in practice. A point emphasized in the seminal work of Cutler et al. (1990). But for a country like Ghana, with an alarming population growth rate of 2.7 percent and low technology to mitigate the challenges to productivity increases, the specter of overpopulation looms high. If this fear materializes then foreseeable variations in population size are going to impact productivity significantly. Majority of the respondents agree, arguing that the population size is a concern and if it is not controlled it will not only lead to productivity decline but also reduction in quality of life. It would be an incomplete exercise if an analysis of optimum population considers only population size (or its growth) to the neglect of dependency. Analysis should take account of the consumption needs of dependent young and dependent old people and the fact that the proportions of young and old in the population are changing (Guest, 2007; RIPS, 2009). Two points have to be questioned here. First, a movement to a path of higher fertility rate necessarily reduces consumption per capita for a number of decades. This will come about because the youth dependency rate increases while it takes some decades for this to be offset by a fall in the old dependency rate. When the old age dependency rate eventually falls, consumption per capita recovers (Gillespie et al., 2009; Guest, 2007; Well, 1999). Second, once the population has become stable at a higher fertility rate after many decades, the total dependency rate (youth plus old age) is likely to be higher than a lower fertility stable population. Thus, the difference in living standards would be much different. Hence we suffer the consequences of an increase in population size for many decades which may not be reversible without government intervention, since private decisions are yielding sub-optimal outcomes (Guest, 2007; Well, 1999). However, examining the dependency effects on living standards only provides us with half of the picture. A further consideration is that a transition to a higher fertility path has implications for intergenerational equity because of productivity growth overtime. The continuous effects of productivity growth through technological growth and technological transfer will mean that living standards will continue to grow irrespective of the fertility rate (Guest & McDonald, 2002; Productivity Commission, 2005). However, this analysis is truer for a developed country than a developing nation. This is because the creation and/or transfer, and application of new technology to improve productivity, are at lower levels in developing countries to bring about the enhanced standard living. It has already been explained in the preceding sections that an increase in fertility would impose a cost on people alive now and in the near future, which will be reversed in several decades later, boosting the living standards of people who would in any case have been probably twice as well off as people today (Productivity Commission, 2005). But this is a description of the scenario in advanced industrial countries like the US, UK and Germany or Australia, whose standards of living are expected to be nearly double their current levels (Productivity Commission, 2005). For developing nations, where the creation of new technology is at a lower level, it is unlikely that their people will enjoy standards of living comparable to the developed world. This means that a transition to a higher fertility rate in Ghana would yield an enhanced standard of living for neither present, nor future generations. One of the respondents, the Director of the Family Health Division of the Ghana Health Service agrees, when she asserts that the ‘FPP brings benefits to the family, benefits to the society and benefits to the country and the world at large’. She adds that, ‘Without FPP Ghana cannot attain the entire 8 Millennium Development Goals’.

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Will the FPP reduce fertility? Effectiveness is the degree to which a policy or program attains its objectives. It is concerned about whether the valued outcome of a policy has been achieved (Ayee, 2000; Dunn, 1994; Howlett & Ramesh, 2003). It has already been demonstrated at length that Ghana does need the FPP. The next question to pose is: will this initiative work? In other words, will it achieve its objectives? Findings internationally indicate that public policies do reduce fertility, albeit part of the calculated effect may be traced to the timing impact where mothers delay childbirth in their lifecycle rather than decrease or increase the number of children they prefer to have over their lifetimes (Gillespie et al., 2009; Guest, 2007). Evidence from China shows that its “One Child Policy” has reduced fertility rate drastically. Rwanda, one of the poorest, most densely populated countries in the world, demonstrates the potential for family planning success in Africa. The country documented one of the most rapid increases in contraceptive use ever recorded, from 10 percent to 27 percent of women of reproductive age (Gillespie et al., 2009). Between 1965 and 2005, use of family planning by women of reproductive age in the developing world (excluding China) rose from less than 10 percent to 53 percent. The actual numbers grew from 30 million users in 2008, a dramatic increase. The result: a significant decline in the average number of children born to each woman during her lifetime, from more than six children to just over three (Gillespie et al., 2009). In Ghana efforts at promoting family planning have yielded modest, but significant results. Knowledge of family planning is almost universal, annual population growth rate has slowed down from a peak of 3 percent in the 1970s to the current 2.7 percent (DHS, 2008; PPAG, 2009). The number of women using modern methods of family planning rose steadily from 6 percent in 1988 to 19 percent in 2003, but reduced to 17 percent in 2008. Total fertility rate consequently reduced from 6.4 in 1988 and stagnated at 4.4 in 2003, and then decreased to 4.0 percent in 2008 (DHS, 2008). However, caution should be exercised in reading too much into these statistics, because the total fertility rate does jump around a bit. For example, the Ghana Maternal Health Survey recorded an increase in the total fertility rate from 4.4 in 2003 to 4.6 in 2008 (PPAG, 2009). The Ghana Health Service (GHS) notes that the average Ghanaian woman marries at the age of 19 years, has her first child a year later and has an average of 4.5 children in her lifetime. Moreover, there are regional variations in total fertility rate, ranging from 3 in Greater Accra Region to about 7 children in the Northern region (DHS, 2003; GMHS, 2007). In addition, there has been a slowing of the pace of decline in fertility rate, with little change demonstrated in the past ten year period. Furthermore, there is the element of an announcement effect of family planning programs. Barberis & Harvey (2001) contend that after the first few years of the implementation of family planning programs the birth rate decreases somewhat, but rises many years later. There is evidence that parents respond to advertisements in making family planning decisions. But when these advertisements are scaled down or are withdrawn altogether a lapse in incentive to stay the course occurs. The general consensus among experts in the 1960s when organized family planning programs were introduced in Africa was that population growth in excess of 2 percent per year is among the structural factors inhibiting the achievement of a wide range of development objectives (PPAG, 2009). This implies that the current rate of growth of Ghana’s population of 2.7 percent is above the standard, and therefore sub-optimal from a developmental standpoint. The analysis implies that the family planning program even though has achieved modest, but significant gains, has failed to drastically reduce the total fertility rate to a level deemed optimal from a developmental point of view. In other words, the adequacy of the FPP is questionable. Adequacy refers to the extent to which a given level of effectiveness satisfies the needs, values, or opportunities that gave rise to a problem. As a summary, it can be stated that on the basis of international evidence, family planning programs reduce fertility, but the Ghana results are mixed or indeterminate.

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Expensive policy From a policy evaluation perspective it is not sufficient to ask whether the FPP will reduce fertility rate. Like any public spending program the FPP must be ultimately financed by taxation, which imposes a deadweight loss on society by distorting private choices, in particular the work/leisure choice. Hence, public spending programs should be delivered as efficiently and effectively as possible, meaning with minimum deadweight loss for a given outcome. This coincides with Howlett & Ramash’s (2003) view that public policy should achieve the public interest by the best possible means. In other words, public policy has to achieve its goals and do so in a way that yields the greatest possible benefit at the least possible cost (Curtain, 2000). Put in another way, we need to determine whether the FPP is an efficient policy. Efficiency refers to the relationship between inputs and outputs. It asks whether we have accomplished more with little. This is where the statistics on the funding of Ghana’s FPP is relevant. Ghana has been heavily reliant on donor funding for implementing the program since its inception in the 1970s. USAID, DFID, DANIDA, the World Bank, IPPF and Engender Health have provided strong financial and technical support for the FPP and other reproductive health programs (see Table 1). The table shows the contributions of the Ghanaian Government (GoG) represented by the Ministry of Health (MoH) and development partners towards funding the FPP. The figures reveal that the contributions of donor agencies far exceed that of the GoG. Donor contribution to the FPP’s budget from 2003 to 2009 was 83.3 percent, whilst the share of Ghana’s Government made up the remaining 16.7 percent. In terms of absolute figures, development partners provided Ghana a total of US$35.25 million, with the GoG contributing a mere US$7.08 million over the same period. The total funding for the FPP therefore stood at US$42.33 million from 2003 to 2009. The implications of these funding shares, by donors and the GoG, are quite obvious. First, since the development partners fund the bulk of the FPP budget it leads to the erosion of policy ownership by the Ghanaian Government. The loss of policy ownership occurs because development partners determine not only when the money will flow to the FPP fund, but also the categories of FPP service repertoire that should be emphasized. These categories may not necessarily be the priority areas the Government of Ghana wishes to promote to harmonize with, and accelerate the pace of its development agenda Table 1: Historical Funding from donors and Ghanaian Government of FPP (in US $ millions) % %MOH USAID DFID DANIDA UNFPA MOH TOTAL YEAR Donor (GOG) (US$) (US$) (US$) (US$) (US$) (US$) Cont. cont. 2003 2.57 1.56 0 1.57 5.69 72.4 27.6 2004 2.55 1.86 0 0.66 5.07 87.0 13.0 2005 1.72 0.90 0 1.85 4.47 58.6 41.4 2006 3.90 0.50 1.0 1.0 6.4 84.4 15.6 2007 4.95 0.30 2.5 1.0 8.75 88.6 11.4 2008 3.21 0.6 2.0 1.0 6.81 85.3 14.7 2009 2.44 0.6 2.1 0 5.14 100 0 TOTAL 21.34 5.11 1.20 7.60 7.08 42.33 83.3 16.7 Source: Deliver/RHI/UNFPA Reports 2007/2008/2009 Cited in PPAG (2009) Secondly, the inability to determine when funds will flow to the FPP account distorts planning and execution of family planning programs with the consequent inefficiencies and ineffectiveness of policies. Thirdly, the sustainability of this funding arrangement, whereby donors provide a disproportionately large share of the money is questionable because there are inconsistencies in the flow of contributions, from both the GoG and development partners. This makes it difficult for program designers and implementers to predict how much it will be donated as the years go

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by. Added to this is the specter of default in contributions by all or any of the development partners. And indeed, as Table 1 indicates, UNFPA for three consecutive years from 2003 to 2005 did not donate to the program. The GoG also could not contribute to the FPP in 2009. The uncertainty about the quantum and timing of the flow of funds into the FPP account has created a funding gap. Forecasting up to 2011 depicts the existence of significant gaps in funding that need to be filled urgently if the FPP is to succeed (see Table 2). In the highly likely event of donors either contributing marginally or not at all, to the FPP, the GoG cannot make up for the shortfall, considering that already about 40 percent of the country’s annual budget is funded by development partners (CDD-Ghana, 2003). As commentators note, the surest way to kill a policy is to starve it of funds. The policy lesson to draw from the above statistics is that even if the response of FPP is strong, the cost can be high and unaffordable in Ghana’s case. Table 2: FP Forecast/Commodity funding commitment gap (2008-2011) in millions YEAR TOTAL COMMITMENTS FUNDING GAP REQUIREMENT (US$) (US$) 2008 9.95 6.81 3.14 2009 9.48 5.14 4.34 2010 8.85 0 8.85 2011 7.80 0 7.8 TOTAL 36.08 11.95 24.13 Source: Deliver/RHI/UNFPA Reports 2007/2008/2009 cited in PPAG (2009) A neglected policy The FPP seemed to have been ignored as a public health priority in Ghana because its services are being increasingly underfunded for a number of reasons. First, the emergence of the HIV/AIDS epidemic in Ghana has pushed FPP activities into the background, in terms of visible political support and funding (GHS, 2006). Evidence indicates that population reduction as a result of the epidemic (1.6 million deaths), in demographic terms, and in the context of the Ghanaian situation, has no major impact on current population growth levels. This means despite current proactive preventive and management programs to combat the epidemic, family planning will remain as relevant as ever, as a key demographic policy instrument, but this is not receiving the needed attention (GHS, 2006). This means the government of Ghana is not managing the agenda setting stage very well, as the FPP should have been maintained despite the current salience of the HIV/AIDS epidemic. This finding is consistent with Grindle & Thomas’ (1991) reflection on the agenda setting circumstances. They note that whether a public policy problem will be treated with dispatch or not, hinges on whether it is labeled as a crisis issue or not. The HIV/AIDS epidemic has been perceived by government and the citizens as a crisis matter that deserves urgent attention. The epidemic also became a topical issue on the international front, with governments being called upon by international bodies, like the UN, to expedite action to control the spread of the disease. Seeing the number of people dying by the disease in hospitals and in the communities, and the consequent drastic loss of productive hands, there was societal pressure for government’s intervention to nip the problem in the bud. The same cannot be said about the problem of the rapid growth of the population, which agenda status has shifted to the bottom of the priority list of not only the Ghanaian government, but also world bodies like the UN. Some people in Ghana particularly, in the rural areas, do not even see the rapid growth of the population as a problem and are therefore less inclined to put pressure on the government to arrest the situation. Second, family planning services are currently not being covered as part of the National Health Insurance Scheme (NHIS), which conspicuously excluded these services from the benefits package when it was launched in 2003. Family planning was determined to be an “essential public good”, such as immunization, and should be offered free through the Ghana Health Service. However, because constrained budgets are unable to cover all basic operational costs at the facility level, in

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actual practice, almost every public facility and all private facilities charge fees for family planning services (PPAG, 2009). This evidence conflicts with Brislin (1981), Moran and Harris’ thoughts on synergetic policy making, which calls for linkages and mutual support for related social policies and programs. By excluding the FPP from the funding arrangement we are literally saying that: “deliver free of charge at any facility, but pay at the same facility to control your births:” In other words, government is creating marginal incentives for women to have more children and marginal disincentive to space their births. This scenario will not augur well for the reproductive health of women, which is the broader goal of government. A cost-benefit analysis of adding coverage of long term and permanent contraceptives, as well as injectables, to the NHIS benefits package revealed that including family planning would cause a decrease in fertility and would avert births that would otherwise have cost the NHIS considerable expenditures. Adding this benefit would lead to an annual savings to the NHIS that would increase over time. The size of the net savings depends on a number of variables, which may change over time. According to the consultant’s assumptions, if family planning had been covered in 2009, by 2011 the NHIS will realize almost GH₡ 11 million in net savings in that year alone. This increases to over GH₡ 18 million in 2017 (USAID/Banking on Health, 2008). In other words, excluding the FPP from the NHIS has generated significant inefficiencies. In contrast, funding is increasingly being made available to support the FMCPW as part of an international effort to improve progress towards the Millennium Development Goals (MDGs). Achieving the MDGs is an international policy agenda that was mooted by the UN and subscribed to by all member nations, including Ghana. Advanced industrialized countries are promoting the agenda by supplying funds to developing countries and monitoring their performance in achieving these goals. Ghana has accordingly included the achievement of the MDGs as part of its domestic policy agenda, with a priority tag attached to it, but has relegated the FPP to the background. This confirms Ohmae (1995) and Falk’s (1997) assertion that nations are increasingly constrained and shaped by global forces. Out of pocket spending for family planning services and commodities is roughly estimated to be $2 million per year. The replacement of these in the light of stagnating donor support and government funding, despite recent increases in need, is woefully inadequate (PPAG, 2009). In 2008, forecast demand for family planning products exceeded the amount allocated in the health budget for family planning by $7 million (PPAG, 2009). Counseling for family planning is free, but reproductive health supply has to be paid for. This findings corroborate the views of Brislin (1981), Moran & Harris (1981) that we are developing and implementing the FPP and FMCPW in Ghana as separate programs; that instead of working on the policies as a joint initiative, we are treating them as separate parts and privileging the former over the latter, and that handling them this way will not bring mutual growth and accomplishment of their respective objectives and the broader goal of achieving a high standard of reproductive health of women. In other words, there is no synergy between the FPP and FMCPW. Policies at odds with each other While FPP is not covered under the National Health Insurance Scheme (NHIS) the FMCPW is well placed on it. The question that arises is: Are the FPP and FMCPW at odds with each other? In answer, it does appear financial incentives now favor more, rather than fewer births. Expanded NHIS coverage for pregnant women makes the medical care costs of additional births zero for women, which provides a marginal incentive to increase average total fertility per woman. Lack of NHIS coverage for family planning services is disadvantageous in delaying or limiting births, providing a marginally negative incentive to delay or limit births (PPAG, 2009). This point of view, however, does not win favor from Ghana’s Eastern Regional Population Officer. He contends that rather than increasing the fertility rate, the FMCPW could result in a decrease in birth rates as it focuses on comprehensive management of pregnancies that include mother and child survival, promotion of family planning and health practices. He added that uptake of education opportunities by girls and women, and the

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lengthening of their time in educating up to the tertiary level has reduced fecund level or the number of children born per woman during her lifetime to 2, although the Eastern Region’s average is still above four (Abinah, 2008). His assessment should be treated with caution since the fertility rate has not dropped for the past several years. It should also be noted that the FPP has a yawning funding gap, and there is a potential for donor support to dwindle and dry up in the future. In contrast, funding for the FMCPW is assured for many years to come, this implies there is a real danger of the FPP being crowded out of government priorities. The consequences of this lack of synergy between the programs is that family planning services and commodities have become more costly to access since parents will have to fully finance these services and products out of their pocket. On the other hand, couples who would have been reluctant to have more children due to the cost of antenatal and post-natal medical care would have an incentive to have them. Perhaps the only way to make the FMCPW costeffective is to limit it to expectant mothers who will be having their first, second or third children. Then from the fourth child onwards a co-contribution from government and couples will apply. The contribution from parents should be means tested where progressively those in the lower income bracket pay less. The idea is that if parents bear part of the cost it will influence their decisions in favor of fewer children. However, majority of the respondents do not agree with the above point that the FPP and FMCPW are conflicting. On the contrary, they think they are complementary. However, minority views put these initiatives at odds with each other. One of these respondents alludes that ‘If you say free maternal care, then the woman should also come for free family planning of her choice’. She adds, ‘Without free family planning, the message seems to be that the government will pay for you to have a baby, but will ask you to pay from your pocket to practice family planning’. She concludes by implying that, ‘the Slogan is: you are encouraged to have more babies but discouraged to limit your birthrate’. Discussion Based on the analytical framework of Grindle & Thomas (1991), the agenda setting circumstances of Ghana’s FMCPW initiative were such that there was a strong perception of a crisis and a need for action among political, as well as technical and bureaucratic actors and civil society. There was strong pressure for change from a “Cash and Carry” system to a national health insurance scheme (NHIS), which would enfold the FMCPW, to make health care costs less burdensome for the masses. The stakes for reform were therefore high. High level decision makers, including the president, were concerned about getting national health insurance and the FMCPW in particular to work in Ghana and made this clear in public statements. The then National Patriotic Party (NPP) government was keenly interested in materializing NHIS and the FMCPW to pride itself that it had delivered on an election promise so as to bolster its electoral advantages in the next elections. For the then opposition National Democratic Congress (NDC) – which sees itself as a social democratic party, it did not want to be seen as opposing a major policy reform that would support the underprivileged and the vulnerable and therefore approved of the policy, but with reservations. These reservations compelled the party to continue to criticize the government on implementation bottlenecks. Thus, the policy decision making focus seemed to have been centered on concerns about political relationships and stability. The priority tag the government attached to the FMCPW was prompted by international bodies like the UN, which had already declared maternal mortality as an international health crisis, and adopted MDG Goal 5 to stem it. As a member of this world body, Ghana accordingly conformed by also placing it high on its policy agenda. Unlike the FMCPW, the FPP has been running in Ghana since the 1970s and even though it was repositioned in 2006 to achieve its goals, it was not perceived as a crisis issue, both internationally and domestically, the stakes were therefore low, and incremental decision making by low and middle level policy makers was acceptable. This confirms Grindle & Thomas’ (1991) contention that the crisis or

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non crisis nature of an issue, and whether the problem is topical or otherwise on the international scene, would determine whether or not it would have placement on a government’s policy agenda. Conclusion The study set out to determine whether the FPP has policy merits and whether it is a neglected government priority. This question has been answered through responses to three further questions. The first question related to whether Ghana needs an FPP. In other words, is the FPP an appropriate policy? The answer to this question is, yes. It is clear from the study that there is a need for it because we are already on or close to an inappropriate or even dangerous demographic track. I have also demonstrated that a higher population growth rate will increase total dependency in the long run and along the transition path. The consequences will be suffered by the present and future generations. Issues about the net effect of economies versus diseconomies of bigger populations are salient to mention, but they remain indeterminate. Yet we cannot ignore them when they are considered against the current demographic trends in Ghana. It thus appears in the Ghanaian situation that the diseconomies of population size are weighing more than the advantages and intervention is certainly needed to at least, restore a balance. The second question demanded an answer as to whether the FPP is efficacious in reducing fertility. The evidence shows that even though the FPP has made modest, but significant gains, it has failed to drastically reduce the total fertility rate to a level deemed optimal from a developmental point of view. Looking at it from another side, the FPP is not adequate because the given level of effectiveness from it has not significantly tamed the rapid rate of growth of Ghana’s population. In terms of equity, both the rich and the poor pay the same amounts to procure family planning products, meaning there is no equity in the provision of family services. The third question probed about whether the FPP is a neglected policy. The answer is in the affirmative, because the salience of the HIV/AIDS epidemic and the FMCPW has pushed the FPP to the background. The evidence shows that unless family planning services and commodities are included for funding under the NHIS, there will be a cost for delaying or limiting births, providing little incentive to delay or limit births. And that the current free maternal health care without a family planning component is serving as an incentive to reduce birth spacing and increase pregnancies, thereby undermining the impact of family planning. In other words there is no synergy between the FPP and FMCPW. A situation appalled by Brislin, Moran and Harris as not engendering mutual growth and accomplishment of broader overall objectives. The FPP appears to be a neglected government policy. References 1.

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