Sensitizing Policy Makers on Population Issues: The PIP Experience in Ghana By A.F. Aryee Abstract Ghana was the third country in sub-Saharan Africa, after Kenya and Mauritius, to adopt a formal and explicit Popula- tion Policy in 1969. But the consensus at a major conference held in 1989 to assess the policy after 20 years of its opera- tion was that on balance it had failed to achieve its main ob- jectives. This chapter examines the reasons why fertility re- mains almost at the same level as it was in 1969 with the Total Fertility Rate (TFR) only a little marginally lower at 6.4 in 1988 as compared with the previous 6.7 (G.D.H.S., 1988). The crude death rate had declined somewhat from the 20's to a level around 15 per 1000, but infant, child and maternal mortality remained at unacceptably high levels, and most importantly, the population growth rate which was projected to decline to 1.7 per cent by the end of the decade still remained at its high level of around 3.0 per cent. Modern contraceptive usage was disappointingly low at only 5 per cent (G.D.H.S., 1988). Professor A. F. Aryee works with the Family and Development Programme (FADEP) at the Department of Geography and Re- source Development, the University of Ghana, Legon. 78 Sensibilisation La des Planificateur de la Demographie: I/experience du "PIP" au Ghana Par A.F. Aryee Resume: Le Ghana etait le troisieme pays en Afrique sub-Saharienne (apres le Kenya et l'ile Maurice) a adopter des mesures formelles et explicites en ce qui concerne la planification de la population, en 1969. Cependant, le consensus lors de la grande conference de 1989, destinee a evaluer la situation au bout de 20 ans d'operation, estimait qu'on etait loin d'atteindre les objectifs vises. Le present chapitre fait ressortir les raisons pour lesquelles la fecondite reste presqu'au mgme niveau qu'en 1969, avec le Taux de la Fatilite Totale (TFT) legerement plus bas que 6,4 en 1988, par rapport au taux precedent de 6,7 (GDHS, 1988). Le taux de mortalite avait quelque peu baisse (de 20 a 15 sur 1.000) mais la mortalite enfantine et maternelle est restee a des niveaux inadmissi- blement hauts. Plus grave encore, le taux de croissance demographique, qui etait cense diminuer a 1,7 pour cent a la fin de la decennie, est reste au niveau eleve de 3,0 pour cent. D'ailleurs, l'utilisation des moyens contraceptifs est restee au niveau decevant de 5 pour cent (GDHS, 1988) Professeur A F Aryee travaille dans le Departement de la Geographie (Realisation des Projets de Development et Familial, FADEP), Devel- opment des Resources, L'Universite de Ghana, Legon. 79 1. Introduction The acceptance of the population factor as an integral component of governmental policy and a guiding principle in the developmental planning process has a fairly long history in Ghana. The Policy recognised the importance of the population factor in the development process and called for a reduction in the growth rate of the population as an important pre- requisite for socio-economic development generally, and more specifically to accelerate the process of enhancing individual welfare. The policy was a well thought-out and comprehensive one covering all the complex web of interrelationships between fertility, mortality, morbidity, migration, urbanization and socioeconomic development generally, and specified both long term and short-term measures which had to be taken to ensure that the demographic factors did not adversely im- pact on societal goals and objectives. At the core of the policy however, was the urgent need to reduce the country's high rate of population growth through a comprehensive national programme of family planning. It is interesting to observe that the adoption of the Policy pre-dated the first major world population conference in 1974 when the World Population Plan of Action was adopted at Bucharest. And even before the adoption of the Policy in 1969, Ghana had been the first Sub-Saharan African nation to sign the World Leaders Declaration on Human Rights Day in 1967 which affirmed, among other things, that The population problem must be recognised as a principal element in long-range planning if governments are to achieve their economic goals and fulfil the aspirations of their people. In many ways, Ghana's firm stand on the population- development issue so early in its political history was a remarkable achievement considering the fact that it repre- sents the very epitome of a society whose traditions, mores and value systems had been, since time immemorial, funda- mentally pro-natalist. 80 2. The Policy in Action Quite clearly however, the formulation of a policy is only one index of a government's recognition of the existence of a problem; the more important question is the readiness, seriousness or tenacity with which these policies are trans- lated into actionable programmes or activities and pursued in order to ensure that the policy objectives are progressively attained. Ghana was the third country in sub-Saharan Africa, after Kenya and Mauritius, to adopt a formal and explicit Popula- tion Policy in 1969. But the consensus at a major conference held in 1989 to assess the policy after 20 years of its opera- tion was that on balance it had failed to achieve its main ob- jectives. This chapter examines the reasons why fertility re- mains almost at the same level as it was in 1969 with the Total Fertility Rate (TFR) only a little marginally lower at 6.4 in 1988 as compared with the previous 6.7 (G.D.H.S., 1988). The crude death rate had declined somewhat from the 20's to a level around 15 per 1000, but infant, child and maternal mortality remained at unacceptably high levels, and most importantly, the population growth rate which was projected to decline to 1.7 per cent by the end of the decade still remained at its high level of around 3.0 per cent. Modern contraceptive usage was disappointingly low at only 5 per cent (G.D.H.S., 1988). The same poor results were discernible in the other notable areas of the policy such as those relating to more equitable spatial distribution of the population, urban growth and improvements in health and nutrition. 3. Reasons for the Failure of the 1969 Policy The reasons for the failure of the policy are diverse and complex, and a full discussion of these is beyond the scope of this paper. Of particular relevance to us however, in attempting to account for the failure of the policy was the political factor and its impact or influence on the develop- mental process and the failure to attain the main objectives of the policy. It is widely acknowledged that lack of political 81 will or commitment on the part of policy or decision-makers at the higher levels of the political cum administrative hierarchy was a major factor accounting for the failure of the 1969 policy. The period between 1969, when the policy was adopted, and 1990, was characterised by a great deal of political instability as a result of a succession of military coups-a situation which did not obviously permit or favour continu- ity in policy formulation and planning. The period also saw a rapid deterioration in Ghana's economy as a result of a combination of several factors. The extent of this decline is shown by the fact that investment as a proportion of GDP fell from 24 per cent in 1960 to 1.2 per cent in 1982, and the economy as a whole experienced negative growth between 1970 and 1982, an average decline of 0.5 per cent per annum. The poor economic situation brought to the fore more forcefully than was otherwise possible the significance of the high population growth rate as a factor in the failure to achieve stated economic goals or targets. But the severe constraints on the economy did not favour long-term perspective planning, a basic pre-requisite for the incorporation of population variables into develop- ment planning activity, but rather short-term or ad hoc measures to deal with crisis situations. Thus population issues per se were often either ignored or relegated into the background as they were not seen as directly relevant to the immediate problem or crisis which had to be "managed." Under these conditions, commitment to the population policy objectives slowly waned or faded. But even under these very difficult conditions some suc- cess in policy implementation was still possible since the very harsh social and economic conditions under which people lived during this period, ironically favoured the adop- tion of smaller family size norms. From the mid seventies to the mid eighties, Ghana was really hit hard by an economic recession. Food prices rose dramatically as basic food items became more and more scarce and limited in range on the market. Nutritional levels fell to their lowest levels in dec- ades, and to the average family the task of obtaining the barest basic necessities such as food, soap and even baby- 82 milk became a nightmarish task. The larger the family of course, the greater the pinch. Unfortunate though the situ- ation was, it seemed ideal for the family planning ethic to break through the cultural barrier. Regrettably, however, the Ghana National Family Plan- ning Programme (G.N.F.P.P.) which had been set up in 1970 specifically to implement the family planning component of the policy, failed, for a wide variety of reasons, and in spite of strong donor support, to have the desired impact both in terms of sensitising the citizenry about the impact of popu- lation on development, and more specifically in increasing contraceptive usage and family planning. When the International Monetary Fund (I.M.F.)-initiated Economic Recovery Programme (ERP) and Structural Adjust- ment Programme (SAP) brought a reasonable measure of stability into the planning process in the second half of 1980- 1990 decade, the need to give more prominence to the population factor in the planning process slowly re-asserted itself. The pressure to re-examine the population factor and give it more prominence emanated from several sources, but remained disjointed and unco-ordinated until a national conference on Population and National Reconstruction was held in 1986. The conference, whose main aim was to assess the 1969 population policy, offered the opportunity to crystallise these disparate attempts into a definite plan of action which would seek to sensitise policy makers at the highest levels about the importance of the population factor, and elicit their total support to on-going attempts to revitalise the population policy and its implementation. 4. The Population Impact Project (PIP) 4.1 The Birth of PIP One tangible result of the 1986 conference on Population and National Reconstruction was that the various forces which had argued strongly for a renewed effort to revitalise the population policy coalesced into a permanent population group or committee based at the University of Ghana whose 83 main task would be to ensure the dissemination and imple- mentation of the conference recommendations through an institutionalised outreach programme. With the financial support from the United States Agency for International Development (USAID), the group formed a partnership with IMPACT, a programme of the Population Reference Bureau, an educational organisation based in Washington, D.C., USA, whose leading and pioneering role in the field of popu- lation was acknowledged world-wide. The Population Impact Project (PIP) was the result of this partnership between the University of Ghana and the Popu- lation Reference Bureau. While the University of Ghana provided the personnel, office space and some logistical support, the Population Reference Bureau through IMPACT, and with USAID funding, provided technical, editing and publishing support. 4.2 PIP Staff Since its inception in 1986, PIP's main targets have been government leaders or decision-makers. These include sec- retaries or cabinet ministers, senior public servants, politi- cal leaders at various levels, and other important opinion leaders such as chiefs and religious leaders. These are all extremely busy people and one of the main reasons for PIP's success in obtaining easy access to this group of people lies in the calibre of the PIP team itself. The Project is currently led by the Vice-Chancellor or head of the University of Ghana. Both the Vice-Chancellor and the current director of the Project, who is also concurrently the head of the Depart- ment of Geography and Resource Development, had at one time or the other held some of the most important political portfolios in government including the ministries of Presi- dential Affairs, Finance and Economic Planning and Lands and Forestry. Not only do they therefore wield enormous influence in society but they also know personally many current holders of political office, the main targets of the sensitisation programme. Of course, their additional reputation as distinguished academics with the requisite expertise and practical experi- 84 ence in the areas under discussion tended further to strengthen the programme and give it wide credibility. The size of the PIP management team also meant that at least two very senior members were always available, however short the notice or odd the appointment time, for all important presentations without any serious disruption to their normal academic activities. Since all appointments for presenta- tions had to be at their convenience, PIP's flexible structure and modus operandi proved to be invaluable assets. Amongst the support staff are two of the country's most experienced journalists who perform a wide range of func- tions such as arranging media coverage for PIP activities, and liaising generally with both institutions and individuals interested in PIP's activities. The composition of the PIP team is undoubtedly one of the main factors accounting for its success since it is seen, and functions, essentially as a locally-motivated effort operated by people who believe passionately in the message they are carrying, rather than as an institution being manipulated externally to serve other interests. 4.3 External Support The financial and technical support which the project has received from its inception, until now from USAID through the Population Reference Bureau, IMPACT, The Futures Group, and OPTIONS, has undoubtedly been a major factor in the success of the programme. The University of Ghana, like many universities in Africa, relies in the main on an already over-burdened government budget for its normal operations, and this has always im- posed a serious limitation on the expansion of its activities. The financial and technical assistance of USAID through its affiliated agencies has therefore permitted this important outreach programme to be carried out since 1986 without imposing a severe strain on the University's limited re- sources. Technical equipment such as a vehicle, computers, audio- visual equipment, books, etc, which otherwise would have been difficult to obtain, have been procured under the proj- 85 ect. Another essential component of this support has been the transfer of technological know-how and capacity-build- ing. Many of PIP's supporting staff have over the years acquired a great deal of expertise from visiting technical experts in the use of the latest computer technology includ- ing desk-top publishing and computer modelling. In recent years, the Government of Ghana has also demonstrated its support for the project in various ways including the dona- tion of a four-wheel-drive car. 5. Activities of PIP The main raison d~ etre of the project is to make relevant population information available to policy makers and other opinion leaders. This is done through publications, semi- nars, conferences, workshops and briefings. 5.1 RAPID Presentions To facilitate the discussion of the interrelationship between population and socio-economic development for an audience with very little time at their disposal, PIP uses a micro computer-based RAPID model (Resources for the Awareness of Population Impacts on Development) developed by the IMPACT organisation but based on Ghana-specific data obtained not only from Ghanaian sources but also from international organisations such as World Health Organisa- tion (WHO), United Nations Children's Fund (UNICEF), Food and Agricultural Organisation (FAO) and United Nations Economic Commission for Africa (UNECA). Using this model, the impact of population growth, using various assumptions, on various sectors of the economy such as health, education, food, labour force, environment, etc. can be visually presented within a relatively short time without the need to absorb or digest a great deal of statistics. The model itself covers a wide range of topics including demographic structure, education, health, labour force, agriculture, family planning and the environment. Two important considerations in determining what goes into any particular presentation, however, are firstly the time avail- 86 able for presentation, and secondly the main sectors of interest to the particular audience. The informal manner in which the presentations are made also allows for a great deal of interaction and exchange of ideas between presenters and audience. The presentations also provide the opportunity for PIP booklets to be explained or presented to selected audiences or participants. Some ten booklets have been produced and distributed so far. 5.2 Publications Topics for PIP publications are carefully selected to highlight some of the most critical issues in the population field. To date, some of the topics dealt with in the publication series relate to Population and Development, Implications of Early Childbearing, Maternal-Child Health and Family Planning and The Ghanaian Woman. Others dealt with Population and Food, Urbanization and the Environment. The booklets, which are of moderate length and meant to be read at a sitting, focus on specific problems as they relate to Ghana. Though some statistics and charts are presented in these publications, these are kept to a minimum, and the language is as much as possible non-technical in order to attract wide readership. PIP staff usually write most of its publications; experts in other population-related fields are sometimes invited to write on some of the topics. The booklets them- selves are attractively designed and printed with illustra- tions and photographs. The aim is not only to persuade people to read the content, but also to circulate and preserve them as useful reading material for their libraries or personal collections. For technical reasons, PIP's booklets have so far been edited and printed in Washington, but local printing alternatives are being explored in the current publication programme. The Project itself has over the years acquired a modest population reference library which attracts users both from within and outside the University community. 87 5.3 Seminars and Workshops PIP's activities are not confined to the capital or seat of government in Accra. It periodically organises seminars in selected regional or district capitals on population-develop- ment issues which are of particular importance to the re- gions or districts concerned. The objective here is not only to focus on local issues which are of particular interest to the areas concerned but also to involve as many local leaders as possible in the organisation of the seminars and in the formulation of strategies and plans to tackle those particular issues. Some of the topics discussed at these regional and district seminars are employment generation, food and nutrition, land use, and education. Special workshops for particular groups of communicators or professional groups such as various categories of pressmen have also been held. The seminars and workshops are particularly useful because of the opportunities they afford the PIP professional staff to learn from the grassroots about the realities of the social and economic situation in different areas of the coun- try and their perspectives on the policies and strategies often imposed on them from the centre. 5.4 Media Activities One of the main functions performed by the two journalists on the PIP team is to promote, co-ordinate and supervise the dissemination of population-related information in both the electronic and print media. The objective is to use these two very-popular media which enjoy very wide patronage through- out the country to address current population issues in order to stimulate both discussion and action on these issues. The topics vary widely, ranging from such problematic issues as teenage pregnancy, drugs, and sanitation to more complex environmental issues such as concerns about the ozone layer and toxic wastes. PIP also collaborates with other international and na- tional organisations e.g., FAO, UNFPA, UNICEF, etc. to celebrate special events such as World Food Day and Family Planning Week. 88 6. Some Basic Issues In the eight years or so of its existence, the Project has been able to present its programme to a wide range of policy makers including secretaries of state or ministers, senior civil servants, various categories of administrators, tradi- tional, religious and opinion leaders. Quite often, the PIP message tends to have a profound effect on its audience, and the immediate reaction or ques- tion is whether PIP has the mechanism for conveying the message to the vast majority of the people who live in the rural areas and who do not understand the English language in which the publications or presentations are invariably made. Some critics see this concentration on highly educated opinion leaders and the use of English (both for presentation and publications) as one of the inherent weaknesses of the Project. It is therefore necessary to explain the bias towards opinion leaders. PIP is fully aware, and agrees fully with the critics that if the family planning programme or message is to have any meaningful impact, it is the average citizen who takes decisions concerning contraceptive usage or family size who must be educated or sensitised. This is an activity which needs to be pursued vigorously for all segments of the population. It is a mistake however, to assume that because policy-makers are often highly educated or knowledgeable, they do not need any sensitisation on population issues. As key players in the developmental process, their decisions or acts tend to have a disproportionately positive effect through- out the system, and they deserve therefore to be treated as a special target group. The often-held belief that such people do not need sensi- tisation is therefore misconceived. Experience dating back from Bucharest when many African leaders took the position that "development is the best contraceptive", and that Africa generally does not need family planning has shown how resistant many on the African continent are to the idea of family planning. The population issue, especially deliberate population control through family planning, continues to 89 remain a very sensitive one for several reasons. This opposition to the principle of family planning con- sists of two main schools. There is firstly the "Julian Simon" school which believes that with the vast natural resources which Africa has at its disposal, a large and growing popula- tion or human resources, would in fact be an asset (Simon, 1981). The second school of thought, mainly deriving its roots from the Marxist anti-colonial tradition, generally argues that the issue in African development is not about the size or rate of population growth, but about an unfair capitalist world economic system in which developing coun- tries such as Ghana, were being progressively impoverished by the policies of the capitalist countries and multinational companies. Both views are widely held amongst many highly educated people in Ghana, and PIP's continuing dialogue with policy-makers over the years has gone a long way in separating the political issues from the realities as far as the direct impact of population on development is concerned, thus making the family planning message more receptive than before. There are therefore sound reasons for concentrating PIP's efforts on this particular segment of the population, but it was expected that PIP's efforts would be fully complemented with a national information, education and communication campaign directed at the general population using a wide variety of media and in as many local languages as possible. Another pertinent criticism, related to the above, is the fact that the RAPID model, in its effort to present the relationship between population and development in its simplest form, tends to over-simplify what is indeed a very complex relationship. Additionally, it is important to observe that a RAPID model is as good as the demographic or statistical data from which it is derived, and given the paucity and generally poor quality of data in many African countries including Ghana, the statistical basis for some of the assumptions or conclusions in the model tends occasion- ally to be rather speculative. The last census in Ghana for example was held in 1984, and whether the current popula- tion growth rate is around 3.0 per cent or 2.6 per cent remains a subject of some debate or contention. 90 The availability of intercensal surveys such as the World Fertility Survey and Demographic and Health Surveys means that more current statistical information is available on some basic demographic parameters, but on some topics such as unemployment, labour force or food supplies, the accuracy or timeliness of the data available for use continues to remain a source of concern to the modellers. The problem of inadequate or poor data has been a major impediment in PIP's current efforts to develop regional and district-specific RAPID models. These issues often constitute a focus of debate or discussion at presentations to highly educated or sophisticated audiences, but the advantage in the PIP modus operandi is that the level of interchange, debate or discus- sion can be varied by its professional staff to suit the particular audience. The fact that some policy-makers have seen the presentations several times, sometimes at their own request, attests to the importance they attach to the ex- change of ideas with the project team. 7. Impact of PIP There are various ways of assessing the impact of the Project in terms of its stated objectives. From the purely impression- istic view, the regular discussion and concern in the media and at various fora about the population issue in all its manifestation by high level politicians and opinion leaders can be taken as one practical measure of success. There are also some indications from unpublished recent surveys that contraceptive usage in Ghana has increased dramatically over the last few years; these results however, have yet to be confirmed. A more objective way is to conduct an impact study as was done by PIP itself to ascertain the extent to which population factors are integrated into planning activities or the decision- making process by policy makers or administrators in gov- ernment ministries, quasi-governmental and non-govern- mental institutions. A total of thirty-four respondents, including secretaries of state (ministers) and executive directors, from seventeen (17) ministries were interviewed. The study revealed overall a 91 very clear understanding of population as a basis for all planning activities. About 62 per cent of respondents had used some of the PIP's materials in their planning activities which most of them considered extremely useful in view of their direct relevance to the situation in Ghana. Outside the country however, PIP's booklets seemed to have had very little impact. In a study conducted in 1990 amongst the donor community including USAID and its co- operating agencies, the World Bank, WHO, International Planned Parenthood Federation (IPPF) and United Nations Fund for Population Activities (UNFPA), it was found that 37 per cent of the respondents had never received any of the Ghana publications, 15 per cent had received but not read the documents, and only 10 per cent had read and used the publications (Philliber et al., 1990). Since only 10 per cent of the respondents had also read and used the booklets on Kenya, the problem appears to be more with the agencies' general attitude to such publications than to the quality or usefulness of the Ghana booklets per se. But even more relevant is the study group's independent assessment of the usefulness of the Ghana PIP materials. Out of a randomly selected sample of 60 end-users in Ghana who were asked how useful the publications were, 49, or 82 per cent, reported that they were excellent or good. About the same proportion of respondents thought the publications were interesting, clearly written, attractive, accurate and had an excellent format. Only a little over half (57 per cent), were however happy about the appropriateness of the lan- guage used. 8. Summary and Conclusions Ghanaian society, like that of many other African societies is basically pro-natalist. The need for labour in a traditionally agrarian economic system, the dependence on children for support in old age, and the hitherto high levels of infant and child mortality had combined in the past to engender a societal preference for large families. Though the conditions which promoted such high fertility norms are slowly breaking down, the institutionalised pref- 92 erence for large families has still not weakened enough to induce a significant change in fertility behaviour. This has very serious implications for the society's rate of socio- economic development. In order to speed up the process of change in fertility behaviour, it is important to inform and educate all segments of the population about the implications of their behaviour, and what needs to be done. Policy and decision-makers constitute a key target group in this sensitisation process. Through a remarkable partnership between USAID, its affiliated agencies, and the University of Ghana, the Popula- tion Impact Project is acting as a key agent in the effort to influence this very important target group whose day to day decisions and policies profoundly affect societal and individ- ual welfare. PIP has tried to reach its target group through a wide range of media and activities. In the process, it has forged very close links with policy-makers, its external collabora- tors and other institutions, both local and foreign. PIP's success can be measured not only in terms of the extent to which it has been able to reach a wide range of audiences, but more importantly in the fact that it is now perceived as a major ally in the search for practical solutions, and its assistance or involvement is now actively sought in the planning process. The result is a gradual expansion in its activities or mandate, such as current support for revision of the population policy and the establishment of the National Population Council. Several other activities such as opera- tional research and the production of a population newslet- ter are currently in the pipeline. PIP thus intends to build on its present successes in order to ensure the attainment of the country's population policy objectives in the shortest possible time. References Philliber, Susan, Friedman, Mattew, andLacey, Lacey, 1990, Midterm Evaluation of Innovative Materials for Population Action (IMPACT) Project, Dual and Associates Inc., Arling- ton, Virginia. 93 Population Impact Project, 1992, Policy Study on Integrating Population Variables into Development Planning, Legon. Population Reference Bureau, Reaching Out to Policy-Mak- ers, The Population Impact Project of Ghana, Legon. Jersey. Republic of Ghana, 1969, Population Planning for National Progress and Prosperity, Accra. Simon, J., 1981, The Ultimate Resource, Princeton, New 94