Ghana

2014

Ghana 2014

Dem

ographic and Health Survey

Demographic and Health Survey

Ghana

Demographic and Health Survey 2014

Ghana Statistical Service

Accra, Ghana

Ghana Health Service Accra, Ghana

The DHS Program ICF International

Rockville, Maryland, USA

October 2015

InternationalLabourOrganization

This report summarises the findings of the 2014 Ghana Demographic and Health Survey (2014 GDHS), implemented by the Ghana Statistical Service (GSS), the Ghana Health Service (GHS), and the National Public Health Reference Laboratory (NPHRL) of the GHS. Financial support for the survey was provided by the United States Agency for International Development (USAID), the Global Fund to fight AIDS, Tuberculosis, and Malaria through the Ghana AIDS Commission (GAC) and the National Malaria Control Programme (NMCP), the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the International Labour Organization (ILO), the Danish International Development Agency (DANIDA), and the Government of Ghana. ICF International provided technical assistance through The DHS Program, a USAID-funded project offering support and technical assistance in the implementation of population and health surveys in countries worldwide.

Additional information about the 2014 GDHS may be obtained from the Ghana Statistical Service, Head Office, P.O. Box GP 1098, Accra, Ghana; Telephone: 233-302-682-661/233-302-663-578; Fax: 233-302-664-301; E-mail: info@statsghana.gov.gh.

Information about The DHS Program may be obtained from ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; Telephone: +1-301-407-6500; Fax: +1-301-407-6501; E-mail: info@DHSprogram.com; Internet: www.DHSprogram.com.

Suggested citation:

Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International. 2015. Ghana Demographic and Health Survey 2014. Rockville, Maryland, USA: GSS, GHS, and ICF International.

Contents • iii

CONTENTS TABLES AND FIGURES ................................................................................................................................... ix

FOREWORD ................................................................................................................................................... xvii

ACRONYMS ...................................................................................................................................................... xix

MILLENNIUM DEVELOPMENT GOAL INDICATORS ........................................................................... xxi

MAP OF GHANA ............................................................................................................................................ xxii

1 INTRODUCTION .................................................................................................................................. 1 1.1 Geography, History, and Economy ............................................................................................ 1

1.1.1 Geography ................................................................................................................... 1 1.1.2 History ......................................................................................................................... 1 1.1.3 Economy ...................................................................................................................... 2

1.2 Demographic Profile .................................................................................................................. 2 1.3 Population Policy and Reproductive Health Programmes ......................................................... 3 1.4 Objectives and Organisation of the Survey ................................................................................ 5 1.5 Sample Design ........................................................................................................................... 5 1.6 Questionnaires ............................................................................................................................ 6 1.7 Blood Pressure Measurement, Anthropometry, Anaemia Testing, and HIV Testing ................ 7 1.8 Pretest ......................................................................................................................................... 9 1.9 Training of Field Staff ................................................................................................................ 9 1.10 Fieldwork ................................................................................................................................. 10 1.11 Data Processing ........................................................................................................................ 10 1.12 Response Rates ........................................................................................................................ 10

2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION ...................................... 11 2.1 Household Characteristics ........................................................................................................ 11

2.1.1 Water and Sanitation .................................................................................................. 12 2.1.2 Housing Characteristics ............................................................................................. 14 2.1.3 Household Possessions .............................................................................................. 16

2.2 Socioeconomic Status Index .................................................................................................... 17 2.3 Hand Washing .......................................................................................................................... 18 2.4 Household Population by Age and Sex .................................................................................... 19 2.5 Household Composition ........................................................................................................... 21 2.6 Birth Registration ..................................................................................................................... 22 2.7 Children’s Living Arrangements, Orphanhood, and School Attendance ................................. 23 2.8 Education of Household Population ......................................................................................... 25

2.8.1 Educational Attainment of Household Population ..................................................... 25 2.8.2 School Attendance Ratios .......................................................................................... 28

3 CHARACTERISTICS OF RESPONDENTS .................................................................................... 31 3.1 Characteristics of Survey Respondents .................................................................................... 31 3.2 Educational Attainment by Background Characteristics .......................................................... 33 3.3 School Attendance ................................................................................................................... 35 3.4 Literacy .................................................................................................................................... 37 3.5 Access to Mass Media .............................................................................................................. 39 3.6 Employment ............................................................................................................................. 41

3.6.1 Employment Status .................................................................................................... 41 3.6.2 Occupation ................................................................................................................. 44 3.6.3 Earnings, Employers, and Continuity of Employment .............................................. 47

4 MARRIAGE AND SEXUAL ACTIVITY .......................................................................................... 49 4.1 Current Marital Status .............................................................................................................. 49 4.2 Polygyny .................................................................................................................................. 50 4.3 Age at First Marriage ............................................................................................................... 52 4.4 Median Age at First Marriage .................................................................................................. 53

iv • Contents

4.5 Age at First Sexual Intercourse ................................................................................................ 54 4.6 Median Age at First Sexual Intercourse ................................................................................... 55 4.7 Recent Sexual Activity ............................................................................................................. 56

5 FERTILITY .......................................................................................................................................... 59 5.1 Current Fertility ....................................................................................................................... 60 5.2 Fertility Differentials ................................................................................................................ 61 5.3 Fertility Trends ......................................................................................................................... 62 5.4 Children Ever Born and Living ................................................................................................ 64 5.5 Birth Intervals .......................................................................................................................... 65 5.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility ................................................... 66 5.7 Menopause ............................................................................................................................... 68 5.8 Age at First Birth ..................................................................................................................... 68 5.9 Teenage Pregnancy and Motherhood ....................................................................................... 69

6 FERTILITY PREFERENCES ............................................................................................................ 71 6.1 Desire for More Children ......................................................................................................... 71 6.2 Desire to Limit Childbearing by Background Characteristics.................................................. 72 6.3 Ideal Family Size ..................................................................................................................... 74 6.4 Fertility Planning ..................................................................................................................... 76 6.5 Wanted Fertility Rates ............................................................................................................. 77

7 FAMILY PLANNING ......................................................................................................................... 79 7.1 Knowledge of Contraceptive Methods ..................................................................................... 80 7.2 Current Use of Contraception .................................................................................................. 82 7.3 Current Use of Contraception by Background Characteristics ................................................ 84 7.4 Trends in Current Use of Family Planning .............................................................................. 86 7.5 Timing of Sterilisation ............................................................................................................. 87 7.6 Source of Modern Contraception ............................................................................................. 87 7.7 Brands of Pills and Condoms Used .......................................................................................... 88 7.8 Informed Choice ...................................................................................................................... 88 7.9 Contraceptive Discontinuation Rates ....................................................................................... 89 7.10 Reasons for Discontinuation of Contraceptive Use ................................................................. 90 7.11 Knowledge of Fertile Period .................................................................................................... 91 7.12 Need and Demand for Family Planning Services .................................................................... 91 7.13 Future Use of Contraception .................................................................................................... 93 7.14 Exposure to Family Planning Messages ................................................................................... 94 7.15 Contact of Nonusers with Family Planning Providers ............................................................. 95 7.16 Attitudes towards Family Planning Among Men ..................................................................... 96

8 INFANT AND CHILD MORTALITY ............................................................................................... 99 8.1 Assessment of Data Quality ................................................................................................... 100 8.2 Levels and Trends in Infant and Child Mortality ................................................................... 101

8.2.1 Childhood Mortality Trends 1988-2014 .................................................................. 102 8.2.2 Recent Trends 2008-2014 ........................................................................................ 103

8.3 Socioeconomic Differentials in Childhood Mortality ............................................................ 103 8.4 Demographic Differentials in Mortality ................................................................................. 104 8.5 Perinatal Mortality ................................................................................................................. 105 8.6 High-risk Fertility Behaviour ................................................................................................. 107

9 MATERNAL HEALTH ..................................................................................................................... 109 9.1 Antenatal Care ....................................................................................................................... 109

9.1.1 Antenatal Care Coverage ......................................................................................... 109 9.1.2 Number and Timing of Antenatal Care Visits ......................................................... 110 9.1.3 Components of Antenatal Care ................................................................................ 111 9.1.4 Tetanus Immunisation ............................................................................................. 113

9.2 Delivery Care ......................................................................................................................... 114 9.2.1 Place of Delivery ..................................................................................................... 114 9.2.2 Assistance at Delivery ............................................................................................. 115

9.3 Trends in Maternal Care ........................................................................................................ 117 9.4 Postnatal Care for the Mother ................................................................................................ 118

9.4.1 Timing of First Postnatal Checkup for the Mother .................................................. 118 9.4.2 Type of Provider of First Postnatal Checkup for the Mother ................................... 119

Contents • v

9.5 Postnatal Care for the Newborn ............................................................................................. 120 9.5.1 Type of Provider of First Postnatal Checkup for the Newborn ................................ 121

9.6 Problems in Accessing Health Care ....................................................................................... 122

10 CHILD HEALTH AND EARLY DEVELOPMENT ...................................................................... 125 10.1 Child’s Size and Weight at Birth ........................................................................................... 126 10.2 Vaccination Coverage ............................................................................................................ 127 10.3 Trends in Vaccination Coverage ............................................................................................ 132 10.4 Acute Respiratory Infection ................................................................................................... 133 10.5 Fever ...................................................................................................................................... 135 10.6 Diarrhoeal Disease ................................................................................................................. 136

10.6.1 Prevalence and Treatment of Diarrhoea................................................................... 137 10.6.2 Feeding Practices ..................................................................................................... 139

10.7 Knowledge of ORS Packets ................................................................................................... 141 10.8 Stool Disposal ........................................................................................................................ 142 10.9 Childhood Early Learning and Development ......................................................................... 143

10.9.1 Support for Learning ................................................................................................ 144 10.9.2 Reading, Book Ownership, and Textbook and Reading Materials .......................... 145 10.9.3 Language for Education ........................................................................................... 148 10.9.4 Travel to school ....................................................................................................... 150

11 NUTRITION OF CHILDREN AND WOMEN ............................................................................... 153 11.1 Nutritional Status of Children ................................................................................................ 153

11.1.1 Measurement of Nutritional Status among Young Children .................................... 154 11.1.2 Data Collection ........................................................................................................ 155 11.1.3 Levels of Child Malnutrition ................................................................................... 155 11.1.4 Trends in Children’s Nutritional Status ................................................................... 157

11.2 Breastfeeding and Complementary Feeding .......................................................................... 158 11.2.1 Initiation of Breastfeeding ....................................................................................... 158

11.3 Breastfeeding Status by Age .................................................................................................. 160 11.4 Duration of Breastfeeding ...................................................................................................... 162 11.5 Types of Complementary Foods ............................................................................................ 163 11.6 Infant and Young Child Feeding (IYCF) Practices ................................................................ 164 11.7 Anaemia in children ............................................................................................................... 167 11.8 Micronutrient Intake among Children .................................................................................... 169 11.9 Adult Nutritional Status ......................................................................................................... 172

11.9.1 Nutritional Status of Women ................................................................................... 172 11.9.2 Nutritional Status of Men ........................................................................................ 175

11.10 Prevalence of Anaemia in Women ......................................................................................... 176 11.11 Micronutrient Intake among Mothers .................................................................................... 178

12 MALARIA .......................................................................................................................................... 181 12.1 Ownership of Mosquito Nets ................................................................................................. 181 12.2 Access to an Insecticide-Treated Net ..................................................................................... 184 12.3 Use of Mosquito Nets ............................................................................................................ 185

12.3.1 Use of Mosquito Nets by Persons in the Household ................................................ 185 12 3.2 Use of Existing Mosquito Nets ................................................................................ 187 12.3.3 Use of Mosquito Nets by Children under Age 5 ...................................................... 188 12.3.4 Use of Mosquito Nets by Pregnant Women ............................................................. 189 12.3.5 Trends in Use of Mosquito Nets by Children under Age 5 and Pregnant Women .. 191 12.3.6 Source and Cost of Nets........................................................................................... 191 12.3.7 Disposal of Nets ....................................................................................................... 192

12.4 Indoor Residual Spraying ....................................................................................................... 194 12.5 Use of Intermittent Preventive Treatment of Malaria during Pregnancy ............................... 195 12.6 Prevalence, Diagnosis, and Prompt Treatment of Children with Fever ................................. 196 12.7 Prevalence of Low Haemoglobin in Children ........................................................................ 199 12.8 Prevalence of Malaria in Children ......................................................................................... 200 12.9 Exposure to Messages on Malaria .......................................................................................... 201

12.9.1 Exposure to Specific Messages on Malaria ............................................................. 203

vi • Contents

13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR .............................. 205 13.1 HIV/AIDS Knowledge, Transmission, and Prevention Methods........................................... 206

13.1.1 Knowledge of AIDS ................................................................................................ 206 13.1.2 Knowledge of HIV Prevention methods .................................................................. 208 13.1.3 Comprehensive Knowledge about HIV/AIDS ......................................................... 209

13.2 Knowledge about Mother-to-Child Transmission .................................................................. 212 13.3 Attitudes towards People Living with HIV/AIDS ................................................................. 214 13.4 Attitudes towards Negotiating Safer Sexual Relations with Husbands .................................. 216 13.5 Attitudes towards Condom Education for Young People ...................................................... 218 13.6 Higher-risk Sex ...................................................................................................................... 219 13.7 Point Prevalence and Cumulative Prevalence of Concurrent Sexual Partners ....................... 221 13.8 Paid Sex ................................................................................................................................. 223 13.9 Coverage of HIV Testing Services......................................................................................... 224 13.10 HIV Testing during Pregnancy .............................................................................................. 226 13.11 Male Circumcision ................................................................................................................. 228 13.12 Self-reporting of Sexually Transmitted Infections ................................................................. 229 13.13 Injections ................................................................................................................................ 230 13.14 HIV/AIDS-Related Knowledge and Behaviour among Young People .................................. 232 13.15 Age at First Sexual Intercourse among Young People ........................................................... 233 13.16 Premarital Sex ........................................................................................................................ 235 13.17 Multiple Sexual Partners among Youth ................................................................................. 236 13.18 Age Mixing in Sexual Relationships ...................................................................................... 238 13.19 Recent HIV Test among the Youth ........................................................................................ 239

14 HIV PREVALENCE .......................................................................................................................... 241 14.1 Coverage Rates for HIV Testing ............................................................................................ 242 14.2 HIV Prevalence ...................................................................................................................... 245

14.2.1 HIV Prevalence by Age and Sex ............................................................................. 245 14.2.2 HIV Prevalence by Socio-economic Characteristics ............................................... 246 14.2.3 HIV Prevalence by Other Socio-demographic and Health Characteristics .............. 248 14.2.4 HIV Prevalence by Sexual Risk Behaviour ............................................................. 249

14.3 HIV Prevalence among Young People ................................................................................... 251 14.4 HIV Prevalence by Other Characteristics Related to HIV Risk ............................................. 253 14.5 HIV Prevalence among Couples ............................................................................................ 254

15 ADULT HEALTH AND LIFESTYLE ............................................................................................. 257 15.1 Blood Pressure ....................................................................................................................... 258

15.1.1 History and Treatment of High Blood Pressure ....................................................... 258 15.1.2 Coverage Rates for Blood Pressure Measurement ................................................... 260 15.1.3 Prevalence of High Blood Pressure ......................................................................... 261

15.2 Consumption of Fruits and Vegetables .................................................................................. 264 15.3 Household Use of Salty Foods ............................................................................................... 265 15.4 Knowledge of Iodised Salt and Its Perceived Benefits .......................................................... 266 15.5 Knowledge and Attitudes on Tuberculosis ............................................................................ 268 15.6 Tobacco Use ........................................................................................................................... 270 15.7 Health Insurance .................................................................................................................... 272

15.7.1 Health Insurance Coverage ...................................................................................... 272 15.7.2 Health Insurance Payment ....................................................................................... 275 15.7.3 Possession of a Valid N/DHIS Card ........................................................................ 277 15.7.4 Out-of-Pocket Payments .......................................................................................... 278 15.7.5 Need for Services Not Covered Under N/DHIS ...................................................... 279

15.8 Perceived Quality of Services and Client Satisfaction ........................................................... 280 15.9 Treatment Seeking and Perceived Quality of Care ................................................................ 284

16 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES .......... 289 16.1 Employment and Form of Earnings ....................................................................................... 290 16.2 Women’s Control over Their Own Earnings and Relative Magnitude of Women’s

and Their Husbands’ Earnings ............................................................................................... 291 16.3 Control over Husbands’ Earnings .......................................................................................... 292 16.4 Women’s and Men’s Ownership of Selected Assets .............................................................. 295 16.5 Women’s Participation in Decision-making .......................................................................... 297 16.6 Attitudes towards Wife Beating ............................................................................................. 300

Contents • vii

16.7 Women’s Empowerment Indicators ....................................................................................... 303 16.8 Current Use of Contraception by Women’s Status ................................................................ 303 16.9 Ideal Family Size and Unmet Need by Women’s Status ....................................................... 304 16.10 Reproductive Health Care and Women’s Empowerment ...................................................... 305 16.11 Infant and Child Mortality and Women’s Empowerment ...................................................... 306 16.12 Entitlement to and Use of Maternity Leave ........................................................................... 307 16.13 Length of Maternity Leave..................................................................................................... 309 16.14 Bridewealth Negotiation ........................................................................................................ 311

REFERENCES ................................................................................................................................................. 313

APPENDIX A SAMPLE DESIGN .................................................................................................................. 317 A.1 Introduction ............................................................................................................................ 317 A.2 Sampling Frame ..................................................................................................................... 317 A.3 Sample Design and Selection ................................................................................................. 318 A.4 Sample Probabilities and Sample Weights ............................................................................. 319

APPENDIX B ESTIMATES OF SAMPLING ERRORS ............................................................................. 327

APPENDIX C DATA QUALITY TABLES ................................................................................................... 343

APPENDIX D PARTICIPANTS IN THE 2014 GHANA DEMOGRAPHIC AND HEALTH SURVEY ....................................................................................................... 349

APPENDIX E QUESTIONNAIRES ............................................................................................................... 355

Tables and Figures • ix

TABLES AND FIGURES 1 INTRODUCTION .................................................................................................................................. 1

Table 1.1 Basic demographic indicators ......................................................................................... 3 Table 1.2 Results of the household and individual interviews ...................................................... 10

2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION ...................................... 11 Table 2.1 Household drinking water ............................................................................................. 13 Table 2.2 Household sanitation facilities ...................................................................................... 14 Table 2.3 Household characteristics .............................................................................................. 15 Table 2.4 Household possessions .................................................................................................. 17 Table 2.5 Wealth quintiles ............................................................................................................. 18 Table 2.6 Hand washing ................................................................................................................ 19 Table 2.7 Household population by age, sex, and residence ......................................................... 20 Table 2.8 Household composition ................................................................................................. 21 Table 2.9 Birth registration of children under age 5 ...................................................................... 22 Table 2.10 Children’s living arrangements and orphanhood ........................................................... 23 Table 2.11 School attendance by survivorship of parents ............................................................... 25 Table 2.12.1 Educational attainment of the female household population ......................................... 26 Table 2.12.2 Educational attainment of the male household population ............................................ 27 Table 2.13 School attendance ratios ................................................................................................ 29 Figure 2.1 Population pyramid ....................................................................................................... 20 Figure 2.2 Children under age 18 living away from home: Place or person with whom

they currently live .......................................................................................................... 24 Figure 2.3 Age-specific attendance rates of the de-facto population 5 to 24 years ........................ 30

3 CHARACTERISTICS OF RESPONDENTS .................................................................................... 31 Table 3.1 Background characteristics of respondents ................................................................... 32 Table 3.2.1 Educational attainment: Women ................................................................................... 34 Table 3.2.2 Educational attainment: Men ......................................................................................... 35 Table 3.3.1 School attendance: Women 15-24 ................................................................................. 36 Table 3.3.2 School attendance: Men 15-24 ...................................................................................... 37 Table 3.4.1 Literacy: Women ........................................................................................................... 38 Table 3.4.2 Literacy: Men ................................................................................................................ 39 Table 3.5.1 Exposure to mass media: Women ................................................................................. 40 Table 3.5.2 Exposure to mass media: Men ....................................................................................... 41 Table 3.6.1 Employment status: Women ......................................................................................... 43 Table 3.6.2 Employment status: Men ............................................................................................... 44 Table 3.7.1 Occupation: Women ...................................................................................................... 45 Table 3.7.2 Occupation: Men ........................................................................................................... 46 Table 3.8 Type of employment: Women ....................................................................................... 47 Figure 3.1 Women’s employment status in the past 12 months ..................................................... 42

4 MARRIAGE AND SEXUAL ACTIVITY .......................................................................................... 49 Table 4.1 Current marital status .................................................................................................... 50 Table 4.2.1 Number of women’s co-wives ...................................................................................... 51 Table 4.2.2 Number of men’s wives ................................................................................................ 52 Table 4.3 Age at first marriage ...................................................................................................... 53 Table 4.4 Median age at first marriage by background characteristics ......................................... 54 Table 4.5 Age at first sexual intercourse ....................................................................................... 55

x • Tables and Figures

Table 4.6 Median age at first sexual intercourse by background characteristics ........................... 56 Table 4.7.1 Recent sexual activity: Women ..................................................................................... 57 Table 4.7.2 Recent sexual activity: Men .......................................................................................... 58

5 FERTILITY .......................................................................................................................................... 59 Table 5.1 Current fertility .............................................................................................................. 60 Table 5.2 Fertility by background characteristics.......................................................................... 62 Table 5.3.1 Trends in age-specific fertility rates .............................................................................. 63 Table 5.3.2 Trends in age-specific and total fertility rates ............................................................... 63 Table 5.4 Children ever born and living ........................................................................................ 64 Table 5.5 Birth intervals ................................................................................................................ 66 Table 5.6 Postpartum amenorrhoea, abstinence, and insusceptibility ........................................... 67 Table 5.7 Median duration of amenorrhoea, postpartum abstinence, and postpartum

insusceptibility .............................................................................................................. 68 Table 5.8 Menopause .................................................................................................................... 68 Table 5.9 Age at first birth ............................................................................................................ 69 Table 5.10 Median age at first birth ................................................................................................ 69 Table 5.11 Teenage pregnancy and motherhood ............................................................................. 70 Figure 5.1 Total fertility rates, selected Sub-Saharan African countries ........................................ 61 Figure 5.2 Trends in age-specific fertility rates .............................................................................. 63

6 FERTILITY PREFERENCES ............................................................................................................ 71 Table 6.1 Fertility preferences by number of living children ........................................................ 72 Table 6.2.1 Desire to limit childbearing: Women ............................................................................ 73 Table 6.2.2 Desire to limit childbearing: Men .................................................................................. 74 Table 6.3 Ideal number of children by number of living children ................................................. 75 Table 6.4 Mean ideal number of children ...................................................................................... 76 Table 6.5 Fertility planning status ................................................................................................. 77 Table 6.6 Wanted fertility rates ..................................................................................................... 78

7 FAMILY PLANNING ......................................................................................................................... 79 Table 7.1 Knowledge of contraceptive methods ........................................................................... 80 Table 7.2 Knowledge of contraceptive methods by background characteristics ........................... 81 Table 7.3 Current use of contraception by age .............................................................................. 83 Table 7.4.1 Current use of contraception by background characteristics ......................................... 85 Table 7.4.2 Trends in the current use of contraception .................................................................... 86 Table 7.5 Source of modern contraception methods ..................................................................... 88 Table 7.6 Informed choice ............................................................................................................. 89 Table 7.7 Twelve-month contraceptive discontinuation rates ....................................................... 90 Table 7.8 Reasons for discontinuation .......................................................................................... 90 Table 7.9 Knowledge of fertile period .......................................................................................... 91 Table 7.10 Need and demand for family planning among currently married women ..................... 92 Table 7.11 Future use of contraception ........................................................................................... 94 Table 7.12 Exposure to family planning messages ......................................................................... 95 Table 7.13 Contact of nonusers with family planning providers ..................................................... 96 Figure 7.1 Trends in current use of contraceptive methods, Ghana 1988-2014 ............................. 87 Figure 7.2 Trends in unmet need and percentage of demand satisfied with modern methods,

Ghana 1993-2014 .......................................................................................................... 93

Tables and Figures • xi

8 INFANT AND CHILD MORTALITY ............................................................................................... 99 Table 8.1 Early childhood mortality rates ................................................................................... 102 Table 8.2 Early childhood mortality rates by socioeconomic characteristics .............................. 104 Table 8.3 Early childhood mortality rates by demographic characteristics ................................. 105 Table 8.4 Perinatal mortality ....................................................................................................... 106 Table 8.5 High-risk fertility behaviour ........................................................................................ 107 Figure 8.1 Mortality trends, Ghana 1988-2014 ............................................................................ 103

9 MATERNAL HEALTH ..................................................................................................................... 109 Table 9.1 Antenatal care .............................................................................................................. 110 Table 9.2 Number of antenatal care visits and timing of first visit.............................................. 111 Table 9.3 Components of antenatal care ..................................................................................... 112 Table 9.4 Tetanus toxoid injections ............................................................................................. 113 Table 9.5 Place of delivery .......................................................................................................... 115 Table 9.6 Assistance during delivery .......................................................................................... 116 Table 9.7 Timing of first postnatal checkup for the mother ........................................................ 119 Table 9.8 Type of provider of first postnatal checkup for the mother ......................................... 120 Table 9.9 Timing of first postnatal checkup for the newborn ..................................................... 121 Table 9.10 Type of provider of first postnatal checkup for the newborn ...................................... 122 Table 9.11 Problems in accessing health care ............................................................................... 123 Figure 9.1 Mother’s duration of stay in the health facility after giving birth ............................... 117 Figure 9.2 Trends in maternal health care, 1988-2014 ................................................................. 118

10 CHILD HEALTH AND EARLY DEVELOPMENT ...................................................................... 125 Table 10.1 Child’s size and weight at birth ................................................................................... 127 Table 10.2.1 Vaccinations by source of information: Children age 12-23 months .......................... 129 Table 10.2.2 Vaccinations by source of information: Children 24-35 months ................................. 129 Table 10.3.1 Vaccinations by background characteristics: Children 12-23 months ......................... 130 Table 10.3.2 Vaccinations by background characteristics: Children 24-35 months ......................... 131 Table 10.4 Vaccinations in first year of life .................................................................................. 132 Table 10.5 Prevalence and treatment of symptoms of ARI ........................................................... 134 Table 10.6 Prevalence and treatment of fever ............................................................................... 136 Table 10.7 Prevalence of diarrhoea ............................................................................................... 137 Table 10.8 Diarrhoea treatment ..................................................................................................... 139 Table 10.9 Feeding practices during diarrhoea ............................................................................. 141 Table 10.10 Knowledge of ORS packets ........................................................................................ 142 Table 10.11 Disposal of children’s stools ....................................................................................... 143 Table 10.12 Activities that promote learning .................................................................................. 145 Table 10.13 Reading and book ownership ...................................................................................... 147 Table 10.14 Textbooks and reading materials ................................................................................. 148 Table 10.15 Language for education ............................................................................................... 149 Table 10.16 Travel to school ........................................................................................................... 151 Figure 10.1 Trends in basic vaccination coverage among children 12-23 months,

Ghana 1988-2014 ........................................................................................................ 133

11 NUTRITION OF CHILDREN AND WOMEN ............................................................................... 153 Table 11.1 Nutritional status of children ....................................................................................... 156 Table 11.2 Initial breastfeeding ..................................................................................................... 159 Table 11.3 Breastfeeding status by age ......................................................................................... 161 Table 11.4 Median duration of breastfeeding ................................................................................ 163 Table 11.5 Foods and liquids consumed by children in the day or night preceding

the interview ................................................................................................................ 164 Table 11.6 Infant and young child feeding (IYCF) practices ........................................................ 166 Table 11.7 Prevalence of anaemia in children ............................................................................... 168

xii • Tables and Figures

Table 11.8 Micronutrient intake among children .......................................................................... 171 Table 11.9 Presence of iodised salt in household .......................................................................... 172 Table 11.10.1 Nutritional status of women ........................................................................................ 174 Table 11.10.2 Nutritional status of men ............................................................................................. 176 Table 11.11 Prevalence of anaemia in women ................................................................................ 177 Table 11.12 Micronutrient intake among mothers .......................................................................... 180 Figure 11.1 Nutritional status of children by age ........................................................................... 157 Figure 11.2 Trends in nutritional status of children under age 5, Ghana 2003-2014 ...................... 158 Figure 11.3 Infant feeding practices by age .................................................................................... 161 Figure 11.4 IYCF indicators on breastfeeding status ...................................................................... 162 Figure 11.5 IYCF indicators on minimum acceptable diet ............................................................. 167 Figure 11.6 Trends in anaemia status among children age 6-59 months, Ghana 2003 2014 .......... 169 Figure 11.7 Trends in nutritional status among women age 15-49, Ghana 2003-2014 .................. 175 Figure 11.8 Trends in anaemia status among women age 15-49, Ghana 2003-2014 ...................... 178

12 MALARIA .......................................................................................................................................... 181 Table 12.1 Household possession of mosquito nets ...................................................................... 183 Table 12.2 Access to an insecticide-treated net (ITN) .................................................................. 184 Table 12.3 Use of mosquito nets by persons in the household ...................................................... 186 Table 12.4 Use of existing ITNs ................................................................................................... 187 Table 12.5 Use of mosquito nets by children ................................................................................ 189 Table 12.6 Use of mosquito nets by pregnant women ................................................................... 190 Table 12.7 Source and cost of nets ................................................................................................ 192 Table 12.8 Household disposal of mosquito nets .......................................................................... 193 Table 12.9 Mosquito net disposal .................................................................................................. 193 Table 12.10 Indoor residual spraying against mosquitoes ............................................................... 195 Table 12.11 Use of intermittent preventive treatment (IPTp) by women during pregnancy ........... 196 Table 12.12 Prevalence, diagnosis, and prompt treatment of children with fever ........................... 198 Table 12.13 Source of advice or treatment for children with fever ................................................. 199 Table 12.14 Haemoglobin

Tables and Figures • xiii

Table 13.13 Male circumcision ....................................................................................................... 228 Table 13.14 Self-reported prevalence of sexually transmitted infections (STIs) and STI

symptoms .................................................................................................................... 229 Table 13.15 Prevalence of medical injections ................................................................................. 231 Table 13.16 Comprehensive knowledge about AIDS and of a source of condoms among youth ... 233 Table 13.17 Age at first sexual intercourse among young people ................................................... 234 Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse

among youth ................................................................................................................ 236 Table 13.19.1 Multiple sexual partners in the past 12 months among young people: Women .......... 237 Table 13.19.2 Multiple sexual partners in the past 12 months among young people: Men................ 237 Table 13.20 Age-mixing in sexual relationships among women age 15-19 .................................... 238 Table 13.21 Recent HIV tests among young people ....................................................................... 239 Figure 13.1 Women and men seeking treatment for STIs .............................................................. 230 Figure 13.2 Trends in age of first sexual intercourse ..................................................................... 235

14 HIV PREVALENCE .......................................................................................................................... 241 Table 14.1 Coverage of HIV testing by residence and region ....................................................... 243 Table 14.2 Coverage of HIV testing by selected background characteristics ............................... 244 Table 14.3 HIV prevalence by age ................................................................................................ 245 Table 14.4 HIV prevalence by socio-economic characteristics ..................................................... 247 Table 14.5 HIV prevalence by demographic characteristics ......................................................... 248 Table 14.6 HIV prevalence by sexual behaviour .......................................................................... 250 Table 14.7 HIV prevalence among young people by background characteristics ......................... 252 Table 14.8 HIV prevalence among young people by sexual behaviour ........................................ 253 Table 14.9 HIV prevalence by other characteristics ...................................................................... 253 Table 14.10 Prior HIV testing according to current HIV status ...................................................... 254 Table 14.11 HIV prevalence among couples................................................................................... 255 Figure 14.1 HIV prevalence among all adults age 15-49 by sex, Ghana 2003 and 2014 ............... 246

15 ADULT HEALTH AND LIFESTYLE ............................................................................................. 257 Table 15.1 History of hypertension ............................................................................................... 259 Table 15.2 History of hypertension and actions taken to lower blood pressure ............................ 260 Table 15.3 Coverage of blood pressure measurement among women and men ............................ 260 Table 15.4.1 Blood pressure status: Women .................................................................................... 262 Table 15.4.2 Blood pressure status: Men ......................................................................................... 263 Table 15.5 Consumption of fruit and vegetables ........................................................................... 265 Table 15.6 Household use of salty foods ....................................................................................... 266 Table 15.7 Knowledge of iodised salt and perceived benefits of using iodised salt ...................... 267 Table 15.8 Knowledge and attitude concerning tuberculosis ........................................................ 269 Table 15.9.1 Use of tobacco: Women .............................................................................................. 271 Table 15.9.2 Use of tobacco: Men ................................................................................................... 272 Table 15.10.1 Health insurance coverage: Women ............................................................................ 273 Table 15.10.2 Health insurance coverage: Men ................................................................................. 274 Table 15.11 Registration with N/DHIS ........................................................................................... 275 Table 15.12.1 Payment for N/DHIS coverage: Women ..................................................................... 276 Table 15.12.2 Payment for N/DHIS coverage: Men .......................................................................... 277 Table 15.13 Possession of a valid N/DHIS card ............................................................................. 278 Table 15.14 Out-of-pocket payment for medicines and services by respondents covered

by N/DHIS .................................................................................................................. 279 Table 15.15 Need for health services not covered by N/DHIS ....................................................... 280 Table 15.16 N/DHIS card holders’ perceived quality of services received ..................................... 281 Table 15.17 Client satisfaction among respondents covered by N/DHIS ....................................... 283 Table 15.18 Treatment seeking behaviour among all respondents .................................................. 284 Table 15.19 Type of health services received among all respondents ............................................. 285

xiv • Tables and Figures

Table 15.20 Awareness of health services for children and pregnant women ................................. 286 Table 15.21 Satisfaction with health services among all respondents ............................................. 287 Figure 15.1 Awareness of high blood pressure and treatment status among women and men

age 15-49 with high blood pressure ............................................................................. 264

16 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES .......... 289 Table 16.1 Employment and cash earnings of currently married women and men ....................... 290 Table 16.2.1 Control over women’s cash earnings and relative magnitude of women’s

cash earnings ............................................................................................................... 292 Table 16.2.2 Control over men’s cash earnings ............................................................................... 294 Table 16.3 Women’s control over their own earnings and over those of their husbands .............. 295 Table 16.4.1 Ownership of assets: Women ...................................................................................... 296 Table 16.4.2 Ownership of assets: Men ........................................................................................... 297 Table 16.5 Participation in decision making ................................................................................. 298 Table 16.6.1 Women’s participation in decision making by background characteristics ................. 298 Table 16.6.2 Men’s participation in decision making by background characteristics ...................... 300 Table 16.7.1 Attitude towards wife beating: Women ....................................................................... 301 Table 16.7.2 Attitude towards wife beating: Men ............................................................................ 302 Table 16.8 Indicators of women’s empowerment ......................................................................... 303 Table 16.9 Current use of contraception by women’s empowerment ........................................... 304 Table 16.10 Ideal number of children and unmet need for family planning by women’s

empowerment .............................................................................................................. 305 Table 16.11 Reproductive health care by women’s empowerment ................................................. 306 Table 16.12 Early childhood mortality rates by women’s status ..................................................... 307 Table 16.13 Entitlement to maternity leave .................................................................................... 308 Table 16.14 Maternity leave ............................................................................................................ 309 Table 16.15 Median number of weeks women do not work before and after birth ......................... 310 Table 16.17 Bridewealth negotiation .............................................................................................. 311 Figure 16.1 Number of decisions in which currently married women participate .......................... 299

APPENDIX A SAMPLE DESIGN .................................................................................................................. 317 Table A.1 Households .................................................................................................................. 318 Table A.2 Enumeration areas and enumeration area size ............................................................. 318 Table A.3 Sample allocation of clusters and households ............................................................. 319 Table A.4 Sample allocation of completed interviews with women and men.............................. 319 Table A.5 Sample implementation: Women ................................................................................ 321 Table A.6 Sample implementation: Men ..................................................................................... 322 Table A.7 Coverage of HIV testing by social and demographic characteristics: Women ............ 323 Table A.8 Coverage of HIV testing by social and demographic characteristics: Men ................. 324 Table A.9 Coverage of HIV testing by sexual behaviour characteristics: Women ...................... 325 Table A.10 Coverage of HIV testing by sexual behaviour characteristics: Men ............................ 326

APPENDIX B ESTIMATES OF SAMPLING ERRORS ............................................................................. 327 Table B.1 List of variables for sampling errors, Ghana DHS 2014 ............................................. 329 Table B.2 Sampling errors for the national sample, Ghana 2014 ................................................ 330 Table B.3 Sampling errors for the urban sample, Ghana 2014 .................................................... 331 Table B.4 Sampling errors for the rural sample, Ghana 2014 ...................................................... 332 Table B.5 Sampling errors for the Western region sample, Ghana 2014 ..................................... 333 Table B.6 Sampling errors for the Central region sample, Ghana 2014 ...................................... 334 Table B.7 Sampling errors for the Greater Accra region sample, Ghana 2014 ............................ 335 Table B.8 Sampling errors for the Volta region sample, Ghana 2014 ......................................... 336 Table B.9 Sampling errors for the Eastern region sample, Ghana 2014 ...................................... 337 Table B.10 Sampling errors for the Ashanti region sample, Ghana 2014 ...................................... 338 Table B.11 Sampling errors for the Brong Ahafo region sample, Ghana 2014 ............................. 339 Table B.12 Sampling errors for the Northern region sample, Ghana 2014 .................................... 340

Tables and Figures • xv

Table B.13 Sampling errors for the Upper East region sample, Ghana 2014 ................................ 341 Table B.14 Sampling errors for the Upper West region sample, Ghana 2014 ............................... 342

APPENDIX C DATA QUALITY TABLES ................................................................................................... 343 Table C.1 Household age distribution .......................................................................................... 343 Table C.2.1 Age distribution of eligible and interviewed women .................................................. 344 Table C.2.2 Age distribution of eligible and interviewed men ....................................................... 344 Table C.3 Completeness of reporting ........................................................................................... 345 Table C.4 Births by calendar years .............................................................................................. 345 Table C.5 Reporting of age at death in days ................................................................................ 346 Table C.6 Reporting of age at death in months ............................................................................ 346 Table C.7 Nutritional status of children based on the NCHS/CDC/WHO International

Reference Population .................................................................................................. 347

Foreword • xvii

FOREWORD

his report presents findings from the 2014 Ghana Demographic and Health Survey (GDHS), a nationally representative survey of 9,396 women age 15-49 and 4,388 men age 15-59 from 11,835 interviewed households. The primary purpose of the GDHS was to generate recent and reliable

information on fertility, family planning, infant and child mortality, maternal and child health, and nutrition. In addition, the survey collected information on malaria treatment, prevention, and prevalence among children age 6-59 months; blood pressure among adults; anaemia among women and children; and HIV prevalence among adults. This information is essential for making informed policy decisions and for planning, monitoring, and evaluating programmes related to health in general, and reproductive health in particular, at both the national and regional levels.

The 2014 GDHS is the sixth in a series of population and health surveys conducted in Ghana as part of the global Demographic and Health Surveys (DHS) Program. The survey was implemented by the Ghana Statistical Service (GSS), the Ghana Health Service (GHS), and the National Public Health Reference Laboratory (NPHRL) of the GHS. Financial support for the survey was provided by the United States Agency for International Development (USAID), the Global Fund through the Ghana AIDS Commission (GAC) and the National Malaria Control Programme (NMCP), the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the International Labour Organization (ILO), the Danish International Development Agency (DANIDA), and the Government of Ghana. ICF International provided technical assistance through The DHS Program, a USAID-funded project offering support and technical assistance in the implementation of population and health surveys in countries worldwide.

Dr. Philomena Efua Nyarko

Government Statistician Ghana Statistical Service

T

Acronyms • xix

ACRONYMS ACT artemisinin-based combination therapy AIDS acquired immunodeficiency syndrome ANC antenatal care ARI acute respiratory infection ASFR age-specific fertility rate BCG Bacille Calmette-Guerin BMI body mass index BOG Bank of Ghana CAFE computer assisted field editing CBR crude birth rate CDC Centers for Disease Control and Prevention CDD Control of Diarrhoeal Diseases CEDAW Convention on the Elimination of All Forms of Discrimination against Women CHPS community-based health planning and services CSPro Census and Survey Processing System CPR contraceptive prevalence rate DANIDA Danish International Development Agency DBS dried blood spot DFID Department for International Development DOTS directly observed treatment, short-course EA enumeration area ELISA enzyme-linked immunosorbent assay EQA external quality assurance GAR gross attendance ratio GAC Ghana AIDS Commission GDHS Ghana Demographic and Health Survey GDP gross domestic product GETFUND Ghana Education Trust Fund GFR general fertility rate GHS Ghana Health Service GPI gender party index GPS Global Positioning System GSS Ghana Statistical Office HCT HIV counselling and testing HepB hepatitis B HIV human immunodeficiency virus IFSS Internet File Streaming System ILO International Labour Organization IMCI integrated management of childhood illnesses IPTp intermittent preventive treatment IRS indoor residual spraying ITN insecticide-treated net

xx • Acronyms

IUD intrauterine device IYCF Infant and Young Child Feeding LAM lactational amenorrhoea method LEAP livelihood empowerment against poverty LPG liquid petroleum gas LLIN long-lasting insecticidal net MDG Millenium Development Goal MoH Ministry of Health MWRWH Ministry of Water Resource Works and Housing NACP National AIDS/STI Control Programme NAR net attendance ratio NDPC National Development Planning Commission NGO nongovernmental organisation NHIS National Health Insurance Scheme NMCP National Malaria Control Programme NMIMR Noguchi Memorial Institute for Medical Research NPHRL National Public Health and Reference Laboratory ORS oral rehydration salt ORT oral rehydration therapy PAHO Pan American Health Organization PHC population and housing census PLHIV people living with HIV/AIDS PMI President’s Malaria Initiative PMTCT prevention of mother-to-child transmission RDT rapid diagnostic test RHF recommended home fluid RTI reproductive tract infection SHS secondhand smoke STI sexually transmitted infection TB tuberculosis TFR total fertility rate UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development VAD vitamin A deficiency WASH water, sanitation and hygiene WHO World Health Organization

Millennium Development Goal Indicators • xxi

MILLENNIUM DEVELOPMENT GOAL INDICATORS Millennium Development Goal Indicators

Ghana 2014 Sex

Total Indicator Male Female

1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under age 5 10.6 11.6 11.0

2. Achieve universal primary education 2.1 Net attendance ratio in primary education1 69.6 69.6 69.6 2.3 Literacy rate of 15 to 24-year-olds2 89.3a 80.9 85.1b

3. Promote gender equality and empower women 3.1 Ratio of girls to boys in primary, secondary, and tertiary education 3.1a Ratio of girls to boys in primary education3 na na 1.0 3.1b Ratio of girls to boys in secondary education3 na na 0.9 3.1c Ratio of girls to boys in tertiary education3 na na 1.0

4. Reduce child mortality 4.1 Under-5 mortality rate4 78 62 60 4.2 Infant mortality rate4 52 43 41 4.3 Proportion of 1-year-old children immunized against one dose of measles 88.2 90.3 89.3

5. Improve maternal health 5.2 Percentage of births attended by skilled health personnel5 na na 73.7 5.3 Contraceptive prevalence rate6 na 26.7 na 5.4 Adolescent birth rate7 na 76.3 na 5.5a Antenatal care coverage: at least one visit8 na 97.0 na 5.5b Antenatal care coverage: four or more visits9 na 87.3 na 5.6 Unmet need for family planning na 29.9 na

6. Combat HIV/AIDS, malaria, and other diseases 6.1 HIV prevalence among the population age 15-24 0.2 1.5 0.8 6.2 Condom use at last high-risk sex10 39.3 19.2 29.3 6.3 Percentage of the population age 15-24 with comprehensive correct knowledge of

HIV/AIDS11 27.2 19.9 23.6 6.4 Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 0.97 0.92 0.94 6.7 Percentage of children under 5 sleeping under insecticide-treated bed nets 47.5 45.6 46.6 6.8 Percentage of children under 5 with fever who are treated with appropriate antimalarial

drugs12 46.8 50.6 48.5

Urban Rural Total 7. Ensure environmental sustainability

7.8 Percentage of population using an improved drinking water source13 57.0 71.4 64.2 7.9 Percentage of population with access to improved sanitation14 20.5 9.6 15.0

na = Not applicable 1 The ratio is based on reported attendance, not enrollment, in primary education among primary school age children (6-11 years). The rate also includes children of primary school age enrolled in secondary education. This is a proxy for MDG indicator 2.1, Net enrollment ratio. 2 Refers to respondents who attended secondary school or higher or who could read a whole sentence or part of a sentence 3 Based on reported net attendance, not gross enrollment, among 6-11-year-olds for primary, 12-17-year-olds for secondary, and 18-24-year-olds for tertiary education 4 Expressed in terms of deaths per 1,000 live births. Mortality by sex refers to a 10-year reference period preceding the survey. Mortality rates for males and females combined refer to the five-year period preceding the survey. 5 Among births in the five years preceding the survey 6 Percentage of currently married women age 15-49 using any method of contraception 7 Equivalent to the age-specific fertility rate for women age 15-19 for the three years preceding the survey, expressed in terms of births per 1,000 women age 15-19 8 With a skilled provider 9 With any health care provider 10 High-risk sex refers to sexual intercourse with a non-marital, non-cohabitating partner. Expressed as a percentage of men and women age 15-24 who had higher-risk sex in the past 12 months. 11 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about transmission or prevention of the AIDS virus. 12 Measured as the percentage of children age 0-59 months who were ill with a fever in the two weeks preceding the interview and who received any antimalarial drug 13 Percentage of de jure population whose main source of drinking water is a household connection (piped), public tap or standpipe, tubewell or borehole, protected dug well, protected spring, or rainwater collection. 14 Percentage of de jure population whose household has a flush toilet, ventilated improved pit latrine, pit latrine with a slab, or composting toilet and does not share its facility with other households a Restricted to men in a subsample of households selected for the male interview b The total calculated as the simple arithmetic mean of the percentages in the columns for male and females

xxii • Map of Ghana

Introduction • 1

INTRODUCTION 1

1.1 GEOGRAPHY, HISTORY, AND ECONOMY

1.1.1 Geography

he Republic of Ghana is centrally located on the West African coast. It has a total land area of 238,537 square kilometres, and it is bordered by three French-speaking countries: Togo on the east, Burkina Faso on the north and northwest, and Côte d’Ivoire on the west. The Gulf of Guinea lies to

the south and stretches across the 560-kilometre coastline.

Ghana is a lowland country except for a range of highlands on the eastern border. The highest elevation is Mt. Afadjato, 884 metres above sea level, found in the Akuapem-Togo ranges, west of the Volta River. Ghana can be divided into three ecological zones: the low, sandy coastal plains, with several rivers and streams; the middle and western parts of the country, characterised by a heavy canopy of semi-deciduous rainforests, with many streams and rivers; and a northern savannah, which is drained by the Black and White Volta Rivers. The Volta Lake, created by the hydroelectric dam in the East, is one of the largest artificial lakes in the world.

Ghana has a tropical climate with temperatures and rainfall patterns that vary according to distance from the coast and elevation. The eastern coastal area is comparatively dry, the southwestern corner is hot and humid, and the north of the country is hot and dry. The average annual temperature is about 26ºC (79ºF). There are two distinct rainy seasons in the southern and middle parts of the country, from April to June and September to November. The North is, however, characterised by one rainfall season that begins in May, peaks in August, and lasts until September. Annual rainfall ranges from about 1,015 millimetres (40 inches) in the North to about 2,030 millimetres (80 inches) in the Southwest. The harmattan, a dry dusty desert wind, blows from the northeast and covers much of the country between December and March, lowering the humidity and visibility, and also creates very warm days and cool nights in the North. In the South, the effects of the harmattan are felt mainly in January.

1.1.2 History

Ghana gained independence from British colonial rule on 6 March 1957, and became a republic in the British Commonwealth of Nations on 1 July 1960 with Accra as its administrative and political capital. Ghana operates a multi-party democracy with an executive president who is elected for a term of four years with a maximum of two terms. There is a parliament elected every four years, an independent judiciary, and a vibrant media.

There are 10 administrative regions in Ghana: Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Northern, Upper East, and Upper West. Ghana’s population was estimated at 27 million in 2014 (GSS 2013a). The Ashanti, Eastern, and Greater Accra regions together constitute about 50 percent of the country’s population. Upper East is the least populated region, accounting for 2 percent of the total population of Ghana. The regions are subdivided into 216 districts to ensure equitable resource allocation and efficient, effective administration at the local level (GSS 2013b).

The Ghanaian population is made up of several ethnic groups, with the Akans constituting the largest group (48 percent), followed by the Mole-Dagbani (17 percent), Ewe (14 percent), Ga-Dangme (7 percent), and others (GSS 2013b).

T

2 • Introduction

1.1.3 Economy

The structure of the Ghanaian economy has seen minimal changes over the past two decades. The agriculture sector, previously the largest contributor to the Ghanaian economy, has been overtaken by the service and industry sectors. By 2014, the service sector was the fastest growing sector of the economy, contributing 52 percent of the gross domestic product (GDP), followed by the industry sector, at 27 percent, and the agriculture sector, at 22 percent. In 2014, the service sector recorded its highest growth, of 6 percent, followed by the agricultural sector with 5 percent growth, and the industry sector with 1 percent growth (GSS 2015).

Overall, the 2014 real annual GDP grew by 4 percent compared with 7 percent growth recorded in 2013 (GSS 2015).

About 45 percent of the economically active population are engaged in agriculture, and 41 percent provide services. A high proportion of the employed population of Ghana works in the informal sector, the majority being self-employed (GSS 2014).

The leading export commodities of Ghana are cocoa, gold, and timber. Recently, the economy has diversified to the export of non-traditional commodities such as pineapples, bananas, yams, and cashew nuts. The tourism industry contributes substantially to the country's economy, as a key driver of economic growth. The industry is currently the third largest foreign exchange earner after merchandise exports and remittances from abroad and has become one of the most important and fastest growing sectors of the Ghanaian economy (BOG 2007).

Over the past decade, the government of Ghana has embarked on various economic and poverty-reduction programmes designed to improve the living conditions of its citizenry. The Livelihood Empowerment Against Poverty (LEAP) programme was introduced in 2007 and, in 2008, the poor began to receive cash support on a monthly basis.

Many changes have occurred in the education sector over the past 15 years. Pre-school education has officially been incorporated into the basic education as a part of primary and junior high school. All primary schools are required to have nurseries or kindergartens. In the 2005-2006 academic year, the government absorbed school fees for all pupils enrolled in basic public schools, resulting in free education (Darko et al. 2009). During the same period, a school feeding programme was introduced on a pilot basis and has since been extended to all basic schools. While the programme aims at improving the nutritional status of school pupils, a secondary effect has been to increase enrolment.

At the secondary level, the senior high school was introduced in the 2007-2008 academic year, expanding the system from three to four years, but this policy was reversed in 2009.

The introduction of the Ghana Education Trust Fund (GETFUND), a public trust set up by an Act of Parliament in the year 2000, has brought many improvements to the education system. The fund provides educational infrastructure such as buildings to support the country’s tertiary institutions and, as a result, has improved teaching and learning within these institutions.

1.2 DEMOGRAPHIC PROFILE

Sources of demographic information about the Ghanaian population include censuses, surveys, and administrative data. Population censuses provide more comprehensive demographic information than other sources. Ghana has completed five censuses since gaining independence in 1957. The first one was conducted in 1960 and reported a population of 6.7 million. The 1970 census recorded 8.6 million people, and the 1984 census, 12.3 million. In 2000, the Population and Housing Census (PHC) recorded 18.9 million, while in the 2010 PHC, 24.7 million were recorded. The average annual growth rate between 2000 and 2010 was 2.5 percent. The growth rates over individual periods were 2.4 percent, 2.6 percent, 2.7

Introduction • 3

percent, and 25 percent during 1960-1970, 1970-1984, 1984-2000, and 2000-2010, respectively (Table 1.1).

The population density has increased over the years from 29 persons per square kilometre (persons/km2) in 1960 to 103 persons/km2 in 2010. The proportion of the population living in urban areas has more than doubled in the last five decades, expanding from 23 percent in 1960 to 51 percent in 2010.

The sex ratio of 102.2 males per 100 females recorded in 1960 has declined to 95.2 males per 100 females in 2010. The proportion of the population under age 15 has also decreased from 45 percent in 1960 to 38 percent in 2010 (Table 1.1), while the proportion of the population age 65 years and older increased from 3 percent to 5 percent over the same period (data not shown separately). Over the last five decades, life expectancy at birth has increased from 38 years to 60 years among males and from 43 years to 63 years among females (GSS 1979, 1985, 2002, and 2013b).

Table 1.1 Basic demographic indicators

Indicators Pop census

1960 Pop census

1970 Pop census

1984 Pop & housing census 2000

Pop & housing census 2010

Population (millions) 6.7 8.6 12.3 18.9 24.7 Annual growth rate (percent) na 2.4

(1960-1970) 2.6

(1970-1984) 2.7

(1984-2000) 2.5

(2000-2010) Density (population/km2) 29 36 52 79 103 Percent urban 23 29 32 44 51 Sex Ratio 102.2 98.5 97.3 97.9 95.2 Population under 15 years 45 48 46 42 40

Life expectancy (years) Male 38 45 50 55 60 Female 43 48 54 60 63

na= Not applicable Sources: Ghana Statistical Service (GSS), 1979, 1985, 2002, and 2013b

Population and housing censuses are resource intensive, expensive to implement, and generally

take place at 10-year intervals. Sample surveys are, therefore, important for informing demographic profiles during inter-censal periods. They are conducted to collect a wide range of data to complement the census data. Sample surveys are cheaper and can be implemented more frequently and at regular intervals. The Ghana Demographic and Health Survey (GDHS), which is a household survey, is an example of a sample survey data collection tool.

Another important but often neglected data source in Ghana is the administrative data. These data are generated as a by-product of events and processes, and they provide relatively up-to-date inform