Structural Adjustment Programs in Ghana

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The Best of Times and the Worst of Times: Structural Adjustment Programs and Uneven Development in Africa: The Case Of Ghana* Kwadwo Konadu-Agyemang The University of Akron Since 1983, Ghana has been undergoing World Bank and International Monetary Fund (IMF) sponsored Structural Adjustment Programs (SAPs). The implementation of the SAPs, it is claimed, has arrested Ghana’s economy from complete collapse, resulted in consistent growth in GDP averaging 6% over the past decade, reduced inflation levels, created budget surplus, and increased export earnings. Compared to the 1970s, these are the best of times indeed. But while these SAPs-derived improvements in the national economy have been recorded at the macro level, the benefits at the micro level are a matter of considerable debate. This study revisits the issue of socioeconomic and spatial disparities that have characterized Ghana since colonial times, emphasizing the period from 1983 when Ghana’s SAPs began. It examines current patterns of socioeconomic disparities with emphasis on the distribution of, and access to, health, education, basic services, and the like. The study focuses on urban-rural as well as interregional disparities in the country. Key Words: Ghana, World Bank, IMF, Structural Adjustment Programs.

Introduction

D

escribing the turbulent times that characterized the setting of his book A Tale of Two Cities, Charles Dickens wrote, “It was the best of times and the worst of times.” This time-honored phrase may, to a great extent, describe the current bittersweet socioeconomic conditions and spatial inequalities in Ghana, Zimbabwe, Kenya, Malawi, and several other African countries, with regard to mixed blessings that have flowed from the World Bank and International Monetary Fund (IMF) sponsored Structural Adjustment Programs (SAPs). While

many African economies undergoing structural adjustment may experience unprecedented socioeconomic growth, judging by standard economic indicators, they may also experience uneven development, decreasing standards of living, increasing poverty, and reduced access to basic services. This study focuses on Ghana, whose economic restructuring experience over the past 15 years has been hailed by the Bretton Woods institutions and their supporters as the most successful case of structural adjustment in Africa. The questions of uneven development and socioeconomic and spatial inequalities in de-

* An earlier version of this paper was presented at the Canadian Association of Geographers Meeting in Ottawa Canada, June 2–6, 1998. I would like to thank Drs. Allen Noble, Charles Monroe, and Larry Ma of the University of Akron for their helpful suggestions; and Dr. Loren Siebert, Sean Lowery, Kivy Pridgen, and Dafna Peled for developing the maps used in this paper. Thanks also to the anonymous reviewers and Dr. Stuart Aitken for their comments.

Professional Geographer, 52(3) 2000, pages 469–483 © Copyright 2000 by Association of American Geographers. Initial submission, June 1998; revised submissions, October 1998, December 1999; final acceptance, December 1999. Published by Blackwell Publishers, 350 Main Street, Malden, MA 02148, and 108 Cowley Road, Oxford, OX4 1JF, UK.

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veloping countries, especially those in Africa, are well documented in the literature. Indeed, socioeconomic and spatial inequalities are listed among the litany of ills that are said to characterize underdeveloped countries (Lipton 1977; Harrison 1979; UNDP 1994; World Bank 1995a, 1996, 1997; Todaro 1996). Wide disparities exist in incomes, access to health care, education, and other services not only between the rural and urban areas, but also between regions and genders. In almost all of the developing countries, especially those in Africa, inequalities seem to have increased throughout the 1960s and 1970s, and gotten worst as the economies deteriorated in the late 1970s and early 1980s (Adedeji 1991). The worsening poverty and increasing socioeconomic and spatial inequalities have been linked to the economic mismanagement that has characterized African countries since the late 1960s. According to neoclassical economic theory that forms the bedrock of World Bank and IMF restructuring programs, socioeconomic and spatial inequalities are merely short-term aberrations that arise from structural factors, in an otherwise well functioning system. Consequently, it is assumed that the inequalities created between the rich and the poor and between prosperous and depressed areas melt away as countries undertake development programs, especially those that are driven by market forces (see Kuznets 1955; Theil 1979; Browett 1984). While this equilibrium theory may have some validity and seems to enjoy support among many social scientists, some geographers have long argued that interregional, spatial, and socioeconomic inequalities never melt away (see Hirschmann 1958; Berry 1969), especially in economies that operate under the capitalist mode of production. If anything, they become self-perpetuating (Myrdal 1957; Healey and Ilbery 1989). Indeed, unevenness of development between different parts of the same country may be the “inevitable and concomitant condition of growth itself” (Berry 1969, 12), and a necessary and essential pre-condition for capital accumulation (Mandel 1968; Browett 1984; Smith 1990). Therefore, at the very least, uneven spatial development should be seen as the geographical expression of the contradictions of capital (Smith 1990, 152). Ghana has participated in such IMF and World Bank sponsored Structural Adjustment

Programs (SAPs) since 1983. The Bretton Woods agencies claim that the implementation of SAPs almost invariably leads to poverty reduction and bridges the gaps between the rich and the poor and between the rural and urban areas, and that countries that adjust tend to be better off than the non-adjusting ones (World Bank 1994). Three main arguments are often presented in support of this claim. 1. Failure to adjust will, ultimately, impose huge costs on the poor, with unsustainable budget and trade deficits leading to hyperinflation, currency instability, and economic collapse (Watkins 1995). 2. SAPs, where properly implemented, have not only created conditions for growth, but growth that benefits the poor. The key contention is that state intervention in the rural sector, where a vast majority of the poor live, lowered prices, reduced market opportunities, and thereby depressed household income. Rural market deregulation, however, raises prices and creates rural employment. In the urban sector, import liberalization makes local industries more competitive by allowing them to take advantage of imported technology. Therefore, liberalization, together with labor market deregulation, will lead to the creation of jobs (World Bank 1991; Watkins 1995, 78). 3. SAPs incorporate “social conditionality” and provisions that aim at protecting welfare service delivery in areas of concern to the poor (World Bank 1993; Watkins 1995). Indeed, the World Bank claims that its central goal is poverty reduction, as is evidenced in an annual speech delivered to the board of governors in 1988 by then-president Barber Conable. The address focused On the central goal of the bank: the reduction of poverty. Poverty on today’s scale prevents a billion people from having even minimally acceptable standards of living. To allow every fifth human being on our planet to suffer such existence is a moral outrage. It is more: it is bad economics, a terrible waste of precious development resources. Poverty destroys lives, human dignity, and economic potential. (quoted in Nafziger 1990, 99)

The question now is: To what extent do the World Bank’s programs lead to poverty reduc-

Structural Adjustment Programs in Ghana tion and resolution of spatial disparities as is often claimed? This study revisits the issue of socioeconomic and spatial disparities that have characterized Ghana since colonial times, emphasizing the period from 1983 when Ghana’s SAPs began. It examines current patterns of socioeconomic and spatial disparities with emphasis on the distribution of, and access to, health, education, and other basic services. The paper examines socioeconomic and disparity indicators to understand how effective 15 years of World Bank and IMF sponsored development have been in eliminating or minimizing poverty and disparities in Ghana, focusing on urban-rural as well as interregional disparities in the country. Ghana is divided into ten administrative regions (Fig. 1) and the organization of most statistical data along these lines makes it logical to focus on regions as the units of study. However, the ecological belts, consisting of the rural northern savanna zone with its poor resources and underdevelopment and the relatively developed and urbanized forest and coastal zones with their cash based economies, have long been synonymous with deprivation and prosperity, respectively. Therefore, this study will not only focus on how the various administrative regions fared under SAPs, but will also examine the extent to which the disparities between the ecological zones have been altered.

Data Sources and Methods Data for this study primarily derive from the 1993 Ghana Demographic and Health Survey (GSS/GDHS 1994). The GDHS is a stratified nationally representative survey of 4,562 women and 1,302 men aged 15–59, chosen from 400 Census Enumeration Areas (CEAs) in all of Ghana’s ten administrative regions. Both rural and urban areas are included in the sample. The survey was conducted between September 1993 and February 1994 by the Ghana Statistical Services and the US-based Macro International, Inc (GSS/GDHS 1994). Other sources include the three Ghana Living Standards Surveys, nationwide surveys undertaken by the Ghana Statistical Service (GSS 1988, 1989a, 1992). World Bank/IMF publications are also cited in this paper. Using comparative statistical analyses from primary survey data, the study draws attention to the

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increasing spatial and socioeconomic inequalities, and lack of access to services under SAPs. Although data pertaining to pre-1983 has been difficult to obtain, efforts have been made to glean bits and pieces from diverse sources, as incomplete as they may be.

Ghana: From Glory to Dirt Ghana came into being when the British granted political independence to their then colony, the Gold Coast. The British ruled, or controlled, the country in one form or another starting from 1844, and through colonial plunder turned their so-called model colony into a “periphery” country, unscrupulously exploited by the “core” country (Omaboe 1966; Howard 1978; Onimode 1982). The result of the exploitative activities of the colonial government itself and European firms (especially cocoa buying, banking, shipping, and mining) was that when the British finally pulled out of Ghana in 1957, they left behind a country which bore all the most important features of underdevelopment. In particular, it suffered from an acute form of structural dislocation. Production and consumption were not integrated within the country but through external trade. Thus the colony exchanged commodities such as cocoa and gold, which it produced but did not consume, for mainly manufactured goods that it did consume, but in many cases could not produce itself (Kay 1972, xv). All the exploitation and symptoms of underdevelopment notwithstanding, the British probably left Ghana in better shape than any other country in Sub-Saharan Africa. Ghana’s primary material export-based economy was well established. At independence in March 1957, Ghana was the world’s leading producer and exporter of cocoa, exported 10% of the world’s gold, and had foreign reserves of £200 million (equivalence of three years’ imports). Furthermore, it had one of the best infrastructure systems in Africa, the most educated, skilled, and experienced workforce in Sub-Saharan Africa, and well-formulated development plans (Huq 1989; Roe and Schneider 1992; Werlin 1994). By all criteria, Ghana was probably much better endowed than most Third World countries, and certainly had better opportunities to develop than any other country in Sub-Saharan Africa. Ghana’s per capita income of £50 in

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Figure 1: Map of Ghana depicting the ten administrative regions, major towns and cities.

Structural Adjustment Programs in Ghana 1957 put it at par with South Korea (Werlin 1994), and it was comfortably placed among the “club” of middle income countries. In 1960, Ghana’s per capita national income of £70 was still higher than that of Nigeria (£29), India (£25), and Egypt (£56), and the growth rate was around 6% (Huq 1989). In the words of Apter: Richer than most (African) countries, carefully groomed for independence, with trained cadres exceeding those of far larger countries, without racial minority problems, having inherited a good and expanding educational system, Ghana is regarded as having the resources, manpower and moral and spiritual qualities to set the pace and tone of political development in all Africa. (Apter 1972, 337)

The bright and promising star of Africa, however, did not maintain its luster for long. By the middle of the 1960s, Ghana was teetering towards bankruptcy. The growth rate of GDP had fallen to 0.4%; foreign reserves had dried up and the nation was in serious debt (US $1 billion); real value of the minimum wage had dropped by 45%; and the public sector earnings and industrial earning had fallen by 20% and 25%, respectively (Huq 1989; Rimmer 1992). Furthermore, the producer price paid to cocoa farmers had decreased by 66% (Fitch and Oppenheimer 1966), and the lower half of income earners shared one-third of the national income as against one-half in 1956. Ghana’s economic woes continued through the rest of the 1960s into the 1970s and early 1980s, orchestrated in part by political instability and corruption. Between 1970 and 1983, import volumes declined by over 33%, real export earnings fell by 52% while domestic savings and investments dropped from 12% of GDP to almost zero, and an unprecedented number of Ghanaians—artisans, teachers, and medical professionals, as well as the unskilled—left the country. By the early 1980s, the inflation rate was in excess of 100%, the per capita GDP had fallen from its 1960 level of US $1009 to $739, and the nation was going through one of the worst droughts and famines in its history. As if these troubles were not enough, the Nigerian government suddenly repatriated well over one million Ghanaians whose arrival worsened the already chaotic socioeconomic environment. (Huq 1989; Chazan 1991; Rimmer 1992; Werlin 1994; Brydon and Legge 1996).

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While it is difficult to pinpoint the exact factors behind Ghana’s fall from a promising middle-income economy to a country teetering on the edge of bankruptcy, researchers have suggested a number of causes. These include economic mismanagement, over-regulation, inability to control inflation, productivity disincentives, an over-bloated and mismanaged public sector, over-subsidized social services (education and health in particular), overvalued currency, political instability, corruption, inept leadership, acts of God, unfavorable terms of trade, and clientelism (Huq 1989; Chazan 1991; Rimmer 1992; Werlin 1994; Brydon and Legge 1996). It was this bleak and dismal economic situation that led to the “invitation” of the twin Bretton Woods “doctors,” the IMF and World Bank, by the Provisional National Defense Council (PNDC) government (which in any case had caused part of the problem) in 1983 to provide solutions.

The IMF Diagnosis and Treatment The IMF and the World Bank came on the scene in February of 1983 and, predictably, their prescription was Structural Adjustment Programs. Indeed, the IMF and World Bank solution to economic maladies in Third World countries since the late 1970s has always been in the form of structural adjustments: a new euphemism for modernization and growth at all costs that had been “abandoned” in the 1970s. The IMF and World Bank inspired structural adjustment programs often consisting of a package of actions that include currency devaluation, reducing inflation, downsizing the public service, drastic cutbacks on government expenditure on education, health and welfare, financial reforms, privatization of public enterprises, export promotion, and other policies geared to enhancing economic growth. According to the IMF and other proponents of SAPs, the economic problems of developing countries have nothing to do with exogenous factors as is often asserted by neo-Marxist theorists (see Amin 1974; Wallerstein 1974; Frank 1975; Onimode 1982), but are rooted in endogenous factors that serve as obstacles to development and therefore need to be removed to pave the way for economic growth. These so-called obstacles to development, such as un-

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warranted state interference in the workings of the price mechanism, over-bloated public service, exchange control, state ownership of manufacturing enterprises, and investment in social welfare, only serve to clog the wheels of efficiency (World Bank 1981; Green 1987). African countries in particular are singled out as carrying an unnecessary and excess baggage of price control, overvalued currencies, political instability, inward-looking trade policy, and heavy government spending. These factors, it has been argued, constitute a drain on the efficiency of the market, and caused Africa’s dismal economic performance, vis-à-vis Asian and Latin American countries, in the past three decades (Roe and Schneider 1992; Sahn 1994; Werlin 1994; World Bank 1994). The only path to the elimination of economic bottlenecks, and hence the fostering of development, is to allow the invisible hands of market forces to determine economic activities unfettered (Roe and Schneider 1992). Consequently, economic efficiency and rational management along the lines of market mechanism, they argue, should constitute the sole scale upon which all national considerations of production, administration and culture are measured (Ould-Mey 1996, 14). In April 1983, Ghana’s economic recovery program designed by the IMF was put into action. The implementation of SAPs in Ghana over the past 15 years has consisted of compressing government expenditure through massive cuts in social services and retrenching public sector workers; adjusting the exchange rate through discrete devaluation of Ghana’s currency, the cedi; abolishing domestic price controls; mobilization of government revenue through broadening of the tax base; and the strengthening of tax administration. Other strategies include completing the privatization of state-owned enterprises, promoting the efficient allocation of resources for growth, rehabilitation of economic infrastructure, increasing reliance on market-based instrument of monetary policy, and encouraging sector development. There has also been a massive export drive to encourage the production and export of both traditional exports (cocoa, mineral resources, timber) and non-traditional exports (crafts, foodstuff, vegetables) (Anyinam 1994; World Bank 1995; Ghana Government 1997, 1998; ISSER 1995).

Impact of Structural Adjustment Programs in Ghana, 1983–1998 The implementation of the SAPS, its proponents claim, rescued Ghana’s economy from complete collapse. Indeed, Ghana’s GDP, which had seen consistent negative growth in the previous decade, started improving with SAPs. Between 1984 and 1991, GDP growth averaged 5%–6%, and since 1992 has hovered between 2.5% and 4%. Furthermore, the annual rate of inflation dropped from an average of 123% in the early 1980s to 32% in 1991, 34% in 1994, and 29% in 1997. Again, it has been argued that but for SAPs, Ghana’s industrial production, which plummeted to less than a quarter of installed capacity in the 1970s, would have died out completely. But thanks to the SAPs, most industries are now operating at 35%–40% capacity. Other achievements of SAPs include repairs in structural imbalances, growth in goods and services, generation of donor confidence and the attraction of foreign investment (Huq 1989; Boachie-Danquah 1992; Anyinam 1994; ISSER 1995; World Bank 1995b, 1996). Compared to the 1970s, these are the best of times indeed. While these SAPs-derived improvements in the national economy are recorded at the macro level, their benefits at the micro level are matter of considerable debate (Anyinam 1994; Panford 1994; Brydon and Legge 1996; Konadu-Agyemang 1998). The implementation of SAPs has not only culminated in the retrenchment of over 300,000 public sector workers, but has also led to unprecedented cuts in state expenditures on public services and social welfare and the introduction of user fees for health and education. Thus access of the poor to health and educational services has been reduced. The effective devaluation of the Ghanaian cedi, from 2.75 5 US$1 in 1983 to 2,300 5 US$1 in 1998 (approximately 80,000% devaluation) has raised the cost of imported machinery, drugs, school supplies, and other essential items. Ghana’s total debt more than quadrupled from $1,398 million in 1980 to $5,874 million in 1995, while external debt as a percentage of GDP also rose from 31.6% to 95% over the same period (World Bank 1997). Debt servicing, now 62% of export earnings, is diverting resources from local needs on a massive scale, thus depriving Ghanaian children of

Structural Adjustment Programs in Ghana their right to education, health, and adequate nutrition. That said, the national income may have been slightly redistributed in favor of the poor given that the percentage share of the bottom 20% increased from 7% in 1988 to 7.9% in 1992 (World Bank 1995a, 1996). Nevertheless, poverty is well and alive, especially in the savanna belt. The three GLSS Reports (GSS 1988, 1989, 1992) all indicate that despite slight improvements in the incidence of poverty between 1987 and 1992, 31% of all Ghanaians fell below the poverty line, which was fixed at a household income of 132,230 cedis per year in May 1992 prices. More than half of the poor were classified as “hard-core” with incomes below the ultra-poverty line which was also fixed at an annual household income of 99,173 cedis in 1992 prices (GSS 1995). Moreover, the rural area’s share of the poor population has increased, for despite the fact that the rural areas contain 64% of the population, 80% of the poor lived there in 1995, compared to 57% in 1981 and 60–65% in 1978. Socioeconomic and spatial disparities also worsened, not only between the urban and rural areas, but also between “core” and “periphery” regions (Roe and Schneider 1992; GSS/GDHS 1994; GSS 1995; Stewart 1995; Brydon and Legge 1996; World Bank 1997). These are all in the face of the World Bank’s assertion that SAPs in Ghana have resulted in the redistribution of resources from urban to rural areas considering the number of small-scale farmers who have benefited from higher producer prices. The worst of times indeed.

Unequal Socioeconomic and Spatial Development in Ghana: The Saga Continues In this section, the impacts of adjustments on the distribution of, and access to, education, health, other services in the both rural and urban areas in Ghana are examined. The absence of data on pre-adjustment conditions notwithstanding, the results of the three GLSS studies covering the 1986–1992 period demonstrate that uneven development may have indeed occurred under SAPs (GSS 1987, 1989, 1992). The issues of poverty, differences in the quality of life between the coastal and forest towns on the one hand and the savanna belt settlements, on the other, interregional disparities, and the

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disparities between cities and the rural areas, are nothing new. Indeed, colonial economic development policies created multiple nations in one country. While efforts were made to create social and economic infrastructure in the form of schools and hospitals, and harbors, railways, and roads in the forest and coastal belts to facilitate the exploitation and export of resources, the resource-poor rural savanna belt was denied any meaningful social and economic development. The quality of life in the towns and cities, although low by international standards, was much better than it was in the villages. Wide differentials also existed between living standards in the northern and southern regions (see Rimmer 1992). Post-independence development policies under Kwame Nkrumah, however, attempted to ameliorate the vast disparities by universalizing free education and health care, and creating roads and other social infrastructure in the hitherto deprived northern and upper regions. This seemed to yield dividends, as evidenced in rise in literacy levels, reduction in infant mortality rates (Ray 1986) and the emergence of large and prosperous towns such as Tamale and Bolgatanga in the north (World Bank 1984; Ray 1986). Although the gains that accrued to the north and other deprived areas under Nkrumah’s broad vision of national equity were partially lost during Ghana’s economic doldrums of the 1970s and early 1980s, I contend that the era of structural adjustments may have made matters worse, and rewidened the gaps. This is due primarily to the philosophy of SAPs, and the cost recovery element attached to the provision of education and health. Primary education may still be free in Ghana, but the requisite parental contribution in the form of books, furniture, and other supplies has effectively driven many children from the deprived north and other rural areas out of the school system. One of the key tasks of SAPs is to reduce governmental budgetary expenses to the barest minimum, and social services tend to become the obvious casualties. Under the first phase of the SAPs (1983–1986) as much as 62% of the total funds was allocated to physical infrastructure, 30%–32% for “productive activities” and export-oriented activities, and less than 5% for social services that include health and education. This trend has continued for the last 15

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years. Allocation to the health sector was 25.1 billion cedis (i.e., 1.16% of the national budget) in 1996, with an anticipated addition coming from foreign donors. Allocation increased to 38.3 billion in 1997, but still represented only 1.3% of the national budget. This is a far cry from 1980 and 1982 when allocation to the health sector represented 7% and 10% of government expenditure, respectively. Even though the proportion of GNP spent on health and education was increased from the 1981 level of 2.9% to 4.86 in 1990, it only restored it to the 1977–1978 level. Education suffered an even worst fate under SAPs, with its share of budgetary allocation falling from 4.3% of government expenditure in 1982 (ISSER 1993, 1995) to less than 1% in both 1996 and 1997. Like the health sector, the government expected the generosity of foreign donors to supplement it with 56 billion cedis in 1996 and 39 billion cedis in 1997 (Ghana Government 1997, 1998). So far as Structural Adjustment Programs are concerned, education, health, and other social services may be treated as unwanted stepchildren who deserve only a small fraction of the family budget, with the rest of their sustenance expected to come from charitable donations. As a result, education, health, and maternal and child health and welfare have suffered tremendously over the past 15 years. More-

over, the hardships and poverty that emerged under SAPs have accelerated malnutrition among vulnerable groups: children, the aged, urban poor, and the residents of rural areas. Stunting and wasting (underweight) are prevalent among Ghanaian children, but in a more acute form in the rural areas where close to 64% of the population live. Between 1988 and 1993, no improvement occurred in the rural areas (see Table 1). A 1986 nationwide study of 14,000 children under five years of age found that 58.4% were 80% below their ideal weight, compared to less than 30% in 1961–1962 and 35% in 1980 (Roe and Schneider 1992; Stewart 1995). The GLSS survey of 1988 came out with a figure of 31.4%, but this is still worse than the situation in the 1960s and 1970s (GLSS 1988). Again, in 1987–1988, 31% of all children under five were classified as undernourished, 7.8% acutely. Infant mortality in the nation as a whole fell from 120 per 1,000 births in 1965 to 86 in 1997, but it was still at the 1978–1982 level. Mortality among children under five however, still remains as high as 155 per 1,000 live births (compared to 152 in 1982), and Ghana is listed in the UNICEF high-risk group of countries (Hunger ProjectGhana 1996). The overall low figures, however, seem to camouflage the wide differences between the different ecological zones, admin-

Table 1 Stunting, Wasting, and Malnourishment among Under-Three Population (%), 1988–1993 Malnourishment Stunting

Wasting

Chronic

Acute

Place of Residence

1988

1993

1988

1993

1993

1993

Rural Urban North Upper East Upper West Greater Accra Western Central Eastern Ashanti Volta Brong Ahafo

30 25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

30.1 15.7 35.9 26 33.3 15.7 33 23 25 27 20 25

8 7 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

12.6 8.6 19 14.5 20.6 15.7 13 12 5.9 8.4 10.4 13

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Rural Coastal Rural Forest Rural Savanna Accra Other Urban ALL

1988 27.2 37.4 36.4 20.6 20.7 30.6

1989 28.7 37.6 35.5 15.5 24.3 31

1988 6.3 5.2 8.7 3.1 5.2 6.1

1989 2.5 3 4.9 4.6 3.2 3.5

24 33 36 22 N/A N/A

8.3 7.1 9.5 6.5 N/A N/A

Sources: GSS/GDHS 1994; GSS 1988, 1989, 1992

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56.9 42.2 26.2 38.3 25.4 30.6 Total

Notes: aFemale Headed Household; bMale Headed Household; cTrained Nurse Midwife; dTrained Traditional Birth Attendant; eUntrained Traditional Birth Attendant; fFriends/Relatives. Source: GSS/GDHS, 1994.

6.2 26.3 13.7 14.7 7.7 27.8 11.4 16.1 15.8 31.9 35.1 54.2 5.3 19.1 12.3 17.4 4.1 15.8 14.8 12.5 8.1 31.9 35.1 54.2 4.7 19.4 27.9 29 4.6 13.7 13.9 12 12.4 13.4 16.9 11.3 64.7 26.8 32.4 36.6 55.6 29.5 48.9 48.3 48.8 13.8 22.1 16.9 16.5 2.7 7.4 0.9 24.4 4.7 6.3 7.4 6.7 2 0 2.1 20.5 70.9 63.7 63.8 20.4 65.8 43.9 45.3 45 85.4 75.3 82.4 79.3 28 36.3 34.8 79.6 33.3 55.3 53.2 53.6 14.6 22.1 16.9 12.2 32.9 17.8 18.5 9.8 20.8 16.9 17.4 21.7 62 56.9 50.9 22.3 46.8 34.1 35.6 19.4 34.3 27.1 33 30.8 75.9 67.9 66.5 74 6 26.4 29.6 80.4 8.5 26.6 38.3 19.1 11.3 10.3 10.3 Urban Rural Western Central G/Accra Volta Eastern Ashanti B/A Northern U/West U/East

75.8 12.8 25.3 48.7 89.3 19.3 28.4 39 19.1 16.4 6.3 15.2

UTBAe Asst. Del. TTBAd Asst. Del. TNMc Asst. Del. Doctor Asst. Del. Home Delivery Health fac. Delivery MHHHb No Educ FHHHa No Educ Access to Piped Water Access to Electricity Place of Residence

Table 2 Access to Basic Services by Place of Residence, 1990–1994

istrative regions, and between the rural and urban areas. Incidence of poverty, malnutrition, and children in poor health is much more severe in the rural areas and in the Northern, Upper East, and Upper West regions. The GDHS makes a strong connection between child health, nutrition, and mortality and mother’s educational attainment. Whereas only 10% of children whose mothers have secondary or higher education are stunted, the average figure for less educated and/or illiterate mothers is around 33 percent. Malnutrition is therefore more prevalent in the North (36%), Upper West (33%), and Upper East (26%) regions where 75%, 68%, and 67%, respectively, of all mothers have no education at all (see Fig. 4). Compare these figures to Greater Accra where stunting is only 16%, with an illiteracy rate of 19%. These figures are low by African standards, yet they do not speak well of a nation that the IMF frequently showcases as the best example of successful structural adjustment in Africa. Spatial disparities are also evident in the delivery of all aspects of healthcare services including access to hospitals and clinics, health care professional, pre- and post-natal care, vaccinations, doctor-assisted deliveries and the like (see Table 2 and Fig. 2). In all cases, urban residents seem to have better opportunities than rural residents. For instance, whereas 79% of urban residents had the benefit of child delivery at health facilities between 1990 and 1993, the same is true for only 28% of rural residents. Such disparities also prevail at the interregional level. According to the data presented in Table 2 and Figures 2 and 3, whereas there is one government-employed physician per 5,300 people in the Greater Accra region, the ratio is as high as 1:64,000 in the North. Since infant and maternal mortality rates, as well as other incidents of morbidity, are higher in the rural areas and the peripheral regions, a strong relationship appears to exist between access to health care facilities and personnel and mortality rates (GSS 1993). One’s place of residence is therefore an important determinant of access to basic services (see Table 2 and Figs. 2, 3a and 3b). While lack of health facilities may prevent people from using healthcare, affordability may also be a significant factor. Residents of the urban areas are generally more educated

FRS/RELf Asst. Del.

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Figure 2: Distribution of medical personnel in government hospitals by region (population) 1993. Source: GSS/GDHS 1994.

and better paid (relatively) and are more likely to afford, and therefore seek, the assistance of hospitals during child delivery than their rural counterparts (most of whom depend upon seasonal incomes). The introduction of hospital user fees in 1985 as part of SAPs, however, affected both urban and rural residents, but the latter more severely. While the fees led to an immediate drop of 25%–50% in hospital and clinic visits in the Accra area, it was as high as 45%–80% in some rural areas during the first eight months (Enyimayew 1988). This trend continues until today, and the poor people of the savanna belt and the rural areas still suffer the consequences of “pay as you use” in healthcare delivery. Moreover, poor transportation links to health centers may pose problems especially if sickness or labor occurs at night or in the rainy season when rural roads become unusable. In the Northern and Upper regions, in most cases, the closest health facilities, often understaffed, may be up to 100 or more miles away, and hence not easily accessible. The culmination of all of these factors is that 74% of all ill persons in the rural savanna consulted practitioners other than doctors in 1991–1992, up from 66% in 1987–1988. While 39% of these healthcare providers include nurses, and medical assistants, 29% is made up of non-professional medical personnel such as spiritualists and traditional healers (GSS 1989, 1992). Although some people, especially those in the rural areas, may opt for treatments outside

biomedicine, considering the fact most Africans tend to classify ailments into “hospital and non-hospital sicknesses” (Stock 1986), available evidence suggests that most Ghanaians prefer modern medicine to traditional treatments (GSS 1992). Therefore, there is no doubt that well-equipped and appropriately staffed health facility in the rural and peripheral areas and at affordable prices will be well patronized. The success of the forty or so mission hospitals scattered throughout the country may attest to this assertion. Access to education continues to be unequal, not only between the urban and rural areas, but also between regions (see Fig. 4 and Table 3). In 1993, 85% of all 6- to 14-year-olds were enrolled in schools in the urban areas, compared to 71% in the rural areas. While, overall, national school enrollment figures have seen considerable improvement over the 1981 levels, Accra and other urban areas still enjoy higher gross enrolment vis-à-vis the rural areas and the poor regions in the north at both primary and secondary levels. Moreover, the number of untrained teachers in the rural areas and “periphery” regions still remains unacceptably high. In 1988–1989, 39.7% of all primary school teachers were untrained, an improvement over the 46.2% reported in 1980–1981 (GSS 1989). However, the figure was as high as 59.4% in the Northern region and as low as 12% in Greater Accra (Ministry of Education, cited in Mikell 1991). In 1997, there was an ex-

Structural Adjustment Programs in Ghana

479

a

b

Figure 3: (a) Tetanus injections received by expectant mothers (in percentages) 1993. (b) Vaccination received by children 12–23 months old (in percentages) 1990–93. Source: GSS/GDHS 1994.

cess of 7,000 teachers in urban areas while 21,000 positions in the rural areas were waiting to be filled.

SAPs and Socioeconomic and Spatial Inequalities Structural Adjustment Programs are designed to change the structure of the economy via policies that encourage increasing exportable goods, and implementing institutional reforms to reduce the role of the state in the economy. This would allow market forces to determine not only production, distribution, and loca-

tional decisions, but also access to goods and services. According to the IMF and the World Bank, African countries are unnecessarily encumbered by oversubsidized state enterprises, and overspend on social services such as education, health, and basic services. Therefore, they call for reduction in government expenditure through privatization, withdrawal of subsidies, and the institution of “pay as you use.” But given the extent of deprivation in most African countries, government involvement in the provision of health and education, inefficient as it may appear to be, still represents the only means of ensuring equitable distribution and

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Figure 4: Educational attainment of female household heads (in percentages) 1993. Source: GSS/DHS 1994.

access for the poor. Total government withdrawal or cutbacks and the subjugating of these services to market forces lead to spatial and socioeconomic disparities, which are inevitable, and even necessary, under capitalism (see Browett 1984). This seems to have been the experience of Ghana over the years, but even more so in the last 15 years. Cuts in government funding for health services and education have not only left hospitals and schools, especially those in the rural areas and “hardship regions,” understaffed, but also made them unaffordable. The country has seen a resurgence or revamping of private schools, day care centers, and hospitals, most of these in the Accra-Tema and metropolitan area, and the other urban centers. While adjustment programs also aim to raise rural incomes and reduce urban bias, and thereby improve the quality of life in the rural areas, this approach seems to have had the opposite effect. The usual hypothesis is that

through currency devaluation and price liberalization, the rural/urban terms of trade would improve dramatically in favor of the rural areas. This would then place more incomes in the hands of rural folks and hence reduce rural poverty. However, the evidence in this paper, as patchy and ambiguous as it may be, seems to suggest that poverty levels in the rural areas have risen. Indeed, most of SAPs-generated rural income increases accrued to cocoa producers, but only 19% of the rural poor are engaged in cocoa production. Wholesale prices of foodstuffs increased in the past 15 years, but the excessive devaluation of the Ghanaian currency has reduced its purchasing power dramatically. Moreover, in the north where the rate of poverty is the highest, the farmers are engaged in subsistence agriculture, and if there were any benefits at all, they did not trickle down to them (Stewart 1995). SAPs thus involve large-scale changes in the distribution and redistribution of resources,

Table 3 School Enrollment by Age, Sex, and Place of Residence, 1993 (Percentages) Male

Female

Total

Age Group

Urban

Rural

Total

Urban

Rural

Total

Urban

Rural

Total

6–14 15–19 20–24

87.4 54.9 14.5

72.6 48.5 12.8

77 50.6 13.5

83 30 7.4

68.5 28.1 4

73.2 29 5.3

85.2 41.3 10.4

70.7 39.9 7.8

75.1 40.5 8.8

Source: GSS/DHS 1994.

Structural Adjustment Programs in Ghana which are certain to leave some people and places worse off. Rising poverty levels, high rates of unemployment, reduced access to basic services, and increasing levels of spatial inequalities have, almost invariably, been the aftermath of SAPs. This has been demonstrated not only in Ghana, but also in Zambia, Madagascar, Bolivia, Chile, Honduras, Mauritania, and indeed in all countries that have taken the IMF “medicine” (Stewart 1995; Brydon and Legge 1996; Ould-Mey 1996). Attempts at putting a human face on the otherwise draconian programs led to the adoption of Programs of Action to Mitigate the Social Cost of Adjustments (PAMSCAD) in Ghana in 1988. While PAMSCAD itself was an admission of failure by the IMF, its objectives of assisting the “new poor” (retrenched workers), “vulnerable group” (low income households hit by price increases) and the “structural poor” were laudable. However, it became tied up in ineffective administration and poor targeting, and hence was an ineffective solution to alleviate the suffering of SAPs’ casualties (Brydon and Legge 1996).

Conclusions Overall, SAPs have not been universally effective in Ghana, and for that matter, all African countries that have accepted the World Bank/ IMF package. While lack of consistent data makes it difficult to reach unambiguous conclusions, it would be fair to say that the distribution of the so-called achievements under SAPs may have been quite uneven. The people in the rural areas as well as the poorest of the poor in the urban areas seem to have suffered significantly due to their inability to compete in the market. While Ghana’s economy may perhaps be experiencing the best of times at the macro level (compared to the 1970s), the benefits have not trickled down to all parts of the country, and to all socioeconomic groups. Living conditions have become harsh for the poor, especially the residents of the rural areas and savanna belt whose access to education, health, and other services has been severely curtailed under Structural Adjustment Programs. Fifteen years of SAPs have not been able to alleviate rural poverty and the long existing socioeconomic and spatial disparities in Ghana as predicted by neo-classical economic theory. If anything the

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gaps have widened in line with neo-Marxist theory that postulates that market-oriented development almost invariably leads to socioeconomic disparities, which are inevitable, and even necessary, under capitalism (see Browett 1984). In order for the supposed benefits of the SAPs to spread evenly, the programs themselves need to be adjusted and become more humane to avoid the worst of times. j

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KWADWO KONADU-AGYEMANG is Assistant Professor in the Department of Geography and Planning at the University of Akron, Akron, OH 44325-5005. His research interests include spatial organization in developing countries, economic restructuring, immigration, housing policy, and urban management.