Across the African continent, state support for healthcare delivery and education is still inadequate, despite claims of huge resources, excellent management and effective policies. Worse is lack of social infrastructure and minimal financial incentive for NGOs to operate especially in rural communities.
However, there are a number of NGOs, such as the Ghana Health and Education Initiative (GHEI), have taken up the challenge to help, at least, a few hundreds of impoverished and underprivileged children in rural communities. As a grassroot NGO, GHEI currently leads the COVID-19 emergency preparedness/response activities and other related operations in rural communities in Ghana. In this interview taken by KesterKennKlomegah for Eurasia Review, the Assistant Country Director of the Ghana Health and Education Initiative (GHEI), Enock Happy Nkrumah, discusses at length some of the success stories, challenges and future directions.
Here are the interview excerpts:
What are the motivating factors for the choice of country and directions of activities?
The founder of Ghana Health and Education Initiative (GHEI), Dr. Diana Rickard, chose Ghana, a peaceful and relatively safe country for her project work. After completing the project work, she decided to work in Ghana, West Africa, to help alleviate human suffering that is more prevalent in rural areas. She is a person who abhors human suffering. Increased access to better health and education can significantly contribute to reducing poverty and empower rural communities. Healthy and well-educated communities can escape chronic poverty and prevent transfer of poverty from generation to generation. This is the primary motivation for the direction of our activities. What are the specific challenges in these health and education areas in the country?
Early Childhood Literacy
In spite of the progress, Ghana has made in improving access to public primary schools in rural parts of the country, children still face challenges that prevent them from improving their literacy and numeracy skills. Overcrowded classrooms, inadequate infrastructure and a lack of trained teachers and educational resources such as textbooks, pens etc. contribute to a school environment that is not conducive to learning.
This lack of friendly infrastructure and learning atmosphere severely compromises learning outcomes, especially in low performing primary school students. Because the learner is expected to adapt to the education system, the challenges have compounded for these students who are often overlooked by both teachers and parents, and consequently become ‘invisible’. The absence of individualized support and learning materials leads to irregular attendance, long periods of absence and finally the child drops out.
At the junior high school level, Ghanaian education system aims to provide a holistic and quality approach to education in order to help young students acquire requisite knowledge, skills and values for the purpose of achieving success and contributing to Ghana’s socio-development. To this aim, it is very relevant to create an environment that helps to promote and sustain quality delivery of education not only in urban areas but also rural Ghana. For the youth residing in communities like Humjibre, teaching and learning should take place in an environment that is healthy, safe and sound and gender sensitive with adequate resources and facilities.
There are however urgent challenges to achieving quality education for junior high school students in rural communities and these include –
• Poor infrastructural facilities such as lack of proper benches, sanitation & hygiene.
• Lack of instructional materials such as school textbooks, notebooks and other stationery items to support learning.
• Low number of well-motivated and committed teachers to deliver quality education.
• High student/teacher ratio. The class sizes in junior high schools in Humjibre exceed 50 students per class.
• Absence of proper guidance and counselling services for junior high school students in rural communities.
In Humjibre, a large percentage of adults in the community are uneducated, hence, they cannot pass on their knowledge about careers and the importance of education, therefore the children often lack motivation to continue their education and lack inspiration to attain careers outside what they know within the village, where the majority of people are farmers.
All these factors contribute to a poor-quality education in junior high schools, hindering academic performances in young children and negatively impacts their future possibilities. It also makes difficult for students to continue their education beyond junior high school.
Progress has been made in closing the gap between girls and boys when it comes to education in Ghana. Disparity in enrollment rates between girl and boys at the junior high school level has been lessened. However, we are yet to reach gender parity at the senior high school level. In addition, the average number of years of education that the poorest girls from rural areas aged 20 to 24 can attain is about four years as compared to 13 years for girls from affluent homes in urban areas.
Poverty severely restricts educational opportunities for girls living in rural communities like Humjibre. They are especially at disadvantage when confronted with the combination of above factors and must also simultaneously adhere to cultural and social norms that include helping with household chores and taking care of young siblings. Teenage girls are often seen as a financial burden by their families and have to earn money to support their families, forcing them to discontinue their education. Without education, they are denied the chance to fulfill their potential and break the cycle of poverty for good.
Between 2000-17, Maternal Mortality Rate (MMR) declined in Ghana from 484 per 100,000 live births in 2000 to 339 in 2010 and to 308 in 2017, representing a 36% reduction in 17 years. In July 2008, Ghana introduced a free maternal health policy under the National Health Insurance Scheme (NHIS). This was a key strategy for the achievement of the Millennium Development Goals (MDGs) and now, the Sustainable Development Goals (SDGs).
Notwithstanding these advances, the fact remains that Ghana’s progress is less than optimal and much more needs to be done. Evidently, the pace of decline in maternal mortality ratio has been slow leading to Ghana’s inability to achieve the millennium development goal target of 190/100,000 live births in 2015. The maternal mortality ratio remains high and requires strenuous efforts if Ghana must achieve the sustainable development goal target of 70 per 100,000 live births in 2030.
Most maternal deaths occur in the rural areas as compared to urban areas. This has largely been attributed to the high prevalence of skilled birth attendance of 74% in urban areas as compared to 43% in the rural areas. There are several other reasons as major contributing factors for high MMR in Ghana and these include –
• Lack of infrastructure in health care facilities
• Lack of sanitation and hygiene facilities in households leading to infections and diseases such as malaria, diarrhea etc.
• Inadequate knowledge and awareness of proper nutrition amongst pregnant women.
• Lack of skilled healthcare workers including absence of emotional support from birth attendants. There is also a lack of faith in birth attendants resulting in mothers accessing health facilities as a last resort.
• Poor transportation system.
Sanitation and hygiene standards in rural households is a key challenge. Only 18% of households in Ghana use improved toilet facilities. Urban households are more likely than rural households to use improved toilet facilities (22% versus 13%). Eight in ten households use unimproved toilet facilities—52% use a shared facility, 15% use an unimproved facility, and 15% have no facility.
Development of infants and young children
Between 1990-2018, the under-five mortality rate reduced from 127 to 48 per 1000 live births, with the annual rate of reduction being 3.5%. In the same period, the infant mortality rate dropped from 80 to 30 per 1000 live births. While this is a considerable progress, it is still not enough to meet the SDG target of ending all preventable deaths of newborns and children under 5 years of age.
Health and Nutrition in young children and infants is a key challenge. One child in every five in Ghana experiences stunted growth during the first thousand days of life caused by inadequate nourishment, frequent illness and an unhealthy environment. These affect the physical, social and cognitive development in children. Their brain development is negatively impacted which further affects learning at an early age, school performance and ultimately their socio-economic development.
Limited knowledge of key infant and young child feeding practices among caregivers remains a challenge in Ghana. This coupled with the lack of skills to prepare nutritious foods and the cost of certain foods, leading to poor diversity in the diets of infants and young children. Only 13 percent of children between 6-23 months receive the appropriate minimum diet diversity. Moreover, only 52% women in the country breastfeed exclusively.
With regard to early childhood stimulation, mere 6% children under age 5 have 3 or more children’s books. Only 41% children under age 5 have 2 or more types of playthings. The challenge is majorly poverty as it limits the parents’ ability to spend time and money to play with, feed, and educate their children, resulting in a less stimulating home environment.
How the local system, that is the structures and cultural norms influence the operations of the NGO?
We believe that progress in health and education is best achieved by the community itself. Therefore, we value empowering local individuals and cultivating local leadership to develop and manage all our programs. To this aim, all GHEI programs are led and executed by community members who are trusted agents of change in their communities, and whose role in mobilizing community members to respond to their health and education issues is well established. Consequently, local systems, structures and cultural norms are embedded in our everyday activities.
As a grassroots NGO, we are sensitive and have high regard for local systems, structures and cultural norms. For nearly 20 years now, we have delivered high quality health and education programs to women and children in rural communities in Ghana. We have ensured that our work is culturally appropriate and reflects the local realities. For instance, our education programs are based on the curriculum followed in Ghanaian public schools and the guidance for a successful career to children is provided by local role models. All health-related learning materials is available in the local language and provides local solutions for improving nutrition, sanitation & hygiene and cognitive stimulation.
In this way, we have won trust and cooperation from not only our direct beneficiaries (women and children) but also key members of the community such as community chiefs, elders, local health/education officials and religious leaders. Our initiative has added value to local systems, structures and cultural norms. They in turn have influenced our operations positively and keep inspiring us to fight poverty through innovative means.
Over the years, local knowledge and perspectives have evolved in the rural communities we work in. Community members are better aware about how NGO’s can meet their needs and what role they can play in this collective fight against poverty.
From an operational viewpoint, local systems, structures and cultural norms sometimes pose a challenge as well. For instance, promoting sexual health education and generating knowledge on similar topics amongst teenagers is seen as infringing local values and culture. While we recognize sensitivities involved in such issues and respect other views, undeniably there is a need to educate teenagers because teenage pregnancies lead to school dropouts especially in rural areas. In addition, local bureaucratic hurdles/redtape hinder opportunities to partner with local government institutions. Since the inception, we have considered partnership as highly important, and continue to find ways to collaborate with like-minded institutions to fight poverty in Ghana.
How would you argue that health and education have received low priority from the government in the country?
Between 2012 and 2018, there has been a 50% reduction in government expenditure on education. In 2012, the government had spent 37.5% on education and by 2018 it dropped to 18.6% (% of total government expenditure). On the health side, we have seen a drop in government’s expenditure as well. Between 2013 and 2017, the government’s health expenditure reduced by 34%. While the trend may look different for if you change the time period, however my point is that these are recent trends and, hence worrying.
Moreover, in rural areas, health and education have received low priority because infrastructural and other social amenities are limited so trained staff refuse to accept transfer to rural areas rather prefer to be in the cities. Moreover, staff refuse to stay in rural settings because it has low incentive to further one’s education. I have come not across any strategy by the government to overcome this challenge in so many years.
What would you consider as achievements since you began this Health and Education NGO?
We believe that every individual – regardless of age, gender, or socio-economic status – should have access to a learning environment where they can expand their knowledge and increase their literacy level. In our communities, there is a lack of literary resources available, which is exacerbated by the lack of textbooks in schools. Moreover, students do not have access to quiet spaces that are conducive to learning.
To give our community, and in particular students, the opportunity to learn and improve their literacy in preparation for obtaining a higher education, GHEI constructed a library in Humjibre in 2007. It has a collection of over 6000 books on wide ranging topics, however there is a special emphasis on children’s books, school textbooks and books authored by African authors.
The library also hosts a reading club where children gather at the Humjibre Community Library to read selected titles from the Junior African Writers Series or African Writer Series, answer comprehension questions, and discuss issues based on materials.
Since 2003, our education programs have helped children achieve their literacy goals, enabled them to think critically and fostered leadership skills. Educational attainment among youth is critical to alleviating poverty. Till now we have helped improve learning outcomes and enhanced career opportunities for 256 children who have graduated from GHEI’s education programs.
Our Youth Education Program (YEP) offers 20 hours of supplemental classes every week to junior high school students in Humjibre, helping them to prepare for the critical Basic Education Certification Examination (BECE). Since 2013, more than 50% students from the program have achieved high passing score in BECE, meaning their performance was excellent. YEP is a journey of empowerment and all graduates have gone on to successfully attend senior high school, university and technical training.
GHEI’s Early Childhood Literacy Program focusses on nonperforming primary school children by providing them extra attention outside their normal school hours. The classes are extremely critical because as I had mentioned before nonperforming primary school children are often not seen as worthy investments in rural communities. The program creates a solid and broad foundation for lifelong learning and wellbeing of children who may have had to drop out of school due to below average performances. Till now, we have also provided 112 academic scholarships to senior high school students and 1 vocational scholarship.
Since its inception, GHEI has established a range of health programs to benefit Humjibre and the surrounding communities. Our health programs focus on preventing malaria, enhancing sanitation and hygiene standards, improving the health outcomes of first-time mothers and their babies, and promoting early childhood stimulation through a peer-to-peer support system between first-time mothers and mentors in the community.
Through our flagship Mother Mentor for Child Development Program, we have provided good health to more than 40 first time pregnant mothers and their babies. The mentors work with the participating mothers and their families from pregnancy all the way through the first two years of the child’s life in order to maximize its health and development. Providing mothers and families with individualized support, education, and vital resources ensures that their child thrives. We have constructed over 30 toilets in rural households, benefitting more than 500 people. We’ve also setup hand washing stations in households by providing veronica buckets and soap.
Last year, we provided over 1000 food vouchers to first time pregnant mothers, ensuring that they can include bread and eggs in their daily diet. We regularly organise stimulation activities for young infants and provide guidance and encouragement to parents on how they can spend time with their children. In this way, we improve development of young infants especially under key indicators such as Gross Motor Skills, Social Emotion and Expressive Language.
Our Health Facility Delivery Incentive Program hosts monthly distribution days for pregnant mothers in Ampenkrom village, Ghana. We started this program in 2015 and since then we have supported deliveries for more than 500 women by providing them pre delivery packages that include antiseptic, soap and bleach. These items are necessary and commonly needed to deliver at the community health clinics.
Unfortunately, without these items’ women are turned away from health clinics and hence the need for our intervention. Our pre delivery packages have encouraged pregnant women to deliver at health facilities, reducing the risk from complications of delivering at home or other place with proper facilities. In 2019, 89% of participants had reported to us that they delivered at the facility after receiving the package from GHEI. However, our work doesn’t stop here. We also provide post-delivery packages that include diapers and blankets for the baby.
Do you get external support? If you get external support, where do these come from WHO, USAID, UN, or just private enterprises?
We receive support and assistance from individual donors and partner organisations such as One Day’s Wages, Project Peanut Butter and David Geffen School of Medicine at the University of California Los Angeles. It is possible to discuss future initiatives for communities that benefit from GHEI’s work. We are keen on partnering with likeminded organisations in Ghana/Africa and work together to defeat poverty. We value collaborative alliances with businesses, health and education agencies. Such partnerships have been key to our success and we are continually looking to collaborate to find innovative solutions to the challenges in our communities.