Poverty assessment in Ghana - using qualitative and participatory research methods

83 * PSP Discussion Paper Series 19705 November 1995 Poverty Assessment in Ghana Using Qualitative and Participatory Research Methods Andy Norton Ellen Bortei-Doku Aryeetey David Korboe D.K. Tony Dogbe November 1995 Poverty and Social Policy Department Human Capital Development and Operations Policy The World Bank  Abstracts This Booklet of Abstracts contains short summaries of recent PSP Discussion Papers; copies of specific papers may be requested from Patricia G. Sanchez via All-in-One. The views expressed in the papers are those of the authors and do not necessarily represent the official policy of the Bank. Rather, the papers reflect work in progress. They are intended to make lessons emerging from the current work program available to operational staff quickly and easily, as well as to stimulate discussion and comment. They also serve as the building blocks for subsequent policy and best practice papers.  Preface This paper is one of a series undertaken as part of the Extended Poverty Study in Ghana. A synthesis of this work is available in Ghana: Poverty Past, Present and Future (Report No. 140504-GH. Population and Human Resources Division, West Central Africa Department, World Bank, Washington D.C., June 29, 1995). Four of the background papers are appearing in the Poverty and Social Policy Discussion Paper Series: Harold Coulombe and Andrew McKay, 'An Assessment of Trends in Poverty in Ghana, 1988-92.' Poverty and Social Policy Discussion Paper No. 81, World Bank, Washington D.C. (November 1995) Lionel Demery, Shiyan Chao, Rene Bernier and Kalpana Mehra, 'The Incidence of Social Spending in Ghana.' Poverty and Social Policy Discussion Paper No. 82, World Bank, Washington D.C. (November 1995) Andy Norton, David Korboe, Ellen Bortei-Dorku and D.K. Tony Dogbe, 'Poverty Assessment in Ghana using Qualitative and Participatory Research Methods.' Poverty and Social Policy Discussion Paper No. 83, World Bank, Washington D.C. (November 1995) Christine Jones and Ye Xiao, 'Accounting for the Reduction in Rural Poverty in Ghana, 1988-1992.' Poverty and Social Policy Discussion Paper No. 84, World Bank, Washington D.C. (November 1995) The papers draw upon the work of many. The contributions of the Ghana Statistical Service, Ministry of Health, and Ministry of Education in the Government of Ghana, and of UNICEF and the Canadian Intemational Development Agency (CIDA), are gratefully acknowledged. The views expressed are those of the authors. They should not be attributed to the World Bank, its Board of Directors, its management or any of its member countries.   Acknowledgments This overview report has been compiled by Andrew Norton, drawing heavily on inputs from the other authors. Fieldwork for this study has been carried out over three phases, with inputs of support from ODA (field costs phase I & 2) GTZ (support to costs of training, phase 1) and UNICEF (support to phase 3). Acknowledgments are due to: the field teams (members listed below) for their enthusiasm and commitment; the two Task Managers who have been involved in the Extended Poverty Study for the World Bank, Lionel Demery and Tom Stephens, for their firm support; the administrative and logistical staff of CEDEP (the NGO who coordinated the study) for their efficiency and hard work; and above all the members of poor rural and urban communities who gave their time to share their analyses of poverty with us. Team members: Phase 1. Research Supervisor - Dr. Andrew Norton Lead Researcher- Dr. Ellen Bortei-Doku Aryeetey Team Leaders - Dr. Felix Fiadjoe - Mr. Dan Inkoom - M. Wim Alberts Members - Mrs.Margaret Doku - Ms. Margaret Assan - Ms. Judith Thompson - Mr. Samuel Dodoo - Mr. Martin Dery - Mr. Dominic B. Kanyoke - Mr. Thomas Kuby - Mr. D.K. (Tony) Dogbe - Mr. Ben Arthur Administrative Officer Mrs. Salome Ahenkora Research Manager - Mr. D.K. (Tony) Dogbe  Phase 2 Research Supervisor - Dr. Andrew Norton Lead Researcher - Dr. Ellen Bortei-Doku Aryeetey Team Leaders - Mr. Wim Alberts - Mr. D.K. (Tony) Dogbe Members - Dr. Felix Fiadjoe - Rev. Fr. Anyomi - Mr. Robert Kuwornu - Mr. Robert Agarku - Mrs. Salome Ahenkora - Mr. Charles Owusu - Mr. Dan Amuah - Mr. Martin Dery - Mr. Samuel Dodoo - Mr. Dominic B. Kanyoke - Mr. Paa Kwesi Afari Administrative Officer Ms. Celia Marshall Research Manager - Mr. D.K. (Tony) Dogbe Travelling Secretariat - - Mr. Kwaku Ahenkora - Mr. Kwame Apiagyei Phase 3 Research Supervisors - Mr D.K. Tony Dogbe - Dr Andrew Norton Lead Researcher - Dr David Korboe Team Leaders - Mr. Kweku Ahenkora - Mr. D.K. Tony Dogbe - Dr. David Korboe Members - Mr. Dela Afenyadu - Ms. Vida Affum - Mrs.Doris Amoyaw - Ms. Mercy Anim - Ms. Theresa Baffoe - Mr. Robert de Graft Agyarko - Mr. Samuel Duodu - Mr. Dominic Kanyoke - Mr. Kwaine Manhyia - Mr. Kojo Mbir - Mr. Kojo Mensah-Abrampa - Mr. Kwame Opoku - Ms. Dora Owusu - Ms. Petrina Owusu Yeboah Administrative Officer - Mrs Salome Ahenkora  * Abstract The Ghana Participatory Poverty Assessment was conducted over three phases in fifteen communities by mixed teams of academic researchers, government staff and personnel of NGOs. Key findings on the local experience of poverty included the following: the main elements in defining the poorest members of communities were disability, age combined with the lack of adult children, widowhood and childlessness; the incidence and depth of poverty is greatest in the rural north; assets at the community level (such as access to water for domestic and productive use, access to services and natural resources) are seen as more important to rural communities than urban; gender dimensions are critical to understanding poverty - this emerged primarily through the finding that there are substantial elements of separation to men's and women's livelihood in much of urban and rural Ghana. The concept of vulnerability captures many dimension of the experience of deprivation in rural Ghana. Seasonal vulnerability is particularly strong in the rural north (especially the Upper Regions), manifested in chronic food insecurity often affecting whole communities. Views of long-term trends in rural communities focused on environmental issues such as declining access and quality of water, declining soil fertility and declining common property resources for the vulnerable to fall back on in times of crisis. Key long-term trends identified by the urban poor related to the evolution of policy frameworks in the era of adjustment. While a considerable improvement is seen as having occurred in the early phase of economic reform (1983 to 1988) there is a general perception that opportunities for the urban poor have been becoming more constrained in the last six to seven years. The investigation of the conmunities' own assessment of their priority needs was a consistent theme in the research. The strongest elements emerging from the priority rankings in the rural north were food security, water (both for domestic and productive use), access to health care, and education. The picture that emerged from priority rankings in the rural south was more diverse. Again, access to curative healthcare emerged as a strong and consistent priority, while improvements in transport infrastructure (roads and bridges) was also a strong theme - reflecting problems in accessing both markets and services. Other common themes included access to credit, off-farm employment and water for domestic use. The most consistent concerns in priority rankings in urban communities were with inadequate employment opportunities and the supply of small-enterprise credit. The condition of the urban infrastructure was also a major issue - with supply of water again a strong theme. Investigation of the barriers the poor face in accessing healthcare services highlighted the following issues: cost barriers are a major issue in accessing formal healthcare, both in terms of overall cost and the lack of flexibility in rescheduling treatments. Furthermore, provisions for exempting the poor from user charges are not working. In education, the major concern of most community members and teachers canvassed was with issues of quality rather than of basic access. Major concerns included: poor quality of teaching and facilities; lack of supervision of teachers; lack of clear feedback to parents on childrens' performance; the policy of retrenchment of untrained teachers leading to shortages of teachers in isolated rural communities.   CONTENTS Executive Summary and Key Policy Findings 1. Introduction 1.1 Background of the Study 1.2 Methodology 1.3 Field Sites 2. Main Findings 2.1 Local Conceptions of Poverty 2.2 Priorities of the Poor in Poverty Reduction 2.2.1 Strategies for Moving out of Poverty 2.3 Vulnerability: Dynamic Dimensions of Poverty 2.3.1 Seasonal Dimensions of Poverty 2.3.2 Long-Term Trends in Poverty 2.4 Survival Strategies and 'Safety Nets' 2.4.1 Survival and Coping Strategies 2.4.2 Formal and Informal Safety Nets 2.5 Perceptions of Service Quality and Access in the Health Sector 2.6 Perceptions of Service Quality and Access in the Education Sector 2.6.1 Access and Utilization 2.6.2 Local Views of Education Quality 2.6.3 Perceived Relevance of Education 2.7 Domestic Water and Sanitation   Executive Summary and Key Policy Messages The Ghana Participatory Poverty Assessment was conducted over three phases, and a total of fifteen communities were involved, selected to give a representative picture of the living conditions of the poor in Ghana. In particular, care was taken to represent adequately the rural and urban dimensions of poverty, as well as the different regions, major livelihood groups and agro-ecological zones in the country. The overall objective of the study was to contribute to social policy formulation in Ghana through expanding understanding of the processes that produce and reproduce poverty in different environments and among different social groups. Special emphasis was given in the third phase of the study to understanding the poor's experience and understanding of the constraints they face in terms of access and quality of delivery of key social services. The main conclusions of the study are as follows. T'he experience and understanding of poven'y The nature of poverty in Ghana. In all communities the local experience and understanding of poverty and vulnerability was examined. In broad terms our conclusions support those of the quantitative analysis of the GLSS within the Extended Poverty Study by emphasizing that the incidence and depth of poverty is greatest in the rural north. This emerged through both the extent to which poverty was judged to be prevalent throughout the whole of communities (even in local terms) and the criteria which were used to define that poverty. In the rural north the predominant feature of poverty was a general crisis of livelihoods in terms of the lack of remotely adequate basic foodstuffs to feed the household for all or part of the year. A summary of the local conceptions of poverty and vulnerability leads to the following key messages: In all sites there were consistent elements in defining 'the poorest of the poor', which focused on the intersection of a variety of conditions which lead to households which have no labor resources, and individuals who have no control over labor resources of any kind. The key elements were disability, age combined with the lack of adult children, widowhood and childlessness. Female household headship was more likely to appear as an indicator of poverty in the rural north than the rural south or urban contexts. While female headship as such is not related in a simple sense to poverty the combination for women of age, widowhood and lack of adult children was frequently seen as associated with chronic vulnerability. * Assets at the community level were seen as more important to rural communities than urban - these included access to water for domestic and productive use, access to public services, access to an abundant natural resource base in terms of fertile farmland and common property resources, and access to transport infrastructure, markets and extension services. i  * The view of poverty as being a dynamic condition impacting on entire communities was particularly strong in the northern rural areas, vulnerable to drought and to the 'hungry season' prior to the single main annual harvest of bulk foodstuffs. The material collected supports the view that the experience of depth of poverty and vulnerability in the rural north is greater than in other areas through the fact that access to food predominates in local views of poverty, and that in some communities serious food insecurity prevails for at least part of the year for virtually every community member. Nonetheless the material is suggestive of some variation - with highly populated areas in the Upper East (Bawku and Bongo Districts) suffering the worst conditions. * In urban areas poverty tends to be seen more as an individual condition - with key elements in defining well-being including access to stable employment, the ability to acquire marketable skills and access to seed capital (as well as the fundamental asset of physical health and strength). * As well as physical assets (livestock, capital etc.) and human assets (health, skills) an individual's social network, and membership of social institutions forms a key dimension of well-being and livelihood security. Access to land often comes through community membership rather than the market, and the accessibility of a supportive kin network is critical at times of personal crisis (urgent need for money to pay hospital bills, etc.). * Gender dimensions emerged primarily through stressing the fact that there are substantial elements of separation to men's and women's livelihoods in many sections of the rural and urban poor in Ghana. In ranking exercises in rural areas there was a tendency for men to rank men and women to rank women, rather than seeing households as unified entities. Men and women thus also stressed different elements to the experience of poverty in some communities. The results of the priority rankings. The issue of the communities' own assessment of their priority needs was a consistent theme in our research. Where possible these views were solicited through focus groups which reflected the diversity of the communities under study in terms, at least, of gender and generational issues. The major findings can be grouped into three broad regional 'blocks': the rural north (the Upper Regions and the Northern Region), the rural south (including the transition zone, forest zone and the coastal savannah - for our purposes communities in Brong Ahafo, Volta, Western and Central Regions) and urban communities (including intermediate rural towns in the Volta and Central Regions, and communities within the major urban centers of Accra, Tamale and Techiman). Priority rankings in the rural north. The strongest themes emerging from the priority ranking exercises in the rural north are food security, water (both for productive and domestic use), access to health care, and education. A particular nexus of conditions ii  affects extremely resource-poor communities in the Upper Regions (especially very densely populated areas such as Bongo and Bawku) which finds expression in the constant emphasis on the provision of dry-season water for productive as well as domestic purposes. In essence rainfed agriculture of a traditional kind has become so unproductive that the provision of a dry-season income is now essential to anything approaching a viable level of livelihoods. Dry season water supply, through wells and dams, provides for vegetable gardening which can be a highly significant support to incomes, and for pasturing animals in the vicinity of the village so that manure resources - invaluable for farming land depleted by decades of continual farming without fallow - can be utilized to a far greater extent than is possible if animals have to move to a distant dry-season transhumance site. Emphasis on domestic water supply is also strong in communities that have not benefited from external programs such as the CIDA and NORRIP community water projects. The other consistent emphasis is on healthcare provision - reflecting both poor conditions in terms of access, and the value of physical health and strength which is a consistent theme in the local views of poverty reflected from all areas. Priority rankings in the rural south. The picture emerging from priority rankings in the rural south is more diverse - reflecting the greater diversity in terms of livelihood systems and environment in this zone, as well as the tendency towards greater social stratification, and therefore intra-community diversity. In some communities, such as Butre in Western Region, food security was not a major concern even for the poor - although this was not true of all the sites (food supply was very insecure for the poorer community members in Afrangua, in Central Region). Again access to curative healthcare emerged as a strong and consistent theme - in only one community was this not listed as a priority need. Improvements in transport infrastructure (roads and bridges) emerged as a major priority in three of the five southern rural communities. This reflects to some extent the ecological conditions of much of southern Ghana, where heavier and more persistent rainfall can in extreme cases lead to communities becoming totally isolated for periods of the year. In addition to denying access to services, poor quality access roads are frequently seen as impacting negatively on the economic opportunities available. Difficulties of road access are a major disadvantage in relation to highly perishable products such as tomatoes. Access to water for domestic use again emerged as a major theme, especially in the village of Butre in Western Region. In communities where water did not feature as a priority in ranking exercises this could often be traced to an intervention by an outside agency. Other common themes included access to off-farm employment and credit for farming (predominantly men) and trading activities (predominantly women). Better sanitation and drainage emerged as themes in three of the five communities. In general the emphasis on education was lower than in the north - though in large measure this is probably because the situation in terms of provision was better (all of these communities had at least one primary school, and two - Derma and Dekpor Horme, also had Junior Secondary Schools). For those communities which did not have Junior iii  Secondary Schools, the distances to travel to such facilities were usually less than in the north. Priority rankings in the urban communities. In the six urban communities differentiation in perceived needs was marked - even in some cases between different sections of the town which experienced different kinds of problems in relation to urban services. The most consistent concerns, reflecting the nature of urban livelihoods were with inadequate employment opportunities and the supply of small-enterprise credit. Although these elements were very consistently scored they were rarely the first priority. An exception was Sekondi - which has seen the almost total disappearance of a once-active labor-market associated with the port and associated services. Priority rankings seemed to reflect to a large degree the condition of the local urban infrastructure. In particular it was interesting to note that three of our five communities had major problems of supply of potable water. Other issues of urban infrastructure that received emphasis in some communities were sanitation (especially in the Techiman Zongo where facilities were almost non-existent) and urban roads. The latter was only mentioned once, but in an interesting context. East Maamobi has had access roads since 1987 (provided under the World Bank Urban 1 Project). The Maamobi field team stressed that this is usually one of the first things that the participants mentioned in terms of new senrices that have come into the area. The roads are said to have brought much improvement to the area for diverse reasons. These included greatly improved physical security making journeys at night (a particularly important benefit for women) and ease of access to health facilities. Strategies for moving out of poverty. There was no uniform perception of how individuals might move out of a condition of poverty. In urban areas there was widespread despondency about the future. Informants noted that recruitment to unskilled wage-labor in government service had virtually dried up with structural adjustment policies - and unskilled wage-labor was disliked for the reasons outlined above. Therefore increasingly well-being is seen as tied to the capacity to acquire skills which can be used in a self-employed context (predominantly within the informal sector). This is said to be leading to increased competition for apprenticeship positions, and thereby increasing costs to individuals of gaining access to such training. In rural areas where there are substantial opportunities in terms of cash crop production (much of southern Ghana) access to capital for farming enterprises is continually raised as the most significant 'blockage' to individual progress. In the poorer communities of northern Ghana, the constraints at the level of the Region or community are continually raised as more significant than those at the level of the household or individual. The individual strategy most commonly used to cope with, or move out of, poverty is labor migration. The paradox here is that in migrating substantial numbers of residents of poor communities end up by severing their ties with the sender community, thus eventually ending transfers to ltheir kin group. In northern Ghana the accumulation of livestock was often seen as an important strategy for moving out of poverty. Apart from the inherent productive value of livestock rearing, the manure provided for the iv  farm is critical to households' farm production (especially under conditions of land scarcity). Rural communities saw far more opportunities for action at the level of the community to increase livelihood security than their counterparts in the urban sector. In urban communities only the occupational associations to which many in the informal sector belong were mentioned in this context. Although local leaderships exist in urban areas they seem to be commonly viewed as distant from the concerns of the poor. Rural communities showed considerable enthusiasm for mobilization to support the provision of social and economic infrastructure, taking the form of assistance with construction and maintenance of facilities such as schools and clinics, as well as more unusual initiatives such as a desire to establish a grain bank in a food-insecure community in the Upper East Region. It is notable that, although northern communities had much the same analysis of the importance of social infrastructure their ability to provide cash to support such construction projects was very highly constrained - while contributions in terms of labor could be mobilized at the same level as the south. Service provision systems that rely to a substantial extent on the capacity of local communities to generate cash will thus lead to equity problems in terms of access. The views of appropriate action to support poverty reduction initiatives which could be taken by government and NGOs reflected to a large degree the priorities listed above. In the rural south and in urban areas provision of improved employment opportunities was seen as a major priority for government action - although the sense of specific details of what actions this might involve were not clear. Similarly credit emerged as a major concern both for farming and small-scale trading activities (the latter particularly for women). This is seen as an area for both government and NGO intervention. Improved access to water and quality of water supply were major issues in some of the urban communities, as was improved sanitation. To a greater degree than in rural communities, urban communities tend to see domestic water and sanitation as appropriate areas for government intervention. In rural areas of the south there was a strong concern in some communities with the condition of the road infrastructure . The improvement of road infrastructure was generally seen as an area suitable for collaboration between community level institutions (mobilizing labor and maintenance funds) and outside agencies, particularly local government (provision of capital, equipment and possibly food-for-work incentives). Partnerships with government ministries were seen as the appropriate means for increasing access to basic health and education services. There is still a tendency to see the community's role in terms of contributing labour (and sometimes materials) to the construction and maintenance of physical infrastructure. In the rural north the view of appropriate support from outside agencies reflected the issues of water supply, food security and service delivery outlined above. In some cases there was a distinction between the kinds of assistance that government and NGOs should best provide (with NGOs seen as having an advantage generally where extensive capacity building support to local institutions is required, e.g. managing a cereal bank). v  Vulnerability. Poor peoples' conceptions of poverty often correspond closely to the notion of vulnerability - a dynamic notion which captures the sense of threat posed by the negative effects of various forms of change over time, whether in the form of seasonal variation, long-term trends, or various kinds of shock. Seasonality and poverty. Seasonal fluctuations were a major aspect of well-being in all research sites. In addition to the well-documented phenomena of stress points in the agricultural cycle, which takes its most severe form in the 'hungry season' problems of many savannah communities, there are significant seasonal cycles in urban occupations related to factors such as weather (impact on building), the cycle of social activity and key festivals, and market flows related to the agricultural year. As has been noted above the major seasonal foodi security issue in Ghana is the extreme 'hunger season' experienced by many communities in the north - especially those where intense population pressure has led to declining soil fertility (for example, Komaka, Beo Tanko and Sombo in our sample). These communities experience major problems of basic food supply even in a normal year - and the impact of drought years can be extreme. As a general rule, the more diverse the farming system, in terms of the mix of basic staples and crops grown to generate income, the less was the degree of vulnerability to seasonal food scarcity. On top of that cassava, as a crop which can be available for harvesting all year round, often plays a special role in mitigating vulnerability. Where there are marked seasonal changes such as in the north, seasonal patterns of illness have been observed. Ill-health is said to be most prevalent at the peak of the dry season in February and March, by which time the food situation has started to worsen. Fevers, stomach disorders and respiratory diseases were described as the most common at this time. By experience the most dangerous time to fall sick is during the rainy season when there is very limited food supply, and no money to go to the hospital. It is also the time when people need their energy most to work on their farms. Worse still, increased poverty during the lean season makes it difficult for the family to respond adequately when someone falls sick at this time. In the middle and coastal belt double maxima rainfall areas of communities such as Butre, Kpando Gabi, Derma and Dekpor Horme, there is apparently little differentiation in the seasonal occurrence of sickness. Cholera and diarrhoea seem to peak during the 'time of mangoes' in the minor rainy season, but other diseases occur all-year round. Long-term trends. Views of trends in rural communities tend to focus on environmental issues such as declining access and quality of water, declining soil fertility and declining common property resources for the vulnerable to fall back on in times of crisis. The view of the urban poor relates in more detail to the evolution of policy frameworks in the era of adjustment. While a considerable improvement is appreciated to have occurred in the early phase of economic reform (from 1983 to 1988) there is a general perception that opportunities for the urban poor have been becoming more constrained in the period since the last six to seven years. In part this is attributed to increased 'crowding' of the informal sector due to both low levels of demand and increasing numbers of people trying to survive in this sector. The increase vi  is variously attributed to retrenchees searching for new livelihoods and Ghanaians returning to the country from other parts of West Africa as a result, in part, of improvements in the general climate in Ghana, and varying kinds of problems affecting other countries (recession, conflict). In all communities there is some concern over what is perceived to be a very poor situation in relation to assistance with credit for trading and productive activities. In the urban areas this is perceived as a declining trend whereas in some rural areas this seems to be perceived more as a continuation of an unsatisfactory situation. The list of aspects of decline in environmental conditions in rural areas included: water access (declining levels of the water table, decreasing quantity, quality and duration of stream flow); availability and quality (fertility) of farm land and pasture for animals; access to a range of products from common property areas, for both own consumption and sale for income (including fuelwood, medicines, foraged foodstuffs such as snails, fruits, mushrooms, bushmeat, and other non-timber forest produce). In the northern savannah communities the key elements of environmental change were perceived to be declining soil fertility due to decreasing fallow periods, declining water resources as outlined above and a shortening of the rainy season, combined with less predictability. In the relatively more agriculturally abundant communities of the middle and coastal belt, important changes have taken place in crop mixes in response to environmental degradation, as well as market demands. The drought and accompanying bush-fires of 1983 were noted in many communities as a 'watershed' point following which there were long-term changes in the local ecology. Another long-term trend which was highlighted in some areas was a tendency to weakening of the bonds of local social institutions of kinship and community. In Nyingare in the Northern Region, for example, focus groups among women revealed a perception that ten years ago there was strong social cohesion in the village. Communal labor institutions were still strong (and acting as a safety net for households experiencing problems in terms of labor due to sickness or disability), respect and authority was still given to the chief and his elders, community solidarity was still expressed through mutual support and assistance for one another. Decline in the traditional institutional framework for such reciprocal arrangements was a fear expressed in other sites in the north associated with increasing levels of temporary and long-term labour migration. Such changes clearly create increased vulnerability for the poorer sections of such communities, by weakening their 'social assets' in terms of networks of kinship and community through which they could mobilise claims on food and labour from their neighbours. In one urban site - which had been affected by the recent ethnic conflict in the north - fear was expressed that Ghana's evolving democratic system could also foment social disintegration. Survival and Coping Strategies. The coping strategies we recorded in the course of the three phases were very diverse. Some of the more common elements included: vii  * For the rural north: Out-migration in search of employment; sending children to stay with kin in times of stress; using 'famine foods' gathered from the bush. * For the rural south: Reducing expenditures (taking children out of school); changes in conjugal patterns (contracting informal unions due to inability of young men to make bridewealth payments). * For the urban south: Reducing expenditures, including relying increasingly on cooked food sellers, withdrawing children from school; diversifying income sources An important point to note on coping strategies, is that different coping strategies at the individual level are not available equally to all categories of the population. For example, market-based fallback mechanisms such as migration from the rural north are more readily available to young men than to many women, children or the elderly (although there is evidence of increasing female migration). The removal of the young man may even have negative effects for the livelihoods of those left behind (depending on the level of transfers received). Where a common 'fallback' mechanism appears to have negative consequences for more vulnerable sections of the population consideration needs to be given to possible alternatives. For example, over the last fifteen years some areas of the Upper East Region have diversified with considerable success into vegetable farming as a dry-season activity, providing an alternative source of income which may firstly, reduce male out-migration, and secondly, provide income on a broader basis within the community. Provision of dry-season water sources to support this kind of activity was the main priority need emerging from the rural communities in the Upper Regions. Assistance of this kind may strengthen community- based fallback mechanisms (local 'safety-nets') through encouraging community solidarity and cohesion. By all accounts many of the long-standing coping strategies that are known in resource- poor communities are becoming less accessible for combating stress periods. This is explained by the fact that most of these strategies are themselves under threat because of worsening ecological conditions and the escalating cost of living. The situation appears to be more grave in northern Ghana, where in communities such as Beo Tanko the consumption of wild foods forms a regular part of strategies of dry-season survival, though one should not under-estimate the looming deprivation in other parts of the country. Fonnal and infonnal 'safety nets". The capacity to help disadvantaged kin or community members was frequently listed as an attribute of the non-poor in our study. At the same time there was a general sense in many communities that community or kin-based systems of mutual aid were becoming weaker (as descnbed under trends in social cohesion above). One area where assistance from kdn was consistently cited as critical was in accessing social services - particularly emergency healthcare. External sources provided valuable but relatively rare assistance in many of the field sites. Best placed were those communities Vi.  with an ongoing NGO program. Governmental safety nets were not mentioned by any informants as being in any way relevant for the poorest members of these communities. Perceptions of access and qualit in healthcare Many small rural communities in Ghana have very low levels of access to modern health facilities. Despite the already low level of coverage, there are situations in which health services have been closed down or withdrawn in the case of mobile services. Where mobile services exist their effectiveness is frequently undermined by problems of lack of punctuality, and the charging of informal, extra-legal fees. As a result people in the rural communities rely extensively on traditional health providers such as traditional birth attendants (TBAs), herbalist/bone-setters, fetish priests drug peddlers and spiritualists. Close proximity to modern health facilities in the urban centres has considerably reduced dependence on these informal sources, though there are certain categories of illness that people prefer to take to a traditional healer. Examples were given of situations in which relatives had withdrawn their patients from hospital to be taken to traditional healers. Everywhere the selection of a health care provider is contingent upon many factors, and as a result visits to a health facility tend to follow a sequence. A visit normally starts with the most accessible and the least expensive of the facilities available, though other considerations such as type of illness rather than cost and convenience may influence the sequence. Sequencing of visits to the health care facility commonly takes the following form. Many people depend on home remedies or visits to the herbalist as the first step in the treatment of illness. When it becomes critical they will proceed to the doctor or the spiritualist / fetish priest, depending on the local classification of the illness. Under current conditions of hunger, the willingness and ability of poor people to spend on amenities such as orthodox healthcare is low. In all three regions studied, high user costs are resulting in the exclusion of the poor from utilization of hospital services. The public medical system -- laden with accessibility constraints, extralegal charges and often requiring high financial outlays for transport -- is widely perceived as expensive. Predictably, hospital consultations fall significantly in the "lean season", even though disease tends to be more endemic then, especially among children. In some of the government hospitals (one in particular) there appeared to be a situation of complete chaos in relation to charges for healthcare. Official staff appeared unable to give consistent figures for charges for the most basic services. Furthermore, unofficial rents were charged for a wide range of small services. There were generally positive perceptions of all healthcare providers who lived in the community. Services provided from healthcare personnel outside of their official roles (as friends, neighbors, kin or community members) were in cases more appreciated than the official facilities they worked in. In the sites where community health workers had been trained the services was perceived positively. The diagnostic services of drug ix  store chemists were highly valued. Chemists were generally perceived as "doctors" and therefore, implicitly, as giving higher status and more reliable advice and treatment than nurses - perceptions which contribute to the dangers of self medication. Provisions for cost exemption for the poor generally do not work. Exemption provisions were found to be much more effective when executed by ailment rather than by direct means testing (i.e. for the poor). Indeed, the latter is proving costly in administrative resources -- money as well as staff time. Only in the mission and charity hospitals is exemption by means found to be working reasonably well; but even then, with high hidden costs. Sometimes, the assistance of the Department of Social Welfare has to be solicited, and transport facilities provided to enable applicants' circumstances to be investigated. This system is slow and bureaucratic - furthermore, once someone has been identified as poor they generally still do not get treated as there is no provision for resources to assist them. In terms of barriers to access to formal healthcare it was noted in all our northern communities that even the wealthy do not generally store their resources in the form of cash. Therefore finding funding for an emergency treatment is not just a problem for the poor - it applies to everyone in such communities. Generally speaking it takes some days to arrange for the sale of an animal (generally the means by which cash is raised). Under these conditions, it is not surprising thatflexibility in accepting deferred payment was often more valued as an attribute of a service provider than the simple level of cost. The main groups affected by retrenchment in the health sector have been the less skilled personnel -- drivers, cleaners, orderlies and similar categories. The most obvious consequence of their retrenchment has been the adverse impact on hospital cleaning services. It must be said, though, that while the situation may have been worsened by the recent retrenchment of lower status personnel, public hospitals in Ghana have had a long history of problems with efficient cleaning. Apart from its inimical effect on cleaning operations, another outcome of the policy of retrenching auxiliary nurses has been to entrench pre-existing staff shortages. Throughout the country, relatives of in- patients are having to stay on the wards to help look after their sick kin. Previously, auxiliaries would have been available to perform this function. At one site, where major losses have been incurred through the retrenchment of auxiliary nurses, necessary cuts are having to be made to the size of outreach teams. Access to outreach services. The mobile health services introduced under the PHC portfolio have' had modest success in reaching remote areas. However, according to our research the achievements in respect of coverage are somewhat offset by the fact that public outreach teams have tended to be rather unreliable with keeping dates and times. Not uncommonly, they arrive a day or more late, when villagers are not expecting them and have leit for their farms. The principal factor constraining outreach visits to peripheral sites was reported to be financial, in particular budgetary cutbacks resulting in reduced transport allocations and fuel rations. The reduction in x  auxiliary nurse numbers has also imposed strains on the capacity of some health administrations to release professionally qualified nurses for outreach work. On occasion, we found outreach teams levying unofficial charges ostensibly to offset their transport expenses and to purchase necessary consumables for treatment and nutritional demonstrations. These kinds of informal charges are, of course, not subject to any form of exemption for the poor - and consequently essential public health services (such as vaccinations) are being priced in some instances beyond the reach of the poor. Perceptions of access and quality in education Factors impeding access to basic education services: * At the community level very poor condition of school buildings (rural communities); disincentives to continuing education due to lack of Senior Secondary School facilities in rural areas (the cost of boarding fees puts secondary education way beyond the reach of the children of the poor). In urban communities parents have a greater range of options and are not constrained to the same degree by the availability of schools within the community area. * At the household level lack of resources to purchase equipment and school fees. Costs of schooling are perceived as having risen rapidly in comparison to capacity to pay. Heavy costs are borne in the first year of JSS due to requirements of households to purchase equipment for students (uniform, table and chair, math sets, technical drawing board), and in the last year due to costs of registration for exams. These costs outweigh that of the official school fees. Rising real costs combine with poverty to keep significant numbers of children out of school, often as drop-outs. Cost barriers also remain significant in relation to education for access to primary schooling. A major component of this is rising PTA fees in line with increasing community responsibility for maintenance of structures etc. The rising costs are more dramatic in relation to the north - as the ending of the policy of free schooling in the early 80s has meant that the rise in costs is steeper there. The bulk of the costs are not composed of formal school fees, however, as with JSS. At all levels in certain households the main perceived cost of education was the opportunity cost of losing the child's labor for domestic and productive purposes. * No evidence was found of any provision for cost exemption for the poor in education. Sympathetic headmasters frequently allow children to attend for some time without paying fees, but headteachers are accountable in the end for collecting fees for all pupils and are not empowered to make exemptions. This runs counter to an assertion the Minister of Education made in a widely broadcast speech that children should not be expelled from school for non-payment of fees. Some NGOs xi  fund the costs of school fees for the poor (the largest to do this for its project sites is World Vision International). * Evidence was found (especially in secondary schools) of schools being forced to tolerate increased levels of absenteeism as many children have to earn the money for their school fees. * The classic pattern of a drop in the ratio of girls to boys between primary and JSS was observed. Some informants felt that the high costs of JSS were a factor in discouraging female attendance. Some informants also drew the classic conclusion of low female school attendance contributing to higher incidence of teenage pregnancy, the contracting of socially inappropriate unions and therefore initiating cycles of poverty. Local perceptions of the quality of education services. The major concern of most community members and teachers canvassed in our study (especially the third phase) was with issues of quality rather than of basic access. The mushrooming of rural schools (through community initiative, particularly under the ongoing reforms) has meant that educational resources have had to be spread quite thin. Thus, while schools may be more accessible (in terms of proximity; not costs), rural communities tend to have so few teachers per school as to render the quality and value of education in such schools questionable. In terms of the quality of education the following main messages emerged from the research: * Consistent with the findings of the second round of the Ghana Living Standards Survey, the quality of education was found to be perceived as low across the sites studied - in the views of both community members and service providers. Sharing of furniture built for individual pupils is common. Many children are doing piecework or helping on their parents farms and pastures after school, leaving them exhausted and with no time for their homework. * In some sites supervision of teachers was a major concem - especially with respect to children being made to work on teachers' farms during class hours. Another concem (particularly in urban areas) was that teachers put all their efforts into 'private' lessons for children who stay behind after the formal class is over. The single greatest factor that seemed to determine the efficiency of the system of teacher supervision was the availability of transportation allowances for schools' inspectors. * Parents complained that under the new (post reforms) system feedback on the performance of children in class was confusing (this appears to be related to the fact that the overall class position of the child is no longer reported - which is the easiest thing for an illiterate parent to understand). Thus the poor performance of their xii  children at examinations frequently comes as a shock - and the parents' help is not enlisted in encouraging the child to perform better. The policy of retrenchment of untrained teachers is leading to a shortage of teachers in isolated rural communities. Our research suggests that trained teachers are often unwilling to take up rural postings, especially in isolated areas. There may also be unfortunate results in terms of the gender balance of the teacher force - the majority of untrained teachers are women. In terms of the perceived relevance of education the following main messages emerged from the research: * The criteria by which local communities defined the 'relevance' of the education service were based on two factors: the ability of children to get jobs, the ability of children to read and write in English (so that illiterate parents no longer have to go elsewhere to get letters read and written, compromising the privacy of the family, and children can perform basic tasks like identifying the correct hospital card for family members etc.). In only one community was literacy mentioned in relation to learning improved techniques in traditional occupations - in relation to farming in the Mamprusi village in the Northern Region. In relation to these criteria education (at the level to which it is pursued by the poor - generally no higher than JSS) is perceived to be failing. People consistently said that their children could not read and write at the end of school. In relation to this parents and teachers in some sites argued that the new educational curriculum was too broad - with insufficient time and attention paid to basic literacy. - Regarding the match between user aspirations and the revised curriculum for first- cycle (ISS) schools, our findings indicate that the reforms are not fulfilling the purpose for which they were designed. In both rural and urban areas, the implementation of the technical training component, king-pin in the educational reform program, is largely perceived as unsatisfactory. In case after case -- in schools, communities and in GES offices -- informants alluded to the lack of tools, working materials, workshop buildings and trained teachers. This situation, a serious impediment to effective skills training in the JSSs, has arisen mainly because, in the current cost-sharing framework, communities are not only responsible for financing capital requirements and school furniture, but also for providing tools and other inputs needed for the program. Consistently, therefore, the skills training objective is being undermined by the high incidence of poverty. There is also a clear regional dimension to this, with our research suggesting that communities in the poorer areas of the country (in this case specifically the sites in our sample in northern Ghana) are less able to meet these extra responsibilities than those elsewhere. Lack of skilled craft teachers is also a major constraint in all the rural areas in our study. The technical training component was consistently described as the weakest link in the JSS agenda. xiii  In terms of the functional literacy program the research teams found that the level of availability of materials was very good. The main constraint in most communities (especially rural ones) was the lack of availability of volunteer facilitators. This was generally seen as resulting from the low level of material incentive for people to do this. The majority of participants in all sites were adult women (there was no evidence of the program picking up school-leavers who had had to abandon their education). Local perceptions of water and sanitation services Within the towns and villages studied, the availability of safe water and sanitation is often a function of NGO, or other donor presence. Many poor households rely on streams and uncovered wells of dubious purity. Except where interventions have been implemented, therefore, water quality tends to be particularly poor during the dry season when natural water sources tend to dry up. In the Northern Region in particular huge amounts of women's labor time during the dry season are expended on fetching water - affecting their potential access to employment and income-generating opportunities. Evidence from all three rounds of the PPA indicate that for communities where water supply is problematic this remains the over-riding priority - especially for women. In all low-income urban sites, we found a high level of indiscriminate defecation, largely resulting from extremely low levels of provision. Understandably, women are more concerned about the deficiencies of water and sanitation: it is they and the children who are responsible for replenishing household water supplies; and cultural norms prevent them from evacuating their bowels in open spaces. Obtaining land is a major issue in relation to some kinds of urban services. There is a particular problem with obtaining land for latrines as it lowers the value of surrounding property. It was found that while VIP latrines functioned excellently in rural communities where population density is low they were virtually impossible to maintain in densely settled urban areas at the concentrations they existed in the areas studied. It is therefore recommended that a review should be made of means by which District Assemblies can find ways of making more land available for latrines in poor urban areas - in order to decrease pressure on existing facilities, and thereby set up a virtuous where the presence of a latrine in a neighborhood is no longer regarded as a health and environmental hazard. Summaiy: key policy messages The following are the key policy issues and recommendations emerging from our work: 1. Policy implications of priorities in poor rural and urban communities. As a result of using a variety of different methods, including needs ranking exercises, and comparing results from a variety of sites the following general messages emerge from local communities: xiv  * improved livelihood security for the rural north: People perceive a general crisis of livelihoods, exacerbated by deteriorating environmental conditions. In much of the north the problems of the 'hungry season' dominate local views of poverty. Raising the productivity and improving the robustness of farming systems in fragile environments is not an easy task, but it is nonetheless one that needs revisiting through all means possible, including: provision of dry season water resources to assist livestock rearing and dry-season gardening initiatives (these are particularly valuable because income can be generated in the lean season); agricultural research and extension services which are attuned to the needs of poor farmers; improved 'safety net' provision for the poorest. Our research suggests that the endemic problems of food security in northern Ghana in particular have never received the serious attention they merit. While all communities surveyed prefer the prospect of assistance to develop the productivity and security of their livelihoods to 'safety net' kinds of assistance, the severity of problems experienced by the poor in the north suggests a need for a more robust response in terms of an ongoing institutional framework for addressing the worst affected social groups and areas. Northern communities also showed a relatively higher level of emphasis on education as a priority - which may reflect the greater importance of accessing the migrant labor market for these communities. * improved access and quality in healthcare is a priority: This was the most consistent message from all of the sites, rural and urban. Accessibility was seen in terms of both cost and non-cost barriers. The key to improved access and quality lies in a vigorous promotion of a community-based approach to both basic curative and preventive services. Detailed recommendations of healthcare are provided below. * improved transport infrastructure is a priority in rural areas: In many rural communities improving access to markets and to services such as hospital care was seen to a large extent in terms of the unreliability of physical access. This was particularly true of some of the southern communities, where access during the rains was highly restricted. * access to water for domestic consumption: Was invariably the top priority in communities experiencing particular difficulties with this. These included communities in the rural north, south, and some urban communities. This was a particularly strong priority for women, and for children - the groups which have primary responsibility for domestic water provision. Schoolchildren in Tamale listed the time spent fetching water as the single greatest problem they faced in pursuing an education. xv  access to employment opportunities, credit and skills training: Emerged as the most consistent priorities in our urban sites - along with specific concerns related to the condition of the local urban infrastructure. It should be noted that apart from the themes outlined above, which emerged with some consistency, many other priority needs reflected closely specific social and economic environments. We would recommend, firstly, that donor agencies and government consider the priorities expressed above as an input in developing poverty-focused sector programs and projects, and; secondly, that bearing in mind the locally specific nature of many of the constraints which communities perceive in seeking to improve the security and quality of their livelihoods, that the process of strengthening the local level capacity to plan and implement programs in a participatory fashion with communities through a District level planning approach should be strongly supported. 2. Regional dimensions of poverty. Our research strongly supports the findings of the quantitative Poverty Profile that the depth and extent of poverty is greatest in the rural north. This emerged principally through the consistent stress on food security as the defining feature of poverty and vulnerability in poor northern communities. We also found considerable varialion in the depth of poverty by community - with the poorest being those communities where the natural resource base has become extremely depleted as a result of high population densities. Particular dimensions of poverty which are worth noting include: the strong identification of poverty with community- level factors (access to natural resources, services etc.); the strong seasonal dimensions of poverty related to water supply and food security. 3. Gender, and the intra-household allocation of responsibilities and distribution of resources. Findings of the PPA confirm conclusions from many other studies of Ghana that men and women have substantially different bases for their livelihoods, and that there is a high separation of income streams within the household. They also confirm the common conclusion that the labor burden of women is generally much greater than that of men, restricting their access to market-based income generating opportunities. The high labor burden of women, of course has a range of other implications for their well-being, including health implications. Two main conclusions can be drawn from this: * if monitoring systems are to provide a comprehensive picture of the impact of economic reform on the poor they need to disaggregate income and consumption trends at a level below the household - trends in terms of gender cannot be 'read off' by looking at the difference between female and male-headed households. * a very wide range of priorities are suggested for sector policy, and project interventions, including: specific attention across a wide variety of fields to making available to women technologies which can lessen their labor burden (including improved year-round access to domestic water, grinding mills to lessen burdens of xvi  food preparation, improved access to travel and transportation, and technologies which lessen the labor burden of fuel collection); paying specific attention to the access of women to health and education services; paying specific attention to increasing the productivity of economic activities in which women are already involved; paying specific attention to the low level of access to women to credit and productive services (e.g. agricultural extension). 4. Access to services: implications of community roles in the provision of social infrastructure. The research found evidence to support the hypothesis that the differential capacity of communities to contribute to cost-recovery in health and education may lead to regional inequities in the provision of social infrastructure, and hence access to services. At a fundamental level, it can be assumed that, given equal population size, the capacity of communities in different areas to provide labor for 'community projects' (typically oriented towards the construction of physical structures, e.g.. clinic, schools) will be fairly similar, but the capacity to raise cash is clearly dependent on a range of other considerations, including wealth and the level of monetization of the local economy. Patterns of settlement also influence the level of relative effort that is being demanded of communities - with economies of scale for larger settlements in the provision of some social infrastructure. As has been noted above, there is a strong regional dimension to the capacity that different communities have to contribute cash to community projects such as the construction of infrastructure for education and health - broadly following the major 'fault lines' of poverty which are confirmed in Ghana by both quantitative and qualitative analysis. 5. Environmental decline and rural livelihoods. Processes of environmental degradation emerge as a major concern in all rural areas of Ghana. These have a number of different dimensions: declining water access and quality in terms of both underground and surface water resources; deteriorating soil fertility in some areas due to reduced fallow periods, increased intensity of land-use; changes in the crop mix due to environmental as well as economic factors (e.g.. the spread of swollen shoot disease for cocoa, St. Paul's wilt disease for coconut). This emphasizes the fact that the issue of accelerated growth is not necessarily the same as that of sustainable growth, in environmental or social terms. Given the importance which the predominant areas of agricultural development in recent years have for the economic future of Ghana (predominantly Western and Brong-Ahafo Regions) there must be a concern that the agricultural productivity of these regions will suffer in the long run as have the central areas of the forest zone over recent years. This will harm incomes for the poor both in the short run (in those areas) and in the long run through declining migration opportunities. 6. Access to education. The research suggests a combination of constraints in access to education which apply at both the level of the household and the level of the community (although provision at the level of the community was seen as less important in poor urban areas). These are summarized above. In terms of specific areas where action could be implemented to improve the situation we recommend: xvii  * a review of the possibility of instituting cost-exemption provisions to those areas of school expenses under the control of schools (regular and special fees, uniform requirements) * the contributions that communities are making in education through provision and maintenance of infrastructure should be recognized - as should the fact that contributions in labor are easier for poor communities to make than contributions of cash (whether at the level of the community or the individual household through school fees) * strengthening of systems of school supervision through provision of transport and traveling allowances * there is a need to develop local institutions to manage scholarship schemes - currently education beyond the JSS level is totally inaccessible to children from poor rural areas - which affects the perceived incentive to send children to school at all levels * the fact that under the new system (since the education reforms) feedback on pupil performance is complex for illiterate parents to understand should be addressed - parents need information about the progress of their children if their help is to be enlisted in encouraging their children, and not over-burdening them with productive or domestic tasks to the point where they perform ineffectively at school * guidelines should be developed to ensure that the policy of retrenchment of unqualified teachers does not remove teaching staff from poor and isolated rural communities. 7. Access, utilization and quality of healthcare. Until the real costs of consultation are reduced substantially (through improvements in fee exemption facilities and procedures, the elimination of graft and by meaningful improvements to outreach as well as regular out-patient services), poor people will continue to avoid the public medical system or postpone consulting it when ill. Especially necessary in this respect are: * awareness creation regarding legitimate costs and exemptions