Public Health Costs of Electricify Shortage:A Ghanaian Case Studv

By

Nastaran Mohammadi

CAPSTONE PROJEC'TSI.JBMII-TED IN PARTIAL FULFILLMENT OFTHE REQI.JIREMENTS FOR THE DEGREE OF'

MASTER OF PUBLIC HEALTI I

In theFaculty of Health Sciences

O Nastaran Mohammadi 2010

SIMON ITRASER I.INIVERSIl'Y

Spring 2010

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iii

ABSTRACT

Health of the population as much depends on health system infrastructure as it

does on other factors. Electricity is an important part of a community‘s infrastructure.

Although the role of electricity in people‘s lives has been continuously mentioned in

various literatures, the magnitude of its direct and indirect impacts on public health has

been mostly ignored. Electricity interruptions results in inefficient healthcare delivery

and hinders goals aimed at improving the health of the population. There is no reference

to energy in any of the eight Millennium Development Goals (MDGs); however, it has

been suggested that ―none of the MDGs can be met without major increases in the

quality and quantity of energy services in developing countries‖ (UNDP, 2004). The

purpose of this paper is to use Ghana‘s case to demonstrate that electricity is an

important determinant of health and that it should be included in the list of 150 WHO

health indicators.

Keywords: public health; energy crisis; power failure; Ghana; developing

countries; health indicator; WHO

iv

Acknowledgements

I would like to thank Dr. Michel Joffres and Dr. Tim Takaro and Dr. Steve

Corber for being such amazing, humble professors and helping me with this project. I

would also like to thank Dr. Susan L. Erikson for her invaluable comments on this paper,

for teaching me useful academic and vocational skills and also for her ongoing guidance

and mentorship over the course of my Master of Public Health degree.

I would especially like to express my gratitude to Ms. Lynn Kumpula and Ms.

Jennifer Van Rassel for their great support and constant administrative assistance

throughout my 2007-2009 studies at SFU.

1

Public Health Costs of Electricity Shortage:

A Ghanaian Case Study

INTRODUCTION TO THE PUBLIC HEALTH PROBLEM

Description of Electricity Shortage

Before proceeding with any arguments about the role of electricity in public

health and the consequences of its deficiency, it is crucial to explain what the electricity

shortage means. When discussing electricity shortage, it is important to distinguish

between complete unavailability of electricity (i.e. absence of power connection grid) in

a specific location and the power outage. A power outage—also sometimes referred to

as power cut, power failure or power loss—is a period when the electricity supply averts

from its norm (MacMillan Dictionary, 2009). A power outage may take one of three

forms: 1) Where power is lost completely, this is called blackout; 2) Where the voltage

level is below the normal minimum level specified for the system, this is called

brownout; and 3) Where the loss of power is only momentary (i.e. milliseconds to

seconds), this is called dropout (Energy Business Reports, 2009).

General Role of Electricity in Health

The functioning of the health system and the health of the population is

influenced by numerous factors. Electricity is one of these factors. Sustainable

production, supply and distribution of electricity is essential for both short- and long-

term health benefits of the population. The essentiality of electricity in the health sector

2

has been pointed out in many studies, each focusing on a different aspect of electricity‘s

role in health. In 2003, Houweling et al argued that local inequities in the availability of

electricity are associated with disparities in access to and quality of health care services.

They added that in some countries health disparities, as a result of electricity, accounts

for some of the regional disparities in wealth and health (Houweling et a, 2003).

For many people around the world, hospitals and clinics serve as the primary

source of health care. The accessibility to and the quality of service provided in those

settings are important determinants of general perception of quality of health care in a

community. Consistent electricity supply is greatly needed for effective delivery of

services in hospitals and other health centers. Illumination, refrigeration and storage,

sterilization, running water and proper sanitation amenities, scanning, patient monitoring

and many other services which are carried out in healthcare facilities by medical

equipments and health workers require electricity. In addition, prolonged shortages lead

to immediate costs to the health care at hospitals, emergency rooms, laboratories, etc

(Costantini and Gracceva, 2004). For instance, power cuts may cause disruptions or

delays in emergency surgeries and emergency medical-service calls; it could also lead to

loss of medicines, organs and blood due to reduced refrigerating capacity (Costantini and

Gracceva, 2004).

The cold chain system in healthcare infrastructure is crucial for effective delivery

of services in hospitals and other health facilities. ―In order to retain their effectiveness,

most vaccines require continuous and reliable refrigeration‖ (Agénor, 2008). Many

3

studies have investigated the direct and applied effects of fluctuation in power supply on

the quality of vaccines. Furthermore, electricity can greatly influence the food industry

by affecting its supply chain. In tropical places, prolonged electricity blackout may

provide favorable condition for microbial growth in different sectors of the supply chain

system such as the processors, wholesalers, retailers, consumers or others (Ruteri and

Xu, 2009).

The abilities of doctors, nurses, and other healthcare workers to work efficiently

depend on the availability of and access to many resources, one of which is electricity.

Power failure in any of its form (blackout, brownout, or dropout) is a barrier to quality

care at hospitals. A 2008 study by the Center for Reproductive Rights pointed out that in

Nigeria power cuts happen frequently and cause serious problems at health centres.

―When a health centre is unable to purchase or maintain a generator, medical personnel

are stretched to the limits of their skills‖ (Center for Reproductive Rights, 2008). Access

to sustainable electricity supply has also been linked to encouragement of physicians and

other healthcare workers to live and practice in villages (Chaudbury and Hammer, 2003).

Living conditions and the quality of health care facilities greatly influence doctors‘

decision to practice in rural areas and as well as their retention (Umer et al, 2004).

Therefore, shortage of electricity, which affects both living conditions and quality of

health services, is one contributing factor to shortage of human resources in rural areas,

which is one of the biggest challenges of the health system regarding rural health care.

4

Information and communication technologies (ICTs) is another area that is

remarkably impacted by power failure. ICT refers to a range of technologies that are

aimed for knowledge transfer (Roberts, 2000). Telecommunication tools such as

television, radio, computer/laptop, mobile phones, internet and others are examples of

such technologies. ICT tools can be used for variety of purposes such as finding,

analyzing, storing, exchanging, and presenting information or data (Roberts, 2000). It is

important to realize that ICTs influence public health. At the World Summit on the

Information Society in Tunis in 2005, Kofi Annan said, ―To achieve the MDGs, we must

harness the potential of ICTs‖ (http://www.itu.int/wsis/tunis/newsroom/background/ict-mdg.html).

Leaders of the Summit suggested, through various examples, that access to ICTs would

improve the agriculture and education sectors; it would help micro-businesses; it would

promote gender equality; and it would help combat both communicable and non-

communicable diseases such as AIDS, influenza, diabetes, and emerging diseases via

spreading vital public health information (http://www.itu.int/wsis/tunis/newsroom/background/ict-

mdg.html). ICTs rely on power to function; therefore power unavailability or failure in

communities would not allow the citizens to benefit from such advantages of ICTs.

Ghana’s Case Study

Ghana‘s energy crisis, in terms of both power unavailability and failure, has had

devastating effects on the lives of the people in this country. In spring 2007, I was a

witness to a tragedy that happened at the labour ward of the Police Hospital in Accra,

Ghana. A distressed premature newly-born baby that I had just helped deliver died in

the incubator shortly after the power outage at the hospital. The failure of the backup

5

generators to produce electricity was to blame for the sudden death of that fragile baby,

who was in constant need of oxygen, warm temperature, intravenous nutrition, and

cardiac function monitoring.

While this is only one example of mortality in the labour ward, other hospital

mortalities have also been reported as the result of the blackouts. ―There have been

times when the surgeon had to postpone surgeries due to power outage. It is also

possible that lights go off suddenly during an operation; in that case, we use flashlights

to see, and we just try to be as quick as we can‖, said Dr. Zakariya, a surgeon at the

Police Hospital. At the Tamale Hospital in Ghana, the situation is no better. There are

no standby-generators for major and minor emergency surgeries (Gunu, 2008). At

Tamale Hospital sometimes the power goes off in the middle of a surgery without prior

notice. ―One doctor in the hospital testified that he had performed emergency surgery on

a woman using the light from his cell phone when the lights suddenly went off……

Well-trained and qualified health workers are scared to be posted or re-assigned to this

hospital.‖ (Gunu, 2008).

The unavailability of electricity in certain regions in Ghana, particularly in

remote areas, has resulted in distancing of health facilities thus putting the health of the

population in those regions at risk. On one hand, some rural villages in Ghana have no

health centers at all due to unavailability of electricity (i.e. no health clinics are built

because of bad infrastructure). On the other hand, the unexpected power failures in

existing hospitals in Ghana lead to low quality of health care delivery in those hospitals.

6

Mortality and morbidity prevalence at hospitals, lack of motivation of healthcare

personnel to work in rural areas due to frequent power failures, and unavailability of

electricity in some regions are all grave reasons for examining the major problem with

Ghana‘s electric power.

CRITICAL REVIEW OF RELEVANT LITERATURE

Scope of the Problem of Electricity shortage:

Africa is a resource-rich place with great potential for energy production;

however, both energy production and consumption in this continent is very low

compared to the rest of the world (Karekezi and Kimani, 2002). According to 2000

data, the average per capita electricity consumption for Sub-Saharan Africa (excluding

South Africa) was approximately 5% of the world average (Wolde-Rufael, 2006). With

the growing economy and change of lifestyle, the world electricity per capita

consumption has been rising gradually over the past few decades, unlike Sub-Saharan

Africa where per capital electricity consumption has been stagnant (Wolde-Rufael,

2006). Africa has the lowest electrification rate in the world, as only 23% of its

population is electrified as compared to the world average of 73% (IEA, 2002). More

than 500 million Africans still have no access to electricity, and most of them live in

rural areas (Wolde-Rufael, 2006). Those who have access to electricity are mostly high-

income households and commercial or industrial enterprises, while the electrification of

the rural and urban poor is inadequate or non-existent (Karekezi, 2002).

7

Disparities in electricity consumption are seen not just between countries, they

are visible within countries as well (Wolde-Rufael, 2006). For instance, in Ghana 62%

of the urban population has access to electricity while only 4% of the rural population

has access to electricity (Saghir, 2002). The latest data from the World Bank shows that

in Ghana 91% of rural households use firewood for cooking, 7% use charcoal, 1% use

gas/kerosene, and 0.1% use electricity (World Bank, 2000). This illustrates that the

power utilities in Ghana have failed to provide adequate levels of electricity services to

the majority of the population, especially to rural communities. Electricity supply has

been frequently referred to as a ―major source of betterment of the standard of living‖

(Wolde-Rufael, 2006); improving the health and educational standards of the poor are

examples of benefits of electricity use (IEA, 2002).

The effect of electricity on public health has not been given enough attention. It

is important that local, national and international communities do not overlook energy

deficiencies while addressing the health system performance and public health issues.

The purpose of this paper is to illustrate the importance of electricity in determining the

health of the population and to regard it as a health indicator. Electricity should not just

be an indicator of community or individual wealth as suggested by Houweling et al in

2003; it must become one of WHO‘s health indicators as it largely contributes to

predicting the performance of the health system. We analyze this further by focusing

more on the public health outcome of electricity shortage in the health system. In the

following section, the role of electricity in public health will be discussed within the

framework of the Millennium Development Goals.

8

Electricity and the Millennium Development Goals

The Millennium Development Goals (MDGs) are eight international development

goals that have been agreed to by all UN member states and the world‘s leading

development institutions, setting out a series of time-bound targets with a deadline of

2015. The eight goals include (http://www.un.org/millenniumgoals/bkgd.shtml):

1) Eradicate extreme poverty and hunger

2) Achieve universal primary education

3) Promote gender equality and empower women

4) Reduce child mortality

5) Improve maternal health

6) Combat HIV/AIDS, malaria, and other diseases

7) Ensure environmental sustainability

8) Develop a global partnership for development

Not all countries are moving towards tangible progress; some countries have

achieved more than others, while some are getting farther from these goals (MDG

Monitor, 2009). For example, countries like China, Rwanda, Brazil, and Ethiopia are

very likely to achieve most of the MDGS, yet countries such as Swaziland, Zimbabwe,

Haiti, Democratic Republic of Congo, and Chad are still struggling with adjusting their

programmes towards the right direction (MDG Monitor, 2009). Ghana is labeled as ‗off

track‘ when it comes to goal number 3, 4, 5, and 6 (MDG Monitor, 2009); yet it is

suggested that it is possible that Ghana could achieve goal targets 2, 7 and 8 only if

certain changes are made (MDG Monitor, 2009). Since the MDGs have been originated

by rich countries—where there is relatively no problem of electricity shortage—

electricity has been assumed and taken for granted in the reaching of the goals (Susan

Erikson, 2009). ―Although there is no MDG specifically on energy, none of the MDGs

can be met without major increases in the quality and quantity of energy services in

9

developing countries‖ (UNDP, 2004). The role of sustainable electricity supply in

facilitating the achievement of the MDGs as well as the public health costs of electricity

inaccessibility/interruptions will be discussed below.

Infant and Under-Five Mortality

Newborn deaths due to electricity cut offs have been reported by a number of

Health Ministries (UNICEF, 2008). Newborn premature babies need to be provided

with special facilities, most of which require electricity for functioning. Incidents such

as that in the Ghanaian hospital could happen anywhere in the world. In his 1991 study

in Nepal, Pant suggested that modern energy sources, such as electricity, could reduce

child mortality and morbidity by as much as 40% (Pant, 1991).

Empirical findings from demographic and health surveys from over 60 Low-

Income Countries conducted by Limin Wang in 2003 showed that infant and under-five

mortality is highly correlated with access to electricity in both urban and rural areas. It

was found that in urban areas, access to electricity as well as asset index and health

expenditure share in GDP all had statistically significant impact on IMR (Wang, 2003).

Other variables which are usually expected to be key determinants of health, such as

female education, access to safe water, access to sanitation, and vaccination coverage,

were found to be statistically insignificant, either individually or jointly (Wang, 2003).

Findings were somehow different for rural areas in that none of the included variables

was individually statistically significant, except for access to electricity (Wang, 2003);

however, it was found that female education, access to safe water, access to sanitation,

10

and vaccination coverage ‗jointly‘ affected IMR (Wang, 2003). Therefore, increase in

the average share of health expenditure in GDP was shown to reduce IMR in urban

areas, but not in rural areas, suggesting that in rural areas access to electricity played

much bigger role in infant health. For under-five mortality, DHS data at the national

level showed similar results to that for IMR, except that the estimated coefficients were

much larger in the U5MR model‖ (Wang, 2003). For example, it was found that the

impact of access to electricity on U5MR was over twice that of IMR, indicating that

―health interventions that improve household access to electricity could have a large

effect on reducing U5MR‖ (Wang 2003). It is worthy to note that Wang and his group‘s

several tests indicated that electricity‘s effect on health was independent of income.

Furthermore, unavailability of electricity in poor households has been shown to

affect health of children. Various studies have examined the health risks associated with

indoor air pollution, especially in poor families (Ezzati, 2005). Using a retrospective

analysis of data from the Demographic and Health Survey in Zimbabwe, Mishra et al

found that babies born to mothers cooking with solid fuels such as wood, dung or straw

weighed less (on average 175 g lighter) than those born to mothers using cleaner fuels

such as liquid petroleum gas, natural gas or electricity (Mishra et al, 2004). This

association implies that the hazards of indoor air pollution from utilization of solid

energy due to inaccessibility of electricity occur within a continuum of exposures during

pregnancy, childhood and adulthood. In addition, indoor air pollution from biomass

fuels has been associated with an increased risk of childhood pneumonia and asthma

(Dionisio et al, 2008).

11

Maternal Mortality

Electricity is needed to improve maternal health in developing countries.

Maternal mortality has many causes, but it is basically due to a number of interrelated

delays which ultimately prevent a pregnant woman from timely access to the required

health care service (UNFPA, 2008). One common reason for delays in receiving

adequate care when a facility is reached is shortage in electricity (UNFPA, 2008).

Various observations in South Asia have indicated poor prenatal and neonatal care

services in the majority of maternity hospitals as a result of energy shortage (The Central

Emergency Response Fund, 2008). Studies in Central Asian countries have shown that

that electricity supply in hospitals is at times limited to four hours a day (Veenema,

2000). In addition, an evaluation of the causes of maternal mortality in Central Asia in

1997 revealed that of a third of all preventable deaths contributed to electricity shortage

(Veenema, 2000).

Maternal mortality due to electricity interruptions has been indicated in other

studies. In his 2007 study of maternal deaths in rural Gambia hospitals, Cham showed

that malfunctioning of the blood transfusion service contributed to 15 deaths, some of

which were attributable to power outage (Cham et al, 2007). It was also recorded that

lack of electricity made it impossible for relatives to donate blood, and this resulted in

death (Cham et al, 2007). Furthermore, Orji‘s 2002 study in rural Nigerian health

facilities revealed the hardship and frustration suffered by doctors and patients due to

irregularity of electricity supplies. It was observed that power failure contributed to 5%

of maternal death, which resulted from delays in estimation of haemoglobin level,

12

grouping and cross-matching of blood as well as delays in surgeries. ―In a particular

maternal death arising from caesarean section in this hospital, the electricity went off for

about 30 minutes during surgery‖ (Orji et al, 2002).

Education/Information

Electricity helps connect individuals with the outside world and spreads

information via appliances such as TV, radio, computer/internet, mobile phones and

others. More years of education has also been associated with electricity‘s contribution

to the community infrastructure (Chernia et al, 2007). Expansion of electricity supply to

remote areas could result in a potential growth of 60% in education (Chernia et al,

2007); this is largely because more teaching hours would be available (i.e. night shifts)

thus accommodating more children each day (Chernia et al, 2007).

Gender Equality and Empowering Women

The preparation of food in most rural areas is the responsibility of women

(Karekezi and Kithyoma, 2002). Women are the major users of traditional energy

sources for household activities. On average, women are in more danger from the risks

associated with indoor pollution-generating fuels. In addition, power failures in health

clinics during night-time deliveries, and the daily drudgery and physical burden of fuel

collection and transport all contribute to poor health conditions for women, especially in

rural areas (UNDP, 2004). If women spent less time on collecting wood for fire and

other tasks that result from lack of electricity, then they would have more time for

13

education and they could engage in income generating activities (UNDP, 2004). This is

the basis for progressing towards empowering women and promoting gender equality.

Extreme Poverty and Hunger

In order to eradicating extreme poverty and hunger, ―energy inputs such as

electricity and fuels are essential to generate jobs, industrial activities, transportation,

commerce, micro-enterprises and agriculture outputs‖ (UNDP, 2004). Electricity, both

directly and indirectly, contributes to reliable and affordable infrastructure, which can

reduce poverty and lead to the achievement of the MDGs (Briceño-Garmendia et al,

2004). More studies have examined the social impact that energy sector

improvements could have in communities. In 1998, Datt and Ravaillon found that

investments in electricity between 1960 and 1990, led to reduction in rural poverty

levels in Indian states (Datt and Ravaillion, 1998). In addition, Deninger and Okidi’s

2003 study in Uganda showed similar findings while exploring factors underlying

growth and poverty reduction in this country during the 1990s. Their work

indicated that such progress resulted from expansion of electricity supply and

investment in other infrastructure, which improved access to basic education and

health care.

Unavailability of or inaccessibility to electricity and rural poverty are closely

correlated (Chaurey et al, 2004). Electricity is essential for productive and economic

activities and it improves living standards. For example, in vulnerable rural areas,

electricity inputs for basic activities such as pumping water for drinking and irrigation,

14

illumination for extending working and learning hours and powering small-scale rural

industry all benefit socio-economic status of families living in those areas (Chaurey et al,

2004). In addition, time that is spent for obtaining electrically pumped and hygienic

drinking water or collection of woods for fuel could instead be used for income

generation activities and education (Cecelski, 2000).

Health Impacts of Various Sources of Electricity in the context of climate

change

Electricity produced from ‗dirty fuels‘ may be harmful to health of the

population, both directly (i.e. through polluted air for breathing or agricultural activities)

and indirectly (i.e. though climate change). Therefore, it is not enough to produce

massive amount of electricity; it is also crucial to use environmentally-friendly means to

accomplish that. Human activities such as burning fossil fuels and using other

inefficient and carbon intensive power sources have drastically increased the

concentration of carbon dioxide in the past few decades and have contributed to global

warming (WHO, 2008). With the changing climate, basic health challenges that are

already faced by developing countries like Ghana, are exacerbated.

It has been indicated that climate change brings about higher levels of certain air

pollutants which increases the risk of cardiovascular and respiratory diseases and triggers

asthma (WHO, 2008). Intensive floods and droughts in different regions of the world

have led to reduction and contamination of freshwater supply (WHO, 2008). In fact,

within the next few years if global warming continues its current trend, Ghana is

15

expected to experience drought or even famine similar to those experienced by Ethiopia,

Chad and Niger (Frimpong, 2008). Extreme weather such as heavy storms could destroy

houses, health facilities and other essential services (WHO, 2008). Moreover, climate

change makes the control of infectious diseases more difficult as it could affect the

ecology and life cycle of highly climate sensitive vector-borne and nonvector-borne

diseases such as malaria, dengue, cholera and diarrheal diseases (WHO, 2008).

Agricultural production is also drastically affected by climate change thus increasing

malnutrition (WHO, 2008).

Hence, countries should not aim for mounting electricity supply at the cost of

climate change, which ultimately reverses the attempts for improving public health.

Focus should be on production of electricity in the cleanest way possible, i.e. though

renewable energies such as wind and solar panels. Renewable energy technologies are

methods of harnessing energy for human use in such a way that the source of energy is

not depleted over time. It is expensive yet efficient and clean method for producing

power. Although, there are abundant renewable energy resources like solar, wind and

bio-diesel energy in Ghana, renewable energy technology is still in its first

developmental stage in this country (ECG, 2007). The rate of development has been

slow mainly because of the lack of financial incentives as well as bad management (UN-

Energy, 2006). Increasing the proportion of energy obtained from renewable energy

sources is a great step in improving the electricity situation in Ghana without major

environmental costs as imposed by other sources of energy.

16

Electricity as a Health Indicator: Inclusion in WHOSIS?

Tables 1 and 2 list the World Health Organization‘s 150 indicators, showing the

latest available data related to the health of the Ghanaian population, including the health

system. Each indicator adds a unique representation to the health status of Ghanaian

population. In overall, Ghana does very poorly in terms of health level performance and

overall performance of the health system (World Health Report, 2000).

Some of the indicators in Table 1 show disaggregated data for rural and urban

areas, for all of which rural areas do worse. Although all differences between rural and

urban areas could not be blamed on electricity, certain disparities in data, such as

education, number of physicians and nurses and pharmacists, number of births attended

by skilled health workers, and number of health clinics and hospitals may be to some

extent attributable to lack of adequate electricity in rural areas. Research should be done

to determine to what extent the energy supply could make a difference in the outcome of

these WHO indictors. For example, various studies similar to that of Wang‘s could

analyze the association between electricity and other variables, i.e. by how much could

improved access to electricity increase maternal health, decrease IMR or U5M, increase

education enrollment by girls/women, and increase the number of health workers as well

as health clinics in specific regions where access to electricity is a major issue.

Access to sustainable electricity has never been considered a ‗health indicator‘.

It has been referred to as an indicator of wealth as well as an indicator of remoteness, but

not health. In fact, electricity has been shown to directly affect health indicators; for

17

example, in their 2007 article, Gonzalez-Eiras and Rossi illustrated that access to electricity

directly affects health indicators (i.e. malnutrition, food-borne diseases, low birth weight,

etc.) without any indication that electricity should itself be named as a health indicator

(Gonzalez-Eiras and Rossi , 2007). In 2003, World Health Organization defined two

categories of indicators: 1) Health Indicators, which refer to indicators that are truly

―health‖ such as Tuberculosis or AIDS prevalence and 2) Health-Related Indicators,

which concern critical factors for health such as access to improved water supply or to

hygienic sanitation (WHO, 2003). Indicators are used in a number of ways. For

instance: ―to monitor changes over time; to monitor differences between population

subgroups; to monitor progress towards targets; to monitor differences between health

facilities in different geographical areas; etc‖ (WHO, 1997).

WHO has suggested some criteria for selection of indicators (directly taken

from WHO website, 2007):

• Valid - the indicator must actually measure the issue or factor it is supposed to

measure.

• Reliable - the indicator must give the same value if its measurement was repeated in

the same way on the same population and at almost the same time.

• Sensitive - the indicator must be able to reveal important changes in the factor of

interest.

• Specific - the indicator must only reflect changes in the issue or factor under

consideration.

• Useful - the indicator must be able to act as a “marker of progress” towards

improved health or health-related status, either as a direct or proxy measure of

impact or as a measure of progress towards specified process goals.

• Representative - the indicator must adequately encompass all the issues or

population groups it is expected to cover.

18

• Understandable - the indicator must be simple to define and its value must be easy to

interpret in terms of health or health-related status.

• Accessible - the data required should be available or relatively easy to acquire by

feasible data collection methods that have been validated in field trials.

• Ethical - An ethical indicator is one for which the gathering, processing and

presentation of the data it requires are ethical in terms of the rights of the individual

to confidentiality, freedom of choice in supplying data, and informed consent

regarding the nature and implications of the data required.

By examining electricity within the framework of these nine criteria, it is realized

that electricity meets all. Electricity can be used as a health indicator in a variety of forms

depending on the context. For example, in the context of the health facilities, the indicator

could be the number of blackouts or brownouts per month; in the context of regional

accessibility, the indicator could be the amount of electricity distributed to rural and urban

areas, or it could be the cost of electricity for different regions or different facilities; in the

context of availability of electricity, the indicator could be the proportion of electricity to

other fuels used in households as a source of energy, or it could be the number of households

that use electricity as their main source of energy. In any case, electricity would be a great

predictor of health outcomes in each specific context. Having discussed the role of

electricity in public health in earlier sections and described its eligibility as a health-

related indicator above, I firmly propose that electricity be considered as one of the

health-related indicators in WHO‘s list of 150 indicators.

19

METHODS

Experience in the field piqued my interest in taking on a project that explored the

relationship between health and electricity supply. At a public hospital (called Police

Hospital) in Accra in April 2007, I gained first-hand knowledge of the inconvenience

and life-or-death nature of power outages at the hospital. After talking to a number of

physicians, who told me stories about the consequences of power outage (both blackout

and brownout) at that hospital, I became interested to know more about the effect of

electricity on health of the population. I then started to search for secondary literature

that would illustrate the relationship between public health and electricity in Ghana as

well as other developing countries. I found a number of articles that illustrated the link

between health and electricity supply. In addition, I searched for literature using

Medline and PubMed Central data search through SFU Library to see if I could find any

relevant literature that would specify electricity as an indicator of health. About 20

articles were found on the subject of the role of electricity and health of the population

using the following combination of terms: 1) electricity, public health, Ghana; 2) power

shortage, hospitals; 3) electricity, maternal mortality; 4) electricity child mortality; 5)

electricity, education; 6) electricity, poverty; 7) MDGs, electricity; 8) hospital mortality,

electricity, Ghana; 9) health centre accessibility, electricity; and 10) power outage, public

health. A number of search combinations were also performed to search for articles that

propose electricity to be a health indicator; however, no article was found.

20

DISCUSSION OF EXTERNAL FACTORS CONTRIBUTING

TO GHANA‘S ENERGY SHORTAGE

Political-Economic Analysis of Electricity Interruption in Ghana

The Main Sources of Electricity in Ghana and Their Costs

It is important to understand where electricity comes from, in what amount, and

what the costs of its production and distribution are within a given period of time

because this information can itself be used as a form of health indicator. For example,

the indicator could be the amount of electricity that is produced by a specific source over

specific time period; it could be the cost of electricity distribution to specific regions

over a time period; or it could be the number of hours without electricity over a time

period. Fluctuations in the quantity of each of these indicators could well represent

fluctuations in the public health or health-related outcome for a region within a specified

period of time.

There are currently two sources of electric power generation in Ghana:

hydroelectric which accounts for 70 percent and thermal which accounts for 30 percent

of the total generated power (Aryeetey, 2005). The Akosombo Hydroelectric Power

Plant located at the Volta Dam generates 88 percent of the hydro-generating electricity

while the Kpong Hydroelectric Power Plant generates 12 percent of that; the Takoradi

Thermal Station generates all the thermal generated electricity (Aryeetey, 2005). The

electric power in Ghana consists of three systems: The generation system makes

21

electricity, the transmission system moves electricity from the power plant closer to the

consumer, and the local distribution systems move electric power from the transmission

system to the most consumers (Aryeetey, 2005). Unfortunately, there is no data

available on the quantity of electricity that is distributed to hospitals and health clinics.

Of course this amount depends on the size of the facility; in this context, an indicator

could be the amount of electricity consumed by public hospitals in either urban or rural

regions of Ghana over a specific period.

Alcoa is an American aluminum making company that currently operates in 31

countries around the world (Alcoa Website, 2009). Valco, the name of Alcoa‘s

operating unit in Ghana was established 40 years ago by Henry Kaiser (Zachary, 2004).

Kaiser made a deal with Kwame Nkrumah (Ghana‘s independence leader back then),

and financially supported building of a massive dam of the Volta River in Eastern Ghana

($149 million of total $258 cost). In return, Kwame Nkrumah gave Valco a 30-year

claim on half the electricity produced by the dam (Zachary, 2004). Valco, the Volta

Aluminum Company that is owned by Kaiser (90 percent) and Alcoa (10 percent),

consumed more than one-third of the total electricity generated by the Volta Dam

(Zachary, 2004) until 2003—when it was forced to close over its disputes with the

Ghanaian Government. The disputes were over reaching a deal which Valco saw as

unfair, ―resisting efforts to make it pay a more realistic price reflecting the current costs

of producing power in Ghana‖. This means that for more than 35 years only two third of

the generated electricity in Ghana was left for Ghanaians for electrifying residents,

hospitals, businesses, schools, factories, etc. In June 200, the Ghanaian Government

22

bought 10% of Alcoa‘s stake in Valco (Wall Street Journal, 2008), nevertheless the

company is still consuming a large amount of power at a relatively low price. The

amount of electricity consumption by different sectors in a community could be used as

an indicator to determine how much electricity is consumed by the health sector. It

could be predicted that the more electricity used by non-health facilities, such as

factories and foreign businesses, the less electricity available for health facilities in

Ghana.

The Volta Dam can no longer cover the electricity needs of Ghana‘s population

as the water level is low and the population has increased (Owusu et al, 2008). Ghana‘s

current dependence on electricity import has caused the electricity rates in the country to

increase substantially (Zachary, 2004)). This means that ordinary people and public

services such as hospitals and schools are paying more for electric power. In this case,

the quantity of imported electricity could serve as an indicator; the more the amount of

imported electricity, the more costly it would be. Not all hospitals can afford the

increased prices and this could lead to reduction of supply to those facilities (in the

absence of regulations/subsidies).

Not everyone is paying the same amount for electricity supply. After 35 years in

Ghana, Valco continues to insist that it should be treated in a unique category and be

allowed to pay rates for power that are far below the cost of providing that power in

Ghana (Kramer, 2003). It costs the Volta River Authority 6.5 US cents/kWh to actually

produce electricity from its mixed hydro/thermal system. It is worthy of note that the

23

cost of producing hydro power alone is 2.5 US cents/kWh (Kramer, 2003). The ordinary

Ghanaian pays in the region of 7.8 US cents/kWh whilst industrial customers pay well

over 4.5 US cents/kWh (Kramer, 2003). Up till today, Valco has been paying 1.1 US

cents/kWh and has resisted efforts to make it pay a more realistic price reflecting the

current costs of producing power in Ghana (Kramer, 2003). A number of negotiations

have taken place in Ghana to resolve an ongoing dispute between the government and

this American mining company. The core issue in the dispute between Kraiser

Aluminum and the government is over lowering the cost of electricity in Ghana. Since

Alcoa insists on a cheap price for electricity, ordinary Ghanaians now increasingly

subsidize the operating expenses of a wealthy American multinational corporation

(Zachary, 2004).

Of the three power system facilities mentioned above, the Akosombo

Hydroelectricity Power Plant is the main source of energy production for Ghana

(Aryeetey, 2005). Therefore, Valco‘s one-third utilization of this seemingly limited

source of power generation for Ghanaian consumers adds to the problem of shortage in

electricity supply. Moreover, the high cost of power generation, transmission, and

distribution is also considered a big challenge for a developing country like Ghana

whose GDP is relatively small (i.e. $16 billion compared to USA‘s $14.4 trillion);

therefore, these are the visible challenges faced by the Ghanaian Government and

addressing those problems would be the first step for improving the current energy crisis

in Ghana. Lowering the cost of electricity for ordinary Ghanaians is likely to bring

24

about improvements in the health outcomes; hence it is essential that necessary steps be

taken by the government to address the issue of electricity cost.

Population Growth and Increasing Demand for Electricity

In 2004, the electricity production in Ghana was 6.489 billion kWh and the total

electricity consumption was 7.095 billion kWh (ECG, 2004). In Australia, which has a

similar population to Ghana (~22 million), the electricity production in 2004 was 225.3

billion kilowatt hours and the total electricity consumption was 209.5 billion kilowatt

hours (EIA, 2004). ―While the developed countries enjoy a highly uninterrupted supply

of electric power all the time, many developing countries such as Ghana have acute

power shortage as compared to the demand‖ (Energy Business Reports, 2009).

The national and global political economic policies all have stakes in the energy

shortage of Ghana. Shortage in electricity production and a massive rise in its cost in the

country and rising demand are all to blame for the shortage of energy supply to hospitals

and other health institutions. In Ghana, electricity consumption has been on the rise by

10-15 percent annually for the last two decades (Aryeetey, 2005). However, the

electricity production has not been keeping up with this pace and has resulted in

shortage. With Ghana‘s growing population, the number of schools, health facilities,

houses, TVs and radios, computers and phones, commercial buildings, and many other

things are also increasing. If the supply does not meet the demand, there will be dire

consequences in not only the health system, but all sectors of the society.

25

Disproportionate Electricity Problems in Rural Areas

Today, only about 15 percent of the people in Ghana‘s rural areas have access to

grid electricity (Aryeetey, 2005). Grid electricity refers to electric energy delivered to a

consumer from the public electricity network (Brown, 2002). Other sources of energy

such as wind and solar have not really been major power sources in rural areas, in spite

of their great geographical potential. In 1990s, some solar photovoltaic (PV) systems

were installed under a pilot project for rural electrification; however these installations

could not be kept operational due to lack of funding for replacement batteries (United

Nations-Energy, 2006). Evaluations by the Energy Commission of Ghana suggested that

the batteries had not been replaced when they had run down, because the rural

community beneficiaries could not afford the replacement cost. Rural areas are

economically at a disadvantage, and this is mostly due to lower income of the people

living in those areas compared to the urban areas. The small percentage of access to

grid electricity reflects the economic disadvantage of rural areas.

It costs more to set up a power system in a rural area than it does in an urban one

this is because rural electrification systems require higher voltages due to longer

distances covered by the distribution lines (Brown, 2002). Electricity is transmitted to

rural areas through the simplest primary distribution system, which consists of

independent feeders (Note: Distribution feeder circuits are the connections between the output

terminals of a distribution substation and the input terminals of primary circuits) with each

customer connected to a single feeder (Brown, 2002). A single error could interrupt all

downstream customers due to lack of feeder interconnections (Brown, 2002). This form

26

of connection—called a radial system—is common for low-density rural areas where

more complex systems are expensive (Brown, 2002). In rural areas, therefore, mini-

faults in the distribution system could have drastic results such as blackouts or burnouts

for all the consumers. This is when generators play a crucial role in avoiding such

catastrophes. But not all facilities have generators or sometimes the available generators

are too old to function properly. There are downsides to diesel generated electricity.

For example, diesel generators have been shown to be a major source of air pollution as

it releases carbon dioxide and nitrogen oxide (Singh, 2001); therefore, not only lowering

the quality of air for breathing, but also contributing to global warming (Singh, 2001).

In addition, the noise pollution resulting from excessively loud generators adds to the

discomfort in the lifestyle of the people in communities.

On the one hand, there are not many hospitals in rural Ghana compared to urban

areas. On the other hand, the existing hospitals in those regions do not usually have a

steady supply of electric power. Frequent and unscheduled blackouts at these hospitals

have caused many health problems for the patients. ―What if, in the middle of the night,

a pregnant woman has to suddenly undergo a c-section due to birth complications? Is she

going to die just because there is no electricity at the hospital?‖, said a rural resident in

Northern Ghana. Hospital staffs have also become frustrated, saying that their level of

service has been greatly affected by the electricity shortage. ―People don‘t trust the

hospitals anymore….they have seen and heard so many stories about how people died in

hospitals because of surgery delays or lack of basic care due to power outage.‖, said a

general surgeon at Police Hospital in Accra.

27

Access to electricity could be also related to the number of hospitals built in a

certain region. According to a resident of Jinbong Village in Northern Ghana, ―local

governments do not invest in building more hospitals in rural areas because there is very

limited access to electricity in rural areas‖. Therefore, there is a link between the

availability of electricity and availability of health facilities: Spending on building

health facilities in the absence of electricity would be considered ‗useless‘ or ‗a waste of

money‘ for the government. Consequently, in rural areas not only the shortage of power

supply has reduced the quality of health service in existing hospitals, it has also

prevented any improvements in the life-style of the people by inhibiting the

establishment of new modern hospitals.

Structural Adjustment Programs

Structural Adjustment Programs (SAPs) have also contributed to the electricity

shortage in Ghana and have resulted in declining public health outcomes over time.

Although structural adjustment in the late 1980s reversed a decade of negative growth in

Ghana caused by episodic fiscal crises associated with government debt, poor financial

performance of state enterprises, and fluctuations in the world price of cocoa (Ghana‘s

main export), it brought about the need for various reforms in different sectors (Williams

et al., 2006). It was at this time that Ghana was required by the World Bank to increase

tariffs, remove barriers to private participation, and to plan a comprehensive reform in

the electricity sector (Williams et al., 2006). Consequently, the electricity sector shifted

28

direction from sustainable and abundant supply as well as a source of economic asset

(due to export to other countries) to a costly, scarce commodity (UNDP, 2004).

Major changes in the health sector followed. For instance, the charging of user

fees for health services was introduced into the system due to stagnating economies and

associated budgetary constraints (Badasu, 2004). Therefore, reforms in the energy sector

directly affected the reforms in the health system. ―The increasing gaps between the

supply and demand for basic services have been characteristic of African countries since

the 1970s‖ (Badasu, 2004). In case of Ghana, the gap increased between electricity

supply and demand and prices went up. Healthcare reforms, including user fees, were

introduced, which eventually resulted in inequities in health care usage and widened

health disparities amongst Ghanaians (Badasu, 2004). Hospitals and other health

facilities also became affected by electricity shortage and fluctuations in the price of

electricity leveraged by national and international pressures (Badasu, 2004).

CONCLUSION

As illustrated in earlier sections, many scholarly articles have illustrated the

importance of sustainable access to electricity for everyday living of people, the

economic development of nations and the health of the public. International

communities have made attempts to address shortage of electricity, especially in Sub-

Saharan Africa, by introducing a variety of initiatives that aim to increase the number of

power plants and generators in different regions. ―Efficient, affordable and clean energy

29

supply is key to poverty reduction and economic growth‖ (World Bank, 2009). Over the

past number of years, the World Bank has been committed to supporting developing

countries' efforts to create cleaner, stable electricity services through policy advice,

funding, partnerships, and knowledge transfer (World Bank, 2009).

There are a number of projects supported by the World Bank and its partners for

improving the electricity accessibility, such as establishment of small off-grid power

plants (e.g. mini-hydro and small scale solar generators) with initiation of renewable

energy projects in certain regions. Attempts have been made to bring reforms to the

energy sector within developing countries. Overall, there have been both successes and

failures during such complex initiatives. Both financial and human resources have been

the drawbacks to achievement of energy projects (UN-Energy, 2007). The

implementation of renewable energy technology requires proper management, sufficient

work force, sustainable funding, political will, and cooperation of different parties.

Lack of any of these interrelated requirements would suppress the process of moving

forward with pursuing renewable energy technologies.

In Ghana, frequent electricity interruptions in hospitals and other health

facilities has lowered the quality of health care delivery. According to Ghana‘s Ministry

of Health, the three top health priorities of Ghana are reducing maternal mortality,

reducing child mortality and increasing the number of health workers (especially in rural

areas); electricity plays an important role in facilitating the achievement of all these

goals. A decentralized, off-grid electricity production would be a viable alternative in

30

helping raise the standard of living for rural poor, who have the least access to electricity

(Chaurey et al, 2004). Ghana should not overlook the extent of electricity‘s impact on

health of the population and must put energy matters on top of national agenda. The

decreasing level of water at the Volta Dam, the growing population of Ghana, the fiscal

crises in the past, the investment of foreign companies (in this case Alcoa) in the country

and their use of energy, and many other factors determine Ghana‘s status in the electric

power sector. The same set of factors could determine the public health outcomes in the

nation via influencing reforms in the health sector.

Electricity is an important part of the healthcare system infrastructure and its

sustainable availability is crucial to public health outcomes. Emphasis on the

relationship between electricity and public health outcomes is required for motivating the

stakeholders to take quicker actions to address the shortage. There are about 150 health

indicators (shown in Table 1 and 2) in the WHO Statistical Information System. It is

surprising that electricity has not been included in this list. Electricity plays a major role

in achievement of the MDGs. It is important that we use electricity as a health indicator

in order to be able to quantify its impact on the health of the population. It is through

logical measurements that new policies and intervention strategies could be introduced

into the system and that improvements can be monitored and evaluated.

There is need for ‗change of assessment‘ when it comes to scoring or examining

the health system of a country. Infrastructure plays a crucial role in determining the

success of health programmes. Electricity is as crucial for performance of the health

31

system as are roads, clean water, medical drugs, schools, and doctors. If electricity

influences maternal mortality, child mortality, education, gender equality, poverty and

income, number of health facilities, number of health workers, reforms in the health

sector, quality of healthcare delivery, and the overall health system performance, why

are we still hesitant in introducing electricity as a health indicator? Fluctuations in

electricity price, electricity production and electricity distribution affects health of the

population. This is the simplest reason why we need to include electricity beside the

‗solid fuel usage in rural/urban‘ indicator in WHOSIS.

32

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Table 1: Ghana's Health Indicators (WHOSIS, 2009)

Indicator Ghana Year Notes

Adolescent fertility rate (%) 74 2001

Adult literacy rate (%) 57.9 2000

Gross national income per capita (PPP international $) 1240 2006

Net primary school enrolment ratio female (%) 71 2007

Net primary school enrolment ratio male (%) 73 2007

Population (in thousands) total 23008 2006

Population annual growth rate (%) 2.1 2006

Population in urban areas (%) 49 2006

Population median age (years) 20 2006

Population proportion over 60 (%) 6 2006

Population proportion under 15 (%) 39 2006

Registration coverage of births (%) 51 2006 f1

Registration coverage of deaths (%) <25.0 2005

Total fertility rate (per woman) 4 2006

Antenatal care coverage - at least four visits (%) 69 2003

Antiretroviral therapy coverage among HIV-infected pregnant women for PMTCT (%) 8 2006

Antiretroviral therapy coverage among people with advanced HIV infections (%) 12 2006

Births attended by skilled health personnel (%) 50 2006 f2

Births by caesarean section (%) 4 2003 f3

Children aged 6-59 months who received vitamin A supplementation (%) 78.4 2003

Children aged <5 years sleeping under insecticide-treated nets (%) 21.8 2006 f4

Children aged <5 years who received any antimalarial treatment for fever (%) 60.8 2006 f5

Children aged <5 years with ARI symptoms taken to facility (%) 44 2003

Children aged <5 years with diarrhoea receiving ORT (%) 63.3 2003

Contraceptive prevalence (%) 25.2 2003

Neonates protected at birth against neonatal tetanus (PAB) (%) 88 2007

One-year-olds immunized with MCV 95 2007

One-year-olds immunized with three doses of diphtheria tetanus toxoid and pertussis (DTP3) (%) 94 2007

One-year-olds immunized with three doses of Hepatitis B (HepB3) (%) 94 2007

One-year-olds immunized with three doses of Hib (Hib3) vaccine (%) 94 2007

Tuberculosis detection rate under DOTS (%) 38 2006

Tuberculosis treatment success under DOTS (%) 73 2005

Women who have had mammography (%) 1 2003 f6

Women who have had PAP smear (%) 3 2003 f7

Dentistry personnel density (per 10 000 population) <1.0 2004

External resources for health as percentage of total expenditure on health 22.4 2006

General government expenditure on health as percentage of total expenditure on health 36.5 2006

General government expenditure on health as percentage of total government expenditure 6.8 2006

Hospital beds (per 10 000 population) 9 2005 f8

Laboratory health workers density (per 10 000 population) <1.0 2004

Number of dentistry personnel 393 2004

Number of laboratory health workers 899 2004

Number of nursing and midwifery personnel 19707 2004

Number of other health service providers 7132 2004

Number of pharmaceutical personnel 1388 2004

Number of physicians 3240 2004

Nursing and midwifery personnel density (per 10 000 population) 9 2004

Other health service providers density (per 10 000 population) 3 2004

Out-of-pocket expenditure as percentage of private expenditure on health 78.8 2006

Per capita government expenditure on health (PPP int. $) 36 2006

Per capita government expenditure on health at average exchange rate (US$) 13 2006

Per capita total expenditure on health (PPP int. $) 100 2006

Per capita total expenditure on health at average exchange rate (US$) 35 2006

Pharmaceutical personnel density (per 10 000 population) <1.0 2004

Physicians density (per 10 000 population) 2 2004

Private expenditure on health as percentage of total expenditure on health 63.5 2006

Private prepaid plans as percentage of private expenditure on health 6.2 2006

Ratio of health management and support workers to health service providers 0.6 2004

Ratio of nurses and midwives to physicians 6.1 2004

Total expenditure on health as percentage of gross domestic product 6.2 2006

Births attended by skilled health personnel (%) highest educational level of mother 67.9 2003

Births attended by skilled health personnel (%) highest wealth quintile 90.4 2003

Births attended by skilled health personnel (%) lowest educational level of mother 29.7 2003

Births attended by skilled health personnel (%) lowest wealth quintile 20.6 2003

Births attended by skilled health personnel (%) rural 30.9 2003

Births attended by skilled health personnel (%) urban 79.7 2003

Births attended by skilled health personnel difference highest lowest educational level of mother 38.2 2003

Births attended by skilled health personnel difference highest-lowest wealth quintile 69.8 2003

Births attended by skilled health personnel difference urban-rural 48.8 2003

Births attended by skilled health personnel ratio highest-lowest educational level of mother 2.3 2003

Births attended by skilled health personnel ratio highest-lowest wealth quintile 4.4 2003

Births attended by skilled health personnel ratio urban-rural 2.6 2003

37

Measles immunization coverage among one-year-olds (%) highest educational level of mother 89.3 2003

Measles immunization coverage among one-year-olds (%) highest wealth quintile 88.8 2003

Measles immunization coverage among one-year-olds (%) lowest educational level of mother 78.2 2003

Measles immunization coverage among one-year-olds (%) lowest wealth quintile 75 2003

Measles immunization coverage among one-year-olds (%) rural 81.8 2003

Measles immunization coverage among one-year-olds (%) urban 85.8 2003

Measles immunization coverage among one-year-olds difference highest-lowest educational level of mother 11.1 2003

Measles immunization coverage among one-year-olds difference highest-lowest wealth quintile 13.8 2003

Measles immunization coverage among one-year-olds difference urban-rural 4 2003

Measles immunization coverage among one-year-olds ratio highest-lowest educational level of mother 1.1 2003

Measles immunization coverage among one-year-olds ratio highest-lowest wealth quintile 1.2 2003

Measles immunization coverage among one-year-olds ratio urban-rural 1 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) difference lowest-highest educational level of mother 40.4 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) difference lowest-highest wealth quintile 40 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) difference rural-urban 25.6 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) highest educational level of mother 84.5 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) highest wealth quintile 88 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) lowest educational level of mother 124.9 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) lowest wealth quintile 128 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) ratio lowest-highest educational level of mother 1.5 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) ratio lowest-highest wealth quintile 1.5 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) ratio rural-urban 1.3 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) rural 118.3 2003

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) urban 92.7 2003

Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) both sexes 331 2006

Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) female 311 2006

Adult mortality rate (probability of dying between 15 to 60 years per 1000 population) male 350 2006

Age-standardized mortality rate for cancer (per 100 000 population) 138 2002

Age-standardized mortality rate for cardiovascular diseases (per 100 000 population) 404 2002

Age-standardized mortality rate for injuries (per 100 000 population) 97 2002

Age-standardized mortality rate for non-communicable diseases (per 100 000 population) 786 2002

Deaths among children under five years of age due to diarrhoeal diseases (%) 12.2 2000

Deaths among children under five years of age due to HIV/AIDS (%) 5.7 2000

Deaths among children under five years of age due to injuries (%) 3 2000

Deaths among children under five years of age due to malaria (%) 33 2000

Deaths among children under five years of age due to measles (%) 2.9 2000

Deaths among children under five years of age due to neonatal causes (%) 28.5 2000

Deaths among children under five years of age due to other causes (%) 0 2000

Deaths among children under five years of age due to pneumonia (%) 14.6 2000

Deaths due to HIV/AIDS (per 100 000 population per year) 131 2005

Deaths due to tuberculosis among HIV-negative people (per 100 000 population) 41 2006

Deaths due to tuberculosis among HIV-positive people (per 100 000 population) 6 2006

Healthy life expectancy (HALE) at birth (years) both sexes 50 2003

Healthy life expectancy (HALE) at birth (years) female 50 2003

Healthy life expectancy (HALE) at birth (years) male 49 2003

Incidence of tuberculosis (per 100 000 population per year) 203 2006

Infant mortality rate (per 1 000 live births) both sexes 76 2006

Infant mortality rate (per 1 000 live births) female 69 2006

Infant mortality rate (per 1 000 live births) male 82 2006

Life expectancy at birth (years) both sexes 57 2006

Life expectancy at birth (years) female 58 2006

Life expectancy at birth (years) male 56 2006

Maternal mortality ratio (per 100 000 live births) 560 2005

Neonatal mortality rate (per 1 000 live births) 43 2004

Number of confirmed poliomyelitis cases 0 2007

Prevalence of HIV among adults aged >=15 years (per 100 000 population) 2225 2005

Prevalence of tuberculosis (per 100 000 population) 379 2006

Under-5 mortality rate (probability of dying by age 5 per 1000 live births) both sexes 120 2006

Under-5 mortality rate (probability of dying by age 5 per 1000 live births) female 118 2006

Under-5 mortality rate (probability of dying by age 5 per 1000 live births) male 121 2006

Years of life lost to communicable diseases (%) 74 2002

Years of life lost to injuries (%) 10 2002

Years of life lost to non-communicable diseases (%) 16 2002

Children under five years of age overweight for age (%) 4.5 2003

Children under five years of age stunted for age (%) 35.6 2003

Children under five years of age underweight for age (%) 18.8 2003

Newborns with low birth weight (%) 11 1998

Per capita recorded alcohol consumption (litres of pure alcohol) among adults (>=15 years) 1.57 2003

Population using solid fuels (%) rural 96 2003

Population using solid fuels (%) urban 75 2003

Population with sustainable access to improved drinking water sources (%) rural 71 2006

Population with sustainable access to improved drinking water sources (%) total 80 2006

Population with sustainable access to improved drinking water sources (%) urban 90 2006

Population with sustainable access to improved sanitation (%) rural 6 2006

Population with sustainable access to improved sanitation (%) total 10 2006

Population with sustainable access to improved sanitation (%) urban 15 2006

Prevalence of adults (>=15 years) who are obese (%) female 8.1 2003 f9

Prevalence of condom use by young people (15-24 years) at higher risk sex (%) female 33 2003

Prevalence of condom use by young people (15-24 years) at higher risk sex (%) male 52 2003

Prevalence of current tobacco use among adolescents (13-15 years) (%) both sexes 11.7 2006

Prevalence of current tobacco use among adolescents (13-15 years) (%) female 10.9 2006

Prevalence of current tobacco use among adolescents (13-15 years) (%) male 11.6 2006

Prevalence of current tobacco use among adults (>=15 years) (%) both sexes 5.5 2005

Prevalence of current tobacco use among adults (>=15 years) (%) female 0.8 2005

Prevalence of current tobacco use among adults (>=15 years) (%) male 10.2 2005

38

© World Health OrganizationThe information in this database is provided as a service to our users.

The responsibility for the interpretation and use of the material lies with the user.

In no event shall the World Health Organization be liable for any damages

arising from the use of the information linked to in this section.

For explanatory notes, please refer to the latest version of the World Health Statistics

publication available at http://www.who.int/whosis/.

Defintions:Age-standardized mortality rate for cancer (per 100 000 population) - http://www.who.int/whosis/indicators/compendium/2008/1mst

Antenatal care coverage - at least four visits (%) - http://www.who.int/whosis/indicators/compendium/2008/3acf

Antiretroviral therapy coverage among HIV-infected pregnant women for PMTCT (%) - http://www.who.int/whosis/indicators/compendium/2008/2pmf

Antiretroviral therapy coverage among people with advanced HIV infections (%) - http://www.who.int/whosis/indicators/compendium/2008/3avr

Births attended by skilled health personnel (%) - http://www.who.int/whosis/indicators/compendium/2008/3bsn

Births by caesarean section (%) - http://www.who.int/whosis/indicators/compendium/2008/1bcn

Children aged 6-59 months who received vitamin A supplementation (%) - http://www.who.int/whosis/indicators/compendium/2008/1va5

Children aged <5 years sleeping under insecticide-treated nets (%) - http://www.who.int/whosis/indicators/compendium/2008/2in5

Children aged <5 years who received any antimalarial treatment for fever (%) - http://www.who.int/whosis/indicators/compendium/2008/1am5

Children aged <5 years with ARI symptoms taken to facility (%) - http://www.who.int/whosis/indicators/compendium/2008/1ar5

Children aged <5 years with diarrhoea receiving ORT (%) - http://www.who.int/whosis/indicators/compendium/2008/1or5

Children under five years of age overweight for age (%) - http://www.who.int/whosis/indicators/compendium/2008/2nu5

Contraceptive prevalence (%) - http://www.who.int/whosis/indicators/compendium/2008/3pcf

Deaths among children under five years of age due to diarrhoeal diseases (%) - http://www.who.int/whosis/indicators/compendium/2008/1ms5

Deaths among children under five years of age due to diarrhoeal diseases (%) - http://www.who.int/whosis/indicators/compendium/2008/1ms5

Deaths due to HIV/AIDS (per 100 000 population per year) - http://www.who.int/whosis/indicators/compendium/2008/1mhr

Deaths due to tuberculosis among HIV-negative people (per 100 000 population) - http://www.who.int/whosis/indicators/compendium/2008/3mtr

Dentistry personnel density (per 10 000 population)

Dentistry personnel density (per 10 000 population) - http://www.who.int/whosis/indicators/compendium/2008/3hwo

External resources for health as percentage of total expenditure on health - http://www.who.int/whosis/indicators/compendium/2008/3exo

Healthy life expectancy (HALE) at birth (years) both sexes - http://www.who.int/whosis/indicators/compendium/2008/1hat

Hospital beds (per 10 000 population)

Incidence of tuberculosis (per 100 000 population per year) - http://www.who.int/whosis/indicators/compendium/2008/3itt

Infant mortality rate (per 1 000 live births) both sexes - http://www.who.int/whosis/indicators/compendium/2008/3mr5

Laboratory health workers density (per 10 000 population)

Life expectancy at birth (years) both sexes - http://www.who.int/whosis/indicators/compendium/2008/2let

Maternal mortality ratio (per 100 000 live births) - http://www.who.int/whosis/indicators/compendium/2008/3mrf

Neonatal mortality rate (per 1 000 live births) - http://www.who.int/whosis/indicators/compendium/2008/4mrn

Neonates protected at birth against neonatal tetanus (PAB) (%) - http://www.who.int/whosis/indicators/compendium/2008/4im1

Newborns with low birth weight (%) - http://www.who.int/whosis/indicators/compendium/2008/2bwn

Number of confirmed poliomyelitis cases - http://www.who.int/whosis/indicators/compendium/2008/3pmr

Number of dentistry personnel

Number of laboratory health workers

Number of nursing and midwifery personnel

Number of pharmaceutical personnel

Nursing and midwifery personnel density (per 10 000 population)

Other health service providers density (per 10 000 population)

Per capita recorded alcohol consumption (litres of pure alcohol) among adults (>=15 years) - http://www.who.int/whosis/indicators/compendium/2008/3alu

Pharmaceutical personnel density (per 10 000 population)

Physicians density (per 10 000 population)

Population using solid fuels (%) rural - http://www.who.int/whosis/indicators/compendium/2008/3sot

Population with sustainable access to improved drinking water sources (%) rural - http://www.who.int/whosis/indicators/compendium/2008/2wst

Prevalence of HIV among adults aged =15 years (per 100 000 population) - http://www.who.int/whosis/indicators/compendium/2008/2phu

Prevalence of adults (>=15 years) who are obese (%) female - http://www.who.int/whosis/indicators/compendium/2008/1pou

Prevalence of condom use by young people (15-24 years) at higher risk sex (%) female - http://www.who.int/whosis/indicators/compendium/2008/2pco

Prevalence of current tobacco use among adolescents (13-15 years) (%) both sexes - http://www.who.int/whosis/indicators/compendium/2008/3pto

Prevalence of current tobacco use among adults (>=15 years) (%) both sexes - http://www.who.int/whosis/indicators/compendium/2008/2ptu

Prevalence of tuberculosis (per 100 000 population) - http://www.who.int/whosis/indicators/compendium/2008/2ptt

Probability of dying (per 1 000 population) between 15 and 60 years (adult mortality rate) both sexes - http://www.who.int/whosis/indicators/compendium/2008/1mru

Tuberculosis detection rate under DOTS (%) - http://www.who.int/whosis/indicators/compendium/2008/4tdr

Tuberculosis treatment success under DOTS (%) - http://www.who.int/whosis/indicators/compendium/2008/4tsr

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) difference lowest-highest educational level of mother - http://www.who.int/whosis/indicators/compendium/2008/3mr5

Under-5 mortality rate (Probability of dying aged < 5 years per 1 000 live births) rural - http://www.who.int/whosis/indicators/compendium/2008/3mr5

Women who have had PAP smear (%) - http://www.who.int/whosis/indicators/compendium/2008/1paf

Women who have had mammography (%) - http://www.who.int/whosis/indicators/compendium/2008/1maf

Years of life lost to communicable diseases (%) - http://www.who.int/whosis/indicators/compendium/2008/1llr

39

Footnotes:f1: Percentage of children less than five years of age who were registered at the time of the survey. The numerator of this indicator includes children

whose birth certificate was seen by the interviewer or whose mother or caregiver said the birth had been registered. The state of the world?s children

2008: child survival. New York, United Nations Children?s Fund, 2008.

f2: Includes deliveries by cadres of health workers other than doctors, nurses and midwives - range not available.

f3: The World Health Report 2005: make every mother and child count. Geneva, World Health Organization, 2005 (http://www.who.int/whr/2005/en/index.html, accessed 17 April 2008).

f4: Compiled by UNICEF from Demographic and Health Surveys (DHS). New York, UNICEF, 2008 (http://childinfo.org/areas/malaria/maldata.php, accessed 17 March 2008).

f5: Compiled by UNICEF from Demographic and Health Surveys (DHS). New York, UNICEF, 2008 (http://childinfo.org/areas/malaria/maldata.php, accessed 17 March 2008).

f6: Coverage for the female population aged 50-69 years. Source: World Health Survey, Geneva, World Health Organization, 2006

(http://www.who.int/healthinfo/survey/whsresults/en/index.html, accessed 17 March 2008).

f7: Coverage for the female population aged 18-69 years. Source: World Health Survey, Geneva, World Health Organization, 2006

(http://www.who.int/healthinfo/survey/whsresults/en/index.html, accessed 17 March 2008).

f8: Hospital beds include inpatient and maternity beds. Maternity beds are included, while cots and delivery beds are excluded.

f9: Upper limit is 49.

40

Table 2: Ghana's Health System (World Health Report 2000)