Chapter 4. Developing human capital.

Chapter 4. Developing human capital. To strengthen women's role in the national economy, it isessential to strengthen education and health. Neither can be said tomeet national expectations, despite serious efforts by the governmentand its partners to improve them. REDUCING GENDER DISPARITIES IN EDUCATION Because of its importance to the economy and the family,women's access to education and information is critical todevelopment. Research shows that girls' and women's educationfavorably fa��vor��a��ble?adj.1. Advantageous; helpful: favorable winds.2. Encouraging; propitious: a favorable diagnosis.3. influences: * Agricultural production. * Family income. * Fertility and health. * The nutrition, survival, and education of children. Investing in women's education yields substantial private andsocial returns, plus payoffs for the next generation. Social rates ofreturn on investments in girls' education are higher than those forboys. Education for both men and women is needed for sustainabledevelopment Sustainable development is a socio-ecological process characterized by the fulfilment of human needs while maintaining the quality of the natural environment indefinitely. The linkage between environment and development was globally recognized in 1980, when the International Union , but there is a compelling case for investing inwomen's education in order to promote economic growth and the moreefficient use of public resources. The Gender Gap in Education Since independence the government of Ghana has vastly expandedaccess Expanded access refers to the inclusion of patients in a clinical trial for a new therapeutic treatment or chemical entity, where those patients would not satisfy the enrolment criteria for the scientific study in progress. to education and is committed to making female education apriority for economic and social development. But there is still a greatdisparity dis��par��i��ty?n. pl. dis��par��i��ties1. The condition or fact of being unequal, as in age, rank, or degree; difference: "narrow the economic disparities among regions and industries"between the educational attainments of men and women, acrossregions and socioeconomic levels (Figure 4.1). According to according toprep.1. As stated or indicated by; on the authority of: according to historians.2. In keeping with: according to instructions.3. the 1993Ghana Demographic and Health Survey, 38 percent of all women six orolder (compared with only 26 percent of men) have never gone to school;31 percent have only a primary education (33 percent of men). In thenorthern regions nearly 70 percent of women have never gone to school. Long-standing gender biases in providing education are reflected incurrent literacy figures. Ghana has greatly increased access toeducation since independence, but despite its efforts the gender gap isnot closing. Recent data show that: * Girls of school age are less likely than boys to be enrolled inschools. * Girls are more likely to drop out of school. * Girls have higher levels of absenteeism. * Girls who remain in school are not likely to perform as well asboys. * At secondary and tertiary levels and in vocational training girlsusually choose only a few limited subjects or vocations. School enrollment rates have generally increased in recent years,for both boys and girls boys and girlsmercurialisannua. , but the gender gap has remained almostconstant. In 1993, 72 percent of girls primary school age were enrolled,compared with 88 percent of boys of the same age (Figure 4.2). Thegender gap in school enrollment grew wider at the higher levels (Figure4.3). At the primary level, only 87 girls were enrolled for every 100boys. At the junior secondary level that figure was 75; in secondaryschool, 53; and at the tertiary level only 35. The widening gender gapat successively higher grade levels is only partly attributable tocohort cohort/co��hort/ (ko��hort)1. in epidemiology, a group of individuals sharing a common characteristic and observed over time in the group.2. effects (the likelihood that for a given cohort enrolled in alower grade the gender gap in a higher grade would have been greaterbecause of greater gender inequities in the past). The main reason forthe increasing inequities is girls' higher dropout (1) On magnetic media, a bit that has lost its strength due to a surface defect or recording malfunction. If the bit is in an audio or video file, it might be detected by the error correction circuitry and either corrected or not, but if not, it is often not noticed by the human rate (Figure4.4). Retention rates (the proportion of a cohort reaching the finalgrade) for primary education are significantly higher for boys than forgirls. These rates consistently increased over 199G-93, for boys andgirls, but the gender gap has persisted. And since few girls make itthrough primary and secondary school, fewer still enter tertiaryinstitutions. Gender concerns could even be improved in nonformaleducation by providing forms and other education-related documents inGhana's main language, which is not currently done. [FIGURE 4.1 OMITTED] Gender-based differentials in enrollments of school-age childrenappear across all regions in Ghana. The gap is widest in the northernpart of the country, where enrollment is much lower to begin with(Figure 4.5). In the northern region, only 54 girls of primary schoolage are enrolled for every 100 boys. The figure is only 34 for girls ofthe age for junior secondary school. There is also a gender gap in academic performance. According tothe living standards living standardsnpl → nivel msg de vidaliving standardsliving npl → niveau m de vieliving standardsliving npl survey for 1987-88, academic performance in mathand verbal skills was consistently lower for schoolgirls than forschoolboys in the same grade (Figure 4.6). On average girls who hadcompleted primary education scored 10.8 in reading and 6.3 in math (on ascale of 0 to 25), compared with boys' average scores of 11.8 and7.7, respectively. The gap is larger at higher grade levels, and greaterfor mathematics than for reading. At secondary and tertiary levels, where the gender gap inenrollment is wider, there is implicit "gender streaming," orsegregation by field of study. African women and girls are educated fora segmented and gender-segregated labor market labor marketA place where labor is exchanged for wages; an LM is defined by geography, education and technical expertise, occupation, licensure or certification requirements, and job experience . Gender streaming pusheswomen and girls into gender-stereotyped careers such as teaching,tailoring, secretarial work, and nursing, and prevents them from gettingtraining in agriculture, forestry, fishing, "hard" sciences,engineering, and management. There are also stark gender-baseddifferentials in vocational training. Men far outnumber out��num��ber?tr.v. out��num��bered, out��num��ber��ing, out��num��bersTo exceed the number of; be more numerous than.outnumberVerbto exceed in number: women intraining for all trades but tailoring (Figure 4.7). The serious gapbetween girls and boys in science and mathematics education is alsocause for serious concern. Barriers Girls and Women Face The parents' decision to send a child to school depends onwhat they perceive as the tradeoff between the benefits and costs ofschooling. In those calculations households are likely to consider onlythe private economic returns to educating their daughters, not thesocial returns. Parents consider the tangible benefits from education,such as remittances Remittance can also refer to the accounting concept of a monetary payment transferred by a customer to a businessRemittances are transfers of money by foreign workers to their home countries. from the child's future earnings, as well asintangible advantages, such as the satisfaction of seeing their childprosper. [FIGURE 4.2 OMITTED] [FIGURE 4.3 OMITTED] [FIGURE 4.4 OMITTED] Parents generally perceive the benefits from educating daughters tobe significantly less certain and more remote than those for sons. Forone thing, the benefits of education may accrue To increase; to augment; to come to by way of increase; to be added as an increase, profit, or damage. Acquired; falling due; made or executed; matured; occurred; received; vested; was created; was incurred. to another family oncetheir daughters get married. And households bear both the direct andindirect cost of schooling. Indirect costs Indirect costs are costs that are not directly accountable to a particular function or product; these are fixed costs. Indirect costs include taxes, administration, personnel and security costs. See alsoOperating cost include the forgone value oflabor and household work and such noneconomic costs as anxiety aboutchildren's safety, the risk of pregnancy, and the violation ofcultural traditions. Those costs are perceived to be higher for girlsthan for boys. Constraints on girls' schooling include the high opportunitycost of the girls' time in school, the direct costs to parents ofschooling, the psychological cost of observing cultural traditions andensuring their children's safety, and the low perceived privatereturns to girls' schooling (Herz and others 1991). Public policiesdirected at households (the demand side) and schools (the supply side)can influence the household view of girls' education. The Opportunity Costs Opportunity costsThe difference in the actual performance of a particular investment and some other desired investment adjusted for fixed costs and execution costs. It often refers to the most valuable alternative that is given up. of Girls' Schooling In Ghana, as in most of Sub-Saharan Africa, the gender-baseddivision of household and economic responsibilities places a greaterburden on girls than on boys. So the opportunity costs for girls'time are higher than the opportunity costs for boys' time(Asomaning and others 1994; Prouty 1991). Girls as young as seven helpwith time-consuming essential daily tasks, such as fetching fetch��ing?adj.Very attractive; charming: a fetching new hairstyle.fetching��ly adv. fuel andwater, cleaning the home, cooking, doing the laundry, and taking care ofyoung children. Boys tend to undertake more seasonal work, such asclearing land for cultivation and bringing in the harvest (Kilo Thousand (10 to the 3rd power). Abbreviated "K." For technical specifications, it refers to the precise value 1,024 since computer specifications are based on binary numbers. For example, 64K means 65,536 bytes when referring to memory or storage (64x1024), but a 64K salary means $64,000. 1994).Because of the greater opportunity cost for girls, parents are lesslikely to send their daughters to school, especially if the travel timeis long or school class schedules are inconvenient in��con��ven��ient?adj.Not convenient, especially:a. Not accessible; hard to reach.b. Not suited to one's comfort, purpose, or needs: inconvenient to have no phone in the kitchen. (Box 4.1). [FIGURE 4.5 OMITTED] The Direct Costs of Girls' Education To many families the direct costs of sending a girl to school aregreater than those of sending a boy, and some parents are unwilling totake on the extra responsibility. Girls' uniforms are often moreexpensive than boys', especially because girls are less likely toattend school in torn or ill-fitting clothes (Odaga and Heneveld 1995;Kapakasa 1992; Lloyd and Gage-Brandon 1992). At the secondary level,girls often attend school away from home and require extra resources forpersonal hygiene, school materials, uniforms, and secure accommodations.If the school is a long way from home, girls who make the trip daily mayincur additional transportation costs; (parents are more willing toallow boys to risk trekking long distances to school). Parents are alsomore likely to visit daughters living in a dormitory or close to theschool with friends or relatives (who offset the burden of extraexpenses by sponsoring the girl in exchange for labor). In one study offamily support for education, 17 percent of secondary students were inschool only because of financial support from relatives, and girlsaccounted for more than 70 percent of that group (Kilo 1994). [FIGURE 4.6 OMITTED] [FIGURE 4.7 OMITTED] The direct costs of education are higher for girls, and demand forgirls' education is more elastic in relation to costs. Even if thedirect costs of education were similar for boys and girls, parents woulddecide differently about educating daughters than sons. An increase indirect costs, such as higher fees, might not appreciably ap��pre��cia��ble?adj.Possible to estimate, measure, or perceive: appreciable changes in temperature.See Synonyms at perceptible. reduce thedemand for boys' education, but might substantially reduce schoolenrollment for girls. This means that subsidizing direct costs shouldaffect girls' enrollment considerably more than boys'.Box 4.1 How Distance from School Affects Girls' EducationIn a 1992 study based on living standards survey data for1987/88, Victor Lavy estimates the determinants of childschooling for girls and for boys. He finds that girls wholive further from primary schools have a significantlyhigher probability than boys of never attending school.For boys, distance from the nearest primary school is nota significant determinant. Lavy also finds that girls wholive further from a primary school attain significantlyfewer years of schooling than similar girls who live closer.For boys, distance from primary school has no statisticallysignificant effect on the length of schooling.For middle and secondary levels, distance negativelyaffects boys' and girls' schooling equally. After primaryschooling, it appears that other factors, such as qualityof education and perceived returns to education,explain gender differentials in schooling.Because distance from school significantly affectswhether (and for how long) girls attend primary school,but is not an important determinant of boys' schoolingpatterns, making schools available closer to home maybe an effective policy response for reducing the gendergap in primary education. But to reduce the gender gapin middle and higher grades, policy should focus more onimproving the quality and relevance of what is taught. Cultural and Social Constraints Because of safety and cultural concerns, parents tend not to sendtheir daughters to school unless schools are located close to home,equipped with appropriate facilities (such as separate lavatories forgirls) and well supervised, and are served by female teachers. Culturalfactors such as early marriage and the high value placed on havingbabies (as opposed to attending school), result in girls' earlyexit from schools, especially in the north (Asomaning and others 1994),and influence the choices that girls can make in such an environment. Throughout Sub-Saharan Africa cultural prejudices adversely affectgirls' academic performance. These are reflected in teacher bias(especially in different expectations of boys and girls), classroomseating arrangements seating arrangementsnpl → distribuci��n fsg de los asientosseating arrangementsseat npl → Sitzordnung fseating arrangements, and an unequal division of school-basedactivities. Evidence from many African countries indicates both male andfemale teachers' tendency to favor boys (Anderson-Levitt, Bloch,and Soumere 1994, Davison and Kanyuka 1992, Kilo 1994, Prouty 1991).Bias demonstrated by teachers, parents, and students was also consideredresponsible for the girls' poor performance in science and math,subjects considered a male domain, in which girls who do achieve areusually discouraged from making further progress. A shortage of female teachers inhibits girls' schoolattendance, especially in the rural and northern parts of the country(where the proportion of women teachers and the availability ofqualified female personnel is low). The proportion of female teachers atjunior secondary and higher levels is low all over the country, exceptin Accra. Only 22 percent of teachers in public schools at the juniorsecondary level are women. Only 14 percent of teachers are female in thenorthern, upper east, and upper west regions, and only 11 percent in theBrong Ahafo region. Low Perceived Returns to Girls' Education Whether parents decide to send their children to school depends onhow relevant they perceive education and how they assess the quality ofteaching. If schooling is unlikely to result in higher income, betterjobs, a better lifestyle, or the acquisition of skills needed for dailylife, parents will have little motivation to educate their children. Andwhen barriers in the labor market or cultural norms in society preventwomen from taking up formal employment, the returns to girls'education are perceived as low. A supervision mission of the GhanaCommunity Secondary Schools Construction Project found that 10 percentfewer girls than boys were enrolled in secondary technical schoolsbecause parents considered the curriculum of the senior secondaryschools inappropriate for their daughters. Improving Girls' Education Efforts to improve girls' access to education must both reducethe direct and indirect costs of education and change parents'perceptions about the benefits of girls' education. Manyinterventions required to increase girls' access to educationextend beyond the education sector. Removing gender-based discriminationin the labor markets, for example, or prescribing special quotas forwomen's employment in the formal sector, would increase theperceived returns to girls' education and persuade more parents tosend their daughters to school. Improvements in the transportationsystem would reduce the time girls need to be away from home and wouldease parental concerns about girls' safety. During preparation of the Ghana Basic Education Sector ImprovementProject, the government of Ghana and World Bank officials workedtogether to identify specific strategies for achieving better genderequity in primary education. Some of those strategies are listed below.Similar collaboration is needed to develop strategies for thepostprimary level and the nonformal subsector, and for"retrofitting" ongoing projects. Strategies to strengthen human capital, especially by improvinggirls' education, include: * Addressing girls'time constraints. To reduce disparities inthe household division of labor between boys and girls probably requiressome communication and public education activities. Interventions thatreduce demands on women's time--such as ensuring closer sources ofwater and introducing fuelsaving technologies--will increase thelikelihood of girls' schooling. Providing school-based childcarecenters would permit girls to attend schools by alleviating theirsibling sibling/sib��ling/ (sib��ling) any of two or more offspring of the same parents; a brother or sister. sib��lingn. care commitments. * Offering a more flexible school schedule. This would entailorganizing school hours so that they do not conflict with girls'household and other tasks. Schools that run double shifts could givehouseholds flexibility in selecting time slots appropriate for theirdaughters. Such strategies should assess both cost-effectiveness and therisk that girls might be overloaded o��ver��load?tr.v. o��ver��load��ed, o��ver��load��ing, o��ver��loadsTo load too heavily.n.An excessive load.Adj. 1. with both household and educationalresponsibilities. * Increasing the reach of the education system. Making sure thatschools are available would substantially increase girls'enrollment by reducing the distance and time required to travel to andattend schools. Distance to schools can be reduced in two ways: bybringing schools closer to homes or by providing boarding facilities, toenable girls to attend distant schools. * Subsidizing education for girls. Given the large positiveexternalities externalitiesside-effects, either harmful or beneficial, borne by those not directly involved in the production of a commodity. associated with educating girls, a strong case can be madefor subsidizing girls' education. Some of the high direct costs toparents of educating girls can be reduced and girls' enrollment andacademic performance can be improved by providing such incentives asscholarships, fee waivers, and free textbooks. Such incentives would beespecially helpful in the northern sector and districts wheregirls' enrollment is particularly low. * Organizing information, education, and communication campaigns toencourage investing in girls' education. A nationwide campaigndirected mainly at parents and community leaders could provideinformation about the economic and social benefits of girls'education. It could raise awareness about how gender discriminationaffects girls' enrollment, retention rates, and academicperformance. * Improving the quality of education by reforming textbooks,curriculum, testing, and teacher training. Incremental spending oncurriculum design, textbooks, and other inputs to improve school qualityare most important for students' learning. Having blackboards inthe classroom, for example, significantly increases students'cognitive achievement. The quality of education is especially importantfor removing the gender gap at middle and higher levels of education. * Making the school environment more gender-sensitive. This willentail gender training for teachers, and creating school facilities thatmeet girls' needs. Because gender-sensitization needs to begin withthe teachers themselves, training needs should be reviewed for both newand experienced teachers. * Recruiting more women to teach at the junior secondary level andhigher. The shortage of female teachers is much greater in the rural andnorthern parts of the country. Several steps can be taken to changethis, including appropriate salary incentives for serving in underservedareas, targeting recruitment of female teachers from local regions orareas, and removing age restrictions for recruitment. * Providing community-managed accommodations for girls in secondaryschools. Girls represent only 10 percent or less of the studentpopulation in secondary schools because schools lack accommodations andmany girls and their parents do not consider the technical educationoffered appropriate for girls. * Encouraging school-age mothers to resume their schooling and helpthem do so. This could require some form of subsidy or community effortsto sustain young mothers for an appropriate period (with babysitting orother assistance). The cultural, economic, and social feasibility ofsetting up school-based childcare centers in Ghana is a sensitive issue. * Expanding nonformal education for out-of-school girls and women.In 1989 the government of Ghana launched the Functional Literacy Programand established the Non-Formal Education Division within the Ministry ofEducation. Supported by the World Bank, ODA ODA - Open Document Architecture (formerly Office Document Architecture). , the Kingdom of Norway, andother sponsors, the program has about 400,000 learners (of which 250,000are women). By collaborating with NGOs and other partners, the programis looking for ways to expand access and become sustainable. Enrollingmore women and out-of school girls in the program would eventually makeit even more responsive to their needs.Box 4.2 The Direct Costs of Girls' Schooling (Ghana, 1991-92)Data for 1991-92 show a marked disparity in the direct costs ofschooling for girls and boys. Households have to spend more ongirls than on boys at all levels of education, and this genderdisparity in direct costs increases with the level ofschooling--from a difference of about 1,000 cedis at the primarylevel to 24,000 cedis at the tertiary level. These differencesremain after taking into account income levels and place ofresidence.At the primary and middle school levels, girls pay more on averagefor almost all components of direct costs. Note the considerablyhigher costs for girls' uniforms and for room and board below.[FIGURE 4.2a OMITTED][FIGURE 4.2b OMITTED] STATUS OF WOMEN'S HEALTH Women's HealthDefinitionWomen's health is the effect of gender on disease and health that encompasses a broad range of biological and psychosocial issues. Women's fertility, health, and economic well-being are closelylinked. The timing and frequency of childbearing and the number ofbirths have important implications for women's health andparticipation in economic activities. A typical Ghanaian woman ispregnant or breastfeeding during 16 years of her productive life. Thislong period of reproduction places heavy demands on women's healthand energy and severely restricts the types of economic activities womencan undertake, the length of time they can devote to them, theirproductivity, and their ability to migrate. And the effects of poorhealth extend beyond physical suffering. Poor health can diminish agirl's learning in childhood and reduce returns to human andphysical capital during the economically productive period of awoman's adult life. Gender Issues in the Health Sector Gender issues in the health sector are difficult to identifybecause of the marked differences in the health needs of men and women.Men and women exhibit different patterns for causes of death, differentpatterns of morbidity and mortality Morbidity and Mortality can refer to: Morbidity & Mortality, a term used in medicine Morbidity and Mortality Weekly Report, a medical publication See alsoMorbidity, a medical term Mortality, a medical term , and different needs and uses ofhealth services health servicesManaged care The benefits covered under a health contract . Lack of disaggregated Broken up into parts. data about health conditions andthe use of health services precludes a detailed gender analysis of thesector, but some priority gender issues emerge based on availableinformation. Clearly some traditional practices (such as female genitalmutilation genital mutilationThe destruction or removal of a portion or the entire external genitalia, which may occur in the context of a crime of passion or as part of a cultural rite. See Bobbittize, Cutter, Female circumcision, Self-mutilation. ) call for immediate and sustained attention. Existing lawsare neither uniformly enforced nor consistently monitored. At first glance the statistics show no striking gap between thehealth status of men and women in Ghana; indeed, the health outcomes ofwomen appear to be better than those of men (Table 4.1). Life expectancy Life Expectancy1. The age until which a person is expected to live.2. The remaining number of years an individual is expected to live, based on IRS issued life expectancy tables. at birth for women (which has improved) was 59.2 in 1993, compared with55.5 for men. The infant mortality rate infant mortality raten.The ratio of the number of deaths in the first year of life to the number of live births occurring in the same population during the same period of time. for girls is significantly lowerthan that for boys and the nutritional status nutritional status,n the assessment of the state of nourishment of a patient or subject. of girls is better, onaverage, than that for boys. Although 61.2 percent of girls between theages of 1 and 2 years were immunized for DPT and polio polio:see poliomyelitis. , compared with63.4 percent of boys the same age, there is no evidence of extremegender discrimination in the immunization immunization:see immunity; vaccination. of children. But this apparent equality between the sexes is at least partlyattributable to women's biological advantage over men. Afterallowing for women's biological advantage, analysis shows womenfacing several gender-specific barriers to health care services.According to one estimate, if there were no discrimination againstgirls, the female infant mortality rate should be 63.8 per 1,000 inGhana (Hill and Upchurch 1995). (This study uses sex-specific mortalityrates from parts of 19th century northwestern Europe as a referencepoint, assuming that discrimination against girls was less pronounced inthose societies). But the prevalent rate of female infant mortality (hardware) infant mortality - It is common lore among hackers (and in the electronics industry at large) that the chances of sudden hardware failure drop off exponentially with a machine's time since first use (that is, until the relatively distant time at which enough mechanical ismuch higher (70.1) suggesting discrimination against girls in someaspects of nutrition and health care. Parents are likely to be more responsive to the health care needsof boys than those of girls (GSS (storage) GSS - Group-Sweeping Scheduling. 1993). Of children who were sick withfever in the two weeks before the survey, 43 percent of boys (and only35 percent of girls) were taken to a health care provider. Access to medical care appears to follow a Kuznet's curve,with smaller gender inequities in the extremes of poor and nonpoorpopulations and more pronounced inequities in the middle of thedistribution (Figure 4.8 shows the distribution of health-care-seekingbehavior, by consumption quintiles Quintiles Transnational Corp. is a contract research organization which serves the pharmaceutical, biotechnology and healthcare industries. HistoryQuintiles was founded in 1982 by Dennis Gillings and as of 2007 it has 18,000 employees. for males and females). Theproportion' of the population seeking health care goes up withconsumption, for both men and women, but the pattern of increase isdifferent for men and women. In the top and bottom two quintiles womenare more likely to seek health care than men; in the middle quintile quin��tile?n.1. The astrological aspect of planets distant from each other by 72�� or one fifth of the zodiac.2. Statistics The portion of a frequency distribution containing one fifth of the total sample. thereverse is true. In the bottom two quintiles men and women may seekhealth care only for absolutely urgent health conditions. Any marginalincome in poor households may go to the health care needs of the malemembers of the household. Women's health care needs and vulnerabilities are alsodifferent from those of men, for social and biological reasons. Menmaybe more vulnerable to heart disease and accidents, but women are morelikely to experience other health problems. In Ghana, for example, theprevalence of HIV HIV(Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. and AIDS is higher among women than men--more thanthree times as many cases of AIDS were reported among women in the primeages of 20-29 than among men (Figure 4.9). (Women are more vulnerable toHIV, AIDS, and other sexually transmitted infections partly because theyhave so little control of their own sexuality, both in and out ofmarriage, partly because they are exposed to an extensive sexual networkthrough their male partners' polygamous polygamousas a male or female, having more than one mate. or promiscuousrelationships, and partly because they are not knowledgeable about howthe infections are transmitted and how to prevent them). No reliabledata are available about sexually transmitted diseases Sexually transmitted diseasesInfections that are acquired and transmitted by sexual contact. Although virtually any infection may be transmitted during intimate contact, the term sexually transmitted disease is restricted to conditions that are largely , but women mayalso have higher rates of such infections than men (University of Sussex1994). A study of a rural community in northern Ghana also shows womenwith a four times higher incidence of lymphatic lymphatic/lym��phat��ic/ (lim-fat��ik)1. pertaining to lymph or to a lymphatic vessel.2. a lymphatic vessel.lym��phat��icadj. filariasis filariasis:see elephantiasis. than men. The direct health consequences of childbearing are borne only bywomen, and the average Ghanaian woman bears and raises six children,which absorbs much time, energy, and nutrition. Ghana's maternalmortality rates are very high; by a conservative estimate, one out of 71women dies from pregnancy-related complications. High levels offertility also lead to high levels of malnutrition malnutrition,insufficiency of one or more nutritional elements necessary for health and well-being. Primary malnutrition is caused by the lack of essential foodstuffs—usually vitamins, minerals, or proteins—in the diet. among women: morethan two-thirds of pregnant women are anemic anemicpertaining to anemia. (GSS 1993). Repeated andfrequent childbearing affects a woman's health and places greaterdemands on her time. The resulting time constraints limit women'sparticipation in economic activities. Early childbearing is a major health issue in Ghana. The median ageof marriage for women is about 19, a figure significantly below thelegal age of marriage (21); the median age of marriage for men is over25, at which age nearly all women are married (GSS 1993). More than 60percent of women are already mothers or pregnant by the time they are20. Early sexual activity, marriage, and childbearing adversely affectboth men and women, but the consequences are more severe for women. Notonly is early childbearing potentially life-threatening for young women,but it ends their education. Together with other factors, earlychildbearing starts a process that reduces women's economicmobility and confines con��fine?v. con��fined, con��fin��ing, con��finesv.tr.1. To keep within bounds; restrict: Please confine your remarks to the issues at hand.See Synonyms at limit. them to low paying work. On top of their higher vulnerability to some diseases and theirmaternal health Maternal health care is a concept that encompasses preconception, prenatal, and postnatal care. Goals of preconception care can include providing health promotion, screening and interventions for women of reproductive age to reduce risk factors that might affect future pregnancies. needs, women are often discriminated against in theintrahousehold allocation of resources allocation of resourcesApportionment of productive assets among different uses. The issue of resource allocation arises as societies seek to balance limited resources (capital, labour, land) against the various and often unlimited wants of their members. for health care and nutrition.And gender-insensitive health facilities and medical procedures mayfurther constrain con��strain?tr.v. con��strained, con��strain��ing, con��strains1. To compel by physical, moral, or circumstantial force; oblige: felt constrained to object.See Synonyms at force.2. women's access to health care. Their resultingpoor health and under-nutrition make them more vulnerable to illness andreduce their economic productivity. Attention to gender issues in health sectors rarely goes beyondwomen's reproductive health Within the framework of WHO's definition of health[1] as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene needs. It should be more comprehensive.A gender-responsive strategy for the health sector would address thediffering health care requirements of men and women. It would especiallyaddress problems related to: * Women's access to health services. * High levels of fertility. * Young adults' reproductive and health needs. [FIGURE 4.8 OMITTED] Women's Access to Health Services Women use health care facilities less than they need to (Universityof Sussex 1994). Their demand for health services is low for severalreasons: * Women are socialized so��cial��ize?v. so��cial��ized, so��cial��iz��ing, so��cial��iz��esv.tr.1. To place under government or group ownership or control.2. To make fit for companionship with others; make sociable. to view pain and illness as a normal part oflife, not worth medical attention. Cultural beliefs sometimes limitwomen's use of health services. In some parts of Ghana, forexample, an unassisted delivery is considered a sign of courage, and adifficult delivery a punishment for infidelity (Thaddeus and Maine1990). * The opportunity cost of time traveling and waiting for healthservices is a major part of the total cost of health care in many partsof Ghana. This deters both men and women but affects women more becauseof their greater time constraints. * The direct cost of health services, such as fees and the cost ofmedicine, is more of a barrier to women than men in many countries. AndGhana is no exception, because its women tend to be poorer than men andhave less bargaining power in the household. Women's access to health care is further constrained con��strain?tr.v. con��strained, con��strain��ing, con��strains1. To compel by physical, moral, or circumstantial force; oblige: felt constrained to object.See Synonyms at force.2. by theway health services are organized and provided. Despite governmentefforts to ensure equity, Ghana's health delivery system stillshows a perceptible bias toward urban areas. As in most developingcountries, Ghana's public health resources are concentrated inurban hospitals, which is both inefficient and inequitable. Theseinefficiencies adversely affect women more than men. Moreover, healthfacilities (usually managed by men) may not be sensitive to women'sneed for privacy, counseling, and confidentiality. [FIGURE 4.9 OMITTED] Barriers to women's access to health services that derive fromdecisions made at the household level may not be amenable AMENABLE. Responsible; subject to answer in a court of justice liable to punishment. to policyinterventions in the short run. Social change that gives women morestatus and bargaining power in the household requires sustained effortsto improve human capital and economic productivity. But even in theshort run, public policies can improve women's access to healthservices by reducing costs to women and by informing households aboutwomen's health needs and problems. To address the problems ofwomen's limited mobility and the higher opportunity cost of theirtime, resources could be allocated to improve the quality of locallyavailable services and to promote community outreach. The governmentcould report to the nation, using TV and radio, the programs andinitiatives it intends to implement. A well-considered, sustainedcommunication policy would be more effective in this respect than aone-time effort. High Fertility Levels Ghana's total fertility rate The total fertility rate (TFR, sometimes also called the fertility rate, period total fertility rate (PTFR) or total period fertility rate (TPFR)) of a population is the average number of children that would be born to a woman over her lifetime if she (the number of children theaverage woman would have if she survived her entire reproductive lifeand followed the current schedule of age-specific fertility) in 1993 was5.5 , but that figure varied regionally. Rural women have about 60percent more children than their urban counterparts. Rural women average6.4 children each; urban women, 4. Women in Accra average 3.4 children;those in the northern region, 7.4. However, there is evidence of adecline in fertility over the past 15 years--from a total fertility rateof 6.4 in 1988 to 5.5 in 1993. But although fertility has declinedoverall, many births are high risk, for both mothers and newborns.(High-risk births include higher than third-parity births, births withintwo years of a previous live birth, and births by mothers younger than18 or older than 34. These births pose higher health risks to bothmother and newborn newborn/new��born/ (noo��born?)1. recently born.2. newborn infant.new��bornadj.Very recently born.n.A neonate. .) In 1993 at least 75 percent of mothers hadexperienced at least one high-risk birth in the previous five years. Itis not surprising that maternal mortality in Ghana is high (GSS 1993,1995). Desired levels of fertility in Ghana are significantly lower thanactual fertility (Figure 4.10). On average, woman have 1.3 more childrenthan they wish to. Unwanted pregnancies happen to educated anduneducated women, both rural and urban, but in urban areas women want2.9 children on average, but actually have 4.0, and in rural areas womenwant, on average, only 4 children, but have 6.4. Contraceptive contraceptive/con��tra��cep��tive/ (-sep��tiv)1. diminishing the likelihood of or preventing conception.2. an agent that so acts. use has risen in recent years (from 13 percent in1988 to 20 percent in 1993). This change is particularly noticeable innorthern Ghana, where there was previously little use of contraception contraception:see birth control. contraceptionBirth control by prevention of conception or impregnation. The most common method is sterilization. The most effective temporary methods are nearly 99% effective if used consistently and correctly. .Influential women (wives of chiefs and queen-mothers) have led thispositive trend, much of which is attributable to the increased use ofmodern contraceptives (which doubled during this period, from 5 percentto 10 percent). The potential demand for contraception is much higher.Many married women want to limit their childbearing or to space thebirth of their next child, but do not use contraception. The percentageof women with this unmet un��met?adj.Not satisfied or fulfilled: unmet demands.need for contraception is 35.4 in urban areasand 40.1 in rural areas (Box 4.3). Program planners should tap thislarge unmet need by developing a more user-oriented strategy for familyplanning family planningUse of measures designed to regulate the number and spacing of children within a family, largely to curb population growth and ensure each family’s access to limited resources. and by fine-tuning the delivery of existing programs. [FIGURE 4.10 OMITTED] Why the prevalence of unwanted fertility and the persistence of anunmet need for contraception? How can programs meet this need? Womenwith an unmet need often differ from contraceptive users in two keyways: * They have little knowledge about contraception. * They have little access to family planning services. Contraceptive use can be increased, and unwanted fertility greatlyreduced, by addressing the unmet need for contraception (Table 4.2).Meeting that need will require providing complete information aboutcontraceptives and where to get them, improving the quality of familyplanning facilities, and involving men in family planning.Box 4.3 Why the Unmet Need for Contraception?Women with an unmet need for contraception usually donot know about contraceptive methods. They have, onaverage, heard of only 1.3 contraceptive methods, comparedwith women who use contraceptives, who haveheard of 2.6 methods. In a 1993 survey women whointended to use contraception were asked their reasonsfor not doing so currently. Significantly, 24 percent ofthose who did not want a child responded that they didnot know enough about contraception. Although knowledgeabout contraceptives is increasing in Ghana, womenmay not have full knowledge about a contraceptive suitableto their lifestyle (Ministry of Health 1992; Koomsonand others 1991). An appropriate information, education,and communication effort is needed.Poor access to services is another reason for thisunmet need, as reflected in the different levels of unmetneed between rural and urban areas (even after controllingfor educational levels). Access to services is crucialin shaping women's demand for health care andcontraception. Because of demands on women's time,if using health care and contraception takes too muchtravel and waiting time, they will not be able to usethem.One of the main reasons for women's unmet needsfor contraception in Ghana is their male partner's oppositionto contraception. Research on the issue showsthat:* Men typically prefer larger families than women do--accordingto a 1993 survey, the average ideal familysize for women was 4.4 children; for men, 4.8.* When men want more children than women, men'spreferences usually prevail. A woman would usuallynot use contraception if the male partner were unwilling(University of Sussex 1994).* Men rarely use contraceptives themselves and often areopposed to their women partners using contraceptives.As table 2 shows, women with an unmet need for contraceptionand women who use contraceptives are similarin their approval of family planning, but they differconsiderably on whether their male partners approveof family planning. Among women who approve of andwant family planning, but do not use contraceptives,63 percent have husbands who also approve of familyplanning. Among women who use contraceptives, 81percent of the husbands also want family planning.Clearly, the husband's attitude greatly affects whethera woman adopts contraception. Currently, distributionand counseling for contraceptives is targeted largelyto women. There should be a greater involvement ofmen in family planning programs. Pregnancy and Child bearing Among Young Adults' In Ghana sexual activity, marriage, and childbearing typicallyoccur early in life. The median age for first marriage is 19 for women,but the median age for first sexual intercourse sexual intercourseor coitus or copulationAct in which the male reproductive organ enters the female reproductive tract (see reproductive system). is 17. Women are waitinglonger than they used to to get married but their age at firstintercourse has not changed. More than 85 percent of women experiencesexual intercourse before the age of 20 and women are increasinglybecoming sexually active before marriage. There are two distinct patterns for adolescent fertility.Childbearing for young married women, mostly in rural areas, begins withthe approval--often the insistence--of their families, either out ofeconomic necessity or because it is the social norm. But a secondpattern, increasingly common in Ghana, is premarital childbearing,usually without society's approval. Both patterns have severenegative effects on health and economic well-being, but premaritalchildbearing may have more serious consequences for women, as they arenot supported by society or, in many cases, by their male partners. Sexually active young women are less likely to use contraceptionthan adults, even within marriage. Only 11 percent of all women and 13percent of married women in the age group 15--19 use contraceptives,compared with overall contraceptive use of 19 percent. Young unmarriedwomen may face even more barriers to getting contraceptives, includingsocial disapproval, and are even less likely to use contraception thanyoung married women. The most common reason young women gave for notusing contraception is that they did not expect to have intercourse Verb 1. have intercourse - have sexual intercourse with; "This student sleeps with everyone in her dorm"; "Adam knew Eve"; "Were you ever intimate with this man?" ; thesecond most common reason is that they did not know about contraception.Other, more subtle, reasons for not using contraception includeembarrassment, inability to discuss and negotiate contraceptive use, andsocial attitudes against using contraception (Adomako 1991; McCauley andSalter salt��er?n.1. One that manufactures or sells salt.2. One that treats meat, fish, or other foods with salt.Noun 1. 1995). Early sexual activity and marriage lead to early pregnancies. Bythe time girls are 20 years old, 64 percent are already mothers or arepregnant. More than 20 percent of women have given birth to two or morechildren by the age of 20. Most of these pregnancies are likely to beunintended; roughly 46 percent of current pregnancies and 69 percent ofbirths among young women (ages 15 to 19) are unwanted or mistimed mis��time?tr.v. mis��timed, mis��tim��ing, mis��timesTo time inaccurately or inappropriately; misjudge the timing of: The basketball team mistimed the final play and lost the game. . Evenamong young married women most births are unintended (GSS 1993). Early sexual activity, childbearing, and marriage have negativelong-term implications for women's health and economic well-being.Risks associated with sexual activity and childbearing are the mostserious health dangers young people face. And the fallout fallout,minute particles of radioactive material produced by nuclear explosions (see atomic bomb; hydrogen bomb; Chernobyl) or by discharge from nuclear-power or atomic installations and scattered throughout the earth's atmosphere by winds and convection currents. from earlychildbearing does not end with delivery; early birth compromiseswomen's lifelong potential as economically productive human beings.The economic consequences of early sexual activity and child marriageinclude less investment in human capital and less earning potential. According to the 1993 Ghana Demographic and Health Survey, girls 10to 19 represent 21 percent of Ghana's female population. Theseyoung women--who represent the potential of future development andgrowth for Ghana--need to protect themselves from unwanted sex,unplanned pregnancy, early childbearing, unsafe abortions, and sexuallytransmitted diseases. But Ghana's health and family planningprograms focus primarily on married adult women. Also important areprograms and approaches that meet young people's needs effectivelyyet remain politically acceptable. The Ministry of Education, in collaboration with the PlannedParenthood Planned ParenthoodA service mark used for an organization that provides family planning services. Association of Ghana, provides family life education tostudents in junior and senior secondary schools, but these efforts arefragmented, the resources spread too thin. Because schools reach fewerthan half of the adolescents in the country, a more comprehensiveapproach is needed. This will require interministerial cooperation. TheMinistries of Health, Education, Employment, Information, and Youth andSocial Welfare could join forces in planning and implementation tosupport and complement each other's activities. Young adults'reproductive and health needs require more attention if Ghana'syouth, especially its young women, are to achieve their potential andcontribute to the country's economic growth. Improving Women's Health Improving women's health in Ghana requires improving theiraccess to health services, satisfying the unmet need for contraception,and satisfying young adults' health and reproductive needs. Improving Women's Access to Health Services * Reorient Re`o´ri`enta. 1. Rising again.The life reorientout of dust.- Tennyson.Verb 1. the health care system to meet women's needs. Somediseases, including HIV and other sexually transmitted diseases, afflict af��flict?tr.v. af��flict��ed, af��flict��ing, af��flictsTo inflict grievous physical or mental suffering on.[Middle English afflighten, from afflight, women more than men, so programs to control and prevent these diseasesshould have a strong gender focus. Health staff at all levels should besensitized sensitized/sen��si��tized/ (sen��si-tizd) rendered sensitive. sensitizedrendered sensitive.sensitized cellssee sensitization (2). to women's needs and problems. * Bring services closer to women by reducing their costs in timeand travel. Improving women's access to services requires improvingoutreach and expanding primary health care. More women can be reached byhealth services if the quality of care on the periphery periphery/pe��riph��ery/ (pe-rif��er-e) an outward surface or structure; the portion of a system outside the central region.periph��eral pe��riph��er��yn.1. is strengthened.There needs to be less focus on urban tertiary care tertiary careManaged care The most specialized health care, administered to Pts with complex diseases who may require high-risk pharmacologic regimens, surgical procedures, or high-cost high-tech resources; TC is provided in 'tertiary care centers', often and more on primarycare. This means providing underserved rural areas with trained healthworkers; essential drugs, equipment, and supplies; outreach programs;and adequate health facilities. * Integrate nongovernment providers into the health system.Ghana's efforts to train traditional birth attendants and privatepractitioners have shown some positive results (Timyan and others 1993).But some have questioned their integration into (and support from) thehealth system (University of Sussex 1994). Intensifying the trainingprograms and strengthening their link with traditional health careproviders are crucial for improving women's access to health care. Meeting the Unmet Need for Contraception * Reorient and intensify in��ten��si��fy?v. in��ten��si��fied, in��ten��si��fy��ing, in��ten��si��fiesv.tr.1. To make intense or more intense: information, education, and communicationactivities to provide detailed information about contraceptives andwhere to get them. One of the main reasons for the unmet need forcontraception in Ghana is the lack of correct information aboutcontraceptives. More intensive public education can help meet this need.Such activities could also be reoriented, as many current efforts aredirected at creating demand for contraception by promoting smallfamilies (instead of providing information about contraception wheresuch demand already exists). Efforts to educate the public aboutcontraception could be based on research that identifies which messageshould go to which audience, using which medium. * Improve outreach of contraceptive services. Much of the demandfor contraceptives in Ghana is for methods for spacing births.Nonmedical people can provide this service so access to contraceptiveservices can be improved by extending the outreach of family planningprograms through community-based distribution of contraceptives, byinvolving local traditional birth attendants, and by using socialmarketing techniques. * Involve male partners more in family planning. Future publiceducation activities could focus on men--seeking their involvement infamily planning and addressing their misgivings about contraception.Contraceptive counseling could include male partners. Contraceptivescould increasingly be distributed through male-dominated work and marketplaces.Box 4.4 How Do Early Sexual ActivityTeenage pregnancies are risky for both mothers and children becauseadolescents are economically and biologically unprepared forchildbearing and childrearing. According to one estimate, mothersaged 15 to 19 are five times more likely to die ofpregnancy-related complications than others (GSS 1995). Andchildren born to these women are 1.5 times more likely to die thanthose born to women 20 to 29 years old (GSS 1993).Young adults are more vulnerable to sexually transmitted disease,including HIV, for biological and social reasons. Pathogens fromsexually transmitted diseases can more easily penetrate the mucusmembranes of young women than of older women. Young women usuallyalso have little knowledge of safe sex or lack the skill andmaturity to negotiate condom use--particularly with an olderpartner (who is more likely to be infected).Faced with unintended pregnancies, many young women turn toabortions. Young unmarried women are more likely than older womento seek abortions from untrained providers and to attempt late,dangerous, and self-induced abortions, which may result in lifelongdisability, infertility, or death (McCauley and Salter 1995).Many young women who become pregnant are still in school. Most ofthem do not return to school after giving birth because they haveto look after the child. In 1993, of women 15 to 19 who had givenbirth or were currently pregnant, only 1 percent attended school,compared with 37 percent of the women who had not startedchildbearing. (Causality is unclear. Is it that educated womendelay their childbearing, or childbearing brings women's educationto an end, or some other factor such as the status of women orurbanization?) Whatever the underlying cause, pregnancy andchildbearing are significant causes of the gender gap in schoolenrollment for this age group.Finally, early parenthood, combined with little formal education,can narrow job options for women, partly by restricting theirmobility. This is particularly true for women who do not getfinancial and emotional support from their male partners.Source: 1991/92 Ghana Living Standards Survey. Based on McCauleyand Salter 1995. Meeting Young Adults' Reproductive and Health Care Needs * Build consensus among parents, teachers, and religious bodies onhow to address the needs of young adults. There needs to be a clearpolicy on how much and what type of information to give to young people,at what age, and whether to use mass media to distribute it. Part ofthis initiative could be to encourage better communication betweenparents and children about reproductive issues. * Extend and strengthen family life education. The national schoolcurriculum needs to convey accurate, useful information aboutreproduction, safe sex, AIDS, and sexually transmitted diseases. Aseparate plan will be needed to reach out-of-school young adults, whocould be reached through mass media or at places where young adultsgather. * Make reproductive health services more friendly toward-youngadults. The idea of providing large-scale service delivery programs tomeet the needs of young adults may be politically explosive. But currentprograms can address those needs by modifying the current programorientation. For example, outreach workers could provide counseling toadolescents during house visits (as they do to married women). Edited by Shiyan ChaoTable 4.1 Health Indicators by GenderHealth indicator Male FemaleLife expectancy 55.5 59.2Infant mortality rate (per 1,000) 79.2 70.1Under-five mortality (per 1,000) 137.5 127.9Nutrition (percent below 3 standard deviation units) (a) Height for age (a) 9.2 8.9 Weight for height (a) 2.7 1.8 Weight for age (a) 8.6 7.4Immunization (percent) (b) BCG (Tuberculosis) 84.6 81.4 Diptheria, pertussis, tetanus 63.4 61.2 Polio 63.4 61.2 Measles 62.5 66.4(a.) Figures are for children born I to 35 months before the survey.Kach index is expressed as a proportion of the sample population under3 standard deviations from the median of the NCHS/CDC/WHOinternational reference population.(b.) Expressed as percentage of children 12 to 23 months old who hadreceived vaccine by the time of the survey.Source: GSS forthcoming, for life expectancy; GSS 1993, for the rest.Table 4.2 How Women Who Use Contraceptives Differ from Those Who DoNot (But Want Fewer Children) Women with unmet need Contraceptive forCharacteristics users contraceptionThink it is difficult to get access to services (percent) 19 28Do not know where to find modern contraceptive methods (percent) 4 26Average travel time to the nearest source (minutes) (a) 49 64Average number of family planning methods known 2.6 1.3Approve of family planning (percent) 98 91Think their husbands approve of family planning (percent) 81 63Have heard family planning messages on radio (percent) 53 31Have not discussed family planning with their husbands in past year (percent) 28 56Live in rural area 52 71Have no education 17 42Have primary education 65 54Have secondary education or above 18 4(a.) Excludes those who do not know a source or the distance to asource.Source: 1991/92 Ghana Living Standards Survey.