Nutrition situation in Ghana

Over the past couple of years, Ghana has achieved significant economic growth leading to its recategorisation as a Lower Middle Income Country in 2011. In 2011, for example, Ghana's economy grew at 14·4 %, boosted by oil production and a rebounded construction sector^{( 1 )}. The most recent Ghana Living Standards Survey estimates that about 24 % of the Ghanaian population are below the poverty line^{( 2 )}. The figure was reported to be 40 % in 2008^{( 3 )}. However, economic gains have not translated into improvements in maternal and child nutrition, as indicators of poor maternal and child undernutrition remain high. According to the 2008 Ghana Demographic and Health Survey, one in ten children in Ghana are born with low birth-weight. The report also revealed that close to 30 % of children younger than 5 years are stunted, while 60 % are anaemic^{( 4 )}. The same report revealed that about 80 % of Ghanaian women are anaemic. Based on her poor child growth statistics, Ghana is categorised among the thirty-six countries with the highest burden of global stunting⁽ Reference Black, Allen and Bhutta ^{5 )}. In 2009, the World Food Programme estimated that about 5 % of Ghanaians (about 1·2 million) were food insecure and an additional 9 % (about 2 million) at risk of food insecurity^{( 6 )}.

Politically, Ghana has demonstrated commitment to addressing her food security and nutrition problems, both locally and internationally. For instance, Ghana is a signatory to a number of international declarations endorsing the right of its citizens to adequate food and nutrition security. Local strategies to address food insecurity and undernutrition include the development of policies and programmes. These include the national breastfeeding policy (1995), the infant and young child feeding strategy (2007), the vitamin A policy (1998) and the food and drugs law and amendments on universal salt iodization (1995). Ghana subscribes to the Comprehensive Africa Agriculture Development Programme. In line with the vision, values and principles of Comprehensive Africa Agriculture Development Programme, Ghana's Medium Term Agriculture Sector Investment Plan for 2009–2015 promises among others, agriculture modernisation. The overall investment plan seeks to achieve agricultural gross domestic product (GDP) growth of at least 6 % annually and government expenditure allocation of at least 10 %^{( 7 )}. Two recent additions to the list are the development of a National Nutrition Policy (2014–2017) and her expression of intent to scale up nutrition as part of the global SUN movement.

However, the implementation of these policies and programmes has been plagued with inadequate financial commitment. This observation was clearly highlighted in the work of Brantuo et al. who evaluated the Ghanaian nutrition landscape to determine readiness to scale up effective interventions⁽ Reference Brantuo, Okwabi and Adu-Afuawuah ^{8 )}. Ghartey has examined the trajectory of nutrition policy and programming in Ghana since independence, and reports that the nation has moved from an era of nutrition education towards developing increased capacity in nutrition planning and cross-sectoral action⁽ Reference Ghartey ^{9 )}. Ghartey's work also demonstrates a history of inadequate financial commitment, including a low priority given to nutrition. The present paper builds on these earlier findings and aims to shed light on Ghana's commitment to nutrition, focusing on government intent as expressed in the national budget statement. National budgets are often seen as political documents; however, they are also important vehicles through which governments demonstrate commitment to addressing specific national challenges.

Why must the government of Ghana invest in nutrition?

Good nutrition is a basic building block of health, and has been argued in recent past as a significant contributor to economic development. There exists ample evidence showing a two-way relationship between nutrition and economic development^{( 10 – 15 )}. Malnutrition undermines economic growth and consequently exacerbates existing poverty. Healthier workers are more productive, and earn higher wages; they also help attract foreign direct investment⁽ Reference Bloom, Canning and Jamison ^{12 )}. A recent report titled, The Cost of Hunger in Africa: Social and Economic Impact of Child Undernutrition in Egypt, Ethiopia, Swaziland and Uganda, has emphasised that the medical costs and working days lost to poor nutrition heavily impacts a country's development (this is up to 16·5 % of GDP in Ethiopia)^{( 15 )}. Bhargava et al. ⁽ Reference Bhargava, Jamison and Lau ^{11 )} provide data in support of the hypothesis that survival rates directly correlate with GDP growth rates in low-income countries. A considerable number of children in less developed countries suffer from poor nutrition, and complete far less years and learn less per year of schooling than their counterparts of developed countries⁽ Reference Glewwe, Miguel, Schultz and Strauss ^{13 )}.

The 2008 Copenhagen consensus of eminent economists concluded that the return of investing in micronutrient programmes tops a list of thirty strategies to meet the world's development challenges⁽ Reference Horton, Alderman, Rivera and Lomborg ^{14 )}. The Lancet series on Maternal and Child Undernutrition published in January 2008 and June 2013 both provide evidence in support of these arguments. Collectively the evidence shows that making nutrition a priority is economically sensible.

Second, investment in nutrition in order to attain and sustain the highest standard of nutritional health is a requirement for the realisation of the population's positive rights. Monica Fish⁽ Reference Fish ^{16 )} describes the global nutrition, health and human rights actions of the last half-century through her review of a range of international instruments whose chief concern is the declaration and codification of basic human rights norms. The instruments reviewed included the Constitution of the World Health Organization (1946), the Universal Declaration of Human Rights (1948), the International Covenant on Economic, Social and Cultural Rights (1966), the International Code of Marketing of Breast Milk Substitutes (1981), the Convention of the Rights of the Child (1989), the Rome Declaration on World Food Security (1996) and the World Declaration on Nutrition (1992). These documents provide a normative and legal foundation for the human right to adequate food and nutrition, and freedom from malnutrition.

In line with the above, Ghana's Constitution acknowledges the right to good nutrition as a fundamental human right. However, it is unknown how these acknowledgements and commitments are translated into investment in nutrition. The present paper assesses the indication of government towards addressing nutrition based on provisions and appropriations for the year 2014. The Ghana 2014 budget was based on the Ghana Shared Growth and Development Agenda (GSGDA II: 2014–17)^{( 17 )}. The budget lists Expenditure & Amortization of Loans for Oil and Gas Infrastructure; Road and Other Infrastructure; Agriculture Modernization; Capacity Building Including Oil and Gas as key national Annual Budget Funding Amount spending priorities.

Resource mobilisation and allocation for fiscal year 2014

The data presented in the following sections are derived from our perusal of the 2014 budget statement of the Republic of Ghana. We studied the budget statement in its entirety and by sectors with the aim to identify allocations for direct nutrition interventions. We expressed allocations in absolute terms, and as a percentage of GDP or total expenditure. To provide a better picture of the overall national-level commitment to nutrition, relevant published literature, technical and programme reports were identified and included in the review.

Our review found that the estimated total non-oil revenue and grants for the 2014 fiscal year is projected at GH¢24 292·5 million, equivalent to 25·0 % of non-oil GDP. The total revenue from oil that will accrue to the budget is estimated at GH¢1709·4 million, equivalent to 1·6 % of GDP. Thus, total revenue and grants, including oil for the 2014 budget are estimated at GH¢26 001·9 million, equivalent to 24·6 % of GDP. Grants from development partners (DP) are estimated at GH¢1130·7 million (Table 1).

Table 1. Summary of revenue and grants estimates for 2014

Data source: Ministry of Finance, Ghana.

* 1US$ = 3·20 GH¢. Source: Bank of Ghana, 28 October 2014.

The total expenditure, including provision made for the clearance of arrears and outstanding commitments in 2014 is estimated at GH¢34 956·8 million, equivalent to 33·1 % of GDP. Of this amount, GH¢2816·2 million, equivalent to 2·7 % of GDP and 8·1 % of total expenditure would be used for the clearance of arrears and outstanding commitments. Compensation of employees which comprises wages and salaries, allowances, pensions, gratuities and social security contributions by government on behalf of its employees is estimated at GH¢10 597·3 million, representing 10·0 % of GDP. Expenditure on goods and services is estimated at GH¢1529·5 million, representing 1·4 % of GDP.

The allocations to various sectors (ministries, departments and agencies) are detailed in Table 2. Of note are the contributions of DP towards the budgeted allocations to selected nutrition-sensitive ministries. The review found that a little over 20 % of the allocated amount to the Ministry of Health were contributions from DP. The DP also contributed 30 % of the allocations made to the Ministry of Gender, Children and Social Protection. About 80 % of the amount allocated to the Ministry of Water Resources, Works and Housing; 61 % for the Ministry of Roads and Highways; 66 % for Ministry of Local Government and Rural Development and 58 % for the Ministry of Food and Agriculture were also contributed by DP (Table 2).

Table 2. Selected budgetary allocations by sector*

GoG, Government of Ghana; IGF, internally generated revenue; DP, development partners.

*Data source: Ministry of Finance, Ghana.

†1USD = 3·20 GH¢. Source: Bank of Ghana, 28 October 2014.

When we further expressed the allocations to the sectors as per cent of GDP (Fig. 1), we found that, with the exception of the Ministry of Health, no allocation to the nutrition-sensitive ministries was up to 1·0 % of the GDP. The allocations to the Ministries of Roads and Highways, Local Government and Rural Development, Food and Agriculture were each 0·3 % of the GDP. An identical trend is observed when the allocations were expressed as per cent of the total expenditure (Fig. 2).

Fig. 1. Selected budgetary allocations as % of gross domestic product (GDP). Data source: Ministry of Finance, Ghana. When the Annual Budget Funding Amount of GH¢136 420 759 for Agriculture Modernisation is incorporated into the budgetary allocation for the Ministry of Food and Agriculture, the allocation to the ministry registers a nominal increase from 0·3 to 0·5 % of GDP.

Fig. 2. Selected budgetary allocations as percentage of total expenditure. Data source: Ministry of Finance, Ghana.

The findings of this review are discussed under three themes: budgetary allocations for direct nutrition interventions, sustainability of current nutrition interventions and overall national-level commitment. The first two are related and are better addressed together.

Allocations for direct nutrition interventions

This review has shown that there is no budget line for nutrition in the 2014 Ghana national budget. Specific allocations for direct nutrition interventions were also absent. Nutrition is assumed to be embedded in other budget lines such as health, agriculture and local government, and rural development. On the basis of these, we argue that the budget statement is not sensitive to nutrition. We are seriously concerned that embedding nutrition in other budget lines portends the risk of perpetually rolling out national spending actions insensitive to nutrition.

Over the years, the Ministry of Health, which is the main ministry expected by the state to address issues of malnutrition, and for which a specific department has been earmarked (Nutrition Department), has had challenges in this regard. The Nutrition Department, which is under the aegis of the Ghana Health Service is one of over twenty departments under the sector. Ghartey⁽ Reference Ghartey ^{9 )} attempted in futility to track budget and expenditure patterns for nutrition at the sector level. However, the current architecture of the national budget and the structures of the Ministry of Health make it impossible to compare budgetary allocations so as to establish the extent of commitment to nutrition. It is obvious that the priority focus and core of the services delivered by the Ministry of Health, which are largely clinical in nature does not include nutrition. On the basis of this, not ring-fencing a budget for nutrition-related activities is problematic.

We call for the introduction of a single budget line for nutrition in the national budget. In support of this call, the goals of the National Nutrition Policy of elevating nutrition to a Supraministerial Agency under the Office of the President, elevating the status of nutrition within the health service structure, ensuring adequate funding for implementing the National Nutrition Policy should be pursued vigorously. Such a structure has been argued for, and has been set up for instance in sister African countries such as Malawi^{( 18 )}. This arrangement has several benefits; it facilitates ring-fencing programmes for funding, and tracking of budgetary allocations for good governance and accountability. The arrangement further makes it possible for impact assessments to be objectively and more meaningfully undertaken. Finally it provides a clear sense of ownership of the national nutrition programmes. Although the ‘pros’ of such an arrangement exceed the ‘cons’, we are blind to the fact that a vigorous advocacy is a requirement for such a change. The Ghana SUN academic platform and other Civil Society Organisations are well placed to embark on such advocacies. To this end, the academic platform since its formation, has played key roles in the SUN movement in Ghana, including serving on the Ghana's National Cross Sectoral Planning Group on nutrition, developing material for and facilitating the workshop on Prevention and Management of Conflict of Interest in SUN, and organising the SUN Symposium at the Sixth African Nutrition Epidemiology Conference in Accra. Ensuring that all ministries, departments and agencies have budget lines for nutrition would be a reasonable interim measure.

We are also concerned about the durability of the financial commitment for nutrition-sensitive sectors in Ghana. As shown in Table 2, the per cent contributions of DP to the allocations made to various nutrition-sensitive sectors dwarf that of the government of Ghana. Even though this is troubling, it is not surprising. Both Brantou et al. ⁽ Reference Brantuo, Okwabi and Adu-Afuawuah ^{8 )} and Ghartey⁽ Reference Ghartey ^{9 )} reveal that nutrition policy interventions have been largely donor-driven, with government providing policy backing, personnel, facilities, logistics and very little financial resources. We concur with Ghartey⁽ Reference Ghartey ^{9 )} that such an arrangement creates and sustains dependence on donors by the government, leading to inadequate government commitment.

Given that agriculture continues to be the largest sector of Ghana's economy, contributing in recent years (2000–2008) an average of about 39 % of GDP^{( 7 )}, and also being a Comprehensive Africa Agriculture Development Programme member that has expressed commitment to restore agricultural growth, food security and rural development in Africa, we found it odd that Ghana's budgetary allocation to the Ministry of Food and Agriculture is 0·3 % of GDP (Fig. 1). Although the budget mentions Agriculture Modernisation as one of four national priority areas worth the Annual Budget Funding Amount, it was earmarked only GH¢136 420 759 (equivalent to US$62 009 436). This contrasts sharply with the Ghana Medium Term Agriculture Sector Investment Plan for 2009 to 2015, which aims to achieve agricultural GDP growth of at least 6 % annually and government expenditure allocation of at least 10 %^{( 7 )}. Indeed, in the interest of budget transparency we demand that the basis for the various allocations presented in the budget be publicised.

Overall national-level commitment to nutrition

te Lintelo et al. ⁽ Reference te Lintelo, Haddad and Lakshman ^{19 )} discriminate between two kinds of political commitment: government actions and governments intentions. Brantuo et al. assessed Ghana's readiness to accelerate actions to reduce child and maternal undernutrition by assessing stakeholders’ ‘willingness to act’ and their ‘capacity to act’ at scale. They show that while commitment in the form of formulation of policies abounds in Ghana, the implementation of these policies has been plagued with inadequate financial commitment⁽ Reference Brantuo, Okwabi and Adu-Afuawuah ^{8 )}. In the present work, we measure the Government of Ghana's commitment or sensitivity to nutrition using a proxy allocational attention given to nutrition in the national budget. We conclude that the invisibility of nutrition in the budget is reflective of the inattention accorded to the subject of nutrition in the country. The works of Heaver⁽ Reference Heaver ^{20 )}, Benson⁽ Reference Benson ^{21 )} and Ghartey⁽ Reference Ghartey ^{9 )} have identified a number of factors accounting for the weak commitment by government of Ghana. These include poor understanding of the prevalence, causes, welfare and economic costs of malnutrition; low political demand for action against malnutrition.

The 2012 edition of the Hunger and Nutrition Commitment Index aimed to among others, rank governments on their political commitment to tackling hunger and undernutrition; to measure what governments achieve and where they fail in addressing hunger and undernutrition; and to praise governments where due. Authors of the Hunger and Nutrition Commitment Index identified three domains within the te Lintelo et al.⁽ Reference te Lintelo, Haddad and Lakshman ^{19 )} bifocal concept of government commitment. These are policies and programmes, legal frameworks and public expenditures. On the basis of these, their report tags Ghana as having exhibited moderate political commitment to tackling hunger and undernutrition. Of forty-five countries, Ghana ranks 12 for hunger reduction commitment; 13 for nutrition commitment and 10 for hunger and nutrition commitment.

Summary

Our review concludes that Ghana's 2014 budget statement is insensitive to nutrition. Allocations to direct nutrition interventions are not perceptible in the budget. By embedding nutrition in other budget lines, Ghana runs the risk of perpetually rolling out national spending actions insensitive to nutrition. In line with the wishes of the National Nutrition Policy, the paper calls for elevation of nutrition to a Supraministerial Agency under the Office of the President, and subsequent introduction of budget line for nutrition in the national budget. It is our view that this will not take place overnight. The Ghana SUN academic platform and other Civil Society Organisations need to meaningfully engage with the Government on Ghana on this subject.