Already a contraceptive success story in West Africa, Ghana seeks to do better

DKT Ghana midwife advising on family planning at a community gathering in Mpraeso, in the Eastern region of Ghana.

This was originally published in the Huffington Post on September 26, 2016.

ACCRA, Ghana — Although West and Central Africa is an underachieving region in terms of family planning compared to the rest of the continent, Ghana is the family planning star within that region: It has a higher rate of contraceptive use than all the other 24 countries except the island nations of Cape Verde, and São Tomé and Príncipe. 

However, Ghana - with 29 percent of married women using modern contraception, is still much lower than Eastern Africa (37 percent) and Southern Africa (59 percent), according to the 2016 World Population Data Sheet. The fertility rate has barely changed since 1998 and more than 1 in 3 pregnancies are unplanned.

Last month, I visited Ghana to see how the country is faring in terms of of its commitment to family planning. Until recently, Ghana had one of the fastest growing economies on the continent. That fact and the peaceful transfer of power in 2008 were recognized by President Barack Obama in 2009 when he made Ghana the first stop of his first visit to Africa as president. Recently, however, the economy has stagnated.

World Contraception Day on Sept. 26 provides a good opportunity to reflect on the current situation in Ghana and how matters can be improved to enable every Ghanaian woman who wants contraception to have access. The government has set an ambitious goal of reaching 50 percent of married women with modern contraception methods by 2020.

Reaching most vulnerable young people with family planning, HIV services

More than half of Ethiopia's population are young people under the age of 24. Credit: Sheikh Rajibul Islam/duckrabbit

This article was originally published on The Huffington Post on Nov. 11, 2013.

Ethiopia -- where international advocates will open their biennial International Conference on Family Planning on Nov. 12 -- has succeeded in bringing down the unmet need for family planning from 36.6 percent of currently married women 15-49 in 2000 to 26.3 percent in 2011. But the unmet need is greatest among those aged 15 to 19. In that age range, almost one-third want contraception and cannot get it.

The great need of young people for integrated family planning, sexual and reproductive health (SRH) and HIV prevention services is not limited to Ethiopia, and is one of the great challenges facing conference participants. This is particularly true of youth from marginalized groups such as people living with HIV, sex workers, men who have sex with men, transgender people and people who inject drugs, who may be particularly vulnerable to sexually-transmitted infections, including HIV, and other reproductive health issues.

Years of investments put health workers on global stage

Two midwives in a low-income area of Jakarta, Indonesia that are part
of DKT's "Andalan" social franchising network.

This article was originally published in The Huffington Post on Sept. 23, 2013.

For almost 10 years, I managed health programs in Africa, Asia, and South America that harnessed social marketing techniques to produce tangible benefits for poor consumers. Our programs made low-cost products such as condoms, contraceptives, and oral rehydration salts available at reduced, affordable prices. We worked mostly through the private sector and were proud of our bottom-line health impact. We didn't think much about underlying health systems or how to improve them. And if we had, we probably would have dismissed health system strengthening as overly ambitious.

But I've been thinking more about health systems lately, as I have seen governments and their nongovernmental partners carefully and patiently nurse ailing systems to health. The payoffs are not immediate -- far from it -- but as we move away from the segmented solutions to global health that prevailed in the 2000s (such as in the cases of AIDS and malaria) and toward greater country ownership, there is a growing consensus that we need stronger health systems to make sustainable improvements in global health.

This means more, better trained, and better managed frontline health workers -- the backbone of health systems.

I've heard that mantra for the last few years but, in 2012 and 2013, I saw it play out repeatedly as I traveled to very different countries in Africa, Asia, and Latin America:

NGOs can also contribute to innovative financing

DKT advertises IUDs in Indonesia.

NOTE: This blog was originally published on Impatient Optimists, the blog of the Bill & Melinda Gates Foundation, on Feb. 2, 2012.

In difficult economic times like these, governments are looking for ways to cut their budgets. Foreign aid is often an easy target. Innovative financing—the idea of using a range of non-traditional tools such as micro-contributions, taxes, and public-private partnerships—has developed over the last 10 years as an alternative to traditional donor aid. Innovative financing mechanisms have raised $2 billion over three years, according to a 2010 report, mostly for health.

Most innovative financing has originated with governments—such as UNITAID and the International Finance Facility for Immunization—and private sector efforts such as Project RED, which engages in “cause marketing.”

But NGOs can also play a role. In fact, they have already been doing this through social entrepreneurs like Muhammad Yunnus (Grameen Bank), Bill Drayton (Ashoka), and Jacqueline Novogratz (Acumen Fund).

Bringing the Avon Lady Philosophy to Rural Ghana

One of the HealthKeepers sales ladies heading out on her rounds.

In many rural areas of Ghana, a ringing bell is the traditional way that itinerant sales agents announce their arrival in a village. More and more, those bells are announcing the arrival of the entrepreneurial women from the HealthKeepers Network who are promoting health while also making a living, with the motto “prevention is better than cure.” And they are forging a new way of using the private sector to deliver health and hygiene to rural areas often overlooked by traditional global health programs.

Daniel Mensah, head of HealthKeepers

Although different private sector strategies have been tried to promote contraceptive use in Ghana (where the 2008 Demographic and Health Survey  indicated a contraceptive prevalence rate for modern methods was 16.6%), the impact of these strategies has been limited due to the long distances to be traveled to reach relatively small numbers of people with limited purchasing power.

In October 2009, I visited HealthKeepers with two colleagues and Executive Director Daniel Mensah in a village about an hour outside of Accra. We were the first visitors just after HealthKeepers had been registered to continue the work begun by Freedom from Hunger. I immediately thought of Avon, a U.S. company I remember from my youth, and its Avon ladies who have sold cosmetics door-to-door since the 1930s. The HealthKeeper difference is that these sales ladies travel by foot, with their products in a basket perched on the top of their heads.

The merchandise includes a mix of health products — such as contraceptives, insecticide-treated mosquito nets, oral rehydration salts and home water treatment tablets —and other carefully selected personal care products which help ensure that the ladies turn enough of a profit to keep them motivated. In 2009, they were also selling low-cost eyeglasses; they gave one of my colleagues an impromptu eye exam under the mango tree.

Cancer Rises in Africa, A Continent Ill-Prepared to Handle It

This article originally appeared in The Huffington Post on Sept. 20, 2011.

"Thank God I have AIDS and not cancer, because that would be a death sentence," an HIV-positive woman told Ann Kim, a freelance journalist on a fellowship from the International Reporting Project, in a clinic in Botswana earlier this year.

Botswana, a well-off country by African standards, has an adult HIV prevalence of 24 percent, the second highest in the world, and a health system well-prepared for dealing with it, but not cancer.

In Togo, Dr. Kokou Agoudavi, the head of non-communicable diseases at the Ministry of Health, told me that Togolese cancer patients sometimes sell their houses or fields to pay for cancer treatment, which is not available in-country. They have to go to neighboring Ghana, if they can afford it. He said this often happens in the late stages of cancer, when survival rates are low.

Accra to Lome: 200 kilometers and 24 years

ACCRA, Ghana to LOME, Togo – Today I traveled 200 kilometers and 24 years, from the booming capital of Ghana with its pothole-free roads and growing economy to the decaying capital of Togo, where I was a Peace Corps volunteer from 1983 to 1985, a place and time that holds an affectionate place in my memories.

During the four hours I was on the road, I experienced a jumble of emotions – hope, fear, nostalgia and sadness.

Hope was what I experienced in Ghana, a country whose economy is growing and which recently experienced a peaceful transfer of power from one party to another, despite a close election, something of a rarity in Africa. This is the hope that brought President Obama here in July on his first presidential visit to Africa. We drove out of Accra on a motorway – the likes of which I have seen in Africa only in Abuja, Nigeria and South Africa – and past a blur of gleaming buildings and a new shopping center. It gave me hope that positive change is possible in West Africa.

The fear came from our driver who, like me, had a Biblical name (Isaac) and succeeded in putting the fear of God in me. He tried to keep the speedometer at 140 kilometers per hour (85 mph) as often as possible, including through villages with a posted speed limit of 50 kph. I said a silent prayer for myself, my Togolese companions and any careless pedestrians who wandered into the road.

It was evident that the driver knew the road extremely well as he braked only for speed bumps and police stops (all the police stops had signs sponsored by a bank that warned “It is an offense to bribe a police officer,” something else that gave me hope). And he knew exactly where to brake. As Isaac was slowing in one village, someone along the road yelled at him and Isaac threw a one-cedi note out the window, perhaps repaying an old debt.

I was astounded by the quality of the Ghanaian roads for the first 170 kilometers. I have never seen such excellent roads outside of an African city except in South Africa. It was only because of the quality of these roads that we were able to maintain such high speeds.

But the closer we got to the Togolese border, the worse the roads got and the more the scenery reminded me of the coastal village in Togo where I spent two years. The last few kilometers to Aflao, the last town in Ghana before the border, were terrible, deteriorating from pothole-pocked roads to no pavement at all.

The nostalgia came as the scenery became prettier and prettier, reminding me so much of the Togolese village of Baguida that I will see tomorrow. I also felt gratitude that I had the good fortune to live in such a charming seaside village for two years.

The sadness came when I arrived in Lome and saw that while Ghana has flourished, Togo has deteriorated. More on that in my next post.

Ghanaian AIDS orphans touch our hearts

ACCRA, Ghana — My heart and those of the members of the International AIDS Candlelight Memorial Advisory Board were moved Wednesday when we visited the AIDS orphans and the HIV-positive adults cared for by the Pathfinders Outreach Ministry, a Ghanaian non-governmental organization working and struggling with minimum resources in a poor area on the outskirts of Accra: http://www.pom-ghana.org

As the adorable toddlers scampered into their arms and our laps, we heard Becklyn Ulzen-Christian, Pathfinders executive director, describe the care she and her staff provide for orphans and vulnerable children and HIV-positive adults in the face of limited resources, great stigma against HIV-positive people and other challenges.

Pathfinders looks after 70 children, 13 of whom lives at the facility, and many HIV-positive adults who have been rejected by their families and friends. We talked to Felicia, a middle-aged woman whose hard life is etched on her face, who has been HIV-positive for 17 years. She said she has found a new life in the warmth of Pathfinders and now has a purpose to her life.

Pathfinders gets its support from three major sources – U.S. Agency for International Development for food aid; Global Fund for AIDS, TB and Malaria for behavior change communication and education in HIV, tuberculosis and malaria; and GHC member Academy for International Development (AED), though AED’s support is ending and Mrs. Ulzen-Christian has no idea how they will carry on without it.

The Advisory Board is in Accra for their annual meeting in which they are examining the Candlelight Memorial event from last May and planning for the next one in 2010. The Advisory Board is made up of two regional coordinators from each of the six regions in the world – North America, Latin American and Caribbean, Europe, West and Central Asia, East and South Asia and Africa.

Much has changed in Accra but not everything...

ACCRA, Ghana -- The last time I was in Ghana was 1985, when I had just finished two years of Peace Corps service and my wife and I had traveled there from Togo in order to catch an Egypt Air flight to Cairo. Here's what I wrote in my diary on Oct. 13, 1985:

"We didn't particularly enjoy Accra. It's a decaying city where it's hard to find items we would take for granted in Lome. The first night we ate dinner at a Chinese restaurant. Fewer than half the items available on the menu were available. On the second day, we took a taxi into the decaying and filthy downtown and found a decaying hotel on the ocean. We looked down on a once-beautiful swimming pool that was now empty and decaying. We were very thirsty. All they had to drink was beer and tonic. I didn't want beer or tonic so I stayed thirsty. When I asked for a glass of water the water said 'It is finished.' That remark will be one of my strongest impressions of Ghana: 'The water is finished.'"

Note the number of times I used the word "decaying" in that short passage.

Those were the bad old days, when Ghana had a dysfunctional economy and food shortages so severe that Peace Corps Ghana had to truck in food from Togo for its volunteers. Fortunately, those days are gone and Ghana now has a vibrant economy and democracy that recently had a peaceful transfer of power after a closely contested election. That is why President Obama had chosen to make it the destination of his first trip to Africa as president.

I arrived here yesterday for my second visit. The Global Health Council manages the AIDS Candlelight Memorial, the world's largest and oldest AIDS awareness raising event, and we are meeting with our regional coordinators from around the world. I found that many things have changed, and for the better, but a few have not.

On my first night in Accra, my two colleagues and I went out to eat at Buku, an African restaurant in the Osu neighborhood, as the Lonely Planet Guide to West Africa had recommended it for its Ghanian, Nigerian, Togolese and Senegalese food. It was a lovely place but I ran into a similar problem from my first trip, albeit no quite so severe. They had no dressing for my salad, they had run out of guinea fowl and had no ginger beer. But they did have most things and we had a delicious dinner in the open air and under a straw roof. I had groundnut (peanut) stew with goat (instead of guinea fowl!), fried plantains and Star beer. All in all, Ghana is vasty improved and I am thrilled to be back in West Africa.