Introduction
Now that the World Health Organisation (WHO) has put cities at the centre of public health and declared 2010 ‘Urbanisation and Health’ year, it is timely to consider public health and cities, especially in developing countries, where there is rapid and chaotic urbanisation.
In fields such as Sociology, Anthropology, Epidemiology, and Urban Planning, the approach has typically been to consider health differentials between rural and urban areas, and between and within cities (Galea et al. 2005). In terms of methodology, such studies are typically written from the standpoint of either public administration or mainstream public health, with the former emphasising administrative efficiency and effectiveness of institutions (for example, Smith 1997, Blore 1999, Olowu 2003), and the latter stressing the relationship between the epidemiological changes that occur with urbanisation and their impacts on health (for example, Yach et al. 1990, McDade and Adair 2001).
These existing studies suffer from two main weaknesses. First, they tend to look at the process of urban growth as a homogeneous phenomenon, even though there are various components of the ‘urban experience’, such as urbanicity, urbanisation, and urban environment. Urbanicity connotes the prevalence of factors such as transport congestion and industrial pollution that are more prevalent in cities than in rural areas. ‘Urbanisation’ refers to a process of change with associated socio-economic and politico-cultural transformations. ‘Urban environment’ goes beyond ‘urbanicity’ because it embraces physical, social and urban resource infrastructure (Vlahov and Galea 2002, pp. 5–6, Ompad et al., 2008, p. 465). Because the urban experience is not one homogeneous transformation, studies on urban health need to consider demographic, social, and political economic changes in cities.
Second, these frameworks do not typically examine economic development – economic growth, redistribution, and poverty reduction. How development interacts with urban health needs more critical consideration (Blore 1999, Galea et al. 2005). This second analytical weakness was recognised and highlighted in the health-related sessions at the 2010 World Urban Forum in Rio de Janeiro. The forum also stimulated civil society publications which stressed the need for better understanding of health issues in cities (for example, Sugranyes and Mathivet 2010).
This article tries to overcome these conceptual and empirical gaps by using a broader political economic framework to examine urban health. It does so by analysing water delivery and waste management. It thereby seeks to explore the challenge of transforming the existing arrangements to achieve the overall goals of improving health and promoting sustainable development (UN-HABITAT 2008, p. 5). Specifically, it examines how water and sanitation services are provided and how the mode and level of service delivery, in turn, impact on urban health and wealth. The geographical focus of the study is Ghana, where two main factors make this study particularly relevant. First, Ghana is one of the most rapidly urbanising countries in Africa. According to the United Nations (UN) Department of Economic and Social Affairs (DESA 2007), Ghana's population was 47.8% urban as of 2005, a figure which was higher than the average for West Africa (41.7%), sub-Saharan Africa (35.0%) and Africa as a whole (37.9%). The rate of urbanisation in Ghana between 2005 and 2010 is estimated at some 3.54% per annum, lower than for West Africa (3.77%) and sub-Saharan Africa, but higher than for all of Africa (3.31%) and the world (1.91%). Second, Ghana is believed to have entered the era of homo urbanus (UN-HABITAT 2009) – Anna Tibaijuka's shorthand for a situation in which more people live in cities than in rural areas.1 Estimates also suggest that by 2050, the share of the population living in urban areas (75.5%) will be about three times the share of the population living in rural areas (24.4%) in Ghana (DESA 2007).
The rest of the article is divided into five sections. The first four sections look at the health conditions of urban citizens, provide an overview of water and sanitation conditions and assess the effectiveness of policies to improve these municipal services, respectively, while section five empirically ascertains the connections which exist between water, sanitation and health.
The state of health of urban citizens
The health situation in Ghanaian cities must be described as a prelude to the subsequent discussion. The description needs to examine trends in disease, morbidity or mortality. Although the data is not comprehensive, it is evident that there are major health problems in the cities. In 2008 alone, 37.5% of children in urban areas sought treatment for diarrhoea and 59.6% had fever; in the same year, there were 50 deaths per 1000 births (Ghana Statistical Service [GSS] and Ghana Health Service 2009a). The perinatal mortality rate is 34 per 1000. Malaria constitutes 30–40% of all outpatient cases in Ghana, with one in five children under five years old receiving malaria treatment in the two weeks preceding the 2008 demographic and health survey (GSS and Ghana Health Service 2009b).
These figures need to be put in a wider context to be meaningful. However, two problems inhibit a detailed comparative analysis with, for example, other African countries. First, obtaining comparable urban figures is difficult because the institutions that compile health data sets do not usually disaggregate these into urban and rural. Second, missing figures make it difficult to compare even national-level figures. In spite of these problems, however, available data suggest that, in comparison with the rest of Africa, the health profile of inhabitants of Ghanaian cities is better than the African average in some sectors and worse in others. For example, from 1990 to 2010, the proportion of the urban population in sub-Saharan Africa living in slums declined from 70 to 62%, while in Ghana the decline was from about 80 to 45% (Economic Commission for Africa and African Development Bank Group 2009, p. 46, UN 2010a, p. 64).2
The limited figures available show that there has been considerable improvement in the health profile of urban citizens. For instance, between 1988 and 2003, the under-five mortality rate in urban areas reduced from 131.1 to 93 per 1000 live births. At the same time, the infant mortality rate dropped from 66.9 to 55.0 per 1000 live births. From 2000 to 2004, supervised delivery increased from 50.2% to 53.4%. Around the same time, postnatal care improved from 46.3% to 53.3%, nationally (Ghana Health Service 2005).
The national health situation in Ghana, however, does not look so good when compared to continental averages. For instance, between 1990 and 2008, infant mortality in sub-Saharan Africa dropped by 22% (UN 2010b) but in Ghana, the figures for 1988 to 2003 show a reduction of only 13% (Ghana Health Service 2006). Furthermore, malaria is more endemic in Ghana than many other tropical African countries. Ghana is classified as one of 31 ‘high-burden countries’ by the World Health Organisation (WHO). Between 2001 and 2006, for instance, there was no evidence that there was a significant reduction in the number of malaria cases nationally, although between 2006 and 2008, the number of malaria cases declined dramatically from 8.3 million to 3.2 million (WHO 2009, p. 102). Still, malaria, delivery, and diarrhoea diseases are the worst causes of death in the country (Ghana Health Service 2006). Twenty per cent of under-five mortality results from malaria and 50% of outpatient cases relate to malaria (Koram 2008).
The health profile of urban citizens is worsened by the nature of the healthcare system. Even though Ghana has switched from a ‘pay as you go’ system of healthcare to health insurance, the scars of for-profit healthcare are present and the current system is limited in its coverage. Generally, about 60% of women and 70% of men are not covered by health insurance (GSS and Ghana Health Service 2009a). Only 10.8% of the urban population is covered by health insurance. Several reasons, such as inability to pay the premiums or a lack of confidence in the insurance scheme, explain this low coverage (GSS 2008, pp. 30–31).
This state of affairs has contributed to low life expectancy in Ghana. From an average of 57.9 years in 2006, life expectancy declined to 56.5 years in 2009 (UNDP 2009), a figure significantly lower than the 64.3 years which was the world average in 2006 (UNDP 2007).
What factors might be driving this poor state of health? Among a plethora of reasons, weak growth-centric developmentalist concerns such as low GDP growth, high levels of inflation and their correlates – whose collective effect is to reduce the ability of the country to invest in a pro-poor health system (see, for example, Government of Ghana 2003, Aryeetey and Kanbur 2004) – are some possible explanations. More recently, researchers, policy makers, and representatives of civil society organisations who come together every year to produce the Ghana human development report have argued that: ‘The factors affecting life expectancy generally in Ghana include access to affordable and quality health care, access to good drinking water, adequate sanitation, HIV/AIDS and infant mortality’ (UNDP 2007, p. 34, emphasis added). A similar diagnosis is contained in the Ghana Poverty Reduction Strategy Paper which emphasises that the causes of the deepest form of poverty in Ghana must ‘be directly attacked through greater investments in health, education, safe water and sanitation’ (Government of Ghana 2005, p. 2, emphasis added). It is estimated that 80% of diseases reported in the outpatient department in Ghana are sanitation-related (Anton 2008).
Globally, there has been a similar flurry of interest in the nexus between water, sanitation, and economic development. For instance, the Review of Radical Political Economics has recently published a special issue on the ‘Political economy of water’ which stresses that water and sanitation are a matter of ‘life and death’ (Barkin 2010, p. 1). For all these reasons, it is important to review how these services are provided, analyse their impacts, and learn from the experience in the Ghanaian context.
Providing water and sanitation to increasing populations in cities
Generally, there are three ways in which municipal services are provided in Ghana. First, the delivery of municipal services is contracted out wholly or partially (through public–private partnerships) to private firms (local or foreign). Second, communities are forced/encouraged to provide services for themselves in the form of self-help projects.3 Third, central government effort to downsize the state has led to the decentralisation of services to local governments, without commensurate financial resources, which has forced local governments to ‘offload’ the ‘new’ responsibilities to the private sector (Crook and Ayee 2006).
The water and sanitation subsectors have been particularly susceptible to the pressure for private-sector participation even though their specific histories differ quite substantially. The story of water management is told in Lindsay Whitfield's comprehensive account (Whitfield 2006, pp. 429–445) and by several other scholars (for example, Amenga-Etego and Grusky 2005, Yeboah 2006, Fuest and Haffner 2007). Without retelling it fully, it is important for the argument in this article to have an overview of the privatisation process.
Attempts to privatise water in Ghana started in 1986 when operational subsidies were removed.4 In 1991, Ghana Water and Sewerage Corporation was downsized and about 40% of the workers retrenched (Whitfield 2006). In 1999, the management and marketing of water was split into two, with the Ghana Water Company Ltd (GWCL) being mandated to manage urban water and the Community Water and Sanitation Agency (CWSA) being put in charge of rural water management. The former had considerable local private-sector participation (initially comprising local non-governmental organisations [NGOs] and businesses, although later concessions were allocated to foreign entities). The latter, on the other hand, was managed mainly by community and state agency (Water Aid 2005, Whitfield 2006).
Significant changes were expected with private sector involvement – improved revenue collection, reduction in illegal water connection, improved access, reliability and improved complaints handling (PURC 2005a, p. 3). However, only modest achievements were made from 1998 to 2003. According to the Public Utilities Regulatory Commission (PURC), a body set up in 1997 to regulate GWCL, it was expected that the latter would, over a period of five years, reduce losses from leakage and illegal connections from 50% to 40% of water produced. GWCL was also expected to increase revenue collection from 77% to 95% of charges billed.
Private participation in water provision led to an increase in the volume of water produced by about 12%. Prior to the privatisation of the facility, the proportion of people with access to potable water was about 65% (UNDP 2007, p. 46). Private-sector participation has led to an increase in the number of connections. For instance, between 2000 and 2005, the share of the urban population with access to piped water increased from 70% to 78% (Government of Ghana 2003, p. 112). Of these, about 98% can access safe water within 30 minutes' walking distance (UNDP 2007, p. 46).
However, most of the other targets could not be attained. For example, water loss between source and tap increased by 25.0 Mm3, from 92.07 Mm3 in 1998 to 117.07 Mm3 (PURC 2005a, p. 3). Thus the increase in water provision is offset by losses. Also, the level of revenue collection did not improve. Therefore, in its review of the operation of GWCL, PURC found that, overall, the headline efficiency of GWCL expressed as the percentage of water produced which is converted into income collected reduced from 37.8% in 1998 to 32.4% in 2003, with a low point in 2002 of 30.7% (PURC 2005a, p. 4, emphasis in original). In any case, despite increases in tariffs, the reliability of water provision did not dramatically improve.
That the water sector was facing serious challenges was incontrovertible (for example, Songsore and McGranahan 1993, Taylor et al. 2002). What was contested was how best to overcome the problems. A favoured strategy was to invite international private-sector investment to recapitalise and make the water sector more efficient. That was not the only perceived solution, however. Civil society groups, such as the Integrated Social Development Centre (ISODEC) and National Coalition Against the Privatisation of Water, Ghana, put forward alternative proposals for restructuring the public services and incentivising workers (Whitfield 2006). However, swayed by factors such as indirect international pressure or influence (Boh and Tsikata [2005] note that to expedite privatisation, the World Bank made the Ghana government a grant of US$103 million), an inadequate number of ‘opponents’ of privatisation who were also capable of presenting coherent alternatives, and a general wave of privatisation in the global economy, the government opted for privatisation (Whitfield 2006), despite civil society protests and criticism (Yeboah 2006).
Thus on 6 January 2005, the Government of Ghana signed the Ghana Urban Water Project, a public–private partnership between the GWCL and Aqua Vitens Rand Ltd (AVRL), a private operator, with the aim of improving water supply to urban areas. The contract took full effect in June 2006 for a five-year duration (Ainuson 2009, Norström 2009, p. 16).
According to the Public Utilities Regulatory Commission (PURC), the regulator of GWCL, the restructuring of the water service has been aimed at improving effective water management. That is, reduction in cost of delivery and service improvement to consumers (PURC 2005a). In the words of the World Bank:
The project will improve access to safe, reliable and affordable water services to thousands of households, targeting especially the urban poor who have been denied this service over the years due to poor performance of the urban water sector. Furthermore, the project will assist the Ghana Water Company Limited (GWCL) to strengthen its management of the sector and pursue long-term financial stability, viability and sustainability. GWCL is also expected to improve its ability to respond to the increasing water needs of the urban population in a more proactive manner. (Boh and Tsikata 2005)
- 1.
To significantly increase access to the piped water system in Ghana's urban centers, with an emphasis on improving access, affordability and service reliability to the urban poor;
- 2.
To restore long-term financial stability, viability and sustainability of the Ghana Water Company Limited. (World Bank 2009)
To what extent have these goals been achieved? A comprehensive assessment of the water sector would need to wait until the contract of AVRL comes to an end in 2011. What is attempted here is only a preliminary reflection on the water question. Based on the objectives underpinning the current mode of service delivery, however, a preliminary assessment can be made based on four main indicators, namely access to water, reliability of service, affordability of service, and the quality of water supplied. Each of these are now examined in turn.
Assessing recent water provision
Access to water in urban areas has increased from 75% of the urban population in 2005 (UNDP 2009) to a current level of 83% (UN-HABITAT 2008).5 This level of access paints an optimistic picture of the water situation and has led some (for example, Norström 2009) to predict that Ghana may meet the Millennium Development Goal (MDG) of reducing by half the proportion of people without sustainable access to safe drinking water and basic sanitation (Goal 7, target 7c). Many reasons explain the expansion of access. For instance, several attempts have been made by AVRL to improve access. It is spending over GhC1.04 million (€700,000) to provide water to about 50,000 people in seven deprived communities under a corporate social responsibility project known as ‘Water 4 Life’. Beneficiary communities include Teshie Old Town in Accra and Nsuatre in the Brong-Ahafo region, where a total of 12,500 people who previously did not have access to potable water now do (AVRL 2009a). Similar commitment has been shown in providing water to residents of Kumasi, Obuasi and Mampong (Haruna 2008). The reasons for this improvement, however, go beyond private sector involvement.
The government has complemented the effort of the company by investing in water infrastructure. For example, it has completed phase one of the Kwanyaku Water Supply Expansion Project, which increased the output of water from three million gallons per day to six million. Also, the east–west water transfer interconnection has been completed. This has improved access to water supply in the eastern parts of Accra. Similarly, the government has completed the Cape Coast Water Supply Expansion Project (MOFEP 2009, p. 102). Thus the improvement registered cannot be solely attributed to private sector participation, as government has invested considerable sums of money in the sector.
The quality of water supplied is also an effective indicator. Despite occasional media reports that potable water in sachets and bottles sold in shops or hawked on the streets is of poor quality, more systematic study by scientists who specialise in water suggest that, generally, the quality of water in Ghana is high and, by and large, consistent with WHO guidelines. It seems the contamination of piped water does not arise from the production of water per se. Rather, it is the processing of already produced water that sometimes leads to contamination (Okioga 2007, Cobbina et al. 2009). Most of the technical scientific studies reveal significant contamination of sources of water such as boreholes, wells and rivers where there are excess levels of chemicals and metals such as lead, arsenic and uranium (for example, Rossiter et al. 2010). Another issue that runs through many of the scientific papers is the rising cost of ‘safe water’, defined as piped water.
How pro-poor is the delivery of piped water? According to PURC, the public regulator, ‘pro-poor’ would mean that everybody, including people with low incomes, is able to pay the official water tariffs. Hence, an upward deviation from the approved fees signals that more cost than is deemed affordable is being incurred. In the words of PURC (2005b, p. 9):
Different customers experience different levels of service including: private connections, yard connections and community standpipe services. In some cases the unit cost of supply to lower levels of service may, in fact, be higher than the unit cost for a higher level of service (largely as a result of low sales) suggesting that the tariff should be higher for a lower level of service. This concept is clearly contrary to the concept of tariffs being ‘pro-poor’ and cannot be supported.
This situation has implications for how much consumers can spend on other necessaries of life. One study of the expenditure pattern of poor households cited in the Ghana human development report 2007 showed that households spend about 9% of their income on water (Manu and Mensah-Abrampa cited in UNDP 2007, p. 95). Another study of two low-income settlements, Ayigya and Anloga in Kumasi, showed that households spend 15% of their income on water (Nyarko et al. 2006). This picture signals deep problems for the poor, especially because 60% of them obtain water via tanker, cart operators and neighbours (Norström 2009, p. 25).
The reliability of water provision has also been problematic. In terms of frequency of supply, which is one way in which PURC measures ‘level of service’ (see Smith and Hanson 2003 for indicators used in other countries), there are major challenges. For instance, in Accra the gap between production and consumption has widened from 74 million gallons per day in 2008 (Benson 2008) to 170 million gallons per day in 2010 (Essel 2010).
One main cause of this deficit is illegal connection and, hence, water that is unaccounted for. Even though over the period 2006–8, considerable effort by AVRL led to a reduction in the amount of water that is not paid for by between 5–10%, about 51% of water produced still could not be accounted for (Beyene et al. 2008, p. 27). Thus, AVRL has not been able to reduce the level of non-revenue-earning supplies to the 40% target set by PURC (see PURC 2005a). According to AVRL, it has been unable to meet the target because of illegal connections. Although a fair explanation, it must also be noted that the poor physical condition of water infrastructure causes about 30% of water to be lost through leakage (Abraham et al. 2007). Still, one has to appreciate that AVRL is working in an increasingly urbanising environment. Thus, its consumer population is growing rapidly and putting increasing pressure on its facilities. This pressure is what may have driven the company to ask government for additional capital of US$1.5 billion to expand its facilities (GNA 2009).
However, several ‘safety nets’ have already been made available to AVRL. Four of these are particularly significant. First, it has been allowed to increase water tariffs by about 67% (Grusky 2001, GNA 2010). Second, AVRL has the option of increasing tariffs based on trends in inflation and currency devaluation in order to insulate it from risks (Weissman 2002, Bayliss 2003). Third, the company benefits from a riskless contract in which the government undertakes to reimburse it with ‘prudently incurred costs’ (Weisman 2002).6 Fourth, the company has been allowed to implement several measures to cut production costs in order to obtain more revenue.
For instance, in 2005, about 1600 trained workers constituting about half of the workforce of GWCL were dismissed and paid total compensation of a paltry €8 million – about US$6000 each. Their replacement, a 12-person ‘expert’ group, is expected to earn over €10 million – about US$13 million – plus other incentives and tax exemptions for a period of five years (Adam 2003). At the same time, the workers who have remained in post have had to work much harder than previously to ensure that profit is generated for the owners. In addition, incentives, wage increases, and promotion opportunities were frozen as the government of Ghana waited for AVRL to take over management (Tanoh 2007). In the first year of its management, AVRL recorded an 83% profit, or an additional 43 million cedis, mainly from blocking access to the poor, whose efforts to acquire potable water are branded ‘illegal connections’ (Adjetey-Sowah 2008). Also, without worker agitation, AVRL granted a pay increase of about 6% to its workers – but with pressure from workers, was prepared to consider increases (under conditions of Ghana government subsidy) of up to 35%, although even this compares unfavourably with salary increases of 45–55% obtained by workers in some public utility companies with similar production levels around the same time (Tanoh 2007).
Nonetheless, recurrent press reports suggest that the company does not seem to be able to solve minor problems such as the purchase of inputs like alum and spare parts for machinery – reports which have not been denied by AVRL. And yet, AVRL has benefited enough in the way of preferential policies which should enable it to respond adequately to the problems it faces, notably the pressure on its facilities. That the problems persist raises questions about whether the private sector is inherently efficient or efficient in social terms. For instance, most people in cities are dissatisfied with the quality of their water-delivery service. Systematic studies such as those by Dornelas and Eldridge (2008) and Suleiman and Cars (2010), which were based on interviews with consumers, suggest that there is widespread dissatisfaction with the service provided by AVRL.
In many ways, the company has admitted that its service delivery has fallen below public expectation. First, many of its spokesmen have publicly apologised for poor service (see, for example, GNA 2009a, GNA 2009b, Aglanu 2010). Second, some of its influential workers have admitted ‘inefficiencies’. For instance, according to one senior revenue officer of AVRL: ‘Many new service connection applicants do not come back after filling the application forms due to the high connection fees charged. Such applicants indulge in illegal connections thereafter. New service connection fees should be reduced to encourage new customers to subscribe legally.’ Another officer has noted that: ‘New service connection applicants are not billed by Data Processing Unit for several months and later billed with accumulated consumption which customers refuse to pay. Adjustments take too long to reflect on customers' bills’ (AVRL 2009a, 2009b).
Assessing waste management
Turning from water to waste management, similar concerns apply. Over two decades ago, ineffective management of urban waste in Ghana led to the formation of several government committees to consider ways of improving the situation. Coinciding with the advent of structural-adjustment programmes, emphasis was placed on service provision by the private sector. Since 1985, the management of solid and liquid waste has been done jointly by government and the private sector (Fobil et al. 2008).7
According to the Environmental sanitation policy of Ghana, all environmental services (waste management, cleansing, and sanitation) must be delivered on full cost-recovery basis by either private firms or government in partnership with private firms. Such a pro-business approach is supported by donors like the World Bank and the Department for International Development (DFID) (Crook and Ayee 2006, pp. 56–57).
As such, the Ministry of Local Government has been partnered by the Urban Environmental Sanitation Project (UESP) of the World Bank to train local government staff on the proper drawing up and management of contracts. This ‘capacity building’ is to enable local government staff to be able to superintend competitive bidding processes for private firms interested in waste management. The arrangements with these private firms vary from franchising, contracting-out, open competition and sub-contracting to equipment leasing. With open competition and franchising, private firms charge end users directly for their services. However, with contracting out, the private firms are paid by the city authorities according to the quantity of solid waste collected and deposited. Contracting out is the most popular form of service delivery among the city authorities, constituting about 60–70% of all waste collected (Post et al. 2003, Awortwi 2004, pp. 215–216).
Tables 1 and 2 present data on how well targets for waste disposal have been met in practice. By this criterion, it appears that the private sector has been efficient in managing urban waste. Targets were not only met in the decade of the 1990s; they were surpassed.
| Year | 1996 | 1997 | 1998 | 1999 | 2000 |
|---|---|---|---|---|---|
| Target (% of waste) | 20 | 21 | 24 | 26 | 28 |
| Actual performance (% of waste) | 25 | 25 | 40 | 58 | Not available |
| Source: Fobil et al. (2008, p. 267). |
| Year | 1992 | 1993 | 1994 | 1995 | 1996 | 1997 | 1998 | 1999 | 2000 |
|---|---|---|---|---|---|---|---|---|---|
| Target | 1 | 2 | 3 | 4 | 32 | 35 | 37 | 40 | 42 |
| Actual performance | 2 | 11 | 11 | 21 | N/A | N/A | N/A | N/A | N/A |
| Source: Fobil et al. (2008, p. 268). |
The tables show that the private sector has successfully widened the coverage of its service. In the liquid waste subsector, it increased its target from 20% to 28% of waste managed, while in terms of solid waste it accounts for about 42% of the waste collected and managed. Significantly, it has consistently exceeded its target by taking on more and more of the waste the city authorities are unable to collect. More recent statistics are hard to come by. However, anecdotal evidence suggests that the situation described in Tables 1 and 2 did not change significantly between 2000 and 2010. For instance, as of 2008, the Waste Management Department of the Accra Metropolitan Authority had the capacity to collect only 60% of the waste generated in Accra (Anton 2008), a drop from 80% in 1998 (Tsiboe and Marbell 2004, p. 11). Indeed, one of the main private waste-management companies, Zoomlion Ghana Ltd (ZGL), has been singled out for particular praise. In the words of one member of parliament, ‘since the emergence of the company, Zoomlion has not only approached waste management issues professionally, but has equally focused on delivering quality waste management solutions that rely on current technical innovations’ (Boyefio 2008).
However, this success story is tainted by several problems. Because the private sector works on a for-profit basis, its activities are mainly focused on high- and middle-income areas where residents can pay for the services of the sector. As such, the much-touted improvement in waste management appears to be more significantly enjoyed by middle and higher income groups. Table 3 shows the bias towards the latter neighbourhoods.
| Residential neighbourhoods | Collected solid waste disposal system (%) |
|---|---|
| Migrant low-class neighbourhood | |
| Nima | 8.6 |
| Sabon Zongo | 15.1 |
| Accra New Town | 25.3 |
| Indigenous low-class neighbourhood | |
| James Town | 11.0 |
| Chorkor Down | 2.9 |
| Nungua | 4.6 |
| Middle-class neighbourhood | |
| Asylum Down | 86.0 |
| Adabraka | 52.9 |
| High-class neighbourhood | |
| Airport | 74.5 |
| Cantonments | 71.1 |
| East Legon | 31.4 |
| Accra (city-wide average) | 20.8 |
| Source: Agyei-Mensah and Owusu (2009). |
The relatively low coverage in East Legon, a high-income area, deserves some explanation. Unlike Airport and Cantonments, specifically developed by government for high-class civil servants and the affluent, East Legon was privately developed by rich individuals. There are still some poor earlier settlers in the area whose waste is not collected, thus reducing the average coverage for waste collection in the area as a whole (Agyei-Mensah and Owusu 2009). Generally, private waste-management companies prioritise collection of garbage from high-income neighbourhoods because this is where these companies can derive profit from service fees, from households directly or from local governments.
The ‘business of waste management’ has its own problems. Consumers do not participate in major decisions as to when or how waste is managed. That is, the procedure of operation is top-down. Further, this business has led to a phenomenon in which politicians use the award of waste-management contracts, especially the private management of public toilets, to reward political cronies (Ayee and Crook 2003, Fobil et al. 2008). Citizen-based organisations operating as private firms employ caretakers who act as ‘gatekeepers’ to regulate use and are responsible for day-to-day cleaning and general upkeep of public toilet facilities.
The management of public toilets is a particularly profitable business. The costs of operation are low, and profit from user fees is high. A Daily Guide reporter, Gomda, has observed that ‘toilet management is a goldmine’. According to him: ‘Toilet management in Accra is a serious business with some managers making millions of cedis daily, depending on the location. Such facilities in places like Tema Station and other crowded areas attract a lot of patronage and therefore money’ (Gomda 2009). This account may be an exaggeration but verifying it is difficult because of the lack of systematic studies. However, anecdotal evidence suggests that income from a medium-sized public toilet is around US$100–200 per day or about US$5000 per month, and as far back as the 1990s, Whittington et al. (1993) estimated that revenue from public toilets in Kumasi amounted to about US$57,000 per month, which is often concentrated in the hands of a few people. According to Ayee and Crook (2003, p. 22), the chairman of the Ayawaso Sub-Metropolitan District Council (SMDC) in Accra from 1994–2000 controlled all the toilets in his electoral area and rendered virtually no account to his SMDC.
Problems of this kind have contributed directly to the growth of slums in the country. Thus the private sector does not collect the waste of the majority of urban citizens who cannot pay for such collection. The city authorities, on the other hand, do not sufficiently cover low-income areas because these areas are often deemed to be illegal settlements. Even in open commercial areas, the private sector fails to collect waste generated, partly because of poor monitoring of its activities. The cumulative effect of these problems is that waste-management problems in urban areas as a whole are worsening for the majority of people and improving only for the rich minority (Baabereyir 2009). In turn, slums and slum conditions persist. One such slum is Old Fadama, which is labelled Sodom and Gomorrah, or sometimes described as ‘one of the most polluted places on earth’ (Benjamin 2007). Such places contain a disproportionate number of the urban poor.
Socio-spatial inequalities and health
In Ghana, there is a high level of correlation between ‘people poverty’ and urban ‘place poverty’. This correlation does not mean that poor urban places are not sometimes inhabited by relatively well-to-do people (Owusu et al. 2008). Rather, it means the poorest people tend to be concentrated in poor areas where HIV/AIDS, malaria, diarrhoea and cholera cases are high. This high incidence of disease in poor areas may be because disease vectors multiply faster in ‘suitable habitats’; in this case, poor environmental and water conditions, such as stagnant water and uncollected rotten garbage. Also, the clusters of poverty in such areas tend to make inhabitants exhibit risky sexual behaviours in response to multiple deprivations which, in turn, increases their likelihood of contracting the HIV virus (Jørgensen 2008). In any case, it seems malaria could hasten HIV progression (or vice versa), and HIV infection increases the likelihood of other viral infections (Laufer and Plowe 2007). Therefore, even though HIV and AIDS prevalence is quite low (under 5%) in Ghana compared to sub-Saharan African levels, the prevalence in cities is higher than in rural areas (Kjellstrom and Mecerdo 2008).
Figure 1 below shows the interconnections between the issues of water and sanitation, on the one hand, and the problems to which they contribute, on the other hand.
The links shown in Figure 1 are mutually reinforcing rather than exclusive. Thus, poverty could intensify the problems of water and sanitation because it determines where one lives, while where one does live could contribute to the deprivations one suffers. Even though water supplied by private agents is usually of good quality, non-affordability and non-reliability force the poor to use unhygienic water sources. Ultimately, poor service delivery to low-income and socially powerless people, and a health system that does not sufficiently cover their needs, combine to impinge negatively on health status. These conditions create stereotypes, because people from these places are marginalised and are likely to be unemployed or underemployed (Obeng-Odoom 2011). Currently, 26.1% of women and 22.1% of men in urban areas are unemployed (GSS and Ghana Health Service 2008).
Even though not all these people live in poor urban neighbourhoods, there are reasons to expect a general correlation between the spatial distribution of the underemployed and the socio-economic and health status of the locality. Processes of circular and cumulative causation operate. There is a cycle of poverty in which poor health leads to poor jobs, which, in turn, lead to poor wealth. Empirically, several studies have shown that people in such places suffer multiple deprivations which impinge on their ability to be employed. For instance, A.T. Amuzu, the Ghanaian environmentalist, and Josef Leitman, an urban planner (Amuzu and Leitman 1994, p. 5), found these tendencies in Accra, prompting them to label such people ‘economically depressed’. Some may have jobs – temporary work – but not usually employment. Boadi and Kuitunen (2005) have also found significant causation between household wealth and child health, fly infestation, and respiratory-health infections. Overall, the poor of all ages in Accra experience higher death rates from infectious diseases than their wealthier neighbours. Also, research by Stephens and his colleagues (1994) over a decade ago showed that adult mortality from strokes and heart diseases is twice as high in poor areas as in rich areas; and that child mortality from infectious diseases is five times worse in poor areas in Ghana (cited in Todd 1996, p. 145).
All these correlations have negative effects on economic growth, redistribution and poverty reduction. Slums generally perpetuate inequality, not only because people there tend to be trapped in a cycle of poverty, but also because the activities of slum dwellers – selling dog chains, scrap metals, providing cheap labour – indirectly subsidise the activities of high-income groups who obtain goods and services from slum labour extremely cheaply. Also, from a macro-economic perspective, economic growth is significantly reduced if labour is not healthy enough to work or when morbidity within the workforce is high. In one case, scholars at the University of Ghana estimated that a one percentage increase in malaria-related morbidity rate in Ghana causes a slowdown of real GDP growth of 0.41% (Asante and Kusi 2005). Such an effect can impinge negatively on poverty reduction, although this is not automatic. Indeed, recent figures from the Ghana Statistical Service show that the number of people living below the official poverty line in Ghana dropped from 39.5% in 1998/99 to 28.5% in 2005/6 (UNDP 2007). In urban areas, this reduction was as follows: urban coastal (31.0 – 5.5), urban forest (18.2 – 6.9) and urban savannah (43.0 – 27.6) (UNDP 2007).
However, levels of inequality in the country as a whole have risen sharply. The Gini co-efficient has worsened from 0.38 in 1987 through 0.42 in 1998 (Vanderpuye-Orgle 2002) to 0.43 in 2009 (UNDP 2009). Currently, the poorest 10% of the population has access to only 2% of the income in the country while the richest 10% control 32.8%. That is, the average income of the richest 10% is 16.1 times higher than that of the poorest 10%. Still, at 16.1, the ratio of inequality in Ghana is more favourable than the average (22.1) for ‘medium HDI [Human Development Index] performers’ like Kenya (21.3), Cape Verde (21.6) and South Africa (35.1), but worse than the situation in Egypt (7.2), Morocco (12.5) and Tanzania (8.9) (UNDP 2009), all three of which have strong interventionist states. Although this statistical evidence for large and widening inequality in Ghana describes the overall rather than the urban situation, qualitative evidence (different housing types, gated and slum dwellings, and so on) suggests that inequality within and between cities is huge and getting wider (Grant 2009, Obeng-Odoom 2010).
This rising inequality has the potential to reverse the falling levels of poverty in cities. The Ghana Statistical Service has observed that: ‘If Ghana had experienced no change in inequality during the last seven years, the actual decline in poverty of 10.4[%] would have been 13.8[%] … the decline in poverty would have been even better if it had not been offset by increasing inequality’ (GSS 2007 p. 17). Thus, in Accra, one of the most unequal cities in Ghana, while urban poverty overall declined between 1998/9 and 2005/6, poverty levels in Greater Accra Metropolitan Authority rose from 4.4% to 10.6% over the same period, as did extreme poverty, which rose from 1.9% to 5.4% (GSS 2007, UNDP 2007).
Clearly, health problems in Ghanaian cities have wide impacts, striking at the very core of national economic development, and require urgent remedial action. Review of existing policies needs to be based on a frank assessment of the capacity of existing government institutions to undertake such a task. As this article has shown, a significant share of the problems discussed arise from the private provision of municipal services, particularly water delivery and waste collection. The private sector has succeeded in providing excellent facilities for those who can pay for their waste to be collected, while the poor have been forced to live in filth and use unwholesome water. It follows that there is the need for greater state interventionist policies, not only in the waste and water sectors, but also in the health sector, focusing on the improvement of slum conditions to reduce the incidence of disease. But would the state be willing to take on these responsibilities? Does the state have the financial resources to intervene? Would state officials who might be profiting from the status quo, either as owners or partners of private firms contracted to the state or municipal government, be willing to let go of these ‘opportunities’? Would politicians be prepared to give up the opportunity they get from controlling provision of public toilets? There are no easy answers to these questions, although it is clear from the analysis of the health situation in Ghanaian cities above that without decisive government intervention, conditions will worsen further.
Conclusion
A major factor underlying the poor health conditions in Ghanaian cities is the private provision of water and sanitation services. Private-sector engagement has increased access to water: more people have become connected to piped water. However, water has been priced beyond the reach of many urban citizens. Consequently, relatively rich people who are more likely to access water sell to poorer neighbourhoods at a profit. In turn, a significant number of people, particularly in slum neighbourhoods, resort to the use of unwholesome sources of water.
Like water, sanitation has also received a boost in efficiency since private-sector participation. The private sector has consistently exceeded its target for waste management and water provision and has, therefore, taken over more and more of the waste-management responsibilities of city authorities, potentially enabling these authorities to refocus their limited resources elsewhere. This success is, however, more beneficial to the minority of rich people who can pay for waste services. The poor, who cannot afford comparable services, are condemned to live in unhealthy conditions. These dynamics, together with a weak health insurance system, have contributed to the poor state of health among the majority of urban citizens in Ghana.
This article has suggested several reasons why the private sector has not been able to deliver municipal services effectively and comprehensively. One reason is state failure to regulate the sector and require firms to provide greater coverage of both rich and poor neighbourhoods, possibly at differentiated rates. Another reason is ‘official cronyism’, in which state and municipal officials see the award of contracts to private-sector participants less as a way of improving service delivery and more as a means of dispensing patronage to political favourites. A third, more structural reason, is the nature of private-sector involvement itself, which is driven more by the profit motive than by a desire to extend municipal services to areas of greatest need.
How to resolve these tensions between private provision of water and sanitation and public concerns for public health is a difficult question. Effective state intervention has considerable potential to improve the situation because, although the state would not normally provide water and sanitation services for free, it would tend to be driven more (rather than less) by public-health concerns and less by an aspiration for profit. However, the state is severely limited in terms of resources. The will to intervene is also impaired to the extent that some government officials benefit from the status quo. The challenge is to make state intervention less a vehicle for the pursuit of selfish individual and group interests and more a tool for widening opportunity, reducing socio-spatial and other forms of inequality and improving ordinary people's conditions of existence.
Note on contributor
Franklin Obeng-Odoom is a Doctoral Research Candidate in the Department of Political Economy, School of Social and Political Sciences, University of Sydney, Australia. Further information on his research work and interests can be found at http://www.jjang.rgro.net/franklin.htm.