Team H. The Effects of Urbanization on Health: Evidence from Ghana
Note/disclaimer: This webpage is for instructional purposes only and the scenario described below is fictional.
This page was developed as a hypothetical report for the Government of the Republic of GhanaConsultants from the University of Wisconsin, Madison:
Maame Brewoo, International Studies
Tanya Carney, Nelson Institute for Environmental Studies
Scenario | Abstract | Introduction | Methods | Results | Limitations & Assumptions | Conclusions & Recommendations | Citations | About the Authors
The Government of Ghana has contracted independent consultants from the University of Wisconsin, Madison to conduct a study on the impacts of urbanization on health in urban centers in Ghana. The government has recognized increased negative health outcomes within large cities and is seeking to determine the causes of decreased health as well as recommendations on potential interventions. The assessment will be used to guide funding distribution and potential interventions in 2020. Findings and suggestions may also be used when seeking external funding for initiatives.
Populations in urban areas have been steadily increasing in Ghana due to natural births as well as rural-urban migration. Along with increases in population, cities are also seeing increases in poor health due to changing urban diets and lifestyles. Unhealthy diets can lead to disease which puts a financial burden on both the state and the individual for health services and lost production. Shifting urban diets and lifestyles also have a negative impact on the environment and negative social ramifications. Ghana has a history of implementing successful, health-related policies. Using lessons learned from the implementation of these policies, Ghana should create more extensive health-focused policies and put more government spending towards healthcare, and health education and literacy.
In 1957, the Republic of Ghana became the first African nation south of the Sahara to gain independence. Prior to independence it was a British colony known as Gold Coast, named after the abundance of gold that fueled the gold trade in the area. It is located in West Africa and bordered by Cote d’Ivoire to the west, Burkina Faso to the north, Togo to the east, and the Atlantic Ocean and Gulf of Guinea to the south. After European colonization, Ghana was made up of the lands of the Ashanti people, and the Trust Territory of Togoland (now the Republic of Togo). Consequently, Ghana shares traditions, beliefs, culture, and foods with parts of these neighboring countries (Hafner 2002).
Industry (oil, gas, and mining) and agriculture play a major role in the economy, with agriculture accounting for about 20% of GDP and employing more than half of the workforce (The World Factbook 2018). In 2015 Ghana signed a $920 million credit facility with the International Monetary Fund which requires Ghana to adhere to neoliberal policies to reduce their deficit (IMF Press Release 2015). The nation has a young age structure, with approximately 57% of the population of close to 29 million being under the age of 25 (The World Factbook 2018).
The introduction of crops from Asia and the Americas to the West-African subregion has had a strong influence on culinary practices (see Table 1). Traditional diets in Ghana are based on staple crops including cassava, maize, plantain, rice, and yams (Andam et al 2018). Meals often consist of a main, energy dense component (yams, maize, cassava, etc.) served with either a soup or stew (Galbete 2017). Popular dishes include fufu, dough made from boiled and ground plantain or cassava; waakye, rice and beans; red red, boiled cowpea beans; and kelewele, fried plantain.
Between 1960 and 2017 the population of Ghana grew from roughly 500,000 to nearly 30,000,000. At the same time, the proportion of people living in urban areas has been increasing. In 1960, 23% of the population lived in urban areas. In 2015, 55% lived in an urban area (World Bank n.d.), and by 2030 that number is expected to exceed 65% (Adua et al 2017). The rate of urbanization peaked in 1985 (5%) and has since been steadily declining. In 2017 the rate of urbanization was 3.4%.
Two major factors contributing to population increases are natural population growth and rural-urban migration. Since 1970 a high rate of natural increase has had a greater impact on population in the cities of Ghana than rural-urban migration (Ardayfio-Schandorf 2012). The current rate of population growth in Ghana is 2.2% (World Bank n.d.). Fertility rates have been steadily decreasing, from around seven births per woman in the 1970s, to around four in 2016 (World Bank n.d.). Along with this trend, there is evidence that suggests that birth rates are lower in cities than rural areas (White et al 2008). Improvements in healthcare in cities have increased life expectancy and decreased infant mortality, both of which contribute to urban growth, despite decreases in fertility. In 1960 life expectancy at birth was 45.8 years, in 2016 it had risen to 62.7. Likewise, infant mortality has dropped from 120 deaths per 1,000 live births in 1960 to 36 in 2016 (World Bank n.d.). In addition to healthcare improvements, these health outcomes can also be attributed to increased government spending on health. Between 2001 and 2017, the government increased its public healthcare spending by 11% (Adua et al 2017).
Urban migrants have been drawn to cities due to the concentration of social and economic infrastructure, and the livelihood opportunities that stem from them, including access to better education (Ardayfio-Schandorf 2012). Access to industry is another draw; thirty-two percent of Ghana’s industrial activities are concentrated in Accra (Boadi 2005).
Urban lifestyles are putting people at risk for non-communicable diseases (NCDs) related to diet and exercise. These diseases include diabetes, heart disease, hypertension, and some cancers. The rate of urban obesity and related diseases in Ghana has been steadily increasing and can be attributed, in part, to changing urban diets and more sedentary lifestyles. Diets are shifting from traditional, which are rich in complex carbohydrates and fiber, to diets that are high in fat and sweeteners (Ofori-Asenso et al 2016). Nearly 43% of Ghanaian adults are either overweight or obese (Ofori-Asenso et al 2016). In rural Ghana 16.7% of adults are considered overweight and 8% are considered obese. In comparison, in urban Ghana, 27.2% of adults are considered overweight and 20.6% are considered obese (Ofori-Asenso et al 2016).
Cardio-metabolic risk factors such as smoking, low physical activity, low fruit and vegetable intake, and high fat and salt intake increase the prevalence of cardiovascular disease and diabetes (Obirikorang et al 2015). These risk factors are often also associated with increased instances of overweight and obesity. Raised body mass index (BMI), resulting from overweight and obesity, is a major risk factor for cardiovascular diseases, hypertension, and diabetes (Ofori-Asenso et al 2016). It is projected that NCDs (including those related to health) will account for 80% of the global burden of disease, causing seven out of every ten deaths in developing nations by 2020 (Tagoe 2012).
We used peer reviewed articles on work undertaken in West Africa and Ghana. Criteria used for these sources were articles that directly related to the topic of the effects of urbanization on health in Ghana or that gave important background information on the subject, and sources that focused on studies carried out in larger cities in Ghana. To supplement these articles we also used books about West African history, particularly as it relates to food. Where we could, we focused on publications that were less than five years old although we strayed from this for sources we derived general background and historical information from.
The principal sources for this data were internet databases including Academic Search Premier, LexisNexus Academic, and the UW-Madison Library Catalogue. When searching we utilized a variety of terms including: Ghana, urbanization, diet, nutrition, health, obesity, diet, meat, greenhouse gasses, economy, nutrition transition, non-communicable disease, and any combination of these terms.
Urban lifestyles have altered patterns of eating and activity. Work has become more sedentary, daily activities have decreased, and access to unhealthy food options have increased. These factors along with rapid increases in urban populations and affluence have led to negative health outcomes. Most noticeable, is an increase in health-related non-communicable diseases (NCDs), which now account for the death of roughly 86,200 people in Ghana each year (Adua et al 2017). While Ghana does have a National Health Insurance Scheme (NHIS) that covered 38% of the population in 2013, the scheme does not cover treatment for NCDs. These shifts in lifestyle have economic, environmental, and social consequences that require addressing.
Shifting Diets & Lifestyles
Individuals who live in the city tend to have access to a greater variety of food options than their rural counterparts. At the same time, increased incomes from urban employment often leaves individuals with an increased disposable income. Recent and rapid economic growth has also led to changes in food processing and availability (Galbete et al 2017). In addition, food choices that value convenience, or cooked meals eaten at street vendor stalls, and easy-to-prepare cereals like rice become increasingly favored (Smith 1998). The combination of these factors has led to shifting diets. Access to refined carbohydrates, red meats, snacks, and processed and fatty foods has become easier, and consumption of salt, sugar, and alcohol are high. In addition, exposure to indoor smoke from solid fuels and the use of tobacco are common (Bosu 2013). In 2004 the per capita consumption of fruits and vegetables was half of the recommended annual amount of 146 kilograms (Meng et al 2018).
Diet-related issues such as obesity, high cholesterol, hypertension, waist to height ratios, etc. are increasing in urban areas. Urban individuals are also generally less active than their rural counterparts which may also explain some of the differences. New urban lifestyles may also make going home and cooking lunch impossible, causing individuals to turn to less healthy, prepared food options (Goody and Goody 1995).
In Accra more than 90% of all food consumed is purchased (Meng et al 2018), and the products available for purchase have been shifting to include more processed foods. In at least one study in Ghana it was found that the availability of processed foods corresponded with the size of the city (Andam 2018). Daily intake (in grams) of sodas and juices, coffee and tea, fish, rice and pasta, vegetables, dairy products, oils (excluding palm), cakes and sweets, vegetarian mixed dishes, processed meat, and red meat is higher in urban than rural Ghana (Galbete et al 2017). In general, diets are becoming more energy-rich which has, in part, led to a shift from undernutrition to overnutrition.
The government of Ghana has successfully taken action on health issues in the past including the implementation of an innovative food standards policy that limits the amount of fat in meat and meat cuts in the hope that it would reduce the availability of high-fat meat in the national food supply, thereby reducing the prevalence of NCDs. The law was passed due to concern about high-fat diets as well as high fat/low quality poultry meats (in particular turkey tails). The standards within the policy apply to both imported and domestic meat and regulations are implemented and enforced by the Ghana Food and Drugs Authority (FDA). The policy has been implemented along with press releases and has been successful in reducing the availability of low quality, high fat meats in the Ghanaian food supply.
The Government has also implemented highly successful tobacco control measures which have led to rates of smoking remaining relatively low in Ghana. In 1982 the Government imposed a directive that banned all cigarette advertisements on state television, radio, and printed media, including billboards (Owusu-Dabo et al 2009). In 2012 they put further restrictions on smoking and banned smoking in public places. Although levels of smoking cannot be tied directly to these two bans, they cannot be viewed as insignificant.
Other government health initiatives have included health promotion through national and international days, the development of educational materials, and an increase in health walks and games (Bosu 2013).
Health-related NCDs are on the rise as are the costs of healthcare. For example, new cases of reported hypertension have risen from roughly 60,000 in 1990, to 700,000 in 2010 (Bosu 2013). While the government has increased spending over the past few years (US $53 per capita in 1995 to US $60 per capita in 2014), it has not been enough to meet rising healthcare costs (Adua et al 2017). The increased prevalence of NCDs strains not only the national budget, but household finances as well. This is especially true considering the fact that Ghana is simultaneously battling other infectious and parasitic diseases (Ofori-Asenso et al 2016). Globally the world will spend $47 trillion between 2010 and 2030 due to economic impacts of NCDs (Bosu 2013).
In addition, imports dominate the food processing sector. In one study of eight Ghanaian cities, between 63% and 86% of products for sale were imported, with 71-83% of them being processed in firms located outside Ghana (Andam 2018). The growing demand for processed foods can lead to greater food imports and impact the profits of small-holder farmers (Andam et al 2018).
Per capita meat availability fluctuated between 1980 and 2009, and has been steadily increasing since around 2002. In 2009 per capita meat availability was 14 kilograms. This is also reflected in the increased production of meat, of which cattle, goat, sheep, and chicken increased between 1998 and 2008. The only livestock animal to decrease in number were pigs. In the 1970s and 1980s around 90% of the meat consumed was supplied domestically. However, due to policies of liberalization that were conditions of World Bank and International Monetary Fund (IMF) loans, by the 1990s, only around 35% of meat was produced locally (Thow et al 2014).
Production of ruminants gives off large amounts of greenhouse gasses (GHGs) including methane and nitrous oxide, gases that have far greater global warming potential than carbon dioxide (Hyland et al 2017). Between 1990 and 2011 the livestock sector in Ghana grew 177%. With this increase came increases in emissions. With meat consumption on the rise, these emissions can be expected to continue to rise as well.
Increases in imports have also led to greater greenhouse gas emissions due to transportation. Most local production sectors (eg rice and poultry) are unable to meet local demand and therefore food must be imported. There is also a high demand for consumer-ready products due to a lack of local production (Ghana Agricultural Sectors n.d.).
Beyond contributing to obesity and related NCDs, lack of physical activity has also shown to have negative consequences on mental health in Ghanaian adolescents. Affluent children are particularly prone to low levels of physical activity due to increases in technology including computer and internet use. In addition, vehicles are viewed as status symbols and therefore many of the wealthy choose to be driven to school rather than to walk. Studies have shown that decreased levels of physical activity have been linked not only to obesity, but also to depression and low self-esteem (Asare and Danquah 2015).
The transformation of local diets and lifestyles presents a shift in cultural tastes as well. Urbanization has been cited as the single dominant factor in the shift towards rice consumption (Smith 1998).
- Lack of extensive, relevant research carried out within the past five years.
- The population of Ghana will continue to grow and urbanize.
- Urban inhabitants will continue to consume in the same way they are currently.
- Urban residents would not act on diet-related health issues without intervention.
- Rates of overweight, obesity, and NCDs are due to diet and exercise alone.
The health of urban citizens requires immediate attention. The rates of obesity in urban Ghanaians is on the rise and contributing to increased diagnoses of NCDs. These increases can be contributed to poor health and lack of exercise, and should be addressed before they place an undue burden both on the state and the individual.
The government needs to put more investment into healthcare for disease prevention and early detection as well as health education and literacy. Particular attention should be paid to children as childhood obesity is associated with negative results in adulthood which will result in an unhealthy future workforce limiting overall productivity (Aryeetey et al 2017).
Health interventions need to be carried out strategically as at least one study has found that most citizens do not favor paying increased taxes for better healthcare. Part of this stems from a lack of trust in the government (Adisah-Atta 2017). Interventions should encourage healthy lifestyle behaviors such as proper diets and physical activity.
The consumption of fruits, vegetables, legumes, and whole grains should be encouraged along with a reduction in salt, saturated fat, sugar, and trans-fatty acids. Meat consumption should only be encouraged in moderation to promote healthy diets and minimize GHG emissions stemming from production and transport. In addition, physical activity should be emphasized in schools and could be added to curriculum. Due to its successful history of health-related policy implementation, the government could also look into strategies that have been implemented by other nations such as the sugar tax in Mexico and UK.
Since many people living with diabetes or hypertension have no symptoms, it is important that individuals be examined regularly. Exams should be encouraged, and for a period of time each year the government could sponsor free blood pressure measurement. At the same time, awareness of premorbid diabetes risk assessment tools should be promoted. Examples include the Finnish FINRISK, Australian AUSDRISK, and the Indian IDRS. In conjunction with this, the government could fund or encourage groups or networks for individuals living with NCDs or other health-related conditions. It has been reported that these networks can encourage individuals to take medicine properly and help out financially as well (Tabong et al 2018).
Further research and analysis should look into the impact of urbanized diets on health particularly in women and other factors (outside of diet and exercise) that may affect the prevalence of obesity in Ghana outside of urbanization and associated lifestyle changes.
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Maame Brewoo studying International Studies, Digital Studies, and African Studies at the University of Wisconsin - Madison. As a native of Accra Ghana, her interests emphasize the presence of culture within the age of globalization.
Tanya Carney is an Environment and Resources master's student in the Nelson Institute for the Environment at the University of Wisconsin, Madison. She is interested in climate change adaptation and resilience in West Africa.