Ghana’s Population Policy Implementation: Past, Present and Future

The effective implementation of population policies is critical in addressing development challenges particularly for developing countries. Ghana’s experience at population policy implementation spans a period over four decades. There have been successes, failures and challenges as new issues which hitherto were non-existent at the inception of the policy, emerge in the course of implementation. This paper assesses Ghana’s efforts at implementing its national population policy and brings out deep insights on lessons learnt and makes proposals for the way forward. The assessment shows that while some successes have been achieved in the area of fertility transition, increasing life expectancy at birth, etc., there are still critical challenges which are socio-cultural and political in character. Institutional structures for coordinating the implementation are undermined by poor resource in-flow from the state resulting in loss of trained human resources for effective implementation. The functional integration of population variables into development planning at the district level is consequently virtually non-existent. It is, therefore, just not enough to have a population policy as a document if the state does not attach the highest level of importance to population dynamics as a development planning priority in the country.


Introduction
According to May (2012), population policies or the lack of such policies play critical roles in influencing the behaviour of people and also shape demographic trends. He further explains that the levels of fertility and mortality, internal and international migration as well as annual rates of population growth determine future demographic outcomes. The demographic processes that occur also have far-reaching consequences for future socio-economic development and all these may lead to demographic imbalances which can be addressed through the design and implementation of population policies. In the light of this, this paper aims at providing an assessment of Ghana's efforts at implementing its national population policy and brings out deep insights on achievements, challenges/weaknesses, lessons learnt, and makes proposals for the way forward.
The global debate on population and development during the 18th, 19th and 20th centuries particularly at the population conferences of 1974, 1984 and 1994, drew attention to the strong interrelationships between population and development. After World War II, both mortality and fertility levels were deemed to be too high especially in developing countries and it was thought that reducing fertility levels would improve socio-economic outcomes. Even though the debate involved divergent views on the importance of population relative to development, there appears to be a general agreement that widespread poverty and social and gender inequalities affect, and are also impacted upon by demographic factors. The general outcome of this debate has been that countries across the globe have become relatively more conscious of the linkages between population and development and have consequently acknowledged the need to adopt comprehensive policies and programmes that are likely to reflect these linkages towards the enhancement of the quality of life of the generality of their populations.
Against this background, countries have initiated strategies and adopted policies to curb high mortality as well as reduce high fertility rates. In Africa, Mauritius was the first country to adopt a population policy in 1958 and was followed by Kenya in 1967. Ghana was the third African country to adopt a comprehensive population policy in 1969, under the theme "Population Planning for National Progress and Prosperity" (Republic of Ghana, 1969). The 1969 Population Policy aimed at reducing the country's high population growth rate which in 1960-1970 was 2.4% per annum. After years of implementation, the 1969 Policy was reviewed to address challenges that inhibited its effective implementation in addition to incorporating new and emerging issues that hitherto did not exist. A key failure of the 1969 policy implementation was its inability to reduce the rapid population growth of the country. This is because at the time of its revision in the early 1990s, total fertility rate was still high and the population was growing at almost three per cent per year which was beyond its 1969 levels.
Following the revision of the 1969 Population Policy and its replacement in 1994 by the Revised Edition, it became quite clear that apart from the new and emerging issues the revised policy incorporated, the general tenets of the 1969 policy were affirmed. It is important to note that although the 1994 Revised Population Policy preceded the 1994 International Conference on Population and Development (ICPD), it not only anticipated the major recommendations of the ICPD, but most importantly mirrored its main tenets. Since 1994, some remarkable progress has been made as reflected in current population and development indicators especially in terms of the on-going fertility transition Ghana is experiencing. There have, however, been obvious challenges which have and continue to undermine its effective implementation to achieve its objectives in line with the development aspirations of the country.
While there have been opportunities to assess the implementation of the policy with the view to strengthening and accelerating its implementation to achieve policy objectives and targets including the Indepth Assessment of the Implementation of the Revised Policy undertaken by the National Population Council in 2004 (ten years after its adoption), this paper presents a comprehensive review of the successes, failures and challenges in the light of recent global and national developments and occurrences. This is particularly important considering that the 2004 In-depth Assessment of the Revised Population Policy was not published. This paper is again considered important within the context of the remarkable economic progress Ghana has made in attaining a lower middle income status and its discovery of oil and gas in commercial quantities. The need for a review of the population policy implementation becomes necessary as efforts are being made to hasten the country's development towards a higher middle income status, mindful of the effects a poorly managed population could have on the attainment of this economic objective, particularly considering new and emerging issues such as the effects of global climate change and the role population factors could play.
Furthermore, the relevance of this paper is conceived within the global ICPD-Programme of Action (PoA) reviews that have been done. It is important to note that the ICPD-PoA was adopted nearly two decades ago, around the same time Ghana's Revised Population Policy was also launched. Currently, in Ghana, further review of the Revised National Population Policy is on-going as is the Adolescent Reproductive Health Policy, a process which is likely to benefit from the contributions this paper makes.
This paper attempts to answer the following fundamental questions: To what extent has the implementation of Ghana's population policies been successful? What have been the best practices and major challenges that have been observed? What lessons are to be learnt to feed into on-going further review of the current policy? To address these questions, the paper presents a brief review of relevant literature and a conceptual framework that highlights the relevant factors that are necessary for the successful implementation of any policy, plan or programme. The paper further discusses the trend of Ghana's population and then provides a brief overview of population policies in Ghana. This is followed by a critical assessment of the policy implementation highlighting the successes, challenges and lessons learnt as a basis for making recommendations for the way forward.

Literature Review
The successful implementation of population policies could be affected by a number of factors which some researchers have pointed out. These range from the period of conceptualization through development to implementation. These factors do affect the successful implementation of population policies however comprehensive they may be. For example, in their evaluation of the 1969 Ghana's population policy, Benneh et. al., (1989) concluded that in spite of the fact that the policy was comprehensive, its implementation was disappointing considering that fertility remained high with low contraceptive usage while population issues continued to receive insufficient recognition in development plans and programmes in the country. Enang and Ushie (2012) also attach much importance to the role of culture in the successful implementation of population policies in Nigeria. In their appraisal of population policy in Nigeria, they argue that although the 1988 Population Policy was said to have been the result of intensive process of consultations and discussions with various interest groups, the Foreword to the policy still had a statement that expressed hope that it would be widely distributed, read and discussed among the generality of the population. According to Enang and Ushie (2012), the consultations were not conclusive because the interest groups might not have included cultural groups. To these researchers, therefore, culture is a very important factor in population regulation and should be considered in any programme towards the implementation of population policies. Enang and Ushie (2012) further support the importance of culture in population management by their suggestion that cultural and religious beliefs contributed to the boycott in some parts of Nigeria against immunization in the early 2000s. They further point out that immunization against polio in Nigeria was negatively affected by cultural and religious beliefs to the effect that the polio vaccine was perceived to be contaminated with anti-fertility drugs that could reduce young women's reproductive capability. Similarly, Dike (2004, cited in Enang andUshie, 2012), points out that Northern Nigeria kicked against imported vaccines from the Western World based on their belief that they were meant to depopulate their population as part of the war against terrorism. The fundamental issue behind all these is that culture and religious beliefs wield much power in any population policy implementation and consequently, ignoring them would mean reducing the rate of success of the policy. Enang and Ushie (2012) concluded by observing that the high rate of population growth may continue if the country continues to rely on a policy document that ignored, from its inception, the cultural pluralism of the nation. This position appears to be consistent with Okono (2003) who attributed the failure of the 1988 Nigerian Population Policy to the implicit assumption of a single monolithic cultural environment, disregarding male reproductive motivation.
While admitting that culture is quite a critical factor to consider in the implementation of population policy in Nigeria, Adegbola (2008) argues that any attempt to attribute the failure of the population policy entirely to cultural differences is not acceptable since there are several important components of the policy implementation that ought to be considered. Other considerations were cited to include the bureaucratic politics that were at play, resources available for implementation and interest groups in support or in opposition to the policy. He considers the implementation strategy that was adopted for the national population programme as a major important consideration in assessing the achievements of the policy. Adegbola (2008) further demonstrates how the ethnic, religious and cultural diversity has contributed to the limited success of population policy implementation in Nigeria. He identifies several problems that this diversity has brought about. For example, based on religious attachments, some educated elites and political leaders openly opposed the population policy particularly regarding the adoption of family planning simply because according to them it was not consistent with their religious injunction. Similarly, women who find themselves in states that have adopted the Sharia Criminal Law, "cannot take independent decisions on the timing and tempo of their pregnancies" (Adegbola, 2008:9).
The wide diversity is also said to pose a problem to population policy implementation from the point of both the majority and minority ethnic groups. While the majority groups would want to continue to maintain their hold on power in Nigeria using their sheer population size, the minority groups are also opposed to the policy of fertility control because of their desire to increase their population in order to be able to claim their share in political and economic power. This is so when considered against the fact that areas populated by the minority ethnic groups are the ones that have the resources that support the economy of the country.
Another problem that is highlighted in Adegbola's (2008:9) paper is the diversity in terms of language in terms of "how to accurately communicate the reproductive health, fertility regulation and family planning technologies to the people in their own language without hurting their sensibilities and thus generate opposition to the program". He further points out the problem of developing a national consensus regarding which languages to be used for translating the population policy documents to ensure broad-based ownership. These problems could prove to be serious challenges to the successful implementation of population policies if they are not adequately addressed.
According to Graff (2013), in spite of some of the positive achievements of Kenya's Adolescent Reproductive Health Policy, it suffered from lack of awareness about the policy; lack of coordination among implementers; low stakeholder involvement, low political will and limited youth involvement as well as limited availability of high-quality adolescent sexual and reproductive health services.
Notwithstanding these problems some of which are similar in many countries in Africa, some progress has been achieved. For example, the African Development Bank (2000) acknowledged that some progress has been made in the area of population policy development and programming in Africa, but points out, however, that member countries continue to face major challenges including insufficient funds, low awareness among public officials on population issues, inadequate intervention strategies, incompatible socio-cultural and religious practices and insufficient decentralization of population activities as well as inadequate interagency collaboration and regional integration. This means that not until these challenges are addressed, population policies would continue to achieve limited success in their implementation.
The challenges population policy implementation is faced with could also be the result of the fact that attention has since moved from population issues to issues pertaining to new development concerns including HIV/AIDS, climate change, and governance (May, 2012). According to him, it has become difficult to address the fundamental population issues over a long period of time with sustained attention they require, thereby calling for the need to develop a more effective approach to institutionalize population policies. Interestingly, however, this can only be achieved with increased political will that identifies population issues as being critical in national development planning activities and programmes, which is often lacking in many countries in sub-Saharan Africa.
In Ghana, some of the challenges which in the past have been identified to affect population policy implementation have included among other things low political commitment towards their effective implementation, low knowledge about population issues and appreciation of their effects on socioeconomic development among higher-level government officials and planners and the general public (Benneh et al, 1989). It is, important to examine the situation within every country setting to identify the key problems some of which are likely to change with time in order to offer realistic recommendations towards reaping the benefits that are likely to accompany any fertility transition and the demographic dividend.

Conceptual Framework
Article 37 of the 1992 Constitution of Ghana enjoins the Government of Ghana to maintain a population policy consistent with the aspirations and development needs of the country. In this context, population policies are expected to be adopted and translated into programmes and projects that respond to the needs of the people and effectively implemented to achieve objectives and targets towards the improvement of the quality of life of the generality of the people. Implementation, in its simplest term, can be described as the carrying out of a plan. Implementation thus, focuses on operationalizing the plan. Among others, it involves a series of activities undertaken by the state and its agencies to achieve the goals and objectives articulated in policy statements. Policy implementation, therefore, sits within the policy cycle which includes policy design, delivery and review, monitoring and evaluation. Implementation is, however, a complex process as those implementing an innovation must manage challenges across multiple levels while anticipating new developments and challenges . O'Toole (1997) looks at the implementation of policy within the context of network settings involving complex institutional structures, interconnected groups or systems which require effective cooperation and coordination to achieve effective policy implementation. This school of thought recognizes the main barriers to implementation as being uncertainty, the absence of trust, and weak or limited institutions, concluding that in order to get new policies successfully implemented, they need to be accepted into the dayto-day work of those responsible for implementing them.
Furthermore, Wandersman et al., (2008) identify three factors that influence implementation. These include individual characteristics, organizational as well as community factors. In terms of the individual characteristics, they argue that there are key variables associated with implementation that include practitioners' education, experience with the same or a similar innovation, and attitude toward the innovation or the motivation to use it. Regarding organizational factors, they link them to a variety of organizational characteristics towards successful implementation including leadership; programme goals/vision; commitment and size; skills for planning, implementation, and evaluation; climate, structure, and innovation-specific factors such as access to information about the innovation, and organizational support for implementation. Community-level factors relevant to the implementation of programmes, on the other hand, include community capacity, community readiness for prevention, community competence, community empowerment, social capital, and collective efficacy. These factors focus on the importance of connections within the community, resources, leadership, participation, sense of community, and the willingness to intervene directly in community problems.
Within the context of this framework, the successful implementation of Ghana's population policies would require strengthened institutions, committed leadership at the highest level in addition to community mobilization that results in a complete ownership of the policy. This is against the backdrop of the multi-faceted nature of population that removes ownership from the institution that the policy identifies as primarily responsible for its implementation to the entire society including their culture and belief systems while ensuring that there is effective coordination of its implementation at all levels of society. Finally, successful implementation is only achievable when, in addition to all these, both human and material resources are mobilized to support full implementation.

Data and Methods
The paper is a review of the population policy implementation in Ghana and uses trend analysis to assess what have constituted the successes, weaknesses and failures of population policy implementation in the country. It is largely descriptive and relies on Ghana's post-independence population census and the Ghana Demographic and Health Survey (GDHS) data and population reports to assess progress made and weaknesses of the population policy implementation in the country. Other data sources and reports used include the Multiple Indicator Cluster Survey (MICS) carried out by the Ghana Statistical Service whose results are available.

Trends in Population Growth
The demographic contrast between developed and developing countries has been widening over time. According to the Population Reference Bureau's (2012) World Population Data Sheet, developing countries accounted for 97% of the recent growth in the global population because of the dual effects of high birth rates and young populations while in the developed countries the annual number of births barely exceeds deaths because of low birth rates and much older populations. The Population Reference Bureau (2012) further predicts that nearly all future population growth will be in the World's less developed countries. The global population growth is, therefore, generally driven by variations in fertility between the developed and developing countries where fertility rates are lower in the former with many countries currently close to replacement levels compared to developing countries where it is much higher. In recent times, however, many developing countries have recorded steadily declining fertility. Ghana is one such sub-Saharan African country which has seen much fertility transition with appreciable fertility declines which could be partly attributed to contributions made as a result of several factors including the implementation of the population policies.
Similarly, mortality rates have dropped substantially since the beginning of the Industrial Revolution. Personal hygiene and improved sanitation as well as modern medicine especially the development of antibiotics capable of reducing deaths due to infection have contributed to the decline in mortality. Generally, mortality rates have also declined in many developing countries. In Africa, maternal and childhood mortality rates have declined but still remain unacceptably high. Declining mortality, coupled with the relatively high fertility rates in developing countries, has translated into a surge in the rate of population growth.
In Ghana, high fertility was a characteristic feature of most traditional societies as a result of a combination of pro-natalist beliefs and customary practices that placed a high premium on large family sizes. Until fairly recently, Ghana's fertility conformed to this pattern in a society which was predominantly rural, agrarian and organized along traditional kinship lines. Low school enrolment, low literacy, coupled with early and universal marriage largely reinforced and sustained these values which in turn produced high fertility among the population. This trend has, however, reversed due largely to improvements in education, rapid urbanization and improved use of contraceptives among women in particular.
With a population of just over two million in 1921, Ghana's population increased to 6.7 million in 1960 and 8.6 million in 1970 at an estimated population growth rate of 2.4% per annum. The population of Ghana, therefore, more than tripled in nearly 50 years from 1921 to 1970. In 1984, Ghana's population was reported at 12.3 million, and reached 18.9 million in 2000 (Ghana Statistical Service, 2002).
In 2010, Ghana recorded a population of 24.6 million with an annual growth rate of 2.5%. At this rate of growth, Ghana's population is expected to double in 28 years. Despite the recorded declines in fertility, the population growth rate has not shown significant decline and has ranged between 2.4% and 2.7% between 1984 and 2010. With a built-in population momentum, further increases in population are expected, at least in the next decade, creating an opportunity for the country to take advantage of the demographic dividend of a large youthful population if the current demographic transition is sustained.
Contraceptive prevalence rate (CPR) for modern methods has not steadily increased over the years. The proportion of currently married women using any modern method of family planning was reported at 7% in 1979-80, declined to 5% in 1988 but doubled to 10% in 1993 (Ghana Statistical Service and ORC Macro, 1989 and1994). This further increased to 13% in 1998 and reached 19% in 2003 before reducing to 17% in 2008 according to the Ghana Demographic and Health Survey (GDHS) reports (Ghana Statistical Service et al, 1999, 2004and 2009). However, the 2011 Multiple Indicator Cluster Survey (MICS) report puts the CPR for modern methods at 23.4% (Ghana Statistical Service, 2012). There was no difference in CPR for modern methods between the urban (23.4%) and rural (23.3%) areas. In terms of any method of contraception, however, a higher CPR of 36.9% was recorded in the urban than in the rural areas (32.5%). There appears to be an inconsistency between increases in contraceptive use and fertility decline thereby fuelling speculations about the contribution of abortion towards the observed fertility transition so far observed in the country. HIV prevalence has, however, declined from its 2003 level of 3.1% to 2.1% in 2011.
Maternal mortality has not recorded sustainable decline. In 2007, it was recorded at 451 per 100,000 live births (Ghana Statistical Service et. al., 2009) and was reported to have declined to 350 in the mid-2000s according to the Ghana Health Service. However, analysis of the 2010 National Population and Housing Census data indicates what appears to be a rise to 485 per 100,000 (Ghana Statistical Service, 2012). It should be noted that while the 2007 maternal mortality figure was based on a maternal mortality survey which is likely to be more accurate, the 2010 was from the national Population and Housing Census which was not specifically targeted at collecting data for maternal mortality analysis. The rate from the census is, therefore, not comparable with that generated from the 2007 Maternal Mortality Survey and, therefore, could not constitute a rise in its true sense.
Ghana's population has rapidly urbanized and now has about 51% to be resident in urban areas compared to the 1960s when about 70% of the population was in rural areas. Slum growth has increased as part of Ghana's rapid urbanization, coupled with sanitation, housing and reproductive health challenges. The population is also beginning to record increases in the size of the ageing population, thereby calling for a lot more attention to be paid to this phenomenon considering the health and economic challenges that ageing populations are associated with. Economic growth has been remarkable and the country has within the last couple of years attained a lower middle economic status. Real Gross Domestic Product (GDP) growth increased steadily from as low as 3.7% in 2000 to 6.2% in 2006 (see ISSER, 2007). GDP further increased to 6.5% in 2007 and continued to increase, hitting the highest rate at 8.4% in 2008, but declined sharply to 4% in 2009 and picked up again in 2010 at 7.7% (see ISSER, 2014). The country is also now an oil producing country, having struck oil and gas in commercial quantities in 2007.

Ghana's Population Policies
Population Policy has been defined as actions taken explicitly or implicitly by public authorities in order to prevent, delay or address imbalances between demographic variables on one hand and the social, economic and political goals on the other hand (May, 2012). The proposed actions of the policy could aim at influencing the three components of demographic change made up of fertility, mortality, migration either directly (through family planning programmes) or indirectly through education and empowerment of women.
As one of the first countries to adopt an explicit and comprehensive population policy in sub-Saharan Africa in 1969, Ghana has had a long history of population policy implementation. The major goal of the policy was to stem the high rate of population growth in order to facilitate socio-economic development. The 1969 policy underscored the fact that "the population of Ghana was the nation's most valuable resource and that it was both the instrument and objective of national development. The protection and enhancement of its welfare is the Government's first responsibility, when that welfare is threatened the Government must Act" (Republic of Ghana, 1969, pg. 3). Kumekpor et al (1989) observed that the policy was unique for its comprehensiveness, it identified the challenges posed by rapid population growth on development and defined short-term targets. The policy was further designed to improve standards of living and quality of life, promote maternal and child health services, and address issues of population distribution and data collection among several others. The central focus of the policy was, however, on issues related to population growth and economic development.
In order to achieve these objectives, the Ghana National Family Planning Programme (GNFPP) was launched in May 1970 as a coordinating department within the Ministry of Finance and Economic Planning for the implementation of the 1969 policy. The key objective of the GNFPP was to reduce population growth and provide the opportunity for people to decide on the number and spacing of their children. Kumekpor et al (1989) again observed that the national family planning programme has also been acknowledged for its non-coerciveness and integration with other health sector activities, multiagency participation and public-private partnership.
In 1986, after years of implementation, it became clear that it had only made partial gains in propagating family planning mainly in the urban areas although about 70% of the population at the time was resident in rural areas. The 1980 Ghana Fertility Survey indicated that the achievements of the programme with respect to the practice of family planning were minimal. Total fertility rate (TFR) was still high (6.4 children per woman) and the population was still growing at 3.0 per cent per annum (National Population Council, 2006).
As earlier pointed out, the challenges encountered in the implementation of the 1969 Population Policy, according to Benneh et al (1989), included the lack of understanding of population issues as they affect development among technocrats, dependence of family planning service provision on an overburdened health delivery system in the public sector, lack of political will and commitment by successive governments in spite of the retention of the policy, pronatalist cultural belief system among the Ghanaian society, the focus of family planning on women to the exclusion of men and the urban-biased approach of the family planning programme notwithstanding the fact that the population of the country was mainly rural at the time. Furthermore, it appeared that the 1969 policy lived by the name of the institutional structure for its implementation, i.e., the GNFPP, to the extent that it focused too much on family planning to the exclusion of other non-family planning-related components of the policy. With time also, there were emerging issues relative to HIV and AIDS, adolescent sexual and reproductive health, environment, which at the launch of the policy were either non-existent or not considered critical to merit policy attention.
These weaknesses largely informed the revision of the 1969 policy that gave birth to the revised 1994 policy. The process for the revision of the 1969 policy was a departure from that which led to its adoption in the use of broad stakeholder consultations at different levels to ensure broadbased acceptance and ownership. In addition, there was an elaborate institutional framework (The National Population Council) established with a National Secretariat in Accra and in each regional capital with responsibility to coordinate the implementation and to advise the government on all population-related issues in the country. The policy also envisioned that its effective implementation would depend on the collective responsibility of government, ministries, institutions, nongovernmental organizations, private agencies, communities, families and individuals. In addition to the national and regional secretariats of the National Population Council, technical advisory committees as well as regional and district population advisory committees were all designed to facilitate and support the smooth implementation of population programmes in the country at different levels.
Furthermore, a six-volume Action Plan was developed along-side the policy to facilitate the implementation of programmes and activities. The action plans covered maternal and child health/family planning, population policy and programmes (including women and development), training and institutional capacity building, information/education and communication and research/monitoring and evaluation. The action plans identified the goals, objectives, strategies and activities to be undertaken and the responsible agencies. The Action plans also indicated physical and financial resources required, expected outcomes and the time frame for each activity.
The 1994 Revised Population Policy and Action Plans were formulated in the context of economic growth and sustainable development, i.e., the ultimate goal of improving the quality of life of the people of Ghana. It emphasized a systematic integration of population variables into development planning, with a renewed emphasis on fertility reduction through family planning programmes. It has fourteen policy goals but these could be summarized under the first two goals: "(i) A national population policy and programme are to be developed as organic parts of the social and economic planning and development and (ii) Measures will be undertaken to improve the standards of living and quality of life of the people" (Government of Ghana, 1994:25).
The Revised Policy also clearly outlined implementation strategies for specific population issues to facilitate the realization of the objectives and targets of the policy. There were strategies for the implementation of programmes and activities in environment, housing, food and nutrition and migration, etc. In the area of education for example, the strategies include the following: "(i) subject to the availability of resources, free and compulsory universal basic education will be provided. Policies and programmes that encourage girls to remain in school up to secondary school will be pursued and (ii) efforts will be made to promote adult education as well as basic and functional literacy with a bias towards maintenance of family values, reproductive health and population and development interrelationships" (Government of Ghana, 1994:35).
The Revised Population Policy also included several targets specifically to reduce the TFR from 5.5 to 5.0 by the year 2000, 4.0 by 2010 and 3.0 by 2020; a contraceptive prevalence rate of 15% by 2000 which is further projected to reach 28% and 50% respectively by 2010 and 2020; a reduction of annual population growth rate from about 3% in 1994 to 1.5% in 2020 (Government of Ghana, 1994).
It is also significant to mention that over the years several population-related policies have been adopted by partner agencies and their effective implementation is expected to contribute to the achievement of the objectives of the Revised Population Policy. They include the Adolescent Reproductive Health Policy (2000), the HIV/AIDS and STI Policy (2004) and the Gender and Children 's Policy (2005). Some of the very recent policies that have been adopted include the National Ageing Policy (2010), the National Youth Policy (2011)

Achievements
On paper, both the 1969 Population Policy and the 1994 Revised Edition have all the necessary components and covered all relevant populationrelated issues pertaining at the time of their adoption to ensure effective implementation. However, there are clear indications that although some modest achievements were made under the 1969 policy and substantial progress has been made under the 1994 Revised Policy, there are still weaknesses and challenges which if identified and addressed could result in a lot more progress being made. According to Kumepkor et al (1989), progress was slow under the 1969 Policy in terms of translating policies into quantifiable achievements, thereby achieving only modest gains. For example, the Ghana Fertility Survey (1979/80) showed that only 13% of married women of reproductive age in Ghana had visited a family planning facility and the proportion attending an outlet was only 6%. A major long-term objective of the policy was to reduce the population growth rate from 2.4% in 1969 to 1.7% by 2020. Yet, by 1984, the population growth rate was higher at 2.6% per annum. However, the results of the 1993 Ghana Demographic and Health Survey showed a moderate decline of TFR from more than 6.0 to 5.5.
Act 485, 1994, of the National Population Council (NPC) established the NPC within the Office of the President in acknowledgement of not only the importance of population within the development agenda of the nation but its inter-disciplinary nature to insulate it from monopoly by any one single ministry. For the first time, therefore, population was elevated to the highest level and placed under the purview of the highest office of the land -i.e., Office of the President of the Republic. In addition, the Council which is the Advisory Board to the NPC Secretariat was given a broad membership including all relevant institutions and population experts. The institutional framework for implementation made up of a National Secretariat in Accra and regional secretariats, supported by population advisory committees in the regions and districts, has also been comprehensive enough in spite of its physical absence at the district level. This suggests that the NPC is well placed to work with all partner agencies including private sector institutions, notably the Planned Parenthood Association of Ghana (PPAG) and development partners to coordinate populationrelated programmes in the country.
Through its yearly programmes and others supported by Ghana's development partners such as the United Nations Population Fund (UNFPA), United States Agency for International Development (USAID), United Kingdoms' Department for International Development (DFID), etc., under programmes such as the Ghana Population Programme Activities (GHANAPA) funded by USAID and the Government of Ghana/UNFPA Country Programmes which currently is in its sixth cycle, further progress has been made. For example, the NPC with technical and financial support respectively from the Planning Department of Kwame Nkrumah University of Science and Technology (KNUST) and UNFPA, has developed Population Integration Modules which have been used to build the capacity of district planning officers to integrate population variables into their district development planning processes. These modules have been revised but are yet to be adopted for further implementation.
Furthermore, programmes have been undertaken to mobilize support to advocate increased government support and funding for family planning in Ghana. A key achievement in this area is the successful advocacy led by NPC working together with PPAG, Ghana Health Service and other partners that resulted in the incorporation of family planning services under the benefits package of the National Health Insurance Scheme. The NPC has also provided technical support to many partner agencies to integrate population variables into policies and programmes at different levels. In this respect, the NPC worked with the National Development Planning Commission (NDPC) to integrate population into national development frameworks.
In 2004, the NPC undertook an In-depth Assessment of the implementation of the Revised National Population Policy to, among other things; identify achievements, outcomes and constraints in the implementation of the policy. The report on the Assessment although remains unpublished, suggested that much progress had been achieved. However, there were constraints and a lot more could have been achieved if the objective of integrating population issues into national development planning had been well articulated in the policy itself, and relevant sector agencies had been well sensitized and educated on their place in the population and development nexus.
The report on the evaluation of the Fifth Government of Ghana (GOG)/UNFPA Country Programme in 2010 also indicated that the Country Programme responded among others to the goals and objectives of the Revised Population Policy. With respect to reproductive health, the report indicated that there were modest but significant contributions regarding the reproductive health outcomes of the programme through increased utilization of highquality reproductive health services, and ensuring a supportive environment that promotes reproductive health and rights.
Key interventions undertaken to achieve these outcomes include conducting facility needs assessment for scaling up reproductive health services, including those for adolescents, building the capacity of service providers in safe motherhood skills and equipping health facilities for emergency obstetric care including post-abortion care services, and in some districts the management and care of fistulas. Support was also provided for programme management; repositioning family planning; improving adolescent sexual and reproductive health; and upgrading and refurbishing health facilities. The Country Programme also supported the production and dissemination of data on population, gender and reproductive health, supported the conduct of the 2010 Population and Housing Census, organization of fora to discuss pertinent population issues such as urbanization. Efforts were also made to accelerate the integration of population variables into development policies and plans as well as mainstreaming gender into the policies and programmes of partner agencies. A key achievement is the inclusion of family planning services as part of the benefits package under the National health Insurance Scheme (NHIS).
The In Table 1, information on selected key demographic indicators that reflect the achievements so far made has been compared with some of the policy targets of 1994. It shows that there has been a decline in the intercensal population growth rate from 2.7% in 1984-2000 to 2.5% in 2000-2010. However, the trend in decline from 1984 through 2000 to 2010 does not suggest that the revised population policy target of 1.5% per annum by 2020 would be met. Again, the 2011 MICS Report indicates contraceptive prevalence rate of 23.4% (Ghana Statistical Service, 2012), which is higher than the 17% recorded by the 2008 GDHS. Yet, this increase is still below the target set in the policy. The 2011 MICS also reports a decline in unmet need for contraception at 26.4% relative to the 35% recorded in the 2008 GDHS. Furthermore, women delivered by skilled personnel also increased to 68.4% from less than 60% in 2008. According to the 2011 MICS, skilled delivery varied by locality of residence at 53.9% in rural areas and 88.2% in urban localities. The policy target for skilled delivery which was 80% by 2010, was, therefore, met in the urban areas, but not in the rural localities. The 2011 MICS further reports that there is near universal knowledge of HIV and AIDS in the country with 98% of women and 99% of men having heard of AIDS with little variation between the urban and rural places of residence. This suggests that the policy objective of educating the general population about the causes, consequences and prevention of HIV and AIDS and other sexually transmitted infections is being achieved.
Childhood mortality rates have also been declining while life expectancy of the people has improved over the years and is currently estimated at 64 years which is almost the target of 65 years set in the Revised Policy. However, it is evident from Table 1 that the target of reducing infant mortality to 44 per 1,000 in 2005 was not achieved and it is unlikely that the target of 22 per 1,000 in 2020 would be met. Similarly, there have been improvements in the status of women as shown by improvement in the enrolment and retention in school of the girl child and the enactment of laws against harmful traditional practices and gender-based violence including child labour and human trafficking. Key among legislations that have been enacted to address discrimination against women in particular and children in general since the adoption of the 1994 Revised Population Policy include The criminal Code (Amended) Act, 1998 (Act 554); The Children's Act, 1998 (Act 554); The Human Trafficking Act, 2005 (Act 694) and The Domestic Violence Act, (Act 732) of 2007. Source: GSS, PHC (1984, 2010; GDHS (1988GDHS ( , 1993GDHS ( , 1998GDHS ( , 2003GDHS ( , 2008; MICS (2006, 2011), and Government of Ghana, (1994. *Govindasamy & Boadi, (2000).

Challenges, Constraints and Weaknesses
While there have been substantial achievements particularly with respect to the 1994 Revised Policy, several challenges and constraints still persist. The gains made particularly with regard to the health indicators had been quite slow and sometimes chequered. It is important to mention that impressive gains made in childhood mortality rates in the 1980s and 1990s have stagnated or even reversed (Government of Ghana, 2007, pg. 78) and although maternal mortality shows a general declining trend in spite of the higher rate reported from the 2010 PHC, the levels are still unacceptably high. It may, however, appear that some of the targets of the population policies were rather ambitious and may be difficult to achieve within the time frame. Kumepkor et al (1989) identified inadequate knowledge about population and development interrelationships alongside inadequate funding in addition to the absence of community participation and support at the grass roots level as some of the most important factors that undermined the smooth implementation of the 1969 policy. Today, not only does population policy implementation suffer from resource inadequacy, but political commitment at the highest level appears to be limited. There is enough evidence to suggest that for a very long time hardly does the NPC, the main organization established and mandated to coordinate population-related programmes in Ghana receive up to 50% of its approved budget in any particular year under the national budget. This situation has been persistent to the extent that it has weakened the strength of the NPC to effectively coordinate population programmes in the country. Programmes and activities planned each year are never fully implemented. Yet, the NPC is supposed to be within the Office of the President. It may thus, unfortunately, appear that population is not considered very important in the development agenda of the country. Otherwise, it is strange to observe why the NPC has for a long time faced budgetary inadequacies from the state. At the moment, the regional offices are weakened leading to the absence of any functional integration of population variables at the district level.
Until 2013 when a Minister of State at the Presidency was appointed to be in charge of the Social and Allied Institutions including the NPC and by extension population programmes in Ghana, the NPC has since its establishment not had a specific Minister responsible for population issues in the country either within or outside the Office of the President. The closest attention population has received was during 2001-2008 when there was a position of an advisor to the President on Population and Reproductive Health within the Presidency. The creation of such a position, however, did not significantly improve on the funding situation as far as Government of Ghana budgetary allocation and release to the NPC was concerned. In the absence of a Minister for population, therefore, little attention is given to institutions established for coordination of the population policy implementation to the extent that they are weakened financially and have had to depend largely on development partner support for programmes. The appointment of a minister for the NPC may be viewed as an achievement after years of advocating for a substantive Minister at the Office of the President for population issues.
In spite of the improved education Ghana has enjoyed, socio-cultural beliefs and practices associated with societal interest in large family sizes especially in the rural areas continue to act as barriers against family planning uptake which is a central component of the population policy implementation in the country. It also appears that population policy programmes are not effectively harmonized with other policies and practices that deal with components of the population. For example, as was earlier stated, during the 2004 assessment of the implementation of the revised policy, many responsible schedule officers of ministries, departments and agencies could hardly recall the existence of the Revised Population Policy. In such situations, therefore, one cannot even contemplate any attempt at harmonizing the population policy with policies and plans of the MDAs they represent. Additionally, the officials of many public sector agencies are not well acquainted with the population policy and thereby work with little or no reference to this policy document. In such situations, it is not possible for these agencies to integrate issues in the population policy into their day-to-day activities.
At the level of Parliament, it is of interest to note that a high ranking member of the Finance Committee of Parliament has once remarked whether there was the need for the continued existence of the NPC to receive government budgetary support. To this Honourable Member of Parliament, the NPC should be subsumed under the umbrella of the NDPC and not a separate agency on its own. This clearly suggests the low importance some law makers in the country attach to the mandate of the NPC and by extension, the implementation of the national population policy. It is, therefore, not surprising that the NPC scarcely receives its annual total approved budget for operation.

Best Practices
A number of best practices have been identified in the implementation of population policies in the country. These include the Population Integration Modules of the NPC, the Community Health Planning and Services (CHPS) implemented by the Ghana Health Service and the Mass Media Support for Adult Education (MMSAPE) Project of the Institute of Adult Education, University of Ghana.
The MMSAPE provides a case study of policy implementation using multiple strategies to address family planning in rural areas. The objectives among others included increasing knowledge and use of family planning among adult learners and their communities; increasing awareness on the importance of girl child education and delay of marriage, prevention of HIV and AIDS in addition to promoting risk avoidance behaviours with the ultimate aim of reducing fertility and improvement in individual and community well-being. Activities undertaken include production and use of IEC/behaviour change communication materials, radio programmes as well as newspaper publications in the local languages of the project areas. This project has contributed to positive behaviour change as reflected in the acceptance of family planning and small family sizes even among low-income groups and rural populations in the country. Although no specific evaluation of this project is readily available, evidence from the 2011 MICS Report indicates that Brong Ahafo (27%) and Greater Accra (27%) regions are second to Central Region (29%) in respect of the proportion of married women using modern methods of contraception (Ghana Statistical Service, 2012) and yet a higher proportion of the population of Brong Ahafo and Central regions was resident in rural areas in 2010 i.e., 55.5% and 52.9% respectively (see Ghana Statistical Service, 2013).
The Population Integration Modules developed by the Department of Planning of the KNUST for the NPC have supported the training of district assembly officials to integrate population variables into district development planning activities. When the on-going review is completed and is supported with adequate funding to re-enforce the district-level training, much progress would further be made through the effective integration of population into planning activities pertaining to the economy, health, housing, agriculture, etc.

Lessons Learnt
Several lessons are there to be learnt in the implementation of population policies, some of them being specific with regard to specific programmes while others are more general. Factors that have facilitated the smooth implementation of programmes include the following: (i) building synergies among implementing partners (ii) effective coordination of programmes and collaboration among stakeholders (iii) consensus building and sustained public education on policies ensure that major players remain an integral part of the process of implementation (iv) active involvement of grassroots structures and traditional leaders influence community involvement in programmes (v) close collaboration between parents, teachers and school authorities facilitate youth programmes.

Conclusions
As has been noted earlier in this paper, the most fundamental challenge that has bedevilled population policy implementation in Ghana has been inadequate resource in-flow from government. There is, therefore, the need for the following steps to be taken: There is need for high-level political commitment towards placing population at the heart of the nation's development discourse. To achieve this commitment, a minister of state from the Office of the President that has been appointed since 2013 to be responsible for population issues in the country should be incorporated in the NPC Act in its next review. If this is not sustained, the NPC should be withdrawn from the Office of the President and placed under any of the Ministries with cabinet status to speak for population at Cabinet meetings.
There is the need to speed up the processes initiated towards the revision of the national population policy to include new and emerging issues such as the demographic dividend, ageing and climate change and how for example climate change in particular interrelates with population dynamics in the country. Besides, strategies that aim at sensitizing the population particularly those along the coastal belt in respect of adaptation mechanisms in response to possible climate change should be built into the policy in the on-going revision.
The regional offices of the NPC should be projected for special attention in terms of logistical and technical support. The state should consider equipping each regional office with a durable vehicle and other office equipment in order to be strengthened to regularly liaise with the district assemblies to provide the necessary guidance towards the integration of population into development planning activities in the districts.
There is also an urgent need to build a strong partnership with the media for effective education on the population-development nexus in addition to issues relative to the population policy implementation. To this end, the NPC Act (Act 485, 1994) should be reviewed to downsize the membership of the Council and include a representation from the Media as a bridge between the Council and the grassroots.
Finally, considering that one major weakness of the policy implementation in Ghana is coordination,, there is need to strengthen institutions to undertake effective coordination across the various sectors while ensuring effective monitoring and evaluation of programme activities. In addition, there should be sustained advocacy and engagement of both public and private sector agencies including religious and traditional authority while at the same time mobilizing grassroots support for full implementation of the population policy. To this end, there may be the need for a comprehensive review of population policy implementation in African countries, particularly the relevance of national population councils with a view to repositioning them as the most appropriate institutions for effective population policy implementation or otherwise.
Ghana has had a long history of adoption and implementation of population policies. Ghana's experience is not different from other countries in Africa. Quite admittedly, the implementation of population policies in the country has influenced individual and societal behaviour which has contributed to shaping demographic trends and the development of the country although not all the objectives and targets of the policy have been achieved or are likely to be attained. It is also clear that there have been challenges in the effective implementation of population programmes. With the growing significance of the linkage between population and development that has resonated in recent global climate change discourse, it is important that these challenges are addressed to facilitate the effective and successful implementation of population policies in the country as one sure way of moving the country faster towards a higher middle income status. It is obvious that it is just not enough to have a population policy as a document if the state does not attach the highest level of importance to population dynamics as a development planning priority in the country.