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Neglected Populations: Safeguarding the Health of Street-Involved Children in Ghana. Osei-Twum, Jo-Ann; Wasan, Kishor M. 2012-07-06

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Title:  Neglected Populations: Safeguarding the Health of Street-Involved Children in Ghana  Running Head:  Health of Street-Involved Children  Authors:   Jo-Ann Osei-Twum,1 Kishor M. Wasan1  Affiliations: 1 Division of Pharmaceutics and Biopharmaceutics, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada, V6T 1Z3  *Corresponding author: Jo-Ann Osei-Twum. Faculty of Pharmaceutical Sciences, The University of British Columbia, 2146 East Mall, Vancouver, British Columbia, Canada, V6T 1Z3. Email:  Legend This is the pre-peer reviewed version of the following article: Neglected Populations: Safeguarding the Health of Street-Involved Children in Ghana, JA Osei-Twum and KM Wasan, Journal of Pharmaceutical Sciences, 101/10, 2012, which has been published in final form at;jsessionid=91506BF55A0444C24 9D7D0D7276270FD.d03t03.  Abstract  Ensuring the health of street-involved children is a growing public health challenge. These children are vulnerable, neglected, and rarely a priority for basic service providers and governments. Sizable populations of street-involved children are present in major urban areas worldwide and current trends in urbanization suggest these populations will grow in the coming years. Whilst migration offers employment and training opportunities, the health and wellbeing of children is negatively impacted by their interactions with the streets. However, systemic barriers may also prevent these children from achieving an adequate health status. The situation of street-involved children in Ghana, West Africa will be discussed.  Key words Street-involved children, vulnerable populations, millennium development goals, Ghana  Abbreviations CAS, Catholic Action for Street Children,; CMS, Central Medicine Store; GDP, gross domestic product; HDI, Human Development Index; MDGs, Millennium Development Goals; NTDs, neglected tropical diseases; STIs, sexually transmitted infections.  Forgotten Children  Despite global recognition of the rights of the child, a large proportion of the world’s children are still marginalized, vulnerable, and impoverished. Of these children, street-involved children (Panel 1) are the most visible. Current estimates suggest that for upwards of ten million children,1 the streets are a source of sustenance and a place of refuge. However, the lack of parental and custodial care places street-involved children at risk of, being detained by authorities, abuse, violence, and physical and sexual exploitation.2,3 In addition, street-involved children are excluded from accessing basic services and their welfare is overshadowed by the needs of the urban poor. The situation of street-involved children has only recently received international attention. The United Nations Human Rights Council devoted the full-day annual meeting on the rights of the child (16th Regular Session, 9 March 2011) to discuss the rights of street-involved children. Ensuring the rights of street-involved children will require reliable and disaggregated data, sustained monitoring, regular evaluation of child-centered programs, and input from children on policies and interventions that impact their wellbeing.4 The current development model is framed by the Millennium Development Goals (MDGs). The MDGs are eight international development goals (Panel 2), established by The United Nations, that strive to address inequities in health and income. However, street-involved children are not explicitly identified by the MDGs. Governments, non-governmental organizations, and civil society must make street-involved children a priority when implementing poverty reduction programming. As countries continue to tackle disparities in income distribution, primary school enrolment, and maternal and child mortality, the difficulty will lie in translating policies into measurable outcomes.  Moreover, low- and middle-income countries have the insurmountable task of providing for street-involved children amidst times of food insecurity, political uncertainty, and economic instability. In such circumstances governments may seek ‘quick- wins’5 by directing resources to accessible populations rather than the equitable distribution of limited resources. Ghana faces this challenge; however, safeguarding the health of street- involved children is a necessity for attaining the MDGs by 2015.  Panel 1: Defining Street-involved children  Numerous terms have been used to describe the aforementioned population, ‘street children’, ‘children of the street’, ‘children on the street’, ‘children working and/or living on the streets’ etc. The lack of consensus on a term that best describes this vulnerable population raise questions on how best to quantify the extent of the problem and where resources should be allocated. The term street-involved children is used here as it encompasses all possible interactions between children and the streets, those who supplement family income by finding employment on the street and those who reside on the street temporarily or permanently.  Ghana – Accelerated yet not Shared Growth   Ghana, a lower middle-income country,6 has seen marked improvements in its economic climate and standard of living, as measured by Gross Domestic Product (GDP) and the Human Development Index (HDI). Since 1990, the GDP (once corrected for population growth) has steadily increased reaching an annual growth rate per capita of 3.5% in 20057 and the recent discovery of oil reserves suggests continued economic growth in the coming years. Similarly, the HDI – a measure of social and economic development used by The United Nations Development Programme – increased from 0.385 in 1980 to 0.541 in 2011 (Figure 1), positioning Ghana above the Sub-Saharan Africa regional average of 0.463.8 The HDI combines measurements of health, education, and income in assessments of national development. This provides a better indicator of development than solely income; however, the quality of services provided is not evident and national averages mask differences within a country. This is evident in Ghana; northern and rural regions are disproportionately affected by poverty – a driving force for internal migration.  Ghana has a long history of internal migration, predating independence.9,10 In the former Gold Coast (present-day Ghana), internal migrants were predominately male adults from northern regions, who moved for employment in the mining sector and agricultural industry (cocoa and palm oil production).10 However, present trends suggest that children and youth aged between 10 – 24 years make up the majority of migrants10 and most often with final destinations of Accra, Kumasi, and Takoradi. Internal migration to urban centers presents opportunities for employment, vocational training, and education. Yet, increasingly for many urban dwellers the “urban advantage” is not a reality11 and in some instances the urban poor experience higher rates of child mortality than their rural counterparts.11,12 Rapid urbanization pose many threats to the health of migrants: inadequate accommodation, absence of running water, poor sanitation, lack of waste removal, and exposure to pollutants. These threats increase the likelihood of communicable diseases and injury. Still, children perceive the benefits of migration to outweigh the risks.  Panel 2: The Millennium Development Goals  Goal 1. Eradicate Extreme Poverty and Hunger Goal 2. Achieve Universal Primary Education Goal 3. Promote Gender Equality and Empower Women Goal 4. Reduce Child Mortality Goal 5. Improve Maternal Health Goal 6. Combat HIV/AIDS, Malaria and Other Diseases Goal 7. Ensure Environmental Sustainability Goal 8. Develop a Global Partnership for Development   Figure 1. Human Develop Index (HDI), Ghana from 1980 – 2011. Corresponding changes in HDI at the regional level of Sub-Saharan Africa and the global level are present8.  Street-involved Children – Due South  Quantifying this phenomenon in Ghana has proved difficult due to the mobile nature of street-involved children. The Catholic Action for Street Children (CAS) estimates that there are more than 20,000 street-involved children in Accra, the capital city.13 An overwhelming number of children migrate to the streets for economic reasons or because of family disintegration.13,14 Economic pressures force street-involved children to find informal work on a daily basis predominately as hawkers and kayayei. Kayayei, primarily girls originating from northern regions, carry heavy loads for traders and costumers in market places and at transportation stations. In addition, girls may be forced to resort to risky activities such as commercial sex work to meet their basic needs; thus, increasing the likelihood of early pregnancy or sexually transmitted infections (STIs).  The health situation of street-involved children in Ghana is similar to that of children in other street circumstances.2,15 Prior assessments have gauged the knowledge of and prevalence of STIs among street-involved children.16,17 Girls generally have less knowledge of STIs and HIV/AIDS as compared to street-involved boys and thus do not take the necessary measures to protect themselves.13,16,18 Unfortunately, research is lacking on the impact of other communicable diseases on the wellbeing of these children. Preventing children, who find shelter on the streets, from contracting communicable diseases is particularly difficult. Understandably, street-involved children are susceptible to malaria as the Plasmodium falciparum parasite is endemic to Ghana. But less is known about the burden of neglected tropical diseases (NTDs), such as lymphatic filariasis, human African trypanosomiasis (sleeping sickness), and onchocerciasis, on this population of children. NTDs are diseases of poverty aggravated by: poor living conditions, insufficient access to clean drinking water, malnutrition, and low levels of education.19 These diseases result in significant morbidity rather than mortality and thus, adversely affect individual and national productivity.20 The prevalence of NTDs in low- and middle-income countries and lack of treatment are clear examples of health inequity.  Inequity in research priorities manifests through the 10/90 gap, where only 10% of research dollars are spent on diseases responsible for 90% of the global disease burden.21,22 In addition, few medications are available in “child-friendly” formulations – appropriate dosing forms are yet to be developed. The lack of safe and effective medication for children is a global problem, which severely hampers efforts to achieve MDG 4 (reduce child mortality) and MDG 6 (combat HIV/AIDS, malaria and other diseases). Accessibility and affordability issues further constrain efforts to improve child health. A multisite study across 14 countries in sub-Saharan Africa reported widely divergent availability of 20 essential medicines for children.23 In Ghana, 40% of surveyed medication was available from the government operated Central Medicine Store (CMS). By contrast, 75% of medication was available from the CMS in Kenya. Moreover, procurement of medication posed a challenge to the public as only 50% of medication was available through retail pharmacies in Ghana. Rather the largest proportion of medication was available through district hospitals. It is unclear how vulnerable populations such as street- involved children will access medication. These barriers negate conventional attempts by street- involved children to sustain their health.  Responding to the Need  The Government of Ghana has made attempts to address the needs of street-involved children through legislation and community-based projects. However, limited resources hinder these efforts and, as such, the government relies on non-governmental organizations (NGOs) to fill gaps in service provision. Continued investment in NGOs is needed to provide health care, vocational training, and education for children. NGOs should seek to strengthen non-formal educational programming and use mobile public health care professionals to reach children in street environments. Responses should not solely be concentrated on urban centers but preventative actions should also focus on rural and remote areas to curb migration. Parents and extended family members also encourage children to migrate;10 thus, all awareness programs should target both potential child migrants and their parents. That being said, these efforts will be futile unless the government and NGOs quantify the extent of this phenomenon.  Furthermore, the government must continue to address the distal causes of street-involved children’s vulnerability through economic measures that mitigate the inequitable distribution of wealth in the country. Decentralization and provision of basic amenities  (water, education, health care, and road networks) in northern and rural regions has begun. Over a period of one year (2005 – 2006) 198 rural communities were added to the national electrical grid, the proportion of rural areas with access to safe drinking water increased from 52.0% to 53.2%, and 18,900 teachers were posted to rural areas.24 Finally as the agricultural sector is the primary income generator for many Ghanaians, the government should quicken the pace of modernization and incentivize participation, supporting both small and large-scale farming ventures. This will generate capital and improve the quality of life for many.  Health care provision for street-involved children is not solely a consideration for the Ghanaian government but also an increasing challenge encountered by governments worldwide. Innovative approaches rooted in social justice and equity are required if governments, community-based organizations, and health care professionals are to ensure the health and wellbeing of this socially marginalized population.  Acknowledgements N/A  Financial Disclosure No funding was sought to support this work.  Author Contributions Wrote the first draft of the manuscript: JO. Contributed to the writing of the manuscript: JO KMW. ICMJE criteria for authorship read and met: JO KMW.  Competing Interests The authors declare that no competing interests exist.   References 1. The United Nations Children’s Fund 2012. The State of the World’s Children 2012: Children in an Urban World. Available: Accessed 24 April 2012. 2. Rose J 2002. All our children: human rights and children of the street. The Lancet 360:1506. 3. The United Nations Children’s Fund 2005. The State of the World’s Children 2006: Excluded and Invisible. Available: Accessed 10 April 2011. 4. United Nations Human Rights Council 2011. Rights of the child: a holistic approach to the protection and promotion of the rights of children working and/or living on the street. Available: Accessed 6 January 2012. 5. Dwatkin D 2005. How much would poor people gain from faster progress towards the Millennium Development Goals for health? The Lancet 365:813 – 817. 6. The World Bank Group 2012. Ghana Data. Available: Accessed 7 May 2012. 7. Coulombe H, Wodon J 2007. Poverty, Livelihoods, and Access to Basic Services in Ghana. Available: Accessed 12 April 2011. 8. The United Nations Development Programme 2010. International Human Development Indicators: Ghana. Available: Accessed 12 April 2011. 9. Kwankye SO, Anarfi JK, Addoquaye Tagoe C, Castaldo A 2007. Coping Strategies of Independent Child Migrants from Northern Ghana to Southern Cities. Available: Accessed 14 December 2011. 10. Kwankye SO, Anarfi JK, Tagoe CA, Castaldo A 2009. Independent North-South Child Migration in Ghana: The Decision Making Process. Available: Accessed 16 December 2011. 11. Bartlett S 2011. Children in Urban Poverty: Can They Get More than Small Change? In Ortiz I, Daniels LM, Engilbertsdóttir S, editors. Child Poverty and Inequality New Perspectives, New York: United Nations Children’s Fund (UNICEF), Division of Policy and Practice. p. 139 – 148. 12. Van de Poel E, O’Donnell O, Van Doorslaer E 2007. Are urban children really healthier? Evidence from 47 developing countries. Soc Sci Med 65:1986 – 2003. 13. Consortium for Street Children 2003. A Civil Society Forum for Anglophone West Africa on Promoting and Protecting the Rights of Street Children. Available: _West_Africa_.pdf Accessed 17 April 2012. 14. Orme J, Seipel MMO 2007. Survival strategies of street children in Ghana. Intern Soc Work 50:489 – 499. 15. Silva TL 2002. Preventing child exploitation on the streets in the Philippines. The Lancet 360:1507. 16. Anarfi JK 1997. Vulnerability to sexually transmitted disease: street children in Accra. Health Transit Rev 7:281 – 306. 17. Wutoh AK, Kumoji EK, Xue Z, Campusano G, Wutoh RD, Ofosu JR 2006. HIV Knowledge and Sexual Risk Behaviors of Street Children in Takoradi, Ghana. AIDS and Behavior 10:209 – 215. 18. Boakye-Boaten A 2011. Surviving in the Streets: the Story of a Street Girl from Ghana. Int J Hum Soc Sci 1:244 – 249. 19. Franco-Paredes C, Santos-Preciado JI 2011. Freedom, Justice, and Neglected Tropical Diseases. PLoS Negl Trop Dis 5:e1235. 20. Conteh L, Engels T, Molyneux DH 2010. Socioeconomic aspects of neglected tropical diseases. The Lancet 375: 239 – 247. 21. Ramsay S 2001. No closure in sight for the 10/90 health-research gap. The Lancet 358:1348. 22. Doyal L 2004. Gender and the 10/90 gap in health research. Bull World Health Organ 82:162. 23. Robertson J, Forte G, Trapsida JM, Hill S 2009. What essential medicines for children are on the shelf? Bull World Health Organ 87:231 – 237. 24. Government of Ghana 2009. The Implementation of the Growth and Poverty Reduction Strategy (GPRS II) 2006 – 2009. 2006 Annual Progress Report. Available: Accessed 9 May 2012. 


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