2025 Global Health Case

The Center for Global Health Equity Presents the 2025 Global Health Case Competition Case Study: Health Impact of Water Pollution in Ghana Authors: Caroline Rich, Isabella Rutta, Magda Mohamoud, Tsion Teklebirhan, Akshara Mahankali, Nanaki Preet Kaur Bawa, Wilma Ama Obenewaa Obeng, Nii Noi Noi, Rudolph Kofi Amewu, and Philip Nortey With guidance and contributions from: Dr Selim Kwawukume, Dr. Naa Sodzi-Tettey, Dr. Sampson Opoku, Family Health University; Dr. Scott Heysell, Navya Annapareddy, University of Virginia

Image 1: Before and After of River Pra from Galamsey (1) I. Introduction II. Overview of Ghana III. Health & Health Systems in Ghana IV. Types of Water Pollution & Associated Health Impacts V. Ghanaian Initiatives VI. International Initiatives VII. Remaining Challenges VIII. Summary and Your Task

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I.

Introduction Mr. Kwame Essien is a 36-year-old fisherman living in Ankobra, a small town in Ghana's

Western Region, named after the Ankobra River. Untreated water from the river serves as the main source of water for households in the surrounding community. Mr. Essien has just returned from fishing in the estuary, where the famous River Ankobra joins the sea. He only caught half a bucket of fish, which he finds disappointing. For the past six years, his fishing yield has been poor. Two days ago, he returned empty-handed after hoping to catch something for seven hours. He attributes his woes to ‘galamsey,’ the illegal small-scale mining along the riverbanks, which are rich in significant gold deposits. The practice attracts many fishermen seeking better profits. Although Mr. Essien is scared to participate in galamsey himself due to a past incident where two miners died in a pit collapse, he struggles with the temptation as his own fishing income dwindles.

The condition of the River Ankobra, once clear and vibrant, has also deteriorated. Mr. Essien remembers a time when it was filled with aquatic life - large and small alike. Now, however, the river flows muddy and lifeless. He heads home to share his catch with his wife, Esi Ackah. She greets him without needing to look in the bucket, knowing the yield is low.

Nevertheless, she is relieved to have enough fish to feed her husband and their two children, Kofi (four years old) and Akua (two years old), for a few days. Esi has also faced challenges related to galamsey; her son Kofi has speech difficulties, which doctors at the district hospital attribute to heavy metal exposure during her pregnancy linked to the river's pollution. While she has seen some improvement in Kofi's communication, he still lags behind his peers, and the family now faces increased financial strain due to the need to resort to sachet water consumption (sachet water consumption describes a delivery method using 500 mL polyethylene plastic bags of water heat-sealed on either end - Stoler) instead of using the polluted river water.

In Teshie, a town just along the coast of the Greater Accra Region, 40-year-old Sowah, an indigene and a lifelong fisherman, shares a similar struggle of dwindling fishing yields. Each fishing trip brings him face-to-face with pollution, as he finds heaps of plastic waste on the shore and comes back with diminishing catches. Sowah and his fellow fishermen believe the pollution, mainly from plastic waste, is harming the fish population, resulting in low yields.

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However, with barely any other alternative to manage their waste, apart from the rather costly local garbage collection service available, Sowah and many other residents in Teshie continue to dump their refuse along the coast, hoping the tides sweep the garbage away.

Facing financial challenges, Sowah is the family's sole provider and often returns home disheartened by his poor fishing returns. Additionally, he has developed Type 2 diabetes, diagnosed after complaints of increased thirst and urination. At the government hospital, doctors tried to establish the cause of his diagnosis. In the absence of major risk factors such as obesity, a sedentary lifestyle, a family history of the disease, or age and gender factors, doctors linked his condition to the pollution. Sowah and his family are heavily reliant on fish from his returns as a protein source for their diet. Hence, he was not surprised to learn that eating contaminated fish over a period of time can contribute to raised blood sugars. Now he needs medication to manage his diabetes or face serious health implications. Unfortunately, the rising costs of his diabetes medication exacerbate his financial pressures, leaving him worried about affording his prescriptions after another disappointing day at sea.

Image 2: Waste on Ghana’s beaches (2)

II.

Overview of Ghana Demographics Ghana is located in West Africa and is bordered by Côte d'Ivoire to the west, Burkina

Faso to the north, Togo to the east, and the Gulf of Guinea to the south. The total population of 2

Ghana is approximately 34.12 million. Around 70% of the population is concentrated in the southern urban areas, primarily in the capital, Accra, and the city of Kumasi located in the Ashanti region (3,4). With over 100 distinct ethnic groups, Ghana is home to a diverse group of people (5). The largest ethnic groups are the Akan (including the Ashanti and Fante), which account for approximately 45.7% of the population, followed by the Mole-Dagbani, Ewe, and Ga-Dangme (6). Minority groups include the Gurma and Guan. Although over 80 languages are spoken in the country, English is Ghana’s official language (7).

Image 3: Map of Ghana (8)

The age structure of Ghana is youthful, with those under the age of 25 making up nearly 57% of the population (9). In 2023, the average education level for Ghanaians aged 15 to 24 was 10.1 years, with high enrollment in primary and secondary education due to free and compulsory schooling. However, tertiary enrollment remains low but is expected to grow. Agriculture is the primary source of employment. Youth unemployment is a concern with over 60% of young people aged 15-24 unemployed. Ghana's GDP per capita in 2023 was $5,286 USD and is projected to rise, reflecting economic growth that translates into higher income per person (10).

Historical Overview

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Before European contact, the area was home to influential kingdoms such as the Ashanti and Fante, which established wealth through the gold trade. European interaction began in the 15th century with the arrival of the Portuguese, who were later followed by the British, Dutch, and other European powers (11). During this period, the Portuguese were the dominant European presence in West Africa, and they established an influential trade relationship with the Ashanti through exchanging wealth and weapons that, in return, helped the small state surpass its neighbors. However, the British ultimately ended up solidifying control over the “Gold Coast,” or the name given to the region in the late 19th century. In 1874, England formally declared the Gold Coast as a British colony (12). The colonial administration prioritized resource extraction – particularly gold and cocoa – with minimal regard for environmental sustainability or developing local infrastructure to mitigate waste and manage sanitation. When the British introduced industrialized practices during the Colonial Era, Ghana’s large urban centers, such as Accra, began experiencing declines in sanitation and water quality (13). Accra, which was established as the administrative capital of the Gold Coast in 1877, served as the centralized area for business and political decisions, and therefore naturally experienced considerable industrialization and pollution.

Ghana became the first sub-Saharan African country to gain freedom from colonial rule in 1957. Post-independence, President Osagyefo Dr. Kwame Nkrumah followed a rapid industrialization and modernization policy, with projects such as the building of the Akosombo Dam to symbolize the nation’s aspirations for economic self-sufficiency (14). However, rapid urbanization during this period caused a strain on existing infrastructure in terms of water and sanitation management. Additionally, cities like Accra and Kumasi experienced unprecedented population growth that outpaced the development of services to ensure safe drinking water and proper waste disposal.

Currently, about 60% of Ghana’s water sources are polluted and rapidly declining in water quality (15) . However, various farming, mining, and manufacturing industries – which strengthen the economic output of the country – require large amounts of water (16). Ghana is Africa’s leading producer of gold, and 30% of their mining is conducted by small-scale miners who often operate illegally and without a license (17). Illegal mining activities, that infiltrate water sources with heavy metals in localized areas, have further escalated Ghana’s water

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pollution (18). Many Ghanaians from economically disadvantaged communities engage in the small-scale mining industry due to its higher monetary rewards, despite the inherent risks involved. Illegal mining is a pressing issue in Ghana, and the army has been called many times to shut down illegal mines. However, illegal miners often restart mining practices after government personnel have left.

These difficulties controlling illegal mining are especially pertinent in the past few months. In October 2024, protestors rallied in the capital of Ghana, Accra, to demonstrate their disapproval of President Nana Akufo-Addo’s inaction towards illegal mining. Instead of spurring action, the protestors were apprehended. These demonstrators now express a similar lack of faith that Ghana’s newly elected president, John Mahama, will act any differently to keep this illegal practice in check (19). However, regional leaders are taking a firm stance against galamsey. On February 5, 2025, there was a report that Daasebre Doctor Twum Ampofo, the Chief of Asiakwa and Nifahene of Akyem Abuakwa Tradition Area, enforced a ban on illegal mining along the Birim and Supong Rivers by storming a mining site and removing excavator control boards, fuel, and generators, halting the work of these illegal miners (20). Additionally, as of February 7, 2025, the Ashanti Regional Minister, Dr. Frank Amoakohene, issued a two-week ultimatum to the illegal miners, forcing them to vacate the area or experience legal consequences (21). The impact of this warning is yet to be seen. Holding these miners accountable remains challenging as tensions rise. In December 2024, a journalist, Ohemeng Tawiah, reporting on illegal mining in the Ashanti region was attacked with stones and machetes. While police suspect the attack was carried out by illegal miners, the perpetrators have not been arrested (22).

Culture Actions addressing this complicated issue must take cultural context into consideration to provide an appropriate and effective solution. In Ghana, culture is heavily influenced by traditional structures. One part of these structures is the influence of chiefs, who traditionally hold stewardship of the land and their communities. Additionally, as they are formally recognized as part of Ghana’s governance system, chiefs hold considerable spiritual, cultural and political power. However, while there are accepted methods for determining political succession after a chief’s death within each tribal system, conflicts still arise due to differing beliefs and

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desires for power. Currently, there are over 350 sustained conflicts around Ghana, with most occurring in the north (23).

Culture in Ghana is also centered on religion and family structure. The majority of the country identifies as Christian, and approximately 20% identifies as Muslim. Islam is most prevalent in the far north of the country and in urban areas, and Christianity is prevalent in the southern part of Ghana. A smaller proportion of the population practices traditional indigenous religions, which contain doctrine more specific to certain locations or groups. However, these indigenous religions generally recognize and respect ancestors who have passed on. These traditional religious beliefs align with Ghanaians’ attitude towards familial relationships. While focus is moving towards the nuclear family in urban areas, relationships with extended families remain important to Ghanaian social norms (3).

Cultural practices and traditional belief systems in Ghana have played an important role in the preservation of natural resources, but their influence has shifted in modern times. It is commonly believed that traditional taboos and belief systems have contributed to sustaining forests and biodiversity. Leaders in both the Gonja traditional area and Ashanti region have attributed their strong spiritual practices to managing the activities that take place in their forests (24). In a qualitative study, folks from Ashanti communities specifically detailed rules about days where entering the forest is prohibited and banning those who violate those rules from entering the forest for many years (25). Those in the Gonja traditional area traditionally regard Fridays as a day where fishing cannot take place, thus protecting fish stocks (24). However, there is also data that suggests that these traditional practices are being increasingly disregarded because traditional beliefs are viewed as barbaric and conflicting with contemporary science (24). These cultural practices are being lost as older generations die and the younger generations are turned to modernized cultural belief systems (24). As the galamsey industry continues to thrive, leading to major destruction of more forests, this cultural shift is important to understand to implement programs that focus on forest conservation and lessening the degradation of water sources.

Educational Attainment Educational attainment in the developing world is a strong indicator for public health outcomes. As a result, it is crucial to examine the landscape of educational attainment in Ghana.

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The percentage of primary school aged children not enrolled in primary school is 11.34%, and 8.74% of adolescent aged students are not enrolled in secondary school (26). As a result, the youth literacy rate for Ghanaians ages 15-24 years for both genders is 93.48%, which is higher than the global average of 91.28% (26). The adult literacy rate is also high at 80.24% for Ghanaians over 25, which is still consistent with the global rate of 84.7% (26). These relatively high rates of literacy are directly linked to government expenditure on education (26). In 2023 the Ghanaian government expenditure on education was 12.04%, which is over double that of the 5% global average GDP expenditure on education (27). However, Ghana performs worse than the global average for higher education attainment levels. For the Ghanaian population 25 and older, only 3.49% have attained at least a Bachelor’s or equivalent degree while the global average is 15.82% (26). The Ghanaian government’s current expenditure in tertiary public institutions is 77.27%, which is low compared to 87% for the region and 86.5% for the global average (26). Overall, Ghana does well in educational attainment and the primary and secondary educational level but is slightly behind similar countries in tertiary education (26).

III.

Health & Health Systems in Ghana Main Health Issues in Ghana A variety of health issues and conditions affect populations in Ghana, particularly

infectious diseases, chronic illnesses, maternal health/mortality, and mental health access (28).

Infectious diseases including malaria, HIV/AIDS, and waterborne diseases like cholera and typhoid affect millions in Ghana. Ghana’s clean water access has trended upward since 2018.

Access in 2022 was 44.47%, a 0.87% increase from 2021 (29). At this time, mercury and heavy metals were contaminating about 65% of water sources due to illegal mining (30).

Malaria persists in Ghana due to the country’s large population and a climate that invites mosquitoes. In 2023, there were about 6.6 million cases, resulting in around 11,464 deaths (31).

Children under five years and pregnant individuals are typically at higher risk of having severe malaria due to lower immunity levels (32). More recently, between 2020 to 2021, Ghana’s caseload has been maintained at 165 cases per 1000 of the population at risk with deaths falling by 1.7%, moving in the right direction. Reasons for such progress include the use of vaccines and the use and distribution of “long-lasting insecticide-treated” mosquito nets. These

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interventions led to a decrease of in-patient audited malaria deaths between 2018 and 2022, from 428 to 155, respectively (33).

HIV/AIDS is another disease that affects millions, exacerbated by social stigma associated with the conditions. Limited healthcare in rural areas of Ghana also decreases and discriminates access to preventative care and treatment. According to data from 2019, the HIV prevalence in Ghana is 1.6%, with regional variation (34). Waterborne illnesses including cholera affect fewer individuals but recent trends point to increases, especially in urban areas, raising questions about the sanitation of water and associated systems (35).

Another large issue is the safety of childbirth and pregnancy, particularly maternal health and mortality. According to the Macrotrends Maternal Mortality Rate, which records the number of women who die from “pregnancy-related causes while pregnant or within 42 days of pregnancy termination per 100,000 live births,” the maternal mortality rate in 2020 was 263/100,000, which was a 7.79% increase from 2019 (36). However, this is an improvement over the last 20 years; the rate improved from 499 in 2000 to 263 in 2020, which is also lower than its regional average (37). Historically, poor quality, lack of care, and cultural beliefs have decreased the safety of childbirth (38). In addition, many women have not received safe care because of poor care in health centers and institutions, particularly in rural areas.

A lack of mental health care access greatly decreases treatment and resources for those in need in Ghana. The country only has three psychiatry hospitals in Accra, Ankaful, and Pantang but other regional units and private practices are distributed throughout (39). Yet, less that 20 psychiatrists are practicing in Ghana and only 38% of the psychiatric employees have formal training in mental health care, according to data from 2011, equating to 1 psychiatrist per every 800,000 Ghanaians (40). Even less clinicians specialize in pediatric psychiatry, further decreasing access to care for children. In addition, little progress has been made in reducing developmental delays and disabilities in children (41). According to the Multiple Indicator Cluster Survey, one-fourth of Ghanaian children are developmentally delayed. These children often experience social exclusion, poorer health outcomes, and higher mortality than those without these disabilities, further necessitating the need for healthcare access. Additionally, during traumatic injuries that require mental health care, patients are often not properly treated

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due to lack of mental health training provided to healthcare professionals, further increasing stigma and lack of resources.

The Ghanaian Health System In the past couple of decades, Ghana has been making a significant effort to improve the healthcare system in the country. The Ghana Health Service (GHS) was established in 1996 and works autonomously to implement national policies under the control of the Ghana Ministry for Health through its governing Council – the Ghana Health Service Council (42). GHS receives public funds, but its employees are not considered civil service workers, meaning that they do not have to adhere to civil policies or regulations. This allows for GHS to proceed with their work independently and gives their employees flexibility that is beneficial for their outreach.

GHS was outlined as a part of the strategies proposed in the Ghana Health Sector Reform process, and it helps to further its mission for establishing a more equitable, efficient, accessible, and responsive healthcare system (42). The Service itself follows the themes of a reformed organization that began in 1993 by the Ministry of Health and thus considers careful stewardship of resources, clear lines of responsibility and control, decentralization, and accountability for performance rather than inputs as priorities (42). GHS implements approved national policies for health delivery in Ghana, allows for increased access to good quality health services, and provides and manages resources available for the provision of health services (42). It seeks to promote healthy modes of living as well as good health habits by people through effective mechanisms for disease surveillance, prevention, and control in Ghana, as well as providing inservice training and continuing education.

Additionally, the National Health Insurance Scheme was established in 2003, adopting free maternal care in 2008 as well as free mental health care services in 2012 (43). A 2021 consensus result reports that about 68.6% of the population is covered by the NHIS (44). The NHIS was created by the National Health Insurance Act, being one of the first attempts by a subSaharan African nation to establish a universal health insurance program at the national level.

While making sure to guarantee the execution of this national health insurance policy ensuring all citizens access to basic healthcare services, they also established and commissioned a National Health Insurance Authority (45). NHIS was also introduced in order to ease the

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financial burden of finding and paying for access to healthcare. Ghana spends, on average, about 6% of its GDP on healthcare infrastructure; it also relies on imports for 85% of its total healthcare consumption (46). Some high-profile items like HIV antiretroviral medications (which are heavily subsidized by the separate National AIDS Program), and some highly costly procedures like organ transplants, dialysis, certain surgeries, and cancer treatments (apart from breast and cervical cancer) are not covered by the NHIS package. There are not many formal restrictions on NHIS members' use of benefits, aside from these excluded services; there are no annual or lifetime caps, no cost-sharing beyond premiums (i.e., no co-payments, coinsurance, or deductibles), and no effective gatekeeping.

In Ghana, the healthcare system is divided into three tiers: national, regional, and district.

They also have five levels of providers: 1) health posts, the first level of primary care in rural areas; 2) health centers and clinics; 3) district hospitals; 4) regional hospitals; and 5) tertiary hospitals; and most of this is provided by the government and administered by the Ministry of Health and the Ghana Health Services (44). A single, nationwide NHIS identity card was recently introduced to replace district-level cards since benefits were supposed to be "portable" from district to district, but real portability has been inconsistent (45).

Ghana is also not able to produce very many local pharmaceuticals and even fewer medical devices and equipment manufacturing (44). Urban areas in Ghana tend to be better stocked when it comes to healthcare services, while the more rural areas lack the infrastructure and support, causing many patients to either rely on African Traditional Medicine or travel long distances to urban centers for health care. Due to this and despite other efforts, Ghana has not been able to reach the Millennium Development Goals (MDGs) 4 and 5 (43), which are goals and a blueprint set by the United Nations to improve the livelihoods of the impoverished. MDG 4 targets the reduction of the under-five mortality rate by two-thirds, and MDG 5 targets the reduction of the maternal mortality ratio by three-quarters.

Health System Challenges Historically, the Ghanaian health system has struggled with a number of critical health issues, such as malnutrition of the under-five population, severe anemia, child mortality, incompletely vaccinated children, and coverage of basic health service. Regarding sanitary water

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access, according to the 2021 Population and Housing Census (2021), while the majority (87.7%) of the population has access to basic water supply services, there is a disparity for rural regions where only 74.4% of rural populace has access to basic water supply services. Further, approximately 8% of Ghanaian households rely on unsafe sources of water, such as sachet water (47). Additionally, the use of contraceptives is notably low throughout the country (only 27.8% of married women use modern methods), and high fertility rates in northern Ghana negatively affect mothers’ health. Sexual and reproductive health is another area of improvement as HIV remains high among female sex workers (4.6%) and among men who have sex with men (18%).

While the National Health Insurance Scheme (NHIS) has improved access to healthcare, the system still has numerous administrative, financial, and other difficulties. One such difficulty is the fluctuating financial stability due to the global economic crisis from the COVID pandemic and the inflation of goods like pharmaceuticals (48). Additionally, the NHIS relies on health insurance payments from the Ghanaian government, so when the government makes delayed payments, the healthcare quality decreases. However, if the NHIS were to rely on out-of-pocket payments from patients as a source of revenue, many clients would turn to self-medicating and self-diagnosis, which worsens their health outcomes (48,49).

Despite the historic challenges, the Ghanaian government has demonstrated a concerted effort to meet the challenges of the healthcare system. Over the past 30 years, the Ghanaian healthcare system has increased expenditures, resulting in many health care achievements including maternal health, sanitation, water, malaria treatment, and HIV/AIDS prevention and treatment (50). In 2016, Ghana adopted the Sustainable Development Goals guidelines from the World Health Organization and is committed to achieving goals like improving well-being by implementing policies to reduce teenage pregnancies and increase family planning resources (51). Additionally, as of April 2022, the Ghanaian government has improved the quality of services in 88 facilities in northern Ghana by mentoring and training 1,300 health workers in emergency care for mothers and small or sick newborns. This initiative reduced institutional maternal mortality from 111 to 73 per 100,000 live births since March 2021 and institutional newborn mortality from 7.6 to 6.3 deaths per 1,000 live births (50). Another health achievement, the Ghanaian government increased the proportion of children consuming a minimum acceptable diet from 10% to 65% in USAID-supported districts in the Northern, Savannah, and North East

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regions (50). Overall, the Ghanaian Health system is making great strides in improving its health care system considering the historical challenges it has faced such as the strained health insurance infrastructure.

IV.

Types of Water Pollution & Associated Health Impacts Microplastics Though a main type of pollution in Ghana is mining pollution and freshwater pollution,

microplastics significantly affect water safety. This form is known as microplastic contamination, which has downstream effects on water, soil, and air pollution. According to a study published in Science Direct, “the amount of plastic that enters Ghanaian water bodies is projected to increase by “190 %, from ∼78,000t in 2020 to 228,000t per year by 2040” (52).

Microplastic pollution in Ghana is significantly influenced by global plastic production and inequitable waste management. According to a 2020 UN Report, 36% of the world’s 50 largest dumpsites are located in Africa, with Agbogbloshie in Accra, Ghana, remaining as one of the leading destinations for microplastics and electronic waste (53). The influx of plastic waste from wealthier nations, especially due to the thousands of second-hand plastic products Ghana imports, plays a large role in polluting the environment. Inadequate waste management systems in Ghana, particularly in urban areas, also contribute to the accumulation of plastics due to poor collection and disposal practices. Such structural issues are magnified by rapid urbanization and population growth, leading to more waste being produced than can be processed across cities in Ghana (54). Furthermore, detection and measurement of microplastics is limited due to constraints in infrastructure, resources, and expertise (53). While some research has been conducted along the coastline, several other regions remain neglected and lack sufficient studies.

The lack of research only exacerbates the problem of microplastic pollution since it restricts efforts to understand, address, and manage microplastic pollution effectively.

The health impacts of microplastic contamination in Ghana are significant, particularly for communities dependent on freshwater ecosystems for both food and water. Microplastics, defined as small plastic particles less than 5mm in size, can easily enter the food chain through both aquatic organisms and drinking water (55). The consumption of microplastics, often through contaminated seafood or drinking water, has been linked to a range of health concerns,

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including developmental issues, endocrine and hormone disruptions, and even cancer. For vulnerable populations, especially pregnant women and children, exposure to these particles poses an even greater health risk, with increased probability of prematurity, stillbirths, as well as cognitive and reproductive impairment (56). Additionally, microplastics can absorb toxic chemicals from the surrounding environment, which leads to further chemical exposure and compounding health risks, including obesity, diabetes, thyroid problems, and a higher risk of cardiovascular disease and stroke (56). It is essential for Ghana to address both domestic waste management challenges and the broader global issue of plastic pollution in order to mitigate the growing health risks posed by microplastics.

Heavy Metals Mining is a huge part of Ghana’s economy. In 2023, Ghana produced about 4.2 million ounces of gold, or 4% of the world's total output (57). Most of the gold exports go to the UAE, India, Switzerland, and Turkey. The mining industry in Ghana is mainly operated by 19 large mining companies operating close to 16 gold mines, one bauxite mine, and one manganese mine (18). However, 36% of Ghana’s gold production was reported to have come from legal smallscale mines, even though the actual amount of gold produced in Ghana is substantially higher and the remaining gold is mined by illicit companies (58). These illegal gold mines smuggle multiple tons of gold out of the country each year, with the UAE being the major destination and Switzerland buying a lot of their gold from the UAE. Government officials from both countries have expressed concern about the illegal activity and commitment to taking steps to combating it (59). The majority (60%) of the water pollution in Ghana comes from illegal mining activities, galamsey (18). These gold mines produce large amounts of waste that contain heavy metals, such as copper and silver, which can leak into surrounding environments via wind dispersal or exposure to local waterways surrounding a mining facility (60). People, notably children, in areas with high contamination of heavy metals are at high risk of developing cancerous and oncological problems (61). With HQ (heavy metal hazard quotient) values above 1 for both adults and adolescents, inhalation exposure to arsenic, cadmium, lead, chromium, and nickel, in particular, pose significant risks, suggesting that these contaminants have serious health risks (62).

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Lead is an especially toxic heavy metal that is considered a carcinogen, even in small amounts. Lead poisoning is classified as either acute or chronic. Acute lead exposure, often in workplaces or manufacturing, can cause symptoms like loss of appetite, headache, hypertension, abdominal pain, kidney issues, fatigue, insomnia, arthritis, hallucinations, and vertigo. Chronic exposure can lead to severe effects, including mental impairment, birth defects, psychosis, autism, allergies, dyslexia, weight loss, hyperactivity, paralysis, muscular weakness, brain and kidney damage, and even death (63). Gold mining requires heavy machinery such as excavators, draglines, shovels, giant trucks, crushers, and grinding mills, along with license and technical expertise, to minimize personal and environmental harm. Therefore, illegal small-scale mining operations have the potential to contribute significant harm to the environment (18).

Image 3: Farmer mixing pesticides at the edge of a river (64)

Pesticides In addition to microplastics and heavy metals, pesticides are an abiotic water pollutant impacting health in Ghana. In northern Ghana especially, pesticides are used for agriculture.

While farmers have demonstrated an understanding of properly using pesticides, one study found that the majority of them did not store, apply, or dispose of pesticides properly (65). Another case study investigating pesticide use and contamination in northern Ghana found that, among 300 farmers, 24.7% mixed pesticides at water bodies, 39.0% improperly disposed of leftover

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pesticides, and 63.0% used inadequate storage methods (66). These results indicate issues with the handling of pesticides and their considerable ability to infiltrate into the ecosystem.

Although other countries do not have a direct role in this type of pollution, they do influence Ghana’s usage of pesticides in less obvious ways. To begin, Ghana’s pesticide problems, along with those of multiple other countries in Africa, stem from a range of global actors seeking to drive the Second Green Revolution across the continent, and these actors include foreign investors, philanthro-capitalists, and more (67). While it can be hard to link them to a single country, we can root the uptake of pesticide usage in Ghana to the strategies and needs of many philanthro-capitalists, who utilize free-market techniques to drive the development that they specifically invest in, often marking such investments are “charitable” even though they expect returns (68). A popular example of such an entity is the Bill and Melinda Gates Foundation (BMGF), which wields an unparalleled hold over many global development agendas, and can be traced back to their home base of the United States of America. The BMGF is responsible for the creation of a commercial agro-dealership development programme called the Alliance for a Green Revolution in Africa (AGRA), which turns out to be one of the main influencers of the recent increase in Ghana’s pesticide use (69).

AGRA and similar initiatives that work as commercial agrochemical dealers at the local level have ensured the Ghanaian farmers have wide access to cheap pesticides in order to further their own goals without care for the negative impacts they have (67). The investments that the BMGF contributes to AGRA and similar programmes may look harmless on its face, but the unintended consequences include the proliferation of pesticides throughout Ghana, endangering the health and lifestyles of the people of Ghana. Similar occurrences happen with countries that are generally considered large producers of pesticides, including China, India, Belgium, and Switzerland. China has always been Ghana’s largest supplier for pesticides, and in 2023, Ghana imported 8,701,740 kg of insecticides from China (70). India follows closely, supplying Ghana with more than 2 million kilograms of insecticides, while Belgium and Switzerland exported about 80,000 kg last year (70). Globally, Ghana had amassed more than 13 million kilograms of insecticides last year from self-interested countries that consider only their own benefits rather than the massive impacts this has on Ghana (70).

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Farmers who use these pesticides generally have very little choice; they can either use them to increase their crop yield or fall behind and go out of business since it is something practically every other farm in Ghana is utilizing. Luckily for them, many agrochemical dealers will sell these materials for cheap, boosting not only their sales, but the misfortunes of Ghanaian farmers. Farmers usually report experiencing headaches, body itching, dizziness, coughing, blurred vision, skin rashes and body weakness, all of which they attributed to exposure to pesticides (71). Additionally, these farmers often lack formal education and/or the ability to read, so they often do not understand exactly what pesticides they are using and the proper disposal methods, leading to them being disposed randomly in fields or tossed in rivers, which can spread pesticide pollution to the rest of the country. This can lead to the skin contact, inhalation, and ingestion of pesticides, which results in the accumulation of pesticide residues in the bloodstream through dermal and inhalation exposure, which can adversely affect their skin, eyes and respiratory system (71). There have also been studies on leukemia and non-Hodgkin lymphoma showing a positive relationship with pesticide exposure and conclude that heavy use of pesticides should be decreased (71). Other effects include defects, fetal death, neurological and neurodevelopmental disorders, which have become increasingly prevalent (71).

V.

Ghanaian Initiatives

The Water Resources Commission of Ghana (WRC) also estimated in 2017 that 60% of the country’s water bodies were polluted (72), attributing the major causes to be illegal mining, industrial and household waste disposal and improper farming methods. In addition, widespread media coverage of water pollution in recent times, especially due to its well-known association with galamsey, has prompted more aggressive interventions from both government and nonprofit organizations to tackle the problem.

As part of the widespread media coverage of what has been termed an ongoing menace, media organizations in Ghana have taken to both print and broadcast platforms in creating public awareness. Media efforts further culminated in the launch of the Media Coalition Against Galamsey (MCAG). The coalition oversees public education and advocacy programs with stakeholders while holding the government accountable for its role in combating the problem (73). These interventions have succeeded in sparking keen public interest, particularly among

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Ghanaian youth who recently took to the streets in protest of the deplorable state of water bodies nationwide due to illegal mining. Notable NGOs such as Friends of Rivers and Water Bodies also lend their voices towards awareness creation and sensitization of policymakers on the need for bolder approaches. Despite significant media contribution, water pollution remains at large in what is regarded as a lack of commitment and leadership towards the problem (73).

The WRC of Ghana is the overall body responsible for water resources management in Ghana (74). The commission, composed of representatives of the Environmental Protection Agency, Minerals Commission and other stakeholders functions to regulate and manage the utilisation of water resources, and to coordinate any policy in relation to them (75). The commission collaborates with other state agencies such as the Ministry of Sanitation and Water Resources (MSWR) to organize outreach programs while undertaking workshops with NGOs and educational institutions primarily to educate the public on the importance of preserving the country’s natural water resource and empowering them to become agents of change in the community. The commission further conducts field operations to check illegal mining and stop encroachment around water bodies in order to control pollution and ensure sustainability.

However, funding for conducting its various activities remains a challenge to the committee’s cause.

The Ghana Water, Sanitation, and Hygiene Sector Development Programme (GWASHSDP) is an initiative of the Ministry of Sanitation and Water Resources which provides a comprehensive framework for inclusive planning, implementation, monitoring, and evaluation of sustainable WASH services in order to establish universal access to water supply, sanitation, and hygiene by 2030 (76). The program includes goals for building water treatment plants, expanding water access in rural and urban areas, and improving sanitation infrastructure.

Additionally, GWASHSDP provides guidelines to regulate waste disposal, aiming to reduce contaminants in water bodies by creating a sustainable system of water and sanitation management. The initiative has resulted in increased access to basic drinking water, reaching 87.7% in 2022, with a target of 91.5% by 2025. Furthermore, a historic Presidential Compact on WASH, signed in August 2024 committed $1.7 billion annually until 2030 to accelerate universal access to WASH services, elevating WASH to the highest political level. While a significant policy advancement, existing constraints in the WASH sector pose significant threat

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to the success of the initiative. Ironically, funding remains the most pressing of them all despite significant allocation over the years. The 2018/19 WASH sector performance report (SPR) indicates that only 20% of budgeted capital expenditure was made available that year, with the figure plummeting to a meager 9% the following year (76). Additionally, the sector remains weakly coordinated despite existing WASH frameworks dating several years back and lacks equitable allocation of resources with more emphasis on water supply than sanitation.

Furthermore, water source contamination due to illegal mining, infrastructure maintenance and community engagement remain key obstacles to the initiative.

Greater Accra Metropolitan Area Sanitation and Water Project (GAMA-SWP) is a World Bank grant to aid the Government of Ghana increase access to improved water supply and sanitation services in low-income urban communities in Accra (77). The initiative further received additional financing to extend its reach to over 500,000 people, contributing to Ghana’s COVID-19 pandemic response by strengthening sector institutions and building resilience against future shocks. The project involves constructing modernized sewage and water supply systems, promoting behavioral changes around hygiene practices and ensuring that treated wastewater is properly managed, helping to prevent untreated sewage from polluting nearby rivers and coastal waters. However, rapid urbanization and ineffective waste management are threats to the project’s success.

The Ghana Water Initiative, launched in 2019, is a public-private partnership which aims to provide access to basic water and improve quality of life in Ghanaian communities by building competencies around water stations (78). The program pilots innovative water system business models for small towns, with plans for expansion. It constructs and operates clean water stations to provide communities with access to safe drinking water and reduce reliance on potentially polluted sources. The initiative also creates job opportunities and trains community members to maintain these water systems, fostering local ownership and sustainable management. Operations are limited by scaling and replication as well as operational sustainability.

Efforts to combat illegal mining are also worth noting, with the Ghanaian government intensifying efforts to address its main effect of water pollution. These activities have led to significant environmental degradation and water contamination. Recent warnings from

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international partners, such as the German Embassy, highlight the urgency of tackling this issue to prevent a looming water crisis (79). In light of this, Ghana has launched stricter regulations, surveillance, and enforcement efforts. There has been a crackdown on illegal miners who pollute rivers with mercury and other toxic chemicals, including confiscating equipment, arresting offenders, and rehabilitating affected water bodies. Ongoing public awareness campaigns also aim to highlight the dangers of “galamsey” to water safety and environmental health. Despite these efforts, illegal mining still poses a significant threat, with estimates suggesting an alarming number of water bodies being polluted due to these activities.

Persistence of this harmful practice can be attributed to enforcement challenges, lack of political will, and economic dependencies.

Each of these initiatives addresses specific aspects of water pollution, from infrastructure development and policy implementation to community engagement and regulation of harmful practices. By targeting sources of pollution and investing in water infrastructure, Ghana is making strides towards improving water quality and protecting public health. However, persistent challenges such as illegal mining, resource constraints, and enforcement limitations hinder significant advancements. Achieving long-term success will require increased investment, robust enforcement mechanisms, continuous community engagement, and adaptive strategies to tackle evolving water management issues.

VI.

International Initiatives

In 2008, Ghana met its Millennium Development Goal for access to water as rural and urban access levels to improved sources were 77% and 93%, respectively (80). However, a remaining challenge of this broader international initiative was ensuring access to quality drinking water (80), considering that the incidence of water- and sanitation-related diseases remained high after meeting this goal (80). As a result, USAID provides a synthesis of the implementation efforts of the water safety plan (WSP) in Ghana. The WSP has a few main goals: to systematically identify and mitigate risks in water supply systems, ensure the delivery of safe drinking water to communities, and build local capacity and infrastructure to support sustainable water management. International bodies such as the World Health Organization (WHO) and other donor agencies provide resources for technical training to local water management

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authorities and community operators, supporting data collection and creating monitoring frameworks to assess water quality. The WSP plan has had some notable successes; for example, by 2018, the WSPs had been implemented in 88 urban water supply systems, which have seen improvements in water quality. Additionally, public and institutional awareness about water safety and pollution issues has risen due to campaigns and education supported by these organizations. Some other challenges, on the other hand, include insufficient technical expertise and training at local levels, impeding effective water management, gaps in coordination between local authorities and international partners, variability in water sources and quality across different regions of Ghana, and resource limitations.

UNICEF’s Water, Sanitation, and Hygiene (WASH) program focuses on improving access to safe drinking water and sanitation while promoting sustainable hygiene practices in underserved communities across Ghana. The program has three main objectives: to increase access to safe and reliable water sources, strengthen sanitation infrastructure in schools, communities, and health centers, and implement good hygiene practices such as handwashing (81). To achieve these goals, UNICEF collaborates with the Ghanaian government, actively supporting the development of guidelines such as the National Water Policy, the Water Sector Strategic Development Plan, and the National Drinking Water Quality Management Framework (82).

UNICEF's WASH program, with vital support from the Ghanaian government, has achieved a number of successes. By 2023, thousands of rural community members had improved access to clean drinking water due to newly constructed water supply services the program supported (82).Public health campaigns, such as the tippy-tap school campaign, have promoted low-cost handwashing, menstrual hygiene, and safe water education and initiatives. Furthermore, the program's emergency response efforts have invested in strengthening hygiene awareness during crises such as fires, floods, and disease outbreaks, benefiting vulnerable populations (83).

However, the program still faces several challenges. Limited funding and dependence on donor contributions constrain the outreach of WASH interventions (84). Additionally, the lack of planning and coordination of sanitation improvement initiatives, inadequate staffing, and limited resources for capacity building all negatively impact basic rural sanitation delivery (85). Despite

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these limitations, UNICEF’s WASH program continues to work towards improving water quality and access in Ghana, focusing on collaborative solutions and community-driven approaches.

VII.

Remaining Challenges

Despite ongoing initiatives to mitigate water pollution in Ghana, significant challenges remain, threatening public health and environmental sustainability. Addressing these challenges requires not only continued commitment but also a recognition of the complex, long-term processes involved in restoring polluted waterways. Below, key challenges are outlined, emphasizing the scale and duration of efforts needed to fully mitigate the health risks posed by water pollution.

1. Lengthy Restoration Timelines ● Waterway Recovery Time: Even when pollution sources are eliminated, it can take decades to restore the health of polluted water bodies. For example, studies suggest that recovery of aquatic ecosystems, such as rivers and lakes, can take years if not decades, depending on the extent of contamination, sediment buildup, and ecosystem degradation (86). This prolonged timeline underscores the need for sustained efforts and funding. ● Repopulation of Aquatic Life: Restoring fish populations and aquatic biodiversity is particularly challenging. Species require optimal water quality, a suitable habitat, and stable ecosystems to repopulate. These factors are slow to improve, especially in rivers affected by industrial and mining pollutants. ● Drinking Water Standards: Achieving safe drinking water standards involves extensive treatment of water sources, which can take years to implement. Additionally, the risk of recontamination remains high in areas with poor sanitation infrastructure.

2. Insufficient Regulatory Enforcement ● Weak Policy Implementation: Several policy instruments, laws and regulations have been developed to control and manage Ghana’s water resources (87). However, Ghana's Environmental Protection Agency (EPA) and other regulatory bodies face challenges

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enforcing them. Limited capacity and resource constraints hinder effective monitoring and enforcement. ● Lack of political will: The persistence of galamsey and its impact on water bodies has long been reported to have deep rooted political ties. Reports suggest politicians who stand to benefit financially from illegal mining activities through its quick financial returns, often block the enforcement of regulations or manipulate the system to protect illegal miners to the detriment of the environment (88). ● Illegal Activities Persist: Despite interventions, illegal small-scale mining (“galamsey”) continues to be a major contributor to water pollution. Efforts to curb such activities have been met with resistance, and ongoing enforcement remains inconsistent.

3. Inadequate Infrastructure (85) ● Sanitation and Waste Management: Poor sanitation infrastructure and insufficient waste disposal facilities contribute to the continuous contamination of water bodies. Open defecation and indiscriminate dumping of solid waste remain pervasive issues, especially in rural areas. ● Water Treatment Limitations: Many municipalities lack the advanced treatment facilities needed to remove contaminants such as heavy metals, pesticides, and pathogens. This results in untreated or partially treated water being distributed to households, posing significant health challenges.

4. Public Awareness and Behavioral Change ● Limited Knowledge of Waterborne Diseases: A lack of awareness about the health risks associated with polluted water hinders behavioral change. Communities often continue unsafe practices, such as use of contaminated water for drinking, washing, and irrigation (85). ● Cultural and Socioeconomic Barriers: Deep-seated cultural practices and economic pressures often lead to resistance against environmental reforms. For example, reliance on artisanal mining as a source of livelihood persists despite its destructive impact on water resources 22

5. Climate Change Impacts ● Increased Vulnerability of Water Resources: Climate change exacerbates water pollution challenges by altering rainfall patterns, intensifying droughts, and increasing flooding. These phenomena wash pollutants into water sources and reduce the natural purification capacity of ecosystems. ● Health Risks from Climate-Driven Changes: The rise in waterborne diseases such as cholera and diarrhea during extreme weather events highlights the intersection of climate change and water pollution. ● Deforestation contributes to water pollution primarily by increasing soil erosion, which leads to a large amount of sediment entering waterways, causing turbidity (cloudiness) and impacting aquatic life, while also allowing chemicals and nutrients from the exposed soil to leach into water sources, potentially leading to algal blooms and disrupting the ecosystem balance (89).

6. Economic and Financial Constraints ● High Costs of Mitigation: Restoring polluted waterways and upgrading water treatment infrastructure demand significant financial investment. Limited national budgets and competing priorities often impede progress. ● Dependence on Donor Support: Ghana heavily relies on external funding to tackle water pollution. This dependence creates vulnerabilities, as inconsistent or reduced donor support can stall critical projects

7. Data Gaps and Research Needs ● Limited Monitoring and Data Collection: Inadequate data on water quality and pollution sources hampers evidence-based decision-making. A lack of comprehensive, real-time monitoring systems also makes it difficult to track progress and adapt strategies. ● Insufficient Health Impact Studies: While the link between water pollution and public health is recognized, there is limited research quantifying the long-term health impacts of specific contaminants, such as heavy metals or pesticide residues

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While Ghana has made notable strides in addressing water pollution, achieving clean and safe water for all remains a long-term endeavor. Restoring waterways requires sustained effort over decades, robust enforcement of environmental regulations, significant investment in infrastructure, and community engagement. Addressing these challenges is crucial not only to safeguard public health but also to support sustainable development and resilience against climate change.

VIII.

Summary and Your Task

The goal of decreasing water pollution in Ghana will require engaging diverse stakeholders and reflecting on the unique needs of its various populations. Through your planning, you should reflect on how to engage with community-based stakeholders (ie: the public, local politicians, galamsey operators, legal small-scale miners, civil society organizations, people seeking healthcare, businesses and corporations, health centers, and clinicians), the government at various levels (including: Environmental Protection Agency and Ghana Minerals Commission, National Politicians), and potentially other countries. Be sure to address cultural, social, political, economic factors or influences when creating your plan. These include (but are not limited to): employment opportunities, affordability barriers, influences of geographic landscape, and the impact of government regulation on economic development. Your task is to incorporate a program that: ● Finds a solution for decreasing water pollution and its negative health impacts in Ghana ● Works to deliver a comprehensive initiative with an emphasis on equality of access to healthcare and educational resources and inequality reduction ● Considers areas and populations that are disproportionately affected by water pollution, especially in rural and other underserved areas ● Mobilizes the community to work towards sustainable empowerment while working to reduce misconceptions or educational gaps ● Strengthens community involvement with key stakeholders such as the community and healthcare providers and locations ● Addresses the socio-economic drivers of industries contributing to water pollution

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In addition, there are several central questions to take into consideration: (1) How will your program properly decrease the deleterious effects of water pollution despite the difficulties associated with treating those in poor communities? (2) How do we assure accessibility and active engagement between communities, individuals, and stakeholders? (3) What funding sources have you incorporated into your proposed solution, and how much will it ultimately cost? If there are stages to your solution, be sure to consider each stage individually as well as the total cost. Provide also a budget and rationale for your proposal that makes sense to achieve your desired goals. Your team may choose to focus on one aspect of ensuring a comprehensive program or take on multiple projects.

Good luck!

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