**1. Introduction**

Violence against women and girls (VAWG) is a critical public health, societal, and economic problem affecting 35% of women globally [1]. Women from all countries, socio-economic status, culture and religion can be affected by violence perpetrated by spouses, other family members, authority figures, work colleagues, acquaintances and strangers. The impacts of such violence are widespread and long lasting, ranging from physical injuries, to functional disorders, to reduced capabilities [1]. Countries in the continent of Africa are not exempt from such experiences. In this chapter we focus on evidence of the impacts of VAWG in Ghana.

Ghana is a middle income country that has made progress in improving the status of women, currently ranking 59th out of 144 countries in the Global Gender Gap Index and 11th in Africa [2]. Nevertheless, VAWG has persisted as a problem affecting approximately one third of women during their lifetime [3, 4]. While there are a wide range of forms of violence that women in Ghana may experience, the most common form of violence reported across multiple studies, is intimate partner violence (IPV). Other forms of violence reported in Ghana include sexual violence by non-partners, violence by other family members, sexual harassment, forced and early marriage, female genital mutilation and other forms of harmful cultural practices [5–7].

Increasing the political will to invest in the prevention of VAWG is an ongoing task that many organisations in Ghana are undertaking. We aim to contribute to such efforts by providing evidence that VAWG affects the health and well-being of those who experience it directly, as well as their families and communities, creating costs that undermine personal capacity, family and community stability, and ultimately the economy as a whole. In this study, we focus on IPV, as well as violence against women by other family members in the home, violence in the workplace, educational institute and/or public space and consider the impact of physical, sexual, economic and psychological violence.

Our study examines the economic losses caused by VAWG and the noneconomic costs of violence that impact economic growth, development, and social stability. The project was supported by the UK Department for International Development (DFID) in recognition of the dearth of knowledge on the social and economic costs of VAWG. The study presented in this chapter is part of a larger project that the National University of Ireland, Galway with Ipsos-MORI and International Centre for Research on Women (ICRW), in collaboration with in-country partners, conducted in Ghana, Pakistan and South Sudan to estimate the economic losses caused by VAWG.

In this chapter we present evidence of the costs of violence as they impact on the health and wellbeing of women who experience violence in Ghana. We further consider the 'costs' to households and communities. Finally, we extrapolate some of these costs to the national level to consider how VAWG impacts the economy of Ghana. Importantly, these findings represent only a small proportion of the overall cost of VAWG, based on costs captured in the study that are tangible and quantifiable. The overall loss to Ghanaian society and economy due to VAWG is certain to be far higher than can be presented here.

### **2. Literature/state of knowledge**

The literature about VAWG in Ghana provides a plethora of evidence about the depth and prevalence of the problem. The 2008 Ghana Demographic and Health Survey (GDHS) suggests that at least one out of every three ever-married women experienced some form of sexual, physical, and/or emotional violence from a husband or partner in their lifetime [3]. Similar findings were also identified in the recent Ghana Family Life and Health Survey (GFLHS) [4]. Here, the study found that 28% of women reported experiencing IPV (including physical, sexual, economic, social, and/or psychological violence) in the past 12 months. The study also highlighted the impact on daily life and wellbeing of survivors of IPV and their families [4].

Feminist contributions to understanding VAWG have identified that unequal gender power relations that are characteristic of patriarchy influence the forms and prevalence of VAWG in Ghana [5], as elsewhere on the African Continent [8], and

**203**

confidence [4].

of the true impact of VAWG in Ghana.

by adequate information about the costs of violence.

*The Health and Economic Costs of Violence against Women and Girls on Survivors…*

globally [9]. Heise's ecological framework further develops the theory in relation to the aetiology of VAWG through recognition of the complex interplay between personal, situational and socio-cultural factors [10]. These contributions clearly situate the drivers of VAWG within social experiences, and thus importantly shift away from explanations of violence that are purely psychological (e.g. as a personality defect) or due to simplistic cause and effect (e.g. the woman burned the dinner so the man beat her). Such understandings have allowed the emergence of a widerange of interventions and programmes targeted at ending, reducing or mitigating VAWG [11]; however, investment and uptake of these remains limited, in part due to failure to fully grasp the impacts of violence on economic stability, growth and development. Heise's application of the social and ecological framework to explain VAWG has been adopted internationally as a theoretical framework that calls attention to the interplay of factors at multiple levels, the individual, the household, the community and society as a whole. Our study uses this framework to discuss the

A number of studies have demonstrated the pervasive effects of violence on the health of survivors. In 2016, in Ghana, a mixed methods nationally representative study found that 44% of women who had experienced domestic physical violence in the previous 12 months had been ill in the 30 days prior to the survey, compared to 31% of women who had not experienced this type of domestic violence [4]. In studies in northern Ghana, women reported feelings of worthlessness, suicidal ideation, hypertension, sleep disruption, genital sores, and premature termination of pregnancy as a result of the violence they experienced [12, 13]. The GFLHS study also identified strong correlations between exposure to IPV and serious mental illness. Relationships were further identified between IPV, health impacts and quality of life, with violence affecting women's ability to go to work, to school, complete domestic chores, and concentrate on activities as well as reducing their level of

In addition to physical and mental health impacts and their sequelae, a number of studies in Ghana have outlined pathways through which VAWG impacts individuals and households in Ghana. For instance, Essel finds evidence of women being prevented from working by intimate partners or who have their earnings taken by them [14]. Cantalupo et al. and Danso document costs to victims of VAWG, such as fees for doctors, that result in losses to household income [15, 16]. The children of women were also found to be affected by their mothers' experience of violence, including impacts on behaviour and education that results in long-term opportunity costs [4]. However, there is a dearth of studies that aim to assess the costs of violence beyond the individual or household, resulting in a fragmented understanding

Despite the high prevalence, there is still a gap between needs and service provision to women and girls who have experienced VAWG. The government of Ghana is a signatory of international treaties that convey a framework for actions to prevent and combat VAWG [17]. Ghana has a Domestic Violence Act, which aims to protect domestic violence victims [18], and approved a National Gender Policy in 2015 [19]. Its main instrument at the local level, the Domestic Violence Victims Services Unit (DOVVSU), has a key role in implementing the law and policy on GBV in Ghana despite having only nearly 180 inadequately resourced units [17]. Advocating for adequate investment in programmes aimed at reducing the prevalence of VAWG or mitigating the impact of VAWG, in line with Government obligations, is facilitated

Understanding the broad range of impacts of VAWG is still a key gap in the literature. Such evidence is particularly compelling to incentivise government investments in programmes and services for survivors. Identifying and quantifying,

*DOI: http://dx.doi.org/10.5772/intechopen.88690*

impacts of VAWG at different societal levels as well [10].

*The Health and Economic Costs of Violence against Women and Girls on Survivors… DOI: http://dx.doi.org/10.5772/intechopen.88690*

globally [9]. Heise's ecological framework further develops the theory in relation to the aetiology of VAWG through recognition of the complex interplay between personal, situational and socio-cultural factors [10]. These contributions clearly situate the drivers of VAWG within social experiences, and thus importantly shift away from explanations of violence that are purely psychological (e.g. as a personality defect) or due to simplistic cause and effect (e.g. the woman burned the dinner so the man beat her). Such understandings have allowed the emergence of a widerange of interventions and programmes targeted at ending, reducing or mitigating VAWG [11]; however, investment and uptake of these remains limited, in part due to failure to fully grasp the impacts of violence on economic stability, growth and development. Heise's application of the social and ecological framework to explain VAWG has been adopted internationally as a theoretical framework that calls attention to the interplay of factors at multiple levels, the individual, the household, the community and society as a whole. Our study uses this framework to discuss the impacts of VAWG at different societal levels as well [10].

A number of studies have demonstrated the pervasive effects of violence on the health of survivors. In 2016, in Ghana, a mixed methods nationally representative study found that 44% of women who had experienced domestic physical violence in the previous 12 months had been ill in the 30 days prior to the survey, compared to 31% of women who had not experienced this type of domestic violence [4]. In studies in northern Ghana, women reported feelings of worthlessness, suicidal ideation, hypertension, sleep disruption, genital sores, and premature termination of pregnancy as a result of the violence they experienced [12, 13]. The GFLHS study also identified strong correlations between exposure to IPV and serious mental illness. Relationships were further identified between IPV, health impacts and quality of life, with violence affecting women's ability to go to work, to school, complete domestic chores, and concentrate on activities as well as reducing their level of confidence [4].

In addition to physical and mental health impacts and their sequelae, a number of studies in Ghana have outlined pathways through which VAWG impacts individuals and households in Ghana. For instance, Essel finds evidence of women being prevented from working by intimate partners or who have their earnings taken by them [14]. Cantalupo et al. and Danso document costs to victims of VAWG, such as fees for doctors, that result in losses to household income [15, 16]. The children of women were also found to be affected by their mothers' experience of violence, including impacts on behaviour and education that results in long-term opportunity costs [4]. However, there is a dearth of studies that aim to assess the costs of violence beyond the individual or household, resulting in a fragmented understanding of the true impact of VAWG in Ghana.

Despite the high prevalence, there is still a gap between needs and service provision to women and girls who have experienced VAWG. The government of Ghana is a signatory of international treaties that convey a framework for actions to prevent and combat VAWG [17]. Ghana has a Domestic Violence Act, which aims to protect domestic violence victims [18], and approved a National Gender Policy in 2015 [19]. Its main instrument at the local level, the Domestic Violence Victims Services Unit (DOVVSU), has a key role in implementing the law and policy on GBV in Ghana despite having only nearly 180 inadequately resourced units [17]. Advocating for adequate investment in programmes aimed at reducing the prevalence of VAWG or mitigating the impact of VAWG, in line with Government obligations, is facilitated by adequate information about the costs of violence.

Understanding the broad range of impacts of VAWG is still a key gap in the literature. Such evidence is particularly compelling to incentivise government investments in programmes and services for survivors. Identifying and quantifying,

*Public Health in Developing Countries - Challenges and Opportunities*

cultural practices [5–7].

sexual, economic and psychological violence.

economic losses caused by VAWG.

far higher than can be presented here.

**2. Literature/state of knowledge**

Ghana is a middle income country that has made progress in improving the status of women, currently ranking 59th out of 144 countries in the Global Gender Gap Index and 11th in Africa [2]. Nevertheless, VAWG has persisted as a problem affecting approximately one third of women during their lifetime [3, 4]. While there are a wide range of forms of violence that women in Ghana may experience, the most common form of violence reported across multiple studies, is intimate partner violence (IPV). Other forms of violence reported in Ghana include sexual violence by non-partners, violence by other family members, sexual harassment, forced and early marriage, female genital mutilation and other forms of harmful

Increasing the political will to invest in the prevention of VAWG is an ongoing task that many organisations in Ghana are undertaking. We aim to contribute to such efforts by providing evidence that VAWG affects the health and well-being of those who experience it directly, as well as their families and communities, creating costs that undermine personal capacity, family and community stability, and ultimately the economy as a whole. In this study, we focus on IPV, as well as violence against women by other family members in the home, violence in the workplace, educational institute and/or public space and consider the impact of physical,

Our study examines the economic losses caused by VAWG and the noneconomic costs of violence that impact economic growth, development, and social stability. The project was supported by the UK Department for International Development (DFID) in recognition of the dearth of knowledge on the social and economic costs of VAWG. The study presented in this chapter is part of a larger project that the National University of Ireland, Galway with Ipsos-MORI and International Centre for Research on Women (ICRW), in collaboration with in-country partners, conducted in Ghana, Pakistan and South Sudan to estimate the

In this chapter we present evidence of the costs of violence as they impact on the health and wellbeing of women who experience violence in Ghana. We further consider the 'costs' to households and communities. Finally, we extrapolate some of these costs to the national level to consider how VAWG impacts the economy of Ghana. Importantly, these findings represent only a small proportion of the overall cost of VAWG, based on costs captured in the study that are tangible and quantifiable. The overall loss to Ghanaian society and economy due to VAWG is certain to be

The literature about VAWG in Ghana provides a plethora of evidence about the depth and prevalence of the problem. The 2008 Ghana Demographic and Health Survey (GDHS) suggests that at least one out of every three ever-married women experienced some form of sexual, physical, and/or emotional violence from a husband or partner in their lifetime [3]. Similar findings were also identified in the recent Ghana Family Life and Health Survey (GFLHS) [4]. Here, the study found that 28% of women reported experiencing IPV (including physical, sexual, economic, social, and/or psychological violence) in the past 12 months. The study also highlighted the impact on daily life and wellbeing of survivors of IPV and their

Feminist contributions to understanding VAWG have identified that unequal gender power relations that are characteristic of patriarchy influence the forms and prevalence of VAWG in Ghana [5], as elsewhere on the African Continent [8], and

**202**

families [4].

where possible, the costs of violence is thus an important contribution towards understanding and addressing VAWG in Ghana.
