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ABSTRACT
This article analyzes the politics behind the consensus on healthcare by major political parties in Ghana’s Fourth Republic since 1993. Using Ghana over the period under review as a case in point, the paper’s main argument is that politics matters when it comes to the origination, design and implementation of healthcare programs, including the influence of constitutional design and practice, evidenced in a relative paucity of veto points, in facilitating the enactment of legislation on healthcare reforms; and the extent to which healthcare is defined as a human right. A high point of the paper is a critical assessment of the effectiveness of Ghana’s healthcare initiative based on the extent to which it meets the needs of citizens, from a human rights standpoint, in the face of a public health emergency of the type that the world currently faces with the COVID-19 pandemic.
RÉSUMÉ
Cet article examine la politique sous-jacente au consensus sur les soins de santé des principaux partis politiques de la Quatrième République du Ghana depuis 1993. En prenant le Ghana comme exemple pour la période examinée, le principal argument de l’article est que la politique est importante lorsqu’il s’agit de l’origine, de la conception et de la mise en œuvre de programmes des soins de santé, y compris l’influence de la conception et de la pratique constitutionnelles, attestée par une relative rareté des points de veto, dans la facilitation de la promulgation de la réglementation relevant des réformes des soins de santé ; et de la mesure dans laquelle les soins de santé sont définis comme un droit humain. L’un des points forts de cet article est une évaluation critique de l’efficacité de l’initiative des soins de santé du Ghana, basée sur la mesure dans laquelle elle répond aux besoins des citoyens, du point de vue des droits humains, face à une urgence de santé publique du type de celle à laquelle le monde est actuellement confronté avec la pandémie de la COVID-19.
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Acknowledgments
We wish to thank the editors and the anonymous reviewers for their helpful comments.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes
1. Multiple lines of evidence this article draws upon to support its argument include floor speeches of Members of Parliament (MPs), the public statements and actions of these lawmakers and interviews with stakeholders, such as members of the public, healthcare professionals, lawmakers, heads and workers of government agencies charged with the implementation of healthcare programs (e.g. the Ministry of Health, Ghana Health Service and the National Health Insurance Authority).
2. This is a proposition so intuitive few people would question it. However, not every democratic state pursues progressive policies, and in many political systems, democratic and authoritarian alike, redistributive policies are controversial.
3. Interview by the first author with former Health Minister Richard Anane in Accra, 16 November 2011.
4. Interview by the first author with former Health Minister Richard Anane in Accra, 16 November 2011.
5. Interview by the first author with Alhaji Malik Alhassan Yakubu, former MP, Interior Minister, and second Deputy Speaker in Chicago, 15 June 2013.
6. Interview by the first author with Alhaji Yakubu (see note 5).
7. The situation changed temporarily under President Barack Obama, from 2009 until 2017, giving way to the passing of the Affordable Care Act of 2010, but has returned, arguably with full force, under President Donald J. Trump since 2017.
8. The reality in politics is that the branch of government that controls financial matters essentially dictates lawmaking. Shugart and Carey argue that the power to initiate a bill enables the president to control agenda setting: “If she or he does not want a matter discussed, it will not be discussed” (Citation1992, 151).
9. In an interview with the first author years later, during the research on which this article draws, Alban Bagbin, the then minority leader of the party, disclosed that the boycott threat was merely “political talk” – a ploy to shore up the NDC’s base, given that the party lacked the votes to stop the NPP from proceeding. Interview by the first author with Alban Bagbin in Accra, 26 March 2013. The proposition makes sense, given that – contrary to the threat – NDC committee members took part in touring the country to consult stakeholders.
10. Interview by the first author in Accra, 26 March 2013, with an NDC MP, minister, and member of the party’s top leadership in the 2000–2004 Parliament. For this interviewee, the threat of boycott was little more than an attempt to energize the party’s base in the parliamentary and presidential elections slated for December 2004.
11. One respondent, an NHIS regional manager, told the first author that an NDC MP had told him he opposed Act 650, the initial healthcare bill, because he hoped the NDC would win the 2004 election and, with it, the opportunity to pass a healthcare bill and claim credit when it came to power. Interview by the first author with respondent in Accra, 16 April 2013. Granted, but there were also some NDC tactics that did not smell of fairness. One such tactic was the behavior of NDC MPs who reportedly told their constituents not to enroll in the national healthcare program because the NPP would use their paid premiums and enrollment fees to run for office in December 2004. Interviews by the first author with respondents in Accra on 22 April and 17 May 2013. The NPP did something similar in 2012 after it lost power to the NDC.
12. At the time of the passing of the 2012 health insurance bill, the former minority leader, Alban Bagbin Bagbin, was the Minister for Health.
13. A bureaucrat who closely followed these maneuvers disclosed to the first author during an interview that what surprised him the most about the debate surrounding the NHIS was “the hypocrisy of politicians.” Interview by the first author with a respondent in Accra, 22 April 2013.
14. Interview by the first author with a respondent in Accra, 17 May 2012; interview with a respondent in Accra, 22 April 2013.
15. Interviews and conversations with members of the general public by the first author during his fieldwork suggested that NPP won the 2004 election mostly because of progress on healthcare reform, including the passing of Act 650 in 2003.
16. Information obtained by the first author during interviews with some NPP MPs was confirmed by some members of the general public, whom the first author spoke with, who claimed to have benefitted from or knew someone who had benefited from an NPP MP paying their NHIS premium or renewal fee.
17. Interview by the first author with a respondent in Accra, 22 April 2013.
18. The NDC promise of a one-time premium health insurance payment was a huge part of the 2008 election campaign. However, not all stakeholders knew the precise meaning of this premium. See e.g. Abiiro and McIntyre (2013).
19. Interview by the first author with a respondent in Accra, Wednesday, 16 May 2012.
20. Investigation by the first author indicated that it is hard to dismiss this charge out of hand. His finding was that both political parties are guilty of the charge. When the NDC took power in January 2009, the National Health Insurance Authority was six months behind in paying NHIS bills, even though Act 650 required payment to be made within four weeks. The NDC government paid up the bills and brought them in line with the requirements of Act 650. However, as the country geared up for the 2012 election, payment of NHIS bills got behind again – and for more than six months. Both political parties have failed to deposit revenues for the NHIS into the National Health Insurance Fund as prescribed by the NHIS Act. Instead, NHIS funds have been deposited into a general account (the so-called Consolidated Fund). No finance minister has been willing to deposit NHIS funds in the proper account because of the flexibility it affords the government to use that money for other projects. Interview with respondent in Accra, 17 May 2012.
21. Conversations of the first author with respondents in Accra, 20 April 2013.
22. First author’s interview with a respondent in Accra, 25 April 2012.
23. This was within the context of the NDC’s move, ultimately successful, to repeal the initial healthcare bill, specifically whether the bill should be referred to the select committee on health and finance (rather than just on health). On a point of order, Anthony Akoto-Osei, the NPP MP for Old Tafo constituency and former Minister for Finance under the previous NPP administration, indicated that since the bill would have financial implications, it should be referred to the select committee on health and finance, just like the 2003 initial bill. However, the NDC presiding officer overruled him (Hansard Citation2012a:3344-3345) and the bill still went to the health committee only. In an interview with the first author in 2013, after the fact, the former finance minister asserted that the main problem with healthcare in Ghana was insufficient resources; therefore, referring the bill to the health committee to the exclusion of the finance committee indicated that the NDC was not serious about tackling the problem of healthcare reform. Interview by the first author with Mr. Akoto-Osei in Accra, 21 March 2013.
24. See Daily Graphic edition of 17 November Citation2011.
25. After the NDC government assumed office in January 2009, the newly appointed chief executive officer of the NHIA, the agency charged with implementation of the national healthcare scheme, blurted, “I am coming to give the NHIS a political edge.” Interview by the first author with one respondent in Accra, 17 May 2012. But this is politics revolving around claiming credit for supposed ownership of healthcare reform, far removed from the healthy politics that we conceptualize in this article.
Additional information
Notes on contributors
Hassan Wahab
Hassan Wahab is a lecturer of political science at the University of Ghana, Legon. He is an affiliated faculty member at the Legon Center for International Affairs and Diplomacy (LECIAD). His current research interests are in politics and state welfare provision, party systems, democracy and democratization. Currently a member of the editorial boards of the International University of Sarajevo (IUS) Law Journal and the Review of Religions (London), he was previously the managing editor of Africa Today. His most recent works include “The Politics of State Welfare Expansion in Africa: Emergence of National Health Insurance in Ghana, 1993–2004” (Africa Today, 2019, 65(3): 91–112); “Are Members of Parliament in Ghana Responsive to Their Constituents? Evidence from Parliamentary Debates on Health Care” (in Ghanaian Politics and Political Communication, edited by Samuel Obeng Gyasi and Emmanuel Debrah, Rowman & Littlefield 2019); “Democracy, Civil Society and the Emergence of National Health Insurance in Ghana” (in Politics, Governance and Development in Ghana, edited by Joseph A. Ayee, Lexington Books, 2019); an edited volume, Servant of The Bestower: Maulvi Dr. A. Wahab Adam (Islam International Publication, 2017); and “Ghana’s Health Insurance Scheme (NHIS) and the Evolution of Human Right to Healthcare in Africa” (with Philip C. Aka, Ibrahim J. Gassama, and A. B. Assensoh, Chicago-Kent Journal of International and Comparative Law, 2017, 17(2): 1–65). He may be contacted by e-mail at [email protected]
Philip C. Aka
Philip C. Aka is a professor of law and former dean of the Faculty of Law at the International University of Sarajevo, as well as a visiting professor at the Southern Illinois University School of Law, Carbondale, Illinois, USA. Aka has published widely on issues related to minority populations in Africa, Europe and the United States, including human rights. His recent publications include “Genetic Counseling and Preventive Medicine in Bosnia and Herzegovina” (California Western International Law Journal, 2020, 50(2), 271-340); “Humor as Pedagogy: Evidence from Bosnia and Herzegovina” (Indonesian Journal of International & Comparative Law, 2019, 6(4), 539 – with Sencer Yeralan); “The EU in Transition and Its Ramifications for Bosnia and Herzegovina” (Emory International Law Review, 34(Fall 2019), 2001); “Precision Medicine in the Era of CRISPR-Cas9: Evidence from Bosnia and Herzegovina” (Palgrave Communications, 2019, 5, 1 – with Sabina Semiz); “Ghana’s National Health Insurance Scheme (NHIS) and the Evolution of a Human Right to Healthcare in Africa” (Chicago-Kent Journal of International & Comparative Law, 2017, 17(2), 1 – with Ibrahim J. Gassama, A.B. Assensoh and Hassan Wahab); and Human Rights in Nigeria’s External Relations: Building the Record of a Moral Superpower (Lexington, 2017). Aka is Associate Editor of Humanities & Social Sciences Communications, and Corresponding Editor of International Legal Materials (a publication of the American Society of International Law). He may be contacted by email at [email protected]