The Politics of State Welfare Expansion in Africa: Emergence of National Health
Insurance in Ghana, 1993-2004
Author(s): Hassan Wahab
Source: Africa Today , Vol. 65, No. 3, Intimacy, Morality, and Precarity: Globalization
and Family Care in Africa—Insights from Ghana (Spring 2019), pp. 91-112
Published by: Indiana University Press
Stable URL: https://www.jstor.org/stable/10.2979/africatoday.65.3.06
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Africa Today
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Politicians in Ghana
clearly felt compelled, even
if indirectly, by citizen
pressure to replace the
cash-and-carry healthcare
system with something
else—and they did.
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The Politics of State Welfare Expansion
in Africa: Emergence of National
Health Insurance in Ghana, 1993–2004
Hassan Wahab
After years of military rule, Ghana returned to democratic
governance in January 1993. Since then, it has consolidated its
democracy, evidenced by seven successive general elections,
three alternations of power, and institutional actors using
the rules of the game to pressure elected officials to influence
policy development and implementation. This article examines the passage of massive state expansion of welfare legislation in 2003, the National Health Insurance Law (Act 650). I
argue that not only was healthcare reform a salient issue in
the 2000 general elections, the new law was the result of civil
society and citizen pressure on the governing New Patriotic
Party to fulfill its campaign promise to overhaul the country’s
healthcare system. This article contributes to the literature
on the welfare state from the developing world, which mostly
focuses on Latin America and Asia.
Introduction
My goal here is to explain why and how voters and civil society organizations
influenced party platforms and consequently healthcare reform in Ghana.
Using months of field interviews of key stakeholders in the healthcare sector
and archival data in the form of parliamentary debate records (between
November 2011 and March 2014), secondary sources, and ethnographic
observations, I argue that the New Patriotic Party (NPP) tapped into a salient
need—accessible and affordable health care—and used the country’s political
institutions to change the course of healthcare delivery in Ghana. Pressure
from civil society organizations and voters left the NPP no choice but to take
advantage of its majority in Parliament to secure passage of the National
Health Insurance (NHI) bill and have it signed into law by the president,
Africa Today Vol. 65, No. 3 • Copyright © The Trustees of Indiana University • DOI: 10.2979/africatoday.65.3.06
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africa today 65(3)
92
The Politics of State Welfare Expansion in Africa
John A. Kufuor, in his first term after wresting power from the National
Democratic Congress (NDC) in the 2000 general election.
That a government of Ghana, a relatively poor country, would commit
to reforming healthcare—a massive, protracted, seemingly incurable issue—
in fulfillment of its campaign promise and against the expressed policy position of the International Monetary Fund and World Bank, which had strongly
supported the existing policy (Public Agenda 2004) is a case worth studying.
Some have suggested that the threshold for an effective modern welfare
program that covers a large part of the population is rare to find in any
country with a gross domestic product (GDP) that falls below $1,000–1,200
per capita (Kasza 2006, 10–11). In 2003, when the national health insurance
legislation became law, Ghana’s GDP was $370; $495 when implementation
of the policy began in 2005, and $920 one year after implementation of the
policy began.1 By 2008, the government was contributing about 70 percent
of the funds to support the healthcare program—a considerable financial
commitment—and the rest through social security and national insurance
trust deductions, informal sector premiums, and other income (Abiiro and
McIntyre 2012). To the extent that society and citizen pressure influenced
the policy, it signaled yet another step in Ghana’s democratic consolidation
status—in sharp contrast to the politics of the 1980s, or even in the early
years of the Fourth Republic, when voters had little to no influence on government policy (Boafo-Arthur 1999; Boahen 1989).
As democratic movements swept across Africa in the early 1990s,
donor countries and agencies began to pressure Flight Lieutenant Jerry John
Rawlings’s Provisional National Defense Council (PNDC) government to
transfer power to an elected civilian government. At first, Rawlings resisted
the calls to cede power to a civilian government (Adedeji 2001, 2). When the
PNDC government succumbed to the pressure to return Ghana to a democratic dispensation and the country prepared to hold its founding elections
in late 1992, voters were preoccupied with issues other than social policy per
se. First, they had to vote in a referendum in April 1992 on a new constitution. Accordingly, a consultative assembly and subsequently a constituent
assembly were formed to draft a new constitution. Six months after approval
of the constitution, Ghanaians went to the polls—once again—on November
3 to elect a president. And on December 29, they went to the polls for a third
time—to elect two hundred legislators to Parliament.
The period between the approval of the new constitution in the referendum and the presidential and parliamentary elections was essentially used
for the formation of political parties, registration of candidates for elections,
and campaigning. The political campaign for the founding election was
short and was devoid of in-depth discussion on specific economic and social
policy issues, such as the creation of jobs for the country’s unemployed and
the replacement of the much-maligned fee-for-service healthcare system.
Rawlings, who formed the NDC and was its flagbearer, won the presidential election, and his party won 189 of the two hundred parliamentary seats
amid allegations by the opposition that the elections were stolen. The main
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Hassan Wahab
Before Ghana’s independence in 1957, few citizens outside the traditional safety net of the extended family in the village had access to
93
Politics and History of Healthcare Delivery in Ghana
africa today 65(3)
opposition, the NPP, boycotted the parliamentary election, following the
presidential election, held about eight weeks earlier (Boahen 1995; Jeffries
and Thomas 1993; Oquaye 1995). Consequently, the two hundred-member
Parliament consisted of the NDC and its coalition partners (together called
the Progressive Alliance), plus two independent parliamentarians.
When Rawlings was sworn into office as the first elected president
under the Fourth Republic constitution on January 7, 1993, the cabinet under
the PNDC government was essentially supplanted as Ghana’s cabinet under
the new NDC administration (Agyepong and Adjei 2008; Boafo-Arthur 1999).
The 1993–96 Parliament did not oppose any bill of the government, and not
a single economic bill was debated, much less rejected. During this period,
the legislature delayed debate and deliberation on controversial bills until
it was about to recess, after which it passed those bills under a certificate of
urgency (Boafo-Arthur 1999, 61). In the 1996 presidential and parliamentary
elections, Rawlings was reelected for another four-year term, and his NDC
won 133 seats in Parliament, while the NPP won sixty-one seats. Unlike the
first Parliament, which lacked robust parliamentary debates because of the
absence of strong opposition parties, the 1997–2000 Parliament engaged in
often vigorous and contentious debates on proposed legislations; however,
with his party’s overwhelming majority in Parliament, Rawlings did not
encounter any major setbacks on his legislative agenda (Agyepong and Adjei
2008, 156; Boafo-Arthur 1999, 61).
Civil society organizations’ and voters’ influence on Ghanaian politicians and policymakers grew with every election (Graham et al. 2017;
Gyimah-Boadi 2009, 2015), so that by the 2000 presidential and parliamentary elections, their influence on party campaign platforms and elected
officials was significant. By this time, the biting effects of the existing
healthcare policy, infamously called the cash-and-carry policy, was inescapable. Therefore, it was not surprising that civil society organizations
and citizens forcefully pressured political parties and elected officials to
change course.
In the remainder of this article, I first sketch the politics and history
of healthcare delivery in Ghana from immediately before independence in
1957 to the passage of the National Health Insurance Act in 2003. Second,
I discuss why and how healthcare became a salient political issue, especially
from the 1996 election campaign period and beyond. Third, I show the role
of civil society organizations and citizens in pressuring elected officials and
policymakers to pass healthcare-reform legislation in 2003. I conclude by
suggesting that while Ghana’s healthcare expansion has faced challenges, it
has been a model for several countries in the subregion.
africa today 65(3)
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The Politics of State Welfare Expansion in Africa
public healthcare in what was then the Gold Coast (Anyinam 1989, 532;
Waddington and Enyimayew 1990, 290). User fees, though minimal, were
charged at the available hospitals and clinics and were waived only for
indigents. After the achievement of independence, the government under
Prime Minister Kwame Nkrumah instituted a policy that extended healthcare to all residents of Ghana as a concrete manifestation of the benefits
of independence. Under the new policy, all Ghanaians could seek medical
attention in any government hospital or health center and pharmacy at no
financial cost to them, and whatever user fees had existed under the colonial
period were abolished. Consequently, state spending on welfare programs,
including healthcare, increased dramatically (Agyepong and Adjei 2008,
154). The independence government made health-education services more
available and accessible and emphasized preventive and community-based
healthcare services, rather than a hospital-based curative system (Carbone
2011, 388). Public health workers, colloquially known as tankas, were sent
to private homes, businesses, market centers, offices, and the like to conduct
cleanliness inspections; they ticketed and fined places that had not met the
required standards.
In the mid-1960s, the Ghanaian economy weakened, partly due to the
fall in the prices of cocoa, timber, and other cash crops in the world market
(Agyepong and Adjei 2008; Arhinful 2003). Dissatisfaction with the government increased, as did political tension between the government and the
opposition. Eventually, in 1966, the government was overthrown in a coup
d’état (Afrifa 1966; Apter 1968). Meanwhile, the population was growing at
a pace faster than anticipated. Recognizing the lack of revenue to support
the free healthcare program, the National Liberation Council (NLC), the new
military regime, issued the Hospital Fees Decree (NLC 360) to reintroduce
fee-for-service in 1969. Later in 1969, the military handed over power to
the Progress Party (PP), a constitutionally elected government, led by Kofi
A. Busia as prime minister.
In 1970, the Busia administration amended NLC 360 to become
the Hospital Fees Act (Act 387), which, to discourage abuse, continued
to require payment of certain minimum fees for service (Agyepong and
Adjei 2008, 154; Seddoh and Akor 2012, 5; Waddington and Enyimahew
1990, 290). On January 13, 1972, the Busia government was overthrown
in a coup d’état. Ghana experienced two subsequent coups d’état (July 5,
1978–June 4, 1979; June 4, 1979–September 24, 1979), a brief democratically elected government interregnum (September 24, 1979–December
31, 1981), and a long period of military rule (December 31, 1981–January
7, 1993) before the beginning of the current constitutional democratic
dispensation.
By December 31, 1981, when the PNDC overthrew President Hilla
Limann, healthcare delivery and services in Ghana had deteriorated so much
that in some public hospitals, patients provided their own beddings, medicine, food, and even stationery for their medical records (Seddoh and Akor
2012). The country’s hospitals and clinics lacked basic and essential medical
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Hassan Wahab
The idea of establishing a national health insurance program was first introduced at the highest levels of government in 1992 by Rawlings, six months
before the country’s return to constitutional rule (Rawlings 1993). It is
only during the fourth republic that high-quality, affordable healthcare has
gained political saliency—all the way to becoming part of the platforms of
political parties in Ghana.2 The first administration in the fourth republic,
the NDC government, began pilot projects in the Dangme West District
in the Greater Accra Region and the Nkoranza District in the Brong Ahafo
Region (with several other mutual health organizations that sprang up
across the country, sometimes with the support of agencies like the United
States Agency for International Development and the Danish International
Development Agency); however, the unpopular fee-for-service healthcare
policy remained. The government sought to minimize that unpopularity
and promote more public acceptance of the policy by introducing measures
that included exempting indigents, the elderly, children under five, and
pregnant women, from paying the user fees (Atim et al. 2001; Gobah and
Liang 2011b; Sulzbach, Garshong, and Owusu-Banahene 2005). Still, these
efforts did not produce the anticipated result. For instance, of the 1,895
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Healthcare Delivery as a Salient Political Issue
africa today 65(3)
supplies, and medical professionals left the country in droves (Anyinam
1989; Ghanaweb 1999a, 2001, 2003e). Patients were detained at healthcare
centers until they paid the bills associated with their care (Ghanaweb 1999b,
2003a, 2003b), and high prescription costs forced many Ghanaians to selfmedicate instead of seeking proper healthcare (Asenso-Okyere, Kwadwo,
and Dzator 1997; Boafo-Arthur 1999; Van De Boom, Nsowah-Nuamah, and
Overbosch 2008).
In 1983, the PNDC government adopted the structural adjustment
program promoted by the International Monetary Fund and the World
Bank, as part of which the government in 1985 instituted the Hospital Fees
Regulation, which sought to recover 15 percent of recurrent health costs by
substantially raising the level of fees for diagnostic procedures, consultations, surgery, and hospital accommodations (Agyepong and Adjei 2008;
Carbone 2011; Nyonator and Kutzin 1999). This policy required patients to
cover the full cost of their healthcare, effectively placing healthcare services
outside the reach of many (Anyinam 1989; Asante and Aikins 2008; Hutchful
2002; Konadu-Agyemang 2000; Seddoh, Adjei, and Nazzar 2011; Seddoh and
Akor 2012; Waddington and Enyimayew 1990). Government expenditures
on healthcare, which had been 10 percent of the national budget in 1982,
dropped to 1.3 percent by 1997 (Konadu-Agyemang 2000, 474). By 2000, the
per capita outpatient department attendance had dropped to 0.3 from 1.9 in
1970 (Seddoh and Akor 2012, 5); the cost of medicine alone accounted for
more than 60 percent of the treatment of malaria, one of the commonest
local illnesses (McIntyre et al. 2006).
africa today 65(3)
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The Politics of State Welfare Expansion in Africa
recorded patient contacts in the Volta Region in 1995, less than 1 percent
received an exemption (Nyonator and Kutzin 1999, 334). The Ministry of
Health found “no clear guidance on how to identify the various persons to
be exempted.”
The NPP made repeal and replacement of the cash-and-carry system a
cornerstone of its 1996 campaign. It promised that its victory would mean
a comprehensive health insurance for all residents of Ghana. Its campaign
platform called the cash-and-carry system “callous and inhuman,” and
the party promised to replace it, if voted into office, with a more equitable
healthcare-financing system. At the same time, the NDC campaign platform declared that the party’s healthcare goals set in its 1992 manifesto
had been achieved. The NDC won reelection in 1996, but no appreciable
change was seen in the healthcare sector. By the time of the 2000 general
elections, Ghanaians had become extremely dissatisfied (Carbone 2011;
Rajkotia 2007, 2009).
The tables were thus set for a major campaign battle between the two
dominant parties on which one could be trusted to bring about accessible
and affordable healthcare-delivery service to the people. The NPP’s 2000
campaign platform promised to abolish the cash-and-carry system. The NDC
campaign platform on healthcare for the 2000 election stated:
Health insurance will be a major strategy for mobilizing additional resources and for ensuring financial access in time of
need. The pilot work already carried out will form the basis for
a mix of insurance schemes, both public and private, national
and local, to cater for salaried employees, the self-employed
as well as both urban and rural communities. The National
Health Endowment Fund whose Coordinating Committee
was inaugurated in July 1999 and whose Board of Trustees
has already been established, will be made operational. We
will review the “cash-and-carry” system in order to improve
on its efficiency and ensure increased access to basic health
services. The exemptions policy will also be reviewed in terms
of coverage as well as disease spread, and more funds will be
provided to support the needy.
The NPP campaign promise of repeal and replace helped it win the parliamentary and presidential elections of 2000 (Blanchet, Fink, and Osei-Akoto
2012; Carbone 2011, 2012; Rajkotia 2009). The party did not lose sight of
the importance of healthcare reform when it formed the new government.
Alhaji Malik Alhassan Yakubu, a former NPP MP, minister for interior,
and second deputy speaker of Parliament, reported in an interview that the
NPP understood that the promise to repeal and replace the cash-and-carry
healthcare law had to be honored without delay. The “whole machinery
of government was brought to bear to assure the passage of the healthcare
reform bill into law.”3
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Civil Society and Citizen Pressure
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Hassan Wahab
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africa today 65(3)
Two approaches that have been utilized to effect policy and/or regime
change in Africa have been civil society and citizens’ pressure. The importance of civil society as a concept for explaining political developments in
Africa cannot be overstated. It played a crucial role in Africa’s struggle for
independence (Alidu and Ame 2012; Coleman 1954; Harbeson 1994; Hodgkin
1956). It has been described as the “main analytic paradigm” (Ikelegbe
2001, 2) and the “most powerful force upon the scene” (Young 1994, 48).
It has been credited with spurring protests that forced Africa’s most recent
attempt at democratization (Bates 1994; Bayart 1986; Bratton 1994; Chazan
1992; Diamond 1997; Gyimah-Boadi 2004; Hutchful 1995; Kasfir 1998;
Widner 1997; Young 1994). These accounts of the power and influence of
civil society are supported by recent political developments in Ghana (Brass
2016; Business and Financial Times 2003; Gyasi 2003).4
The use of popular protest to influence policy was common in the
Gold Coast (Owusu 1986; Simensen 1974), but the idea of citizens putting
direct pressure on public officials—or petitioning their government—to
influence policy has not been a common occurrence in independent Ghana.
In contemporary Ghanaian history, protest of a government or a policy
has typically been spearheaded by organizations. The kind of political participation that allows or provides ordinary citizens unfettered access and
opportunity—including use of such methods as writing letters to representatives, visiting representatives’ offices, attending townhall meetings, and
petitioning representatives and government on policy—are atypical. It is
reasonable to suppose that this situation reflects the fact that Ghana, for
the better part of its existence as an independent country, was a dictatorship, and avenues for citizens to petition their government were largely
nonexistent. The opening of political space for citizens to vote to select
their representatives, however, has meant that voters can use their voting
power to influence policy. They punish their representatives not only for
dissatisfactory constituency service, but also for being unhelpful, wicked,
and mean if they do not support them by giving such personal favors as
help in paying hospital bills, school fees, funeral expenses, and so forth.
Citizens’ demands for financial support from representatives put direct pressure on officials, usually guided by a desire to be reelected, to do something
about the cash-and-carry healthcare policy. Indeed, a new phenomenon in
Ghanaian politics is split-ticket voting (colloquially called skirt-and-blouse
voting), where some voters vote for a presidential candidate from one party
and a parliamentary candidate from a different party (Boafo-Arthur 2008;
Frempong 2017; Kelly and Benning 2013). More and more, citizens are using
skirt-and-blouse voting to punish parliamentary candidates thought to be
inattentive to their needs (Kokutse 2012).5
A highly regarded newspaper columnist informed me in an interview
that he would never vote for the long-time NPP MP in his constituency
because he did not see him as looking after the needs of all his constituents.
africa today 65(3)
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The Politics of State Welfare Expansion in Africa
The columnist recounted a story about meeting with the MP and pleading
with him to use his good offices not only as his representative, but also as
minister for roads and highways, to help pave a road from his house to the
main road. He said the minister had assured him that funds for paving that
road had already been budgeted and work was to begin soon. The roadwork
began shortly thereafter, as the minister has indicated, but the work ended
in a place where the minister was said to have had personal differences with
a resident. As it turned out, the part of the road left unpaved to punish the
resident with whom the minister was feuding included the columnist’s area.
Thus, the columnist asked rhetorically, “how can anyone be elected to be a
member of Parliament if he punishes some . . . citizens of his own constituency by denying them a paved road because of personal differences? As far
as I am concerned, he is not fit to be MP, and I will not vote for him.”6 In the
end, the MP and former minister, with fifteen other sitting NPP MPs, were
themselves punished, as NPP primary voters in their respective constituencies rejected them as candidates for the December 2016 general elections
(Myjoyonline 2015).
Civil Society and the NHIS
Several civil-society organizations, not unlike in Kenya, have been active and
quite influential in Ghana during the fourth republic (Brass 2016; Dowuona
2008; Ofori-Mensah 2011; Yeboah 2013).7 At the height of the fee-for-service
healthcare policy, the media and other civil-society organizations brought
home to politicians and policymakers the state of the country’s healthcare
(Ghanaweb 1999a, 1999b). For instance, Kusi-Ampofo and others (2014)
quoted a media report about a tomato seller to show the devastation of the
cash-and-carry policy:
My son was bitten by a snake and was taken to the hospital by
his friends. The doctors and nurses refused to attend to my son
because they had not deposited any money. So, the children
left my son at the hospital and rushed to the market to call
me. By the time I got to the hospital, my son had passed away
just some seconds earlier.
Similarly, a radio announcer is quoted as using his position to admonish the
government on the state of healthcare this way: “I seize the opportunity to
appeal to the minister of Health. The cash-and-carry system is telling on the
average Ghanaian. Something must be done about it. If you care to know, my
name is Frank Aidam” (Brande 1997). Many nonstate faith-based organizations, such as the Ahmadiyya Muslim Mission and Catholic, Methodist, and
Seventh-Day Adventist churches, stepped-up to provide healthcare services
to citizens, mostly in rural communities where the lack of, or inadequate,
healthcare professionals and centers was acute (Miralles et al. 2003). They
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Hassan Wahab
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africa today 65(3)
provided intermittent health camps, where certain types of surgery (such as
eye operations) and vaccinations against certain diseases were done.
Some have suggested that civil-society influence on the NHI legislation was minimal—that although the media tried to cover the debate surrounding the NHIS, their reporting was sensational, rather than focused
on substantive issues (Agyepong and Adjei 2008; Rajkotia 2007; Seddoh
and Akor 2012). However, contrary evidence supports the view that civilsociety organizations played a major role in influencing the legislation.
Negating the idea that the media’s influence on the debate was minimal,
one survey showed that 99 percent of respondents reported hearing about
the NHIS through the electronic media (Gobah and Liang 2011a). An MP
and former minister for health reported in an interview that “stakeholders
and nongovernmental organizations” exerted pressure on elected officials
to do something about the cash-and-carry policy, notwithstanding the fact
that all seventy-two or more stakeholders in the healthcare sector were not
united, and their demands, in some cases, were confusing.8 Never mind also
that when the NPP government decided on a legislative proposal to fund the
NHI program, partly with a 2.5 percent workers’ contribution from the Social
Security and National Insurance Trust (SSNIT), and that the bill was going
to be passed through a parliamentary procedure called certificate of urgency
(which would in effect have limited debate to just one week), labor unions
vehemently opposed it. Unions and other organizations took to the streets
in protest. Their opposition to the bill was based on two major grounds: how
the program was to be financed and the parliamentary maneuvering used by
the ruling NPP government to pass the legislation. On the first point, unions
were against funding the proposed US $13-million-a-year program by imposing on the backs of their members taxes that included a 2.5 percent NHI levy
on all goods and services that attracted value added tax (VAT), a monthly
deduction of 2.5 percent of workers’ contributions to the SSNIT fund, and
the use of $5 million from the highly indebted poor-country index and individual member contributions to the NHIS (Rajkotia 2009, 25–26). Moses
Asaga, the NDC spokesperson on finance and MP for Nabdam, accused the
government of using the NHIS as a cover to increase taxes on already burdened citizens (Ghanaweb 2003c). Fearing that civil-society organizations
and the NDC-led public demonstrations and protests would garner bad press
and public disaffection, the NPP delayed deliberations and passage of the bill
for a month (Daily Graphic 2003). Thus, civil society not only succeeded
in delaying the passage of the NHI bill by about a month, but also obtained
assurances from the government that no one’s pension would be adversely
affected because of partly funding the program with a 2.5 percent monthly
SSNIT contribution. Furthermore, labor unions received assurance that all
contributors to SNNIT would receive free healthcare—an assurance that
eventually quieted labor organizations (Seddoh and Akor 2012, 9). Some
organizations—including the Ghana Chamber of Commerce, the Ghana
Employers Association, the Ghana Pensioners Association, and other social
clubs and health insurance groups—submitted written memoranda to the
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The Politics of State Welfare Expansion in Africa
parliamentary select committee on health and finance for consideration. In
addition, representatives of various groups made oral presentations to the
parliamentary select committee (Hansard 2003a, 76–103).
Agyepong and Adjei (2008) have argued that the parliamentary select
committee on health and finance hearings occurred in the larger urban areas
where there was not a single mutual health organization before the passage
of the NHI bill and that the influence of organizations on the legislation was
minimal because the process was dominated by the government and the task
force.9 Empirical evidence, however, counters that argument in favor of the
view that organizations influenced the health insurance legislation. During
the parliamentary debates on the bill, political opposition was absent from
Parliament because NDC MPs boycotted the proceedings, leaving only NPP
MPs in the chamber; yet MPs sought to include provisions in the legislation that would address the expressed concerns of organizations. Just a day
before the health insurance bill was passed (with only the NPP MPs debating the proposals), sixteen new amendments, reflecting concerns expressed
by various groups, were introduced to improve the bill (Ghanaweb 2003d).
Even after the passage of the bill, the Kufuor administration continued to
negotiate with unions and other organizations to address their concerns
(Ghanaweb 2003e).
MPs’ floor speeches directly referenced the concerns of organizations,
evidenced by extracts from Hansard. Felix Owusu Adjapong, the NPP MP
from Akyem Swedru in the Eastern Region, majority leader, and minister
for parliamentary affairs, made the following statement before Parliament
adjourned for the day on August 22, 2003:
Mr. Speaker, yesterday, we held a meeting with organized
labor. We also met the Social Security and National Insurance
Trust and we seem to have had some general understanding
as to how we shall go forward to ensure that this Bill becomes
the best. Yesterday, we agreed on a time frame with organized
labor which we believe is reasonable [to discuss the final bill]
if we are able to meet on Monday to complete the rest of the
exercise [to complete debate on the bill and finalize the bill].
(Hansard 2003d, 390)
In the next session, the majority leader offered a proposal to amend the
language of the bill to include a representative from organized labor on the
governing body of the National Health Insurance Authority, National Health
Council, giving this rationale:
Mr. Speaker, this [bill] is being amended to recognize the
fact that if workers’ contributions are going to be involved
in the raising of the fund, then it is just right that we get the
workers represented on the Council so that they can make
meaningful contributions when decisions are being taken
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rather than waiting until after a decision has been taken.
It is very straightforward, and I therefore urge all Hon.
Members to support this harmless amendment. (Hansard
2003e, 453)
Mr. Speaker, part of workers’ contributions to SSNIT is going
to be used to support the health insurance scheme. Most of
them [i.e., workers] have been asking what benefit they would
be getting. It is appropriate to compensate them in a way; and
therefore, I believe that this amendment would go a long way
to assure them that they would be catered for in their time of
retirement. They are going to have medical care even when
they do not have money[,] and therefore it is proper to capture
this to assure them. (Hansard 2003b, 316)
These concessions to labor and other civil society organizations were important because the position of the government and the NPP MPs had previously
been that contributors to the SSNIT fund would pay the health insurance
premium as well. Here is how S. K. B. Manu reacted to the proposed amendment to exclude SSNIT from paying the premium:
Mr. Speaker, I rise to oppose the amendment in the sense that
it is a very dangerous one. Mr. Speaker, if he is thinking about
those in the formal sector going to pay so much so that they
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Hassan Wahab
To address another concern of organized labor, Kwame Osei-Prempeh,
the MP for Nsuta-Kwamang Beposo, proposed the inclusion of a clause
to section 79 of the bill, which dealt with sources of funds for the health
insurance program: “Any worker who contributes two and half percent of
his social security contribution shall have that as his contribution or part
thereof on the premium payable to his district mutual health insurance
organization.” He added:
101
Mr. Speaker, I rise to support the amendment. If you listen
to the debates going on where people are misconstruing the
facts that workers[‘] contributions are going to be misused and
that they are going to lose something, and all those half-truths
being said about the fund, then it is proper that a representative of workers who are contributors be on the Board so that
he would know the ins and outs of the operations and the fund
so that when there is any controversy or misunderstanding he
would come out to clarify the situation to the working masses
of this country. (Hansard 2003f, 454)
africa today 65(3)
In support of the amendment, S. K. B. Manu, the MP for Ahafo Ano South
in the Brong Ahafo Region, stated:
africa today 65(3)
have to be reimbursed in a form that he is proposing, what
are we saying about cocoa farmers, for example, who over the
years have offered their monies to build this nation? . . .
Mr. Speaker, how many of those farmers today even have the
capacity to send their children to the universities that their
toils and sweat helped to build? So, if today, those in the
formal sector are also to contribute something that would
benefit those in the informal sector, I do not see the place of
the amendment. I therefore vehemently oppose it. (Hansard
2003c, 319)10
102
The Politics of State Welfare Expansion in Africa
These excerpts challenge Lindberg’s (2010) observation that civil
society organizations do little to hold MPs accountable; on the contrary,
they show that MPs were concerned about the misgivings of organized
labor, arguably the loudest of the civil society organizations, and wanted
to demonstrate that those expressed concerns had been addressed. The
majority leader and some leaders of the NPP in Parliament had met with
representatives of organized labor to discuss how to modify the language
of the proposed legislation to address their concerns. And as the majority
leader’s statement suggests, the NPP leaders committed themselves to sharing the final legislation with labor unions before passage. The parliamentary
debate records do not show that civil-society influence on the development
and passage of the NHI bill was at best minimal: on the contrary, the record
shows great sensitivity to civil-society concerns and serious efforts made
to addressing them.
Citizen Pressure and the NHIS
I present the evidence of citizen pressure on MPs to do something about
healthcare delivery in Ghana from three sources. First, quite a few newspaper and other published accounts suggested that citizens were increasingly
demanding elected officials to pay for their healthcare and other expenses
(Adu-Gyamerah 2006; Ghanaweb 2005; Lindberg 2010; Wardle 2008). Second,
evidence can be gleaned from the following two narratives. I met an MP who
happened to be a minister at a wedding in Accra and arranged to visit him at
his official residence on a Monday morning at 10 o’clock.11 Upon reaching
the gate at the residence, I informed a police officer on hand that I had an
appointment with the minister, but the officer responded, “Chief is not in
the house, Sir.” After insisting that it could not be correct that the minister
was not at the residence, given that I had spoken with him an hour earlier
to confirm the appointment, the officer asked me to wait while he made a
call to someone inside the residence. Soon thereafter, the minister’s personal
assistant or bodyguard, who had been with the minister at the wedding,
appeared and asked me to come along. When I entered the residence, more
than fifty people were waiting to see the minister. The two living rooms of
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Hassan Wahab
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103
The pinch of out-of-pocket fees was felt not only by the
poorest, who usually suffer most from regressive taxation,
but also by middle-income groups. Even those in the higher
income brackets felt the pinch, especially given that traditional extended family structures and social responsibilities
africa today 65(3)
the residence and a garden beside the house were filled with people. The
minister’s wife received me warmly, as though I was a family member, and
walked me through the living rooms on the first floor to the second floor and
into the minister’s bedroom, where he met me. Upon inquiry, the minister
reported that the people in the living rooms and garden are constituents
who had come to demand a private good of some kind—money to cover
healthcare cost, school fees, funeral expenses, help with employment, and
the like. He explained that constituents would frequently arrive early in
the morning to ensure that they would see him before he left for work. He
added that sometimes he would leave the house by about 6 o’clock to avoid
these constituents, and he would normally return home late at night, often
after 10 o’clock.12
On the second narrative, I was walking with an MP in a lobby at the
Parliament House in Accra on our way to a lounge on the second floor to
conduct an interview when a young man approached us and informed the MP
that he was from his constituency—about two hundred miles away—and had
come to plead with him to get him 8 million old Ghana cedis (about US$80 at
the time) to enable him to pay his school fees. The MP told the young man to
go back home and give his name to his constituency chairman. Later the MP
revealed that this kind of occurrence was not infrequent.13 Asked what he
would do for the young man, the MP responded that often such people would
not go to see the constituency chairman. When they did, the constituency
chairman would typically make investigations to ascertain the veracity of
the petitioner’s story and then make a recommendation to him (the MP).14
The third evidence comes from interviews with MPs. One NPP MP
and former minister responded to my inquiry about why Act 650 was passed
by saying the cost of healthcare was so high that he personally paid some of
his constituents’ healthcare costs.15 Osei Kyei Mensah-Bonsu, stated in an
interview that the NPP passed Act 650 because “the constitution of Ghana
provides clear guidelines on providing good healthcare to citizens of Ghana
. . . and the public demanded” it.16 Constituents’ incessant pressure on MPs
for private goods, as the above examples show, strengthened the resolve of
the latter to do away with the cash-and-carry health policy (Lindberg 2010).
Citizen pressure to effect policy change often arises from personal or
community need. Ghanaian voters expect their representatives to provide
them with private and collective goods, but their votes are more often
influenced by the provision of collective goods (Lindberg 2013). Elected
officials’ fear of losing elections was enough pressure for them to pursue
policy changes on salient issues, as they did in the case of healthcare reform
in 2003.
are still strong in Ghana. Better off members of the extended
family are socially obliged and pressured to provide the safety
net for poorer members in financial crisis, such as exposure to
sudden unplanned catastrophic health expenditure. (Agyepong
and Adjei 2008, 153–54)
africa today 65(3)
Politicians in Ghana clearly felt compelled, even if indirectly, by citizen
pressure to replace the cash-and-carry healthcare system with something
else—and they did. Citizen pressure on MPs and other political leaders might
have been indirect, yet effective.
Conclusion
104
The Politics of State Welfare Expansion in Africa
The passage of Act 650 by the NPP government in 2003 was because healthcare reform had been a salient issue in the 2000 general election, and civilsociety and citizen pressure ensured that healthcare reform would remain
an issue until reform occurred. It was clear through media reports, studies,
and constituents’ personal problems shared with elected officials, that the
existing healthcare system required a major overhaul. By this time, there was
enough evidence that Ghanaians were increasingly voting on issues; both the
NDC and NPP believed that the promise to reform the healthcare system
would yield political dividends. The NPP government was clear-eyed that
passage of Act 650 in 2003 would give it an edge over the NDC in the 2004
election, and it was right: it did.
The debate on state provision of healthcare did not end with the
passage of Act 650 in 2003, however. Implementation of the policy, which
began in 2005 after NPP had been reelected for another four-year term in
2004, faced several challenges. Although 45 percent of Ghana’s estimated
population of 21 million had enrolled in the NHIS by 2008 (Carbone 2011,
395), a large segment of the population could still not afford the premiums,
or was less likely to enroll (Asante and Aikins 2008; Dixon, Tenkorang,
and Luginaah 2011), and the program was plagued with reimbursement
delays to service providers (National Development Planning Commission
2009; Zakariah et al. 2014). Not surprisingly, the NDC promised in its 2008
election campaign to fix such problems. Following its electoral victory, it
repealed and replaced Act 650 with new legislation, Act 852, in 2012. The
new law was not completely different from Act 650, but it addressed some
of the problems of the earlier law (Hansard 2012a). The NPP strenuously
but unsuccessfully contested the repeal and replacement of Act 650, arguing that improvements could be made to the law through amendments. If
improvements could be made under an NDC-controlled Parliament and its
president, the party was going to take credit for it. This point was not lost on
the NPP MP for Nhyiaeso constituency, the ranking member of the health
committee and former minister for health, under whom the development
of the policy outline for the 2003 bill had begun, who described the NDC’s
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See GDP per capita graphed at http://data.worldbank.org/indicator/NY.GDP.PCAP.CD?order
=wbapi_data_value_1981%20wbapi_data_value%20wbapi_data_value-last&sort=asc.
2.
That it is only during the fourth republic that the saliency of healthcare has become part of
campaign platforms of major political parties perhaps reflects the fact that the country had
been under virtual one-party or no-party dictatorship shortly after independence, from 1960,
with brief civilian interregnums (1969–1972 and 1979–1981). Rawlings, in his broadcast to the
nation following his second military seizure of power, stated that the civilian government that
he and his group had overthrown had turned the country’s “hospitals into graveyards and . . .
clinics into death transit camps[,] where men, women[,] and children die daily because of lack
of drugs and basic equipment” (Adedeji 2001, 4).
3.
Interview with informant in Chicago, June 14, 2013.
4.
For other examples, see Bratton (1994) on Zambia, Harsch (1993) on Cote d’Ivoire, and Brass
5.
Presidential candidates fear this phenomenon so much that they have pleaded with their sup-
(2016) on Kenya.
porters in the last several elections not to vote skirt and blouse. The presidential candidates
have generally argued that a vote for them but without a corresponding vote for their parties’
parliamentary candidates would make governing and honoring campaign pledges difficult or
impossible, for opposition members of Parliament might not support them with their votes.
For more, see Ghanaweb.com 2012.
6.
Interview with columnist in Kumasi, April 21, 2012.
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Hassan Wahab
1.
105
NOTES
africa today 65(3)
move as “unjustifiable and indefensible” and a “political chicane—act
of stealing the legacy of a past government to the good people of Ghana”
(Hansard 2012b). The push to pass both acts 650 and 852 signified a level
of democracy in which politicians believed they would be punished—that
is, not reelected—if they did not honor a key campaign promise (Carbone
2011, 398).
A survey of citizens in thirty-four African countries showed that healthcare, tied with poverty, was second only to unemployment as the most important problem citizens want their governments to address (Dome 2015). Where
the institutionalization of democracy is taking place across Africa, governments have begun to tackle the problem of access to adequate and affordable
healthcare by expanding state provision of healthcare. Although the NHIS
has continued to face challenges, it has received several international awards
(Andoh-Adjei and Adjetey 2011; Ghanaweb 2015; National Health Insurance
Authority 2013). And as a trendsetter, in terms of consolidating its democracy
and expanding state provision of healthcare in sub-Saharan Africa, Ghana has
hosted several fact-finding delegations from the subregion, including Nigeria,
Liberia, Senegal, Ethiopia, and Benin (Adomonline 2013; Allafrica 2013;
Citifmonline 2014; Ghanaweb 2013)—certainly a movement away from the
period when African politicians little concerned themselves with providing
welfare programs for most of their peoples.
7.
Despite its influence in shaping bills, one study observed that Ghanaian MPs agreed that
civil-society organizations did not hold them accountable to any great extent (Lindberg 2010),
but unlike in Kenya, these organizations in Ghana are not known to sit on governmental
policymaking bodies (Brass 2016).
africa today 65(3)
8.
Interview with informant in Accra, March 26, 2013.
9.
See Chankova, Sulzbach, and Diop (2008); Sulzbach, Garshong, and Banahene (2005); and
10.
Although these views were shared by many in the chamber, including the minister for finance
Nsiah-Boateng and Aikins (2013).
and economic planning, the amendment was passed (Hansard, August 21, 2003, 319–325).
11.
Parliament does not usually meet on Mondays.
12.
A meeting with a minister and MP in Accra, August 15, 2005.
13.
Both kinds of illustrations I provide here—constituents thronging the residences of elected
officials and approaching them in the halls of Parliament—have been observed by other
106
researchers; see, for instance, Lindberg 2003.
14.
Apart from MPs in leadership positions (majority and minority leaders, and majority and
The Politics of State Welfare Expansion in Africa
minority whips, the speaker and the three deputy speakers, and MPs who have ministerial
positions), the MPs did not have personal offices. One MP stated that lack of personal offices
impedes their ability to work effectively (interview in Accra, March 26, 2013). To that end,
President John Mahama stated on February 25, 2014, in his state-of-the-nation address,
“Mr. Speaker, I will continue to work to enhance the dignity and respect of this august house.
We need to work closely to strengthen public input in the legislative process. After years of
delay, I am pleased that Members of Parliament would soon have decent offices from which
to conduct their business. The days of using our car trunks to conduct business will finally be
a thing of the past” (Mahama 2014, 61). Few MPs have constituency offices. Most of the constituency offices are open during election campaign periods and are closed after the election.
Thus, if constituents wish to bring a matter to their MPs’ attention, they typically find them in
the halls of Parliament, or at home.
15.
Interview with informant, Thursday, March 21, 2013.
16.
Interview with the Honorable Osei Kyei Mensah-Bonsu on March 21, 2013, then the minority leader in Parliament, but currently the majority leader and minister for parliamentary
affairs.
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HASSAN WAHAB is a lecturer of political science at the University of
Ghana, Legon. He is an affiliated faculty at the Legon Center for International
Affairs and Diplomacy (LECIAD). His current research interests are on
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
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All use subject to https://about.jstor.org/terms
Hassan Wahab
africaines 8 (1): 25–41.
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111
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africa today 65(3)
Rawlings, Jerry J. 1993. Selected Speeches of Flight Lieutenant J. J. Rawlings, Chairman of the P.N.D.C.
africa today 65(3)
(London), Wahab was previously the managing editor of Africa Today.
His most recent works include “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 (Roman & Littlefield 2019,
forthcoming); “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, forthcoming),
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.
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The Politics of State Welfare Expansion in Africa
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