The Political Development of the Ghanaian National Health Insurance System: Lessons in Health Governance
Campaigning on the promise of affordable health care, the leading opposition party in Ghana won the national elections of December 2000, marking Ghana’s first democratic presidential change of power. Shortly thereafter, Ghana established a national health insurance system (NHIS). Within two years, over a third of the country had enrolled – an unprecedented accomplishment on the African continent. At the same time, the NHIS was plagued by design flaws and questions of sustainability. Though the development of the NHIS was politically driven, most analyses have focused on design issues. This study examines the political dynamics behind the development of the NHIS, with a particular focus on the role of health sector governance in policy development. Thirty-five interviews with key stakeholders and extensive secondary data analysis was conducted using grounded theory methodology. We find that stakeholders with politically incongruent viewpoints were marginalized while party loyalists were empowered, leaving the process vulnerable to rent-seeking behavior. Thus, this study argues that the political nature of health reform requires strong institutional mechanisms to safeguard transparency and accountability throughout the policy development process. Countries and their development partners must incorporate governance-related activities into their long-term health sector development plans to maximize the impact of public health policy.
