Resistance and Change: A Multiple Streams Approach to Understanding Health Policy Making in Ghana Owuraku Kusi-Ampofo John Church University of Alberta Charles Conteh B. Timothy Heinmiller Brock University

Abstract Although much has been written on health policy making in developed countries, the same cannot be said of less developed countries, especially in Africa. Drawing largely on available historical and government records, newspaper publications, parliamentary Hansards, and published books and articles, this article uses John W. Kingdon’s multiple streams framework to explain how the problem, politics, and policy streams converged for Ghana’s National Health Insurance Scheme (NHIS) to be passed into law in 2003. The article contends that a change in government in the 2000 general election opened a ‘‘policy window’’ for eventual policy change from ‘‘cash-andcarry’’ to the NHIS. Keywords Ghana, agenda setting, health politics, multiple streams framework

Introduction

Ghana’s health care policy saw a remarkable shift in 2003. The government of Ghana passed into law the National Health Insurance Scheme (NHIS) to replace out-of-pocket payment of fees at the point-of-service, known in Ghanaian parlance as ‘‘cash-and-carry.’’ Cash-and-carry was a health care system in Ghana that demanded on-the-spot payment of money before a hospital would administer treatment. The phrase essentially means ‘‘cash before care.’’ The system was the brainchild of the International Monetary Fund (IMF) and the World Bank economic recovery program. It existed We are grateful to Chance Minnett Watchel, Dorah Conteh, Tobey Berriault, and the anonymous reviewers for their useful comments and edits on the earlier draft of this manuscript. A previous version of this article was presented at the Prairie Political Science Association at Kinnear Center, Banff, Alberta, Canada, September 13–15, 2013. Journal of Health Politics, Policy and Law, Vol. 40, No. 1, February 2015 DOI 10.1215/03616878-2854711  2015 by Duke University Press

196

Journal of Health Politics, Policy and Law

until 2003 when a change in government in the 2000 general election opened a political window for a shift to the NHIS. This singular event ignited enthusiasm and hope among the many poor Ghanaians denied access to health care because of the cash-and-carry system. Despite the enthusiasm, many Ghanaians wondered why it took over twenty years to end cash-and-carry health care. This article uses John W. Kingdon’s multiple streams framework (MSF) to explain how a window of opportunity opened for a successful policy change in Ghana’s health care system. The article contends that the change in government in the 2000 general election prepared the grounds for eventual policy change in 2003. The article also explains how a policy window opened at a time when Parliament had one month before recessing in July 2003. Finally, the article shows that Kwaku Afriyie’s coming into office as the minister of health in April 2003 was important to the realization of the NHIS. Afriyie, along with then finance minister Yaw Osafo-Marfo, acted as a policy entrepreneur and was ultimately responsible for the coupling of Kingdon’s problem, policy, and politics streams, thus allowing for the eventual policy change from cashand-carry to the NHIS. The article employs a Type I case study approach. According to John Gerring (2004: 343), ‘‘Type I case studies examine variation in a single unit over time, thus preserving the primary unit of analysis.’’ This type of case study fits the research objectives of this article, which analyzes the politics of Ghana’s health reforms from the 1970s to 2003. The reason for this time frame is that hospital user fees were introduced in the 1970s and the NHIS was adopted in 2003. Thus examining this policy development beyond 2003 would fundamentally alter the basic question that shapes this research. Moreover, the article examines two different governments over time, thereby making the choice of a Type I case study appropriate. The article begins with historical background on Ghana’s health care policy from 1957 to 2003. The article then conceptualizes the MSF as a theoretical construct to understanding how the problem, politics, and policy streams converged to allow a policy change that favored a nationwide health insurance system. An analysis then follows of the political evolution of health policy in Ghana based on the interactions of the three streams (Kingdon 1995; Zahariadis 2007). This analysis builds on the earlier works of Irene Akua Agyepong and Sam Adjei (2008) and Giovanni Carbone (2011) on the historical and political factors that enabled health policy change in Ghana. However, the use of Kingdon’s MSF provides a richer analysis of the processes that allowed health policy change in Ghana.

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

197

This article provides a detailed empirical analysis of how the problem, politics, and policy streams converged for Ghana’s NHIS to be passed into law in 2003. Therefore, this article contributes to the relative dearth of empirical research on social policies in Ghana by providing a robust analytical explanation of the complexities of health policy making in Ghana. Trends in Ghana’s Health Policy since Independence

The euphoria that followed Ghana’s independence in 1957 brought hope to the newly independent state. The country pursued rigorous policies and programs aimed at diversifying the economy via import substitution industrialization (Boafo-Arthur 1999). Before independence, the colonial administration instituted a health care system that demanded out-of-pocket payment of fees at the point-of-service (Arhinful 2003; Carbone 2011). However, after independence, the government of Ghana abolished the existing user-fee charges in all public hospitals. As such, from 1957 to 1969, Ghanaians enjoyed free universal health care (Agyepong and Adjei 2008; Nyonator and Kutzin 1999; Carbone 2011). This policy initiative was partly due to the socialist ideas of President Kwame Nkrumah’s government. During this time, more emphasis was placed on preventive health care as compared with a ‘‘hospital-based curative’’ health system (Carbone 2011: 388). However, the military overthrow of Nkrumah’s government in 1966 changed the social policy direction of Ghana. In 1969, for the first time since independence, hospital fees were introduced with the enactment of the Hospital Fees Decree of 1969, which was later amended to the Hospital Fees Act of 1971 (Nyonator and Kutzin 1999; Carbone 2011). Despite the introduction of user fees in 1969 and 1971, the government heavily subsidized the cost of health care (Nyonator and Kutzin 1999; Agyepong and Adjei 2008). In 1983, following the adoption of the structural adjustment program, Ghana’s health care financing changed considerably. The new managerial reform program, which became known as the new public management, changed the dynamics of government spending on Ghana’s health care. The new public management reform was aimed at achieving efficiency and effectiveness in service delivery through the adoption of policies that were well tested in the open market (Hood 1991; Moore, Stewart, and Hudock 1994). As a result, the Provisional National Defense Council (PNDC) government passed into law the Hospital Fee Regulations Act

198

Journal of Health Politics, Policy and Law

Table 1

Key Developments in Ghana’s Health Policy Policy

Main Features

Financing

1957

UK-type national health service

General revenues

1969–71

Hospital Fees Decree/Act

1985

Hospital fees regulation

1992

Drugs revolving fund (cashand-carry)

1996

Medium Term Health Strategy

2003

National Health Insurance Act

Creation and expansion of territorial health services Universal coverage Free provision Containment of health care costs Cost recovery (minimal) De facto free provision Cost recovery (substantial: partial to full) Decentralization: health facilities retain 25%–50% of fees charged to patients Exemptions (not implemented) Full cost recovery for drugs Decentralization: 100% of fees retained by health facilities Exemptions (not implemented) Sector-wide planning Aligning national policy and partners’ agendas Harmonizing donors’ procedures Health fund at the MOHa for pooling donors’ resources Health insurance (mandatory) Universal coverage (within five years) Decentralized, district-based mutual schemes plus private (commercial or mutual) schemes Minimum benefits package Exemptions

General revenues User fees (low) General revenues User fees (substantial)

General revenues User fees (substantial) General revenues User fees (substantial) Donors General revenues Premiums (graduated) Sales levy Social security contributions Donors General revenues User fees (for the uninsured)

Source: Giovanni Carbone, ‘‘Democratic Demands and Social Policies: The Politics of Health Reform in Ghana,’’ Journal of Modern African Studies 49, no. 3 (2011): 394.  2011 Cambridge University Press. Reprinted with the permission of Cambridge University Press. a MOH = Ministry of Health. It is headed by a minister appointed by the president.

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

199

(1985 (L.I.1313)) (Carbone 2011).1 This law was aimed at charging user fees for health care in all public hospitals. The law specified that fees be charged for consultations and for surgical, laboratory, and other diagnostic procedures. Also, dental services and hospital accommodation attracted user fees (Asenso-Okyere et al. 1997; Larbi 1999; Nyonator and Kutzin 1999; Agyepong and Adjei 2008). The aim of the 1985 hospital user fees was to recover not less than 15 percent of the government’s recurrent expenditure (Agyepong and Adjei 2008). This system of health care financing (i.e., cash-and-carry) existed until 2003 when the Parliament of Ghana passed the NHIS into law. Table 1 summarizes this policy transformation. Theoretical Approach: John Kingdon’s Multiples Streams Framework

The MSF is particularly useful in understanding the complexities of policy making and is equally useful in explaining why some policy initiatives are able to catch the attention of policy makers and eventually become policy while others fizzle out. The MSF pays particular attention to three streams: problem, politics, and policy. According to Kingdon (1995), the coupling of the three streams allows a policy window to open for a policy change to occur. The strength of the MSF is that policy making is not a linear process but an interaction of three independent streams with different logics and dynamics (see fig. 1). Therefore, in a complex society like Ghana, policy change and agenda setting demand a wide array of considerations and consultations. Nonetheless, Kingdon (1995) argues that in attempting to understand why some policy initiatives get the attention of policy makers while other policy initiatives die prematurely, one always encounters some element of chance. For example, in the case of Ghana, the change in government in the 2000 general election made national health insurance a reality because the new government, having campaigned with a message of health reform, made changing health policy a political priority on forming the new government in January 2001. Similarly, in the case of Canada, a combination of several factors, such as a government fiscal crisis, a new government with a health reform agenda and a clear vision for reform, and a political champion for reform, have been key to effecting health policy change (Lazar et al. 2013). 1. The PNDC took power through a military coup on December 31, 1981, from the then democratically elected government. The leader of the PNDC, J. J. Rawlings, later metamorphosed into a civilian to lead the government in 1992 under the National Democratic Congress (NDC). Rawlings governed Ghana for nineteen years, eleven years as a military ruler and eight years as a civilian head of state.

200

Journal of Health Politics, Policy and Law

Figure 1 John W. Kingdon’s Multiple Streams Framework Source: Copyright 2003 by Georgetown University Press. Ambiguity and Choice in Public Policy: Political Decision Making in Modern Democracies, Nikolaos Zahariadis, p. 153. Reprinted with permission. www.press.georgetown.edu

The problem stream of Kingdon’s framework consists of issues identified and recognized by citizens and policy makers as problems. These include issues such as inflation, carbon emissions, environmental degradation, piracy, armed robbery, motor accidents, drug abuse, teenage pregnancy, HIV, and rising medical and health care costs (Zahariadis 2007). To identify a situation as a problem, policy makers use indicators, focusing events, and feedback to ascertain whether a situation merits attention (Zahariadis 2007). In many situations, dramatic events like crises tend to get the attention of society and policy makers (Parsons 1995: 193; Lester and Stewart 2003: 76). As described by Kingdon (1995: 110), problem identification contains a ‘‘perceptible interpretive element.’’ Problem definition in the policy process is therefore based on people’s values and beliefs (Zahariadis 1996, 2003, 2007). In accordance with Nikolaos Zahariadis’s arguments (2007: 71), people describe situations as problems by ‘‘letting their values and beliefs guide their decisions, . . . by comparing current to past performance, and by comparing conditions in different countries.’’

2.5% of SSNIT

2.5% VAT

Premiums

Taxation

Premiums

Nationwide health insurance system Not in favor of 2.5% of SSNIT

Trade Union Congress (TUC)

Not in favor of 2.5% from SSNIT

Not in favor of 2.5% VAT

Opposition Political Party (National Democratic Congress) Community mutual health insurance scheme Taxation

Notes: SSNIT = Social Security and National Insurance Trust; VAT = value-added tax

Source of Finance

Nationwide health insurance system Taxation

Government

Interest Groups and Policy Options

Summary of Interest Groups and Policy Options

Policy Options

Table 2

Direct or out-ofpocket payment

Private nongroup (individual market)

Private insurance companies Employer-sponsored insurance

Private Insurance Companies

International Organizations (USAID) District/community health insurance Taxation Premiums

202

Journal of Health Politics, Policy and Law

The politics stream consists of three elements: the national mood, pressure group campaigns, and administrative or legislative turnover. Ideas and solutions that combine all three elements tend to get the attention of policy makers (Zahariadis 2007). The national mood of a country is determined when a sizable portion of a country’s population shares the same set of convictions on a particular issue. Depending on the circumstances of the issue, this mood changes from time to time. Governments monitor the national mood through opinion polls and surveys (Zahariadis 2007). Pressure groups and labor unions assume enormous influence in the politics stream. Pressure group resistance to a policy can swing the national mood. According to Zahariadis (2007), governments use the support or opposition from pressure groups as an indicator of consensus or dissent to a particular policy. In the case of Ghana, the most vociferous pressure group resistance throughout the debate on Ghana’s national health insurance policy was from the Trade Union Congress (TUC).2 In addition, legislative turnovers have a great impact on the development or otherwise of a policy. Zahariadis (2007) in his explanation of legislative turnovers reiterates that administrative turnovers, like a sudden influx of new congresspeople with differing ideological orientations, can change the course of a policy. Moreover, certain policies may receive attention based on the political manifesto and the electoral promises made by a government. Suffice it to say that in the politics stream, the combination of national mood and turnover of governments exerts the most powerful influence on agenda setting (Zahariadis 2007). This stage of incisive solutions is referred to as the ‘‘policy stream.’’ In the words of Zahariadis (2007: 72), the policy stream includes a ‘‘soup of ideas’’ that competes for acceptance in the policy process. At this stage, varied policy brokers like bureaucrats, congressional staff, interest groups, policy analysts and other stakeholders may provide inputs for a solution. The sharing of ideas at this stage does not mean that all ideas will be accepted as solutions. Thus some ideas will combine with others into a new proposal, while others fade out, and some remain part of the policy process. The acceptance or otherwise of an idea will depend on value acceptability, technical feasibility, budgetary constraints, and future ramifications of the idea (Parsons 1995: 193; Lester and Stewart 2003: 76; Zahariadis 2007). However, solutions that suit the political and sociocultural setting of the country have a higher degree of survival. A policy is formed or an agenda is set when the three independent streams interact for a window of opportunity to open. Kingdon (1995: 165) 2. The TUC is a civil society group that promotes the interest of labor in Ghana.

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

203

refers to this opening as a ‘‘policy window’’ and defines it as a fleeting ‘‘opportunity for advocates of proposals to push their pet solutions, or to push attention to their special problems.’’ The success or failure of this stage in the policy process is dependent on a policy entrepreneur. A policy window is opened when certain unforeseen events (e.g., an airplane crash) or certain disruptions in the politics stream (e.g., a change in government) occur. This period is crucial in the policy process. Kingdon likened it to a launch window in a ‘‘space flight mission’’ (Parsons 1995: 194). Thus once ‘‘the window is lost, then the launch has to wait for another time when conditions and alignments are appropriate’’ (Parsons 1995: 194). For that reason, policy entrepreneurs are needed to effectively match solutions to problems once the policy window is opened. Policy entrepreneurs are those individuals or corporate actors who seize an opportunity to effect policy change before the opportunity is lost (Zahariadis 2007). The role of policy entrepreneurs in the policy process goes beyond mere advocacy; indeed, they are power brokers in the policy process. Policy entrepreneurs are therefore seen as those individuals with the resources and skills for ‘‘coupling’’ and manipulation. They have the skills to put together complicated problems and solutions in ways that appeal to the political arena. However, not all policy entrepreneurs are successful in this regard; the most successful are those with greater access to policy makers (Zahariadis 2007). Also, policy entrepreneurs with well-developed strategies and resources, especially those who are ready to employ manipulative tools, stand the best chance of effecting policy change. Having discussed Kingdon’s theoretical framework, we present in the following section an explanatory analysis of how political actors interacted to achieve health policy change in Ghana. Ghana’s National Health Insurance Scheme: Multiple Streams of Change

In August 2003, the Parliament of Ghana passed the NHIS into law. In the run-up to the adoption of the NHIS, some Ghanaians were skeptical about the proposed policy; some viewed the cash-and-carry system as an IMF– World Bank construction and therefore not amenable to change. Again, some Ghanaians viewed the national health insurance proposal as mere political rhetoric, because the ideology of the new government, that is, the New Patriotic Party (NPP), favored market-driven policies.3 Contrary to 3. The NPP was the main opposition party during the 2000 general election. It formed a government after winning that election. In 2003 the NPP introduced the NHIS.

204

Journal of Health Politics, Policy and Law

the conservative-leaning center-right political philosophy of the NPP, the new government viewed a national insurance scheme as a necessary condition to reassert local control over health care and, it hoped, fix the problems created by this externally driven policy. The opposition National Democratic Congress (NDC) was also against the timing of the proposed national insurance bill.4 Some civil society groups, especially, the TUC and other labor organizations, opposed some aspects of the proposed policy. Nonetheless, in August 2003, the NHIS was passed into law amid resistance from the NDC and the TUC. The Problem Stream

Several factors emerged that defined the cash-and-carry system as a problem the government needed to address. First, cash-and-carry was the brainchild of the IMF and World Bank’s structural adjustment and economic recovery programs (Larbi 1999). As an austerity measure, cash-andcarry unleashed serious consequences for Ghanaians. In less than three years after its implementation, cash-and-carry had worsened health care delivery in Ghana. By the end of 1989, for example, Ghana recorded an infant mortality rate of 86 per 1,000 live births (Singleton 2006). Second, in 1992 Ghana restored multiparty democracy; the then military government founded a political party, the NDC. The party contested the 1992 general election and won a landslide victory. The transition from military rule to democratic rule offered most Ghanaians the freedom and the confidence to openly express their concerns over cash-and-carry. During this time, the media assumed a tremendous role in reporting this frustration with cash-and-carry (Ofori-Birikorang 2009). The opposition NPP and some social commentators used the media to chastise the government for killing Ghanaians slowly with the cash-and-carry system of health care. In reporting the problems of cash-and-carry, the media repeatedly conveyed emotionally charged news (Ofori-Birikorang 2009). For example, a tomato seller at Makola market recounted her ordeal with cash-and-carry, stating: ‘‘My son was bitten by a snake and was taken to the hospital by 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’’ 4. The NDC went into opposition from 2001 to 2009. It was the main opposition party during the passage of the NHIS. Currently, the NDC is the government in power.

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

205

(AllAfrica.com 2006).5 Stories of this nature were frequently reported in the news, and Ghanaians became increasingly aware of the problems of the cash-and-carry system.6 In 1997 a worker at the Ghana Broadcasting Corporation (GBC), Frank Aidam, used the opportunity after his daily announcement to talk about the problems of cash-and-carry.7 His statement was the first time a statebroadcasting worker had publicly spoken on state radio against government policy (Brande 1997). Although Aidam was not dismissed, he was banned from reporting live on air. This action by the government ignited anger and emotions and resulted in spontaneous public debates across the country. As a result, the Parliament of Ghana decided to deliberate on cashand-carry (Brande 1997). Around this time, it became clear that Ghana’s health care system was in crisis, yet the political commitment to effect policy change was lacking, partly because cash-and-carry was a product of the IMF and World Bank’s structural adjustment program. In an article titled ‘‘Kill or Cure: Ghana Is Faithfully Following IMF Prescriptions, but Its Health Service Has Fallen Sick as a Result,’’ published in the magazine the New Internationalist (Brande 1997), a medical officer was quoted as saying the following about cash-and-carry: ‘‘The system is stinking and dehumanizing. . . . Patients who do not have the ability to pay for medical service are turned away from hospitals only to die at home. The poor, the disabled and accident victims are being asked to pay on the spot before getting medical attention. This system has no human face. Our health service is in confusion.’’ Third, in the midst of this growing crisis, the problem of cash-and-carry was exacerbated by the exploitative behavior of some health officials. These officials directed patients to buy drugs and have their laboratory examinations performed at specifically designated places in town because they owned most of the drugstores and laboratories or they had affiliations with their owners. Under these circumstances, overprescribing developed to maximize pharmaceutical sales (Asenso-Okyere et al. 1999: 588). Fourth, Ghanaian beliefs and values contributed to the government’s decision to do away with cash-and-carry. The traditional Ghanaian family has a central mutual fund to which family members contribute periodically 5. Makola market is the largest and most populous market in Accra, Ghana. 6. In a related development, the August 30, 2006, edition of the Statesman published an editorial against cash-and-carry. The newspaper minced no words when it stated: ‘‘The cruel cash and carry has turned Ghana’s hospitals into typical death chambers that [bear] the mark of Adolf Hitler’’ (quoted in Ofori-Birikorang 2009: 17). 7. A state-managed broadcast company, GBC is financed by the Ghanaian taxpayer. Its television station is still the only one in Ghana with nationwide coverage. Until 1997, it was the only television company in Ghana.

206

Journal of Health Politics, Policy and Law

to prepare for unforeseen contingencies. Called susu in local Ghanaian parlance, the traditional fund covers expenditures for marriages, funerals, and childbirth. Thus the cash-and-carry system of health care was inconsistent with the sociocultural and traditional practices of Ghanaians. That cash-and-carry failed to succeed as public policy is therefore not surprising. Fifth, in 1992 Nkoranza, a small rural town in the Brong-Ahafo region of Ghana, developed a district health insurance scheme for its community, which was made up predominately of farmers. The initiative, started by the St. Theresa’s Catholic Mission Hospital, proved successful and endured the test of time (Atim and Sock 2000). The Nkoranza mutual health insurance scheme became the trailblazer for Ghanaians clamoring for a national health insurance policy. As such, it became the model many Ghanaians used to justify the call for a national health insurance policy. With pressure mounting for health reforms, the government, in the mid-1990s, created a unit within the Ministry of Health to oversee the implementation of a pilot feasibility program in community-based health insurance schemes in the eastern region of Ghana. By 1999 this pilot project had died without any official explanation (Agyepong and Adjei 2008: 154). Sixth, Ghana’s international development partners like the Danish International Development Agency (DANIDA), the United States Agency for International Development (USAID), and the United Nations International Children’s Emergency Fund (UNICEF) became aware of the problem of cash-and-carry. For example, in 1993 UNICEF funded a feasibility research project in community-based mutual health insurance in the Dangme West District of Ghana (Arhin 1995). By February 2002, the problem stream was highly activated. For the first time, the World Bank and the IMF openly accepted that cash-and-carry had failed to achieve the needed results. They urged the Ghanaian government to confront the health care problems with all seriousness. The commitment to reform cash-andcarry was shown in Ghana’s Poverty Reduction Strategy (GPRS), which was prepared by the government of Ghana in consultation with the World Bank and the IMF (IMF 2002; Singleton 2006). The midterm goal of the GPRS program was to replace the cash-and-carry system of health care (National Development Planning Commission 2004: 21). Because of these developments, the problem stream became highly active; the IMF and the World Bank had called for urgent health care reforms. Seventh, public opinion was in favor of policy change because Ghanaians identified a nationwide health insurance system as consistent with their socioeconomic and communal life. The research of W. Kwadwo AsensoOkyere and colleagues (1997) revealed that 90 percent of participants

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

207

sampled in three districts of eastern Ghana agreed to participate in a nationwide health insurance system if established by the government. The trade unions had expressed great interest for policy change. A general consensus was that cash-and-carry was a problem. The then opposition NPP (1996) described the cash-and-carry health care policy as callous, inhumane, and a health care crisis. In sum, both international and domestic actors recognized that the cash-and-carry system of health care was problematic, ineffective, discriminatory, and inconsistent with the socioeconomic realities of Ghana. The Politics Stream

In January 2001, history was made in Ghana. For the first time in the postindependence period, a democratically elected government handed over power to another democratically elected government. The new government, led by John Agyekum Kufuor, enjoyed popular support in six out of ten regions of Ghana, according to the 2000 election results (Electoral Commission of Ghana 2000). The new government also commanded a clear majority in Parliament. This shift in power had a tremendous effect on the policies and programs of the previous administration. The new government had a strong commitment to health care reform.8 The NPP (1996: 36) had promised in a manifesto that it would abolish the ‘‘callous and inhuman’’ system of cash-and-carry after taking office. On capturing political power, the NPP was mindful of its promise, fully aware of the dire consequence if it failed to abolish cash-and-carry before the 2004 general election; it thereby made comprehensive health care reforms a priority of the government. Nationwide support for the NHIS was not in doubt. The media gave generous support to a nationwide health insurance system. Influential newspapers like the Graphic, the Ghanaian Times, the Chronicle, and the Guide were still revealing the horrors of cash-and-carry. The media portrayed people who opposed the NHIS as antiprogress, selfish, and greedy. The government intensified its campaign on TV and radio to galvanize support for the health insurance bill. The campaign resurrected widespread support for a nationwide health insurance system. On September 16, 2003, the TUC held a press conference to protest the government’s deliberate attempt to turn the public against it. The head of the TUC’s education department, David Dorkenoo, said that it was ‘‘wrong to vilify the TUC and allied labour unions when all they were doing was to 8. For a similar pattern of health policy change in Alberta, Canada, see Lazar et al. 2013.

208

Journal of Health Politics, Policy and Law

ensure a health insurance scheme that would not jeopardise the interest of workers’’ (Modern Ghana 2003a). At this point, the national mood was in favor of a nationwide health insurance system. The government had succeeded in branding the TUC as antiprogress. Some groups within the TUC threatened secession, thereby weakening the labor front. Meanwhile, the civil service association branch in the Ashanti region had converted its civil service medical fund schemes into a mutual health fund in compliance with a government directive (Agyepong and Adjei 2008). Signs were visible that the NHIS was not far from reach. In April 2003, the president reshuffled his cabinet; the minister of health, who had started the health insurance process, was moved to another ministry (GhanaWeb 2003a). While in most cases one would have expected the reshuffle to delay the policy-making process, in this instance it speeded the process. Apart from the new appointee’s special expertise as a medical doctor and a health policy analyst, he was also a trusted political ally of the president. The arrival of Afriyie as the new minister was important to the realization of the health insurance scheme. He brought his special expertise and international connections to bear on the policy-making process.9 The new minister reconstituted the Joint Parliamentary Committee on Health and Finance, which visited all ten regions in Ghana to solicit fresh ideas and input from the public. The parliamentary joint committee had fortyfour proposals for amendments to the bill, out of which thirty were adopted. According to the minister, the aim was to allow grassroots participation in the policy process (Agyepong and Adjei 2008). The appointment of the new minster was indeed timely, as he brought a wide range of experience to the debate. He worked closely with then minister of finance Osafo-Marfo, who was a banker and financial analyst. Together these men were determined to ensure the passage of the bill into law. All this activity foreshadowed an opportunity for policy change. Signals of imminent policy reforms were noticeable. Kingdon’s three streams were converging for eventual policy change. Nonetheless, the opposition NDC intensified resistance to the bill and called on its parliamentary caucus to vote against the legislation (Rajkotia 2007). Despite the opposition’s resistance, the problem stream identified cash-and-carry as harmful. The government and policy makers proposed an alternative policy to replace cash-and-carry. The government was politically determined to use all legitimate means to reform the health care system. 9. For an analysis of how a change in minister triggered health policy change in the Canadian context, see Lazar et al. 2013.

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

209

In sum, the politics stream was very active, and the political elites of the ruling NPP were determined to fulfill their manifesto promise to the people of Ghana. At the same time, they had a majority in Parliament to ensure smooth passage of the NHIS. The government knew that the 2004 election was just around the corner and that Ghanaians would punish it if it failed to deliver on its political promise. The NPP was also committed to a popular policy change that would distinguish it from the opposition NDC. In addition, Ghana’s development partners supported such a move, as the IMF and the World Bank had given full political and economic backing to the reform program. The Policy Stream

Initially, policy makers were sharply divided on an alternative to cash-andcarry. Three main solutions competed for acceptance in the ‘‘primeval soup of ideas’’ (Zahariadis 2007: 72). Some policy makers argued for a comprehensive national health insurance scheme (the then NPP government and the TUC), while others argued for a community-based health insurance scheme (the opposition NDC). Another group of policy makers preferred a privately managed health insurance scheme (the private insurance companies). In line with Kingdon’s MSF, these three proposals were competing for acceptance. According to Kingdon (1995), the survival of policy solutions at this level depends on value acceptability, technical and budgetary feasibility, and future viability. Each of these considerations played a role in the final policy choice in Ghana. Policy makers (the government), interest groups (trade unions and the Association of Private Insurance Companies), and the main opposition party (the NDC) were highly divided on a policy alternative to cash-andcarry. The government of Ghana proposed comprehensive national health insurance schemes for the country. The source of finance was through the collection of individual premiums of US$8–$10 per annum; a 2.5 percent value-added tax on all commercial transactions, called the National Health Insurance Levy; and, finally, 2.5 percent of ‘‘formal sector workers’ contributions towards retirement benefits, taking from the Social Security and National Insurance Trust [SSNIT]’’ (Agyepong and Adjei 2008: 156; Carbone 2011: 393).10 Of all these potential sources of finance, the health levy amounted to 70–75 percent of NHIS funding, while SSNIT 10. The SSNIT is a trust fund for workers’retirement and pension benefits. Workers contribute monthly to the fund to their pension age.

210

Journal of Health Politics, Policy and Law

contributions and premium collections amounted to 20–25 percent and 5 percent, respectively (Carbone 2011). To this end, the funding arrangement combined features of a tax-based health insurance system with a social health insurance scheme (Carbone 2011). In contrast, international organizations like the USAID favored a decentralized, district-based health insurance scheme (Rajkotia 2007). Its consultancy agency had conducted research into district mutual health organizations in Ghana and was therefore convinced that a district-based health insurance scheme was the answer to Ghana’s health care problems (Singleton 2006). In 2001 the USAID-funded agency in Ghana undertook a survey of the country’s health financing schemes. Its final report to the government concluded the following: ‘‘While they [the district mutual health organizations] are not a panacea for resolving health care financing and delivery issues, many of their limitations—small size, limited benefits, and inability to cover all segments of the population, especially the poorest—can be overcome with appropriate design and management’’ (quoted in Singleton 2006: 25). Similarly, the opposition NDC also proposed a highly decentralized community health insurance scheme. Some individuals also wanted the government to stay out of the economy and allow private insurance operators to run the health insurance scheme. The most vociferous proponent was Kwaku Sintim Misah (popularly known in Ghana as KSM). Well respected and popular among Ghanaians, he used his influence as a standup comedian, social commentator, scriptwriter, and career counselor to argue against the proposed nationwide health insurance system (GhanaWeb 2003b). However, the TUC and other labor groups agreed with the ruling government on the proposed NHIS but resisted the proposal to use 2.5 percent of formal-sector workers’ contributions to SSNIT to finance the insurance scheme. The TUC, led by Kwasi Adu Amankwa, threatened court action against the government if it acted on its proposal to deduct 2.5 percent of workers’ contributions to SSNIT. According to the TUC, SSNIT contributions are for workers and not for the government. Again, the TUC argued that the deductions would affect the long-term viability of the fund and pension payments (Agyepong and Adjei 2008: 156). In a related development, the director of SSNIT came out with actuarial studies showing that a 2.5 percent deduction from SSNIT would reduce its lifespan from fifty to twenty-five years (GhanaWeb 2003b). This statement by the SSNIT raised a lot of questions on the future of the national insurance scheme and the SSNIT fund for workers. The public became alarmed;

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

211

public opinion started swinging against the government’s alternative policy solution to cash-and-carry. Thus technical feasibility was an important determinant of policy acceptability in the policy stream.11 During this period, the policy stream was much divided among the TUC, the NDC, and the government. A lot of ideas and solutions were floating in and around the primeval soup. At this stage, the challenge of how to harness all these solutions and ideas was a Herculean task in the policy process. Nonetheless, as suggested by Zahariadis (2007), some ideas combined into a new proposal, others fizzled out, and some remained part of the policy. In this respect, the government agreed to incorporate the proposal of the district mutual health insurance scheme into the national health insurance proposal. This decision was agreed on because Ghana had an already existing local governance structure, and a decentralized-based health care system was administratively prudent and feasible. However, after its proposal was incorporated into the overall NHIS, the opposition NDC still joined the TUC in opposing the financial aspect of the proposed policy. Many Ghanaians and the government ignored the proposal for a private managed health insurance scheme. The government stated that private insurance companies in Ghana lacked the capacity to insure over 20 million Ghanaians. It also argued that premiums from private insurance companies were beyond the means of many Ghanaians. Therefore, the private insurance proposal was deemed inconsistent with Ghana’s socioeconomic realities. According to Yogesh Rajkotia (2007: 5), the government gave the existing private mutual health funds the option to join the NHIS in their respective districts or pay US$600,000 to remain private. This move forced some private health insurance schemes to join the NHIS or collapse. Nonetheless, the policy stream remained divided on the source of financing the proposed NHIS, although not on the structure or form of the scheme. The TUC had intensified its opposition against the use of the proposed 2.5 percent of SSNIT contributions to finance the NHIS. According to the TUC, SSNIT funds belong only to workers, who invariably already enjoy health care in their respective workplaces. Again, the TUC asserted that over a long period, the deduction would compromise the solvency of the SSNIT (GhanaWeb 2003c). The government vehemently opposed this assertion, insisting that workers’ future pension plans would not be affected by the 2.5 percent deductions from their SSNIT contributions. 11. For an understanding of the role of technical feasibility, see Zahariadis 2007 and Lazar et al. 2013.

212

Journal of Health Politics, Policy and Law

At this point, the situation looked to be stalemated. The TUC and the main opposition party were bent on resisting the government’s proposed funding of the NHIS. However, ‘‘value congruence,’’ as explained by Kingdon (1995), favored the use of 2.5 percent of SSNIT funds.12 Although the TUC had a legitimate concern, the government emphasized that the overall national interest and the future viability of the health insurance scheme required a solid financial base; hence it argued for the need to use 2.5 percent of SSNIT funds. In August 2003, President Kufuor invited the leadership of the TUC to Osu Castle, then the seat of government in Ghana (Modern Ghana 2003b). In his speech, the president appealed to the trade unions to consider the majority of rural Ghanaians whose sweat and toil in the agricultural sector had brought Ghana this far. This moral appeal became the talk of the nation. Some Ghanaians started criticizing the trade union position. Some social commentators went to the extent of referring to the TUC as greedy, unpatriotic, and self-centered. In August 2003, the government of Ghana announced a new deal for the TUC. The government agreed that as a benefit for using 2.5 percent of SSNIT funds, affected workers would not pay the mandatory yearly premium (Agyepong and Adjei 2008: 156). This announcement divided the ranks of the TUC; some members within the labor front were satisfied with the new deal, while others were not. The policy alternative to cash-andcarry became clear to all actors in the policy stream. They had all agreed on a nationwide health insurance system, but the means of financing the scheme were being contested by both the opposition NDC and the TUC. The government and other actors in the policy stream rejected the idea of a private health insurance scheme. Policy Window

Kingdon (1995: 165) refers to the convergence of the three streams as a policy window for power brokers to effect policy change and describes it as a fleeting opportunity. Indeed, Ghana’s policy window opened at a critical time when Parliament had one month before recess. The government’s special task force feared that the national mood and public support would diminish if it did not act before Parliament recessed. As such, the minister 12. Value congruence is where the policy in question reflects certain constructs widely held among actors in the policy community as important and generally beneficial. For example, policies that capture the principles of efficiency, equity, and effectiveness are likely to achieve large appeal among actors in the policy community. For a more practical explanation, see Abiola, Colgrove, and Mello 2013: 647.

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

213

of health directed the special task force to ensure that the bill was sent to Parliament before its July 2003 recess. Prior to this period, Afriyie, the new minster of health, had disbursed the Heavily Indebted Poor Countries (HIPC) fund to the various district assemblies to build the infrastructure for the proposed NHIS.13 The minister was confident that his party had a comfortable majority in the House to ensure a smooth passage of the bill (Agyepong and Adjei 2008). At this fleeting moment, the special task force had no time to wait. In July 2003, one week before Parliament went on recess, the task force, led by the health minister, the finance minister, and their respective technocrats, pushed the final version of the NHIS before Parliament under a ‘‘certificate of urgency’’ (Agyepong and Adjei 2008).14 All indicators pointed to a policy window at a critical moment one week prior to parliamentary recess because the government’s special task force had prepared the first draft of the NHIS for legislative approval. By this time, the three streams had converged, despite opposition and the TUC’s resistance. This convergence occurred because the problem stream was clear that cash-and-carry was inconsistent with the socioeconomic realities of Ghana. In the policy stream, policy makers had accepted the proposal of having a nationwide health insurance system that would be administered by individual districts in Ghana but financed by the national government through the national health insurance authority. The politics stream was active because the new government made national health insurance a top priority. Resistance to the national health insurance policy from the trade union and from official opposition revolved around how the proposed health insurance scheme would be financed and not the principle of national health insurance. The opposition NDC threatened to boycott parliamentary discussions because the government was determined to use its majority advantage in the House to push the bill into law. The TUC also intensified its opposition to the bill, staging demonstrations to register its concerns about the disparities in the bill, rather than the entire bill. The 13. In 1996 the IMF and the World Bank launched the HIPC initiative with the primary goal of providing debt-relief packages to countries that are overburdened with debt. Since the implementation of this initiative, the global financial community along with multilateral organizations and governments have worked together to relieve most poor countries of their debt. Not all poor countries with debt can access this initiative, however. Countries must meet the following criteria: (1) they must be eligible to borrow from the World Bank; (2) they must be facing a high debt burden that cannot be addressed by traditional debt-relief arrangements; (3) they must have a solid track record of reform and sound policies with IMF and the World Bank; and (4 ) they must demonstrate commitment to poverty reduction through the broad-based participatory development of a Poverty Reduction Strategy Paper, as defined by the IMF and World Bank (IMF 2014). 14. When a certificate of urgency is placed on a bill, it attracts priority attention from members of Parliament. The degree of responsiveness on such a bill is very high.

214

Journal of Health Politics, Policy and Law

TUC appealed to Parliament to defer the bill to allow for more deliberations and consultations. Parliament heeded its demands and deferred the bill to August 2003. Between July and August 2003, when Parliament was on recess, a lot of lobbying occurred in the policy process. At this time, the government needed persons of special talent and charisma to ensure that the national mood was sustained in favor of the NHIS. Led by the health minister (Afriyie) and the finance minister (Osafo-Marfo), the special task force was tasked by the president to ensure the passage of the bill by August 2003. These two politicians played a significant role as policy entrepreneurs in moving the policy proposal through the legislative process once a policy window appeared to be emerging. Although the role of the special task force can be likened to that of policy entrepreneurs, we are careful not to overemphasize the latter’s role in the policy-making process, since the NPP enjoyed a significant majority in Parliament to pass the policy into law. Moreover, since 1992, majority members of Parliament (MPs) have never missed important votes on any landmark issues. However, as Kingdon (1995) explains, the policy entrepreneurs coupled the three streams with their influence and resources. Their political strategy involved running prominent advertisements in the national dailies to rally national support for the policy. They directed all the information departments in all the regions of Ghana to advertise and educate Ghanaians on the NHIS. Quickly, the leadership of the TUC studied the proposed legislation and made a formal petition to Parliament (Agyepong and Adjei 2008). During the parliamentary break, the special task force conducted broad public consultations to confirm the proposed policy direction. Also, the special task force briefed members of the majority caucus in Parliament on the proposed legislation and strongly encouraged them to be present when the final bill was brought before the House for a vote.15 Of note here is that, since 1992, the majority in Parliament has not voted against any bill from the government. Therefore, all NPP MPs were expected to be present for voting. Parliament resumed sitting in August 2003. Immediately, the bill was placed before the House for consideration. Concerns expressed by the TUC and the opposition NDC could not sway the thinking of the overwhelming 15. As noted, since 1992, the majority in Parliament has never missed out on any landmark case; however, majority nonattendance is generally high in regular parliamentary proceedings, since some MPs double as ministers and thus may be busy with executive responsibilities. As such, chief whips from both sides of the House are responsible for making sure that MPs are present, especially for landmark cases, where every vote is needed.

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

215

ruling party majority. The bill was finally presented in the House for passage. Both the majority and minority sides of the House were full to capacity. During the parliamentary debate on the bill, the opposition NDC robustly opposed the bill and requested that the Speaker of Parliament, Peter Ala Adjetey, adjourn any further debate on the bill.16 The Speaker flatly rejected the opposition proposal and called for further debate on the bill. The debate degenerated into accusations and counteraccusations from both sides of the House. As a result, the opposition NDC walked out of Parliament and boycotted any further discussion on the bill. Despite the boycott, the majority moved forward to pass the bill into law (Agyepong and Adjei 2008). The bill became known as the National Health Insurance Act (Act 650) of 2003. When the news broke, the TUC embarked on a demonstration to register its displeasure over the law; however, the die was cast. Twenty years of cash-and-carry had been replaced with the NHIS (GhanaWeb 2003d). Conclusion

Following from Kingdon’s MSF of agenda setting, this article has demonstrated that the change from cash-and-carry to a nationwide health insurance system was made possible because a new government with a health reform agenda was elected in the 2000 general election (see Carbone 2011). As noted, the cash-and-carry health care policy was constructed by the IMF and the World Bank in the 1980s. Because of its long practice, cash-and-carry was seen by some Ghanaians as less amenable to change. Despite these impediments, the problem, policy, and politics streams favored health care reform. The article has shown that Kingdon’s problem, policy, and politics streams converged at a critical moment, creating a policy window when the Parliament of Ghana had one month remaining before recessing in July 2003. The problems of cash-and-carry were identified as being inconsistent with the socioeconomic reality of Ghana. The policy stream was transformed when the government incorporated the proposal of district health insurance plans into the overall national health insurance strategy. Nonetheless, the policy stream was highly divided on the source of financing the NHIS. In the politics stream, the government was resolute and highly committed to reforming the health sector. The main opposition party resisted the reform, but the government had the parliamentary majority to 16. Adjetey was the speaker of the Parliament of Ghana from 2001 to 2005.

216

Journal of Health Politics, Policy and Law

pass the bill into law. Several policy entrepreneurs played important roles in resolving the politics once a policy window had opened. Kingdon’s framework provides a useful lens through which to understand the underlying policy dynamics. Kingdon’s MSF has attracted more attention and application among scholars and policy practitioners in Western countries like the United Kingdom, Canada, Australia, the United States, and New Zealand (see, e.g., Lazar et al. 2013; Zahariadis 1996, 2004; Bakir 2003; Hyshka 2009; Howlett 1998; Bird 2010; Catalinac 2004; Blankenau 2001; Exworthy and Powell 2004; Elson 2004; Abiola, Colgrove, and Mello 2013). However, the successful application of Kingdon’s MSF to Ghana’s health policy signifies that it can also be applied to young democracies in Africa with implications for understanding similar policies that are resistant to change.

n

n

n

Owuraku Kusi-Ampofo is a second-year PhD student in political science (comparative politics) at the University of Alberta. He holds a master’s degree in political science (public policy) from Brock University. His research interests are in the areas of comparative health systems, tobacco control policy, global health structure, and international policy response to microbial threat. His doctoral research seeks to investigate and explain the ways that institutional properties, policy ideas, and material interest affect the processes through which tobacco control policies are made in three African countries: Kenya, South Africa, and Mauritius. John Church is associate professor in the Department of Political Science at the University of Alberta. His research interests revolve around the role of institutions, ideas, and interests in health care policy making. He has worked with international, national, provincial, and regional health agencies in the evaluation of health care reforms. Recently, he appeared as an expert witness before the Alberta Health Services Preferential Access Inquiry. He is the coeditor of and a contributing author to Paradigm Freeze: Why It Is So Hard to Reform Health-Care Policy in Canada (2013). Charles Conteh is associate professor in the Department of Political Science at Brock University. His research and teaching interests are in the areas of comparative public policy, public management, political economy, and governance. His current research focuses on governance structures and processes in complex and dynamic policy systems, particularly collaborative and strategic policy formulation and implementation. He currently investigates how local, regional, and national policy systems are reinventing themselves in the face of seismic global economic changes.

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

217

B. Timothy Heinmiller is associate professor in the Department of Political Science and the Environmental Sustainability Research Centre at Brock University, where he teaches public policy, public administration, environmental politics, and research methods. His research articles have been published in Politics and Policy, Canadian Journal of Political Science, Canadian Public Administration, and Governance. He is also a contributor to and (along with Mark Sproule-Jones and Carolyn Johns) coeditor of Canadian Water Politics: Conflicts and Institutions (2008).

References Abiola, Sara E., James Colgrove, and Michelle M. Mello. 2013. ‘‘The Politics of HPV Vaccination Policy Formation in the United States.’’ Journal of Health Politics, Policy and Law 38, no. 4: 645–81. Agyepong, Irene Akua, and Sam Adjei. 2008. ‘‘Public Social Policy Development and Implementation: A Case Study of the Ghana National Health Insurance Scheme.’’ Health Policy and Planning 23, no. 2: 150–60. AllAfrica.com. 2006. ‘‘Ghana: NHIS versus Cash and Carry.’’ September 22. allafrica .com/stories/200609250949.html. Arhin, Dyna Carol. 1995. Rural Health Insurance: A Viable Alternative to User Fees? A Review and Evidence from Three Countries. Public Health and Policy Departmental Publication No. 19. London: London School of Hygiene and Tropical Medicine. Arhinful, Daniel Kojo. 2003. ‘‘The Solidarity of Self-Interest: Social and Cultural Feasibility of Rural Health Insurance in Ghana.’’ PhD thesis, University of Amsterdam. Asenso-Okyere, W. Kwadwo, Isaac Osei-Akoto, Adote Anum, and Augustina Adukonu. 1999. ‘‘The Behaviour of Health Workers in an Era of Cost Sharing: Ghana’s Drug Cash and Carry System.’’ Tropical Medicine and International Health 4, no. 8: 586–93. Asenso-Okyere, W. Kwadwo, Isaac Osei-Akoto, Adote Anum, and Ernest N. Appiah. 1997. ‘‘Willingness to Pay for Health Insurance in a Developing Economy: A Pilot Study of the Informal Sector of Ghana Using Contingent Valuation.’’ Health Policy 42, no. 1: 223–37. Atim, Chris, and Madjiguene Sock. 2000. An External Evaluation of the Nkoranza Community Financing Health Insurance Scheme, Ghana. Technical Report No. 50. Bethesda, MD: Partnership for Health Reform Project, Abt Associates Inc. Bakir, Caner. 2003. ‘‘Who Needs a Review of the Financial System in Australia? The Case of the Wallis Inquiry.’’ Australian Journal of Political Science 38, no. 3: 511–34. Bird, Malcolm G. 2010. ‘‘Alberta’s and Ontario’s Liquor Boards: Why Such Divergent Outcomes?’’ Canadian Public Administration 54, no. 4: 509–30. Blankenau, Joe. 2001. ‘‘The Fate of National Health Insurance in Canada and the United States: A Multiple Streams Explanation.’’ Policy Studies Journal 29, no. 1: 38–55.

218

Journal of Health Politics, Policy and Law

Boafo-Arthur, Kwame. 1999. ‘‘Structural Adjustments Programs (SAPS) in Ghana: Interrogating NDC’s Implementation.’’ West Africa Review 1, no. 1: 1–25. Brande, Daniel M. 1997. ‘‘Kill or Cure: Ghana Is Faithfully Following IMF Prescription, but Its Health Service Has Fallen Sick as a Result.’’ Letter from Ghana. New Internationalist, January 5. newint.org/features/1997/01/05/ghana. Carbone, Giovanni. 2011. ‘‘Democratic Demands and Social Policies: The Politics of Health Reform in Ghana.’’ Journal of Modern African Studies 49, no. 3: 381–408. Catalinac, Amy L. 2004. ‘‘The Establishment and Subsequent Expansion of Waitangi Tribunal: The Politics of Agenda Setting.’’ Political Science 56, no. 1: 5–22. Electoral Commission of Ghana. 2000. ‘‘Constituency Analysis—First Run.’’ 2000 Election Results. www.ec.gov.gh/page.php?page=397§ion=51&typ=1. Elson, Peter R. 2004. ‘‘Advocacy and Third Way Politics: Canada and the United Kingdom.’’ Philanthropist 18, no. 3: 215–24. Exworthy, Mark, and Martin Powell. 2004. ‘‘Big Windows and Little Windows: Implementation in the ‘Congested State.’’’ Public Administration 82, no. 2: 263–81. Gerring, John. 2004. ‘‘What Is a Case Study and What Is It Good For?’’ American Political Science Review 98, no. 2: 341–54. GhanaWeb. 2003a. ‘‘Government Names New Cabinet.’’ April 1. www.ghanaweb .com/GhanaHomePage/NewsArchive/artikel.php?ID=34819. GhanaWeb. 2003b. ‘‘The National Health Insurance Scheme (NHIS), the Real Issues.’’ October 2. www.ghanaweb.com/GhanaHomePage/features/artikel.php?ID=44014. GhanaWeb. 2003c. ‘‘TUC, Civil Servants Kick against Insurance Bill.’’ July 16. mobile.ghanaweb.com/wap/article.php?ID=39364. GhanaWeb. 2003d. ‘‘Workers in Accra Demonstrate against SSNIT Deduction for NHIS.’’ September 24. www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel .php?ID=43552. Hood, Christopher. 1991. ‘‘A Public Management for All Seasons?’’ Public Administration 69, no. 1: 3–9. Howlett, Michael. 1998. ‘‘Predictable and Unpredictable Policy Windows: Institutions and Exogenous Correlates of Canadian Federal Agenda Setting.’’ Canadian Journal of Political Science 31, no. 3: 495–524. Hyshka, Elaine. 2009. ‘‘Turning Failure into Success: What Does the Case of Western Australia Tell Us about Canadian Cannabis Policy-Making?’’ Policy Studies 30, no. 5: 513–31. IMF (International Monetary Fund). 2002. ‘‘Poverty Reduction Strategy Papers: A Factsheet.’’ February. www.imf.org/external/np/exr/facts/prsp.htm. IMF (International Monetary Fund). 2014. ‘‘Debt Relief under the Heavily Indebted Poor Countries (HIPC) Initiative.’’ September 30. www.imf.org/external/np/exr /facts/hipc.htm. Kingdon, John W. 1995. Agendas, Alternatives, and Public Policies. 2nd ed. New York: HarperCollins. Larbi, George A. 1999. ‘‘The New Public Management Approach and Crisis States.’’ Discussion Paper No. 112. Geneva: United Nations Research Institute for Social Development.

Kusi-Ampofo et al.

-

Understanding Health Policy Making in Ghana

219

Lazar, Harvey, John N. Lavis, Pierre-Gerlier Forest, and John Church, eds. 2013. Paradigm Freeze: Why It Is So Hard to Reform Health-Care Policy in Canada. Kingston, ON: McGill-Queen’s University Press. Lester, James P., and Joseph Stewart Jr. 2003. Public Policy: An Evolutionary Approach. 2nd ed. Beijing: Renmin University Press. Modern Ghana. 2003a. ‘‘Govt Playing the Public against Organized Labour—TUC Official.’’ September 16. www.modernghana.com/news/41076/1/govt-playing-public -against-organized-labour-tuc-o.html. Modern Ghana. 2003b. ‘‘President Kufuor Confers with Organised Labour on NHIS.’’ September 19. www.modernghana.com/news/41304/1/president-kufuor-confers -with-organised-labour-on-.html. Moore, Mick, Sheelagh Stewart, and Ann Hudock. 1994. Institution Building as a Development Assistance Method: A Review of Literature and Ideas. Swedish International Development Authority (SIDA) Evaluation Report 13. Stockholm: SIDA. National Development Planning Commission (of Ghana). 2004. ‘‘Ghana Poverty Reduction Strategy: 2003 Annual Progress Report.’’ March. www.imf.org/external /pubs/ft/scr/2004/cr04207.pdf. NPP (New Patriotic Party). 1996. ‘‘The Manifesto: Development in Freedom, Agenda for Change.’’ September 20. img.modernghana.com/images/content/report_content /npp_manifesto.pdf. Nyonator, Frank, and Joseph Kutzin. 1999. ‘‘Health for Some? The Effects of User Fees in the Volta Region of Ghana.’’ Health Policy and Planning 14, no. 4: 329–41. Ofori-Birikorang, Andrews. 2009. ‘‘Promoting a New Health Policy in the Ghanaian Media: Newspaper Framing of the National Health Insurance Scheme from 2005–2007.’’ PhD diss., Ohio University. etd.ohiolink.edu/ap:10:0::NO:10:P10 _ACCESSION_NUM:ohiou1249077245. Parsons, Wayne. 1995. Public Policy: An Introduction to the Theory and Practice of Policy Analysis. Cheltenham, UK: Edward Elgar. Rajkotia, Yogesh. 2007. ‘‘The Political Development of the Ghanaian National Health Insurance System: Lessons in Health Governance.’’ Bethesda, MD: Health System 20/20 Project, Abt Associates. Singleton, Jennifer L. 2006. ‘‘Negotiating Change: An Analysis of the Origins of Ghana’s National Health Insurance Act.’’ Honors project, Macalester College, St. Paul, MN. digitalcommons.macalester.edu/soci_honors/4. Zahariadis, Nikolaos. 1996. ‘‘Selling British Rail: An Idea Whose Time Has Come?’’ Comparative Political Studies 29, no. 4: 400–422. Zahariadis, Nikolaos. 2003. Ambiguity and Choice in Public Policy: Political Decision Making in Modern Democracies. Washington, DC: Georgetown University Press. Zahariadis, Nikolaos. 2004. ‘‘European Markets and National Regulation: Conflict and Cooperation in British Competition Policy.’’ Journal of Public Policy 24, no. 1: 49–73. Zahariadis, Nikolaos. 2007. ‘‘The Multiple Streams Framework: Structure, Limitations, Prospects.’’ In Theories of the Policy Process, edited by Paul A. Sabatier, 65– 92. Boulder, CO: Westview.