• Agenda setting
Publications in relation to failed fee-for-service policy implementation and experience with social health insurance schemes provided good material to convince those who were evidence inclined. These were translated into policy briefs and flyers in simple language to bring attention and catalyse discussion among key stakeholders. There was a deliberate and systematic effort by the Committee members to engage think tanks and civil society organisations such as the Institute of Economic Affairs, the Ghana Medical Association and academic institutions to interrogate and debate the merits of an insurance scheme. The Health Partners Summit held twice in a year also became a convenient platform for keeping the agenda on the table. Between 1999 and 2002 the effect of user fees and health insurance featured on every health summit and was captured in the aid memoire of four of the summits as the preferred policy.
However, to get the health insurance to become a national agenda required more than academic evidence and aide memoirs. It had to be translated into the realities of the population lived experiences to which the political decision makers and legislators can relate. The technical experts turned to the media for support. Primarily, civil servants started exposing the media to the challenges of the sector. One of the reported issues within clinical practice was what became known as ‘medical prisoners’. These were in-patients who have been cured of their ailment but are being detained by health facilities until their debts were redeemed by relatives or philanthropists. The uncomfortable effect of these publications led to politicians asking questions about what could be done to resolve the issues.
As ministers turn to technical experts for advice, they pointed to health insurance as a way out and ‘sneaked’ them into speeches of ministers as an issue on the table to ameliorate the situation and held several discussions on radio and television. However, the debate on what form insurance should take was not without its own complications. The debates at the various forums and in the media sometimes polarised the issues along political lines and the facts got misrepresented particularly when non-technical persons within the media attempted to translate technical words into vernacular or local dialects. Some of the words simply could not be translated. For instance, it was difficult to precisely translate premium into a single word. Attempts to use imagery and figurative sentences sometimes complicated understanding and lent it to manipulation. There were also so many interests and complications to be negotiated of which constituency preservation was key.
• Constituency preservation
The pluralism of pilot models caused public opinion on the models proposed by the National Democratic Congress (NDC) to be so diverse that major political parties started issuing statements on the implementation of the scheme in order to preserve their constituencies. Each political party defined what their positions were while attacking the position of the other.
The major political parties engaged in a battle of the hearts and minds of the electorate. Each party attempted to represent itself as having something distinct from the other but not always with clarity. It however did not matter in so long as a certain noise was generated which attacked the other parties positions as unacceptable propositions. It was not clear what the National Democratic Congress (NDC) government that started the current phase proposal’s position was and it is still very difficult to date to articulate what its policy is on health insurance. The NDC had no written document on their position on health financing and this made it difficult for its constituencies to align with a single vision. Its position was generally a cross between individual responsibility for health but without alienating itself from the core principles of social democracy. Providing government subvention in health financing was seen as providing that opportunity.
The lack of clarity in its position on the matter made it difficult for its followers and members of parliament to defend the party agenda on insurance and decimated its constituency. One of its deputy Ministers of Health in 2000 argued that a single national system as was being piloted was not feasibly and called for district schemes. This did not sit well with his colleagues in parliament. He was accused of selling out and forced to reword his presentation during questioning in parliament on the issue. The lack of focus led to the introduction of multiple pilot schemes with none being given priority attention for replication.
The New Patriotic Party (NPP) in their medium term priorities made clear its intent to phase out the cash and carry system and replace it with a more humane and effective system of financing health care. The party on assuming power in 2001 quickly sent out a clear sign of government intent on introducing insurance. As noted earlier one of the key performance measures in the letter appointing the Minister of Health to the position in October 2001 was the introduction of social health insurance. On December 19 2001, the Minister of Health announced the processes for drafting of a bill that would regulate the health insurance industry, create a national insurance fund and provide procedures for resolving conflicts. This allowed its followers to comment on issues being discussed by the public even if sometimes their arguments were incoherent. What clarity did for them was that they were able to rally support among party faithful, gave the voice to participate in debates and preserve their constituencies.
When government position is not clear, technical experts turn to preserve their own constituencies by ignoring government directives or engage with it in a lukewarm manner usually resulting in the failure of the policy. The relative clarity on the part of the NPP and its commitment to achieve the introduction of health insurance gave technical experts within the Ministry of Health a direction on what the government policy was without compromising the position of Ministry of Health officials as pursing a non-technical agenda. In our opinion, it is this lack of clarity on the part of the National Democratic Congress when it started its own schemes that contributed to its inertia.
• Symbols manipulation
Symbols have long been known to be manipulated to both positive and negative by various actors. This is because words and statements presented are not always ubiquitous in meaning particularly if they are ambiguous and can be reinterpreted and re-presented.
The policy paper submitted to cabinet contained a proposed design of health insurance and the possible financing sources. Three scenarios were presented for financing. The first was to raise funds based entirely on premiums as derived from the ILO actuarial analysis. This will have meant a minimum of the equivalent of US$360 per annum for each citizen if the entire population was to be covered for a suggested benefit package mainly outpatient services and referred cases. The second was to draw funds from three sources: government budget, payroll deductions of 15% from formal health workers and an additional contribution of the equivalent US$120 from the entire population irrespective of employment status per annum. The third is to drop the contributions entirely, replace payroll deduction with allocations from the Social Security and National Insurance Trust fund, source funds from government budget and raise the percentage on the ad-valorem tax (VAT) by about 3.5% and allocate that to the insurance fund.
The first two were rejected on grounds that at a per capita income of US$360 at the time and the level poverty these were not feasible propositions. On the third, the reaction from cabinet was that using ad valorem tax (VAT) though attractive posed its own political problems. VAT as a symbol will easily be manipulated by the opposition. The National Democratic Congress introduced VAT in 1998 when the NPP was in opposition. The NPP described the tax as regressive, in-human and insensitive to the plight of Ghanaians. Following very heated debates and heckling in parliament and casualties resulting from a demonstration dubbed ‘kumi preko’ meaning ‘better kill me now’ insinuating that it is better to die than live under a VAT regime, the NPP then in opposition parliamentarians walked out of the proceedings and refused to vote on the issue.
The NDC passed VAT into law because they formed the majority in parliament then. To mention an increase in VAT by any figure will be playing right into the hands of the NDC now in opposition. After a lengthy debate, it was agreed to call it a National Health Insurance Levy (NHIL). At Akosombo in 2003 where the Parliamentary Sub-committee on Health met to deliberate on the matter, there appeared to be bi-partisan consensus. When the policy was tabled in parliament under the draft bill, the NDC were quick to latch on the NPP ‘double standard’ and decried a tax increase that will translate into higher prices on goods and services. It argued that a tax that is collected by the VAT agency, on the same qualifying goods and services and administered under the same tax regime can be nothing but an increase in VAT.
The debates on the floor of parliament were uncompromisingly polarised, technically deficient and focused on government insincerity at opposing a previous policy on which it is building its fortunes. The images and accounts of mass demonstrations led by the NPP, the loss of lives, the embarrassment of withdrawing an earlier VAT bill in 1995 and reintroducing it three years later with a much lower rate and loss of revenue were too strong to ignore. The NDC recounted these vividly on the floor of the debate and raised strong sentiments among its sympathisers against the proposal.
Academicians joined in the debate and put out the mathematics to show that the increase of 2.5% is actually an increase of 20% in the tax regime. The production sector protested that the new levy will increase production cost and make them uncompetitive against imported finished products. The general population weighed in through mass media but the president and his constituents were resolute in their resolve. In almost a payback faction, the NDC walked out of parliament when it came to vote on the issue. The NPP being in majority voted to pass the bill.
• Coalition building
Enrolment and membership in a District Mutual Health Insurance Scheme is mandatory for all residents of Ghana except those working with the Ghana Armed Forces, the Ghana Police Service or those who have proof of holding a health insurance policy. Persons eligible to membership are expected to pay a contribution of GHC 7.2 per year equivalent of US$ 7.74 at time of passage of Act.
While the debate on VAT or not VAT was on going, labour took issue with the 2.5% of the Social Security and National Insurance Trust (SSNIT) to be appropriated to the insurance fund. Labour had earlier in 2002 agreed to the 2.5% as a matter of principle. Because the Trade Union Congress (TUC) representative served on the Ministerial Committee it was assumed TUC endorsed the proposal.
First, the TUC opined that as a matter of principle they had agreed to having a scheme that benefitted their members and to contribute in a way. However, that was policy. SSNIT money was workers money was the tune. Government should have in their opinion come back to the table to negotiate the details and not spring it out on them in a proposed law. Secondly, they put forward a crude calculation. Taking 2.5% from the SSNIT fund will actually amount to 14.7% of the SSNIT fund. The total amount also meant that each worker was contributing an approximate 3.6 Ghana cedis, an equivalent of US$ 3.87 in 2003. Workers considered that this was unfair and it will affect their pension benefits. The TUC decided to call on its membership to reject the proposal.
Fighting a two front war was never a good idea. The government chose to build coalitions through careful compromises. The NPP with advice from the technical experts within the Ministry of Health did three things. (i) It offered Labour guarantees that government was only borrowing the money and that no part of the funds appropriate will be transferred or accounted against any worker’s end of service benefit. (ii) All contributors to SSNIT and their dependants as well as all pensioners on SSNIT benefit will not have to pay premiums to be registered on the scheme. In effect, labour and for that matter the formal sector will have free health care in Ghana. (iii) Since formal sector labour has put up calculations on how much the 2.5% will be in terms of individual obligations, the informal sector will have to make up an equivalent in premiums. However, each informal sector contributor will have to carry one child so that all other dependants may benefit. Above 70 year olds were to be entirely exempted to be consistent with end of pension calculation for surviving pensioners which was pegged at 72 years. It was these negotiations that led to the setting of the premium at 7.2 Ghana cedis per annum or US$ 7.74.
Once these compromises were negotiated, a coalition was built between government and labour that led labour to tone down and not engage with the VAT issues. It was possible that without this coalition building government could not have passed the bill. Here, labour as civil society, proved more powerful an ally to have than to compromise with opposition political parties in parliament. Technically, it should be admitted that a better engagement process should have been developed with the key stakeholders by the technical experts to ameliorate some of these issues coming up late in the process.