How, when and why do governments respond to citizens?

Blog | August 2, 2016 | Terence Darko

One of the most challenging issues faced by organisations using technology to support open and accountable governance is understanding just how governments work, and where the opportunities to affect change actually lie. As the tech for transparency and accountability (tech4T&A) sector has grown, so has its skill in creating new, digital communities, opening up information on governments’ activities, and organising huge public campaigns that have engaged millions across the world.

But, while information dissemination and public engagement are staples of the tech4T&A world, evidence of how this has actually created more accountable, responsive governance is scarce, and it is clear that we need to work harder to make sure lessons from non-tech governance processes are not being forgotten.

As part of the Making All Voices Count ‘When Does the State Listen?’ series, which explores the stories of four landmark social justice policy processes - health insurance in Ghana, ICTs in Kenya, welfare in South Africa and education in Tanzania - Terence Darko reports on what it took to make Ghana’s government respond to its health service crisis.


More than ten years ago, Ghana began implementing a universal health insurance scheme. This became necessary when the ill-effects of paying for health services at the point of access – known in Ghana as ‘cash and carry’ – reached a tipping point.

The media carried stories of children bitten by snakes dying due to not receiving medical care, or babies and mothers being detained in health facilities until they could pay. It was clear that most Ghanaians could not pay for health care at the point of call.

This made the ruling National Democratic Congress (NDC) government unpopular, with most opposition parties at the time advocating for a health insurance programme. The process of establishing such a scheme, largely political, saw strong civil society involvement from the start.

I see this as one of the few stories of successful state–citizen communication in Ghana since the country returned to democratic rule in 1992. As part of a wider study to see how the state listens to its citizens, I looked at the process of establishing Ghana’s National Health Insurance Scheme (NHIS) to track the state’s responsiveness to citizens’ demands at different stages.

Specifically, I was curious to see whether the extent to which citizens engaged with state officials during the design, implementation and revision stages offered them an opportunity to make the state more accountable. I found that policy processes provide a window of opportunity for collectivized citizens and other non-state actors to demand accountability, both from bureaucrats and politicians - read the full paper here.

Civil society participation in the design and implementation of the NHIS was not without its difficulties. For starters, there was a lack of information for non-state actors to engage meaningfully; another issue was the willingness among state actors to do more than listen.

Civil engagement at the start

Health insurance was a common theme in the manifestos of most political parties in the run-up to the 2000 elections in Ghana. Indeed, it was a key campaign message for the main opposition party – the New Patriotic Party (NPP) – that won the elections.

In 2001, to fulfil its electoral promise, the new NPP administration began the processes of designing and implementing a national health insurance scheme, despite concerns about the viability and costs of such a scheme in a developing country like Ghana. Given the urgency of putting the scheme into place, and without having a clear plan on how to do this, the new government was very open to inputs from civil society organisations (CSOs) during these early stages.

However, this participation was not without its difficulties. For starters, there was a lack of information for non-state actors to engage meaningfully. Another issue was one of willingness among state actors to do more than listen; while there was some cooperation from government officials, they were not always open to the views of stakeholders during the process.

By 2009, the NDC were back in power and promised a revision of the NHIS, to make it more functional and address the implementation challenges. There was, however, a significant change made at this time. In its original state, administration of the NHIS was decentralised, meaning there were clear opportunities for citizen oversight. The revised scheme was – and still is – centralised, with all funds going to the health insurance authority. This leaves little opportunity for citizen oversight.

Ten years after implementation, there is growing discontent among the beneficiaries and service providers in the NHIS. This is largely a result of the current NDC government’s inability to pay claims to health service providers on time. These delays have caused some healthcare providers to revert to ‘cash and carry’, while some people have been denied access to healthcare unless they can pay for the services.

There is a growing perception among the electorate that the scheme is bound to collapse; the opposition parties, chiefly the NPP, are lambasting the government for this potential collapse; to which the President, John Dramani Mahama, can be seen on a number of platforms defending the scheme.

This situation has compelled the CSOs that participated at various stages of the policy process to interrogate the scheme’s financial sustainability ahead of the upcoming national elections. In response to these concerns, the government has decided that it needs to go back to the drawing board and rework the financial arrangements of the scheme. Ahead of the 2016 general election, the Minister of Health commissioned a seven-member technical committee to review the scheme and recommend ways to improve it.

Health – a political issue once again

During its brief history, the policy processes behind the NHIS have provided opportunities for collectivised citizens and other non-state actors to demand accountability from the state. I find interesting, though, to see the government acting once again on the concerns of citizens. Since its adoption, the scheme has been used by politicians to secure votes among the electorate. Even now, with the scheme facing huge financially challenges, the National Health Insurance Authority has increased its drive to register vulnerable groups, such the elderly. Such shows of compassion are always a good vote-winner ahead of an election.

Despite its challenges, the NHIS has made a significant positive impact on Ghana's healthcare delivery system. The few evaluations done suggest that maternal and child healthcare have improved, coupled with increases in access to formal healthcare by the majority of the citizens. And, to a certain extent, it has provided a window of opportunity for non-state actors to demand accountability from the state – not just ahead of national elections.


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