Date added: November 30, 2016

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Much of the literature on citizen accountability focuses on citizen voices. This research briefing is one of four which turn the spotlight on the how the state behaves in instances of accountable governance. Each examines a landmark social justice policy process in Africa, asking when and how the state listened, and to which actors; and why, at times, it chose not to listen.

The creation of Ghana’s National Health Insurance Scheme (NHIS) in 2004 was a major health policy reform. It was shaped by both internal and external factors. Domestically, the NHIS was born of a moment of political transformation in the relationship between state and citizens. The government responded to the realities and demands of a newly-established democracy, and a media campaign that highlighted the ill effects of existing healthcare structures. Externally, access to debt relief and the adoption of a Poverty Reduction Strategy Paper influenced the government’s decision to enact a health insurance policy.

A multitude of state and non-state actors had a voice in the design, implementation and revision process of the NHIS. Tracing the evolution of the NHIS through its pre-design, design and implementation phases shows how the NHIS policy process offered political accountability to citizens. State and non-state actors in the health sector shared the same urgency and a common goal, even if they did not agree on the course of action needed to meet that goal.

The research concluded that:

  • as Ghana went through democratic consolidation, having a vibrant political society – including a vocal media – made government more responsive to citizens’ demands
  • when the government had urgent goals but no clear road map for reaching them, reform-minded officials were more open engaging in two-way dialogue with non-state actors, and to involving them in action for accountability
  • once urgency subsided, the government continued to consult non-state actors, but two-way dialogue only resulted in one-way action
  • as the fate of NHIS unfolds, elections, media exposure and deliberative meetings through sector working groups will continue to be important spaces for holding the state accountable on health.

This Research Briefing is part of the When Does the State Listen? series.

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