Political economy and the pursuit of universal health coverage in Ghana: a case study of the National Health Insurance Scheme

The road to universal health coverage depends on resources committed to the health sector. In many cases, the political structure and strength of advocacy play an important role in setting budgets for health. However, this has, until recently, not been of interest to health system researchers and policymakers. In this study, we document the political path to the establishment of the Ghana National Health Insurance Scheme (NHIS) as well as continuous political interest in the scheme. To achieve our objectives, we used qualitative data from interviews with key stakeholders. These include stakeholders instrumental in the design and establishment of the NHIS. We also reviewed party manifestoes from the two main political parties in the country. Promises relating to the NHIS were extracted from the various manifestos and analysed. Other documents that account for the design and implementation of the scheme were reviewed. We found that the establishment of the NHIS was down to political commitment and effective engagement with relevant stakeholders. It was considered a solution to the political promise to remove user fees and make healthcare accessible to all. A review of the manifestos shows that in almost every election year after the NHIS was established, there has been some promise related to improving the scheme. There were several policy propositions repeated in different election years. The findings imply that advocacy to get health financing on the political agenda is crucial. This should start from the development of party manifestos. It is important to also ensure that proposed party policies are consistent with national priorities in the medium to long term.