This essay analyzes the impact of global health actors on Health Policies in the Republic of Ghana, specifically focusing on the World Trade Organization, The World Bank, and the International Monetary Fund. Policy issues arise from both positive and negative effects of global processes associated with development, which involve the movement of funds, commodities, and services across national borders. These processes also contribute to multinational corporations, inequality, disease prevalence, and limited access to social services (Dodgson et al., 2002; Frenk et al., 2002; Hurrell and Woods, 1995; Vieira 1993). Health policies need to consider how actions or lack thereof influence institutions, organizations, services, and funding arrangements within the healthcare system. It should encompass policies from both public and private sectors (Buse et al., 2005).
The role of global actors in policy making and health care funding is significant (Gilson and Walt, 1994; Buse et al, 2007). In the field of health policy, global actors refer to individuals, organizations, or state governments. Their actions determine the health policy of their respective states, including agenda setting, legitimizing health issues, and resource allocation based on changing needs (Gill Walt, 1994; Shiffman, 2008).
The actors involved in this process will consist of individuals from donor agencies, medical practitioners, pharmaceutical companies, civil servants, academics, and health ministers. In liberal democratic countries, the mass media holds significant importance when it comes to policy-making. Both print and electronic media are recognized for their ability to draw attention to issues, shape public opinion, exert influence on decision-makers, and even provoke government action (Gill Watt, 1994; Chomsky, 1998; Koh, 2000; Sheehan 200 Shiffman, 2008; Buse et al., 2005).
The rapid spread and emergence of new infectious diseases pose a threat to many countries. This has led to the creation of a horizontal system of new partnerships and actors in healthcare at the global level, challenging the protection of goals in public health (Sid et al 1999; Walt, 2001; Dodgson et al, 2002; Shiffman, 2008). Global actors such as the World Bank and the Gates Foundation have introduced partnerships, conflicts, and new ideas into the health policy system. These actors have taken over the power previously held by organizations like the World Health Organization and the United Nations, which were leading international health matters in the 60’s (Buse and Gwin, 1998; Wuyts et al, 1992). This shift from nation-based health policy making and a decline in funding from the Organization for Economic Co-operation and Development agency has brought diversity from the private sectors into policy making. By providing resources, expertise, and addressing emergencies, these global actors have been able to maintain power and influence global processes (Ollilia, 2005).
Health policies in developing countries are facing pressure both internally and externally due to economic decline and reliance on external funds (Buse et al, 2005). Ghana experienced economic setbacks in the 1980s, which prevented the government from financing public services despite growing demands from the population (Konadu-Agyemang, 2000). Consequently, non-state actors became the primary source of funding, granting them significant influence over policy processes and outcomes. However, these outcomes often lack rationality and fail to accurately reflect the genuine needs of the population (Buse et al, 2005; Deacon et al, 1997).
The health policies of Ghana have been heavily influenced by the World Bank, IMF, and the Structural Adjustment Programme (SAP). When Ghana gained independence in March 1957, there was widespread optimism from the international community regarding progress and development. It was expected that Ghana, being a significant producer of cocoa, gold, timber, and possessing abundant natural resources, would make substantial advancements in social, economic, structural, and political areas (Hutchful, 2002:9; Shillington, 1992:21).
Due to misguided policies, external and internal shocks, such as a decline in trade, a drought that affected agricultural output, and Nigeria’s expulsion of over one million Ghanaian workers, Ghana faced a severe economic downturn in the 1980s. This downturn pushed the country towards bankruptcy during a time of widespread poverty and hopelessness (Gyimah-Boadi, 1993:2). As a result, there was a significant drop in Ghana’s gross domestic product (GDP) and reduced government funding for social and welfare initiatives (Lavy et al, 1996).
Ghana, facing financial deprivation and insecurity, sought financial aid from the IMF and World Bank. These organizations promote neo-liberal ideologies that emphasize market values and ethics in healthcare and public sectors (Mohindra, 2007). To address the crisis, Ghana implemented two reform initiatives known as the Economic Recovery Programme (ERP) and Structural Adjustment Programme (SAP), which received support from the World Bank and were co-financed with the IMF (Dzorgbo, 2001:2).
SAP, which stands for Structural Adjustment Program, involves the restructuring of important institutions and policies to promote economic growth. It usually includes measures aimed at achieving sustainable deficit reduction and lowering inflation rates. The goals of SAP include market liberalization, promoting privatization of public services, reducing budget allocations for welfare, and rejuvenating infrastructure.
According to Mohan (2009), SAP is considered a political tool by eroding the sovereignty of developing countries. The presence of financial bodies, usually at the request of government authorities, allows these institutions to influence national agendas through conditionality’s, sanctions, or collaboration with policy elites of the state.
The World Bank, in 1987, implemented conditionality measures as part of policy reforms. These measures included decentralizing government health services, reducing public health sector funding costs, implementing risk coverage or insurance, introducing user fees, and privatizing health services. While these measures empower financial institutions, they can be enslaving for the States. This manipulation of policy-making processes highlights the role of the World Bank in policy formulation.
The neglect of problems that arise during implementation and the undermining of the policy process can occur (Koivusalo and Ollilia, 1997). To fulfill certain conditions, a user pay system was implemented in the healthcare system, with patients being responsible for the majority of the fees. This action allowed for the expansion of profit-driven industries like pharmaceuticals and insurance companies (Koivusalo and Ollilia, 1997).
Another devastating consequence is the significant brain drain of health professionals from the public health sector to the private sector and abroad to seek financial gains (Chabot and Brenner, 1988; Hien et al, 1995).
During the SAP era, acute malnutrition also became prevalent (MacIntosh, 1995).
In 1998, under pressure from Donors and the World Bank to decentralize, the Ghanaian government implemented political decentralization, resulting in the creation of a total of 110 district councils from an initial 65, with the aim of reducing the government’s management role (Ayee, 1994).
The Ministry of Health faced challenges due to uncoordinated activities and unclear roles, leading to centralization of decisions on financial, human and operational issues. This hindered achievement in Ghana’s development programs. However, Ghana has witnessed significant transformation and improved growth rate based on standard economic indicators of GDP and GNP, as noted by Konadu-Agyemang (2000).
Despite significant improvements, poverty persists among a large number of Ghanians in rural and urban areas. This is primarily caused by the unequal distribution of benefits from the Structural Adjustment Program (SAP) and the consequences of extensive borrowing during SAP. Even today, a substantial portion of Ghana’s export revenue is allocated to debt servicing resulting from SAP (Konadu-Agyemang, 2000). Therefore, it raises doubt about the true extent of Ghana’s development. Are the growth rates in GNP and GDP reliable indicators for measuring development?
It is evident from the previous discussions that the implementation phase of policy making is often overlooked. This is due to global actors primarily emphasizing on the formation stage of health policy making and usually employing a top-down non-participatory approach (Buse et al, 2005). The government of Ghana and other developing nations face similar difficulties in implementing policies, such as decentralization.
The participation of important stakeholders in the policy process fosters a sense of ownership and dedication to policies (Labri, 1998; Buse et al, 2005). GHANA AND THE WORLD TRADE ORGANIZATION (WTO) is an international organization founded on January 1, 1995, with the purpose of regulating trade among nations. It is widely acknowledged as the most influential global legislative and judicial entity but has faced criticism for its negative impact on democracy worldwide.
Despite aiming for fairness and equality, the World Trade Organization (WTO) is widely seen as favoring citizens of developing nations. Many criticize the WTO for prioritizing multinational corporations over the well-being of working families, local communities, and the environment (Bloche, 2002). The growing gap between developed and developing countries is evident in the unequal availability of medicine and unfair trade policies. Pharmaceutical companies, along with the United States and the WTO, contribute to perpetuating this inequality.
There are multiple reasons why multinational pharmaceutical companies resist the efforts of developing countries to obtain or produce drugs in sustainable ways. These reasons include the need for financial incentives for research and development, as well as the safeguarding of drug patents under Trade Related aspects of Intellectual Property (TRIPS). According to Wright (1999), these companies strongly oppose the production of generic drugs in developing areas and exert influence on both generic drug providers and governments to change their policies, even if those policies comply with international law (Thomas, 2002).
Pharmaceutical companies’ powers hinder developing countries from legally accessing affordable and appropriate drugs, leading to preventable infections and diseases that significantly contribute to the death toll in these nations (Bloche, 2002). The case of Ghana, Cipla, and GlaxoSmithKline in August 2000 exemplifies this issue. By employing legal threats and exerting pressure on Cipla, GlaxoSmithKline successfully ceased the supply of generic antiretroviral drugs to Ghana. Tragically, this resulted in dashed hopes for HIV victims in Ghana who had dreamed of healthier and more productive lives (Sharma, 2000; Schoofs, 2000; Thomas, 2002).
Pharmaceutical companies caused a scarcity of the drug Pentamidine in sub-Saharan Africa and Southeast Asia. Initially, this drug was affordable and easily obtainable. However, its price increased by more than 500% after it was found to be effective in treating AIDS-related pneumonia caused by Pneumocystis carinii (Duckett, 1999:5).
Due to its lack of funding for both itself and its health system, Ghana has seen significant influence and determination of its health policy process by global actors including the World Bank, WTO, and the IMF. Additionally, global health policy making is increasingly merging with industrial and trade policies, as shown in the case of Ghana. This collaboration with business weakens the necessary firewalls for effective regulation and normative actions at both the global and national levels.
The inclusive processes of policy making should involve all actors and stakeholders, rather than being controlled by a select few with resources and technical expertise. By incorporating everyone, joint ownership and effective participation are guaranteed, which is crucial for the sustainability of future policies. Additionally, this approach holds donor organizations and government accountable for decisions made and outcomes achieved in relation to state health policies.
