INTRODUCTION This essay would inquire in to the impact of global health actors on Health Policies in the Republic of Ghana highlighting the World Trade Organization, The World Bank and the International Monetary Fund as reference points. Policy issues have emerged from both constructive and unconstructive effects of various global processes associated with development in the trans-national movement of funds, commodities, services, a rise in multinational corporations, widening inequalities, diseases coupled with poor access to social services. Dodgson et al, 2002; Frenk et al 2002; Hurrell and Woods, 1995; Vieira 1993). Health related policies should involve the actions (and inaction) that affects institutions, organizations, services and funding arrangements of the health systems. It should incorporate policies from the public as well as the private sectors (Buse et al 2005).
Global actors play an important and central role in policy making and health care funding (Gilson and Walt, 1994; Buse et al, 2007), In health policy perspective, global actors are defined as individuals’ organizations or state governments whose individual or collective actions defines the health policy of their states in terms of setting agendas, legitimizing health issues or allocating resources to various priorities as the need arises (Gill Walt, 1994; Shiffman, 2008).
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These actors will include principal players such as representatives of donor agencies, medical practitioners, pharmaceutical companies, civil servants, academics and health ministers. The mass media, both of the print and electronic worlds play a vital role in policy in most liberal democratic countries. They are perceived as a potent force in highlighting, shaping, influencing and provoking the government to action (Gill Watt, 1994; Chomsky, 1998; Koh, 2000; Sheehan 200 Shiffman, 2008; Buse et al, 2005).
Rapid spread and emergence of new infectious diseases posing as a threat to many countries has seen to the emergence of the creation of a horizontal system of new partnerships and actors in health care at the global level thus posing as a challenge towards protection of goals in public health (Sid et al 1999; Walt, 2001; Dodgson et al, 2002; Shiffman, 2008). This is characterized by partnerships, conflicts and the introduction of new ideas by global actors such as the World Bank and the Gates foundation into the health policy system. This new actors have dramatically taken over the hold of power held y the likes of the World Health Organization and the United Nations who were at the fore front of 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 brought in diversity from the private sectors and thus their subsequent involvement in policy making. Overtime through provision of resources, expertise and the drive to address emergencies, these global actors have been able to hold onto power and direct global processes (Ollilia, 2005).
I n developing countries health policies are subjected to pressure from within and out due to economic decline and reliance on external funds (Buse et al, 2005). Ghana in the 80’s experienced economic setbacks which led to the state being unable to fund public services against growing demand from the populace (Konadu-Agyemang, 2000). This led to funding dependence on non-state actors thus empowering them to influence and dictate terms of policy process and outcome, in most situations these outcomes are not usually rational and more often than not, they do not represent the true needs of the populace (Buse et al, 2005; Deacon et al, 1997)
IMPACT OF THE WORLD BANK, IMF AND THE STRUCTURAL ADJUSTMENT PROGRAMME (SAP) ON HEALTH POLICIES OF GHANA Ghana attained independence March 1957 with brilliant predictions for developments and high optimism from the international community, it was preconceived that an irreversible course of social, economic, structural and political growth was about to unfurl, being the world’s largest producer of cocoa, gold, timber and also blessed with natural resources (Hutchful, 2002:9; Shillington, 1992:21).
Twenty- three years after this, in the 80’s due to wrong policies, internal and external shocks (trade deterioration, drought reducing agricultural output, and Nigeria expelling over one million Ghanaian workers), Ghana experienced a drastic decline in its economic performance, teetering towards bankruptcy in an era of destitution and despair (Gyimah-Boadi, 1993:2). This led to a massive decline in gross domestic product (GDP) and government funding on social and welfare programmes (Lavy et al, 1996).
Financial deprivation and insecurity led Ghana to seek financial aid from the IMF and World Bank both recognized to pursue neo-liberal thoughts that uphold market values and ethics in health and public sectors (Mohindra, 2007). In response to the crisis, a series of reform initiatives specifically, the Economic Recovery Programme (ERP) and the Structural Adjustment Programme (SAP) was launched. The World Bank supported these programmes, which was co-financed by the IMF (Dzorgbo, 2001:2).
SAP, defined as the ”process by which key institutions and policies are restructured with the aim of advancing economic growth”, REF is normally supported by policies designed to achieve sustainable deficit reduction and also reduction in the rate of price inflation. The objectives of SAP include liberalization of markets, encouraging privatization of public services, budget reductions on welfare allocation and rehabilitation of infrastructure.
According to Mohan, (2009) despite the presence of the financial bodies usually at the request of government authorities, he is of the opinion that SAP is a political tool for eroding the sovereignty of developing countries. It serves as an opportunity for these institutions to influence national agendas through conditionality’s, sanctions or collaboration with policy elites of the state.
Conditionality’s attached in the form of policy reforms include; decentralization of government health services with diminishing cost of public health sector funding, provision of risk coverage or insurance, introduction of user fees and privatization of health services (World Bank, 1987). This conditionality’s are empowering to the financial bodies but enslaving to the States and are tactics employed in manipulating policy making processes thus the role of the World Bank in policy formulation is promoted.
This usually undermines the actual policy process and also neglects problems arising during implementation (Koivusalo and Ollilia, 1997) In order to meet these conditions, a user pay system was introduced into the health system with bulk of this fees being paid by the patients. This action created room for growth of profit oriented health-related industries such as the pharmaceuticals and insurance companies (Koivusalo and Ollilia, 1997).
Another devastating consequence of this is the considerable brain drain of health professionals out of the public health sector into the private sector and also out of the country in order to achieve financial gains (Chabot and Brenner, 1988; Hien et al, 1995). Acute malnutrition was also characteristic of the SAP era (MacIntosh, 1995). In 1998, due to mounting pressures from the Donors and the World Bank for the need to decentralize, the Ghanaian government introduced political decentralization thus creating a total of 110 district councils from an initial 65 so as to reduce the management role of the government (Ayee, 1994).
However, much was not achieved because decisions over financial, human and operational issues were still centralized, largely due to uncoordinated activities and unclear roles within the Ministry of Health (WHO/MOH, 1992-1994). Arguably Ghana has experienced considerable change over the years with its development programmes and improved growth rate based on standard economic indicators of GDP and GNP (Konadu-Agyemang, 2000).
However as remarkable as these improvements are, majority of Ghanians in the rural and urban centers are still living in poverty due to uneven distribution of the dividends of SAP and the results of extensive borrowing under SAP. In Ghana today debt servicing incurred from SAP accounts for a considerable proportion of its export revenue (Konadu-Agyemang, 2000). The question really is how much has Ghana really ‘developed’? Are growth rates in GNP and GDP conclusive signs of development?
From the discussions above, it is obvious that the implementation phase of policy making is usually the most ignored, this is said to be due to the concerted efforts global actors place on the policy formation phase of health policy making and the top down non participatory approach usually employed (Buse et al, 2005). This is characteristic of the issues faced by the government of Ghana and most developing countries in implementing most policies like decentralization.
The involvement of key stakeholders in policy process encourages ownership and commitment in planning, implementation and sustainability of policies (Labri, 1998; Buse et al, 2005). GHANA AND THE WORLD TRADE ORGANIZATION (WTO) A multilateral organization and international body saddled with the sole responsibility of dealing with the rules of trade between nations, Created on the 1st of January 1995. It is considered to be the most powerful legislative and judicial body in the world by systematically undermining democracy around the world.
Despite having one of its major objectives as equity and fairness, the WTO is considered as one of the global law makers today with the citizens of developing countries as the law takers, incessantly it has been accused of protecting the interests of the multinational corporations above the survival of working families, local communities and thee environment. (Bloche, 2002). Inequalities to accessing drugs and unfair trade policies are a good reflection of the growing inequalities between the developed and the developing world propagated by the likes of the pharmaceuticals, the United States and the WTO.
Explanations to this include; financial incentives are necessary for research and development, also there is a need to protect drug patency under the Trade Related aspects of Intellectual Property (TRIPS). According to Wright, (1999), multinational pharmaceutical companies fervently resist efforts by developing countries to obtain or manufacture drugs through sustainable ways. They are against manufacture of generics in the south pressurizing generic drug providers and the state to change their policies despite acting within international law (Thomas, 2002).
These powers frustrate the efforts of developing countries at legally assessing relevant and affordable drugs for their populace whose deaths are predominantly due to preventable infections and diseases (Bloche, 2002). To corroborate this, is the case of Ghana, Cipla and GlaxoSmithKline in August 2000, through legal threats and pressure on Cipla, GSK succeeded in terminating supplies of generic antiretroviral drugs to Ghana, at the expense of its HIV victims whose dreams of living a more productive and healthy life has been cut short (Sharma, 2000; Schoofs, 2000; Thomas, 2002).
Another worthy example is Pentamidne, a drug choice for the treatment of sleeping sickness found to be cheap and easily accessible. However when found to be effective in management of aids associated pneumocystis carinii pneumonia, a drastic price increase of over 500% was noticed, hiked by the pharmaceuticals. Subsequently in sub-Saharan and the Southeastern parts of Asia a scarcity of the drug was created by the pharmaceuticals (Duckett, 1999:5). CONCLUSION
In Ghana, due to its inability to fund itself and its health system, the health policy process has been greatly influenced and determined by various global actors such as the World Bank, WTO and the IMF. Also as seen in the case of Ghana, global health policy making is increasingly being aligned with industrial and trade policies, and is being done hand in hand with business thus weakening the firewalls necessary for effective regulation and normative actions both at the global and nation levels.
The processes of policy making should not be hijacked by a selected few due to provision of resources and technical expertise but should incorporate all actors and stakeholders. This is to guarantee joint ownership through effective participation for the sustenance of future policies. This would also ensure that the donor organizations and government are answerable to decisions taken and outcomes regarding the state health policies.