This article is part of the following series: Health for all? Critical perspectives on Universal Health Coverage
“Health for All?” critically explores global moves towards Universal Health Coverage and its language of rights to health, equity, social justice and the public good. Highlighting emerging ethnographic and historical research by both young and established scholars, the series explores the translations and frictions surrounding aspirations for “health for all” as they move across the globe. The series is edited by Ruth Prince.
This photo-essay was written as a reflection on the accumulated strata of healthcare infrastructure in Ghana, the histories which gave rise to this accumulation, and what these might mean for the turn to Universal Health Coverage as a new idea in national health policy. It discusses some of the historiographical risks in writing about older structures and their persistence in the present, including when we consider contemporary landscapes in terms of ‘ruins’ or ‘ruination’. Some of these risks are evident in the article itself. The discussion and photographs focus mainly on material health infrastructure, a counterpoint to the more vital world of healthworkers, officials, patients and others who interact with these concrete aspects of the health system.
I wrote this piece before the pandemic, from earlier experiences and observations of Ghana’s healthcare infrastructure. Re-reading it now, much remains the same, and the turn towards Universal Health Coverage in Ghana will continue beyond COVID-19. But in the following images and discussion, there is also now a sense of the exceptional weight that this infrastructure may soon have to bear.
At the time of writing, Ghana had confirmed 834 cases and 9 deaths from the virus, based on limited testing. A range of social distancing measures have been imposed, and the government has proposed a package of welfare measures, but many people have lost jobs or been temporarily laid off without pay. Ghanaians joke about the ‘colonial virus’ as a disease of the wealthy, and debate whether it is safer to remain in urban centres or return to family villages: the life of early lockdown unfolds with a comparable logic in many places. There is the sense of waiting for a wave to break. Some of the world’s wealthiest countries have already seen parts of their health systems overwhelmed, with the disruptions of coronavirus contributing to increased mortality from the other diseases that go untreated at the height of pressure on clinical facilities. Will Ghana’s health system be overwhelmed? Will its accreted layers of old and new infrastructure, personnel, capacity and funding show resilience as case numbers begin to rise faster, if they do? Will Ghana’s enduring situation at the periphery of the world economy contribute to worse outcomes and a lack of resources to fight coronavirus, as it has with some other diseases in the past? This marginality gave some early advantage, delaying the outbreak because of the country’s relative isolation from international travel and trade, but this is changing with increased in-country transmission.
The pandemic has already been a cautionary tale about the risks of making predictions and rushing to print, and these questions can’t yet be answered. The article surveys a landscape of healthcare infrastructure from the decades before COVID-19, which will persist long after the disease recedes. But it has to be read with the uncertain near-future in mind.
In Sekyere Afram Plains district, the largest and least-developed administrative division in Ghana’s relatively wealthy Ashanti Region, we were shown to the shuttered site where construction of a large hospital had begun, but never finished. Close to Burkina Faso in the Upper East Region we visited one of the empty Catering Rest-Houses, expansive modernist complexes built by a 1970s government to promote public interactions and the promotion of broader social health, then cancelled by a successor regime. In the middle Volta Region, the leader of a Nigerian mission clinic showed us shelves piled with insurance paperwork and claims for remuneration, and explained the possibilities and difficulties in operating on the margins of the country’s National Health Insurance Scheme.
In the cities, busy teaching hospitals and regional hospitals were in various phases of proposed or actual renovation and renewal: government tender notices announcing the appointment of contractors who will reconfigure or efface structures from the colonial period, the independence era, the years of military rule and rapid political change from 1966, the structural adjustment years, or those built in the 25 years since Ghana’s return to general elections in 1992. In rural districts across the country we passed Community-Based Health Planning and Services (CHPS) compounds, the front line of national primary healthcare, developed since the late 1990s and often cited internationally as an exemplar for effective rural health services.
In the mineral-rich Western Region, many of the CHPS compounds were built with funding from London- and Toronto-listed gold mining companies. In villages on the eastern side of the country, near the Togo border, buildings were maintained by the ‘Concerned Citizens of Agotime’, a small town nearby. Most of the smaller towns offer several options for treatment: perhaps a district hospital or polyclinic, or a smaller government health centre in tandem (or competition) with partly state-funded mission clinics, herbalists, private hospitals and Christian-healing centres. Going down some of the main roads in the capital, Accra, you pass a different private or public health facility every 50 metres.
These are some of the physical structures: large and small iterations of healthcare infrastructure in various conditions, with different limitations or efficiencies of design, varied histories and projected lifespans. Beyond this, histories of funding and finance constitute another superordinate layer of the health system. On the walls of each facility, signs and advertisements suggest different ways for people to pay for their care.
There is Ghana’s National Health Insurance Scheme (NHIS), created in 2003 as one of the first attempts in Africa to build a single payer national health insurance programme, with exemptions for the poor and including the informal sector. But along with its continued promise, the NHIS has faced difficulties with central funding and remuneration, and in some places with the perception of local corruption: registration in the scheme peaked at 41% of the population in 2015, but this had fallen to 35% by 2017. Those who can afford it might use the NHIS and also have membership in a growing number of private health insurance schemes, underwritten by multinational companies who increasingly draw on the language of Universal Health Coverage (UHC) as legitimation for what is evidently a profitable business. Those who can’t, and who are either unregistered for the NHIS or find their health problems aren’t covered by national insurance, turn to high-cost instant cash loans, community savings schemes, family and friends or the exchange economy of herbalism, where this hasn’t also been displaced by a requirement for cash payment in advance.
Ghana’s accumulated health infrastructure is a physical testament to the histories (economic, political and social; local, national and global) which gave rise to particular distributions of healthcare resources and successive policy shifts, and which now might appear to be converging towards UHC, the most extensively-promoted policy paradigm in global health since the Alma Ata Declaration of 1978. My current research examines how different generations of people remember the arrangements and costs of state healthcare over time: from the late colonial period to the years of socialized medicine and free treatments under the first independent government from 1957; the experiments with co-funding the health system which took place as the result of local government and WHO initiatives from 1966-1981; and the turn to full ‘Cash and Carry’ which came in the early 1980s, passing all health costs on to patients and deterring many from using government services. The formative experiences of different generations over decades gives rise to disparate moral economies of health in the present, shaping people’s expectations for what can be achieved: with the current pandemic, in the longer future, and with attempts to implement UHC.
Many of these descriptions of infrastructure will be familiar to those who live in Africa. But Ghana’s health history is as distinct as any other country, and apparently-familiar health structures and signage can be the product of very different historical trajectories. This is the terrain on which UHC arrives, speaking a language of universality. As the principal idea shaping current global health policy, Universal Health Coverage is presented as something new: a novel vision of fair and affordable access to care for all, which rose to prominence after the 2008 financial crisis destabilized prevailing (broadly neoliberal) economic certainties, and which participates in widespread optimism regarding the possibilities of new technologies.
In the context of this turn towards UHC, the varied structures, health signage and other concrete manifestations of Ghana’s health system are markers for past and present attempts at reforming access and expanding care. In their variety, their longevity or obsolescence, levels of upkeep or disrepair, and in the way they are understood by people around them, these physical instantiations of policy raise questions about how the past has shaped the present, about which reforms have been more or less fair or sustainable, about what was hoped for and what has counted as success. They also raise questions about what will eventually count as ‘Universal Health Coverage’, and which aspects of Ghana’s past health systems will be submerged, displaced or perpetuated by coming UHC reforms.
Briefly, some thoughts on the historicisation of health infrastructure, and particularly of its older colonial parts. Old structures and processes of ruination have long provided a starting point for writing histories and ethnographies which reflect on their decrepitude and senescence, or persistence and continued valence, and the meanings and legacies that attach to either condition. In Imperial Debris (2013), Ann Stoler argued for turning attention away from monumental ruins and settled assumptions about legacy (here of colonialism in particular), proposing instead that a central question is how ‘formations persist in their material debris, in ruined landscapes and through the social ruination of people’s lives.’ Stoler suggests that ‘to think with ruins … is to emphasize less the artifacts [of empire] as dead matter or remnants of a defunct regime than to attend to their reappropriations and strategic and active positioning within the politics of the present’.
This has been a productive perspective, but it can be difficult to maintain consistently, or to countenance the possibility that these aspects may not always be important to those who live and work with old infrastructure. Thinking about histories and ethnographies of health in Africa, surveying more nuanced physical and social scapes of what may or may not be construed as ruination, moving well beyond monuments and grand structures, there is still the risk that nostalgia or misplaced sentiment about the past subtly enters in, even in critical readings.
The continued physical presence of ruins or, in terms of infrastructure, of older health structures and equipment which have seen continued quotidian use across different periods within a national health system, with their emblematic embodiment of particular (sometimes imagined) pasts, and the gravity which is sometimes uncritically or unconsciously accorded to their relative age (also to the evocative language of ‘ruins’ and ‘ruination’), may overshadow recognition of the less significant place that many of these structures now occupy as bit-parts of an active and evolving health system. One in which their age or origins are incidental to the people working in or using them, and their particular histories sometimes not as significant in the working present as the literature might suggest. These may involve only relatively minor accommodations: to circumvent the poorly-designed entryway of an old colonial hospital for receiving large numbers of patients; to traverse the hot expanses of concrete slab that surround some of the district health posts built during Ghana’s independence era. For colonial infrastructure in particular, there is sometimes also a risk that analyses of this kind imply a persistent attenuation of agency. Even with an emphasis on reappropriation, and awareness of the problems of either imperial nostalgia or an insistent mourning of empire’s ill effects (its ruinations), the past may still be presented as implicitly untranscendable.
To point out these historiographical risks is not to say that the past doesn’t shape or constrain the present. However it is implemented, and whatever it comes to mean in practice, Universal Health Coverage will have to accommodate at least the recent past – there is no blank slate upon which this global vision for national healthcare can be imposed, and UHC itself is a contested amalgamation of older and more recent ideas about the roles of the state and private sector. Old health infrastructures and ways of doing things will have to be engaged with, included, dismantled, excluded or absorbed. But as recent writing on health infrastructure in Africa demonstrates, analytical emphasis can productively be placed elsewhere, and away from ruination. In Ghana and elsewhere, health infrastructure has sometimes been lyricised as a ‘palimpsest’: a sheet of historical parchment on which older, scraped-away terms insistently seep through and speak to or over the present. But if a metaphor is needed, perhaps it is more like a coral reef. Aside from a few places, from 1945 to the present the older forms have been grown over and remade at an increasing rate. As the strain on Ghana’s health infrastructure increases with the probable spread of COVID-19, this may test the cohesion of these relics and substructures – varied health facilities and shifting priorities emplaced over successive generations – in unanticipated and unprecedented ways.
The recent political declaration of the United Nations General Assembly, emerging from the High Level Meeting on Universal Health Coverage in September 2019, allows ‘governments at all levels to determine their own path to achieving universal health coverage, in accordance with national contexts and priorities’. With few clear definitions or prescriptions, and beyond the immediacy of the pandemic, some unanswered questions remain. Under what financial and infrastructural conditions will UHC eventually be considered to have been achieved, and in what political context? Who will make the determination, and for whom will it be made? What will change on the ground? And how will Ghanaians who remember past health reforms, advances and disappointments see this new policy, in light of their understandings of the past?
The photos below show some aspects of Ghana’s health system, in light of the turn to UHC.
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These images show some of the physical and connective infrastructures of healthcare in Ghana. The set presents only a few of the different contexts, physical settings and pasts with which the ideas and implementation of UHC will have to reach an accommodation – a varied landscape of clinical healthcare in Ghana, now preparing for the coronavirus pandemic.
These images show some of the choices that Ghanaians make to obtain healthcare and treatment through insurance, cash payment or other means. Funding as well as infrastructure may have to change for UHC to be achieved on its own terms: after debate and negotiation between governments of different political leanings at the UN in September 2019, the most current definition of UHC ‘implies that all people have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative, rehabilitative and palliative essential health services, and essential, safe, affordable, effective and quality medicines and vaccines, while ensuring that the use of these services does not expose the users to financial hardship’. In Ghana, will this mean a strengthening and expansion of the National Health Insurance Scheme, an increased role for the for-profit sector, or something else? Various paths seem possible, with long-term implications beyond healthcare itself. As one of the most socially consequential and economically significant areas of activity in any country, healthcare reforms required by the turn to UHC will affect electoral politics and the broader role of the state in society, shaping people’s discussions about solidarity and choice, what constitutes a fair contribution and a fair share of health resources.
 See Eric Nsiah-Boateng and Moses Aikins, “Trends and Characteristics of Enrolment in the National Health Insurance Scheme in Ghana: A Quantitative Analysis of Longitudinal Data,” Global Health Research and Policy 3 (November 13, 2018), doi:10.1186/s41256-018-0087-6.
 See for example “Ghana on Course for Universal Health Coverage — Minister – Graphic Online,” accessed December 4, 2019, https://www.graphic.com.gh/news/general-news/ghana-on-course-for-universal-health-coverage-minister.html; “Let’s Double Efforts to Achieve Universal Health Coverage – Graphic Online,” accessed December 4, 2019, https://www.graphic.com.gh/daily-graphic-editorials/let-s-double-efforts-to-achieve-universal-health-coverage.html.
 For a discussion see Jennifer Summit, “Topography as Historiography,” Journal of Medieval and Early Modern Studies 30, no. 2 (May 1, 2000): 211–46.
 Another approach, exemplified in the case of African medical science by essays collected in the edited volume “Traces of the Future”, attends to historical remnants and their specificities more gently and in a different idiom: as the ambiguous vestiges of non-epochal pasts, and as the traces of once-possible or once hoped-for futures. See Wenzel Geissler et al., Traces of the Future: An Archaeology of Medical Science in Africa (Illinois: University Of Chicago Press, 2016); And Ann Laura Stoler, “Imperial Debris: Reflections on Ruins and Ruination,” Cultural Anthropology 23, no. 2 (2008): 194,.
 Among others listed below, see Alice Street, “Rethinking Infrastructures for Global Health: A View from West Africa and Papua New Guinea,” Somatosphere, December 11, 2014, https://somatosphere.com/2014/rethinking-infrastructures.html/.
 At least from the days before climate change began to send reefs the same way as palimpsests.
 UN General Assembly, “Political Declaration of the High-Level Meeting on Universal Health Coverage,” September 2019.
David Bannister is a postdoctoral research fellow at the University of Oslo, and member of the European Research Council-funded project, ‘Universal Health Coverage and the Public Good in Africa’. His current research uses oral histories, regional and transnational sources to examine generational moral economies of health – how the historical experience of different generations of people may give rise to divergent understandings of what is effective or fair in public health, and varied expectations about what can be achieved in the present.
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