Transnational actors and health care reform: Why international organizations initially opposed, and later supported, social health insurance in Ghana

Much has been written about the impact of transnational actors on health and social policy. In this article, we show how some international organizations' efforts to prevent Ghana from enacting a social health insurance program in 2003 failed. We then explain why the Ghanaian government ignored these organizations' advice and even excluded them from the policy formulation process altogether. Finally, we explore these organizations' logic as they came to accept and even promote the new Ghanaian policy internationally. As argued, a temporal perspective on the impact of transnational actors and the way their prescriptions change over time is necessary if one is to capture transnational policy influence and its limitations. A temporal perspective is also important in explaining the logic of accommodation on the part of these actors, since this only becomes apparent over time. This is precisely why our qualitative analysis traces both domestic policy development and the changing nature of transnational ideas and prescriptions.