Workers, citizens, and health policy : a gendered political and economic history of social citizenship in ex-British colonies, with a focus on Ghana and India.

Abstract

This is a study about citizen’s entitlements to healthcare, how these have been defined, how and why these definitions have shifted over time, and what implications they have for future health provision in countries outside of the Global North. It focuses on two countries, Ghana and India, which were a part of the British Empire, and on key international organisations, exploring changes that occurred during the colonial and post-colonial period, and using these to shed light on shifts in the terms of inclusion that are currently occurring within the rejuvenated drive towards Universal Health Coverage (UHC). A driving motivation for this work is the need to make sense of these present day changes, particularly those that revolve around the need to include informal workers – workers who work in unconventional places of work, either as self-employed operators and/or with blurred employment relationships – into health provisions. UHC is a term that arose out of the social democratic era, when health became a right of social citizenship. Yet within this model a tension always existed between entitlements to health based on status as a citizen, and entitlements based on status as a worker. Due to their unconventional nature, informal workers present complex difficulties for the extension of UHC within the social democratic tradition. This thesis aims to draw out and explore these difficulties, looking at both the “top-down” politics of health policy making, and the “bottom-up” struggles of informal worker organisations as they engage with these policies. In doing so it explores the tension between a model of the good society that was developed and worked well in a particular context (post-World War Two Britain), and the difficulties and questions that arise in the translation of that model to the very different contexts of Ghana and India. Theoretically, the study draws largely on Marxist theory, in particular using the Gramscian international political economy model developed by Robert Cox. It is also inspired by Frederick Cooper’s work Decolonization and African Society: The Labor Question in French and British Africa (1996), which argues that the roots of modern day social policy in Africa lie in the decolonization and post-colonial periods. Methodologically, the nexus of inclusion/exclusion is explored in this study using two concepts which have underpinned inclusion into modern forms of health provision: that of “the worker” and that of “the citizen.” The inclusion of both the person-as-worker and the person-as-citizen is not a common feature in the analysis of health policy and provision, but it is the central contention of this thesis that keeping the relationship between the two in view over a period of time allows for important insights to emerge into past and contemporary health policy which are otherwise lost or made obscure. This includes seeing questions of public health in relation to occupational health, a health discipline which has been criticised for its narrow, Northern orientation, and often ignored within the health and development literature. Looking at them in parallel clearly brings into view questions about the responsibility of capital towards the social good. This relational focus is the original contribution to knowledge of this study, and a contribution to the call by Mackintosh and Tibandebage (2004) to add analytical depth to the study of health policy and provision in the developing world. This method has an additional nuance laid over it, through a gendered and contextualised analysis of the worker. Gender analysis here is used as a lens through which to explore the specific context of workers in India and Ghana. Primary data was drawn largely from archival sources, as well as key informant interviews and project notes. The thesis concludes that it is damaging to the idea of social citizenship to advocate for universal state provision without regard for questions about the responsibility of capital, employment dynamics, and the specificity of social and economic context. It argues that the international organisations – particularly the International Labour Organization (ILO) and the World Health Organization (WHO) – have a potentially constructive role to play in thinking through forms of social citizenship which do take the above considerations into account. However this is circumscribed both by their rootedness in the post-World War Two social democratic model, and by the tensions which exist between the two organisations, which embody the tensions between the state-citizen relationship and the state-employer-worker relationship within this model. It argues that the relationship between the two organisations has reproduced this tension in a manner which has negative implications in the present moment.