A bit on the longish point and some of the ideas are subtle, but there is a critical thread running through this talk that I summarise below.

1. National Interest is a corollary of nationalism.

2. Nationalism is a project of elites.

3. Nationalism rests on ‘effective myths’ of communal solidarity

4. For the myths to be effective, large sections of the masses must buy into it.

5. Sometimes what is purported to be in the ‘national interest’ will self-evidently not coincide with ‘public interest’, classically defined.

6. Yet, the logic of national interest is what usually builds the institutions that enables effective state capacity (including the ‘rational consensus’ institution), which in turn galvanise the elites in control to respond to public interest at all.

7. Never having had a proper national interest framework, the ‘public interest’ conversations and processes of most African countries are usually hollow and patchy.

8. Never having had a culture of elite solidarity around sacred doctrines of any kind, which a national interest framework would have lent, the public interest efforts of most African countries are usually confused, disorganised and incapable of galvanising elite action.

9. Civil society makes do with what they can get.

10. So they step in purporting to define the public interest but are met with cynical claims of misunderstanding national interest, which action breeds further dissonance, as there has never been any real articulation of national interest to begin with. So in the confusion of articulating a confused public interest against a confused national interest, African activists encounter a messy din in which rational consensus suffers even further.

1. Ghana has what it purports to be a social insurance scheme.

2.  This means that it is a scheme designed to cover as many people as possible and not necessarily make profit.

3. In this scheme, public money (taxation, development aid and direct subventions etc.) makes up about 95% of all revenues into the scheme. Essentially, the government pays up 95% of the money used to run the program.

4. Only about 30% of the users of this “insurance” program contribute anything at all, and their contributions make up less than 5% of the insurance scheme’s revenue. Take that in slowly. DOES THIS RESEMBLE IN ANY FORM ANY INSURANCE SYSTEM YOU’VE HEARD OF?

5.There are regular announcements of Ministries and local government agencies providing ‘free registration’ to indigents who will thereafter be exempt from paying premiums. So what we have is one part of government using public money to, wait for it, REGISTER people onto a scheme when these people are too poor to ever contribute to the scheme. Which makes you wonder, if these people are so poor that they can’t even afford to pay a few Ghana Cedis to register for the service, what then are they doing in an *insurance* program??? And if the government is going to be paying for their access to the actual service after the registration anyway, then why not simply scrap the registration fee?

6. In fact, why not create two completely separate programs: a Universal Health Care Fund, that is free for all poor and vulnerable people (using a combination of geographical indicators of poverty – i.e. some districts are nearly universally poor – and means-testing in the towns), and is free to register for? And then create a separate, ACTUAL, insurance scheme that BEHAVES like a proper insurance scheme, where premium contributions actually work to pool risk, cross-subsidise the sick with the contributions of the healthy, and invest the contributions in high-yielding financial products?

7. That way, the government can ensure that insurance fund can properly function as such, growing the investment base of the system to pay service providers on time, thus enabling them to invest in infrastructure, reverse outbound medical tourism and retain the money that would have flowed out in this country, and enhance the value chain of health in Ghana on top of it all. Surplus income may then be generated to reduce the government’s direct payments to the Universal Healthcare Fund (UHCF). Equally critically, we will then transparently see that growing the numbers of those dependent on the UHCF is nothing to be proud of, as it will demonstrate growing poverty and dependency.

8. Currently, the confusing setup of the NHIS mean that we rightly celebrate the growing subscriber base without pausing to reflect whether this mean that more and more Ghanaians are unable to make any financial contribution to their own healthcare, a metric that can by no means be celebrated by any sane society.

9. Why carry on a charade of an insurance scheme that is at one and the same time a ‘single-payer (government) universal health program’ and a ‘social health insurance program’? It is a mess, and that is why all studies show that the scheme will go bankrupt at the current rate of expenditure (even at the same time that it is struggling to pay its bills!)

10. Can’t every one see that by mixing this mess in one pot. we have made the whole thing fully unsustainable and unlikely to ever succeed in driving outcomes? It is lost on the leadership that a scheme that by evolution is now designed primarily to distribute free healthcare cannot incentivise its management to prioritise premiums mobilisation and the attraction of paying members. The skillsets and attitudes needed for the two competing goals are so different as to warrant a contradiction in terms. No wonder there are many people who can afford to contribute to the health insurance scheme but do not because they are never targeted as potential customers by the Scheme. The current setup of the system encourages the mass enrollment of non-paying beneficiaries and discourages the development of a customer-centric model capable of attracting mid-income earning Ghanaians capable of paying their share of premiums.

11. The only alternative to radical surgery to create two separate agencies with different mandates so that one of them can focus on premiums growth is to increase taxation across the board in order to plug the mounting deficits being witnessed by the scheme.


Obviously what a society values it rewards. And by what it rewards one can tell a lot about how it functions and will likely evolve.

Ghanaians seem to prize ‘humility’ a lot. Rarely do you see a person measured by integrity, skill, fortitude, steadfastness, diligence, candour, or several other virtues that other cultures seem to value much more.

This is intriguing as in most other places you don’t often hear ‘humility’ being used as the cardinal virtue when describing major reformers or leaders (presumption: cardinal virtues are often associated with those held up as exemplifying the society’s values). I mean, was Churchil humble? Martin Luther? Roosevelt? Da Vinci? Shaka? Osei Kwadwo Okoawia? Rameses II? Marcus Garvey? Feynman?

Is Gates humble? Soyinka? Desmond Tutu? Jack Welch? Is ‘humility’ the key attribute people associate with them?

What I mean is, can you mention a truly transformative figure in world history whose name immediately springs the word ‘humility’ into your mind as soon as you hear the name? I struggle to mention one. Even the case of Jesus Christ is debatable. Most of his claims (‘I am the bread of life…’ etc) won’t pass the Ghanaian test of ‘humility’.

So why do we put such an emphasis on ‘humility’? I suspect I am beginning to get a hint of why we do. I think when we say that someone exhibits ‘humility’ it is often another way of saying that the person appeals to our ego by making us feel adequate and sufficient even when we don’t merit it. In that respect, anyone who unsettles our sense of self-sufficiency or our easy notions can’t be humble. Anyone who makes us uncomfortable about our unexamined ideas and prejudices can’t be humble.

So it is not really ‘humility’ we prize but ‘mental comfort’. In some Ghanaian secondary schools, they call those who make people feel mentally comfortable ‘possi’.

If you are a young entrepreneur, you have no doubt heard the saying, “ideas are a dime a dozen; what matters is execution”, more times than you care to remember.

There is a morsel of truth in this but be careful you don’t fall for the notion entirely, because in a certain perspective it is quite fallacious.

‘Single ideas’ are indeed almost always worthless.

What really matters are ‘idea clusters’. Great ideas need dozens and dozens of other small ideas to ‘flesh them out’. I like to call this fact of life: ‘serial microinnovation’.

When you hear of a great idea executed flawlessly, it is virtually always because of several supporting ideas that guided the core idea into practice. And those ideas taken together form the ‘idea cluster’.

Don’t get it twisted. Idea-clusters are critical for execution.

When Apple writes that: “Apple’s innovation is embodied in its Intellectual Property, including Patents, Trademarks, and Copyrights”, they know what they are talking about. That’s why they spend billions defending the cluster of ideas that constitute their market advantage. As does any company worth their salt.

Empirical research has actually shown that for the S&P 500 companies, intangible assets (aka ‘ideas’) constitute a crazy 84% of their market capitalisation!

The problem therefore is not that ideas are worthless, but that single ideas are worthless. When ideas are too few, they are worth less and less.

Several ideas organised into a definite structure however reinforce each other; are harder to copy because the permutations of configuration increase dramatically; become indispensable to sound execution; and are critical for business success.