Ghana is at an important crossroads. There is a need for a new and sustainable response to contain the alarming spread of the COVID-19 virus amongst the population. On Thursday, 9th July 2020, four health unions, comprising the Ghana Medical Association (GMA), Registered Nurses and Midwives Association of Ghana (GRNMA), the Health Services Workers Union of the TUC (HSWU) and the Government and Hospital Pharmacists Association (GHOSPA) held a press conference to express concern over the increasing rate of infections and the severe impact on health workers. In terms of figures, they disclosed that 770 health workers had contracted COVID-19. The number includes 190 doctors, 416 nurses, 156 health service workers and 23 pharmacists. In total, 10 health professionals from this group had died. The Unions identified the alarming rate of infections and the lack of Personal Protective Equipment (PPEs) and other protective consumables as the main threat to health workers.
At the same time, election activities are ramping up and the Electoral Commission’s (EC) compilation of a new register, which aims to register some 18 million Ghanaians is in full swing. Political parties are also preparing to move fully into campaign mode. Given the reality that the country is heading for a public health crisis if nothing is done quickly, and the reality that Ghana faces a constitutional crisis if elections are not held on 7th December 2020, what are the options to consider to avert both a public health and constitutional crisis?
The Public Health Reality
Ghana is facing an imminent public health crisis. The recent alarming rate of increase in the COVID-19 case count, particularly the seven-day positivity rate is a serious concern. First, total cases as at 31st May was 7,881. Within four weeks (June), the number of cases increased from 9,860 to 17,441. According to the Ghana Health Service (GHS), total case count as at 12th July 2020 was 25,430, meaning 7,989 cases have been added in just 12 days of July. According to Kwame Asiedu Sarpong, CDD-Ghana Democracy and Development Fellow on Public Health, the signs were there as far back as 17th April 2020 when Accra and Kumasi were placed under lockdown, during which period, Ghana’s cumulative case count began to double weekly.
From 641 cases on April 17th to 1,279 cases within seven days. Before that, it had taken four weeks from 12th March when the first two cases were announced to get to 506 cases.
Second, the increase in the cumulative rate reflects the increase in the prevalence rate. The prevalence rate has reached alarming proportions in the last few weeks. Currently, we are at 84 out of every 100,000 persons infected. This has more than doubled since 5th June 2020 when it was 31 out of 100,000 persons infected. In its 12th July update report, the GHS stated that the average positivity rate for routine surveillance was 8.29% and enhanced contract tracing was 7.15% on average from March to July, suggesting an already high number of people testing positive from the tests conducted. However, even this figure requires additional reconciliation, given the current cumulative increase. A week by week case count suggest a higher positivity rate, some as high as 23% which should give a greater cause for concern in terms of estimating a breaking point for Ghana’s health infrastructure and personnel.
Third, there were 21, 511 recoveries/discharges, 139 deaths, 3,780 active cases as at 12th July. We still don’t know what proportion of the total cases are discharges (one test) or recoveries (two tests) to estimate the patient management burden per week. Moreover, with the time lag between testing and test results, it is also difficult to track how the active case count compares with the cumulative case every seven days. Lastly, another dimension which is troubling and should motivate a much stronger, urgent and long-term response is the threat of a chronic disease burden on the population, particularly respiratory complication in the years to come. In essence, the fewer people who get the disease, the better it is for the management of the country’s disease burden now and in the future. It is, of course, no surprise that the recent spikes in the case count have coincided with the gradual easing of government restrictions, the failure of enforcing strict adherence to COVID19 protocols and the high incidence of non-compliance by the majority of citizens. On 31st May 2020, President Nana Akuffo Addo announced further easing of restrictions to allow the resumption of churches, schools and political activities, among others.
With a high incidence of community spread by the end of May, the reintroduction of limited forms of mass gathering from the beginning of June appears to have increased the risk of infection. So far, the churches have proven to be better equipped in enforcing the restrictions. Unfortunately, all other categories of activities allowed to operate have struggled to enforce the observance of COVID protocols. A few days ago, the Ministry of Education reported some Second Cycle Schools have reported COVID-19 cases, a month after final year students were asked to return to school.
A high incidence of political activity related infections has also been reported. Several high profile politicians contracted the virus after the governing New Patriotic Party (NPP) held its parliamentary primaries, with one unfortunate fatality. Also, following an event to acclaim President Nana Akuffo-Addo as the NPP’s flagbearer for the 2020 elections, leading political figures have contracted the virus, forcing the President to undergo self-isolation for 14 days. Infections in the workplace are also rising and prominent state institutions like the Ministry of Finance and Economic Planning (MOFEP) and Ghana Cocoa Board (COCOBOD) have had to shut down their physical premises temporarily. Given the public health reality and the impending crisis, something needs to be done in the next two to four weeks to stem the rate of infections. Otherwise the consequences will be dire for all citizens.
The Elections and Governance Reality
The alarming spread of the COVID-19 cases has led to calls for the ongoing voter registration exercise to be stopped. There have been similar calls for schools to be closed to allow students to return home. Unfortunately, when it comes to elections, it is difficult to see any viable alternative option for conducting an election on 7th December. Article 66 (1) and (2) of the 1992 Constitution of Ghana sets out the term of office of a President as four years from the day he is sworn in. A person elected as President can only serve two terms. No provision in the Constitution caters for a situation where a President’s term can be extended even by a day after its expiration. Article 298 empowers Parliament to enact legislation to provide for a matter not provided for in the Constitution. However, it is important to note that an Act of Parliament is subordinate to the Constitution. Therefore, any legislation aimed at ‘providing for [a] matter’ which is inconsistent with the Constitution would be unconstitutional. Thus the Article 298 window cannot be used to extend a President’s term after it expires because the Constitution is crystal clear on the duration of a President’s term.
It has been suggested that Article 113 may provide a solution. Article 113 envisages a situation where Parliament has been dissolved but fresh elections cannot be held, due to a public emergency (including war). Under such circumstance, the ‘lame duck’ President, with the support of two-thirds majority votes of MPs, may extend the life of Parliament. The extension of Parliament’s life under Article 113 (2) is valid for a 12-month period at a time, but cannot exceed 4 years. In this Article 113 scenario, the President (whose term has/may have expired) leaves the scene. Whether or not the Speaker of Parliament in this scenario, can act as President pending fresh elections, is a matter of constitutional interpretation.
The Article 113 scenario may seem practical but it is problematic on two fronts. First, Article 60, which allows the Speaker to act as President, in the absence of the President and the Vice President, envisages a situation where the President and Vice President are temporarily absent, not when the President’s term has expired. The expiration of the term of the President – coterminous with that of the Vice President – is permanent unless the President is re-elected.
Second, Article 112 (4) provides that parliamentary elections should be held latest 30 days before Parliament is dissolved. It is important to note that Article 112 (4) is subject to Article 113 (2) discussed above. Therefore, Article 112 (4) can only be applicable in the absence of a public emergency contemplated by the framers of the Constitution under Article 113(2). No public emergency has been declared in Ghana by the President yet as a result of the COVID19 pandemic. Therefore, we can assume that Article 112 (4) is in full effect and must be complied with.
Ghana combines its presidential and parliamentary elections. The dissolution of Parliament occurs on the 6th of January, the same day the President’s term expires. As such, the circumstances where a President can recall a dissolved Parliament before an election is held cannot exist in the current arrangement. This means elections must be held on 7th December 2020 to either renew the mandate of the current President or give a fresh mandate to another person.
If elections must be held in December, we cannot walk back on the ongoing voter registration exercise. Already the process has been significantly delayed even as the EC tries to address different challenges including the failure of applicants to comply with COVID-19 protocols. Some of the delays mean the plan by the EC to conduct a mop-up exercise after 38 days or so will have to be extended to mop up some applicants, particularly from phases 1 to 3 of the exercise. After that, there will be an exhibition of the voter register and other processes before a magistrate certifies the register to be valid for the elections. If further delays are managed then it is likely nomination of candidates will be taken at the end of September or in October. This will be followed by the transfer of votes, special voting and voting day. Political campaigns are likely to be in full swing after the voter registration at the beginning of September. All these election-related activities mean that there are going to be many instances of large crowds gathering for one activity or the other and therefore an increase in the risk of COVID-19 infection. In essence, we are between a rock and a hard place. No amount of screaming and shouting will shift the two realities. Therefore, as a country, we must stay calm, think smart, be proactive and respond to the challenge.
The irony of the country’s predicament and that of many countries in our situation is that we need the structure and stability of government to coordinate an effective response to the COVID-19 pandemic. There is no substitute for an effective State. Unfortunately, our country is also caught up in the chaos of competitive and highly partisan electioneering. Parties do not want to share the limelight as they make their case to the electorate. At the same time, opposition parties are waiting for the smallest mistake or public disaffection to jump on and show voters the incompetence of their rivals. However, the State, the government or the Executive cannot do it alone. There is a need for a broader ‘Co-Leadership’ amongst the State, the Government, the Executive, the political parties, organized citizens (CSOs), traditional authorities, religious bodies, media and the creative arts. Combining these institutions would significantly improve the trust between the State and its citizens. These groups also have the reach and social capital to influence citizens across Ghana in ways that the State will struggle to. Lastly, they would help cut through the ‘partisan noise’ to get citizens to take more responsibility.
The next two to four weeks are crucial for Ghana and the following actions can help to reduce the spread of COVID-19 and build the much needed trust to move the country in the same direction:
1. Enhanced citizen engagement – The “all hands on deck” strategy: The National COVID-19 Team used the Enhanced Surveillance Monitoring strategy to identify positive cases and isolate them for treatment. Using the same logic, Ghana must go beyond the current structure of education and information to an enhanced strategy. The President should empower the Coordinator of Ghana’s Coronavirus Response Programme, Dr Anarfi Asamoa-Baah, to convene a two-day national meeting to discuss the role of various stakeholders in educating and promoting compliance with COVID19 anti-spread protocols. This should be small and short meetings with various groups, including political party leaders (general secretaries, national organizers and national youth and women organisers); the National House of Chiefs; heads of religious bodies; editors and owners of media houses; heads of Civil Society Organizations; creative arts persons from the music and film industry; among others.
Some of the interventions for political parties could include using information and educational materials developed by the National Commission on Civic Education (NCCE) to educate citizens jointly at registration centers; all party leaders can appear together in ‘infomercials’ to educate citizens. Besides, political parties working with law enforcement have to strategize on political campaigns. Traditionally, even if candidates arrive at a town or city at night, their supporters will still mobilize people to meet them and it will turn into a rally. But large gatherings at night would be a disaster. So, there must be some consensus that allows for effective compliance with the protocols. For traditional leaders, it can involve the Yaa Naa or the Asantehene doing an occasional broadcast to citizens in their respective traditional areas. For the creative arts, working with artists like Sarkodie, Shatta Wale, Nana Ama McBrown, Lil Wayne and Stoneboy can transform the way the public health message will be received by the youth. A number of these citizen groups can self-finance their interventions as part of their contribution to support their fellow citizens.
2. Co-financing mass testing and PPEs: It is very difficult to fight the disease if we do not know who has it, who does not, who is sick and who is not. The country must look at ramping up testing again. Considering the challenges that health workers are facing and the threat to our capacity to manage the current impact on our health infrastructure, we will have to prioritize health sector workers, not just frontline workers. Also, if we have to keep the schools open then we will have to also prioritize students. In addition, we will need to identify some essential workers (security services, election officials, electricity and water provision staff) and prioritize them. The challenge is the cost of the Polymerase Chain Reaction (PCR) test is a $100. Ghana has performed some 327,000 tests which equates to $32.7million so far. Currently, some private hospitals are charging about 200 Ghana Cedis to collect samples and send to Noguchi for processing. Citizen-led fundraising to fund testing can make a significant difference to our current response. The private sector can also help test their employees if they have the means to do so to reduce the burden on the state. The COVID-19 Trust Fund is generating some good amount of resources that can be used to fund testing for health workers and students. The approach should be extended to financing PPEs for health workers. These are consumables and we should expect shortages if cases surge.
Bearing in mind that cost is a factor, it is surprising that Ghana has not embraced the cheaper (about $40) Rapid Diagnostic Test (RDT) used to test for antibodies. Basically, the RDTs, which can give you results in 20 minutes or less, detects whether there is the presence of antibodies in a person’s body which indicates that a person has contracted the disease before or is currently infected. RDTs are considered less accurate but is increasingly being used in a number of jurisdictions to improve testing. Interestingly, a Ghanaian start firm Incas Diagnostics and the Kwame Nkrumah University of Science and Technology (KNUST) have developed an RDT test kit which gives results in 20 minutes. Their product is currently going through Food and Drugs Authority (FDA) approvals. Our COVID-19 disease profile shows a lot of people are asymptomatic. Given that reality and the cost of PCRs, an anti-body test should suffice to identify a lot of people so we can isolate or track them to even learn more about the disease.
Another government policy which requires explanation is the decision to prevent private hospitals from administering the test for COVID-19. Considering the financial burden, would it not be helpful if citizens who can afford to take the test pay for it fully, so that the State can worry about those who cannot afford it. It is simply a game of identifying infected persons and isolating them. At the moment, you will pay GHS188 at Nyaho Hospital for them to take your sample, and the sample will be sent to Noguchi for processing, which will take two to three weeks for the results to be ready. It means the government is absorbing the $100 cost of the PCR kit. Why should a government with scare resources insist on bearing all the cost which can be absorbed by some citizens?
Lastly, if the testing strategy is to work then the turnaround time for results have to improve significantly. The average 2-3 week time lag would be a problem. Certainly, RDTs will help in this regard but beyond that, there is need for more test centers. There is some indication that some of the regional testing centres that were set up to boost testing would become operational soon to augment the response. If the financial burden for testing is reduced, the state could invest in infrastructure for processing the test.
3. Donating more makeshift isolation centers: Several churches and individuals have donated various structures to the government to be used as isolation centres. This should be encouraged and publicly recognized. The state must also provide some incentives for people who have taken this step. Unfortunately, such people have been stigmatized for doing their civic duty, and it is for this reason that we must turn this issue of stigma on its head.
4. Fighting COVID-19 stigmatization: It is incredible to hear the horror stories from friends who have tested positive for COVID-19 and are having to hide from people for fear of being stigmatized. It is such a shameful act but it is one borne out of ignorance and fear of the unknown. The NCCE and the President have had cause to raise concerns about this issue but it continues unabated. The messaging around stigmatization must be central to the Enhanced Public Engagement Strategy.
Ghana is in a precarious situation in terms of the rate of spread of the COVID-19 virus. At the same time, we have no option but to hold elections come 7th December 2020. It means activities in the electoral calendar such as the voter registration exercise would have to be implemented. To reduce the spread of the virus and ensure the country avoids a constitutional crisis, the Executive must adopt a Co-Leadership Strategy by bringing several non-State actors political parties, traditional authorities, religious leaders, CSOs, media and the creative arts together to support an enhanced engagement strategy. Citizens should support the financing of testing for health workers, students and essential State workers. Government should also review its policies on the use of RDTs and allow private hospitals to support testing. Lastly, we will need more testing sites to improve turnaround time and we must intensify the antistigma campaign.
By Kojo Pumpuni Asante (PhD) Director, Advocacy and Policy Engagement, Ghana Center for Democratic Development (CDDGhana)