Our participatory wealth ranking (PWR) process has provided a qualitative understanding of community defined indicators of poverty in Ghana. The process and its findings are of importance for several reasons. First it highlights the fact that given the social and contextual nature of poverty rigid application of over simplified and standardized lists of identification criteria are not the way to go. Poverty is best identified by a composite of variables rather than one or a few simple (monetary) variables [8, 30, 31]. Our study revealed that with regard to material indicators of poverty, the range of indicators covered the themes of employment, ability to put and keep children in school, food availability and consumption, physical appearance, housing conditions, asset ownership, and health seeking behavior. With regard to the more non material indicators, social exclusion and marginalization was a recurring theme. From our key informant perspectives, a combination of these indicators rather than any single one defined the poorest households. Indeed in comparing similar indicators from our household survey of the same communities, we observed that households within the lower quintiles had lower levels of education, high levels of unemployment, limited number of assets and poor housing conditions.
Second, the community defined indicators of poverty were different from the indicators applied as criteria for exemptions under the National health insurance law in Legislative Instrument (LI) 1809. The defined criteria of unemployment with no visible source of income; no fixed place of residence according to standards determined by the scheme; not living with a person who is employed and who has a fixed place of residence and not having any identifiable consistent support from another person are clearly inappropriate from a community perspective in all the rural and semi urban sites. It was only in the urban community that unemployment was mentioned an indicator of poverty. In all the other communities, the poorest were employed predominantly in the traditional methods of farming and fishing which yielded lower remuneration.
The process of the national health insurance legislation development was a highly centralized one, often dominated by a small group of policy elite . These sharply divergent criteria and perspectives on poverty between the national level policy elite who developed the Legislative Instrument and community members bring to the front the inappropriateness of purely centralized approaches to designing social reform policies and legislations for the poorest. In developing such policy and accompanying programs, it is important to engage communities and make sure an understanding of their situation and perspectives informs the process. This will require special strategies targeted at getting the voice of the poorest, given the observations from our study of the social exclusion and marginalization of the poorest in community decision making.
Third, the ranking patterns of who is poor varied widely across communities as perceived state of poverty was relative to the context of the communities. In the typically farming (cash crop farming) community for example, households were perceived and ranked predominantly with middle class status contrasting extremely poor perceptions and ranks assigned to households in the typically fishing community. These perceptions did not overlap very well with the purely material indicators of poverty from our accompanying quantitative work that compared number of poor households from PWR versus MT. Clearly the more quantitative measures are measuring somewhat different dimensions of poverty as compared to PWR [17, 19]. The question that arises is which of these measures is of more importance in addressing poverty? Are households who are perceived in the context of the communities as “poorest” indeed the poorest regardless of where they fall on a means test? In a social context, perceptions and appearances can have more influence on the experience of individuals and households than their poverty or lack of it as measured on a quantitative scale such as means testing. There is a need to further explore how perceptions of the wealth and poverty status of households by their community members affect their experiences and vulnerability regardless of their actual material means.
Fourth, marginalization and social exclusion are also critical in the understanding of poverty in the study context. It is of interest that several of our key informants raised the issue of the poorest not being taken seriously or being ignored when community or family meetings are organized. The poorest are therefore the silent ones in society whose suggestions and contributions are considered, if ever, with less importance. The finding confirms earlier one by Van der Geest (1997)  in a study of money and respect among the elderly in a rural community in Ghana that having money measures the quality of the elderly with regard to the respect and prestige they receive within the community. Being poor was described as being ‘useless’ and lacking respect. Such notions about the poor is conveyed in the Akan proverb that Ohiani bu bε a yεnnfa; literally translated “a poor man’s proverb does not spread” . The deep meaning is that no one takes notice of what the poor says. That perception of the poor certainly points out a significant dilemma of poverty; those who are poor and more likely to require social support for health care are also the more likely to be ignored because they are the voiceless.
A number of key issues are important in interpretation of our results: first, in our current study, the indicators identified showed similarities across communities. The study was conducted in one region and there could be some variation when applying PWR to another region like the north with higher poverty levels and differences in socio cultural context and lifestyles. Second, the use of subjective measures implies that the definition of who is poor may vary widely across settings, as sometimes people’s expectations about benefits of the identification process and variations in relative perceptions of “poverty” may exaggerate or underestimate the numbers of identified poor. This may provoke in some way unequal exemption policies in a country like Ghana. Hence, the acceptability of PWR, in the population and among policy makers, as a uniform strategy to identify the poor in Ghana may be questionable. Third, the implementation of PWR is more feasible in terms of community interest, time and ease of administration in rural communities than urban. Rural communities are generally more are closely knit, and people know each other well to ascertain their poverty status. In this regard, our observations are in conformity with similar studies where PWR and other programs for the poorest have been carried out mainly in rural communities [19, 22]. Fourth, community members who represent the key informants are crucial in the outcome of the results. If there are imbalances in the representation, it may influence the results in ways that will not ensure true ranking of households.