Public Organization Review https://doi.org/10.1007/s11115-021-00520-w Perspectives on Public Policy Implementation in Developing World Context: The Case of Ghana’s Health Insurance Scheme Daniel Dramani Kipo‑Sunyehzi1 Accepted: 18 March 2021 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021 Abstract This paper examines factors that affect public policy implementation in develop- ing world context, with some evidence from Ghana. It looks at how public policy design; organisational and individual factors affect implementation. Public policy implementation debate is along with top-down, bottom-up or mixed approaches. The health insurance scheme in Ghana is a home-based initiative of a developing country to provide health insurance cover for all persons resident in Ghana including those who cannot afford to pay-the poor and vulnerable groups. It utilises more qualita- tive comparative research approach and used public and private health organisations (hospitals/clinics) in analysing policy implementation process. The results show pol- icy design and individual factors have more explanatory power than organisational factors. Also, results show more private health organisations received accreditation than the public ones. The public-private collaboration helped to increase policy ben- eficiaries’ access to healthcare services. But, these implementation challenges exist over-billings, over prescriptions, disagreements over tariffs and no prompt payments for healthcare services. It concludes that the private organisations exhibited more of agency than stewardship in protecting their profit-oriented/external interests. Keywords Public policy · Implementation · Health insurance · Health facilities · Developing world * Daniel Dramani Kipo-Sunyehzi dkipo-sunyehzi@ug.edu.gh 1 Legon Centre for International Affairs and Diplomacy (LECIAD), University of Ghana, Accra, Ghana Vol.:(012134 56789) D. D. Kipo-Sunyehzi Introduction Implementation involves carrying out policy decision, the transmission of policy into action, turning policy intentions into action (Hill & Hupe, 2009). Implementa- tion is linked to action, executing a policy or decision. O’Toole links policy imple- mentation to governmental intention and the actual results (O’Toole, 2012). This connects policy intentions (official documents like a legislative act, executive order, judicial action) to execution. Public policy implementation is turning policy into action. Policy implementation research has multiple loci, layers and levels; it can be studied from multi-levels, different units or a variety of loci observed. Policy implementation can take place between national and local level units or look at how civil servants in public bureaucracies’ work or cope with their working conditions (Lipsky, 1980, 2010). It can also focus on the relations between public and private organisations as in this study. Overview of Literature on Public Policy Perspectives and Theories Public Policy Perspectives Public policy implementation field was dominated by the two main perspectives: ‘top-down’ and ‘bottom-up’ approaches. Other scholars sought to merge or synthe- sise the approaches (Hill & Hupe, 2009). Top-downers assume that once the policy is formulated, it has to be implemented (in achieving its stated goals/objectives). The top-downers like Pressman & Wildavsky defines policy implementation as the “process of interaction between the setting of goals and actions geared to achieving them” (Pressman & Wildavsky, 1984, xxiii). Other top-downers like Van Meter and Van Horn conceptualise policy implementation as the “actions by public and private individuals (or groups) that are directed at the achievement of objectives outlined in prior policy decisions” (Van Meter & Van Horn, 1975: 447). The top-downers or the top-down implementation scholars focus more on decisions or intentions of policymakers (top politicians, senior officials) and how their decisions or intentions are carried out by implementers over time in achieving goals (Ayee, 2000; Howlett et al., 2009; Pressman & Wildavsky, 1984; Van Meter & Van Horn, 1975). However, the top-down perspective has been criticised for ignoring local level staff (street- level bureaucrats (SLBs) or front-line workers), the private actors and local imple- menters’ initiatives. Thus, the top-down perspective ignores those whose problem the policy seeks to address or solve (Hill, 1997; Lipsky, 1980, 2010; Sabatier, 1986). The bottom-up perspective grew stronger in the late 1970s and 1980s. Proponents of the bottom-up approach or perspective argue that implementation should engage or involve local level staff where their concerns, views, strategies and initiatives are paramount in policy implementation. The decisions that the local level staff/SLBs make, the procedures they establish as well as the devices or strategies they invent to cope with their work “effectively become the public policies they carry out” (Lip- sky, 1980: xii). This implies the local level staff or street-level bureaucrats make 1 3 Perspectives on Public Policy Implementation in Developing… and implement public policies. Bottom uppers argue implementation studies should start with those affected by the policy and the involvement of local actors in the implementation of public policy. This bottom-up perspective promotes ownership of public policies as the local implementers are actively involved (Hill, 1997; Hill & Hupe, 2009; Lipsky, 1980, 2010). This paper does not focus on the strengths and weaknesses of the two main perspectives but rather the study focuses on how the two perspectives complement each other. Thus, the emphasis is on their complemen- tary nature and but not the contradictions of the two perspectives. Other implementation scholars seek to end the debate on the two main perspectives and to merge or synthesise them. Sabatier acknowledges the methodological strength of the bottom-up approach in areas of networks, evaluating the influence of policy out- comes (Sabatier, 1986). Matland advocated for the merger of the top-down and bottom- up perspectives along with ambiguity/clarity of policy goals and means and the extent of the conflict. Thus, Matland emphasis is on policy’s ambiguity and level of conflict (Matland, 1995). Besides, Winter opines that the continuing debate between the top- down and bottom-up approaches as ‘unfruitful’. Winter’s view is that there is the need to integrate the key factors that affect policy implementation in the two perspectives into a single model which he calls the ‘integrated implementation model’ (Winter, 2012). Some Theories on Public Policy Implementation Winter’s integrated implementation model presents key factors and mechanisms that affect both implementation outputs and outcomes (Winter, 2012). These fac- tors include character of the policy formation process for the policy to be imple- mented; organisational and inter-organisational implementation behaviour; street- level bureaucratic behaviour; the response of target groups and the socio-economic context or conditions (Winter, 2012). The policy formulation process and design are identified as the factors that affect implementation results. Winter argues that public policies that have well-designed structure improve their implementation prospect. May also argues that “well-designed policies with effective instruments are neces- sary but not sufficient for improving implementation prospects” (May, 2012, p. 258). Then one may ask what constitutes policy design? Policy design is made of the goals, the instruments for obtaining policy goals and the agency charged to execute policy goals as well as the allocation of resources for ‘requisite tasks’ (May, 2012). Apart from policy design factors like policy goals/instrument that is crucial in implementation research, Winter’s model also identifies other crucial factors such as organisational behaviours. The emphasis is on organisational and inter-organisa- tional behaviours which represent different levels of commitment, cooperation and coordination at the intra-and inter-organisational levels (O’Toole, 2012; Saetren, 2005; Winter, 2012). Winter (2012) argues that implementation success is more likely when organisations have an interest in the policy or have resources to pursue their interests. Another area of importance to implementation scholars is the behaviour of indi- viduals. This includes behaviours of street-level bureaucrats and kind of relationship 1 3 D. D. Kipo-Sunyehzi Fig. 1 The Study Analytical Framework. Source: Author’s Design from Literature Review between their working conditions and the coping strategies and mechanisms they adopt in executing public policies (Lipsky, 1980, 2010). Other individuals that are crucial in policy implementation are the target groups of public policies. Hence, street- level bureaucrats and target groups behaviours/actions can bring positive or negative implementation results. This implies that street-level bureaucrats and target groups can influence policy implementation process to achieve or fail to achieve the policy goals. When target groups are in favour of public policy (have interest and resources), it is most likely to be successful, but where they are opposed to the public policy, an implementation may be unsuccessful (Skodvin et al., 2010; Winter, 2012). This study analytical framework focuses on three factors namely policy design factors, organi- sational factors and individual factors as in Fig. 1. History of Ghana’s Health Insurance Scheme and the Implementation Context of Ghana The cash and carry system practised in Ghana brought hardships to the people in the late 1980s and 1990s. On return to democracy in 1992, political parties espe- cially the then main opposition party-New Patriotic Party (NPP) campaigned to change the cash and carry system and to introduce the National Health Insurance Scheme (NHIS). This dominated 1996 and 2000 election campaigns and fortu- nately, the NPP won 2000 elections and introduced the NHIS. Hence, the NHIS 1 3 Perspectives on Public Policy Implementation in Developing… was formulated and passed into law (an Act of Parliament, Act 650) in 2003, and implemented in 2004 with Legislative Instrument (L.I.1809) (Government of Ghana, 2003, 2012). There has been extensive research works on NHIS includ- ing these studies (Agyepong, 1999; Agyepong & Adjei, 2008; Amporfu, 2011). Research Methodology The Study Design and Setting This study utilises a qualitative explanatory research strategy where participants were contacted in their ‘natural setting’ (homes/facilities) through interviews, observations and documentation. The study took place in Northern Ghana city of Tamale. Tamale Metropolis was selected as a study site due to its cosmo- politan nature and the numerous accredited NHIS health facilities (the public non-profit, the private non-profit and the private for-profit facilities). Four cases were purposively selected, two as clinics and two hospitals with three crite- ria namely ownership (government, private and mission/faith-based), duration (more than ten (10) years) and categories of service provision (out-patient, in- patient, pharmacies, diagnostic services). The four cases are Bilpeila Clinic (public non-profit), Haj Adams Clinic (private for-profit), West Hospital (public non-profit), and the Seventh Day Adventist (SDA) Hospital (private non-profit), all in Tamale Metropolis of Ghana. The Selection of Study Participants, Sampling and Sample Size This study included three categories of participants’ namely facility-based staff (medical doctors, nurses and other paramedics) and NHIS-based staff (manager, line managers and other clerks). These staffs constitute public policy implementers. The following categories also constitute health insurance beneficiaries: Social Secu- rity and National Insurance Trust (SSNIT) contributors (formal); premium payees (informal sector workers); persons less than 18 years; poor in society (indigents); pregnant women; persons 70 years and above (aged); and SSNIT pensioners. The public policy implementers were purposively selected based on the positions they occupy in their respective health facilities and organisations, and the roles they play at the workplace. This criterion was necessary in order not to randomly select any person in the health facilities (clinics/hospitals) and health insurance offices who may not have the relevant knowledge on the implementation of NHIS. Similarly, the NHIS beneficiaries (participants) were also ‘purposively selected’ through ‘purpo- sive sampling’-non-probability technique (Bryman, 2012; Creswell, 2009; Twumasi, 2001). Both in-depth and focus group discussions were used. This study sample size was 40 participants, 30 policy beneficiaries and 10 policy implementers. 1 3 D. D. Kipo-Sunyehzi Data Collection and Instruments/Tools Used The instrument or tool used for data collection was the interview guide. Each inter- view guide had two sets of questions for implementers: facilities staff, NHIS staff and another for beneficiaries. The implementers’ questions seek to solicit their views on how design factors, organisational and individuals’ factors affect the implemen- tation of NHIS at the local level (Tamale Metropolis). The questions covered three broad thematic areas namely quality of services and drugs, tariffs and timeliness in reimbursement for services and drugs/medicines rendered to beneficiaries. The beneficiaries interview guide covered three thematic areas namely attitude of imple- menters, referrals and prescription forms. The semi-structured interview guides were conducted by me (lead researcher) and the two research assistants. The inter- views and FGDs were recorded, which lasted between 40 min to 1 h. Fieldwork data was collected in 2012 (two months) and 2014 (four months which ended in Octo- ber 2014) from multiple data sources to increase reliability and validity of research findings. Data Analysis The audiotape recorded information in the local Dagbani language was transcribed, organised and analysed after translation from Ghanaian Language to English. The NVivo 10 software was helpful in data analysis, in which the participants’ responses were coded. Informed consent of participants was obtained, issues of privacy, ano- nymity were respected and adhered in the study. Results/Main Findings Policy Design Factors Accreditation On accreditation, it was found public and private healthcare facilities submitted their credentials and received approval by NHIA. This was how the regional official com- mented on accreditation: In the past public facilities were exempted from this process but now it is no more so, every facility must follow the accreditation process, present creden- tials, get approval before they can provide services to subscribers. I also solicited the views of district health insurance scheme officials on the accreditation process for public–private healthcare facilities and this was what Pub- lic Relation Officer said: Service providers by the health insurance law are required to follow the accreditation process, get approval from NHIA before they render health care 1 3 Perspectives on Public Policy Implementation in Developing… services to beneficiaries across Ghana. Any facility that provides services without following the due process of the law commits an offence and offenders will suffer the consequences of their illegalities. Some facilities are awarded higher grades others with lower grades and some are rated as primary, second- ary or tertiary health facilities. Thus, facility type, level and grade matters in the accreditation process. The interview responses from health insurance officials confirmed that healthcare facilities must receive accreditation before they render services to NHIS subscrib- ers (beneficiaries). Moreover, healthcare facilities are accredited based on facil- ity type (hospitals, polyclinics, clinics et cetera), facility-level (primary, secondary and tertiary) and facility grade (A + , A, B, C, D) and granted full accreditation but those who failed to meet basic requirements are awarded grade F (failed). Officials at both public and private health facilities (hospitals and clinics) confirmed what the health insurance authority officials at both district and regional offices said on accreditation. Also, I reviewed documents to examine the number of facilities that have been accredited. At the national level, the number of accredited healthcare facilities in 2012 was 3,575 which increased to 3,822 in 2013. Out of this number, 54% rep- resented government health facilities, 40% private, 5% mission and 1% quasi-gov- ernment (NHIA Annual Report, 2013, p. 9). This finding showed an increased in government, private and quasi-government while a decreased in mission/faith- based facilities. The overall figure showed that more public health facilities were accredited at the national level than private health facilities. However, at the local level (Tamale Metropolis) more private health facilities were accredited. I found 55 healthcare facilities were accredited within the ten years of the implementation of Table 1 Categories of Health Facility Type Facility Ownership GR.Total Care Facilities (Service Providers) and Ownership Public (Gov- Private (Indi- ernment) vidual/Mission) Tertiary Hospitals 1 - *Primary Hospitals 2 5 Poly Clinics - 1 *Clinics - 4 *Health Centres 6 - Maternity Homes - 5 CHPS Compounds 8 - Pharmacies - 10 Laboratories - 2 Diagnostic Centres - 4 Ultrasound Scan - 1 Chemical Shops - 6 Total 17 38 55 Author’s design from fieldwork Data 2012–2014 1 3 D. D. Kipo-Sunyehzi NHIS from 2004–2013 (National Health Insurance Authority, 2014). Out of the 55 health care facilities that were accredited for NHIS, the public (government) health facilities were 16 (29.1%), privately owned health facilities were 36 (65.5%), faith- based (mission) health facilities were two (3.6%) and quasi-government one as 1.8% (NHIA Accreditation Report, 2014). The categories or types of health facilities that were accredited at the local level to render various health services to NHIS beneficiaries are shown in Table 1. Table 1 shows that private actors and organisations had more accredited health facilities in Tamale Metropolis. It also shows private health facilities had more cat- egories of health service providers (polyclinics, laboratories, maternity homes, diag- nostic centres, pharmacies, chemical chops, ultrasound scan centres) accredited to provide a wide range of health services to NHIS beneficiaries in Tamale metropolis than the accredited public health care facilities. Policy Goals on NHIS Benefit Package, Excluded Services, Tariffs and Claims Implementation On NHIS benefits package and excluded services, both public and private staff were positive on benefits package as it covered 95% of common diseases in Ghana. But they did not agree on the excluded services. While the staff of private facilities were not enthused with the coverage rate and wonder why some key diseases were excluded, the staff at the public sector facilities indicated that some of the excluded services and diseases were necessary to keep NHIS from possible collapse due to the high cost of treatment for HIV retroviral drugs, dialysis for chronic renal failure et cetera. Interview findings from beneficiaries on the same issues of benefits pack- age, excluded services, tariffs, and claims, NHIS beneficiaries were either unwilling or lack of money to buy drugs and medicines outside NHIS approved lists during health service delivery. The beneficiaries were not happy with payments for certain services and drugs but commented less on tariffs and claims. On tariffs, it was found that tariffs were fixed on services rendered to NHIS ben- eficiaries. Also, the study found there were tariffs on categories of services like drugs and medicines, diagnostics (laboratory tests), X-rays, body scans, et cetera. The process of tariffs determination as in policy design (NHIS) was to be negoti- ated by NHIS authorities and NHIS service providers. However, the study found that tariffs were determined at the national level where prices were fixed on cat- egories of services for service providers. This arrangement was not favourable to local staff. This was how one health service provider complained about NHIS tariffs on the implementation of NHIS: you render services but you get fewer prices for the services rendered to clients. This complaint was found to affect the quality of health care services rendered to beneficiaries. The study found some service provid- ers were unwilling to provide effective and expensive health care services for lower NHIS tariffs to beneficiaries. Private service providers were the culprits as they were not willing to prescribe and disperse expensive drugs for lower tariffs. On claims, there were two problems namely delays and deductions. Findings have shown that service providers who failed to comply with strict NHIS service tariffs experienced deductions on their monthly claims. The NHIS staff indicated 1 3 Perspectives on Public Policy Implementation in Developing… that such deductions were made after rigorous vetting of monthly claims, while ser- vice providers particularly the private ones think otherwise. NHIS staff claim vetting of claims aim to check fraud while the tariffs aim at cost containment. Organisational Factors The focus is on intra-and inter-organisational relationships which address issues of cooperation and collaboration between and among public and private health facili- ties (organisations) during the implementation of NHIS. It was found in the study that organisational cooperation took the forms of referrals and prescriptions at the local level. Findings show that the four health facilities often refer patients/benefi- ciaries from one facility to another usually from a lower facility to higher facili- ties in times of emergencies. The observations were that the clinics often referred beneficiaries to primary hospitals. Primary hospitals also referred beneficiaries to the tertiary hospital (Tamale Teaching Hospital). This constitutes a vertical referral system. For non-emergency cases or situations are those that involved the absence of service or medicine and directing clients to other facilities where such services or medicines are available. This may also constitute the horizontal referral system. The cost of referrals is charged on NHIS since NHIS recognise such inter-organisational collaborations during health service delivery. Moreover, the NHIS covered emer- gency services. On inter-organisational coordination, it was found that all facilities had national health insurance offices. These offices coordinated the activities of NHIS and linked their facilities to district and regional offices of the National Health Insurance Authority (NHIA). Within each of the four healthcare facilities where the study was conducted, it was noted that all the facilities established sub-units. The sub-units work closely with the health insurance offices on all matters concerning the imple- mentation of NHIS. This was how private hospital staff commented on organisa- tional coordination: Our health insurance office here coordinate activities concerning health insur- ance among all the sub-units, we do submit our monthly claims on behalf of the hospital, work directly with all sub-units and other organisations to see to it that health insurance work for clients to access services. The public hospital health insurance official corroborated what the private hospi- tals official said: This health insurance office is the engine of the hospital, it is the main source of revenue for the hospital and every health insurance subscriber passes through this office first before moving to any other unit in the hospital. I also sought the views of NHIS beneficiaries on their access to health care ser- vices at facilities. A client at the private clinic commented on her access to health care services at the facility: 1 3 D. D. Kipo-Sunyehzi Any time I come to Haj Adams they take good care of me; they give me drugs and sometimes ask me to go to town with a form for other drugs at PK Gom- bila drugstore. I like this clinic a lot. When asked why she likes the Haj Adams clinic, she replied: They have a lab for a malaria test, and I don’t go out to another clinic for a lab test. I must tell you I don’t like when they ask me to pay for some drugs, this is cheating because health insurance covers all drugs and I don’t see why I should pay for anything why. Please, I don’t like to pay, pay matter at all. NHIS client at a public clinic expressed his views on distance travel to access health services: You can see for yourself my house is very close to Bilpeila clinic. I always go there for malaria treatment. That is my main sickness you know plenty of mos- quitoes in this house. When I asked what he dislikes about the clinic, this was what he said: There is no lab there so the nurses will tell you to go to Deaha Clinic. Twice they asked me to go there that is why I stopped this clinic and now go to Zog- beli hospital. There too there is a long queue so that is a problem but is ok. The responses above show NHIS clients have access to health care services due to intra-and inter-organisational collaboration between the implementing organisa- tions (public–private health facilities). The responses also revealed that the main coordinating unit within health facilities is the health insurance office, which worked with all other sub-units within the health facilities. The responses also revealed delays in reimbursement or non-payments for health care services while some cli- ents expressed frustrations in areas of long queues and many prescription forms. It was found that the private clinic provided more health care services than a public clinic because the private clinic had a laboratory to conduct diagnostic services but such a service was not found in the public clinic based on clients’ responses and my direct observation at the clinic (study site). The laboratory was not in operation in the public clinic at the time this study was conducted. Though there are many accredited service providers in the metropolis, yet some locations are far from service providers and have to find their means of transport (walking, riding bicycles, use motorbikes or taxi) to access health care services in Tamale Metropolis. Findings showed that NHIS beneficiaries can move from one service provider to another. The interview responses indicated that where one pro- vider lacked a medicine or drug, clients were provided prescriptions forms to access services free from other service providers. But payment for excluded services or drugs was found to be unfavourable to many beneficiaries. Thus, NHIS beneficiar- ies complained and expressed dissatisfaction overpayments for excluded services or drugs at facilities in Tamale. 1 3 Perspectives on Public Policy Implementation in Developing… Individual Factors The actions, behaviours of SLBs and target groups matter in implementation of pub- lic policies (Skodvin et al., 2010; Lipsky, 1980). In this regard, the actions of indi- viduals in public offices like NHIS office, facilities (hospitals and clinics) matter in policy implementation. Also, individual policy beneficiaries are crucial in imple- mentation. The views of individual workers and beneficiaries were sought for in implementation of NHIS in Tamale Metropolis. The individuals freely express their views, opinions and experiences on NHIS. The individual workers in NHIS office complained about congestion in the office during registrations and renewals. Due to delays or long queues, some clients turn to engage the workers in health insur- ance office or facilities with verbal exchanges on who should be served first. But the workers remained focus to serve their clients diligently and patiently. Some NHIS beneficiaries accused some individuals in NHIS office of bias, favouritism and trib- alism in their selection of clients for service provision. I also looked at working relations between NHIS staff and facilities staff. The individual workers in health care facilities indicated that they often cooperate with NHIS workers in areas of claims processing, vetting and often act on the direc- tives from NHIS workers. They expressed interest in the lump sum received from NHIS claims payments. But they expressed dissatisfaction at the time taken to reim- burse claims. I found all managers and administrators in the four health care facili- ties complaining so much about delays in payments of claims. They indicated the delayed payments over six months was against the laws that established NHIS and did not see why such delays. This was how a manager in private hospital commented on working relations with NHIS office: We like health insurance; we often try to prepare our monthly claims as far as we can without delays but when it comes to payment of claims it will take months to be paid. Just look at 2013 six to seven months before we were paid and that payment came after a series of strikes, why? This was how the hospital administrator commented on working relations and claims payments: You know we are government workers and are paid by the government so when they are delays in payments it does not affect us so much when com- pared with those in the private sector who will have to use the claims to pay their workers. Also, we receive more drugs from the regional medical store, so it helps a lot. We always have fruitful interaction and cooperation with health insurance officials in Tamale. The responses suggest health facilities staff did cooperate with NHIS staff in the preparation of monthly claims and following directives of NHIS staff on implemen- tation of NHIS. The delays have more negative effects on private providers than their public counterparts. Interviews with NHIS beneficiaries, I found some malpractices. Some individuals indicated that they could visit more than one facility a day and, in some cases, they 1 3 D. D. Kipo-Sunyehzi visit the facilities to collect drugs for their friends or relatives who are not members of NHIS. I observed that most health facilities often receive NHIS beneficiaries’ cards without checking their pictures thoroughly to ascertain if they are real health insurance cardholders. I made those observations in the field. What matter most to the implementers is to see that the card is valid and that it has not expired. Discussions Study findings revealed that things that happened at policy formulation and design stages (design factors) are essential for the successful implementation of public pol- icies. It was found that the NHIS has ‘vague’ or ‘ambitious’ goals which created implementation challenges at the local level. As policy designers made NHIS cover 95% of common diseases in Ghana, this appeared good to the people but difficult to implement due to financial, human and technical resources constraints at the local level. This Grindle and Thomas (1991) argue that for public policy to be success- fully implemented, it is necessary for policy proponents or makers to make enough resources available and such resources should be provided on time. This study found several policy design challenges. The study found a lack of clarity on some excluded services, approved drugs for beneficiaries. While policy designers or framers used the high cost of treatment to exclude some services and drugs/medicines from NHIS benefits package, some implementers especially the private service providers did not see why crucial services and diseases like HIV retroviral drugs and dialysis for chronic renal failure should be excluded from the NHIS benefit package list on grounds of cost. Another challenge found was that there were ‘complexity of joint actions and multiple clearance points’ in submission and reimbursement of claims to service providers as contained in the NHIS laws (Government of Ghana, 2003, 2012). The study found delays in submission and reimbursement of health insurance claims to facilities. This was attributed to the rigorous vetting processes from districts to regional claims processing centres before clearance from the head office in Accra. This finding is consistent with Pressman and Wildavsky (1984) findings on imple- mentation challenges in the Oakland programme on job creations. Also, coupled with the bureaucratic procedures, routines of street-level bureaucrats, working conditions and their coping strategies in executing policies (Lipsky, 1980, 2010; Tummers et al, 2015). This partly summarises key findings in this study on how policy design fac- tors affect the implementation of NHIS in Ghana. Ghana’s health insurance scheme goals towards universal coverage for all appeared to be far from attainment, partly due to its voluntary nature, attitudes of implement- ers, beneficiaries and the narrow tax-base of the scheme. Findings from documents in this study have shown that the ten years of implementation (2004–2013) only 38% of Ghana’s population was covered by NHIS in 2013 (NHIA Annual Report, 2013). Other findings confirmed the low coverage of the NHIS in Ghana towards universal coverage (Lagomarsino et al., 2012; Nyonator & Kutzin, 1999; Fusheini et al., 2016). 1 3 Perspectives on Public Policy Implementation in Developing… This study disagrees with Averill (2013) finding that the coverage of NHIS is as low as 18% for the same ten-year period of the implementation of NHIS in Ghana. One methodological strength of this study is the decision to adopt a comparative case study approach, this enabled me to look for patterns among four cases in terms of similarities and differences. This, Yin urges social science scholars to do compar- ative case studies despite its challenges (Yin (2014, p.3). This approach enabled this study to contribute to the knowledge of individuals, groups or organisations. Original Contribution of this Research This study has contributed to organisational behaviours in terms of goals congru- ence or incongruence and organisational culture in public policy implementation in a developing world context of Ghana. It was found in the study that where organisa- tional interests conflict with the goals of the policy, some organisations particularly private-for-profit ones turn to either shirk or sabotage the policy goals. This was found more in the private healthcare facilities (service providers) who could embark on strikes over delays in payments of their monthly claims. This finding concurs with Nguyen, 2011 findings in Vietnam where private health service providers have the desire to prescribe and dispense more drugs and medicines for clients with higher health insurance tariffs and conditions. In this context, the private service providers/facilities act more towards agency (self-seeking interests) than steward- ship (serving public interests). This study adds to the limited studies that relate to ‘motivational factors’ (Tummers et al., 2015). This was the case where the faith-based facility (SDA Hospital) organi- sational culture was found to be rooted in ‘service to man service to God’ in exhibit- ing more motivational factors -positive attitude towards beneficiaries/clients than as observed in the other healthcare facilities. It also contributed to knowledge on attitudes of individuals during public service delivery. It was found in the study that some policy beneficiaries tend to abuse the NHIS through their ‘shopping spree’ attitude as they moved from one health care facility to another for drugs and medicines for non-members (friends or relatives). Interestingly some policy implementers (facilities staff) were found to be engaged in acts like over prescriptions or over-invoicing against NHIS. These findings on abuses on NHIS are consistent with Amporfu, 2011; Kipo, 2011; Fusheini et al., 2016. Limitations One limitation is the inability to address the issues of statistical generalisation of findings from the four cases in a single district. This notwithstanding, the study is worth in terms of analytical generalisation and transferability of findings from this study to similar settings in other places. 1 3 D. D. Kipo-Sunyehzi Conclusions This study found that several factors contributed or facilitated the implementation of NHIS in the Tamale Metropolis. These factors include intra-inter-organisational col- laboration, the clarity of the policy goals, beneficiaries’ support for the health insur- ance scheme, organisational culture particularly from the faith-based health facilities inclination that service to man is service to God. Others include beneficiaries’ will- ingness to register and renew their membership to NHIS and the lump sum claims payments received from the health insurance authority are some of the facilitating factors. The study found myriad of factors that inhibited the implementation of NHIS in Ghana. Some of these factors include inadequate funding, delays in payments of claims, abuses on NHIS by some beneficiaries in terms of many visits to health facilities for drugs/medicines for some friends and relatives who are not beneficiar- ies of NHIS. Some health facilities are found to be engaged in some acts of fraud/ malpractice like over-invoicing, wrong application of tariffs and negligence of some health insurance officers in times of vetting of claims, delays in payments of claims to health facilities due to multiplicity of joint action and multiple clearance points from local to national levels. Also, long queues at health facilities and health insur- ance offices are some of the factors seen to have affected the implementation of NHIS in Ghana. Recommendations The study thereby recommends that it is essential for public policy makers to be crit- ical of policy design factors as well as organisational and individual factors. In this regard, policy makers need to consider policy means-resource availability, organi- sational interests and organisational culture, and individuals’ needs- socio-cultural factors and incorporate them well in policy design. Moreover, there should not be a dichotomy between policy design and implementation (Winter, 2012). This suggests there should be no separation between policy design and implementation. Also, the study findings support that frontline workers or SLBs are not only policy imple- menters but policymakers (Lipsky, 1980, 2010). Also, timely claims reimbursement/ payment is essential in the implementation of NHIS and for quality of healthcare services for beneficiaries. Finally, to deal with some moral hazards issues, NHIA needs to contract the right agents (health facilities) through a rigorous accreditation process. This is because moral hazards problems exist and apply to most developing countries. Acknowledgement My acknowledgement goes to the four health care facilities and the health insurance authority. Funding This research did not receive grant from any funder or agency (private, public or commercial). Declarations 1 3 Perspectives on Public Policy Implementation in Developing… Research Involving Human Participants and/or Animals Institutional permissions were sought for at the National, Regional and Local offices/authorities before the commencement of the fieldwork which involved human participants/persons. Informed Consent The informed consent forms were given out to the study participants, where their con- sents were obtained in writing (signing/thump print) or in some cases orally before interviews. Participa- tion was strictly voluntary, privacy, anonymity and other ethical issues were adhered to in the study. Disclosure of Potential Conflicts of Interest The author declares no conflict of interest. References Agyepong, I. A. (1999). Reforming health service delivery at district level in Ghana: The perspective of a district medical officer. Health Policy and Planning, 14(1), 59–69. https://d oi. org/1 0. 1093/ heapol/ 14.1.5 9 Agyepong, I. A., & Adjei, S. (2008). Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme. Health Policy and Planning, 23(2), 150–160. https:// doi.o rg/ 10.1 093/ heapol/ czn002 Amporfu, E. (2011). Private hospital accreditation and inducement of care under the Ghanaian national insurance scheme. Health Economics Review, 1(1), 13. https:// doi. org/ 10. 1186/2 191- 1991-1- 13 Averill, C. (2013). Universal health coverage: Why health insurance schemes are leaving the poor behind. Oxfam International. Ayee, J. R. A. (2000). Saints wizards demons and systems: Explaining the success or failure of public policies and programmes. Ghana Universities Press. Bryman, A. (2012). Social research methods. (4th ed.). Oxford University Press. Creswell, J. W. (2009). Research design: Qualitative, quantitative and mixed methods approaches. (3rd ed.). Sage Publications Inc. Fusheini, A., Marnoch, G., & Gray, A. M. (2016). Implementation challenges of the national health insur- ance scheme in selected districts in Ghana: Evidence from the field. International Journal of Public Administration, 1–11. https:// doi.o rg/1 0. 1080/0 1900 692. 2015.1 1279 63 Government of Ghana (2003). National health insurance act. (Act 650). GoG. Government of Ghana (2012). National health insurance act. (Act, 852). GoG. Grindle, M. S., & Thomas, J. W. (1991). Public choices and policy change: The political economy of reform in developing countries. Johns Hopkins University Press. Hill, M. (1997). The policy process: A reader. 2 nd ed. Princeton Hall. Hill, M., & Hupe, P. (2009). Implementing public policy. (2nd ed.). SAGE Publications. Howlett, M., Ramesh, M., & Perl, A. (2009). Studying public policy: Policy cycles and policy subsystems. Oxford University Press. Kipo, D. D. (2011). Implementation of public policy at the local level in Ghana: The case of national health insurance scheme in Sawla-Tuna-Kalba District. Master of Philosophy Thesis, University of Bergen, Norway. Lagomarsino, G., Garabrant, A., Adyas, A., Muga, R., & Otoo, N. (2012). Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. The Lan- cet, 380, 933–943. https://d oi.o rg/1 0. 1016/S 0140-6 736(12) 61147-7 Lipsky, M. (1980). Street-level bureaucracy: Dilemmas of the individual in public services. Russell Sage Foundation. Lipsky, M. (2010). Street-level bureaucracy: Dilemmas of the individual in public service. 30th (Ann). Russell Sage Foundation. Matland, R. E. (1995). Synthesizing the implementation literature: The ambiguity-conflict model of pol- icy implementation. Journal of Public Administration and Theory, 5(2), 145–174. https:// doi. org/1 0. 1093/o xford journ als.j part.a 03724 2 May, P. J. (2012). Policy design and implementation. In B. G. Peters & J. Pierre (Eds.), Handbook of Public Administration. Sage. National Health Insurance Authority. (2013). Annual report. NHIA. 1 3 D. D. Kipo-Sunyehzi National Health Insurance Authority. (2014). Accreditation Report-July 2009-December 2013. NHIA. Nguyen, H. (2011). The principal-agent problems in health care: Evidence from prescribing patterns of private providers in Vietnam. Health Policy and Planning, 26, i53–i62 Nyonator, F., & Kutzin, J. (1999). Health for some? The effects of user fees in the Volta Region of Ghana. Health Policy and Planning, 14(4), 329–341. https:// doi.o rg/1 0.1 093/ heapol/ 14.4. 329 O’toole, L. J., Jr. (2012). Interorganizational relations and policy implementation. In B. G. Peters & J. Pierre (Eds.), Handbook of public administration. Sage Publications. Pressman, J. L., & Wildavsky, A. (1984). Implementation. (3rd ed.). University of California Press. Sabatier, P. A. (1986). Top-down and bottom-up approaches to implementation research: A critical analy- sis and suggested synthesis. Journal of Public Policy, 6(1), 21–48. https://d oi. org/ 10.1 017/ S0143 814X00 0038 46 Saetren, H. (2005). Facts and myths about research on public policy implementation: Out of fashion, allegedly dead but still very much alive and relevant. The Policy Studies Journal, 33(4), 559–582. https://d oi. org/1 0.1 111/j. 1541- 0072. 2005.0 0133.x Skodvin, T., Gullberg, A. T., & Aakre, S. (2010). Target-group influence and political feasibility: The case of climate policy design in Europe. Journal of European Public Policy, 17(6), 854–873. https:// doi. org/ 10.1 080/1 3501 763.2 010. 486991 Tamale Metropolitan Mutual Health Insurance Scheme. (2011). Annual report. Tamale. Tummers, L. L., Bekkers, V., Vink, E., & Musheno, M. (2015). Coping during public service delivery: A conceptualization and systematic review of the literature. Journal of Public Administration Research and Theory, 25(4), 1099–1126 Twumasi, P. A. (2001). Social science research: In rural communities. (2nd ed.). Ghana Universities Press. Van Meter, D., & Van Horn, C. E. (1975). The policy implementation process: A conceptual framework. Administration and Society, 6(4), 445–488 Winter, S. (2012). Implementation. In B. G. Peters & J. Pierre (Eds.), Handbook of Public Administra- tion. Sage Publications. Yin, R. K. (2014). Case Study Research: Design and Methods. (5th ed.). Sage Publications Inc. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 1 3