UNIVERSITY OF GHANA IMPLEMENTATION OF THE DISTRICT- WIDE MUTUAL HEALTH INSURANCE SCHEME IN GA WEST MUNICIPALITY BY DIANA AMONI NTEWUSU (10358057) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL PUBLIC ADMINISTRATION DEGREE JUNE, 2014 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I do hereb y decl are that t his work is the result of m y own res ear ch and has not been pres ented b y an yon e for an y ac ademi c award in thi s or an y ot her universit y. All ref ere nces used in the work have be en full y acknowl edged. I bear sole responsi bil it y for the shortcomin gs. ………………………….... … ………………………….. DIANA AM ON I NTEW USU DATE (STUDENT) University of Ghana http://ugspace.ug.edu.gh i i CERTIFICATION I he reb y certif y th at thi s thesis was supervised in accord ance with proc ed ures laid down by the Universit y. …………………………... …………………………….. DR. KWAME ASAMOAH DATE (SUP ERV IS OR) University of Ghana http://ugspace.ug.edu.gh i i i DEDICATION This thesis is dedicated to three important people who contribut ed so much in m y upbrin ging but have all be en call ed to gl or y: Mr. J . D. Amoni (my dad and ‘teacher’), Rev. Fr. Bolek Gielata (SVD ) and Rev. Sis. Gen evieve Siese gh (SM I) . Ma y th e y have etern al rest. University of Ghana http://ugspace.ug.edu.gh i v ACKNOWLEDGEMENT The succ essful compl eti o n of thi s thesis depended on the go odwill and assi stance of a number of people to whom I owe a debt of grati tude. M y sin cer e grati tude go es to m y supervisor Dr. Kwame Asamoah for his academi c guid ance, support and tol e ranc e. His pati ence, advic e and critical insi ghts from the proposal sta ge throu gh to drafts and finall y the compl eted work dese rve much comm endati on. I am equall y indebted t o the mana g ement and staff of Ga Dist rict Mutual Healt h Insuran ce Scheme (GDMH IS ) fo r all the data the y gav e for thi s work and their assi stance and coop erati on during th e pe riod of stu d y. I am equall y gr ateful to the Admini strati on and staff of Amas aman gove rnment hospit al, Fr anco gina Labo rator y Se rvices in Amasaman an d St. Moses Cli nic in Pokuase for providi n g me with information on the Healt h Insur anc e in their respecti ve facil it ies. Great thanks also to the numerous subscribe rs of the Ga Scheme who mad e themselves av ail able and provided information for the purpose of thi s stud y. I also want to sa y thank you to m y coll ea gues and friends especiall y Poli ce Superi ntendent S ylv ester Bo yuo, Michael Anson g Diawuo and La wren ce Offei Asa re fo r their suppo rt and encou ra gem ent . I also want to appreci ate the care and conc ern fro m m y mot he r Madam Al ice Amanki Attah who supported in diverse wa ys especiall y in the upke e p of m y chil dren whiles I undertook thi s stud y. I cannot also for get m y si bli ngs Ken, Sist er Laadi, Theresa and Fl ora for the ir moral and spirit ual support. Finall y m y hea rtfelt gr ati tude go es to m y husband Dr. Samuel Anie g ye Nte wusu and m y chil dren Kingsle y and Samm y J unior. The y have be en a source of support and ex hibi ted a lot of understandin g as I pu rsued thi s cou rse. University of Ghana http://ugspace.ug.edu.gh v TABLE OF CONTENTS Contents DEC LARAT ION ................................ ................................ ................................ ........................ i CERT IF IC AT IO N ................................ ................................ ................................ ..................... ii DED IC AT IO N ................................ ................................ ................................ ......................... iii ACKNOW LED GEMEN T ................................ ................................ ................................ ........ iv TABLE OF CONTE NTS ................................ ................................ ................................ ........... v LIS T OF TA BLES ................................ ................................ ................................ ................. vii i LIS T OF FIGUR ES ................................ ................................ ................................ ................. i ix ABS TRAC T ................................ ................................ ................................ ............................... x CHAPTER ONE ................................ ................................ .... Error! Book mark not def in ed . GENERAL INTRODUCTION TO THE STUDY .............. Error! Book mark not def in ed . 1.0 Back ground to the Stud y ................................ .................... Error! Book mark not def in ed . 1.1 Statement of the Problem ................................ ................... Error! Book mark not def in ed . 1.2 Objecti ves of the Stu d y ................................ ...................... Error! Book mark not def in ed . 1.3 Research Questi ons ................................ ............................ Error! Book mark not def in ed . 1.4 Scope and Lim it ati ons of the Stud y ................................ ... Error! Book mark not def in ed . 1.5 Significanc e of the St ud y ................................ ................... Error! Book mark not def in ed . 1.6 Organisati on of the S tud y ................................ .................. Error! Book mark not def in ed . CHAPTER TWO ................................ ................................ ... Error! Book mark not def in ed . REVIEW OF RELEVANT LITERATURE ........................ Error! Book mark not def in ed . 2. 0 Introdu cti on ................................ ................................ ........ Error! Book mark not def in ed . 2.1 Concept of Impl emen tation ................................ ................ Error! Book mark not def in ed . 2.2 Poli c y Impl ementati o n: Top -Down and Bott om -Up Approa ches ................................ ..... 10 2.2.1 Top-down Model ................................ ............................ Error! Book mark not def in ed . 2.2.2 Bott om -up Model ................................ ............................ Error! Book mark not def in ed . 2.2.3 S ynt hesis of bott om -up and top-down app r oaches ......... Error! Boo k mark not def in ed . 2.3 Brief insi ghts into Successful and fail ed imple mentati on poli c y ...... Error! Book mark not def in ed . 2.4 Facto rs that aff ect po li c y implementation .......................... Error! Book mark not def in ed . 2.5 Bar riers to poli c y implementation in developi ng countri es Error! Book mark not def in ed . 2.6 Conceptual Fr amewo rk ................................ ...................... Error! Book mark not def in ed . 2.6.1 Poli c y Content ................................ ................................ . Error! Book mark not def in ed . 2.6.2 Comm it ment of implementers to the poli c y ................. 3 Error! Book mark not def in ed . 2.6.3 Support of cli ents and coali ti ons for implementation ..... Error! Book mark not def in ed . 2.6.4 Capacit y to Impl ement Poli c y ................................ ......... Error! Book mark not def in ed . 2.6.5 Atti tudes of implementers towards the poli c y ................ Error! Book mar k not def in ed . 2.6.6 Contex t of Impl em entation ................................ ............. Error! Book mark not def in ed . 2.7 Summ ar y and Conclu sion ................................ .................. Error! Book mark not def in ed . University of Ghana http://ugspace.ug.edu.gh vi CHAPTER THREE ................................ ............................... Error! Book mark not def in ed . IMPLEMENTATION OF THE NATIONAL HEALTH INSURANCE SCHEME IN GHANA ................................ ................................ ................... Error! Book mark not def in ed . 3.0 Introdu cti on ................................ ................................ ........ Error! Book mark not def in ed . 3.1 Hist orical contex t of the healt h insu ranc e in Ghana .......... Error! Book mark not def in ed . 3.2 The Nati onal He alt h Insu ranc e Scheme ............................. Error! Book mark not def in ed . 3.3 Impl ementin g he alt h insu rance in Gh ana .......................... Error! Book mark not def in ed . 3.4 Actors in the implementation of healt h insu ran ce ............. Error! Book mark no t def in ed . 3.4.1 Role of Governmen t in the impl ementati on of healt h insu ranc e ... Error! Book mark not def in ed . 3.4.2 The Nati onal He alt h Insu ranc e Authorit y ....................... Error! Book mark not def in ed . 3.4.3 Service provide rs ................................ ............................ Error! Book mark not def in ed . 3.4.4 Staff of the Scheme ................................ ......................... Error! Book mark not def in ed . 3.4.5 Subscribers ................................ ................................ ...... Error! Book mark not def in ed . 3.5 Summ ar y and Conclu sion ................................ ................................ ................................ .. 50 CHAPTER FOUR ................................ ................................ ................................ .................. 51 METHODS OF DATA COLLECTION AND ANALYSIS Error! Book mark not def in ed . 4.0 Introdu cti on ................................ ................................ ........ Error! Book mark not def in ed . 4.1 The Resea rch Design ................................ ......................... Error! Book mark not def in ed . 4.2 Population and Sample Siz e of the Stud y .......................... Error! Book mark not de f in ed . 4.3 Sampl ing and Sampl ing Technique ................................ ... Error! Book mark not def in ed . 4.4 Sampl e Siz e ................................ ................................ ........ Error! Book mark not def in ed . 4.5 Types and Sourc es of Data ................................ ................ Error! Book mark not def in ed . 4.5.1 Secondar y Data ................................ ............................... Error! Book mark not def in ed . 4.5.2 Primar y Data ................................ ................................ ... Error! Book mark not def in ed . 4.6 Data Collecti on Instr uments ................................ .............. Error! Book mark not def in ed . 4.7 Ethi cal Consi derati ons ................................ ....................... Error! Book mark not def in ed . 4.8 Anal ysis of th e Da ta ................................ ........................... Error! Book mark not def in ed . 4.9 Summ ar y and Conclu sion ................................ .................. Error! Book mark not def in e d . CHAPTER FIVE ................................ ................................ ... Error! Book mark not def in ed . DATA PRESENTATION, ANALYSIS AND DISSCUSION ON THE IMPLEMENTATION OF THE NATIONAL HEALTH INSURANCE SCHEME Error! Bookmark not def in ed . 5.0 Introdu cti on ................................ ................................ ........ Error! Book mark not def in ed . 5.1 Demographic info rmati on of respondents ......................... Error! Book mark not def in ed . 5.1.1 Occupati onal b ack ground of respond ents ....................... Error! Book mark not def in ed . 5.2 Facto rs that contribut e to successful impl emen tation of healt h insu ranc e in Ga West Muni cipalit y ................................ ................................ ................................ ............................. 60 University of Ghana http://ugspace.ug.edu.gh vii 5.2.1 Mana gement pe rc e pti on of the factors that contribut e to successful i mpl ementati on of NHIS in Ga West Municipali t y ................................ ................................ ................................ 60 5.2.2 Subscribers per cept ion of the factors th at co ntribut e to successful impl ementati on of NHIS in Ga West Municipali t y ................................ .......................... Error! Book mark not def in ed . 5.2.3 Healthcare providers’ perception of the factors that contribute to successful implementation of NH IS in Ga West Municipali t y ................................ ........... Error! Book mark not def in ed . 5.3 Chall enges to the im plementation of the Nati onal Healt h Insur ance Sc heme in the Ga West Muni cipalit y ................................ ................................ ............. Error! Book mark not def in ed . 5.3.1 Mana gement pe rc e pti on of the chall en ges to the successful impl emen tation of NHIS in Ga West Municipali t y ................................ ................................ .... Error! Book mark not def in ed . 5.3.2 Subscribers per cept ion of the chall en ges to t he success ful implementation of NH IS in Ga West Municipali t y ................................ ................................ ................................ .................... 82 5.3.3 Healthcare providers’ perception of the ch all enges to succ essful impl ementati on of NHIS in Ga West Municipali t y ................................ ................................ ................................ .......... 84 5.4 T he impact that diffe rent actors have on imple mentati on of the NH IS in the Ga West Muni cipalit y ................................ ................................ ............. Er ror! Book mark not def in ed . CHAPTER SIX ................................ ................................ ...... Error! Book mark not def in ed . SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATIONS ....... Error! Bookmark not def in ed . 6.0 Introdu cti on............................................................................................................. ...........94 6 . 1 Summ ar y of Ke y Fin dings ................................ ................. Error! Book mark not def in ed . 6 .2 Recomm endati ons ................................ .............................. Error! Book mark not def in ed . 6. 3 Conclusi on ................................ ................................ ......... Error! Book mark not def in ed . 6. 4 Further R esea r ch ................................ ................................ Error! Book mark not def in ed . REFERENCES ................................ ................................ ................................ ..................... 100 APPENDIX ................................ ................................ ............. Error! Book mark not def in ed . QUEST IONNA IR E FO R HEA LT HCARE PROV IDERS ...... Error! Book mark not def in ed . QUEST IONNA IR E FO R STAFF OF THE SCH EME ........... Error! Book mark not def in ed . QUEST IONNA IR E FO R SUBS C R IBERS (BEN EFIC IARY) Error! Book mark not def in ed . University of Ghana http://ugspace.ug.edu.gh vii i LIST OF TABLES Page Table 2.1 Critical variables fo r the success of poli c y implem entation 2 3 Table 5.1 The age dist ributi on of respondents 5 8 Table 5.2 The educ ati onal back gro und of respondents 59 Table 5.3 Factors th at facil it ate im plementation of NH IS in GWMA by Management of th e sche me Publi c accepta bil it y of the Healt h Insu ranc e Scheme 6 6 Table 5.4 Factors th at facil it ate im plementation of NH IS in GWMA by subscribe rs 73 Table 5.5 Factors th at facil it ate im plementation of NH IS in GWMA by healt hcar e provide rs 7 5 Table 5.6 Factors th at constrain the implementation of NHIS in GWM by m ana gemen t 82 Table 5.7 Factors th at constrain im plementation of NH IS in GWMA by subscribers 84 Table 5.8 Factors th at constrain the implementation of NH IS in GWMA by healt hcar e provide rs 86 Table 5.9 Role pla yed b y subs cribe rs in the impl ementati on of the NH IS in GWM 90 Table 5.10 Role pla yed by healt hcar e provide rs in the impl em entation of the NHIS in GWM 91 Table 5.11 Role pla yed by man a gement i n the impl ementati on of the NHIS in GWM 92 University of Ghana http://ugspace.ug.edu.gh i x LIST OF FIGURES Page Figu re 2.1 Ambi guit y-C o nfli ct Matrix : Poli c y Imp lementation processes 17 Figu re 2.2 Advo ca c y Coali ti on Framewo rk 18 Figu re 2.3: The vertical and horiz ontal dim ension s of poli c y 20 Figu re 2.4: Conceptu al Framework 31 University of Ghana http://ugspace.ug.edu.gh x ABSTRACT The Nati onal Healt h Ins urance Sch eme (NH IS ) was int roduced in Ghana in 2003. Its main goal was and stil l is to ensure healt hcar e access and bri dge th e inequali t y gaps i n healt hcar e. Ghana’s NHIS is unique in the sense that it is a hybrid of Social Healt h Insu ranc e and Comm unit y Bas ed Heal th Insu ranc e sc hemes. This stud y is about the i mpl ementati on of the Dist rict -wide Mutual Healt h Insuran ce Scheme (DMH IS ) in Ga West Municipali t y. The stud y is necessi tated b y the per ceived suc cess of the scheme suc h as incre a se in enrolm ent, and uti li z ation of healt h fa cil it ies. Furthermor e, th ere are gaps and ch all enges which include inadequate medical faci li ti es, escalating cost, and difficult y in reim bur sement of provi d ers, which hav e not onl y em er ged in the pro c ess of t he implementation of th e scheme but have also threatened its sust ainabili t y. The stud y used a mix ed methods approach to gathe r data from a sampl e of subscribe rs in Ga West (the seat of the Ga Dist rict Scheme), M a nagement and Staf f of the Ga scheme and healt h providers to discuss th e implementation proc es s of the scheme. In all , information was gather e d from 100 subscribers, 30 healt hcar e providers, and 30 staff members and mana gement of th e Ga sch eme. It was foun d out that comm unit y participati on, i ntensive educati on and special regist rati on ex ercises , amo ng others wer e par amount in bringing about the successes chalked b y the Ga West sch eme whiles inadequate offic e spa ce, human resou rces and funding, as well as illi terac y and cor ruption accou nted for the fail ures of th e scheme in Ga West Muni cipalit y. The stud y recomm ends the dev elopm ent of a co mprehensive comput eriz ati on s ystem that will help in an ef fecti ve proc essi ng of claims to minim iz e the fraud and cor r upti on associated with the manual s yst em. It is also strongl y recomm en ded that more and well trained pe rmanent staf f be rec ruited to ensur e a smoot h operati on of the Ga West Scheme. University of Ghana http://ugspace.ug.edu.gh ABSTRACT The Nati onal Healt h Ins urance Sch eme (NH IS ) was int roduced in Ghana in 2003. Its main goal was and stil l is to ensure healt hcar e access and bri dge th e inequali t y gaps i n healt hcar e. Ghana’s NHIS is unique in the sense that it is a hybrid of S ocial Healt h Insu ranc e and Comm unit y Bas ed Heal th Insu ranc e sc hemes. This stud y is about the i mpl ementati on of the Dist rict -wide Mutual Healt h Insuran ce Scheme (DMH IS ) in Ga West Municipali t y. The stud y is necessi tated b y the per ceived suc cess of the sche me such as incre a se in enrolm ent, and uti li z ation of healt h fa cil it ies. Furthermor e, th ere are gaps and ch all enges which include inadequate medical faci li ti es, escalating cost, and difficult y in reim bur sement of provi d ers, which hav e not onl y em er ged in th e pro cess of t he implementation of th e scheme but have also threatened its sust ainabili t y. The stud y used a mix ed methods approach to gathe r data from a sampl e of subscribe rs in Ga West (the seat of the Ga Dist rict Scheme), M a nagement and Staf f of the Ga s cheme and healt h providers to discuss th e implementation proc es s of the scheme. In all , information was gather e d from 100 subscribers, 30 healt hcar e providers, and 30 staff members and mana gement of th e Ga sch eme. It was foun d out that comm unit y participat ion, int ensive educati on and special regist rati on ex ercises , amo ng others wer e par amount in bringing about the successes chalked b y the Ga West sch eme whiles inadequate offic e spa ce, human resou rces and funding, as well as illi terac y and cor ruption accou nt ed for the fail ures of th e scheme in Ga West Muni cipalit y. The stud y recomm ends the dev elopm ent of a co mprehensive comput eriz ati on s ystem that will help in an ef fecti ve proc essi ng of claims to minim iz e the fraud and cor r upti on associated with the manual s yst em. It is also strongl y recomm en ded that more and well trained pe rmanent staf f be rec ruited to ensur e a smoot h operati on of the Ga West Scheme. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE GENERAL INTRODUCTION TO THE STUDY 1.0 Backgrou n d to the Study The socio-economi c dev elopm ent of a nati on to a ver y la r ge ex tent depend s on a healt h y population. A healt h y people with the requisi te skil ls and knowledge become the backbone throu gh whi ch the developm ent agend a of an y societ y is implemented. Quali t y human resourc e base is therefor e ca rdinal to the att ainm ent of develop ment goals of countries (Kwart en g, 20 11). Healt h is often cons idered as a state of compl ete ph ysical, social and mental well -being and not merel y th e absence of diseas e or infirmit y. More importantl y, healt h is a resource fo r ever yd a y life, not the object of living. The att ainm ent of the hi ghest possi ble level of healt h is ver y important world wide for so cial and econom ic se ctors in addit ion to the healt h s ector. This is because healt h pr eserv es human capit al, which is the major resourc e for ec onomi c developm ent in all of the social and economi c se ctors. It is in thi s light that all countries in the world place much premi um on ensuring an improved healt h condit ion for thei r cit iz ens. The significan ce of healt h iss ues relatin g to people is further epit o mi z ed by th e ex ist ence of glob al inst it uti ons dedicated to the promot ion of human hea lt h. For ex ampl e , the World Healt h Or ganisati on (W HO) is one of such global insti tut ions dedicated to the promot ion of the healt h of peopl e. Most countries in th e world have dev eloped so me form of healt h car e s ys tem aim ed at ensuring that sick people are cater ed fo r efficientl y and spe edil y without an y inhi bit ions. University of Ghana http://ugspace.ug.edu.gh 2 Ghana is no ex ce pti on to thi s phenomenon. Healt hcare facil it ies in the for m of hospi tals, pol ycli nics, cli nics and heal t h ca re centr es hav e been provided in the countr y for deli vering quali t y healt h care to people. Man y of these fac il it ies are oper ated b y the stat e with a few oper ated b y private indi viduals and inst it uti ons eit her for profit or as social service. Until the recent emer gen ce of the private se ctor in the provisi on of healt h car e, the state has alw a ys pla yed a domi nant an d pione ering role in ensurin g tha t people acc ess afford able healt h care. It has therefore become the state’s r esponsi bil it y to provide healt h car e to the people of Ghana and thi s respon sibi li t y comes with finan cial chall en ges in view of the difficult ec onomi c iss ues that confr ont the countr y (Kw arten g, 2011). Financin g an effici ent an d eff ecti ve healt h c are s ystem is of a major con ce rn to countri es all over the wo rld. This is even more critic al in developi n g countries where there ar e several developm ent al cha ll enges of which limi ted resourc es a nd povert y are domi nant. Healt h ca re fin ancin g is a gene ral term which re fers to the res our ces use d in providi ng healt h car e. Thes e includ e mone y, and othe r res ources such as labour, equipm ent and suppl ies (Goodman and Wad dington, 1994). In Gh ana, he alt hcar e fin ancin g has gon e throu gh several phases. After in dependen ce in 1957, Ghana adopted a sociali st centrali st developm ent approach with the state taking absol ute control over th e provisi on of social servi ces includin g he alt h . Th e provisi on of healt h car e was financ ed by the st ate throu gh tax revenue. Howev er, it became obvious that thi s method of fin a ncing healt h c are was no t sust ainable followin g t he economi c difficulti es the countr y ex perienced from the be ginni ng of the 1 960s (Osei - Akoto, 2004). University of Ghana http://ugspace.ug.edu.gh 3 As part of effo rts to revamp the Ghanaian econom y, the state be gan to redu ce ex pendit ure on the pr ovisi on of social servi ces and the healt h se ctor witnessed consi derable reducti on in state funding. The er stwhi le Provisional Nation al Defenc e Council (PNDC ) gov ern ment in 1985 passed a le gisl ati ve inst rument, pop ularl y ref err ed to as L. I. 1313 which int roduced use r fees for all medical condit ions ex cept cert ain specified comm unicabl e diseases. The main ai m of L. I. 1313 was to ena ble hospi tals to tot all y recov er all costs invol ved in thei r operati on. This s ystem wh e re people who access public health facilities pay user fees became knoZn as ³cash and carry´ and result ed in sever al oper ati onal chall en ges (Asenso -Ok yer e et al., 1998). The int roducti on of the user fees and the full cost recov er y for dru gs as a wa y of gen erati n g rev enue led t o a remarkabl e decli ne in the uti liz ati on of health service in the countr y. Poor people in the countr y wh o require d healt h c are were not ab le to access it because the y could not afford the use r fees. Self -medicati on and th e use of herbal medicine be came comm on in the countr y. It was esti mated that onl y 2 0% of people who require healt h ca re were able to acc ess it ( Mensah et al ., 2010). In order to amelior ate the problems associated Zith the ³cash and carry´ system the then New Patriot ic Pa rt y (NP P ) gov ernment int roduc e d the Nati onal Healt h In surance Law, Act 650 in 2003.The A ct sought to provide basic healt h car e s ervices to persons resident in Ghana throu gh mut ual and private healt h insurance s chemes, and to establi sh a Nati onal Healt h Insuran ce Fund that will provi de subsi d y to licensed Dist rict Mutual Healt h Insuran ce Sche mes. Healt h Ins u ranc e is an alt ernati ve healt h care fin ancin g s ystem which invol ves re source pooli n g and risk sharing amon g membe rs (MOH, 2003). It is important to indi cat e howev er, that prior to t his, the Nati onal Democ rati c Congress University of Ghana http://ugspace.ug.edu.gh 4 (NDC) gov ernment sta rte d to pilot the Mutual Hea lt h Insur anc e Schem e in some select ed dist ricts in Ghana towards a Nati onal Healt h In surance Schem e (NH IS ) . Ex ampl es of such dist ricts are, Dan gb e West in the Greater Ac cra re gion, Kwahu South in the Eastern region and Nkor anz a in the Bron g Ahafo region. As previous l y indi c ated, the Dist rict Mutual Healt h Insu ra nc e schemes cover the enti re geo graphic al area of one or more admi nist rati ve dist ricts. The private Mutual Healt h Insu ranc e sch emes are th ose that are not based on admi nist rati ve dist rict boundaries. For ex ampl e, these could be workplace based, fait h based and comm unit y based schemes. The private comm er cial schemes ar e those operat ed for purpose of pro fit. Secti on 31 of the Act grants eve r y indi vidual or group of indi vi duals the right to belon g to an y of the three sch emes identifie d above. Th e state sup port s the developm ent of the Dist rict Mutual Healt h Insuran c e Scheme (DMH IS ) as a strate g y for deli verin g its pro -poor poli c y to th e unde r -privi l eged se gm ent of th e soci et y, from both th e fo rmal and inform al sectors. The implementation of the Nati onal Healt h Insur anc e Scheme has achieved several suc cesses but also encounter ed some ch all enges. 1.1 State men t of the Problem Healt h insuran ce schem es ar e inc reasin gl y reco gni z ed as a tool to fina nce healt h ca re provisi on in developi ng countries and have th e potenti al to increas e uti li z ati on and bett er protect peopl e against healt h ex penses and ad dress iss ues of equit y (W HO, 2000). Gha na’s National Health Insurance S cheme, i ntroduced in 2003, ai ms to remo ve financial ba rriers to heal th care acc ess and brid g e the inequ ali t y gaps in healt h car e. The scheme has been praise d for its cov era ge, asso ciated le gal reforms and cli nical audit University of Ghana http://ugspace.ug.edu.gh 5 mechanism s and for ser ving as a hub for know ledge sharin g and learni ng withi n the contex t of South -S outh Cooperati on (Fusheini et al, 2012) . Since its incepti on, seve ral studi es have been co nducted on the NH IS . S ome of these cover finan cial aspects (Ag yepon g and Adjei, 2008; Abekah -Nkrum ah et al. , 2009), others focus on, cover a ge lev els (Wit ter and Garshon o g, 2009 ). Again, some of the studi es concentrated on the effe cts of NHIS on out -of-pocket ex pendit ur es, healt hcar e demand, healt h status and labour producti vit y, assessment as to wh ether NH IS is providi ng an affo rdable healt hcar e finan cing arr an gem ent (NDPC , 2008 ). As the scheme is bein g e x tended to cover a number of comm unit ies in the countr y, th ere is the need for evaluating its implementation at both the local and nati onal level. Howeve r, litt le resea rch has been conducted on t he implementation of the scheme at the dist rict level and mor e s pecificall y the Ga West Muni cipalit y. What is readil y kno wn about the scheme and its implementation at the district level is often based on newspape r reports and ane cdotal ev idence. This le aves us wit h littl e empi rical evidence about the implementation of the scheme at the local lev el. Yet, a deep er appr e ciation of the implementa ti on of the sc heme is crucial in und ers tanding the ex tent to which the sch eme has been succ essful in Ga West Muni cipalit y . This thesis therefo re set s to fill thi s gap and provide empi rical ev idence about the implementation of NHIS at the local level b y using the Ga West Municipali t y as a case. University of Ghana http://ugspace.ug.edu.gh 6 1.2 Objectives of the Study The gen eral obj ecti ve of thi s stud y is to find out the factor s that facil it ate o r const rain the implementatio n of NHIS in Ga West Muni cipal Assembl y. S pe cificall y, t he stud y s eeks to: 1. Find out the factors th at facil it ate the impleme ntation of NHIS in Ga West Muni cipal Assembl y. 2. Find out the factors th at const rain the impleme ntation of NH IS in Ga West Muni c ipal Assembl y. 3. Find out the roles playe d b y diff erent ac t ors such as healt h ca re provid ers, subscribers and staff of the insurance schem e in the i mpl ementati on of NHIS in Ga West Muni cipalit y . 1.3 Resear ch Question s The rese ar ch questi ons emanati ng fro m the proble m statement are as follows: 1. What factors fa cil it ate the impl ementati on of NHIS in Ga West Municipal Assembl y? 2. What are the factors th at const rain the impleme ntation of NHIS in Ga W est Muni cipal Assembl y? 3. What are the roles playe d b y di ffe rent actors i n the implementation of NHIS in the Ga West Municipali t y? 1.4 Scope and Limitation s of the Study The geo gr aphical s cop e of thi s stud y cov ers the Ga West Muni cipal Assembl y. Insti tut ionall y, the stud y covers the m an a gem ent, subscribers and healt h c ar e providers of NHIS und er the Ga West muni cipalit y. Issues of impl ementati on of NHIS i n the Ga West University of Ghana http://ugspace.ug.edu.gh 7 Muni cipalit y wer e also part of thi s stud y. The focus is on the process through wh ich poli cies are transform ed int o acti on. It fo cuses on four iss ue s that influence processes of poli c y implementation: the actors invol ved and their beli efs, service deli ve r y arran gements, mana geme nt practi ces, and cit iz en participati on. The stud y is not, howeve r, conce rned with the act ual content of the poli c y or their eff ects on healt h out comes. Th e stud y is also limi ted to th e Ga Dist rict Mutu al Hea lt h Insu ranc e Scheme (GDM H IS ) in t he Greate r Accr a Re gio n. It does not se ek to di scuss in details the economi c and poli ti cal impli cati ons of the sc heme. The stud y does no t seek to draw relations hips nor does it seek to compare scheme s. It is onl y con cern ed wit h describing the views and the ex periences of the stakeholders withi n GDMH IS . The stud y is limi ted to the implementation, chall enges and ex perien c es of stakeholde rs abo ut the scheme in the Ga West Muni cipalit y. 1.5 Signif icance of the Study Thi s stud y discussed the const raini ng facto rs of th e implementation of NH IS in the Ga West Muni cipal Assembl y. Hen ce the result s will help the concerned part ies to re- ex ami ne the con strains and find bett er wa ys of addressi ng them based on empi rical evidence. It will also give some hi ghli ghts to gov ernment al and non -gov ernmental organiz ati ons working in thi s area to focus on the chall en ges and be invol v ed in effo rts to improve the situ ati on. The stud y has both poli c y and s cholarl y impli ca ti ons: At the macro -leve l, the stud y is relevant to poli c y m aker s as it will help in the designin g of approp riate pr ogr amm es and poli cies to tackle implementation chall en ges of NHIS . It will also offe r both poli ti cians University of Ghana http://ugspace.ug.edu.gh 8 and service provide rs a guide for fut ure poli c y an d decisi on making. A ca demi c all y, the stud y will contribut e to ex isti ng knowled ge on the mana gement of NHIS in Ghana. This stud y will provide insi ghtful empi rical data that will enhance u nderstandin g of the iss ues related to scheme , there b y contribut ing to the design and implementation of universal healt h insurance in Gha na. Finall y, the stud y wi ll act as a basis for further rese ar ch on healt hcar e finan cin g in various metropoli s, muni cipal it ies and dist ricts in Ghana. Th e resea rche r also stands to gain consi der able know ledge and skil ls in both resear ch and healt h financin g iss ues. 1.6 Organi sation of the Study Thi s thesis is divided into six chapters. Chapter One provides the back ground to the stud y. In thi s ch apter, a gen eral int roducti on i s given as well as the problem statement, objecti ves, rese arch qu es ti ons, scope and limi tations of the stud y, and si gni ficanc e of the stud y. Chapter Two revi ews releva nt literature on the concept of poli c y i mpl ementati on, top down and bott om up approach es to poli c y imp lementation, and a synth esis of the two models, successful and fail ed implementation, factors that aff ect poli c y i mpl ementati on, barriers to poli c y imp lem entation as well as the co nceptual fr amework for t he stud y. The focus of Chapter Three is the implementation of the Nati onal Healt h Insur ance in Ghana. Issues discussed in thi s chapter include h ist orical contex t of the healt h insurance in Ghana, the Nati onal Healt h Insur ance Scheme and its implementation an d the act ors in the implementation of NHIS . C hapter Fou r di scusses methodolo gical iss ues and the profil e of the st ud y ar e a. Chapter Five presents the study’ s result s, dat a anal ysis and discussi ons of the findin gs of the stud y. Finall y, Chapter S ix gi ves a summ ar y of th e ke y findings, recomm endati o ns and conclusi on of the stud y. University of Ghana http://ugspace.ug.edu.gh 9 CHAPTER TWO REVIEW OF RELEVANT LITERATURE 2.0 Introd u ction The purpose of thi s ch a pter is to provide literat ure o n the con cept of i mpl ementati on. Other important th emes discussed includ e top down and bott om up approach es to implementation as well as success and fail ures of implementation. Additi onal iss ues discussed in thi s chap ter include factors that aff ect implementation and various definiti ons of impl ementati on. Discussi ng such literatur e is important as it help s address the resea rch questi ons an d at the same time form the basis for empi rical st udies relating to the topi cs and sub -the mes discussed in subsequent chapters. 2.1 Concep t of Imple me n tation Impl ement ati on inevitabl y takes diffe rent shap e s and forms in diff eren t cult ures and inst it uti onal sett ings. Implementati on literall y means car r yin g out, accompl ishi ng, fulfil li ng, producin g or compl eti ng a given task. Pressm an and Wil davsk y (1973) de fine implementati on in terms of its rel ati onshi p to poli c y as laid down in of ficial documents. Accordin g to them, poli c y implementation ma y be view ed as a proc ess of int era cti on between the sett ing of goals and acti ons gea re d t o achieve them . Poli c y i mpl ementati on encomp asses those acti o ns b y publi c and private indi viduals or groups that are dir ected at the achievement of obje cti ves set forth in polic y decisi ons. This includes both one -ti me efforts to tr ansform decis ions int o operati onal te r ms and conti nuing ef fort s to ac hiev e the large and small ch an ges mandated b y poli c y de cisi ons (Van Meter and Van Horn, 1975). University of Ghana http://ugspace.ug.edu.gh 10 Accordin g to Mazmania n and Sabati er (1983 ), poli c y implementation is the car r yin g out of a basic poli c y decisi o n, usuall y in corpor ated in a statut e, but which ca n also take the form of important ex ecut ive orders or cou rt decisi ons. It impli es centrall y l ocated actors, such as poli ti cians, top -level bure aucr ats and oth ers, who ar e se en as mo st relevant to producinJ the desired effects. 2’7oole (23) defines policy implement ati on as wh at develops betwe en the establi shment of an app aren t intention on the part of gove rnment to do somethi ng or stop doi ng somethi n g and the ult im ate impact of world of acti ons. More concisel y, he remark s th at poli c y implementatio n refers to the connecti o n between the ex pressi on of gove rnme ntal int enti on and actu al result . As part of poli c y c yc le, poli c y implementation concern s how governm ents put poli cies int o eff ect (Howlett an d Ramesh, 2003). From the above discussi on, implementation ca n be conceptu ali z ed as a process, output and outcome. It is a pro c ess of a series of decisi ons and acti ons direct ed towards putt ing a prior authorit ati ve de cisi on int o effect. The essential char acte risti c of i mpl ementati on process is the timel y an d sati sfa ctor y pe rform an ce of certain necess ar y t asks related to carr yin g out of the int e nt of the law. Impl em en tation can also be defin ed in terms of output or ex tent to which progr amm ati c goals have been sati sfied. Final l y, at highest level of abstr acti on, implem entation outcome impli es that there ha s been some measurable chan ge in th e lar ger problem that was addressed b y the pro gr am m e , publi c law or judicial decisi ons (Lester et al., 1995). 2.2 Policy Imple men tati on : Top-Down and Bottom-Up Approach es A revie w of liter ature on poli c y implement ati on reveals that two schools of thought have evolved. Diffe rent scho lars view them differently. Some talk about ³forZard and University of Ghana http://ugspace.ug.edu.gh 1 1 backZard mappinJ´ models ( lmore, 1980); wh il e others ref er to them as ³top- doZn´ and ³bottom- up´ models (Fata ar, 1999). The top -d own and bott om up schools of thought are se en as providing the most effe cti ve methods for stud yin g and desc ribing implemen tation ( Gorni tz ka et al., 2005; Sabati er, 2005; Sehoole, 20 02 ). Top -down theorist s see poli c y mak ers as the central actors and concentr ate on facto rs that can be controll ed at a central le vel. Bott om -up theorist s emphasise a fo cus on participants and service provid ers, ar guin g that poli c y is made at t he local level (Go rnitz ka, et. al., 2005; Matland, 1995). 2.2.1 Top-dow n Model The essential features of a top -down approac h were developed b y Pressm an and Wil davsk y (1973). This model assum es that poli c y implement ati on is a linear pro cess that is char acteris ed b y a hiera rchic all y orde red set of ev ents, whic h can be centrall y controll ed (Cer ych and Sabati er, 1986; Mazmanian and Sabati er, 1981; 1983; 1989; Pressm an and Widavsk y, 1973; Sabati er, 19 86 ). In thi s model, poli c y pro c ess is divi ded int o sequenti al steps, ea ch of which is treat ed as fu ncti onall y dist i nct (Christi e, 2008; Sehoole, 2002; Sabati e r, 2005). Poli c y implemen tation viewed throu gh th e lens of thi s perspective is reJarded as the ³rational administrative activity of a political neutral bureauc ra c y whose acti ons are dire cted at the achievement of the poli c y objecti ves or directives of the politicians´ (De &lercq,  ). 7his vieZ separates implementation from formul ati on, sugge sti ng a separ ati on betwe en theor y and pra cti ce (Badat, 1991; Fata ar, 1999; Maz mania n and Sabati er, 1981; 19 83; 1989; S abati er, 1986) . Supporters of thi s linea r view desc ribe imple mentati on as the ex ecu ti on of poli c y obMectives. 2ne e[ample of this interpretation can be found in Hayes’ (2) description University of Ghana http://ugspace.ug.edu.gh 12 of poli c y implem entation. Ha yes d escribes imple mentati on as a compos it i on of or ganised acti vit ies by governmen t, directed towards the achievem ent of goals and objecti ves sti pulated in the poli c y. Sim il ar descriptio ns can be found in Sabati er and Mazmanian. 7hese theorists define implementation as ³the carryinJ out of a basic poli c y decisi on, usually made in statute´ (Sabatier and 0a]manian,  53). :ith reJard to methods of poli c y anal ysis , thi s framework provides a hi erar chical model of poli c y anal ysis as well as th e an al yti c al too ls for actors to use to regulate, meas u re, and con trol the poli c y processes. The poli c y implement ati on that is plann ed in li ne with thi s model follows sequenti al steps such as: Establis hing implementation structures; Designin g a pro gr amm e that incorporates t ask sequen ces and clea r statements of objecti ves; Developi ng perform anc e standards; Buil ding in moni toring and control devices to ensure that t he pro gramm e proceeds as int ended. Impl ement ati on anal ysis that is located in thi s mo del tends to fo cus on fact ors that app ear to centrali se contro l and that are easil y manipul ated b y poli c y mak ers. These factors include fundin g formul ae, or ganisati onal stru c tures, authorit y relation ships among admi nist rati ve unit s and admi nist rati ve control (E lm ore, 1980). An earlier stud y b y Van Meter and Van Horn (19 75) provides an ex ampl e of top -down thi nking. In their model of how to anal yse the implementation process, variables such as poli c y standards and objecti ves and poli c y res ources are re gard ed as cr it ical. Pressm an and Wil davks y (1973) were the first impl emen tation anal ysts to indi c a te that the outcomes of even the best supported poli c y ini ti ati ves depend eventuall y on what happens when the indi vidual implementers throughout the polic y s ystem interp r et the poli c y (Mc Lau ghli n, 1987). University of Ghana http://ugspace.ug.edu.gh 13 There are seve ral cri ti cism s that are dir ected at top -down models. Fi rstl y, top down models take poli c y de cisi ons as their starti ng point in the anal ysis and thus fail to consi der the signi ficanc e of acti ons tak en duri ng oth er sta ges of the i mpl ementati on process (Matl and, 199 5). Bowe, Ball and Gold (1992) contend that thi s linear conc epti on of poli c y in which theor y and pra cti ce ar e separ ated, dist orts the polic y process. The y ar gue furthe r that thi s top down model is not the best start fo r rese arch int o the pr acti c al effe cts of poli c y, as the poli c y pro cess is not simpl y a matter of implementers following a fix ed tex t and putti ng the poli c y int o pr acti ce. R ather, poli c y is contested. A similar arJument Zas made by (lmore ( 3) Zhen he contends that ³the notion that pol ic y m akers ex erc ise ± ought to ex ercise ±some kind of dire ct an d determi nant control over poli c y implementation might be cal led a noble lie of conve nti onal publi c administration and policy analysis.´ /oZry (2 5) arJues that ³3olicies are not sim pl y cr eated b y nati onal offici als and th en rou ti nel y implemented b y state and local Jovernments as if they Zere unquestioninJ automations in some :eberian machine.´ Proponents of the top -do wn appro ach have been accused of seein g imple mentati on as a purel y admi n ist rati ve pr ocess, eit he r i gnorin g poli ti cal aspects or tr yin g to eli mi nate them (Matl and, 1995; Saetren, 1986). These auth ors argu e that the call for clear, ex pli cit and consi stent go als dis torts the reali t y of how le gisl ati on is passed. Finall y, the top down model has been criticised for its emphasis on poli c y make rs as key actors. It is arJued that this approach has a tendency to neJlect local implementinJ officials’ ini ti ati ves and to underesti mate the strate gies used by implementi n g actors to divert central pol ic y fo r their own purposes. University of Ghana http://ugspace.ug.edu.gh 14 2.2.2 Botto m- up Model In contrast to the top -do wn approa ch, those emp hasiz ing a bott om -up ap proach such as Berm an (1980), Hjern an d Porter (1981 ), Hje rn (1 982), Hjern and Hull (19 82) , Hull and Hjern (1987), Elmo re (1 98 0), and Lipsk y (1978) , suggest a model that starts from the bott om of implementation. The bott om -up app ro ach of Han f, Hje rn and Porter (1978) starts b y mappin g th e ne twork of actors in the actual field wher e imple mentati on is to take plac e and asks the m ab out their goals, str ate gies, acti vit ies, and contact persons. This, acco rding to Sabati er (2005 ), provides a vehicle for movi ng from th e acto rs at the bott om to poli c y mak ers at the top. One of the ke y propon en ts of thi s approach is Elmo re (1980). He ar gu es for ³backZard mappinJ´ approach as an alternative to ³forZard mappinJ´. (lmore challenJes the assum pti ons of the top -down approa ch on the gro unds that the y ar e an ina ppropriate wa y of describin g real life pol ic y implementation. They ar gue that a more reali sti c understandin g of implementation can be gain ed by looki ng at the poli c y fro m the view of the tar get i mpl ementers and the ser vice providers. These theorist s ar gue tha t successful implementat ion depends more on the skil ls of local implementers than upon efforts of centr al gover nment officials. Matlan d (1995: 148) notes ³At the macro-im plementation level, cent r all y loc ated actors devise a government programm e, at the mic r o -im plementation level; local or ganisati ons react to the macro - level plans, deve lop their oZn proJrams and implement them.´ :hile a bottom-up approach is regard ed as a useful starti n g point for identif yin g actors invol ved in a poli c y arena, Sabatier (25 2) arJues that ³it needs to be related via an e[plicit theory to University of Ghana http://ugspace.ug.edu.gh 15 social, econo mi c and l egal factors which stru cture the pe rcepti ons, resources and participation of those actors.´ Criticism has been lev ell ed against the bott om -up approa ch fo r under esti mating the role of the poli c y objecti ves (Gornit z ka, 2005; Matla nd, 1995; Sabati e r, 2005 ). It is ar gu ed that in a democrati c s ystem, poli c y control shoul d be ex ercised by centr a l actors whose mandates come from the ir accountabili t y to their voters (Matl and, 1995). The bott om -up approach views poli c y i mpl ementati on as an int egral pa rt o f the poli c y making pro cess and rega rds poli c y form ulation and implementation as iterati ve proc esse s (Ba rrett and Fud ge, 1981; Bowe and Ball , 1992; D ye r, 1999; Elmo re, 1 980; Fataar, 2006; Lowr y, 1992; Mc Lau ghli n, 1998). Poli c y implementation is thus defin ed as all the acti vit ies and int eracti ons that ar e di rectl y rel ated to the achievement of th e env isaged poli c y int enti ons. 2.2.3 Synthesis of bottom-up and top-dow n app roach es In an effort to reconcil e the two major schools of thought on poli c y im plementa ti on, different groups of rese arche rs such as Matland (1995), Goggin, Bowm an, Lest er and 2’7oole (), Sabati e r ( 2005 ; 1998; 1991; 1988; 1986 ) and Elmo re (1985; 1982 ), have proposed different Zays of combininJ the tZo approaches. (lmore’s concept of ³forZard´ and ³backZard mappinJ´ Zas an early attempt to combine top-down and bott om -up perspecti ves. Elmore ar gu es that poli c y mak ers ne ed to consi de r both the poli c y inst ruments and other sources at their dispo sal (forw ard mappin g), as well as the incen ti ve structure of tar get groups (backwa rd mappi ng) bec ause su ccess in implementation depends on combi ning University of Ghana http://ugspace.ug.edu.gh 16 the two (M atl and, 1995; Sabati er, 2005). Th e s e cond att empt at s ynthesi s was m ade b y Goggin et al. (1990). The y developed a comm unicati on model of int e rgov ernmental implementation in the Unit ed States of Americ a. The y view states as the critical actors. The y claim that m essa ge s are received from the top (government ) and fro m the bott om (local acto rs). In 1995, Matland sough t a combi nati on of top -down and bott om -up approaches that would identif y the condi ti ons under which poli c y recomm endati ons woul d be eff ecti ve (Matl and, 1995). Matland proposes that these approach es shoul d be used when appropriate, and not sim ult aneousl y. He ar gu es t hat the y are appli c abl e i n the followin g four diffe rent situations : in sit uati ons of low -poli c y conflict and l ow - policy ambiJuity, ³administrative implementation´ is the appropriate strateJy - in other words a rati onal dec isi on - making process (top-do wn persp ecti ve) is more appropria te; in sit uati ons of high - poli c y con flict and low-poli c y ambi gui t y, wh ere actors hav e clearl y defined objecti v es (top -down perspecti ve ) but the y ca nnot agree on approp ria te objecti ves, a t op -do w n approa ch is appropriate, 0atland terms this ³political implementation´i n sit uati ons of hi gh -poli c y ambi guit y and low polic y con flict, the emphasis shoul d be on learning (bottom -up perspective) 0atland terms this ³e[perimental implementation´i n sit uati ons of low - poli c y con flict and high - poli c y ambi guit y, letti ng local acto rs find local solut ions, ³symbolic implementation´ is the appropriate strateJy this suJJests a bottom up perspecti ve. T hi s comprehe nsi ve impl e me nta ti on mode l is capt ure d in Figure 2.1 University of Ghana http://ugspace.ug.edu.gh 17 Figure 2.1 Ambigui ty-Conf lic t Matrix : Policy Imple me ntati o n proc e sse s . Source: Matlan d (1995: 160) A fifth model was propo sed b y Colebatch (2002) . This model also combi nes top down and bott om -up approach es. Colebatch su ggests that a poli c y process shoul d be perc eived as a product of two int ersecti ng dim en sions : vertical (top -down) and horiz ontal (bottom - up) sets of acti vit ies (Christ ie, 2008). The ve rtical dim ension in thi s model cove rs authorised decisi on -mak ers and their decisi ons. The horiz ontal dim ension covers the acti vit ies of man y actor s in the poli c y pro cess, both insi de governmen t and in non - gove rnmental or ganis ati ons. This dim ension emphasis es the importance of negoti ati ons and consensus. &olebatch’s model, unlike 0atland’s AmbiJuity-C onflict Model, invol ves both approach es simul taneousl y. This mo del is captured in Figu re 2.2. Conflict Ambigu ity Low High Low Admini strati ve Impl ement ati on Resources Poli ti cal Impl ementati on Power High Ex perimental implementati on Contex tual condit ions S ymbol ic impl ementati o n C oali ti on strength University of Ghana http://ugspace.ug.edu.gh 18 Figure 2.2 Advocacy Coalitio n Framew ork Source: Sabatier, (2005:27) RELATIVELY STABLE PARAMETERS B asic attrib utio n of natur al reso ur ce s Fund a me ntal so cio - cult ur al val ues a nd so cial struct ur e Basic co nstit utio nal struct ur e D e g r ee of co nsen s us nee d ed fo r maj o r po licy chan ge Co n strain ts a n d Reso u rces o f S u b syste m Acto rs POLICY SUBSYSTEM Co alitio n A Policy Coalitio n B Bro ker s a. Policy belief s a. Policy bel iefs b. Reso ur ce b. Reso ur ce s Strateg y A1 Stra teg y B1 re. guid ance re. guid ance instr u ment s instr u ment s Decisio n s b y Go ver n men tal Au tho r itie s Instit utio nal Rules, Reso ur ce s Allo ca tio ns, a nd Ap p o int me nt s Po licy O utp ut s Policy I mp ac t s Exter nal syste m e ve nts Cha n ge in socio - ec o no mic co nd itio ns Cha n ge in syste mic go ver n in g co alitio n Cha n ge in pub lic op in io n Po licy dec isio ns and i mp ac ts fro m sub s yste ms University of Ghana http://ugspace.ug.edu.gh 19 A six th approach, the Advocac y Coali ti on Fram ework (Sab ati er, 1998 ), was dev elop ed as an att empt to combi ne the best features of top -down and bott om -up approach es to implementation (Sabati er, 1998; 2005). This framework draws from both top -down and bott om -up models. It sta rts from the premi se that the most useful unit of anal ysis for understandin g poli c y cha nge is a poli c y subs yste m - those actors from a variet y of publi c and private or ganisati on s who are invol ved with the poli c y (Sabati e r, 2005). This framewo rk assum es that these subs ystems can be grouped int o a numbe r of co ali ti ons, which consi sts of int erest groups, poli ti cians, agen c y of ficials and int ell ectu als who share common beliefs. It arJues that ³actors perceive the Zorld throuJh a set of beliefs that filters information cons ist ent with pre - e[istinJ beliefs´ (Sabatier, 200 5: 28). In an att empt to implement poli c y, th ese coali ti ons might use conflicti n g st rate gies which could create tensions. 7hese tensions are then mediated by ³policy brokers´ to find compromi se. The end pr oduct of this process wou ld be polic y output s. The Advoca c y Coali ti on Frame work (AC F) al so assum es that there are stable and dynami c variables whic h affe ct the const r aint s and resour ces of subs yst em actors. Th e stable variables include basic dist ributi on of natural resourc es, the basic socio -cult ural values and social stru ctu re (Sabati e r, 2005). Th e re ar e also d ynami c factors, including chan ges in socio -econ o mi c condit ions and s yst ems which provide principal sources (funding and resour ces) for chan ge. This is t yp ical of a top -down model. Figu re 2.3 presents an ov erview of an Advocac y Co ali ti on Fr amework. University of Ghana http://ugspace.ug.edu.gh 20 Figure 2.3: The verti cal an d horizontal dimen sion s of poli cy Source: Colebatch (2002:24) 2.3 Brief insigh ts into Successf u l an d failed imp lemen ta tion poli cy P oli c y, b y its nature, is no t value neutral but it is ³a matter of authoritative allocation of values´ (Ball,  2). Ball arJues that policies cannot be divorced from interests, from conflict and from domi nati on or just ice. Poli cies are contested, ne goti ate d and fought over b y dif fer ent int eres t groups or poli c y comm unit ies. Therefo re, ho w one judges the implementation outcomes is subj ecti ve and depends on whose values ar e vali dated in poli c y. Impl ement ati on fail ure, like implemen tation success, is there fore a hi ghl y Ot her agenc i es Other level of go ver nment Subordi nat e s impl ement i ng pol icy Par ti ci pant s out si de go ver nment Int er nat ional par ti ci pant s Aut hori zed decisi on - ma ker Vertica l Horizo ntal University of Ghana http://ugspace.ug.edu.gh 21 contested conc ept. Its de scriptio n depends on the int enti ons, ex pectations and values of those invol ved in pol ic y i mpl ementati on. The majorit y of donor - funded pro gramm es ar e evaluat ed in order to determi ne the success or fail ure of the programm e. In most case s fail ure or succ ess is me asured against the agre ed upon indi ca tors for succ ess or the tar get objecti ves. This approa ch to determi ning suc cess is mainl y used b y those who perceiv e poli c y impl ementati on as a sim ple and linea r pro ces s that entails compl iance with sti p ulated goals. Resear chers like Pressm an and Wil davsky (1973) who adopt a top-down approa ch, desire to measure success in rel ati on to the ex pected outcomes tie d to sti pulated poli c y go als. One such e[ample can be found in InJram and Schneider’s () defin it ion of su ccess ful implementation. These authors define su ccess ful implementation in terms of compl iance with statutor y guidelines, indi cators of succ ess and achievem ent of poli c y goals. If one sees implementation as a compl ex process, then one is likel y to con sider outcomes result ing from a negoti at ed process as well as uni ntended posi ti ve gain. Re search ers who prefe r thi s bott om -up approach start b y looki n g at how local actors solve societal problems in different ar eas, and ex ami ne the role that the gov ernment pla ys in that (Gornit z ka, 2005). The criteria fo r succ essful or fail ed implementation are then not focused on the degre e of match or mismatch between formal int enti ons of the poli c y and acti ons of the implement ers, or on the deviant be haviour of im plementers. Inste ad, the y measure the pro gramm e in terms of the posi ti v e gains. Th ese gains might be due to int ended or unint ended outcomes. J ansen (2001 ) ar gu es that poli c y itself can af fect implementation negati ve l y. For ex ampl e, poli cies that ar e laun ch ed during electi on University of Ghana http://ugspace.ug.edu.gh 22 campai gns and poli cies t hat ar e announ ced to app ease dono rs are not alwa ys me ant to be implemented. Jansen (2001) uses a theor y of poli c y s ymbol ism as ex planati on for non -impl ementati on of policies. He terms these policies ³symbolic policies´ and arJues that they Zere never meant to be implemented in the first plac e. He ar gues that poli c y implemen tation fail ures are due to over-investm e nt of the state in the political s ymbol ism of poli c y rather than its practi cal implementation. This inc ludes lack of att enti on to polic y i mpl ementati on strate gies and poorl y m ana ged poli c y decisi ons. Christ ie (2008: 152) shares the s ame vieZ. She arJues that Jovernment ³has favoured structural chanJes Zith hiJh symbolic value.´ 2.4 Factors that af f ect p ol icy imp le men tation P oli c y implementation anal ysis requires und ersta nding of all stages whic h int eract and influence each other. It shoul d be reco gnised, however, th at not all implementation problems can be identifi ed during the sta ges that preced e it. Man y of the problems can onl y be discover ed during the implementation stage, whi ch is the primar y int er fac e between poli c y and pra c ti ce. It shoul d be noted t hat thi s stud y confines it s scope to the implementation stage. The choic e of thi s focus does not dispu t e the fact t hat some of th e compl ex it ies that manifest during the implementation stage ar e as a result of events that occurr ed in other sta ges. This stud y has adopted a combi nati on of top -dow n and bott om -up app roa ches to poli c y implementation in anal ys ing reasons fo r succ ess and fail ure in the implementation of the mut ual healt h insurance scheme in Ga West Mu nicipali t y. These appro a ches informed University of Ghana http://ugspace.ug.edu.gh 23 the selecti on of literatur e to be reviewed, and the factors to be ex tracte d. Whil e it is acknowled ged that the contex t in which polic y i mpl ementati on takes place is unique, factors that aff ect the im plementation in differ ent contex ts were s ynthesiz ed in this stud y. These factors emer ged from diff erent s cholar s adherin g to dif fer ent perspe cti ves, working with diff erent poli cies, in different co untries. Those who uti liz e a top -down approach emphasise cen tral control as a means to secure succ essful implementation while a bott om -up approach fo cuses more on the discreti on of the actors in the implementation contex t. The central ch ara cterist ic of both top -down and bott om -up studi es is the assum pti on that if implementation proces ses can be controll ed b y relevant va riables, imple mentati on will be successful. For ex am ple, Sabati er (1986:23) proposed five requirem ents necessa r y to max im ise successful implementation. Sabati er ar gues that efforts must be made to ensure that: the progr amm e of acti on is based on sound theor y, which relates cha nges in tar get group behaviour to the achievement of desir ed an d stated objecti ves; Th e s tatute or other basic decisi on is compos ed of unambi guous poli c y directi ves of the i mpl ementati on process; The leade rs of implementi ng bodies possess the necessar y mana geri al and poli ti cal skil ls, and ar e comm it ted to statut or y obj ecti ves; The pro gramm e bein g implemented is acti vel y supported by or ganiz ed const it uenc y groups and by a few legisl ators or chie f ex ec uti ves throughout the implementation process, with the courts being neutral or suppo rtive; The relative priorit y of objecti ves of th e pro gramm e is not significantl y undermined over time by th e emer gence of con flicting poli c ies or chan ges in relevant soci al condit ions that undermine the t echnical theo r y or poli ti cal support of the programm e. University of Ghana http://ugspace.ug.edu.gh 24 These factors are also cit ed in a stud y on poli cy implem ent ati on in higher educ ati on conducted b y C er ych an d Sabati er (1986). In an a l ysin g reasons fo r the su ccess or fail ure of the high er educati o n reforms, thes e two resea rche rs (Cer yc h an d Sabati er, in Gornit z ka, 2005:39 -40) provided a list of factors affecti n g p oli c y implem entation: Le gal (official) obje cti ves: (a) Clarit y and consi stenc y (b) Degre e of system ch a nge envisa ged; Adequac y of the causal theor y und erl yin g the reform; Adequac y of fina ncial resourc es provided to implementi ng inst it uti ons; The degr e e of comm it ment to various progr am objecti ves among those char ged with its implementation withi n the educati on minist r y and the aff ected inst it uti ons of hi gher educ ati on; Degre e of comm it ment to various program m e objecti ves among le gisl ati ve and ex ecuti ve offic ials and affect ed groups outsi de the implementi ng agenci es; Chan ges in so cial and economi c condit ions affe cti ng Joal priorities or the proJram’s causal assumptions. Simil ar variables are cit ed by Sab ati er (2005: 19):Cl ear and consi stent objecti ves; Adequa t e causal theor y; Impl ementati on pro cess le gall y stru ctured to enhance compl iance b y implem enti ng officials and ta rget groups; Comm it ted and skil ful implementi ng officials; Support of int erest group s and sovereigns ove r time; Changes in socio-economi c cond it ions which do not subst a nti all y undermine poli ti cal support or causal theor y. The variables suggested by Sabati e r (1986), an d Cer ych and Sabati er (1986) can be cate gorised under five variables, namel y, pol ic y content, comm it me nt, contex t of implementati on, support of cli ents and coali ti ons, and capa cit y to implement poli c y. These va riables are al so cit ed by oth er pro ponents of top -down and bott om -up University of Ghana http://ugspace.ug.edu.gh 25 approach es to poli c y im plementation. Table 2.1 shows these critical vari ables and the scholars who propos ed them. Table 2.1 Critical variab les for the success of poli cy imp le men tation Variab le Scholars who prop ose variab le P oli c y content Van Meter and Van Horn (1975), Barr et and Fud ge (1981), Maz manian and Sabati er (1983), Sab ati er (1986; 2005) Contex t Wa rZick (2), Berman (), 2’7oole ( ), 9an Meter and Van Horn ( 19 75) Comm it ment Pressm an and Wil davsk y (1973), Go ggin et. al. ( 1990), Berm an (1978), Van Met er and Van Horn (1975) S upport of cli ents and coali ti ons P ressm an and Wil davsk y (1973), Berman (1978), Elmo re ( 1980), Sabati er ( 1986; 2005), Ba rret and Fud ge (1981) Capacit y McLau ghli n ( 1987, 199 8), Mazmanian and Sabat ier (), 2’7oole () In addit ion to the above anal ysis , contribut ions from various social scienc e discipl ines on improving the eff ecti ve ness of implementation wer e ex plored. Ho gwo od and Gunn (1984) use four approa c hes to ex plain variables that affect implementation. These are: structural, mana gerial, behavioural and poli ti cal approach es. The struct ural approa ch em phasises the need to establish orJanisational structures in the ³planninJ of chanJe´ and ³planninJ for chanJe´ (HoJZood and Gunn, ). 7hese structures are reJarded as crucial fo r the suc cess of implementation. The mana gerial appro ac h, on the oth er hand , views implementation as a man a geri al problem. This approach emphasises the developm ent of appropriate processes and mana gerial proc edures (Hogwood and Gunn, 1984). These proc edures and proc esses University of Ghana http://ugspace.ug.edu.gh 26 include cle ar st atements of obje cti ves, pe rform a nce stand ar ds, funding and resourc es, and moni toring and cont rol devices to ensu re tha t the programm e proce e ds as int ended. Laz a rus (2001) has also point ed out the importan ce of le gisl ati ve pr essure , control and ownership, finan ces an d sust ainabili t y, cle ar visi on, p rincipl es and procedur e, and int enti onal forward plann ing in the proc ess of ch a nge. The structural and man agerial app roach es reso nate with the top -down approach to implementation. The beh avioural appro ach starts from the reco gnit ion that there is often re sistance to chanJe, and arJues that ³human behaviour and attitudes must be influenced if policies are to be implemented´ (HoJZood and Gunn 22). In support of this view, Laz arus (2001) re gards succ essful ex perien ces and readiness to cha nge as some of the crucial va riables in the chan ge pro cess. Mc Lau ghli n (1987; 1998) asserts that the implementers’ ³Zill´ or ³motivation´ is the most crucial variable for successful implementation. She arJues that ³local choices about hoZ (or Zhether) to put a policy int o practi ce hav e more s ignifican ce for poli c y ou tcomes than do such poli c y featu res as technoloJy, proJram desiJn, fundinJ levels, or Jovernment requirements´. 0c/auJhlin asserts that the ³Zill´ or ³motivation´ to embrace policy obMectives is a necessary co ndit ion for eff ecti ve i mpl ementati on. The poli ti cal approa ch ta kes int o account the reali ti es of power. Impl ement ati on success in this approach is linked to the ³ZillinJness and ability of some dominant Jroup or coalitions of Jroups to impose its Zill´ (Hogwoo d and Gunn, 1984:216). To support thi s view, some resear che rs emphasise the importance of negoti ati ons and the bar gaini n g process durin g implementation (Christi e, 2008; Fata ar, 2006; Lowr y, 1992; Maharaj, 2005; Sehoole, 2002). The y ar gue that poli c y i m plementation is not about transmi ssi on University of Ghana http://ugspace.ug.edu.gh 27 but about bargaini ng and negoti ati on. Laz arus (2001) supports the importance of invol ving strate gic peopl e in the process of chan ge. Both the behavioural and poli ti cal approach es mirror the bo tt om -up approach to pol i c y implement ati on. In con clusi on, it is important to note that ther e i s conver genc e on the cri ti cal variabl es relating to poli c y imple mentati on identified by the scholars refe rred to above. Fa ctors that are found to facil it ate or const r ain poli c y implemen tation in the literature are summ arised as follows: The content of the poli c y itself; The contex t through which the poli c y must be implemented; The comm it ment of implementers to the poli c y; The capa cit y of impl ementers to impl ement the poli c y; The att it udes of impl em enters towa rds the poli c y; The support of cli ents and coali ti ons whose int erests are af fected b y the poli c y. 2.5 Barriers to pol icy imp le men tation in develop in g cou n tries The problem of poli c y i mpl ementati on in developi ng countries could be lik ened to the asserti on of Honadl e (19 79) who ar gu ed that poo r implementation or the ex ist ence of an implementation gap can be viewed as social carp enters and masons who fail to buil d to specificati ons and thus dist ort the beauti ful blue print . Egonmwan (197 1) noted that there is often a gap betwe e n poli c y desi gne rs and the powerful for ces of poli ti cs and admi nist rati on and imple menters. Th e gaps weake n the pro cess. An y imple mentati on gap result s in the widening of the dist ance between stated poli c y go als and actual goals reali z ed. Any implement ati on gap ma y be att ributed to the poli c y itsel f, the poli c ymakers or the environment withi n whic h the poli c y is made and implemented (M akinde, 2005). Thus, University of Ghana http://ugspace.ug.edu.gh 28 in the case of the top -d own appro ach the probl em emanat es fro m the top and not the other stakeholde rs in the poli c y implementation process. This is the ca se in Ga West Muni cipalit y wh er e the beneficia ries of the insurance poli c y su ch as the subscribers of the insurance s cheme are not included in the policy fo rmulati on process. Another problem that m a y fac e implementation in developi ng count ries is the iss ue of briber y and co rrupti on. This ma y arise wh ere hu ge amount s earma rked for proje cts get diverted b y of ficers in char ge of implementation for their personal us e ( Makinde 2005). &orruption has been the bane of most African Jovernment’s policy implementation processes and has gre atl y aff ected the implementat ion of poli cies in develop ing countri es especiall y. The abandon ment of projects refer red to as planned indi scip li ne ac cordin g to Egonmw an (1991) also result s in implementation deficit s. The abandonm ent of projects ma y result from poli tical regim e ch an ges, pe rsonal int erests and the adopti on of sophi sti cated technique s that are not well understood b y loc al agenci es and implementers. Other factors identified as causin g implementation problems in developi ng countries include the problem of not taking int o consi der ati on the socio -cult ural contex t of the poli c y on poli c y ben efici aries. An y poli c y that go es against the s ocio - cult ural beli efs and practi ces of int ended be neficiari es ma y not be successful and ther efor e result s in a gap. In adequat e or l ack of fu nds ma y also result in implementation gap. Ego nmwan (1984) identifies some problems that affect poli c y implementatio n in developi ng countri es as inadequate definiti on of goals (la ck of clarit y an d int ernal consi stenc y) , over -ambi ti ous goals; and the choic e of an inappropriate or ganisati onal structure in the implementation of poli cies. University of Ghana http://ugspace.ug.edu.gh 29 Grindl e (1980) and Gri ndle and Tho mas (1990 ) appea r to have a lot of reasons wh y implementation in developi ng countries fail . Some of the factors ide nti fied to be responsi ble for implementation fail ures include: lack of capa cit y (Palmer , 2000; La rbi, 1998; Mill s et al, 2001); bureaucr ati c inerti a (Brinkerhoff and Crosb y, 2002); lack of poli ti cal and bureauc rat ic comm it ment (Grindle and Thomas, 1990; Grindl e, 1997; Cleaves, 1980; M cCourt, 2001; A ye e, 1997); unclear poli c y obje cti ves (A ye e, 1995; Grindl e and Thomas, 1991); poli c y cha ract erist ics (Quick, 1980; Grindl e, 1980; Grindl e and Thomas, 1991); pol it icisation of implementi ng agenc y and its lead e rship (Quick, 1980) and inst it uti onal and resourc e const raint s (Batl e y and La rbi, 2004; Brinkerh off and Crosb y, 2002; McCourt and Sola, 1999). Malama (2003) identifie d five ke y condit ions for ensuring effe cti ve implementation of publi c poli c y: (1) poli ti cal support; (2) sufficient funding; (3) appropriat e inst it uti onal arran gements; (4) buil ding of suffi cient consens us to have enough bro ad based s upport for the poli c y; and (5) proper moni torin g of the reform proc ess. Yet anot her factor that affe cts implementation is the nature of the impl ementing agen c y. Wit h particular refe renc e to decentr ali sa ti on of implementation, Cheema and Rondinelli (1983) a r gue that effecti ve implement ati on of reform poli c y in developi ng countries is closel y related to four sets of facto rs, namel y: Environm ental condit ions; Int er -or ganisati onal relations hips; Resources for programm e and poli c y ex ecuti on ; Characterist ics of impl ementing agen cies . The factors that aff ect implementation agencie s acco rding to Cheema and Rondil li (3) include technical, manaJerial, policy implementation skills of the aJency’s staff, University of Ghana http://ugspace.ug.edu.gh 30 the aJency’s capacity to apply all the principles of manaJement to the implementation; the ingenuit y of personnel invol ved in int egr ati ng th e dec isi ons of all secti ons/ departments pl us the benefits gained from both poli ti cal and bureau crati c leadership and m aking good use of the stren gth of bur eau -p rofessi o nal and ot her cli entele groups. Thes e are ver y important or ganis ati onal featur es that com e int o pla y for poli c y implement ati on success. The tacti cal appr oach that the agen c y ad opts in deali ng with its cli ents, stakeholders, benefici aries, the private sector and opin ion leaders and all ied civi l societ y grou ps are equall y ver y imp ortant. The qu ali t y of le adership withi n the implementi ng or gan isatio n, the accept ance, cooperati on and com mi tm ent to the policy obMectives amonJ the orJanisation’s staff and, often the location of the organisati on in the bu reauc rati c hi erar ch y al so ex ert a critic al impact on the implementation of a poli c y. 2.6 Concep tual Framew ork This secti on presents a syn thesis of variables that affect poli c y implement ati on based on the literature review pr ovided above. The s yst ems approa ch is rega rd ed as the most valuable tool for the conceptualis ati on of these variable s. This approach is specifi call y helpful in ex ploring the variable s at diffe rent levels of the healt h sys tem, namel y, nati onal, region al, dist rict and hospi tal. This framework was dev elope d to guide the investi gati on of the fac tors that affe cted the i mpl ementati on of the mut ual healt h insurance s cheme in Ga West Muni cipalit y. Thi s framewo rk consi sts of five elements which will be discusse d below. These el eme nts include: poli c y con tent, contex t, comm it ment, capacit y, s upport of cli ents and co ali ti ons. A diagr am of t he conc eptual framewo rk is depicted in Figu re 2.4 University of Ghana http://ugspace.ug.edu.gh 31 Figure 2.4: Concep tual Framew ork Source: Research e r (2013) 2.6.1 Po licy Conten t P oli c y content is one of t he critical pil lars on which poli c y implementatio n is based. It is gen erall y regarded as a crucial factor in establi shing the par ameters and directi ves for implementation, alt hough it does not determi ne the ex act cour se of implementation (Br yn ard and De Coning, 2006). The content of poli c y includes: what it sets out to do, that is the objecti ves, how it relates to the pro blem to be solved whic h is the causal theor y, and how it aim s to solve the problem , that is , method s (Br ynard an d De Coning, 2006). In top -down app roaches to poli c y imple mentati on, goal clarit y is seen as an important variable that directl y aff ects poli c y i mpl ementati on. Matland (1995: 157) states that ³Joal ambiJuity´ is seen as le ading to misunderstan ding and un certaint y and Element s of conce pt ual f ram ew ork  Policy cont ent  Commi t ment of impl ementi ng agenc i es  Capa cit y to impl ement pol icy  Cont ext ual factor s  Support of cli ent s and coalit i ons for pol i c y University of Ghana http://ugspace.ug.edu.gh 32 often is culpable of implementi ng fail ur e. Suppor ti ng thi s view, Gornit z ka et al. (2005) note that cle ar and un a mbi guous poli c y go als are easie r to implement than a set of compl ex and contradictor y goals. Cer yc h and Sab ati er (19 86 ) be gin from the prem ise that success or fail ur e of poli c y is dependent on the ex tent of the ch an ges required, and the cla rit y and consi s tenc y of poli c y goals. These authors ar gue that the more compl ex the changes required b y poli c y ar e, the lower the de gre e of suc cess of poli c y implem e ntation. Also, there is more ch ance of success if the poli c y is cl ear and consi stent. The emphasis on consi stent poli c y objecti ves as a condit ion for eff ect ive implementation was criticised b y schol ars su ch as Elmo r e (1980) and M c Lau ghli n (1998) who suppo rt a bott om -up appro ac h to poli c y implementation. These scholars do not focus on poli c y objecti ves as pr escribed b y the gove rnment, but rathe r focus on poli c y obje cti ve s as const ructed b y loc al implementers through the bar gain in g and negoti ati on process, as well as the ini ti ati ves from these actors. With rega rd to causal t heor y, sev eral rese arch e rs ar gu e that poli cies are someti mes ineffe cti ve, not because the y are badl y implemented, but because the y ma y be based upon an inad equate und erstandin g of the proble m, its causes and the po ssi ble solut ions (Cer ych and Sab ati er, 19 86; Hogwood and Gunn, 1984; Pressm an and Wildavsk y, 1973; Sabati er, 1986; 2005 ). In othe r wo rds, if the theor y unde rpinning the poli c y is fundamentall y incorr ect, the polic y implementatio n will fail . University of Ghana http://ugspace.ug.edu.gh 33 2.6.2 Commit men t of imp le men ters to the poli cy It is gen erall y assum e d that the most important factor in indi vidual success is comm it ment. Commi tm ent means pledgin g onesel f to a certain purpose or line of acti on. Comm it ment, like all other abstra ct thi ngs, is subj ecti ve and ver y difficu lt to measure. Howeve r, there are indi c ators that show the level of comm it ment of an indi vidual to a particular t ask. One indi cator is fulfil li n g obli gati ons and promi ses, esp eci all y wh en one knoZs Zhat one’s role and responsibilities are. Scholars Zho support both the top-down and bott om -up approa ch es to poli c y implement ati on consi der comm it men t to be critical to effe cti ve implementat ion. These schol ars ar gu e that poli c y ma y be go od , but if the implementers ar e un will ing to carr y it out, imple mentati on will not occ ur (Br ynard and De Coning, 2006; Mazmanian and Sabati e r, 1981; Mc Lau ghli n, 1987; 1998; Van Meter and 9an Horn, , :arZick, 2). 8N(S&2’s Global 0onitorinJ Report (25) also notes that gov ernme nt commi tm ent and leade rship is crucial for polic y success. Br yna rd and De Coning (2006: 199) reinfor ce th e importance of th e com mi tm ent factor in pol ic y implementation and make two proposi ti o ns: First, comm it ment is important n ot only at the ³street level´ but at all levels throuJh which poli c y passes ± in cases of int ernati onal comm it ments, thi s includes the regim e level, the state level, the street level, and all levels in between. Second, in keeping wit h a web -li ke conc epti o n of int er -li nkages bet ween the five variables, indi c ated fi gur e 2.1 comm it ments will influence and be influ en ced b y all the four variables: content, capacit y, contex t and cli ents and coali ti ons. Those int erested in effe cti ve implementatio n cannot afford t o i gno re an y of these linkage s and ar e best University of Ghana http://ugspace.ug.edu.gh 34 advised to identify the ones most appropriate to ³fi[´ particular implementation processes. As stated earlier, commitment is difficult to measure but can be seen throuJh a person’s acti ons. The re are critical qu esti ons that on e can ask to dete rmine wh ether the re is comm it ment to the poli cy. For ex ampl e, what resources do implementatio n parties have, and how much are the y will ing to en ga ge in th e i mpl ementati on? What is the durati on of their comm it ment? To what ex tent are of ficials at nati onal, regional, dist ri ct and hospi tal levels will ing to imple ment the mut ual healt h insuranc e poli c y? Is mut ual healt h insurance poli c y part of t he nati onal / regional / di strict / hospit al developm ent plans? 2.6.3 Support of cli en ts and coali tions for imp lemen tation As stated earlier in thi s chapter, the res ear ch highli ghts the importa nce of havin g coali ti ons of int erest gr oups, leaders, and other actors outsi de the government, who support implementation. Elmo re (1980), in parti c ular, consi ders the for mation of loc al coali ti ons of those affe ct ed b y the poli c y to be one of the most cru cial el ements durin g implementation. The success or fail ure of poli c y depends on the support the poli c y gen erat es among those who are aff ected (Br yna rd and De Coning, 2006; Maharaj, 2005). Christ ie (2008: 149) states that though poli c y ma kers ma y pr efe r to emph asis e structural chan ges, the y cannot sid estep human agen c y and its influenc e on poli c y outcomes. To investi gate the support of differ ent coali t ions in the stud y the followin g questi ons could be asked: Who are the potential cli ents? What parties (inside and outsi de gove rnment) are likel y to support the poli c y? What support do the y give to the i mpl ementati on process? University of Ghana http://ugspace.ug.edu.gh 35 2.6.4 Capacity to Imple men t Policy P oli c y implement ati on studi es have shown that the success of an y publi c poli c y rests on the capacit y to implement it (Fukuda -P arr, Lo pez and Malik, 2002; Makoa, 2004; Mc Lau ghli n 1987). In t he Ghanaian contex t, ca pacit y is rega rded as a strate gic entr y point to the dev elopm e nt and implementation of poli cies. It is gener all y kno wn that man y developm ent effo r ts have fail ed in man y countries bec ause the y l a ck inst it uti ons with the abil it y to imple ment and sust ain poli cies, and Ghana is no ex cepti on. One of the comm onl y cit ed reasons is lack of cap acit y to sust ain developm ent. Capacit y is gener all y def ined as the abil it y to perf orm functi ons, solve pro blems and set and achieve obje cti ves (Fukuda -P a rr, Lopez and Malik, 2002; McLau ghli n, 1987; 1998). This concept is vague and means dif fer ent thi ngs to dif fer ent people. Some people assume a narroZer approach that does not Jo beyond individuals’ abilities to perform certain functi ons, while others assum e a bro ader and s ystemi c approa ch. This s ystemi c approach looks at the capacit y of other subs yste ms as the y int er act with each other to produce outcomes. One such ex ampl e is found in Br ynard and De Coni ng (2006) who vieZ capacity in terms of the Jeneral system’s (structural, functional and cultural) ability to impl ement the poli c y objecti ves. Honadle (1 981) views cap acit y as the abil it y to perform six tasks, namel y: to anti cipate an d influ ence chan ge, make infor med decisi on about poli c y, develop pr ogr amm es, att ract and absorb resourc es, mana ge resources and evaluate acti vit ies. Willems and Baume rt (2 003), on the other hand, pa y att enti on to all the dim ension s of inst it uti onal capacit y. These dim ension s inclu de: empowerm ent, soci al capit al, an enabli ng envi ronment, cult ure, values, and the way indi viduals and or gan is ati on int eract University of Ghana http://ugspace.ug.edu.gh 36 in the public sector and Zithin society as a Zhole. :illems and Baumert’s capacity assessment framework dist inguishes betw een thr e e levels of inst it uti onal capacit y: micro level (indivi dual); meso level (organis ati on) and macro level (broade r contex t). The macro level is further divi ded int o three dist inct levels. These levels include: network of organisati on, publi c gov e rnance and societ y, norm s, values and pr acti ces. 2.6.5 Attitu d es of imp le men ters tow ard s the pol icy Lessons from poli c y im plementation rese ar ch s how that the healt h se ctor can provide good poli c y, suppo rt, an d resour ces and buil d the cap acit y of participant s to implement the poli c y, but if att it udes have not changed, the implementation will fail (Mc Lau ghli n , 1987; 1998). Mc La u ghli n ar gu es that su ccess of an y poli c y implementati on depends on two broad factors: loc al capa cit y and will ingn ess . She further ar gu es that traini ng can be offer ed, consul tants can be hir ed and funds can be mad e avail able, but if ther e is no will ingness on th e part of the implementers, i mpl ementati on will not be suc cessful. Therefo re the su ccess of mut ual healt h insuranc e is dependent on the at ti tudes of the actors invol ved. Praisner (2003:3) conte nds that lead ers demons trate their beli efs and priorit ie s in the following wa y: How the y mak e and honou r com mi tm ents; What the y sa y in formal and informal sett ings; What t he y ex press int er est in an d what questi ons the y as k; Where the y choose to go and with whom the y sp end time; How the y or ganis e their staff and their ph ysical su rroundin g. The question is HoZ can one determine Zhether role players’ attitudes are positive or not" It is Jenerally accepted that the concept ³attitude´ is a very compl ex phenomenon. It is compl ex in the sense that it is difficult to o bserve dir ectl y. 2ne can only infer people’s attitudes from their e[pressed vieZpoints and from Zhat University of Ghana http://ugspace.ug.edu.gh 37 the y do. Atti tudes ar e ge nerall y divi ded int o thre e components: affe cti ve, co gnit ive and conati ve components. An att it ude is therefore a combi nati on of thr ee conceptuall y dist inguishable re acti ons to a certain obj e ct (Avr a mi dis, Ba yli ss and Burd e n, 2000). 2.6.6 Context of Imple men tation R esearch ers are in gen e ral agr eement that poli c y implementation is aff ected b y the contex t in which poli cies are implement ed (Br ynard and De Conin g, 2006; Maharaj, 25 2’7oole,  9an 0eter 9an Horn, 5 :arZick, 2). 3olicies that Zork in one contex t ma y fail in another. Gornit z ka et al. (2005) also state t hat the socio - cult ural, socio -e conomi c and socio -poli ti cal co ndit ions of the implementi ng agenc y shape the outcomes of poli c y implementation. To investi gat e the so cio -e c onomi c, socio - cult ural and socio -poli ti cal factors that affe ct the inclusi ve nature of im plementation, several qu esti ons could be asked. These ar e: Ho w ar e decisi ons made in the nati onal, regional and dist rict hospi tal s about mut ual healt h insurance schem e? What structures influence pol ic y implementation at nati onal, regional and dist rict hospi tal levels? Are finances av ail able to pro vide the servi ces ne eded in the implementation of the mut ual healt h insurance sch eme ? How do cult ural practi ces in fluence the implem entation of the mut ual healt h insu rance s cheme? 2.7 Summary and Conclu sion In an att empt to understand factors that impinge on the implem entation of poli c y, two domi nant approa ches th at ar e used in ex plaining and an al ysing poli c y processes wer e ex plored, namel y, top -do wn and bott om -up. In ad dit ion, different framew orks that seek to synthesise thes e appr oaches were ex ami ned. A top -down approach begins with the objecti ves and goals of the poli c y, and me asure s implementation succ es s or fail ure in University of Ghana http://ugspace.ug.edu.gh 38 terms of the original obj ecti ves. This approa ch as sumes that clear objecti v es and control by poli c ym ake rs will lead to a more effecti ve im plementation . The bott om -up approach, on the other hand, plac es value on the role of loca l implementers and on th e or ganisati on that is tr yin g to solve the problem. This approac h acknowled ges that pol ic y is not the onl y determi nant aff ect ing the implementation, but th at loc al condit i ons influence implementation. Theories th at combi ne top -down and bott om -up appro aches ackno wled ge the role of poli c y obj ecti ves, as wel l as the discreti on of local implementers and the effe cts of local condit ions. The con clusi on that can be drawn is t hat poli c y implementation is a compl ex process and there are man y factors that contribut e or hinder effecti ve im plementation. These factors can be best captured b y usin g a combi nati on of these approach es. A sim pli fied combi nati on model has bee n const r ucted in order to or ga nise the data coll ected in thi s stud y. University of Ghana http://ugspace.ug.edu.gh 39 CHAPTER THREE IMPLEMENTATION OF THE NATIONAL HEALTH INSURANCE SCHEME IN GHANA 3.0 Introd u ction This chapter adopts a bro ad persp ecti ve on the con tex t of the stud y. It nar rat es the hist o r y of the implementation of the mut ual healt h insurance s cheme throu gh the Nati onal Healt h Insuran ce Author it y. The ch apter first outl ines the hist orical contex t of the healt h insurance in Gh ana, the nati onal healt h insuranc e in Ghana, the implem entation o f the healt h insurance sch eme and the actors invol ved in the implementation. The healt h insurance s cheme is implemented in the whole nat ion, but thi s chapter limi ts its focus to the Ga West Municipali ty cont ex t. 3.1 Historical con text of the health insu ra n ce in Ghana Under coloni al rul e, Gha na, as man y other Afric a n countries, or ganiz ed its healt h s ystem prim aril y to ben efit a small eli te group of coloni sers and th eir wo rkers (Arhin - Tenkoran g, 2001). Heal th car e provisi on occur r ed mainl y throu gh hosp it als in urban areas, with direct pa ym ent at the point of use. The rest of the population reli ed on services from a ran ge of providers such as trad it ional healers and missi onar y healt h centres . Afte r indep ende nce, the governm ent of Ghana provided medi cal car e fr e e of char ge to their popul ati on at publi c healt h facil it ies. Healt h care was finan ced b y gene ral tax es and ex ternal donor support, user fees were removed and att enti on was directed to developi ng a wide ran ge of primar y he alt h car e fa cil it ies across the co untr y. University of Ghana http://ugspace.ug.edu.gh 40 B y the earl y 1970s, gen e ral tax revenue in Ghana, with its stagnati ng econ om y, could not support a tax based healt h financin g s ystem. In th e healt h sector the re wer e shorta ges of essential medicines and equipm ent, leading to poor quali t y of car e. In 1985 , Ghana ini ti ated healt h sector reforms as part of broad er structural adjust ment progr ams aim ed mainl y at reducin g gov ernment spending. Cutt ing down on spending was to address budget ar y defi cit s. In the healt h sector, cost recov er y mech anism s throug h user fees wer e introduced (traditionally knoZn in Ghana as ³cash and carry´). Furth ermore, healt h services were libe rali z ed which all owed more pri vate sector invol veme nt. The financi al aim s of the reform were achieved and shorta ges o f essential medicines and some suppl ies improved. Howeve r, these achievem ents were accompanied b y inequiti e s in financial acc ess to basic and ess en ti al clini cal services (Wa ddington and En yim a ye w, 1990). During the 1990s sever al comm unit y he alt h insurance schem es, popularl y call ed Mutual Heal th Or ganiz ati ons (MHO) emer ged in Gh ana with som e ex terna l funding and technical support. Most of them focused on providi ng financial protecti on against the potentiall y catastrophic costs of a limi ted range of inpatient services (Fusheini et al., 2012). In 2, as part of their campaiJn, the NeZ 3atriotic 3arty, promised to abolish the ³cash and carry´ system and to remove financial barriers to utili]ation of health care (Fush eini et al 2012). In line with thi s objecti ve, the Nati onal Healt h Insur ance S cheme (NH IS ) was launched and the Nati onal Healt h Insuran ce Act (Act 650), pass ed int o law in 2003. The scheme was aim ed at replacin g out -of -pock et fees at point of servi ce use and of making he alt h car e afford able, improvin g acc ess and he a lt h out comes. The implementation of NHIS in terms of acc ess to ben efits be gan in 2005. University of Ghana http://ugspace.ug.edu.gh 41 3.2 The Nation al Health Insuran ce Scheme The Nati onal Healt h Ins urance Act (650, 2003 ) establi shed a Nati onal Healt h Insuran ce Authorit y, govern ed b y a Council , to regu late the healt h care s ystem , including the accr edit ati on of provid er s, agre eing on contributi o n rates wit h the schemes, mana gin g the Nati onal Healt h Insur an ce Fund and approvin g cards fo r membership. The Nati onal Healt h Insur anc e Act al so stated that thre e t ype s of healt h insuranc e sc hemes ma y be establi shed and oper ate d in the countr y: (a) di strict mut ual healt h ins urance sch eme (DMH IS ), on e for eac h dist rict, with a minim um of 2000 memb er s; (b) private comm ercial healt h insur ance s chemes and (c) pr ivate m utual healt h insur ance s chemes. Wit h the ex cepti on of the first insuran ce s che me, the last two ar e not eli gibl e for subsi dies from the gov er nment since the y ar e priv atel y op erat ed. The Council , which inc ludes repr esentatives of main stakeholder grou ps, e stabli shes formul a for all ocati on of funds to pa y for subsi dies to schemes, cost of enroll ing the indi gent and supportin g access to healt h ca re. The funding sour ces come m ainl y from the Nati onal Healt h Insur an ce Le v y (2.5% of V. A .T.): second ar y sou rc es ar e pa y roll deducti ons (2.5% of income) for formal sector empl o ye es and premi um for informal sector members. Other fu nds come from donati ons or loans. In terms of m embership of the NH IS , the Act establi shes that it is mandator y for all Ghanaian cit iz ens, un le ss alt ernati ve private healt h insurance can be demons trated. Howeve r, in pra cti ce, membership is opti onal for non - formal se ctor workers who repres ent the bulk of the population. For form al sector wo rkers, a pa yroll deducti on of 2.5% is transfer red to th e NHIS fund as part of t heir contribut ion to the Social Securit y University of Ghana http://ugspace.ug.edu.gh 42 and Nati onal Insur anc e Trust (SS N IT ) fund. In formal se ctor work er s are char ged premi um that shoul d be income related. Contribut ions by thos e outsi de the formal s ector are supposed to be define d acco rding to income s uch that the lowest -inco me group pa ys a premi um of 7.20 Ghanaian cedi (GH¢) or US $ 8 while those in the highest income group pa y a premi um of GH¢ 48.00 or US$ 53.2. In reali t y, a flat premi um pa ym ent of GH¢ 7.20 per annum is char ged du e to the difficul t y of cate goriz ing people int o differ ent socio-economi c groups. There is a six -mont h gap between joi ning and bei ng eli gibl e for benefits. All providers must offe r a minim um pa cka ge of servic es that is quit e comprehensive, coverin g gene ral outpatie nt and inpatient services at accr edit ed facil it ies, oral healt h, eye care, eme r gen cies and m aternit y care, such as pr enatal car e, normal deli v er y and some compl icated deli veries (H IV retrovir al dru gs, ass ist ed reproducti on and ca ncer tre atm ent are not in cluded). Diseases cover ed include malaria, dia rrhoe a, so me respir ator y infecti ons, skin dise ases, hyp ertension , asthm a, di abeti cs etc. Th e benefit packa ge is the same fo r all dist ricts that pa y providers on a fee -fo r-se rvice basis . Ac cording to th e legisl ati ve Instrum ent which accomp anied Act 650, about 95% of all co mm on healt h problems in Gh ana are covered (Ghan a Minist r y of Healt h, 2004a and 20 04b). How ever, it is difficult to establi sh how thi s esti mate was obtained. The drugs provid ed are liste d in the Nati onal He alt h Insu r ance Dru g List (See App endix ). 3.3 Imple men ting health insu ran ce in Ghana In discussi n g the implementation of healt h insurance in Ghana, Wit ter and Garshon g (2009) indi cated that the NH IS is heavil y reli ant on tax funding sin c e abo ut 70-75% of revenue accruin g to th e programm e derives from t ax . Inde ed , the rev elation that much of University of Ghana http://ugspace.ug.edu.gh 43 the contribut ion comes from tax ati on itself is an indi cati on that insurance is not too dist inct from the tradit ional funding - since ear li er gov ernmen ts sti ll provided some budget ar y support in add it ion to donor funding to the healt h sector. The authors also discussed membership to the scheme. The y indi cate that in principle NH IS is le gall y mand ator y (unless alt ernati v e private healt h insur ance can be demons trated) how ever membership is opti onal for non -form al sector workers who incidentall y comprise th e bulk of the population. Their resear ch reve al ed that there was gro wth of memb ership as the number of card holders ros e from 6.6% of the population in 2 005 to 45% three yea r s later in 2009. Th e inc rease compar es ve r y favourabl y with earlier discussi ons of oth er states in Afric a pa rticu larl y, Tanz ania. Th e auth ors concluded that even though the NH IS ex tends towards full covera ge ther e wer e some equit y concerns. For ex ampl e , there were iss ues regardi ng regional membership patt erns. There was also a high lev el of regist rati on in the Bron g Ahafo Re gion and the North of Ghana and less so in Great er Ac cra (W it ter and Garshon g, 2009). Since thi s stud y is about the implementation of the scheme in on e of the m unicipal areas withi n a region which h as low re gist rati on, the ar gument of Wit ter and Garshon g is useful for thi s stud y in discussi ons on regist rat ions in the area. It mus t however be indi cated that the auth or s have not provided suff icient reasons wh y the Gre ate r Accra had low enrolm ent . Catherine et al., (2008) ex plored comm unit y base d healt h insuran ce from t he persp ecti ve of the suppl y of medici nes in low income countries , including Ghana. Their findings highli ght the pau cit y of evidence about medicin e s covera ge and medicine s uti li sati on in University of Ghana http://ugspace.ug.edu.gh 44 comm unit y based healt h insurance pro gramm es as well as the need for bett er understandin g of the role of medicines in the overall healt h care financin g of low income countries. It was establi shed that in Ghana, s ever al factors make s ystemati c anal ysis of data about the structure and process of comm unit y he a lt h insurance pl ans chall en gin g. These factors include: small siz e, diversit y of comm unit ies, where the y functi on a nd lack of infrastructur e or technic a l capacit y. The y also indi cated that the focus of t he comm unit y healt h insuranc e sinc e 2005 to date has been on strate gic and poli ti cal acc eptanc e of comm unit y he alt h insu ra nce rather than on comm unit y he alt h pe rforman c e . Over all , their findings su ggest th at volunt ar y insuran ce whi ch i ncludes Comm unit y Hea lt h Insur anc e has a ver y small penetr at ion in low income countries where private pa ym e nt represented over half of healt h care ex pendit ures (Catherine et al., 2008). The conclusi on drawn by th e authors on low income levels vis -a-vis regist rati on are not without flaws. Bec ause i t has been observ ed alre ad y that, en rolment to healt h insurance is low in the Greater Accra region and high in areas such as the Bron g Aha fo and Northern regions (Wit ter and Garshon g, 2009 ). The Gh ana Statist ical Service (200 7) report places the upper povert y line of the Bro ng Aha fo and the whole of the north higher than the Greate r Accr a Region, but the Greate r Acc ra regist er ed low enrolm ent. Wit h this, one would not but agr ee to the fact that it is not onl y pov ert y wh ich can af fect regist rati on. As pr ecisel y indi cated low access to healt h ca re in the Greate r Acc ra i s not due to pov ert y but du e to a comfortabl e lev el of income reali sed b y some of its resi d ents. Despit e the criticism , the resea rch provided an i mportant framework fo r thi s stud y. Fo r University of Ghana http://ugspace.ug.edu.gh 45 ex ampl e, using their stud y as a guide , thi s study consi de red implementation vis -a-vis acc ess to medicines in the various he alt h facil it ies in the stud y ar ea. Gobah et al., (2011) in t heir stud y of NHIS in th e Akatsi Dist rict conclu de that, NH IS has improved access to healt hcar e se rvices , to diff erent cate gories of peopl e b y removi n g significant finan cial ba r riers to access. Th e findings su ggest that NH IS posi ti vel y affe cted he alt h seekin g behaviour, access to mod ern he alt h car e servic es and likeli hood of deli ver y at a healt h facil it y and bein g assi sted by tra in ed healt h person nel. Gobah et al., (2011) furthe r indi cat e that NH IS also had pos it ive effe ct on post nat al care but found no evidence of it on usa ge of anten atal ca re. Mensah et al., (2010) ev aluate ed Ghana ’s NH IS withi n the contex t of the M i l l e n n i u m D e v e l o p m e n t G o a l s ( M D G s ) 4 and 5 which deal with the healt h of women and chil dren. Their findings su ggest that with NH IS , women are more likel y to receiv e prenatal care, deli ver at a hospi tal, have their deli veries att ended b y t rained he alt h professi onals, and ex peri ence less birth compl ica ti ons. The y conclud e that NH IS is an effe cti ve tool for impro ving he alt h outcomes among those who ar e covered, whi ch shoul d encoura ge the Ghanaian government to promot e further enrolm en t, in particular among the poor. Indeed the NH IS has been seen as an effecti ve tool to reach the three healt h MDGs, namel y: reducin g inf ant mortal it y; improvin g mat ernal healt h; and, fighti n g malari a and HIV / AIDS (go als 4, 5, and 6). Howeve r, att ributi ng increas ed uti li z ati on of maternal he alt h care se rv ices solel y to NHIS is inconclusi ve because the stud y shoul d have t aken th e impa ct o f the free maternal he alt h car e pol ic y int o consi de rati on. The poli c y was rolled out in 2004 and University of Ghana http://ugspace.ug.edu.gh 46 accordin g to Wit ter et al (2009), the ex empt ion poli c y was cost eff ec ti ve in that it increas ed uti li z ati on significantl y and made mode st equit y gains. More so the impact of NHIS cove ra ge on the ut il iz ati on of maternal heal thcare servic es ma y var y signific antl y across the cou ntr y. USA ID (2009) also inve sti gated the impa ct of NH IS on mat ernal he alt h in Ghana. Th e y found that there were no significant chan ges in the proportion of women who received an y pren atal care, or in the ave ra ge number of reported pren atal care visi ts between baseli ne and end -li ne, in dicati ng that th e NH IS did not increase uti li z ati on of pren atal care. In Nkoranz a, wh er e the stud y was conduc t ed, it indi cated that the proportion of women with deli ver y i n the past 12 mont hs who wer e insur ed at ti me of deli ve r y increas ed from 30% in 2004 to 45% in 2007. Women of reproducti ve age (15 -49 ye ars ) from wealt hier househol ds enroll ed in th e NH IS at hi g her rat es, compa r ed to women from poorer hous eholds . Osei -Akoto (2003) also studi ed the social inclusi on aspects of comm unit y based healt h insurance schemes b y i nvesti gati n g the deman d for th e sch emes b y the poor and ex ploring desi gn featu re s that could enhan ce bett er cover a ge and impr ove finan cial protecti on for he alt h ca r e servic es. The result s from thi s stud y sho w tha t the schemes perform quit e well in ter ms of pa yin g hospi taliz ati on bil ls for ben efici aries . Howev er th e findings portr a y a rema rk able ex c lusi on of the poo rest of the poo r, eve n fro m other forms of risk -sharin g arran gem ents in the informal secto r. Apart from pove rt y, the anal ysis also reve als that high -risk households ar e less likel y to participate full y in th e insuran ce s chemes. These fin dings ex pose one of the University of Ghana http://ugspace.ug.edu.gh 47 im plementation chall en ges of NH IS in that the poorest of the poor and th e indi gent ar e ex empt ed from the pa ym ent of premi ums as the Act sti pulates cate goric all y. However in practi ce thi s provisi on is becomi ng illusi ve with the ex cus e that identif yin g the poor is a difficult task. From what has been dis cussed so far it is evide nt that healt h insurance in Ghana has several dim ension s and also includes a number of actors. The nex t component is a brief discussi on of some of the actors in the impl ementa ti on of the healt h insu ran ce in Ghan a. 3.4 Actors in the i mp le men tation of health insu ran ce The implementation of the Nati onal Healt h Ins urance Scheme invol ves a variet y of actors in the pro cess. All these actors have ce rtain roles that th e y are suppos e d to pla y for the smoo th implementation and reali z ati on of the goal of the scheme. This secti on provides a brief literatur e on the role of the various actors in the implementation process of the scheme. 3.4.1 Role of Govern me n t in the imp le men tatio n of health in su ran ce The gov ernment is the major poli c y actor in the implementation of the nati onal healt h insurance sch eme. Gove rnment ex ercises oversi ght responsi bil it y in the implementation of all healt h poli cies. Again government s ets poli c y a genda and int ro duces bil ls to chan ge poli cies, desi gn poli cies with the aid of bureauc rats in th e minist r y as well as enga ge developm ent pa rtners and oth er stak eh olders on iss ues in the healt h sector. Government also seeks to reduce healt h ex pendit ure by gett in g the publi c to contribut e to the scheme. As we hav e alread y observ ed abov e, gove rnment ensu res that VAT is levied University of Ghana http://ugspace.ug.edu.gh 48 and deducti ons made on SSN IT contribut ions and giv es mandate to t he DMH IS to coll ect contribut ions through pr emi ums. 3.4.2 The Nation a l Health Insuran ce Authority The Nati onal Healt h In surance Autho rit y (NH IA) is the statut or y bod y mandat ed to secure the implementati on of the NHIS . It is responsi ble for the regist r ati on, licensing and regul ati on of all hea lt h insurance s chemes in Ghana. The NH IA also overse es the operati ons of DMH IS s, gr ants accr edit ati on to healt hcar e providers and moni tors their performan ce for ef ficient and quali t y se rvice deli ver y, mana ge the NH I fun d and devises mechanism s to ensure that indi gents ar e proper l y cat er ed fo r b y th e DMH IS (NH IA Annual Report, 2010). 3.4.3 Service provid ers S ince independenc e, the Ghana Healt h Services has alwa ys implemente d gove rnment healt hcar e poli cies together with partners. The Muni cipal Healt h Direc tor ate in conjunction with the Mi nist r y of Healt h al so pla ys an import ant role in the implementation of the insurance sch eme. In term s of implementation , they govern and provide oversi ght respo nsibi li ti es of the scheme in addit ion to providi ng or suppl yin g services. Th e healt h dire ctorate assi sts governme nt in developi ng and sha ping poli cies in the countr y, ch ar ged with the responsi bil it y of providi ng quali t y he alt h car e servic es based on int ernati onal sta ndards. 3.4.4 Staff of the Scheme To ensure accountabili t y NH IS is decentr ali z ed to regional and dist rict leve ls. The office of the DMH IS in Amasa man was establi shed in 2005 to assi st the implementation of th e University of Ghana http://ugspace.ug.edu.gh 49 healt h insuran ce pro gr amm e at the dist rict level. Staffs in Amas aman are th e implementi ng officials and management bod y of the Ga Dist rict Scheme. Their core functi ons are the regist ra ti on of subscribers, iss uing of ID cards to regist e red members, renew al of membership , coll ecti ng pr emi um from members in the informal sector, vett ing and pro cessi n g claims subm it ted b y healt hc are provi ders. The y are also responsi ble for gener ati ng enou gh funds to ens ure sust ainabili t y. Usu all y the Dist rict mana ger of th e sch eme t akes de cisi ons in consul t ati on with the Boa rd. Th e oper ati onal office in Amasam an is semi -autonom ous; in part some of their de cisi ons are tied to the decisi ons taken by the C EO and mana gement in consul tation with the Healt h Insur ance Authorit y. 3.4.5 Subscrib ers In th eor y the subs cribers are mainl y consum ers of services o ffe red b y gov er nment, healt h providers and man a gers of the scheme. In pra cti c e how ever the subs criber s pla y a ver y important role in the implementation of the progr amm e. As we shall reali se soon the increas e in numbers of subscribers to the schem e is not mainl y du e to the effo rts of the staff or mana ge rs of the scheme but also due to indivi dual subscribers who took it upon themselves to educ ate m embers of the comm unit y to subsc ribe to the sch e me. Again it is the subscribers who prov ide information to the scheme mana ge rs about the nati onali t y of subscribers so as to redu ce the numbe r of non -Gh anaians who are che ati ng the s ystem b y gett in g regist er ed as res ident Ghanaians. If one consi ders these roles pla ye d by the subscribers’ one Zill not but aJree that they indeed play an important role in the im plementation. University of Ghana http://ugspace.ug.edu.gh 50 3.5 Summary and Conclu sion This chapter de alt with the review of related lit eratur e on the impleme ntation of the NHIS in Ghan a . Th e re view includes the hist or ical contex t of the healt h insurance in Ghana, the nati onal he alt h insuranc e sch eme and the various a ctors and th eir role in the implementation of the scheme . University of Ghana http://ugspace.ug.edu.gh 51 CHAPTER FOUR METHODS OF DATA COLLECTION AND ANALYSIS 4.0 Introd u ction This chapter focuses on the methods used in cond ucti ng thi s stud y. The iss ues discussed in thi s chapter include the rese arch d esi gn, the population of the stud y, sampl e siz e, sampl e technique and procedur e, sour ces of dat a, data coll ecti on inst ru ment and dat a anal ysis . The ch apter als o entails the t ypes of data coll ected from the management of the scheme, varied healt hc ar e servi c e providers, and subscribers of the sch e me who were contacted. 4.1 The Research Design A res ear ch desi gn sp ecif ies the methods an d pro cedures for acqui ring the information needed to st ructure and s olve the resea rch proble m and sti pulates what in formation is to be coll ected, from wha t sources, and by what procedures. A good research desi gn ensures th at the inf ormat ion obtained is relevant to the resea rch problem, and that it is coll ected b y obje cti ve pr ocedur es . Ther e is no single best resea rch design. Inst e ad, different designs of fer an arr a y of choic es, each with certain ad vanta ges and disadvanta ges. A surve y res ear ch desi gn was used to undertake th e stud y on implementation of NHIS in the Ga West Muni cipalit y. This res ear ch desi gn was consi de red approp ri ate be cause it is the best method to des cribe the cha ract eristi cs, perc epti ons and pr efe rences of th e Scheme under stud y (Sa unders et al., 2009 ). This design was also chosen because it has University of Ghana http://ugspace.ug.edu.gh 52 the advanta ge of prod ucing a good amount of respons es from a wide ran ge of respondents. It also provides a clear picture of events and people’s behaviour on the basis of data gather ed at a poi nt in time. The stud y ho wever adopted a mix method approa ch where both qu anti tative and quali tative techniques were us ed to anal ys e the data. 4.2 Population and Sample Size of the Study The population for thi s stud y is all regist er ed he alt h insurance cli ents, mana gement or staff of the scheme , and staff of healt hca re providers in th e Ga West Muni cipal Assembl y. Ther efor e, th e unit s of anal ysis in thi s stud y ar e thr ee, th at is: the regi stered healt h insurance cli ents; mana gement or staf f of t he scheme ; staf f of healt hcare providers in the Ga West Municipali t y. Respondents wer e rando ml y, as well as , purposiv el y drawn from the appro priate se cti ons of the stud y. In the end , one hundred and fo rt y s ubscribers, thi rt y he alt hc are pro viders, and thi rt y staff and mana gem ent of th e sch eme were s ampl ed . Brin gin g th e tot al number of questi onnaires dist r ibut ed to two hundre d. Howeve r, out of two hundred questi onnaires dist ribute d, one hundred and six t y questi onnair es, rep res enti ng 80.0% were retri eved. This was made up of on e hund red respondents from th e subscribe rs, thi rt y from the managem ent of the scheme and thirt y from the healt hca re providers in Ga West Muni cipalit y in the Gre ater Accr a Re gion. These sampl es wer e use d based on the assum pti on that all the subscribers, man a gement and healt hca re provid ers are ex posed to the same workin g envir onment. Thus, all thi ngs being equal, the answer s provi ded b y an y of them at an y tim e were unli kel y to va r y fro m those of the others. University of Ghana http://ugspace.ug.edu.gh 53 4.3 Sampli n g and Sampli n g Techniq u e The sim ple random an d purposive sampl ing technique s were used to select the respondents for the stud y. The sim ple random sampl ing technique was us ed to select the subscribers to the scheme. In usinJ this technique, subscribers at the schemes’ office were admi nist ered questi onnaires while at th e healt h providers end, pati e nts at the out - pati ent and in-pati ent departments wer e given questi onn aires to answe r. A purposive sampl ing te chnique was also used to sel ect the st aff and man a gement of t h e schem e. In spit e of the purposive sampl ing technique, a care ful att empt was made to ensure that top officials of the sch eme were pu rposivel y s ampl e d as the y are the right pe ople to answer such questi ons relating to the implementation of the scheme. Therefo re, ke y staf fs like the scheme man a ger, th e claims mana ger and M IS mana ger wer e part of th e respondents. Wit h respect to the healt hcare providers, a sim ple random s ampl ing te ch nique was used to first select the he alt h facil it y and the n the respo ndents. 4.4 Sample Size The tot al population of thi s stud y is lar ge co nsidering the fact that it invol ves all subscribers of the schem e in the Ga West Muni ci pal Asse mbl y, the m ana gem ent of the scheme and healt hc are providers. But due to time and difficult y in data coll ecti on, few respondents were sele cted for the stud y. A to tal of one hundr ed an d fort y (14 0) subscribers, thi rt y (30) members of the management of the sc heme and thi rt y (30 ) healthcare providers’ Zere sampl ed for the surve y. In all , two hundred (20 0) respondents we re used fo r the stud y. 4.5 Types and Sources of Data Both second ar y and primar y data wer e used for th e stud y. University of Ghana http://ugspace.ug.edu.gh 54 4.5.1 Second ary Data S econdar y data is pro ces sed information th at is readil y avail able to be uti li z ed. Some of the second ar y data used i nclude Statist ical fi gures on implementation, uti li z ati on, claims and quali t y of service fro m NH IS , as well as annual reports of GDMH IS in the Ga Wes t Muni cipalit y . Lit er ature was also review ed. Th e literatur e revi ewed co vered relev ant iss ues, which were cons idered important to the resea rch topi c. Ex ampl es include the hist or y of healt h car e in Ghana, as well as, literat ure on implementation and the gen eral appli cati on of the NH IS i n Ghana. 4.5.2 Primary Data P rimar y data provid es first hand information on an y subj e ct under stud y. The prim ar y data was coll e cted fro m respondents th rou gh the use of a questi onna ire which was admi nist ered to thre e sets of respond ents; subscribers, healt hca re providers and mana gement of the sche me at the Ga West Municipal Assembl y. 4.6 Data Collection Inst ru men ts The main dat a coll e cti on inst rument for the stud y was qu es ti onnaire. This was consi dered th e best inst r ument as i t en abled indi v iduals to sta y quietl y alo ne at their own free will to answer the questi ons. Questi onnaires were thus used to gather prim ar y data from the three s ets of t he respondents. Qu esti onnaire was us ed be caus e of the lar ge number of the sampl e s iz e and also its conveni ence. Gene rall y, the qu esti ons in the questi onnaire were car ef ull y framed, since answ ers given to questi ons depend on how the questi ons are asked. In desi gning the questi onnaire adequ ate att enti on was paid to ensuring that the objec ti ves of the resear ch were cov er ed. The que sti onnaire was developed mainl y throu gh a review of relevant documentar y m aterials. The questi ons University of Ghana http://ugspace.ug.edu.gh 55 were most l y close - ende d with few open -ended ones. Whil e the open -e nded questi ons enable the respondents t o give elabor at e responses and ex press themselv es bett er, the close-end ed questi ons enabled the res ear cher to guid e the respond ents to answer the questi ons appropriate l y. There wer e three set s of questi onnaire for the staff of th e schem e , the s ubscribers and healt hcar e providers. 7he questionnaires Zere divided into four sections section ³A´ Zas made of demoJraphic information of the respondents section ³B´ contained questi ons on the factor s that facil it ate implementation of the scheme, section ³&´ dZelt on the factors that const rain the implementation of the scheme , ³D´ had questions on the roles pla yed b y th e various actors in implem entation, Zhile section ³(´ solicited recomm endati ons and su ggesti ons fo r improveme nt in the impl ementati on of the schem e. Please che ck appendi ces A, B and C fo r details. 4.7 Ethical Consid eration s R espondents were assur ed of confidenti ali t y, as their consent was appro priatel y sou ght with respe ct to all info r mation the y provided. Respondents were also inf ormed that the work was pur el y for aca demi c purposes and not for reasons other than th at. The privac y and confidenti ali t y of all participants was assured . All documents used and sit es visit ed have also be en prope rl y acknowled ged and docum ented to avoid issues of plagia rism. 4.8 Analysis of the Data The questi onnaires wer e anal yz ed usin g the Statist ical Package for Social Sciences (SP S S ) version 16.0 software and were suppo rted by the appli cati on of fre quenc y tables. The int erpret ati on of the frequen c y tables has bee n thoroughl y given. University of Ghana http://ugspace.ug.edu.gh 56 4.9 Summary and Conclu sion This chapter discussed t he methods of data coll e cti on for thi s stud y. It concentrated on the resea rch desi gn, sam pli ng and the sampl e pro cedure, s ampl e siz e as well as the data coll ecti on inst rument which was basicall y a questi onnaire. The nex t chapter will therefor e an al yz e the dat a that was obtained from the field. University of Ghana http://ugspace.ug.edu.gh 57 CHAPTER FIVE DATA PRESENTATION, ANALYSIS AND DISSCUSION ON THE IMPLEMENTATION OF THE NATIONAL HEALTH INSURANCE SCHEME 5.0 Introd u ction This chapter anal yses data coll ected from the actors in the implementation of the Nati onal Healt h Insura nc e Scheme in Ga West Muni cipalit y. In all , a tot al of 160, peopl e made up of 100 subscrib ers, 30 people responsi ble for the implementation of the scheme and 30 respondents of t he healt h facil it ies. To be able to dr aw me anin gful, vali d and reli able conclusi ons fro m the data gather ed as well as make relevant conclusi ons and recomm endati ons, desc riptiv e and quanti tative anal ysis in the form of fre quenc y tables were const ru cted showin g the frequenc y as well as the percent a ge for eac h item on the questi onnaire. The data was anal yz ed b y usin g th e Statist ical Packa ge for Social Sciences (SP S S ) version 16.0 software and was support ed by the appli cati on of fr eq uenc y tables. 5.1 Demograp h i c in f orma tion of resp on d en ts This secti on gives brief demogr aphic back groun d of the respond ents. Th e demo graphi c information here compri sed those of the subscrib ers, mana gem ent of the scheme and the healt hcar e faci li ti es which is displ a yed in Table 5.1. Th e responses of the subscribers show that majorit y of t he respondents fall withi n the ages of 26 -35 (4 0.0%) while a minorit y of them were over 65 years (3.0 %). Wit h respect to th e management of the scheme, 56.7% of the res pondents fell withi n the ages o f 18-25 and 6.7 % were also in the ages of 51 -55. The det ail s are shown in T able 5.1 below. Wit h respect to the respondents University of Ghana http://ugspace.ug.edu.gh 58 of the healt hc are facil it ies, majorit y of the resp ondents wer e withi n the ages of 36 - 5 0 (43.3%) whil e the minori t y were withi n the ages o f 18-25 (10.0% ). Table 5.1: The age distrib u tion of resp on d en ts S ubscribers Mana gement of NHIS Age ( ye ars) Frequ enc y Percenta ge Age ( ye ars) Frequ enc y Percenta ge under 18 6 6.0% 18 - 25 17 56.7 % 18 - 25 24 24.0% 26 - 35 7 23.3 % 26 - 35 40 40.0% 36 - 50 4 13.3 % 36 - 50 17 17.0% 51 - 55 2 6.7 % 51 - 65 10 10.0% 56 - 65 0 0.0% Over 65 3 3.0% Over 65 0 0.0% Total 100 100.0% Total 30 100.0% In relation to the gend er of the respond ents, 53.3% of the subsc ribers wer e males while 47.0% were femal es. In the cat e gor y of the mana gem ent of the scheme, 54.8% of them were males while 45.2% wer e females. Sim il arl y, 66.7% of the responden ts were males while 33.3% wer e fem ales in the cate gor y of the h ealt hcar e provide rs. In all the cate gories m ale respond e nts domi nated. The educ ati onal back gro und of t he respond ents is presented in T able 5.2. It shows th at onl y 12.0% of the subs c ribers do not have fo rma l educati on with the rem aini ng 96.0% having all forms of fo r mal educati on. In the categor y of the healt hc are providers, onl y Healt h providers Age ( ye ars) Frequ enc y Percenta ge under 18 0 0.0% 18 - 25 3 10 . 0 % 26 - 35 10 3 3.3 % 36 - 50 13 43.3 % 51 - 55 4 13.3 % 55 - 60 0 0 .0% Total 30 100.0% University of Ghana http://ugspace.ug.edu.gh 59 6.7% of th e respondents do not have form al edu c ati on while the remainin g 93.3 % have all forms of formal educ ati on. The educati onal le vel of the mana gement of the scheme indi cates that 54.8% of them had a dipl oma, 29.0% had first de gr ee wh il e 9.7% had masters degr ee. Table 5.2: The education al back grou nd of respon d en ts S ubscribers Healt hca re Provi ders Educati on Frequ enc y Percent Educati on Frequ enc y Percent No educati on 12 12.0% No educati on 2 6.7% Elementar y 11 11.0% SHS 1 3.3% SHS 9 9.0% Nursing 5 16.7% Teach er 's Cert A 6 6.0% Diplom a 7 23.3% Diplom a 13 13.0% Degre e 6 20.7% Degre e 26 26.0% Masters 8 26.7% Masters 18 18.0% Secreta rial 1 3.3% PhD 1 1.0% Total 30 100.0% Technical 2 2.0% Mana gement DBS 1 1.0% Diplom a 17 56.7 Secreta rial 1 1.0% Degre e 8 26.7 Masters 3 10.0 PhD 2 6.7 Total 100 100.0% Total 30 100.0% 5.1.1 Occupation al back grou n d of resp on d en ts W it h the ex cepti on of the subscribe rs, the othe r two cate gories of respondents (the scheme man a ge rs and the servi ce providers) ha d sim il ar back ground and related job ex periences. The schem e mana gement team was working with the scheme while the service providers also were workin g in a healt h or healt h relat ed facil it y. Unlike th e scheme man a ge rs and the provide rs, the subs cribe rs to the scheme indi cate d a wid e ran ge of jobs. The occupati onal back grounds indi cated b y t h e respond ents included: University of Ghana http://ugspace.ug.edu.gh 60 pension ers, students, assembl y members, priva te busi ness men and women , civi l servants , drivin g, mining, teachin g and farmin g. It was found that the three most comm on occ upati ons amo ng the sub scribers were private busi ness (33%), farmin g (18%) and civi l/ publi c servants (14%). Farmin g and trading const it uted 42% of the respondents as co mpared to the civi l /publ ic servants who formed onl y 14%, while unempl o yment ac counte d for 7% of the subscribers. It could be said that thi s finding refl ected the low educ ati ona l background of the subs cribers in the dist rict. As a result , civi l and public service s which invariabl y req uired highe r educati onal qu ali ficati on wer e not ver y comm on in the dist rict (14%) compar ed to trading which re gist e red 24 percent. 5.2 Factors that facil itat e the i mp le men ta tion of NHIS in Ga West Municip ali ty This secti on presents data coll ected, descriptiv e anal ysis of data and discussi on of the findings in the stud y, con cernin g the factors that facil it ate implementation of NHIS in Ga West Mun icipali t y. The anal ysis he re is based on the three cate gories of actors in the scheme: mana gement of the scheme, healt hcar e pr oviders and subscrib ers. 5.2.1 Manage men t ’s percep tion of the factors that faci li tate the imp le men tatio n of NHIS in Ga West Municip ali ty The mana gem ent of NHIS at the MMDAs is one of the m ajor actors in the impl ementati on of NHIS . The y ar e in char ge of regist r ati on, coll ecti ng premi ums, iss uing ca rds, proc essi ng claims and the over all mana geme nt of the sche me. The factors that facil it ate impleme ntation of the scheme are partiall y att ribute d to how the mana gement of the sch e me act s. In a questi on as whether the impleme ntation of the University of Ghana http://ugspace.ug.edu.gh 61 scheme has been succ es sful or not, 86.0% of th e mana gement ar e of the view th at th e implementation of the scheme was suc cessf ul while 14.0% of them thi nk the implementation was not successful. Cle arl y majo rit y of the man a gement are of th e view that the implementation was success ful. It is ther efore important to find out the factors that facil it ate impl ementa ti on. Public accep tabi li ty of the health insu ran ce sche me The acc eptabili t y of a poli c y b y membe rs of the publi c is a ver y good sta rting point for the implementation of that poli c y. The data fro m the field shows that 87. 0 % of th e mana gement of NHIS in Ga West Muni cipalit y agr ees that its ac c eptabili t y and cooperati on b y the pub li c contribut e greatl y in facil it ati ng implementa ti on . Another 10.0% stron gl y agrees whil e 3.0 % stron gl y disa gree s with thi s. Inde ed he alt h is wealt h and a major concern to the Ghanaian populac e, therefor e an y ef fort or int erventi on to make Ghan aians healt h y will be warml y welcome d . Thus from the res ear ch , 87.6% of the man a gem ent of NH IS in Ga Wes t Muni cipalit y agrees that its acceptabi li t y and coop erati on b y the publi c facil it ates impl ementati on gr eatl y. This is consi stent with other findings in the implementation literature. Fo r inst ance, Sabati er (1986 ) concluded th at when a pro gr amm e bein g i mpl emented is acti vel y supported b y or ganiz ed const it uenc y gro u ps it is highl y and mor e likel y to be successfull y implement e d. Indeed one would ex pect the gene ral publi c to respond naturall y to a poli c y that promot e s good he alt h iss ues, especiall y if such poli c y has the tendenc y to all eviate or minim ise financial dif ficult ies and chall enges. The fact ther efor e, remains that the support and the will ingness of the gen eral publi c to participate and University of Ghana http://ugspace.ug.edu.gh 62 acc ept a poli c y and coo perate with both the management and healt hca r e providers is essential to facil it ate imp lementation. Increasin g poli tical commit men t C omm it ment on the part of admi nist rat ors and poli ti cians goes a lon g wa y to facil it ate the implementation of a poli c y. This comm it ment will let people put in all their effort s for a succ essful proje ct. From the t able below , 76.7% of the mana gement of the scheme agrees that poli ti cal com mi tm en t has facil it ated i mpl ementati on of NH IS while 20.0 % strongl y agrees with thi s. Also 3.3% remai ned neutral as to wh ether poli ti cal comm it ment facil it ates implementation of the scheme or not. It is no wonder that poli ti cal comm it ment was rated hi ghe r be cause NH IS has be en a poli ti cal messa ge and has won votes for poli ti cians. This has made them to be comm it ted to the poli c y as it can chan ge their poli ti cal fo rt unes . The will ingness and com mi tm ent of both implementers and poli ti cians is ver y important if a poli c y is to suc ce e d. This was one of the critical iss ues that w er e raised b y th e respondents in thi s study. Inde ed subscribers al so mentioned that political will and comm it ment facil it a ted i mpl ementati on of the sch eme. In fact, NH IS has b ecome a major poli ti cal iss ue in Ghana and poli ti cians are reall y t hrowing th eir wei ght beh ind it to make it successful. 0c/auJhlin () asserts that the ³Zill´ or ³motivation´ to embrace poli c y obj ect ives is a nec essar y condit ion for ef fe cti ve implementation. As some authors put it, poli ti cal aspect plays a si gnific ant role in po li c y implementation. University of Ghana http://ugspace.ug.edu.gh 63 Supportive legal and regu latory framew ork A le gal frame work is ver y important for the i mpl ementati on of an y poli c y in seve ral wa ys , su ch as making it legal and en forc eable among others. Against thi s background, 70.0% of the mana gem e nt of the scheme agr ees that a supportive and regulator y le gal framewo rk facil it ated implementation of the scheme while 26.7 % str ongl y agr ee s . Howeve r, 3.3% of the respondents remained neutral , therefor e decidi n g neit her to agr ee n or disagr ee. The obvious iss ue here is that a supporti ve legal framework is important for the success of a poli c y. For ex ampl e , acco rding to man a geme nt, thi s framework has made it possi ble for som e tax es to be levied to fi nance th e schem e and some moni es to be deducted at sourc e fro m the salaries of gov ern ment workers to finan ce t he scheme. Proper coo rd in ation amon g the va riou s actor s The actors invo lved in th e implementation of NHIS at the loc al level are th e mana gement of the scheme, healt hca r e providers and subscrib ers. There fore it is important that the y cooperat e and coordin ate wit h one an other to facil it ate implementation . For inst ance, a secti on of management of the scheme in Ga West Muni cipalit y indi cated that uncooperati ve he alt hcar e provide rs will not fac il it ate implementation of NHIS . Data from mana gem ent of th e scheme sho ws that 46 .7% disa gre es corpo rati on among th e act ors has facil it ated the implemen tation of the scheme. On the oth er hand , 33.3% of them agrees the prop er coordinati on amon g the actors h as facil it ated implementation. The data also shows that 20.0% of th e respond en ts remaine d neutral as to whether thi s facil it ated impl ementat ion or not. University of Ghana http://ugspace.ug.edu.gh 64 Adequate health facil ities One of the most importa nt factors in the implem entation of the NH IS is t he avail abil it y of healt hcar e facil it ies. Clearl y, he alt h facil it ies are important fo r the subscribers to benefit from bein g part of the schem e. The data col lect ed from the management of the scheme as pres ented in the table below shows that 46.7% disagr eed that the avail abil it y of healt h facil it ies facil it ates implementation of t he schem e. On the other hand , 33.3% agreed while 20.0% rem ained neu tr al as to whet her the avail abil it y of h ealt h facil it ies facil it ates implementatio n of the sch eme. Clea r l y, thi s data shows tha t there is no connecti on betw een th e avail abil it y of heal t h facil it ies and the s ucc ess of the implementation of NHIS . This ma y be due to the fact that, the subscr ibers are onl y concern ed and comfo rta ble with the fact that th e y have insur ed their heal th and wheth er the facil it ies ar e there or not the y will go ahe ad to insure their healt h. Managerial ab il i t y Human resour ces and parti cularl y mana ge ri al abi li t y are ver y important for implement ing an y publi c poli c y. Wit hout sufficient managerial abil it y it means that laws will not be enforc ed, se r vices will not be provide d and reasonable regulati ons will not be developed. Admit tedl y, 13 .3% of the respond ents strongl y agr ee that ma nagerial abil it y of the management of the scheme of Ga West Muni cipalit y has so much facil it ated implementation of the scheme while 36.7% agre ed. A tot al of 30.0% remained neutral while 16.7% and 3.3% disagr eed and stron gl y disagr eed respe cti vel y t hat mana ge rial abil it y h as facil it ated im plementation of NHIS i n Ga West Muni cipalit y. This data has demons trated to us the i mportance of man a geri al abil it y in th e implement ati on of NH IS poli c y. Ind eed the avail a bil it y of the ad equate m ana geri al abil it ies has th e potential to influence the su ccessful poli c y implementation. University of Ghana http://ugspace.ug.edu.gh 65 Trainin g and cap acity bu ild in g progra mmes for staf f The avail abil it y of mana ge rial abil it y could also be made possi ble by frequent traini ng and cap acit y buil ding pr ogr amm es for the imple menters of th e poli c y. Therefo re 50.0 % of the respondents agre e that frequent traini n g and capa cit y buil ding pro gr amm es h av e facil it ated implementation of NHIS in Ga West Muni cipalit y. Howev er, 3.3% strongl y disagr eed whil e 23.3% disagr ee d and anoth er 23. 4 % remain ed neutr al. The importance of traini ng and cap acit y buil ding is vit al in the implementation of public poli cies and therefor e shoul d be incor porated as part of the poli c y implementation itself to be able to cope with the ch all en ges as the implementation process unfolds. Efficien t sup ervisi on of District Health Insuran ce Efficient supe rvision is a ver y important compone nt of poli c y implementati on. Howeve r, most of the management of the scheme (5 3 .3 %) te nds to disa gre e that thi s has facil it ated implementation of NHIS in Ga West Muni cipalit y. Again, 26.7% rem ained neutral on thi s iss ue as the y coul d not decide wheth er efficient supe rvision of Di strict Healt h Insu ranc e has facil it ate d implementation of the scheme or n ot . In spit e of thi s disagr eement, 20.0% of the respondents agre e that efficient supervisi on of Dist rict Healt h Insura nce has facil it ated implementation. Adequ ate tech n ology an d accessories Technolo g y has now be e n incorporated int o eve r y aspect of life an d as suc h has become a signific ant component of mana ge rial work an d decisi on making in thi s 21 st centur y. Wit h respect to NHIS , technolog y and its acce ssories are used to capt ure records of subscribers, pa y cl aim s to healt hcar e providers among others. In s pit e of the major role that technolog y pla ys i n the scheme, 60. 1 % st rongl y disa gree while another 33.3% University of Ghana http://ugspace.ug.edu.gh 66 disagr ee that technolo g y and its accessories has contribut ed to the success of the scheme in Ga West Municipali t y. The impli cati on could be that eit her the y have litt le technolog y and its ac cessories the re or even with the t echnolo g y you sti ll ne ed comm it ted mana gement, finan ce an d human resourc es to carr y out the task of imple mentati on. Yet another 3.3% rem ained neutral on thi s iss ue. But 3.3% of the respondents strongl y agr ee that techno lo g y has facil it ated greatl y, the imple mentati on proc ess of the scheme in Ga West Municipali t y. Adequ ate fin an cial sou rces Financ e is the life blood of poli c y implement ati on and its avail abil it y or otherwise cannot be over emphasised i n an y implementation process. Admit tedl y , 53.0% of th e respondents stron gl y agr eed that adequate finan ce h as contribut ed so mu ch in facil it ati ng the impl ementati on of NH IS in Ga West Municipali t y. Anoth er 30.0% of the respond ents agreed that finan ce is a major facil it ati n g factor while 10.0% rem ained neutral. How ever, 6.7% disa gre ed that fin a nce has facil it ated implementation while 0.3% of them strongl y disagr eed. Table 5.3 Factors that facil itate imp le m en tation of NHIS in GWMA by Manage men t of the sch e me Public accep tabi li ty of the health insu ran ce sche me Respon se Frequen cy Percen tage S trongl y disa gre e 0 0.0 Disagree 1 3.3 Neutral 0 0.0 Agree 26 86.7 Strongl y agr ee 3 10.0 Total 30 100.0 University of Ghana http://ugspace.ug.edu.gh 67 Increasin g poli tical commit men t Respon s e Frequen cy Percen tage S trongl y disa gre e 0 0.0 Disagree 0 0.0 Neutral 1 3.3 Agree 23 76.7 Strongl y agr ee 6 20.0 Total 30 100.0 Supportive legal and regu latory framew ork s Respon se Frequen cy Percen tage S trongl y disa gre e 0 0.0 Disagree 0 0.0 N eutral 1 3.3 Agree 21 70.0 Strongl y agr ee 8 26.7 Total 30 100.0 Prope r coo rd in ation amon g the va riou s actor s Respon se Frequen cy Percen tage S trongl y disa gre e 0 0.0 Disagree 14 46.7 Neutral 6 20.0 Agree 10 33.3 Strongl y agr ee 0 0.0 Total 30 100.0 Adequ ate health facil ities Respon se Frequen cy Percen tage S trongl y disa gre e 0 0.0 Disagree 14 46.7 Neutral 6 20.0 Agree 10 33.3 Strongl y agr ee 0 0.0 Total 30 100.0 Managerial abil ity Respon se Frequen cy Percen tage S trongl y disa gre e 1 3 .3 Disagree 5 16.7 Neutral 9 30.0 Agree 11 36.7 Strongl y agr ee 4 13.3 Total 30 100.0 University of Ghana http://ugspace.ug.edu.gh 68 Train in g and cap acity bu ild in g progra mmes for staf f Respon se Frequen cy Percen tage S trongl y disa gre e 1 3.3 Disagree 7 23.3 Neutral 7 23.4 Agree 15 50.0 Stro ngl y agr ee 0 0.0 Total 30 100.0 Efficien t sup ervisi on of District Health Insuran ce Respon se Frequen cy Percen tage S trongl y disa gre e 0 0.0 Disagree 16 53.3 Neutral 8 26.7 Agree 6 20.0 Strongl y agr ee 0 0.0 Total 30 100.0 Adequ ate tech n ology and accessories Respon se Frequen cy Percen tage S trongl y disa gre e 18 60.1 Disagree 10 33.3 Neutral 1 3.3 Agree 0 0.0 Strongl y agr ee 1 3.3 Total 30 100.0 Adequ ate fin an cial resou rce Respon se Frequen cy Percen tage S trongl y disa gre e 0 0.3 Disagree 2 6.7 Neutral 3 10.0 Agree 9 30.0 Strongl y agr ee 16 53.0 Total 30 100.0 University of Ghana http://ugspace.ug.edu.gh 69 5.2.2 Subscrib ers ’ perce p tio n of factors that facil itate imp le men tation of NHIS in Ga West Municip ali ty S ubscribers ar e one of th e major actors of th e NHIS and indeed th e y ar e th e essen ce fo r which the scheme is in place. Ther efor e it is important to look at their percepti on of the success and what fact ors that facil it ate implementation of the scheme. Clearl y, the data shows that 97.0% of the subscribers are of the vie w that the implementation of NHIS in Ga West Municipali t y ha s been a succ ess. On the other hand, a small propo rtion made up of 3.0% indi cated that th e implementation of the scheme has not be en suc cessful. From thi s it shows that majorit y has s een it as a succ ess an d it is important to find out the factors that facil it ate impl ementati on . Financ e has been on e of the m ajor iss ues in the implementation of an y po li c y includin g the NH IS . Th e data as presented in Table 5.4 sh ows that 18.0% who rep resent majorit y of the respondents are of the view that the su cce ssful implementation of the scheme is due to its affordabil it y. This iss ue is ver y impor tant as NHIS came int o ex ist ence for financial reasons . Th ere fore if th e y could sti ll not pa y, it will be uns uccessful. Th e impl icati on here is that premi ums must be affor dable and most importantl y withi n the means of the subscribe rs. The fact is th at, apa rt from the premi ums being afford able the y also remove the heav y burden of pa yin g upfront for treatm ent servic es which has been the gr eatest b arrie r for th e poor to access he alt hca re. Accessi bil it y of healt hc a re has be en a major iss ue in the Ghanaian healt hc are s ystem fo r long. In fact, apart from the fact that most people cannot pa y to enjo y quali t y healt h services, the iss ue of accessi bil it y is also threat ening. From Tabl e 5.4, 16.0% of the University of Ghana http://ugspace.ug.edu.gh 70 subscribers ar e of the vi ew that the success ful implementation of NHIS is partl y due to the acc essi bil it y of the scheme and healt hca re faci li ti es. This ma y be du e t o the fact th at, private he alt hcar e facil it ies have been acc redit ed to take part in th e provisi on of healt hcar e to the subscr ibers. For inst an ce in t he Ga West Muni cipalit y about one hundred and ei ght privat e healt hca re facil it ies have been accr edit ed to provide services under NH IS . This is coupl ed with the fact that, with NH IS ca rd, subscri bers can ac cess healt hcar e from an y NH IS acc redit ed healt h faci li t y throu ghout the nati on. Again, the regist rati on of NHIS in t he Ga West Muni cipalit y has been so decentr ali z ed and flex ibl e that subscribers can easil y hav e access to regist er without travell ing for lon g dist anc es. Another important factor tha t has facil it ated implementation of NH IS is the avail abil it y of skil led and qu ali fied personnel. Resour ces in terms of human ar e ver y cruci al in the implementation of an y poli c y. From thi s an gl e 13.0% of the subscribe rs are of the vi ew that the succ essful implementation of NH IS in Ga West Muni cipalit y is due to the avail abil it y of quali fied and train ed pe rsonnel. This is clea r from th e educ ati o nal back ground of th e mana gem ent of the sch eme i n Ga West Muni cipalit y as 43.3% of them have a hi gher de gr ee and to the ex tent that 16.7% have high er th an a first de gree. The second ar y dat a coll ected from the Muni cip ali t y also shows that th ere has been consis tent traini ng fo r t hese staff. S ever al work shops and traini ng s essi ons have be en organiz ed for them to be handled to mana ge the scheme su ccess ful l y . It i s there fore no wonder that the subsc ribers have att ributed the su cc ess of the implement ati on of NHIS to avail abil it y of qu ali fied and trained personn el. Massive educ ati on of the gen er al publi c has be en listed by the subsc ribers as one of the factors that facil it ate the implementation of NHIS in Ga West Muni cipality. From T able University of Ghana http://ugspace.ug.edu.gh 71 5.4, it can be reali z ed th at 12.0% of the subscribers att ributed its successful implementation to the massive publi c educ ati on. The popularit y o f NHIS can be att ributed to the politi cal nature and slogan under which NH IS was int roduced. Ther efor e poli ti cal parties wer e tr ying to us e that to scor e poli ti cal point s and thi s to some ex tent made it popular. For inst ance in 2008, where as NP P was campaignin g that the y shoul d be voted for bec ause the y int rodu ce d NH IS , ND C was also prom isi ng on e time pr emi um under NH IS . Th ere is no doubt th is went to a large ex tent to make it popular. It was also made popular b y other s who have benefited from the scheme and preach ed its importance to their coll e agu es. Th e Muni cipal Assembl y also made si gnificant effort in thi s directi on as the Municipal Info rmati on Se rvices Department has been to all the comm unit ies in the Muni cipalit y to edu cate pe ople about the benefits of the sch eme. Educati on was also done through both Assembl y and Unit Comm ittee members. Closel y related to th e ma ssi ve educ ati on of t he pu bli c is its acc eptanc e. NH IS receive d a massive endors ement b y the Ghan aian pop ul ace. Ind eed thi s shoul d not be a su rprise as healt h is wealt h and the fact that healt hca re has become ex pensive to mos t Ghanaians. Thus, the data presented in Table 5.4 indi cates that 10.0% of the subscribers att ributed the succ essful implement ati on of NH IS to the acc eptance and participati on of the gene ral publi c. Inde ed NH IS is among one of Ghana’s most popular policies as a result of its poli ti cal association and necessi t y as a basic ri ght and need of an y indi vidual. Issu es of ad equate t ech nolog y and lo gist ics, ef fecti ve man a gement an d supervisi on, financial cont ributi on by the state and subscribe r s as well as le gal backi ng and A ct of parliament were also list ed as factor s that facil it ate implementation of NHIS in Ga West Muni cipalit y. Thus, the data shows that 8.0% of the subscribers att ributed its successful University of Ghana http://ugspace.ug.edu.gh 72 im plementation to adeq uate technolo g y and lo gist ics. Another 7.0% were of the view that its success was due to eff ecti ve mana gement and supervisi on while 9.0% att ributed thi s to the financial contribut ion by both the state and subscribers. Also, 2.0% lean the success of the scheme on the fact that the sch eme is backed b y law and an A ct of parliament. In anoth er cate gor y m ad e up of 5.0% of the subscribers, the y att ributed the successful implementation of the sc heme to the comm it ment of healt hca re facil it ies staff, poli ti cal will and comm it ment, su pport from forei gn dono r s, cooper ati on of th e gen eral publ ic and ease of entr y int o the sc heme. Inde ed poli ti cal comm it ment is a necessar y in gr edient in poli c y implementation as the comm it ment of the poli ti cians serve as the ener g y to drive the poli c y to a success ful end. Sim il arl y, the com mi tm ent of the implementers (includi n g healt hcar e facil it ies staff ) is key as the y are the end point and their comm it ment is much needed. The ease of entr y int o the scheme has be en much appre ciated b y t he subscribers and to them thi s has contribut ed to its successful implementation. Info rmati on from the subscribers shows that entr y int o the scheme has been made flex ibl e to them , where the y can pa y b y inst all ments to the local repres entativ es of the scheme. This does not strain them to pa y upfront and therefo re th e y ar e abl e to afford . All the det ail s are shown in Table 5.4 below. University of Ghana http://ugspace.ug.edu.gh 73 Table 5.4 Facto rs that facil itate i mp le men tatio n of NHIS in Ga W est Municip ali ty by sub scrib ers Respon se Frequen cy Percen tage S cheme back ed b y law and act of parliament 2 2.0 Comm it ment of healt hcare fa cil it ie s staff 1 1.0 Accept ance and particip a ti on by the gen eral publ ic 10 10.0 Poli ti cal wil l and comm itment 1 1.0 Support from forei gn do nors 1 1.0 Cooperati on of the gen er al publ ic 1 1.0 Ease of ent r y int o the sch eme 1 1.0 Financial contribut ion b y both gove rnment and subscribers 9 9.0 Avail abil it y of quali fied and trained personnel 13 13.0 Massive educ ati on of the publi c 12 12.0 Technolo g y and ad equat e logist ics 8 8.0 Effecti ve m ana gem ent an d supervision 7 7.0 Afford abil it y of the sch e me 18 18.0 A ccessi b il it y 16 16.0 Total 100 100.0 5.2.3 Healthcare providers’ perception of the facto rs that facil itate i mp lemen tation of NHIS in Ga West Municip ality The healt hca re provide rs have a critical role to pla y in ensu ring t he successful implementation of NHIS . Indeed the y are the fi nal and consum pti on point of NHI servi ce and that is where subscribers actu al l y feel the service. The refo re , the quali t y of healt h car e that subsc ribe rs will enjo y is la r gel y dependent on the healt h providers who work in coll aborati on with all stak eholders . As a critical stake holder in the impl ementati on of NHIS, the y wer e as k ed as to whether th e impleme ntation of the scheme has be en succ essful or not, 91.7% of them are of the view that the implementation of the scheme has been su ccess ful. On the other hand, 5.0% of the healt hcar e provide rs indi cated that the impleme ntation of the scheme has not been successful while 3.3% remained neut ral as the y could not tell whether the implementation of the scheme has be en succ essfu l or not. University of Ghana http://ugspace.ug.edu.gh 74 On the iss ues of the fac tors th at facil it ate implementation of the scheme , a number of factors were enume rate d. Among them were , i ncreas e in the number of subscribers, acc essi bil it y of the sch eme, cooper ati on between the mana gement and healt hcar e providers, ad equate equ ipm ent and logist ics, fi nance, eff ecti ve man a gement of the scheme and ac ceptan ce by the gener al publi c. As can be seen from T able 5.4, majorit y of the healt hc are provide rs repres enti ng 29.7% indi c ated that finan cial suppo rt was cru cial in facil it ati ng implemen tation of NHIS while 13.3% are of the vi ew that the gen er al acc eptanc e of the sch eme by th e publi c has facil it ated implementation of NHIS in Ga West Municipali t y. The respondents also at tribut ed the successful i mpl ementati on of the sch eme to the effe cti ve mana gement of the scheme. In thi s case , 16.7% of them indi cate d thi s factor. Ind eed m ana ge rial skil ls have been noted in the i mpl ementati on literature as critical fo r success. The refo re, it i s not surprisi ng that t he healt hc are provide rs are also re- emphasiz in g thi s va riabl e in NH IS and pa rticula rl y in the Ga West Mun icipali t y. Th e data also sho ws that 13. 3% of the healt hcar e pr oviders mentioned that the succ essful implementation of the sc heme is due to the fact t hat it has made healt hc ar e ac cessi ble to all . Inde ed that is the essence of NHIS and once the y are able to access he alt hcare, the y will definitel y en roll, pa y the premi ums and there f ore succ ess is likel y to fo ll ow. In cre asing subscribe rs representi n g 10.0% was mentioned by th e healt hcar e providers as contribut ing to the su cce ssful implementation. Subscribers ar e major stake holders in thi s ex ercise of NH IS and on ce the y hav e be come inc reasin gl y invol ved, it me ans it is well acc epted b y th em and most likel y to contribut e to the su ccess of the implementation. Cooperati on between the managem ent and healt hcare provide rs is critical and 10.0% of University of Ghana http://ugspace.ug.edu.gh 7 5 the healt hca re provid e rs indi cated that thi s has contribut ed to the success ful implementation of NH IS in Ga West Muni cip ali t y. Ind eed , these fa ctors have be en enumerated in the impl ementati on literature as being some of the critica l factors that contribut e to the succ essf ul impl ementati on of publi c poli cies. Table 5.5 Facto rs that facil itate imp le men tatio n of NHIS in GWMA by healthcare provid ers Reason s Frequen cy Percen t In cre ase numbe r of subsc ribers 3 10.0 Make healt hc ar e ac cessi b le 4 13.3 Cooperati on betw een mana gement and heal thcare providers 3 10.0 Adequate equipm ent and logist ics 3 10.0 Financ e 8 29.7 Effecti ve m ana gem ent of the scheme 5 16.7 Accept ance b y th e gene r al publ ic 4 13.3 Total 30 100.0 From the abov e discussi ons, it was concluded tha t, the NH IS has enabl ed Ghana to make significant advan ces in movi ng awa y from dir ec t pa ym ent at point of ser vice to the use of insurance ca rds to acc ess healt h. A care ful anal ysis of the data shows that one of the major factors that facil it ated the implementation of NHIS in Ga West Muni cipalit y is support and ac c eptance of the scheme b y the gene ral publi c. Thus from the resear c h 87.6% of the m ana gement of NHIS in Ga West Muni cipalit y agre e that its acceptabili t y and coop erati on by the publi c contribut e gr eatl y to i ts success. This is co nsis tent with other findings in th e implementation literatur e. Fo r inst anc e , Sabat ier (1986) con clude d that when a programm e bein g imple mented is acti vel y suppo rted b y or ganiz ed const it uenc y groups it is highl y and more likel y to be suc cessfull y imple mented. Ind eed on e wo uld ex pect the gen eral publi c to respon d naturall y to poli c y that promot e good healt h iss ues, especiall y University of Ghana http://ugspace.ug.edu.gh 76 if such poli c y has the tendenc y to all eviate or minim ise financial difficulti es and chall en ges. But the fact remains that, the support and the will ingness of the gen er al publi c to participate and acc ept a poli c y and coo perate with both the ma nagement and healt hcar e provide rs is es senti al to its successful impl ementati on. Another signific ant fac tor that facil it ates implementation of NHIS in Ga West Muni cipalit y is resou rce s. These resourc es include finance, human and t echnolo g y. In re lation to fundin g, the scheme had fundin g from subscribers ’ premi um and from gove rnment coff ers. Fina nce is ver y important in poli c y implementation. This is testified by a 53.0 % of the m an agement of the scheme who stron gl y agreed to the noti on of finance as a factor in i mpl ementati on while most of the subscrib ers t oo related th e successful implementatio n to financial contribut ion by both governm ent an d subs cribers. The findin gs also show that about 30.0% of the healt hcar e provid ers sup port the view that financ e has cont ributed ver y mu ch to the implementation of NH IS in Ga West Muni cipalit y. On the part of the human resourc es, 13.0% of the subscrib ers indi cated that the adequ ac y of the hu man resour ces s erves as a critical factor in the i mpl ementati on process. Also 50.0% of t he mana gem ent of the scheme agr eed to this. Technolo gical resour ces also contribut ed to the s uccessful implementati on of NH IS in the Ga West Muni cipalit y. Technolog y is used i n processi n g ID cards for subscribers, processi n g claims , sendi ng inform ati on to regional and nati onal headqu ar ters (Nati onal Healt h Insuran ce Auth orit y). From the findings, all the actors which include mana gement, he alt hcar e providers and subscri bers strongl y agre ed to the fact that technolog y has counted partl y for the suc cessful implementation of the scheme. Thes e University of Ghana http://ugspace.ug.edu.gh 77 findings are consi stent with the literature of i mpl ementati on. For inst ance, Ed ward (1980) noted lon g ago th at resourc es are a critical factor in impl ementing publi c poli cies. Manageri al cap acit y and abi li t y has also contribut ed to the suc cessful impl ementati on of NHIS in the Ga West Municipali t y. Thus from the findi ngs, 50.0% of the mana gement of the scheme in Ga West Muni cipalit y are of the view that managerial abi li t y has be en a facil it ati ng factor. On the part of the subscrib ers, out of the avail abl e factors that contribut e to the success of the scheme, 7.0% of the respondents att ribut ed success to mana gerial abil it y and s kil ls. Also among all the factors, 16.3% of healt hcare provid ers att ributed success to ma nagement. Clearl y man a gem ent of the sch eme is important and has gon e a lon g w a y to facil it ate impl ementati on. From the literature , it has been noted b y vari ous writ ers that mana gerial skil ls and capa cit y is a critical factor if a poli c y is to suc ce ed. Thus to Edward (1980), an organiz ati on's human resources can be rega rd ed as the most important factor in implementi ng poli cies. It includes staff of sufficient siz e and with proper skil l s to carr y out assi gnments and inf ormation, ex ercise authorit y, and prop erl y sup er vise and take care of facil it ies includi ng buil din gs, equipm ents, land and suppl ies necess ar y to translat e proposals on paper int o functi oning servic es. Sabati er (1986) also supported thi s view when he made the poi nt that the lead ers of i mpl ementing bodies mu st possess the necessa r y mana gerial an d poli ti cal skil ls to bring to light the obje cti ve s of a publi c poli c y. The will ingness and com mi tm ent of both implementers and poli ti cians is ver y important if a poli c y is to suc ce e d. This was o ne of the critical iss ues that w er e raised b y th e University of Ghana http://ugspace.ug.edu.gh 78 respondents in thi s stud y. Ind eed subscribe r s mentioned that poli tical will and comm it ment had contribut ed to the successful im plementation of the sche me. Sim il arl y, 96.7% of the manageme nt of the sc heme agre e to thi s. In fact, NH IS has become a major poli ti cal iss ue in Ghana and poli ti cians are reall y t hrowing th eir wei ght beh ind it to make it successful. 0c/auJhlin () asserts that the ³Zill´ or ³motivation´ to embrace poli c y obj ecti ves is a nec essar y c ondit ion for ef fe cti ve implementation. As some authors put it, poli ti cal aspect plays a si gnific ant role in po li c y implementation. Other authors and schol ars such as Br ynard an d De Coning (2006), M az manian and Sabati er (1981 ), and Warwick (1982 ) ar gue th at poli c y m a y be good, but if the implementers ar e unwill ing to car r y it out, imp lementation will not oc cur. Th ere fore comm it ment from poli ticians or admi nist rators is ver y important for the successful implementation of an y poli c y. On e of the int eresti ng t hin gs in relation to the comm it ment of the poli ticians is the key invol ve ment of the Muni cipal Chief Ex ecut ive in the implementation of NHIS to mak e it a succ es s. Other factors that also facil it ate implementation of NH IS in the Ga West Muni cipalit y include le gal ba ckin g which inst il led confide nce in the subsc ribers as well as afford abil it y of the sche me. As indi cated alr ead y, a ke y init i at i ve take n ver y earl y in the deve l opme nt of NHIS i n the Ga West Muni ci pa l it y was the dec i si on to set prem i um cont ribut i ons at a very lo w leve l . In othe r words it was rec ogni ze d from the beginni n g that participati on of the self - empl o yed and low -inco me population would ha ve to be heavil y subsi diz ed, while high premi ums woul d be a major barrie r to participati on. University of Ghana http://ugspace.ug.edu.gh 79 In spit e of the few perso nnel and their chall en ges , the man a gement is ef ficient and thi s has contribut ed to the su ccessful implementation of NHIS in the Ga West Muni cipalit y. In fact good man a gemen t is often cit ed as one of the ke y factors for ensu ring suc cessful poli c y implementation in the new publi c manage ment literature (Kaul 1997; Mc Lau ghli n et al. 2001). Thus, th e enthus iastic and opti mi sti c behavior of mana ge ment and their abil it y to adapt to the prevail ing chall en ges and circumst anc es has cont ributed to the successful impl ementati o n. 5.3 Factors that con stra in the imp le men ta tion of the Nation al Health Insuran ce Scheme in the Ga West Municip ali ty Impl ement ati on problems occur when the desired result s on the target bene ficiaries is not achieved. This occu rs when the crucial factors necessa r y for ef fecti ve i mpl ementati on are not present. Th e fac tors do not act in isol at ion but compl ement ea c h other. The int eracti on of thes e facto rs is the cause of imple mentati on success or fail ure as the cas e ma y be. This se cti on w ill therefor e look at the factors that const rain implementation of NHIS in the Ga West M unicipali t y. This will be based on the vie ws of th e mana gement of the scheme, th e subscr ibers as well as healt hca r e providers und er the sch eme. 5.3.1 Manage men t ’s percep tion of the factors that con strain the imp le men tation of NHIS in Ga West Municip ali ty This secti o n looks at the factors that const rain i mpl ementati on of NH IS in the Ga West Muni cipalit y from the perspecti ve of the mana ge ment of the scheme. Management of the scheme were asked abou t the factors th at const rai n their implementation of the schem e. The follo wing ar e some of the factors mentioned by the mana gement of the scheme. The first factor mentioned by th e mana gement was i nadequate lo gist ics. This has been the University of Ghana http://ugspace.ug.edu.gh 80 major chall en ge as 16.7 % of th em indi cated thi s. Inde ed the implementation of the NHIS invol ves the use of sev eral lo gist ics such as comput ers, came ras, vehi cles, scannin g machines, batt eries, amo ng oth ers. Th e avail abil it y or othe rwise of th ese equip ment can go a lon g wa y to affect t he implementation of the NHIS in the Ga West Municipali t y. Another facto r that was recorded b y the mana ge ment of the scheme was finance as 13.3% of the respond ents agre ed to thi s. Fi nanc e has been rec orded in the implem entation literature over and ov er again as a chall en ge to implementation and therefor e not surprisi n g to rep eat itself in Ga West Muni cipalit y. Of cou rse , no admi nist rati ve work and particularl y a hu ge ex ercise like the impleme ntation of the NHIS can do without adequate finan cial support . Other major ch all enges to the implementation of the NHIS in the Ga West Muni cipalit y ar e unnec essar y dela ys and lack of skill ed and actuar ial insurance sta ff. In thi s cas e, 16.3% of th e mana gement indi c ated that unnecess a r y dela y i s a chall en ge. Dela ys in whatever fo rm and t ype , such as dela ys in subm itt ing claims , processi n g and pa ym ent, the y ta ke hav e been an en em y to imple mentati on for quit e a long time and it is high time implementers took thi s int o serious consi derat ion. There is no doubt and thi s does not deviate from what is known in the implementati on literature , that lack of skil led and adequ ate human resources is a chall en ge of poli c y implementat ion. This has record ed 16.7% of the ch all enges that con front the imp lementation of the NH IS in the Ga West Muni cip ali t y. Clear l y, poli cies remain on the tables of admi nist r ators and on papers if there is no skil led personnel to put it into action and thi s is a s ource of worr y as it shoul d be dealt with appr opriatel y even b efor e implementation be gins. University of Ghana http://ugspace.ug.edu.gh 81 Fraud and co rrupti on al so regist ered its pr esenc e her e as a const raini n g factor to the implementation of NH IS in the Ga West Muni cipalit y. This recorded a per centa ge of 3.3%. Whereas mana ge ment is yearnin g for more financ es t o be able to implement the scheme, the small financ es in the schemes coffer s are bein g sipho ned aw a y b y some of the mana gem ent for their person al gains. This comes in the form of over infl ated receipt s, claims , amon g others. This is adding to the alread y e x ist ing fina ncial problems const raini ng the implem entation of the scheme. This is ver y unfortun ate and must be tackled seriousl y if the success of the scheme is to be achieved. Unprofe ssi onal att it ude of management towards cli ents has been a chall enge an d 3.3% of the res p ondents agr eed to thi s and it shoul d be att ended to as these cli ents ar e majo r stakeholde rs who need to be treated wit h care. The iss ue of fo rei gne rs enroll ing onto the s ch eme is a ch all en ge as 6.7% of the respondents indi cat ed th is. Th is ma y be du e to iss ues of imprope r rec ord s yst em in Ghana and th e fact th at most mana gement of the scheme are compromi sing on the rules of the scheme. Lon g pr ocesses hav e be en noted in the literature as on e of the critical iss ue in implementation. As a result 3.3% of t he mana gement are of the view that bureauc ra c y and long processes of th e NHIS is serving as a const raint to the implementation of the scheme in the Ga West Mu nicipali t y. University of Ghana http://ugspace.ug.edu.gh 82 Table 5.6 Factors th at con strain the imp le men tation of NHIS in Ga W est Municip ali ty by man age men t Factors Frequen cy Percen t In adequat e educ ati on 1 3.3 Forei gne rs enroll in g in the scheme 2 6.7 Unprofessi onal atti tude towards cli ents 2 6.7 Unnecess ar y dela ys 3 16.3 La ck of skill ed and actua rial insurance st af f 5 16.7 Ex tortio n from the subscribers 2 6.7 Difficult y in d ata proc ess ing 2 6.7 In adequat e logist ics 5 16.7 Financial chall en ges 4 13.3 Bure aucr ac y 2 6.7 Embez z lement and fraud 2 6.7 Total 30 100.0 5.3.2 Subscrib ers ’ perce p tion of factors th at con strain the imp le men tati on of NHIS in Ga West Municip ali ty The subscribers also hav e their own version of the factors that const rain implementation of NHIS in the Ga West Muni cipalit y. This secti on of the stud y then takes a cr it ical look at these fact ors . From tab le 5.7, majorit y of the subscribers rep resenti n g 26.7% are of the view that their major ch all enge with the implementation of the scheme i s the fact that most of the drugs ar e not in the NHIS medicine pr escribed list. This means that the y end u p payin g for most of the drugs presc ribed to them at the healt hc are facil it y. This renders the essen ce of the insur a nce me aningl ess as th e y have to pa y fo r dru gs which t he y were tr yin g to avoid b y en rollin g to be memb ers of the insurance s cheme . Another chall en ge which was high on the list of the subscribers was the bureauc ra c y th at chara cteriz es the s yst em and thi s recorded 30.0 % of the respondents. This bureaucr ati c procedur e comes in the form of del a ys in car d ren ew al , dela y of mana gement to respond to their needs, dela ys at the various healt hc ar e ce nters, amon g others. Thi s bureauc ra c y and the undue dela ys end up making the subs cribers slow in acc essi ng he alt hca re. University of Ghana http://ugspace.ug.edu.gh 83 C orruption and briber y could not escape on the list of the subscribers as a chall e nge to the implementation of NH IS in th e Ga West Muni cipalit y. This factor regi stered 13.3%. This is ver y dist urbin g as it reall y reduces t he moni es that will be used for the implementation of the scheme. This could be i n the fo rm of demandin g from cli ents before s ervic es are provi ded, embez z lement and misappli cati on of the fun ds. Dela ys in reim bursement are also a ch all en ge to t he implementation of th e scheme in the Ga West Muni cipalit y. The data as pres ented in table 5.7 shows that 10.0% of the subscribers menti oned dela y in reim bursem ent as a chall en ge. One will wonder wh y subscribers shoul d ment ion dela y in reim burse ment. Could the y hav e heard it from healt hcar e providers or some other chann els? Th e ex tent to which the NH IS has been poli ti ciz ed and often debate d in the media could have accounted fo r thi s knowledge of dela ys in reim bursem e nt. Simil arl y, 10.0% talk about inadequate personnel as a chall en ge. This is obvi ou s as subscribe rs can enco unter thi s chall en ge from the end of th e mana gement of the sche me and that of the healt hcare provid ers. This could result to the dela ys in the proc essi ng of documents and acc essi ng he alt hcar e. Financial and poor data entr y was also listed as chall enges. Thus, financial chall en ge const it uted 6.7% while poor data entr y was 3 .3%. Financ e is critical for poli c y implementation and onc e it is a chall en ge the implementation will definitel y be aff ected and coupled with the fact that some of the fu nds are also bein g siph oned awa y b y mana gement. In terms of poor data entr y, thi s is l ikel y to aff ect implementation as the beginni n g point is acc urat e be cause it en ables proper for e casti n g and planning. Subscribers often encou nter thi s through the iss ue of wron g identit y car ds and related documents. Details of the above discussi on ar e pre sented in table 5.7 below. University of Ghana http://ugspace.ug.edu.gh 84 Table 5.7 Factors that con strain imp le men ta ti on of NHIS in Ga West Municip ali ty by sub scrib ers Constrain ts Frequen cy Percen tage Financial const raint s 2 6.7 Bure aucr ac y 9 30.0 Poor data entr y 1 3.3 Most medicines out of the presc ribe d list 8 26.7 In adequat e personn el 3 10.0 Corruption and briber y 4 13.3 Dela ys in the reim burs e ment 3 10.0 Total 30 100.0 5.3.3 Healthcare providers’ perception of factors that constrain implemen tation of NHIS in Ga West Municip ali ty Th is secti on of the chapter is also to seek the views of the healt hca re pr oviders about some of the factors that const rain the implementation of NHIS in the West Muni cipalit y. The he alt hcar e provide rs listed a numbe r of factor s which are not so diff er ent fro m those of the m ana gem ent and subscribers. Top amon g the list is corru pti on and limi ted dru gs on the NHI dru g list. To thi s end, 16.7% of the healt hcar e providers indi cated that the drugs which are oft en pr escribed b y the doctors are most l y not on the NHI dru g list. It means that subscribers have to bu y thes e dru gs themselves and thi s defea t s the purpose of the insuranc e that the y hold. To them the sch e me covers most l y basic drugs and most ex pensive drugs are not covered he re. But the fact is that most subs cribers can pa y fo r thi s basic drugs, it is the ex pensive ones that the y cannot afford. On the list is also corruption and 16.7% of the healt hcare provid ers stated thi s. To them there have been massive corruption and fraud cas es both on the part of the ma nagement of the sch eme and healt h care providers. Mana gement embez z le the moni es of the sch eme while most healt hcare providers inflate the ch ar ges and even add some unnecessa r y drugs to the list just to make mone y. Thus, whe re there have been s ever al compl ain s of University of Ghana http://ugspace.ug.edu.gh 85 inadequate funds to run the scheme, th e few m onies in th e coff ers of the scheme ar e being takin g awa y b y bot h mana gement and healt hcare providers. This sit uati on ought to be corr ected and de alt with serious l y if the schem e is to be sust ainable. Clo sel y related to corruption is the const rai n t of finance and 13.3% of the respondents mentioned thi s. This is ver y ironic bec ause whereas the re is a cr y th at there ar e no funds , the limi ted ones are being sipho ned. Th ere for e there is the need to ch e ck thi s to save the syst em. Dela ys has be en on e of the major const rains to the implementat ion of NH IS in the Ga West Muni cipalit y. That has run throu gh as a co nstraini ng factor, from mana gement to subscribers and finall y to the healt hcare providers. In thi s cas e 10.0% of the respondents mentioned thi s as a const raini ng factor. Howeve r there are diff eren ces in these dela ys. The conce rn of th e healt hcare provide rs here ha s to do with the dela y i n processi ng claims and reim bursing them. Healt hcar e providers need to be reim bursed withi n the shortest possi ble time to help them to conti nue to provide s ervic es to the subscribers of the scheme. Besides del a ys, th ere have been con cerns about inadequat e personnel and 10.0% of the respond ents are of thi s vie w. The ma nageme nt of the NH IS needs ad equate personnel to handle all t he worklo ad and thi s inadequa c y ma y l ead to dela y and slow processi n g of docum ents and claims . Related to the iss ue of in adequate personnel is la c k of traini n g for personn el. Thus, 6.7% of the respon dents indi cated that the personnel do not have the necessar y traini n g and skil ls to handle the man agement of the scheme. The healt hca re provide rs might have noti ced thi s from their deali ngs with them in ter ms of processi n g of clai ms and other related acti v it ies. Managin g healt h insuranc e means that the personnel have to be University of Ghana http://ugspace.ug.edu.gh 86 knowledgeable in actua r ial and financial manage ment as well as human relations . The onl y wa y to get these is through tr aini ng which is often lackin g in the sch e mes office. Poli ti cal int erferen ce is also a const raini n g factor , as well as improp er coo rdinati on and lack of prop er dat a. All these factors to gethe r wer e rated 26.7 % of the cha ll enges to the implementation of the NHIS in the Ga West Muni cipalit y from the perspecti ves of healt hcar e provid ers. In deed dat a is ver y impo rtant as thi s helps in projecti ons and forec ast. It is also important for the healt hcar e providers and mana gement to coordinate well with each other because the healt hc are pro viders are also implementi ng a major compon ent of the schem e. Poli ti cal int erferenc e has been part of thi s scheme since its incepti on. Inde ed the birth of the NHIS is the result of poli tics and has conti nued to follow it till toda y and will conti nue. Details of the abov e pr esentation and discussi on s are pr esented in table 5.8 below. Table 5.8 Factors th at con strain the imp le men tation of NHIS in Ga W est Municip ali ty by healthcare provid ers Constrain s Frequen cy Percen tage La ck of prop er data 2 6.7 Corruption 5 16.7 Improp er coo rdinati on 3 10.0 Dela y and slow pro cess 3 10.0 In adequat e fa cil it ies 2 6.7 Lack of fin ance 4 13.3 In adequat e personn el 3 10.0 La ck of traini ng for staf f 2 6.7 Poli ti cal interferenc e 3 10.0 Most prescribed dru gs ar e not on NH IS dru g list 5 16.7 Total 30 100.0 The implementation of NH IS in Gh ana and pa rticularl y in the Ga West M unicipali t y ha s so man y const raini n g fa ctors as cl earl y indi c ate d above . Th e findin gs i ndicate that the most domi nant const raini ng facto rs included ineff ecti ve cl aim s mana gem e nt and cont rol, University of Ghana http://ugspace.ug.edu.gh 87 lack of effe cti ve mechan ism for tracking claims , inconsist ent bil ling s yste m and undue d ela y of pa yment of clai ms due healt hca re provid ers. Other chall en ges and fac tors that const rained the implementation of the NH IS in the Ga West Muni cipalit y as menti oned by the man agement of the scheme included the following: inadequ ate lo gist ical support for runni ng the of fice, un att racti v e remune rati on and incenti ve packa ges for staff. In spit e of the successes, ther e wer e sti ll some human resourc e ch all en ges. For ex ampl e, some cl aim s mana gers do not have basic medic al back ground and it is ofte n difficult for them to chall enge the medical pro fe ssi onals about prescriptio ns and bil li ng of the schemes. Healt hca re provid ers on their part mentioned undue dela y of pa ym ent of cl aim s, ex clusi on of some drugs from approved list and low tariff. The domi nant problem mentioned by the providers was the dela y in the paym ent of claims b y the scheme. Further worr yin g chall e nges to th e implementation of the NH IS in the Ga West Muni cipalit y are fraud and malpracti c e b y the ma nagement of the sch eme and healt hc are providers. Th ere are a lot of inciden ces of m alpracti ce b y som e accr ed it ed healt hc are providers and thi s is as a result of la ck of an effici ent moni toring and evalu ati on mechanism . Fraud is af fe cti ng the sc heme seriousl y in te rms finances. From the data presented in chapter five, 6.6% of t he mana gement indi c ate d embez z lement and corruption as a chall en ge to the impleme ntation of the NH IS in th e Ga West Muni cipalit y. Agai n, 13.3% of the subscribers mentioned that corruption and briber y is a cha ll enge to the University of Ghana http://ugspace.ug.edu.gh 88 im plementation of the NHIS in the Ga West Muni cipalit y. Sim il arl y, 16.6% of the healt hcar e providers indi cated corruption and fina ncial malpr acti ces as cha ll enges to th e implementation of the NH IS in the Ga West Mun icipali t y. From the abov e it is clear that incide nce s of corrupt i on act as an impe dim e nt in the imple me nta t i on of the insura nce poli c y. To add to the chall enges to the implementation of the NHIS in the Ga We st Muni cipalit y is the fact that most of the dru gs ar e not listed in the NHIS pres cribe d drug list. This means that most of the subscribers end up pa yin g for the dru gs at the healt h centers . The data prese nted above sho ws that 16.7% of the subscribers indi cated th at some prescrib ed drugs are not on NHIS drug list. The non - inclu sion of some of the drugs def eats the purpose of the insurance, a sit uati on which has m ade some of the subs crib ers to consi der even withdra wing from the scheme. A stud y co nducted b y W it ter et al ., (2009) found that most subscribers ar e compl aini n g about the iss ue of in adequa c y of dru gs in the NHIS dru g list. Hath et al., (2007) cam e to a sim il ar conclusi on in Nkora nz a when the y found out that inst it uti ng insurance b y itself is no t ade quate to remov e ful l y the out - of - packet pa ym ents for he a lt h care. Insured pati ents are sti ll requir ed to pa y for items that shoul d be cover ed b y ins urance and fo r informal care. This in turn is a hindering factor in covera ge and ex pansion and thus ult imat el y affe cti ng the prosp ect s of achieving universal cove ra ge. 5.4 The roles played by the variou s actors i n the imp le men tation of NHIS in the Ga West Municip ali ty The abov e discussi on ha s concentr ated on a m yri ad of fact ors that const r a in or facil it ate the implementation of NH IS in the Ga West Muni cipalit y. This secti on will look at the roles pla yed b y the thr ee actors, in th e form of their acti ons and inacti ons in the University of Ghana http://ugspace.ug.edu.gh 89 im plementation process. This is important because these actors both const rain and facil it ate the implemen tation of NHIS b y th e roles the y pla y in the Ga West Muni cipalit y. The behav iour of the healt hcare pr oviders , in the view of the subscribers , pla ys b oth posi ti ve and negati ve roles in the implementation of NHIS the Ga West Muni cipalit y. On the posi ti ve side of the role of subscribers , thei r financial contribut ion, in the form of premi ums, has helped in facil it ati ng implementat ion of the scheme. Ev en though , these premi ums are small the y have a si gnificant impact on the implementation of th e scheme. Financ e is the lifeblood and en gine of providi n g h ealt hc are and if subs cribers do not contribut e in the form of finan ce it wo uld put more stress on the gov e rnment. In thi s wa y, 40.0 % of the subscribers indi cated thi s as a significant posi ti ve con tribut ion to the implementation of the scheme. Again, 50.0 % of the subscribers are of the view that their comm it ment to the scheme has impacted posi ti vel y on the implementation of the NHIS in the Ga West Muni cipali t y. Thus, in spit e of the unprofessi onal a tt it ude of both mana gement and he alt hc are provide rs, subscriber s sti ll remain comm it ted to the scheme and thi s has brou ght it far. Also 10.0 % of them state d that their role in th e dis semi nati on of inform ati on to people in their comm unit y has impacted pos it ivel y on the implementation of the scheme. Subscribers pla y an impo rtant role in the diss emi nati on of in formation abo ut the NH IS to other members in their various comm unit ies. By prea chin g ³good ´ abo ut the scheme , the y get their coll ea gu es to regist e r wi th the sche me. University of Ghana http://ugspace.ug.edu.gh 90 On the ne gati ve rol e , thr ee main iss ues wer e raise d. Firstl y, 60 . 0 % indi c ate d that most of the subscribe rs do not fi nish their medic ati on aft er visi ti ng the hospi tal. Bec ause the y know the y are enjo yin g healt hcar e fo r free, the y do n’t finis h the medic ati on giv en the m and there fore tend to visi t hospi tal regula rl y the re b y putt ing pressure on healt h facil it ies as well as causin g finan cial loss to the scheme. Also, 23.0 % of the subscribers cit ed inconsist ent behaviour as a role th at has a negat iv e impact on the impleme ntation of the scheme. In thi s way, subscribers ar gu e that, most of them change healt hcare facil it ies making it difficult for Do ctors to have their corr ect medical histor y. Finall y, 17 . 0 % of them are of the view that the low rate at which subscrib ers rene w their cards is servin g as a negati ve role in the impleme ntation of the scheme. Thus, in spit e of the fact that most of the subscribers ar e regist erin g to join the scheme, others are also not renewin g their ca rds. The role of sub scribers in the implementation of NHIS in the Ga West Municipali t y is pr e sented in Table 5.9 belo w. Table 5.9 Role played by sub scrib ers in the imp le men tation of NHIS in Ga W est Municip ali ty Positive Roles Negative Roles Role Frequen cy Percen tage Role Frequen cy Percen tage Financial 40 40.0 Unfini shed 60 60.0 Comm it ment 5 0 50.0 In consi stent 23 2 3. 0 Dissemination 10 10.0 Non renew ed 17 17 . 0 Total 30 100.0 Total 30 100.0 From the perspe cti ve of the healt hcare provide r s, a number of iss ues were also raised concernin g the role of healt hcar e providers in the implementation of NHIS in the Ga West Muni cipalit y. From the posi ti ve side, 46 . 7 % of the respond ents ar e of the view that the provisi on of healt hc are b y the providers has gone a lon g wa y to ens ure a posi ti ve University of Ghana http://ugspace.ug.edu.gh 91 im pact on the implemen tation of the schem e in Ga West Muni cipalit y. Also, 53.3 % of them indi cated the fact that the healt hcare provid ers are comm it ted and thi s has pla yed a posi ti ve role on the imp lementation of the sche me. The avail abil it y of the healt hc are facil it ies and th e comm i tm ent of the worke rs to the provisi on of healt hcare hav e no doubt contribut ed posi ti vel y to the implementa ti on of the scheme in the Ga West Muni cipalit y. On the negati ve roles , a numbe r of iss ues wer e also raised an d amon g them is corruption, rude att itude towards pati ents and the small number of Doctors in the various healt hc are centre s . To thi s effect, 35.0% of respondents mentioned corruption, 43.0% cit ed rude att it ude towards pati ents and 20. 0% indi cated corru pti on. The iss ue here is that most holders of NHIS ca rds are often not responded to as quic kl y as those who pa y upfront at th e hospi tal. This often makes subscribe rs to lose int erest in the scheme and someti mes the y have to greas e the palm s of healt hcare offici als to receive treatm ent when the y visi t the hospi tal. Healt hcar e providers often inflati n g the cost of dru gs, takin g some sought of moni es from subsc ribers at the healt h centr es an d not att endin g to th e needs of NH IS card holde rs. The role of healt hcar e provide rs in the implementation of NHIS in Ga West Muni cipalit y is shown in Table 5.10. Table 5.10 Role played by healthcare provid ers i n the imp le men tation of the NHIS in Ga West Municip ali ty Positive Roles Negative Roles Role Frequen cy Percen ta ge Role Frequen cy Percen tage P rovision 1 4 46 . 7 Corruption 11 36.7 Comm it ment 1 6 5 3 . 3 Rude 13 43.3 Few Doctor s 6 20.0 Total 30 100.0 Total 30 100.0 University of Ghana http://ugspace.ug.edu.gh 92 On the part of the man agement of the scheme, human resourc es hav e been cit ed as pla yin g a posi ti v e rol e in the implementation of the schem e. Thus a tot al of 5 3.3 % of the respondents mentioned t his. This is ver y importa nt as the need ed hum an resourc es are a pre-r equisi te for the implementation of publi c policies not onl y the NH IS . This has gone a long wa y to help in processi n g NH IS ca rds for subscribers, pro cessi ng claims and reim bursing he alt hca re providers and mobi li z ing subscribers for the scheme. Comm it ment on the par t of the man a gement ha s also contribut ed to war ds a posi ti ve implementati on of the s cheme and 46.7 % of the mana gement stat ed thi s. On the negati ve side, iss ues of cor ruption and rude tow ards subs criber reapp ear ed he re and the fact that mana gement of the sche me lack basic educati on i n insurance and medicin e. Thus, 46.6 % mentioned corruptio n whil e 36.7% indi cated ru de behaviou r towards s ubscribers and 16.7% stated lack of basic educati on in insurance and medicine. This i s presented in Table 5.11 her e. Table 5.11 Role played by man age men t in the imp le men tation of NHIS in Ga W est Munici p a li ty Positi ve Roles Negat ive Roles Role Frequency Percent age Role Frequency Percent age HR 1 6 53 . 3 C or r upt ion 14 46.6 Commi t ment 1 4 46 . 7 Rude att it ude 11 36.7 No educ at ion 5 16.7 Total 30 100.0 Total 30 100.0 From the above discussi ons , the stud y conclud e d that t he roles pla yed by the various actors in the implementa ti on of the NHIS in the Ga West Muni cipalit y ar e both posi ti ve and ne gati ve. On the posit ive side , subscribers have contribut ed fin an ciall y to the successful implementation of the sch eme. Anothe r set of the subscrib ers are of the view that their comm it ment to the scheme has impacte d posi ti vel y on the implementation of the NHIS in the Ga West Muni cipalit y whil e some stat ed that th e ir role in the University of Ghana http://ugspace.ug.edu.gh 93 diss emi nati on of information to people in their comm unit y has impacte d posi ti vel y on the implementation of t he schem e. From the perspecti ve of th e healt hcare provide rs , provisi on of healt hca re by the providers has gone a long wa y to ensu re a posit ive impact on the implementation of the sch eme in Ga West Muni cipalit y. Some of t hem indi cated the fact that the healt hca re providers are comm it ted a nd thi s has impacted posi ti vel y on the implementation of th e schem e. On th e part of the mana gem ent of th e scheme, human resourc es have been cit ed as a posi ti ve role in the implementation of the scheme. Comm it ment on the par t of the man a gement ha s also cont ributed to war ds a posi ti ve implementation of the scheme. On the negati ve rol e of t he actors to the impleme ntation of the scheme in the Ga West Muni cipalit y, it came up that most of the subscri bers do not finish their medicati on afte r visi ti ng the hospi ta l. Some of the subscribers also cit ed inconsist ent behaviour as a negati ve impact on the implementation of the sc heme. Finall y, 17.0% of respondents are of the view that subscribers and the low rate at which t he y ren ew their ca r ds is having a negati ve impact on th e i mpl ementati on of th e sch eme. From the pe rspecti v e of healt hcar e providers, a number of iss ues were also raised and among them ar e co rrupti on, rude att it ude towards pati ents and the small number of Doctors in the various healt hcare centres. Final l y from the mana gement of the scheme on th e negati ve side, iss ues of corruption and rud e att it ude towards subscribe r s reappe ared her e and the fact th at mana gement of the sche me lack basic educati on i n insu rance and medicine . University of Ghana http://ugspace.ug.edu.gh 94 CHAPTER SIX SUMMARY OF FINDINGS, CONCLUSION AND RECOMENDATIONS 6 .0 Introd u ction It has been observ ed in the publi c admi nist rati on literature that poli c y imp lementation is one of the m ajor ch all enges con fronti ng deve lopi ng nati ons. Accordi ng to poli c y implementation ex perts, such as Wil davsk y, Pressm an, Mazmanian , O'Toole and Sabati er implementatio n chall en ges occu r wh en the desir ed result on the tar get beneficia ries is not achie ved. Whereve r and whe never the basic critical factors that ar e ver y cru cial to implementi ng publi c poli c y are missi ng, the re is bound to be impl ementati on chall enges and NH IS in the Ga West Municipali t y is no ex cepti on. The previous chapt er discussed the findings of th e stud y. The purpos e of thi s chapter is to summ arise the mai n findings of the stu d y, draw a con clusi on and provide recomm endati ons fo r red ressi ng th e identified ch a ll enges. 6 .1 Summary of Key Findin gs P oli c y implement ati on is the significant stage of poli c y m aking, between the establi shment of a poli cy and the cons equenc es of the poli c y for the people whom it affe cts. Poli c y implemen tation is a compl ex cour se of acti on ( Van M eter and Van Horn (1975). A good poli c y if poorl y implemented ma y fail to achieve the goals of its designe rs. Impl ementin g a publi c poli c y ma y incl ude a wide variet y of acti ons, including factors like finan cin g, personnel, plannin g, coll ecti n g data and diss emi nati ng information. Poli c y implementation requires a compl ex effort to acco mpl ish it. The University of Ghana http://ugspace.ug.edu.gh 95 reason is that people wh o origin all y determi ne publi c poli cies ar e usuall y not the ones who implement them. M oreover, at the nati onal l evel, poli c y implement ati on has had a low priorit y among mos t of the elected officials . The problems are due to the lack of ex pertise and ex perience in admi nist rati on. Besid es, ex ecuti ves are ex tre mel y bus y, and litt le incenti ve is emphas iz ed to the implementation of poli cies. Th e sum mar y of th e ke y findings of this stud y are group ed int o three based on the objecti ves of the stud y. One of the most importa nt findings was th e incre ase in patrona ge of he alt h facil it ies by subscribers in the Ga West Muni cipalit y. It is important to indi cate that unt il the onset of healt h insuran ce th ere was a decli ne in the cons umpt ion of healt h car e i n most of the healt h facil it ies in the area. The lack of patron age also had consequen ti al effect on maternal, infant and gen eral mortali t y. As one of the nurses in the Amasaman Hospit al indi cated: ‘Death Zas the unavoidable choice of patients’ especiall y pre gn ant wome n, unti l healt h insurance was int roduce d. It was a sad sit u ati on; pre gnant women could si mpl y not pa y. Now be cause of the sch eme anten atal car e and deli veries - both no rmal and assi sted ar e free ’ Another important find i ng in th e cou rse of th e res ear ch was improv ement in the infrastructur e of most healt h facil it ies in the Ga West Muni cipalit y especiall y the privatel y owned he alt h facil it ies that had the opportunit y to be part of the sch eme. Init iall y hi gh oper ati ona l cost had driven some of the healt h facil it ies to the point of closure. But with claims from the sche me such facil it ies have not onl y become vibrant but have also ex panded t heir infrastru cture. University of Ghana http://ugspace.ug.edu.gh 96 Finall y the implementat ion of the scheme has also led to some nega ti ve practi ces. In formants have indi c ated frequent and va rious forms of abuse of th e scheme. Whi le some of the abuses hav e alr ead y been discusse d in the gener al findin gs one that has receiv ed much criticism and which is consi de r ed ke y is the iss ue of false cl aim s. Majorit y of the informan ts indi cate d that some of the healt h provide rs in some inst ance s in connivanc e with sta ff of the schem e subm it claim forms cov erin g tr ea tm ents which were not given or ev en drugs that were not adm ini stered. Also some of the staff of the scheme submi t claim for ms for cert ain ex pendit ure which in reali t y were not incurre d. 6 .2 Recommen d ation s This secti on makes three concrete recomm end ati o ns to strengthen the implementation of the scheme and also to overcome those th at constrain its successful impl e mentati on. It was emphasiz ed in previous discussi on that the gre atest chall e nge facing th e implementation of the NHIS in the Ga is in the area of claim admi nist rati on. After five ye a rs of implementation of the NH IS in Ghan a, there has not been an y comprehensive developm ent of an y com puter software or mech a nism for the admi ni strati on of claims. The process has alwa ys adopted the manual appr oach wher e Claims Managers have to subj ect ever y sin gle claim to a thorough ma nual vett ing alon gside thous ands of prescriptio ns subm it ted by the numerous healt h ca re provide rs. On e would not but agre e that such a process is rea ll y cumbersome, time co nsum ing and evidentl y prone to fraud. It has also be en the major cause of undue dela ys in the releas e of funds fo r reim bursement from the Secreta riat of the Nati onal Healt h Insu ranc e Fund to the v arious schemes. It is therefo re important to develop a comprehensive comput eri z ati on s ystem University of Ghana http://ugspace.ug.edu.gh 97 that will help proc ess cla im s fast and minim iz e the fraud and cor ruption as sociated with the manual s yst em. In terms of staff stren gt h, the Ga West Muni cipal Schem e has about fift een reco gnised staff members on the pay- r oll of the Nati onal Healt h Insuran ce Authorit y. The Sch eme reli es he avil y on the Nati onal Service Personn el and students on int e r nshi p who ar e Jiven some alloZances from the scheme’s internally Jenerated funds. This tends to place a heav y burd en on the finances of the sch eme. Th e se people also do not sta y lon g enou gh to gather an y me aningfu l ex perience which could be helpful to the scheme in the long term. It is hereb y proposed that more and well tra i ned permanent sta ff be recruited so as to ensure smoo th operati ons of the scheme. Corruption has been a great enem y to the implementation of the NHIS i n Ghana. It is therefor e important th at stringent m easur es be pu t in place to control th e corruption. Th e int ernal audit ing unit mu st be stren gthened to det ect all the fraud and corr upt practi ces. Corrupt offici als shoul d be punis hed se riousl y without fear or favou r i n addit ion to a refund of all the mone y that has been embez z led and with int erest. This will serve as a deterr ent to other offici als. 6 .3 Conclu sion Ghana’s social health insurance scheme remains one of the biJJest assets for the country’s socio - econo mi c developm ent. Th e schem e s ymbol iz es the poli ti cal comm it ment to improve healt h status and re du c e the major healt h problems that have confronted the countr y for several dec ades. Ther e are wid espr ead publi c comm ents that NH IS is comp arati vel y bett er than the cash -and -c arr y (us er fees) s ystem. The cash - and - University of Ghana http://ugspace.ug.edu.gh 98 carr y s ystem is discrim inator y as it favour s only th e rich in societ y. Addit ionall y the s ystem made ac cess to healt hcare mo re difficult on emer gen c y sit uati ons. This stud y showed that there were a lot of people using the healt h facil it ies now as compared to the er a wh ere cash -and - car r y was i n vogu e, a factor which att ests to the success of implementation of the scheme. The stud y also showed that addit ional factors that contribut ed to the succ essful implementatio n of NH IS in clude staf f or mana gers of the scheme, poli ti cal comm it ment from government , financial contribut ion by both the state and subscrib ers am ong othe rs. It was also noted that there wer e cons traini ng factors that frustrated ef forts towards the succ essful implementation of NHIS . Th ese chall en ges include cor ruption and fraud, del a y in the proc es sing of documents and claim forms as well as the limi ted number of dru gs on NH IS pres cribe dru g list. It appe ars that a major priorit y of the NHIS is to make healt hcare affordable an d acc essi ble to all . Although a noble objecti ve, it is importan t to state that healt h status and healt h outcomes cannot be improved if the sche me conti nues to face m yriad problems. The int roducti on of an y healt h plan, such as that of NHIS , shoul d be followed with an improvement in human resource. Human resou rce const i tut es the most valuable asset fo r effe cti ve deli ver y of car e and w it hout them the i ntention of NHIS , which is to improve healt hcar e deli ver y will lack a solid ground. 6 .4 Furthe r Resear ch The findin gs in thi s stud y sho w that financial m ana gement in term s clai ms processi n g and cor ruption ar e the m ajor const r aini ng facto rs in the implementation of the Nati onal Healt h Insur ance in the Ga West Muni cipalit y. As stated earlier dela ys i n processi n g of University of Ghana http://ugspace.ug.edu.gh 99 claims , improper prepa ring of cl aim s forms by healt hcar e pro viders, ov er bil li ng and corruption are major ch a ll enges to the suc cessful implementation of the NH IS in th e Ga West Muni cipalit y. However the natur e of the relations hip between finan cial mana gement and the successful implementati on of the NH IS in t he Ga W est Muni cipalit y is compl ex and an accu rate assess ment of thi s is lacking. It is the refo re suggested that furth er quali tative and quanti tative resea rch be condu cted to investi gate how the NH IA can ensur e good financial mana ge ment as a way of ensurin g an ex cell ent implementation of NH IS . Bec ause the focus of thi s stud y was limi ted to the factors that facil it ate and const rained the implementation of the NHIS in the Ga West Muni cipalit y as well as t he impact of the relations between the actors on the impleme ntation of the scheme. Therefo re the dynami cs of how these affe ct implementation could not be adequatel y probed in thi s stud y. Quanti tative and quali tative resear ch sh ould also be conducted to concretel y understand the d ynami cs of these fa ctors on the im pl ementati on of the NH IS in Ghana. University of Ghana http://ugspace.ug.edu.gh 100 REFERENCES Abekah - Nkrumah G., Di nklo T., Abor J . (2009). Financing the health sector in Ghana: Review of the budgetary processes, Eu rope an jo urnal of economi cs, fin a nce and admi nist rati ve sciences, Issue 17. Agye pon g I, Adjei S (2008). Publi c social poli cy dev elopm ent and implementation: a case stud y of the Ghana Nati onal Healt h Insur a nce scheme. 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International Journal of Health Planning and Management, 4 , 17 -47. W arwick, D. P. (1982). Bitter Pills: population policies and their implementation in eight developing countries . Cambridge: Cambrid ge Universit y Press. Willems, S., and Baumer t, K. (2003). Institutiona l capacity and climate actions. Franc e: Organisati on of Economi c Co -operati on and Deve lopm ent. W it ter S. and Garshong B. (2009). Something old or somethi ng new? Social healt h insurance in Gh ana. BMC International Health and Human Rights, 9 :20 -41 WHO (2000). The World Health Report 2000—Health Systems: Improving Performance Geneva. Ret rieved on 29 t h March, 2013 from htt p:/ /www.who.int/ whr/2000/ en/ University of Ghana http://ugspace.ug.edu.gh 108 APPENDIX QUESTIONNAIRE FOR HEALTHCARE PROVIDERS UN IVERS ITY OF GHA NA BUS IN ESS SCHOOL I am an MPhil student at the Universit y of Ghana Business School under the supervisi on of Dr. Kwame Asamo ah . The focus of m y th esis is the implementation of the Nati onal Healt h Insur anc e Schem e in the Ga West Muni ci pal Assembl y. The aim of the rese arch is: To investi gate factors that facil it ate or const ra in the implementation of the Nati onal Healt h Insuran ce Sche me and to ex ami ne how these factors aff ect i mpl ementati on. Please read the following questi ons care full y and answ er ac cordin g to you r own ex periences. Please not e that answers to these qu e sti ons will be treated as confidenti al. SECTION A: DEMOGRAPHIC DATA 1. How old are you? Under 18 [ ] 18-25 [ ] 25-35 [ ] 36-5 0 [ ] 51-65 [ ] Over 65 [ ] 2. Are you Male [ ] Femal e [ ] 3. Educat i onal level No educ at ion [ ] Element ar y [ ] SHS [ ] Nursing [ ] Dipl oma [ ] DeJree > @ 0asters > @ 3hD > @ 2thers (specify)…………………………… 4. In ter ms of reli gi on, ar e you? &hristian > @ 0oslem > @ 7raditional > @ 2thers (specify)……………… 5. Mar it al Stat us Singl e [ ] Marr ied [ ], Divor ce d [ ], widowed [ ], Cohabit at i on [ ] 6. Posit ion_____________________________________________ 7. How man y year s have you wor k her e?_____________________________ University of Ghana http://ugspace.ug.edu.gh 109 SECTION B: FACTORS THAT FACILITATE IMPLEMENTATION OF HEALTH INSURANCE How do you see the impl ementati on of the Nati on al Heal th Insur ance so far in terms of the successes in the impl ementati on? _______________________________________________________________________ _______________________________________________________________________ How can you contribut e to the success ful im plementation of the Nati onal Healt h Insu ranc e Scheme? _______________________________________________________________________ _______________________________________________ ________________________ SECTION C: FACTORS THAT CONSTRAIN IMPLEMENTATION OF HEALTH INSURANCE Do you thi nk the imple mentati on of the Nati onal Healt h Insuran ce Sch eme en counter s some chall en ges? Yes [ ] No [ ] What are som e of the main facto rs that const r ain the implementation of the Nati onal Healt h Insura nce Sch eme ? 1.____________________________________________ __________________________ 2.____________________________________________ __________________________ 3.____________________________________________ __________________________ 4.____________________________________________ _ _________________________ 5.____________________________________________ __________________________ What can be done to mit igat e some of the chall en ges? _______________________________________________________________________ ________________________________ _______________________________________ SECTION D: ROLES PLAYED BY DIFFERENT ACTORS IN THE IIMPLEMENTATION OF THE SCHEME What are your rol e s as hea l t h provi de rs in the implem e nta ti on of the sche me? _______________________________________________________ ________________ _______________________________________________________________________ _______________________________________________________________________ University of Ghana http://ugspace.ug.edu.gh 110 SECTION E: S UGGESTIONS FOR IMPROVEMENT IN NHIS P lease kindl y provide s uggesti ons or recomm en dat ions that will help to improve the implementation of the Nati onal Healt h Insur ance Scheme. _______________________________________________________________________ _______________________________________________________________________ _______________________ ________________________________________________ University of Ghana http://ugspace.ug.edu.gh 111 QUESTIONNAIRE FOR STAFF OF THE SCHEME UN IVERS ITY OF GHA NA BUS IN ESS SCHOOL I am an MPhil student at the Universit y o f Ghana Business School under the supervisi on of Dr. Kwame Asamo ah . The focus of m y th esis is the implementation of the Nati onal Healt h Insur anc e Schem e in the Ga West Muni ci pal Assembl y. The aim of the rese arch is: To investi gate factors that facil it ate or const ra in the implementation of the Nati onal Healt h Insuran ce Sche me and to ex ami ne how these factors aff ect i mpl ementati on. Please read the following questi ons care full y and answ er ac cordin g to you r own ex periences. Please not e that answers to these qu e sti ons will be treated as confidenti al. SECTION A: DEMOGRAPHIC DATA 1. Age: Un der 18 [ ] 18-25 [ ] 25-35 [ ] 36-50 [ ] 51-65 [ ] Over 65 [ ] 2. Gender: Male [ ] Femal e [ ] 3. Educati onal Level : No educ at i on [ ] Element ar y [ ] SHS [ ] Teacher s Cer t A [ ] Dipl oma [ ] Degr ee [ ] Mast ers [ ] PhD [ ] Other s ( specify)………………… 4. Religi on: &hristian > @ 0oslem > @ 7raditional > @ 2thers (specify)……………… 5. Marital Status : Si ngl e [ ] Marr ied [ ] Divor ce d [ ] widowed [ ] Cohabit at i on [ ] 6. Your posi ti on? ____________________________________________________________ 7. How many year s have you w ork here? _________________________________ SECTION B: FACTORS THAT FACILITATE IMPLEMENTATION OF HEALTH INSURANCE The followi n g stat emen ts relate to the factors t hat facil it ate impleme ntation of the Nati onal Healt h Insuran ce Scheme in Ga West Muni cipal Assembl y. Please indi cate yo ur lev el of agr eemen t or disagr eement with each of the followin g statements by circli ng th e approp ri ate number. University of Ghana http://ugspace.ug.edu.gh 112 Strongl y agre e [5] Agree [4], Neutral [3], Disagree [2], Strongly disagree [1]. Public acce pt abi li t y of the healt h insur ance sche me 1 2 3 4 5 Incr ea si ng acceptanc e of peopl e to use healt h insur ance Part ners and act ors have simi l ar expec tati ons and confl i ct ing mot i vat i ons Technical and indi vi dual istic focus of poli cy int er vent ions Non - par t i cipator y focus of the sche me Consi st ent wit h other health poli cies Incr ea si ng poli ti cal commi t ment Support i ve legal and regul at or y frameworks Proper coor dinati on among the vari ous act or s Eff icient and counter pr oduct i ve rol es and proce dur es Proper cooperati on among the var i ous act or s Adequa te healt h faci li ti es Poor stat e of healt h facil it i es Manageri al abi li t y Trai ni ng and capacit y bui l di ng progr ammes for staf f Eff icient super vi sion of Dist ri ct Healt h Insur ance Moti vat i onal packages for staff Attrac ti ve remuner ati on and incenti ves Adequa te per sonnel at t he var i ous offi ces Adequa te technol ogy and accessori es Adequa te comput er s and equi pment for the work Appr opri at e recor di ng keepi ng Adequa te financial resour ce Proper account i ng recor ds Client s will i ng to pay the premi um SECTION C: FACTORS THAT CONSTRAIN IMPLEMENTATION OF HEALTH INSURANCE The followin g statem ents relate to the factors th at const rain the impleme ntation of the Nati onal Healt h Insuran ce Scheme in Ga West Muni cipal Assembl y. Please indi cate yo ur lev el of agr eemen t or disagr eement with each of the followin g statements by circli ng th e approp riate number . Strongl y agre e [5] Agree [4], Neutral [3], Disagree [2], Strongly disagree [1]. CULTURAL AND SOCIAL CHALLENGES 1 2 3 4 5 Lack of publ i c acceptabili ty Incr ea si ng rel uct ance of peopl e to use healt h insur ance Part ners and actor s have dif f er ent expect ati ons and conf li ct i ng mot i vat i ons University of Ghana http://ugspace.ug.edu.gh 113 POLITICAL AND LEGAL CHALLENGES 1 2 3 4 5 T echnical and indi vi dual istic focus of poli cy int er vent ions Non - par t i cipator y focus of the sche me Conf li ct s wit h other pol i ci es Waver i ng pol it i cal commi t ment Unsupport i ve legal and regul at or y frameworks ORGANISATIONAL/ INSTITUTIONAL CHALLENGES 1 2 3 4 5 Lack of coor dinati on among t he var i ous act ors Inef f i cient and counter pr oducti ve roles and proce dur es Appl i cati on of gene ral st andar ds Lack of cooper ati on among the vari ous act or s Inade quat e healt h faci li ti es Poor stat e of healt h facil iti es HUMAN RESOURCE CHALLENGES 1 2 3 4 5 Ma nageri al inabil it y Lack of capaci t y buil ding progr ammes Poor super vi si on of Distr i ct Healt h Insur anc e Lack of mot i vat i on Inequi t able distr i buti on of healt h profes si onal s Unat tr act i ve remuner at i on and ince nt i ves Inade quat e per sonnel TECHNOLOGICAL AND INFORMATION BARRIERS 1 2 3 4 5 Poor dat a qualit y and quanti t y Inade quat e equi pment s Engi nee ri ng des i gn of the inf or mat i on syst em Inade quat e mai ntena nce of equi pment FISCAL/FINANCIAL CHALLENGES 1 2 3 4 5 Inef f ec ti ve clai ms mana ge ment and cont r ol Incons i st ent bill ing syst em Del ay of payment of clai ms Inappr opr i at e recor di ng keepi ng Inade quat e financial resource Weaknes ses in the p ri ci ng and fisc al frameworks Fraud and cor rupti on Del ay in re - i mbur se ment Inef f ec ti ve mechani sm for trac ki ng cl ai ms University of Ghana http://ugspace.ug.edu.gh 114 SECTION D: ROLES PLAYED BY VARIOUS ACTORS IN THE IMPLEMENTATION OF THE SCHEME What specific roles do yo u pla y as ma na ge rs of the scheme in the impl emen tation process? _______________________________________________________________________ _______________________________________________________________________ _____________________________________________________________ __________ SECTION E: SUGGESTIONS FOR IMPROVEMENT IN MANAGING NHIS W hat do you thi nk shoul d be done to improve the mana gement of Nati onal Healt h Insu ranc e Scheme ? _______________________________________________________________________ ___________________ ____________________________________________________ _______________________________________________________________________ What are some of the cha ll enges o f the Nati onal Healt h Insuran ce Schem e? __________________________________________________________ _____________ _______________________________________________________________________ _______________________________________________________________________ Thank you for completing the questionnaire University of Ghana http://ugspace.ug.edu.gh 115 QUESTIONNAIRE FOR SUBSCRIBERS (BENEFICIARY) UN IVER S ITY OF GHA NA BUS IN ESS SCHOOL I am an MPhil student at the Universit y of Ghana Business School under the supervisi on of Dr. Kwame Asamo ah . The focus of m y th esis is the implementation of the Nati onal Healt h Insur anc e Schem e in the Ga West Muni ci pal Assembl y. The aim of the rese arch is: To investi gate factors that facil it ate or const ra in the implementation of the Nati onal Healt h Insuran ce Sche me and to ex ami ne how these factors aff ect i mpl ementati on. Please read the following questi ons care full y and answ er a c cordin g to you r own ex periences. Please not e that answers to these qu e sti ons will be treated as confidenti al. SECTION A: DEMOGRAPHIC DATA 1. Age: Under 18 [ ] 18-25 [ ] 25-35 [ ] 36-50 [ ] 51-65 [ ] Over 65 [ ] 2. Gender: Male [ ] Femal e [ ] 3. Educati onal Level : No educ at i on [ ] Element ar y [ ] SHS [ ] Teacher s Cer t A [ ] Dipl oma [ ] Degr ee [ ] Mast ers [ ] PhD [ ] Other s ( specify)………………… 4. Religi on: Chri st ian [ ] 0oslem > @ 7raditional > @ 2thers (specify)……………… 5. Marital Status : Si ngl e [ ] Marr ied [ ] Divor ce d [ ] widowed [ ] Cohabit at i on [ ] 6. Occupation _____________________________________________ SECTION B: FACTORS THAT FACILITATE IMPLEMENTATION OF HEALTH INSURANCE As a bene ficiar y of the Nati onal Healt h Insur ance Sc heme, what factors fac il it ate the successful impl ementati o n of the scheme? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ SECTION C: FACTORS THAT CONSTRAIN IMPLEMENTATION OF HEALTH INSURANCE W hat are the main factor s that constrain the impl ementati on of the scheme ? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ University of Ghana http://ugspace.ug.edu.gh 116 SECTION D: ROLES PLAYED BY THE VARIOUS ACTORS IN THE IMPLEMENTATION OF THE SCHEME Wha t rol e do you pla y as bene fi c ia rie s in the implem e nta ti on of the sche me? _______________________________________________________________________ _______________________________________________ ________________________ _______________________________________________________________________ SECTION E: SUGGESTIONS FOR IMPROVEMENT OF THE IMPLEMENTATION OF NHIS P lease kindl y provide s uggesti ons or recomm en dati ons that will help to improve the implem entation of the Nati onal Healt h Insur ance Scheme. _______________________________________________________________________ _______________________________________________________________________ ________________________________________________________________ _______ Thank you for completing the questionnaire University of Ghana http://ugspace.ug.edu.gh