UNIVERSITY OF GHANA FACTORS AFFECTING THE IMPLEMENTATION OF THE NATIONAL HEALTH INSURANCE POLICY. BY KWASI ADDEI MENSAH (10256037) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF PhD PUBLIC ADMINISTRATION DEGREE. OCTOBER, 2016. University of Ghana http://ugspace.ug.edu.gh ii DECLARATION This thesis is a presentation of my original research work. Wherever contributions of others are involved, every effort has been made to indicate this clearly, with due reference to the literature, and acknowledgement of collaborative research and discussions. The work was done under the guidance of the supervisory committee at the Department of Public Administration and Health Services Management, University of Ghana Business School. Kwasi Addei Mensah ………………………………………… (10256037) Date:………………………………… University of Ghana http://ugspace.ug.edu.gh iii CERTIFICATION We do hereby certify that the candidate's thesis has been completed to our satisfaction and that it is in a format and of an editorial standard recognised by the school as appropriate for examination. Professor Kwame Ameyaw Domfeh ………………………………………… Date:………………………………… Dr. Kwame Asamoah ………………………………………… Date:………………………………… University of Ghana http://ugspace.ug.edu.gh iv DEDICATION This work is dedicated to God and my family. University of Ghana http://ugspace.ug.edu.gh v ACKNOWLEDGEMENTS I would like to express my sincere gratitude to all who contributed to the successful completion of this work. It would not have been possible to complete this work without the immense support, guidance and contribution of the members of the supervisory committee. I would like to thank Professor Kwame Ameyaw Domfeh and Dr. Kwame Asamoah for their patience, care and guidance, throughout my research work. I am also grateful to them for providing me with a conducive research atmosphere and giving me practical experience in addition to the theoretical knowledge they provided. I am also grateful to the faculty and staff of the Department of Public Administration and Health Services Management, particularly the Head of Department, Dr. Justice Bawole. I also sincerely thank also Professor Kojo Sakyi, Dr. S. K. Asibuo, Dr. Albert Ahenkan, Dr. Thomas Buabeng for providing the needed academic support to supplement the work of the supervisory team. I am also grateful to Mrs. Matilda Tetteh and Mrs. Mary Larbi for providing administrative support. I thank the management, faculty and staff of Wisconsin International University College, Ghana, who supported me at the workplace so I could successfully complete this work. My sincere gratitude goes to Mrs. Emelia Amoako Asiedu and Mr. Elias Megbetor. Also, I am indebted to my family for their support throughout the period of study. I want to thank my wife Mrs Paulina Mensah for her support, love and care. I also want to acknowledge the inputs my parents and siblings made to ensure that I successfully completed this work. I am grateful to Ms Rosemary Attibu for her support during data collection. I wish to thank the management and staff of the Ayawaso, Ablekuma, Ga and Dangme West district offices of the NHIA for their contribution to the study. Finally, I would want to thank all research assistants and participants of the study. University of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENTS DECLARATION .......................................................................................................................... ii CERTIFICATION ....................................................................................................................... iii DEDICATION ............................................................................................................................. iv ACKNOWLEDGEMENTS ......................................................................................................... v TABLE OF CONTENTS ............................................................................................................ vi LIST OF FIGURES AND BOXES .............................................................................................. x LIST OF TABLES ...................................................................................................................... xii LIST OF ACRONYMS ............................................................................................................. xiv ABSTRACT ............................................................................................................................... xvii CHAPTER ONE ........................................................................................................................... 1 INTRODUCTION ........................................................................................................................ 1 1.0 Background to the study ................................................................................................... 1 1.1 Statement of the Problem ................................................................................................. 6 1.2 Research Objectives ......................................................................................................... 9 1.3 Research Questions ........................................................................................................ 10 1.4 Significance of the research ........................................................................................... 10 1.5 Scope of the study .......................................................................................................... 11 1.6 Organization of the study ............................................................................................... 11 CHAPTER TWO ........................................................................................................................ 12 LITERATURE REVIEW .......................................................................................................... 12 2.0 Introduction .................................................................................................................... 12 2.1 Public Policy Implementation ........................................................................................ 13 2.1.1 The Top-Down and Bottom-up Theoretical Approach to Implementation ............ 16 University of Ghana http://ugspace.ug.edu.gh vii 2.1.2 A Synthesis of the Top-down and Bottom-up Approaches to Implementation ...... 23 2.2 Systems View of Policy Implementation ....................................................................... 25 2.3 Health Financing ............................................................................................................ 31 2.4 Functions of Health Financing ....................................................................................... 33 2.5 Types of Health Insurance (Risk Pooling Mechanisms) ................................................ 37 2.6 Social Health Insurance Systems ................................................................................... 41 2.7 Social Health Insurance (SHI) in Low- and Middle-Income Countries (LMICs) ......... 42 2.8 Impact of Social Health Insurance (SHI) on Low- and Middle-Income Countries (LMICs) .................................................................................................................................... 44 2.9 Health Financing In Ghana ............................................................................................. 48 2.10 Factors Affecting the Implementation of the National Health Insurance Scheme ......... 51 2.11 Conceptual Framework for the study ............................................................................. 55 2.12 Conclusion ...................................................................................................................... 65 CHAPTER THREE .................................................................................................................... 67 METHODOLOGY ..................................................................................................................... 67 3.0 Introduction .................................................................................................................... 67 3.1 Research Paradigm and Philosophy ............................................................................... 67 3.2 Research Design ............................................................................................................. 72 3.3 Study Context.................................................................................................................. 75 3.4 Units of Analysis ............................................................................................................. 78 3.5 Target Population ............................................................................................................ 79 3.6 Sample Size ..................................................................................................................... 80 3.7 Sampling Techniques ...................................................................................................... 81 3.8 Sources of Data .............................................................................................................. 83 University of Ghana http://ugspace.ug.edu.gh viii 3.9 Data Collection Instruments ........................................................................................... 84 3.10 Data Management and Analysis .................................................................................... 87 3.11 Validity and Reliability .................................................................................................. 89 3.12 Ethical Considerations .................................................................................................. 90 3.13 Assumptions and Limitations of the Study ................................................................... 91 CHAPTER FOUR ....................................................................................................................... 93 DATA ANALYSIS AND PRESENTATION ............................................................................ 93 4.0 Introduction .................................................................................................................... 93 4.1 Demographic Characteristics ......................................................................................... 94 4.2 Participation in NHIS ..................................................................................................... 96 4.3 Factors Affecting the Implementation of NHIS ........................................................... 101 4.3.1 Actors .................................................................................................................... 102 4.3.2 Client Satisfaction ................................................................................................. 106 4.3.3 External (PEST) Factors ....................................................................................... 114 4.3.4 Other Factors Affecting the Implementation of the NHIS .................................... 135 4.4 Relationships between the Factors ............................................................................... 138 4.5 Conclusion .................................................................................................................... 140 CHAPTER FIVE ...................................................................................................................... 142 DISCUSSION OF FINDINGS ................................................................................................. 142 5.0 Introduction .................................................................................................................. 142 5.1 Respondent’s Participation in the NHIS ...................................................................... 142 5.2 Factors Affecting the Implementation of the NHIS ..................................................... 146 5.2.1 Actors .................................................................................................................... 147 5.2.2 Inputs..................................................................................................................... 150 University of Ghana http://ugspace.ug.edu.gh ix 5.2.3 Conversion Stage .................................................................................................. 152 5.2.4 Outputs .................................................................................................................. 155 5.2.5 The Environment .................................................................................................. 157 5.2.6 The Feedback Loop............................................................................................... 162 CHAPTER SIX ......................................................................................................................... 167 CONCLUSION ......................................................................................................................... 167 6.0 Introduction .................................................................................................................. 167 6.1 Summary of Empirical Findings .................................................................................. 167 6.2 Theoretical Implications ............................................................................................... 171 6.3 Policy Implications ....................................................................................................... 171 6.4 Contribution of Research to Knowledge ...................................................................... 172 6.5 Recommendations of the Study.................................................................................... 175 6.6 Conclusion .................................................................................................................... 177 REFERENCES .......................................................................................................................... 178 APPENDIX A ............................................................................................................................ 200 APPENDIX B ............................................................................................................................ 210 APPENDIX C ............................................................................................................................ 213 APPENDIX D ............................................................................................................................ 216 APPENDIX E ............................................................................................................................ 225 APPENDIX F ............................................................................................................................ 226 University of Ghana http://ugspace.ug.edu.gh x LIST OF FIGURES AND BOXES List of Figures Figure 2.1: The Political System 27 Figure 2.2: Interactions among the NHIS Implementation System and the Environment 64 Figure 2.3: The NHIS Implementation System in the Environment 65 Figure 4.1: Services NHIS Subscribers had to Pay for in Health Facilities 101 Figure 4.2: Respondents’ Perception on the Quality of Services Received by NHIS Subscribers Compared to Non-Subscribers 110 Figure 4.3: Respondents’ Perception on the Quality of Services Received by NHIS Subscribers Over Time 111 Figure 4.4: Respondents’ Overall Satisfaction with the NHIS 113 Figure 4.5: Responses to the Statement - “I joined the NHIS primarily because I need 138 the card for other transactions” Figure 5.1:Revised Framework: Interactions among the NHIS Implementation system 164 and the Environment Figure 5.2:The NHIS Implementation System in the Environment 165 Figure C1: Ghana’s Health Delivery System 213 Figure C2: Organisation of Ghana’s Health System 214 List of Boxes Box 4.1: Regression Model: Effect of the Level of Satisfaction on the Success of Implementation of NHIS 113 University of Ghana http://ugspace.ug.edu.gh xi Box 4.2: Correlation and Chi-Square Analyses of the Factors Affecting the Implementation of the NHIS 114 Box 6.1: Ways of Contributing to Knowledge 173 Box B1: Factors Affecting the Successful Development of Social Health Insurance 212 University of Ghana http://ugspace.ug.edu.gh xii LIST OF TABLES Table 2.1 Membership, Utilisation and Claim Payments (2005 – 2012) 53 Table 4.1: Participation in Health Insurance 96 Table 4.2: Reasons for not Registering for NHIS 97 Table 4.3: Participation in NHIS 98 Table 4.4: Benefit Status of Respondents under NHIS 99 Table 4.5: Coverage of Household Health Needs under NHIS 100 Table 4.6: Respondents’ Perception on the Importance of Actors in the Implementation of NHIS 102 Table 4.7: Influence of Political Activities on the NHIS 115 Table 4.8 Correlation and Chi-Square Analyses of Political Variables and the Success of the Implementation of the NHIS 116 Table 4.9: Respondent’s Perception on the Contribution of the District Assembly to the NHIS 119 Table 4.10 Correlation and Chi-Square Analyses of Economic Variables and the Success of the implementation of the NHIS 121 Table 4.11: Average Reduction in Health Expenditure of NHIS Participants 123 Table 4.12: Correlation Matrix – Relationship between Social Variables 127 Table 4.13: Contribution of Religious Organisations to the NHIS 129 Table 4.14 Correlation and Chi-Square Analyses of the Activities of Religious Organisations and the Success of the implementation of the NHIS 130 Table 4.15: Correlation Matrix – Relationships between Factors Affecting the NHIS 139 Table A1: Demographic Characteristics of Respondents (Age, Gender, Literacy, University of Ghana http://ugspace.ug.edu.gh xiii Education) 200 Table A2: Employment Information of Respondents 201 Table A3: Reasons Non-Renewal of Insurance 202 Table A4: Number of Times Benefitted from the NHIS 203 Table A5: Factors Facilitating the Implementation of NHIS 204 Table A6: Factors Hindering the Implementation of NHIS 205 Table A7: Experiences of NHIS Subscribers in Health Facilities 205 Table A8: How Economic Factors affect Respondents’ Participation in NHIS 206 Table A9: Social Factors Affecting Respondents’ Participation in NHIS 207 Table A10: Respondents’ Experiences at NHIA District Offices 208 Table A11: Availability of NHIS Accredited Providers 208 Table A12: Income Levels of Respondents 209 Table B1: Health Financing Performance Indicators 210 Table B2: Factors Contributing Positively to an Enabling Environment for SHI 211 Table C1: Ghana’s Health Sector Funding, 2014 215 Table C2: Ghana’s Health Sector Staff Strength 215 Table C3: Distribution of Health Professionals 215 University of Ghana http://ugspace.ug.edu.gh xiv LIST OF ACRONYMS CBHIs Community-Based Health Insurance Schemes CHAG Christian Health Association of Ghana CHPS Community-Based Health Planning and Services CPP Convention Peoples Party CWIQ Core Welfare Indicator Questionnaire DFID Department for International Development DMHIS District Mutual Health Insurance Scheme DRG Diagnosis-Related Group FFS Fee for Service G-DRG Ghana Diagnosis-Related Group GHS Ghana Health Service GNP Gross National Product GSS Ghana Statistical Service HIFA Health Institutions and Facilities ICT Information and Communication Technology ID Cards Identification Cards IGF Internally Generated Funds ILO International Labour Office ISD Information Services Department LI Legislative Instrument LMICs Low- and Middle-Income Countries MDGs Millennium Development Goals University of Ghana http://ugspace.ug.edu.gh xv MIS Management Information System MMDAs Metropolitan, Municipal and District Assemblies MOH Ministry of Health NDC National Democratic Congress NDPC National Development Planning Commission NGO Non Governmental Organisation NHI National Health Insurance NHIA National Health Insurance Authority NHIF National Health Insurance Fund NHIL National Health Insurance Levy NHIS National Health Insurance Scheme NLCD National Liberation Council Decree NPP New Patriotic Party OECD Organisation for Economic Cooperation and Development OOPs Out-of-Pocket Payments PEST Political, Economic, Social and Technological PHSP Private Health Sector Policy PNDC Provisional National Defense Council PRO Public Relations Officer SAP Structural Adjustment Programme SHI Social Health Insurance IBM SPSS IBM Statistical Product and Service Solutions SSA Sub-Saharan Africa UAB Universal Accreditation Board University of Ghana http://ugspace.ug.edu.gh xvi USAID United States Agency for International Development VAT Value Added Tax VHI Voluntary Health Insurance WHO World Health Organisation WTP Willingness to Pay University of Ghana http://ugspace.ug.edu.gh xvii ABSTRACT Public policy implementation has been a critical issue in the local, national and international political discourse, and its importance cannot be overemphasized. The essence of arriving at the intended results of public policies and the subsequent debate on means to achieve this end has been an overarching issue in policy circles, among policy actors, and within policy communities during the past four decades. The study identified the factors affecting the implementation of National Health Insurance Policy. The study also identified the relationships that exist among these factors and the determinants of participation in the National Health Insurance Scheme (NHIS). To do this, the researcher used a combination of quantitative and qualitative approaches. Easton’s political systems theory was used as the theoretical lens for the study. Ghana’s NHIS was conceived as a system which takes demand and support inputs from the environment and converts them into outputs which are released back into the environment. The framework for the study also showed how political, economic, social and technological factors affected the implementation of the NHIS. The researcher adopted a pragmatic approach. This involved the use of a mixed methodology, using both qualitative and quantitative approaches. Also, the researcher adopted a descriptive case study design for the study. In all, the study was conducted in four districts of the NHIS, namely Ablekuma, Ayawaso, Ga, and Dangme West districts. These districts have a total population of 1,721,095 out of which the study targeted 1,101,770 persons who were 18 years old and above. To obtain the necessary empirical data, the researcher sampled 442 participants out of which 422 participated in the quantitative survey; and 20 participated in in-depth qualitative interviews. The sample size for the quantitative study was based on the recommended table for sample size determination by the Universal Accreditation Board which used a ±5% margin of error, yielding a 95% confidence interval. The concept of University of Ghana http://ugspace.ug.edu.gh xviii saturation guided the determination of the sample size for the qualitative study. Respondents for the quantitative survey were selected using a convenience sampling technique. However, the respondents for qualitative interviews were purposively selected. The researcher found that age and marital status of respondents significantly affected respondents’ participation in the NHIS. Gender, educational status and employment did not significantly predict participation in the NHIS. The study also found that the government and politicians, the National Health Insurance Authority (NHIA) and health sector organisations/institutions (including healthcare providers, regulators and professionals greatly affected the implementation of the NHIS. In addition, the political, economic, social and technological segments of the environment significantly affected the NHIS implementation system. The economic segment was found to have the strongest influence on the NHIS implementation system and that the economic relief the NHIS brings to participants as well as the current economic conditions have greatly affected its implementation. It was also found that the pronouncements and activities of politicians have had a significant effect on the NHIS. The society on its part has contributed to the implementation of the NHIS by accepting it, supporting it and encouraging its members to join. Technological advancement also affected the implementation of the NHIS. Furthermore, the researcher found that there exist significant interrelationships between these factors. The political factor had the strongest relationships with all the other factors. The study made a significant contribution to knowledge by introducing a modified framework (which combines Easton’s Systems Theory and the Political, Economic, Social and Technological [PEST] environmental analysis) to investigate the implementation of public policy. Considering the fact that this hybrid framework is new and has not been adequately tested, the researcher recommends subsequent testing and use on the NHIS and other implementation issues. University of Ghana http://ugspace.ug.edu.gh xix University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.0 Background to the study Public policy implementation has been a critical issue in the local, national and international political discourse, and its importance cannot be overemphasized. Without it, the policy cycle will be incomplete. Furthermore, the success of any policy is determined by the success of its implementation. Public policy implementation is widely viewed as the process by which governments put policies into effect (Howlett and Ramesh, 2003; Howlett, Ramesh and Perl, 2009; Wu et al., 2012). It is the link between the expression of governmental intention and actual results (O’Toole et al., 1995). Policy implantation in Ghana, like in most other developing countries has been fraught with challenges (Larbi 1998; Batley and Larbi, 2004). The National Health Insurance Policy, a major entrant into Ghana’s policy landscape has also had its share of implementation challenges (see Nsiah-Boateng and Aikins, 2003). There have been several contributions by scholars and practitioners to ensure that the implementation of the National Health Insurance Scheme will lead to financial risk protection as intended by the framers of the policy. It must be noted that efforts to achieve intended results of policies are not new in policy circles. Among policy actors, and within policy communities, there have been debates on how to ensure that policy implementation leads to the realization of initial policy goals, starting with the work of Pressman and Wildavsky (1973). Pressman and Wildavsky (1973) sought to establish a concrete theory of policy implementation, and examine its relevance on the basis of existing literature. Further on, there have been phenomenal research outcomes on policy implementation which provide University of Ghana http://ugspace.ug.edu.gh 2 excellent frameworks for use by policy with goal of enabling them to achieve successful implementation of their policies. Nevertheless, policy actors are still faced with the challenge of ensuring successful policy implementation. Researchers seem not to have solved the implementation puzzle, and practitioners seem to be entangled in the vexing challenges of converting policy intent into efficacious action (O’Toole, 2000). O’Toole further in his seminal article posited that: Policy failures continue to be prominent, and evidence of implementers' desires to be informed in appropriate ways by the research community suggests that many implementation conundrums remain salient in the world of action. (O’Toole, 2000: 265). The complexity of the policy implementation process has challenged researchers to develop theories or models with a limited number of explanatory variables that predict how and under what conditions policies are implemented (O’Toole and Montjoy, 1984). Nonetheless, the empirical data that could provide an adequate understanding of how to surmount the barriers, delays, and disincentives associated with implementing policies are usually lacking (Alesch and Petak, 2001; Matland, 1995; Sabatier, 1991). The challenge of policy implementation is further accentuated by the fact that it inevitably takes different shapes and forms in different cultures and institutional settings. Thus, the setting within which a policy is being implemented has a bearing on the success or otherwise of its implementation. Also, the context within which a policy is introduced, the relationships required to implement it and the stakeholders whose paths it crosses affects its implementation (Busche, 2010). Additionally, scholars have indicated that the complexity and multi-faceted nature of issues on the policy agenda at both national and local levels need to be understood if effective implementation is University of Ghana http://ugspace.ug.edu.gh 3 to prove possible. Understanding issues at both the national and local levels is critical since most policies are formulated at the national level and implemented at the local level. For instance in Ghana, the sector ministries, which operate at the national level are mandated to give broad policy directions while the decentralized local units (the metropolitan, municipal and district assemblies) implement such policy directions (Republic of Ghana, 1993). However, it must be noted that the policy cycle rarely follows the often-hoped-for, bureaucratic logic in which the role of some is to formulate and others to implement. Sometimes, in addition to such policies’ inability to fit into the local context, there are local factors which might impinge their implementation. Furthermore, the position and influence of the purported ‘street level bureaucrats’ (who normally operate at the local level) is a principal determinant of where power ultimately lies and of what gets, and does not get, implemented; and this cannot be ignored (Lipsky, 1980). The history of Ghana’s policy implementation landscape has not been very encouraging. This is evident in the works of some prominent Ghanaian and African scholars who have indicated that the country has had a plethora of almost failed attempts to implement national policies (Makinde, 2005; Ayee, 2001; Agyepong and Nagai, 2011; Owusu, 2006; Larbi 1998; Mills, Bennet and Russel, 2001; Ayee, 1995; Batley and Larbi, 2004). Such attempts to effectively and efficiently implement the country’s policies cut across the various sectors of the country, hampering the development of these sectors and the country at large. The health sector has had its own share of policy implementation challenges. The sector is crucial to development of the country, and failure of its policies deprives the country of the necessary social development, which adversely affects the economic development and also widens the poverty and inequality gap. University of Ghana http://ugspace.ug.edu.gh 4 Ghana’s health sector is led by the Ministry of Health (MoH) which is responsible for policy development, planning, donor coordination and resource mobilization. The vision of the health sector is to create wealth through health. Its mission is to contribute to national socio- economic development and wealth creation through (i) the promotion of health and vitality; (ii) ensuring access to quality health and nutrition services for all people living in Ghana; and (iii) facilitating the development of a local health industry (MoH, 2007). The sector also seeks to meet targets enshrined in the Millennium Development Goals (MDGs); especially the poverty and health related goals (i.e. MDG 1, MDG 4 MDG 5 and MDG 6). Ghana has made steady progress in attaining its health sector goals. For instance, under-five mortality rate declined from 111 per 1,000 live births in 2003 to 80 per 1,000 live births in 2008, while infant mortality rate decreased from 64 to 50 per 1,000 live births within the same period. Also, institutional maternal mortality rate reduced from 216 per 100,000 live births in 1990 to 164 per 100,000 live births in 2010 (UNDP Ghana & NDPC/GOG, 2012; WHO, 2014). The number of health facilities increased by 7% in two years; from 3011in 2007 to 3,217 in 2009 (Ghana Health Service, 2008; 2010). However, although the health sector has made significant strides in attaining the sector goals, there have been inherent problems which have stifled the success of the implementation of policies, priorities and programmes. Significant among the factors militating against the successful implementation of health sector policies and priorities is the problem of inadequate financial and physical access to facilities (WHO, 2014). Researchers have revealed that the Government of Ghana has instituted several measures to improve geographical accessibility to health facilities (Witter and Garshong, 2009). For instance, the Core Welfare Indicator Questionnaire (CWIQ) survey revealed that between the 1997 and 2003 the percentage of people who had access to a health facility increased from 37% to 58% (Ghana Statistical University of Ghana http://ugspace.ug.edu.gh 5 Service, 2005; Agyepong and Adjei, 2008). Financial accessibility to health facilities however remained an insurmountable hurdle for most Ghanaians thus depriving them of essential health care (Agyepong and Adjei, 2008). This called for the Government of Ghana, supported by the international community, to initiate drastic measures which saw the formulation of the National Health Insurance Policy and its associated National Health Insurance Law in 2003. This was subsequently followed by the inception of the National Health Insurance Scheme (NHIS). The policy sought to establish a scheme which would assure equitable and universal access for all residents of Ghana to an acceptable quality package of essential healthcare. The policy objective was to ensure that 5 years after the commencement of the health insurance scheme, every resident of Ghana would belong to a health insurance scheme that adequately covers him or her against the need to pay out of pocket at the point of service use, in order to obtain access to a defined package of acceptable quality of health service. Considering this initial policy intent, all residents of Ghana were supposed to have been covered by a health insurance scheme by the year 2010; a situation which would eliminate out-of-pocket payments at the point of service. However, there is reliable evidence that the country has not been able to achieve 100% coverage under the national health insurance scheme after 5 years of effective implementation, and enrolment rate in 2010 stood at 34%. The NHIA, later in its strategic plan sought to expand coverage to 60% (National Health Insurance Authority, 2011) in 2014 but this was also not achieved. The enrolment rate in 2014 was 41.56%; (Jehu-Appiah, 2015). Furthermore some researchers (Wahab, 2008; Nsiah-Boateng and Aikins, 2013) and operators of the scheme have indicated the persistence of insurmountable challenges confronting the scheme which even further threaten the achievement of the initial objectives University of Ghana http://ugspace.ug.edu.gh 6 and even the continuing operation of the scheme. These problems range from political interference to low financial sustainability and poor governance. There have also been concerns that the scheme is more anti-poor than pro-poor, which tends to defeat one of the main purposes of the scheme, which is to provide accessible healthcare to the poor (National Health Insurance Authority, 2011; Oxfam, 2011; World Bank, 2012). The question thus arises concerning the cause(s) of the failure to achieve the policy objective. Earlier researchers have sought to find answers to this question (Wahab, 2008; Nsiah-Boateng and Aikins, 2013) and this research seeks to supplement the earlier efforts by investigating the factors affecting the implementation of the NHIS. This research, using the systems theory as its main theoretical lens, seeks to examine the factors that have impeded (or in some cases facilitated) the implementation of the National Health Insurance Policy. 1.1 Statement of the Problem Public administration scholars and practitioners have indicated that the actual implementation of a policy is a rather complicated process (Pressman and Widavsky, 1984; O’toole, 2000). Policy implementation is a complex activity and thus prescribing a model for effective implementation has been a puzzle which researchers have not been able to unravel. This has created a situation where practitioners are continuously confronted with the vexing challenges of converting policy intent into efficacious action. Policy failures continue to be prominent, and evidence of implementers' desires to be informed in appropriate ways by the research community suggests that many implementation conundrums remain salient in the world of action. Ghana has evidenced the ineffectiveness of well-intentioned and excellently formulated policies. Most of the time, these policies fail to achieve most of their objectives and in some University of Ghana http://ugspace.ug.edu.gh 7 instances cause social tensions and widen the inequality gap (Batley and Larbi, 2004; Ayee, 1995). One major implementation challenge in Ghana has been ensuring the effective execution of health financing policies. The review of Ghanaian historic literature on health financing shows that most health financing policies have not been effective. Firstly, the free health-care initiative that was implemented in the post-independence era failed due to the government’s inability to sustain it (Sulzbach, Garshong, and Banahene, 2005). In the 1970s, the government introduced the nominal fee policy which also failed due to the same sustainability problems. In an attempt to solve the problem of low sustainability and also lessen the health expenditure burden on the government, the then Provisional National Defense Council (PNDC) military junta introduced the policy of full cost recovery (popularly called ‘cash and carry’) under the Structural Adjustment Programme (SAP). The SAP, though benefited the country economically, had significant negative social effects which made health care inaccessible to majority of Ghanaians due to their inability to pay at the point of service. The country, in its effort to curb these social ‘ills’ then enacted the National Health Insurance Policy and its accompanying National Health Insurance Law and the NHIS. However, despite the fact that the National Health Insurance Policy is well crafted with the necessary provisions for a successful implementation, the scheme still faces a lot of challenges. The participation in the scheme is still very low (Gobah and Laing, 2011). In 2010, only about 34% of Ghanaians were enrolled on the scheme (National Health Insurance Authority, 2011); which is far from the initial policy objective of ensuring 100% coverage after five years of its commencement. The NHIA modified the initial objective in its 2010- 2014 strategic plan, and targeted 60% coverage by the end of 2014. The Authority could not also meet this strategic objective, and enrolment stood at 41.56% at the end of 2014 (Jehu- University of Ghana http://ugspace.ug.edu.gh 8 Appiah, 2015). Also, some studies have established that the actual coverage is below the figures reported by the NHIA. For instance, a study commissioned by Oxfam UK, indicated an enrolment rate of 18% in 2009 (Oxfam, 2011) which was far below the 62% that the NHIA reported. This is further compounded as the available evidence shows that the NHIS does not adequately cover the poor (Oxfam, 2011; World Bank, 2012; NHIA, 2011). The NHIS has been regarded as anti-poor and not pro-poor as it tends to benefit the rich more than the poor; benefiting about 64% of the rich as opposed to 29% of the poor (Oxfam, 2011). Also, the 2008 Demographic Health Survey indicates that the proportion of people covered under the NHIS for the lowest wealth quintile is 29.3% while that for the highest wealth quintile is 47% (GSS, GHS and ICF Macro, 2009). This supports assertions that the scheme benefits the rich more than the poor. Furthermore, the funding of the scheme has emerged as a challenge which has been a threat to its survival. The NHIA, in its 2010 annual report indicated that the scheme risked “dipping down” by the close of 2012. This was re-echoed in a World Bank report that indicated a threat of insolvency (World Bank, 2012). Publications by some individuals and other organisations have also expressed similar concerns (Gobah and Laing, 2011; Health Systems 20/20, 2009; Ledger, 2006; Oxfam, 2011). In 2009, the total income generated to support the NHIS could only cover a little over 95% of the expenditure and this decreased to a little over 90% in 2010 (NHIA, 2011). Additionally, the premiums paid by adults in the informal sector have been woefully inadequate (Gobah and Laing, 2011) and unsustainable as they are not actuarially determined (NHIA, 2011). The problem of inadequate funding has been compounded by cost escalation as a result of multiple attendances, increasing cost of drugs and increase in the number of drugs per prescription (Gobah and Laing, 2011). These have heightened the implementation problems at the local level. University of Ghana http://ugspace.ug.edu.gh 9 Another challenge concerns political interference. Considering the nature of the National Health Insurance Policy/Scheme as a social intervention, politicians have regarded it as a ‘fertile ground’ to advance their political agenda. A notable example is the promise by the NDC in the 2008 elections, who indicated in their manifesto to implement the one-time premium payment. This promise was made without any prior feasibility studies and as such could not be fulfilled although the government made attempts to ensure its implementation. Such interferences ultimately impinge on the success of the implementation of the policy. There have been other challenges concerning the governance, management and organizational arrangement of the NHIS. In the light of these challenges, there is the fear that the NHI Policy will likely fail like its predecessor health financing policies. Although these challenges and the general factors affecting the implementation of the NHIS have been acknowledged by several authors, what literature on NHIS fail to provide is how these factors are interrelated. The literature reviewed show that there are environmental forces that affect the implementation of the NHIS, but there is not much literature to explain the complexity of the interaction of these environmental forces and how they affect the NHIS. Therefore approaching implementation from a systems point of view using Easton’s political systems theory (Easton, 1957; Anderson, 2006), the study describes how the relationship between the factors affecting the NHIS. Using the PEST model, the study explains the complexity of the inter relationships. 1.2 Research Objectives The main objective of the research was to investigate the factors affecting the implementation of the National Health Insurance Policy. Specifically, the study sought to acheive three objectives namely:  To identify the level and nature of participation (enrolment) in the NHIS in the study areas. University of Ghana http://ugspace.ug.edu.gh 10  To identify the factors affecting the implementation of the NHIS in the study areas.  To examine the relationships between the factors affecting the implementation of the NHIS. 1.3 Research Questions To acheive the study objectives, the research sought to answer the question “what factors affect the implementation of the National Health Insurance Policy in the study areas?” Specifically, the study was guided by three questions as listed below:  How are residents of the study areas participating in the NHIS and what factors affect their decision to enrol?  What are the factors affecting the implementation of the NHIS in these areas?  How are these factors related to each other and to the NHIS? 1.4 Significance of the research The research is significant in several respects. First, it will contribute to the explanation of the factors that are affecting the implementation of public policy in Ghana. It will be a necessary resource that governmental and nongovernmental actors will make use of in designing and implementing policy initiatives. Closely linked to the first contribution, the study will also refine the attitudes and orientations of policy-makers and other actors in the policy process concerning the targeting and the right measures for the successful implementation of policies. Also, the study will inform political actors and civil society organizations on the required interventions and the extent of their involvement in policy making and implementation. Additionally, the study will be a guide to the citizenry on their participation in policy making and implementation. Finally, this study will contribute to the literature on policy making and implementation in Ghana and will also complement the work of several other authors by adding up to the intellectual resources on public policy. University of Ghana http://ugspace.ug.edu.gh 11 1.5 Scope of the study The research was conducted in four districts of the NHIS in the Greater Accra Region. These are Ablekuma, Ayawaso, Dangme West and Ga district purposively selected from the 14 NHIS districts in the region. These districts therefore constituted the geographic scope of the study. Also, the study was conducted within the context of the factors affecting the implementation of the NHI Policy. 1.6 Organization of the study Chapter One, lays the conceptual foundations of the research in terms of problem formulation and structuring, research objectives and research questions, the conceptual framework, and the country context of the analysis. Chapter Two contains the literature review. The first part of the chapter reviews literature on policy and policy implementation. The second part of the chapter reviews literature on health financing and health insurance. The final part of the chapter provides the conceptual framework for the study. Chapter Three deals with the research methods and data analysis focusing on sampling methods and sample sizes; data collection instruments used; and how data analysis was done. Chapter Four provides the analysis of research findings. The chapter commences with a situational analysis of the study areas. It then focuses on analyzing the findings from the primary data collected. Chapter Five presents the discussion of research findings. It examines the contribution of the research findings to the key issues of this research. It also describes how the research relates to literature and how it fills the gaps in existing literature. Chapter Six, the concluding chapter, presents a summary of empirical findings, theoretical implications and policy implications of the study. The chapter also indicates how the research has contributed to existing knowledge and makes recommendations for future research. University of Ghana http://ugspace.ug.edu.gh 12 CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter provides a review based on theoretical and empirical literature and places the study in context. The review identifies and discusses scholarly contributions to the research area and forms a basis for the current research. The first part of the chapter reviews literature on policy implementation. Public policy implementation has been a major issue and has accounted for a significant proportion of the literature on public administration and political science. However, there remains more work to be done in explaining these concepts fully. Policies are made and implemented in specific contexts that impact and redefine the process to suit that specific context and thus making it difficult to arrive at a general conception that conforms to every context. Nevertheless, this chapter seeks to synthesize these pieces of literature to arrive at a theoretical backbone for the study. The second part of the chapter reviews theoretical and empirical literature on health financing and health insurance. This is to complement the previous review on policy and policy implementation to produce a broad overview of literature in the study area. This review is seen as important as it familiarizes the author with the health insurance landscape. It also helps in positioning the current research in the context of research on health insurance. The review is also beneficial as it helps to shape the methodology for the study. The conceptual framework for the study is provided in the third part of the chapter. The framework formed the basis of the research and guided data collection and analyses. University of Ghana http://ugspace.ug.edu.gh 13 2.1 Public Policy Implementation Defining public policy in clear and unambiguous terms has proven to be a herculean task. Earlier scholars and political scientists have devoted considerable attention to the problem without reaching a consensus on what public policy actually is. Nevertheless, this review presents some contributions of these earlier scholars in their attempt to define this term. Public policy according to Dye (1976; 2002), is government action, its intention and the influence such action makes in society. He further expressed it in simple terms as whatever government chooses to do or not to do. This view was also espoused by Brooks (1993) who indicated that policy involves a conscious choice that leads to deliberate action or inaction. According to Heidenmer et al (1990), policy has to do with how, why and to what effect, governments pursue a particular course of action or inaction. With an emphasis on the ‘why’ of public policy, Dewey (1927), a pioneer in public administration and public policy, in his presentation indicated that the centre of public policy is public problems. This was an indication that policies would not be relevant in a situation of absence of public problems. This is because it is such problems that policies are meant to address (Lasswell, 1971; Wildavsky, 1979). Easton (1965) presenting a similar view but concentrating on the behavioural aspect of society defined policy as consisting of decision rules adopted by authorities as a guide to behaviour. Cochran et al. (2009) presenting a broader perspective, defined policy in their book as “an intentional course of action followed by a government institution or official for resolving an issue of public concern” (p 3). This definition highlighted 3 key elements: the ‘what’, ‘how’ and ‘why’ of public policy. Firstly, concerning the ‘what’ of policy, the definition indicates that it is an intentional course of action. Also in line with earlier scholars (Dye, 1976; Brooks, 1993; Heidenmer et al., 1990), Cochran et al mentioned that the intentional course of action University of Ghana http://ugspace.ug.edu.gh 14 includes decisions made not to take a certain action. The second element of this definition (i.e. the ‘how’ of policy), indicates that public policies are made and followed by actors who belong to governmental institutions. Finally, the definition makes it clear that the central reason for the need of policy (the ‘why’ of policy) is to resolve issues of public concern. From a general perspective, the Merriam Webster’s Dictionary (2012) defines policy as “a definite course or method of action, selected from alternatives and in the light of given conditions to guide and determine present and future decisions.” Alternatively, the dictionary considers policy as a “high level overall plan embracing general goals and acceptable procedures, especially of a governmental body”. Giving antonyms such as imprudence and indiscretion, it can be ascertained that the dictionary considers policy as an output of a rational process. This definition is similar to that offered by the Oxford English Dictionary which defines policy as “a course of action adopted by a government or a superior body”. Again, the dictionary gives phrases such as prudent conduct, political sagacity and craftiness as the meaning of public policy. Although there have been different definitions for public policy by different scholars and from different sources, there seem to be common attributes running through these various definitions. Heclo (1972) was right on point when he indicated that policy, unlike other academic concepts, seems to have a certain amount of definitional agreement. A critical assessment of the definitions provided above gives credit to Heclo’s statement. The definitions agree on a number of issues concerning the definition of policy. First of all, the definitions indicate that a policy is a statement of intent and a course of action. Making policy requires choosing among goals and alternatives, and choice always involves intention (Dye, 1976; Brooks, 1993; Heidenmer et al., 1990; Cochran et al., 2009). Additionally, another point of convergence of most definitions by earlier scholars is that policies are meant to University of Ghana http://ugspace.ug.edu.gh 15 address problems or issues of public concern (Dewey, 1927; Lasswell, 1971; Wildavsky, 1979; Cochran et al, 2009). Furthermore, earlier definitions of policy have indicated that a policy is a choice between alternatives (Dror, 1989; Cochran et al, 2009). Some scholars have indicated that policy is more than just a statement of intent. These researchers have indicated that the term policy may be used to connote different things, which makes it multi-faceted. Hogwood and Gunn (1984), for instance, in their paper specified ten uses of the term policy. They indicated that policy can be used as a label for: a field of activity; an expression of general purpose or desired state of affairs; as a specific proposal; as decisions of government; as formal authorization; as a programme; as an output; as an outcome; as a theory or model; or as a process. However, these ten labels of policy can be narrowed to three. Policy can refer to a process, an output and an outcome. This thesis is interested in the outcome of a policy (policy as an outcome); the National Health Insurance Policy. However, how policy is implemented, is the most important determinant of the output and outcome of policy and as such there is the need to look at the policy process in any work on policy analysis. Policy implementation has been traditionally thought of as a top-down process (Pressman and Wildavsky, 1973). This traditional process begins with a clear statement of the policy maker’s intent and proceeds through a sequence of increasingly more specific steps to define what is expected of implementers at each level. At the end of the process, one states, again with as much precision as possible, what a satisfactory outcome would be, measured in terms of the original statement of intent. Pressman and Wildavsky view implementation as establishing chains of causation between initial conditions and future consequences. So, to them, implementation is the ability to forge subsequent links in the causal chain so as to obtain the desired results. University of Ghana http://ugspace.ug.edu.gh 16 Bardach (1977) offers little in the way of disagreement with the core theory of linkage offered by Pressman and Wildavsky. His major contribution was in describing the implementation process as a series of ‘games’. Thus, Bardach sees implementation as not just a process which ‘begins’ with the legislators and ‘ends’ with street-level bureaucrats, but as an iterative process. Implementation is equally about how the policy gets carried into action on a day to day basis. Research and scholarship in relation to policy implementation sought to achieve among others the objective of enlightening not only the academic community, but also the broad community of policy-interested parties (Pressman and Wildavsky, 1984; O’Toole, 2000). The initial study by Pressman and Wildavsky (1973) provided the ‘spring-board’ for the advancement of scholarship in the area of policy implementation. This move by Pressman and Wildavsky (1973) also sought to invigorate the study of policy implementation and also catalyse attention to implications for practice (O’Toole, 2000). A review of literature indicates that there have been several scholarly works that seek to unravel the ‘mystery’ behind policy implementation. The increased research in policy implementation at the time culminated in the proliferation of implementation theories (O’Toole, 2000). The main theoretical approaches to policy implementation have been the top-down and bottom-up approaches, and a synthesis of these two approaches. The following section reviews literature on these approaches. 2.1.1 The Top-Down and Bottom-up Theoretical Approaches to Implementation The top-down approach to implementation was pioneered by Pressman and Wildavsky (1973) in their quest to shed more light on policy implementation (Mushkat, 2008). These two authors in their influential book explored how local government units responded to guidelines provided by the central government. As expressed by Mushkat, the idea behind University of Ghana http://ugspace.ug.edu.gh 17 this exploratory study could be likened to the logic (propounded by some scholars) that administrative authority should flow seamlessly from the political centre to the political periphery. This is the ‘spine’ of the top-down approach which has the basic assumption that policy goals can be specified by policymakers and that implementation can be carried out successfully by setting up certain mechanisms (Palumbo and Calista, 1990; Paudel, 2009). The top-down model is imbued with the idea that implementation is about getting people to do what they are told, and keeping control over a sequence of stages in a system; and about the development of a programme of control which minimizes conflict and deviation from goals set by the initial policy hypothesis (Pressman and Wildavsky, 1973). Control is an essential part of the top-down model and analysts argue that there should be a good chain of command and a capacity to control and coordinate for policies to be effectively implemented. The top-down model depicts a process that begins at the top with a statement of the policy- maker’s intent. This statement ought to be clear and unambiguous. The process which commences with a broad statement of intent, proceeds through a sequence of increasingly more specific steps to define what is expected of implementers at each level. The process then ends with a more precise statement of the expected outcome, and how it would be measured in relation to the original statement of intent (Elmore, 1978; Paudel, 2009). Additionally, the proponents of the top-down approach perceive the success of implementation as the degree to which the actions of implementing officials and target groups coincide with the goals embodied in an authoritative decision (Van Meter & Van Horn, 1975; Mazmanian & Sabatier, 1981; 1983; 1989a). They therefore highlight the need to follow implementation down through the system with a focus on higher level decision- makers. The model also emphasizes centralization and formalism. Elmore (1978) for instance indicated that the funding, organizational structures, authority relationships, regulations; and administrative controls (such as budgeting, planning and evaluation requirements) should be University of Ghana http://ugspace.ug.edu.gh 18 formalised and centralised. Furthermore, some scholars have indicated that due to the formal nature of the top-down approach, the ‘relevant’ actors which researchers include in their research agendas are those formally in the implementation of the programme or policy (Winter, 1990; Paudel, 2009). The top-town perspective again emphasizes formal steering of problems and factors, which are easy to manipulate and lead to centralization and control (Paudel, 2009). The top-down approach was later developed by some scholars (Dunsire, 1978a; 1978b; 1990; Hood, 1976; Gunn, 1978; Mazmanian and Sabatier, 1989b) who proposed models which asked what a ‘perfect implementation’ would ‘look like’. Hood (1976 cited in Parsons 1995), being one of the pioneers who sought to answer this question identified five conditions for perfect implementation using the top-down approach. To him, a perfect implementation is possible if:  The ideal implementation is a product of a unitary ‘army’-like organisation, with clear lines of authority;  Norms will be enforced and objectives given;  People would do what they are told and asked;  There is perfect communication in between units of organisation;  There is no pressure of time. (Parsons, 1995) Gunn (1978), on his part, expanded the work of Hood (1976) and proposed 10 comprehensive conditions necessary for achieving desired outcomes for a top-down approach to implementation. He enumerated these conditions as: 1. Circumstances external to the implementing agency do not impose crippling constraints. 2. Adequate time and sufficient resources are made available for the programme. University of Ghana http://ugspace.ug.edu.gh 19 3. In addition to there not being any constraints with respect to the overall availability of resources for implementation, the right combination of resources needed for every stage of the process should be provided. 4. The policy to be implemented is based on a valid theory of cause and effect. 5. The relationship between cause and effect is direct and there are few, if any, intervening links. 6. There is a single implementation agency which needs not depend upon other agencies for success. If other agencies must be involved, the dependency relationship is expected to be minimal in number and importance. 7. There is a complete understanding and agreement upon the objectives to be achieved; and these conditions persist throughout the implementation process. 8. In moving towards agreed objectives, it is possible to specify in complete detail and perfect sequence, the tasks to be performed by each participant. 9. There is perfect communication among, and coordination of, the various elements or agencies involved in the programme. 10. Those in authority can demand and obtain perfect obedience. (Gunn, 1978 cited in Parsons, 1995) Elmore (1979) agreeing with Hood (1976) and Gunn (1978) and adopting a simplified approach identified four main ingredients for effective implementation. According to Elmore, the tasks and objectives must be clearly specified and accurate, to reflect the intent of the policy; there should be a plan that allocates performance standards to subunits; there should be objectively verifiable indicators and means of verification to measure performance; and there should be a system of management controls and social sanctions sufficient to hold subordinates accountable for their performance (Elmore, 1979). University of Ghana http://ugspace.ug.edu.gh 20 Dunsire (1990; 1993), approaching the issue from the opposite dimension and linking the top- down approach to Weber’s ideal bureaucracy, looked at the causes of failure of policies and programmes. He attributed implementation failure to factors such as the selection of wrong strategy or wrong machinery or instruments; incorrect programming of the bureaucracy; poor operationalisation; problems at the shop floor level; and poor response to problems (Dunsire, 1990; Parsons, 1995). Mazmanian and Sabatier in 1989 presented a more simplified approach which comprised of only three factors responsible for the success of implementation with the top-down approach (Mazmanian & Sabatier, 1989b). Nevertheless, a critical analysis of these factors shows that each of them is very encompassing and includes a number of variables. The factors specified in their paper include the tractability of the problem, ability of statute to structure implementation, and non-statutory variables affecting implementation (Mazmanian & Sabatier, 1989b). The synthesis of the literature provided above on the success factors of top-down implementation shows significant similarities. First of all, there is a general agreement on the fact that objectives and problems, as well as what is expected of the implementers need to be specified. Additionally, these earlier scholars agreed on the fact that there should be a structure for the implementation that has inbuilt control mechanisms. The timely availability of resources is also a major factor that runs through most of the works of these earlier scholars. However, other scholars (e.g. Lipsky, 1976; Elmore, 1985; Wetherly and Lipsky; 1977; 2002; Parson, 1995) had a different opinion. Although they agreed that most of these factors are necessary ingredients for successful policy implementation, they argued that the top-down approach does not give a holistic account of implementation. University of Ghana http://ugspace.ug.edu.gh 21 The bottom-up approach, also referred to as, backward mapping was then developed by renowned scholars including Elmore (1978; 1979), Lipsky (1971), Berman (1978), and Hjern, Hanf, and Porter (1978) in response to the accentuating criticisms of the top-down approach. This approach, unlike the top-down approach, starts at the ‘bottom’ by identifying the network of actors involved in service delivery in one or more local areas and asks them about their goals, strategies, activities, and contacts (Lester et al., 1987; Sabatier, 1986). It then uses the contacts as a means for developing a network technique to identify the local, regional, and national actors involved in the planning, financing, and execution of the relevant governmental and nongovernmental programs (Sabatier, 1986). Proponents of the bottom-up approach further argue that, in most instances, central initiatives are poorly adapted to local conditions. To them, local conditions are very critical to the success of implementation. These include factors such as the skills of individuals in the local implementation structure, and how these individuals can adapt the policy to local conditions. The bottom-up perspective does not limit itself to only formal relationships but also highlights informal relationships within the policy sub-system and between actors involved in making and implementing policies (Howllet and Ramesh, 2003; Paudel, 2009). Starting with a problem in society, the approach focuses on individuals and their behaviour with a revived interest in the street-level bureaucrat (Paudel, 2009). The street-level bureaucrat, whether in the public or private sector, becomes the ‘centre of attention’ in the political/policy process and is elevated from the ‘bottom’ to the ‘top’ (Hjern et al., 1978; Hjern and Porter, 1981; Hjern and Hull, 1985; Sabatier, 1986; Paudel, 2009). The renewed interest in street-level bureaucrats stems from the fact that they have a better understanding of what clients need since they have direct contact with the public (Paudel, 2009). Michael Lipsky’s (1980) theory of ‘street-level bureaucracy’ highlights the excessive discretionary power the street-level bureaucrat wields and how it impacts significantly on the delivery/implementation of policies University of Ghana http://ugspace.ug.edu.gh 22 and programmes. In fact, as Winter rightly indicated, Lipsky considers the street-level bureaucrats as policymakers (Paudel, 2009). Furthermore, with the bottom-up approach, policy is determined by the bargaining (explicit or implicit) between members of the organization and their clients and not strict control by decision makers (Lester et. al., 1987). In this regard, programmes are expected to be compatible with the desires and behaviours of the lower level implementers (Linder & Peters, 1987; Lester et. al., 1987). Also, the bottom-up perspective has myriads of actors (both public and private) all of whom are very relevant to the process and thus the need to map relations between them (Hull and Hjern, 1981) to avoid the ‘unpleasant’ consequences of what Van Meter and Van Horn (1975) call the complexity of joint action. Considering the complex nature relations and interconnections within a bottom-up implementation process, there is the need to map a network that identifies the relevant implementation structure for a specific policy at the local, regional and national levels (Paudel, 2009). A synthesis of the literature on decentralization indicates that the bottom-up approach to implementation functions well in a highly decentralized economy. The bottom-up approach, like decentralization, requires power to be devolved to the local level to be effective. Furthermore, the ideals of decentralization are critical to successful bottom-up implementation. As Burns et. al. (1994) indicated, ‘ideal type’ decentralization should ‘embrace’ conditions including localization, flexibility, devolved management, and organizational culture and change. These factors, it can be argued, are relevant to the success of bottom-up implementation. There is the need for relocation of agencies (or at least the creation of semiautonomous local level sub-agencies) from the centre to the local level to facilitate implementation (localisation). Also, considering the multiplicity of actors in a bottom-up implementation process, and the varying behavioural and skill mix, there need to University of Ghana http://ugspace.ug.edu.gh 23 be flexible forms of management and work organisation through multi-disciplinary team working, multi-skilling local mangers. Devolution also gives decision-making powers to the local-level actors and street-level bureaucrats which is very relevant to the bottom-up implementation since it forms the core of the process. Additionally, there is the need for reorientation of management and staff values to promote quality of service and local empowerment (organizational culture and change) to easily incorporate the local actors in decision-making. The bottom-up perspective sought to address some weaknesses of the top- down approach but as other scholars have determined, (the bottom-up approach) also has its own challenges and weaknesses. 2.1.2 A Synthesis of the Top-down and Bottom-up Approaches to Implementation The top-down and bottom-up approaches seek to explain the same concept (implementation) but these approaches seem to be conflicting. Nevertheless, each tends to complement the other by explaining the portion of implementation ignored by the other. The fact that each seeks to address the weaknesses of the other is the sole basis on which some scholars advocated for a synthesis of the approaches. The call for a synthesis of the top-down and bottom-up approaches to policy implementation dates back to the 1980s. Pioneering advocates for a synthesis include Elmore (1980, 1982, 1985), Goggin et al. (1990), Thomas and Grindle (1990), and Matland (1995). Elmore (1982 and 1985) was one of the first scholars to attempt a synthesis of the two perspectives. He based his argument on simultaneously adopting forward mapping and backward mapping. In this case, he added that policy-makers should ensure that their policy designs reflect and take into consideration the incentive structure of target groups. However, as Matland (1995) indicated, Elmore’s prescription lacked explanatory power and could only be useful as a tool. He did not hypothesise and test any specific relationship which makes it University of Ghana http://ugspace.ug.edu.gh 24 too weak to be considered as a theory (Paudel, 2009). Matland (1995) however sought to improve upon Elmore’s work by introducing the ‘ambiguity and conflict model’. The ambiguity and conflict model, like Elmore’s forward and backward mapping, combines the top-down and bottom-up perspectives. Matland’s (1995) model suggests that the relative value assigned to the top-down and bottom-up approaches should be a function of the degree of ambiguity in goals and means of a policy and the degree of conflict. The model distinguishes between four main implementation scenarios: administrative implementation (i.e. low conflict – low ambiguity); political implementation (i.e. high conflict – low ambiguity); symbolic implementation (i.e. high conflict – high ambiguity); and experimental implementation (i.e. low conflict – high ambiguity) (Matland, 1995). Although Matland’s (1995) model provides a more theoretically grounded approach to implementation, other authors argue that it oversimplifies a rather complicated and ‘messy’ process (Hill and Hupe, 2006). Thomas and Grindle (1990) on the other hand saw the implementation process as interactive rather than linear. With a primary focus on the drivers of issues and proposals onto the government’s agenda, Thomas and Grindle (1990) introduced a model which combined the participation of high level government officials and lower level implementing agencies and actors. A core proposition in this piece of work was that policy reform initiatives were as a result of pressures exerted by interested parties (from the top and/or the bottom). With this, the relative value of the approaches (i.e. top-down and bottom-up approaches) is dependent on the pressures for change from either the top or the bottom and how the other party reacts to such pressures. Understanding the location, strengths and stakes involved in these attempts to promote, alter or reverse policy reform initiatives is central to understanding the outcomes (Thomas and Grindle, 1990). Paudel (2009) indicated that this model can lead to a more University of Ghana http://ugspace.ug.edu.gh 25 realistic approach to policy especially where the question of implementation feasibility assumes major importance. To support the earlier contributions on synthesising the top-down and bottom-up perspectives of implementation, Goggin et al (1990) introduced an interactive model which concerns itself with intergovernmental implementation with import from the communications theory. The model incorporates some variables from the top-down and bottom-up approaches. The model indicates that implementation in the states is influenced by a combination of inducements and constraints from the federal, state and local levels; by a state’s decisional outcomes; and by a state’s capacity to act. How exactly implementation proceeds in specific policy areas is dependent on the interaction of these elements of the model. 2.2 Systems View of Policy Implementation The systems view of policy implementation is based on David Easton’s (1957) model of political systems. Easton (1966: 147) considered a system as "any set of variables regardless of the degree, of interrelationships among them”. With emphasis on the political system, Easton (1966) provided this definition to free the researcher from the need to prove whether a political system is a system (Fisher, 2010). As mentioned earlier, Easton’s thesis was on political systems. Because of this focus, there was little emphasis on other systems, and though it penetrates the political arena, it seemed to be a little narrow. Building on Easton’s initial conception of a system, Anatol Rapoport (1966; 1968) referred to a system as a set of interrelated units connected by behaviour and history. He added that a system must satisfy the following criteria: 1) have an identifiable set of elements; 2) the relationships among some or all the elements must be identifiable; 3) certain relations may imply others; 4) a complex relation at a given time would lead to a complex relationship (or a University of Ghana http://ugspace.ug.edu.gh 26 series of complex relationships) at a later time (Rapoport, 1966). Rapoport (1966, 1968) provided a broader view of a system that fits majority of systems in the world. However, with emphasis on public policy implementation, this work is much concentrated the political system with emphasis on implementation. Easton considered political life as a system of interrelated activities (Easton, 1957). In his view, the interrelationships or systemic ties of political activities spring from the fact that they all influence the formulation and execution of authoritative decisions for society. Easton (1966) considered political systems to be concerned with the authoritative allocation of values for a society. With this, he distinguished the political system from other systems. Nevertheless, he recognised that the political system, like all other systems, must possess some properties of a system (Easton, 1957; Anderson, 2003). These properties include ‘identification’ which indicates that the political system must be easily identifiable and distinct from other systems. Such distinction must be clearly demarcated by the system’s units and boundaries. Secondly, he indicated that a political system should have inputs and outputs. Easton called the authoritative decisions a political system makes for society as outputs and the external events that affect, alter, or modify it as inputs. As the third property, Easton (1957) indicated that there should be differentiation in a system. He recognized the need for such differentiation and division so the system could generate the required output and perform effectively. The differentiation may be the different actors, institutions etc. in the political system. In addition to the differentiation, Easton (1957) saw the need for integration as the fourth property. Such integration is necessary so that there is cooperation (at least to some degree) in making authoritative decisions (Hock, 1994). Otherwise, Easton indicated that the differentiation in the system can trigger potentially disintegrative forces. Easton’s conception of a political system is indicated in Figure 2.1 University of Ghana http://ugspace.ug.edu.gh 27 Figure 2.1: The Political System Source: Easton, 1957 p. 384 In his conception, Easton (1957) considered a political system as a goal‑setting, self‑transforming and creatively adaptive system. This idea was also pioneered by Bertalanffy (1968) who introduced the General Systems Theory (GST). According to these scholars, members of the system are not just passive transmitters of things taken into the system. Rather, they are active human beings who are capable of anticipating, evaluating, and acting constructively to prevent disturbances in the system’s environment. Such members, he indicated, are able to regulate, control, direct, modify, and innovate with respect to all aspects and parts of the processes involved (Easton, 1957; 1965a). Furthermore, Easton (1966) and later Anderson (2003), recognised that the environment is very influential on the political system. They however added that stability or changes in a system is primarily a result of the functioning or dysfunctioning of its internal variables. Easton noted that: University of Ghana http://ugspace.ug.edu.gh 28 political systems accumulate large repertoires of mechanisms through which they may seek to cope with their environments. Through these [mechanisms] they may regulate their own behaviour, transform their internal structure, and even go so far as to remodel their fundamental goals (Easton, 1965b: 19). The political system in Easton’s view is connected to its environment in an input-output relationship. The inputs are stimuli in the environment required by the system. In the political system, these inputs are labeled as ‘demands’ and ‘support’. These inputs according to Easton (1965a; 1965b) have some consequences for the operations of the system. The outputs on the other hand are “the consequences flowing from the behaviour of the members of the system rather than from actions in the environment” (Easton, 1965b: 27). The outputs of a system are the decisions and actions of the authorities and are distinguishable from outcomes which are the consequences of the outputs (Easton, 1965b). The primary focus of this theory is how the demand and support inputs affect the system’s behaviour and outputs. One other issue relevant for political analysis is the tracking of the effects of a system’s behaviour on the system itself. It should be noted that, while outputs influence events in the wider society, they also play an important part in subsequent rounds of political inputs (Easton, 1966). This complex relationship provides a way to investigate how a system copes in a dynamic manner with environmental challenges and pressures. Easton also places more emphasis on the feedback mechanism than most other systems theorists. He noted that political systems, just like other large-scale systems, usually have diverse and multiple feedback loops. Although it is important for the system to be organized to achieve its goals, Easton was rather concerned about how the ability to achieve a goal or otherwise reacts back on the input of support (Easton, 1965b). In this sense, he placed more emphasis on the ongoing viability of a system rather than just achieving goals. University of Ghana http://ugspace.ug.edu.gh 29 Furthermore, Easton considered the feedback loop to be more than just a mechanism at the output side specifying relationships between authorities and their specific goals. He conceived it as a more systemic loop that reflects the contributions of all politically relevant members in a system and upon whose support the system must rely for its persistence over time (Easton, 1965b). In effect, the feedback loop energizes the whole system, and connects its outputs (authoritative decisions and actions) to inputs (support and demands). For Easton, systemic feedback flows from the system and may return to it at the starting point. The feedback mechanism therefore allows the system to operate in a continuous and never-ending manner. In this way, political processes need to be understood “as a continuous and interlinked flow of behaviour” (Easton, 1965b: 29). There have been several criticisms of the systems theory mainly on the grounds of its methodological weaknesses, its unsuitability for empirical research, and its strong political bias (Fisher, 2010; Mitchell, 1968; Susser, 1992). Concerning methodological weaknesses, Mitchel (1968) asserted that Easton’s view of society is potentially flawed as it consists of far more individuals and isolated events than the theory is capable of handling. Other critics were more concerned about the difficulty in identifying boundaries and variables; making it difficult to formulate operational definitions and perform empirical research (Fisher, 2010). Benard Susser (1992) criticised Easton’s theory based on its little contribution to empirical research. His criticism stemmed from the fact that researchers find it difficult to use Easton’s theory since it does not make adequate provision to perform a historical analysis of a system. The utility of the systems theory was therefore questioned since it is practically impossible to study a system without looking at the past. University of Ghana http://ugspace.ug.edu.gh 30 The systems theory has also been criticised based on its conservative tone and emphasis on the status quo. Critics stressed that it ignored the contribution of behaviourists, although they had made significant contribution to political research. Furthermore, the view of political systems by Easton as equilibrium seeking, self-balancing entities also suggested clear ideological biases (Fisher, 2010). Despite all these criticisms, Easton’s theory has made, and continues to make significant contributions to political science and public administration research. Nevertheless, it should be acknowledged that several other authors have made significant contributions and modifications to the systems theory. Morcol (2012) saw this initial conception as very simple and fails to adequately project the complexities in the real world. He specified that the relationships between the actors of the complex system are basically non-linear and co- evolutionary. A real world system (such as the political system) is regarded as so complex that Gershenson et al. (2007) argued that there is no formalism that will be able to adequately capture all its properties. Valle (2000) characterised such systems by: “a) a large number of similar but independent elements or agents; b) persistent movement and responses by these elements to other agents; c) adaptiveness so that the system adjusts to new situations to ensure survival; d) self-organization, in which order in the system forms spontaneously; e) local rules that apply to each agent; and f) progression in complexity so that over time the system becomes larger and more sophisticated” (p4). Morcol (2012) again purports that a real world complex system is dynamic and its actors are self-conscious, purposeful, and interdependent. These later contributions have aided in moulding Easton’s initial conception and making it more relevant to current circumstances. This work adapts the systems theory not in the form of Easton’s initial conceptualisation, but modified to suit activities involved in policy implementation. With emphasis on University of Ghana http://ugspace.ug.edu.gh 31 implementation, the theory seeks to explain how the inputs, process, and the environmental influences of the implementation system are able to generate outputs that will stimulate public acceptance of, their participation in the implementation of government policies. Also, the systems theory is being used for this research as a means of achieving collective goals from diverse individual demands on the implementation system. The systems theory is also being adopted in this research to identify the processes of detecting and dealing with problems within the implementing/public administration system. The following section reviews literature on health financing and insurance. 2.3 Health Financing Health financing is a universal concern and there is a general call for its effectiveness. Actors in the health policy arena (including bi-lateral and multi-lateral agencies) have sought to find ways to mobilise, allocate and manage financial resources for health. Additionally, there have been attempts to improve health financing to increase access to healthcare and help achieve the health related Millennium Development Goals (MDGs). The health financing literature also suggests that the state has a vital role to play in health financing, especially when it wants to ensure equity and protect the poor (Kutzin, 2008; 2010). Also, state involvement in health financing helps to achieve better aggregate health outcomes. Furthermore, effective structuring and management of health financing is critical to achieving universal coverage and an equitable health system. There are three main functions of health financing. The first function of health financing is to mobilise resources in an equitable way to ensure sufficient and sustainable revenues. The second function is to pool funds to ensure that costs of accessing health-care are shared and there is financial accessibility. The third function, the purchasing function, seeks to ensure University of Ghana http://ugspace.ug.edu.gh 32 that funds to buy and provide health-care services are used in the most efficient and equitable way (Kutzin 2001; Savedoff & Carrin 2003; Carrin & James 2005). The ultimate goal of every health financing system is to achieve universal coverage. Universal coverage is ensuring that there is equitable access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost (WHO, 2000; 2005). To facilitate the achievement of universal coverage through effective health financing, Kutzin (2010) operationalised the core health financing functions and goals into 8 performance indicators (as shown in Table B1 in Appendix B). He added that the achievement of these health financing objectives and performance indicators is contingent upon two important features. The first of these is the underlying institutional design of health financing functions (that is the set of institutions that operate in relation to the three health financing functions). The second important feature is the organizational practice within health financing functions; particularly, the way that rules are put in practice and implemented by health financing actors. It must be noted that the organizations in charge of health financing tasks are guided by rules and incentives as well as other organizational and individual motivations such as profit and utility maximization (Carrin et al., 2008; Mathauer, 2009). Aside these core principles for effective health financing, there is the need to periodically evaluate and possibly reform the health financing system to adjust it to the changing health needs of the people. There must also be effective health financing policy objectives in place. In this light, Kutzin (2010) developed health financing policy guidelines based on the health system performance goals outlined in the World Health Report, 2000. According to him, policy objectives are to serve as criteria to be used to assess the attainment and performance of health financing systems and the effects of reforms. Also, the objectives of a health financing system are expected to promote universal protection against financial risk as well University of Ghana http://ugspace.ug.edu.gh 33 as promote a more equitable distribution of the burden of funding the system. He finally added that policy objectives should promote equitable use and provision of services relative to the need for such services; improve transparency and accountability of the health (financing) system to the population; promote quality and efficiency in service delivery; and improve efficiency in the administration of the health financing system. 2.4 Functions of Health Financing Every health financing system performs three main functions. These are resource mobilization/revenue collection, pooling of funds/risks and, purchasing (Kutzin, 2008). However, the success of countries in carrying out these functions has important implications for several factors. Kutzin (2008) identified these factors as availability of funds, fairness, economic efficiency of revenue raising, levels of pooling and prepayment, allocative efficiency, technical efficiency, and financial and physical access to services. The following sections discusses the health financing functions. Resource mobilisation The first function of every health financing system is revenue collection. The sources of funds are very critical, and such sources must be sufficient to generate the needed resources. In classifying funding sources, emphasis is given to the contribution mechanisms which include: general (that is, unearmarked) tax revenues; payroll tax revenues that are usually earmarked for compulsory health insurance (often called “social health insurance contributions”); voluntary pre-payment (usually for voluntary health insurance [VHI]), and direct out-of-pocket payments [OOPs] at the time of service utilization (Kutzin, 2008). There are several contribution mechanisms available to prepayment schemes, each having its advantages and disadvantages (Kutzin, 2010). Also, the choice of a system depends on several factors, particularly the split between formal and informal sector players in an University of Ghana http://ugspace.ug.edu.gh 34 economy (Kutzin, 2010). Kutzin (2010) explained that an economy which is predominantly formal (such as that of Germany) can easily define its tax base especially when direct taxes and payroll taxes are used to fund the system. However, those dominated by the informal sector (as found in most low-and middle-income countries) face difficulties in defining the tax base and also applying payroll taxes. A largely informal economy constrains the government regarding the use income tax revenues to fund the system. Rather, such governments rely on consumption taxes [such as VAT] (Gottret and Schieber 2006). Although revenue collection is a sub-function of health financing policy, contextual constraints limit the scope for reform in many countries, rendering revenue sources and collection agencies more a product of the wider context than objects that can be affected greatly by health financing policy reforms. Pooling Pooling is the accumulation and management of revenues with the objective of ensuring that members of the pool bear the risk of having to pay for health-care and not individual contributors (WHO, 2000). This definition implies that the degree of pooling is dependent on the financing mechanism. The degree of pooling defines how fair the financing process is, since a low degree of pooling implies that much of the risk has to be borne by the individual. Gottret and Schieber (2006) identified four main health insurance mechanisms used to pool health risks, promote prepayment, raise revenues, and purchase services. In their book, they indicated that health insurance could be state-funded systems (i.e. through ministries of health or national health services); social health insurance systems; voluntary or private health insurance; or community-based health insurance. They indicated that the characteristics of the financing mechanisms and their applicability differ and therefore no one system can be universally accepted as the best. To arrive at the best for any specific region or country, policy-makers need to examine their contexts and country specific economic, institutional, and cultural characteristics. Also, in selecting, they must take into consideration equity, University of Ghana http://ugspace.ug.edu.gh 35 efficiency sustainability, administrative feasibility, and administrative cost of the system (Gottret and Schieber, 2006; Kutzin, 2010; 2008). In addition, there is the need to avoid multiple public and private pooling arrangements (as exist in most low- and middle-income countries) as this causes fragmentation and increases administrative cost (Gottret and Schieber, 2006). In this way, there is equity and efficiency for effective risk pooling and purchasing. Purchasing Resource allocation and purchasing mechanisms determine for whom to buy, what to buy and from whom, how to pay, and at what price. Determining the price to pay (i.e. fixing the right level of payment) can be a herculean tax. Fixing it too high increases profits rather than quality but fixing it too low reduces quality (Waters & Hussey, 2004). Furthermore, if the level of payment is too low, the quantity of care offered might be too low or there will be under-the-table payments by patients to providers to complement official payments (Roberts et al., 2004). How price are fixed is influenced by several factors, and most importantly, the forces of demand and supply. It is even more important to carefully determine the mechanism of payment. However, in most cases, the organization of the health sector defines the most likely method of payment. Radermacher and Laaser (2006) identified four main payment methods. If the same institution is responsible for pooling, purchasing and service provision, the annual funds are often passed on as budget to it. Such arrangements normally fail to link performance to payments and can lead to low responsiveness to patients as well as under- provision of services. Providers are reluctant to attend to more patients as the extra patient does not increase remuneration. However, the upholding of professional ethical standards by such providers may contribute to the reduction of this negative effect. University of Ghana http://ugspace.ug.edu.gh 36 Another payment mechanism is the capitation system. Under this, providers receive a fixed amount per person served. The amount is paid prospectively, shifting the risk to the providers of care. This method has the potential of incentivising providers to increase efficiency in service provision. However, it also has a negative effect of causing providers to enroll as many people as possible while providing as little service as possible. Also, some providers might want to refer patients to other providers if possible to minimize the range of services offered to clients and increase their profits. This method is faced with the risk of under- provision of services but helps in controlling the costs of the health system. With this system, providers will only attend to patients with good risks if they have the opportunity to choose (Roberts et al., 2004; Barnum et al. 1995). Another payment system available to health insurance schemes is the case-based system. With this, providers are paid according to predefined and fixed charges per illness. This is an incentive for providers to lower the cost of care by ensuring effectiveness and efficiency in service provision, so it can be profitable. However, in so doing, providers will be tempted to decreased quality of treatment. It can also result in the reluctance of providers to attend to ‘expensive patients’ or cause them to diagnose such patients into higher paid categories. Case-based systems also have the potential of increasing administrative costs since the several payment categories must be clearly defined (Barnum et al. 1995). The fee-for-service (FFS) systems, another payment mechanism, reimburses for each service rendered. The fee is predefined as a monetary value in a fee schedule, as points with varying monetary value (like that of Germany and France) or unregulated, i.e. according to the provider’s bill (which is common to many developing countries and the US). Under this system providers are likely to provide extensive services (including those that might not be necessary) to increase their remuneration. This phenomenon is known as supplier induced University of Ghana http://ugspace.ug.edu.gh 37 demand. Such systems are often less cost effective and can result in less value for money even if it helps to improve health status of the population (Waters & Hussey, 2004; Barnum et al., 1995; Roberts et al., 2004). Mixed systems can help in overcoming some of the shortcomings of the “pure systems” presented above. And in fact many systems worldwide are mixed systems. A mix of different systems can: (i) be applied for different providers, (ii) be applied by using different methods of paying one provider and (iii) or be applied by using different methods of paying for different services rendered. Consequently, the incentives vary with the mix applied (Barnum et al., 1995). Different payment methods do not only imply different outcomes, they also require different input. Some methods require much more information than others and thus might increase the administrative and information costs. In some cases, these costs might level out the benefits of more performance related payment mechanisms. Hence, the payment mechanism to choose very much depends on the respective situation of a country. 2.5 Types of Health Insurance (Risk Pooling Mechanisms) Generally, there are four types of health insurance used to foster prepayment, raise revenues, pool risks, and purchase services. These are the state-based systems funded by the government and operated through ministries of health or national health services, social health insurance, community-based health insurance, and voluntary health insurance. State-funded health-care systems are widely used throughout the world. Generally, government budgetary allocations represent a major source of revenue to the health sector (Savedoff, 2004). State-funded systems have the advantage of providing universal access to healthcare. Such systems can rely on many different financing resources, and can be relatively simple to manage. However, they normally suffer from insufficient and unstable University of Ghana http://ugspace.ug.edu.gh 38 resources since they have to compete annually for a share of the state budget. Like most other publicly managed services, state-funded systems (especially in developing countries) tend to be inefficient (Mossialos and Dixon, 2002). Also, state-funded systems tend to be pro-rich and not pro-poor, particularly in developing countries. This therefore emphasises the need to establish conditions to raise sufficient revenues, to be able to successfully implement a state- funded system. Such conditions may be sustained economic growth, a competent tax administration, and a consensus within the population in favour of taxation. There should also be institutions in place to make the system work. In addition, there should be specific efforts to target the poor while preserving the universal character of the system (Mossialos and Dixon, 2002). Social health insurance schemes are also recognised worldwide as major and viable pooling mechanisms. Some researchers have identified that although social health insurance (SHI) has the highest potential to achieve universal coverage (at least in theory), this has been difficult to achieve in low-income countries (GTZ, 2005; Doetichem et al., 2006). However, they have been instrumental and have helped to reach universal coverage in other countries. Mostly, membership to SHIs is mandatory, and premiums set are in proportion to income. Also, payment into the system is generally shared by employers, workers, and the government. Social health insurance schemes are usually more participatory, considering their relative transparency and stability. However, the viability of such schemes depends on the political and socioeconomic characteristics of the specific regions or countries within which they are implemented. Nevertheless, such schemes require strong institutional presence, especially for revenue collection (Carrin and James, 2005). Also, the sustainability of such systems, especially in low-income countries, particularly those with stagnant economies and an ever growing informal sector, has been a challenge (Hsiao and Shaw, 2007; Wagstaff, 2007). It is therefore advisable that before implementing a social health University of Ghana http://ugspace.ug.edu.gh 39 insurance scheme, a thorough examination of a country’s socioeconomic and political conditions is carried out. This aids in the assessment of potential problems and the determination of how to overcome them so as to reap the full benefits of the social health insurance scheme. Such preparatory may determine when to commence implementation of the scheme. Experience also shows that, in its initial stage of development, social health insurance has a tendency to divert resources from the poorer segment of the population to the richer segment (Wagstaff, 2007). Consequently, countries considering the establishment of a social health insurance system should be aware of this side effect and include mechanisms to protect the poor within their system framework. Finally, social health insurance can induce cost escalation, as observed in many countries of the Organisation for Economic Cooperation and Development [OECD] (Sava and Abovskaya, 2006). Therefore, governments wishing to implement social health insurance schemes must design appropriate mechanisms to contain costs. Community-based health insurance is another risk pooling mechanism normally used to provide financial protection for people who otherwise would have no access to health care. It has been referred to as ‘micro health insurance’ (Dror and Jacquier, 1999), ‘local health insurance’ (Criel, 2000) and ‘mutuelles’ (Atim, 2001). Such schemes are small and often barely financially viable. As such, they are not particularly effective in reaching the poorest segments of the population (Precker, et al., 2002; Gilson, et al., 2000). Nevertheless, such schemes offer some financial protection to the poor who otherwise would have been left unprotected (Dror and Jacquier, 1999). Community-based health insurance schemes are mostly established in areas dominated by informal labour markets with limited institutional capacity but a strong sense of local community solidarity (Atim, 1998). Furthermore, it is argued that government intervention through financial and technical assistance is vital for the efficiency and sustainability of such schemes (Bennett et al., 1998; Criel,1998; Atim, 1998). University of Ghana http://ugspace.ug.edu.gh 40 Although community-based health insurance schemes have been instrumental in protecting the poor, they should be regarded more “as a complement to—not a substitute for—strong government involvement in health care financing” (Preker et. al., 2004, p. 41). However, the challenges facing community-based health insurance schemes have been how to design them to ensure the best possible compatibility with larger systems and also make them evolve toward more comprehensive and sophisticated health financing systems. Another type is voluntary health insurance. Voluntary health insurance schemes are mostly private and require a certain level of commercial institutional capacity. Such schemes can also benefit from some level of public sector institutional capacity. Unlike social health insurance, voluntary systems do not rely as much on local or national social solidarity and stable formal labour markets, although those conditions may help. Some researchers have indicated that voluntary health insurance has a great potential in Africa (Jütting and Drechsler, 2005). However, due to their commercial nature, such systems primarily benefit people and businesses who have the resources to pay (Oxfam, 2006; Jütting and Drechsler, 2005; Barrientos and Sherlock, 2002). The poor and the less privileged can only participate in them when the government intervenes, especially through the introduction of subsidies (Jütting and Drechsler, 2005). Moreover, these systems may be prone to certain types of market failures in addition to equity challenges (Tapay and Colombo, 2004). They must therefore be developed cautiously and with an appropriate regulatory framework. This research is focused on the National Health Insurance Scheme of Ghana which is a social health insurance system. The following section therefore gives a detailed account of the social health insurance system. University of Ghana http://ugspace.ug.edu.gh 41 2.6 Social Health Insurance Systems Social health insurance schemes (SHIs) are mostly health insurance schemes provided by governments to its citizens, especially to low and middle income populations. However, the efforts of governments in providing SHIs have been complemented by several non- government organisations (NGOs) at the community level, especially in developing countries (Churchil, 2006; Dror and Precker, 2002). Social health insurance schemes institute mechanisms to ensure that the health risks of its members are covered by the contributions of enterprises, households and government (Carrin, 2002, WHO, 2004). Most of these schemes combine different sources of funds, with supplementary funding from the government to cater for people who are unable to pay (WHO, 2004). Also, SHI differs from ‘tax based financing’ which which provides coverage to all citizens (and sometimes residents). In the case of SHI, one’s entitlement is linked to a contribution made by, or on his/her behalf (WHO, 2004). The prime objectives of social health insurance are to provide health-care that avoids large out of pocket expenditure; increase of health services; and improve appropriate utilisation health status (International Labour Office, 2008). In line with this objective, SHIs have been found to have led to welfare improvement through improved health status and also the maintenance of non-health consumption goods through ensuring that health expenditures are smoothed over time and that there is no significant decline in household labour supply (Varian, 1992; Townsend, 1994). Gottret and Schieber (2006) in their book Health Financing Revisited, indicated that the successful development of social health insurance depends several factors. They itemized these factors as 1) the level of income and economic growth; 2) dominance of formal sector versus informal sector; 3) room to increase labour costs; 4) strong administrative capacity; 5) University of Ghana http://ugspace.ug.edu.gh 42 quality health-care infrastructure; 6) stakeholder consensus in favour of social health insurance, together with political stability and rights; and 7) ability to extend the system (see Box B1 in Appendix B). Hsaio and Shaw (2007) also summarised the factors that create an enabling environment for SHI as: large formal sector employment, high wages and salaries, low poverty rate, strong human resource capacities, government capacity to regulate, strong administrative support, efficiently functioning provider networks, small family and/or household size (See Table B2 in Appendix B). 2.7 Social Health Insurance (SHI) in Low- and Middle-Income Countries (LMICs) SHI is recognized to be a very powerful method for granting the population access to health services in an equitable way. As a result, a number of high-income countries have chosen SHI as their main health financing system. However, the adoption of SHI in low-income countries with a gross national product (GNP) per capita below US$ 761 started only after 1998. Among the lower middle-income countries (with a GNP per capita between US$ 761 and US$ 3,030), Costa Rica was the only country with a fully fledged social health insurance scheme in the early 2000s (Carin, 2002). However, it is becoming more and more popular due to the increasing evidence that some countries have achieved universal coverage through this method (Carin and James, 2005, based on Carin et al., 2004). Health financing in many LMICs is characterized by high levels of out-of-pocket expenditure and the citizens of such countries are forced to make catastrophic payments to access healthcare (WHO 2007). For instance in 2002, the WHO reported that 67.3% of Nigeria’s total expenditure on health were out-of-pocket payments. India’s out-of-pocket payments constituted 77.5% of total health expenditures and that for Ecuador was 56.6% (WHO, 2007). University of Ghana http://ugspace.ug.edu.gh 43 In these countries, the catastrophic out-of-pocket payments deprive the marginalized sections of society from accessing quality healthcare and have further impoverished such people (Xu et al., 2003; Peters et al., 2002; Garg, 2009; Pradhan, 2002; Ranson, 2002; Wagstaff, 2003; Russell, 2004). Xu et al. (2003) after studying 59 countries found that out-of-pocket payments constituted up to 40% of household expenditure of residents in those countries, due to the lack of health insurance. They therefore recommended the provision of some form of financial risk protection (Xu et al., 2003). Furthermore, Garg (2007) has indicated that 3-5% of the Indian annual poverty rate can be attributed to high level of health expenditure relative to total household expenditure. Such situations have been the main motivation for LMICs to adopt SHIs. The LMICs are further motivated by the fact that most of the countries that have achieved universal coverage through SHIs were in the lower middle-income category at the time of inception (Carrin and James, 2005). Nevertheless, it is a fact that the characteristics of such countries and the LMICs differ significantly. As such, though such developed nations were able to achieve universal coverage through SHI, the context in most low-income countries might not be conducive to expanding coverage. The low-income countries are dominated by informal sector workers (in some countries 80 per cent of the economically active population) and unemployed people who are very difficult to capture even if the schemes are mandatory. Such people are almost always excluded. For instance, insurance schemes in Sub-Saharan Africa are able to cover only about 1.8% of the people and most of whom are employed in the formal sector (Criel et al., 2008). University of Ghana http://ugspace.ug.edu.gh 44 2.8 Impact of Social Health Insurance (SHI) on Low- and Middle-Income Countries (LMICs) Social health insurance is gaining popularity among low- and middle-income countries as an avenue for improving health-care utilization and protecting households against catastrophic out-of-pocket expenditures (Spaan et al., 2012). LMICs continue to adopt SHI with the hope of reaping the positive benefits that some developed countries such as Germany and France have enjoyed. Some bilateral and multi-lateral agencies have also been supporting SHI initiatives in LMICs because of its potential in promoting universal coverage and also, the achievement of the Millennium Development Goals (MDGs) (Doetinchem, Schramm and Schmidt, 2006). This section of the chapter reviews literature on the impact of SHI on LMICs with emphasis on access to use, financial protection and health status. Impact of SHI on Access to Use Health Facilities Social health insurance (SHI), by providing financial protection from the economic consequences of illness, seeks to improve access to health and the use of health facilities (Nyman, 1999). Evidence show that developed countries who have established SHIs have been able to improve access to, and use of health facilities (Buchmueller and Kronick, 2005; Hadley, 2003). This is however not limited to the developed world, there is empirical evidence that SHIs have had significant impact on access to, and use of health facilities in some LMICs. Giedion and Diaz (2010) reviewed 51 studies in LMICs and found that in majority of these studies (28 out of the 51 studies), health insurance increased access to and use of health services. Also, Spaan et al. (2012) after reviewing 159 studies in Africa and Asia of which 86 (18 in Africa, 68 in Asia) were on SHI, concluded that there is a strong positive relationship between SHI and utilisation. Other studies have also provided empirical evidence on the impact of SHI on access to use (e.g. Wagtaff and Y, 2007; Wagstaff et al., 2007; Wang et al., 2009; Chen et al., 2007). This seems to confirm what insurance theory University of Ghana http://ugspace.ug.edu.gh 45 predicts: health insurance reduces the price of health-care and thereby promotes access and use. However, there are demographic, economic and social disparities with the distribution of this impact. Some studies found that the most vulnerable groups benefit more (Chen et al., 2007; Trujillo, Portillo, and Vernon 2005; Giedion, Díaz, and Alfonso 2007), while others found otherwise, indicating that the better off benefit more than the other segments of the population (Wagstaff et al., 2007). Other researchers also found that that the middle-income population benefitted the least from SHI in terms of access to, and use of health facilities (Yip, Wang, and Hsiao, 2008). However, there are other researchers who did not find any significant relationship between population characteristics and access to use. Spaan et al. (2012) for instance found a not so strong link between SHI and social inclusion (as indicated by enrolment and utilization patterns among vulnerable groups). They found that although targeted policies of the National Health Insurance Program in the Philippines and Thailand led to increases in the number of insured indigents and the poor, it was not the same in other countries such as Cameroon, Guinea and Senegal. This therefore shows that although generally, health insurance improves the access to use, there must be deliberate attempts to distribute this gain across all groups to ensure equity in the system. Impact of SHI on financial protection Providing financial protection, especially to the poor and vulnerable, is a primary objective for SHIs and all other health insurance schemes. An SHI scheme which fails to provide financial protection has failed to achieve its primary objective (Nyman, 1999). It is therefore logical to assess the impact of SHI in terms of providing financial protection. There have been several studies that have shown that SHI provides financial protection to participants. University of Ghana http://ugspace.ug.edu.gh 46 For instance, Wagstaff and Yu (2007) after evaluating the impact of the World Bank Health VIII project (containing an insurance component) in the Gansu Province (China) found that the project had reduced both out-of-pocket payments and the incidence of catastrophic payments, especially among the poorest. Also, a study by Yip, Wang, and Hsiao (2008) reached similar conclusions. Spaan et al. (2012) also found a strong positive impact of health insurance on financial protection after reviewing empirical literature on the impact of health insurance. This position is further supported by Giedion and Diaz (2008; 2011) who reviewed 51 studies and found a positive relationship between health insurance and financial protection. However, there are studies that have contrary findings. Wagstaff et al (2007)—after evaluating the impact of the NCMS in 12 of China’s 30 provinces and using data from 2003 (pre-intervention) and 2005 (post-intervention)—found no statistically significant effect of the intervention on average out-of-pocket spending by households. Rather, the findings provided a hint that it may have increased the cost per inpatient episode. The impact of SHI on financial protection is mixed although evidence of positive impact dominates. However, the studies reviewed showed that financial protection is not automatically achieved and SHI decision makers need to consider premium levels, benefit packages, and effective risk pooling, if financial protection is to be realised. Also, financial protection should not be narrowly conceived as the elimination of out-of-pocket payments, but other health-related expenditures such as the cost of transportation to a health facility should also be considered (Ekman, 2007). It is therefore possible to eliminate out-of-pocket payments but not financially protect the citizens if other health related costs are high and catastrophic. University of Ghana http://ugspace.ug.edu.gh 47 Impact of SHI on Health Status The ultimate outcome expected of any health financing arrangement (including SHI) is improved health status. There is the need to examine the impact of SHI on health status to ascertain progress towards this outcome. However, despite the logical linkage between SHI and health status, there is limited empirical evidence on it. Most research findings show a weak or no link between them. Dow, Gonzalez, and Rosero-Bixby’s (2003) found an almost insignificant effect of social health insurance on child and infant mortality (health status) after studying Costa Rica’s social insurance scheme. Another study in the same country by Dow and Schmeer (2003) had similar findings. Similarly, Giedion, Díaz, and Alfonso (2007), using data from standard Demographic and Health Surveys, found that although the Colombian subsidized health insurance scheme had greatly improved the use of curative and preventive services by the poor, there was no circumstantial evidence that such gains had transformed into improved health status. They used indicators such as child mortality, birth weight, or self-perceived health status for health status. Chen et al. (2007) also studied Taiwan’s National Health Insurance and found that although there had been a great improvement in the use of both outpatient and inpatient services, such increase had rarely reduced mortality or led to better self-perceived general health status for the Taiwanese elderly. Spaan et al. (2012) in their review looked at the quality of care which is perceived to impact on health status. However, there was not much substantial evidence to prove that SHI improves the quality of care as they reported a weak negative link between the two. Also, in evaluating the impact of social health insurance versus a general tax-financed system in former communist countries in Eastern Europe and Central Asia, Wagstaff and Moreno-Serra (2009) (with an extensive list of health outcomes) found no association between SHI and better health outcomes; once concurrent differences in provider payment systems are controlled. University of Ghana http://ugspace.ug.edu.gh 48 Some studies have also revealed mixed impact. For instance, although Wagstaff and Yu’s (2007) evaluation of the World Bank Health VIII project in China revealed a positive impact concerning the reduction of sick days, there was no conclusive evidence regarding the incidence of chronic illness, and self-perceived health status. A limited number of research findings have also showed a positive impact of SHI on health status. One of such is a study by Wagstaff and Pradhan (2005), who using panel data, evaluated the impact of SHI on health status. They established that Vietnam’s health insurance program favourably affected the health status of its beneficiaries (using indicators such as height-for-age and weight-for-age among young school children and body mass index among adults). The impact of SHI in developed countries has been varied. Some of these countries have subsequently attained universal coverage. Although a few middle income countries such as Thailand (see Hsiao and Shaw, 2007) have also attained universal coverage, there have been obstacles to the expansion of SHI in LMCIs. A major reason for this is that most LMICs do not meet the criteria by identified Hsaio and Shaw (2007) as providing the enabling environment for SHI. Ghana’s National Health Insurance Scheme (NHIS), an SHI, has also faced challenges in its attempt to progress towards universal coverage. However, prior to instituting the NHIS, several health financing arrangements had been introduced by different governments. Before examining the NHIS, there is the need to look at the general landscape of health financing in Ghana. 2.9 Health Financing In Ghana Ghana has gone through various regimes of health-care financing such as free health care, and varying degrees of user fee systems (Addai et al., 2000). Prior to attaining independence, University of Ghana http://ugspace.ug.edu.gh 49 access to ‘insured’ health-care was reserved for the European population, a few educated elites and government officials (Akortsu & Abor, 2011); and its funding was the sole prerogative of the colonial government or the missionaries (Dummett, 1993). Majority of the indigenous population funded their health-care mainly through out-of-pocket payments at the point of service delivery (Arhinful, 2003). After independence, the CPP Administration (led by Dr. Kwame Nkrumah) adopting a socialist policy, introduced free health-care (Owusu- Sekyere & Chiaraah, 2014). However, with increasing population and healthcare needs, it became apparent that the government could not sustain the initial arrangement of free health- care (Wagstaff, 2009; Twum-Barima, 2012; Smithson, Asamoa-Baah & Mills, 1997). Several laws were therefore passed by some of the post-Nkrumah era governments to legitimise the introduction of some kind of user fees, examples of which are the Hospitals Fees Decree, 1969 (NLCD 360), later amended in the Hospital Fees Act, 1970 (Wagstaff, 2009). The fees imposed were not targeted at ensuring cost recovery and could not yield any significant revenue (Addai et al., 2000). Moreover, laxity in the enforcement of the hospital fees legislations and regulations by hospital authorities, and corruption on the part of some health staff rendered hospital fees policies ineffective (Addai et al., 2000). By the late 1970s and the early 1980s, health financing had declined in real terms to about 20% of former levels (Addai et al., 2000). A user fee system aimed at substantial cost recovery for drugs and non-drug consumables was therefore introduced in 1985 through the passage of LI 1313 (Seddoh, Adjei & Nazzar, 2011). This was necessitated by the general economic decline in the early 1980s that significantly reduced government spending in all sectors of the economy. The hospital fees system introduced under LI 1313, which became known as ‘cash and carry’ system had good intentions. It sought to resuscitate the ailing health delivery system (Seddoh, Adjei & Nazzar, 2011). The main problem was the inhumane manner in which it was implemented. It attracted public outcry right from its inception, and its unpopularity with the University of Ghana http://ugspace.ug.edu.gh 50 majority of Ghanaians was too glaring (Nyonator & Kutzin, 1999). It made it difficult for the poor and low-income earners to access health care services (Waddington & Enyimayew, 1990; 1989; Agyepong & Nagai, 2011). This prompted policy-makers to look for a more practical, innovative, and sustainable way of financing healthcare for the country (Agyepong & Nagai, 2011). A health insurance scheme was seen as the best option for the country (Arhin-Tenkorang, 2000). This fact was acknowledged by the erstwhile Provisional National Defense Council (PNDC) government in 1988 when it expressed that a health insurance scheme would improve the health status of the residents of Ghana and relieve them of catastrophic out-of-pocket payments. However, for almost two decades, policy makers were caught up in a debate as to the character and details of such a health insurance scheme 2003 (Mensah, Oppong & Schmidt, 2009). In 2003, after years of debate, feasibility studies, and piloting (which began under the administration of the National Democratic Congress [NDC]), Parliament of the Republic of Ghana enacted the National Health Insurance Law (NHIL) which introduced the National Health Insurance Scheme (NHIS) as the new national strategy of financing health-care in Ghana (Agyepong and Adjei, 2008). The new scheme for health-care financing, which operates on the concepts of solidarity, equity, risk-equalization, cross-subsidization etc., is viewed by policy-makers as one of the most promising development initiatives in the country within the past decade. It was asserted that the NHIS, when it becomes operational, would functionally transform the health-care system in the country (Agyepong and Adjei, 2008). At the national level, the new scheme was expected to improve overall resource flow into the health sector through the proactive mobilization of funds from prospective clients to facilitate prompt reimbursement of providers under a pre-financing arrangement. In effect, the capacity of the Ministry of Health (MOH) and her implementing agencies to achieve their health-care University of Ghana http://ugspace.ug.edu.gh 51 objectives would be greatly enhanced. The NHIS was also expected to increase health facility utilization rates and thus in the end ensure a reduction in maternal, infant and under-five mortality rates, and improve life expectancy considerably. 2.10 Factors Affecting the Implementation of the National Health Insurance Scheme There have been several factors affecting the smooth running of the scheme. This review borrowed Jehu – Appiah et. al,’s (2011) framework and identified them as scheme factor, individual factors, and provider factors. The NHIS, in the first, place is a social protection initiative, and aims among other things to provide financial risk protection against the cost of basic health;care for residents of Ghana. As such, its success depends on its ability to provide the risk protection for all (especially the poor and marginalised). In other words, the success of the NHIS depends on its ability to reduce and possibly eliminate out-of-pocket payments which put a lot of financial burden on the people, especially the poor. Several studies have revealed that the economic situation of people is a motivating factor for joining the NHIS. For instance, a study by Jehu-Appiah et al. (2011), found that majority of poor households (68%) were not able to renew their cards because of renewal payments. There have also been other studies that indicate that the NHIS has relieved poor households of excessive financial burden. Dalinjong and Laar’s (2012) qualitative study revealed that the NHIS has reduced the burden on the poor and improved their access to healthcare. Thus, considering the economic benefits the NHIS promises the poor, the government has made a provision in the NHIS Act 852 to ensure that premiums by the informal sector are fixed based on the people’s ability to pay. This is to ensure that more of the poor are covered and the aim of financial protection is achieved. Also, since its inception the NHIS has been mobilising revenue for healthcare providers to be able to function properly. Providers in the Bolgatanga municipal area and the Builsa District University of Ghana http://ugspace.ug.edu.gh 52 attested to this when they responded to Dalinjong and Laar’s (2012) study. However, in that same study, providers indicated that the delay in the payment of claims had adversely affected their service delivery. The study also found that such delays have also been responsible for changes in provider attitudes and behaviours. This is an indication that healthcare providers’ ability to function well and contribute to the achievement of the objectives of the NHIS is to a large extent dependent on the availability of funds and the economic situation of the providers. Also, a study by Twum-Barima (2012) revealed that aside the claims payment which affects the functioning of providers, other factors such as staff at post and the availability of patient support facilities play a significant role. These factors must be considered when providing accreditation to providers to ensure effective implementation of the NHIS. There are several other factors which also affect the scheme and its ability to function effectively to ensure successful implementation. Research findings show that prominent among them is funding. Most annual reports of the NHIA show that financing the scheme has been a challenge (NHIA, 2010; 2011; 2012). Sustainable health financing has been an overarching concern of the NHIS. In a presentation at the 10th anniversary conference of the NHIS, the chief executive mentioned that the rate of increase in active membership and revenues is far lower than the rate of increase in out-patient attendance, in-patient attendance and claim payments (NHIA, 2013). The NHIS 2012 report indicated that although subscription rates increased more than 500% since inception, it could not match the increases in in-patient and out-patient rates, not to mention claims payment (as shown in Table 2.1). This has resulted in a deficit every year. The current economic condition has affected the operations of the NHIS and has resulted in problems such as delay in the payment of provider claims (Jehu-Appiah et al., 2012). However, other researchers have unravelled that the University of Ghana http://ugspace.ug.edu.gh 53 increasing utilisation and claims are also partly due to provider and subscriber fraud, as well as subscriber-provider shopping. Table 2.1 Membership, Utilisation and Claim Payments (2005 – 2012) 2005 2012 % Change Active Membership 1,348,160 8,885,757 559.10 Out-Patient Utilisation 597,859 23,875,182 3893.45 In-Patient Utilisation 28,906 1,428,192 4840.82 Claims Payment 7,600,000 616,470,000 8011.45 Source: NHIA, 2009; 2012 Twum-Barima (2012) in his article mentioned that sometimes, patients move to different providers with the same ailments thereby resulting in duplication. He added that facility provider shopping always throws the budget of the NHIS overboard because the various providers visited by members of the scheme must be paid claims for the duplication of the consultation services they give and the repetition of same quantity of drugs they serve. The report of the NHIS ten year anniversary conference indicated that the extent of fraud averages from 7% to as high as 15% of healthcare expenditure. Some types of subscriber fraud indicated in the report included impersonation – a non-member using a member’s identity; ganging – members of a family using one member’s card; provider shopping, illegal cash exchange for prescriptions and frivolous use of services. Provider fraud identified within the NHIS included billing for services not rendered, up-coding of services, double billing/duplicate claims, misrepresentation of diagnosis, un-bundling of services, unnecessary services, inappropriate referrals for financial gain and insertion/substitution of medicines (NHIA, 2013). These, they indicated, have worsened the financial position of the NHIS. University of Ghana http://ugspace.ug.edu.gh 54 Another issue/factor identified as affecting the implementation of the NHIS is the administrative set-up and costs of the scheme. The Act 852 (the current NHIS Law) specified the administrative set-up of the NHIA so it will be able to function well. A review of the Act 650 (Old NHIS Law) and the Act 852 shows a reorganisation of the NHIA to make it a more centralised institution. With such a change, it can be concluded that management saw the need to change the set-up of the authority for it to be able to perform the necessary duties efficiently and effectively. There are other inefficiencies identified by researchers as factors affecting the operation of the scheme. These factors include poor management of records, a complex, slow and expensive system for claim payments, and poorly trained staff (Oxfam, 2011). These have affected the implementation of the NHIS by causing problems such as delay in claim processing. Although this has been partly solved by introducing the computerised claim processing system, this is still a problem in some schemes that do not have qualified people and are glued to the manual system (Oxfam, 2011). Administrative costs have also been identified by researchers as an important factor affecting the operation of the scheme. There have been research findings showing that the NHIS incurs huge administrative expenditure which decreases the funds available to pay health-care providers (Oxfam, 2011; World Bank, 2012). These researchers reiterated that the scheme should institute measures to decrease the administrative costs to make more resources available for healthcare. There are also political factors that affect the scheme. Agyepong and Agyei (2008), acknowledged in their paper the politics involved during the initial phases of the NHIS. They added that, although health insurance had started in Ghana earlier and on a small scale, the inception of the NHIS was shrouded in politics. It was a political campaign promise by the New Patriotic Party (NPP) to establish the NHIS. Their article made it clear that the wheels of politics propelled the NHIS into being. The use of the NHIS in political campaigns has University of Ghana http://ugspace.ug.edu.gh 55 continued since the first promise by NPP. Oxfam (2011) for instance indicated in its research report that during campaigning in 2008, and after being sworn as a president, the Professor J. E. A. Mills with his NDC government made a political promise to deliver a truly universal health insurance scheme that reflected the contributions of all the country’s residents. The promise included guaranteed access to free health-care in all public institutions, and to cut down the health insurance bureaucracy in order to ‘plough’ back the savings into the health- care services. Although promises such as these win public support, they still remain unfulfilled. Nevertheless the effects (positive and negative) of such political pronouncements cannot be ignored. The National Health Insurance Act, 2012 (Act, 852) also makes the NHIS susceptible to political influence as the president is given the sole prerogative of appointing the chief executive and the deputy chief executives, the management staff, as well as members of the NHIS board. Based on the literature reviewed so far, the following section presents the conceptual framework for the study. 2.11 Conceptual Framework for the Study The NHIS was conceived through the introduction of the National Health Insurance Policy. The implementation of the policy began with the initial drafting the NHIS Law, Act 650 and the legislative instrument L. I. 1809. The law provided a synthesis between the top-down and bottom-up approaches to implementation (although more emphasis was on bottom-up implementation through the creation of District Mutual Health Insurance Schemes (DMHIS). However, the current NHIS Law Act 852, has centralised some of the functions such as determining the premiums to be paid by the informal sector, thereby making the University of Ghana http://ugspace.ug.edu.gh 56 implementation more top-down. Although the top-down and the bottom-up approaches to implementation provide sound theoretical bases to implementation research, the study did not use it because, the new law (Act 852) which defines the approach to implementation, is still new to most people in the target population. The conceptual framework is primarily based on Easton’s (1965) input-conversion-output view of the political system. Although Easton’s initial conception of a system is based on political decision-making at the policy formulation stage, it is adapted here at the implementation stage. The implementation of the NHIS is conceived as a system and as such it has an input stage, a conversion stage and an output stage. Easton also conceived the system as operating in an environment which affects and is affected by the system. Inputs The inputs to a system, as identified by Easton (1957) can be categorised as demands and support. Demands Easton views demands into a system as emanating from two main sources; from the system itself or from the environment (Easton, 1965a). Easton explained that although there are several demands, not all of them become political issues. In the words of Grindle and Thomas (1991), not all problems (‘demands’, in the case of Easton) come on the political agenda. This shows that there are several demands on the system but not all of them are processed by the system. Considering the National Health Insurance Scheme (NHIS), researchers have identified several demands on its implementation system. Researchers have indicated that one prime demand on the NHIS is financial protection (Jehu-Appiah et al., 2011; Twum-Barima, 2012). Studies show that prior to the introduction of the NHIS, out-of-pocket payments constituted up to 40% of the household expenditures of those in the lower income quintiles University of Ghana http://ugspace.ug.edu.gh 57 (World Bank, 2012). Such catastrophic expenditures have been the most important basis for people demanding financial protection. The provision of financial protection is central to health insurance. Eisenhauer (2006) for instance indicated that the prime motive to enrol in health insurance is one’s desire to obtain an income transfer from the risk pool if he/she becomes ill. Additionally, ‘regret and disappointment’ theorists argue that the individual’s inability to obtain such protection as expected leads to regret and disappointment in the system which can affect his/her decision to reinsure. It is therefore evident that the demand for financial protection is legitimate and a major input into the system. There have been provisions for the NHIS implementation system to process this demand. In the first place, the legal provisions in Act 852, the vision and mission of the NHIA as well as the goal of the NHIS are all directed towards providing financial protection. This has informed people’s demand. Political promises have also intensified some of these demands (Oxfam, 2011). Also, individuals demand access to quality health-care. There are also demands on the NHIS by the Executive and the Legislature of Ghana as stipulated in the NHIS Act 832(25(1)). All these are inputs to be processed by the system. Support Easton (1957) identified support as an input into a system. In his thesis, Easton identified the political community, the regime and the government, as the domain of support in a political system (Easton, 1957). This domain identified by Easton for policy decision-making is also applicable to the implementation phase. During the implementation phase, there is the need for a political community whose members are sufficiently oriented towards each other and are willing to contribute their energies to settle their various demands (Easton, 1957). With the NHIS, the different interest groups including politicians, civil society organisations, religious organisations, the health sector, development partners and the residents come together to form a political community to support the implementation system. Regime was University of Ghana http://ugspace.ug.edu.gh 58 also identified to be in the domain of a system’s support mechanism. The existence of a regime to regulate the ways in which demands are put into an implementation system is vital to its functioning. In the implementation system, the policy, together with other legal provisions, act as a regime. The prime regime for the NHIS implementation system is the Act 852. The government as the third element in the domain of the support mechanism is critical in every policy implementation process. The government is there to resolve conflicts that arise as a result of the competing demands on a system. In the case of the NHIS, the role of the government in supporting the system is very necessary and cannot be underestimated. The regime (which is the Act 852) clearly spells out the functions of the government in supporting the NHIS system. Easton (1957; 1966) further underscored the need for constant support so the system could maintain a steady state. There are two main ways in which the system generates support. Firstly, the system is able to get the needed support if it generates outputs that meet demand. The second is politicisation. In the case of the NHIS, the establishment of the National Health Insurance Levy and the 2.5 percent deduction from workers’ social security contributions are all outputs created to meet the demands of the NHIS implementation system. Also, sanctions to ensure that providers and subscribers comply with the regulations are outputs created to ensure that the demands of the system are met. The government also entices people to join the NHIS using different mechanisms such as exemption of certain groups in society and the reduction of the waiting period from three months to one month for new registration and late renewals. These are also outputs generated to ensure that the demands of the system are met. Politicisation as another mechanism to sustain support has been extensively used by various political interests in Ghana. When members adopt the right political attitudes, it helps in the support and stabilisation of the system. To ensure that members of the society have adopted University of Ghana http://ugspace.ug.edu.gh 59 the right political attitudes towards the NHIS, various governments have ensured that there are rewards and punishments for individual political attitudes and behaviours. When the right support structures are instituted, the NHIS will get all the support in terms of resources, and general acceptance and participation. Funding is a major input into the NHIS implementation system. To provide this input, the NHIS Act 852 specifies the sources of funds in Section 41. These sources include: (a) the National Health Insurance Levy provided for under section 47; (b) two and one half percentage points of each person's contribution to the Basic National Social Security Scheme; (c) moneys that are approved for the Fund by Parliament; (d) moneys that accrue to the Fund from investments made by the Authority; (e) grants, donations, gifts and any other voluntary contributions made to the Fund; (f) fees charged by the Authority in the performance of its functions; (g) contributions made by members of the Scheme; and (h) moneys accruing under section 198 of the Insurance Act, 2006 (Act 724). The Act also provides for in different sections the human resource inputs needed for the effective functioning of the NHIS implementation system. Another form of support the NHIS needs for its effective functioning is the acceptance and participation. Conversion Process This represents the political system where the demand and support inputs are converted to authoritative decisions. Easton referred to these decisions as policies (Easton 1965b; 1966). Easton indicated that there should be distinct components in a system. In other words, the components should be differentiated and easily identifiable through the functions they perform (Easton, 1957). According to Kutzin (2008; 2010) and the WHO (2000), the health University of Ghana http://ugspace.ug.edu.gh 60 financing system is differentiated. The system performs three main functions namely: resource mobilisation, pooling and purchasing. These functions are distinct but not unrelated. Easton (1957; 1966) indicated that there should be integration within the system as well. The system’s components should be seen as functioning as a coherent whole. In the health financing system, the functions of revenue mobilisation, pooling and purchasing are all to ensure that health-care services are provided to the people (Kutzin, 2008; 2010). The NHIS performs these functions identified. The NHIA has identified core activities that will ensure the effective and efficient performance of the functions of a health financing system. The activities are grouped as primary and secondary. The primary activities are membership registration and ID card management, provider accreditation and quality assurance, claims management and provider payments (NHIA, 2012). These are supported by secondary activities which include research and development, monitoring and evaluation, ICT infrastructure and data management, financial and clinical audits, effective communication with internal and external publics, human resource management, conflict resolution and stakeholder management (NHIA, 2012). Output The output of Easton’s political system is an indication of how the system is functioning. Easton indicated that the output of the system is its main mechanism of influencing the environment and the broader society of which it is part (Easton, 1965a). The output also determines the succeeding rounds of inputs that are fed into the political system (Easton, 1965a; 1957). This makes the output of a system critical to its survival. Although Easton acknowledged the fact that the environment affects the output a system generates, he indicated that the outputs are primarily determined by the system’s internal processes. University of Ghana http://ugspace.ug.edu.gh 61 The NHIS is essentially supposed to ensure that healthcare is made accessible and affordable to all. To be able to achieve this, the functions of revenue collection, pooling and purchasing should be performed effectively and efficiently. The output of the initial out-of-pocket health financing system was a reduction in financial accessibility to healthcare since the poor were further impoverished after accessing healthcare (World Bank, 2012). The NHIS seeks to improve this situation by ensuring that the financial situation of a person does not become a barrier to accessing quality healthcare. Therefore, the output of the NHIS system is directed towards ensuring financial risk protection (NHIA, 2012). This is expected to lead to improved health status and patient satisfaction. In assessing the performance of the NHIS, researchers mostly concentrate on these outputs/outcomes (e.g. Oxfam, 2011). The environment reacts to the output and sends a feedback to the system. The Environment The system is subject to constant stress from its surroundings. The environment in Easton’s conception refers to the total set of external factors that affect the system. Easton (1957) indicated that the behaviour of a system is partly conditioned by the setting within which it functions. Furthermore, Easton argues that the most significant changes in a system originate from external variables. The environment according to Easton is not an undifferentiated mass. Rather, it is made up of clearly differentiated components, distinguishable from each other and from the political system. Grindle and Thomas (1991) identified these the factors in the environment as the legacy of colonial rule; the nature of state-building and nation-building activities; and the structural vulnerability to international and domestic economic and political forces. They also indicated that the understanding of the environment and the factors that influence their interaction is critical to decision-making. Thomas (1982) also stresses the need to consider the set of conditions, personalities, and circumstances critical to a particular environment affecting the outcome of government programmes. University of Ghana http://ugspace.ug.edu.gh 62 A critical study of the environments within which the political system operates revealed that such environments can be categorised as political, economic, social and technological segments. These factors constitute what is termed PEST in strategic management. Strategic management literature reveals that an effective PEST analysis is vital for the continual existence and operation of the firm. Considering the fact that the NHIS operates as an independent system and is affected by the environment like any other firm, the concept of PEST can be applied to it. Saburi (2012) indicated that the utility of this PEST analysis in other fields of study cannot be underestimated. Also, it must be noted that as there exist a relationship between the system components, there is also a complex relationship between the environmental factors, and between the environmental factors and the system. Determinants of participation in Health Insurance There have been several studies to establish some important factors that determine participation in health insurance. Some authors have indicated that personal and demographic characteristics of persons have significantly influenced their participation in health insurance. One demographic factor that affects participation in health insurance is the gender of the individual. Some researchers have identified gender as an important factor influencing participation in health insurance (Abrebrese, 2009; Asenso-Okyere, 1997). However, there have been other studies that also did not find any significant relationship between gender and participation in health insurance (Jutting, 2003; Savedoff and Sekhri, 2004; Bhandari, 2002; Mhere, 2013; Donfouet et. al., 2011). Age has also been found by researchers as a determinant of participation in health insurance (Makoka et. al., 2007; Asenso-Okyere, 1997). Age has been found by some researchers to have a positive relationship with participation in insurance (see Pollack and Kronebusch, University of Ghana http://ugspace.ug.edu.gh 63 2008). However, other researchers have found the opposite where age is inversely related to health insurance participation (Mhere, 2013; Donfouet et. al., 2011). Educational level is also another demographic characteristic that has been found to significantly affect people’s participation in health insurance (see Abebrese, 2009). Studies have also found that people’s income levels are strong determinants of their participation in health insurance (e.g. Jehu-Appiah et al., 2011; Owusu-Sekyere and Chiaraah, 2014). As discussed earlier, economic, political, social and technological factors affect participation in health insurance. Based on the issues presented in this section, the researcher has developed a conceptual framework for the study as presented in Figure 2.2. Figure 2.3 explains the operation of the system in relation to the study. University of Ghana http://ugspace.ug.edu.gh 64 Figure 2.2: Interactions beyween the NHIS Implementation System and the Environment Legend Relationships that exist within the environment and between environmental factors and the system Source: Authors own construct, 2014. THE ENVIRONMENT The NHIS Implementation System Political Segment Social Segment Economi c Segment Technological Segment University of Ghana http://ugspace.ug.edu.gh 65 Figure 2.3: The NHIS Implementation System in the Environment INPUTS Demand - Financial protection - Quality healthcare Support - Funding - Acceptance - Decision to participate in NHIS Source: Adapted from Easton, 1957 and NHIA, 2012 2.12 Conclusion The review shows that the issue of implementation which forms a critical stage in the process even complicates the process further. Researchers have been torn between the adoption of the rational top-down approach, and the bottom-up approach to policy implementation. However, some other researchers concluded that it was impossible to treat the top-down and the bottom-up approaches distinctly and as opposing perspectives to implementation, and came out with models and approaches that sought to synthesize these perspectives. The review also looked at the utility of using Easton’s political system theory to explain implementation. ENVIRONMENT CONVERSION PROCESS - Revenue Mobilisation - Pooling - Purchasing Financial Risk protection Improved health status Patient satisfaction OUTPUTS FEEDBACK University of Ghana http://ugspace.ug.edu.gh 66 The chapter has given a general overview of health financing. The review has showed that to improve the health status of a country’s residents, the government and policy makers need to make the formulation of effective and efficient health financing policies a priority. Various authors have also agreed that health financing and poverty are in a symbiotic relationship with each having an impact on the other. It is apparent that health financing is about revenue collection and expenditure (purchasing of health services), but the review showed that without the performance of a very important function of risk pooling, there can be deteriorating health outcomes affecting the general wellbeing of a country’s residents. Evidence shows that out-of-pocket payments (with which there is no pooling) have resulted in deteriorating health indices of most LMICs as they end up impoverishing the people when they consume health services. Thus, various scholars have recommended that various governments use financing methods that enable pooling (including state-funded systems, social health insurance, voluntary private (commercial) health insurance or community-based health insurance) for financial protection and equity (horizontal and vertical). Social health insurance has been a major alternative for a number of countries due to its advantages. However, the review revealed that its adoption in LMICs has faced several challenges as such countries normally do not have the enabling environment for SHI. Ghana’s NHIS is an SHI which has several achievements, making it a model for other countries. Nevertheless, it has its own challenges as well. The current research, studying the NHIS, will add to the existing depth of knowledge on the scheme as well as SHI and health financing. The following chapter details the methodology for the study. University of Ghana http://ugspace.ug.edu.gh 67 CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter details out the research methodology employed in undertaking this research. It explains the research objectives and a suitable methodology to achieve those objectives. The main objective of this study is to identify and examine the factors affecting the implementation of the NHIS in Ghana. This involves an exhaustive study of the scheme and its implementation. The nature of the study requires a rigorous and in-depth analysis of the programme and also an extensive review of literature. These factors were considered in arriving at the methods to adopt in this study. This chapter describes the formulation of a research design and methodology adopted to achieve the stipulated goals for the study. The chapter also presents the philosophical assumptions underpinning the research as well as introduces the research strategy and the empirical techniques applied. Additionally, the limitations of the study are presented here. 3.1 Research Paradigm and Philosophy The study adopted the pragmatic philosophy. This paradigm emphasises multiple perspectives over a “monistic” theory of truth, once such multiplicity is able to achieve the purpose of the inquiry. The study to adopted the pragmatic paradigm after carefully considering the objectives of the study, the factors affecting the implementation of the NHIS, the research questions, the limitations and the scope. The axiological, ontological, epistemological and methodological underpinnings of this research are presented in this section. University of Ghana http://ugspace.ug.edu.gh 68 3.1.1 Axiology The researcher is guided by consequential and utilitaian ethical theories (Mertons, 2010). In effect, the quest to gain knowledge is guided by the pursuit of desired ends as influenced by the researcher’s values and politics. Three main ethical principles guided this research. These principles are the beneficence, respect and justice. Throughout the conduct of the study, the researcher instituted measures to ensure that the good outcomes for science, humanity, and the individual research participants were maximised while unnecessary risk, harm, or wrong were avoided or minimised. Also, participants were treated with respect and courtesy, and procedures adopted were reasonable, nonexploitative, carefully considered, and fairly administered. The research also complied with the six norms of scientific research outlined by Mertons (2010) as shown in Box 3.1. Box 3.1: Six Norms of Scientific Research Source: Mertons (2010) A detailed write-up of the ethical considerations of this research are provided in section 3.5 of this chapter. 1. A valid research design 2. A competent researcher 3. Identification of the consequences of the research 4. The appropriate sample 5. Voluntary informed consent of participants must be sought 6. Informing the participants whether harm will be compensated. University of Ghana http://ugspace.ug.edu.gh 69 3.3.2 Ontology and Epistemology Pragmatists have for the most part avoided the use of metaphysical concepts such as truth and reality that have caused (in their eyes) much debate among the other paradigms (especially the constructivists/interpretivists and positivists/postpositivists) (Teddlie & Tashakkori, 2003). They argue that, rather than finding some true condition in a real world, effectiveness should be used as the criteria for judging value of research (Maxcy, 2003). To contribute to the ontological stance of pragmatists, Rorty asserts that they hold an ‘‘antirepresentational view of knowledge’’ and that research should ‘‘aim at utility for us’’ and not to provide an ‘‘accurate account of how things are in themselves” (i.e. an accurate representation of reality) (Rorty, 1999: xxvi). Pragmatists believe that there is a single reality and that all individuals have their own unique interpretation of reality (Guba & Lincoln, 2005; Mertons, 2010 and Morgan, 2007). Following the pragmatist philosophy, the researcher decided to sidestep the contentious issues of truth and reality, and accept, philosophically, that there are singular and multiple realities that are open to empirical inquiry and orient themselves towards solving practical problems in the ‘‘real world’’ (Creswell & Plano Clark, 2007, pp. 20-28; Dewey, 1925; Rorty, 1999). Thus, although the researcher admits that there is a single truth concerning the factors affecting the NHIS, this truth is subject to different interpretations due to contextual and other differences. This ontological position is what guided the research. Pragmatists have indicated that relationships in research should be determined by what the researcher deems as appropriate to that particular study (Mertons, 2010.) As a pragmatic researcher seeking the usefulness of the research findings, the researcher’s epistemological assumptions centred on effectiveness. In line with Maxcy’s (2003) assertion, the researcher University of Ghana http://ugspace.ug.edu.gh 70 was more concerned about achieving the purpose of the research and not the relationship between him and the researched. In other words, the relationship between him and the researched was what he deemed fit to enable him answer the research questions. At a point, the researcher had to opt for a more personal, interactive mode of data collection, and, at another point, he had to position himself as a distant objective observer who made sure that his biases did not affect the research outcomes. All these were to ensure that the research questions were appropriately answered. 3.3.3 Methodology Pragmatism does not require a particular method or methods mix and does not exclude others. The method is decided by the purpose of the research (Patton, 2002). It allows the researcher to freely decide on the method or combination of methods that will best suit the purpose of the research. In effect, pragmatists may use quantitative methods to measure some aspects of the phenomenon in question and qualitative methods for others once these methods and their applications will properly answer the research question(s). With this flexibility, the study to adopted a mixed quantitative and qualitative methodology. The researcher also recognises that every method has its limitations and that the different approaches can complement each other. In other words, in using the mixed methodology, the researcher benefited from the combined the strengths of both qualitative and quantitative approaches to enrich the work (Marshall and Rossman, 2006; 2011). Also, the qualitative and quantitative data gathering techniques complemented each other to substantiate the findings and make them more concrete. Additionally, this method provided a holistic account of the phenomenon under study by triangulating the findings of both the qualitative and quantitative techniques. It also helped to provide additional data to work with and ultimately a more accurate assessment (O’Neill, 2006). A quantitative methodology was used to collect household data to obtain their views on the implementation of the NHI Policy through the NHIS. This was done mainly through the use University of Ghana http://ugspace.ug.edu.gh 71 of questionnaires. On the other hand, the study used a qualitative methodology to collect qualitative data from key informants and officials of the NHIA and some health workers. Qualitative data was collected mainly through interviews and observations. This methodology enabled the researcher gain in-depth insight into the operations of the NHIS and the interplay of factors/variables shaping the implmentation of the NHIS. The study adopted a complementary mixed methodology (Cameron, 2009; Caracelli and Greene, 1997) where the qualitative data complemented the quantitative. In line with Cresswell and Plano Clark’s (2007) categorisation, the study adopted an embeded mixed methodological approach to the study. It used the qualitative data to enhance the quantitative data. In most instances, the data collection had to be sequential so that the qualitative data collected could help clarify the quantitative data/information (Tashakkori & Teddlie, 2003; Cameron, 2009; Cresswell and Plano Clark, 2007). However, the dominance of the quantitave method does not suggest its superiority over the qualitative. Such embedded and sequential design was neccesary to better answer the research questions. The most important motive for using the mix methodology is to improve the quality of research (e.g. Kaplan and Duchon, 1988). Also in using this approach, the researcher avoids methodological monism (i.e. the insistence on using a single research method). However, this stance should not be attributed to the researcher’s inability to decide between the merits and demerits of the alternatives. Rather, it is the belief that although each method is valuable if used appropriately, a combination will yield better results when well managed. Furthermore, this is to ensure that the research is relevant to the research questions and also rigorous in its operationalisation. Overall, the qualitative data was required for the purpose of understanding how factors affect the characteristics and operation of the National Health Insurance Scheme. Here, the study University of Ghana http://ugspace.ug.edu.gh 72 sought to gain insights into the NHIS through discovering meanings out of the data collected. The objective was to explore the richness, depth, and complexity of the factors affecting the implementation of the NHIS. In this light, the qualitative method was a better option than the quantitative. However, the lack of objectivism with the qualitative approach, a quantitative approach is adopted to collect household data to provide an objective assessment of the implementation of the policy. With the quantitative method, the researcher sought to observe and describe from an objective viewpoint (Levin, 1988), and minimize the interference with the phenomena being studied. The methodology adopted for this research is further explained in the following sections. 3.2 Research Design Research design essentially refers to the plan or strategy for shaping the research (Henn, Weinstein and Foard, 2006) that might include the entire process of research from conceptualizing a problem to writing research questions, and on to data collection, analysis, interpretation and report writing (Creswell, 2007). It provides the framework for the collection and analysis of data and subsequently indicates which research methods are appropriate (Walliman, 2006). Generally, research seeks to explore, describe or explain a phenomenon based on data (Richardson, 2000; Richardson and Piere, 2005; Babbie, 2007). The study adopted a descriptive case study design. Descriptive case studies seek to describe the natural phenomena which occur within the data in question (Yin, 1984; Zainal, 2007). By using the descriptive design, the study sought to describe the data as they occur. Also, the descriptive research design provided the opportunity for the research to go beyond just focusing on the topic and providing a picture of it, to looking at the causes and reasons. To identify how the policy is being operationalised and the obstacles to its implementation, four University of Ghana http://ugspace.ug.edu.gh 73 districts were selected for the study (details about the selection process are provided in sections 3.6 and 3.7 of this chapter). A descriptive design was chosen to describe a phenomenon of interest (the implementation of the NHIS) (Salkind, 2000; 2003). Such description has been documented (Marshall and Rossman, 1998; 2006) and seeks to provide a clear answers in terms of who, what, when, where, why, and way (6 Ws) of the research problem and data was typically collected through a questionnaire survey, interviews and observations (Gay and Diehl, 1992). The research also adopted the case study strategy. Yin (1994) argues that the case study strategy allows an investigation to retain the holistic and meaningful characteristics of real- life events. Therefore, the case study approach is especially useful in situations where the contextual conditions of the event studied are critical and where the researcher has no control over events as they unfold such as applies to this research. The current study draws much on the experience of actors and the contextual factors and this makes the case study strategy appropriate as it is considered to be particularly useful for practice-based problems where the experience of actors is important and the context of action is critical (Lee, 1989; Galliers, 1991). Pere and Elam (1997) in their work indicated that aside the conceptual depth that case studies help achieve, they can be used to achieve a variety of aims using diverse data collection and analysis techniques. To add to this assertion by Pere and Elam (1997), Montealegre (1995) mentioned that case studies (particularly in-depth ones) provide the opportunity for a comprehensive approach to historical and social analysis of complex phenomena such as policy implementation. Also, the case study approach is not only comprehensive in its approach but can also be used for analytical generalisations where the study aims to University of Ghana http://ugspace.ug.edu.gh 74 generalise particular sets of some broader theoretical propositions (Yin, 1994). This approach (i.e. case study) also enhances the validity of the research. Such validity, which according to Walsham (1993; 1995) is derived from an interpretive epistemological stance, is based on the plausibility and cogency of the logical reasoning applied in describing and presenting the results from cases and in drawing conclusions from them. Taking insights from Yin (1993), the study has a theoretical backbone (or a conceptual framework) that guided the collection of data. Again, Yin (1993) noted that the more thoughtful the theory, the better the descriptive case study will be. This necessitated a comprehensive literature review to arrive at a more thoughtful theoretical and conceptual framework which consequently improved the quality of the research. Additionally, the descriptive case study approach allowed for ‘thick descriptions’ of the factors affecting the implementation of the NHIS (Yin, 1994). Such ‘thick descriptions’ gave the researcher access to the subtleties of changing and multiple interpretations (Walsham, 1995), which would have been lost in purely quantitative or experimental strategies (Yin, 1994). Going by the categorisation of Stake (1995), the study has an instrumental nature. One objective of studies with instrumental nature is to provide insight into a particular phenomenon as this study seeks to do. Additionally, the study is characterised by depth, detail and contextual scrutiny, which are very critical in instrumental cases (Stake, 1995). Additionally, it is a multiple case study with four districts as the cases. The case study approach is particularly being used because of its attribute as a very good evaluative tool for assessing the effectiveness of an intervention (Kreuger and Newman, 2006). The case study approach has nevertheless been criticised in several respects. Critics have indicated that this approach in most instances is not representative and lacks statistical University of Ghana http://ugspace.ug.edu.gh 75 generalisability. Furthermore, the richness and the complexity of the data collected expose this strategy to different interpretations, and potential researcher bias (Conford and Smithson, 2006). This notwithstanding, Pettigrew (1985; 2013) has the conviction that case studies are useful in developing and refining generalizable concepts and that multiple case studies can lead to generalisations in terms of propositions. Additionally, the use of a mixed qualitative and quantitative methodology will enable the researcher to overcome some of the shortcomings of the case study strategy. 3.3 Study Context The study was conducted in the health sector of Ghana. In Ghana, the state is primarily responsible for the health of its residents as provided in Article 36(10) of the country’s 1992 Constitution (Republic of Ghana, 1992). The sector is headed by the Ministry of Health which is responsible for policy planning processes and information management, particularly concerning the areas of financing, human resources and infrastructure (MOH, 2008). The country has seven main laws that govern the activities of this sector. These laws include the Ghana Health Service Act, (Act 525); the National Health Insurance Act, (Act 852); the Health Institutions and Facilities (HIFA) Act, (Act 829); the Public Health Act, (Act 851); the Mental Health Act, (Act 846); the Specialist Health Training and Plant Medicine Research Act, (Act 833); and the Health Professions Regulatory Bodies Act, (Act 857). Ghana has a well-developed, integrated, multilevel health system distributed throughout the country. The system comprises Community-based Health Planning and Services (CHPS) zones; health centers; district, regional, and teaching hospitals; private health providers; and nongovernmental health-related organizations (see Figure C1 in Appendix C). The health system consists of health service providers, the National Ambulance Service, regulatory bodies, the National Health Insurance Authority, and training and research institutions (see University of Ghana http://ugspace.ug.edu.gh 76 Figure C2 in Appendix C). Urban centres in Ghana are well served; having most hospitals, clinics, and pharmacies in the country. However, rural areas often lack these essential healthcare facilities. The study is specifically concerned with the implementation of the NHIS in the Greater Accra Region. The Greater Accra Regional Directorate of the NHIS has been decentralised into fourteen (14) districts. These districts are the Ga District, Ayawaso District, Ablekuma District, Dangme West District, Adentan District, Ashaiman District, Ashiedu Keteke District, Osu Klottey District, Okaikoi District, Kpesie District, La District, Weija District, Tema District, and the Dangme East District. Four of these districts were sampled for the study. The sampled districts were the Ayawaso, Dangme West, Ga, and Ablekuma districts. According to the 2010 population census report, the four selected district have a combined population of 1,721,095 constituting 42.9% of the population of the region. This population is made up of 48.4% males and 51.6 females. Sixty-four percent (64.0%) of the population are 18 years old and above; the target for this study. The Ayawaso District of the NHIS covers three sub-metropolitan areas in the Accra Metropolis. These sub –metros are Ayawaso East, Ayawaso West Wogon and Ayawaso Central. The total population of the Ayawaso District according to the 2010 population census is 396,497 people; made up of 48.9% males and 51.1% females. Also, 67.9% of the population are 18 years old and above. The district has a total of 57 health facilities which constitutes 26.1% of all health facilities in the Accra Metropolis. Out of this, there are 9 hospitals, 33 health centres/posts and 15 other facilities including pharmacies and laboratories. Of the four districts being studied, Ayawaso has the largest concentration of health facilities. However with the exception of Dangme West which is a rural district, Ayawaso is the least populated compared to all the other districts. This is an indication that University of Ghana http://ugspace.ug.edu.gh 77 compared to other districts being studied, Ayawaso has more readily available health facilities. The NHIA was able to register 29% of the population of the district under the NHIS in 2014. The Ablekuma District, also in the Accra Metropolitan area covers three sub metropolitan areas: Ablekuma North, Ablekuma South and Ablekuma Central. The population stands at 679,362 people (GSS, 2012). This population is made up of 47.7% males and 52.3% females. People who are 18 years or older constitute 64.1% of the population. Also, the district has 33 health facilities made up of 6 hospitals, 13 health posts/centres and 14 other health facilities. In the year 2014, the Ablekuma office of the NHIA registered 19.5% of the population. However the scheme has plans of increasing this in 2015. The third district studied is the Ga District. This district comprises four municipalities. These are Ga East, Ga West, Ga Central and La-Nkwantanang-Madina. Formerly, Ga South Municipality was part of the NHIS demarcated Ga District until it was removed to be a district on its own due to its large population. However, the Ga District remains the largest district in terms of geographical coverage, and is one of the heavily populated districts in the region. The Ga District in 2010 had a population of 522,410 people. The males constitute 47.9% as against 52.1% females (GSS, 2012). The Ga District has about 60 healthcare facilities. The adult population (people 18 years and above) constitute 62.9% of the population. The NHIS covers 22% of the population of the district. The Dangme West District was also included in the study. This district currently comprises two administrative districts: Shai Osudoku and Ningo Prampram. The Dangme West District is one of the districts in which mutual health insurance schemes were piloted in the 1990s. The district therefore has more years of experience with health insurance than all the other University of Ghana http://ugspace.ug.edu.gh 78 districts in the region. The population of the district stood at 122,836 persons in 2010 (GSS, 2012). This population is made up of 47.9% males and 52.1% females. The adult population (people 18 years old and above) form 55.5% of the total population. The district is predominantly rural, with the rural population constituting almost two-thirds of the district’s population. There is a total of 24 accredited health facilities in the district; comprising 1 district hospital, 4 health centres, 9 CHPS zones 1 private hospital, 4 clinics, 1 maternity home, 2 CHAG institutions, 1 lab/diagnostic centre, and 1 pharmacy. The district NHIA office has registered 29% of its population for the NHIS. 3.4 Units of Analysis The unit of analysis denotes the degree to which the level of investigation (Zikmund, 2000) or the level of aggregation (Sekaran, 2000) of collected data focuses specifically on objects or an object. It is very critical in research (Yin, 1994), and it defines the variables of interest in the study (Yin, 1993). Therefore, defining and specifying the units of analysis is one of the fundamental decisions made in the study (Weber, 1990). However, it must be specified that, just as in this study, the units of analysis can be highly complex. The study has several units of analysis. These include concepts, individuals, variables, and factors. The concepts are the systems theory and the PEST model. As the main constituents of the conceptual framework, these models are very critical in this research and define the variables of interest in the study. To be able to effectively answer the research questions, there is the need to consider various parts of the conceptual framework. These are the various parts of the system and the environmental factors that affect the system. Together, these serve as units in analysing the factors affecting the implementation of the NHIS and also highlight their interrelationships to answer the research questions. These factors include the input, conversion and output components of the system, and the political, economic, University of Ghana http://ugspace.ug.edu.gh 79 social, and technological segments of the environment. The units of analysis also included the variables that constituted these factors and also other variables deemed to be important in answering the research questions such as registration for health insurance as well as the benefits derived from registering and participating in it. The units of analysis also include the individuals that participated in the study as respondents and interviewees. These individuals have different characteristics that affect their responses and also their decision to register for the NHIS. The methodology outlined in this chapter, the instruments used to obtain data and the general sources of data, are expected to generate data to be analysed using the units outlined in this section. To obtain the data needed for such analysis, there is the need to specify the target population from which the samples are taken. 3.5 Target Population By definition, population is the group to which a researcher would like the results of the study to be generalizable. It could also be set of all cases of interest (Richardson and Piere, 2005) and might be virtually any size or might cover almost any geographical area (Gay and Diehl, 1992). Theoretically, a researcher can specify the study population which provides a more accurate and specific description. The population for the study comprised the residents of Ablekuma, Ayawaso, Ga and Dangme West districts of the NHIS as well as the management members of the NHIA district offices in those districts. According to the 2010 Population and Census Report, these districts have a combined population of 1,721,095 persons. Out of this population, the study targeted 1,101,770 persons who were 18 years old and above. These people were mostly targeted to provide quantitative data. As the direct beneficiaries of the NHIS, the study sought their opinion on the factors affecting success of implementation and their judgement on how successfully the NHIS had been implemented. Since these people had directly observed the operation of the NHIS or had been beneficiaries, they possessed useful information that could help answer the research questions. University of Ghana http://ugspace.ug.edu.gh 80 There are five core management members in each district: the district manager, marketing manager/PRO, claims officer, MIS manager, and accountant. These people together constituted 20 people; the population from which the sample for the interviewees were selected. The researcher concentrated on the core management members since they are mostly experienced and knowledgeable concerning the activities of the NHIA in their various districts. Also with the managers, the researcher could obtain the richness and depth of information needed as well as supporting documents which the other staff members may not be able to produce. 3.6 Sample Size A sample is a subset of the population being studied (Richardson and Piere, 2005) to become the basis for estimating or predicting a fact, situation or outcome regarding the bigger group (Kumar, 1996). Samples should be as large as possible; in general the larger the sample the more representative and the more generalisable the results of the study are likely to be. In all, there were two sample groups. The first group was for the quantitative study. Here, a total of four hundred and twenty two (422) respondents were studied. They comprised one hundred and twenty three (123) respondents from Ablekuma, One hundred and sixteen (116) from Ga, One hundred and ten from (110) Ayawaso, and sixty three (63) from Dangme West districts. The sample distribution among the study areas was based on their respective populations. Thus, more people were selected from areas with larger population sizes and vice versa. The sample size for the quantitative study was based on the recommended table for sample size determination by the Universal Accreditation Board (UAB, 2010; Krejcie & Morgan, 1970; Israel, 2013) which indicates a sample size of 384 for up to a population of University of Ghana http://ugspace.ug.edu.gh 81 hundred thousand (100,000) or more persons. This calculation used a ±5% margin of error, yielding a 95% confidence interval. The second sample consisted of ten residents from the study districts (3 each from Ablekuma and Ayawaso; 2 each from Ga and Dangme West) and seven officials from the district offices of the NHIA in the selected districts (2 from Ayawaso, 2 from Dangme West, 2 from Ga and 1 from Ablekuma). The qualitative interviews with residents of the various districts were necessary to help the researcher gain deeper insights into the factors affecting the implementation of the NHIS. With the NHIA being the core implementing institution, there was the need to include its officials in the study. Although not part of the initial design, three hospital managers were interviewed to enrich the data obtained and also obtain some data necessary for the study. In all, twenty interviews were conducted to obtain qualitative data. The concept of saturation guided the determination of sample sizes for the qualitative study. 3.7 Sampling Techniques The researcher adopted a combination of convenience and purposive sampling techniques due to the potential difficulty in obtaining a relevant sample frame for probability sampling. Although the Ghana Statistical Service (GSS) has collected data which could be used as a sample frame, this data was old and as such the developments, land-use and other changes that had taken place over the period made it inappropriate for the study. Also, the demarcations the GSS used do not coincide with some of the NHIS districts, therefore making it difficult to use the GSS information. The study therefore had to resort to the use of convenience sampling to collect the required data. However, though the selection of respondents for the quantitative study was based on a convenience sampling technique, the researcher sought to make it systematic by selecting every tenth person who was willing to participate in the study. For the qualitative aspects of the research, there was the need to University of Ghana http://ugspace.ug.edu.gh 82 purposively select interviewees whose knowledge and/or experience would be relevant to the phenomenon being studied and would be able to provide appropriate answers to aid the researcher make valid conclusions. The selection of districts was purposively done. The researcher sought to select two urban districts, a peri-urban district, and a rural district. This was to ensure that the sample will be representative of the different categories of people in the region. With the urban districts, the researcher sought to select one with a significant proportion of urban poor residents and another district which is relatively richer. According to the Ghana Poverty Mapping report by and the Accra Poverty Mapping report, the Ablekuma district is one of the relatively poor communities in the metropolitan area (GSS, 2015; CHF International, 2010). The reports noted that the Ablekuma district has some of the poor areas in the metropolitan area such the Ga-Mashie (notably places such as Korle Gonno and Chorkor). The Ayawaso district on the other hand was considered by the reports as relatively richer and has communities such as Ridge, Airport Residential Area, and Dzorwulu (GSS, 2015; CHF International, 2010). These two urban districts were therefore selected to ensure that different segments of the urban population are covered in the study. The rural district selected is the Dangme West District and the Peri-urban district is the Ga district. The Ga district is the most populated peri-urban district (according the 2010 population and housing census report), and it has more communities than any other peri-urban district; making it more appropriate to be selected. There are two rural districts in the Greater Accra region, which are the Dangme West District, and the Ada District. The Dangme West District was selected for the study since it was more populated (according the 2010 population and housing census report) and was introduced to health insurance earlier than the Ada district. The respondents for the study were then selected based on the sampling techniques described earlier. University of Ghana http://ugspace.ug.edu.gh 83 3.8 Sources of Data Data was collected from two main sources – secondary (documentary) and primary sources. The primary source included observation, self-administered in-depth interviews and a survey. a. Primary Sources. The sources are categorised into sources of qualitative data and sources of quantitative data. Qualitative data was obtained from in-depth interviews and simple observation. The researcher passively and unobtrusively observed the participants, their environments, taking note of their interaction with their environment, to obtain qualitative data for the study. This was in the form of the observation of exterior body and physical signs, analysis of expressive movements, physical location analysis, and the observation of language behaviour. Another source, interview, was essential because of the researcher’s need to produce a piece of work with textual depth as well as empirical strength. The need to understand the NHIS implementation process as well as factors affecting it, necessitated the use of in-depth interviews to obtain richness and depth of information required. Questionnaires were administered to households in the study areas as a means for obtaining quantitative data. An advantage of using questionnaire is that it is an entirely standardized measuring instrument that ensures that questions are phrased exactly in the same way for all respondents (Sapsford, 2007). The use of questionnaires was advantageous because it was cheap and also saved time on the part of the researcher and the respondents (Sapsford, 2007). The use of questionnaires has been proven to be useful and is often used in social science and management research (Richardson and Piere, 2005).For this study, questionnaires were administered to sampled households in selected districts. University of Ghana http://ugspace.ug.edu.gh 84 b. Secondary/ Documentary Sources These include reports and other documents produced by the Government of Ghana, and other relevant institutions to the research. It also includes texts written by scholars and experts on the subject matter. Some relevant secondary sources were the population and housing census reports, NHIA publications and reports, reports from the Ministry of Health, and World Bank publications and reports. Extensive data was also gotten from the various peer reviewed journal articles and other publications and reports. To obtain the relevant literature sources, frequent visits were made to libraries such as online libraries, school libraries, libraries of the National Health Insurance Authority, relevant Ministries, Departments and Agencies, non-state actors, and academic institutions. Other internet sources and relevant websites were used. The researcher gleaned relevant information journals, (printed and online), newspapers, reports, books, articles, and other commentaries on relevant web pages. These written documents were reviewed and relevant data extracted for the study. 3.9 Data Collection Instruments To obtain the necessary data for the study, the researcher constructed separate instruments for qualitative data collection and quantitative data collection. Instruments for qualitative data The researcher used interviews to capture most of the qualitative data for explanation. Most of the interviews were conducted in a face-to-face fashion in order to ensure a high response rate. In this stance, the researcher captured extensive non-verbal communications to enrich data. It also allowed for longer sessions and extensive probes. University of Ghana http://ugspace.ug.edu.gh 85 However, in instances where face-to-face interviews were not possible, the researcher resorted to telephone interviews to obtain data. Though this has the advantage of reaching people over long distances, it precluded extensive probing and non-verbal communication. Furthermore, it is a very expensive technique. The telephone interviewing method was used for only one interviewee in the Dangme West district, who was not available for a follow-up interview. Respondents/interviewees were purposively selected and interviewed using the prepared semi-structured interview guides. In addition, some interviews were conducted at the district offices of the National Health Insurance Authority (NHIA). The researcher was the main instrument for the qualitative study (Cresswell, 2007). Cresswell noted that although there may be an interview guide, the conduct of the interview, the questions and follow-up questions asked, and the criteria for the assessment of responses mainly depend on the interviewer, who is the researcher. Furthermore, qualitative studies are known to be value laden; the values and other characteristics of the researcher significantly affect the outcomes of the research. Interview guides were extensively used in the qualitative data collection. Separate interview guides were prepared each category of respondents. Each interview guide contained six open ended question. The wording of interview question was a major concern for the researcher so that each question will be clear and neutral as much as possible. The researcher avoided wording that might influence answers as well as those that are offensive and sensitive. University of Ghana http://ugspace.ug.edu.gh 86 The interview questions primarily sought to identify the major factors that affect the implementation of the NHIS. Respondents were given the chance to give recommendations regarding how the challenges facing the NHIS will be curtailed. Instruments for quantitative data The researcher adopted this method in collecting the household data since it is less expensive, very effective and can have a high response rate compared to mail surveys. In addition the questionnaires were mostly closed ended to make it easier and quicker for respondents to answer; for easy comparison; for easy coding analysis; and to reduce the volume of irrelevant issues. However, for the sake of explanation, there were some open ended questions so that respondents can qualify and clarify responses; discover unanticipated findings; and permit creativity, self-expression, and richness of detail. Questionnaires were administered to households mostly in selected districts. The selection of these households was through a non-probability convenience sampling technique. The questionnaires were designed to contain enough questions to be able to meet survey objectives but not so many as to be off-putting to respondents. The questions were long enough to elicit the information that is required but short enough to encourage an optimum response rate. The question development process took several steps: a) Overview of the research situation took into considerations all the institutions involved in NHIS implementation. This also involved the various facets of implementation and the modification that have been made since the commencement of implementation. Information gathered at this stage was a very important input into the instrument development process. University of Ghana http://ugspace.ug.edu.gh 87 b) The developed instruments were pretested using a few selected households and institutions. Their suggestions and comments were considered to perfect the questionnaire and filling in any loopholes. This was the stage where the researcher ascertained the reliability and validity of the instruments. c) The modified instruments were used for the data collection. d) The data collected was processed using qualitative and quantitative means. 3.10 Data Management and Analysis Data was analysed using both quantitative and qualitative methods of analysis. a. Qualitative data management and analysis The interview responses were digitally recorded and then transcribed on the same day, when observations and information was fresh in the memory of the researcher. The transcribed interviews were read and the essential issues reported were categorized and annotated in various units for analysis. Also, field notes taken to capture non-verbal cues were added to enrich the transcripts. This was to ensure that such valuable information will not be omitted in further analysis. Thematic principle was applied in the process of qualitative data analysis. The collected information was sieved, sorted, grouped and assembled in accordance with the question numbers that acted as the coding system in order to solicit the emerging issues/points and to establish certain patterns in all the answers. The summarization of the collected information was done mainly based on typology and quasi statistics i.e. classified, grouped, themed or patterned and the number of times or frequencies a subject/topic was mentioned in the interview process. University of Ghana http://ugspace.ug.edu.gh 88 In the process of report writing and for the purpose to increase the credibility of qualitative data, the process of member checking was done vigorously. Follow up phone calls and e-mail communications were made to the interviewees, both to clarify and verify their statements and to validate whatever that they had said. Respondents’ validation was considered important to improve accuracy, validity and transferability of the information from the interview transcript. More often the process of validation was concerned with ensuring that their comments or thoughts have been correctly described and interpreted. Descriptive and interpretative validities took most of the time as there were many recursive points that were similar in nature but provided by various respondents. b. Quantitative data management and analysis The survey or quantitative data was captured and analysed using the IBM statistics software – the Statistical Product and Service Solutions (IBM SPSS) Version 20.0. The researcher pre- coded the questions before going to the field. However from the field, the questionnaires were cross examined to eliminate those which were not properly answered. After the re- examination, the responses of the valid questionnaires were keyed into the SPSS software. After this, the data entered were cleaned and edited to ensure that data entry errors will not threaten the validity of the research. The first stage of data analysis was an examination of the data using basic statistics. Frequencies were generated to show the general characteristics of study variables and respondents’ demographic characteristics. The researcher used different statistical techniques including correlation analysis, chi-square, and regression analysis to generate meaningful analysis and examine the relationships that exist in the data. Reports generated by the software was interpreted and combined with the qualitative data in reporting the findings of the study. University of Ghana http://ugspace.ug.edu.gh 89 While this may seem to suggest a separation between the quantitative and qualitative research data analysis, it is important to note that this was intended solely to acquire conceptual clarity. In the study itself, the two research methods and the data collected were combined and triangulated, and the final analysis integrated the findings from these two approaches. 3.11 Validity and Reliability To ensure validity and reliability of the findings of the study, the study adopted a purposive sampling technique for the collection of qualitative data and sought to interview only persons who are relevant to the subject. Furthermore, the researcher adopted a method of triangulation of data collection techniques (by using a combination of participant observation, personal interviews as well as a survey). Findings of the study were presented to the respondents for their feedback and modification. Finally, the work was peer reviewed by some scholars in the field of the research. Also, the instruments were pretested and the necessary modifications made to ensure validity and reliability. The objective of the pretesting was to ensure that respondents understand the instructions, the questions being asked and the terminologies used. It ensured that misleading questions were eliminated and clarity established. All inputs in the form of comments, suggestions, ideas, proposals, corrections and views were taken into consideration to improve, improvise and upgrade the level of reliability of the instrument. To ensure that the measures and variables developed as the instruments in the questionnaire were appropriate, the instrument was tested for its reliability. The SPSS test for reliability produced a Cronbach alpha of 0.73. This showed that the instrument was reliable. Prior to the actual data gathering exercise, reliability test was done on the data collected from the pilot study. After the reliability test, the instrument was modified to improve its reliability. University of Ghana http://ugspace.ug.edu.gh 90 3.12 Ethical Considerations Ethical concerns were paramount in the course of this research and the researcher ensured that every aspect of the work conformed to ethical standards of research and academic work. The researcher complied with the institutional requirements by obtaining an ethical clearance from the Ethical Review Committee for the Humanities in University of Ghana. Strict ethical standards were adhered to in the review of literature for the study. The researcher ensured that all literature used are appropriately cited and referenced. The researcher employed Kolin’s (2002) ethical principles of clarity, accuracy, honesty and fairness throughout the literature review and beyond. All documents used and sites visited have been properly acknowledged and documented to avoid issues of plagiarism. Ethical principles were also followed during the data collection and analysis phase of the study. The research was thoroughly explained to respondents and interviewees to seek their consent before proceeding with the survey or interview. Respondents and interviewees were also assured of confidentiality with respect to all information they provide. The researcher explained to the interviewees and respondents that their participation was voluntary and could stop at any point if they so wished. Interviewees were informed that the work is purely for academic purposes and not for reasons other than that. The researcher also made sure that the duration of the interview communicated to the interviewee/respondent was not exceeded. In few instances where the researcher couldn’t complete within the stipulated time, permission was sought to either progress or continue on another day. During the collection of qualitative data, interviewees’ consent were sought to enable the researcher record the interviews. The researcher also transcribed the data himself to comply with the issue of confidentiality. Transcription was done verbatim to avoid misrepresentation University of Ghana http://ugspace.ug.edu.gh 91 and misinterpretation. Respondents were also assured of the safe keeping of recorded data and their subsequent destruction after the completion of the research. Also to ensure that the interviewees understood and gave appropriate responses, the researcher also communicated in languages they understood. The languages used for the research were mainly English and Twi. Finally on completion of research, participants were again assured of privacy and confidentiality. 3.13 Assumptions and Limitations of the Study It is assumed that the study population was of adequate size to provide valid and comprehensive interview responses. Key informants and all respondents were also assumed to be knowledgeable enough to provide the needed and relevant information and finally the responses of the respondents were assumed to be accurate and honest. The study encountered some methodological problems such as limitation associated with the sampling of respondents as well as the techniques adopted for the research. Also, some of the relevant issues have not been documented and in such cases the researcher relied on the memory of persons to be interviewed. The accuracy and chronological sequence of data and resulting information is therefore likely to be affected by the limitations of the human memory. Another limitation inherent in this research is the limitation of qualitative research being the non-generalizability of some findings. By combining qualitative and quantitative approaches this was partially addressed. Also, the study is relevant for illustrating the current condition of policy implementation in Ghana. University of Ghana http://ugspace.ug.edu.gh 92 Being the instrument and the sole interviewer of the study (especially with the collection and analysis of qualitative data), the researcher’s biases may have influenced the interpretation of the research findings. Nonetheless it is argued that the study helps to understand the condition of the management implementation of the NHIS in Ghana. University of Ghana http://ugspace.ug.edu.gh 93 CHAPTER FOUR DATA ANALYSIS AND PRESENTATION 4.0 Introduction The chapter presents the results of the data analysis. The data was collected and then analysed in response to the problem and objectives stated in chapter one of this thesis. The chapter also seeks to answer the research question posed in the same chapter (chapter one). Data was collected from individuals and institutions. The primary objective that guided the data collection, and upon which the analyses are presented in this chapter was to develop knowledge on the factors that are affecting the implementation of the NHIS. In developing this knowledge, the chapter explains how these factors are interrelated. This primary objective has been achieved in the chapter, which is an add-on to existing knowledge in the research area. The data presented here was obtained from four hundred and forty two (442) people mainly in four districts of the NHIS. Four hundred and twenty two (422) of these people responded to the survey questionnaires. These respondents represent a response rate of 84.4%. A total of five hundred (500) questionnaires were distributed but 422 of these questionnaires were retrieved. The remaining twenty (20) persons who participated in the study took part in qualitative interviews. Ten (10) out of the twenty (20) interviewees were individuals interviewed in the four districts under study. Out of the remaining ten (10) interviewees, seven (7) were officials from the NHIS district offices in the four study districts and three (3) were hospital managers/administrators. The chapter starts with an introduction, followed by a presentation of the demographic characteristics of the survey respondents. The remaining sections of the chapter present analyses of the factors that affect the implementation of the NHIS, and the relationships that exist between them. University of Ghana http://ugspace.ug.edu.gh 94 4.1 Demographic Characteristics This section of the report gives the demographic characteristics of the respondents. Out of a total of 422 respondents for the study, 208 (representing 49.3% of the total) were males and 214 (representing 50.7% of the total) were females as shown in Table A1 in Appendix A. Also, more than 90% of the respondents were less than 50 years of age and more than three- quarters were less than 40 years. The median age was within the range 30 – 39 years with the mean age falling within that same range. The modal age was however in the range 18 – 29 years. This showed that the respondents were not normally distributed in terms of age. Only nine people constituting 2.1% of the respondents were above 60 years. As shown in Table A1 (in Appendix A), there was not much difference between the male and female respondents in terms of age distribution. Also, a greater proportion of the respondents (48.3%) were married. The singles however formed the second largest group (37.7% of the respondents) in terms of the marital status. A large proportion of the singles (43.6%) were less than 30 years old. Though statistically significant, only a small proportion of the respondents were divorced, separated, widowed, or were in loose/informal union. In terms of marital status, the distribution of males was not very different from that of females. In terms of the educational attainment, almost half (i.e. 47.4%) of the total respondents had had tertiary education. Respondents with Basic Education Certificate/Middle School Leaving Certificate or lower constituted a small percentage (5.7%) of the total respondents. The educational attainment of the respondents explains why the literacy rate is very high among these respondents (i.e. 97.9%). The high level of literacy positively affected the findings of the study as the respondents will be understood the questions and provided the relevant answers. University of Ghana http://ugspace.ug.edu.gh 95 Other demographic characteristics presented are the employment status, employment category and the occupation of the respondents. Majority of the respondents (52.3%) were regular employees. Also about 16.7% of the respondents were self-employed of which 13.8% had employees and 2.9% didn’t have any employee. Although the number of male and female employees were the same (i.e. 110 respondents each which constituted 53.1% of the males respondents and 51.4% of the female respondents), there were more self-employed males than females. Students (10.7%) and casual workers (9.0%) also formed a significant proportion of the respondents. Only 5.5% of the respondents were unemployed (see Table A2 in Appendix A). The study further enquired about the employment category of the respondents. The results of this showed that more than half of the respondents (61.1%) were employed in the public and private formal sector (i.e. 34.1% were employed in the public sector and 27.0% were employed in the private formal sector). The respondents from the private informal sector on the other hand constituted 17.5%. With the private informal sector employing majority of the working class in Ghana, it was expected that majority of the respondents will be in this sector. Since respondents were selected using a non-probability sampling technique, characteristics of the sample are likely to deviate from that of the population. Those employed in the parastatals and the NGO/international organisations formed the minority. Furthermore, most of the respondents were employed in the service sector; mainly the Finance/Insurance/ Services sector (21.1%), Education/Consultancy/Research sector (19.9%), Community/Social Services sector (10.0%) and the healthcare sector (3.8%). The respondents from distribution sector which is a large proportion of the informal sector constituted only 6.4% of the total respondents (i.e. 5.0% in the wholesale/retail trade and 1.4% in the transport/distribution/ communication sector). University of Ghana http://ugspace.ug.edu.gh 96 4.2 Participation in NHIS The researcher sought to find the proportion of the respondents who had ever belonged to a health insurance scheme. This enquiry was necessary because the prime objective of the National Health Insurance Authority, is to have every Ghanaian resident belong to a health insurance scheme. As shown in Table 4.1, 344 people (representing 81.5% of the total respondents) registered for a health insurance. Out of this number, 322 (representing 93.6% of persons who had registered for health insurance and 76.3% of the total respondents) had registered for NHIS. The remaining had registered under other health insurance schemes as shown in Table 4.1. Table 4.1: Participation in Health Insurance Male Female Total Count % Count % Count % Registered for Health Insurance 168 80.8 176 82.2 344 81.5 Type NHIS 155 74.5 167 78.1 322 76.3 Health insurance through employer 8 3.8 3 1.4 11 2.6 Mutual health organisation/ community health insurance 2 1.0 3 1.4 5 1.2 Other private purchased commercial health insurance 3 1.4 3 1.4 6 1.4 Not registered for Health Insurance 40 19.2 38 17.8 78 18.5 208 49.3 214 50.7 422 100 Table 4.1 also shows that 78 of the respondents (representing 18.5% of the total respondents had not registered for any form of health insurance. With the NHIS being the focus of the study, the researcher proceeded to ask why some people have decided not to belong to NHIS (i.e. belong to other forms of health insurance or University of Ghana http://ugspace.ug.edu.gh 97 do not have health insurance at all). These people gave several reasons for not belonging to the NHIS (see Table 4.2). Table 4.2: Reasons for not Registering for NHIS Male Female Total Reasons for not registering for NHIS Count % Count % Count % Not heard of NHIS 3 5.6 0 0.0 3 3 Cannot afford the premium 6 11.1 6 13.0 12 12 Does not trust the organisers 10 18.5 13 28.3 23 23 Does not need health insurance 12 22.2 7 15.2 19 19 NHIS does not cover my health needs 22 40.7 18 39.1 40 40 Haven’t had the time to register 1 1.9 2 4.3 3 3 54 54 46 46 100 100 Table 4.2 shows that a greater proportion of the respondents (40% of people not registered for NHIS) have not joined the NHIS because it does not cover their health needs. Majority of the others gave reasons such as they do not trust the organisers (23%) or they do not need health insurance (19%). On the issue of affordability, only 12% of the people without health insurance (i.e. 2.8% of the total respondents) indicated that they couldn’t afford the premium. Although this is not a random sample and may not be very representative of the total population, it is an indication that affordability is not a prime reason for some people’s reluctance to join the NHIS. The reasons given shows that some people’s refusal to join the NHIS, can be attributed mostly to apathy and their lack of confidence in the scheme. The study further showed that although 322 respondents (representing 76.3% of the total) had registered for NHIS, 23.0% of this number (i.e. 74 respondents) did not have valid NHIS cards (see Table 4.3). The remaining had valid NHIS cards and these people (248) constituted 77.0% of persons who had registered with NHIS and 58.8% of the total respondents. Most University of Ghana http://ugspace.ug.edu.gh 98 (71.1% of those who have valid NHIS cards) of the people who didn’t have valid NHIS cards had not renewed their registration. The others were either in the process of registration (17.8%) or had lost their cards (11.1%). Explanation for this high non-renewal rate was diverse as shown in Table 4.6. The most common reason for non-renewal of NHIS cards was the perception that NHIS subscribers receive poor quality care (39.7% of those who had not renewed their cards and 7.1% of all NHIS registered members mentioned this). Most others said they had not been sick (21.8% of those who had not renewed their cards) or they had to wait for a long time to receive their cards (25.6%) and so were not interested in renewing them (see Table A3 in Appendix A). Cost of renewal was not a problem as only 3.8% mentioned that as a reason for not renewing their cards. Findings show that customer satisfaction with the scheme is a much more important consideration when renewing their cards than the cost. Other customers were also suffering from moral hazard and thought the money they pay for insurance is a waste since they rarely fall sick. This is likely due to their limited understanding of health insurance. Table 4.3: Participation in NHIS Male Female Total Count % Count % Count % Total number registered for NHIS 155 48.1% 167 51.9% 322 100.0% Active card holders 120 77.4 128 76.6 248 77.0 Others without valid NHIS card 35 22.6 39 23.4 74 23.0 In the process of registration 6 16.3 8 19.2 13 17.8 Not renewed registration 24 69.8 28 72.3 55 71.1 Lost card 5 14 3 8.5 8 11.1 University of Ghana http://ugspace.ug.edu.gh 99 The results as presented in Table 4.4 show that 58.1% of the respondents who had registered for the NHIS renewed their cards within the past 1 year. Those who did not renew constituted 17.1% and the remaining 24.8% were either first timers whose cards had not yet expired (18.3%), in the registration process (4.0%) or had misplaced/lost their cards (2.5%). The data was further analysed to show how the benefits people derive from NHIS affect their decision to renew their NHIS cards. The results of this analysis (in Table 4.4) show that the two are positively correlated. Most of those who benefited renewed their cards and most of those who did not benefit did not renew their cards. A spearman correlation showed a moderate correlation between the two (r = 0.545, p = 0.000, α = 0.05). A Pearson chi square test of dependence/association also showed that there is some dependence between the two variables (χ2 = 125.424, p = 0.000, α = 0.05). This finding show that the accreditation of more facilities (so services will be easily available), the widening of the coverage of the NHIS in terms of drugs and ailments and education of the public are very necessary for continued participation in the NHIS. Table 4.4: Benefit Status of Respondents under NHIS Renewed Not Renewed Others Total Count % Count % Count % Count % Benefited from NHIS 138 42.9 10 3.2 15 4.6 163 50.7 Not benefited from NHIS 49 15.2 45 13.9 65 20.2 159 49.3 Total 187 58.1 55 17.1 80 24.8 322 100 A further analysis to determine whether out of the respondents the number of times one had benefited from the NHIS in the last six months had an effect on the decision to renew or not to. The results are shown in Table A4 in Appendix A. This results show that 93.1% of all those who benefited renewed their insurance. It further showed that majority of the people University of Ghana http://ugspace.ug.edu.gh 100 benefited less from the insurance. For instance, those who benefitted up to three times in the last 12 months are far more than those who benefited more than three times. As much as 78.8% benefited up to three times with while only 21.2% benefited more than three times. Those who benefited once are more than 10 times those who benefited 5 times. With this distribution, it appeared those who benefited less were more eager to renew their cards, which is misleading. However, what is clear is that the number of times a person benefits is positively correlated (though not strong) with the intention and actual renewal of the insurance (Pearson r = 0.474, p = 0.000, α = 0.05). This was confirmed by a chi-square test which showed that the association between the number of times a person benefits from NHIS and the decision to renew the card is statistically significant (χ2 = 131.212, p = 0.000 α = 0.05). Respondents were further asked whether there are services that their households require but are not covered by NHIS. This enquiry revealed the health services that most of them and their households require are covered by the NHIS. This is shown in Table 4.5. Table 4.5: Coverage of Household Health Needs under NHIS Count % All services needed currently are covered by NHIS 201 62.3 Need health services not covered by NHIS 121 37.7 Also, the findings of the study showed that majority of the services not covered under the NHIS were either surgical operations (26.4%) or drugs (26.4%). Some respondents also indicated that their households had sought some laboratory, radiological or cardiovascular services (19.8%) and other emergency and specialist services (13.2%) which were not covered under the NHIS. Also, although in the minority some respondents indicated that their University of Ghana http://ugspace.ug.edu.gh 101 households had sought eye and dental services (6.6%), and cancer treatment services (7.5%) services which were not covered under NHIS (see Figure 4.1). Figure 4.1: Services NHIS Subscribers had to pay for in Health Facilities The data was further analysed to uncover whether the extent of coverage of household health needs is correlated with their decision to renew health insurance. This test showed a weak positive correlation between the two (r = 0.121; p = 0.013 α = 0.05). This showed that people’s decision to renew their card does not have any significant relation with whether the extent of coverage of household health needs under the NHIS. A further interview revealed that for most of the subscribers, the diseases which are not covered by the NHIS is minimal and cannot be a major determinant of whether they will renew their card or not. 4.3 Factors Affecting the Implementation of NHIS The goal of the research is to identify the factors affecting the implementation of the NHIS. On this issue respondents generally indicated the factors facilitating the implementation of the NHIS as well as those hindering its implementation. These responses were processed and are presented in Tables A5 and A6 in Appendix A. The factors affecting the implementation University of Ghana http://ugspace.ug.edu.gh 102 of the NHIS have been categorised into three: the actors, client satisfaction, and external factors, which include political, economic, social, and technological (PEST) factors. 4.3.1 Actors The study sought to find the main factors affecting the implementation of the NHIS. Actors and other institutions have a major role to play in the implementation of any policy and therefore respondents were asked to indicate the institutions and other stakeholders they perceive to be vital in the implementation of the policy. The analysis of the responses is shown in Table 4.6. Table 4.6: Respondents’ Perception on the Importance of Actors in the Implementation of NHIS Actors/Stakeholders/Institutions Count % Rank Government/MMDAs/Politicians 92 21.8 1st Health Facilities and Health Professionals 81 19.2 2nd NHIA/DMHIS 77 18.2 3rd Ghana Health Service and Ministry of Health 70 16.6 4th Religious and Civil Society and Media Organisations 48 11.4 5th Citizens 33 7.8 6th The International Community 20 4.7 7th 422 100 Table 4.6 shows that respondents considered all the stakeholders and actors as having some role to play in the effective implementation of the NHIS. However, comparatively a greater proportion of respondents considered the government, politicians and MMDAs to be very important actors and determinants of the success or failure of the NHIS. The government especially was considered as the most important actor in the implementation of the NHIS. This was also confirmed in an interview when some interviewees indicated the government is University of Ghana http://ugspace.ug.edu.gh 103 the most important stakeholder whose decisions can affect the success or otherwise of the scheme. One of them mentioned that: “…the National Health Insurance Authority (NHIA) will at the end of the day implement the policies of the government and if those policies are bad, it will definitely affect the success of the scheme.”[Interviewee, Dome] Another interviewee added that the appointment of the Executive Secretary and other Board Members of the NHIA is political and the government of the days chooses who to appoint. If such decision is faulty, it will definitely affect the success of the scheme. Respondents considered the health facilities and health professionals as the next key set of actors very important to the implementation of the NHIS. Generally, respondents were concerned about the availability and conditions of these health facilities as well as their operation and accreditation. As seen in Tables A5 and A6 in Appendix A, the availability and condition of health facilities was mentioned as a factor facilitating the implementation of the NHIS in some areas and a hindering factor in other areas. Form interview responses, it became apparent that there are some areas with health facilities but not accredited by the NHIA. For instance one interviewee mentioned that: “Although the University of Ghana Hospital is at a vantage point and serves a lot of people it is not an accredited provider of the NHIS and so those who mostly patronise it might not be motivated to register for the NHIS.”[Interviewee, Madina] Other interviewees also noted that the policies of the hospitals concerning how NHIS subscribers should be treated also have a bearing on the success of the scheme. Regarding University of Ghana http://ugspace.ug.edu.gh 104 this issue, some interviewees mentioned that they had been to accredited facilities that refused to take the health insurance in the evening and this, according to them, was unfortunate. This, one interviewee mentioned, has been a barrier to the success of the scheme. The importance of health professionals to the successful implementation of the NHIS was summed up by an interviewee who mentioned that: “Health professionals are the frontline staff and have direct impact on the decision of people to register or continue with the NHIS. Their failure to treat NHIS subscribers well will have dire consequences on the scheme.”[Interviewee, Dansoman] As the main implementing agency, the NHIA/DMHIS also appeared as the third factor which respondents perceived to be significant in affecting the success or failure of the NHIS. As it is evident in Table 4.6, 10.8% of the respondents indicated this. According to interviews, the importance of the NHIA to the successful implementation of the NHIS cannot be overemphasised. The NHIA is the main implementing and regulatory agency, and also charged with the management of funds generated from premiums paid, it has the main responsibility of seeing to the success of the scheme. Furthermore they added that with a new law governing the operation of the scheme (Act 852) which centralises most of the decentralised function of the District Mutual Health Insurance Scheme makes their role more critical to the success of the scheme. The Ghana Health Service and the Ministry of Health, major stakeholders in the provision of health services were ranked fourth by respondents as institutions that affect the implementation of the NHIS. The interview and desk research showed that the Ghana Health Service (GHS) is the largest regulator of providers in the health sector. Furthermore it was University of Ghana http://ugspace.ug.edu.gh 105 revealed that most facilities under the GHS are accredited providers of NHIS. Thus, as an interviewee mentioned, the policies of the GHS to a great extent can affect the implementation of the NHIS and can affect its success or otherwise. The Ministry of Health is the steward for the provision of health in Ghana. All health care institutions (including the NHIA) and actors function under the Ministry. The Ministry of Health, according to one interviewee is the mother of health activities and institutions in the country and as such is very key to the implementation of the NHIS. Although some respondents saw the Ministry of Health and the Ghana Health Service as the most important actors, others considered them as not directly involved in the implementation of the NHIS but just give policy directions and therefore cannot be the most important actors. Nevertheless, the research findings show that their contribution to the NHIS cannot be underestimated making them important actors in the NHIS implementation process. Some respondents (11.4%) indicated that civil society, religious and media organisations are key actors in the implementation of the NHIS. According to some interviewees, although these organisations are not directly involved in the implementation, they have contributed immensely to the success of the implementation of the scheme. One interviewee mentioned that the Imam and other religious leaders at his mosque sponsored 100 people to register for the NHIS. Additionally most of the interviewees mentioned that their religious leaders always sensitise the people about the necessity to join the scheme. The study also revealed that civil society organisations are also active contributors to the success of the scheme. One interviewee for instance, mentioned that they have been instrumental (through their advocacy role) in ensuring smooth implementation of the NHIS. University of Ghana http://ugspace.ug.edu.gh 106 She added that civil society organisations such as SEND Ghana and ISODEC have contributed immensely to research on the NHIS. The media, as indicated by the respondents, is also an important actor in the implementation of the NHIS. Interview respondents elaborated how the media had published different issues on the NHIS. According to the interviewees, the media has been very instrumental in educating people on the NHIS. A search on Graphic online (www.graphic.com.gh) showed that it published 150 articles on NHIS in 2014 out of a total of 20534 articles published that year. The Residents of Ghana were seen as the sixth most important actors in the implementation of the NHIS and the international community was considered as the seventh most important actor. An interview with the manager of the Ablekuma district office of the NHIA revealed that donors were very active during the initial implementation stage. She however added that there has been a drastic reduction in donor support in recent years. Nevertheless she added that donors and development partners such as the Danish Government, Netherlands Government, the DFID, USAID, and the World Bank have been significant actors in the implementation of the NHIS. 4.3.2 Client Satisfaction The satisfaction of the clients with the NHIS is a very important factor that affects its implementation. The clients receive services mainly from the NHIA and the health providers. Client satisfaction is therefore dependent on the quality of service obtained from these institutions. At the NHIS (district offices), client satisfaction is judged mainly from the services received; in terms of customer relations, and also the registration process. The variables measured for client satisfaction at the district offices of the NHIA are indicated in Table A10 in Appendix A. University of Ghana http://ugspace.ug.edu.gh 107 The information obtained from the field showed that the cumbersome registration process has been a hindrance to some people joining the scheme. Majority of the respondents (53.8%) indicated that the cumbersome process has prevented them or someone they know from joining the NHIS. This shows that the nature of the registration process is a major factor that affects client’s satisfaction, and subsequently their participation in the NHIS. Also, as shown in Table A6 (in Appendix A), a significant number of respondents indicated that the slow biometric process is a factor hindering the implementation of the NHIS. They mentioned that the slow process affect clients satisfaction with the system which eventually affects their willingness to join/renew their cards. Also, respondents indicated that the instant issuance of cards is a factor facilitating the implementation of the NHIS. Thus the registration process is identified by respondents as a factor that affects the satisfaction of clients and consequently, the implementation of the NHIS. A chi-square test of association between this variable (the registration process) and the satisfaction of the respondents with the scheme shows that there is significant association between the two variables (χ2 = 46.408; p = 0.000; α = 0.05). The data obtained also revealed that the attitude of staff at the district office also affect the level of satisfaction of clients. It was found that 41.4% of the respondents were not satisfied with the attitude of the staff of the NHIA district offices and added that such attitude had discouraged them or someone they know from joining the scheme. However, more than a third (35.6%) of the respondents indicated that they were comfortable with the attitude of the staff and were not influenced in any negative way by it. Nevertheless, as indicated above, the attitude of the staff is an issue of concern and affects the satisfaction of clients. The analysis shows that there is a strong association between these two variables (χ2 = 40.145; p = 0.001; α = 0.05). University of Ghana http://ugspace.ug.edu.gh 108 The nature and quality of services received at the health facilities also affect the satisfaction of clients which eventually affect the implementation of the NHIS. First of all, the researcher sought to find out whether there are adequate accredited health providers for clients. The findings (as indicated in Table A11 in Appendix A) show that almost half (49.1%) of the respondents indicated that there are adequate NHIS accredited providers in their area. Nevertheless, a similar percentage (47.4%) also indicated that they are not satisfied with the operations of the NHIS. A correlation analysis showed that the availability of accredited health facilities does not significantly predict respondents’ satisfaction with the NHIS (p = 0.067; α = 0.05). This shows that client satisfaction is affected by factors other than the availability of accredited facilities. It is also an indication that there are enough accredited facilities in the study area and thus the people ignore that as a factor that determines their satisfaction with the NHIS. Other variables concerning the quality and nature of services received were also measured. These variables are indicated in Table A7 in Appendix A. The researcher further enquired how the physical conditions of the facilities affect the satisfaction of clients. Specifically, the researcher sought to find out whether the facilities available to the clients are in deplorable state or not. As indicated in Table A7 (in Appendix A), the responses to this issue were mixed. Although a greater proportion (39.1%) mentioned that the facilities available to NHIS subscribers are in good condition, close to that figure (35.3%) indicated otherwise. Thus, although some respondents are satisfied with the state of the health facilities they use, it cannot be generalised for all. The dissatisfaction rate, though lower than the satisfaction rate cannot be ignored and there should be steps to improve the conditions of health facilities available to NHIS subscribers. It can also be seen in Table A6 (in Appendix A) that respondents consider the poor state of health infrastructure and facilities as a major factor hindering the implementation of the NHIS. University of Ghana http://ugspace.ug.edu.gh 109 Furthermore, some respondents perceive that non-subscribers receive better service than NHIS subscribers (see Table A7 in Appendix A). On this issue, 61.6% of the respondents indicated that health workers are friendlier to non-subscribers than subscribers. Also, 60.1% of the respondents perceived that there are more staff available to non-subscribers than subscribers. However, responses from qualitative interviews conducted showed that it may not be totally true that there are more staff available to non-subscribers than subscribers. Some interviewees mentioned that in most accredited facilities, the number of NHIS subscribers exceed that of non-subscribers. With this situation, non-subscribers seem to be attended to quickly than subscribers which make the subscribers think that the non- subscribers are given priority treatment. Nevertheless, the figures indicate that this is an issue of concern and it can likely cause people not to renew their cards since they perceive that NHIS subscribers are discriminated against. It is therefore not unusual that respondents indicated that the ‘poor services’ available to NHIS clients is a factor hindering its (NHIS) implementation. Again, the responses in Table A7 (in Appendix A) show that although most accredited facilities do not charge fees, patients are sometimes forced to make payments due to delay in the payments of claims. For instance although only a third of the respondents (33.7%) indicated that they are made to pay fees (even as NHIS clients), more than half (51.6%) of them (total respondents) said they were forced to pay monies because providers complain of non-payment of claims. This indicates that the non-payment of claims has an adverse effect on clients’ satisfaction with the NHIS. In Table A6 (in Appendix A), some respondents indicated that the delay in the payment of claims is hindering the implementation of the NHIS. University of Ghana http://ugspace.ug.edu.gh 110 Taking all these factors into consideration, the researcher enquired from the respondents and the interviewees whether they perceive that NHIS card holders receive quality services than non-card holders. The responses to this issue are shown in Figure 4.2. A significant proportion of the respondents perceive that the quality of services being offered by the various health facilities to card holders is poor. As seen in Figure 4.2, more than a third of the respondents (34.1%) indicated that NHIS card holders get worse health care services than non-card holders. Figure 4.2: Respondents’ Perception on the Quality of Services Received by NHIS Subscribers Compared to Non-Subscribers The researcher also sought to ascertain whether there has been any change in the quality of healthcare services patients received under the NHIS. The responses to this enquiry are shown in Figure 4.3. University of Ghana http://ugspace.ug.edu.gh 111 Figure 4.3: Respondents’ Perception on the Quality of Services Received by NHIS Subscribers Over Time A further analyses of the quantitative data revealed that, the quality of services obtained at health care centres affect the satisfaction level of NHIS clients which consequently affect their participation in the scheme. A regression analysis showed that there is a positive relationship between the quality of service and the level of satisfaction. The resultant model from the regression analysis is shown below. y = 1.102 + 0.322x Where: y = level of satisfaction (dependent variable) x = quality of service Responses from the interviews show that the quality of service has not changed significantly from what used to exist. Most of the interviewees said that there have not been any changes in services rendered by the health facilities they use. For instance one interviewee said that: University of Ghana http://ugspace.ug.edu.gh 112 “Although I can see that the hospital I frequently visit is putting up a new building which shows some physical changes, the quality of services rendered has not changed. The nurses continue to talk to you anyhow, especially when you come with health insurance.” [Interviewee, Amasaman] This confirms results of the quantitative analyses. Although more than a third of the respondents (i.e. 34.8%) did not have any knowledge or refused to comment about the quality of service provided over time, more than a half of the remaining (i.e. 32.9% of the total respondents) indicated that there has been no change in the quality of service. This shows that there is quite a significant number who do not see any changes in the quality of care over time. Also, almost a quarter of the respondents (22.7%) indicated that the quality of services has gone worse over time (see Figure 4.3). Viewing this issue from a different perspective, an interviewee had this to say: “I know that there have been some changes. However, some people have preconceived ideas (especially as a result of previous experiences) before going to the hospital and so do not notice minor changes such as slight reduction in waiting times and service times, slight increases in the number of workers and changes in attitude. Also some of the changes are not visible to patients such as replacing machines at the lab, etc., so these people will say there have not been changes when there have.” [Interviewee, Dome] The quantitative analyses also showed that although majority of the respondents indicated that the quality of services over time has either remained the same or worsened, there were still others who perceived the quality of services to have improved over time. University of Ghana http://ugspace.ug.edu.gh 113 The researcher also assessed respondents’ overall satisfaction with the NHIS. The analyses show that as much as 47.3% of the respondents were dissatisfied with the NHIS (see Figure 4.4). Only 18.0% indicated that they were satisfied with the scheme. Most respondents indicated that they were not satisfied because they were not given the necessary attention and care at the health facilities as well as at the NHIA offices. They were mostly concerned about the attitudes of workers in these institutions. Figure 4.4: Respondents’ Overall Satisfaction with the NHIS The researcher also sought to find how the level of satisfaction predicts respondents’ perception of the success of NHIS implementation. This analysis is shown by the regression model provided in Box 4.1. Box 4.1: Regression Model: Effect of the Level of Satisfaction on the Success of Implementation of NHIS Where Y = the perception on the success of NHIS X = the level of satisfaction with the NHIS University of Ghana http://ugspace.ug.edu.gh 114 The regression analysis showed that there is a strong relationship between the variables (r = 0.871). Additionally, an R2 of 0.758 and an adjusted R2 of 0.757 is an indication that over 75% of the variations in Y are explained by X. This implies people’s perception about the success of implementation of the NHIS is to a large extent determined by their satisfaction with it. Thus client satisfaction is a major factor that affects the implementation of the NHIS. 4.3.3 External (PEST) Factors Further on the factors affecting the implementation of the NHIS, the researcher sought to ascertain the effects of political, economic, social and technological factors on it. In doing this, the researcher employed the use of the correlation and chi-square analysis to test how political factors, social factors, and economic factors have affected the implementation of the national health insurance scheme (See Box 4.2). Box 4.2: Correlation and Chi-Square Analyses of the Factors Affecting the Implementation of the NHIS Factors X1 X2 X3 X4 X5 Correlations 0.046 -0.382 0.192 -0.026 0.171 Sig (p) 0.447 0.000 0.060 0.592 0.000 Chi-Square 65.130 201.0 125.7 121.3 78.352 Sig (p) 0.000 0.000 0.040 0.002 0.000 Where x1 = the district assembly x2 = economic factors x3 = social factors x4 = political factors x5 = religious organisations University of Ghana http://ugspace.ug.edu.gh 115 Political Factors The study examined how political factors affect the implementation of the NHIS. Concerning national politics, the variables measured showed an insignificant negative/inverse linear relationship with the perception of success of the National Health Insurance Scheme (NHIS) (r = -0.026; p = 0.592). Nevertheless, a chi-square analysis showed an association between the two variables (χ2 = 121.3; p = 0.002). This revelation shows that although there is an association between political factors and the perception of success of the National Health Insurance Scheme (NHIS) this association is not linear and linear measures cannot give an accurate description of this association. This is a depiction of the complex relationship between the environment and the system. Thus although the study shows political factors do affect the success of the implementation of the NHIS, the effect is not simple and direct but rather complex and indirect. To give a further explanation on how the political factors affect the implementation of the NHIS, Table 4.7 summarises the variables measured and the analysis of these variables. Table 4.7: Influence of Political Activities on the NHIS Strongly Disagree Disagree Neutral Agree Strongly Agree Count % Count % Count % Count % Count % Uninterested due to over-politicisation 71 17.1 96 22.7 94 22.3 84 19.9 76 18.0 Scheme jeopardised by unfulfilled political promises 69 16.4 48 11.4 50 11.8 111 26.3 144 34.1 Aware of NHIS due to politicisation 118 28.0 117 27.7 94 22.3 61 14.5 32 7.6 Negative political statements adversely affecting NHIS 69 16.4 53 12.6 79 18.7 109 25.8 112 26.5 University of Ghana http://ugspace.ug.edu.gh 116 As indicated earlier, the model shows minimal negative relationship between the political factor and the perception of success of the scheme. Additionally, Table 4.7 makes some interesting revelations. As shown in Table 4.7, respondents perceive that the current trend of politicisation of the NHIS to has had more negative than positive consequences. A greater percentage of the respondents indicated that unfulfilled political promises about the scheme are jeopardizing the future of the scheme (60.4%). Again more than half (52.3%) of the respondents were of the view that negative statements made by some political parties about the NHIS is jeopardizing the future of the scheme. However, those who indicated that the politicisation of the scheme has helped create awareness were less than a quarter of the total respondents (22.1%). Also, a significant proportion (37.9%) of the respondents indicated that the over-politicisation of the scheme has killed their interests in it, although those who indicated otherwise were more (39.8%). When considered individually, two of the political variables had significant relationships with the respondents’ perception of success. These variables are the effects of unfulfilled promises, and the effects of negative statements by some political parties on the NHIS. The regression model that revealed these relationships is shown below. Table 4.8 Correlation and Chi-Square Analyses of Political Variables and the Success of the Implementation of the NHIS Variables X1 X2 X3 X4 Correlation 0.027 -0.018 0.015 -0.051 Sig (p) 0.578 0.709 0.761 0.296 Chi-Square 33.231 37.970 19.793 15.030 Sig (p) 0.000 0.000 0.230 0.522 University of Ghana http://ugspace.ug.edu.gh 117 Where: X1 represents The over-politicisation of the NHIS has killed my interest in it X2 represents Unfulfilled political promises about the scheme is jeopardizing the future of the scheme X3 represents I became aware/had renewed interest in the NHIS as a result of the intense politicisation X4 represents Negative statements made by some political parties about the NHIS is jeopardizing the future of the scheme The analysis provided in Table 4.8 showed no linear relationship between the political variables and the success of the NHIS. However, there were statistically significant associations between two of the variables and the success of the NHIS. The study showed that unfulfilled political promises has affected the success of the NHIS as there is a statistically significant association between the two (χ2 = 37.970; p = 0.000). Also, over- politicisation of the NHIS has a non-linear association with the success of the NHIS (χ2 = 33.231; p = 0.000). Considering these complex non-linear associations between these variables it is evident that what politicians say and do can have dire consequences on the NHIS and its success. This is an indication that over-politicisation of the scheme can be detrimental to its success. However, politicisation can have its own positive effects. It can, and to some extent publicise the NHIS. Although the positive effects this has on the success of NHIS is not statistically significant, the correlation coefficient shows that such publicity can positively affect the implementation of the NHIS. However, the NHIS is more likely to succeed if politicians divert more energy into sensitising the people on the NHIS and encouraging them to join. It became apparent from the interviews that such sensitisation will help increase the enrolment rates since a significant number of people have confidence in their political leaders. University of Ghana http://ugspace.ug.edu.gh 118 Some other respondents also indicated that the political will has also been a factor which has facilitated the implementation of the NHIS (as shown in Table A5 in Appendix A). On this issue, an interviewee indicated that: “Although there have been different governments during the implementation of this scheme, they have all given priority to the success of its implementation.” [Interviewee, Dodowa] Other findings point to the fact that the various governments have been committed to ensure effectiveness in all aspects of the implementation of the policy. One other interviewee indicated that politicians even in opposition are committed to the successful implementation of the scheme. Having this notion, she commented that: “Opposition parties help put the ruling government on its toes by criticising it. This consequently affects the implementation of policy positively.” [Interviewee, Dome] At the local level, the study sought to ascertain how the district assembly (as the main political institution) has affected the implementation of the NHIS. Just like the national level political variables, the activities of the district assembly did not have a direct or linear relationship with the success of the implementation of the NHIS (r = 0.046; p = 0.447; α = 0.05). However, there is an association between the two (χ2 = 65.130; p = 0.000; α = 0.05), which can be thought of as complex. Two main variables were measured for the district assembly. These variables are respondents’ perception on how the district assembly has sensitised and encouraged people to join the NHIS and the second was how the district assembly has supported the implementation of the NHIS. The responses to these are shown in Table 4.9. University of Ghana http://ugspace.ug.edu.gh 119 Table 4.9: Respondent’s Perception on the Contribution of the District Assembly to the NHIS Strongly Disagree Disagree Neutral Agree Strongly Agree Count % Count % Count % Count % Count % The District Assembly encourages people to join the NHIS 68 16.1 59 14.0 115 27.3 128 30.3 52 12.3 The district assembly supports the NHIS 77 17.5 74 18.2 100 23.7 114 27.0 57 13.5 Table 4.9 shows that the respondents’ rates of agreement with both issues were higher than their rates of disagreement. However, about a quarter of the respondents in each instance decided to be neutral on this issue. In general, respondents who decided not to agree (strongly disagree, disagree and neutral) were more than those who agreed (agree and strongly agree) (see Table 4.9). Also, the high rate of neutrality is an indication that the district assembly might be less active when it comes to the issue of the national health insurance scheme. Thus the assembly’s support to the implementation of the NHIS has not been strongly felt by the residents. Nevertheless, although not significant, there is a positive relationship between the contribution of the district assembly and the perception of the success of implementation of the NHIS. Interviews with management at the NHIA district offices also revealed that there are adequate legal provisions for the NHIS. Interviews and desk study revealed that the law that brought the NHIS to being is the National Health Insurance Scheme Act, 2003 (Act650). This Act was backed by a legislative instrument L.I. 1809. This law was replaced by the National Health Insurance Act of 2012, Act 832. Without political discourse, these bills could not be passed into law. Interviewees again revealed that with the chief executive and the board University of Ghana http://ugspace.ug.edu.gh 120 members and chairman being political appointees, politics will continue to infiltrate into the NHIS. Also, as the interviews revealed, although work on health insurance had started earlier, the NHIS was largely an outcome of the need to honour a political campaign promise. These interviewees were of the view that without politics, there cannot be NHIS, and the politics started right from the conception of the idea of health insurance, through to its implementation. The MIS manager at the Dangme West District office of the NHIA mentioned that: “… the NHIS cannot be devoid of politics and the current political atmosphere cannot ignore the NHIS. The issue that is disturbing is not politicisation but over politicisation”. [MIS Manager, Dangme West] Economic Factors The analysis provided in Box 4.2 shows that economic factors have statistically significant linear correlation with the success of the NHIS (r = -0.382; p = 0.000; α = 0.05). There is also evidence of a strong association between the two (χ2 = 65.130; p = 0.000; α = 0.05). However, although there is evidence of a linear relationship, there can also be non-linear relationships between these variables. There is therefore the need to consider linear and non- linear measures when measuring the strength of the effect and relationship. To better understand the effect of the economic factors, the study analysed how individual factors affect the success of the implementation of the NHIS. The analysis of these enquiries are summarised in Table A8 in Appendix A. The figures shown in Table A8 (in Appendix A) clearly depict (as shown in the model) that the NHIS has had a significant effect on the economic conditions of the people. For instance, almost half (49%) of the respondents specifically indicated that their participation in the NHIS has reduced their expenditure on health and has reduced their cost of living. Also, University of Ghana http://ugspace.ug.edu.gh 121 44.8% of the respondents believe that the NHIS has been a relief to their households economically. Furthermore, 48.1% of the respondents indicated that the current economic trend is a major reason why they registered with the NHIS. This is a major indication that the economic situation of the people has an influence on their decision to join the scheme and its consequent success. A further correlation and chi-square analysis showed that there is a strong association between these variables and the success of the implementation of the NHIS. The results of these analyses are shown in Table 4.10. Table 4.10 Correlation and Chi-Square Analyses of Economic Variables and the Success of the implementation of the NHIS Variables X1 X2 X3 Correlation -0.184 -0.324 -0.380 Sig (p) 0.000 0.000 0.000 Chi-square 55.246 76.925 115.8 Sig (p) 0.000 0.000 0.000 Where X1 represents decision to register due to current economic conditions X2 represents the level of agreement that the NHIS has reduced expenditure on health X3 represents the level of agreement that the NHIS has been an economic relief The analyses in Table 4.10 show statistically significant linear associations between the variables and the success of the implementation of NHIS. This shows that that the people will perceive the NHIS to have been successfully implemented if their economic burden on health is reduced. In other words a successfully implemented NHIS will reduce the peoples’ economic burden on health. This finding is not out of place as a core objective of the NHIS is to reduce and eventually eliminate catastrophic health expenditure. University of Ghana http://ugspace.ug.edu.gh 122 The study also sought to identify whether the premium amount has been a barrier to people and prevented them from joining the scheme. Responses to this issue (as shown in Table A8) show that the premium payment has not been an obstacle for majority of the respondents (65.2% of the respondents). Those who admitted that premium payment was a problem for them due to the economic condition constituted 19.4% of the respondents. Thus it cannot be generalised that premium payment has been a barrier to people joining the scheme. Nevertheless, according to some interviewees, to ensure success of the scheme, the selection of the poor to be exempted should be streamlined so resources are not diverted to the rich who can pay. Also there is the need for the private sector to complement government’s effort by supporting some of the poor. Another variable incorporated into the economic factor was the average decrease in health expenditure. Respondents were asked about the average reduction in health expenditure as a result of the health insurance. In all 248 respondents who were active cardholders responded to this question. The results are shown in Table 4.11. Table 4.11 evidently shows that the reduction in health expenditure has an effect on the respondents’ perception of the success of implementation. In other words the burden of health expenditure has a relationship with respondents’ perception of the success of implementation. This relationship is expected because one of the main objectives of the NHIS and the NHI Policy is to reduce the burden of health on the people. Thus the more the burden is reduced the more successful will be the scheme. In Table 4.11, about 70.6% (i.e.14.7% of respondents with health insurance) of respondents who had their health expenditures reduced by 90% or more indicated that the NHIS has been a success so far. Less than 10% (9.8%) of respondents in this category indicated otherwise. University of Ghana http://ugspace.ug.edu.gh 123 Table 4.11: Average Reduction in Health Expenditure of NHIS Participants The NHIS has not been successful Neutral The NHIS has been successful Total Count % Count % Count % Count % A v . re d u ct io n i n h ea lt h e x p en . 90% + 5 1.9 10 4.0 36 14.7 51 20.6 70 – 89% 3 1.2 17 6.9 27 10.9 47 19.0 50 – 69% 7 2.8 21 8.3 23 9.4 51 20.6 20 – 49% 27 11.0 27 10.7 15 6.1 69 27.7 < 20% 18 7.1 6 2.4 6 2.6 30 12.1 Total 62 24.0 80 32.3 111 43.7 248 100 A further interview revealed that most of such respondents have had a bad experience with NHIS staff during registration or health workers when accessing health care. On the contrary, most (60%) of the respondents who have not really experienced much decline in health expenditure (having 20% or less decrease in health expenditure) judged the NHIS to be unsuccessful. Nevertheless within this same category, 20% of the respondents judged the NHIS to be successful. This indicates a relationship between the average reduction in health expenditure of individuals and households and their perception of the success of the NHIS. A Pearson correlation test confirmed this relationship (r = -0.465; α = 0.05; p = 0.000). The correlation shows that there is an inverse relationship between the variables. Furthermore a chi-square (χ2) test of association showed a significant association between these two variables (χ2 = 137.458; α = 0.05; p = 0.000). It can therefore be concluded that respondents’ perception about the success of the NHIS is dependent on the reduction in their health expenditures. With the inverse relationship depicted by the Pearson correlation, it can be deduced that the University of Ghana http://ugspace.ug.edu.gh 124 extent of the reduction health expenditure of NHIS subscribers affects their perception of the success of the scheme. The higher the reduction, the more successful they perceive the NHIS to be. The researcher again sought to investigate if the levels of income also have an effect on respondents’ perception of the success of the NHIS. The results of this are shown in Table A12 in Appendix A. The Analysis does not depict any significant relationship between the average incomes of the respondents and their perception of the success of the NHIS. In all income ranges, more people indicated that the NHIS has been successful than those who indicated otherwise. There is not a clear trend of people’s perception of the success of the NHIS depending on their levels of income. Although a Pearson correlation test revealed an inverse relationship between the two, a p-value of 0.641 shows that, the relationship is not statistically significant and cannot be used to make any inferences. Therefore it can be said, based on these findings that the income levels of people does not affect their opinion on the success or otherwise of the NHIS. In all, correlation coefficient indicates a negative relationship between the economic situation of the people and the success of the NHIS. This shows that people who perceive that the NHIS scheme has been successfully implemented are likely to be those whose economic burden has been significantly reduced by the NHIS. Thus people will perceive the NHIS to be a success once they experience significant reduction in their economic/financial burden on health as a result of the NHIS, and feel more relieved. In other words, one important factor that affects peoples’ perception about the success of the NHIS is their health expenditure. When this expenditure decreases significantly as a result of the NHIS, then the policy/scheme University of Ghana http://ugspace.ug.edu.gh 125 is seen as successful. When the expenditure is same or the decrease is not significant for the people to feel relieved, then the NHIS is seen as a failure. Also according to Table A5 (in Appendix A) the most mentioned factor (by 13.5% of the respondents) facilitating the implementation of the scheme was the fact that the NHIS has proven to be a relief to some households and has provided financial protection. As such for the quest for financial protection and relief, people have decided to always renew their membership while new people also join. Findings from qualitative interviews supported this. Majority of the interviewees were of the view that with the introduction of the NHIS and their subsequent participation, their expenses on health has been reduced to an average of 15% to 20%. This they indicated that has been the reason why they will always renew their insurance. Interviews with officials from the district offices of the NHIA in the four districts under study indicated that the economic effect of the NHIS is the most important to the scheme. The district manager at Ayawaso district for instance said that: “One goal the NHIA wants to achieve is to ensure that people don’t pay anything to access healthcare.” [District Manager, NHIA, Ayawaso] The interviewees mentioned that the NHIS is considered successful when out-of-pocket health expenditure decreases. Thus the success of the health insurance is directly related to the economic condition of the people. Social Factors The PEST analytical framework shows that another important segment of the environment that will significantly affect an intervention such as the NHIS is the social segment. The study University of Ghana http://ugspace.ug.edu.gh 126 therefore sought to ascertain how this all important segment has affected the successful implementation of the NHIS. Chi-square analysis provided in Box 4.2 show a statistically significant association between social factors and the successful implementation of the NHIS (χ2 = 125.7; p = 0.040; α = 0.05). Additionally, there is a minimal direct linear relationship between the two (r = 0.192; p = 0.060; α = 0.05). Although this linear relationship is not statistically significant, it is an indication that social factors to some extent affect the successful implementation of the NHIS. However, the significant association between social factors and the successful implementation of the NHIS shows that there is an indirect and complex relationship between the two. However the degree of complexity of the relationship was not measured as it is beyond the scope of this study. Nevertheless, this finding is a guide to future researchers in this field that simple linear measures might not be appropriate to measure the effect of social factors on the implementation of an intervention such as the NHIS. The variables combined as the social factor and the responses to those variables are indicated in in Table A9 (in Appendix A). It can be observed from Table A9 that respondents mostly disagreed with all the issues except the fact that their communities encourage people to join the NHIS. This is an indication that most of the respondents to not associate these issues with the NHIS. Nevertheless, these issues cannot be completely neglected as may have some influences on the success of the NHIS. For instance, almost a third (29.6%) of the respondents indicated that their families’ influence played a key role in their decision to or not to join the scheme. As such the influence of the family to the success of the NHIS cannot be ignored. Also, society’s views on the NHIS and its treatment of NHIS subscribers cannot be ignored. For instance, 27.5% of the respondents indicated that their respective societies perceive NHIS subscribers as having a lower social status. This issue if not properly addressed can affect the success of the NHIS negatively. The issue of some social groups University of Ghana http://ugspace.ug.edu.gh 127 being given priority treatment under the NHIS was also supported by 27.8% of the respondents. This issue can also be detrimental to the success of the scheme if the scheme subscribers perceive it as discrimination. However, if those given priority treatment are persons the general society recognises as having higher statuses such as chiefs, senior civil and public servants, etc., or the vulnerable such as the elderly, children and pregnant mothers, then it will not affect the success of the scheme. Also, 15.6% of the respondents indicated that NHIS subscribers are given priority during social functions. If this is the case, especially in rural areas, it will encourage more people to join the scheme. Nevertheless none of these issues significantly affected the respondents’ perception about the success of the NHIS. Further on this, a bivariate correlation test was employed to investigate whether there are significant correlations between the variables as well as with respondents’ perception about the success of the NHIS. The results are shown in Table 4.12. Table 4.12: Correlation Matrix – Relationship between Social Variables X1 X2 X3 X4 X5 X6 X7 X1 1 X2 0.110* 1 X3 0.218* 0.426* 1 X4 0.163* 0.316* 0.345* 1 X5 -0.005 0.041 0.027 0.036 1 X6 0.028 0.164* 0.083 0.091 0.180* 1 X7 0.264* 0.010 0.069 0.069 -0.003 -0.064 1 Where: X1 represents My community encourages residents to participate in the NHIS X2 represents NHIS participants are given priority during social functions X3 represents My participation in the NHIS has improved my social relations University of Ghana http://ugspace.ug.edu.gh 128 X4 represents Some social groups are given priority treatment under the NHIS X5 represents Society sees participants of the NHIS as having a lower social status X6 represents My family influenced my decision to/not to join the NHIS X7 represents Perception of the implementation success of the NHIS * shows that the correlation is significant at α = 0.05 The correlation matrix in Table 4.12 shows that only one variable has a significant correlation with respondents’ perception of the success of the NHIS. This variable measures whether communities encourage and sensitise their residents to join the NHIS. There was a significant positive correlation between the two. First of all, it must be noted that without communities accepting the NHIS, they won’t encourage their residents to join it. Therefore that variable invariably measures community acceptance of the NHIS. Thus the greater the community acceptance, the more likely the people will have a positive image of the scheme and consider it successful. Thus community acceptance is a necessary to the success of the NHIS. It can be again realised in the correlation matrix that some variables are also correlated with X1. These include X2, X3 and X4. This shows that as ones social relations is changed positively as a result of registering with NHIS, the person in-turn encourages others to join. This implies the more people’s social relations are changed by their participation in NHIS, the more they will encourage others to join. This will then contribute to the success of the scheme. Another dimension of the social factors that that was of interest is the contribution of the religious organisations (see Box 4.2). The correlation and chi-square analysis provided in Box 4.2 show a statistically significant association between the contribution of religious organisations and the implementation of the NHIS (χ2 = 78.352; p = 0.000; α = 0.05). A Spearman correlation showed that there is a linear relationship between the two (r = 0.171; p University of Ghana http://ugspace.ug.edu.gh 129 = 0.000; α = 0.05). Religious organisation has contributed to the NHIS in two main ways. First of all, they have been sensitizing their members to join the NHIS. Secondly, they sometimes provide support and sponsorship for their members to join the NHIS. The study therefore sought to establish how they have contributed to the implementation of the NHIS. Table 4.13 summarises the results obtained for these two variables. Table 4.13: Contribution of Religious Organisation to the NHIS Strongly Disagree Disagree Neutral Agree Strongly Agree Count % Count % Count % Count % Count % Sensitisation by religious organisations 65 15.4 54 12.8 92 21.8 144 34.1 67 15.9 Sponsorship by religious organisations 66 15.6 78 18.5 123 29.1 103 24.4 52 12.3 Table 4.13 shows that religious organisations religious organisations have encouraged people to join the scheme more than they have financially supported people to join. The figures in the table show that about 60% of the respondents indicated that their religious organisations encourage people to join the NHIS. On the other hand, those who indicated that their religious organisations financially sponsor people to join the scheme constituted 46.7%. These figures show the importance of religious bodies in the implementation of the NHIS and its eventual success. Correlation and chi-square analyses showed that these variables have significant association with the success of the implementation of the NHIS. The results of these analyses are shown in Table 4.14. University of Ghana http://ugspace.ug.edu.gh 130 Table 4.14 Correlation and Chi-Square Analyses of the Activities of Religious Organisations and the Success of the Implementation of the NHIS Variables X1 X2 Correlation 0.180 0.112 Sig (p) 0.000 0.021 Chi-square 43.718 47.137 Sig (p) 0.000 0.000 Where X1 = Religious bodies encouraging people to join the NHIS X2 = Religious bodies sponsoring people to join the NHIS The correlation and chi-square analyses provided in Table 4.14 indicate significant associations and correlation between the activities of religious organisations and the success of the implementation of the NHIS. This shows that religious organisations have had and continues to have a significant role to play in ensuring the success of the NHIS. Although the relationships are less linear as depicted by the correlation coefficients in in Table 4.14, the results of the chi-square tests show that there are strong associations. For instance, the results in Table 4.14 show that the direct increase as a result of the sponsorship drive of the religious organisation by assisting some of their members to register for the NHIS will lead to about 1% increase in NHIS membership (this computation is based on the square of the r to get the coefficient of determination) and as such may not be a statistically significant predictor of the success of the NHIS. However, this drive of the church may set in motion other social and economic processes such as the beneficiaries encouraging others to join, or using their resources to also assist others, or being an example for other wealthy church members to also individually support the needy to join the scheme. These other processes will then have a significant effect on the success of the NHIS. University of Ghana http://ugspace.ug.edu.gh 131 Additionally, the religious organisations may sensitise and encourage their members to join the scheme and this will have a minimal direct effect on the success of the scheme. This will however create the awareness and some members will first want to observe the benefits others will derive from joining the scheme or will ascertain whether the religious leaders have registered for the NHIS before they also decide to join and even encourage others to join. This is therefore an indication that the indirect effects of the activities of the religious activities are much more that the direct effects on the implementation of the NHIS. Thus a linear measurement, such as linear regression may not be appropriate. However, non linear models will be more appropriate to measure the effect of religious activities on the implementation of the NHIS. This is not included in this study as it is beyond its scope. However, it is a recommendation for future research in this area. The qualitative data collected also provided information to support the quantitative findings. For instance, the interviews revealed that the religious organisations do more than just simply encouraging their members to join. On this issue, an interviewee mentioned that: “Religious bodies have been involved in the education/sensitisation of members on the NHIS. Additionally, during mass registration exercises, some religious bodies give out their premises to be used as registration centres.” [Interviewee, Dome]. The foregoing analyses show that religious bodies have some influences on the success of the NHIS and cannot be ignored. To conclude on this issue, the respondents indicated that there has been a wide acceptance of the NHIS and this is a factor that has facilitated its implementation (as shown in Table A5 in Appendix A). This acceptance as indicated by the respondents has been as a result of the University of Ghana http://ugspace.ug.edu.gh 132 active involvement of all stakeholders (including religious bodies, opinion leaders and the traditional authorities) in the creation of awareness on the importance of participating in the NHIS. One interviewee added that the acceptance is been demonstrated by congestion at the registration centres. Some interviewees also indicated that though the registration process has been slow and frustrating, people bear all the inconveniences because of the general acceptance and quest to participate in the scheme. This shows that the public has not just accepted the scheme but participation has been increasing. Respondents indicated that the increasing enrolment has been a facilitating factor which has positively affected the implementation of the NHIS. The increasing enrolment, according to the respondents, has been a factor motivating others to join the scheme. Technological Factors Finally, the researcher sought to ascertain effects technological factors on the implementation of the NHIS and how they had facilitated or hindered the implementation of the NHIS. Data on this was obtained mainly through qualitative interviews. Interviews with some managers at the NHIA district offices indicate that technology has been a factor that has had a positive influence on the implementation of the NHIS. Their basis was with the introduction of the biometric system. They indicated that the biometric system has had several effects on the NHIS such as the reduction in waiting times since cards are issued instantly. The interviews further revealed that another way by which the biometric system has positively affected the NHIS is the reduction in subscriber fraud (although this has not been fully realised). Some managers indicated that the biometric authentication has reduced the incidence of impersonation, which has been one of the ways subscribers defrauded the system. The district manager of the Ayawaso district office of the NHIA mentioned that: University of Ghana http://ugspace.ug.edu.gh 133 “With the old magnetic cards, people could easily access healthcare with another person’s card since there was no means of verifying the owner. Also some people use their expired cards by photocopying the personal information on their expired cards with the validity information of another person’s valid card. However, there is more to be done since the authentication machines are woefully inadequate.” [District Manager, NHIA, Ayawaso] However, the responses from the questionnaires and other individual interviews indicated that although the biometric system is good, its implementation has been fraught with several problems causing delays and long queues at registration centres. They mentioned that unstable power supply, and disruptions in the internet connectivity have been major factors affecting the biometric registration process negatively. Responses from the interviews indicate that some people have been discouraged from registering with the NHIS due to the long delays at registration centres. Thus although the biometric system is good, the long delays at the registration centres are having a negative effect on the NHIS. In explaining the cause of the congestion at the registration centres, the claims officer at the Dome satellite office of the Ga District NHIS, mentioned that aside the problems with the network and the unstable power supply, people perceived that the biometric registration had a deadline and therefore rushed to register, even when their cards had not expired. Further on technology, another issue mentioned by the MIS manager at the Dangme West district office of the NHIA was the lack of system analysts at the district offices. According to him, there is the need to have system analysts who will ensure that systems designed meet operational requirements and local conditions, and are user friendly. He added that due to their absence, most district offices have been using generic systems which might not meet their local needs. University of Ghana http://ugspace.ug.edu.gh 134 It was revealed that the NHIA has also established an ICT centre to serve as a hub of its ICT developments. Also, interviewees mentioned that the NHIA has improved its system and software packages for claim processing and other activities; changing them from primarily manual systems to electronic ones. There has also been the use of the internet to network its facilities to enhance operations. These factors were identified in the interviews as factors facilitating the implementation of the NHIS. Further on technology, some interviewees mentioned that the provider payment technology (system) has undergone has undergone some changes. Claims payment began in 2005 as fee- for-service for all services (FFS) and drugs. In 2008, the Ghana Diagnostic Related Groupings (GDRGs) was introduced in 2008 for outpatient and inpatient services, while drugs still remained FFS. In 2012, the Authority began the introduction of the capitation system by piloting it in the Ashanti region. These, the interviewees said, are changes meant to lead to improvement in the NHIS. The technology being used by providers also emerged as a factor affecting the implementation of the NHIS. Some in-depth interviews with the residents of the survey districts mentioned that some accredited providers do not have modern technological systems and this affect the healthcare service they provide. They mentioned that some of these providers do not have diagnostic kits to diagnose common diseases such as malaria and therefore administer malaria treatment for all reported cases of fever. In cases where such treatments do not work, some people feel that they were given inferior treatment because they are NHIS subscribers, and this leaves a negative impression on their minds which can affect the implementation of the scheme. Also on this issue, an interviewee from Abelemkpe mentioned that: University of Ghana http://ugspace.ug.edu.gh 135 “Due to the lack of equipment and appropriate technology, patients are asked by some providers to have some tests or investigations done at a bigger hospital which causes inconvenience for the patients and congestion at these hospitals. To add to this, most of such patients will in future only patronise the bigger hospitals (even when the services they need can be provided by smaller hospitals) and further worsen the problem of congestion in these hospitals.” [Interviewee, Abelemkpe] Some interviewees also concluded that the technology some providers use makes some people lose confidence in the NHIS thus affecting it negatively. 4.3.4 Other Factors Affecting the Implementation of the NHIS Responses obtained from the participants (as shown in Tables A5 and A6 in Appendix A) of the study indicate that there are other factors affecting the implementation of the NHIS. Management of the NHIS Respondents indicated that the management of the NHIS is one major factor affecting its implementation. Respondents indicated that there has been improved coverage. This was confirmed by interviews with NHIA officials in the districts under study. These officials mentioned that there has not only been an increase in the number of NHIA district offices, but also there has been an increase in the number of NHIS accredited providers. The interviews also revealed that the NHIA has instituted several measures including the establishment of the ICT centre and claim processing unit as well as the institution of clinical audits. This, the PRO at Dangme West district office of the NHIA indicated that: “The institution better claims processing and management and clinical audits has resulted in significant savings.” [PRO, Dangme West – NHIA] University of Ghana http://ugspace.ug.edu.gh 136 They indicated that these interventions by management have to a large extent facilitated the implementation of the NHIS. Nevertheless, some other respondents specified that there has been improper management of the scheme. They explained that there have been instances of bribery and corruption, coupled with huge administrative expenditure, inefficiencies in the procurement system, and ineffective monitoring and supervision. As such in their view, some activities of management as well as their inefficiencies and negligence are stifling the smooth running of the scheme. Funding of the NHIS Inadequate funding was mentioned as a very important factor hindering the implementation of the NHIS. Interviews indicate that the current funding of the NHIS is not sustainable. The MIS manager at the Ga district for instance mentioned that the current expenditure exceeds the revenue. According to him, the current resources are overstretched and there is the need for more innovative funding. He added that if the deficits currently being experienced continue, the financial situation will worsen. However, he was optimistic that the scheme will not collapse and the government will definitely secure funds to sustain it. Nevertheless, all the interviewees admitted that without adequate funding, the scheme cannot run smoothly. Also concerning funding, most NHIA officials (scheme management staff) in the districts interviewed mentioned the current practice where the revenue realised from the NHIL is paid into the consolidated fund before making it available to the NHIA when needed has been a major setback. They added that such practice has been a major cause of the delay in the release of funds which has led to several problems (such as the delay in the payment of claims) which are adversely affecting the smooth running of the scheme. The Legal Framework of the NHIS Interviewees also mentioned that the current legal framework is a factor affecting the implementation of the scheme. Majority of them (5 out of 7) revealed that the current University of Ghana http://ugspace.ug.edu.gh 137 National Health Insurance Act 2012, Act 832 over-centralises the most of the activities/functions which is adversely affecting the operations of the schemes. On this issue, MIS manager of the Dangme West district of the NHIA retorted that: “The previous arrangement under the Act 650 is better than what we are currently experiencing under Act 832. We were allowed to set our own premiums to conform to the economic situation in the district and also manage the premiums collected internally which made us able to respond adequately to local needs. However the current practice where things are over-centralised is adversely affecting our ability to respond to local needs.” [MIS Manager, Dangme West – NHIA] However, the remaining two interviewees who lauded the new Act 832 mentioned that it ensures uniformity. Their responses also indicated that the new Act has helped seal loopholes through which scheme officials misappropriate funds and also ensures effective pooling of resources as poor districts can be supported by funds generated from rich districts. The Use of the NHIS Card for other Transactions Another issue investigated was whether people register for the NHIS because they need the card (which is recognised as a national identification card) for other transactions. The responses obtained for this enquiry are indicated in Figure 4.5. University of Ghana http://ugspace.ug.edu.gh 138 Figure 4.5: Responses to the Statement - “I joined the NHIS primarily because I need the card for other transactions” Figure 4.5 shows that majority (51.6%) of the respondents joined the NHIS for its own sake but not because they needed the card for other transactions. However, over a third (34.9%) of the respondents indicated otherwise. This shows that a significant number of people register for the NHIS for the purpose of receiving the card for other transactions. This is an indication that people may renew their insurance not because they are satisfied but because of the necessity of the card. 4.4 Relationships between the Factors Another objective of the study was to identify and examine the relationships between the factors affecting the implementation of the NHIS. As presented in the previous sections of the chapter, the implementation of the NHIS is either facilitated or hindered by several factors. The factors identified include the actors, client satisfaction, political factors, economic factors, social factors and technological factors. To identify the relationships between these factors, the researcher made use of correlation analysis. However the correlation analysis did not include all the factors identified. Data for some of the factors were mostly qualitative and could not be analysed quantitatively. These factors are the actors and technological factors. University of Ghana http://ugspace.ug.edu.gh 139 However, the qualitative responses indicated some relationships between these factors and the others. Interview responses indicated that the implementing actors are influenced by the general environment which includes the political, economic, social and technological factors. The responses from the field show that as expected there is a strong relationship between the actors and all the other factors. Although there is a general consensus that technology affects every aspect of society, the interviewees from the district offices of the NHIA were of the view that of all the factors, it (technology) mostly affects client satisfaction. They argued that technological interventions are to improve service delivery and ensure client satisfaction. However, one of these interviewees added that the technological factor has far reaching effects which affects all other factors directly or indirectly. The relationships between the other factors are shown in Table 4.12 Table 4.15: Correlation Matrix – Relationships between Factors Affecting the NHIS Political Economic Social Client Satisfaction Political 1 Economic 0.348* 1 Social 0.339* 0.349* 1 Client Satisfaction 0.465* 0.285* 0.267* 1 * shows that the correlation is significant at α = 0.05 The correlation matrix in Table 4.12 shows significant positive relationships between all the factors. The strongest correlation is between the political factor and client satisfaction, and the weakest is the social factor and client satisfaction. Again, it is only the political factor that University of Ghana http://ugspace.ug.edu.gh 140 had correlations of above 0.3 with all the other three factors. Interview findings and responses from the survey has revealed that politics has been part of the NHIS since its inception. One interviewee mentioned that there is politics in all aspects of the NHIS. She retorted that: “When the NHIS is failing, opposition parties will use it for political gain, and when it is succeeding, the ruling party will want to score political points with it.” [Interviewee, Dansoman] With these findings, it is expected that politics will have a significant relationship with all the other factors. The interviews further revealed that the extent of political activity is mainly dependent on client satisfaction with the NHIS and the economic situation of the people. Also the correlation revealed a moderately strong relationship between the social and economic factors. This relationship is expected as one’s social status and acceptance has a strong relationship with the person’s economic status. The significant correlations between the factors may be an indication that changes in one factor is likely to be the cause of changes in the other. This shows that none of these factors should be ignored even if it has a little direct impact on the success of the NHIS. 4.5 Conclusion The chapter presented the major findings of the qualitative and quantitative data on the factors affecting the implementation of the National Health Insurance Scheme. The analysis show that the implementation of the NHIS is affected by various factors including actors, client satisfaction (i.e. ability to meet expectations of clients), external factors (which include political, economic, social and technological factors). The analysis also showed the existence of complex relationships between these factors. University of Ghana http://ugspace.ug.edu.gh 141 The study found that economic factors had the most significant influence on the implementation of the NHIS. The economic condition of the people was identified as a factor that motivated them to join the scheme. The political factor was also seen as significantly affecting the implementation of the NHIS. The NHIS being a social policy and appealing to the masses has attracted political interferences in all aspects of its implementation. It was found that pronouncements made on political platforms have in a way affected the implementation of the NHIS. Social and technological factors were also found to be significantly affecting the NHIS implementation process. Finally, it was found that there existed significant relationships among these factors. The political factors were found to be strongly related to all other factors. The following chapter discusses the findings presented in this chapter. University of Ghana http://ugspace.ug.edu.gh 142 CHAPTER FIVE DISCUSSION OF FINDINGS 5.0 Introduction This chapter discusses the findings of the study. It examines the contribution of the research findings to the key issues of this research. It focuses on the implications of the research findings, identifies the contribution to knowledge and makes suggestions for future research. In doing these, the chapter seeks to answer the research question posed in the introduction of the study; explains how the results presented in chapter four supports the answers; and fit in with existing knowledge on the topic. The first part of this chapter discusses the findings on respondent’s participation in the NHIS. The discussion centres on the rate of participation as well as the demographic (personal) factors that affect ones decision to enrol in the NHIS. The second part then focusses on the discussion of factors affecting the implementation of the NHIS. This part starts with the most important elements in an implementation process; the actor who make the decisions. Further on these factors, the chapter views the implementation of the NHIS through the systems theoretical lens and discusses the factors at the input, conversion and output stages, as well as environmental and feedback factors. The third part of the discussion presents the revised framework based on the findings and discussion. 5.1 Respondent’s Participation in the NHIS The findings of the study provided in chapter four reveals that 76.3% of the respondents had registered for the National Health Insurance and 58.8% (of the sample) had valid NHIS ID University of Ghana http://ugspace.ug.edu.gh 143 cards. However, these figures cannot be generalised for the nation nor the Greater Accra Region since the sampling was non probability. Nevertheless, they indicate that there are people who have participated in the NHIS and have decided not to register again due to several reasons. It was also found that the proportion of female respondents (78.0%) who had registered for the scheme is greater than that of their male couterparts (74.5%). However, there were almost equal proportions of male and female respondents with valid NHIS ID cards (proportion of males: 57.6%; proportion of females: 57.9%). This is an indication that respondent’s particpation in the NHIS is not significantly affected by gender (χ2 = 0.196, p = 0.693 ‖ r = -0.022, p = 0.659). This however does not support the findings of some earlier researchers. A study by Abrebrese in the Shama district in Ghana revealed that gender, in addition to other factors such as dependency ratio, income, marital status and age determined health insurance participation. Asenso-Okyere’s (1997) study on the informal sector also identified sex (gender) as a factor that influences one’s willingness to pay for health insurance. However, there are other studies that also did not find any significant relationship between health insurance participation gender. Donfouet et. al.’s (2011) study in rural Cameroon for instance didn’t find any relation between people’s willingness to pay (WTP) for insurance and gender. Rather, other variables (knowledge of basic concepts of health insurance, income and social capital) had positive relationships with WTP. Other studies (Jutting, 2003; Savedoff and Sekhri, 2004; Bhandari, 2002; Mhere, 2013) have also not found any significant relationship between health insurance participation and gender. However most of these studies were conducted in other African countries. On the other hand, most studies conducted in Ghana on this issue found significant relationship between participation in health insurance and gender. University of Ghana http://ugspace.ug.edu.gh 144 Although this study did not find any significant relationship between gender and participation/enrolment in the NHIS, it doesn’t provide enough bases to refute earlier findings such relationship exist. Apart from the fact that the scope of the current study is differs from that of earlier studies, the respondents were selected using a non-probability sampling technique which affects its generalisability. Furthermore, the negative relationship (though not statistically significant) is an indication that more females have the propensity to participate in health insurance than the males. This supports the findings of the NDPC’s 2008 citizen assessment survey which found that more women were enrolled on the NHIS (NDPC, 2009). There is also empirical evidence that a female headed household increase the odds of enrolling in the NHIS (Jehu-Appiah et al., 2011). Nketiah-Amponsah (2009) explained that females have some vital health needs which makes it beneficial to enrol on the NHIS and that may explain their propensity to enrol than males. All these show that females are more inclined towards enrolling in the NHIS than males. However, considering the fact that most these studies were conducted outside the Greater Accra Region, this study serves as a basis for future research in the region to confirm or refute the hypothesis that gender is related to participation in health insurance in the Greater Accra Region. The analysis further showed that age is a determinant of respondents’ participation in the NHIS. There was a statistically significant positive correlation between the two (r = 0.110; p = 0.024). This showed that older people are more inclined to register for the NHIS than younger people. This finding supports that of Makoka et. al.’s (2007) study in Malawi on the determinants of health insurance. This study found that age significantly increases the probability of enrolling in health insurance. Asenso-Okyere’s (1997) study made similar revelations. The study showed a significant relationship between age and women’s willingness to pay for health insurance. Studies have shown that the burden of diseases increases with age and older persons are more vulnerable to illnesses. This makes health insurance necessary and possible (Pollack and Kronebusch, 2004). It is also generally University of Ghana http://ugspace.ug.edu.gh 145 asserted that age comes with a sense of responsibility as well as getting more knowledgeable so the older people get the more responsible they will be concerning their health. There have been other studies that have found a negative relationship between age and participation in health insurance. Mhere’s (2013) study in Zimbabwe found a significant negative relationship between age and participation in health insurance. Also Donfouet et. al. (2011) found that young people are willing to pay for health insurance than older people. Another demographic variable found to be a predictor of health insurance participation is marital status. The study found that unmarried persons participated in the NHIS than married ones. There was a negative relationship between marital status and participation in NHIS. This finding supports the finding of earlier researchers including Abebrese (2009) who found marital status to be a significant predictor of participation in health insurance. However it would have been expected that married people are more responsible and will take good care of their health and be willing to be register for health insurance. It is therefore recommended that future research critically examine the relationship between marital status and willingness to participate in health insurance especially in the Greater Accra Region. Income level was also found to be a partial predictor of participation in the NHIS. The study revealed that the higher one’s income, the more likely the person will participate in the NHIS. This finding is not out of place and it supports the work of some earlier researchers who had found income as a predictor of one’s participation in health insurance (e.g. Jehu-Appiah et al., 2011; Owusu-Sekyere and Chiaraah, 2014). Other variables investigated including educational level and employment status were not significantly related to participation in health insurance (NHIS) although several studies found significant relationships see (Mhere, 2013; Donfouet et. al., 2011; Abebrese, 2009). University of Ghana http://ugspace.ug.edu.gh 146 Participation in NHIS of 58.8% exceeds the national participation recorded in the year 2014 of about 41.6% (as revealed in the study based on 2010 population). The 58.8% participation rate is partly due to the fact that the researcher used a non-probability sampling technique to obtain the respondents. The discussion provided on the demographic determinants of participation revealed that the findings of the study have been partially consistent with literature. This partial consistency raises research questions for future research as indicated in the earlier discussion of the findings. The questions whether gender, educational level and employment status significantly affect participation in NHIS in the Greater Accra Region should be explored in the future. 5.2 Factors Affecting the Implementation of the NHIS The study identified numerous factors affecting the implementation of the NHIS. Kutzin (2008) identified the main function of a health financing system (such as the NHIS) as resource mobilisation, pooling of funds/risks and purchasing. The ability of the system to properly perform these functions determines its effectiveness and success. In the 2012 national report of the NHIA, it sought to perform these functions to realise its three main goals. These goals include 1) attaining a financially sustainable health insurance scheme; 2) To achieve universal financial access to basic health care services and 3) To secure stakeholder satisfaction (NHIA, 2013). To be able to achieve these goals set, the NHIA outlined the following objectives: 1. To mobilise 100% of the required funds by the end of 2014. 2. To increase efficiency in the financial operations of the scheme. 3. To increase active membership to 60% of the population by 2014. 4. To increase coverage of the vulnerable including the poor and the indigent to 70% by 2014. University of Ghana http://ugspace.ug.edu.gh 147 5. To provide support to increase access to quality basic health care services in all districts. 6. To strengthen governance systems and improve human resource capacity. 7. To improve the quality of services accessed by members in the national health insurance system. 8. To improve the level of provider experience within the NHIS. 9. To improve involvement and participation in health insurance programmes. (NHIA, 2012) The findings will therefore be discussed mainly on the objectives NHIS sought to achieve in relation to the main functions of a health financing system. 5.2.1 Actors To be able to achieve the objectives of the NHIS, the NHIA works together with other institutions and actors. The literature identifies actors as very important in the implementation process and can have significant influence on the success of the policy or programme (See Kamuzora and Gilson; 2007; Grindle and Thomas, 1991). Respondents considered the government to be the most important actor in the implementation of the NHIS. Considering the provisions of Act 852 (NHIS Law), the government has a lot to do in the NHIS. The Act recognises the role of the executive as well as the legislature in the NHIS (Republic of Ghana, 2012). Act 852 gives the President (who is the Head of the Executive) the sole prerogative of appointing the Board Members (Section 4(2)), the Chief Executive (Section 14(1)), and the staff of the National Health Insurance Authority (NHIA) (Section 16). Additionally, there was a considerable amount of Executive involvement during the drafting of the Bill (Agyepong and Adjei, 2008). Parliament as the legislative arm of government has been involved in the NHIS from the legislation stage to implementation stage. In Act 852, University of Ghana http://ugspace.ug.edu.gh 148 NHIS cannot spend from the NHIF without Parliament’s approval. The Authority (NHIA) is supposed to submit the appropriation Act to Parliament for approval (Section 42(2)). Parliament also monitors the revenue of the NHIA (Section 52(1)). Government is therefore seen as a major actor in the NHIS. Other scholars have confirmed the necessity for the government’s active involvement. Sikosana (2005) alluded that government’s involvement by enacting policy is very key to ensuring participation. He made mention of examples such as Mozambique, Zambia, Tanzania, South Africa and Zimbabwe whose introduction of public policy at inception induced participation. The government is also expected to participate in the NHIS by increasing the flow of funds and also provide health infrastructure and facilities to support it. Considering the enormous role of the government identified, it is not out of place if respondents rated it as the most important actor of the NHIS. The NHIA was also identified by the respondents as another key actor in the implementation of the NHIS that affects its success or otherwise. The Act 852 establishes the NHIA as a body corporate with perpetual succession (Section 1(1)); giving it the requisite authority (Section 2) to execute its core mandate of implementing, operating and managing the NHIS (Section 3(a)) (Republic of Ghana, 2012). As the main implementing agency, its desposition and that of key persons within it affect the success or otherwise of the NHIS (see Van Meter and Van Horn, 1975; Van Horn, 1978; Ross, 1984). With reference to the work of Grindle and Thomas (1991) the implementation of the NHIS will be affected by the personal attributes and goals; professional expertise and training; memories of similar policy experience; positional and power resources and political and institutional commitments and loyalties of the key actors in the NHIA. Considering the prime role the NHIA plays, it is evident that it affects the NHIS more than any other institution. University of Ghana http://ugspace.ug.edu.gh 149 The existing literature and the findings of this study also agree that health providers and health professional as key to the effective implementation of the NHIS (NDPC, 2008; Jehu- Appiah et. al., 2011; Asante et. al., 2013). The outcome of the NHIS is expected to be improved health condition (NHIA, 2012; Republic of Ghana, 2012), and this cannot be possible without the involvement of the health providers. Jehu-Appiah et. al (2011) in their study found that some factors affecting the implementation of the NHIS are the technical quality of care, perceived benefits and convenience of NHIS at the point of service, which are all determined by health providers. Barima and Mensah (2013) also found from their study that health provider behaviours significantly affect the implementation of the NHIS. Providers are thus seen as significant in the NHIS implementation system. The findings also indicate that aside these core actors; there are multiplicity of direct and indirect actors who affect the implementation of the NHIS. Even concerning health providers, there are different types of providers at different levels/grades and different regulatory agencies. Earlier scholars have acknowledged the possibility of multiplicity of actors during implementation (Ross, 1984; Pressman and Wildavsky, 1984) and have called for the need for clarity and effective organisation of the implementing structure (Gross et al., 1971). The multiplicity of actors of the NHIS is not seen as a core concern since the Act 852 provides the legal and institutional framework for effective management of these actors. The study adapted Easton’s political systems theory as its conceptual framework and considered the implementation of the NHIS as a system. The remaining part of this chapter therefore focusses on this conceptual framework to discuss the findings. The implementation of the NHIS is conceptualised as a system which has three main parts; inputs, conversion, outputs. These parts are affected by the environment which provides the inputs, impacts on the conversion stage and receives the outputs (Easton, 1957). University of Ghana http://ugspace.ug.edu.gh 150 5.2.2 Inputs The literature reviewed identified that the inputs to a system can be categorised as demand inputs and support inputs (Easton, 1957; 1966). Based on Easton’s (1957) conception of demand and support inputs, it can be argued that the NHIS as a system has a variety of these inputs. It was found from the study that the people (residents of Ghana and especially from the study areas) demand quality and affordable health care from the NHIS. These people also support the system through their general acceptance and participation in it. Resource support (especially financial, technical and human) was also identified (from the study) as a major input into the NHIS implementation system. The study again found that the resource support primarily came from the people (residents of Ghana), the government, and development partners. In providing this support, they (the people, government and development partners) demand that the system functions to fulfil its mandate as stipulated in the NHIS Law, Act 852. Although participation in the system is not as high as expected, the study found that there has been a general acceptance of the NHIS in the various communities. For instance, 47.1% of the respondents indicated that their communities encourage residents to participate in the NHIS. Also there has been a wide range of support from religious organisations by encouraging people to participate in the NHIS (as indicated by 50% of the respondents) and also by registering some of its members (as indicated by 36.7% of the respondents). The study also found that there have been instances where philanthropic organisations and individuals have provided support by sponsoring the registration of some individuals. There have been other studies that have also indicated that there is a general acceptance of the scheme (Nketiah-Amponsah, 2009; Asante et. al., 2013). University of Ghana http://ugspace.ug.edu.gh 151 To support the responses of the residents, providers also mentioned that the acceptance of the NHIS is forcing them to get accredited. They added that patronage drastically reduces when a provider (especially hospitals, clinics and other health care centres) is not accredited by the NHIA. From the foregoing discussion this research agrees with previous researches and the NHIA that there is a general awareness and acceptance of the NHIS; which is a significant input into the NHIS system. Nevertheless, the NHIA and some earlier researchers have found from their researches that actual participation is not as high as the acceptance (see Oxfam, 2011; Jehu-Appiah et. al., 2011). They attributed this to a myriad of factors including poverty and client dissatisfaction. The study also found funding to be a major input into the NHIS implementation system. Considering the necessity of funding as an input into the system, the NHIA sought to develop an all-encompassing, innovative funding technology right from the onset of the NHIS (NHIA, 2013; 2012; Agyepong and Adjei, 2009). All interviewees (managers of NHIA district offices and health providers) mentioned funding as critical to the survival of the scheme. The NHIA has admitted that the key factor that determines the sustainability of the NHIS is funding (NHIA, 2012). Thus ensuring sustainability of funding is a priority to the Authority and this has been reflected in its corporate goals (NHIA, 2012). Other researchers have also indicated the importance of funding and indicated the need to ensure its sustainability (Addae- Korankye, 2013). On the issue of sustainable funding, the study found (from the interviews with district managers) that the NHIA is currently considering some alternative funding methods to ensure that the scheme is sustainable. This indicates progress towards the achievement of the goal to ensure sustainable financing. Considering the implementation of the NHIS as a system, without adequate and sustainable funding it will likely experience entropy (see Easton, 1957). However, interviewees from the NHIA indicated that the system will never collapse due to its political nature. They mentioned that the ruling government at any time will find resources to sustain it. Nevertheless, the findings of the study show the University of Ghana http://ugspace.ug.edu.gh 152 importance of funding and how inadequate funding has led to malfunctioning of the system resulting in the delayed payment of claims among others. Jehu-Appiah (2015) for instance indicated that out of a total provider claims of 968.48 Million Cedis submitted to the NHIA in 2014, it was able to pay less than two-thirds leaving 360.4 Million Cedis (37.2%) outstanding. Such situations will definitely affect the NHIS adversely. The study again revealed that there have been varying demands on the NHIS from different sections of society. These demands have had great influences on the operation of the system (Easton, 1957; 1966). For instance the demands of the politicians on the NHIS serve as checks to ensure effective functioning of the NHIS. It was also revealed that the NHIS drug list is continuously revised to conform to demand. Results from the field indicate that there have been several demands which have caused the NHIA to modify its processes to ensure effective functioning. Based on these findings, the researcher agrees with Easton (1957) that the demands form a necessary input into the system that affects its processes and outputs. 5.2.3 Conversion Stage In Easton’s conceptualisation, the conversion stage is when inputs are tuned into outputs (Easton, 1966). The conversion stage represents the stage where the functions of the health financing system (revenue collection, pooling and purchasing) are performed (Kutzin, 2008; 2010; WHO, 2007). At this stage the NHIA seeks to (according to the corporate objectives for the period 2011 – 2014):  increase efficiency in the financial operations of the scheme;  increase coverage of the vulnerable including the poor and the indigent to 70% by 2014;  mobilise 100% of the required funds by the end of 2014;  strengthen governance systems and improve human resource capacity; and University of Ghana http://ugspace.ug.edu.gh 153  improve the level of provider experience within the NHIS. (NHIA, 2012) The study reveals that there are some factors that are affecting the smooth operation of the NHIA in performing its functions at this stage. Interviews show that there has been significant progress towards increasing the financial operations of the scheme. Notable interventions in this respect include the introduction of clinical audits, and the computerised processing of claims. However, the interviewees also mentioned that the depreciation of the Cedi and the energy crises in Ghana over the 2013/2014 period has eroded some of the gains made earlier. The economic and energy crises during this period led to increases in administrative expenditure as well as the cost of drugs and other medical equipment. This evidently shows how the environment can impact on the system processes. It was also found that the efficiency in financial operation have been stifled by delay in the release of funds by the Ministry of Finance (which collects the 2.5% National Health Insurance Levy (NHIL)) into the National Health Insurance Fund (NHIF). The study further shows that mobilisation of 100% of the needed revenue has also not been possible due to the inability of the NHIA to devise innovative funding mechanism to support the existing ones during the period. In 2014, the NHIA recorded a deficit of over 300 million Cedis (Jehu-Appiah, 2015). The economic situation in the country during then 2013/2014 period also led to increases in expenditure, making it difficult to mobilise revenues to meet such expenditures. The coverage of indigents still remains a challenge for the NHIS (NHIS, 2012; 2013; World Bank, 2012, Oxfam, 2011). During the interviews with the NHIA, it was revealed that discovering the indigent was a challenge particularly because the definition the Act 650 (the initial NHIS Law) gave to indigents. Although the current Law (Act 852) gives the responsibility for the identification of indigents to the social welfare department (Section University of Ghana http://ugspace.ug.edu.gh 154 29(d)) it still remains a challenge. This is an indication that the NHIS is finding it difficult to institute an effective pooling mechanism to protect the poor. There have been several studies that indicate that the NHIS is becoming a pro-rich policy since it has more rich than poor on the scheme (Oxfam, 2011; World Bank, 2012). According to the NHIA, indigents formed 4.4% of total membership which is approximately 390,973 people (NHIA, 2012). Also, according to the Ghana Statistical Service (GSS), (during the 2012/2013 enumeration year) the extremely poor constituted 8.4% of the population (24,658,823) which is averagely 2,071,341 people (GSS, 2014). Thus the NHIS covers only about 18.8% of the extremely poor, which is way below its target. Respondents recommended that there should be a more comprehensive way of identifying the indigents so the policy will indeed be seen as pro-poor as Oxfam, (2011) had already indicated. The study further revealed that the main factor affecting the governance of the NHIS is political. Interviewees indicated that the NHIS Law Act 852 gives the president the sole prerogative of appointing NHIA Board Members as well as the Chief Executive and the Deputy Chief Executives. They indicated that in some instances, party colour is given priority over competence during such appointments. This tends to affect the work of the NHIA, especially in instances when not so competent persons are employed to serve on the board or at the management level of the NHIA. As part of its corporate objectives, the NHIA sought to improve the level of provider experience within the NHIS (NHIA, 2012). Interviews with the NHIA revealed that the Authority has instituted several measures to achieve this. These measures include the computerisation of claims processing and the introduction of the Ghana Diagnostic Related Groupings (GDRGs) for outpatient and inpatient services to replace the fee for service which brought controversy between the scheme and providers. The creation of the claims processing unit, the call centre and the ICT centre were all measures the NHIA introduced to better University of Ghana http://ugspace.ug.edu.gh 155 manage the relationship between it and the providers. However, it was again revealed these measures have not been effective due to financial challenges. Although provider claims are now processed quickly, the payment has been delaying due to the delay in the release of funds from the consolidated fund into the NHIF. Providers also lamented that the NHIA has been making unwarranted deductions in the claims submitted and paying only a fraction of the amount submitted. Findings from the study show that provider experience has been worsening and not improving due to these challenges providers face as reported by Darlinjong and Laar (2012). 5.2.4 Outputs With reference to the NHIS value chain, the operation of the scheme is expected to lead to financial risk protection (which is the main reason for insurance) which will ultimately lead to improved health status and patient satisfaction (NHIA, 2012). The findings of the study show that the NHIA has advanced towards ensuring financial risk protection. Interview findings and literature sources indicate that the NHIS covers up to 95% of all diseases (Jehu- Appiah et. al., 2011; Asante et. al., 2013; Owusu-Sekyere and Chiaraah, 2014). The survey findings also show that over 60% have seen 50% or more reduction in health expenditure, with about 40% having more than 70% reduction. There have been other studies that found that the NHIS has been a financial risk protection mechanism for the insured (Dalinjong and Laar, 2012; Dixon et. al., 2014). However, the study also revealed that although health expenditures for the insured had generally reduced, there is still the incidence of out-of-pocket payments (cash and carry) which defeats the intent of providing financial risk protection. The study found that 51.6% of the respondents were asked to make payments at the point of service delivery. Over seventy percent (73.1%) of these respondents (i.e. 37.7% of the total respondents) made such University of Ghana http://ugspace.ug.edu.gh 156 payments because the services they sought were not covered by the NHIS. An interview with insured persons revealed that patients go to health facilities and they are made to pay for services without knowing whether those services are covered by the insurance or not. Providers interviewed also confirmed this and mentioned that due to the delay in the payment of claims, some providers make patients pay for services or drugs instead of billing them to the NHIA. Other providers make patients pay the difference between the amount the insurance pays for a particular service and how much the facility charges for that service. There have been other research findings (e.g. Oxfam 2011; World Bank, 2012) attesting to the fact that sometimes patients are made to pay out-of pocket by the provider before obtaining the necessary services. Therefore for the NHIA to be able to attain its goal of ensuring financial risk protection, it has to ensure that out-of-pocket payments are minimised and finally eliminated for all insured persons. Another output of the NHIS implementation system is ensuring that patients or clients are satisfied (NHIA, 2012). The study however shows a higher dissatisfaction rate of 47.4% of the respondents compared to 18.0% who were satisfied. The respondents indicated that they are dissatisfied with the cumbersome registration processes (53.8% of the respondents) and also the attitude of the NHIA staff during registration (41.4% of the respondents). They (respondents) also showed dissatisfaction with healthcare service providers. They were particularly concerned about the poor services rendered to NHIS clients as against uninsured persons (50.1%) and the out-of-pocket payments they are forced to make at the point of service delivery (51.6%). The study further revealed that the dissatisfaction with the NHIA was due to the network challenges with the biometric registration which is seen as temporary and will be resolved. This high dissatisfaction rate however contradicts an earlier report by the National Development Planning Commission (NDPC). This report indicated a high satisfaction rate of about 58% among study participants in the Greater Accra Region (NDPC, 2008). However, some recent studies recorded a high rate of dissatisfaction. For instance University of Ghana http://ugspace.ug.edu.gh 157 Imuran et. al.’s (2014) study indicated that 57.6% of the respondents were dissatisfied with the NHIS because it did not give them value for money. The providers mentioned that congestion in their facilities congestion which has led to dissatisfaction is due to the government’s failure to expand them coupled with the delay in the payment of claims. Some providers have decided to ask patients to make out-of-pocket payments to defray their costs. However, to be able to boost client/patient satisfaction, the government needs to increase funding to the health sector and find more innovative ways of funding the NHIS. An effective health financing system should eventually lead to improvement in the health of the people (WHO, 2007). The NHIS is expected to impact on the health status of Ghanaian residents (NHIA, 2012). There have been reports indicating improvement in the health of Ghanaian residents. However, the research could not establish whether such improvements were mainly a result of the operation of the NHIS. Nevertheless, the contribution of the NHIS to the current health status of Ghanaians cannot be ignored. The percentage of the respondents who had subscribed to the NHIS, and the increases in outpatient and inpatient attendances (NHIA, 2012), leaves no doubt that the NHIS has been beneficial to Ghanaians. 5.2.5 The Environment Easton (1966) indicated that a system is impacted by diverse environmental forces. Borrowing from a strategic management concept of PEST analysis, the environment can be political, economic, social or technological. There has been very little utilisation of the PEST analysis in issues other than strategic management. However, its utility in other fields of study such as public policy cannot be underestimated (Saburi, 2012). With the use of the PEST tool in this study, it can be inferred that the combination of the political, economic, social and technological environmental forces impacts on the system to affect its functioning. University of Ghana http://ugspace.ug.edu.gh 158 The findings of the study (presented in chapter four) also provided evidence that these environmental forces impact on the NHIS as a system which affects its operation. It was found that the political environment has some effects/impact on the success of the NHIS. The findings show that the NHIS is engraved in politics and cannot be devoid of it. Some other researchers have also seen the necessity of the involvement political activity in health insurance. Sikosana (2005) reiterated the need to make health insurance a policy of government to ensure and possibly enforce participation. Asante et. al. (2013) also found a significant relationship between participation in NHIS and political factors (with emphasis on access to political resources and political participation). This study on the other hand shows that the political environment affects the success of implementation of the NHIS. Respondents indicated that unfulfilled political promise (60.4% of the respondents) and negative statements by political parties (52.3% of the respondents) have the potential of jeopardizing the future of the scheme. However, it was also found that the over-politicisation has contributed positively to the scheme by creating awareness (according to 22.1% of the respondents). It was found that political parties both in government and in opposition have the potential of affecting the smooth running of the NHIS implementation system. The political environment right from the enactment of the National Health Insurance Policy to the formation of the initial legislation (Act 650 and L.I 1809) through to the revision of this legislation (Act 852) has affected and continues to affect the implementation of the NHIS. A major motive of health insurance (like the NHIS) is to reduce the economic/financial burden of health on the people so they will be able to seek care without restrictions or impoverishing them (WHO, 2007). This makes the economic environment vital to the operation of the NHIS. The NHIS has impacted on the economic conditions of its participants by reducing healthcare expenditures (49% of the respondents). Furthermore, the University of Ghana http://ugspace.ug.edu.gh 159 study found that the current economic conditions have pushed people (48.1% of the respondents) into the NHIS so they can be relieved of the exorbitant health expenditures. Also, it was revealed from the interviews that current economic conditions including the volatile exchange rate, inflation, unemployment, etc. have had negative effects on the NHIS. Interviewees mentioned that these macro-economic imbalances have led to increases in the cost of drugs (which forms the major component of the NHIS expenditure), and operational and administrative costs. These have put a strain on the revenue and have affected the activities of the NHIA and healthcare providers. Other respondents also indicated their willingness to join the scheme but have not been possible because they lack the needed funds to register. Thus poverty levels as an economic indicator has affected participation in the scheme and has been an obstacle preventing the NHIA from attaining the 60% coverage in the year 2014 (NHIA, 2012; Asante et al., 2013). A study by Asante et al. (2013) also found a significant relationship between the economic conditions of respondents and their participation in the NHIS. They saw that almost half (47%) of the insured persons were in the top two wealth quintiles compared to 26% of never insured persons in that same category. This is a clear indication that wealth (as an economic variable) plays a significant role in NHIS participation (Asante et al., 2013). The level of income has also been identified as a factor affecting the implementation of the NHIS due to its great influence on participation (see Jehu-Appiah et al., 2011; Abebrese, 2009; Donfouet et al.; 2011). Thus conforming to the initial conceptualisation of a system, the economic environment plays a major role in the general environment to affect the NHIS implementation system. Another environmental factor which according to the PEST analysis framework can impact on a system is the social environment (Law, 2006). The social environment is particularly University of Ghana http://ugspace.ug.edu.gh 160 relevant since the NHIS primarily is about people. The findings indicate that, as expected, the NHIS implementation system is affected by the social environment. Societal support and awareness creation were seen as the main factors affecting the implementation of the NHIS. Concerning societal support, almost half of the respondents mentioned that people in their communities encourage each other to join then NHIS and also 50% indicated that the leaders of their respective religious organisations encourage members to join it. It was found from the study that some members of the public and church leaders have supported others to register for the NHIS. These and other social support mechanisms have affected the implementation of the NHIS positively. Aside the support society has given to its members; it has also helped to create awareness which is necessary for effective implementation of the NHIS (Owusu-Sekyere and Chiaraah, 2014). The findings again show that social influence affected the implementation of the NHIS. Almost a third (29.6%) of the respondents were influenced by their families and 33.6% were influenced by societal beliefs and values to join the NHIS. There have been other studies that have also shown the effect of social factors on the NHIS. Dixon et al. (2014) using data from the 2008 Ghana Demographic and Health Survey revealed that social factors such as religion and ethnicity affect participation in the NHIS which will affect its eventual success. Also, although this study did not show any significant relationship between education level and participation in the NHIS, there have been other studies that have confirmed otherwise (Owusu-Sekyere and Chiaraah, 2014; Dixon et al., 2014; Jehu-Appiah et al., 2011). Thus there is every indication from previous studies and the current one that the social environment impacts on the NHIS implementation system. Technology has been seen as the driving force behind several activities and programmes. Considering its importance in ensuring effectiveness and efficiency, it is of necessity to University of Ghana http://ugspace.ug.edu.gh 161 assess how the technological environment has influenced the implementation of the NHIS. The study revealed that the changes in technology and its application have had significant effects on the NHIS. For instance, the adoption of the biometric verification technology is an approach the NHIA is using to minimise fraud in the system. The study also revealed that technology made it possible for the NHIA to process more claim forms as it migrated from manual claim processing system to a computerised one. However there have been challenges with the application of technology in the NHIA. The study showed that these challenges negatively affected the operation of the NHIS. For instance, 53.8% of the respondents indicated that the slow and cumbersome biometric registration has discouraged them from further renewal of their cards. Also there have been software challenges. For instance Nsiah- Boateng and Aikins (2013) indicated that claim processing in the Ga District has been delaying due to software challenges. Interviews at the NHIA district offices revealed that these software challenges can be attributed to the lack of systems analysts to ensure the design of systems that will perform the services required. Thus the technological environment has had positive and negative effects on the implementation of the NHIS. One of the objectives of this study is to find the relationship between the factors that affect the implementation of the NHIS. It is expected that as the environmental factors together form the broad environment, there will be interrelationships between them as presented in chapter two of the thesis. The findings show strong interrelationships between the political, economic and social environmental forces (quantitatively and qualitatively confirmed). However, the relationship between the technological environment and the three could not be quantitatively confirmed due to the fact that details about the technological environment were collected through qualitative interviews. Although the interviewees generally asserted that the technological forces will affect all the other environmental forces, they could only confirm the relationship between technological and economic forces affecting the NHIS University of Ghana http://ugspace.ug.edu.gh 162 implementation system. They mentioned that the improved technology they have adopted has led to efficiency and cost savings, which has improved the economic situation of the scheme. Also they added that the improved economic situation gives the implementing agencies the necessary resources to acquire technologically advanced systems to further improve their processes and service delivery. It is therefore being recommended that future research work look into the relationships that exist between technological forces and other forces of the environment. 5.2.6 The Feedback Loop Easton (1957) specified in his paper that systems do not exist in vacuum, but lives in an environment which provides feedback on the outputs of the system. This feedback is a “response by the members of the society to these outputs, the communication of information about this response to the authorities, and finally, possible succeeding actions by the authorities” (Easton, 1966: 147). Most modifications made to the system are a response to the feedback provided by the environment. The study revealed that the NHIS implementation as a system has also received a lot of feedback from the environment which has led to the modification of several activities. For instance, the study revealed that the introduction of the instant biometric cards was a response to the public complains about the long waiting periods and also the use of the old magnetic cards to defraud the system (see Asante et al., 2013). The electronic claims processing system was also introduced because the manual one resulted in delay and was not very effective in detecting provider fraud (Nsiah-Boateng and Aikins, 2013). The study also revealed that the feedback comes from all segments of the environment. The political segment provides feedback for modification in the system if it is functioning in politically imprudent ways and not achieving political objectives. Political feedback has been University of Ghana http://ugspace.ug.edu.gh 163 in the form of suggestions, reconstitution of the governing board, removal of the chief executive or any other staff appointed by the government, revision of legal instruments etc. The economic segment of the environment also provides feedback for modification of the system processes. For instance, in determining the premium to be paid by the informal sector, the Authority and the Board need to take the economic conditions into consideration. This also implies that if a rate is fixed and the Authority realises that it is bringing economic hardship on the people it would have to revise it. The social environment has also been providing feedback into the system. The issue of poverty that the NHIS seeks to address is both social and economic. In instances where the NHIS is not able to effectively deal with this problem, it receives feedback from this environment so it can modify its processes to deal with it. The NHIS Law itself (Act 852) provides in Section 28(3) that the determination of premiums and other contributions should factor the social nature of the scheme into it. This shows the importance of the social environment and its feedback to the NHIS. The technological environment also provides feedback to the system when technology is not being applied properly or the right technology is not being used. For instance, the use of inappropriate software in the Ga district to process claims resulted in delays (Nsiah-Boateng and Aikins, 2013). Also the study revealed that the use of low capacity computers and unstable internet networks to capture huge amount of data during the biometric registration slowed down the process as a feedback into the system. It is therefore evident that there is a strong feedback loop which has also affected the performance of the NHIS implementation system. University of Ghana http://ugspace.ug.edu.gh 164 Figure 5.1: Revised Framework: Interactions between the NHIS Implementation System and the Environment Source: Authors own construct, 2014 Key: Quantitatively and qualitatively proven relationship Qualitatively proven relationship Perceived but not proven relationship THE ENVIRONMENT The NHIS Implementation System Political Segment Social Segment Economic Segment Technological Segment University of Ghana http://ugspace.ug.edu.gh 165 Figure 5.2: The NHIS Implementation System in the Environment INPUTS Demand - Financial protection - Quality healthcare Support - Acceptance - Participation - Resources Financial Human Technical Source: Adapted from Easton, 1957 and NHIA, 2012 Figures 5.1 and 5.2 and confirm the relationships predicted by the conceptual framework in chapter two. Figure 5.1 shows that, the environment has four main components: the political, economic, social and technological components as predicted (based on the PEST tool). The relationships between the environmental components/segments as well as between them and the system are indicated by Figure 5.1. The relationships between three components (political, economic and social) of the environment as well as with the system were confirmed based on quantitative data and qualitative data. However data on the technological ENVIRONMENT CONVERSION PROCESS Revenue collection Pooling Purchasing Financial Risk protection Improved health status Patient satisfaction OUTPUTS FEEDBACK University of Ghana http://ugspace.ug.edu.gh 166 environment were collected only through qualitative interviews. Also as indicated in previous sections, the data obtained confirmed relationships between the technological environment and the system as well as the economic environment. However, although the data suggest relationships between all segments of the environment, it couldn’t confirm relationships between the social segment and technological segment and also the political segment and the technological segment. Figure 5.2 also shows the processes the system goes through from the input stage to the output stage. Findings of the study corroborate the conceptual framework developed in chapter two. The findings show that if the NHIS implementation system is able to receive the necessary inputs it will be able to convert them through the processes of revenue collection, pooling, and purchasing. The expected outputs from this NHIS implementation system are financial risk protection, patient satisfaction and improved health status. This process as described in Figure 5.2 is the ideal. However the findings show that the system is not functioning as it is supposed to due to inefficiencies especially at the input and conversion stages. At the input stage there is the problem/challenge of unsustainable and inadequate funds which has affected the system’s ability to function properly. At the conversion stage, the discussion of findings shows that there are inherent problems especially with the pooling and purchasing. This has led to the system’s inability to effectively generate the required outputs of financial risk protection, patient satisfaction and improved health status. Despite all these challenges the NHIS implementation system has been able to function satisfactorily to increase enrolment from 1.3 million in 2005 to 10.2 million in 2014. It is also expected that a human system will not function mechanistically to produce predictable results always. University of Ghana http://ugspace.ug.edu.gh 167 CHAPTER SIX CONCLUSION 6.0 Introduction The study was set out to identify the factors affecting the implementation of the National Health Insurance Scheme. This main purpose was achieved using the systems theoretical lens. Additionally, the study sought to identify the participation in the NHIS and the determinants of participation. Specifically, the researcher sought to answer the following questions:  How are respondents participating in the NHIS and what factors affect their decision to enrol?  What are the factors affecting the implementation of the NHIS?  What relationships exist between these factors? Through the review of literature (in chapter two), the researcher provided a sound basis for the research by providing theoretical and empirical support and justification for the study. Also, the researcher adopted a mixed methodological approach, to find answers to the research questions as presented in the previous chapters. This chapter, the final of the thesis, summarizes the detailed work presented in previous chapters, gives the conclusion and provides the way forward. The following section summarizes the empirical findings of the study. 6.1 Summary of Empirical Findings The main empirical findings are provided in chapter four of the study. This section summarises the empirical findings to provide answers to the three main research questions. University of Ghana http://ugspace.ug.edu.gh 168 Research question 1: How are respondents participating in the NHIS and what factors affect their decision to enrol? a. Participation in the NHIS is satisfactory though it falls short of the expected. Over three quarters of the respondents had previously registered for the NHIS and more than three-quarters of the number are active card holders (i.e. 58.8% of the respondents of the study). Although the participation rate reported by the NHIA falls lower than this, there is clear evidence that participation has consistently increased since the inception of the NHIS in 2005. b. The decision to enrol in the NHIS or renew insurance is found to be mostly affected by some personal factors and also, experiences with the scheme. The research found that the decision to enrol in the NHIS was associated with age, marital status, influence of family. Renewal of insurance was also found to be associated with these factors and the benefits enjoyed. Research Question 2: What are the factors affecting the implementation of the NHIS? The implementation of the NHIS was found to be affected by several factors. a. Actors. The actors that respondents identified as affecting the implementation of the NHIS are the government, the NHIA, health providers and health professionals. b. System factors. The implementation of the NHIS was conceived as an input- conversion-output system. The study identified that there are factors affecting the functioning of the system at every stage. - Input factors: It was identified that there is inadequate resource support at the input stage especially concerning funding. Considering the necessity of funding in such a social health insurance, this funding gap was identified by University of Ghana http://ugspace.ug.edu.gh 169 respondents as a major factor that has stifled the operation of the NHIS implementation system. - Conversion factors: The researcher found that there were problems with pooling due to the inadequate funds. As such the scheme only covers a small proportion of the extremely poor. There were problems with purchasing, especially regarding delayed payment of provider claims. - Output: Due to the challenges faced at the input and processing stage, it was found that the system did not produce the required outputs (financial risk protection, improved health status, and patient satisfaction) effectively. There was inadequate financial risk protection for registered persons since they are sometimes asked to make payments before receiving health services. The health of those who couldn’t pay was adversely affected. Also, inadequate equipment and other facilities as well as problems with registration negatively affected patients’ satisfaction. - The Environment: The implementation of the NHIS was found to be mostly affected by the economic segment of the environment. The other segments (i.e. political, social and technological were found to have significant influences on the implementation of the NHIS. - The Feedback Mechanism: The researcher found the existence of a strong feedback mechanism that also affects the functioning of the system. Several changes made at the offices of the NHIA (including the computerisation of claims processing, institution of clinical audits, and biometric authentication) were based on the feedback mechanism. The feedback mechanism has also resulted in decreased support since some people who registered initially University of Ghana http://ugspace.ug.edu.gh 170 decided not to renew their insurance mainly due to dissatisfaction with the system. Research Question 3: What relationships exist between the factors affecting the implementation of the NHIS? a. Environmental factors: the research showed significant relationships among the various segments of the environment and between the environment and the NHIS implementation system. - Quantitatively and qualitatively proven relationships: There existed relationships among and the political, economic and social segments of the environment as well as well as with the NHIS implementation system. It was found that the political segment had the strongest relationship with the other segments and the economic segment had the strongest relationship with the NHIS implementation system. - Qualitatively proven relationships: With inadequate quantitative data on this, the qualitative data obtained showed that changes in the technological segment of the environment affects the NHIS implementation system as well as the economic segment. - Perceived but not proven relationships: It was perceived that the technological segment of the environment has relationships with the social and political environment but there was not enough evidence to support it. b. Relationships between components of the system: the study revealed that, as expected, the various components have strong relationships between them. A change at any component affects the other components. A major problem of financing at the input stage led to ineffective pooling and purchasing at the processing stage which led to inadequate financial protection. University of Ghana http://ugspace.ug.edu.gh 171 6.2 Theoretical Implications The research used the systems theory as its theoretical backbone with inputs from the PEST analysis, a tool mostly used in strategic management. The political system, as conceived by Easton (1957; 1966) is made up of the input-conversion-output components. The theory also specifies that the system affects and is affected by the environment. Although Easton originally used the political systems theory to explain political decision making (policy making) the researcher used it to explain the implementation process. The findings of this study support Easton’s (1957; 1966) conception, and provides enough evidence to suggest that the various components of the environment affect the system differently. Also there exist different levels of relationships among the various segments which make the environment and its relationship with the system a complex phenomenon. The systems theory therefore needs to be revisited in order to understand the dynamics of external environmental effects/impact. The findings also suggest that scholars and practitioners need to understand the effects of the various segments of the environment on a system to be able to effectively analyse it. 6.3 Policy Implications Ghana’s health financing policy has undergone several changes (Tinorgah, 1999). The NHIS is seen as a system which is sustainable and coverage enhancing making it superior to all previous health financing systems implemented in Ghana. Empirical evidence shows that the initial conception of improving the overall resource flow into the health sector and facilitating prompt reimbursement of providers under a pre-financing arrangement has not been achieved due to problems with financing and operations. There is the need to review the existing policy to make provision for adequate and more sustainable flow of funds into the National Health Insurance Fund (NHIF). Also, authorities University of Ghana http://ugspace.ug.edu.gh 172 should enforce the mandatory membership provided in Act 852 as this will help generate additional resources as well as move the NHIS towards universal health coverage. There is also the need to revise the provider payment system and make it more sustainable and coverage enhancing. Finally there should be a revision of policy and legal framework to minimise political interference and make the Authority more autonomous. 6.4 Contribution of Research to Knowledge The study has contributed to existing knowledge in several respects and this is presented in this section. Making a significant contribution to knowledge, as explained by Petre and Rugg (2010: 15) in their book ‘the unwritten rules of a PhD research’, is simply ‘providing evidence to substantiate a conclusion that’s worth making’. In other words, it deals with how the work has unearthed ‘new’ knowledge that contributes to the on-going discourse on the subject matter (Petre and Rugg, 2010). Typically, contribution to knowledge can be in any of the areas indicated in Box 6.1. University of Ghana http://ugspace.ug.edu.gh 173 Box 6.1: Ways of Contributing to Knowledge Based on the ways of contributing to knowledge identified by Petre and Rugg (2010), as shown in Box 6.1, the study can be said to have contributed to knowledge in four main ways. Firstly, the researcher re-contextualised an existing model to fit the study; secondly, there was the need to corroborate and elaborate an existing model for improved analysis, which the study provided; thirdly, the research has contributed to knowledge by drawing together of existing ideas and showing that their combination reveals something new and useful; and fourthly, codifying the obvious.  Re-contextualization of an existing technique, theory or model  Corroboration and elaboration of an existing model  Falsification or contradiction of an existing model, or part of one  Drawing together two or more existing ideas and showing that the combination reveals something new and useful  Demonstration of a concept: showing that something is feasible and has utility  Implementation of theoretical principle  Codification of the ‘obvious’: providing evidence about what ‘everyone knows’  Empirically-based characterization of a phenomenon of interest  Providing a taxonomy of observed phenomena  Well-founded critique of existing theory or evidence  Providing a new solution to a known problem  Filling a small technical gap - Petre and Rugg (2010) University of Ghana http://ugspace.ug.edu.gh 174 Re-contextualizing an existing model The study made use of two main models. The political systems theory/model and the political, economic, social and technological (PEST) analysis tool/model. Although the political systems theory/model is a known model in policy discourse and research, the PEST tool/model is better known in the strategic management context and not in public policy. Thus using the PEST tool in an implementation research to determine how environmental forces affect the implementation of public policy is a contribution to existing knowledge on the methodologies for assessing the impact/effect of the environment on policy. Corroborating and elaborating an existing model The PEST tool has been used to identify how the political, economic, social and technological forces in the environment affect strategic planning and management. Strategic management literature show that these forces are analysed individually and there is little analysis on their linkages and how such linkages also affect the strategic plan. Applying this model to the implementation of the NHIS, the researcher did not only analyse the effect of the political, economic, social and technological forces but also how they are linked and how such linkages affect implementation. The findings of the research show that these forces are interlinked and only analysing them individually will not give a holistic account of how they affect implementation. Therefore it is evident that not only has the study showed the utility of the PEST tool in policy implementation research but has also shown the need to analyse the linkages between the environmental forces to obtain a better result. Drawing together existing ideas and showing that their combination reveals something new and useful The combination of the political systems theory/model and the PEST analysis tool is also a contribution to the on-going discourse on policy implementation research. The research University of Ghana http://ugspace.ug.edu.gh 175 findings indicate that this combination improves the understanding of implementation processes and how the environment affects policy and its implementation. Although the political systems theory as initially conceptualised by Easton has been a useful model for assessing factors affecting implementation, the addition of the PEST analysis tool improves the depth and breadth of such analysis. The political systems theory looks at the environment as a whole but the addition of the PEST tool necessitated deeper analysis of the political, economic, social and technological factors of the environment. Codifying the obvious There have been several studies on the factors affecting the implementation of the NHIS. Some of such previous studies include Nsiah-Boateng and Aikins (2013), Asante et al (2013), Owusu-Sekyere and Chiaraah (2014), Dixon et al., (2014) and Jehu-Appiah et al., (2011) among others. The media in Ghana has also been vibrant in reporting on the NHIS. For instance in 2014, the Daily Graphic newspaper in Ghana published 150 articles on the NHIS (www.graphic.com.gh), some of which elaborated on factors affecting its implementation. Most of the findings of this research are therefore not entirely new and have already been reported by earlier studies. Also, with reference to the work of scholars such as Sabatier, O’Toole, Pressman and Wildavsky, Riggs, Easton, etc., it is obvious that the implementation of policies is affected by key factors which the findings of the study confirmed. However, although the findings in themselves are not new, and some are expected, their presentation in this work differs from all previous works. This therefore can be said to be a significant contribution to the discourse. The foregoing shows that the study has made both theoretical and empirical contribution to knowledge. 6.5 Recommendations of the Study Several recommendations can be drawn from the study. First of all, the study sought to find the enrolment level in the study area, and factors affecting one’s decision to enroll or renew University of Ghana http://ugspace.ug.edu.gh 176 insurance. Although the study found that enrolment levels have been increasing, findings show that there can be further increase if the NHIS receive more publicity. It was further revealed that publicity by political actors, community opinion leaders, and religious organisations will have a significant effect on the enrolment levels. Also, the monitoring of health facilities and the facilities should be encouraged to expand their range of services to benefit more people and influence them to renew their insurance. The range of benefits available under the NHIS was found to be adequate and will not need any major modifications. However, registered persons under NHIS receive limited benefits. Therefore frequent and effective monitoring will ensure service providers do not limit the benefits under the scheme. This will ensure that a lot more people renew their insurance since the study established that the benefits derived is a major determinant of willingness to renew his/her insurance. Secondly, the study identified the factors affecting the implementation of the NHIS. The government was identified as the most important actor and decisions of the government significantly affect the implementation of the scheme. Since the study found that the NHIS is suffering from financial set-back, it is recommended that the government increases its budgetary allocation and also remove all obstacles to the flow of funds into the scheme. It is recommended that the government make the National Health Insurance Fund independent from the Consolidated Fund to make it easier to access funds for the effective operation of the scheme. Thirdly, the study found that there are complex relationships between the factors affecting the implementation of the NHIS. It is recommended that studies seeking to measure the nature and magnitude of such relationships consider more complex multivariate measures and not University of Ghana http://ugspace.ug.edu.gh 177 simple linear measures since the relationships are to a large extent, nonlinear. It is also recommended that this study be replicated for other interventions. 6.6 Conclusion The National Health Insurance Scheme (NHIS) has been a major policy thrust of government and has attracted interests from diverse facets of society. There have been different arguments on the performance of the NHIS. While some scholars and practitioners believe (based on the empirical findings) that the NHIS has performed poorly, other laud it for its performance. However, there is a general consensus that it is better than the erstwhile out-of-pocket payment (popularly called cash and carry). The findings of this study show that although the NHIS is fraught with challenges (including unsustainable financing and delayed payment of provider claims) there is hope in the system considering the fact that enrolment has been constantly increasing. The findings also show that there is the need to consider the environment of the NHIS; even factors that seemingly do not directly affect it since such environmental factors can affect other factors that directly affect it. The study has provided a useful precedence for other studies to follow for improvement in research on implementation. University of Ghana http://ugspace.ug.edu.gh 178 REFERENCES Abebrese, F. (2009). Determinants of Participation in the National Health Insurance Scheme.A case study of the Shama District.An unpublished MPhil thesis, University of Ghana. Addae-Korankye, A. (2013). Challenges of financing healthcare in Ghana: The Case of the National Health Insurance Scheme (NHIS). International Journal of Asian Social Science, 3(2):511-522. Addai, E., Agbe, L., Awittor, E., Gaere, L., Osei, E. and Tinorgah, A. (2000): Health Policies in Ghana-Implications for Equity, A Policy and Literature Review. Unpublished Research Work. Addo-Cobbiah, V.(undated (n.d.)) Ghana NHIS Accreditation Implementation. [Online], Available: http://www.jointlearningnetwork.org/sites/jlnstage.affinitybridge.com/files/Vivian_N HIS_Accreditation_Implementation_final.pdf [accessed 2nd August, 2013]. Agyepong, I.A. and Adjei, S. (2008). Public Social Policy Development and Implementation: A Case Study of the Ghana National Health Insurance Scheme. Health Policy and Planning, 23(2): 150-160. Agyepong, I. and Nagai, R. (2011). We charge them; otherwise we cannot run the hospital front line workers, clients and health financing policy implementation gaps in Ghana. Health Policy, 99, 226–233. Alesch, D., and Petak, W., (2001), Overcoming Obstacles to Implementing Earthquake Hazard Mitigation Policies: Stage 1 Report, Technical Report MCEER-01-0004, Multidisciplinary Center for Earthquake Engineering Research, University at Buffalo. Arhin-Tenkorang, D.C. (2000). Mobilising Resources for Health: The Case for User Fees Re- visited, report submitted to Work Group Three of the Commission of Microeconomics and Health, World Health Organization, Geneva. Arhinful, D.K. (2003). The Solidarity of Self-Interest: Social and Cultural Feasibility of Rural Health Insurance in Ghana. University of Amsterdam, Doctoral Thesis. Aikins, M. and Okang, G., (2006). Utilization and cost of health care under the district health insurance schemes: A case study of Brong-Ahafo and Eastern regions. JSA Consultants. Akortsu, P. A. Abor, P. A. (2011). Financing public healthcare institutions in Ghana. Journal of Health Organisation and Management, 25,128-141. Anderson, J.E. (1975). Public Policymaking. New York: Praeger. Anderson, J. E. (2003). Public Policy Making (5th Ed.). U. S. A.: Houghton Mifflin Company. University of Ghana http://ugspace.ug.edu.gh 179 Asante, F. and M. Aikins. (2007). Does the NHIS Cover the Poor? [Online], Available: http://www.moh-ghana.org/moh/docs/NHIS%20issue/NHIS%20pro-poor%20 research.pdf [accessed 5th August, 2013]. Asante, F. A., Arhinful, D. K., Fenny, A. P. and Kusi, A. (Ghana Health Inc Team) (2013). NHIS Country Case Study Report. Accra: Ghana Health Incorporated. Atim, C. (1998). Contribution of Mutual Health Organisations to Financing, Delivery, and Access to Health care: Synthesis of Research in Nine West and Central African Countries. Bethesda, Maryland: Abt Associates Inc. Atim, C. (2001). Contribution of Mutual Health Organisations to Financing, Delivery, and Access to Health care: Nigeria Case Study. Geneva: ILO. Ayee, J. (1995). An Anatomy of Public Policy Implementation: The Case of Decentralisation Policies in Ghana. Aldershot, UK: Avebury. Ayee, J. R. A. (2001). Civil service reform in Ghana: A case study of contemporary reform problems in Africa. African Journal of Political Science, 6(1), 1–41. Babbie, E. (2007). Conducting qualitative field research. In The practice of social research (11th ed.). U.S.A.: Thomson Wadsworth. Baltussen, R., E. Bruce, G. Rhodes, S.A. Narh-Bana, and I. Agyepong. (2006). Management of Mutual Health Organizations in Ghana. Tropical Medicine and International Health, 11(5): 654-659. Bardach, E. (1977). The implementation game: What happens after a bill becomes law. Cambridge, MA: MIT Press. Barnum, H.; Kutzin, J., and Saxenian, H. (1995), Incentives and provider payment methods. International Journal of Health Planning and Management, 10(1): 23–45. Barimah, K. B. and Mensah, J. (2013). Ghana’s National Health Insurance Scheme: Insights from Members, Administrators and Health Care Providers. Journal of Health Care for the Poor and Underserved, 24(3), 1378-1390. Barrientos, A. and Lloyd-Sherlock, P. (2002), Older and Poorer? Ageing and Poverty in the South, Journal of International Development, 14(8), 1129-1131. Batley, R. and Larbi, G.(2004). The Changing Role of Government: The Reform of Public Services in Developing Countries. Basingstoke: Palgrave Macmillan. Baumgartner, F.R., and Jones, B.D. (1993). Agendas and Instability in American Politics. Chicago: University of Chicago Press. Baumgartner, F.R., and Jones, B.D. (2003). Positive and negative Feedback in Politics. In Baumgartner, F.R. and Jones, B.D. (eds.), Policy Dynamics, (pp. 3–28). Chicago: University of Chicago Press. Bennett, S., Creese, A. and Monash, R. (1998). Health Insurance Schemes for People Outside Formal Sector Employment. Geneva: World Health Organization. University of Ghana http://ugspace.ug.edu.gh 180 Berman, P. (1978). The Study of Macro and Micro implementation. Public Policy 26(2): 57- 184. von Bertalanffy, L. (1968). General system theory: Essays on its foundation and development, rev. ed. New York: George Braziller. Bhandari, S. (1997). Employment based health Insurance. Household Economic Studies, pp 70 – 81. Blanchet, N. J., Fink, G. and Osei-Akoto, I. (2012). The effect of Ghana’s National Health Insurance Scheme on health care utilisation. Ghana Medical Journal, 46(2), 76-84. Blomquist, W. (2007), The Policy Proces and Large-N Comparative Studies. In P. A Sabatier (ed), Theories of the Policy Process, (2nd ed), Cambridge, MA: Westview Press, pp 269 – 289. Boateng, R.A. (2009). Performance Review March (2008). PowerPoint. Brehm, J., and Gates, S. (1997), Working, Shirking, and Sabotage: Bureaucratic Response to a Democratic Public. Ann Arbor: University of Michigan Press. Brewer, G., and deLeon, P. (1983). The Foundations of Policy Analysis. Monterey, Cal.: Brooks, Cole. Brooks, S. (1993). Public Policy in Canada (2nd ed). Toronto: McClelland & Stewart. Brynard, P.A. (2009). Mapping the Factors that Influence Policy Implementation. Journal of Public Administration, 44 (3), 557-577. Buchmueller, T. C., Kronick, R., Grumbach, K. and Kahn, J. G. (2005). The Effect of Health Insurance on Medical Care Utilization and Implications for Insurance Expansion: A Review of the Literature. Medical Care Research and Review 62 (1): 3– 30. Burns, D., Hambleton, R. and Hoggett, P. (1994). The politics of decentralisation: revitalising local democracy, London: Macmillan. Burstein, P. (1991). Policy Domains: Organization, Culture, and Policy Outcomes. American Review of Sociology 17: 327–350. Busche, S. (2010). Clean Energy Policy Analyses: Analysis of the Status and Impact of Clean Energy Policies at the Local Level. Golden, CO: National Renewable Energy Laboratory. Carrin G. & James C. (2005). Social Health Insurance: Key Factors Affecting the Transition Towards Universal Coverage. International Social Security Review, 58(1), 45–64. Carrin, G. (2002) Social Health Insurance in Developing Countries: A Continuing Challenge. International Social Security Reviews, 55, 57-69. University of Ghana http://ugspace.ug.edu.gh 181 Carrin, G., Mathauer, I., Xua, K. & Evans, D. B. (2008). Universal coverage of health services: tailoring its implementation. Bulletin of the World Health Organization, 86, 857–863. Carrin, G.; Zeramdini, R.; Musgrove, P,; Pouillier, J.-P.; Valentine, N. and Xu, K. (2004). Impact of risk sharing on the attainment of health system goals. In A. Preker and G. Carrin (Eds.), Health financing for poor people: Resource mobilization and risk sharing (chap. 12). Washington, DC: World Bank. Chen, L., Yip, W., Chang, M., Lin, H., Lee S., Chiu, Y. and Lin, Y. (2007). The effects of Taiwan's National Health Insurance on access and health status of the elderly. Health Economics, 16:223-242. CHF International (2010). Accra poverty map: A guide to urban poverty reduction in Accra. Accra: CHF International. Churchill, C. (2006). What is insurance for the poor? In C. Churchill (Ed.), Protecting the poor, A microinsurance compendium. Geneva: International Labour Organisation. Cochran, C., Mayer, L., Carr, T.R., Cayer, N. (1986). American public policy. Englewood Cliffs, NJ: Prentice Hall. Cornford, T., & Smithson, S. (2006). Project research in information systems: a student's guide (2nd ed.). Basingstoke: Palgrave Macmillan. Creswell, J. W. (2007). Qualitative Inquiry & Research Design: Choosing among five approaches (2nd ed.). Thousand Oaks, CA: Sage. Criel, B. (1998). District-Based Health Insurance in Sub-Saharan Africa. Part II: Case- Studies. Studies in Health Services Organisation and Policy, Antwerp. Criel, B. (2000): Local Health Insurance Systems in Developing Countries: A Policy Research Paper. Antwerp: ITM. Criel, B., Waelkens M. P., Soors W., Devadasan N. & Atim C. (2008). Community health insurance in developing countries. In K. Heggenhougen and S. Quah (Eds), International encyclopedia of public health (Volume 1), (pp 782-91). San Diego, CA: Academic Press. Crozier, M. (2007). Recursive Governance. Political Communication, 24(1) -18. Dalinjong, P. A. and Laar, A. S. (2012). The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana. Health Economics Review, 2(13), doi:10.1186/2191-1991-2-13. Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH (2005): Social Health Insurance: A contribution to the international development policy debate on universal systems of social protection, edited by Katja Bender, Ole Doetinchem, Jürgen Hohmann, Jens Holst, Sonja von Möller, Bernd Schramm. Eschborn. Available online: http://www.gtz.de/social-protection-systems. [Accessed, 20th June, 2014]. Dewey, J. (1927), The public and its problems, New York: Holt. University of Ghana http://ugspace.ug.edu.gh 182 Dixon, J., Tenkorang, E. Y., Luginaah, I. N., Kuuire, V. Z. and Boateng, G. O. (2014). National health insurance scheme enrolment and antenatal care among women in Ghana: is there any relationship? Tropical Medicine and International Health, 19(1), 98–106 Doetinchem, O., Schramm, B. and Schmidt, J-O. (2006). The Benefits and Challenges of Social Health Insurance for Developing and Transitional Countries. In U. Laaser, and R. Radermacher (Eds.), Financing Health Care. A Dialogue between South Eastern Europe and Germany (Series International Public Health, Vol. 18) (pp 27 - 44). Lage, Germany: Hans Jacobs. Donfouet, H.P.P., Essombè, E.J.R., Mahieu, P-A.andMalin, E. (2011). Social capital and Willingness-to-pay for Community-Based Health Insurance in Rural Cameroon. Global Journal of Health Science, 3(1):142-149 Dow, W. H., and Schmeer, K. K. (2003). Health Insurance and Child Mortality in Costa Rica. Social Science & Medicine 57 (6), 975 – 986. Dow, W., Kristine H., Gonzalez A. and Rosero-Bixby L. (2003). Aggregation and Insurance Mortality Estimation. National Bureau of Economic Research Working Paper Series, No. 9827. Drechsler, D. and J. Jütting (2005). Private Health Insurance in Low- and Middle-Income Countries – Scope, Limitations, and Policy Responses, paper presented at the 2005 Wharton Impact Conference, 15-16 March, http://hc.wharton.upenn.edu/impactconference/ [Accessed 20th June, 2014]. Dror, D. M. and Jacquier, C. (1999). Micro-Insurance: Extending Health Insurance to the Excluded. International Social Security Review, 52 (1), 71-98. Dror, D. M. and Preker, A. S. (2002). Social Reinsurance: A New Approach to Sustainable Community Health Financing (pp xvii+518). Washington D. C.: World Bank & ILO. Dror, Y. (1989), Public Policy Reexamined, (2ed) New Brunwick NJ: Transaction Publishers. Dummett, R. (1993). Disease and mortality amongst gold miners of Ghana: Colonial government and mining company attitudes and policies, 1900-1938. Social Science and Medicine, 37(2), 213-232. Dunsire, A. (1978a) The Execution Process, Volume 1: Implementation in a Bureaucracy. Oxford: Martin Robertson. Dunsire, A. (1978b) The Execution Process, Volume, 2: Control in a Bureaucracy. Oxford: Martin Robertson. Dunsire, A. (1990). Holistic Governance. Public Policy and Administration 5(1), 3-18. Dunsire, A. (1993). Modes of Governance. In: J. Kooiman (ed.), Modern Governance: new government-society interactions, (pp 21-34). London: Sage. University of Ghana http://ugspace.ug.edu.gh 183 Durrheim D. N., Williams H. A., Barnes K., Speare R., and Sharp B. L. (2003). Beyond evidence: a retrospective study of factors influencing a malaria treatment policy change in two South African provinces. Critical Public Health, 13, 309-330. Dye, T. R. (1976), What Governments do, Why they do it, What difference it makes. Tuscaloosa, Ala: University of Alabama Press Dye, T. R. (2002). Understanding public policy (10th ed.) Upper Saddle River, NJ: Prentice Hall. Easton, D. (1965), A Framework for Political Analysis. New Jersey: Prentice Hall. Easton, D. ( l965b).A systems analysis of political life. New York: Wiley. Easton, D. (1957). An approach to the analysis of political systems. World Politics, 9, 383- 400. Easton, D. (1965a). A framework for political analysis. Englewood Cliffs, NJ: Prentice Hall. Easton, D. (1966). Categories for the systems analysis of politics, In D. Easton (Ed.), Varieties of political theory (pp. 143-154). Englewood Cliffs, NJ: Prentice Hall. Edella, S. (2007), “A Comparison of Frameworks, Theories, and Models of Policy Processes.” in Sabatier, P. A. (2nd ed), Theories of the Policy Process, Cambridge, MA: Westview Press, 293–319. Ekman, B. (2007). Catastrophic Health Payments and Health Insurance: Some Counterintuitive Evidence from One Low-income Country. Health Policy, 83 (2–3), 304–313. Elmore, R. (1978). Organizational models of social program implementation. Public Policy, 26: 185 – 228. Elmore, R. (1979). Backward Mapping. Political Science Quarterly, 94: 606 – 616. Elmore, R. (1985). Forward and Backward mapping. in Hanf, K. And Toonen, T. (eds), Policy Implementation in Federal and Unitary Systems, Dordrecht, Holland: Martinus Nijhoff. Fisher, J. R. (2010). System theory and structural functionalism. In Ishiyama, J. T. and Breuning, M (Eds), 21st Century Political Science: A reference handbook (vol 1), (pp 71-80). Los Angeles: Sage. Galliers, R. (1991). Choosing appropriate information systems research approaches: A revised taxonomy. R. Galliers, ed. Information Systems Research: Issues, Methods and Practical Guidelines. Blackwell, Oxford, U.K., 144–162. Garg, C. and Karan, A. (2009). Reducing out-of-pocket expenditures to reduce poverty: a disaggregated analysis at rural-urban and state level in India. Health Policy Plan, 24, 116-128. Gay, L.R. & Diehl, P.L. (1992). Research Methods for Business and Management. New York: Macmillan. University of Ghana http://ugspace.ug.edu.gh 184 Gershenson, C., Diederik, A. and Edmonds, B. (2007), Worldviews, science and us. Singapore: World Scientific Publishing. Ghana Health Service (2008). The Health Sector in Ghana: Facts and Figures, 2007. Accra, Ghana: Ghana Health Service. Ghana Health Service (2010). The Health Sector in Ghana: Facts and Figures, 2009. Accra, Ghana: Ghana Health Service. Ghana Ministry of Health, (MOH) (2008). Legal and Policy Framework for Health Information and Health Data Reporting. Ghana Ministry of Health (MOH) (2014). Holistic Assessment of the Health Sector Programme of Work 2014, Ministry of Health. Ghana Statistical Service (2005). Ghana 2003 Core Welfare Indicators Questionnaire (CWIQ II) Survey Report. Accra: Ghana Statistical Service. Ghana Statistical Service (GSS) (2012). 2010 Population and Housing Census: Summary Report of Final Results. Accra: Ghana Statistical Service. Ghana Statistical Service (GSS) (2014). Ghana Living Standards Survey Round 6 (GLSS 6): Poverty Profile in Ghana (2005 – 2013). Accra: Ghana Statistical Service. Ghana Statistical Service [GSS] (2015). Ghana Poverty Mapping Report. Accra: Ghana Statistical Service. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro (2009). Ghana Demographic and Health Survey 2008. Accra, Ghana: GSS, GHS, ICF Macro. Giedion, U. and Díaz, B. Y. (2008). The Impact of Health Insurance in the Developing World: A Review of the Existing Evidence. Washington, DC: The Brookings Institution. Giedion, U. and Díaz, B. Y. (2011). A Review of the Evidence. In M. L. Escobar, C. C. Griffin, and R. P. Shaw (Eds). The Impact of Health Insurance on Low- and Middle- Income Countries. Washington, DC: The Brookings Institution Press. Giedion, U. and Díaz, B. Y. (2011). A Review of the Evidence. In M. L. Escobar, C. C. Griffin, and R. P. Shaw (Eds). The Impact of Health Insurance on Low- and Middle- Income Countries. Washington, DC: The Brookings Institution Press. Giedion, U., Díaz B. Y., and Alfonso E. A. (2007). The Impact of Subsidized Health Insurance on Access, Utilization and Health Status: The Case of Colombia. Washington, DC: World Bank. Goggin, M.L., Bowman, A. O’M., Lester, J. P. and O’Toole, L.J. Jr. (1990). Implementation Theory and Practice: Toward a Third Generation. USA: Harper Collins Publishers. Googin, et al. (1990), Studying the Dynamics of Public Policy Implementation : A Third Generation Approach, in Implementation and the Policy Process: Opening up the University of Ghana http://ugspace.ug.edu.gh 185 Black Box, edited by Dennis J Palumbo and Donald J.Calista, New York: Greenwood Press, pp 181-197 Gordon, I. Lewis, J. and Young, Y. (1997), Perspectives on policy analysis, Public Administration Bulletin, 25, 26 -30. Gottret, P. and Schieber, G. (2006). Health Financing Revisited : A Practitioner's Guide. Washington, DC: World Bank. Grindle, M. S. and Thomas, J. W. (1991), Public Choices and Policy Change: A Political Economy of Reform in Developing Countries, Baltimore: Johns Hopkins University Press. Gross, N. et al (1971). Implementing organizational innovations. New York: Basic Books. Gunn, L. (1978) Why Is Implementation So Difficult? Management Services in Government, 33(4),169-176. Hadley J. (2003). Sicker and poorer. The consequences of being uninsured: A review of research on the relationship between health insurance, medical care use, health work, and income. Medical Care and Research Review 60 (supp 2): 3S – 75S; discussion 76S – 112S. Hardy, S, and Koontz, T. (2009). Rules for collaboration: institutional analysis of group membership and levels of action in watershed partnerships. Policy Studies Journal, 37: 3, pp. 393-414. Harsanyi, J. C. (1969). Rational Choice Models of Political Behaviour vs. Functionalist and Conformist Theories. World Politics, 21(4), pp 513 – 538. Health Systems 20/20 Project and Research and Development Division of the Ghana Health Service. (2009). An Evaluation of the Effects of the National Health Insurance Scheme in Ghana. Bethesda, MD: Health Systems 20/20 project, Abt Associates Inc. Heclo, H. (1972). Review Article: Policy Analysis. British Journal of Political Science, 2, 83 – 108. Heinerman, R. A., Bluhum, W. T., Peterson, S. A., and Kearney, E. N. (1990), The World of the Policy Analyst: Rationality, Values and Politics, Chatham, NJ: Chatham House Henn, M., Weinstein, M. & Foard, N. (2006). A short ıntroduction to social research. London: Sage. Hill, M. Hupe, P. L. (2006). Implementing public policy, London: Sage Publication. Hill, M.J. and Hupe, P.L. (2002). Implementing public policy: Governance in theory and practice, London: Sage Publications. Hjern, B. (1982). Implementation Research. The Link Gone Missing. Journal of Public Policy, 2, 301308. University of Ghana http://ugspace.ug.edu.gh 186 Hjern, B. and Hull, C. (1982). Implementation Research as Empirical Constitutionalism. European Journal of Political Research, 10(2), 105-116. Hjern, B. and Hull, C. (1985). Small Firm Employment Creation: An Assistance Structure Explanation. In K. Hanf and T. Toonen, (Eds). Policy Implementation in Federal and Unitary Systems. Dordrecht: Martinus Nijhoff. Hjern, B. and Porter, D.O. (1981). Implementation Structures. A New Unit of Administrative Analysis. Organization Studies, 2, 211-227. Hjern, B., Hanf, K. and Porter, D. (1978). Local networks of Manpower Training in the Federal Republic of Germany and Sweden. In K. Hanf and F. W. Scharpt (Eds) Interorganizational Policy Making: Limits to Coordination and Central Control, (pp 303-341). London, Beverly Hills: Sage Publications. Hock, D. (1994). Institutions in the age of mindcrafting. Unpublished presentation at the Intermountain Health Care System, Salt Lake City. Hogwood, B., and Peters, G.B. (1983). Policy Dynamics. Brighton: Wheatsheaf. Hogwood, B.W., and Gunn, L.A. (1984). Policy-analysis for the real world. Oxford: Oxford University Press. Hood, C. (1976) The Limits of Administration, London: Wiley. Howlett, M., and Ramesh, M. (2003). Studying Public Policy. Policy Cycles and Policy Subsystems. 2nd Edition. Oxford: Oxford University Press. Hsiao, W. C. and Shaw, R. P. (2007). Social Health Insurance for Developing Nations. Washington, DC: World Bank. International Labour Office (ILO) (2008). Social Health Protection: An ILO strategy towards universal access to health care. Geneva: International Labour Office. Israel, G. D., (2013). Determining Sample Size, Agricultural Education and Communication Departmental series, University of Florida IFAS Extension. Jann, W. and Wegrich, K. (2007). Theories of the Policy Cycle. In Fischer, F., Miller, G. J., Sidney, M. S., (eds), Handbook of Public Policy: Thepry, Politics and Methods, Boca Raton: Taylor and Francis Group, pp 43 – 62. Jehu-Appiah, C. (2015). Experiences of Ghana’s National Health Insurance Scheme: Achievements, Challenges & Way Forward. PowerPoint presentation. Retrieved from rghi.nl/wp-content/uploads/.../Ghana-NHIS-Caroline-Jehu-Appiah.pdf [Accessed, July 27, 2015] Jehu-Appiah, C., Aryeetey, G., Spaan , E., de Hoop, T., Agyepong, I. and Baltussen, R. (2011). Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling, who is not and why? Social Science & Medicine, 72, 157- 165. Jenkins, W.I., (1978). Policy-Analysis. A Political and Organisational Perspective. London: Martin Robertsen. University of Ghana http://ugspace.ug.edu.gh 187 Jones, B, D. (2001), Politics and the Architecture of Choice: Bounded Rationality and Governance. Chicago: The University of Chicago Press. Jones, B. D., Boushey, G., and Workman, S. (2006), ‘Behavioral Rationality and the Policy Processes: Toward a New Model of Organizational Information Processing’. In Moran, M., Rein, M. and Goodin, R. E. (eds) The Oxford Handboook of Public Policy, Oxford: Oxford University Press. Jutting J. (2003) Health Insurance for the poor? Determinants of participation in community based health insurance schemes in rural Senegal or2 CD Den/ Doc (2003) 02. Kamuzora, P and Gilson, L. (2007). Factors affecting the implementation of the Community Health Fund in Tanzania. Health Policy and Planning 22(2):95–102. Kaplan, B. and Duchon, D. (1995). Combining Qualitative and Quantitative Methods in interviewing : the art of hearing data. San Diego: Sage Publications. Kingdon, J. W. (1995). Agendas, Alternatives, and Public Policies, 2d ed. New York: Harper Collins. Kiser, L. & Ostrom, E. (1982), The three worlds of action, in: Ostrom, E. (Ed.), Strategies of political inquiry, Beverly Hills: Sage, pp. 179-222. Klok, P. J. (1995), A classification of instruments for environmental policy, in: Dente, B. (Ed.), Environmental policy in search of new instruments, Dordrecht: Kluwer, pp. 21- 36. Kolin, F. C. (2002). Successful Writing at Work, 6 th Edition. Houghton Mifflin. Krejcie, R.V. & Morgan, D.W. (1970). Determining sample size for research activities. Educational and psychological measurement. 30. p. 607-610. Kreuger, L. & Neuman, W.L. (2006). Social work research methods: Qualitative and quantitative approaches. Boston: Alllyn and Bacon. Kutzin, J. (2008). Health Financing Policy: A Guide for Decision-makers. Health Financing Policy Papers. Geneva: WHO. Kutzin, J. (2010). Conceptual Framework for Analysing Health Financing Systems and the Effects of Reforms. In J. Kutzin, C. Cashin, and M. Jakab (Eds), Implementing Health Financing Reform: Lessons from Countries in Transition (pp 411). The European Observatory on Health Systems and Policies. Kutzin, J., (2001). A descriptive framework for country-level analysis of health care financing arrangements. Health Policy, Elsevier, 56(3), 171-204. Larbi, G.A.(1998). Implementing New Public Management Reforms in Public Services in Ghana: Institutional constraints and capacity issues. PhD thesis, Birmingham: University of Birmingham, School of Public Policy. University of Ghana http://ugspace.ug.edu.gh 188 Lasswell, H. D. (1956), The Decision Making Process: Seven Categories of Functional Analysis, Maryland: University of Maryland. Lasswell, H. D. (1963). Experimentation, Prototyping, Invention. In H. D. Lasswell,. (Ed) The Future of Political Science, New York: Atherton. Lasswell, H. D. (1971). A Pre-view of policy sciences. New York: Elsevier Law, J. (2006). Managing change and innovation in public service organisations. Public Administration 83 (3), 794 – 801. Lee, R. (1989). A scientific methodology for MIS case studies. MIS Quarterly, 13(1), 33 – 50. Leger, F. (2006). Financial assessment of the National Health Insurance Fund. Geneva: International Labour Organization. Lester, J. P., O’Bowman, A. M., Goggin, M. L. and O’Toole, L. J. Jr. (1987). Public Policy Implementation: Evolution of the Field and Agenda for Future Research. Policy Studies Review 7 (1): 200–216. Levin, D. M. (1988). The opening of vision: Nihilism and the postmodern situation. London: Routledge. Ligteringen, J. (1999). The feasibility of Dutch environmental policy instruments, Enschede: University of Twente. Lindblom C.E. (1959). The Science of Muddling Through. Public Administration Review, 19(2), 79–88. Lindblom, C. E. and Woodhouse, E. J. (1993), The Policy-making Process, (3ed), Englewood Cliffs N. J.: Prentice-Hall. Linder, S. H., & Peters, B. G. (1987). A design perspective on policy implementation: The fallacies of misplaced prescription. Policy Studies Review, 6(3), 459-475. Lipsky, M. (1971). Street Level Bureaucracy and the Analysis of Urban Reform. Urban Affairs Quarterly, 6, 391-409. Lipsky, M. (1980), Street-Level Bureaucracy: Dilemmas of the Individual in Public Services. New York: Russell Sage Foundation. Mack, R. P. (1971) Planning On Uncertainty; Decision Making In Business And Government Administration, New York: Wiley‑Interscience. Makinde, T. (2005). Problems of Policy Implementation in Developing Nations. Journal of Social Sciences, 11(1), 63 – 69. Makoka, D., Kaluwa, B. and Kambewa, P. (2007). Demand for Private Health Insurance Where Public Health Services are Free: The Case of Malawi. Journal of Applied Sciences. 21, 3268-3273. University of Ghana http://ugspace.ug.edu.gh 189 Marshall, C. & Rossman, G. (2006). Designing qualitative research, (4th Ed.). Thousand Oaks: Sage. Marshall, C. & Rossman, G. B. (1998). Designing Qualitative Research (3rd Edition). Thousand Oaks, CA: Sage Publications. Marshall, C., & Rossman, G. B. (2006). Designing Qualitative Research (4 th ed.). Thousand Oaks, CA: Sage. Marshall, C., & Rossman, G. B. (2011). Designing qualitative research (5th ed.). Thousand Oaks, CA: Sage. Morçöl, G. (2012). A complexity theory for public policy. Routledge: London. Mathauer I. (2009): User Manual and Instructions to undertake an OASIS Health Financing (Organizational Assessment for Improving & Strengthening Health Financing), Department of Health Systems Financing, Geneva: WHO . Matland, R. E. (1995), Synthesizing the Implementation Literature: The Ambiguity-Conflict Model of Policy Implementation, Journal of Public Administration Research and Theory: J-PART, 5(2), 145-174. May, J.P., and Wildavsky, A. (ed.) (1978). The Policy Cycle. Beverly Hills, CA: Sage Mazmanian, D. A. and Sabatier, P. A. (1981). A Multivariate Model of Public Policy- Making. American Journal of Political Science 24, 439–468. Mazmanian, D. A. and Sabatier, P. A. (1983). Implementation and Public Policy, Scott, Foresman & Co., Dallas. Mazmanian, D.A. & Sabatier, P.A. (1989a) Implementation and Public Policy (2nd ed). Lanham, London: University Press of America. Mazmanian, D. A. and Sabatier, P. A. (1989b). Top-down and bottom-up approaches to implementation research: a critical analysis and suggested synthesis. In Mazmanian, D.A. & P.A. Sabatier (Eds), Implementation and Public Policy with a New Postscript Lanham, London: University Press of America. Merriam Webster Incorporated (2012). Merriam Webster’s Dictionary. New York: Merriam Webster Incorporated Mertens, D. M. (2010). Research and evaluation in education and psychology: integrating diversity with quantitative, qualitative, and mixed methods (3rd Ed.). Carlifonia: SAGE Publications Inc. Mhere, F. (2013). Health insurance determinants in Zimbabwe: Case of Gweru Urban. Journal of Applied Business and Economics, 14(2), 62 – 79. Mills, A., Bennett, S. and Russell S. (2001). The Challenge of Health Sector Reform: What must Government Do? Basingstoke, New York: Palgrave. University of Ghana http://ugspace.ug.edu.gh 190 Mushkat, R. (2008). Implementing environmental law in transitional settings: the Chinese Experience. Southern California Interdisciplinary Law Journal, 18(1), 45-94. Howlett, M. R. and Perl, A. (2009). Studying Public Policy: Policy Cycles and Policy Subsystems, [3rd edition]. Toronto: Oxford University Press. Mitchell, W C. (1968). Political systems. In D. L. Sills (Ed.), International encyclopaedia of the social sciences (Vol 5, pp. 473-479). New York: Macmillan. Montealegre, R., (1995). The risk of large-scale information technology failure: lessons from the Denver international airport. Faculty Working Paper 96-01, College of Business and Administration, University of Colorado, Boulder, November 1995. Mossialos, E. and Dixon, A. (2002) Funding health care: an introduction. In E. Mossialos, A. Dixon, and J. Figueras, (Eds.), Funding Health Care: Options for Europe. Buckingham, UK: Open University Press. Nakamura, R. (1987), ‘Then textbook Policy Process and Implementation Research’, Policy Studies Review, 7, 142 – 154. National Development Planning Commission (NDPC) (2013). Implementation of the Growth and Poverty Reduction Strategy (GPRS II) 2006 – 2009: 2008 Citizens’ Assessment Report of the National Health Insurance Scheme – Towards a sustainable healthcare financing arrangement that protects the poor. Accra: NHIA. National Health Insurance Authority (NHIA) (2009). National Health Insurance Scheme Annual Report 2009. Accra: National Health Insurance Authority. National Health Insurance Authority (NHIA) (2007). National Health Insurance Medicines List 2007. Accra: National Health Insurance Authority. National Health Insurance Authority (NHIA) (2010). National Health Insurance Scheme Annual Report 2010. Accra, Ghana: National Health Insurance Authority. National Health Insurance Authority (NHIA) (2011). National Health Insurance Scheme Annual Report 2011. Accra: National Health Insurance Authority. National Health Insurance Authority (NHIA) (2012). National Health Insurance Scheme Annual Report 2012. Accra: National Health Insurance Authority. National Health Insurance Authority (NHIA) (2013). National Health Insurance Scheme: 10th Anniversary Report. Accra: National Health Insurance Authority. Nketiah-Amponsah, E. (2009). Demand for Health Insurance among Women in Ghana: Cross Sectional Evidence. International Research Journal of Finance and Economics. 33:179-191 North, D. (1989). Institutions and economic growth: A historical introduction. World Dev 17 (9): 1319-1332. Nowlin, M. C. (2011), Theories of the Policy Process: State of the Research and Emerging Trends, Policy Studies Journal, 39: S1, pp 41- 60. University of Ghana http://ugspace.ug.edu.gh 191 Nsiah-Boateng, E. and Aikins, M. (2013). Performance Assessment of Ga District Mutual Health Insurance Scheme, Greater Accra Region, Ghana. Value in Health Regional Issues, 2, 300 – 305. Nyman, J. (1999). The Value of Health Insurance: The Access Motive. Journal of Health Economics, 18 (2): 141–152. Nyonator, F., & Kutzin, J. (1999). Health for some? The effects of user fees in the Volta Region of Ghana. Health Policy Planning, 14(4), 329 - 341. O’Neill, R. (2006). The advantages and disadvantages of qualitative and quantitative research methods. Retrieved from http://www.learnhigher.ac.uk/analysethis/main/quantitative1.html. [Accessed 20th September, 2013]. Osei- Akoto, I. and Adamba, C. (nd). Ethnic and Religious Diversity as Determinants of Health Insurance Uptake in Ghana.www.nai.uu.se/ecas-4/panels/121-140/panel- 128/Osei-Akoto-Isaac-full-paper.pdf.Accessed on 15th September, 2014. Ostrom, E. (1990), Governing the commons: The evolution of institutions for collective action, New York: Cambridge University Press. Ostrom, E. (2007), ‘Institutional Rational Choice: An Assessment of the Institutional Analysis and Development Framework’, in Sabatier, P. A. (2nd ed), Theories of the Policy Process, (2nd ed), Cambridge, MA: Westview Press, 21–64. O'Toole, L. J. (1995). Rational choice and policy implementation: Implications for interorganizational network management. The American Review of Public Administration 25(1), 43-57. O'Toole, L. J. (2000). Research on policy implementation: Assessment and prospects. Journal of public administration research and theory, 10 (2), 263-288. O'Toole, L. J. and Montjoy, R. S. (1984). Interorganizational policy implementation: A theoretical perspective. Public Administration Review, 491-503. Owusu, F. (2006). Differences in the performance of Public Organizations in Ghana: Implications for Public Sector Reform Policy. Development Policy Review, 24(6), 675-687. Owusu-Sekyere, E and Chiaraah, A. (2014). Demand for Health Insurance in Ghana: What Factors Influence Enrollment?. American Journal of Public Health Research, 2(1), 27-35. Oxfam (2012). Achieving a Shared Goal: Free Universal Health Care in Ghana. Accra: Oxfam. Palumbo, D. J. & Calista, D. J. (1990). Implementation and the Policy Process, opening the Black Box. New York, Wetport: Greenwood Press. University of Ghana http://ugspace.ug.edu.gh 192 Pare, G. and Elam, J. J. (1997). Using Case Study Research To Build Theories Of IT Implementation, in Information Systems And Qualitative Research: Proceedings Of The IFIP TC8 WG 8.2 Conference On Information Systems And Qualitative Research, Philadelphia, Pennsylvania, pp. 542-569. Parsons, W. (1995), Public Policy: An Introduction to the Theory and Practice of Policy Analysis, Massachusetts: Edward Elgar. Paudel, N. R. (2009), ‘A Critical Account of Policy Implementation Theories: Status and Reconsideration’, Nepalese Journal of Public Policy and Governance, Vol. xxv, No.2, pp 36 – 54. Peters, D., Yazbeck, A., Sharma, R., Ramana, G., Pritchett, L., and Wagstaff, A. (2002). Better health systems for India’s poor: findings, analysis, and options. Washington DC: World Bank. Peters, G. (1986). American public policy: Promise and performance (2nd ed.). Chatham, NJ: Chatham House. Petre, M. and Rugg, G. (2010). The unwritten rules of PhD research (2nd Ed.). England: McGraw Hill. Pettigrew, A. (1985). Contextualistic research: a natural way to link theory and practice', in E. E. Lawler, A. M. Mohrman, S. A. Mohrman, G. E. Ledford, T. G. Cummings and Associates (Eds.), Doing Research that is useful in Theory and Practice. Jossey-Bass: San Francisco, C.A., pp 222 – 248. Pettigrew, Andrew (2013). The Conduct of Qualitative Research in Organizational Settings. Corporate Governance: An International Review, 21 (2). pp. 123-126. Pollack, H. and Kronebusch, K. (2004). “Health Insurance and Vulnerable Populations.” In C. G. McLaughlin, Health Policy and the Uninsured, (ed), (pp 205-255). Washington D.C: The Urban Institute Press. Pradhan M and Prescott N. (2002). Social Risk Management Options for Medical Care. Indonesia Health Economics, 11, 431-446. Preker, A. S., Carrin, G., Dror, D., Jakab, M., Hsiao, W., Arhin-Tenkorang, D. (2002). Effectiveness of community health financing in meeting the cost of illness. Bulletin of the World Health Organization, 80(2), 143-150. Pressman, J. L. and Wildavsky, A. (1973) Implementation. How Great Expectations in Washington are Dashed in Oakland. Berkeley: University of California Press. Pressman, J. L. and Wildavsky, A. (1984) Implementation: 3rd edn. Berkeley: University of California Press. (1st edn, 1973; 2nd edn, 1979). Radermacher, R and Laaser, U. (2006). Elements of the Health Care Financing Process. In U. Laaser and R. Radermacher (Eds), Financing Health Care. A Dialogue between South Eastern Europe and Germany (Series International Public Health, Vol. 18) (pp 167 – 186) (pp 9 –25). Lage, Germany: Hans Jacobs. University of Ghana http://ugspace.ug.edu.gh 193 Rajkotia, Y. (2007). The Political Development of the Ghanaian National Health Insurance System: Lessons in Health Governance. Bethesda, MD: Health Systems 20/20 project, Abt Associates. Ranson M. (2002). Reduction of Catastrophic Health Care Expenditures by a Community based Health Insurance Scheme in Gujarat, India: Current Experiences and Challenges. Bulletin of the World Health Organization, 80(8), 613-631. Rapoport, A. ( 1966). Some system approaches to political theory In D. Easton (Ed.), Varieties of political theory (pp. 129-142). Englewood Cliffs, NJ: Prentice Hall. Englewood Rapoport, A. (1968). General systems theory. In D. L. Sills (Ed.), International encyclopaedia of the social sciences (Vol 5, pp. 452-457). New York: Macmillan. Republic of Ghana (1996). Ghana Health Service and Teaching Hospitals Act, 1996 (ACT 525). Accra: Ghana Publishing Corporation. Republic of Ghana (2003). National Health Insurance Act, 2003 (Act 650). Ghana Publishing Corporation. Republic of Ghana (2003). National Health Insurance Policy. Accra: Ghana Publishing Corporation. Republic of Ghana (2004). National Health Insurance Regulations, 2004 (L.I. 1809). Accra: Ghana Publishing Corporation. Republic of Ghana (2011). Health Institutions and Facilities Act, 2011 (Act 829). Accra: Ghana Publishing Corporation. Republic of Ghana (2011). Specialist Health Training and Plant Medicine Research Act, 2011 (Act 833). Accra: Ghana Publishing Corporation. Republic of Ghana (2012). Public Health Act, 2012 (Act 851). Accra: Ghana Publishing Corporation. Republic of Ghana (2012). Mental Health Act, 2012 (Act 846). Accra: Ghana Publishing Corporation. Republic of Ghana (2012). National Health Insurance Act, 2012 (Act 852). Accra: Ghana Publishing Corporation. Republic of Ghana (2013). Health Professions Regulatory Bodies Act, 2013 (Act 857). Accra: Ghana Publishing Corporation. Richardson, L. (2000). Writing: A method of inquiry. In N. K. Denzin and Y. S. Lincoln (Eds.), Handbook of qualitative research (2nd ed, pp 923-948). Thousand Oaks, CA: Sage. Richardson, L., and St. Piere, E. A. (2005). Writing: A method of inquiry. In N. K. Denzin and Y. S. Lincoln (Eds.), Handbook of qualitative research (3rd ed, pp 959-978). Thousand Oaks, CA: Sage. University of Ghana http://ugspace.ug.edu.gh 194 Roberts, M. J., Hsiao, W., Berman, P. and Reich, M. R. (2004). Getting Health Reform Right. New York: Oxford University Press. Rose, R. (1973). Comparing Public Policy: an Overview. European Journal of Political Ressearch, 1, 67 – 94. Ross, L. (1984) The implementation of environmental policy in China: A comparative perspective, Administration and Society, 15(4) 489-516. Russell S. (2004). The Economic Burden of Illness for Household in Developing Countries: A Review of Studies Focusing on Malaria, TB and HIV/AIDS. American Journal of Tropical Medicine and Hygiene, 71(Supp 2), 147-155. Sabatier, P. A. (1986) Top-Down and Bottom-Up Approaches to Implementation Research: A Critical Analysis and Suggested Synthesis. Journal of Public Policy 6(1), 21-48. Sabatier, P. A. (1991). Towards Better Theories of the Policy Process. Political Science and Politics, 24, 123 – 277. Sabatier, P. A. (1993). Policy change over a decade or more. In Sabatier, P. A. and Jenkins- Smith, H (eds), Policy Change and Learning: An Advocacy Coalitions Approach, Boulder, Col.: Westview Press. Sabatier, P. A. (2007)(ed), Theories of the Policy Process, (2nd ed), Cambridge, MA: Westview Press Sabatier, P. A. and Jenkins-Smith, H. (eds) (1993). Policy Change and Learning: An Advocacy Coalitions Approach. Boulder, Col.: Westview Press. Saburi, A. A. (2012). Determining the Consistency in Implementing Rural Road Transport Development using PEST Analysis: The Case of Kilimanjaro Region, Tanzania. International Journal of Trade, Economics and Finance, 3(4), 262 – 266. Saleh, K. (2013). The Health Sector in Ghana. Washington, D.C.: The World Bank. Salkind, A. (2003). Exploring research (5th ed.). Upper Saddle River, NJ: Prentice Hall, Inc. Salkind, N.J. (2000). Statistics for People Who (Think They) Hate Statistics. Thousand Oaks, CA: Sage Publications. Sapsford, R. (2007). Survey Research (2nd ed.), London: Sage. Sava, V. and Abovskaya, O. (2006). Mandatory Health Insurance – a Challenge for Sustainable Moldova Health Care System. In U. Laaser, and R. Radermacher (Eds.), Financing Health Care. A Dialogue between South Eastern Europe and Germany (Series International Public Health, Vol. 18) (pp 167 –186). Lage, Germany: Hans Jacobs. Savedoff W. & Carrin G. (2003). Developing Health Financing Policies. In C. J. Murray and D. B. Evans (Eds), Health Systems Performance Assessments: Debates, Methods and Empiricism Geneva: World Health Organisation. University of Ghana http://ugspace.ug.edu.gh 195 Savedoff, W. D. (2004). “Tax-Based Financing for Health Systems: Options and Experiences.” Discussion Paper No. 4, EIP/FER/DP.04.4. Geneva: World Health Organization. http://www.who.int/health_financing/taxed_based_financing_dp_04_4.pdf Savedoff, W. and Sekhri, N. (2004). Private Health Insurance: Implications for developing countries. Geneva: World Health Organisation. Schieber G., Cashin,, C., Saleh, K., and Lavado, R., (2012) Health Financing in Ghana. Washington D.C: World Bank. Seddoh, A., Adjei, S. and Nazzar. A. (2011). Ghana’s National Health Insurance Scheme. New York: Rockefeller Foundation. Siadat, B. (2013). The Impact of Ghana’s National Health Insurance Scheme on Patient and Provider Behavior. Dissertation, Harvard School of Public Health. Unpublished. Sikhosana, P. L. N (2005). Challenges in reforming the Health Sector in Africa: Reforming the health system under economic siege. The Zimbabwean Experience. Canada: Trafford Publishing. Simon, H. A. (1947), Administrative Behavior: A Study of Decision-Making Processes in Administrative Organizations. 4th ed. New York: Simon and Schuster, Inc. Simon, H. A. (1977), Models of Man, New York: Wiley. Smith, P. C. & Witter, S. N. (2004). Risk pooling in health care financing. The implications for health system performance. Health, nutrition and population family (HNP) of the World Bank’s Human Development Network, Discussion paper. Retrieved July 20, 2013 from: http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resou rc es/281627-1095698140167/Chap9SmithWitterRiskPoolingFinal.pdf. Smithson, P., Asamoa-Baah, A. and Mills, A. (1997) .The Role of Government in Adjusting Economies. The Case of the Health Sector in Ghana, Paper 26, Development Administration Group, University of Birmingham, Birmingham. Sniderman, P. Brody, R. and Tetlock, P. (1991) Reasoning and Choice. New York: Cambridge University Press. (pp. 1-27). Spaan, E., Mathijssen, J., Tromp, N., et al. (2012). The impact of health insurance in Africa and Asia: a systematic review. Bulletin of World Health Organization, 90, 685-692. Stake, R. E. The Art Of Case Study Research, Sage Publications, Inc, Thousand Oaks, Stone, D. A. (1989), ‘Causal stories and formation of policy agendas’ Political Science Quarterly, 104: 281 – 300. Sulzbach, S., Garshong, B. and Banahene, G. (2005). Evaluating the Effects of the National Health Insurance Act in Ghana: Baseline Report. Bethesda, MD: The Partners for Health Reformplus Project, Abt Associates Inc. University of Ghana http://ugspace.ug.edu.gh 196 Susser, B. (1992). Approaches to the study of politics. New York: Macmillan. Tapay, N and Colombo, P. (2004). Private Health Insurance in OECD countries: The Benefits and Costs for Individuals and Health Systems. In OECD, Toward High-Performing Health System, (pp.265-311).OECD Publishing. Tetlock, P. (2000), Coping with Trade-offs: Psychological Constraints and Political Implications. In Arthur, L., McCubbins, M. D. and Popkin, S. L. (eds.), Elements of Reason. Cambridge: Cambridge University Press. Thomas J. W. (1982). National Decision Making and Management of Food Aid and Food Policy: Some Issues from East African Experience. In C. Christensen et al. (Eds), The Developmenrtal Effectiveness of Food Aid in Africa, (pp. 113 – 136). New York: Agricultural Development Council. Thomas, J. W. & Grindle, M. S. (1990), After the Decision: Implementing Policy Reforms in Developing Countries, World Development. 18: 8 pp 1163-1181. Townsend R. (1994) Risk and Insurance in Village India. Econometrica, 62(3):539-591. Trujillo A. J., Portillo J. E. and Vernon J. A. (2005). The Impact of Subsidized Health Insurance for the Poor: Evaluating the Colombian Experience Using Propensity Score Matching. International Journal of Health Care Finance and Economics, 5(3), 211– 239. Twum-Barima, L. M. (2012). Health financing in Ghana: Perceived factors that help healthcare facility providers to render services to clients of National Health Insurance Scheme, Research Journal of Finance and Accounting, 3 (6), 132-137. UNDP Ghana and NDPC/GOG (2012). 2010 Ghana Millennium Development Goals Report. Accra, Ghana: UNDP Ghana and NDPC/GOG. Universal Accreditation Board (UAB) (2010). Study Guide for the examination of accreditation public relations: A preparation tool for candidates. Retrieved from http://old.praccreditation.org/ documents/ aprstudyguide.pdf on 12th September, 2012. Valle, V. (2000). Chaos, Complexity and Deterrence: A Term Project for the National Academy of War, Canberra, http://www.au.af.mil/au/awc/awcgate/ndu/valle.pdf. [Accessed: March, 18th 15th, 2014]. Van Meter, D., and Van Horn, C. (1975). The policy implementation process. Administrution and society.6, 445 – 488. Van Horn, C. E. (1978) Implementing CETA: The Federal role, Policy Analysis, 4(2), 159 – 183. Varian H. (1994). Microeconomic Analysis. New York: W.W. Norton and Co. Waddington, C. J., & Enyimayew, K. A. (1989). A price to pay part 1: the impact of user charges in the Ashanti-Akim district, Ghana. International Journal of Health Planning and Management, 4, 17 - 47. University of Ghana http://ugspace.ug.edu.gh 197 Waddington, C., & Enyimayew, K. A. (1990). A price to pay, part 2: the impact of user charges in the Volta region of Ghana. International Journal of Health Planning and Management, 5(4), 287 - 312. Wagstaff, A. (2007). Health Insurance for the Underprivileged: Initial Impacts of Vietnam's Health Care Fund for the Poor. Washington DC: World Bank, Mimeo. Wagstaff, A. and Menno P. (2005). “Health Insurance Impacts on Health and Nonmedical Consumption in a Developing Country.” Working Paper Series. Wagstaff, A., and Moreno-Serra, R. (2009). Europe and Central Asia’s Great Post-communist Social Health Insurance Experiment: Aggregate Impacts on Health Sector Outcomes. Journal of Health Economics, 28(2), 322–340. Wagstaff, A., and Yu, S. (2007). Do Health Sector Reforms have their Intended Impacts? The World Bank’s Health VIII Project in Gansu Province, China. Journal of Health Economics 26 (3): 505–535. Wagstaff, A., E. van Doorslaer, and N. Watanabe. (2003). On Decomposing the Causes of Health Sector Inequalities, with an Application to Malnutrition Inequalities in Vietnam. Journal of Econometrics 112(1): 219–227. Wagstaff, A., M. Lindelow, J. Gao, L. Xu and J. Qian (2007). Extending Health Insurance to the Informal Sector: An Impact Evaluation of China's New Cooperative Medical Scheme. Washington DC: World Bank, Mimeo. Wahab, H. (2008). Universal Healthcare Coverage: Assessing the Implementation of Ghana’s NHIS law. Paper presented at the Workshop in Political Theory and Policy Analysis Mini‑Conference, Indian University, Bloomington, April 26‑28. Walliman, N. (2006) Social Research Methods. London: Sage. Walsham, G. (1993). Interpreting Information Systems in Organizations. Wiley, Chichester. Walsham, G. (1995). Interpretive case studies in IS research: nature and method. European Journal of Information Systems, 4(2), 74–81. Wang, H., Yip W., Zhang L. and Hsiao W. C. (2009). The Impact of Rural Mutual Health Care on Health Status: Evaluation of a Social Experiment in Rural China. Health Economics 18, S65–S82. Waters H.R., Hussey P. (2004), Pricing health services for purchasers – a review of methods and experiences, „Health Policy”, 70. Weatherly, R. A., & Lipsky, M. (1977). Street-level bureaucrats and institutional innovation: Implementing special education reform. Harvard Educational Review, 47, 171– 197. Weatherly, R. A., & Lipsky, M. (2002). Street-level bureaucrats and institutional innovation: Implementing special education reform. In S. P. Osborne (Ed), Public Management: A Critical Perspective. London: Routledge. University of Ghana http://ugspace.ug.edu.gh 198 WHO Executive Board (2004). Social health insurance. EB115/8 115th Session, Provisional agenda item 4.5, 2–12–2004. Geneva: World Health Organization WHO Global Health Observatory. (2013). Ghana: Health Profile. Available: http://www.who.int/gho/countries/gha.pdf [accessed 4 Sept 2013]. Wildavsky, A. (1964). The Politics of the Budgetary Process. Boston, MA: Little Brown. Wildavsky, A. (1979), Speaking the Truth to Power: The Art and Craft of Policy Analysis, Boston: Mass Winter, S. (1990). “Integrating Implementation Research.” In D. J. Palumbo, and D. J. Calista (eds), Implementation and the Policy Process: Opening Up the Black Box, (pp 19– 38). New York: Greenwood Press. Witter, S., Garshong, B. and Ridde, V. (2013). An exploratory study of the policy process and early implementation of the free NHIS coverage for pregnant women in Ghana. International Journal for Equity in Health, 12(16), doi: 10.1186/1475-9276-12-16. Witter, S. and Garshong, B. (2009), Something old or something new? Social health insurance in Ghana, BMC International Health and Human Rights, 9(20), 1-13. Online at http://www.biomedcentral.com/1472-698X/9/20 [Accessed 7th September, 2013] World Bank. (2007). Project Appraisal Document on a Proposed Credit in the Amount of SDR10 Million to the Republic of Ghana for a Health Insurance Project. Available: http://wwwwds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2007/0 6/14/000020439_20070614085937/Rendered/PDF/39198.pdf [accessed 6 Sept 2013]. World Bank. (2011). Private Health Sector Assessment in Ghana. World Bank Working Paper No. 210. Washington, D.C.: The World Bank. World Bank (2012). Health Financing in Ghana. Washington D. C.: World Bank. World Bank. (2013). World Data Bank: World Development Indicators. Available: http://databank.worldbank.org/data/views/reports/tableview.aspx [accessed 4 Sept 2013]. World Health Assembly (2005). Sustainable health financing, universal coverage and social health insurance, Resolution 58.33, Geneva: World Health Organisation. World Health Organisation (WHO) (2000). The World Health Report 2000 – health systems: improving performance. Geneva: World Health Organization, [http://www.who.int/whr/2000]. World Health Organisation (WHO) (2007). Financing health promotion Discussion paper, Number, Geneva:WHO World Health Organisation (WHO) (2014). Ghana Country Cooperation Strategy at a glance. Geneva: World Health Organisation. Wu, X., Ramesh, M., Howlett, M. and Fritzen S. (2012). The public policy primer: managing the policy process. New York: Routledge. University of Ghana http://ugspace.ug.edu.gh 199 Xu, K., Evans, D., Kawabata, K., Zeramdini, R., Klavus J. and Murray C. (2003). Household catastrophic health expenditure: a multi-country analysis. The Lancet, 362, 111 -117. Yin, R. K. (1994). Case Study Research: Design and Methods. Thousand Oaks, CA: Sage Publications. Yin, R. K. (1993). Applications of case study research. Applied Social Research Series, Vol. 34. London: Sage. Yip, W., Hong W., and Hsiao W. (2008). The Impact of Rural Mutual Health Care on Access to Care: Evaluation of a Social Experiment in Rural China. Washington DC: World Bank. University of Ghana http://ugspace.ug.edu.gh 200 APPENDIX A Table A1: Demographic Characteristics of Respondents (Age, Gender, Literacy, Education) Male Female Total Age Dist. Count % Count % Count % 18-29 84 40.4 100 46.7 184 43.6 30-39 75 36.0 72 33.6 147 34.8 40-49 37 17.8 29 13.6 66 15.6 50-59 7 3.4 9 4.2 16 3.8 60-69 5 2.4 3 1.4 8 1.9 70+ 0 0.0 1 0.5 1 0.2 Marital Status Single 76 36.5 83 38.8 159 37.7 Married 106 51.0 98 45.8 204 48.3 Divorced 6 2.9 10 4.7 16 3.8 Separated 8 3.8 4 1.9 12 2.8 Widowed 2 1.0 2 0.9 4 0.9 Loose/informal union 10 4.8 17 7.9 27 6.4 Literacy Literate 203 97.6 210 98.1 413 97.9 Illiterate 5 2.4 4 1.9 9 2.1 Educational Attainment None 1 0.5 1 0.5 2 0.5 KG 1 0.5 0 0.0 1 0.2 Middle/JHS 9 4.3 12 5.6 21 5.0 SHS/O’ Level 42 20.2 33 15.4 75 17.8 A’ Level 5 2.4 10 4.7 15 3.6 Tech/Voc/Comm 8 3.8 11 5.1 19 4.5 Training Col. 14 6.7 27 12.6 41 9.7 Professional 24 11.5 24 11.2 48 11.4 Tertiary 104 50.0 96 44.9 200 47.4 208 49.3 214 50.7 422 100 Source: Field Data, 2014 University of Ghana http://ugspace.ug.edu.gh 201 Table A2: Employment Information of Respondents Male Female Total Employment Status Count % Count % Count % Unemployed 12 5.8 11 5.1 23 5.5 Self-employed with employee(s) 34 16.4 24 11.2 58 13.8 Self-employed without employee(s) 3 1.4 9 4.2 12 2.9 Unpaid family worker 4 1.9 6 2.8 10 2.4 Casual worker 21 10.1 17 7.9 38 9.0 Regular employee 110 53.1 110 51.4 220 52.3 Student 17 8.2 28 13.1 45 10.7 Apprentice/intern 1 0.5 1 0.5 2 0.5 Retired 2 1.0 1 0.5 3 0.7 National service person 3 1.4 7 3.3 10 2.4 Employment Category Public 73 35.1 71 33.2 144 34.1 Private (Formal) 61 29.3 53 24.8 114 27.0 Private (Informal) 32 15.4 42 19.6 74 17.5 Semi-public/parastatal 4 1.9 5 2.3 9 2.1 NGO/Intl Org. 8 3.8 5 2.3 13 3.1 Not Applicable 30 14.4 38 17.8 68 16.1 Sector of Employment Agric./Fishing/Forestry 9 4.3 8 3.7 17 4.0 Mining/Quarrying 7 3.4 5 2.3 12 2.8 Manufacturing 14 6.7 16 7.5 30 7.1 Finance/Insurance/Services 44 21.2 45 21.0 89 21.1 Electricity/Gas/Water 17 8.2 7 3.3 24 5.7 Community/Social Serv. 20 9.6 22 10.3 42 10.0 Education/Consultancy/Research 41 19.7 43 20.1 84 19.9 Healthcare 6 2.9 10 4.7 16 3.8 Transport/Storage/Comm. 1 0.5 5 2.3 6 1.4 Construction 8 3.8 5 2.3 13 3.1 Wholesale/ Retail trade 11 5.3 10 4.7 21 5.0 Not Applicable 30 14.4 38 17.8 68 16.1 208 49.3 214 50.7 422 100 Source: Field Data, 2014 University of Ghana http://ugspace.ug.edu.gh 202 Table A3: Reasons Non-Renewal of Insurance Male Female Total Count % Count % Count % Has not been sick 4 16.1 8 25.5 12 21.8 Premium is expensive 1 6.5 1 2.1 2 3.8 Poor quality care for subscribers of NHIS 8 35.5 14 42.6 22 39.7 Waiting time for card too long 7 32.3 7 21.3 14 25.6 Preferred services not covered under NHIS 1 3.2 1 4.3 2 3.8 Use health facilities that are not accredited 1 6.5 1 4.3 3 5.1 22 40.0 32 60.0 55 100.0 Table A4: Number of Times Benefitted from the NHIS Number of times benefited Renewed Not Renewed Total Count % Count % Count % Once 49 30.0 5 3.0 54 33.0 2 times 45 27.4 3 1.8 47 29.1 3 times 25 15.2 2 1.5 27 16.7 4 times 9 5.6 0 0.0 9 5.6 5 times 5 3.0 0 0.0 5 3.2 > 5 times 19 11.8 1 0.6 20 12.4 Total 152 93.1 11 6.9 163 100 University of Ghana http://ugspace.ug.edu.gh 203 Table A5: Factors facilitating the implementation of NHIS Factors Count % Public awareness and acceptance 41 9.8 Increasing enrolment and active involvement by the general public 26 6.1 Political will 21 5.1 Active involvement of religious bodies, traditional authorities, opinion leaders and other stakeholders 34 8.1 Reduced financial burden and the quest for financial protection 57 13.5 Exemption of some sections of the population making it easier for them to join 13 3.0 Availability of facilities and accredited providers 16 3.7 Quality of services provided 13 3.0 Improvement in registration and prompt issuance of cards 17 4.0 Better management of the scheme 17 4.0 Availability of infrastructure and other facilities to aid in the access to healthcare 10 2.4 Availability of funds through premium payments, SSNIT deductions and NHIL 7 1.7 Politicisation performing a gate keeping role 1 0.3 Use of card for other purposes 3 0.7 Supply of drugs 1 0.3 Increased coverage 3 0.7 Don’t know 142 33.7 Total 422 100 University of Ghana http://ugspace.ug.edu.gh 204 Table A6: Factors hindering the implementation of NHIS Factors Count % Slow registration/Biometric process 40 9.4 Delay in payment of claims 26 6.2 Over-Politicisation of NHIS 27 6.4 Poor/Inadequate health facilities and equipment 31 7.3 Inadequate funds 35 8.2 Poor services at health facilities 41 9.7 Inadequate skilled health workers 27 6.4 Congestion at health facilities 5 1.2 Corruption/Improper management and implementation of NHIS 26 6.1 Current economic situation in the country 7 1.7 Critical services and drugs not provided under the scheme 15 3.6 Inadequate information flow, sensitisation and information asymmetry 14 3.3 Poor attitude of NHIS staff towards the public 10 2.3 Low level of education among the public 4 1.1 Poor attitude of the public towards the NHIS 5 1.2 Poor/Inadequate supporting infrastructure and services 12 2.7 Inadequate drugs 2 0.5 Ineffective monitoring and supervision 3 0.6 Don’t know 93 22.0 Total 422 100 Source: Field Data, 2014 University of Ghana http://ugspace.ug.edu.gh 205 Table A7: Experiences of NHIS Subscribers in Health Facilities Strongly disagree Disagree Neutral Agree Strongly Agree Count % Count % Count % Count % Count % The NHIS accredited facilities that I use most of the time charge fees. 76 18.0 102 24.2 102 24.2 86 20.4 56 13.3 Facilities available to NHIS subscribers are normally in a deplorable condition. 81 19.2 84 19.9 108 25.6 95 22.5 54 12.8 There are more health staff available to non- subscribers than subscribers in the health facilities I use. 23 5.5 53 12.6 92 21.8 131 31.0 123 29.1 The staff at the health facilities are more friendly to non- subscribers than subscribers 36 8.5 44 10.4 82 19.4 119 28.2 141 33.4 Most health facilities I use complain of delayed payment of claims and therefore sometimes were are made to pay for services rendered 60 14.2 58 13.7 86 20.4 120 28.4 98 23.2 Source: Field Data, 2014 University of Ghana http://ugspace.ug.edu.gh 206 Table A8: How Economic Factors affect Respondents’ Participation in NHIS Strongly Disagree Disagree Neutral Agree Strongly Agree Count % Count % Count % Count % Count % I have not been able to pay the premium and register for the NHIS due to current economic trends 138 32.7 137 32.5 65 15.4 43 10.2 39 9.2 Current economic trends made me register or the NHIS to avoid paying exorbitant bills at the health facility 67 15.9 83 19.7 69 16.4 110 26.1 93 22.0 My participation in the NHIS has reduced my expenditure on health and this has encouraged me to always renew my membership 43 10.2 72 17.1 100 23.7 131 31.0 76 18.0 NHIS is really a relief to me and my household 82 19.4 67 15.9 84 19.9 132 31.3 57 13.5 Society sees participants of the NHIS as having a lower economic status 105 24.9 107 25.4 68 16.1 98 23.2 44 10.4 Source: Field Data, 2014 University of Ghana http://ugspace.ug.edu.gh 207 Table A9: Social Factors Affecting Respondents’ Participation in NHIS Strongly Disagree Disagree Neutral Agree Strongly Agree Count % Count % Count % Count % Count % My community encourages residents to participate in the NHIS 60 14.2 66 15.6 97 23.0 141 33.4 58 13.7 NHIS participants are given priority during social functions 158 37.4 118 28.0 80 19.0 44 10.4 22 5.2 Participation in the NHIS improves ones social relations 152 36.0 122 28.9 100 23.7 27 6.4 21 5.0 Some social groups are given priority treatment under the NHIS 114 27.0 98 23.2 93 22.0 83 19.7 34 8.1 Society sees participants of the NHIS as having a lower social status 123 29.1 115 27.3 68 16.1 74 17.5 42 10.0 My family influenced my decision to/not to join the NHIS 121 28.7 101 23.9 75 17.8 81 19.2 44 10.4 Source: Field Data, 2014 University of Ghana http://ugspace.ug.edu.gh 208 Table A10: Respondents’ Experiences at NHIA District Offices Strongly disagree Disagree Neutral Agree Strongly Agree Count % Count % Count % Count % Count % The cumbersome registration process has discouraged me or someone I know from joining the scheme 58 13.7 57 13.5 80 19.0 128 30.3 99 23.5 The attitude of staff at the scheme offices has discouraged me or someone I know from joining the scheme. 70 16.6 80 19.0 97 23.0 98 23.2 77 18.2 Source: Field Data, 2014 Table A11: Availability of NHIS Accredited Providers Satisfaction with the NHIS Satisfied Neutral Dissatisfied Total Count % Count % Count % Count % T h er e ar e en o u g h N H IS ac cr ed it ed p ro v id er s in m y a re a Strongly Agree 20 4.7 26 6.2 45 10.7 91 21.6 Agree 26 6.2 35 8.3 55 13.0 116 27.5 Neutral 14 3.3 46 10.9 27 6.4 87 20.6 Disagree 9 2.1 27 6.4 42 10.0 78 18.5 Strongly Disagree 7 1.7 12 2.8 31 7.3 50 11.8 Total 76 18.0 146 34.6 200 47.4 422 100.0 Source: Field Data, 2014 University of Ghana http://ugspace.ug.edu.gh 209 Table A12: Income Levels of Respondents The NHIS has not been successful Neutral The NHIS has been successful Total Count % Count % Count % Count % A v er ag e m o n th ly i n co m e (G H ₡ ) Up to 100 35 8.3 41 9.7 70 16.6 146 34.6 101 – 300 37 8.8 33 7.8 68 16.1 138 32.7 301 – 500 18 4.3 28 6.6 19 4.5 65 15.4 500 – 1000 13 3.1 10 2.4 19 4.5 42 10.0 Above 1000 3 0.7 14 3.3 14 3.3 31 7.3 Total 106 25.1 126 29.9 190 45.0 422 100.0 Source: Field Data, 2014 University of Ghana http://ugspace.ug.edu.gh 210 APPENDIX B Table B1: Health financing performance indicators Health financing performance indicator: Indicative performance indicator target(s) 1. Level of funding:  - The existing resource mobilization potential is exhausted.  - Total health expenditure per capita is at least US$34 (in 2000 prices) (cf. WHO 2001) and within the range of the regional average. 2. Level of population coverage:  The total population is covered by a social health protection mechanism, i.e. having access to key health interventions at an affordable cost. 3. Extent of financial risk protection:  At least 85% of total health expenditure is based on prepaid funds (e.g., taxes, health insurance contributions), and less than 1% of households experience catastrophic expenditure. (Catastrophic expenditure occurs when households spend more than 40% of their disposable income on health (Xu et al. 2003)). 4. Level of equity in health financing:  Health financing payments (e.g., SHI contributions, taxes, out- of-pocket payments) as a share of household capacity-to-pay (non-subsistence expenditure) are equal across income quintiles. 5. Level of pooling:  Health spending per person is equal across pools (i.e., health financing schemes), adjusted for health risk units. 6. Level of cost- effectiveness and equity in benefit package composition:  The benefit package composition is based on equity and efficiency criteria. 7. Level of efficiency in benefit package delivery:  Remuneration mechanisms minimize incentives for over- /under-provision or cost-shifting. Resource allocation reflects health care needs and health care costs. Source: Kutzin, 2010; based on Carrin/James (2005) and Mathauer (2009) University of Ghana http://ugspace.ug.edu.gh 211 Table B2: Factors Contributing Positively to an Enabling Environment for SHI Structural feature Contribution Large formal sector employment • Ease of administering mandated payroll tax on employers and/or employees • Ease of locating employers and collecting premiums High wages and salaries • Reduced economic burden of payroll tax • Opportunity to finance broader benefit entitlements Low poverty rate • Reduced need to subsidize membership of poor households Small family and/or household size • Reduced need for worker contributions to cover large number of dependents Efficiently functioning provider networks • Improved access by members to providers • Greater choice of providers • Possibility of quality-based competition among providers Strong human resource capacities • Available skills to manage SHI and monitor and evaluate quality Strong administrative support • Banking, accounting, actuarial, and legal support available Government capacity to regulate • Greater capacity to regulate for quality and manage grievance procedures Source: Hsaio and Shaw (2007) University of Ghana http://ugspace.ug.edu.gh 212 Box B1: Factors affecting the successful development of Social Health Insurance Source: Gottret and Schieber (2006) • Level of income and economic growth. The systems often begin in lower-middle income countries, and expansions to universal coverage generally occur during periods of strong economic growth • Dominance of formal sector versus informal sector. The systems are easier to administer in countries with a high proportion of industrial or formal sector workers, because employers will likely have a formal payroll system for contributions. • Population distribution. The systems are successful in countries with growing urban populations and increased population density but face slower implementation in countries with a large rural population. • Room to increase labour costs. Countries where the economies can tolerate increased payroll contributions without negative effects on employment and growth are better candidates for such systems. • Strong administrative capacity. The ability to implement a social health insurance system without excess administrative costs—and in a transparent, well governed fashion—is critical for population support and for financial and political sustainability. • Quality health care infrastructure. The systems can be successful only if the services they fund are available and of good quality, which will support membership in the scheme and avoid a system where the wealthier populations opt for a separate, privately financed system and do not provide needed political support. • Stakeholder consensus in favour of social health insurance, together with political stability and rights. Societies that place a high value on equity and solidarity are likely to support the redistributive aspects of such systems. But significant differentials in contributions may not be tolerated in systems where solidarity plays a less prominent role. • Ability to extend the system. Governments seeking to expand their social health insurance systems must design realistic and progressive goals that reflect the operating context. These goals include the ability to encourage the affiliation of informal sector workers and the means to collect regular contributions from them. Transparent and participatory schemes are more likely to garner population support. And governments may need to subsidize the extension of social health insurance to the poor. University of Ghana http://ugspace.ug.edu.gh 213 APPENDIX C Figure C1: Ghana’s Health Delivery System Source: Seddoh, Adjei and Nazzar, 2011 University of Ghana http://ugspace.ug.edu.gh 214 Figure C2: Organisation of Ghana’s Health System Source: Schieber et al., 2012 modified by author Private Hospitals and Maternity Homes Board Food and Drugs Board Nurses and Midwives Council Medical and Dental Council Pharmacy Council Traditional Medicine Practice Council Private Providers Ghana Health Service (GHS) Christian Health Association of Ghana (CHAG) Teaching Hospitals Psychiatric Hospitals National Health Insurance Authority Ministry of Health Service Providers National Ambulance Service Regulatory Bodies Research & Training Centre for Scientific Research into Plant Medicine Training Institutions Ghana College for Physicians and Surgeons University of Ghana http://ugspace.ug.edu.gh 215 Table C1: Ghana’s Health Sector Funding, 2014 Source Contribution Government of Ghana 12% Internally Generated Fund 58% Sector Budget Support 8% MOH Prog 22% NHIA 1% Source: MOH, 2014 Table C2: Ghana’s Health Sector Staff Strength Category Number DOCTORS 2857 COMMUNITY HEALTH NURSES 13659 ENROLL NURSES 12424 GENERAL NURSES 14773 STAFF MIDWIFE 4760 PHARMACISTS 650 BIOMEDICAL SCIENTISTS 720 RADIOGRAPHERS 91 MANAGEMENT (DIR, DEP DIR, ETC.) 243 ADMINISTRA TORS & HRM 675 Health Trainee & Intern 4500 OTHERS 30209 TOTAL 85561 Source: MOH, 2014 Table C3: Distribution of Health Professionals 2013 2014 Doctor : Population ratio 1:10,170 1:9,043 Nurse : Population ratio including CHNs 1:1,084 1:959 Midwife : WIFA Population ratio 1:1,525 1:1,374 Source: MOH, 2014 University of Ghana http://ugspace.ug.edu.gh 216 APPENDIX D RESEARCH INSTRUMENTS DEPARTMENT OF PUBLIC ADMINISTRATION AND HEALTH SERVICES MANAGEMENT, UNIVERSITY OF GHANA Ph.D. RESEARCH: FACTORS AFFECTING THE IMPLEMENTATION OF THE NATIONAL HEALTH INSURANCE POLICY HOUSEHOLD QUESTIONNAIRE INTRODUCTION This questionnaire forms part of a Ph.D. research work being carried out at the Department of Public Administration and Health Services Management, University of Ghana The study seeks to solicit information, opinions and perceptions on the implementation of the National Health Insurance Scheme. I would be seeking your views and perspectives on the performance and the accessibility of the health insurance scheme. The study is purely for academic purposes and the information you provide will be kept in strict confidence and that your name will not in any way be associated with the comments you make. There are no right or wrong answers. The researcher is interested in your experiences, so please answer each question honestly. Thank you. 1. Socio-Demographic Characteristics 1.1 What is your Gender Male [ ] Female [ ] 1.2 Please indicate your age range 18 – 29 [ ] 30 – 39 [ ] 40 – 49 [ ] 50 – 59 [ ] 60 – 69 [ ] 70+ [ ] 1.3 Please indicate your marital Status? Married [ ] Divorced [ ] Separated [ ] Widowed [ ] Loose/Informal Union [ ] Other (please specify) ………………………………………………………………………… 1.4 Can you read or write in any language? Yes [ ] No [ ] 1.5 What is the highest level of education you completed? None [ ] KG [ ] Primary [ ] Middle/JHS [ ] SHS/O’ Level [ ] A’ Level [ ] Tech/Voc/Comm [ ] Training College [ ] Professional [ ] Tertiary [ ] Other (please specify) ………………………………………………………………………… 1.6 What is your employment status? If unemployed, move to Q 2.1 Unemployed [ ] Self-employed with employee(s) [ ] Self-employed without employee(s) Unpaid family worker [ ] Casual worker [ ] Regular employee [ ] Domestic employee [ ] Student [ ] Apprentice [ ] Other (please specify) ………………………………………………………………………… University of Ghana http://ugspace.ug.edu.gh 217 1.7 What category will you put your current employer? Public [ ] Private (formal) [ ] Private (informal) [ ] semi-public/parastatal [ ] NGO/ Intl Org. [ ] Other (please specify) ………………………………………………………………………… 1.8 What is the activity at your place of work? Agric/Fishing/Foretry [ ] Mining/Quarrying [ ] Manufacturing [ ] Construction [ ] Transport/Storage/Comm [ ] Wholesale/ Retail trade [ ] Finance/Insurance/Services [ ] Electricity/Gas/Water [ ] Community/Social Serv. [ ] Education/Consultancy/Research [ ] Healthcare [ ] Other (please specify) ………………………………………………………………………… 1.9 What is your average monthly income [ ] Up to 100 Cedis [ ] 101 – 300 Cedis [ ] 301 – 500 Cedis [ ] 501 – 1000 Cedis [ ] Above 1000 Cedis 2. Health Insurance Participation 2.1 Have you had any health insurance, or are you a member of a mutual health organisation? Yes [ ] Move to Q2.3 No [ ] 2.2 If no, why have you not registered with NHIS? Move to Q 3.1 Not heard of NHIS [ ] cannot afford the premium [ ] Does not trust the organisers [ ] Do not need health insurance [ ] NHIS does not cover my health needs [ ] Other (please specify) ………………………………………………………………………… 2.3 If yes, what type of health insurance scheme do you have? Tick all that apply NHIS [ ] Health insurance through employer [ ] Mutual health organisation/community health insurance [ ] Other private purchased commercial health insurance [ ] Other (please specify) ………………………………………………………………………… 2.4 Who is currently paying your health insurance cost/premium? Self [ ] Spouse [ ] Other relative [ ] Friend [ ] Employer [ ] SSNIT contribution [ ] Exempted as child [ ] Exempted as elderly [ ] Exempted as pregnant woman [ ] Exempted as pensioner [ ] Exempted as indigent [ ] Other (please specify) ………………………………………………………………………… 2.5 Do you hold a valid NHIS card? Yes [ ] Move to Q2.7 No [ ] 2.6 If no, why don’t you hold a valid NHIS card? Registered but not fully paid [ ] Registered but not received card [ ] Registered and in waiting period [ ] Not renewed registration [ ] Move to Q2.12 Lost card [ ] Other please (specify) ………………………………………………………………………… 2.7 If, yes, how much did you pay or expect to pay for this insurance year?................. 2.8 How long did it take you to receive your NHIS card after the final premium has been paid?…………………………………………………………………………… 2.9 Have you ever benefited from the NHIS/ used your card? Yes [ ] No [ ] University of Ghana http://ugspace.ug.edu.gh 218 2.10 If yes, how many times did you benefitted in the past 12 months? ……………………… 2.11a Have you ever renewed your card since first the since your first registration? Yes [ ] No [ ] 2.11b If yes, how times have you renewed your NHIS card......... 2.12 If no, why have you not renewed your NHIS insurance? Has not been sick [ ] Premium is expensive [ ] Poor quality care for subscribers of NHIS [ ] Waiting time for card too long [ ] Preferred services not covered under NHIS [ ] Use health facilities that are not accredited [ ] Other (please specify) ………………………………………………………………………… 2.13 What is your average reduction in health expenditure as a result of participating in NHIS [ ] Above 90% [ ] 70 – 90% [ ] 50 – 69% [ ] 20 – 49% [ ] Below 20% 3. Respondent’s Perception of NHIS 3.1 Please indicate your agreement or otherwise of the following statements using the following scale: 1 2 3 4 5 Strongly Disagree Neutral Agree Strongly Disagree Agree [ ] I have not been able to pay the premium and register for the NHIS due to current economic trends [ ] Current economic trends made me register or the NHIS to avoid paying exorbitant bills at the health facility [ ] My participation in the NHIS has reduced my expenditure on health and this has encouraged me to always renew my membership [ ] NHIS is really a relief to me and my household [ ] Society sees participants of the NHIS as having a lower economic status [ ] My community encourages residents to participate in the NHIS [ ] NHIS participants are given priority during social functions [ ] My participation in the NHIS has improved my social status [ ] Some social groups are given priority treatment under the NHIS [ ] Society sees participants of the NHIS as having a lower social status [ ] My cultural background influenced my decision to/not to (please choose one) join the NHIS [ ] The politicisation of the NHIS has killed my interest in the scheme [ ] Unfulfilled political promises about the scheme is jeopardizing the future of the scheme University of Ghana http://ugspace.ug.edu.gh 219 [ ] I became aware/had renewed interest in the NHIS as a result of the intense politicisation [ ] Negative statements made by some political parties about the NHIS is jeopardizing the future of the scheme [ ] There are not enough NHIS accredited health facilities in my area and so I don’t find it important to join the scheme [ ] The NHIS accredited facilities that I use most of the time charge fees for one reason or the other so I am better off not joining the scheme. [ ] Facilities available to NHIS subscribers are normally in a deplorable condition [ ] NHIS subscribers obtain better services the non-subscribers in the health facilities I use. [ ] There are more health staff available to NHIS subscribers than non-subscribers in the health facilities I use. [ ] The staff at the health facilities are more friendly to NHIS subscribers than non- subscribers [ ] Most health facilities I use complain of delayed payment of claims and therefore sometimes were are made to pay for services rendered [ ] The cumbersome nature of the registration and card distribution process has discouraged me or someone I know from joining the scheme [ ] The attitude of staff at the scheme offices has discouraged me or someone I know from joining the scheme. [ ] Leaders of the religious organisation I belong to, encourage members to join the NHIS [ ] The religious organisation I belong to sometimes sponsors less endowed members to join the NHIS [ ] The district assembly encourages citizens to join the NHIS [ ] The district assembly has provided finanacial and other support to the implementation of the NHIS in my district [ ] I joined the NHIS primarily because I need the card for other transactions; using to access healthcare is secondary. [ ] The NHIS has been successfully implemented 3.2a Are there services that your household need from a health provider that are not covered by NHIS? Yes [ ] No [ ] 3.2b What are theses services?.............................................................................................. ………………………………………………………………………………………………… ………………………………………………………………………………………………… 3.3a In your opinion, do NHIS card holders get better/worse health care services than others? Better [ ] Same [ ] Worse [ ] Don’t know/ not sure [ ] 3.3b Please state the reason for your answer. ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… 3.4a In your opinion, have the quality of services provided gotten better/worse since you joined the NHIS? Better [ ] Same [ ] Worse [ ] Don’t know/ not sure [ ] University of Ghana http://ugspace.ug.edu.gh 220 3.4b Please state the reason for your answer. ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… 3.5a Taking everything into consideration, are you satisfied with or dissatisfied with the performance of NHIS in your district? Very satisfied [ ] Satisfied [ ] Indifferent [ ] Dissatisfied [ ] Very dissatisfied [ ] 3.5b State reasons for your answer……………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… 3.6 Please rank the following from 1 – 13 (1 being the least important and 13 being the most important) in terms their importance in ensuring the success of the NHIS Rank NHIA Government Political Parties/Politicians DMHIS Health Facilities Health Professionals Religious Organisations Civil Society Organisations Ghana Health Service (GHS) Ministry of Health (MOH) Citizens The International Community MMDAs NHIA – National Health Insurance Authority DMHIS – District offices of the NHIS MMDAs – Metropolitan, Municipal and District Assemblies 3.7 What are the factors facilitating the implementation of the NHIS in your district? ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… University of Ghana http://ugspace.ug.edu.gh 221 ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… 3.8 What are the factors hindering the implementation of the NHIS in your district? ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… 3.9 What suggestions do you have to improve the effectiveness of the NHIS? ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… University of Ghana http://ugspace.ug.edu.gh 222 DEPARTMENT OF PUBLIC ADMINISTRATION AND HEALTH SERVICES MANAGEMENT, UNIVERSITY OF GHANA Ph.D. RESEARCH: FACTORS AFFECTING THE IMPLEMENTATION OF THE NATIONAL HEALTH INSURANCE POLICY INTERVIEW GUIDE – SCHEME INTRODUCTION This questionnaire forms part of a Ph.D. research work being carried out at the Department of Public Administration and Health Services Management, University of Ghana The study seeks to solicit information, opinions and perceptions on the performance and accessibility of the National Health Insurance Scheme. I would be seeking your views and perspectives on the performance and the accessibility of the health insurance scheme. The study is purely for academic purposes and the information you provide will be kept in strict confidence and that your name will not in any way be associated with the comments you make. There are no right or wrong answers. The researcher is interested in your experiences, so please answer each question honestly. Thank you. Scheme. ………………………………………………………………………………….. Designation …………………………………………………………………………………. 1. If you were asked to evaluate the NHIS/policy what would you say? 2. What are the achievements? What factors are facilitating the implementation of the policy? Which of these factors are peculiar to your facility/district and which are general? Are they administrative, political, economic, social, cultural, etc.? What are the factors hindering the implementation of the policy? Which of these factors are peculiar to your facility/district and which are general? Are they administrative, political, economic, social, cultural, etc.? 3. If you were asked to make recommendations to the Health Minister about how you might improve quality of health services in your district, what would you suggest? 4. If you were asked to make recommendations to the Health Minister about how you might improve motivation of health staff in your district, what would you suggest? 5. What factors are facilitating the implementation of the policy? a. Which of these factors are peculiar to your district and which are general? b. Are they administrative, political, economic, social, cultural, etc.? 6. What are the factors hindering the implementation of the policy? a. Which of these factors are peculiar to your district and which are general? b. Are they administrative, political, economic, social, cultural, etc.? University of Ghana http://ugspace.ug.edu.gh 223 DEPARTMENT OF PUBLIC ADMINISTRATION AND HEALTH SERVICES MANAGEMENT, UNIVERSITY OF GHANA Ph.D. RESEARCH: FACTORS AFFECTING THE IMPLEMENTATION OF THE NATIONAL HEALTH INSURANCE POLICY PROVIDERS INTERVIEW GUIDE INTRODUCTION This questionnaire forms part of a Ph.D. research work being carried out at the Department of Public Administration and Health Services Management, University of Ghana The study seeks to solicit information, opinions and perceptions on the performance and accessibility of the National Health Insurance Scheme. I would be seeking your views and perspectives on the performance and the accessibility of the health insurance scheme. The study is purely for academic purposes and the information you provide will be kept in strict confidence and that your name will not in any way be associated with the comments you make. There are no right or wrong answers. The researcher is interested in your experiences, so please answer each question honestly. Thank you. a) Name of Health Care Unit: __________________________________________ b) Type of facility: _________________________________________ c) District: _______________________________________ d) Region: ________________________________________ e) Date of Interview: _______________________ f) Title of person interviewed: _________________________________ g) What is the catchment population of this facility? ________________ h) Is the facility accredited under the NHIS? 1. Yes 2. No i) 9. When was the facility accredited to provide services for the NHIS’ members? 1. In your opinion what are the effects of the scheme on the operations of the scheme on the operations of this health care facility? 2. What problems/challenges does this facility face with regards to the operations of the NHIS? 3. How has the management of this facility dealt with these problem(s)/challenge(s)? 4. What can be done to improve the operations of the NHIS in this facility/district? 5. What factors are facilitating the implementation of the policy? a. Which of these factors are peculiar to your facility/district and which are general? b. Are they administrative, political, economic, social, cultural, etc.? 6. What are the factors hindering the implementation of the policy? a. Which of these factors are peculiar to your facility/district and which are general? b. Are they administrative, political, economic, social, cultural, etc.? University of Ghana http://ugspace.ug.edu.gh 224 DEPARTMENT OF PUBLIC ADMINISTRATION AND HEALTH SERVICES MANAGEMENT, UNIVERSITY OF GHANA Ph.D. RESEARCH: FACTORS AFFECTING THE IMPLEMENTATION OF THE NATIONAL HEALTH INSURANCE POLICY INTERVIEW GUIDE - USER INTRODUCTION This questionnaire forms part of a Ph.D. research work being carried out at the Department of Public Administration and Health Services Management, University of Ghana. The study seeks to solicit information, opinions and perceptions on the performance and accessibility of the National Health Insurance Scheme. I would be seeking your views and perspectives on the performance and the accessibility of the health insurance scheme. The study is purely for academic purposes and the information you provide will be kept in strict confidence and that your name will not in any way be associated with the comments you make. There are no right or wrong answers. The researcher is interested in your experiences, so please answer each question honestly. Thank you. 1. Please tell us about the National Health Insurance Scheme (NHIS)/Policy. Probes: Do you know about the policy? If so how did you get to know? 2. I am interested in knowing of things have changed in any way since NHIS came in. 3. What are your impressions of service provision under the NHIS policy in comparison to before? 4. What is your opinion of the free NHIS/policy in practice? Probes: What do you like most about the policy? What difference, if any, has it made to your ability or willingness to use health services? What, if anything, do you not like about the NHIS/policy? 5. So tell me a little more about where you go for health care. What health facility do you usually use? Probes: Why do you use that particular health facility? Do you have a choice of what facility to use? What do you think about services provided at your health facility? Is the care provided at your facility different from care at other facilities you know? How is it different? 6. I want you to imagine you have been chosen to talk to the government on behalf of the people in your community on the NHIS! - Please tell me the factors that in your perception are facilitating the implementation of the NHIS (service providers, political, administrative, economic, actors, etc.) - Please tell me the factors that in your perception are hindering the implementation of the NHIS (service providers, political, administrative, economic, actors, etc.) - Please tell me what ideas you would suggest for improvement of the NHIS. University of Ghana http://ugspace.ug.edu.gh 225 APPENDIX E LIST OF INTERVIEWEES District Officials of the NHIA Ayawaso Israel Ayeh District Manager Simons PRO Ablekuma Linda Acquah District Manager Ga Benjamin Mensah MIS Manager Raymond Barnes Claims Officer (Dome Satellite Office) Dangme West Simon Nyarko PRO Ebenezer Hooper MIS Manager Hospital Managers Dr. Boasiako Antwi Yeboah CEO, Hannah Mbir Administrator, Dansoman Polyclinic Esther Neequaye Administrator, Psychiatric Department, Korle-Bu Teaching Hospital Residents 1. Patience Solomon 2. Elisabeth Nti 3. Robert Nsiah 4. Solomon Tolokpoe 5. Kwame Asare 6. Albert Gonda 7. Augustina Ofosu 8. Samuel Achiodem 9. Gilbert Manu 10. Wolarnyo Elom University of Ghana http://ugspace.ug.edu.gh 226 APPENDIX F ETHICAL CLEARANCE LETTER University of Ghana http://ugspace.ug.edu.gh 1 University of Ghana http://ugspace.ug.edu.gh