The implementation of the National Health Insurance in Ghana (2003-2013)

Abstract

The study explores the implementation process of the National Health Insurance Scheme (NHIS) policy within the context of the North/South divide (Northern and Southern Ghana); and the rural-urban spatial location in Ghana-a context that has received little attention from implementation researchers yet is very significant to understanding implementation outcomes across regions in Ghana. Four district mutual health insurance schemes were used as cases. These are Nanumba North and South mutual schemes in the Northern region (North) and Ashiedu Keteke and Osu Klottey mutual schemes in the Greater Accra region (South). The analytic process involved in understanding implementation is made simpler by the naturally afforded opportunity to make geographic comparison between the NHIS in poor, remote, under-served regions such as those of the North with those of relatively better-off urban regions like the South.

The study adopts a qualitative, comparative and embedded case study approach; and draws from a synthesis of three theoretical methodological approaches: top-down, bottom-up and interactive models in the implementation literature. However, the study has been largely guided by Hasenfeld and Brock’s political-economy model as well as Meter and Horn’s framework in explaining implementation of the NHIS. Empirical evidence gathered from 33 in-depth interviews collected over eight months in the two geographical regions and supplemented by document analysis reveals implementation of the NHIS is undermined by economic, political, technical, managerial, administrative but also physical infrastructural factors. Local contextual variables such as hard-to-reach communities in the North, the patriarchal system in the North are equally crucial in implementation terms. The study also establishes that the policy making process was irrational and characterised by dominance of political actors because of the high political stakes involved. The dimension of the North/South divide and rural-urban spatial location explored in the study adds an additional perspective to the implementation literature, and the extent to which geographic conditions impact on implementation outcomes of the same national policies.

Findings of the study also show that while the scheme has made a positive impact on utilisation and access, it is difficult to conclude if the quality of care has improved. The conclusions reached in the study are that improvement in health status of Ghanaians since implementation cannot be explained by the NHIS alone. Also, attention was not paid to the North/South divide in the policy making process; policy makers hastened to legislate in order to gain votes; the policy has also failed to adequately address the equity and redistribution challenges to healthcare access.

Above all, the study shows that the NHIS has resulted in the creation of a European/US type bureaucracy in healthcare in Ghana; it points to the need to distinguish between positive and negative solidarity in the SHI literature; and implementation researchers need to understand that implementation cannot be devoid of politics for they require each other to succeed.

Date of Award	Oct 2013
Original language	English
Sponsors	VCRS
Supervisor	Gordon Marnoch (Supervisor) & Ann-Marie Gray (Supervisor)