According to [24], there is an increasing realization that policies do not succeed or fail on their own virtues; instead their progress is reliant on the process of implementation. The seemingly appealing top-down view of policy and its implementation is based on three questionable assumptions: a sequential order in which articulated intentions herald action; a linear causal logic whereby goals determine instruments and instruments determine results; and a hierarchy within which policy formation is more important than policy implementation ([24]). In spite of several decades of criticism, it is a model that still preserves some admiration with policy-making authorities.

The policy context is, nonetheless, now understood to be much more complex than had been previously recognized. The earlier literature on the “policy-implementation gap” ([21]) has been supplemented in recent years by complex systems thinking informed by notions of unpredictability, nonlinearity, and adaptability ([6]). According to [37], the factors that outline and impact implementation are usually complex, multifaceted and multileveled with public policies invariably resembling “wicked problems” that are resistant to change, have multiple possible causes, and with potential solutions that vary in place and time according to local context ([37]). In the implementation of the NHIS, gaps in implementation and how they affected the policy process will be discussed in context.

With increase in understanding of this level, governments have accordingly come to recognize that more needs to be done to ensure intentions are turned into results—so that policy failure is avoided. Instead of just allowing policies to drift into full or even partial failure, governments are now beginning to take an interest in ways in which the policy process—and especially the implementation phase—can be strengthened and supported. It is prudent therefore to understand the major causes of policy implementation failures and have mitigating factors to deal with them when they arise ([25]). This study therefore examined some common causes of policy failures and relate them to how these issues were dealt with during the implementation of the scheme.

The level of ambiguity in a particular intervention will often determine the degree of success implementation will have and how replicable results across various sites will be ([31]). According to [31], there are different types of ambiguity, which fall into two categories, ambiguity of goals and ambiguity of means. In top-down models goal clarity is an important independent variable that directly affects policy success. Goal ambiguity is seen as leading to misunderstanding and uncertainty and therefore often is culpable in implementation failure. The position of top-downers is quite explicit-policies should be pushed in the direction of greater goal clarity ([31]).

As opposed to ambiguity of means, which gives rise to policy conflict, in this section we focus on ambiguity inherent in the goals themselves, abstracted from how to achieve them. Goal ambiguity influences policy implementation in many ways—for example, larger variations in how the policy is implemented and the actors that are involved in different sites.

But scholars agree that ambiguity is inevitable. Few policies are designed by one actor thinking rationally ([26]). Some interventions have a degree of ambiguity baked in by design, so that they will succeed at placating opponents in the policy formulation process. Goal ambiguity in public organizations may be ‘inevitable’ because they must respond to multiple external stakeholders, especially when the levels of policy complexity and political conflicts are high. Ambiguity can also come from the process of implementation. These difficulties may arise from intricate interdependencies of processes and structures, uncertainties inherent in the dynamic nature of social issues and processes, the incommensurability of potential risks, and the diversity of stakeholders. Even the concept of measuring whether goals are achieved can be problematic, since the nature of politics indicates some policies are formulated ambiguously and the goals in plain sight may be subsumed by “latent goals” or other priorities altogether ([31]; [11]; [35])—which is problematic for scholars like [18], who insist on goal clarity.

The ambiguity problem is connected to a variety of strategies scholars generally agree help ensure “good” implementation. Take, for example, the evaluation of a policy as it is implemented. [31] notes that “Statutory mandates often are exceedingly vague. They do not incorporate specific goals and they fail to provide reasonable yardsticks with which to measure policy results. Broader evaluation standards need to be used when significant ambiguity exists regarding the specific goals of a policy. For example, efficiency gains and economic growth may be used in one case, whereas enhanced support of the political system may be valid in another. Increased understanding and alleviation of local problems are two measures of success that frequently are likely to be relevant” ([31]).

Furthermore, [26] adds that with ambiguity the very nature of policy success or failure can be called into question. He states, “With ambiguous policy goals not only implementation may vary, but evaluation, too. The point is that given the political nature of policy formation in most public policy processes, policy goals laid down in official documents often will be compromises, and therefore susceptible to multiple interpretations. Several authors have shown that most public policies can hardly be explained as rational decisions of single policy designers” ([26]). Politics is significantly involved.

The implementation of a new health policy demands more than providing instructions around a policy document or designing a set of standard operating procedures ([38]; [17]). Effective health policy implementation requires the aggregation of the separate actions of many individuals, and (an understanding of) how and why the actions in questions are consistently reproduced by the behavior of individuals ([30]). One fundamental implementation challenge is that the responsibility for health policy implementation usually rests with a different set of governmental actors than the ones who designed the policy ([33]). Policy designers often do not understands the perspective of the implementers. The process of policy implementation thus requires working with and through a set of actors and organizations to communicate policy objectives, ensure availability of resources, achieve ownership of the policy by implementers, manage conflict and cooperation, and sustain policy changes. To start a new program and maintain it, joint efforts and contributions from multiple governmental agencies or private actors are needed. This frequently results in delays, renegotiation of resources and responsibilities, and confusion among the beneficiaries ([33]). In short, implementation is messy.

To move health policy forward into practice, implementers must realistically consider the difficulties of implementing a policy in their particular national context ([38]). Policy implementers or changes teams need to recognize the complexities and characteristics of the administrative context in which their policies will become operational ([23]). Those leading policy implementation need persistence, discipline, and rigor to work within their particular contexts, and they need to make difficult decisions regarding staffing, organizational structure, and relationships with stakeholders ([4]) to make policy implementation happen. Doing all of this in real time is not easy.

A qualitative approach was used for this study. Data was collected through face-to-face interviews using semi-structured questionnaires. The sample was chosen to include respondents randomly selected from the headquarters of the national health insurance scheme, Ministry of Health, Ghana Health Service, some hospitals and some subscribers across the Greater Accra region. Total number of respondents included was 18.

The purpose of this study is to assess the challenges of social policy implementation in Ghana by examining the implementation of the National Health Insurance Scheme. The study was conducted in the Greater Accra Region of Ghana. This is mainly due to the fact that most of the respondents were from government agencies whose offices are located in Accra (the capital city of Ghana). The Greater Accra Region is the capital city of Ghana and the seat of government. The headquarters of all the government agencies for health is located in the National capital Accra. The National Health Insurance Authority (NHIA), Ministry of Health, Ghana Health Service, Christian Health Association of Ghana and 37 Military Hospital are all located in Accra. Respondents were selected from these agencies and institutions for the study.

The study population consisted of different groups, namely directors and managers of National Health Insurance Authority who have been with the scheme within the last decade and a half. They cut across and included managers who were also at the district mutual schemes giving it a National picture. Managers from the Policy Planning, Monitoring and Evaluation (PPME) department of the Ministry of Health, managers from the research and policy department of GHS, administrators from primary hospitals, secondary hospitals and tertiary hospitals, directors of CHAG, and subscribers who have been with the scheme for 10 years or more were included.

All agencies of the MoH who were directly involved with the policy formulation and implementation of the NHIS policy were included in the study. All MoH agencies who were not directly involved in the formulation and implementation were excluded. Managers and directors from the respective organizations (NHIA, GHS, CHAG, MoH (PPME)) with ten years’ experience or more were included in the study whilst those with less than 10 years’ work experience were excluded. Beneficiaries or subscribers who had been with the scheme for 10 years or more were included whilst those with less than 10 years were excluded. Only hospital administrators who have worked in the area of NHIS were included in the study. All administrators who have had no direct involvement in the running of NHIS in the hospitals were excluded.

In this research, multilayered sampling procedures were employed. This involves identification of stakeholders. In this case the Ministry of Health was identified as a major stakeholder considering the subject matter of implementation of the NHI policy. The agencies of the Ministry concerned with the implementation were sampled and the NHIA, PPME, GHS and CHAG were further sampled from all the agencies and departments of the Ministry of Health. A purposive sampling technique was adopted to select the primary participants.

This study was designed to interview at least three managers from the various categories. In total, twenty (20) participants were contacted to be interviewed. It was anticipated that this would generate the required data to address the study’s research objectives and questions, although it was also acknowledged that there would need to be some flexibility to increase or decrease numbers according to the needs of the study. Two of the participants however declined for personal reasons. A total of eighteen participants were therefore interviewed. Table 1 below shows the distribution of respondents.

The semi-structured interview approach was selected in order to provide more flexibility for both the participants and the researcher ([8]). This enabled participants to lead the discussion when they wished to do so and build an argument around their understanding of the issues and events, as well as enabling the researcher to explore unexpected issues as they arose without leading the discussion. Each interview took place in a convenient place and lasted approximately 30-80 minutes, as recommended by [12]. In all fourteen (14) participants were interviewed face-to-face and four (4) via telephone. The instruments focused primarily on exploring respondents’ experiences on the implementation of NHIS, the challenges encountered and how they affected the policy process. A pre-test of the research tool was undertaken on some of the respondents from the NHIA.

Recorded interview data was examined and interpreted using thematic analysis.

Table 1. Demographic data of Respondents showing years of experience and position with organization of respondents.

[7] process was applied flexibly to this study’s research questions. The process started during the early phase of data collection by actively looking for issues relating to the research questions in the data, thinking about the patterns of meaning, and through a process of reflection on the experience of collecting the data (interviews).

The endpoint of this process of analysis was the reporting of the final themes. The analysis phase involved an iterative process of constantly moving back and forward between the data set of analysis, data items and the coded extracts of data.

Familiarization with data begun at the initial stages of the field exercise and continued through storing audio recordings of conducted interviews and transcription. The data collection exercise was conducted by the researcher, as it is vital that the researcher immersed himself with the data to familiarize himself with the depth and breadth of the content. The total number of responses received were read through severally for the researcher to familiarize himself with the text and generate initial codes. the collated codes were carefully examined and sorted into potential themes. This was done together by identifying major theme categories and sub-themes that fit into the major themes for each objective ([8]). The initial themes and sub-themes were refined via a process of reviewing both the coded data extracts and the whole unit of analysis. Initially the themes were reviewed against the coded data extracts. Themes were then defined and refined for the purposes of analysis. This was done by identifying the relevance of each theme, and the part of the data that individual themes captured. The final report was then produced.

Ethical clearance was obtained from the University of Ghana’s Research Ethics Committee. The aim was to ensure that all research involving human subjects, and/or their data is conducted in such a way as to minimize risk to participants and researchers, and that best practice is followed at all times.

4.1.1. Party Politics

From the interviews, it can be deduced that one of the major challenges facing social policy implementation in Ghana is party politics. The NHIS from its inception to date is been plaqued by party politics. Social policies are often birthed as manifesto promises and political parties are therefore saddled with the mandate of ensuring they are formulated and implemented. The whole NHIS was birthed as a manifesto promise in the run-up to the 2000 election. Upon election, therefore, processes were initiated for the promise to be fulfilled. This was met with some opposition from the main opposition party. Initially they did a lot of propaganda against the scheme saying it was a fraud and could never be achieved. Even though some members of the opposition, National Democratic Congress (NDC) showed their support for the scheme, the party staged a walk out of parliament during the debate and the passing of the bill that established the NHIS. Over several elections, the scheme has also been used as a campaign tool with several manifesto promises from both parties.

4.1.2. Propaganda against the Social Policies

The interviews revealed a lot of propaganda against social policies from politicians. In the case of the NHIS, when the scheme began, the NDC discouraged its members from registering claiming it was a facade and that the scheme was for the benefit of New Patriotic Party (NPP) members. The initial numbers were therefore quite low. When the NDC also came into power in 2009, NPP propaganda was that the scheme had collapsed. A lot of badmouthing also went on when the NHIA tried to introduce capitation as a cost saving measure for the scheme in 2015. The Ashanti region was chosen for the pilot and the NPP did a lot of propaganda with it including the fact that the Ashanti region was too big to be chosen for such a pilot. They also argued that the region was chosen because it was their stronghold.

During the scheme’s inception in 2003, the then opposition party, the National Democratic Congress (NDC) claimed that the scheme was for the ruling government that is the New Patriotic Party (NPP). Due to this propaganda, many NDC members did not want to register with the scheme… [Seyram, NHIA]

There was a lot of badmouthing about the capitation from the NPP even though it was a good policy. It could therefore not be introduced and all the pilots were stopped… [Andy, NHIA]

In 2009, when the NDC also took over power, NPP members also made a lot of publicity with the scheme. Some of their leaders claimed on campaign platforms that the scheme had collapsed, resulting in subscribers losing trust in the scheme… [Albert, MOH]

Politicians only look at issues from the political side and always ignore the technical side. The capitation was technically good but the politicians played politics with it and so it could not stand... [Andy, NHIA]

4.1.3. Manifesto Promises

From the interviews it also became apparent that the scheme had suffered a lot of manifesto promises. The NDC promised in its manifesto to make payment of premiums a thing of the past. Thus, subscribers were only going to pay premium only the first time they join the scheme. This was very highly accepted by the general populace but after they won the election they could not implement the policy. In the run-up to the 2016 elections, the NPP promised to revive the scheme which was saddled with debt and owed providers huge amounts over long periods.

Prior to their election into office, the NDC also promised to make the yearly payment of the premium a one-time payment in their manifesto. This however never materialized throughout their eight (8) years in power, since the implementation dates were always being postponed… [Seyram, NHIA]

Political parties have made promises in their manifestoes on the scheme. Even as recently as 2016, the NPP said it was going to revive the scheme when they come to power by paying off the debt owed providers but most providers are still owed... [Emmanuel, Hosp Admin]

4.1.4. Lack of Consensus in Passing the Bill

The interviews revealed that there was lack of consensus from both political parties in passing the NHI Act. Whilst the NPP wanted to pass the bill quickly and move ahead with the implementation, the NDC were not for it. Even though during the consultative process some members of the NDC including parliamentarians declared open support for the policy, they staged a walk out of parliament when it was time to vote to pass the bill. Since the NPP were in the majority, they went ahead and passed the bill.

One ranking member of the opposition NDC openly supported the idea but later on when it was time to pass the bill they protested for political reasons with elections just around the corner. So the NDC boycotted it… [Andy, NHIA]

The opposition NDC staged a walk out of parliament in protestation to the passage of the bill… [Albert, MOH]

The initial efforts of the NPP were challenged by the NDC I believe for political reasons including not staying in parliament during the passage of the bill but the NPP were in the majority and so got the bill passed… [Kwame, NHIA]

4.1.5. Effect of Party Politics on Operations of the Scheme

The interviews showed that the effects of party politics on the policy were two prong. Positive effects and negative effects. The positive side looks at the competition between the two major parties. Because the two major political parties are always competing for power, they use the NHI policy as a medium for campaign and therefore rely on it to come to power. They therefore pay a lot of attention to the scheme whilst in power since it has also become a measure of how well they perform in government. The policy therefore tends to enjoy both ways.

The negative aspect is to do with the actions of the same political actors when they are out of power. Standing against key policies that will affect the policy and sometimes badmouthing initiatives. The introduction of capitation which was a very good initiative was talked down by the NPP. Another negative effective is unfulfilled manifesto promises such as the one time premium promise by the NDC.

Let me look at it from the positive side. Because there is competition between the two major political parties to run the country and both parties have recognized the HI policy as a vehicle or one of the vehicles to come to power. Due to this they pay attention to the scheme and readily address their needs and even if there is inefficiency they quickly come to our aid to arrest the situation… [Kwame, NHIA]

Whenever a change in policy is mooted by one party it is vehemently opposed by the other. They sometimes badmouth policies without consulting us the technocrats. Politicians always ignore the technical side of policies and stick to the politics and this affects the scheme… [Andy, NHIA]

One other effect of partisan politics on the scheme is the change of key appointments whenever power changes hands and employment of party people. Since the inception of the NHIS, the chief executive is always changed whenever a new government assumes power. Also, the two major parties employ their party people into managerial positions affecting promotions of neutral old hands at the scheme. This has led to a lot of internal grumblings among staff resulting in lack of motivation.

The appointment of CEOs and more than necessary staff, most of whom have no skill and experience any time political power changes hands have serious effect on the scheme... [Richard, CHAG]

Some of us have been working here since inception of the scheme but anytime there are changes in government, new staff are employed into senior positions leaving us where we are… [Steve, NHIA]

During the interviews it was apparent that there was undue delay in the setting up of the management teams that were meant to regulate the district schemes and manage their finances as well. Due to the delay in the setting up of this key component, the districts had a free hand and did things on their own for a long time. Complacency set in and there were issues to do with mismanagement of funds and corruption. The district schemes were autonomous and since there was no proper regulation at the time, there were a lot of issues left unresolved.

I think it took too long for the management team to be set up so it allowed the districts to do things on their own and so the actual regulation was not too effective so they took advantage to move into implementation instead of regulation… [Andy]

The delay in setting up of the management teams led to the district schemes doing things on their own… [Steve]

From the interviews some respondents were of the view that the implementation was done in a rush. At the time of initiating the scheme, some areas lacked proper health facilities to serve the people. There was also the issue of unfair distribution of health care professionals across the country. Some areas lacked doctors, nurses, pharmacists and other key health personnel to support the delivery of health care services in these areas. These issues could have been resolved somewhat before the scheme was introduced. The absence of a proper provider payment system also affected implementation and could have been resolved before rolling out the scheme.

I believe the implementation was rushed because key operational aspects were not in place before rolling out. The lack of clearly defined provider systems for instance led to expensive claims and left most schemes saddled in debt in no time… [Andy]

Areas with little or no health facilities suffered because of how the scheme was localized. What it meant was that districts without proper health facilities had very poor service… [Mark]

The interviews further revealed that the many problems that bedevilled the district schemes coupled with the fact that the schemes were becoming too ‘powerful’, the National Health Insurance Council (NHIC) decided to abandon its regulatory role and took on the implementation role. This was clearly a misplaced priority since the systems required for regulation was not vigorously pursued like they should. Setting up the management teams for regulating the schemes should have been priority but yet they abandoned that and pursued implementation instead. Another school of thought also had it that the focus of the NHIC changed when the main person who led the design of the policy framework left the council unceremoniously and another person was brought in. The new man changed the concept and brought in his own ideas which led to the centralization of the scheme.

What happened was that the executive secretary (Dr. Samuel Akor) who understood the whole thing decided to back out and a huge gap was created… [Andy]

Hon Kwaku Agyeman Manu was appointed to fill the gap and the priority of the council changed and the focus was more on implementation rather than regulation… [Ama]

From the interviews, it became apparent that one of the major challenges of implementation was the scheme’s inability to attract the right caliber of human resource to run technical aspects of the claims. Claims management and vetting required clinicians who understand the language of the service providers and could therefore properly vet the submitted claims. Health care professionals were not really interested in joining the schemes since they were not too sure of its long term survival. Other people therefore had to be employed and trained to be able to handle those technical aspects of the scheme. This also affected the area of tariffs since the service providers could present any bill for services provided and the officers had no way of knowing whether the scheme was being over-charged or under-charged.

Targeted health professionals were reluctant to join because it was new and no one knew the future of the scheme so we had to employ people with little or no qualification and build up their capacity… [Kwame]

I remember going for recruitment interview in Cape Coast for claims personnel and a lady who was an accounts clerk was the one who showed up. Because there was no one she had to be selected like that and trained to build her capacity… [Andy]

The interviews revealed that some of the district schemes were not being managed properly and the officers in charge of these schemes were misappropriating funds for running the scheme. Some schemes had excessive funds due to low claims payment. Some districts had no district level hospitals and therefore claims only came from lower facilities. This left the schemes with a lot of idle funds and the officers misappropriated the funds. There were also reports of some officers conniving with some facilities to engage in activities that left the schemes with huge bills. These assertions were never really proven as some respondents were of the view that the lack of capacity in vetting claims by the officers in the district actually accounted for this.

The district schemes could not perform as expected and most staff abused their position and enriched themselves… [Richard]

There were widespread reports from the public and some providers on some staff of the NHIS schemes, conniving with providers to engage in fraudulent activities incurring huge cost to the NHIS. The limited resources of the scheme were also purported to be misused by officials for personal gains… [Seyram]

The interviews revealed that there was a challenge with funding of the schemes. The claims started piling up and monies were not coming so the schemes became saddled with debt. The funds allocated for the schemes were no longer being paid and claims were now to be vetted at the districts and forwarded to the NHIC for payment. This created a huge backlog of claim and led to delay in reimbursement of claims.

After a while the schemes were asked to submit indebtedness to the NHIC for payment. Thus they received claims, vetted them and forwarded them for payment by the NHIC… [Mark]

The districts were unable to pay claims promptly due to cost escalation of claims... [Seyram]

From the interviews it was apparent that in the face of the numerous challenges, attempts have been made to deal with each and every one of those challenges as they arise. Issues such as decoupling partisan politics from the policy, amending the Act and building capacity can go a long way to improve the policy. Some have been implemented and others are yet to take off. There is the need to find practical and workable solutions to help overcome the challenges the scheme faces.

4.8.1. Decoupling Party Politics from the Policy

From the interviews, most respondents were of the view that there was a strong need to decouple party politics from the policy. The managers of the scheme must have a free hand to work and put in place measures that will ensure quality service provision, prompt payment of claims as well as other measures that will help sustain the scheme. Politicians have to consult the technocrats before making promises with the scheme. Technical aspects of the policy must also be handled by the technocrats in order not to truncate measures meant to improve the scheme such as happened with the introduction of the capitation as a form of reimbursement for outpatient services. One major challenge is with the release of the NHIL to the authority for prompt payment of claims. The NHIL is paid into the consolidated fund and the Ministry of Finance does not release the monies on time for the authority to be able to honour its obligations. This poses a big challenge to managers of the scheme.

In my opinion, I believe separating politics from the scheme will help a lot… [Ama, MOH]

The political parties must stop the promises they make with the scheme and consult the technocrats to find out what is workable and what is not before making promises that sometimes end up embarrassing them... [Steve, NHIA]

From where I sit, I think there is too much politics in our insurance and this sometimes affects ‘we’ the subscribers. Sometimes you have to top up for your drugs or hospital bills meanwhile they say it is free… [Dodzi, Beneficiary]

As an administrator, I get worried when I hear on radio claims have been paid and yet my facility doesn’t receive anything. The politics is too much… [Atadwe, Hosp Admin]

4.8.2. Amending the Law

In order for the changes to the initial arrangements of the scheme to take place, the Act had to be amended. The Act 650 passed initially decentralized the scheme into district mutual schemes. Challenges in portability and management were therefore very difficult. For these challenges to be overcome therefore, the Act had to be amended to allow for the creation of the NHIA that will centralize the policy for ease of administration and also allow subscribers to access service everywhere. The amended Act transferred the power from the DMHIS to the NHIA. Act 852 was thus passed to correct some of the challenges of the Act 650.

You see one of the ways to solve the portability problems was to amend the Act so that the scheme could assume a national picture and subscribers could access service from all over the country… [Steve, NHIA]

The district schemes were becoming too powerful and some officers were abusing their office and therefore the scheme had to be centralized for more control… [John, CHAG]

For proper control and ease of work things had to be reshaped administratively and a new structure was proposed. For the changes to be legal, the Act had to be amended… [Seyram, NHIA]

4.8.3. Building Capacity

From the interviews one of the ways the human resource problems with personnel of the scheme was resolved was to employ staff from the district schemes and build their capacity. There were challenges of getting doctors, nurses, pharmacists and other health professionals to join and work for the scheme so initially many people without any health background had to be employed to play the various roles such as claims officers and accreditation officers. With time however, most of these personnel have built their capacity through further studies and experience on the field and are now the best at what they do.

Most of the staff employed by the scheme initially had no health background so had to take courses in order to keep up with the work… [Seyram, NHIA]

It’s been established that party politics is one of the main challenges facing the NHIS. The whole scheme was birthed as a manifesto promise by the NPP in the run-up to the 2000 election. The parties promised the electorate they will provide free health care if voted into power. It is common fact that many public policies are connected with a political ideology brought forward by political actors who may formally or informally hold positions in all circles of government ([34]; [10]; [41]; [22]). When the NPP was elected therefore processes were initiated for the promise to be fulfilled. This was also met with some opposition from the NDC. As discussed earlier, there were challenges from the main political parties during the initial stages of the scheme. Initially, there was a lot of propaganda against the scheme to the effect that it was fraudulent and could never be achieved. Even though some members of the NDC showed their support for the scheme, the party staged a walk out of parliament during the debate and the passing of the bill which established the NHIS. These activities posed a huge challenge to the implementation of the scheme. These positions changed when the NDC won power in 2008 and the running of the scheme became their responsibility. [22] opines that public officials must obtain the necessary skills and abilities to take part and carry out the functions of government, regardless of the party in power, as the task of the public official is to adopt the aims (objectives) presented to them by the policy and work towards achieving those aims of the policy ([22]). This was evident in the scheme when after much opposition the NDC won power and had to manage the scheme.

One of the gaps was the undue delay in the setting up of the management teams that were actually meant to regulate the district schemes and manage their finances as well. Delays in instituting key aspects of set policies can result in huge challenges in achieving set goals and objectives. This was clearly spelt out in the Act and was unambiguous. The level of ambiguity in a particular intervention will often determine the degree of success implementation will have and how replicable results across various sites will be ([31]). The need to set up the management teams was clearly stated as well as those who were to form them and give them their mandate. The NHIC was the body mandated to form the management teams to regulate and supervise the activities of the DMS. The attitude of implementers at the frontlines could also have caused this gap in implementation. There is an inherent problem with a governance framework that combines centralized political authority with decentralized administration, in which central officials may have unchallenged authority but lack the institutional and organizational means to ensure that their decisions are fully implemented. The NHIC decided to look at their own interests and therefore did not form the management teams on time. Due to the delay in the setting up of this key component, the districts had a free hand and did things on their own for a long time. Complacency set in and there were issues to do with mismanagement of funds and corruption. There were no set standards for operations at the districts and the districts themselves set their own standards for operation. The district schemes were autonomous and since there was no proper regulation at the time, there were a lot of issues left unresolved.

One of the gaps in implementation of the scheme was the fact that the implementation was done in a rush. Political pressures and the need to score political points can result in policies being implemented hurriedly. A lot of time is therefore not given to the processes and procedures and alternative plans are often not clearly laid out. There are also time ambiguities here since the actual time for a policy to start is usually not too clear. [26] posits that with ambiguity the very nature of policy success or failure can be called into question. He states, with ambiguous policy goals not only implementation may vary, but evaluation, too. The point is that given the political nature of policy formation in most public policy processes, policy goals laid down in official documents often will be compromises, and therefore susceptible to multiple interpretations ([26]).

One of the major challenges that can affect policy implementation is when actors move away from their assigned roles to take on roles assigned to others. Zhan and colleagues examined what they defined as an inherent problem with a governance framework that combines centralized political authority with decentralized administration, in which central officials may have unchallenged authority but lack the institutional and organizational means to ensure that their decisions are fully implemented. This leads to misplaced priorities and key aspects of the implementation process can be left unattended. Due to the many problems that bedevilled the district schemes coupled with the fact that the schemes were becoming too ‘powerful’, the NHIC decided to abandon its regulatory role and took on the implementation role. This was possible due to ambiguities in the roles and functions of the NHIC and other implementers. This is in line with the results and conclusions on some studies which opine that the level of ambiguity in a particular intervention will often determine the degree of success implementation will have and how replicable results across various sites will be ([31]). Goal ambiguity is seen as leading to misunderstanding and uncertainty and therefore often is culpable in implementation failure. The position of top-downers is quite explicit—policies should be pushed in the direction of greater goal clarity ([31]). The NHIC clearly took advantage of the gaps in the policy goals to take on responsibilities that were not meant to be theirs. This was therefore clearly a misplaced priority since the systems required for regulation were not vigorously pursued like they should. Setting up the management teams for regulating the schemes should have been priority but yet they abandoned that and pursued implementation instead.

One major challenge with the scheme in the implementation phase was the fact that some of the district schemes were not being managed properly and the officers in charge of these schemes were misappropriating funds for running of the scheme. Some schemes had excessive funds due to low claims payment. Some districts had no district level hospitals and therefore claims only came from lower level facilities. This left the schemes with a lot of idle funds and the officers misappropriated the funds. There were also reports of some officers conniving with some facilities to engage in activities that left the schemes with huge bills. Access to available funding and resources is a precondition for successful implementation. While funding alone will not generate success, without it there is often an inability to mobilize other aspects of an implementation strategy. Stable funding is an instrumental necessity to successful implementation ([14]). This was not the case with this study as excess funding only led to misappropriation of funds and not successful implementation.

Another major challenge to affect the scheme early on was the funding of the schemes. The claims started piling up and funds were not readily available so the schemes became saddled with debt. The funds allocated for the schemes were no longer being paid and claims were now being vetted at the districts and forwarded to the NHIC for payment. This created a huge backlog of claims and led to delay in reimbursement of claims. According to [14], access to available funding and resources is a precondition for successful implementation. While funding alone will not generate success, without it there is often an inability to mobilize other aspects of an implementation strategy. Stable funding is an instrumental necessity to successful implementation ([14]). Even though the funding for the scheme was well planned, politics between the NHIC and the district schemes also created a bottle neck where monies were no longer being paid directly to the districts for claims payment but they had to forward all claims to the NHIC for reimbursement. This created a huge backlog of claims and providers were not paid for a long time. [13] argue that resources need to be made available for implementation to succeed. They also need to be available in the right combination.

Numerous strategies were employed in dealing with the challenges of implementation. Issues such as decoupling partisan politics from the policy, amending the Laws and building capacity. These were some of the suggested ways in which the challenges could be dealt with to improve the policy. Some have been implemented and others are yet to take off. There is the need to find practical and workable solutions to help overcome the challenges the scheme faces.

5.7.1. Decoupling Party Politics from the Policy

There is a strong need to decouple party politics from the policy. The managers of the scheme must have a free hand to work and put in place measures that will ensure quality service provision, prompt payment of claims as well as other measures that will help sustain the scheme. Politicians have to consult the technocrats before making promises with the scheme. Technical aspects of the policy must also be handled by the technocrats in order not to truncate measures meant to improve the scheme such as happened with the introduction of the capitation as a form of reimbursement for outpatient services. The political system will formulate policies but must allow technocrats with the technical abilities to implement. Policy designers often do not understand the perspective of the implementers. The process of policy implementation thus requires working with and through a set of actors and organizations to communicate policy objectives, ensure availability of resources, achieve ownership of the policy by implementers, manage conflict and cooperation, and sustain policy changes. To start a new program and maintain it, joint efforts and contributions from multiple governmental agencies or private actors are needed. This frequently results in delays, renegotiation of resources and responsibilities, and confusion among the beneficiaries ([33]). One major challenge is with the release of the NHIL to the authority for prompt payment of claims. The NHIL is paid into the consolidated fund and the Ministry of Finance does not release the monies on time for the authority to be able to honour its obligations and poses a big challenge to managers of the scheme. There have been several attempts to separate the NHIL from the consolidated fund so the NHIA can handle its own revenue and invest and also be able to meet its financial obligations to service providers. Policy implementation therefore inevitably involves politics ([9]). Separation of key aspects of the policy during implementation so gaps can be reduced was also very necessary.

5.7.2. Amending the Law

In order for the changes to the initial arrangements of the scheme to take place, the Act had to be amended. The Act 650 passed initially decentralized the scheme into district mutual schemes. Challenges in portability and management were therefore very difficult. For these challenges to be overcome therefore, the Act had to be amended and allow for the creation of the NHIA that will centralize the policy for ease of administration and also allow subscribers to access service everywhere. The amended Act transferred the power from the DMHIS to the NHIA. Act 852 was therefore passed to correct some of the challenges of the Act 650. This was swiftly done in order to bring the schemes under the bigger umbrella of an authority which became responsible for the day to day running of the scheme. Health sector reform requires organizations and individuals to behave differently ([38]). Modifying behavior is however a difficult task because change is almost always resisted. People resist change because change disrupts established power structures and ways of getting things done ([5]); change often requires breaking old habits and relationships and starting new habits and relationships. The change of the Act 650 to Act 852 was warmly welcomed by the NHIC but the DMSs did not like it. This was because this virtually came to centralize all the power with the NHIC (now NHIA). Officers were also brought from the various district mutual schemes to form the nucleus of the main NHIA and continue their activities at the national level. New expertise such as doctors, pharmacists and nurses were also employed to beef up the strength of the staff at the headquarters. This proved to be very effective as some were given further training to take on extra roles.

5.7.3. Building Capacity

One major challenge that affected the implementation of the scheme was with the human resource. Initially a lot of personnel were employed for the schemes with little or no expertise. These problems with personnel of the scheme was resolved by building their capacity through further trainings and workshops as well as taking requisite courses as well. There were challenges of getting doctors, nurses, pharmacists and other health professionals to join and work for the scheme so initially lots of people without any health background had to be employed to play the various roles such as claims officers and accreditation officers. With increase in understanding of these challenges, governments have accordingly come to recognize that more needs to be done to ensure intentions are turned into results—so that policy failure is avoided. Instead of just allowing policies to drift into full or even partial failure, governments are now beginning to take an interest in ways in which the policy process—and especially the implementation phase—can be strengthened and supported. It is prudent therefore to understand the major causes of policy implementation failures and have mitigating factors to deal with them when they arise ([25]). Building capacity and employing the right caliber of staff is therefore very crucial for the success of every policy. With time however, most of these personnel have built their capacity through further studies and experience on the field and are now the best at what they do.