Expertise Utilization in Public Policy: The Experience of Ghana’s National Health Insurance Authority (NHIA)

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MASTER THESIS

Topic: Expertise Utilization in Public Policy: The Experience of Ghana’s National Health Insurance Authority (NHIA)

Name: Christine Hannah Maassen

Student ID: S2110598

Supervisor: Johan Christensen

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LIST OF FIGURES

Fig 2.1: Conceptual framework depicting the factors influencing expertise use by the NHIA….18

LIST OF TABLES

Table 3.1: Breakdown of qualitative Interviews………23

Table 3.2: Data collection techniques used for the study………...25

Table 3.3: Research matrix depicting how variables were operationalized…………...……… 26

Table 3.4: Data Analysis process………...…...…………...28

Table 4.1: Key components of Ghana’s NHIS………...………... 32

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LIST OF ABBREVIATIONS CEO Chief Executive Officer

DANIDA Danish International Development Agency DMHIS District Mutual Health Insurance Schemes EML Essential Medicines List

HR Human Resource

ILO International Labour Organization IMF International Monetary Fund JLN Joint Learning Network M&E Monitoring and Evaluation MOH Ministry of Health

NGO Non-governmental organisations NHIA National Health Insurance Authority NHIC National Health Insurance Council NHIF National Health Insurance Fund NHIS National Health Insurance Scheme

SSNIT Social Security and National Insurance Trust UHC Universal Health Coverage

UNFPA United Nations Population Fund

UNICEF The United Nations International Children’s Emergency Fund USAID United States Agency for International Development

WB World Bank

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Abstract

This study investigated the extent to which the National Health Insurance Authority (NHIA) uses expertise in managing Ghana’s National Health Insurance Scheme (NHIS). The focus was on identifying the factors that underlie expertise use and its associated challenges. The study adopted a qualitative research methodology with semi-structured interviews, and documentary reviews as the data collection tools. The data was analysed in themes in a six-staged process.

The study found that the NHIA relied on expertise in managing and delivering the NHIS effectively. Factors that influence the authority’s use of expertise include, need and relevance of expertise, trust and legitimacy, cost, networks and collaborations, and political imperatives of policy makers. It was also established that the NHIA uses more of local and internal expertise compared to international or external ones, and this is due to considerations over cost and organizational policy. However, owing to issues of trust and legitimacy, international expertise was preferred. The authority faces challenges in using expertise, and these include cost, abuse of trust by expertise and contextualization of policy knowledge to suit the organization’s needs. The study has a number of policy implications for expertise use in developing countries. It draws the attention of policy makers to important drivers of expertise use in these contexts. The factors and challenges identified serve as a baseline to guide policy makers in Ghana and other developing countries in formulating appropriate policies on expertise utilization.

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CHAPTER ONE

GENERAL INTRODUCTION 1.0 Introduction and Background

There is a growing interest in the use of expertise in achieving public policy outcomes. The interest is in recognition of the complicated and technical nature of public policy making in recent years, which necessitates the competence, knowledge and skills of experts from diverse backgrounds (Béland & Howlett, 2016; Haas, 2015; Stone, 2017). The use of expertise for public policy hinges on the logic that experts have relevant technical knowledge in different policy domains, and not only do they help frame policy issues, but they also guide policy makers to achieve desired ends (Haas, 1992; Mukherjee & Howlett, 2015).

While there is some consistency among scholars and practitioners on the importance of expertise to the policy making process, it has been found that expertise is predominantly used at the agenda setting and policy formulation stages, compared with the implementation stage (Blewden, Carroll & Witten, 2010; Howlett, Wu, Ramesh & Fritzen, 2017; Krick, 2018). Thus, the tendency is for policy makers to marshal the necessary expertise during the early stages of formulation, while the implementation stage is left in the hands of traditional bureaucrats who may not have the expertise to manage policies to achieve the desired goals (Bhat & Sharma, 2016). Yet, the implementation stage has been found to be inherently difficult and therefore warrants expertise input (Ohemeng & Ayee, 2016; Sapru & Sapru, 2018).

It is against this background that this study investigates expertise use in policy management with a focus on Ghana’s National Health Insurance Authority (NHIA), managers of the country’s National Health Insurance Scheme (NHIS). The NHIS was implemented in 2003 to replace the

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previous cash and carry system, which had negative consequences on access to quality healthcare particularly by the poor. While the policy is credited with some improvements in the health-seeking behaviour of a significant portion of the Ghanaian population with a current coverage of about 11 million subscribers, the scheme faces challenges of financial sustainability, and capacity to extend coverage to all Ghanaians (Atinga et al., 2015; Fenenga et al., 2014).

As part of addressing the challenges, there are issues regarding the technical capacity of managers, and the extent to which the NHIA utilizes expertise on health insurance. Considering the role that expertise plays in the management of policies, it becomes pertinent to explore the extent to which the NHIA makes use of available expertise on health insurance in managing the NHIS, in the face of its challenges.

1.2 Problem Statement

Although research on expertise use by policy-makers has increased over the years, much of the attention has been on developed country contexts and organizations (see for example, Rimkutė & Haverland, 2015; Van Ballaert, 2015). This concentration has steered the discussions off developing countries, with limited knowledge on the factors that influence expertise use in these settings. According to Abekah-Nkrumah, Issiaka, Virgil & Ermel (2018, p. 2), there is “an expertise utilization gap in developing countries which is worsened by weak capacity (skill set and systems) to carry out policy-relevant research and translate findings into a form that can be easily utilised by policy-makers”. This makes it necessary for more research into expertise use and its underlying drivers in developing countries. Given that developing countries have different

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institutions, it is possible that researching on expertise use in such contexts could yield different results and thereby contribute new insights on existing knowledge on expertise.

In the particular case of Ghana, existing literature on the NHIS policy has focused on the challenges confronting the scheme particularly, its financial sustainability and organizational capacity (Dalinjong & Laar, 2012; Fusheini, Marnoch, & Gray, 2017, Sakyi et al., 2012; Awoonor-Williams et al., 2016). In seeking answers to the challenges however, there has been less attention on the use of expertise in the management process. Thus, of the number of studies on the NHIS, those that examine the use of expertise on health insurance in the scheme’s management are either rare or non-existent. This study fills this void by investigating the extent to which expertise is utilised by the NHIA. This will enhance a comprehensive understanding of the management of the policy, and contribute insights on expertise use in dealing with the challenges confronting the NHIA.

1.3 Research Objective

The study aims at investigating the extent to which the NHIA utilizes expertise in managing the NHIS and the factors that influence the use of expertise by the NHIA.

1.4 Research question

To address the above objective, the study is guided by the following research question:

To what extent does the NHIA utilize expertise in the management of the NHIS, and what are the underlying factors?

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1.5 Definition of Key Terms

Expertise/Expert knowledge

In this study, expertise is understood as an individual or group of individuals with technical knowledge on a particular issue or policy (Haas, 1992).

Social Health Insurance

This study focuses on the National Health Insurance Scheme of Ghana, which is a kind of social health insurance or health financing arrangement in which members pool resources in advance to cover them in times of ill health. It is a preferred health care financing option in low-income countries (Carrin & James, 2005).

1.6 Value of the research

This study is significant in three main respects: research, policy and practice. In terms of research, it contributes knowledge on expertise use from a developing country context. It contributes insights on the context specific factors that influence the use of expertise in managing social health insurance from a developing country context.

In terms of policy, the study provides information on the utilization of expertise in managing the NHIS policy in Ghana. It directs the attention of policy makers to previously overlooked, context specific factors such as affordability and relevance of expertise that are important for managers. These insights are useful not just in providing pointers on expertise use, but also helping policy makers design appropriate polices to guide the use of expertise by the NHIA and other similar public organizations in Ghana.

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In terms of practice, the study provides useful information on the challenges in using expertise and ways of surmounting them. In addition, per its recommendations, the study provides information that will assist the NHIA incorporate best practices and guidelines for effective utilization of expertise.

1.7 Chapter Disposition

The study is organized into five main chapters. Chapter one introduces the study and outlines what constitutes the research problem. It also covers the research objective and research question. Chapter two provides a background literature to the study. The chapter reviews the conceptual and empirical literature on expertise with a focus on the factors influencing its use by policy makers. Following a review of the factors, a conceptual framework is developed to guide data collection and analysis.

Chapter three presents the methodology employed for the study. It details the research approach, design and sources of data used for the study. In addition, the chapter discusses the purposive sampling technique, the sample size, methods of data collection, the data management, operationalization, and analysis techniques. Ethical decisions made in the study are also presented.

Chapter four presents the data and its analysis; providing a detailed discussion of the results and where it all fits in existing literature and theory. Chapter five sums up the study with key research findings, conclusions, policy recommendations and directions for future research.

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CHAPTER TWO

EXPERTISE IN POLICY MANAGEMENT: A REVIEW 2.0 Introduction

This chapter aims at achieving a number of objectives. First, it is to provide a background literature within which to position the current study. Second, it is also to identify existing gaps in the current discourse on expertise use in general and developing countries in particular. The chapter is also to review the factors that influence expertise use by policy makers. Consequently, the chapter first overviews the general theoretical literature on expertise, evidence-based policy making with a focus on the rationale for expertise utilization and its implications for public policy. This is followed by a discussion of the factors influencing expertise use in developing countries. In the final part of the chapter, the factors are built into a conceptual framework to guide data collection and analysis.

2.1 Defining the Concept of Expertise

The concept of expertise is conceived from different perspectives and disciplines in the literature. In terms of policy development, expertise is used to mean expert knowledge or skill that is relevant for public policy (Rich; 2004). Haas (1992) defines expertise as a network of knowledge-based experts who bring their technical knowledge to bear on the development and implementation of public policies.

Based on this group dimension, Haas later popularized the notion of ‘epistemic communities’, as a “network of professionals with recognized expertise and competence in a particular domain and an authoritative claim to policy-relevant knowledge within that domain or issue-area” (Haas, 1992,

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p. 3). Viewed this way, expertise helps policy makers with policy relevant information and thereby influence which policies are selected in various policy arenas. Due to the cross-cutting nature of policy issues and interrelatedness of policy problems, expertise is drawn from both national and international sources, across various established consultancy firms, research institutions, international organizations, think tanks, and NGO’s.

2.2 Evidence-based Policy Making

Closely related to the concept of expertise is evidence-based policy making, which features prominently in recent literature (Head, 2016). Although a clear definition of what is meant by evidence-based policy making seems rare, the concept is generally used to refer to systematic efforts to ensure that research evidence is used as an important input into policy-making (Lavis et al., 2006). According to Howlett (2009, p. 32), evidence-based policy-making is “a contemporary effort to reform or re-structure policy processes in order to prioritize evidentiary or data-based decision-making”. Rooted in the belief that policies should be data-based on strong and methodologically tested evidence, evidence-based policy making is the use of the innovative research and information to guide decisions at all stages of the policy process. Conceptually, the term is linked to the scientific approach to knowledge production and the rational decision making process in public policy making (Evans, 2017).

Evidence based policy making hinges on the idea that public policy that are based on scientific evidence, leads to optimal distribution and fair distribution of resources, responds to scientific and technological advances, and consequently improves health outcomes (Abeka-Nkrumah et al., 2018). Due to this interest in achieving effectiveness in outcomes, evidence-based policy making

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has become the focus of a variety of policy communities, including research organisations, think tanks and government departments.

2.3 Expertise Utilization in Policy Development

Generally, the increasingly complex, and technical nature of public policies have increased the level of uncertainty associated with policymaking and ultimately, expertise use by policy makers (Holst & Christensen, 2016). The literature discusses several reasons why policy makers utilize expertise and the manner in which expertise is utilized. The reasons vary on account of types of policies and contexts, but it also depends on the importance attached to the policy and the implications of policy solutions on the public and political actors (Christensen & Velarde, 2018; Schrefler, 2010). These variations notwithstanding, there are common reasons for drawing on expertise irrespective of the type of policy or contexts.

In her classic study of ‘the many meanings of research utilization’, Weiss (1979) set out seven distinct uses of expertise. These are knowledge driven; problem-solving; interactive; political; tactical; enlightenment; and research as part of intellectual enterprise of society (Weiss, 1979). In the knowledge-driven use, expertise is used to inform new policy development.

In the problem-solving model, policy makers fall on expertise to help fix a particular policy issue or to reach some form of consensus that would help identify the most appropriate means of addressing the problem. In such cases, expertise is required to help structure the problem, while evaluating the possible alternatives through cost-benefit analysis, societal relevance and implications.

The interactive model describes a collaborative process, by which policy-makers actively search for solutions to issues from a range of sources. A host of stakeholders or actors including policy

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experts, politicians, think tanks, journalists, planners, organised unions are involved in these interactions in search of solutions. Through such interactive processes, emergent policy solutions and strategies are derived.

Under the political model, expertise is used strategically to bolster or undermine opposition to existing policy stances. Under the tactical model, expertise is used as a kind of ammunition in support or critical of certain strategic positions, with the findings largely irrelevant (Weiss, 1979, p. 429). In such situations, the rationale is clear, and expertise does not do much to change government’s position on the issue. Nevertheless, research or expertise that feeds into the government’s preconceived position is still relevant as it serves as ammunition to provide some form of legitimacy to government’s policy choice (Christensen, 2018).

Under the enlightenment model, research gradually influences policy through being able to shape prevailing paradigms and the way problems and their solutions are framed. Expert analysis and research findings do shape opinions and sensitizes decision makers to novel ideas and issues. While Weiss’ (1979) typology has been influential in the theoretical understanding of expertise use, it has been punctured in several respects. Nutley et al., (2007) contends that expertise utilization is not that distinct as presented by Weiss, but are rather more fluid, with the various uses interacting, overlying and building upon each other.

Consequently, other scholars like Blewden et al., (2010), have re-categorized Weiss’s (1979) typology into three broad models of expertise utilization; conceptual, instrumental and symbolic. Conceptual use refers to utilizing expertise to clarify or reframe thinking, challenge existing assumptions, and provide new understanding. Instrumental use involves the use of research to directly and specifically influence policy and program decisions. Such use flows from the

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assumption of ‘a rational decision-making process’, with direct use of research to ‘solve clearly predefined problems’ (Albaek, 1995, p. 85).

In symbolic terms, research is used to legitimize and support existing positions, decisions or programs (Landry et al., 2001; Nutley et al., 2007). In such cases, expertise is used to “to increase legitimacy by providing a veneer of competence and rationality” (Christensen & Velarde, 2018; Schrefler, 2010).

There are several reasons why policy-makers may draw on expertise, and for this study into the use of expertise by the NHIA, these models are relevant to enhance understanding of the reasons why the authority may fall on expertise in its management of the NHIS. Insights can be gleaned from these models to understand the rationale behind the use of expertise by the NHIA. These models to the NHIA case can enhance understanding in terms of whether expertise is used for germane purposes as explained by the problem solving or interactive models for instance, or whether they are for symbolic or strategic purposes as assumed by the political model.

2.4 Factors Determining Expertise Utilization in Policy Development

The general literature on expertise examines factors influencing the utilization of expertise by policy-makers. These factors are the considerations or influences that affect expertise use in policymaking. A number of studies discuss them as facilitators or barriers (see Oliver et al., 2014). While some of the factors border on broad issues such as the general features of policy and the policy context, others detail specific factors that drive expertise use (see, Campbell et al., 2009; Hamel & Schrecker, 2011). Albert, et al., (2007), point out that within the broad factors influencing expertise use are specific considerations such as interactions and personal contacts between experts

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and policy-makers, timeliness and relevance of policy advice, level of trust between experts and policy-makers, as well as budget considerations.

In a systematic review on the barriers and facilitators of the use of evidence use, Oliver et al., (2014) categorizes the factors into four broad themes namely: “organizations and resources; contact and collaboration; research and researcher characteristics; policymaker and policy characteristics”. They indicate that in the organizational and resource category, factors such as access or availability of research, dissemination, material and personnel resources affected research use. For contact and collaborations, relationships between policy makers and experts, trust and mutual respect are key. They found that factors such as clarity, relevance and reliability of research findings are important in the research and researcher characteristics category as was quality and authoritativeness of research. Under policymaker characteristics, personal experiences, judgments and beliefs about evidence-use are important. In the policy characteristics category, the complexity of the policy, legal support and existence of guidelines, political pressures, finances, and competing priorities were also found to impact expertise use. These factors generally determined expertise utilization, however, it depended on how individual factors within the categories are combined effectively.

It must however be noted that while most of the factors identified in the literature relate to the general characteristics of expertise, the particular policy context within which expertise is used also plays a central role (Dobrow et al., 2006; Fafard, 2008). According to Bock (2014), internal and external context factors determine what experts and whose expertise are deemed valid or acceptable in a policy-making context. In the study by Oliver et al., (2014), the role of local context, privacy and security of data were found as important contextual factors. According to Carroll et al. (2008, p. 14) ‘‘‘push and pull’’ forces such as election promises, policy priorities,

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ministry advice, pressure from foreign governments and the personal priorities of individual ministers’ are important. Hamel and Schrecker (2011), discuss the contextual factors to include shifts in political agenda, access to information, trust in experts, priority given to expertise by policy actors in the policy process, and accountability.

2.5 Factors Influencing Expertise Utilization in Developing Country Contexts

Although there is a rich literature on expertise use and its underlying factors, much of it focuses on developed country contexts (Oliver et al., 2014; Woelk et al., 2009). Abekah-Nkrumah et al., (2018), notes that there is a knowledge gap on the factors influencing the uptake of expertise in developing countries and therefore calls for more research in these settings. In line with such calls, research on expertise in developing countries is receiving some scholarly attention in recent times, albeit at a slow pace.

The burgeoning literature discusses a number of factors that influence the use of expertise in various developing countries. In their study on evidence use in Mali, Albert, Fretheim, and Maïga (2007) for instance established that considerations over access to information, relevance of expertise, level of trust or authority of organization, accountability and priority or importance of research in the whole policy making process were important for the essential medicines list (EML) policy.

Also, in a literature review on the barriers and facilitators of evidence use, Oliver et al., (2014) established that the most frequently reported barriers were the lack of availability to research, lack of relevant research, having no time or opportunity to use research evidence, policymakers’ and other users not being skilled in research methods, and costs. They further found that frequently reported facilitators included access to improved dissemination of research, and existence of and

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access to relevant research. Based on these findings, they categorize the factors influencing expertise use in developing countries under five main themes namely; need and timeliness of expertise, interactions, networks and collaborations between experts and policy-makers, trust and legitimacy of expertise, power relations which also bother on political considerations, and budget considerations. Oliver et al.’s (2014) typology, serves as a major framework around which the factors influencing expertise use by the NHIA are discussed.

2.5.1 Need and Relevance of Expertise

The use of expertise is largely determined by the needs of policy makers at any point in time as well as the relevance of expertise to an impending policy problem. These are important because policy makers are constantly confronted with a complex mix of challenges and are therefore in search for relevant solutions to address these challenges. In developing countries, the need for expertise and relevance of expertise is even more important because policy makers are confronted with a myriad of challenges and they want expertise that best serve their needs. As pointed out by Orem et al., (2012), the use of expertise in policymaking plays an important role especially in developing country where effective policies are critically needed to solve their challenges. Therefore, the extent to which the policy advisor or consultant meets the policymaking need or is seen to be capable of requirements of policymakers in terms of providing policy relevant knowledge influences their use by policy makers.

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2.5.2 Trust and Legitimacy of Expertise

Expertise use in developing country contexts is a function of the credibility of the individual experts and the institutions to which they are attached. According to Mbonye and Magnussen (2013), it also depends on how workable the policy advice is, to policy makers. These concerns border on trust and legitimacy of expertise, and it depends on whether expertise is recognized, or trusted by the public officials who have the mandate to hire (Turner, 2003, p. 33).

Several empirical findings give credence to this position. In their study on expertise use by policy-makers at the national level in Argentina, Egypt, Iran, Malawi, Oman and Singapore, Hyder et al., (2011), found trust and legitimacy as key components of the decision to use expertise. Based on such findings that Stone (2012, p. 141), argues that decision-makers in developing countries generally respond better to well-organized and established expert groups.

2.5.3 Cost and Budget Considerations

The research on expertise use in developing countries also identifies cost and other budget considerations as important factors influencing expertise use (Orem et al., 2012). Scholars argue that the extent to which expertise is utilized depends on the cost to an organizations budget. Thus, policy makers consider the affordability of experts even though the need for expert knowledge may be compelling. Santesso and Tugwell (2006), confirm this position, in their study on expertise use in lower and middle-income countries, which found insufficient economic/budget resources as a major barrier to knowledge translation. Therefore, cost is important for expertise use in resource-constrained contexts (Orem et al., 2012).

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2.5.4 Collaborations, Networks and Associations

Collaboration, networks and relations between policymakers and experts have also been reported as important in influencing expertise utilization in developing countries. In a systematic review of research on developing countries use of expertise, Oliver et al., (2014) established that contact, collaboration and relationships are a major facilitator of evidence use, reported in over two thirds of all studies. A similar study by Walugembe et al., (2015), established that the networks and associations serve as an immediate resource to policy makers who wanted to engage clients in Bangladesh. Against this background, Stephenson et al., (2006) call for increased collaboration between experts and policy-makers as a key strategy toward increasing the uptake of expertise into policy and program development.

2.5.5 Political Imperatives and Expertise Utilization

The utility of expertise for policymaking lies in the capacity to simplify policy problems, and shedding light on the potential implications of different policy options (Béland & Howlett, 2016). However, there is some consistency in the theoretical literature to the effect that public policy-making does not happen in a vacuum, but is influenced by certain local factors (Bock, 2014; Sending, 2015). Key among these, are political factors, which influence the decision to use expertise and why a particular expertise is chosen over another. The argument is that although expertise is used because of their technical relevance, they are sometimes used for political purposes; thus, to serve the interest of decision makers. Saint-Martin (2000) argues that: “…governments not only rely on consultants to help them strengthen their management capacities […] [but] consultants also strengthen the political capacities of those who are responsible for leading the reform process by helping to overcome bureaucratic resistance and mobilizing support for the policy ideas that they promote and that decision makers seek to implement” (p. 198).

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In such cases, the major consideration driving the use of expertise is the extent to which it supports their chosen course of action or advances their interest. These political imperatives in expertise use is supported by the empirical literature on expertise in developing countries (see Green & Lund, 2015). The political factors are relevant to the analysis of expertise utilization in a developing country’s context.

2.6 International versus Local Expertise

An important aspect of the discourse on expertise use in developing countries relates to distinction between foreign or international expertise and local ones. In this regard, the general narrative is that, policy makers in developing countries tend to depend more on expertise from international organizations like the World Bank, International Monetary Fund (IMF) and World Health Organization (WHO), rather than on existing local expertise or think tanks (Rodriguez et al., 2015).

Over the years, experts from these multi-national organisations have played an important role as knowledge brokers by sharing experiences in developed countries with policy makers in developing country contexts. By this, international expertise influence policy in profound ways offering policy-makers in developing countries a sound basis for making informed-decisions through continued and increased technical support (Abekah-Nkurmah et al., 2018; Bock, 2014; Dalglish et al., 2015).

The reasons for the preference of expertise from these institutions are manifold; ranging from trust and legitimacy, to the fact that funds provided for most of developing country programs and policies tend to come from these international organisations, and with it comes their own expertise. According to Bock (2014), the World Bank and the international donor community are two of the

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main actors driving expertise use in developing countries because of conditionality’s on loans, which place specific requirements on the recipient country including using their expertise in policymaking.

There are also other contextual factors such as the absence of expertise on the local front and other political considerations (Oliver et al., 2014; Tricco et al., 2015). Stephenson et al., (2006), argue that the strong presence of donor agencies in developing countries explains why they influence policy makers so much. Bock (2014, p. 380), affirms that developing countries use expertise from international sources like the World Bank due to a lack of capacities and expertise.

However, other studies reveal a changing trend. Studies by Rodriguez et al., (2015) for example found that policy makers in developing countries depend more on expertise in policymaking and they prefer local evidence to foreign ones. A study by Burchett et al., (2013) reports similar findings from Ghana regarding the uptake and transferability of ‘foreign’ research. Their study found that although policy makers depended on expertise from other settings, they were most concerned about how implementable the interventions are, rather than their potential effectiveness. This is also because there is a growing development of local research institutions, think tanks, NGO’s and consultants in these areas.

These findings notwithstanding, expertise from multi-national organisations are still predominant, because they are a more trusted network and enjoy more legitimacy. A study by Albert, Fretheim, and Maïga (2007), found that, the main reason why most of the medicines on the national EML were chosen is because the WHO initiated the EML policy and supplied the commission with a model list. Be this as it may, the literature is consistent that at the local level, the use of expertise and transfer of information from local research institutions to policy-makers is poor.

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2.7 A Framework for Analysis

From the review of various models of expertise use, and a synthesis of the literature on the factors influencing utilization of expertise, the key issues emerging are integrated into an appropriate conceptual model to guide data collection and analysis. Fig 2.1 depicts the conceptual framework illustrating the factors influencing expertise use. The framework identifies five main factors (independent variables) that may influence the use of expertise (dependent variables) by the NHIA. These are; need and technical nature of the policy, cost and affordability, trust and legitimacy of expertise, collaborations and networks amongst experts/ managers and political considerations.

Fig 2.1: Conceptual framework depicting the factors influencing expertise use by the NHIA

The factors captured in the conceptual framework give rise to a number of theoretical expectations. First, because of the technical nature of the NHIS, and the fact that developing countries in general lack expertise on several fronts, it is expected that the need and technical factor will be a major influence on expertise use by the NHIA. It is also expected that trust and legitimacy will be a major driving consideration for the NHIA because of its consequences on health in general.

Need/technical nature of policy Political considerations Expertise use by the NHIA Local/ International Cost and affordability Trust and legitimacy of expertise Collaborations networks amongst experts/ managers

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Collaborations and networks will be important factors that will influence expertise use by the NHIA. In addition, given the theoretical arguments that cost is a determinant of expertise use, and the fact that developing countries have a challenge of inadequate resources, it is expected that cost considerations will have a major influence on the use of expertise by the NHIA. Finally, political considerations will present stronger reasons why the NHIA uses expertise, because it is a major explanatory factor underlying policy decisions in developing countries. Also, given the predominance of international organizations like the World Bank, International Monetary Fund (IMF) and the World Health Organization (WHO) in developing countries generally, and their role in the implementation of the NHIS in particular, it is expected that the NHIA will use more expertise from international sources.

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CHAPTER THREE METHODOLOGY 3.0 Introduction

This chapter presents the research procedure used in conducting the study. The chapter discusses the choice and suitability of the qualitative research approach and case study design for the study. There are themes on purposive sampling technique, the main data gathering sources and operationalization. Issues of data management and analysis techniques are also covered in this section. These were important to provide a suitable methodological frame to guide the conduct of the study as well as provide justifications for the choices made in seeking answers to the research question.

3.1 Research Approach

In line with the underlying objective, the study is conducted from the qualitative approach. According to Creswell (2013), the approach, which is a systematic process of understanding social reality, based on the building of a complex and holistic picture of detailed views of participants is suitable for studies that seek understanding. Adopting the qualitative approach therefore made it possible to understand the experiences of officials on the NHIA’s utilization of expertise in managing the NHIS. The approach was also relevant to understand the contextual factors that come to bear on the decision by the NHIA to utilize expertise as well as the challenges from the perspectives and interpretations of officials.

Overall, the approach made it possible to detail the factors that influence the utilization of expertise, and its underlying dynamics (Creswell, 2013).

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3.2 Case Study Design

For qualitative studies, a number of designs are available. These include; ethnography, case studies, phenomenology, grounded theory and historical and participatory strategies (Creswell, 2013). This study is however designed as a case study, which is appropriate for studies that are interested in in-depth understanding of a phenomenon within a bounded context. The design best suited my objective of seeking to understand the in-depth utilization of expertise by the NHIA, and its underlying factors and challenges (Saunders & Lewis, 1997; Yin, 2009).

Besides, designing my research as a case study afforded the opportunity to use dual sources of gathering data and evidence and to be able to interact with my respondents in their own contexts. As observed by Creswell (2013), case studies allow for the use of multiple sources of information that are interactive and humanistic. In this study, interviews were combined with document reviews, to have a comprehensive view of the extent to which the NHIA utilises expertise, and the ensuing challenges.

3.3 Purposive Sampling

Sampling is the process of selecting respondents from a study’s target population (Saunders et al., 2011). This study used the purposive sampling technique to select the institution as well as respondents from whom data was collected. The National Health Insurance Authority, which is the main body for managing the NHIS was the unit of analysis and respondents were drawn from the national headquarters in Accra. The NHIA office in Accra is important because as the headquarters, that is where the decision on the use of expertise is made.

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Similarly, relevant officials were purposively selected from the NHIA to be interviewed. Since the study details the extent to which the NHIA utilizes expertise and its associated challenges, the technique was to allow for the selection of officials involved in the decisions on expertise use in the organization so they could appropriately respond to the interview questions (Abrams, 2010; Creswell, 2013). Accordingly, the decision on which officials to interview was made before fieldwork (Abrams, 2010), although the exigencies of fieldwork, made it impossible to follow this plan.

Primary data collection was carried out over a one-month period in Ghana, beginning on December 6, 2018 and ending on Jan 11, 2019. The first three days of fieldwork was planned to be used to establish contacts and book interview appointments with relevant officers at the NHIA. This proved to be extremely difficult and frustrating with officials asking for approval from the Chief Executive Officer before getting involved even though introductory letters had already been delivered to the authority. Although not explicit stated, the attitude of officials suggested an unwillingness to participate and my persistence for interviews was becoming a nuisance, and pushing me to the bounds of ethical concerns. The only two officers who initially offered appointments later cancelled them on reason of other engagements. It was later established that officials were not willing to cooperate because the NHIA had decided to reduce access to researchers because of previous abuse of NHIA data.

After several unfruitful attempts to get any interviews, some contacts were made with an old friend in Ghana, who used his informal networks to facilitate my meeting with the CEO of the NHIA. Although the meeting was brief, it proved very useful in helping me have access to the NHIA for interviews. Upon entry into the NHIA, I was aided by officials to identify the best-placed

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respondents who could answer the questions. Thus, the snowballing technique was used to reach the most appropriate respondents.

Overall, eleven interviews were conducted for the study (See table 3.1) for a breakdown of the interviews. Officials were drawn from the operations, policy, planning and administration, provider payments and actuarial departments. It is pertinent to note that as a qualitative piece, the study’s sampling regime did not aim at achieving statistical representativeness but rather to yield analytical insights. Respondents were selected by virtue of their offices or experience.

Table 3.1 Breakdown of qualitative Interviews. Source: Fieldwork data, December 2018 –

January 2019

Place of interviews / Department Number of Interviews

NHIA, Accra; Operations 2

NHIA, Accra; Research, policy, monitoring and Evaluation 3

NHIA, Accra; Actuarial 2

NHIA, Accra; Provider Payments 2

Ghana Health Service, Accra 1

NHIA, Kumasi 1

Total 11

3.4 Data Sources and Collection Tools

Data for this study was derived from both primary and secondary sources. The primary source consisted of data collected through interviews with officials of the NHIA. The interviews provided new empirical data and insights for analysis.

The secondary sources on the other hand, consisted of a review of already documented information on the NHIS; the NHIS policy document, NHIA annual reports, books, journals, internet reports -

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both published and unpublished. These sources provided a background understanding of the study and provided critical inputs in writing the introductory chapter. They also helped to triangulate and validate the primary data that was collected during fieldwork as well the analysis and reporting of findings.

3.5 Data Collection tools

3.5.1 Interviews

The study used interviews, as the main data collection tool. Interviews are central to qualitative studies because of their ability to elicit information that enhance understanding of phenomena (Myers & Newman, 2007). Bearing in mind the nature of the topic as well as the nature of the research objective, the interview protocol was semi-structured. The technique offered an opportunity to steer the interview process along the study’s research question, while giving respondent’s ample room to explain issues in depth and share experiences on the use of expertise by the NHIA (Yin, 2009). The semi-structured interview guide was prepared based on the research question derived from literature and theoretical framework.

3.5.2 Documentary reviews

The implementation of Ghana’s NHIS has generated a lot of reports and documents over the years. Therefore, to complement the data collected through the interviews, the researcher reviewed a number of documents to derive data for the study. Documents reviewed included, the NHIS policy document Act 650 (2003), the new Act 852 (2012), NHIA annual reports, NHIS performance trends, internet reports and media reports - both published and unpublished-. Other official

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documentations from agencies connected to and working with the NHIS were also reviewed. These documents provided a sense of the extent to which the Authority has made use of expertise on health insurance.

Table 3.2: Data collection techniques used for the study

Technique Source Collection

Method

Duration/Period

Semi-structured

interviews NHIA management Audio recording and writing 30 minutes average One month

Document reviews The NHIS Act 650 (2003); 852 (2012), NHIA annual reports, HR policy, Ghana Health Service Policy briefs

Writing Three months

3.6 Operationalization of Variables

In this study, the variables are operationalized by identifying the kind of empirical patterns that serve as a basis for conclusions to be drawn. It also covered the questions that are posed to get at each of these dimensions. For the first part of the research question, to find out to what extent expertise is utilized by the NHIA, questions will be asked to form a basis to dive deeper into the content. For example, questions like “to what extent do you use expertise or what are relevant sources of expertise to your institution?” To address the second part of the research, the dependent variable is the use of expertise (local or international), by the NHIA. The independent variables are the factors determining the use of expertise and they include need and technical nature of the policy, trust and legitimacy of expertise, cost and affordability, collaborations and networks amongst expertise and policy makers, as well as other political considerations. To assess whether

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a factor is important, specific questions were asked and the frequently occurring answers and repeated responses that were important for most respondents were analyzed as most important factors.

Table 3.3 Research matrix depicting how variables were operationalized

Dependent Variable Independent Variable Explanation

Use of expertise • Local

• International (The dependent variable consists of two aspects. It considered that the independent variables may vary depending on whether expertise is local or international).

Need and technical nature Based on the technical nature of health insurance policy this would cause it to be interrelated to the need to utilize

expertise. Which means when policies within the organization are technical, it might affect expertise utilization.

Questions asked to measure this variable are “does the technical nature of health insurance influence the NHIA’s decision to resort to expert knowledge?”

Cost/affordability Based on the organizational cost of hiring consultancy (both in-house and external). Question that was used to measure this variable was “is cost or affordability a factor in your use of expertise?”

Trust and legitimacy This is about the reputation and reliability of the source. In addition, how a source is perceived by the NHIA. Questions that were used to measure this variable are “is trust or legitimacy for a particular source a consideration in your use of expertise?” Networks, collaborations and

associations

The involvement of the NHIA in broader networks within the health sector and the role of those alliances or partnerships. Question used to measure this variable is “how is the NHIA involved with external institutions?”

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3.7 Data Analysis Procedure

Analysis of data in this study was done thematically. Thematic analysis is an “iterative procedure of identifying, classifying, analyzing, interpreting and expressing patterns in a data set” (Braun & Clarke, 2006). The technique was used for two important reasons. First, it provided a useful approach of reducing the data into meaningful themes to ease analysis and interpretation. It also offered me some flexibility in providing a rich and detailed account of expertise utilization at the NHIA, its underlying factors and challenges (Attride-Stirling, 2001; Braun & Clarke, 2006). The analysis followed a six-staged process, i.e. data familiarization, initial code generation, theme search, theme review, theme definition and naming, and the final stage of writing up the report.

The researcher collected data personally and therefore analysis began from the field. At the end of each day, recorded interviews were played over to identify possible gaps or weaknesses for correction in subsequent interviews (Gibbs, 2007). The formal data analysis however started with transcription of all recorded interviews into text, using a VideoLan media player. The researcher then read and re-read the text to identify initial patterns, and to have a fair idea of what the data contained and what was interesting about them.

Political considerations The strategic use of expertise for furthering a political agenda or strengthening government’s position rather than just solving problems. Questions used to measure this variable are “are there any political considerations in your use of expertise?”

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The next stage involved generating initial codes from the data. Notes were made on the texts to indicate patterns and to see whether they could be linked to theory. Attention was paid to details in terms of frequently occurring issues, repeated expressions, dominant words and observations that were important for most respondents.

After coding all the data, the researcher searched for themes as a means of reducing the data through focusing, abstracting and transforming it. The different codes were sorted into potential themes, and all the relevant coded data extracts within the identified themes collated. The themes were fine-tuned to fit the overall story they tell about the data.

After this, the themes were defined and named for analysis. The researcher identified the essence of each theme, and which aspect of the overall data it captures. They were then organized into a coherent and internally consistent account with accompanying narratives. The accounts and descriptions provide the context of expertise utilization at the NHIA, the factors determining the use of expertise and the challenges. These were important to achieve the study’s objective of not just understanding but also explaining the use of expertise at the NHIA. The final stage involved writing the report in a concise, logical, non-repetitive and interesting manner. Table 3.4 below summarizes the analysis process followed in analyzing the data collected.

Table 3.4: Data Analysis process. Source: Adapted from Braun & Clarke (2006)

Stage Activities undertaken during the stages Familiarization

with data

Transcribing data; synchronizing transcripts into one data journal; reading and re-reading the data and noting down initial ideas.

Generating initial codes

Coding interesting features of data across the entire data set. Collating data relevant to each code.

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Theme search stage

Collating codes into potential themes, gathering all data relevant to each potential theme.

Reviewing themes

Checking if the themes work in relation to the coded extracts and the data set.

Defining and naming themes

Analysis to refine the specifics of each theme, and the overall story the analysis tells, generating clear definitions and names for each theme.

Producing the report

Relating back to the research question and literature; producing report

3.8 Ethical Considerations

The study complies with ethical guidelines/policies on research of Leiden University. Consequently, the researcher observed a number of ethical principles to ensure confidentiality, anonymity and interest of respondents and the NHIA in general.

First, I sought ethical clearance from the NHIA before data was collected. This was done by forwarding an introductory letter signed by my supervisor and a copy of my research protocol detailing the objectives, benefits and potential risks of the study to the NHIA. It must however be noted that the access negotiation process turned out to be very cumbersome and frustrating, and it took a lot of back and forth before final clearance was given.

Before the commencement of interviews, respondents were assured of the use of information given for academic purposes only. To ensure their anonymity and confidentiality, respondents were not required to indicate their names and they were also informed of their right to voluntary participation and withdrawal at any time (Tracy, 2010). Interviews were scheduled to suit the

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convenience of officials and they were given opportunity to ask questions at any stage of the interviews.

Data was stored on the researcher’s personal laptop, a cloud storage (iCloud) and an external hard drive to minimise security risks such as theft or loss of work. All storage files were protected with passwords, and backed up weekly on the cloud storage and external hard drive whenever new changes were made. To ensure that the data collected is a true reflection of diversity and its challenges at the NHIA, officials were made to review the transcripts before the final report was compiled.

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CHAPTER FOUR FINDINGS AND ANALYSIS 4.0 Introduction

This chapter presents the key findings and analysis of the study. The findings are from a thematic analysis of qualitative data collected from 11 key informants, purposively selected from various departments of the NHIA (see Table 3.1 in chapter 3). The interviews were triangulated with secondary data comprising internal publications from the NHIA, policy documents, evaluation reports as well as other peer-reviewed articles on the NHIS and expertise utilization. These sources provided the basis for making the necessary inferences. The findings are presented in the form of narratives. In presenting the findings, selected extracts from interviewees are presented in italics to buttress the various issues, and to also enrich and contextualize the discussion.

4.1 Case Description: Ghana’s National Health Insurance Scheme (NHIS)

Ghana introduced a National Health Insurance Policy in 2003 with the passage of the National Health Insurance Act 650. The NHIS policy was in the context of negative consequences of the previous cash and carry policy, by which patients had to pay money upfront at the point of health service use. The NHIS was therefore a means to provide a social health policy framework that provides a financially viable and socially inclusive healthcare system to all Ghanaians. The scheme was set in motion by a legislative Instrument (LI) 1809, which was passed in 2004. The LI detailed the regulations under which the NHIS was to operate, and paved the way for actual implementation in 2005. Per the NHIS Act 650, the objective of the scheme is to “secure the provision of basic healthcare services to persons’ resident in the country” (p. 3).

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The Act also provided for the establishment of a National Health Insurance Fund (NHIF); a fund into which all sources of funding of the NHIS is to be lodged. Three types of health insurance schemes were authorized to exist and operate in Ghana under the Act. These are district mutual health insurance schemes (DMHIS), private commercial health insurance schemes and private mutual health insurance schemes. In 2012, a new legislation, Act 852 was enacted to replace Act 650 and that has affected the structure and operation of the NHIS. An important implication of the new Act is that the district mutual schemes, which hitherto were the basic units of the NHIS, have been merged into a fully centralized NHIS. Table 4.1 summarizes the key elements of Ghana’s NHIS (NHIA, 2003; 2017).

Table 4.1: Key components of Ghana’s NHIS; culled from Act 650 (2003), LI 1809 (2004) and Act 852 (2012).

Legislative instruments The main legal frameworks guiding the implementation of Ghana’s health Insurance; Act 852 2012 (which replaced Act 650 (2003) and LI 1809 2004

Governance A Fifteen (15) member National Health Insurance Council manages a National Health Insurance Fund, regulate the private health insurance market and accredit and (in collaboration with relevant agencies) monitor service providers under the scheme Administration A national Health Insurance Authority responsible for the

implementation of the Scheme and provides administrative support to the National Health Insurance Council. The NHIA has regional and district offices throughout Ghana

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Membership Enrolment and membership in the National Health Insurance Scheme is mandatory for all residents of Ghana. Persons eligible to membership are expected to pay a contribution every year. Some persons are exempted from paying membership fees; • Contributors to the Social Security and National Insurance Trust (SSNIT)

• Persons under the age of 18 and above 70 years

• Persons in need of ante-natal, delivery and post-natal health care services

• Persons classified as indigents by the Minister for Social Welfare and other categories prescribed by the Minister

Service Provision The legislative instrument defines a benefit and an exclusion package for which a member of the scheme may have access Interested service providers service may apply to the NHIC for accreditation to provide a specified set of services from the benefit package according to their assessed competency.

4.1.2 The National Health Insurance Authority (NHIA)

The NHIA is the central body that manages Ghana’s National Health Insurance Scheme. Per the establishing Act, the authority has the mandate to “secure the implementation of a national health insurance policy in a manner that ensures access to basic healthcare services to all residents” (NHI Act, 2003: 4). The Act also established a governing body known as the National Health Insurance Council (NHIC), comprising 16 members appointed by the president of Ghana.

The NHIA is responsible for the daily administration of the NHIS and dispenses allocations from the NHIF to the various districts and service providers for their operations. Specific functions performed by the NHIA under section 2 of the establishing Act are;

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1. To register, license, regulate and supervise the operations of the National Health Insurance Scheme.

2. To grant accreditation and monitor the activities of health care service providers of the NHIS.

3. To ensure that health care services provided under the scheme is of good quality.

4. To manage the National Health Insurance Fund and disburse monies to various service providers for services rendered.

The NHIA is headed by a Chief Executive Officer, supported by three deputies, all appointed by the President. The deputies are responsible for specific areas of operation namely; administration and human resource, finance and investment. The NHIA has a Board of Directors, which steers the affairs of the Authority. The chair and other members of the Board are appointed by the president, upon advice of the Minister of Health and other stakeholders. The NHIA is under the control of the ministry of health, the overall body that supervises all health related activities in Ghana. Until recently, the NHIA was centralized in Accra, Ghana’s capital, but now regional and district offices have been set up across the country. Currently the NHIA has 17 Directorates, 10 Regional Offices and 166 District Offices (NHIA, 2017).

4.2 The Extent to which the NHIA Utilizes Expertise

Health insurance as a means of improving access to healthcare is a major policy option for Ghana. This study found that in implementing the reforms, the NHIA faces several challenges particularly in terms of introducing new models of health insurance systems and service organisation. There are also issues relating to enrolment and financial sustainability of the scheme. According to

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officials, these challenges have necessitated some demand for expertise. Thus, out of need to deliver health insurance services more effectively and address the associated challenges, the NHIA relies on technical expertise drawn from various sources including established consultancy firms and research institutions, international organizations, think tanks, and NGO’s. An official explained;

“The NHIA works on scientific evidence as much as possible so expertise plays a key role. Obviously, this is a national programme and sometimes public opinion may take a key role. We are very much aware that experts have the capacity to simplify issues and bring some knowledge to bear on the problems we face as an authority. So yes, we depend on expertise to an appreciable extent even though I must say that, it also depends on our need at any point in time. Our recent service innovation of renewal by mobile phone for instance was done in consultation with international expertise.” [Interview 1]

Another official corroborates the NHIA’s use of expertise;

“Managing a policy like the NHIS requires a lot of technical competence and that has made it necessary for the authority to consult expertise at one time or the other. We also collaborate with development institutions in the sector, like the World Bank, UNICEF and USAID. They are part of the health sector with many technical experts. Most of them have offices here so we tap into their expertise when the need arises.” [Interview 9]

These findings suggest that the NHIA relies on expertise in managing the NHIS. Discussions with NHIA officials further revealed that apart from directly utilizing relevant experts for the needed technical knowledge and support, the authority also went by standard protocols, practice guidelines and adaptations from regulators and key global institutions such as WHO, UNFPA, UNICEF and

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World Bank. In the reckoning of officials, these organisations are reputed to rely on expertise in the production of the guidelines, and so using them implies they are also utilizing expertise. Such indirect adaptations of expertise give credence to the use of expertise by the NHIA. These findings resonate with Weiss (1979) on knowledge utilization. The findings suggest that, the NHIA uses expertise in instrumental terms, to directly to inform policy and action.

4.2.1 Foreign or Local Expertise

While the study established that the NHIA utilizes expertise in its management of the NHIS, a related issue that came up was the kind of expertise used be it foreign or local. Respondents agreed that the NHIA used foreign experts very much in the early stages of the policy, because the authority and Ghana for that matter lacked expertise on managing social health insurance. This was also because, the ILO and other agencies like the World Bank and UNICEF, which were the initial funding partners of the policy, supported the NHIA with their own consultants. However, that is found to have changed over the years, because the NHIA developed its own internal expertise to the current point where close to 80% of expertise is derived from internal or local sources. Officials noted that the NHIA had instituted a policy of building in-house capacity anytime they engaged foreign consultants on any particular project and that helped to develop their own staff to acquire the necessary expertise.

An official noted;

“Yes…, this is a very technical program so expert opinion plays a role. Those days we depended heavily on international consultants and so we have had experts around the building of our e-claims, membership database, and we had consultants do the initial coding of the medicines list,

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and our diagnosis related groupings tables. Most of them were done in-house but with external consultants. But, over the years, we have tried to build in-house capacity across all fronts so we now have our own actuarialists, health economists, clinicians, chartered accountants, and MIS experts. Now we develop most of our applications ourselves.” [Interview 1]

Another official explains;

“NHIA we have the experts around, there was a project that we developed Navis, where one of our staff developed a system which was installed in most of our banking institutions so when you go there it is able to check whether the NHIS card you are presenting is genuine, valid or that you are not faking any document to get money from the bank. So Navis was developed in-house and was installed in several banks and it was fetching us income. The e-receipt idea was also in-house, but instances where we don’t have it in-house or locally, we then look to our international partners or agencies in the sector.” [Interview 3]

Furthermore, another official details the situation;

“…As at now, we have developed to the point where we depend more on local and internal expertise than international ones. It is much cheaper and convenient. International expertise tends to be expensive but sometimes they do not understand local issues so they are not able to offer context specific solutions to us. We however do collaborate with development partners in the country, because they put money in our health sector as well.” [Interview 9]

These go to suggest that largely, the NHIA depends on internal and local expertise compared with international experts, and that is related to considerations over cost of international expertise and

Expertise Utilization in Public Policy: The Experience of Ghana’s National Health Insurance Authority (NHIA)

Table of Contents

LIST OF FIGURES

LIST OF TABLES