1. SPSW - University of York1 The Impact of Coordination and Policy Networks on the NHIS Gina Teddy AfHEA CONFERENCE MARCH 10 TH -12 TH

2. SPSW - University of York2 Outline  Aim of the paper  Policy Background  Methodology  NHIP Implementation structure  Coordination and Policy Network  Discussion  Result  Conclusion

3. SPSW - University of York3 Aim Of the Study  Outline the complex implementation structure of the National Health Insurance Policy (NHIP)  To identify actors/stakeholders of the scheme  To examine coordination processes, participation and policy networks among actors  To evaluate the impact of coordination and policy networks in implementing the NHIP at the macro, meso and micro levels

4. SPSW - University of York4 Policy Background  National Health Insurance Policy (NHIP) initiated in 2001, legalized in 2003 and implemented in 2004.  Main purpose of policy is to replace OOP/C&C system and increase access  NHIP consist of 3 main health systems – DMHIS, PMHIS and PCHIS  DMHIS is the SHI aspect of the policy  Implemented nationwide (136) DMHIS

5. SPSW - University of York5 Data  Interviewees Policy makers, implementers, scheme and healthcare providers, revenue collectors, donor agencies, local authorities and other community level stakeholders like traditional councils and BOG. 75 officers in 27 institutions Limitation to the Study Mainly Qualitative Study Face-To-Face In- Depth Interview Group Interview Semi-Formal Conversation Telephone Interview

6. SPSW - University of York6 Coordination and Policy Networks  Multiple agencies intended or unintended to work together  Network of action from the various actors  Participation, motivation, problem of cooperation and negotiation

7. SPSW - University of York7 Who are the actors in the scheme  Macro Level - Actors at the national level include Regulatory bodies Financial institutions Ministerial bodies Donor Agencies Other service providers and regulators Pressure groups  Meso Level - Actors at the regional level The NHIS Regional Coordinators for GHS Regional offices for NHIS The Regional Board Network of Mutual Health Organization (RBNMHO)  Micro Actors at the district level Traditional Council, Scheme Providers, Health Providers, DA, BOG, GHS District Directorates, Fieldworkers, Religious leaders, etc

8. SPSW - University of York8 Levels of Participation and Motivation  Levels of Participation by actors Active - Passive – Consultative – Remote  Source of motivation Mutual Interest Benefit Sense of Duty or Legal Obligation  Continuum  Explicit or implicit

9. SPSW - University of York9 Coordination and Policy Network 1  The NHIP brought together multiple agencies - institutions, actors, implementers, stakeholders, intended or unintended to work together to achieve the primary aim of the NHIP.  Actors perform independent functions  Implementation modeled to follow national decentralized structure  But how does it work?

10. SPSW - University of York10 Coordination And Policy Networks 2  Coordination through information sharing Meetings, reports, emails, stats and data sharing  Coordination through resource sharing Funds, logistics, contracts, expertise, grants, loans, donations,  Coordination through joint actions Collaborative actions in service provision, information gathering, training, sensitization, technical support, monitoring, supervision, and planning.

11. SPSW - University of York11 NHIP Implementation Structure Implementation through Decentralization National Implementation Structures Regional Implementation Structures District Level / Local Council Implementation of the NHIP National Stakeholders and Implementing Agencies District Level Stakeholders and Implementers Regional Implementing Agencies Major Policy Decision Making Major implementation level

12. SPSW - University of York12 Administrative Structure of the Scheme National Level Actors Regulatory Bodies Ministerial Institutions Financial Institutions Donor Agencies Other Regulators and Service Providers Pressure Groups Regional Level Actors GHS - Regional Coordinators for NHIS Regional Offices for NHIS National Board Network of Mutual Health Organization (NBNMHO) District Level Actors Macro Level – NHIC, Danida Meso Level – Regional Coordinators, Regional Offices and RBNMHO Micro Level – DMHIS, District Residents, BOG, DHD, Health Providers, DA, Traditional Council, etc..

13. SPSW - University of York13 NHICGHSVAT MOFEPMOHDANIDA CEPSSSNIT DFIDWorld Bank EECUSAIDWHOJICAOther Donor Agencies GPB GHAGMDCSPMDP RAGB Regional Coordinators (GHS) NBNMHORBNMHO Regional Offices (NHIS) DABOG Scheme Providers Traditional Council CAG GHS District Directorate Service Providers Religious Leaders Fieldworkers

14. SPSW - University of York14 Challenges in coordination and policy Networks Coordination is challenged by: autonomous actors - less comitments power relations ambiguity in functions, problematic task consensus inconsistencies in implementation practices uncoordinated actions, lack of trust and suspicion among actors

15. SPSW - University of York15 Discussion 1- Vertical Coordination  Coordination at the national level Highly limited, formal and less negotiative Very problematic although some degree of coordination exist Coordination with other actors is much more effective than the NHIC – meetings and reports which can be problematic Pivotal organization is reluctant to coordinate with other actors Coordination with district actors is more easier than at national level  Coordination at the regional level Is absent  Coordination at the district/community level Coordination is very active, informal, interactive and communal Active participation among actors at the district levels Engage actively in coordination and policy networking in all spheres of operational and implementation processes.

16. SPSW - University of York16  …there is no official communication …. Basically there has been no coordination with the council… our duty is just collecting money and we don’t have any business beyond that (Financial Officer)  … interactions, if it comes to the national level, for now it is poor between providers and the NHIS secretariat [NHIC] … in fact there have been the wish that, there will be regular interaction, but this has been partly because of the way the setting up process was…. (GHS Coordinator)

17. SPSW - University of York17 Discussion 2 – Horizontal Coordination  Coordination and policy networks – very formal and limited in content. E.g to meetings, directives,  Top- down coordination, is established and active among selected few actors e.g. NHIC GHS, Danida and the DMHIS  Top-down structure lacks the necessary means for the devolution of authority down the system to confer mutual responsibility among actors  organizational relationship is not accommodative of deferring interest and lack effective conflict management  Implication of horizontal coordination to the scheme – Inadequate communication and interaction between national and regional actors, and structured coordination between national and district actors

18. SPSW - University of York18 Coordination and Network Structure Regulatory Bodies, Financial Institutions, Ministerial Institutions, Donor Agencies, Other Regulatory And Service Providers And Pressure Groups Regional coordinator Regional Secretariat RBNMHO Macro – NHIC, Donor Agencies Meso – Regional Coordinators, Regional Secretariat, RBNMHO Micro – DMHIS, Service Providers, Community Residents,, BOG, DA, DHD, Religious Groups, Fieldworkers, Etc Gap in communication at the regional level Gap in policy networks at the macro actors

19. SPSW - University of York19 Conclusion  Coordination and policy networks is problematic at the national and regional levels because poor communications within the implementation process.  Horizontal coordination is structured to include selected macro and meso level actors but does not follow the administrative structure of implementation. Structure is imbalanced due to coordination gap at the regional level  Participation, coordination and policy networks at the micro level is relatively active, effective and informally efficient.  Coordination and policy networks must be strengthen to enable achieve maximum participation and commitments of actors at all levels.  Recommendation – NHIC have to negotiate coordination more often with other actors and create appropriate channels of constant interaction with other actors at all levels of implementation and institute transparent means of sharing infor

20. SPSW - University of York20 Thank you