Table 4 Summary of Findings

Information

Fully informed and aware of NHI policies and intended benefits

District and senior staff aware but many frontline actors have little understanding of their roles [10]

Resources

Some actors had access to budgets

District, subdistrict and facility staff cited lack of human, material and infrastructural resources to fully implement policies [10, 26]

Motivation

Some actors were new appointees to drive the NHI policy implementation and were generally motivated

District and subdistrict actors were demotivated by dysfunctional systems particularly supply chain [10, 26]. Facility staff were demotivated due to lack of resources, dysfunctional systems including employee performance and management systems and lack of support from above [10, 26] Facility staff were demotivated due to being caught in between with pressure from both patients and supervisors [10, 26] Facility actors were demotivated due to longstanding problems that do not get resolved [10, 26]

Power

Some actors had access to budgets and power to appoint personnel Other functions are only advisory in nature e.g., NHI project Manage

District, subdistrict and facility staff all cited no power to appoint staff [10, 26] Facility actors have no access to budgets [10, 44] District and subdistrict Managers cited having limited power and financial delegations [10, 44] According to Elmore funding affects implementation [45]

Interactions

Actors were housed in one building and had regular meetings though many posts vacant

PHC supervision not frequent enough [10, 26] PHC supervisor not able to solve facility challenges [10, 26]. PHC supervision seen as policing and not supportive [10, 29] National core standards failing facility staff for issues beyond their control [10, 26] According to Elmore, authority relationships affect implementation [45]