Advocacy Coalition Framework and Policy

Changes in a Third-World Country

MARTIN IKE NWALIE
University of Port Harcourt

This work concerns health sector reform in Nigeria between 2003 and
2014. Using qualitative content analysis, I investigate the factors that
led to the reform, the reform process, and its outcome. The objective
is to assess the conformity of the policy reform to Sabatier and
Weible’s Advocacy Coalition Framework (ACF) in order to ascertain
the applicability, or otherwise, of the ACF in policy analysis in stable
democratic African states. In the article, external shock, policy
subsystem, stable parameter, technical experts, advocacy coalitions, the
“devil shift,” and policy core beliefs—which are basic components of
ACF—were all identified in the policy reform process. I conclude that
the ACF can be applied in policy reform in democratic African states, so
long as there is the rule of law, a separation of powers, freedom of speech
and association, a fairly stable political environment, and the presence
of policy participants with expert knowledge of the policy issues.
Keywords: Advocacy Coalition Framework (ACF), Nigeria, Sub-Saharan
Africa, Nigeria Health Sector, Policy, Health Policy Reform, Third-World
Countries, Policy Change in Developing Countries.

Related Articles:
Morris, Mary Hallock. 2007. “The Political Strategies of Winning
and Losing Coalitions: Agricultural and Environmental Groups in
the Debate over Hypoxia.” Politics & Policy 35 (4): 836-871. https​://doi.
org/10.1111/j.1747-1346.2007.00086.x
Swigger, Alexandra, and Bruce Timothy Heinmiller. 2014. “Advocacy
Coalitions and Mental Health Policy: The Adoption of Community
Treatment Orders in Ontario.” Politics & Policy 42 (2): 246-270. https​://doi.
org/10.1111/polp.12066​

Acknowledgements: The author would like to thank Professor Eme Ekekwe, Professor Nna
Johnson, and Associate Professor Allen of University of Port Harcourt for their encouragement
and valuable suggestions. The author would also like to thank the anonymous referees at Politics
& Policy whose comments helped to improve the final quality of the text.

Politics & Policy, Volume 47, No. 3 (2019): 545-568. 10.1111/polp.12302

Published by Wiley Periodicals, Inc.
© 2019 Policy Studies Organization
546 | Politics & Policy / June 2019

Udjo, Eric O., and Barney Erasmus. 2014. “Impact of Retirement Age
Policy on the Workforce of a Higher Education Institution in South
Africa.” Politics & Policy 42 (5): 744-768. https​://doi.org/10.1111/polp.12092​
Related Media:
CNBC Africa. 2017. “How Can Nigeria Improve Its Healthcare System?”
https​://www.cnbca ​f rica.com/video ​s /2017/09/14/how-can-niger ​i a-impro​
ve-its-healt​hcare-syste​m /
Opeyemi, Agbaje. 2012. “Health Sector Reforms in Nigeria 1.” https​://
www.youtu​be.com/watch​?v=0YvV_xj0meU
Marco de la Coalición de Defensa (ACF) y cambio de políticas en un país del
Tercer Mundo

Este trabajo se trata de la reforma del sector de la salud en Nigeria entre

2003 y 2014. Usando el análisis de contenido cualitativo, investigué los
factores que llevaron a la reforma, el proceso de reforma y su resultado.
El objetivo es evaluar la conformidad de la reforma de políticas con
Sabatier y Weible’s Advocacy Coalition Framework (ACF) para
determinar la aplicabilidad o no de ACF en el análisis de políticas en
Estados africanos democráticos estables. En el estudio, se identificaron
en el proceso de reforma de políticas el shock externo, el subsistema de
políticas, los parámetros estables, los expertos técnicos, las coaliciones
de defensa, el devil shift y las creencias fundamentales de las políticas,
que son componentes básicos de ACF. Por lo tanto, llego a la conclusión
de que ACF se puede aplicar en la reforma de políticas en los Estados
democráticos de África siempre que exista un estado de derecho,
separación de poderes, libertad de expresión y asociación, un entorno
político bastante estable y la presencia de participantes en políticas con
conocimiento experto en cuestiones de política.
Palabras Clave: Marco de la Coalición de Defensa (ACF) y África
subsahariana, Sector de la salud de Nigeria, Reforma de la política de
Nigeria, Países del Tercer Mundo, Estados estables de África democrática.
第三世界国家的倡议联盟框架 (ACF) 和政策变化
本文研究了2003-2014年间尼日利亚的卫生部门改革。通过使用定性内
容分析，笔者考察了导致改革的各个因素、改革过程和结果。本文目的
是评估政策改革与萨巴蒂尔（Sabatier ） 和 韦伯（Weible ）提出的倡
议联盟框架（ACF）的一致性，进而确定稳定民主的非洲国家中ACF在政
策分析中的适用性或不适用性。本文确定了政策改革过程中的外部冲
击、政策子系统、稳定参数、技术专家、倡议联盟、困境转变和政策核心
信念，这些都是ACF的基本要素。笔者结论认为，ACF能被应用于民主非
洲国家的政策改革，前提是存在法治、权力分散、言论自由、结社自由、
公平稳定的政治环境，以及具备政策议题专业知识的政策参与者。
关键词: 倡议联盟框架（ACF）, 撒哈拉以南非洲, 尼日利亚卫生部, 尼日利亚
政策改革, 第三世界国家, 稳定民主非洲国家.
 Nwalie / ACF AND THIRD-WORLD POLICY CHANGE | 547

During the decades of military regimes in Nigeria up to the advent of

democratic governance in 1999, the Nigerian health sector was at the brink
of total collapse. Nigerians were dying from known curable and preventable
ailments such as malaria, diarrhea, stroke, complications during childbirth,
and HIV/AIDS. During those three decades, health policies and programs in
Nigeria were usually subsumed under national development plans and annual
budgets. Notable among these development plans were the Third and Fourth
National Development Plans of 1975-80. Under these programs teaching
hospitals were expanded, and Hospital Management Boards and the Basic
Health Service Scheme were established.
However, due to inconsistencies in policy, policy reversals, corruption,
the weak implementation of strategies, high levels of poverty, and general
environmental uncertainty, the Nigerian health sector and index deteriorated
(Anyika 2014; Eneji, Dickson, and Onabe 2013). In 1999, the World Health
Organization (WHO) ranked Nigeria 74th out of 115 countries surveyed. The
downward spiral of the health situation of the citizens became very evident when,
in the year 2000, the WHO World Health Report ranked Nigeria 187th out of
191 countries (Asuzu 2004; WHO 2000). Therefore, when the Nigeria National
Health Bill of 2004 was introduced on the floor of the National Assembly, many
analysts viewed it as long overdue. The bill was seen as the instrument for a
comprehensive overhauling of the entire Nigerian health sector. This reform
process—which lasted for over ten years—is the focus of this article.

Overview of Health Sector Reform in Nigeria 1999-2015

Nigeria runs a federal system of government consisting of three tiers:

federal, state, and local government. Areas of jurisdiction are appropriately
divided into an exclusive list (areas exclusive to the federal government), a
concurrent list (where the three tiers share jurisdiction), and a residual list (for
the local governments). The health sector falls within the concurrent list of
the constitution. These are areas where the three tiers of government—federal,
state, and local government—have joint jurisdiction. As such, the institutions,
personnel, and resources in the health sector fall into the three categories,
decentralizing the national health system. Each tier of government is involved
in financing, engagement of personnel, and provision of services in the sector.
While the tertiary health institutions and federal medical centers are managed
by the federal government, the state government has the responsibility
for the secondary hospitals, while primary health care is handled by local
governments. At the peak of the organizational structure, however, is the
National Council of Health—which coordinates the activities of the health
ministry, the parastatals/agencies in the ministry, as well as the activities of the
state ministries of health. Below the National Council of Health is the State
Council of Health, overseeing the state and local government health issues.
548 | Politics & Policy / June 2019

A major challenge of this arrangement is that it comes with duplications and

confusion of roles often resulting in counterproductivity, wastage of funds, and
interdepartmental and agency clashes. Moreover, based on fiscal federalism,
the state and local government have the sole right to decide on how to spend
its federal health fund allocation. As such, the federal government has no
influence on funds allocated to either primary or secondary health units.
Health sector reform in Nigeria can be said to have started in 2003 with the
advent of democratic governance in 1999. The reform packages from then to
2015 include: the Health Sector Reform (2003-07); the Review of the National
Health Insurance Scheme (2003); the National Health Policy (2004); the National
Health Bill (2004); the Blue Print for Revitalization of the Primary Health Care
(2004); the National Policy on Public-Private Partnership (PPP) for Health
(2005); the National Strategic Health Development Plan Framework (2009-15);
and the National Health Act of 2014. The main policy tool is the National Health
Policy Review and National Health Bill of 2004, which was finally signed in
2014. The act, among other things, provides for the establishment of a National
Health System, a National Health Research and Information Center, a National
Tertiary Hospital Commission, and a Primary Health Care Development Fund.

Research Objective

The modest objective of this article is to ascertain the extent to which the
policy changes in the Nigerian health sector between 2003 and 2014 fit the
conditions required by the Advocacy Coalition Framework (ACF) model.
This, to a great extent, will show the applicability—or otherwise—of the ACF
to policy reforms in a fairly stable democratic underdeveloped country. The
ACF has been acknowledged as one of the foremost theoretical frameworks
for analyzing policy processes (Nohrstedt 2009; Sabatier and Weible 2007;
Sotirov and Memmler 2012). However, its applicability to subsystems outside
the United States has been questioned by critics (see Carter 2001; John 1988;
Parsons 1995). It has been argued that—due to differences in political systems,
institutions, and cultures—the ACF cannot claim universal applicability. Thus
far, the published literature on the applicability of the ACF has come from
Europe and the United States. For instance, a publication from the Policy
Studies Journal contained eight collections of ACF application, yet none of
the articles came from developing countries (Weible, Sabatier, and McQueen
2009). The major hindrance to its applicability—outside of the United States
and Europe—has initially been the lack of expansive sets of actors that needed
to be involved in policy making, the weakness of the civil society, and lack of
technical expertise.
The authoritarian regimes in most African and Asian countries count as a
prime cause of this institutional anomaly. The authoritarian states leave little
room for external policy advocacy, growth, and participation of the civil society
 Nwalie / ACF AND THIRD-WORLD POLICY CHANGE | 549

in policy making. However, with the worldwide liberal revolution and the
ascendency of social democracy as a dominant world political system (Fukuyama
2006), most African, Asian, and Latin American countries have democratized.
Civil societies, labor unions, and professional bodies have sprouted out and
are making their impact felt in policy formulation. Consequently, researchers
are currently making attempts at applying the ACF in analyzing policy change
in these former authoritarian territories and there has been an increase of
interest in such studies as noted by Sabatier and Weible (2007). For instance,
Albright (2011) focused on policy change in postauthoritarian Hungary, while
Bukowski (2007) dealt with Spanish postauthoritarian water policy change.
Furthermore, Kim (2012) discusses the effects of regime change in South Korea
on environmental policies in the late 1980s, while in Latin America, Piffre (2015)
uses ACF to analyze the health policy change in postauthoritarian Chile. This
work, therefore, is to be seen in the same light as it applies to Nigeria’s situation.
The research question of this article therefore is: can an ACF be employed
successfully in explaining the policy changes that occurred in the Nigerian health
sector between 2003 and 2014? The article is basically a contribution toward
advancing ACF research in Africa. It offers insight into the suitability—or
otherwise—of applying ACF in explaining some policy changes in democratic
African states. It has the possibility of generating or reigniting debate among
specialists on the flexibility and wide applicability of the framework. As stated
in Ainuson (2009), the ACF can be employed in explaining policy change in
African countries so long as there is real public commitment to rule of law that
allows coalitions to operate without hindrance. This article offers a case study
for the verification of such claims. Furthermore, the article contributes to the
understanding of the Nigerian health sector subsystem. In explaining the why
and how of the factors and processes that led to policy change in that sector,
it discloses the issues, coalitions, and beliefs involved. This will be of immense
importance to health policy advocates in Africa in identifying areas of interest.

Basic Assumptions of the ACF

While introducing ACF, Sabatier (1988) described it as a policy process

framework that has been developed to simplify the complexity of public policy
processes. The primary unit of analysis within an ACF is the policy subsystem
that has been said to consist of, “those actors from a variety of public and
private organization who are actively concerned with a policy problem or issue
and who regularly seek to influence public policy in that domain” (Sabatier
and Jenkins-Smith 1999, 119). These organizations and actors may include
journalists, researchers and policy analysts, interest groups, administrative
agencies, and/or legislative committees. Those policy actors who share a
common belief usually form a coalition over time and engage in advocacy to
turn those beliefs into public policy. Hence, policies are viewed as a translation
550 | Politics & Policy / June 2019

of beliefs, while the policy process becomes a battle ground for contending
beliefs. This postulation, however, that coalition beliefs are the drivers of
policy change has been severally criticized (Hoberg 1996; Nohrstedt 2005;
Schlager 1995). It has been described as being one-sided while ignoring the
primacy of members’ interest in coalition advocacy. It runs counter to König
and Bräuninger (1998), who claim that coalition actors are mostly driven by the
maximization of their political and economic interest. As a result, there has
been a revision of the actors’ belief system. The belief system has been graded
into three levels of beliefs: deep core beliefs, policy core beliefs, and secondary
beliefs. Deep core beliefs are the most essential in policy change—and are
mostly normative, altruistic, broad-based beliefs that hardly change over time.
On the other hand, policy core and secondary beliefs are the domain of narrow
and empirical political and economic interests that change according to the
political and economic environment (Weible, Sabatier, and McQueen 2009).
In the ACF hypothesis, policy changes do not occur without a stimulator—
an external shock is needed to ignite it (Birkland 2006; Sabatier and Weible
2007). Weible, Sabatier, and McQueen (2009) show how external shock is defined
as broad changes in socioeconomic conditions, public opinion, governing
coalitions, and changes in other subsystems. It has, however, been observed by
Mintrom and Vergari (1996) and Ameringer (2002) that not all external shocks
lead to policy change and not all policy changes result from external shocks.
But Sabatier and Weible (2007) stress the point that the most important effects
of external shocks are that they can shift agendas, focus public attention, and
attract the attention of key decision-making sovereigns. Moreover, they also
cause the redistribution of resources or opening/closing of venues within a policy
subsystem. Another way of accommodating the criticism is by the addition of
two more paths to policy change—internal shock and negotiated agreement—
in current ACF revisions (Sabatier and Weible 2007). Internal shock is said to
occur when it becomes apparent that the current subsystem practice has failed,
making the policy core belief of the dominant coalition questionable (Birkland
2004; Busenberg 2000).
In the ACF, therefore, policy change is seen as a function of competition
within the subsystem as well as of events outside the subsystem. The competi­
tions within the subsystem usually involve a substantial conflict in goals and
important technical disputes. Actors from different coalitions are likely to
perceive the same information in very different ways leading to mistrust and
antagonism among different coalitions (Weible et al. 2011). This mistrust and
antagonism has been termed “the devil shift” (Sabatier, Hunter, and McLaughlin
1987). This represents the tendency for actors to view their opponents as less
trustworthy and more evil or powerful than they probably are—exacerbating
the conflict across the competing coalitions. In any policy subsystem there are
always two or more advocacy coalitions and the devil shift will make it less likely
that the policy participants will interact with opponents because of the value
conflict, distrust, and suspicion. Each coalition therefore mobilizes its resources
 Nwalie / ACF AND THIRD-WORLD POLICY CHANGE | 551

for the grand battle of belief supremacy. Such resources include: formal legal
authority, public opinion, information dissemination, financial resources, and
skillful leadership. This hostility in most cases has the tendency of scuttling,
halting, or prolonging the policy change (Leong 2015). In the end, the resultant
policy output will either be the policy core belief of the dominant coalition
or in a situation where a negotiated path to policy change was taken, leading
to collaborative policy making (Weible et al. 2011), it will be an aggregate of
the contending beliefs. In this article, the model/hypothesis was tested on the
Nigerian Health Sector Reform of 2003-14.
It should, however, be noted that the formation of coalitions, the mobilization
of its members and resources, information dissemination, and their overall
advocacy will—to a great extent—depend on the existing political system. A
pluralistic, democratic, and stable political system is vital for these processes to
be accomplished. This has been the major bone of contention concerning the
applicability of the ACF in countries outside the United States that may have
different, or not so stable, political systems.1

Research Method
This is a qualitative research article based solely on secondary data.
The data were obtained from relevant documents including memorandum,
communiques, press briefings, resolutions of unions and groups, transcripts
of Senate and House public hearings, mass media reports on health summits,
and presentations, as well as submissions of unions/bodies. Qualitative content
analysis was adopted for document analysis. As stated in Sabatier and Jenkins-
Smith (1993), qualitative content analysis is a suitable method for analyzing
relevant documents and publications of actors in a policy subsystem in order
to empirically identify the actors’ policy core beliefs (Markard, Suter, and
Ingold 2014). The event under study occurred between 2004 and 2014—thereby
eliminating direct observation. The available research option, therefore, was
collection of information in a methodical manner from relevant documents to
identify the policy actors and core beliefs.

1 Sabatier and Weible (2007) made a distinction between matured and nascent subsystems, while
the former is associated with the Organisation for Economic Co-operation and Development
(OECD) countries with decades of political stability, the latter represents countries with unstable
political systems. ACF was designed to explain policy changes in the matured subsystems that
seem to suggest it is applicable only to OECD countries. However, since matured subsystems have
been defined as a product of relative political stability of a decade or more, it has become
acceptable for a policy change to qualify for ACF applicability—though it must have lasted for at
least a decade. Since the late 1990s when the third wave of democracy swept across Africa, most
African countries have democratized and remained fairly stable. Therefore—as acknowledged by
Ainuson (2009), Nohrstedt (2009), along with Sabatier and Weible (2007)—there has been an
increase in applications of the ACF for policy changes in Africa, Asia, and South America. In
advocating for wide applicability of the ACF, Weible and Sabatier (2007, 132) state, “The ACF is
very applicable to different governing structures, cultural-societies, and policy areas. The ACF has
been applied to a wide variety of public policy areas and in many different countries. We expect
that researchers will continue to apply and test the ACF in different socio-political contexts.”
552 | Politics & Policy / June 2019

I relied on mass media reports for identifying the government agencies,

documents, and actors relevant to this article. The policy process covers a period
of ten years, from 2004 to 2014. During this period two Senate/House public
hearings were conducted, one in 2006 and the other on February 11, 2014. In
each of these public hearings, over 40 different bodies participated through
presentations and submitting memorandum. Outside the public hearings, the
policy process also involved over seven stakeholders interactive sessions, five
summits/workshops, and four Senate/House policy review sessions. Information
relating to and emanating from these processes were extracted and organized.
Answers were sought for: who were the organizers of the hearings, workshops,
forums, etc.?; why were the sessions and workshops organized?; who were
the participants; what issues were discussed?; what were the positions of the
participants?; and what were the outcomes? Documents relating to these events
were marked as being relevant in providing answers to above questions. They
were relied upon by:

1. Identifying what ignited the policy change.

2. Identifying the key actors.
3. Identifying the policy core beliefs of the actors.
4. Analyzing the relationship between the key actors.

The next step involved the creation of identification codes for the documents.
Codes were created in the format below (Table 1).

Table 1. Documents Identification Codes

S/N Document Code

1 Federal government official gazettes and transcripts of A1

Senate/House proceedings
2 Mass media reports, press briefings and statements, B1
communiques and resolutions
3 Memorandum and presentations at public hearings, summits/ B2
conferences, and interactive sessions/workshops
4 Academic papers C1
Note: S/N, serial number.

Results and Discussion

External/Internal Shock
Academic papers (C1) and mass media reports (B2) formed the basis
for identifying what ignited the policy change. In identifying the stimulator
of health sector reform in Nigeria, analysis was conducted on relevant
publications in two national dailies—The Guardian and Punch)—two online
 Nwalie / ACF AND THIRD-WORLD POLICY CHANGE | 553

publications—The Nigeria Health Watch and Nigeria Health Review—and

one academic journal published in Nigeria—The Savana Journal of Medical
Research. The Guardian and Punch were chosen for being the most widely read
newspapers in Nigeria during the years under review (Uwom and Oloyede
2014). Moreover, both dedicate a page once a week for health matters, while
Punch has Wednesdays as its health day, The Guardian uses Thursday for issues
on health. Nigeria Health Review is an organ of Health Reform Foundation of
Nigeria, a key player in the health reform process. The Nigeria Health Watch is
the most prominent online publication on Nigerian health issues, existing as an
independent publication that is supported by New Ventures Fund and receives
support from the Bill and Melinda Gates Foundation.
According to Sabatier and Weible (2007), an external shock is a necessary
cause of major policy change. It provides a stimulus to change that is totally
outside the control of the subsystem. Those external events are important
because they not only shock the policy subsystem, but also shift public attention
toward the subsystem. Twenty-four documents were located in B1 and two (Obi
2014; Saka 2012) in C1 dealing with the history of the reform process. Within
these documents, the WHO’s World Health Report of 2000 appeared in 21
documents amounting to 80.7 percent frequency. The Change Agent Program
(CAP) appeared on ten documents recoding 38.4 percent frequency, while the
U.K. Department for International Development (DFID) appeared eight times
with 30.7 percent frequency.
From the above information, it could be deduced that the WHO report on the
health situation in Nigeria in 2000 was the turning point. The report ranked Nigeria
187th out of the 191 countries in the World Health Index. The document was a
source of shock to international development agencies and concerned health-care
practitioners in Nigeria. It attracted global attention to the health situation in
Nigeria. Based on its findings, the U.K. DFID supported and encouraged some
concerned Nigerians to form a group named the CAP in 2001 with the sole aim of
advocating for health sector reform in Nigeria. Their advocacy triumphed when
a director of the group was appointed as the health minister in 2003. By 2004
the Ministry of Health presented a health reform bill that was mostly drafted by
CAP to the National Assembly. This result and pattern of events is in agreement
with the submissions of Obi (2014) and Saka (2012) as contained in C1.
My submission, therefore, is that the 2004-14 health sector reform in
Nigeria was instigated by an external event. This event was beyond the control
of the subsystem—it not only shocked the policy subsystem, but also shifted
international and local attention toward the Nigerian health situation and sector.
The event was the publication of World Health Report by the WHO (2000).

Policy Subsystem
According to Sabatier and Weible (2007), identifying the appropriate
scope of a subsystem is one of the most important aspects of an ACF research.
554 | Politics & Policy / June 2019

The policy subsystem consists of those actors from both public and private
organizations who are actively concerned about a policy problem. Usually,
they are those who are acquainted with, or even have a specialty in, the issues
involved and have been, over time, actively participating or have sought to
participate in policy formulations in the domain.
The criteria used in selecting the key actors was simple frequency and
recurrence of representation and paper/position presentation through all the
public hearings, workshops, summits, conferences, and interactive sessions
for the ten years (2004-14) that the process lasted. My judgment in selecting
the key actors was based on information from B2. Forty-five documents were
analyzed for this purpose. The documents were transcripts and/or reports from
the following:

1. The Senator Yellowe-led public hearing on the Health Sector Reform Bill
in 2006.
2. The Senator Obasanjo-led workshop on the Health Sector Reform Bill held in
Ghana in 2008.
3. The Health Sector Reform stakeholders’ forum held in Abuja on August 2011
organized by the Health Sector Reform Coalition (HSRC).
4. The Senator Okowa-led public hearing on the National Health Bill on February
19, 2013.
5. The Catholic Health Summit of October 23, 2013.
6. The Health Sector Stakeholders interactive session organized by the HSRC on
June 5, 2014.

At the inception of the reform between 2004 and 2009, more than 50
professional bodies, civil society organizations, and faith-based organizations
were being represented and making presentations in the process. However, not
all actors continued to be represented as the process progressed. While some
lost interest along the way, others coalesced under a bigger union/coalition—in
tune with the postulation of the ACF—with the aim of making a bigger impact.
From the 45 documents analyzed, the result indicated that only six bodies
recorded up to 70 percent frequency on representations and presentations in all
the public hearings, workshops, stakeholders’ forums, and interactive sessions.
They include: the Federal Ministry of Health (FMoH), the Senate/House
Committee on Health, the Nigeria Medical Association (NMA), the Joint Health
Sector Unions (JOHESU), the HSRC, and the Catholic Secretariat of Nigeria.
The policy reform emanated from the FMoH with inputs from the CAP, the
NMA, JOHESU, and the Catholic Secretariat. CAP seemed to fizzle out once
the drafting was completed. The HSRC focused on sensitization of the public,
harmonization of the opposing policy positions, and the political lobbying for
the passage of the bill. In ACF terminology, it acted as the policy broker in
conjunction with the courts and Senate/House Committee on health—which
oversees the necessary legislative processes. The process and pattern of the
advocacy coalitions of the policy actors is illustrated in Figure 1.
 Nwalie / ACF AND THIRD-WORLD POLICY CHANGE | 555

Policy Core Beliefs

Policy core beliefs, when translated to policy preferences, become core
policy preferences. These are divergent preferences of the policy key actors
regarding one or more subsystem-wide policy proposals (Sabatier and Jenkins-
Smith 1999). They are the actors’ normative beliefs of how the policy subsystem
ought to be. These preferences are usually what unites the coalitions and
divides the opponents. In identifying the core policy preferences of the actors,
the themes in the union/body’s presentations/submissions, memorandum,
communiques, resolutions, and press statements were identified, categorized,
and coded. Those themes that occurred more frequently and remained
unchanged throughout the policy process indicate the actor’s policy core
beliefs. I analyzed all the available submissions/presentations made by each
actor in all the public hearings, summits, workshops, interactive sessions,
and stakeholders’ forum. I also analyzed the press briefings/statements and

Figure 1.
The Policy Subsystem
Coalition A Policy Brokers Coalition B

Technical Experts Civil Society Coalitions Technical Experts

Health Reform Foundation of Association of Medical Laboratory Scientist of
Medical and Dental Consultants' Nigeria (HERFON), Save the Children Nigeria (AMLSN), Association of Pathologist of
Association of Nigeria (MDCAN), International, Evidence for Action,
Nigeria (APN), Association of Private Radio
Federation of Women Lawyers (FIDA),
National Association of Community
Federation of Muslim Women Diagnostic and Imaging Directors, Association of
Health Practitioners of Nigeria, Association of Nigeria (FOMWAN), Radiographers of Nigeria (ARN), Committee of
National Association of Government Advocacy Nigeria, Nigerian Urban
Heads of Pharmacy in Nigeria Health Institutions,
General Medical and Dental Reproductive Health Initiative
(NURHI), Civil Society for Environmental Health Officers Association of Nigeria
Practitioners (NAGGMDP), Nigerian HIV&AIDS in Nigeria (CISHAN), (EHOAN), Guild of Medical Laboratory Directors,
Dental Association (NDA), Medical National Association of Women
Health Information Managers Association of Nigeria
and Dental Council of Nigeria Journalists (NAWOJ), White Ribbon
Alliance, Nigeria Wellbeing (HIMAN), Medical and Health Workers Union of
(MDCN), Nigerian Optometrists
Foundation, Medical Women Nigeria (MHWUN), National Association of Nigerian
Association (NOA), National Association of Nigeria (MWAN), Nurses and Midwives (NANNM), Nigerian Society
Association of Doctors in University National Council of Women Societies,
Association of Reproductive and of Physiotherapy (NSP), Nigerian Union of Allied of
Health Services, and National
Family Health (ARFH), Partnership for Health Professionals (NUAHP), Pharmaceutical
Association of Resident Doctors Transforming Health Society of Nigeria (PSN), Senior Staff Association of
System (PATH), Conference of Catholic
University Teaching Hospitals (SSAUTH), Allied
Bishops of Nigeria (CCBN)
Health Professional Association

Nigeria Medical Association Federal Ministry of Health Joint Health Sector Unions

NMA FMoH JOHESU

Senate and House

Committee on Health.
Federal Appeal Court
and Federal Industrial
Court
556 | Politics & Policy / June 2019

communiques issued by the leadership of each of the actors. In other words, I

relied on documents within the B1 and B2.
In identifying the policy core beliefs of the NMA, the following documents
were analyzed:

1. The NMA presentation and submission on the 2006 public hearing on the
Health Sector Bill.
2. The NMA presentation and submission on the 2013 public hearing on the
National Health Bill.
3. The Resolution of NMA Officers’ committee meeting held on June 10, 2014.
4. The NMA presentation and submission at the Yayale Ahmed-led Presidential
Committee on Inter-Professional Relationship in the Public Health Sector in
2014.
5. The NMA President’s press briefing at Abuja on January 5, 2014.
6. The communique issued by the NMA at the end of her National Health Summit
on January 27, 2013.

Categorization and coding of themes was actually straightforward, for there

was a constant reoccurrence of the same themes in all the analyzed documents.
The NMA, it appeared, never changed or modified its core policy preferences
from 2006 to 2014. The identified themes that appeared in all the six analyzed
documents were, “integrated and harmonized,” “single management body,”
“single channel of regulation and standardization,” “Surgeon General of the
federation,” and “PPP.” In sum, the NMA policy core belief that emerged from
the documents was that the different sectors in the health system need—and
should be—harmonized and integrated under a single management body with
a unified system of regulation and standardization. Based on this finding, an
office of the Surgeon General of the federation should be created to act as a
kind of health sector czar. Any sector that by its nature cannot be integrated
within this system should be outsourced through PPP.
JOHESU core policy beliefs seemed to not be autochthonous, but rather
were reactions to the positions of the NMA. In all JOHESU documents
analyzed, constant references were made to the NMA’s position on the policy.
Analyzed documents included:

1. The JOHESU presentation and submission in the 2013 public hearing on

the National Health Bill.
2. The press briefing by leadership of JOHESU and the Allied Healthcare
Professional Association (AHPA) on contemporary health matters held on
March 10, 2014.
3. The report on the interactive meeting between the leadership of JOHESU/AHPA
and the Speaker of the House of Representatives on June 6, 2014.
4. The press release by the leadership of JOHESU on January 6, 2014.
5. The submission of JOHESU at the Yayale Ahmed-led Presidential Committee
on Inter-Professional Relationship in the Public Health Sector in 2014.
 Nwalie / ACF AND THIRD-WORLD POLICY CHANGE | 557

6. The JOHESU letter to the President on the report of the Yayale Ahmed-led
Presidential Committee on Inter-Professional Relationship in the Public Health
Sector.

After categorization and coding, the key themes that resonate in these
six documents are: “multiprofessionalism,” “hegemony,” “professional
autonomy,” and “clinical and administrative.” When fleshed up, JOHESU core
policy beliefs—which seemed to be a one-on-one counteraction to the NMA’s
positions—were with how the health sector is a multiprofessional system and to
avoid the hegemony of one profession over another there should be professional
autonomy for each profession with regard to regulation and standardization.
Clinical and administrative functions should be separated and not subsist
in the same body, individual, or profession. This position ran counter to the
beliefs of the NMA who were pushing for unification and integration of all the
sectors under one authority. While the NMA was calling for a single source
authority, JOHESU was for fragmentation and devolution of authority. This
rift created the devil shift that had nearly torn the Nigerian health sector apart.
To forestall a total breakdown of interprofessional relationships in the public
health sector, the president sets up a Presidential Committee of Experts on
Inter-Professional Relationship in the Public Health Sector in June 2014 for
reconciliation and position harmonization.
The Catholic Secretariat of Nigeria participated and made submissions in
all the public hearings, had an interactive/advocacy meeting with the Minister
of Health on February 21, 2013, and organized the Catholic Health Summit
to sensitize the public on its position in October 2013. The five documents that
emanated from these activities included: the Catholic Secretariat presentations
at the 2006 and 2013 public hearings on the Health Reform Bill; the summation
of the Catholic Secretariat’s position on the National Health Bill presented
at the Catholic Health Summit of October 13, 2013; the report from a one-
day interactive workshop between the representatives of the FMoH and the
Catholic Secretariat of Nigeria on the National Health Bill; and the report
of the advocacy visit of the Catholic Bishops of Nigeria to the Minister of
Health on February 21, 2013. The Catholic Secretariat’s position remained that
there should be a specific and unambiguous clause in the bill prohibiting the
trafficking of human eggs, manipulation of embryos, and abortions, as well as
stem cell research and cloning. For details of the policy core beliefs of each
coalition see Table 2.

Policy Outcome

The National Health Act of 2014—which is the policy outcome of the

Nigerian Health Sector Reform of 2003-14—is a comprehensive document that
provides a framework for regulation, development, and management of the

S/N Issue
1 PPP in the health sector
2 Honorary consultants in
tertiary hospitals
3 Chief medical directorship
4 The constitution of the
members of boards of
management of tertiary
health institutions
5 Executive chairmanship of the
proposed National Tertiary
Hospital Commission
6 Creation of more directors
to include nonmedical
personnel
7 Extension of retirement age for
hospital workers
Table 2. The Policy Core Beliefs of the Subsystem
NMA Position
The NMA fully supported the policy
of PPP in the health sector and
calls for outsourcing of most of the
hospital services such as drugs and
commodities services, radiology
and laboratory, catering, cleaning,
mortuary and ambulance services
In support of the allowances granted
to the honorary consultants for
clinical services, they perform in
the tertiary hospitals
Claims that doctors all over the world
are the undisputed head of any
medical team therefore ought to
head all hospitals
Support the current constitution of
members of the board which has
more doctors than all other bodies
combined
In support of the reservation of the
post for medical doctors
Oppose multiplicity of directorship in
tertiary hospitals
No position taken
558
|
JOHESU Position Catholic Church
Vehemently opposed PPP as No position
unnecessary, calls it a neoliberal
agenda that will cause untold
hardship to the poor masses
Opposed the granting of allowances No position
to the honorary consultants, calls
it double salary as they are already
in the payroll of the university that
employs them
Opposed the exclusive right of No position
doctors to produce the chief
Politics & Policy / June 2019
medical director of hospitals
Calls for the reconstitution of the No position
board, to reflect the diversity of
professional bodies engaged in the
health sector
Opposed the policy direction No position
Calls for creation of more directors No position
to include qualified nonmedical
personnel
In support of extension from 60 to No position
65 years

S/N Issue
8 Appointment of nonmedical
doctors as consultants
9 Creation of the office of the
Surgeon General of the
federation
10 The supervisory role of
pharmaceutical regulatory
body
11 Granting the AMLSN the
sole right to approve the
importation of in-vitro
diagnostics
12 Abortion, cloning, genetic
modification
Table 2. (Continued)
NMA Position JOHESU Position Catholic Church
Opposed the position as it will In support of the position No position
exacerbate the acrimonious and
chaotic situation in the health
sector
Proposed and in support of the Opposed the policy as unnecessary No position
creation of the office as a national duplication of offices
health czar
Opposed extension of the regulatory In support of overall supervisory role No position
role of the body to pharmacies and of the regulatory body
pharmacists in private hospitals
NMA is in opposition to this policy JOHESU is in support of this policy No position
No position No position Proposed and
strongly pushed for
the prohibition of
those practices
Nwalie / ACF AND THIRD-WORLD POLICY CHANGE
| 559
560 | Politics & Policy / June 2019

nation’s health system. It addresses administrative, legal, and ethical issues in

the health sector. Some of the main features of the Act include the establishment
of the National Health System. Under this act, the framework for standards
and regulations of health service in the country was defined and provided;
it also set out the duties, obligations, and rights of health workers, health
establishments, and users. The Act further established the National Tertiary
Health Institutions Standard Committee for inspection, accreditation, and
the standardization of tertiary health institutions and another committee for
the promotion of health research in Nigeria. The Basic Health Care Provision
Fund was established for the provision of essential drugs, vaccines, equipment,
and consumables for primary and secondary health facilities.
On ethical issues, the Act prohibited the removal of tissue, blood, or blood
products without the consent of the person from whom the tissue, blood, or
blood product is removed except in the cases of medical investigation or
emergency treatment. Also, removal of tissue or blood products for the purpose
of merchandise and the manipulation of any genetic material such as gametes,
embryo, or zygotes are expressly prohibited. It also made it a crime in Nigeria to
engage in importation or exportation of human zygotes or embryos and nuclear
transfer or embryo spitting for the purpose of cloning.

Summary
The World Health Report of 2000 drew world attention to the health
situation in Nigeria (WHO 2000). As a result, the U.K. DFID sponsored,
supported, and organized 30 individuals—drawn mostly from Nigerian health
professionals—to form an association called the CAP in 2001. The sole aim
was to advocate for health sector reform in Nigeria. By 2004, the National
Health Bill had been drafted by CAP and tabled in the National Assembly
through the FMoH. However, fierce competition of core policy preferences
from the key actors—professional bodies, civil societies, technical experts,
and the like—delayed the bill for ten years, reflecting a wide gap in technical
and professional beliefs, orientations, and interests within the Nigerian health
sector.
During this period, actors with common policy beliefs formed coalitions
and engaged in intensive advocacy to translate those beliefs into national policy.
Ultimately, two major coalitions emerged: the NMA, consisting mainly of
clinical professionals/technical experts on health matters, and the JOHESU,
made up of mostly allied medical professionals. Reconciling differences in order
to produce a coherent and acceptable health sector reform package was a huge
problem for the policy brokers—Senators, House Representative members,
the courts, and some nongovernmental organizations (NGOs). During these
years, political activism and radical unionism reached a peak among Nigerian
health professionals as each pushed for its agenda through various industrial
actions. As such, during this period the public health sector was virtually shut
 Nwalie / ACF AND THIRD-WORLD POLICY CHANGE | 561

down due to antagonism and interprofessional rivalry (Akindele 2015; Inyang

2008; Nwabueze 2014; Onyekwere 2013; Oyewunmi and Oyewunmi 2014). The
noncollaborative attitude of the two major coalitions in this policy process
made it very difficult for their opposing views to be reconciled. The antagonism
flowed from top leaders of the coalition to the mass members at the bottom. In
accordance with Sabatier, Hunter, and McLaughlin (1987), this “devil shift” was
actually based on a sociopsychological mechanism. JOHESU saw the NMA as
an elitist organization that seeks to dominate and impose its will on the rest of
health sector professionals. On the other hand, the NMA viewed JOHESU as
a leftist organization consisting of nonclinical professionals in the health sector
with little or no knowledge of hospital management and administration.
However, with the reconciliation effort of the HSRC and the presidency
which set up the Presidential Committee of Experts on Inter-Professional
Relationship in the Public Health Sector, positions were harmonized and the
bill was finally signed into law in 2014 after a period of ten years.

Conclusion

The applicability of the ACF to subsystems outside the United States

has been questioned by critics on the grounds that, due to differences in
political systems, institutions, and cultures, the ACF cannot claim universal
applicability, particularly outside developed Western democracies. The present
article sought to ascertain if this claim is warranted—at least as it applied to
Nigeria. My findings suggest that, in fact, it does seem decidedly overstated to
say the least.
Democratization has brought political stability in Nigeria. It has also
institutionalized the rule of law, the separation of powers, freedom of speech, and
association—therefore creating room and availability for multiple policy actors
as well as technical experts in the country. This illustrates the main contention
of this article: the ACF can indeed be successfully applied to policy reform in
the country. This is in tune with Sabatier and Wieble (2007), who noted that
democratic countries with a separation of powers, the rule of law, and technical
experts lend themselves very well to the ACF as an analytical framework for
policy changes. The focus of this article, health reform in Nigeria between 2003
and 2014, lasted for eleven years and involved a wide range of actors, including
the Senate, House of Representatives, Federal Appeal Court, Federal Industrial
Court, professional bodies, NGOs, and other civil society coalitions (see Figure 1).
Using qualitative content analysis, I covered the factors that led to the reform,
the reform process, and its outcome. External shock, policy subsystems, stable
parameters, technical experts, advocacy coalitions, the devil shift, and policy
core beliefs—which are basic components of the ACF—were all identified in the
Nigerian policy reform process.
562 | Politics & Policy / June 2019

The multiplicity of policy actors could not have been possible under military
dictatorship or an unstable political system, both of which bedeviled the country
prior to 1999. Moreover, the policy process could not have lasted for over a decade
as a result of goal disagreements and technical disputes without the availability
of stable and mature subsystems that were made up of technical experts with
stable policy beliefs. Based on a 2006 survey, professionals in the Nigerian
health sector included: 39,210 doctors, 124,629 nurses, 88,796 midwives, 2,773
dentists, 12,072 pharmacists, 3,059 medical lab scientists, 117,568 community
health providers, 769 physiotherapists, and 519 radiographers (Federal Ministry
of Health 2007). There are 14 regulatory bodies in the country charged with the
responsibility of regulating practices and maintaining the standard of training
for these professionals. Overall, Nigeria has 33,303 general hospitals, 20,278
primary health centers, as well as 59 teaching hospitals and federal medical
centers. All the professional and nonprofessional bodies engaged in the health
sector have both central labor unions and local ones at each of the hospitals
and health centers. However, during the reform period, many unions merged as
a result of their affinity of beliefs and interests. This resulted in the emergence
of two mega labor unions in the Nigerian health sector: The NMA and the
JOHESU—which is made up of mostly allied medical professionals. The NMA,
formed in 1951, is the largest medical association in the West African subregion
and is composed of doctors and dentists who are mostly of Nigerian origin who
practice in Nigeria. It has over 40,000 members and 19,000 diaspora members
covering over 38 branches. The above facts, and the time span of the reform
process itself, are enough evidence for the availability of a mature and stable
subsystem in the health sector of the country.
Moreover, Nigeria has had a fairly stable democratic political system
from 1999 to 2014, a period of about 15 years exceeding the decade milestone
prescribed by the ACF founders. Table 3 offers a summary of the application of
the ACF to this policy reform.
There was never a coup, or violent and unconstitutional change of
government from 1999 onward. A Freedom House (2013) report on Nigeria
affirmed the following: (1) freedom of speech and expression is constitutionally
guaranteed, and Nigeria has a lively independent media sector; (2) academic
freedom is generally honored; (3) freedoms of assembly and association are
generally respected in practice; and (4) the higher courts are relatively competent
and independent. However, there were still some shortcomings as a result of
which the organization rated Nigeria as “partly free.” From the above we can
conclude that Nigeria has had a relatively stable democratic political system for
more than a decade during the period of the policy change.
With a stable democratic political system, multiple policy actors, and an
availability of technical experts, the ACF can be successfully applied in analysis
of the Nigerian Health Sector Reform of 2003-14. Most of these factors were
absent in Africa in the 1980s and early 1990s due to military dictatorship that was
prevalent in the continent. However, with the restoration of democratic rule in
 Table 3. Summary of Application of the ACF Applied to Health Sector Reform of 2003-14 in Nigeria

Territorial Substantive Policy Policy Advocacy External Shock Policy Brokers Policy
Scope Scope Participants/ Core Coalitions/ Outcome
Subsystem Beliefs Devil shift

Federal Federal See Figure 1 See Table 2 Pro-centralized World Health Report Senate and House National
Republic Health structure of of the year 2000 Committee on Health Health
of Nigeria Policy health system Act 2014
(NMA)
vs. pro-
fragmented
structure of
health system
(JOHESU)
Nwalie / ACF AND THIRD-WORLD POLICY CHANGE
| 563
564 | Politics & Policy / June 2019

most of the African countries the situation has altered. This has opened the way
to see the ACF as a potentially suitable and applicable tool for examining certain
policy changes in African countries—and perhaps others in the developing
world—where the requisite democratic conditions have held for over ten years.

About the Author

Martin Ike Nwalie is a PhD student in political economy and development

at the Department of Political and Administrative Studies, University of Port
Harcourt Nigeria. He obtained a BSc in Politics, Philosophy, and Economics
from the Obafemi Awolowo University of Ile-Ife Nigeria in 2000. After working
as a research assistant at the Advanced Aesthetic Consult of Port Harcourt,
he joined the University of Port Harcourt, where he obtained an MSc in
Development Studies in 2014. He is currently conducting research on informal
enterprises in Southeast Nigeria as a form of political resistance.

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