ASSIGNMENT 1: STAKEHOLDER ANALYSIS AND STRATEGY

This presentation is a stakeholder analysis and strategy of Onoka et al. (2014) Towards Universal Coverage:
a policy analysis of the development of the National Health Insurance Scheme in Nigeria.
The analysis is broken into three sections. Section 1 will identify the contextual factors that help explain
the experience of policy change that took place in the four phases in the article. Section 2 will use the
information presented in the paper which describes the commencement phase of the FSSHIP. Three actors
have been chosen to try and understand the position of support or opposition assigned to them by the
authors of this article. Furthermore, the power resource each actor holds will be considered and their level
of influence assigned to them by the authors. A decision on agreement or disagreement of the authors
views will also be made. The three actors chosen are the minister of health, HMOs and NHIS. Lastly section
3 will be an analysis of what the FMOH/NHIS did to influence other actors over phases 3 and 4.
Section 1
Situational factors: In the late 1970s until the early 1980s a global economic recession transpired. This
resulted in the fall in oil prices globally, thus affecting the Nigerian economy that had focused most of its
revenue into the exportation of crude oil, likewise increasing its debt and interest rates to money owed by
Nigeria to the World bank and international monetary fund (IMF) (1). Thus forcing the Nigerian
government to reduce their expenditure on health to make up for the deficit on the money owed to the
IMF and World bank African(2). The Nigerian government had to discontinue free health care to all
Nigerians and thought of a contributory method to supplement funding to sectors of healthcare(3). The
national health insurance was thus (3).
Structural factors: There was a dependence on private providers by private and public sectors as a result of
the economic recessions that had taken place. The head of state was determined to implement the NHIS,
furthermore HMOs and HCPs were approached to offer assistance in the policy process. HMOs and HCPs
saw this as a window of opportunity to increase their own profits, thus being more enthusiastic to drive
the policy process(3). Furthermore, in 1998 General Sani Abacha was found dead and with it saw the end
of his dictatorship in Nigeria(4). Thus 1999 saw a democratic government being elected. However the
change in political structure slowed the policy process as different stakeholders saw this as their window of
opportunity to voice their concerns pertaining to the policy. This is evident when the minister of health
needed to co-ordinate contentious issues that constrained the NHIS implementation(3). However the rapid
growth of HMOs established by wealthy, influential businesses ultimately had allot of influence in directing
the policy process from June 2003- May 2007.
International or exogenous factors: The minister of health through the FMOH attracted development
partners through the health sector reform, this led to the development partners assisting in the NHIS
policy process.
Further information pertaining to International or exogenous factors may have helped in ascertaining what
other factors may have hindered or encouraged the policy process. These include the opinions and
changes occurring in international communities at the time, such as the world health organisation,
International monitory fund and United Nations and the added knock effects it had on their policy process.
It would have been beneficial to know about the cultural factors that affected the policy process. For
example in Nigeria they have four main languages, three major religious beliefs are practiced, and more
than 250 ethnic groups(5). Factors such as these may help in understanding the difficulties and barriers
faced by the stakeholder in implementing the policy. As it is common that certain ethnic/religious groups
may have ideological difference that may hinder the actual communication between stakeholders(6).

Section 2
The minister of health is described as having the most support and influence than any other actor. One can
agree that this is an accurate analysis. He was a newly appointed minister who was selected to address the
difficulties of the policy implantation(3). He displayed commitment by addressing contentious issues in
Table 3 and 4 of the article. The source of power exhibited stems from his formal, political, bureaucratic
authoritative and position he held, including support from the president. This is evident when he imposed
changes of significant staff within the NHIS Secretariat to maintain good working relations with HMOs. In
addition, his source of power was likely attributed to the policy process and personal gains due to alleged
financial interest shown for the HMO industry. One can agree that he had the most influence. This is
evident through his ability to ensure the HMOs remained in the FSSHIP implementation process and
remained confident in the government programme.
The HMOs are described as being as supportive as the minister of health. This is an accurate analysis by the
authors. A policymaker reported that powerful/wealthy/influential Individuals and businesses identified
HMOs as being lucrative markets(3). In addition, the President and Minister of health readily listened to
the concerns of HMOs, suggesting that with their patronage theyd be more inclined to support the policy.
The power resources they held was informal because of the political senators that set up HMOs, including
the minister of healths alleged involvement as previously mentioned. Furthermore, they had an effective
ability to resist the NHIS from proceeding with dislikeable activities. Their ability to shape the preference of
the minister of health was an effective method of influence. This is evident in the co-ordinating roles
played by the minister of health as presented in table 3 and 4 of the article(3). An example of this is where
the minister of health is described as being sympathetic and obliging towards the HMOs. The reason was
attributed to their experience gained in past operations. In addition the HMO as a stakeholder is made up
of multiple HMOs, and we know every HMO was started by professional with varieties of expertise. Thus
their source of power can be described as organizational. One can also agree that the HMOs did have a
high level of overall influence, although the minister of health had slightly more. Majority of the obstacles
faced by HMOs were swiftly resolved, but they relied on the minister of health to take action.
The last actor chosen is that of the NHIS. The authors have described this actor as being highly supportive
of the policy. A former executive secretary of the NHIS was quoted in CareNet Nigeria (2005) as
optimistically saying that the scheme although having imperfections was to commence, and with time the
problems would be addressed (3). Furthermore the NHIS is said to have been a public institution that had
operational and regulatory responsibilities for the policy (3). The NHIS presents decision making power by
opening an account in a commercial bank on behalf of the NHIS, thus opposing the agreement made with
stakeholders. However the NHISs power was limited as a result of the growing influence by the HMOs
that were supported by the minister of health. This resulted in NHIS having less power to act freely and to
resist any opposition. The overall level of influence assigned by the authors was suitably low, as a result of
the minister of health and HMOs being close allies and successfully limiting disliked actions made by NHIS.
Section 3
Power strategy: The NHIS used the power strategy when it opposed an agreement made with other
stakeholders by opening a commercial bank account on behalf of the NHIS and not the Central Bank of
Nigeria. Thus undermining the HMOs in particular(3). It should however be noted that in some cases a
strategy such as this may be considered unethical and sometimes even ineffective(7). Further, the HMOs
had federal agencies and departments assigned to them by NHIS(3).
In the consolidation phase the authors mention the NHIS leadership sought less assistance from HMOs for
technical advice and became less dependent for leadership from FMOH(3). This shows that the NHIS was
keeping these actors uninformed by not providing them with information and reducing their access to to

make decisions. Furthermore the NHIS communicates directly to HCPs and establishes firmer guidelines
for HMOs to be recognized, thus further undermining the HMOs. However the NHIS also distanced itself
from stakeholders, when the mangers intended to establish a NHIS to centrally manage the health
insurance pool for Nigeria. This is an example of an ineffective power strategy.
Perception strategy: NHIS opened an account in a commercial bank thus influenced developmental
partners to be more supportive as the NHIS was then seen as being an influential and appealing
organisation(3). In the consolidation phase they urged states to implement the NHIS programme and
discouraged the initiation of state-level health insurance schemes(3). In addition, separate pools for
different sectors of society were established by the NHIS to expand coverage to state employees of the
state government and to foster public interest in its programmes(3).
Player strategy: The FMOH and minister of health had a mutual interest in the FMOHs reformation
programme(3). Thus in an attempt to demobilize the NHIS who was seen as a restricting actor towards the
HMOs and to maintain good relations with the HMOs, the minister of health imposed changes to the NHIS
Secretariats key staff members in the commencement phase. In addition, the president who would have
been allied to the minister of health chose a new executive secretary of the NHIS, further demobilising the
NHIS and strengthening relations with HMOs. The FMOH implemented a health sector reform programme,
this led to HMOs gaining power, and developmental partners (initially not mobilised) then invested into
the NHIS policy(3). In the consolidation phase the NHIS fruitlessly attempted to spur on support of the
stakeholder by revising the NHIS Act and making it compulsory for all Nigerians to have health insurance.
Position strategy: The minister of health through the FMOH, uses various position strategies in the
commencement phase as can be seen in table3. This is evident when addresses the states and labour
unions who initially highly opposed the policy implementation. He decides to delay employee contributions
and drafts a new NHIS law to create roles for the states, lessening their opposition to the policy(3).
Other strategies: The HCPs had to be mobilised by the NHIS by means of the player strategy during the
commencement phase. They had high levels on influence and also opposed the HMOs(3). Thus persuading
them, by identifying what they had to lose may have gained the NHIS an ally. Furthermore the FMOH may
have wanted to use perception strategies in gaining the support of the public and private employers at the
same time. Advertisement campaigns and the use of celebrities such as sport personalities through the
media may have allowed the FMOH to gain support, by simplifying the issues of concern and presenting
essential facts to the public, especially during the consolidation phase.
The then minister of health should have arranged a negotiations meeting involving all stakeholders. The
aim would be to settle any difference or challenges experience between key stakeholders such as HMOs
and the NHIS. Secondly the interest of each actor should be addressed to lay down agreements(7). It may
influenced the overall policy process to progress effectively.
The three sections covered in this analysis have shown the important roles every stakeholder has in the
policy process. At the same time it highlights how factors that are uncontrollable can hinder policy process,
whether they be global events as was the case in the early 1980s or whether it be spread of disease across
boarders as was recently the case in western Africa. Furthermore knowing which stakeholder to mobilise
and befriend was highlighted as being an important task when faced by stronger opposition. However the
overall encompassing task of any policy process is to have strategic ethical negotiations that involves all
stakeholders(7). This ultimately can be a key factor in preventing stagnation or decline in the policy making
process.

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Onoka C a., Hanson K, Hanefeld J. Towards universal coverage: a policy analysis of the development
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McFADDEN RD. NEW CHAPTER IN NIGERIA - THE OVERVIEW - NIGERIA DICTATOR DIES AFTER 5
YEARS OF RUTHLESS RULE [Internet]. NYTimes.com. 1998 [cited 2015 Aug 10]. p. 2. Available from:
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About Nigeria | UNDP in Nigeria [Internet]. [cited 2015 Aug 15]. Available from:
http://www.ng.undp.org/content/nigeria/en/home/countryinfo/

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Buse, K., Mays, N., Walt G. Making Health Policy. 2012;1221.

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Roberts MJ, Reich MR. Getting Health Reform Right. Getting health reform right. 2002. 264 p.