Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process

Document Type : Original Article

Authors

1 School of Health and Health Related Research, University of Sheffield, Sheffield, UK

2 Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK

3 The Department of Community Medicine, University of Jos, Jos, Nigeria

Abstract

Background 
Health workers are central to health policy-making. Given health systems’ complex, dynamic and political nature, various forms of ‘hidden power’ are at play as health workers navigate health systems. This study aims to explore the dynamics of power and its sources, and how this shapes policy-making and implementation within the Nigerian health systems context.

Methods 
The case study was the Global Fund grant in Nigeria, and results are based on an in-depth qualitative study involving 34 semi-structured key informant interviews (KIIs), board-meeting observations, and documentary analysis conducted in 2014 and 2016. Participants held mid to senior-level positions (eg, Director, Programme Manager) within organisations involved with Global Fund activities, particularly proposal development and implementation. Data were analysed using thematic analysis in order to gain insight into the power dynamics of health professionals in policy processes.

Results 
Medical professionals maintained dominance and professional monopoly, thereby controlling policy spaces. The structural and productive power of the biomedical discourse in policy-making encourages global actors and the local government’s preference for rapid biomedical models that focus on medications, test kits, and the supply of health services, while neglecting aspects that would help us better understand the poor uptake of these services by those in need. The voices of the repressed groups (eg, non-clinical experts, patients and community based organisations) that better understand barriers to uptake of services are relegated.

Conclusion 
Professional monopoly theories help illustrate how medical professionals occupy and maintain an elite position in the health system of Nigeria. Structural and agential factors specific to the contexts are key in maintaining this professional monopoly while limiting the opportunities for other health occupations’ rise up the social status ladder.

Keywords


  1. Buse K, Mays N, Walt G. Power and the policy process. In: Buse K, Mays N, Walt G, eds. Making Health Policy. London: Palgrave Macmillan; 2012. p. 27.
  2. Adam T, de Savigny D. Systems thinking for strengthening health systems in LMICs: need for a paradigm shift. Health Policy Plan. 2012;27 Suppl 4:iv1-3. doi:1093/heapol/czs084
  3. Paina L, Bennett S, Ssengooba F, Peters DH. Advancing the application of systems thinking in health: exploring dual practice and its management in Kampala, Uganda. Health Res Policy Syst. 2014;12:41. doi:1186/1478-4505-12-41
  4. Agyepong IA, Kodua A, Adjei S, Adam T. When 'solutions of yesterday become problems of today': crisis-ridden decision making in a complex adaptive system (CAS)--the Additional Duty Hours Allowance in Ghana. Health Policy Plan. 2012;27 Suppl 4:iv20-31. doi:1093/heapol/czs083
  5. Ooms G. From international health to global health: how to foster a better dialogue between empirical and normative disciplines. BMC Int Health Hum Rights. 2014;14:36. doi:1186/s12914-014-0036-5
  6. Ooms G. Navigating between stealth advocacy and unconscious dogmatism: the challenge of researching the norms, politics and power of global health. Int J Health Policy Manag. 2015;4(10):641-644. doi:15171/ijhpm.2015.116
  7. Lee K. Revealing power in truth: comment on "knowledge, moral claims and the exercise of power in global health". Int J Health Policy Manag. 2015;4(4):257-259. doi:15171/ijhpm.2015.42
  8. Dalglish SL, Sriram V, Scott K, Rodríguez DC. A framework for medical power in two case studies of health policymaking in India and Niger. Glob Public Health. 2019;14(4):542-554. doi:1080/17441692.2018.1457705
  9. Topp SM, Chipukuma JM, Hanefeld J. Understanding the dynamic interactions driving Zambian health centre performance: a case-based health systems analysis. Health Policy Plan. 2015;30(4):485-499. doi:1093/heapol/czu029
  10. Lewis JM. Being around and knowing the players: networks of influence in health policy. Soc Sci Med. 2006;62(9):2125-2136. doi:1016/j.socscimed.2005.10.004
  11. Shiffman J. A social explanation for the rise and fall of global health issues. Bull World Health Organ. 2009;87(8):608-613. doi:2471/blt.08.060749
  12. Gore R, Parker R. Analysing power and politics in health policies and systems. Glob Public Health. 2019;14(4):481-488. doi:1080/17441692.2019.1575446
  13. Shiffman J. Knowledge, moral claims and the exercise of power in global health. Int J Health Policy Manag. 2014;3(6):297-299. doi:15171/ijhpm.2014.120
  14. Hanefeld J, Walt G. Knowledge and networks - key sources of power in global health: comment on "knowledge, moral claims and the exercise of power in global health". Int J Health Policy Manag. 2015;4(2):119-121. doi:15171/ijhpm.2015.25
  15. Brown GW. Knowledge, politics and power in global health: comment on "knowledge, moral claims and the exercise of power in global health". Int J Health Policy Manag. 2015;4(2):111-113. doi:15171/ijhpm.2015.20
  16. Freidson E. Professionalism, the Third Logic: On the Practice of Knowledge. University of Chicago Press; 2001.
  17. Larson S. The Rise of Professionalism: Monopolies of Competence and Sheltered Markets. Los Angeles, California: University of California Press; 1977.
  18. Global Fund. Country Coordinating Mechanism Policy Including Principles and Requirements Purpose and Structure. 2018. https://www.theglobalfund.org/media/6019/core_globalfund_framework_en.pdf. Accessed November 3, 2020.
  19. CCM Nigeria. About Country Coordinating Mechanism (CCM). CCM Nigeria. http://www.ccmnigeria.org/?q=content/about-country-coordinating-mechanism-ccm. Accessed October 2, 2015. Published 2015.
  20. Mansell MA. Research governance--global or local? Med Leg J. 2001;69(Pt 1):1-3. doi:1258/rsmmlj.69.1.1.
  21. Chima CC, Homedes N. Impact of global health governance on country health systems: the case of HIV initiatives in Nigeria. J Glob Health. 2015;5(1):010407. doi:7189/jogh.05.010407
  22. Dalglish SL, Surkan PJ, Diarra A, Harouna A, Bennett S. Power and pro-poor policies: the case of iCCM in Niger. Health Policy Plan. 2015;30 Suppl 2:ii84-ii94. doi:1093/heapol/czv064
  23. Brown GW. Multisectoralism, participation, and stakeholder effectiveness: increasing the role of nonstate actors in the Global Fund to fight AIDS, tuberculosis, and malaria. Glob Gov. 2009;15(2):169-177.
  24. CCM Nigeria. Country Proposal – Round 1. CCM Nigeria; 2001.
  25. OIG Report. Country Audit of Global Fund Grants to the Federal Republic of Nigeria. OIG Report; 2016.
  26. Gilson L. Health Policy and Systems Research: A Methodology Reader. WHO. 2012. http://www.who.int/entity/alliance-hpsr/resources/alliancehpsr_readercontentsabout.pdf. Accessed December 14, 2012.
  27. Marchal B, Dedzo M, Kegels G. A realist evaluation of the management of a well-performing regional hospital in Ghana. BMC Health Serv Res. 2010;10:24. doi:1186/1472-6963-10-24
  28. Yin RK. Case Study Research: Design and Methods. London: SAGE; 2003.
  29. Braun V, Clarke V. Thematic analysis. In: Handbook of Research Methods in Health Social Sciences. Hoboken, New Jersey: Springer; 2019.
  30. Barnett M, Duvall R. Power in international politics. Int Organ. 2005;59(1):39-75. doi:1017/s0020818305050010
  31. Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan. 1994;9(4):353-370. doi:1093/heapol/9.4.353
  32. Abbott A. The System of Professions: An Essay on the Division of Expert Labor. Chicago: University of Chicago Press; 1988.
  33. Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021;18(3):328-352. doi:1080/14780887.2020.1769238
  34. The Global Fund. Global Fund Information Note: Strategic Investments for HIV Programs. The Global Fund; 2015.
  35. CCM Nigeria. TB and HIV Concept Note: Investing for Impact against Tuberculosis and HIV. CCM Nigeria; 2015.
  36. Topp SM, Schaaf M, Sriram V, et al. Power analysis in health policy and systems research: a guide to research conceptualisation. BMJ Glob Health. 2021;6(11):e007268. doi:1136/bmjgh-2021-007268
  37. Crook D. Some historical perspectives on professionalism. In: Cunningham B, ed. Exploring Professionalism. London: Institute of Education, University of London; 2008. p. 10-27.
  38. Harrison M, Jones M, Sweet H. From Western Medicine to Global Medicine: The Hospital Beyond the West (New Perspectives in South Asian History). Telangana, India: Orient Blackswan Pvt Ltd; 2009.
  39. Cunningham A, Andrews B. Western Medicine as Contested Medicine. Manchester: Manchester University Press; 1997.
  40. Schräm R. A History of the Nigerian Health Services. Ibadan: Ibadan University Press; 1971.
  41. Arnold D. Warm Climates and Western Medicine: The Emergence of Tropical Medicine, 1500-1900. London: Rodopi; 1996.
  42. Arnold D. Imperial Medicine and Indigenous Societies. Manchester: Manchester University Press; 1988.
  43. Davies C. The sociology of professions and the profession of gender. Sociology. 1996;30(4):661-678. doi:1177/0038038596030004003
  44. Timmermans S, Oh H. The continued social transformation of the medical profession. J Health Soc Behav. 2010;51 Suppl:S94-106. doi:1177/0022146510383500
  45. Mechanic D. Sources of countervailing power in medicine. J Health Polit Policy Law. 1991;16(3):485-498. doi:1215/03616878-16-3-485
  46. Johnson T. Imperialism and the professions. In: Halmos P, ed. Professionalisation and Social Change. Keele: University of Keele; 1973. p. 218-309.
  47. Fischer SE, Strandberg-Larsen M. Power and agenda-setting in Tanzanian health policy: an analysis of stakeholder perspectives. Int J Health Policy Manag. 2016;5(6):355-363. doi:15171/ijhpm.2016.09
  48. Mutizwa-Mangiza ND. Doctors and the State: The Struggle for Professional Control in Zimbabwe. Ashgate Publishing; 1999.
  49. Dussault G. The health professions and the performance of future health systems in low-income countries: support or obstacle? Soc Sci Med. 2008;66(10):2088-2095. doi:1016/j.socscimed.2008.01.035
  50. Temido M, Dussault G. How can a country learn from the experience of another? Expanding nurses' scope of practice in Portugal: lessons from England. Health Policy. 2015;119(4):475-487. doi:1016/j.healthpol.2014.12.005
  51. Kawulich BB. Participant observation as a data collection method. Forum Qual Soc Res. 2005;6(2):43.
  52. Carlson MD, Morrison RS. Study design, precision, and validity in observational studies. J Palliat Med. 2009;12(1):77-82. doi:1089/jpm.2008.9690
  53. Koon AD, Mayhew SH. Strengthening the health workforce and rolling out universal health coverage: the need for policy analysis. Glob Health Action. 2013;6:21852. doi:3402/gha.v6i0.21852
  54. Sheikh K, Gilson L, Agyepong IA, Hanson K, Ssengooba F, Bennett S. Building the field of health policy and systems research: framing the questions. PLoS Med. 2011;8(8):e1001073. doi:1371/journal.pmed.1001073
  55. Mackey TK, Liang BA. A United Nations global health panel for global health governance. Soc Sci Med. 2013;76(1):12-15. doi:1016/j.socscimed.2012.09.038
  56. Maddock S, Morgan G. Barriers to transformation: beyond bureaucracy and the market conditions for collaboration in health and social care. Int J Public Sect Manag. 1998;11(4):234-251. doi:1108/09513559810225807
  57. Kapilashrami A, McPake B. Transforming governance or reinforcing hierarchies and competition: examining the public and hidden transcripts of the Global Fund and HIV in India. Health Policy Plan. 2013;28(6):626-635. doi:1093/heapol/czs102
  58. The Global Fund. Report of the Technical Review Panel on the Concept Notes Submitted in the Third and Fourth Windows of the Funding Model. The Global Fund; 2014.

Articles in Press, Corrected Proof
Available Online from 29 March 2022
  • Receive Date: 05 March 2021
  • Revise Date: 16 March 2022
  • Accept Date: 28 March 2022
  • First Publish Date: 29 March 2022