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  Table of Contents 
Year : 2019  |  Volume : 22  |  Issue : 5  |  Page : 682-691

Muddling through policymaking: A complex adaptive systems perspective on policy changes in a free maternal and child healthcare program in Enugu State, Nigeria

1 Department of Health Systems and Policy, Sustainable Impact Resource Agency; Department of Health Administration and Management, University of Nigeria Enugu Campus, Enugu, Nigeria
2 Department of Health Administration and Management, University of Nigeria Enugu Campus; Health Policy Research Group, Enugu, Enugu State, Nigeria
3 Health Policy Research Group, Enugu, Enugu State; Department of Sociology/Anthropology, University of Nigeria, Nsukka, Nigeria

Date of Acceptance04-Feb-2019
Date of Web Publication15-May-2019

Correspondence Address:
Dr. D C Ogbuabor
Department of Health Systems and Policy, Sustainable Impact Resource Agency, P.O. Box 15534, UNEC, Enugu, Enugu State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_379_18

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Background: Studies on the application of complex adaptive systems (CAS) framework to describe variations in free healthcare policies during implementation are limited. This study uses a CAS framework to explore interactions among actors and to explain how specific characteristics of CAS framework change in institutional designs of a Free Maternal and Child Healthcare Program (FMCHP) in Nigeria. Materials and Methods: A qualitative, case study approach was used to collect data on variations in features of FMCHP from policymakers (n = 16) and providers (n = 16) selected by purposeful sampling from the Ministry of Health and two health districts in Enugu State based on their posts in FMCHP, using semi-structured interview. Additional qualitative data were collected through document review. Main actors, their roles, incentives, and power were identified. Data were analyzed using thematic analysis guided by a CAS framework. Results: Six core features of FMCHP changed during implementation, namely, revenue collection, the role of Ministry of Health, the role of the state teaching hospital, introduction of evidence of tax payment, provider payment process, and establishment of a Financial Monitoring Committee. Formal rules alone did not guarantee consistency and stability of policies. Power imbalances, coordination, and cooperation among actors affected fidelity of policy implementation. The CAS phenomena associated with these changes include path dependence, feedback, lever points, emergent behaviors, and phase transition. Conclusion: Managing changes in free healthcare policies requires recognizing the power shifts, nonlinearity of outcomes, unpredictable consequences and feedbacks, and addressing the context, adaptive behavior, and network of actors.

Keywords: Complex adaptive systems, free healthcare, Nigeria, policy changes

How to cite this article:
Ogbuabor D C, Onwujekwe O E, Ezumah N. Muddling through policymaking: A complex adaptive systems perspective on policy changes in a free maternal and child healthcare program in Enugu State, Nigeria. Niger J Clin Pract 2019;22:682-91

How to cite this URL:
Ogbuabor D C, Onwujekwe O E, Ezumah N. Muddling through policymaking: A complex adaptive systems perspective on policy changes in a free maternal and child healthcare program in Enugu State, Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2022 Jan 19];22:682-91. Available from:

   Introduction Top

Free healthcare policies are recognized as important to achieving universal health coverage (UHC) in low- and middle-income countries.[1] However, free healthcare policies are complex adaptive interventions and their effectiveness can be limited by health system organization, changing behaviors of actors and institutions, and accountability relationships.[2],[3] Complex adaptive systems (CAS), composed of relatively autonomous agents interacting dynamically in nonlinear and unpredictable manner, but capable of self-organization, adaption. and learning from experience,[4],[5],[6],[7] are useful in understanding processes by which actors interact in designing and implementing free healthcare policies and in explaining how and why free healthcare policies change.[3],[4],[5],[6],[8]

CAS provides a useful framework for analyzing policy implementation and strategic change processes.[4],[5],[6],[7],[8],[9] The interactions of actors in a policy process produce an emergent effect that is different from the effects of the individual actors, which persists over time and adapts to changing contexts.[4],[10] Health inequities, for example, insufficient access to maternal and child health services, result from, and might persist due to, nonlinearity of processes and institutional changes during policy implementation.[11] CAS framework uses a whole-system perspective to explore changes in complex health programs, provides insight into how social processes may affect outcomes such as inequities, and supports the design of appropriate interventions to reduce health inequities.[11],[12]

Even though there are other attributes of complexity theory, five characteristics have been used to explain CAS in this study, namely, path dependence, feedback, lever points, emergent behavior, and phase transitions because studies do not systematically evaluate all CAS characteristics.[5],[6],[7],[13],[14],[15] Path dependence refers to nonreversible processes that have similar starting points or same guiding rules but have different, nonlinear outcomes dependent on its initial conditions and different choices made along the way.[5],[6],[7] Feedback denotes effect of an output of a process within a system when it is fed back as an input into the same system, which either balances or reinforces policy response.[5],[6] Balancing feedback indicates that actions neutralize policy responses, while reinforcing loops show that actions sustain policy responses until policy cycle breaks. Lever points mean points at which small intervention produces large changes in a system.[7] Actors, which serve as points of power, exert influence on other actors to elicit desired outcomes in a system. Emergent behaviors are new patterns of actors' behaviors that result from complex interaction of actors and embedded cultural characteristics, which could take forms such as resistance, inertia, unforeseen relationships, and consequences or cooperation.[5],[6],[7],[8] Phase transition is a shift from one relatively stable arrangement or regime to another occurring at tipping points when systems show sudden drastic change without additional inputs.[5],[6],[7],[15]

Evidence of application of CAS framework to health policy and systems is growing.[5],[13],[16],[17] Although most studies have focused on long-term care,[13] CAS has been used to explore leadership practices that promote sensemaking in primary health care in South Africa,[18] implementation of essential drugs policy in China,[19] coverage of immunization services in India,[6] evaluation of performance-based financing in Uganda,[20] priority setting and resource allocation practices in Kenyan hospitals,[21] interaction among healthcare teams,[14] and scaling up of complex public health interventions.[10] These studies provide insights into what actions can be used to sustain and scale up complex health programs and how these actions modify the context in which they are implemented by paying attention to local context, incentives, institutions, and behavior of actors.[5] Also, the studies examine the impact of local interaction in self-organization and how actors respond to the unintended consequences that influence the design and implementation of health programs.[5],[16]

Literature on policy changes in healthcare financing schemes in low- and middle-income countries discovered underfunding of free healthcare policies in India, Nicaragua, Nigeria, and Eastern European countries;[22],[23],[24],[25] termination of copayment policy in Thailand;[26],[27] introduction of selective contracting in China;[28] transfer of purchasing function from Ministry of Public Health to National Health Security Office in Thailand;[26] transition from fee-for-service to diagnostic-related groups in Ghana;[29] change from flat rate payment to actual expenditure reimbursement in Burkina Faso;[30] and abuse of referral system, informal payments to providers, shortages in drugs supply, and delayed reimbursements led to decline in perceived quality of free health services.[30],[31] Three studies explicitly used CAS perspectives to investigate policy changes in health financing schemes in Ghana, China, and Mexico.[32],[33],[34] Using causal loop diagram, Agyepong et al.[32] identified the pathways of policy changes in Ghana's National Health Insurance Scheme (NHIS). In China, phase transitions in the evolution of the rural health financing scheme resulted in emergent behaviors among different actors and self-organized behaviors in the rural health system.[33] Similarly, policy changes in Mexico's Seguro Popular were associated with phase transition, network emergence, resistance to change, path dependence, and feedback loops.[34]

Enugu State introduced tax-funded Free Maternal and Child Healthcare Program (FMCHP) in 2007 to protect households from financial hardship emanating from the use of maternal and child health services in publicly owned, health facilities by pregnant women and children under 5 years old.[35] A Steering Committee (SC), based at the Ministry of Health (MOH), is responsible for strategic direction, pooling, and fund management. An Implementation Committee (IC), which is housed in the State Health Board (SHB), supervises service delivery and pays health facilities for free services delivered. District FMCHP ICs, housed within District Health Boards (DHBs), monitor implementation of FMCHP in district hospitals and Local Health Authorities (LHAs), and LHAs monitor FMCHP implementation in cottage hospitals and primary healthcare facilities within their authorities.

Since inception, little attention has been paid to how and why the FMCHP policy differs from its implementation guidelines. As a result, the pathways of policy changes, reasons for those policy modifications, and roles of different actors remain poorly understood. Applying CAS concepts to FMCHP suggests that different actors act, react, and adapt based on their individual perspectives and experiences.[36] We argue that the (in) actions of these actors contribute to (in) effectiveness of FMCHP. Yet, relatively little is known about how and under what conditions the FMCHP may be scaled up to benefit more people. Adopting a CAS-informed approach would be relevant to understand the pathway for increasing and sustaining coverage of FMCHP. CAS would enhance transition from models revolving around linear, predictable processes to models that embrace uncertainty, nonlinear processes, peculiar local context, emergent characteristics, and intentional adaptation.[5],[16] In addition, CAS would enhance understanding of patient-centeredness and collaborative ways that leaders manage policy changes while encouraging innovative ways of implementing ideas and assessing the system during scale up.[16] This study, therefore, uses a CAS framework to explore interactions among actors in FMCHP implementation and to explain how specific characteristics of CAS change during FMCHP implementation. Understanding how processes of complexity may influence FMCHP outcomes could help decision-makers adapt FMCHP to local context and enhance institutional designs and organizational practices needed to optimize equity and financial protection envisaged by the policy.

   Materials and Methods Top

Study setting

The study was carried out at MOH headquarters and at two sites in Enugu State: (1) Enugu Metropolitan district and (2) Isi Uzo district. Each district is governed by a DHB, has a district general hospital, and a network of cottage hospitals and primary health centers. Enugu Metropolitan and Isi Uzo districts have estimated population of about 990,225 and 203,364 people, respectively, in 2016.[37] Whereas Isi Uzo district is entirely rural, Enugu Metropolitan district is largely urban.

Research design

The study adopted a qualitative case study design, which is suitable for investigating “how and why questions” posed in evaluation of complex interventions.[38]

Study population and sampling strategy

The study population comprises policymakers and providers involved in FMCHP implementation at the state level and in the study districts. The selection of study districts has been reported elsewhere.[39] The seven health districts were categorized into two groups of well-performing and less well-performing districts guided by provider payment data. From each group, one district was randomly selected. In each district, two public hospitals and six health centers with active health facility committees were selected by purposeful sampling. We used purposeful sampling to select 16 policymakers from MOH, SHB, DHBs, and LHAs and 16 providers comprising officers-in-charge from four public hospitals and 12 primary health centers. Whereas 16 of 19 policymakers approached participated in the study, all the providers recruited took part in the study.

Data collection methods

We collected data through document review and in-depth interviews. Information about changes in the institutional design of the FMCHP were abstracted from policy documents. Interviews of policymaker and providers were conducted, using semi-structured in-depth interview guide, until data saturation was reached.[40] The interview guide, which was piloted in a different district to ensure clarity of questions, explored policy changes in revenue collection, pooling, and purchasing functions and how different actors shaped FMCHP implementation [Appendix 1]. Interviews, lasting 60–90 min, were conducted in English and tape-recorded. The transcripts were checked by interviewees for accuracy.

Data analysis

Thematic analysis was used in data analysis using NVivo 11 software.[41] Deductive and inductive coding strategies were used. Deductive codes were based on five common characteristics of CAS framework, namely, path dependence, feedback, lever points, emergent behavior, and phase transitions.[5],[6],[7] Inductive codes reflected different policy changes that emerged from interviews and documentary analysis. We identified patterns of behavior and the underlying systemic interrelationships which are responsible for the variabilities in the implementation of FMCHP and the impacting factors and matched them against the characteristics of CAS framework.[42] Illustrative quotes were edited for clarity and used to substantiate the themes. Coding was done by two independent coders, and inconsistencies were resolved by consensus. Findings were validated through dissemination meeting with relevant stakeholders.[43]

Ethical consideration

Ethical approval was obtained from the Health Research Ethics Committee of University of Nigeria Teaching Hospital, Enugu, Nigeria. Participants gave written informed consent for participation and digital recording of interviews.

   Results Top

All the participants have been involved in implementation of FMCHP since inception. Six of the 16 policymakers work at the district level, while 10 are state-level policymakers. All 16 healthcare providers were heads of their health facilities. Whereas the policymakers were predominantly male (94%), the providers were mostly females (81%).

Main actors in FMCHP implementation

Several actors were involved in FMCHP implementation. [Table 1] shows key actors, roles, and power.
Table 1: Actors involved in the FMCHP implementation in Enugu State, Nigeria

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CAS perspective on policy changes during FMCHP implementation

Six features of FMCHP policy changed during implementation and were associated with different CAS characteristics [Table 2]. These changes indicate that formal rules are not sufficient to ensure predictable funding of FMCHP, the MOH had more power than any other actor in FMCHP implementation, institutional conflicts underlie interrelationship among different actors, and institutional designs adapt over time.
Table 2: Application of complex adaptive systems framework to policy changes in FMCHP implementation

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Rule for state and local government contributions to FMCHP fund

Rules for revenue collection did not guarantee predictable state and local government funding of FMCHP. Most policymakers stated that the state and local governments' monthly contributions to FMCHP fund were not regular. The delayed transfer necessitated the Economic Planning Commission to reset rules for direct deduction and transfer of state and local governments' contribution from government general revenue to FMCHP fund through the Joint Accounts and Allocation Committee (JAAC) in 2009.

The revised rule for budget transfer to FMCHP fund was a policy response to balance unpredictable state and local governments' budget transfer to FMCHP pool (feedback). Notwithstanding the revised revenue collection rule, only the local governments complied with the guideline. This nonlinearity in implementing the revised rules for revenue collection indicates path dependence. Document review shows that since 2010, the state government has not released promised funds to FMCHP. A policymaker noted that “the state government has not actually lived up to its own responsibilities of making regular contributions” (Policymaker 1).

State Ministry of Health as steward, pooling agent, and purchaser

The MOH had more power than the other actors in the governance and implementation of FMCHP. Policy stipulated that the SC, composed of multisectoral stakeholders from health ministry, departments and agencies, and other stakeholders including user representatives, has responsibility for pooling and purchasing in FMCHP. In contrast, most policymakers indicated that MOH usurped pooling and purchasing functions of the SC. SHB, the service arm of MOH, also usurped the purchasing function of the IC. As a result, the MOH became the decision-making and financial hub of FMCHP and wielded both official and discretionary power (lever points). A provider observed that “majority of the decisions are taken by the Ministry of Health with little input from districts” (Provider 14).

Three emergent behaviors were associated with establishment of MOH as steward, pooling agent, and purchaser. First, MOH used funds for unauthorized purposes. Second, MOH withheld remittance of LHAs' share of administrative cost due to lack of clarity of roles of LHA secretaries. Third, provider reimbursement became unpredictable and even when there are funds in the FMCHP account, reimbursement depended on “whether the commissioner was willing to approve funds” (Policymaker 6). Phase transition explained the collapse of drug revolving fund in many health facilities when delayed reimbursement of providers reached a critical point. In the words of a provider, “Because of delayed reimbursement, the drug revolving fund program collapsed” (Provider 7).

In contrast to guidelines, most district FMCHP committees were not established, and where they existed, they were not functional. Nonestablishment of and/or dysfunctional district committees despite policy stipulations shows path dependence. District Chief Executive Officers (CEOs) assumed roles of District FMCHP ICs, which limited monitoring of provider performance and local stakeholders' involvement in FMCHP. In the words of one policymaker, “though the district implementation committees are not functional as of now, somehow, decisions are passed through district chief executive officers to the local health secretaries” (Policymaker 5).

Role of the state teaching hospital

The change in institutional design regarding the role of the State Teaching Hospital depicted feedback, phase transition, and emergent behavior. At inception, the teaching hospital served as primary care provider, but in 2009 it was designated a referral center to resolve overuse of FMCHP services (feedback). One policymaker said, “at the outset people had to come in from all around Enugu state to access service at the tertiary health institution” (Provider 9). Increase in free care clients resulted in huge FMCHP claims which threatened financial sustainability of FMCHP pool. By transiting into a referral center, the hospital provides free care only to clients who adhered to referral guidelines (phase transition). As a result, the teaching hospital was not “readily accepting those people on referral from the lower facilities” (Policymaker 10).

Introduction of evidence of tax payment

Even though evidence of tax payment neutralized overuse of free services, the policy lacked coordination and cooperation of different actors. Feedback, path dependence, phase transition, and emergent behavior applied to implementation of evidence of tax payment. Presentation of evidence of tax payment by users was introduced in 2011 as balancing feedback to neutralize overuse of free services in health facilities. It was argued that “people from neighboring states (Benue, Anambra, Imo, Ebonyi) rushed into Enugu to access free healthcare services” (Policymaker 7). As a result, automatic, residence-based service entitlement was phased out. Unexpectedly, although evidence of tax policy was not evenly implemented across health districts (path dependence), providers used discretional powers to ration free services (emergent behavior). According to a provider, “we no longer provide free services because patients do not bring evidence of tax payment” (Provider 2). The change in pattern of utilization depicts phase transition.

Provider payment process

Feedback, phase transition, and emergent behavior shaped the institutional changes in provider payment. At inception of FMCHP, funds were transferred through LHA secretaries for reimbursement of facilities for service and drugs costs, but since 2010, providers were reimbursed directly, which indicates phase transition. It was explained that change in reimbursement of providers was “because state policymakers thought that LHA secretaries were embezzling program funds” (Policymaker 12).

Provider payment reforms neutralized poor transparency in allocation of funds to facilities by LHA secretaries (feedback), and also reinforced their withdrawal from FMCHP (emergent behavior). Policymakers acknowledged that the change to direct facility reimbursement of FMCHP service expenditure and crediting providers' drug account at central medical store for FMCHP expenditure on drugs accounted for the inertia and resistance among LHA secretaries. LHA secretaries no longer monitored implementation of FMCHP in health facilities. One provider observed that “Initially, LHA secretaries were supporting facilities to implement the program but after some disagreement, they withdrew and left the program for the officers-in-charge” (Provider 3).

Establishment of Financial Monitoring Committee

Introduction of Financial Monitoring Committee (FMC) promoted institutional conflict among key actors. Feedback and emergent behavior characterized establishment of FMC. Policymakers stated that FMC was constituted to ensure the SHB adhered to financial rules guiding transfer of funds to central medical store and health facilities. Policymakers observed that MOH officials were concerned about limited transparency in business practices of SHB. A policymaker claimed that “the money that has been approved 2 months ago,… may still be in their (State Health Board) account, not yet disbursed. They will tell you that they are writing all the papers” (Policymaker 1). Nevertheless, introduction of FMC reinforced conflict between MOH and SHB. The SHB officials defied financial information disclosure instructions of the FMC, claiming that the establishment of the FMC was inappropriate and not backed up by “written document” (Policymaker 8).

   Discussion Top

The study's findings highlight four key lessons, which could improve the governance of free healthcare policies. First, formal rules alone do not guarantee consistency and stability of policies. Second, power imbalances shape policy changes. Third, commitment, coordination, and cooperation among different actors are imperative. Finally, there is the need for thorough institutional design and continuous monitoring of organizational practices during implementation.

The findings of this study revealed that formal rules alone do not guarantee consistency and stability of policies overtime. Policies could follow different pathways depending on the behavior of actors. The FMCHP incorporated a process of self-organization by revising the rule for revenue collection. Although enforcement of contribution rules would make resource generation stable, sufficient, and sustainable, state government showed poor commitment, indicating nonlinearity of policy implementation. Poor government commitment to funding user fee exemption policies was also seen in India, Nicaragua, Nigeria, and Eastern European countries.[22],[23],[24],[25] Disconnect between MOH and JAAC could have been responsible for nonimplementation of the rule. Also, the state government may not have the incentive to transfer its contribution to FMCHP fund when funds accumulate in the pool due to poor absorptive capacity of the program. There is need to strengthen accountability relationships in revenue collection as implementation of complex interventions cannot always be linear.

This study's findings showed that fidelity of policy implementation depends on power imbalances among actors across networks. The MOH represents the power hub in FMCHP. The FMCHP Steering and ICs deferred authority, responsibility, and decision-making to MOH. For example, the MOH usurped roles of FMCHP SC consistent with findings in Thailand and Mexico.[26],[34] Consequently, MOH officials developed figurations of power relations which excluded other actors or limited their decision space. Withholding of administrative costs meant for LHAs by MOH typifies how actors could be excluded due to shifts in power. Nonetheless, self-organizing meant that LHA secretaries had to withdraw from provider performance monitoring. A strong and diffuse leadership in which authority, responsibilities, and decision-making are decentralized and distributed across all levels of the health system is needed to build trust among stakeholders.

This study further highlighted the need for decision-makers to cooperate and coordinate policy responses to limit the unintended consequences of concurrent policy options. Decision-makers should expect unpredictable consequences and use them as opportunities for learning, sense-making, and innovation. Most unanticipated outcomes during FMCHP implementation emerged as resistance to actors, with opposing interests, or dysfunctional interorganizational relationships. Distrust and perception of unfairness among different actors were the key drivers for opposition to financial monitoring by SHB and inertia among LHA secretaries. Resistance to change was also associated with introduction of some concurrent policies in Seguro Popular in Mexico and China's rural health scheme.[33],[34] Decision-making should be coherent, transparent, and participatory to limit opportunistic behavior and ensure complementary actions.

This study's finding also revealed need for thorough institutional design of free healthcare policies and continuous monitoring of organizational practices during implementation. Absence of rules for eligibility of beneficiaries, referral, and provider payment were major design flaws of FMCHP which underpinned phase transition. Despite setting of these rules, transition was partial. There were allegations that the state teaching hospital refuses referrals from district health facilities, evidence of tax policy was not evenly implemented across health districts, and reimbursements were delayed. These examples highlight the need for stakeholder participation, transparent decision-making, and clarity in communicating policies to implementers. Phase transition was also observed in China's rural health scheme due to changes in broad development strategy,[33] Mexico's Seguro Popular notably transition from family allocation to per capita allocation of funds and introduction of expenditure ceilings for medicines and personnel,[34] and transition from fee-for-service to Ghana diagnostic-related groups in Ghana's NHIS.[32],[44] Strengthening free healthcare policies should emphasize creating learning organizations capable of responding to dynamic complexity of policy implementation.[45]

Our study adds to the growing literature examining changes in institutional designs following the introduction of user fee removal policies in low-income countries using CAS framework. The study may be limited by recall bias and quality of self-reported information, but inclusion of participants from different components of the health system, triangulation with document review, and validation of findings through dissemination meeting enhanced trustworthiness of our findings.

   Conclusion Top

This study has, through insights into the variability of implementation and factors impacting effectiveness of FMCHP, provided evidence of the potential mediating role of CASs phenomena in policy changes during free healthcare policy implementation. As low-resource countries implementing free healthcare policies advance toward UHC, system thinking offers useful set of tools to decision-makers to understand the mechanisms and unanticipated consequences of policy changes. Decision-makers must elicit commitment, coordination, and cooperation among actors and create learning organizations capable of responding to policy changes during free healthcare policy implementation.


The authors owe special thanks to all the participants of the study.

Financial support and sponsorship

This work was partially funded by the African Doctoral Dissertation Research Fellowship (ADDRF) (grant No. 2014-2016 ADF003) through the African Population and Health Research Centre (APHRC), Nairobi, Kenya.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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