A narrative exploration of policy implementation and change management. Conflicting assumptions, narratives and rationalities of policy implementation and change management: the influence of the World Health Organisation, Nigerian organisations and a case study of the Nigerian health insurance scheme.

Abstract

Purpose - The thesis determined how policy implementation and change management can be improved in Nigeria, with the health insurance scheme as the basis for narrative exploration. It sets out the similarities and differences in assumptions between supra-national organisations such as the World Bank and World Health Organisation on policy implementation and change management and those contained in the Nigerian national health policy; and those of people responsible for implementation in Nigerian organisations at a) the federal or national level and b) at sub-federal service delivery levels of the health insurance scheme. The study provides a framework of the dimensions that should be considered in policy implementation and change management in Nigeria, the nature of structural and infrastructural problems and wider societal context, and the ways in which conceptions of organisations and the variables that impact on organisations¿ capability to engage in policy implementation and change management differ from those in the West. Design/methodology/approach - A qualitative approach in the form of a case study was used to track the transformation of a policy into practice through examining the assumptions and expectations about policy implementation of the organisations financing the policy's implementation through an examination of relevant documents concerning policy, strategy and guidelines on change management and policy implementation from these global organisations, and the Nigerian national health policy document. The next stages of field visits explored the assumptions, expectations and experiences of a) policy makers, government officials, senior managers and civil servants responsible for implementing policy in federal-level agencies through an interview programme and observations; and b) those of sub-federal or local-level managers responsible for service-level policy implementation of the health insurance scheme through an interview programme. Findings - There are conflicts between the rational linear approaches to change management and policy implementation advocated by supra-nationals, which argue that these processes can be controlled and managed by the rational autonomous individual, and the narratives of those who have personal experience of the quest for 'health for all'. The national health policy document mirrors the ideology of the global organisations that emphasise reform, efficiencies and private enterprise. However, the assumptions of these global organisations have little relevance to a Nigerian societal and organisational context, as experienced by the senior officials and managers interviewed. The very nature of organisations is called into question in a Nigerian context, and the problems of structure and infrastructure and ethnic and religious divisions in society seep into organisations, influencing how organisation is enacted. Understandings of the purpose and function of leadership and the workforce are also brought into question. Additionally, there are religion-based barriers to policy implementation, change management and organisational life which are rarely experienced in the West. Furthermore, in the absence of future re-orientation, the concept of strategy and vision seems redundant, as is the rationale for a health insurance scheme for the majority of the population. The absence of vision and credible information further hinder attempts to make decisions or to define the basis for determining results. Practical implications - The study calls for a revised approach to engaging with Nigerian organisations and an understanding of what specific terms mean in that context. For instance, the definitions and understanding of organisations and capacity are different from those used in the West and, as such, bring into question the relevance and applicability of Western-derived models or approaches to policy implementation and change management. A framework with four dimensions - societal context, external influences, seven organisational variables and infrastructural/structural problems - was devised to capture the particular ambiguities and complexities of Nigerian organisations involved in policy implementation and change management. Originality/value - This study combines concepts in management studies with those in policy studies, with the use of narrative approaches to the understanding of policy implementation and change management in a Nigerian setting. Elements of culture, religion and ethical values are introduced to further the understanding of policy making and implementation in non-Western contexts.