Exploring Sense-Making in Health Policy: Implementing Health Policy in Nigeria

This study employed the concept of sense-making as an interpretive lens to explore the cognitive dimensions of the actions of policy actors implementing the Nigerian Health Insurance Scheme (NHIS) – a major health policy reform launched in 2005.The research follows emergent body of work by cognitive implementation theorists who have demonstrated that the conventional (top-down compliance model) of policy implementation is fundamentally deficient because it pays scant attention to the link between the sense-making of implementing actors and deviations from policy intentions (Spillane et al., 2002; Peck and 6, 2006).Put differently, the sense-making of implementers results in evolution of policy during implementation (Browne and Wildavsky, 1983; Spillane et al, 2002).Using a case study design, the research investigated individual, and collective/distributed sense-making across a spectrum of the actors implementing the NHIS. More specifically, the study investigated the role of formal and informal interactions on actor sense-making , the impact of communities of practice on collective sense-making , and the shaping influences of the political, organisational and bureaucratic context on the sense-making of actors. The conceptual framework for the study assembled theories and concepts covering individual, and collective/distributed sense-making, sense-giving , communities of practice theory, and the role of power and politics in sense-making. A sample of 29 purposively selected policy actors from the ranks of NHIS/Community insurance Scheme officials, HMO executives, medical providers, and three external health policy advisers were interviewed to generate the primary data. Secondary data was obtained from in-depth examinations of various archival and publicly available documents. The research findings confirm the central thesis that sense-making is socially re-constructed, negotiated and organised. Significantly, individual sense-making variations (based on cognition and affect) in the cues that actors extracted from the NHIS policy message resulted in different framings of that message. The limitations of the notion of homogeneity within communities of practice, and the relevance of power as a dynamic in communities of practice, were also revealed. Notably, the findings empirically demonstrate the critical impact of power and politics in sense-making. A significant contribution of the study to the literature is the linkage that it establishes between power distance orientation and sense-making.