Development of oral health policy in Nigeria: an analysis of the role of context, actors and policy process.
BACKGROUND
In Nigeria, there is a high burden of oral health diseases, poor coordination of health services and human resources for delivery of oral health services. Previous attempts to develop an Oral Health Policy (OHP) to decrease the oral disease burden failed. However, a policy was eventually developed in November 2012. This paper explores the role of contextual factors, actors and the policy process in the development of the OHP and possible reasons why the current approved OHP succeeded.


METHODS
The study was undertaken across Nigeria; information gathered through document reviews and in-depth interviews with five groups of purposively selected respondents. Analysis of the policy development process was guided by the policy triangle framework, examining context, policy process and actors involved in the policy development.


RESULTS
The foremost enabling factor was the yearning among policy actors for a policy, having had four failed attempts. Other factors were the presence of a democratically elected government, a framework for health sector reform instituted by the Federal Ministry of Health (FMOH). The approved OHP went through all stages required for policy development unlike the previous attempts. Three groups of actors played crucial roles in the process, namely academics/researchers, development partners and policy makers. They either had decision making powers or influenced policy through funding or technical ability to generate credible research evidence, all sharing a common interest in developing the OHP. Although evidence was used to inform the development of the policy, the complex interactions between the context and actors facilitated its approval.


CONCLUSIONS
The OHP development succeeded through a complex inter-relationship of context, process and actors, clearly illustrating that none of these factors could have, in isolation, catalyzed the policy development. Availability of evidence is necessary but not sufficient for developing policies in this area. Wider socio-political contexts in which actors develop policy can facilitate and/or constrain actors' roles and interests as well as policy process. These must be taken into consideration at stages of policy development in order to produce policies that will strengthen the health system, especially in low and middle-income countries, where policy processes and influences can be often less than transparent.
Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. eetiaba@gmail.com.|Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. eetiaba@gmail.com.
Enyi
E
Etiaba
Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. nkuguru@gmail.com.|Department of Preventive Dentistry, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. nkuguru@gmail.com.
Nkoli
N
Uguru
Nuffield Centre for International Health and Development, Leeds Institute for Health Sciences, University of Leeds, Leeds, LS2 9JT, UK. B.E.Ebenso@leeds.ac.uk.
Bassey
B
Ebenso
Instituto de Higiene e Medicina Tropical (IHMT), The Nova University of Lisbon, Campus de Campolide, 1099-085, Lisbon, Portugal. grusso@ihmt.unl.pt.
Giuliano
G
Russo
Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. ezumahnk@yahoo.com.|Department of Sociology/Anthropology, University of Nigeria, Nsukka, Nigeria. ezumahnk@yahoo.com.
Nkoli
N
Ezumah
Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. bscuzochukwu@gmail.com.|Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. bscuzochukwu@gmail.com.|Department of Community Medicine, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. bscuzochukwu@gmail.com.
Benjamin
B
Uzochukwu
Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. onwujekwe@yahoo.co.uk.|Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. onwujekwe@yahoo.co.uk.
Obinna
O
Onwujekwe
D000288:Administrative Personnel; D035843:Biomedical Research; D003657:Decision Making; D003906:Developing Countries; D055094:Evidence-Based Dentistry; D005179:Faculty, Dental; D005378:Financial Support; D006076:Government; D018166:Health Care Reform; D006291:Health Policy; D006801:Humans; D007400:Interprofessional Relations; D009549:Nigeria; D009909:Oral Health; D011050:Policy Making; D012107:Research Design