Introduction
Universal health coverage (UHC) has been a global objective since 2005 when it was established as a commitment of United Nations member states. UHC—“a system in which everyone in a society can get the health-care services they need without incurring financial hardship” (Savedoff et al., 2012)—is increasingly seen as a human right and important for economic growth and social development. Global attention on UHC will continue as it has been included in the 2030 Agenda for Sustainable Development (United Nations, 2019). Although many countries have made great progress toward UHC, it is marked by significant debate about how much to cover for which populations and through which mechanisms. These debates have historically been greatly affected by country-level advocacy efforts spearheaded by civil society organizations (CSOs) to create significant domestic pressure on government actors to implement the legal, regulatory, and policy changes required to achieve UHC (Savedoff et al., 2012). If the global health community is interested in supporting local pressure for UHC, it is important for us to understand the specific role of CSOs.
Advocacy and SNA—What’s the Link?
In the context of UHC, we have seen a variety of advocacy tools, strategies and tactics applied. Examples from South Africa (Ravenscroft & Marcos, 2012) and Thailand (Ravenscroft & Marcos, 2012; Social Protection, 2024) demonstrate the importance of advocacy organizations, advocates, and communities working together to achieve change. Although advocates exist at multiple levels and in many forms, change is achieved through a groundswell of advocacy. Coordination and collaboration for advocacy depend on the networks between advocates and advocacy organizations. Social network analysis (SNA) is a methodology that “is effective in helping to understand how the stakeholders view one another, share information, cooperate, and take joint action” (Abbot et al., 2022). SNA can be used to dive deeper into a network’s characteristics, identify stakeholders with requisite networks and reputations, and develop a better understanding of relationships between organizations (Abbot et al., 2022).
We therefore embarked to understand whether SNA has been used to discern key network characteristics that can support advocacy for UHC by reviewing the literature and ground-truthing our findings with those engaged in advocacy for UHC in Nigeria, where increasing access to healthcare is a national priority.
SNA and Health Advocacy in Nigeria
SNA has been used in Nigeria to understand vaccine decision-making in relation both to vaccine introduction and program implementation. The processes involved stakeholders who provided technical information, mobilized finance, implemented programs, and garnered political support and who had different levels of interest, knowledge, and motivations to introduce new vaccines (Gilson et al., 2018; Wonodi et al., 2012). It was also used in analysis of child health, HIV, and malaria policies in Burkina Faso and demonstrates the approach of theory-driven policy analysis. The study found that although network changes were associated with policy reform, the relationship was mediated by one or more institutions, interests, or ideas (Gilson et al., 2018; Shearer et al., 2016).
We selected Nigeria as a country of focus because there have been significant advocacy achievements in advancing healthcare in Nigeria. These achievements also contributed to new legislation and subsequent policies and strategies to implement the Basic Healthcare Provision Fund (BHCPF) and Primary Healthcare Under One Roof (PHCUOR) to expand access to healthcare. However, large inequities remain—the population suffers from the highest child mortality rate in the world, a high burden of chronic and infectious diseases, and rolling epidemics (Abubakar et al., 2022). Unsurprisingly, the Nigerian health system is complex, with stakeholders working at multiple levels and sectors and often in an uncoordinated fashion (Abubakar et al., 2022). A study on advocacy coalitions of maternal and child health advocates in Nigeria by one of this policy brief’s authors identified homogeneous and heterogeneous advocacy groups, and they have their advantages and disadvantages. The homogeneous groups tend to engage in greater collaboration because they belong to the same professional background, with a shared mission and a good network. On the other hand, the heterogenous groups enjoyed having members of various professions in their coalition groups. This, they said, was due to increased access to information sharing, increased access to resources, heightened accountability, and improved problem-solving, bringing in resources and shared ideas from a diverse array of persons as instrumental to their achieved success (Okeke et al., 2021).
As policymaking structures and processes need to engage communities more (Abubakar et al., 2022), a coordinated and collaborative civil society can potentially better affect change. How Nigeria proceeds in its health sector planning will be affected by advocacy efforts. As a result, understanding the factors that supported advocacy networks previously may be helpful in identifying further opportunities for strengthening advocacy networks as they embark to shape and influence the future of UHC efforts in Nigeria.
This brief describes the findings from our literature review and results from our qualitative research in Nigeria
SNA and Advocacy for UHC in the Literature
We conducted a nonsystematic literature search via Google Scholar, RTI Library Services, and USAID Development Experience Clearinghouse. We searched the databases using key terms, pulling 28 articles for review. After applying a four-part inclusion criterion to papers—(1) published in English, (2) published after 2011, (3) describing SNA of advocacy coalitions regardless of health issues, (4) with an international focus—reviewers selected eight papers for full review and analysis (see Table 1).
Advocacy coalitions evaluated ranged from large “network of networks,” including hundreds of maternal child health advocacy networks, to smaller policy workings groups. Key informant interviews (KIIs) and focus group discussions (FGDs) were the most cited network evaluation method (Douwes et al., 2018; Fofah, 2021; Johnson & Chew, 2021; Wang, 2012). Respondents often included policy makers, health professionals, private sector individuals, academics, media members, and nongovernmental organization personnel. In some cases, the authors randomly selected participants from lists of stakeholders, developed in concurrence with local partners (Johnson & Chew, 2021). Other sampling methods included blockmodeling, multidimensional scaling and purposive sampling (Douwes et al., 2018; Fofah, 2021; Wang, 2012). Interview questions often focused on the relationships among network actors, centering around trust and solidarity (Douwes et al., 2018). Other questions pertained to levels of collaboration, leadership, clearly defined common goals, or strategies and tactics used to advocate (Johnson & Chew, 2021; Shearer et al., 2016; Wang, 2012). From the qualitative data, researchers drew conclusions of proximity and strength of advocacy networks.
Some authors conducted qualitative analyses of KII and FGD data, drawing conclusions about trust, solidarity, and relational influence, which impact network success (Douwes et al., 2018). Others used the data to conduct full network analyses (Fofah, 2021; Johnson & Chew, 2021). Other methods of evaluating advocacy coalitions included participant observations, document analysis, and written survey responses.
Regardless of methodology, these analyses led authors to conclusions around what makes strong advocacy coalitions. Network cohesion is vital to strong organizational capacity (Fofah, 2021; Johnson & Chew, 2021). High levels of network cohesion often imply like-minded policy vision among network members. The analyses also suggest advocacy coalitions are more successful when they are decentralized, allowing for more civil society engagement and community influence over policy (Fofah, 2021; Shearer et al., 2016). Douwes and colleagues highlight the importance of collective action and trust (Douwes et al., 2018). Trust and solidarity shift the focus to the most vulnerable, which is a critical component to the case for universal healthcare (Reynolds et al., 2014). Furthermore, the literature highlights clear communication and collaboration as crucial for strong advocacy coalitions (Douwes et al., 2018; McDougall, 2016a, 2016b; Wang, 2012). Evaluating coalitions through SNA and other qualitative methods can produce key lessons on strengthening advocacy coalitions and achieving health policy wins.
This review highlights a potential limitation of using SNA to understand advocacy coalition performance. The birth and evolution of advocacy networks can be drivers of advocacy coalition performance (Resnick et al., 2022). However, SNA typically focuses on relationships at a specific point of time, and network measures do not necessarily reveal elements of network birth or evolution. Therefore, understanding these other elements of coalition success likely requires combining SNA with additional methodologies.
Nigeria Qualitative Data Findings
Although CSOs are not the only stakeholders that engage in advocacy efforts, we chose to focus on CSOs as the unit of analysis because they are often the most representative of diverse community voices and the primary link between governments and their citizens. To ground-truth the literature findings, we conducted FGDs with CSOs who were part of advocacy coalitions, and we conducted KIIs with key policy makers, academics, media personnel, and implementing partners in Nigeria who had experience working with UHC advocacy networks in Nigeria and would be able to provide insights on CSO engagement in advocacy networks. We asked respondents about their experience advocating for UHC in Nigeria. We present the findings from the interviews under thematic headings: advocacy wins, the role of coalitions, network factors that led to successful advocacy, network challenges to achieving UHC, as well as outline the interactions among stakeholder group participants.
Advocacy Wins
Respondents detailed recent CSO-led advocacy wins, including contributing to drafting of legislation and policy and advocacy action in support of adoption and implementation. These wins included the National Health Act (NHA), which provides a framework and legal backing for the regulation; development and management of a national health system; the BHCPF, which was established under section 11 of the NHA to provide catalytic funding to improve access to primary health care; and lastly, the National Tobacco Control Act of 2015, which regulates all aspects of tobacco. These acts were noted as pivotal policy achievements, credited to advocacy coalitions by the respondents.
In addition to these policies, respondents identified successes in establishing partnerships and programs that supported policy wins, such as the subsidy reinvestment and empowerment program (SURE-P) and the HIV trust fund. Respondents also noted contributing to increasing access to primary healthcare by advocating for new facilities and providing 24-hour services in select locations.
The Role of Coalitions
Coalitions played critical roles in achieving these advocacy wins. Respondents frequently referred to coalitions’ roles in defining key challenges, holding government accountable to action, and educating community members and decision-makers on benefits from UHC as most critical in these successes. Respondents from academia and the media highlighted coalitions’ role in educating community members and decision-makers on how the healthcare system could be improved under a universal model. In advocating for the NHA, one CSO member reflected on the role advocacy coalitions play in illustrating the need for UHC through evidence gathering: “this is what we have to do to showcase the inadequacy of the provisions in the primary health centers, directing to why are people not able to access the facilities, is it because of the cost, or is that the requirement in the facilities are not available at all or inadequate.”
Network Factors That Led to Successful Advocacy
Respondents cited various network factors that made these advocacy wins successful. Frequently, respondents highlighted strong collaboration within and among coalitions, transparency and trust among stakeholders, long-term commitment of coalitions, and clear collective goals as factors of networks that have contributed to successful advocacy in Nigeria.
CSO members and the media identified strong collaboration among coalitions as paramount to a network’s success. The power of “leveraging on one another’s strength to make a kind of taskforce, a unifying mechanism” was highlighted in many interviews. Respondents emphasized this group-to-group collaboration often, further suggesting collaboration is key to developing strong networks with shared common goals and streamlined momentum.
When describing examples of specific multi-sectoral engagement, respondents most often discussed a strong history between advocacy coalitions and the media. Both sectors see communication, especially between coalitions and communities, as vital to strengthening networks. One respondent described that when working with “people in education on health issues, we work with the media on health issues, the media is a constant, if you want your message to go far, you have to involve media.” Most respondents agreed that the media’s relationship with advocacy coalitions was strong. Respondents did not find consensus when evaluating the relationships between UHC advocacy groups and the private sector or education. Although all respondents believed these sectors to be important to engage with, some respondents noted solid engagement whereas others believed their relationships needed to be strengthened.
Other network success factors that policy makers, CSO members, and the media further highlighted were transparency and trust, grounded in the open exchange of information. One government official reflected on creating transparency between government and CSO networks, saying, “I think it works magic really… invite them to the table… they ask you questions and you’re transparent with what you’re telling or what you’re asking from them.” Respondents from each sector noted transparency as a key attribute of successful networks—as well as a lack of transparency as a challenge—furthering the importance of building trust early in the advocacy journey.
Respondents identified long-term commitment, and the credibility that follows, as an important quality of strong networks. CSOs and implementing partners spoke about gaining credibility from the government. One CSO member reflected that “over the years, we have built credibility…promoting accountability and advocacy, the government [sees] the genuineness, the commitment, and agrees with our approach.” CSO members agreed that strong, unified commitment from a group of organizations can build credibility with government officials and enhance network efficacy.
Other factors that were less frequently noted include strong interpersonal relationships and strong coalition leadership.
Network Challenges to Achieving UHC
When asked about challenges to creating and maintaining strong advocacy networks, respondents noted poor collaboration among health advocacy groups and between health and other sectors, failure to gain community understanding, and insufficient funding.
Although respondents agreed that collaboration among advocacy groups and among sectors is paramount to maintaining successful networks, they discussed barriers to establishing collaborative relationships. Respondents identified disjointed leadership as a key reason for poor collaboration, with one stating “it is just the failure of leadership, you know… you see the birthing of a network, comprising of probably 50, or 70 CSOs but because of lack of leadership, lack of direction and visions you see that begin to disintegrate.”
Respondents elaborated that poor collaboration results in competing goals and a lack of clear understanding of roles and responsibilities. One respondent reflected, “[Between] health, water, education, the greatest challenge one we face would be, in my opinion, prioritization.” Respondents acknowledged that creating a shared vision was a challenge. This was deemed especially difficult when sector-specific policy makers believe their sector is of utmost importance. One policy maker explained that “health should be put first and that way you have health sorted out all other economic prosperity basically follows.” In sum, overcoming competing priorities to advocate for cross-sectoral issues like UHC is a challenge.
Respondents further cited poor community understanding and buy-in and insufficient funding as challenges facing advocacy networks. CSO members highlighted community misunderstanding as a point of tension with some media, saying, “some of the media houses do not pass the message right… I remember when WHO gave certification to Nigeria on wild polio, that there’s no wild polio virus in Nigeria, some of the media houses misinterpreted that polio eradicated.” These types of mixed messages pose challenges to community engagement, highlighting a need for improved communications to better educate civil society.
Finally, some less frequently mentioned challenges included limited capacity within coalitions and lack of political support.
Defining the Relationship Between Advocacy Coalitions and the Government
Nongovernment respondents considered it critical to engage government for advocacy success, yet many found collaboration challenging given government bureaucracy and lack of transparency. One academic described that “the CSOs were supposed to be elected among themselves by themselves and nominated to the Ministry of Health. Yeah, but then the question is, was that process really followed? Because I think, from my experience, I think the ministry invited the CSOs they were more comfortable with.” Conversely, policy makers believed themselves to be accessible. One policy maker stated “we can knock at the door of any NGO and say, let’s collaborate, they can also come here. We can go to your place and work together, they can come here, our council meet anywhere to collaborate.” This official described a positive, almost easy collaboration—something not shared by the CSO members and academics.
One official did believe there was a poor link between government and CSOs. Specifically, they shared that “I am not so conversant with the civil society organizations… maybe some are focused purely on advocacy, some are focused on some other issues, I am not sure. But generally, I think they are supposed to be the link between us.” One policy maker highlighted another challenge related to poor intra-government collaboration, citing sparse relationships among sectors of government around health issues.
Lessons Learned
The literature findings suggested that key factors contributing to network success include network cohesion, decentralized network structure, the use of collective action, strong transparency and trust among actors within an advocacy network, and clear communication and collaboration around advocacy objectives and the roles of all involved. In this section, we discuss the findings from Nigeria as they relate to these components.
Nigeria Data Generally Support Literature Findings
Discussions in Nigeria confirm continuity between the literature findings and the specific success factors in achieving advocacy wins in Nigeria.
Respondents frequently mentioned network cohesion—the concept that assesses how connected network actors are—describing relationships within advocacy coalitions or among those coalitions and the media, champions, and the government. Echoing the literature, respondents noted that this cohesion, which had been established over a long period of time, helped support goal setting and strategic communications.
Data collected in Nigeria did not reveal explicit findings around decentralization, but it was clear that the respondents valued coalitions’ wide reach. Respondents noted that wide reach was instrumental in leveraging champions, connecting with stakeholders, and communicating messages to a wide audience.
Respondents spoke highly of their ability to work together through collective action, which included clear communication and collaboration, for key legislative and policy victories that advanced UHC. Furthermore, this collective action was based on transparency and trust, which relied on being able to have frank discussions around key goals, objectives, needs, and strategies.
Areas for Further Exploration and Next Steps
Although respondents were able to highlight advocacy coalitions’ engagement in key high-level wins such as the NHA, adoption of BHCPF and PHCUOR, engagement in the policy process is not consistent. This was made evident through discrepancies in the perception of the strength of the relationships between advocacy coalitions and government. Although government respondents reported that they had a strong relationship with advocacy coalitions, advocacy respondents disagreed. This suggests that there are more questions around the nature of this particular relationship and how to sustain it over years.
Furthermore, respondents spoke of coalitions’ decentralized structure within the health sector and suggested they could further facilitate decentralization by creating new relationships with different sectors, especially the education sector.
Future Research Needs
This effort demonstrates the value in applying at the very least a social network lens to understanding advocacy coalitions or UHC. Although we did not complete an SNA, using SNA thinking to conduct qualitative interviews in Nigeria highlighted specific strengths and areas of potential growth for UHC advocacy coalitions. The dearth of literature that looks at the nexus of SNA and advocacy coalitions for UHC suggests that this is an opportunity for further exploration and could range from incorporating SNA frameworks into standard participatory engagement processes to develop programs and activities or into evaluations that can help identify new avenues for improving UHC advocacy.
Acknowledgments
We would like to acknowledge Eneng Ogah, the research assistant who supported the interviews and subsequent transcription and translation for this brief. We also thank the interviewees—Nigeria health policy officials, civil society organization members, media members, and implementing partners—for their time and insight.
RTI Press Associate Editor: Joanna Springer