The Lancet Nigeria Commission: investing in health and the future of the nation
Authors: Ibrahim Abubakar, Sarah L Dalglish, Blake Angell, Olutobi Sanuade, Seye Abimbola, Aishatu Lawal Adamu, Ifedayo M O Adetifa, Tim Colbourn, Afolabi Olaniyi Ogunlesi, Obinna Onwujekwe, Eme T Owoaje, Iruka N Okeke, Adebowale Adeyemo, Gambo Aliyu, Muktar H Aliyu, Sani Hussaini Aliyu, Emmanuel A Ameh, Belinda Archibong, Alex Ezeh, Muktar A Gadanya, Chikwe Ihekweazu, Vivianne Ihekweazu, Zubairu Iliyasu, Aminatu Kwaku Chiroma, Diana A Mabayoje, Mohammed Nasir Sambo, Stephen Obaro, Adesola Yinka-Ogunleye, Friday Okonofua, Tolu Oni, Olu Onyimadu, Muhammad Ali Pate, Babatunde L Salako, Faisal Shuaib, Fatimah Tsiga-Ahmed, Fatima H Zanna
Journal: The Lancet (2022)

Health is central to the development of any country. Nigeria's gross domestic product is the largest in Africa, but its per capita income of about ₦770 000 (US$2000) is low with a highly inequitable distribution of income, wealth, and therefore, health. It is a picture of poverty amidst plenty. Nigeria is both a wealthy country and a very poor one. About 40% of Nigerians live in poverty, in social conditions that create ill health, and with the ever-present risk of catastrophic expenditures from high out-of-pocket spending for health. Even compared with countries of similar income levels in Africa, Nigeria's population health outcomes are poor, with national statistics masking drastic differences between rich and poor, urban and rural populations, and different regions. Nigeria also holds great promise. It is Africa's most populous country with 206 million people and immense human talent; it has a diaspora spanning the globe, 374 ethnic groups and languages, and a decentralised federal system of governance as enshrined in its 1999 Constitution. In this Commission, we present a positive outlook that is both possible and necessary for Nigeria to deliver equitable and optimal health outcomes. If the country confronts its toughest challenges—a complex political structure, weak governance, poor accountability, inefficiency, and corruption—it has the potential to vastly improve population health using a multisector, whole-of-government approach. Major obstacles include ineffective use of available resources, a dearth of robust population-level health and mortality data, insufficient financing for health and health care, sub-optimal deployment of available health funding to purchase health services, and large population inequities. Nigeria's demographic dividend has unguaranteed potential, with a high dependency ratio, a fast-growing population, and slow reduction in child mortality. Effective, quality reproductive, maternal, and child health services including family planning, and female education and empowerment are likely to accelerate demographic transition and yield a demographic dividend. This Commission was written in the context of the COVID-19 pandemic, which has laid bare the inability of the public health system to confront new pathogens with threats to human health. However, despite a history of weak surveillance and diagnostic infrastructure, the scale up of COVID-19 diagnostics suggests that it is possible to rapidly improve other areas with sufficient local effort and resources. The Lancet Nigeria Commission aims to reposition future health policy in Nigeria to achieve universal health coverage and better health for all. This Commission presents analysis and evidence to support a positive and realistic future for Nigeria. The Commission addresses historically intractable challenges with a new narrative. Nigeria's path to greater prosperity lies through investment in the social determinants of health and the health system. Nigeria is not making use of its most precious resource—its people—by not adequately enacting policies to address preventable health problems. Health is influenced by access to quality health services, but other influencing factors lie outside this sphere. Huge gains in health can and must be made by ensuring adequate sanitation and hygiene, access to clean water, and food security, especially for children, and by addressing environmental threats to health, including air pollution. Nigeria has a young population, yet, despite spending more on health than many countries in west Africa (mostly from out-of-pocket payment), Nigerians have a lower life expectancy (54 years) than many of their neighbours. Nigeria's lower life expectancy is partially due to having more deaths in children of 5 years and younger than any other country in the world, including more populous India and China and countries experiencing widespread long-term conflict, such as Somalia. Chronic diseases and a high infectious disease burden, and an ever-present risk of epidemics of Lassa fever, meningitis, and cholera, present additional challenges. A rising population and inadequate infrastructure development over the past 30 years have contributed to increasing deaths from trauma through road injuries and conflicts driven by inequitable distribution of resources. Addressing Nigeria's health challenges requires a whole-of-government and whole-of-society approach to prevent ill health. This means investing in highly cost-effective health-promoting policies and interventions, which have extremely high cost–benefit ratios, and offering clear political benefits for implementation. Interventions are needed to improve child nutrition, reduce indoor and outdoor air pollution, address unmet family planning needs, and improve access to safe drinking water and sanitation. Key messages•We call for a new social contract centred on health to address Nigeria's need to define the relationship between the citizen and the state. Health is a unique political lever, which to date has been under-utilised as a mechanism to rally populations. Good health can be at the core of the rebirth of a patriotic national identity and sense of belonging. A commitment to a "One Nation, One Health" policy would prioritise the attainment of Universal Health Coverage for the most vulnerable subpopulations, who also bear the highest disease burden.•We recommend that prevention should be at the heart of health policy given Nigeria's young population. This will require a whole-of-government approach and community engagement. An explicit consideration of equity in the implementation of programmes and provision of social welfare, education and employment opportunities should be paramount.•We propose an ambitious programme of healthcare reform to deliver a centrally determined, locally delivered health system. The goal of government should be to provide health insurance coverage for 83 million poor Nigerians who cannot afford to pay premiums. Implementation of a reinvigorated National Strategic Health Development Plan (NSHDP III) should be supported by structured and explicit approaches to ensure that Federal, State and Local Governments deliver and are held accountable for non-delivery. NSHDP III should be supported by a ring-fenced budget and have a longer horizon of at least a decade during which common rules should apply to all parts of the system.•At the same time, the system should encourage innovation. Future health system reform should engage communities to ensure that existing nationally driven schemes have local buy-in and are sustainable. Further, since more than 50% of health services are provided in the private sector, often with poor quality and high costs, reforming the policy and regulatory landscape to unleash the market potential of the private sector is important.•We outline options for improving health financing and ensuring better accountability and distribution of resources. The rationalised governance schemes we have proposed should improve the efficient use of existing resources devoted to health. Ultimately, the proportion of spending allocated to health needs to be increased. We envision a future of Nigeria's health without foreign aid. This will require substantial increase in domestic investments. Foreign aid (multilateral, bilateral, and philanthropic) has led to fragmentation of the already complex health development landscape, with huge asymmetries in legitimacy between foreign actors and the Nigerian state as well as weak accountability. Defragmenting and decolonizing the Nigerian health landscape requires domesticating health financing.•We recommend a whole system assessment of the invest-ment needs in Nigeria's health security. The COVID-19 pandemic has exposed the weaknesses of Nigeria's health security system. Nigeria needs better manufacturing capacity for essential health products, medicines and vaccines, the provision of diagnostics, surveillance and preventive public health measures in health facilities and community settings, as well as other preventive and curative measures.•We call on the Federal Government, working with state governments, to fund and lead the development of standards for the digitisation of health records and better data collection, registration and quality assurance systems. A National Medical Research Council with 2% of the health budget and central government funding to award competitive peer reviewed grants will support high quality evidence and innovation. •We call for a new social contract centred on health to address Nigeria's need to define the relationship between the citizen and the state. Health is a unique political lever, which to date has been under-utilised as a mechanism to rally populations. Good health can be at the core of the rebirth of a patriotic national identity and sense of belonging. A commitment to a "One Nation, One Health" policy would prioritise the attainment of Universal Health Coverage for the most vulnerable subpopulations, who also bear the highest disease burden.•We recommend that prevention should be at the heart of health policy given Nigeria's young population. This will require a whole-of-government approach and community engagement. An explicit consideration of equity in the implementation of programmes and provision of social welfare, education and employment opportunities should be paramount.•We propose an ambitious programme of healthcare reform to deliver a centrally determined, locally delivered health system. The goal of government should be to provide health insurance coverage for 83 million poor Nigerians who cannot afford to pay premiums. Implementation of a reinvigorated National Strategic Health Development Plan (NSHDP III) should be supported by structured and explicit approaches to ensure that Federal, State and Local Governments deliver and are held accountable for non-delivery. NSHDP III should be supported by a ring-fenced budget and have a longer horizon of at least a decade during which common rules should apply to all parts of the system.•At the same time, the system should encourage innovation. Future health system reform should engage communities to ensure that existing nationally driven schemes have local buy-in and are sustainable. Further, since more than 50% of health services are provided in the private sector, often with poor quality and high costs, reforming the policy and regulatory landscape to unleash the market potential of the private sector is important.•We outline options for improving health financing and ensuring better accountability and distribution of resources. The rationalised governance schemes we have proposed should improve the efficient use of existing resources devoted to health. Ultimately, the proportion of spending allocated to health needs to be increased. We envision a future of Nigeria's health without foreign aid. This will require substantial increase in domestic investments. Foreign aid (multilateral, bilateral, and philanthropic) has led to fragmentation of the already complex health development landscape, with huge asymmetries in legitimacy between foreign actors and the Nigerian state as well as weak accountability. Defragmenting and decolonizing the Nigerian health landscape requires domesticating health financing.•We recommend a whole system assessment of the invest-ment needs in Nigeria's health security. The COVID-19 pandemic has exposed the weaknesses of Nigeria's health security system. Nigeria needs better manufacturing capacity for essential health products, medicines and vaccines, the provision of diagnostics, surveillance and preventive public health measures in health facilities and community settings, as well as other preventive and curative measures.•We call on the Federal Government, working with state governments, to fund and lead the development of standards for the digitisation of health records and better data collection, registration and quality assurance systems. A National Medical Research Council with 2% of the health budget and central government funding to award competitive peer reviewed grants will support high quality evidence and innovation. We call for the thoughtful use of existing institutions as an approach to achieve better governance and prioritisation of health. Although corruption has undermined the Nigerian health system, we can harness existing institutions for the benefit of population health. All levels of Government in Nigeria (federal, state, and local), and traditional leadership structures, civil society, the private sector, religious organisations, and communities, influence health. Efforts towards a balance between centralisation and localisation should focus on common policies, standards, and accountability. Concurrently, there is an equal need for localisation of implementation, meaning actual community and local government ownership of health service delivery. All three levels of Government are crucial, and we provide recommendations for each level. Differences in regional needs and context must also dictate programmes and interventions. What is needed in the northeast, in a context of ongoing insecurity and a crisis of internally displaced persons, is quite different from needs in wealthier, more secure urban centres, or in the face of the different level of insecurity found in oil-producing areas in the Niger Delta. Prioritisation of health requires additional funds. We have provided a clear investment case on health to convince politicians and governments that improved population health will reap political, demographic, and economic dividends. Our call for a whole-of-government approach to health will allow the delivery of multisectoral policies to address the social determinants of health, prioritise health-care expenditure to major causes of burden of diseases, and substantially increase healthy and productive lifespans. Nigeria's health system was built in an ad hoc way, layering traditional community health systems with colonial medicine aimed at maximising resource extraction. This origin has resulted in inbuilt inequalities, a dysfunctional focus on curative care, and a detrimental social distance from users and communities. Post-independence policies to redress problems have only been partially implemented. However, the current health system is sprawling, multifarious, disintegrated, and frequently inaccessible, with very minimal financial risk protection and low financial accessibility of services. Nigerians variously seek care from medical personnel and auxiliaries, community health workers, medicine vendors, marabouts and spiritual healers, traditional birth attendants, and other informal providers. The system relies on a mixture of quasi-tax-funding, fee-for-service, and minimal health insurance coverage. What kind of health system do Nigerians deserve, and should the country's leaders work towards? The core need of most Nigerians today is for accessible basic health services, and for this to be achieved, improvements in public sector delivery supported by an enhanced complementary private sector, including faith-based organisations, is the way forward. We lay out a path for Nigeria to move towards a system that, although remaining diverse, better serves the needs of the population. Within this diversity, we believe there is an opportunity for a "one nation and one health" approach, whereby Nigeria guarantees a minimum standard and delivery of health care for all with an emphasis on strengthening public and private (including faith-based and non-profit) systems. Nigeria should also leverage the private sector for certain functions, such as expanding innovation, discovery, and manufacturing capacities to claim a leadership role on the African continent and globally. Government investment in private industry should be mission-driven, supporting innovation and claiming dividends for society from its investments. Core functions of the health system require immediate attention, in particular, good quality health data. This Commission strongly recommends better recording, storage, and use of data. Paper systems are unworkable. A drive towards digitisation can result in major improvements, for both patient care and devolved health decision-making. Mobile digital technologies should allow a relatively rapid expansion of population health data and linked existing datasets. Human resources in rural and poor regions of the country are worsened by brain drain. We propose prioritising the optimal development and redistribution of health workers at all levels. A viable health system requires dedicated, efficient, and equitable health financing mechanisms, complemented by optional health insurance. Countries with systems comparable with Nigeria's, such as Ethiopia and Indonesia, have planned or implemented ambitious programmes to deliver health insurance coverage.