The past, present, and future of health in Nigeria

Ibrahim Abubakar, Tolullah Oni, and Obinna Onwujekwe join The Lancet Voice to discuss how Nigeria's history affects the modern-day health system, and the challenges and opportunities for Nigeria in the future.

Read the Commission and see infographics and videos:
The Lancet Nigeria Commission: investing in health and the future of the nation

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Jessamy: Hello and welcome to the Lancet Voice. I'm Jessamy Bavanel. It's the middle of March 2022 and I'm here with my co host Gavin Cleaver. Nigeria's population is projected to increase from approximately 200 million people in 2019 to an estimated 400 million people in 2050. and 733 million people by 2100.

This will make it the world's third most populous country after India and China. Today we talked to some of the authors of the Lancet Nigeria Commission, Investing in Health and the Future of the Nation. We'd love to hear from you on our Twitter handles at jessamibaganal and at gavincleaver. We hope you enjoy the discussion.

Gavin: Thanks Jessamie. So we're joined by three people who worked on the commission. Ibrahim Abubakar, Tolu Oni, and Abina Onwujekwe. And of course, if after this, you're interested in reading more, you'll be able to find the whole commission online at thelancer. com, along with some great infographics and video.

Jessamy: Thank you so much for joining us. Nigeria is Africa's most populous country with 206 million people. It's got immense human talent, has a diaspora spanning the globe, 374 ethnic groups and languages and a decentralized federal system of governance from the 1999 constitution. So there are really clear geopolitical and demographic reasons to support a full commission on justice.

Nigeria as a country, but perhaps you could spell them out for us and give us a bit of background about how this commission came about. 

Ibrahim: My name is Ibrahim Abbu and I am the dean of the UCL University College, London Faculty of Population Health Sciences as a group of Nigerians from very different health related backgrounds.

We've had innumerable conversations about the failed potential of our giant on the continent. And while we are all very keen to see Nigeria progress, it's really frustrating. All stakeholders within the country and in the diaspora agree that Nigeria can do a lot better than its current state in terms of health outcomes.

All too often we get countries name mentioned in the health space and it's always about having the highest burden of disease. This is X, or this is Y, and there's no shortage of list of conditions where we comfortably sit at the bottom of any league table, by bottom the worst outcomes possible.

It's also apparent that the failure to realize our potential as a country is multifactorial, and therefore it does require multidisciplinary approaches. The idea of a commission, which is a platform that brings together the intellectual input of multiple disciplines and creates a space for a conversation is a logical one to take in solving the problems.

Our discussions led to a decision to address these challenges using a very broad length from prevention to health systems. And I'm delighted that I'm leading this stellar group of Nigerians who have produced a report which takes an optimistic but realistic view about the future, identifies the key challenges, but also solutions that we can use and hopefully solve Nigeria's intractable challenges.

And improve on the stalled health outcomes. Okay, 

Obinna: so I'm Obinna Onwujekwe. I'm a professor of health economics and policy, University of Nigeria, Nsukka. I'm also director of research in the university. And I coordinate the health policy research group. The Nigerian health system is organized on three levels the local level local government level, state level, and federal level.

Our health system is funded by the households because more than 70 percent of health expenditures are from out of pocket. And then the government spending actually is just there to mostly pay government salaries and, just around the system. Very little goes to, for active, actual delivery of services.

And then because of this very high level of spending, out of pocket spending by households. You have a lot of catastrophic spending, because of these many households, once they spend on healthcare, they're not able to spend on other things, which, leads to poverty and so many other things.

So that's and then this is also in a country where the, looking at demographics is a young population. So the the average life expectancy is about 54 years. Majority of the citizens are unemployed youths, we have very high level unemployment level in Nigeria. So that's the story of Nigeria.

So when you look at it, at the, the contributions of health expenditure from, coming from out of pocket spending from a population that is most people are living beyond, below the poverty line. with a very low life expectancy, then I think that's giving you a good picture. 

Jessamy: If I'm interpreting you right, you're saying there's a real tension there between these different levels that are trying to direct and interact with the health system.

And what does that result in at the moment? 

Obinna: It results in so many things. For instance, the very low coverage with the social health insurance can be, is due to that because the, we have a national health insurance scheme, which is a federal organ that has decided to enroll federal civil servants, and the state said we're not enrolling our civil servants.

So those tensions, they can, make things not to work. So I'm just using the example of National Health Insurance Scheme. That's why it has almost no penetration at the state level. But now states have started forming their own state health insurance schemes. So it leads to a lot of things not being implemented.

But sometimes the federal government comes with a lot of money to convince states to buy into what they want to do. So it's only when the federal government comes with money to support federal initiatives where we see states queuing up. But if there's no money, if there's no I don't know what that's a carrot.

If there's no carrot, states are usually very slack to file behind the federal government in implementing federal, federally driven initiatives. Obina 

Ibrahim: has articulated the fact that Nigeria is a complex country. Actually, it's more akin to India and Ethiopia. than it is to the United Kingdom in that there isn't a National Health Service.

And therefore the solutions in looking at how you tackle serious challenges in a system where there is autonomy for some elements of the health system and our recommendations are such that we tackle governance and we think governance is where you need to start. Really important to get the buy in of those with authority to make a difference at the federal, at the state, and at the local level.

As Obinna correctly articulated, the local level is an important one, especially for delivery. We also come up with this idea that the standards that need to be achieved need to be agreed so that the minimum level of quality is done centrally. Implementation and the delivery of the service have to be done Locally, and in that sense, actually, the autonomy that is now being created at the local level presents an opportunity.

We think that the way to utilize that is to make sure that the leadership understands that there will be held to account through using better data systems. We also think that we need stronger institutions at all levels, borrowing from ideas of thinkers such as Douglas North. We feel Institutions are the key to making sure that you change the systems that are now relatively corrupt.

As long as there's transparent provision of data, then if you hold individuals to account through institutions at the national, at the subnational and at the local level, then there's a chance. We also think that there's an opportunity to utilize the private sector. And the things that they're really good at delivering.

And then finally, we need to be able to show where there are tangible gains. And there are examples of success. So Obinna mentioned the state health insurance systems. And we provide case studies in the reports of some of them that have made good progress. I'm actually delighted that so many Nigerian states now have their own act in relation to, that is a law in relation to the provision of health insurance.

And we need to learn from the best of this and make sure that everywhere in the country, There is high health insurance coverage as well as we make a bold recommendation that the federal government needs to think about how to find the resources to provide cover for the 83 million poorest Nigerians.

We estimate the amounts of money needed and the way that could be raised through spatial new revenue sources, but also increasing the efficiency with which those resources have been spent. We make a number of innovative recommendations that should, if acted on by the leaders, lead to change. The right programs.

and the right health outcomes. 

Gavin: So I'm really fascinated by the history that's put forward in the commission, the kind of history of health in Nigeria. I'm really interested to, to talk about how the kind of pre colonial and colonial health systems feed into this idea of a kind of modern Nigerian health system where we are today.

So I guess what I was interested in finding out was how important you think this proper understanding of pre colonial and colonial health care is when it comes to understanding where Nigeria is right 

Obinna: now. Yeah, it's a, it's quite important. Yeah. So I'm involved in another project, not part of Lancet Commission, looking at community health systems and part of looking at community health systems means understanding what has been there, even before pre colonial times, because some of them are still in operation.

What sort of systems do we have and then how do we link that system or integrate that system properly? With the current system. So I deliver services for everybody because the pre colonial, system it's available, still the traditional healers, the, the system of healthcare in the communities, they have refused to go away.

In fact, with the the more out of pocket payments people make, the more they go back to those ones they think that are affordable. And so they are going back more to. to the pre colonial ones since the new ones most times are not affordable. But I think, but the challenge is how do we, to bring proper linkages, introduce proper governance structures that will link both of them, and find ways of improving the capacity of those pre colonial that are still there, the capacities to develop, to provide appropriate health services.

Because sometimes they do good, but sometimes they also cause more damage than the good that they do. They are not going away. It's how do we bring them into the system, into the formal system, and support them, so that both systems will work in synergy. I swore on the health system. 

Jessamy: I guess that provides a legacy for what you are trying to build on with this commission.

That's difficult, as you say, incorporating these different strands and trying to get those governance and institutions in place. We hear quite a lot about leapfrogging in terms of lower middle income countries and, health systems being able to leapfrog forward. over, say, high income health systems.

And what does it really mean in this context? And what did the Commission take a view on this? Tallulah, maybe you could take that one? 

Tolu: Okay, so I'm Tolu Oni. I'm a public health physician and urban epidemiologist, and I work at the University of Cambridge MRC Epidemiology Unit, where I lead a research group on global diet and activity focused on urban and planetary health.

Yeah, so I'll take it from a perspective of the systems for health, actually, and then maybe Obinna can pick up on, on the health system. So one of the things that I really enjoyed about being a commissioner on this project, on this report, was how future focused the mindset was, thinking about yes, we have to understand what the situation is at the moment, but really critically, we have to be able to imagine another way and really think about, What strengths we have to work with.

So I want to use that to talk a little bit about social determinants of health because from a prevention perspective from a disease prevention perspective, one of the real really critical opportunities for us to leapfrog is on centering our health around prevention, right? So it's Nigeria is one of the youngest countries on the youngest continent, we show that, almost half the people under 15 over half people of working age.

We know that a healthy population is crucial for development. We also know that the majority of factors that influence health lives are the health care sector and they lie in the environments where people live, where people Work where people's play where people study. And so one of the opportunities to leapfrog as a country is to think about leveraging that opportunity.

Can you imagine an alternative world where we say, we have a young population? Let's ensure that Most people are born healthy. Let's actually try to keep them that way as a way of supporting our economic development. How do we center, think about health as investment and not a cost?

How do we center ourselves? systems focused on prevention? And how do we take a more holistic and integrated view across the different sectors that actually influence health? So if we talk about, for example, the universe, universal health coverage, WHO, which we do talk about in the in the report.

A lot of that is often focused, and rightly on the reforms needed at the primary care level, but often less known is that the UHC, the universal health coverage, actually comprises much more than health care, and it does actually talk about the importance of multisectoral action of tackling the very preventable factors that, that, that influence, that cause and drive disease.

And so we ask in this kind of future focused mindset, we asked what if access to health enabling natural and built environments was a central guiding principle for the country's development? What would that look like? And one of the recommendations we give in the report is the importance of adopting this multisectoral response to health.

We talk about this health in all policies. as a concept, but actually bringing that down to very practical approaches. I think at the cabinet level, how can we actually implement a whole of government approach to, to ensure that this multisexual response cuts across, because you could argue that the health.

Professionals are not just in the healthcare sector, right? Because you have these sectors that are actually driving the population the health of the population. And so that is a real opportunity to leapfrog completely in our thinking of how we harness a young population for a country's, for the country's development.

And the one thing is that we note that we're not starting from scratch here. We're not proposing something from complete from the from the scratch. There is an action plan, a multisectoral action plan for the prevention and control of non clinical diseases that was published in the country in 2019 that we highlight.

And so it really is putting that into action. We also share some case studies that are already on the ground on intersectoral projects that are starting to shift these norms in a couple of cities in Nigeria starting to shift the norms to think about what could this look like if we see health as an investment, what would it look like if in our rapidly urbanizing country, we actually centering the urban development on health, what would that look like?

And it's really important to, to show in this context that. we're already doing that on the ground. And I think the last thing to note is that we do identify some, the investment case. So in thinking about health as investment in the report, we show some of that investment case of why it's actually.

It's actually logical to not leapfrog because we have such a critical opportunity at such a, with such a young population and such a dynamic space and time really. And what was interesting, and this is after the report, but what we've seen with the COVID responses on the ground in the country is we've seen some of these innovative cross sectoral collaborations, often bottom up, often civil society led, but working with governments on so we know it's.

possible. And it really is trying to ensure that we frame the economic development of the country on health and really shedding, shining a light on that opportunity. 

Jessamy: And I love that about the commission. It's so exciting. It flips what we the narrative that is often heard about, an increasing population.

How's everybody going to cope? What's it going to look like? And says this is an opportunity because they're young. Maybe you could talk to us a little bit about this sort of the population. growth that's expected and how that fits into the Commission's vision. 

Tolu: So I talked about the the young population and why that is so critical.

In the report, we also explore the reality that we have a large population that is rapidly, still rapidly increasing. We can, we show the estimates in terms of the projections of the population as it stands at the moment. I think it is worth noting that those are just projections, right? And we work within that.

And so one of the things that we grapple with in, in the in the report is saying alongside harnessing this incredible potential and this incredibly young population. Can we look at the projections in of populations and recognize that none of that is entirely inevitable, right?

So if we think about what the key issues are, think about access to family planning, access to appropriate maternal and child services, how can we actually ensure that it is that we are meeting the demand of the, for the of the population in terms of strategies to give people the choice.

Where that may not be as easily accessible and that links also with the health care access and what is happening on the ground. But that is more Ibrahim's specialty. So I'll pass on to Ibrahim on that. 

Ibrahim: Yeah. So the population trajectory of Nigeria. It can actually be a very positive thing.

So the issue is that at the current trajectory, most estimates, and we go with the UN estimates, suggest that there would be of the order of, on average, a woman gives birth to five kids at the moment. The projections estimate that the numbers in the future will be lower than that, considerably lower than that.

And yet, even with those assumptions, Nigeria would ultimately, by UN projections, be the third most populous country in the world by the end of the century. Now, that's a huge increase and the attraction of that, the positive element of that is that if that population is skilled, if that population is educated, if that population is healthy, then Nigeria could become a global superpower.

And our commission pitches the narrative exactly in that direction, that what Nigeria needs is to ensure that growth is accompanied by education of women. Growth is educated, accompanied by appropriate provision of family planning for people that want to use it and support it to use family planning, appropriate provision of health care for children, for pregnant women and for the society at large, and then appropriate education to scale that workforce so that they become an asset to the country.

and a demographic dividend can be secured for the future. We think it is possible, it just requires governments to put health at the centre of this thinking so that health essentially becomes wealth. 

Gavin: So it's a huge opportunity, isn't it? But it's one that could easily be 

Ibrahim: missed. Absolutely. So without the right actions and conscious policy decisions, which we articulate in the report, it could become a challenge for the region and possibly for the whole world.

The converse of that is the populations of most Western countries is shrinking. While as Tolu rightly articulated, if you put the right measures, you could reduce the growth of Nigeria. The reverse is actually quite difficult. So it is unlikely that in the next 50 to 100 years, the population of Western countries will be sufficient to deal with the other problem, which is an increasing number of people that are old and unable to work.

So it may be that the asset of young people, if they're appropriately trained, becomes a powerful tool for Nigeria, not only to support its development, but actually to support the global economy and being the workforce that drives production. and therefore health for everybody on the planet. 

Tolu: Yes, I just wanted to add to Abraham's point about the, on the importance of upskilling.

We also highlight the importance of coupling that with participation and inclusion. So when we talk about a young population, yes, we have to upskill them and make sure that the educational opportunities and the livelihood opportunities are there, but from a governance. And from a governance perspective, we're talking about this innovative governance.

Really key to that is ensuring that, and this is another leapfrogging example. So in a young country on a young continent, could we be the first country where actually this governance for health is youth? Lead, right? And by youth, the majority of people, right? So often we think about youth as this marginal sector group that is nice to include in a young country.

It just means you're inclusive and you're making use of the assets that you have. And that is a really critical opportunity that we mustn't miss. 

Jessamy: Absolutely. And we've seen, I think we see globally examples of youth movements and youth sort of inclusivity in terms of governing, governance, even, lowering the voting age as having a huge payoff for individual countries.

And I just wanted to come back to you, Tolu, on Some of the things that you alluded to that are already going on in Nigeria in terms of, putting health at the center in terms of urban development, just out of interest, whether you could give us some examples of that, that, listeners might like to hear and tidbits.

Are you looking for, you're 

Tolu: looking for spoilers? Yeah, so sure. One of the examples that we give in the report is actually a civil society organization. Called the Lagos Urban Development Initiative, and what they've actually been doing is looking at developing different projects that look at opportunities in the urban environment for social inclusion and for health and for climate resilience.

So we gave a couple of examples. I'm rapidly scrolling to to do them justice. Maybe I'll give another example in a second, but one, one key example is the open streets movement that we see in in Abuja. Organizations working to say, can we actually claim these streets for people?

Can we flip what, when we think about urban development, can we? Can we claim space, public space, for the public and what would that look like? Incidentally, we've got some research outside of the report that recognizes that people, even when you don't provide this public space, people claim these public spaces for to meet up and for exercise.

And often they're doing it in ways that are unhealthy. So they're doing it in spaces where they're exposed to air pollution. They're doing it in spaces where their injury risk or their safety risk are compromised. So these initiatives like the Open Streets Movement program in Abuja shuts off bits of the street for periods of time to recognize that there is this unmet demand.

Another initiative of the, of the Lagos Urban Development is, was looking at green space. So how can you actually work with developers who were. And a lot of that is in the private sector. And I see that Ibrahim mentioned the importance of public private partnership that isn't just in the healthcare sector, right?

Public private partnership in the health determinants sector. So how do we partner with urban developers to say, Okay, what are we doing here? How can we actually bring in accountability for health as part of the governance of part of this decision making that informs what developments go ahead?

And so there's some examples of this civil society organization that is working with really as a ground up working in in poor areas of the city in Lagos to look at what they would want. the public space to look like in ways that support physical activity, which we know is a really important risk factor for non clinical diseases, which is on the rise in countries like Nigeria.

What would they need in terms of greater access to healthy foods within their neighborhoods and what would that look like? And how could they actually use the public space that is either poorly utilized and underutilized and lying fallow? or is not supportive of this basis, and how can you actually think about governance and bringing in those key actors at the local government level, at the community society level, at the private sector level, to actually align priorities of what to do with.

public space to the health of the public. So there's some examples that are given there. There's actually other examples. We just ran out of space. There's examples in Lagos around academic organizations, university working with the state government on a community.

bottom up approach to what integrating governance for climate resilience and health would look like in an informal settlement in Lagos. These examples are there and so it really is how do we scale up and how do we replicate because people are keen to engage and be part of governance. People are keen for their public spaces and the environments to help.

make the healthy choices easier. And so really, we just want to highlight that this is possible, that this is happening, and we just need to align all systems for health. 

Gavin: I wanted to talk about the climate emergency. Now, obviously, it's vital that we tackle the climate emergency all over the world for the future of health.

But it sounds like from the commission that it's especially important for Nigeria. 

Tolu: Yes. Absolutely agree. I thought that was a multi choice question. True. Yeah. 

Gavin: Perfect. End of interview. There we go. 

Tolu: Absolutely. If we think about. Actually talk about a pla planetary health endemic. So looking at how the interdependencies between climate vulnerabilities and the health vulnerabilities and how we are actually seeing that playing out.

So if you look at some of the consequences of climate change at the moment in terms of desertification, in terms of reducing access to arable food production, what that does in terms of displacement of people, what that does in terms of conflict, what that does in terms of food insecurity.

we can't really disentangle efforts to protect a population from ensuring that those efforts and those interventions are climate resilient. And so we we touch on that. And if you think about the nationally determined contributions, so in terms of climate from the climate change perspective.

So the nationally determined contributions are the country commitment to deliver the goals of the Paris Agreement. There was actually a study, this is outside of the report, but there's actually a work done by the Global Climate and Health Alliance looking at healthy NDC scorecards, right?

And what is interesting, so they look in terms of health impact, health and adaptations, health co benefits, and in general integration of health into climate action. The first thing is that we know that the lower middle income countries bear the greatest burden of the health impacts of this climate change, but what's interesting is that despite limited resources, the countries that fare the highest in terms of scoring the highest points of healthy NDCs are the same countries, right?

Are these lower middle income countries. So we actually see The innovation coming from these from this basis. So resources are absolutely critical, but we actually seeing a lot more innovation coming out of this basis. So I think it's really important to highlight that. And one of the one of the recommendations.

We put out was to adopt an integrated planetary health governance approach, right? So speaking about health as an investment case, if you look at the cost of air pollution to health in just one city. So in Lagos that we know that in 2018, there's a World Bank report that showed that illness and premature deaths from ambient air pollution caused losses of over 2 billion.

to the state's GDP, right? So we can't afford not to act in this way. So I'm really excited about that recommendation of looking at how essentially all ministerial sectors could have a planetary health portfolio that looks at both in rural and urban centers, how we focus on Protecting the population through improved housing through access to cleaner fuels to through regulation that enforces limits on thinking about air pollution standards thinking about the transport sector.

So that is for me. I'm a bit biased for me. That is one of the most exciting parts of this and really. would be the most innovative thing. If Nigeria is, saying, we could be the economic powerhouse globally because of our population, we could be the innovative, the most innovative in thinking about integrated governance for health, that both breaks the things health, takes health as an investment case and really breaks the silos of health from single What?

thinking about health singularly within one sector to actually this planetary health approach that is our identity and what we give to the world. I think that is an incredible opportunity for the country and for the continent and for the world, I'd say. 

Ibrahim: Yeah. So to reinforce the point that Tolu has made, actually our first recommendation includes.

a wide range of elements that exactly say what she's articulated. And we take a very broad planetary health view which is other environmental damages, not just simply anthropogenic climate change that is leading to the climate crisis, but air pollution, tangible, practical things that humans are doing to damage the environment and how we could tackle them and improve healthy living.

The wider issue of are low and middle income countries more vulnerable actually is one that is specific to Nigeria. So in the report we cite that when you look at how countries are affected, Nigeria is in the top 10 most vulnerable countries and it suffers from both extremes of the problem. Rising sea levels, we have a huge cost and then to the north there is the Sahara Desert encroaching and affecting livelihoods in fundamental ways.

So ultimately when we get it wrong globally, Nigeria would bear a huge brunt of it. And when we get it right, what makes the policy debate difficult and challenging is, I think, what you were alluding to at the beginning, Gavin, which is that the absolute amount of Nigeria's contribution to the overall global problem is actually quite modest.

And therefore making the policy change to reduce production is more complex than just saying, If we solve our pollution problems, we solve the global problem. So Nigeria's role is putting the mitigation against the consequences for its population. It's about contributing as little as it can and advocating globally and ensuring that it supports the trajectory where we save the planet by tackling the climate crisis.

Gavin: That's it for this episode of the Lancet Voice. Thanks to Ibrahim, to Tolu and Ziobina for talking with us. If you'd like to join the conversation, you can find Jessamy and I on Twitter, and our handles are at Jessamy Bagonall and at Gavin Cleaver. You can, of course, subscribe to the Lancet Voice, wherever you usually get your podcasts, and we'll see you again in two weeks time for another episode.

Thanks for listening.