Thought Leadership

Accountability: The Key to Improving Health in Nigeria – Op-Ed

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Editor’s Note: This week’s blog piece comes from Adam Talsma, Regional Director for Africa, Reboot. He writes in this Op-Ed about the importance of accountability in governance to improving health outcomes, and how international donors are key partners to Nigeria’s citizens if good governance that makes an impact on our health indices… is to become a reality.

The key to improving health care in Nigeria is not necessarily better doctors, more advanced medicine, or technological advances. It’s better governance. Dr. Mike Adeyemi-Lawal made this point clearly in a recent Thought Leadership piece, in which he encourages politicians to commit to tangible health goals—and encourages citizens to hold them accountable. I direct the African portfolio of a social impact firm, Reboot, that specializes in good governance issues; our work offers many examples that validate and build on Dr. Adeyemi-Lawal’s points, showing how accountability from political leaders can be the lynchpin in improving access to essential services.

But our work has also shown, in the work of holding government actors to their promises, citizens have an important ally: International donors. Many donors have long invested in Nigeria’s health sector and created positive outcomes. Now, to create lasting impact, donors have an important opportunity to shift strategy. To ensure everyone can access the health, education, and other services they need to thrive, more donors need to commit to accountability and to pursue strategies that improve governance.

Image credit: Reboot

Nigeria Needs New Solutions in Health

Dr. Adeyemi-Lawal cites a number of powerful health statistics that show the need for improved health care. I’ll add just one more sobering fact: New mothers and newborn children are less likely to survive childbirth in Nigeria than in most other countries in Central and West Africa. Because Nigeria is the most populous country in Africa, this is a massive, global issue—in 2015, Nigeria accounted for one out of every five women (19%), and one out of every ten newborns (9%), that died from childbirth globally.

International donors are aware of this stark reality and have played a significant role in the effort to improve Nigeria’s health outcomes. In 2016, 45 percent of “Official Development Assistance” to Nigeria went to “health and population,” which was more than the budget for the Federal Ministry of Health and equivalent to about 80 percent of all Federal Government of Nigeria budget allocations to the health sector for that year. And that figure does not include aid directly from major philanthropies, such as the Bill & Melinda Gates Foundation and MacArthur Foundation, that also invest significantly in health.

Broadly speaking, donors have not focused on accountability with these investments; instead, strategies have generally focused on direct spending to extend essential health services, often targeting marginalized populations. This approach has led to a number of individual success stories and improved health care outcomes. But on the whole, these donor investments have not contributed to the kinds of widespread results that one might expect, and that are needed to improve health outcomes at scale.

Accountability Impacts Our Health

In order to create change, international donors need to develop strategies to increase accountability. That’s because every donor, in any context, is already acting as part of what Reboot calls the “accountability ecosystem.” We call it an ecosystem because we recognize that all actors—including political leaders, government actors, CSOs, media organizations, international donors, and citizens themselves—influence and impact each other. True accountability requires a healthy ecosystem, one in which watchdog actors, like media and CSOs, have enough trust and influence with the public to effectively hold the powerful to account. If a donor invests in Nigeria’s health sector without considering how and whether their work may support Nigerians to hold their leaders accountable, that donor may be unintentionally contributing to an unbalanced accountability ecosystem—and harm.

Unbalanced ecosystems lead to poor or unavailable services. Often, the key barrier between citizens and essential services lies with a governance issue: Corruption may siphon off dedicated funding. Opaque procurement processes may lead to privately contracted providers that may not offer effective services. And when high-up officials are not ensuring that needed resources are available, downstream service providers can’t do their work. The failure of the government to release the Basic Health Care Provision Fund of one percent of Consolidated Revenue Fund until the very end of the fiscal year, as recently analyzed in The Premium Times, is just one example of the government’s broken promises. Had it not been for sustained media attention by civil society, this fund may not have been released at all.

Media practitioners and Civil Society Organizations strategizing and discussing at Reboot’s  “Amplifying Accountability” boot camp held in Lagos. Photo credit: Reboot

A New Approach, A Big Opportunity

While the challenges I’ve just listed may seem daunting, they can be addressed: Accountability is an effective leverage point for change. By pursuing accountable governance, development donors can create more strategic and systematic change, which can, in turn, drive stronger service delivery. On this path, the MacArthur Foundation is currently offering a strong example, through its “On Nigeria” program. Formerly, the Foundation invested significantly in healthcare service delivery. But, as part of its long-standing commitment to improving outcomes in Nigeria, and based on years of learning, MacArthur has recently taken on a new strategy to focus on accountability. Led by a staff team in Nigeria and Chicago, the “On Nigeria” program is supporting Nigerian-led efforts to promote good governance as a pathway to improved service delivery. MacArthur and Reboot are now investing in a Nigerian accountability ecosystem which is increasingly capable of holding the government accountable for delivering public services across all sectors. We are catalyzing meaningful collaboration between people in civil society and media, to help both sectors better achieve their collective power to mobilize citizens and drive government action.

For example, we are helping build a “Media Alliance.” This emerging network of collaborators has already pushed for greater press freedom: The recent release of journalist Jones Abiri, who was detained extrajudicially for two years after criticizing the government, was partly driven by the Alliance’s efforts. You can read more about our recent successes in this report. This work is helping to build the accountability ecosystem, setting precedents that will build grassroots pressure on government officials. And in the future, with the right support, these same journalists and activists will also take up issues with health and other essential services, helping ensure that development funds translate into local policy and implementation. For any innovator and advocate who wants to see Nigeria’s health outcomes reach as high as our country’s potential, these successes can be an inspiration for a new approach. And the MacArthur Foundation is just one institution; the results may be truly transformational if a larger section of the field gets involved. Unfortunately, we at Reboot have experienced firsthand the challenges of changing approaches for institutions like the World Bank, which has undervalued and underinvested in its own social accountability initiatives in Nigeria, leaving them unsustainable. But if more large organizations are willing to learn from and build on important local accountability efforts, we may have a chance of truly realizing good governance—and good health—for all.

BIO: Adam Talsma is the Regional Director for Africa, Reboot. He has experience designing and implementing innovative programs globally, building local organization’s capacity in research and user-center design, and directing the implementation of effective programs with leading international partners like World Bank and the Bill and Melinda Gates Foundation. He oversees Reboot’s portfolio of work on the Africa continent.

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