Nigeria, like many countries around the world, faces the challenge of integrating its health agendas to build a comprehensive and effective health system. A Lancet Commission, established in 2018, has undertaken an extensive study to understand how Nigeria can achieve synergies between universal health coverage, health security, and health promotion, while also identifying the factors that contribute to dis-synergies. The findings of the commission shed light on the need for a holistic approach and highlight the lessons learned from the COVID-19 pandemic.
The commission’s research, which involved desk reviews, case studies, consultations, and regular meetings, revealed that fragmentation and dis-synergies between health agendas are prevalent and detrimental to the overall health system. Regardless of a country’s income level, counterproductive competition and fragmented investments hinder progress towards achieving any of the health agendas. For instance, investments in health security may overshadow efforts to achieve universal health coverage, or the focus on universal health coverage may miss opportunities to promote healthy lives through health promotion initiatives. These dis-synergies weaken health systems, making them less capable of meeting day-to-day healthcare needs and responding effectively to emergencies, as evidenced during the COVID-19 pandemic.
The COVID-19 crisis has served as a warning sign, emphasizing the importance of comprehensive health systems that integrate health security, health promotion, and universal health coverage. The commission’s COVID-19 case study revealed that countries with robust universal health coverage and healthier populations were better equipped to handle the pandemic. By accommodating the surge of COVID-19 patients without overwhelming healthcare facilities and minimizing the burden of comorbidities, these countries demonstrated the benefits of synergistic health agendas.
The drivers of dis-synergies identified by the commission are diverse and multidimensional. They include inappropriate laws and policies, imbalanced investments, siloed programs, inadequate capacities, politically driven interventions, and ill-considered national self-interests. The concept of coloniality also emerged as a significant factor, involving frameworks of thinking and doing that perpetuate power imbalances and disregard contextual nuances. This manifests in central decision-making processes, exploitation of power disparities, and a failure to critically evaluate the validity of decisions. Coloniality can hinder the alignment of health priorities between countries, as powerful global-health actors may not support nationally identified health priorities if they do not align with their own interests.
While recognizing that national self-interest is a priority for all governments, the commission argues that supporting health security in a manner that is synergistic with universal health coverage and health promotion can benefit a country’s ability to control infectious diseases. This highlights the potential for global solidarity in health, which can be aligned with enlightened self-interest.
To advance towards comprehensive health systems that achieve universal health coverage, health security, and health promotion, the commission proposes three essential changes. Firstly, there must be a change in mindset, reframing health in a comprehensive and holistic manner and establishing shared values and principles to guide actions. It is crucial to recognize the necessity of realizing synergies between health agendas rather than promoting one at the expense of others.
Secondly, a shift in decision-making processes is imperative. Decision-making should move away from top-down approaches that prioritize global or donor interests over those of implementing countries. Instead, evidence-based decisions should be context-specific, valuing the knowledge required to make interventions work effectively. National health leaders should assert their health priorities, and global health agencies should offer flexibility for countries to adapt investments, policies, and programs accordingly.
National and subnational governments bear primary responsibility for the health of their populations and should be held accountable for maximizing synergies within their health systems. Improved methods to measure and track synergies and dis-synergies, resilience, and performance of health systems over time are essential. Development assistance providers also play a role and should be accountable for their contributions to dis-synergies or synergies in health systems. Furthermore, enhancing synergies between global actors at the international level should be a priority, ensuring that monitoring and accountability frameworks address power disparities both within and between countries.
Nigeria, as a country with a diverse and complex health landscape, stands to benefit significantly from adopting the recommendations put forth by the Lancet Commission. By integrating its health agendas and maximizing synergies between universal health coverage, health security, and health promotion, Nigeria can build a stronger and more resilient health system. The path to comprehensive health systems will require long-term commitment, changes in mind-set, decision-making processes, and enhanced accountability. However, the efforts invested in achieving these changes will ultimately result in improved health outcomes and a more prosperous future for all Nigerians.
Okeke writes from the Centre for Social Justice (CSJ) Nigeria