"There is no power or authority without responsibility, and he who accepts the one cannot escape or evade the other." -- Haile Selassie
The power and responsibility of authority
There is an inseparable link that exists between authority and the responsibility and consequences of the power that arises from it. In public service especially, effective leadership should harness power and responsibility, while maintaining a commitment to serve the people under the individual's leadership. This authority and significant responsibility have been placed on the shoulders of the newly appointed Commissioners for Health.
The two-day induction forum for new commissioners of health, organised by the Nigeria Health Commissioners Forum in partnership with the Nigeria Governors Forum and other partners, has just ended. A "revolving door" for Commissioners of Health resulted in the appointment of some commissioners to two terms, whilst in other states, new commissioners have assumed their new responsibilities. The induction was designed to ensure a seamless transition and give incoming commissioners a chance to familiarise themselves with the healthcare governance and policy landscape.
Dr. Oyebanji Filani, Chairperson, Health Commissioners Forum and Commissioner for Health and Human Services, Ekiti State, opened the ceremony by outlining the purpose of the forum and mentioning that it was the first of such induction ceremony for health commissioners in Nigeria. "The forum is unified by a vision to significantly improve health outcomes in Nigeria, using data, peer-learning, stewardship, and accountability," he said. He went on to state that "Commissioners need a profound understanding of the complex and dynamic healthcare landscape in Nigeria" .
Health leadership in critical times
Leadership in health is very crucial in Nigeria right now. The new administration has brought about several leadership changes in the health sector, including the appointment of the Special Advisor to the President on Health, Dr Salma Ibrahim Anas, Coordinating Minister for Health and Social Welfare, Professor Muhammad Ali Pate, Minister of State for Health, Dr. Tunji Alausa, and the recent changes in leadership at the National Primary Health Care Development Agency and National Health Insurance Authority, with the appointments of Dr. Muyi Aina and Dr Kelechi Ohiri respectively. It is not incorrect to state, that there are high hopes and expectations for the health sector.
Development partners also play a very important role in Nigeria's health system. According to data from R4D, external funding and development aid account for 11.8% of health financing in Nigeria according to the National Health Accounts. They shared their perspective on the critical challenges that the commissioners face. Tekabe Belay, World Bank Programme Leader for Human Development, spoke to the incoming commissioners about their roles as healthcare leaders in their respective states. He highlighted a need for each of them to develop a clear vision of where they want to take the health sector in their respective states in terms of health outcomes and financial protection, over the next three to four years. He also advised them to use this vision as the foundation for coordinating collaborations with development partners as well as coordination with state Ministries, Departments, and Agencies (MDAs) in order to prevent the current fragmentation and have a sector-wide approach.
Alignment around a unified purpose
This is in line with the Coordinating Minister for Health and Social Welfare's four-point health agenda, as well as the Nigeria Health Sector Renewal Investment Programme (NHSRIP), which calls for a sector-wide approach to resource optimisation and aligning health investments with Nigeria's priorities. It will be critical to evaluate how this vision is properly converted into resource allocation at the subnational level.
In her message to the commissioners, Dr Rownak Khan, Deputy Representative of Programmes, UNICEF Nigeria, highlighted the implications on the African continent, if population health outcomes in Nigeria were improved, as well as its strategic importance. "The whole of Africa, the whole of the world is looking to you because anything that happens in Nigeria actually moves the needle in global health."
The induction provided an opportunity for a reset and the forging of meaningful connection with critical stakeholders, which will help in better understanding the complexities of the healthcare system while improving patient outcomes. Former Ekiti State Governor Dr. Kayode Fayemi reminded the commissioners that population health outcomes in Nigeria continue to be dismal and that the country is "not where we want to be."
Taking stock of challenges and opportunities for progress
With the projected population increase to 400 million by 2050, the road ahead will be challenging with concerns about the implications on health outcomes in the country. Nigeria's federated governance system has consequences for the division of power and the implementation of health policies at the subnational level. The commissioners will have to manage this dynamic, and any potential misalignment between their individual governor's health priorities and their vision for what they want to achieve will be part of their health leadership position.
The perception of "performance" in the health sector frequently sees a disproportionate amount of funds allocated to tertiary care, in the pursuit and acquisition of expensive state-of-the-art medical equipment that is more likely to elicit praise and congratulatory acknowledgement, as opposed to primary healthcare, where the most basic health needs of the population can be met, and whose underinvestment is not insignificant in the abysmal population health outcomes that we continue to see.
Experience sharing from experienced hands
Past commissioners also shared their insights, and the induction provided a forum for discussions on emerging trends. Dr. Dayo Adeyanju, former Commissioner for Health in Ondo State, shared lessons on how alignment with the state governor around the Abiye Safe Motherhood Initiative saw him improve maternal health outcomes. He had a clear understanding of the problem that needed to be addressed. He shared with the commissioner to always carefully consider how they "give in to the donor's priority in the state". At the time when implementing the Abiye Inititiative, the donor's interests had overlooked "the local context", however, he was driven by the conviction that understanding the context-specific needs of pregnant women would improve outcomes.
During a panel discussion, the issue of political will and allocative efficiency of limited resources were also raised. Dr. Muhammad Lawn Gana, Commissioner for Health in Yobe State, mentioned the expectations that he was tasked with meeting and how his state governor gave him autonomy. He also emphasised the necessity of teamwork in enabling the optimal use of resources across all departments, as well as "investing in areas that would provide good health outcomes quickly," such as, in the case of Yobe State ramping up immunisation.
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Dr. Jide Idris, former Commissioner for Health in Lagos State, explained the accountability measures that were implemented during his tenure. He said "a health reform agenda was put in place that was domesticated and addressed the issue of leadership and governance." Lagos State decentralised and gave hospital management boards greater autonomy and responsibility, as such they were now accountable for the operations within their facilities.
Collective effort for improved outcomes
Following engagement with development partners and heads of health parastatals, the induction aimed to equip the new commissioners with the knowledge and networks they need to make informed decisions and contribute to improved population health outcomes in their states.
In his remarks, the Coordinating Minister for Health and Social Welfare emphasised the need to respond to Nigerians' needs and "putting the person at the centre" of healthcare services. The Honourable Minister also stressed the value of data in making informed decisions, saying, "There is no point knowing four years down the road if you are off-track. We need data that is able to allow up to collectively change course, if things aren't going well". 'Ultimately, gains in population health outcomes will result from Commissioners of Health working collectively and being more accountable, using their power and authority, and taking on the responsibility for effective healthcare delivery and improved health outcomes in their respective states.
