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Last month, Muhammad Ali Pate was conferred with the National Honour of the Commander of the Order of the Niger (CON) by President Muhammadu Buhari. After felicitating him, the Managing Editor of Financial Nigeria, Jide Akintunde, interviewed the foremost global health development expert on the state of global health post-pandemic, issues in Nigeria’s national healthcare delivery, his contributions to the country’s healthcare, and his 10-year outlook of global public health.

Short profile

Muhammad Ali Pate is a global leader in health policy, a physician, administrator, educator, and philanthropist. Dr. Pate is currently a Professor of the Practice of Public Health Leadership, at Harvard T. H. Chan School of Public Health. He is also Co-chair, Future of Health and Economic Resilience in Africa (FHERA), a multidisciplinary and multistakeholder platform fostering the emergence of a better future of health and economic resilience in Africa.

In 2019, Dr. Pate was appointed the Global Director, Health, Nutrition and Population Global Practice, and Director of the Global Financing Facility, by the World Bank Group. In these roles, he led the Bank’s 390 global development professionals in six regions of the world. He also led the World Bank’s health response to the Covid-19 pandemic, including the design and implementation of the $18 billion global health Multi-Phase Approach which supported more than 100 countries. Under his leadership, Nigeria benefited from the World Bank’s commitment fund to mitigate the social and economic impact of the pandemic.

Dr. Pate was a Minister of State for Health (2011 – 2013), Federal Republic of Nigeria. Prior to his cabinet position, his stellar contribution to the national healthcare includes his work as Chief Executive, National Primary Health Care Development Agency, which laid the foundation for the eventual elimination of the polio epidemic in Nigeria.

Jide Akintunde (JA): The Covid-19 pandemic is not over yet. But its serious threat to global public health seems to have receded. What is the major concern now for global public health?

Muhammad Ali Pate (MAP): One of the most important lessons of the Covid-19 pandemic is that health is linked closely to economic and national security. What started as an infectious disease outbreak in Wuhan China, became a public health crisis and rapidly escalated to become an economic crisis for all countries of the world. Beyond the tragic loss of lives and livelihoods, the economic consequences of the pandemic extended to several sectors, including education, food and agriculture, aviation, transportation, and the wider macroeconomy.

Investing in health is not a luxury. With the threat of global economic contraction – which reached 5% of global GDP in 2020 – we saw countries pumping trillions of US dollars in fiscal stimulus to deal with the fallout of the infectious disease. Now that the pandemic is at a stage where we see the end of its acute phase, the worry is that national governments and the global community may become complacent again, because the panic phase of the pandemic has receded, and other issues on the global stage are becoming prominent. This is not the first time the world has gone through the cycles of panic and neglect. After a public health panic, when the crisis recedes from the front pages of newspapers, governments and leaders tend to move on, neglecting the necessary investments in basic health delivery and core public health functions, such as the human resources, laboratory infrastructure and surveillance systems. They wait until the next crisis.

It’s easier and more cost-effective to prevent a crisis from emerging or escalating by investing beforehand in preparedness and in preventing disease outbreaks.

But as we speak, there are other infectious disease outbreaks in Nigeria, like Lassa fever and cholera. There is an outbreak of Ebola in Uganda and other outbreaks elsewhere in Africa.

The level of investments that is needed to bolster the healthcare capacity would be less before a crisis escalates. I hope that the policymakers and leaders will realize that it is important, and in our collective interest, to ensure that in-between crisis we are investing in health systems to deliver for everyone. This is very important for the health of our people, and for our economic and national security.  

JA: Healthcare delivery in Nigeria remains in a precarious state. What is your view of the current issues in the sector?

MAP: Nigeria has a mixed health system, with sizeable public and private sector roles in financing and delivery. Over the last few decades, we have, as a country, put policies and programmes in place to improve the primary care system – such as the Primary Health Care Under One Roof Policy in 2010, State Primary Care Agencies, Midwives and Community Health Schemes, NSHIP, Saving One Million Lives, and the National Health Act that created the Basic Health Care Provision Fund. Most recent is the National Health Insurance Authority Act. But it is still very much work in progress.

Our population health outcomes are relatively lower than in other countries who are spending less than what we are spending on health. That then begs the question: are we allocating our resources in the most optimal way for population health?

While primary healthcare has been touted as the foundation of Nigeria’s health system, a lot of work still has to be done in ensuring that every Nigerian is guaranteed access to quality primary care services. If you take immunization as a proxy of health system performance, we have among the world’s largest pool of children under five years old who have never received a single dose of a vaccine. There are parts of this country where almost 90% of children are not fully immunized, such as in Sokoto State; in others, half of the children have not been immunized by age 2, such as in Borno State. We still have the circulating mutant polio virus, even though we have eliminated the wild polio viruses and been certified.

So, there are still huge gaps when it comes to primary care delivery. While there have been some improvements in the past, they have not been sustained, particularly in certain states and certain LGAs. Maternal mortality is also still unacceptably high. All of these are on the basic services arena.

At the secondary and tertiary levels, where the services are available, their quality still leaves much to be desired. We still hear stories of mishaps in our facilities. So, it is not only access, but also the quality of what is being accessed, that we have to pay attention to. Reflecting this gap, those who can afford it end up depending on expensive medical tourism abroad for their health care.

We have a large private sector delivering care. But the private sector itself has to be appropriately regulated to deliver the needed quality of care. Otherwise, people could spend resources and not get the right care – whether it’s diagnostics or treatment – from the private or public sector.

The private sector can be helped to improve its services, in terms of setting, monitoring, and enforcing the right standards, better policy environment and improved access to financial capital, so that the value chain of the health sector – not limited to hospitals and clinics but also training, manufacturing, service delivery – can contribute to economic development of the country. The health sector can promote economic growth and jobs. It can reverse medical tourism outflows and draw others from the region.

In terms of the core public health agenda, we now have a strong Nigeria Center for Disease Control, but have to equip and deploy sufficient frontline health workers to be able to quickly detect disease outbreaks, coordinate responses, deliver the tools that are necessary, and have the trust of the communities in which they reside and serve. When there is an outbreak, whether it is cholera or Lassa fever, people should be able to trust the public health workers on the front line, follow the directives they give, and they must be able to deal with misinformation and counter-information that may be spread by others.

I’m not discounting all the efforts that have been made. I’m only saying that we still have a lot of work ahead to improve the state of population health.

JA: In the remaining seven months of the Buhari administration, what do you think it can still do to safeguard or improve the country’s healthcare delivery?

MAP: The National Health Insurance Authority (NHIA) Act signed by President Buhari is an important plank to mandate health insurance that will provide predictable financing to health providers, both public and private, and also regulate the quality of what they provide. In the few months before the next administration, if the federal government and the subnational leaders would focus on preserving even the modest gains made, for instance in immunization and controlling disease outbreaks, so things do not get worse, that itself would be progress. So also, would be provision by states and local governments of the resources needed by health workers in the front line to support delivery of primary healthcare services so that we don’t slide back in areas of maternal and child health in the midst of the elections season.

During an election cycle, attention given to healthcare easily becomes secondary to other needs, especially in states where there will be leadership transition. Political leaders should pay attention so that health does not become deprioritized in the face of the fiscal constraints facing us. Political activities should not take attention away from things that are as vital as the ongoing health and education needs of the people.

JA: For the new administration coming in at the end of May 2023, what would you recommend for it as the key agenda for health sector development over the next four years?

MAP: I think the foundational policies are in place, as I had mentioned above. We have the National Health Act (2014), which provides an overarching governance framework for health in Nigeria, including financing Primary Health Care; we have State Primary Care Agencies and Insurance Agencies; well-established NCDC; the NHIA; and network of primary, secondary and tertiary facilities in public and private sectors.

I think the focus needs to be on domesticating our health agenda to fit our peculiarities and on execution – getting things done – to ensure delivery of services at the quality that is needed to improve health outcomes, both physical and mental well-being. This requires improving not only the allocation of resources but also efficient use of the resources to improve population health using the platforms of the public and private sectors for service delivery. It requires harnessing the market potential of the health sector as well as the incredible innovation of Nigeria’s youth to leapfrog the sector through digital transformation. It requires focused leadership at all levels, to move Nigeria from its current status to a world leader in health.

What I also hope is that the next set of leaders would adopt a whole-of-government approach to improving health, by engaging proactively other sectors that have contributions to make to population health. Health goes beyond the health sector itself. It entails disease prevention mindset, proper food and nutrition, environmental sanitation, personal hygiene which requires water, education which actually enhance the understanding of the citizens, road safety, emergency services which require telecommunications, and properly regulated manufacturing and trade in health commodities and services.

Health contributes to the performance of other sectors and there are contributions that other sectors can make to health. We must move from “public health policies” to “healthier public policies” to improve the health and wellbeing of the population.

As a country, the most important asset we have is our people. We have about 6 – 7 million children born every year; they will grow up in 25 years’ time to be graduates and parts of the labour force. Some of them will become doctors, nurses, pharmacists, scientists, engineers, and leaders of the future. What happens to them before they are born, and in their transition stages, are very important for the economic development of Nigeria. Investing in health of mothers, infants, and children safeguards our human capital.

JA: Nigeria’s fiscal stress has become quite acute, and it will challenge the next administration. How can we achieve progress in health given the financing constraint?

MAP: It is now evident that we face significant fiscal space constraints. It is also not limited to health. Fundamentally, the government needs to generate more revenues and channel the resources to the priority areas. Collecting less than 10% of GDP as tax revenue is very low. If the government can collect more tax revenue, then it can channel the improved collections into investments in health, education, and other critical areas. When we don’t collect enough, and the little we collect is consumed by debt service and inefficient, pro-rich subsidies, then we are up for some difficult times.

In the face of these constraints, protecting social spending, such as on health, and reducing waste, would signal commitment of the government to its people. This will enhance the willingness of bilateral and multilateral partners, the private sector, and philanthropists to complement government’s efforts with their resources. Development partners watch for signals of political commitment and ownership from government and then rally around it. If government commits, not in terms of what it says but what it does, puts in more resources to address a particular issue, it will signal to the world that this is something that the country takes very seriously, and others are likely to rally to provide complementary support to those priorities.

Without this signaling of what is important to us, we will likely find ourselves following different priorities set by others outside the country. When you don’t put your resources where your mouth is, you end up following someone else’s resources to where they want to put it.

There is an effort by the Federal Government on vaccine manufacturing and broader healthcare industrialization through intervention by the Central Bank of Nigeria (CBN). The impact of this is not yet very clear, but it should be in the right direction.

A key aspect to promote pharma and biotech industry development is appropriate regulation. At the moment we have products produced or imported into the country, but the quality of the products is not fully assured. So, one may take anti-hypertensive or diabetes drug, but it may not work or could cause harm. NAFDAC has done well, over time, from the time of late Professor Dora Akunyili, until now with Professor Moji Adeyeye. It has achieved maturity level 3 in the WHO global benchmarking tool, one of only three countries in Africa to achieve this feat, but there is still much to be done to ensure that products that come into the country, whether from India, China, or other places, meet the safety and quality standards to safeguard people’s health.

If we don’t have a strong regulatory framework, it will discourage the best manufacturers from investing. They will not invest in a product when someone else can produce or sell counterfeit products and not be held accountable.

JA: In recognition of your stellar contributions to national and global health, President Buhari conferred you with a National Honour last month. How is your global leadership and experience benefitting Nigeria?

MAP: First of all, it is humbling to have been conferred with the National Honour in the rank of Commander of the Order of the Niger (CON), by President Muhammadu Buhari, GCFR. I am grateful to the government, not only for recognizing what we contributed to nation’s service, but also to do so alongside some of the people that I respect such as Dr. Ngozi Okonjo-Iweala and Hajiya Amina Mohammed.

I was opportune to work alongside and lead thousands of volunteers and diligent health workers all over the country when I served in the government between 2008 – 2013. We did amazing things. Some of the health workers and volunteers lost their lives in the fight against polio. But it was such an honour for me to lead them and the National Honour that was conferred on me, I take it beyond the recognition of my modest contribution; it is in fact an honour for all the people that I worked with and led.

Since leaving government, I have been so fortunate to contribute to developments in many other arenas, nationally, regionally, and globally. Initially, I was at the Duke University teaching future leaders comparative study of health systems. I then led as its CEO, a global philanthropy that helped African heads of states and ministers to improve human capital in their countries. Recently, as the Global Director, Health, Nutrition and Population (HNP) Practice of the World Bank, and the Director of Global Financing Facility for Women, Children and Adolescents (GFF), I led a fantastic group of health development professionals working in the six regions of the world to improve health systems and contribute to the fight against extreme poverty.

Nigeria benefited from the World Bank during my tenure as Global Director. Currently at Harvard where I hold a professorship, and also co-chairing the Future of Health and Economic Resilience in Africa, I am contributing to the building of a better future for global public health, including in Nigeria. All my international engagements have been enriched by the experience that I had at home, in Nigeria, during my service in government and even before then during my education in the country.

While I have played extensively at the global level, my country of origin, Nigeria, and Africa, are always very close to my heart. Whatever I have done, I have always related it to how it can help improve the health and well-being of people in places like where I came from and those who are most vulnerable. In the specific case of Nigeria, since leaving government, I have had great personal relationships with all my successors as health ministers and continued to informally support and advice leaders in Nigeria at the Federal and State government levels. I have used my wide global network to continue to contribute to Nigeria’s development even while outside formal governmental role.

In addition, I founded the Chigari Foundation, in 2014, now a world-class NGO, which is currently working with community leaders all across the 19 states in the north to increase population demand for immunization and primary health care services.

So, as you can see, I have transcended from my locality, to national, regional, and global domains. My aim is always to improve the health and well-being of people, to give voice to the aspirations of those who are not usually heard in powerful places.

JA: What is your outlook for global public health in the next decade?

MAP: In projecting the future of health, our current pandemic experience is an important marker to start. Pandemics have generally marked the start of important transformations globally since ancient history, till today. Covid-19 won’t be different. It has introduced a certain atmosphere that is accelerating transformations in global, regional, and national health systems.

In the global community, I hope that we will take the threat of possible future pandemic seriously and invest in prevention and preparedness to do a better job when the next serious infectious disease threat emerges. This means inclusive global governance, financing, addressing inequities, and more political will and cooperation to address common threats together – not every country on its own. The new Pandemic Treaty when ready, I hope will cement those changes, alongside a reformed global financing architecture.

At the national level, we are likely to see more drive towards domestication and localization – more countries linking their health security with their economic security, and moving towards boosting their investment in health infrastructure, work force, and healthcare industrialization, so they are medically not held at ransom by other countries. I hope the domestication and localization would be pursued with a mindset of genuine cooperation, collaboration, and not isolation. In Africa, a continental approach is taking hold, but it is one that takes a global Africa approach – not Africa on its own.

As a country, Nigeria will be starting from a relatively lower base. But I see opportunities for the country to be transformed, for example, in rapid increase in access to quality, basic healthcare for everyone. We have a healthcare system that involves strong public and private sectors. We can attract the best people and investment, such that people do not have to go abroad for surgery or other medical care.

We can have in Nigeria all the latest advancements we see in medicine, including in transplantation and molecular medicine. We can do that with our brothers and sisters in other African countries. We have got the capabilities and human resources – in global terms. There are lots of Nigerians doing amazing things in the US, UK, Europe, Australia, all over the world. And in Nigeria itself, while the ‘Japa’ movement is real, there are still good people doing exceptional jobs despite the constraints that we are all familiar with. Pooling all these together, Nigeria has all it takes; I am optimistic that in 10 years, we can become a more significant and respected player in the global health arena. And if what happens is good in Nigeria and Africa, it is good for the world.