The Covid pandemic has taught us once again that good governance and leadership in health are critical ingredients of resilient health systems. Often, governance is misconstrued as a sole responsibility of the government and civil society. However, that is only part of the story, as citizen engagement and meaningful participation, by electing competent leadership, co-creating the systems, policy frameworks, regulations, and structures, is fundamental for effective oversight and accountability. With that in mind, this article will reflect on some of the participatory governance milestones achieved in the past few years and during Nigeria’s recent presidential campaign (2022-2023). Some transferable lessons for improving participatory health governance will also be provided.

Before focusing on this electoral campaign, let’s first go back to the previous election to set the scene.

In the last (2015) general election, Nigeria had a 43.65% voter turnout. The remaining 56% that decided not to exercise their civic duty may not realize that by doing so, they excluded themselves from decision making and governance, including health systems governance. Having said that, it is important to understand that many Nigerians consider voting a futile exercise because they believe that the election results are predetermined before votes are cast. Electoral violence and the dearth of credible people contesting for political office over the years caused several Nigerians to lose interest in participatory governance. The current disconnect between (too many of) the governed and the government has led to a vicious cycle of mediocre governance that needs to be broken. Nigeria, a nation with so much potential, has paid a heavy price for allowing self-serving politicians to manage its affairs. 

The current dysfunctional state of the health sector is just one casualty of poor governance. As a recent Lancet Nigeria Commission pointed out, Nigeria’s health system is riddled with layers of challenges, including corruption, absenteeism, brain drain, and inequitable access to quality health care. Investment in health is very low – an abysmal 3% of GDP (2019) -, leaving Nigerians to foot the bill, with out-of-pocket spending accounting for over 70% of Nigeria’s current health expenditure. In a country where the leaders jet off abroad to seek medical treatment, Nigeria loses between $1.2 and $1.6 billion every year on medical tourism. Despite these challenges, Nigeria has the potential to improve its population’s health, if corruption, inefficiency, accountability, and weak governance are tackled and resolved.

 #EndSARS: a turning point  

A turning point for governance in Nigeria happened in 2020 with the #EndSARS protest, where Nigerian youths challenged police brutality. It birthed Nigerians’ consciousness of the power of collective action and showcased the possibilities of CivicTech for governance. CivicTech has been described as any innovative use of technology to improve governance and engagement between government and citizens. Twitter, “Nigerian twitter”, is a good example of using technology as a powerful tool for organizing, raising funds, and mobilizing people. Twitter use is estimated at 20 % of Nigerians ( or 40 million users ), so it is a force to be reckoned with.

Barely a year after the protest, political parties nominated presidential candidates, and Nigerians found themselves in the usual quagmire of being subjected to pick between the devil or the deep blue sea. However, the tide turned when Peter Obi, the former governor of Anambra State, announced his candidature under the Labor Party (LP).  His supporters, who were initially mostly youths, took to Twitter to make a case for his candidature. At the start of the campaign, the major political parties, PDP and All Progressives Congress (APC), were unimpressed and unperturbed by a structureless party and Obi’s supporters were dismissed as “two people tweeting from a room”. They were wrong, though. These early supporters have now become a powerful force called the “Obidient” movement. Although the movement took off on Twitter (with mostly young people), by now they have mobilized and engaged hundreds of thousands of people both online and offline (via mega rallies, town halls, sensitization campaigns at grass roots level, …). In the process, they also managed to turn Nigerian elections from a “stomach infrastructure” model (vote-buying) to an interview for an important job. Indeed, with the momentum garnered on Twitter, Nigerians took to the streets to sensitize people on exercising their right to vote for good leaders. They created awareness and mobilized people to engage in rallies across the federation to express their support for Peter Obi’s presidential campaign. In turn, the Peter Obi presidential campaign developed a partnership with “Obidients” that made them feel heard by acting on their suggestions and feedback.  

Nigerians’ engagement and influence during this political campaign using Twitter and other digital technologies proffers invaluable insights for improving Nigerians’ participation in health systems governance. The newly elected president should embrace CivicTech, by leveraging social media platforms like Twitter, as well as websites, portals, and other reporting initiatives for a more transparent, open, and collaborative health system. Nigerians should be able to provide input during the decision-making process for health interventions and feedback on the efficacy and quality of healthcare services. In addition, the public consultations held in town halls and social media platforms during the election campaign are a sustainable model for encouraging interactions between the government and citizens for setting the health agenda and implementing appropriate solutions. This would fulfil one of the Lancet Nigeria Commission’s recommendations to the federal government “to use technological and mobile platforms to strengthen and amplify Nigerians’ voices on needed health reforms and accountability”. Participatory governance at the decision-making stage is important for Nigeria because Nigeria is not bereft of sound health laws, policies, and programs, but typically fails to implement and sustain them. By including citizens at the design stage and beyond, it will build citizens’ trust and encourage them to take shared ownership and responsibility in ensuring the health intervention’s success.

Health in respective manifestos

As you probably know, the election takes place in a few weeks, on February 25. By now you’re probably curious about what the various parties have in store in terms of health policies. Well, all three major contenders for Nigeria’s presidential office have made commitments to health in their manifestos:

· In Atiku Abubakar’s (PDP)  manifesto, he promises administrative reforms, accelerating Nigeria’s transition towards achieving Universal Health Coverage (UHC), improving quality of care and clinical governance, and private sector engagement to unlock the health sector’s market potential.

· Peter Obi’s (LP)  manifesto commits to tackling medical tourism and enforcing non-sponsorship of public officers seeking treatment abroad, providing health insurance coverage for the 133 million poorest Nigerians, increasing government’s budgetary allocation for health, and improving the quality and service delivery of Nigeria’s health system.

· Bola Ahmed Tinubu (APC) has committed to increasing the annual budgetary allocation to health to over 10%, reversing the brain drain, improving Nigeria’s healthcare infrastructure, reviving the National Health Insurance Scheme (NHIS) and imposing a medical tourism ban on public officers, in his manifesto.

These commitments are a remarkable improvement from an almost absent health agenda in the previous election. The upcoming election is thus an opportunity for Nigerians to shape and build a more resilient health system. So pick up your permanent voters’ card (PVCs) and vote for a leadership that prioritizes health, but don’t stop there. Leverage digital technology to participate in co-creating policies and interventions for improved health and quality healthcare service delivery.

Remember that you are an integral part of governance and your engagement and participation are critical for improved health outcomes in Nigeria!