Leading the Way to Better Health in Nigeria

Mairo Mandara doesn’t have a lot of patience for endless talk about sexual and reproductive health issues. The senior country advisor for The David and Lucile Packard Foundation prefers action.

“If I have my way, we would not produce any more policy in Nigeria for next 10 to 20 years because we have some of the most fantastic policies in the world,” Mandara says. They just need to be implemented, she says.

A native Nigerian who is well-versed in the political and reproductive health challenges in Nigeria, Mandara knows that the federal Ministry of Health creates health policies, but it’s up to Nigeria’s 36 autonomous states to implement them. Governors in each of the states wield most of the political power, and health infrastructure and spending has traditionally not been a top priority.

“You have to be strategic and know what buttons [to push], what buttons are the real buttons and use your political connections, who you know, for the good, for what you want to do,” she says.

In August 2007, Mandara, MD, and her colleagues tried a new tack. They got a meeting with the newly elected governor of Bauchi state. Knowing he was committed to improving health and that he had inherited a government full of people he did not know, Mandara got a meeting with him. They told him they knew he wanted to accomplish great things but that he would need to refine his agenda and persuade his cabinet and political leaders in the state to follow his vision. Mandara suggested she could help arrange leadership training for him and his cabinet.

The governor agreed and devoted three days to the training, bringing along his cabinet ministers. “He was there and so everybody was there,” Mandara says. “We got him to articulate his own ideas of what he wanted to do. He wanted to improve education, health, youth development and small scale industry.”

After two days of leadership training by internationally respected consultants, the governor and his team were ready to take on a practical challenge: maternal mortality. She brought in experts to convey its prevalence and what caused it. “We were talking about leadership but the context was the maternal mortality issue,” she says.

At the end of the training, the governor was persuaded to make several health commitments. First, he agreed that maternal services should be free. The action was put into law. He also planned to develop a primary health care agency. “It was done 2 months ago, then a law was also passed” preserving the arrangement for the future (since laws are more difficult to change than executive decrees). Another victory: the state allocates more than 10 percent of its budget to health (far surpassing other states that mark only about 5 percent for health and the federal government, which allocates about 8 percent for health.) “All this was done within six months,” Mandara says.

The governor is now an advocate for the leadership training and for health, Mandara says. Four other governors have contacted her for similar training, and Mandara is seeking additional funding.

“We in the health sector need to engage with the strategic people that translate our ideas into action. These are the people that control budgets. It’s only by their understanding the gravity of the issues that our ideas can be turned into reality.”

Brian W. Simpson is editor of Johns Hopkins Public Health magazine.