Background
Over several decades, Nigeria has confronted major health crises characterized by a double burden of disease — preventable infectious diseases and a rising prevalence of non-communicable diseases (Li et al., 2022). Vaccine-preventable diseases, in particular, have contributed to the country’s high child and maternal mortality rates (Ophori et al., 2014).
Minister Muhammad Ali Pate was appointed Nigeria’s Minister of State for Health in June 2011. Before he was appointed Minister of Health, he served as the Chief Executive Officer of the National Primary Healthcare Development Agency (NPHCDA) for three years, made significant progress in improving Nigeria’s primary healthcare system, and initiated crucial health sector reforms during his tenure.
President Goodluck Jonathan appointed Dr. Pate Minister of Health to continue his previous work at NPHCDA. His mandate included improving efforts to eradicate polio and enhancing routine immunization. Initially focusing on polio, his goal as Minister of Health expanded to encompass child and maternal health through the Saving One Million Lives campaign. The Saving One Million Lives campaign by Minister Pate was developed to ensure that efforts to improve health in Nigeria also addressed other urgent health issues such as measles and malaria.
This case study explores how Minister Pate was able to navigate the fraught politics of Nigeria and win the support of the President, key Cabinet allies, and 36 state governors for a country-wide transformative health initiative.
Building a Guiding Coalition
When Minister Pate took office, there were rumblings of discontent regarding Nigeria’s health system, but health issues were not high on the national political agenda. Plus, given the decentralized nature of the health system, the Minister had limited control over how each of the 36 states spent their federal budget allocation. Although a significant part of the state budget came through federal allocations by a constitutionally determined formula, the fiscally decentralized federal system of government allowed states fiscal autonomy. The result was limited federal oversight or accountability regarding how much states allocated to health and how such resources were allocated. National Health Account data showed that most health resources were spent on politically popular curative facilities. These were often geared to the health needs of wealthy citizens. Even though the federal government had conceptually sound health policies, execution and enforcement at the state level were difficult.
Developing a Legacy Goal
Soon after taking office, Minister Pate assembled a core leadership team, led by a long-time trusted colleague, Dr. Kelechi Ohiri. With the support of his core team, Minister Pate reflected on the healthcare landscape in Nigeria to determine what he wanted to accomplish during his limited term of a maximum of four years. He said:
“I built a very strong team, including some I had mentored before, like Dr. Kelechi Ohiri. I chose people who were not only competent but had the right mindset and character attributes to help me deliver on our goals. As a Minister, very early on, you need to know what you want to accomplish. Build a good team, mobilize resources, and ensure everyone is accountable, including yourself. Focus on execution, or you will not achieve much.”
Minister Pate wanted to focus his agenda on something that would help Nigeria achieve something tangible, particularly given the multiplicity of problems within his main portfolio of primary healthcare. As he reflected, he realized that all around him was a culture of input-based thinking. Healthcare policy was made based on what else could be put ‘in’ to the health system. He wanted to shift the conversation to what was coming ‘out’ of the system, i.e., an outcomes-based approach. To drive this mindset, Minister Pate asked his ministry:
“What are we here for?”
When they thought about primary healthcare, saving lives was the most concrete outcome. The next step was to define ‘saving lives’ in a way that was easy to communicate. From this discussion, Minister Pate’s signature program, “Saving One Million Lives (SOML),” was born.
SOML was an aspirational target that was big enough but also tangible enough to focus people on the outcomes that matter and to work backward toward the inputs. SOML aimed to strengthen primary healthcare and prioritize interventions that could save lives, such as improving maternal and child health, eliminating mother-to-child transmission of HIV, strengthening immunization, scaling up access to essential medicines, controlling malaria, and improving child nutrition.
SOML built on existing policies outlined by the National Strategic Health Development Plan and the President’s Transformation Agenda rather than introducing new ones by way of strengthening existing delivery channels.
Minister Pate also used the Lives Saved (LiST) tool to prioritize the critical intervention areas that would contribute the most to lives saved. Based on this analysis, the six key priorities of SOML were improving maternal and newborn child health, eliminating mother-to-child transmission of HIV, strengthening routine immunization and achieving polio eradication, scaling up access to essential medicines, malaria control, and improving child nutrition. The underlying idea was that to save one million lives; the primary healthcare system would have to be strengthened by increasing health personnel, introducing performance management systems to increase health worker productivity, improving quality of care, and using information and communication technology for the supply chain management. By linking health systems strengthening to concrete outcomes, Minister Pate hoped that beyond saving one million lives, the benefits of these systemic changes would continue. Nonetheless, Dr. Pate realized that SOML’s success depended on the political will that supported it. This began with the President.
Working with the President
According to Minister Pate:
“When I started in 2008 as CEO of the Primary Healthcare Development Agency, it was polio that led the previous President to appoint me. To deal with polio and immunization, I had to build a primary healthcare system. By 2011, when the new President was elected, he asked me to join his government to build on the work I had started.”
Soon after his appointment as Minister of Health, Dr. Pate made sure to meet with President Goodluck Jonathan to thank him for the honor of appointing him to serve. In that meeting, he promised to serve the President with his very best and asked him for one thing in return:
“If I make any mistakes or if I am not doing something you really want, I want you to call me directly. And if I have a similar issue with you, I want to be able to come to you directly.”
This conversation formed the foundation for an effective working relationship and proved useful for the duration of Pate’s term.
To communicate SOML to the President, Minister Pate recollected what he knew about the President. Two key factors proved important. Firstly, President Jonathan had lost several siblings to preventable diseases at a very young age. Secondly, President Goodluck’s term had begun with a deeply unpopular move – the cancellation of longstanding subsidies to Nigerians on oil and petroleum gas.
Saving children from death and disease was something the President had a connection to, and the public was concerned about it, so it made for a compelling goal.
After the President’s support for the SOML campaign, Minister Pate provided monthly written updates to the President to regularly reinvigorate his political will and to maintain their connection. The President wanted to say that he had eradicated polio and ‘saved one million lives’ as part of his Transformation Agenda. His and Minister Pate’s legacies were aligned. Minister Pate said:
“Polio and immunization were embedded within the context of primary healthcare revitalization. We reframed the polio fight to include vaccines and saving the lives of children and mothers, rather than isolating it as a separate issue.”
Minister Pate gained this high-level backing by aligning SOML with the President’s personal experiences and the public’s needs.
Finance Minister
After the President, Minister Pate set his sights on bringing the Minister of Finance, Ngozi Okonjo-Iweala, on board with SOML. He knew Minister Okonjo-Iweala as a senior colleague from their time together at the World Bank, where she remained until her cabinet appointment. He had built on this pre-existing relationship with her by visiting her in Washington, DC, after her appointment but before her taking office. He also knew that during her previous tenure as Minister of Finance, she had been frustrated with the health sector because she did not have a clear sense of what had been accomplished with the funds she had allocated.
To get Okonjo-Iweala on board, Minister Pate had to stress the outcomes-based approach to SOML. Okonjo-Iweala was swayed by SOML’s clear definition of goals and deliverables because she could easily see and understand it as Minister of Finance. Thus, she was willing to support it. She asked Minister Pate to serve on the Economic Management Team and the Economic Management Implementation Team – two intersectoral working groups housed within her ministry. This was the first time the health sector was fully represented in such a body.
As part of the Minister of Finance’s Economic Management Team, Minister Pate gained a higher-level understanding of government priorities and connected with his colleagues on the team – including the Minister of Planning, the Director General of the Budget Office, and the Chief Economic Advisor to the President. He made SOML one of the key deliverables of the Economic Management Team, which further solidified their buy-in to its success.
Consequently, Minister Pate convinced both the President and the Minister of Finance to invest part of the money recouped from the cancellation of oil subsidies in maternal and child health to deliver results for the public. In September 2011, with President Jonathan’s and Minister Okonjo-Iweala’s support, Dr. Pate made a public announcement about defining his term with the goal of Saving One Million Lives in Nigeria.
Step 3: Managing Stakeholders with Influence
With the support of the President, the Minister of Finance, and high-level officials from the Ministry of Health, Minister Pate moved to identify other key stakeholders that needed to be managed. Later in his career, he would learn more about using stakeholder analysis to explicitly map supporters and opponents against their level of influence. Still, at this time, he took a more intuitive approach. He maintained an internal inventory of the relationships he had cultivated and leveraged his social networks to forge connections with those who were truly influential, regardless of their positional authority.
Within his own ministry, Minister Pate had traditional authority by virtue of his position as Minister of State for Health, but this was supplemented by good relationships with the Federal Minister of Health (whose primary focus was on tertiary care and health insurance, among other areas), the Permanent Secretary, key directors, and the Primary Health Care Agency.
Nonetheless, within his own health ministry, Minister Pate sensed a feeling of “passive resistance.” The Health Ministry had traditionally taken responsibility only for the allocation of the federal health budget to states without monitoring the use of the state health budgets, with minimal state accountability and little regard for impact. At the outset, senior officials in the health ministry thought they could ignore Minister Pate’s SOML initiatives and “let it die on its own.” Nonetheless, Minister Pate persisted onwards with the higher-level health officials who formed his guiding coalition to prove to these opponents that SOML was not going away.
As SOML gained traction in the form of support from the President, the Finance Minister, and more state entities, and by raising substantial funds, the naysayers not only came on board but also began to be champions of the initiative.
As Minister Pate continued to work to achieve his mandate, he had a secret weapon on his side: the initiative’s name – “Saving One Million Lives.” By framing the program this way, opposing stakeholders, particularly those in the political sphere, had a challenging time voicing their opposition to “Saving One Million Lives.”
Engaging Governors and Community Leaders
Minister Pate leveraged his previous relationships with governors and community leaders to understand the importance of state-level cooperation, especially when it came to vaccinating citizens. He organized forums and secured commitments from state governors to support primary healthcare improvements. Additionally, he established the Northern Traditional Leaders Committee on Primary Healthcare to engage trusted community leaders in vaccination and health campaigns. He explained:
“When it came to vaccination hesitancy, we worked to earn the trust of communities and community leaders. We created the Northern Traditional Leaders Committee on Primary Healthcare, which engaged religious and community leaders across Northern Nigeria. This network became crucial in planning and implementing vaccination campaigns. To select the Northern Traditional Leaders, we went to the Sultan and asked him to convene a group of representatives from each of the 19 states in the North. The Sultan and a committee selected leaders who were relatively younger, stronger, respected, and trusted. We then organized them into a committee and enabled them to act effectively. To engage communities, we provided them with information and involved them in planning, which built legitimacy in the eyes of the people.”
As he had anticipated, Nigeria’s 36 state governors were key stakeholders whose support Minister Pate needed to save one million lives. Fortunately, Minister Pate had existing relationships with several governors and with the Director General of Nigeria’s Governors’ Forum. The Governors’ Forum had preexisting goals to eradicate polio and implement effective routine immunization programs as part of Nigeria’s 2009 Abuja Commitments to Polio Eradication. Minister Pate said:
“When I became Minister, it was easier for me to build on the relationships I had already established with the governors. As CEO of the Primary Healthcare Development Agency, I had worked closely with the Governor’s Forum, helping to organize their secretariat and getting them to sign the Abuja Commitment Declaration in 2009. This previous work allowed me to leverage those relationships when I became Minister.”
While this was helpful in aligning them with SOML, convincing them to relinquish their budget autonomy was still a challenge. Ultimately, the President had to play a significant role in bringing the governors on board.
The President asked the Governors to be accountable for progress in their states. Minister Pate’s team provided each state with a ‘Countdown to 2015’ one-page document summarizing how many lives the state could save by expanding specific services relevant to its context. This provided each state with its own baseline and endline target.
Once the states had pledged their commitment to their targets, Minister Pate’s team set up a scorecard system tracking progress state-by-state. The data comparing state performance was presented at the quarterly meeting of the Presidential Task Force on polio eradication, with the governors in attendance, presided over by the President, and quickly became a major incentive for the states to improve performance. Initially, some governors were uncomfortable with the pressure to be accountable and pushed back. However, according to Minister Pate, the measurement of performance became:
“An inflection point shifting the dialogue to focus on the data to its use in decision-making and results.”
Furthermore, the scorecards on state performance were published in newspapers. This decision was made to ensure that data collected from the public was ‘given back’ to the public and to further motivate state progress.
Finally, there were donors. Minister Pate needed donor support to generate more innovative ideas for technical assistance and strategy for the maternal and child health programs associated with SOML. Traditional and particularly non-traditional donors were eager to fund the initiative, and he was able to work with philanthropic foundations with flexible sources of funding to recruit world-class experts to help with ideation and design. He explained:
“As Minister, I was very active in mobilizing resources. I leveraged traditional domestic financing, multinational financing, and other sources to move the agenda quickly. We raised resources through innovative financing, which helped draw states in the direction we wanted.”
Implementing Strategically
As he worked to bring stakeholders on board, Minister Pate was invited to attend the Harvard Ministerial Leadership Forum in June 2012. This gave him the opportunity to learn about tactics for effective policy implementation and organization. In his own words:
“I was internally strengthening my hand while externally learning and strengthening relationships to succeed.”
The President officially launched SOML in Nigeria on October 16, 2012. The idea behind this campaign was a national rallying cry to end preventable infectious diseases and curtail infant and early childhood mortality. SOML had a strong brand identity (including a logo) and a deliberate communications strategy.
Minister Pate created a culture of collaboration and a sense of obligation amongst public and private sectors to do their part by positioning the campaign as a collective social movement across the nation. The communications strategy allowed key actors to pledge how many lives they would save – the private sector initially pledged to save 30,000, which later increased. Finally, and perhaps most importantly, SOML’s multichannel messaging plan created a sense of accountability to the people. This made it more difficult for state governments to allocate resources away from the program’s initiatives.
Once launched, Dr. Pate had to ensure implementation success. He needed some control over state-level health spending to ensure compliance with the national goals.
To this end, he introduced three key nationally managed elements to the program. The first was developing a robust data management system to monitor and evaluate performance. Historically, data had been collected independently at the state level, but in order to improve its reliability and comparability across states, he implemented a centralized data management system to enable the tracking of outcomes for the nationally outlined priorities. Furthermore, this data would be used for decision-making purposes regarding future state health budget allocations.
The second element was stewardship and stakeholder engagement. It involved introducing a steering committee housed within his ministry comprising representatives from federal and state government, professional associations, civil society associations, and donor groups. The goal of this committee was to enhance coordination through increased transparency and mutual accountability for the outcomes determined by the data collection. Pate chaired meetings with the steering committee every three months to review progress and ensure stakeholder alignment.
The final element introduced by Minister Pate was a program delivery unit, jointly accountable to the health and finance ministries, to support execution and ensure effective, high-quality delivery. This was led by competent professionals with a focus on results.
After Strategic Implementation
Minister Pate resigned in July 2013, confident that SOML was institutionally secure and embraced by his successors. By 2018, one million lives had been saved, and SOML had raised over US$1 billion in investments. The initiative had survived three Ministers of Health and fundamentally shifted the mindset towards primary healthcare. SOML’s principles were further institutionalized through a partnership with the World Bank, rewarding federal and state governments based on performance.
Looking back, Minister Pate was gratified by the adoption of outcomes-based thinking within the ministry and state governments. However, he reflects on areas for improvement, such as spending more time with state governors, consolidating information management systems, focusing on public sector supply chains, and integrating health insurance into SOML plans. His final reflection underscores the importance of strategic decision-making in complex systems:
“In a complex system, you cannot always fight in all directions. You have to choose which battles to fight and when.”
In 2020, “Nigeria was declared free of wild polio in 2020” (The WHO, 2023).
2023 Reappointment
In 2023, Minister Pate was again appointed Coordinating Minister of Health & Social Welfare, Federal Republic of Nigeria. He said:
“I’m refreshing and learning from every experience I have had. When I enter a new role, I treat it as a fresh start and apply the lessons learned from previous experiences, ensuring we build strong teams, mobilize resources, and maintain a clear focus on execution. In my current role, I quickly did a stock take together with my colleague the Honorable Minister of State, engaged with the ministry bureaucracy and agencies, and developed an agenda and blueprint. We are focused on saving lives, reducing pain, and producing health for all Nigerians. I brought in capable hands, the best I could find, to ensure we could deliver on our objectives.”
References
Li, Z., Shi, J., Li, N., Wang, M., Jin, Y., & Zheng, Z. (2022). Temporal trends in the burden of non-communicable diseases in countries with the highest malaria burden, 1990–2019: Evaluating the double burden of non-communicable and communicable diseases in epidemiological transition. Globalization and Health, 18(1). https://doi.org/10.1186/s12992-022-00882-w
Ophori, E. A., Tula, M. Y., Azih, A. V., Okojie, R., & Ikpo, P. E. (2014). Current Trends of Immunization in Nigeria: Prospect and Challenges. Tropical Medicine and Health, 42(2), 67–75. https://doi.org/10.2149/tmh.2013-13
The WHO. (2023, August 24). Protecting every child in Nigeria from poliovirus. WHO | Regional Office for Africa. https://www.afro.who.int/countries/nigeria/news/protecting-every-child-nigeria-poliovirus#:~:text=Nigeria%20was%20declared%20free%20of