INTERVIEW: Global aid cuts a blessing in disguise for Nigeria, says Gates Foundation Country Director 

TheCable’s MAYOWA TIJANI spoke with UCHE AMAONWU, the Gates Foundation Nigeria country director, on the sidelines of the United Nations General Assembly (UNGA) and the foundation’s Goalkeepers event in New York. Their conversation covered a broad range of issues, including malaria, Nigeria’s child survival crisis, the financing gaps threatening global health progress, and Amaonwu’s expected legacy as a Nigerian leading the Foundation’s work in the country.

The Institute for Health Metrics and Evaluation estimates that by 2045, the world could eradicate some of the deadliest childhood diseases, saving millions of lives. For that to happen, Amaonwu explains that a country like Nigeria, with some of the biggest global burden of disease, has to build a politically-immune structure for sustainable health financing.

With five million children under the age of five dying from preventable causes globally, Amaonwu breaks down how sustainable health financing, digital public infrastructure, and genuine political will could bend the curve in Nigeria — and how the next five years can lay the foundation for the nation’s health and wealth.

TheCable: Current data shows that reducing malaria deaths and cases can significantly boost economic growth. However, the impact isn’t immediate. So, governments may lack the incentive to tackle malaria aggressively because the economic benefits often become visible 20 years down the line — long after the next election. So, how do you make the case that these interventions matter, even when they won’t yield short-term political gains?

UCHE AMAONWU: That’s a good question. The typical thing about ‘how do you make health  politically salient’, especially in a country like Nigeria where it traditionally hasn’t been. That’s why I think what has happened with the ODA [Official Development Assistance]  shifts is actually a blessing in disguise.

About two weeks ago, the DG NHIA [National Health Insurance Authority] called for a four-day dialogue on health financing. Initially, I was like ‘is anybody going to come here?’ But it was actually an eclectic mix of people from local governments, who just got financial autonomy through a Supreme Court judgment; to states, who are under pressure to do more; and the federal. There was a collective discussion on how can we do better? How can we take this sovereignty call as a call to action? How can we make health financing important?

I’m focusing on health financing because you need financing to be able to do the interventions in malaria and things like that. It’s time to have that discussion because the global space is looking challenging — a lot of people have exited and those that are there are very interested in making sure that whatever money they are giving is being put to the best use and that countries are actually putting their fair share. So, I was encouraged to see that conversation happening. I saw state governments say it’s clear right ‘we are not doing our share and we need to do more’. I saw local government areas saying ‘now we’ve got this money as financial autonomy but we’re going to use it to be able to hold states accountable to make sure they’re delivering the right thing’. So, once that starts happening, then I think the question is how do you sustain that momentum?

The most hopeful piece was an unexpected commitment around health insurance. You saw that the President recently mandated health insurance. Coming into that session I’ve always been telling the government folks that ‘you guys are actually not spending a lot on health — 30% is supply side spend; government, donors, but 70% of the money in health is from citizens paying out of pocket. So, even if you’re successful in optimising that 30% making sure every naira is spent efficiently, it is still 30%. What do you do with the other 70%? So that’s where that promise of health insurance comes to play. And I think something like that is one that could reach people’s pocket.

It was the head of the senate committee on health, Senator Ipalibo Banigo, who actually said  ‘this is the first thing I’ve seen that it’s actually something I can lean on and campaign on’. She was like, ‘I can use my own constituency allowance to actually pay for [health insurance] premiums for everybody in my constituency’. So, think about that for a second. Now, think about if she does that, can other people do it? Then all of a sudden can it be a campaign thing where you’re actually paying for people to have access [to healthcare] so they don’t go broke. They don’t sell their land and everything just because something happened to their child. 

So, the scarcity of funds has forced the system to start thinking differently — that gives me hope. It’s a structural thing; for a long time we haven’t done the hard structural work. And this is why we are where we are. If you listen to Ethiopia, Rwanda, those guys have built systems from the ground for years and now they are reaping the benefits of it. Nigeria has to get there. For me it’s a 20-year thing but in the next five years, any arm of government who is serious about doing the right thing, we are going to support them with the right planning, the right budgeting, with the right structural changes to make sure those things are aligned. 

Question: Digital public infrastructure (DPI) has been evolving, and we know that having a strong identity system and proper infrastructure is important. Are the programs you’re implementing designed to support and strengthen this digital public infrastructure?

UCHE AMAONWU: DPI for us are three things: ID, payment infrastructure, then what we’re calling data exchange. Nigeria does have an ID system, they’ve always had multiple, but NIN is the one that has actually taken traction. Today, I think they’ve crossed over 100 million unique NINs. That is a big number.  So, the push now needs to be saying, ‘how do we actually use that to be able to start getting services to our citizens’. How can we use that to identify people and actually put it into practice? Can we get to a point where we are not doing multiple captures? Today, you want to vote, you capture, you want to get a driver’s license, you capture. You want to get a passport, you capture.  But the common thing around them is NIN. So, all you need to do is to capture it once and share it. 

The payment platform is actually another one where we have to give Nigeria a little bit of credit. We actually have a very robust you know interbank payment settlement, which is actually better than a lot of a lot of Western countries. And that’s something that was home grown. The trick is how do we build on it? Nigeria has actually made a lot of strides in inclusion. And it’s through things like Money Point. It was a private sector intervention. So, I think Nigeria is that one place where when the private sector wakes up and wants to do something, they can actually move. So, for me, the elements of DPI are there. You just need to push further. 

When we met the NIMC team, we said we know you’re trying to deploy agents all over to be able to scale ID but have you thought of actually bringing in cell phone companies because they are there in the community selling their thing. For each ID they enroll, give them N500, you will get from 100 million to 170 million quickly. Just be more creative right and it’s not a competition. You’re trying to create this database. 

For the payments people, how do we leverage this 80% that we reached in Findex (Financial inclusion data), then actually start using that to provide savings, credits to people. Can we start thinking about creating credit profiles for people? 

There’s a lot of random things happening, but what you find sometimes in Nigeria that we always don’t look across. So, that’s one of the things we’re discussing with Kaduna state, and Kaduna is one of the states who’ve actually gone very far in financial inclusion because the governor declared it as one of his first executive order when he came, saying I want to increase my financial inclusion numbers and he’s done it. So, we’re saying okay now can we use your state to actually say how do you now use this to improve payment and put in use cases.  So, I think those are things where we just need to be intentional. Leadership is important, there needs to be somebody demanding it in government.

I’ll end with one thing which continues to resonate that we did when Paulin Basinga was country director of Nigeria. We worked with the governors’ forum and brought seven or eight governors to Seattle. Sat with them and said, ‘let’s explain primary health care to you and see if each of you can commit to strengthening primary health care in your spaces’. Since then, the governors  came back and we did this PHC [primary health care] challenge, where we challenged governors to do more. I was very inspired by the governor of Gombe, since he came back he declared a state of emergency. He got very serious and now small Gombe is one of the exemplars and if you look at the numbers from the DHS you will see how they’ve improved. That has had long lasting impact. So, don’t underestimate the power of just motivating people — if you have leaders who are willing to take that inspiration and run, magic can happen. 

Question: Does the Gates Foundation match government funds with its own funding? Do you do counterpart funding? 

UCHE AMAONWU: No, we don’t have to because that’s the old development approach. Our position is: if you don’t know the solutions, we can commit to helping set up the solution and get them running. But once you see it and you like it, run with it.

The Gates Foundation doesn’t focus on counterpart funding, because the problem with that model is sustainability. For example, if you say, “We’ll each pay 50% of health worker salaries,” the moment the donor funding stops, say, when USAID leaves, the program collapses. The government must see these programs as its own.

What we can do is help them get started and give them time to adjust. For instance, if we say, ‘go and hire 500 midwives today,’ the government will say we have to put it in next year’s budget. We say okay, hire them now, put them on the books. We’ll give you one year to adjust your priorities. Then we can say, ‘okay, we’ll pay for the first year’. But after that, 100% you pay for the rest. It’s not counterpart funding, it is buying time for them — it’s catalytic funding.

TheCable: One of the advantages of having a large population in a country like Nigeria is that we can also be among the biggest beneficiaries of reductions in maternal and malaria deaths. Looking at the progress over the years, recent challenges from 2020 to 2025, coupled with this year’s theme of “not stopping at almost,” how would you define Nigeria’s ‘almost’?

UCHE AMAONWU: Nigeria has always been the country of potential. We’ve always had potential since independence. This is 2025, we are still having potential. This potential, when will it ever materialise? I think that’s the thing with us, we need to have this habit of being able to see things through. And it boils down to planning, and not just plan and leave it there, but put the plan, put the metrics, and hold yourselves accountable to be able to to drive it. 

And when you have that end in mind and you have a partner that is actually pushing you to get there, then you can get there. So I think that’s  out ‘almost’. 

So that’s the part where I think Nigeria is stuck in that cycle because we are a graveyard full of nice plans but the people follow through are very little. 

TheCable: Right now, we have a minister of health who understands and aligns with the vision. But with elections and politics, things change. Does the Gates Foundation have a plan for such potential changes? 

UCHE AMAONWU: For politics, nobody has. What we’re trying to do is ask them to think through how to operationalise what they do, so it’s not a one-man thing. This his sector-wide approach was initially set up as a special delivery unit, a presidential initiative with a national coordinator appointed by the President. But we advised them early on: while that setup helps you move quickly, you have to embed it within the existing system.

The work they’re doing is essentially the work of the Department of Health Planning, Research, and Statistics (DHPRS). It is their function to plan, coordinate resources on one budget, and one monitoring and evaluation framework. So, we told them: make sure civil servants within that department are sequestered in the SWAp coordination office. Don’t duplicate efforts. That way, if the next president comes and they close it, that civil servant in SWAp is there, he’s learnt how to do the plan. So, that’s what we are trying to convince them to do. And I said use the goodwill that you Minister Pate are getting from us, from others to build those structures. 

Come up with one way to measure how much the Global Fund is giving you, how much is GAVI giving, how much is Gates, how much is everybody giving you, put it on a template, make it visible. Tell them what you’re doing with each of those things. Then you put how much the government is putting in. Don’t just stop on us. How much is the federal government putting? How much are states adding to it? So that’s why they’re developing this thing called an AOP (annual operating plan) that is going to say all that. 

Put in your website so it’s transparent. The next donor that comes in, whether you’re there or not. So, that’s what we’re encouraging them to do to be able to put those things in there. The second thing where we’re also trying to hedge against the transition is working with states again. I bring it back to Kaduna State. Most state governors typically will have eight years. So, someone like the Governor [Uba Sani], he’s just finishing his first term, so he has another four years. 

So, even if something happens at federal, if you have that runway [at state level], and we’ve seen it, states who’ve had eight years of continued leadership — Gombe, Jigawa. Go to the DHS, you will see it. Over the past two cycles of DHS, they’ve been the states that have improved the most. 

It takes doing, and that’s where development partners have failed over the years because we just do things outside the system, then we just start again when the next person comes. It’s hard work but I think what this thing has sparked for us as Gates is that even we, will have to do things differently. We have to find people, again, who are willing, who are demanding it, interested in doing structural change and then we back them to do that. 

We know it’s hard work and that’s why the grants we make over the next five years is going to be ‘can we put those structures in place?’ So, five years from now, transition from administration is not going to change it. 

Question: How do you get the buy-in of governors and drive them to have the political will to get changes in healthcare done? 

UCHE AMAONWU: There are two ways to approach that. One is friendly competition. You’ve listened here today, people keep citing Rwanda, Ethiopia — where are those exemplars in Nigeria?

The other is to go where the numbers tell you the women and children are dying the most and say, ‘by fire, by force, we’re going to fix this’. We’ve done that in places like Kano and Sokoto. But over time, the metrics haven’t changed. Why? Because the governors themselves haven’t been demanding it. Everyone does the same things; donor darlings — everybody puts money there. There are other states who don’t get a lot of donors but they are doing the hard work. Can we find those ones and give them a little boost so they can be examples. 

Nigeria is a unique country, you have to understand people’s motivations and design interventions around them. For us at the Gates Foundation, we are a strategy-driven organisation guided by what our co-chairs want and the reality is that we don’t do everything. We have a very acute focus on the things that kill children, and we follow the numbers.

So, for example, something like jaundice, while serious, represents a very tiny percentage compared to malaria, which accounts for roughly 30% of child deaths. But broadly though, if we are successful in strengthening health system, which is my main thing, whether you’re working with jaundice, you’re working with anything, the system is strong enough. In that part, we are disease agnostic. Whether it’s jaundice, malaria, or anything else, a strong system with well-trained midwives, capable physicians, and fully stocked facilities can handle it. We believe that at least 80% of these conditions can be effectively managed at the primary healthcare level.

TheCable: For every country director that comes into the foundation, there’s the goal that at the end of my time, this is what I did. If you’re looking at your time in that sort of sense, what would you say as ‘yes, I’m glad that within this period of time I did this’?

UCHE AMAONWU: I’d say three things.The first is figuring out how to sustainably introduce one or two health innovations in Nigeria. At the Gates Foundation, we fund a lot of R&D for interventions that save lives, you saw some of them at Goalkeepers. But developing them is one thing; getting them introduced and scaled in a country as complex as Nigeria is harder.  But I feel like if you’re able to do it with one or two things and show the pathway; what was the innovation? How did you do the implementation research to make sure it’s contextualised? What were the things that you needed to scale that innovation? Is it midwives? Is it service guidelines? Is it making sure the supplies are manufactured locally? Is it making sure NAFDAC clears it? I’d like to be able to figure that out because once you figure that out, then you can rinse and repeat. The next innovation that comes in is easy to plug it in. 

The second thing I love to do is to see how far we can bend the curve on malaria. Particularly for Nigeria. Malaria is a big, big, big burden for us. We are the number one in the world in terms of the burden. So, I want to see how we can make real progress around being able to get that done. 

The third one, which is probably the most important, is that I’d like to help Nigeria get on a path where the economy is growing. If I look at countries like India and China, it wasn’t individual health interventions. They grew their economies, and they had enough money that they were able to adopt any health innovation and it wasn’t a problem to fund it. 

Today, Nigeria is using about 54% of its revenues to service debt. How much do you have to do anything? So, I think, if you can solve that revenue side it will help Nigeria. This is what India did; it was an agriculture-based economy, and they were able to grow their productivity and the farmer was able to earn a little bit more money. He used it to buy a mill in his village. He hired people to run the mill, next thing there is a thriving community. 

People have done it and there’s a clear stack of policies for how you grow, and we talk about it a lot but you don’t see the doing. ‘Oh, we need to diversify from oil, and the next day everybody is still focused on that one oil. So, it’s an area that when I came in I opened up because we haven’t done a lot of that in space but I’m really going aggressive on that. If that is done, that’s the single most important thing that can solve all those other things I’m talking about.