Week 5: Nigeria

Life expectancy and Braised Goat in Obe Ata

Last month, I was dissecting Chimamanda Ngozi Adichie’s latest book, Dream Count, with my mentee and friend, Goodness Ogeyi Odey. Over the course of our conversation about our shared favorite author, we discussed the horrific and deeply tragic death of one of her twin boys - aged only 21 months - in an elite Lagos hospital early in January. According to reports, Adichie alleges “criminal negligence”, specifically an overdose of propofol and oxygen deprivation, leading to the death of her son. The hospital maintains it followed international standards. Goodness noted a common saying, “ ‘May Nigeria not happen to you.’ It’s both a prayer and a sad reality.” It indicates a helpless feeling wherein a weak and fragmented health system is seemingly beyond repair, and even acts as a great leveler - whether or not you are able to afford care in expensive private hospitals.

This is borne out in the data. Nigeria has the lowest life expectancies in the world, at 54 years, well below the regional average at 58 and the global benchmark of 73 years. So today, I want to focus on that aspect of demography and why it matters.

What is life expectancy?

Simply stated, life expectancy is the average age of death based on a number of assumptions. The Our World In Data primer is excellent if you want to dive in further. It is the primary indicator of human, social, and economic development, reflecting a population’s overall health, nutrition, sanitation, and access to healthcare. A higher life expectancy generally correlates with higher, more developed, and stable societies. It is one of the three key indicators used to calculate the Human Development Index (HDI) along with education and GNI per capita, and informs Sustainable Development Goal 3 (Ensure healthy lives and promote well-being for all at all ages.)

Sidebar 1: You might have heard about it most recently with respect to the pandemic which saw massive global mortality, with an influential study finding that COVID-19 triggered significant mortality increases in 2020 of a magnitude not witnessed since World War II in Western Europe or the breakup of the Soviet Union in Eastern Europe. According to the WHO, the pandemic wiped out nearly a decade of progress in improving life expectancy within just two years. Between 2019 and 2021, global life expectancy dropped by 1.8 years to 71.4 years (back to the level of 2012). Many countries seem to have rebounded to pre-pandemic levels, most recently the U.S. which still notably lags behind other peers, agnostic of COVID-19.

Sidebar 2: Incidentally, USAID’s Atul Gawande wrote a lovely piece in the New Yorker in 2021 about how Costa Rica bolstered its average life expectancy from 55 in the 1950s to nearly 81 today—above the United States’ average life expectancy while spending less than the world average on health care as a percentage of income—by unifying two approaches to health that are largely kept separate in America: public health and medical care.

There’s a few different types of life expectancy, each usually reported for males, females, and both sexes (at birth, at age 60, healthy life expectancy, poverty adjusted life expectancy and I’m sure there are others), revealing distinct nuggets of information. For the purposes of this piece (and next week’s), we will focus on life expectancy at birth as the sort of bread and butter demography indicator that is important for all the reasons I described above.

Life expectancy in Nigeria

Life expectancy is fundamentally shaped by the Social Determinants of Health- the conditions in which people live, work, and age. These include economic status, access to education, quality housing, and food security. In the Nigerian context, these social factors are inextricably linked to the country’s macroeconomic stability. Specifically, a growing real GDP per capita acts as a primary driver of longevity by providing the essential resources required for nutrition and modern healthcare.

However, the positive influence of economic growth is often neutralized by volatile financial stabilizers. While a strong exchange rate is vital for the affordable importation of essential pharmaceuticals, the depreciation of the Naira has made healthcare increasingly inaccessible for the average citizen. Further, high interest rates act as a significant drag on public health; they not only increase the cost of medical supplies but also deter critical private and public investment in health infrastructure.

While economic stability provides the framework for longevity, the last mile of life expectancy is determined by the physical environment and basic infrastructure. Access to safe drinking water remains one of the most powerful predictors of survival, acting as a primary catalyst for improved health outcomes. Similarly, primary school enrollment serves as a vital foundation; education correlates directly with increased health literacy and better hygiene practices, creating a more resilient population from the ground up.

However, these gains face a steep uphill battle against Nigeria’s biological and climatic burdens: Nigeria bears a disproportionate share of the global malaria burden, accounting for 27% of cases and over 31% of deaths worldwide. This is not just a health crisis but an economic one, as it systematically drains national productivity and suppresses child survival rates. Emerging data shows that environmental pressures are now silent drivers of mortality. Climate-driven heatwaves are significantly impacting infant health, while air pollution further complicates the public health landscape.

Causes of death in Nigeria

I mentioned earlier that life expectancy at birth is this catch-all indicator for all things. The most direct way (I think) to unpack it is by starting at causes of death to then consider how poverty, sanitation, infrastructure, health spending etc., influence morbidity and mortality.

The Global Burden of Disease study shows that communicable diseases (malaria, neonatal disorders, respiratory tract infections, HIV/AIDS, diarrheal diseases, meningitis, and tuberculosis) comprise 7 of the top 10 causes of death in the country.

Nigeria represents about 3% of the global population, but accounts for about 17% of global deaths under age 5 (albeit improving.) Globally, infectious diseases including pneumonia, diarrhea, and malaria are a leading cause of under-five deaths, along with preterm birth and intrapartum-related complications. Maternal mortality is also extremely high, with reports indicating that 1 woman dies every 7 minutes giving birth in the country, and accounts for almost 30% of all maternal deaths worldwide.

Taken together, these are largely issues for which we know what needs to be done. Solutions exist that can go a long way in reducing deaths due to infectious diseases and birth-related complications.

Financing for health

But for that, one needs funding and commitment. And therein lies the biggest obstacle yet. Increased spending on health and infrastructure needs to be a matter of national urgency. Nigeria spends less on health as a share of GDP than nearly every other country in the world. I was looking for a straightforward explainer about Nigeria’s health system financing, and the WHO delivered, see below.

Three things stood out to me - the ballooned figure for out-of-pocket (OOP) spending, the very low health insurance coverage, and the reliance on external donor funding. Importantly, from a fiscal standpoint, Nigeria’s rising debt profile means more resources are being allocated to servicing domestic and foreign debt, which impacts the allocation of funds available for essential public services, including health (from this excellent Medium piece.) The government is making inroads to increase spending on health, with the previously cited Global Burden of Disease initiative projecting that piece expanding (in orange in the figure below.) but not nearly where it needs to be.

You might have noticed the black bar, which reflects development assistance for health. Of course I am going to get on my soapbox now and talk about how USAID’s (unjust, illegal) closure shrinks that piece, with massive mortality worldwide, including in Nigeria.

From ForeignAssistance.gov (above), over the last 5 years alone, you can see how overseas development assistance (ODA) has been for the country, notably from the US along with other bilateral aid. The US also plays a funding role in some of the other organizations listed here (Global Fund etc.), so the US footprint is actually bigger.

Critically, bilateral funding is not only used for health (although is a big chunk of what was spent in Nigeria); improving life expectancy as noted above requires more than health improvements - investment in education, infrastructure, poverty alleviation - is also crucial. See figure below for what I mean - economic growth (530M), Education (1.7B), Infrastructure (2B) were among the “long game” investments in Nigeria.

Sidebar 3: USAID had recently launched a new initiative called Primary Impact (2022)- which aimed to strengthen primary health care (PHC) systems by integrating services that were otherwise quite siloed (e.g., combining HIV/TB screenings with maternal care) across health divisions. It aimed to improve, coordinate, and finance PHC, focusing on improving health systems, training Community Health Workers (CHWs), reducing mortality, and enhancing service access - in Nigeria among 10 countries. This was a partnership with countries of course, and in Nigeria, it worked in conjunction with the 2023–2026 National Health Sector Renewal Investment Initiative (NHSRII), which takes a sector-wide approach to improving health outcomes and access to primary health care. You can read more about the specific work in Nigeria under Primary Impact here.

What the destruction of USAID (and reduction in bilateral and multilateral funding) means globally is beyond catastrophic. This Lancet paper (from just this week) finds that ongoing, severe cuts to USAID programs could cause between 9.4 million and 22.6 million additional, preventable deaths in low- and middle-income countries (LMICs) by 2030. This includes 2.5 million to 5.4 million additional child deaths (under age 5) by 2030. This other Lancet article spells out specifically what this means for Nigeria and what comes next. I wanted to quote everything - read the article, it’s short - but this stood out to me.

Critics of aid would argue this should have been the case all along, and they are not wrong. Reduction in donor dependence is a goal of many aid programs; it’s the abruptness without any room for planning causing death and destruction worldwide that is the tragedy. There have been a number of great insights about what the country can and should do next with respect to domestic financing for health, and you can read one of them here. I hope it happens.

The brain drain

Burna Boy is not the greatest export from Nigeria (I know some friends who may fight me on this); it’s actually highly educated people, including doctors. No surprises, given what we have discussed about the abysmal state of the health syustem above - which likely means long hours, low salaries, and difficult working conditions for many.

From this article:

According to the Medical and Dental Council of Nigeria, the country had only 74,543 registered doctors for a population of about 218 million in 2022 – a doctor–patient ratio of 1:3,500, which falls alarmingly short of the World Health Organization’s recommended 1:600. Such numbers are not just statistics; they are a reflection of a healthcare system on the brink of collapse.

As of 2023, the United Kingdom remains the leading destination, with over 12,000 Nigerian doctors, while the United States, Canada, and Germany follow closely. This “brain drain” is accelerating as health workers seek better infrastructure and salaries abroad.

The Lancet article I cited above also says this:

The ongoing emigration of health-care workers must also be given adequate attention. Incentivising health-care workers to remain in Nigeria through better salaries, improved infrastructure, and research opportunities can reverse the trend and reduce the long-term consequence of the USAID suspension.

Remember the big chunk of out of pocket (OOP) expenditures from the GBD graph I showed earlier? A large part of that OOP money comes from remittances, sent from the diaspora, back home. Without them, the safety net would disappear for thousands of households.

Consider the massive downstream impact on not having (or rather, not being able to keep/retain/entice) enough trained health workers in already fragmented health systems, and what that means for health and development outcomes, including life expectancy.

The Perfect Storm

The tragedy of Nigeria’s health system is not just found in the statistics of a low life expectancy, but in the preventable nature of its decline. We are witnessing a perfect storm: the abrupt withdrawal of a decades-long USAID funding without commiserate domestic resource mobilization, the brain drain of the most talented physicians, and new fiscal burdens like the 1% remittance tax that strip away the final informal safety net for the most vulnerable. Perhaps the saying, ‘May Nigeria not happen to you’ was a prayer-shield against systemic failure; today, as we see programs shuttered, that saying feels increasingly like a lament for a future we knew how to build, but chose to defund. Demography matters because these are not just numbers—they are the children we lose in hospitals (and elsewhere) and the millions of children whose fighting chance is being traded for a line item in a foreign budget.

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The Food!

I love NYT’s Yewande Komolafe, and made her braised goat in obe ata. We also made jollof rice (of course!) and a loosly inspired Nigerian salad. We listened to the aforementioned Burna Boy and various other afrobeats music, and the kids schooled us with amazing facts ranging from stories about the Nok people, butterfly diversity, fashion, and of course, famous soccer players.