…Nigeria has made very significant progress in financial inclusion. Formal financial inclusion in Nigeria grew from 36 per cent in 2010 to 64 per cent in 2023. Access to digital payments more than doubled from 22 per cent in 2010 to 52 per cent in 2023, according to EFINA Access to Finance data. I will like to share ten lessons from financial inclusion that can be applied to scaling health solutions for systems impact and tackling Nigeria’s health equity challenges successfully.
There are huge correlations between financial exclusion and health exclusion in Nigeria. Financial exclusion is highest in North-West and North-East of Nigeria, and significantly above 60 per cent in many states. These same regions are also where Nigeria has the highest health exclusion and health equity challenges. Financial exclusion is also highest among women, particularly in the North, and the same is for health exclusion and health equity challenges. Financial exclusion is heavily rural skewed in Nigeria, and the same goes for health exclusion.
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You can virtually superimpose Nigeria’s financial exclusion data (the EFINA Access to Finance Research) on top of the Nigeria health exclusion data in the Nigeria Demographic Health Studies (NDHS) and both will be near mirror images of each other. The connecting LINK between Nigeria’s financial exclusion and health exclusion is POVERTY. The more endemic the poverty, the higher the exclusion to health and financial access. There must therefore be ways in which the lessons of how Nigeria has significantly solved its financial exclusion access could be extrapolated or applied to solving its health access exclusion and equity challenges.
Nigeria has a big health exclusion and equity challenge. Nigeria’s under–five mortality is 102 per 1000; i.e. one child out of every ten dies before the age of five. Maternal mortality is 500 per 100,000. Malaria prevalence is 15 per cent, while Nigeria has the highest share of the global malarial burden at 27 per cent. On the other hand, Nigeria has made very significant progress in financial inclusion. Formal financial inclusion in Nigeria grew from 36 per cent in 2010 to 64 per cent in 2023. Access to digital payments more than doubled from 22 per cent in 2010 to 52 per cent in 2023, according to EFINA Access to Finance data. I will like to share ten lessons from financial inclusion that can be applied to scaling health solutions for systems impact and tackling Nigeria’s health equity challenges successfully.
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- Scale, Reach and Access as the Core Mindset for Solving the Problem: Financial exclusion is seen as opportunity for focused innovators to create solutions at scale. This is what the fintechs, along with the banks, have done to financial access. The mindset has not been about a linear incremental growth of financial access, but the thinking of solutions that can deliver multiple growth in financial access. How could the same kind of core mindset be applied to finding innovation at scale to solve Nigeria’s health access challenge?
- Digital Technology as a Tool for Scaled Innovations: The largest economic impact of digital technology is that it massively crashes transaction costs to fractions of what it was traditionally. No one has to travel to a bank branch anymore, especially from our rural and peri-urban communities, to cary out a financial transaction. They can do so on their mobile phone or visit a nearby financial POS agent. A one hundred dollar Point of Sales (POS) terminal can now do work that once constituted half of the reasons why people used to visit a bank branch, which could cost tens of millions of naira to build. Digital technology bridges geography, extends markets and access, and delivers financial services fulfilment at fractions of the old historical costs. How could and where could digital technology crash transaction and fulfilment cost in health care and deliver access at scale with huge systems impact?
- Technology as An Enabler of New Innovative Business Models: Digital technology also enabled innovative business models in the financial services. Mobility and cloud technology massively crashed transaction costs, enabled innovative business models and commercial solutions different from traditional financial services. Digital technology enabled the unlocking of historical excluded markets where there was no consumption of formal financial services, and the demographics had been traditionally ignored by commercial markets. Banking that used to be where I go was transformed to what I what I do wherever I am. That fundamental change unleashed new business models that have revolutionised financial access. What are the potential equivalence of these on the health systems side? What are the potential innovative and revolutionary business models in health systems that digital technology can enable to solve health equity challenges at scale? While we have seen good progress in these areas with health-tech firms, what more can we do to accelerate and scale health systems impact?
- Progressive Regulations that Support Innovators and Competition: Nigeria’s strong progress in financial inclusion would not have been possible without the progressive regulations and support of the Central Bank of Nigeria (CBN). The CBN created new fintech licenses to compete with traditional banks. It established a new Department of Payment Services out of its Department of Banking Services that supervises traditional banks. It recognised that fintechs and new digital non-traditional payment companies need a special focus and a different mindset from core traditional banking for its regulation. If it was left to traditional banks alone, everyone would still have had to largely depend on a bank branch to access financial services. Even when there were concerns about the potential risks of fintechs, CBN created platforms for fintech engagements and sandboxes to test innovative ideas before scaling to larger markets. The Central Bank has been both a regulator and an adviser of new digital financial services companies. How can we have the open and more intentional equivalence of these on the health systems side, in addition to progressive regulations that support and encourage innovators seeking to solve Nigeria’s health access and equity challenges at scale?
- Digital Public Infrastructure as Public Good on Which Private Innovators Can Build their Solutions, Such that Reduces the Heavy Lifting of Private Innovators: Financial inclusion at scale in Nigeria would not have been possible without Digital Public Infrastructure such as the national digital identity system (NIN) and the BVN (the Bank Verification Number). Private financial services innovators build their payment, credit, insurance, pension solutions on top of the national digital identity system. Without it, they would never have scaled, or the cost of scaling would have been out of reach for many players. What coordinated digital public infrastructure do we need in the health systems that reduces the heavy lifting of private innovators solving the problem of health access and health equity in Nigeria? The Nigerian health services industry and regulators, for example, have been largely absent in the conversations on the next-layer applications of the national digital identity system. Nigeria’s national digital identity system has been largely appropriated alone by the financial services industry and its regulators, with visible scaled impact on their industry.
- Interoperable Systems to Enable Complemented and Accelerated Scaling: Today, you can send payments and transactions from one bank to the other, to a fintech, to switches and payment terminal operators and processors, credit bureaus, and pension funds because all players in the financial system are connected by interoperable systems. Financial access, reach and impact would have been impossible without such interoperable systems. How can we build interoperable health system platforms among health service players that reduces frictions and enables accelerated, efficient, complementary and interdependent scaling in the reach and equity of health services?
- Platform Thinking: Financial system players have a platform mindset when they are building their solutions. They are not thinking of one silo solution long term, but a platform on which several solutions could be layered, thereby leveraging the access rail or platform that had been built earlier. A payment platform can, therefore, also deliver credit, savings, insurance or pension solutions. Such platform solution thinking creates accelerated efficiencies for scale and the access of broader financial services. While Ping An of China, one of the world largest health insurance companies, started with digital health insurance (HMOs), it has evolved into a broader health ecosystem digital platform offering a range of health and wellness services, including adult and senior care, online healthcare and pharmacy service, working with millions of service providers in China. Such platform thinking thats leveraging digital technology would be very useful in designing solutions for scaled and efficient access in our health systems.
- Ecosystem Partnerships: Without ecosystem partnerships and collaborations, financial services providers would not have been able to scale access and financial inclusion. Behind all successful transactions are players such as digital apps, banks, switches, payment processors, payment terminal aggregators working together to deliver financial services and access at scale. How can we build stronger ecosystem partnership among service providers in the health system enabled by digital technology such that minimises collaboration frictions, while enabling innovative health services and access at scale, even in the remotest locations?
- Data as Gold: There are too many disparate, silo, unconnected and uncollected data in Nigeria’s health system. Their value is huge and enormous when connected, especially in these days of Artificial Intelligence and high data analytics capabilities. Connected health systems data would unleash innovative and well targeted products and services that would tackle health access and equity challenges, as we have seen in financial inclusion with diverse services, such as digital wallets, agent banking, payments, microcredits and micropensions.
- Design Thinking: Customer Co-creation of Solutions with Scale: Financial inclusion and financial access have also scaled in Nigeria because of good, intuitive product and service design that are convenient, easy to use and adapted to the use context of the customer. Products and services that have scaled are those that are co-created with customers, not as a finished product forced down to the customer, but adaptive solutions co-created iteratively for massive adoption with the customer. How can such design thinking and customer co-creation methods be adapted/adopted in the design of health system solutions to deliver on scale and with impact, while tackling Nigeria’s health equity challenges? How do we bring health service providers, patients and mothers into health solutions design as co-creators with us and deliver far wider, effective and innovative access to health services?
Conclusion
Health for all by year 2000 was a millennium goal of the World Health Organization that we also adopted in Nigeria three decades ago. The lofty goal then was to deliver an inclusive healthcare system in which no one is left behind no matter who they are, what they have or where they live. While we have massively fallen behind on the goal, in Nigeria, we have greater opportunities today with digital technology to close the gaps, accelerate and deliver an inclusive healthcare system. The rails of digital technology can be as extensive as we imagine, reach anywhere, do so affordably with very low cost, as we have seen with financial inclusion. Both sectors, health and financial inclusion, can continuously learn from each other towards the supra-larger goals of having a more inclusive society and country – a Nigeria in which no one is left behind. That is the purpose of these ten lessons from financial inclusion on scaling health systems impact, which is commended to our health access and equity programmes. May we all succeed together.
Olu Akanmu is a pharmacist and was the COO of Society for Family Health-Nigeria about two-and-a-half decades ago.
This is the text of a Keynote speech given at the Society for Family Health “Health-Tech” catalyst event on 11th June.
