Playing the payer’s tune to govern health through security in Nigeria – A realist analysis

ABSTRACT The use and the application of health security, both as a frame and a set of practices, have increased and become central to global health governance. Nigeria navigates complex pressure in health priority setting, shaped by domestic political realities, economic constraints and a longstanding relationship with international donors. Yet how the framing of health as security interacts with these dynamics, and how the actors involved shape health system priorities and practices, remains under-examined. We conducted 28 realist-informed interviews with national and state government actors, actors working at international organisations, and implementing partners across eight states and the Federal Capital Territory. Analysis was informed by an existing realist framework and focused on how contextual conditions activate actor reasoning (uncertainty, self-protection, self-preservation, self-reliance, and norm-setting) to generate the outcomes of securitised responses. We identified four interrelated outcome patterns (1) centralisation of governance, where priorities were steered by global agendas and reinforced through federal structures; (2) shaping of resource allocation, often prioritising diseases of international concern over locally salient health needs; (3) reconfiguration of health services, including vertical programming and administrative reporting burdens; and (4) institutionalisation of security norms, normalising military and security actor involvement in health response. Our findings show that health security is more than a technical exercise; it is a dynamic phenomenon co-created across multiple dimensions, including global norms and domestic governance. To mitigate the negative consequences of this phenomenon, we recommend that policy, practice, and research actors – internationally, in Nigeria, and elsewhere – engage more critically with global framings of health and security.