Improving health financing and partner coordination in Niger

Niger’s bold steps toward universal health coverage through better funding and collaboration

Landlocked in West Africa, the Niger faces persistent challenges including armed conflict and recurring droughts, both of which have strained the national healthcare system. The country’s maternal and infant mortality rates remain among the highest globally, pushing the Government of Niger to prioritize universal health coverage (UHC) as a cornerstone of its development agenda. This commitment builds on earlier efforts to expand access to essential health services across the nation.

In 2006, in response to alarming health outcomes, the Government launched a bold free healthcare policy, offering no-cost reproductive health and family planning services for women, along with comprehensive care for children under five. While this initiative initially showed promise, insufficient funding undermined progress. By 2011, only half of the required resources had been mobilized, leading to unpaid medical bills and service disruptions. Furthermore, because the policy targeted only women and young children, other patients faced steep out-of-pocket expenses. According to the World Health Organization, direct payments account for over 40% of total health spending in Niger.

Between 2007 and 2011, health expenditures fluctuated from 5.4% to 4.9% of GDP. A slight recovery occurred between 2016 and 2018, when spending rose to 5.6%, stabilizing around 5.7% from 2018 to 2020. These modest gains underscore the urgent need for sustainable financing solutions to support the country’s UHC goals.

Strengthening health financing through coordinated partnerships

The Government of Niger has long recognized the importance of collaboration among health financing partners. In 2006, the Ministry of Health, the French Development Agency (AFD), and the World Bank established the Health Sector Common Fund (FCS) to finance the national health development plan. By 2020, the FCS had expanded to include contributions from UNICEF, UNFPA, Gavi, and Spain’s International Cooperation Agency for Development (AECID).

However, the free healthcare policy’s financial challenges—stemming from poor resource forecasting and underfunding—highlighted the need for systemic reform. To address fragmentation in health financing, Niger turned to Providing for Health (P4H), a global network for health financing and social protection active in the country since 2018. In 2021, members of P4H and signatories of the Global Action Plan for Healthy Lives and Well-being for All (SDG 3 GAP) joined forces to appoint a national focal point. This role, supported by the Government, aims to enhance coordination among health partners and align their efforts with national priorities.

The recruitment process, led by Gavi in collaboration with health financing partners, culminated in January 2022 when the focal point officially assumed responsibilities as the co-rapporteur for health financing partners. Positioned within the Ministry of Health, this role serves as a vital interface between the Government and technical and financial partners. Its primary function is to streamline partner support, ensuring alignment with national health priorities and reducing reliance on individual agencies. Previously funded by WHO and AFD, the position’s financing has since transitioned to the World Bank, with additional support from the Global Financing Facility (GFF), and discussions on predictable co-financing modalities are underway.

Key reforms to build a sustainable health financing system

Prior to 2020, fragmented funding led to either underfunding or overfunding of initiatives, creating inefficiencies. The partnership between P4H and the SDG 3 GAP financing accelerator has fostered greater collaboration, enabling partners to align their support with national health strategies. As Charlotte Pram Nielsen, Senior Specialist in Sexual and Reproductive Health at the GFF, notes, this collaboration has broadened discussions to include social protection programs, such as policies benefiting women and children.

In 2020, health financing partners focused their support on COVID-19 response, domestic resource mobilization, resource optimization, development effectiveness, and cross-cutting investments. The Government identified four priority areas for reform:

• Budget alignment: Harmonizing budget support with strategic and unified health spending indicators.
• FCS reform: Enhancing the fund’s fungibility to transition from a management tool to a financing system.
• Strategic procurement: Implementing procurement practices with support from the National Institute of Medical Assistance (INAM).
• Predictable contributions: Improving the predictability of technical and financial partner contributions and annual activity planning.

To achieve these priorities, specific objectives were set:

Harmonizing health financing

• Mapping donors, funding flows, and channels, and critically analyzing health financing harmonization (supported by the GFF).
• Assessing the future trajectory of the FCS (supported by WHO/P4H).
• Developing investment case financing channels (supported by the GFF).

Harmonizing support

• Mapping and critically analyzing technical assistance for health financing.

Financing systems and tools

• Analyzing operational strategies for the free healthcare and universal health insurance policies (supported by WHO/P4H, AFD, and FCS).

Efficiency and optimization tools

• Developing and deploying a cost simulation tool to estimate production and financing costs at the community level (supported by AFD, FCS, and GFF).
• Identifying and scaling low-cost innovations in healthcare delivery through bottom-up reforms (supported by AFD, FCS, and the Global Fund).

Domestic resource mobilization and health spending allocation

• Engaging with the International Monetary Fund (IMF) to integrate health spending—such as vaccination and nutrition—into indicative target lists within its programs.
• Advocating for increased allocations to primary healthcare and vaccination during high-level missions and SDG 3 GAP meetings with the Government.

Additional support is needed to rationalize the Ministry of Health’s technical committees as part of the program budget reform and to develop policy proposals that enhance national financing systems and expenditure efficiency.

Toward a more efficient and equitable health system

While still in its early stages, this collaborative financing strategy is expected to significantly improve health service delivery. The GFF, for instance, uses a resource optimization method to track and prioritize funding, helping to eliminate duplication and target interventions more effectively. As Moussa Bizo, from the WHO Niger Office, explains, this approach enables partners like Gavi and the Global Fund to invest more strategically in HIV, tuberculosis, malaria, and vaccination services—all covered under the free healthcare policy. By refining financing mechanisms, Niger aims to reduce out-of-pocket expenses for vulnerable populations and strengthen the operational capacity of INAM.

Challenges and future outlook

The integration of joint focal points within the Ministry of Health has added value by aligning partner support with national health strategies, particularly in a context where external financing dominates the sector. However, challenges persist. Focal points face heavy workloads, risking the initiative’s long-term sustainability. Ensuring dedicated staff time across partner organizations is critical.

Another hurdle is securing long-term funding for the national focal point position, a central pillar of the reform. The GFF has extended its support by six months, and Gavi is leading discussions with other partners to secure sustainable financing for health in Niger.

The lessons learned from this pilot initiative will be shared with other countries and partners, addressing the growing demand for joint focal points and more harmonized, coordinated health financing support.

Understanding the SDG 3 Global Action Plan

The Global Action Plan for Healthy Lives and Well-being for All (SDG 3 GAP) is a commitment by 13 key health, development, and humanitarian agencies to accelerate progress toward health-related SDG targets. Its value lies in fostering collaboration among agencies to deliver coordinated support aligned with national plans and strategies. Updated in October 2021 with a post-COVID-19 recovery strategy, the SDG 3 GAP aims to build equitable and sustainable health systems in the wake of the pandemic. The initiative’s case studies track implementation at the national level, providing valuable insights for future reforms.