Strengthening health financing in the heart of the Sahel: Niger’s coordinated approach
Collaborative partnerships to transform health financing in Niger
The Republic of Niger, a landlocked nation in West Africa, has faced prolonged armed conflicts and persistent droughts, severely straining its healthcare system. These challenges have contributed to some of the world’s highest maternal and infant mortality rates, prompting the Government of Niger to prioritize universal health coverage (UHC). This commitment builds on earlier efforts to expand access to essential health services across the country.
In 2006, as the country grappled with its most severe health outcomes, the Government launched an ambitious initiative to provide free healthcare services. The policy targeted women of reproductive age, offering free reproductive and family planning services, alongside comprehensive healthcare for children under five. While the initiative initially showed promise, insufficient funding hindered its full potential. By 2011, only half of the required resources had been mobilized, leading to unpaid medical bills and disrupted service delivery. Additionally, the policy’s narrow focus left other patients facing high out-of-pocket expenses, with direct payments accounting for over 40% of total health expenditures in Niger, according to the World Health Organization (WHO).
Between 2007 and 2011, Niger’s health expenditures dropped from 5.4% to 4.9% of its GDP. A slight improvement followed, with expenditures rising to 5.6% between 2016 and 2018, before stabilizing around 5.7% from 2018 to 2020.
Prior to the free healthcare policy, Niger recognized the critical need for coordinated action among health financing partners. In 2006, the Ministry of Health, the French Development Agency (AFD), and the World Bank established the Health Basket Fund (FCS) to support Niger’s health development plan. By 2020, the initiative had expanded to include four additional partners: UNICEF, the United Nations Population Fund (UNFPA), Gavi, and the Spanish Agency for International Development Cooperation (AECID). However, challenges persisted due to inadequate resource assessments and insufficient funding, highlighting the need for sustainable reforms to advance UHC and meet Sustainable Development Goal (SDG) 3 targets.
A mother cuddles her baby in Soki village, located in central Niger. © UNICEF/Dejongh
Leveraging global networks to strengthen health financing coordination
Given the urgency of achieving free healthcare and UHC in Niger, the Government embarked on ambitious reforms to restructure its health financing system. The fragmentation of external health funding had long posed challenges, necessitating better coordination and alignment among partners. Drawing from lessons learned through the FCS, Niger turned to Providing for Health (P4H), a global network dedicated to health financing and social protection, which has been active in the country since 2018.
In 2021, members of the P4H network and signatories of the Global Action Plan for Healthy Lives and Well-being for All (SDG 3 GAP) joined forces to recruit a focal point within Niger’s Ministry of Health. This role aimed to enhance coordination among health financing partners and align their efforts with the Government’s priorities. Gavi, in collaboration with other health financing partners, facilitated the recruitment process, including the validation of shared objectives and the development of a clear mandate.
By January 2022, the role of Gavi as the official “co-rapporteur” of health financing partners transitioned to the national focal point of the SDG 3 GAP Financing Accelerator. This position serves as a critical interface within the Ministry of Health, bridging technical and financial partners. Its primary function is to coordinate partner support, ensuring alignment with national health priorities and reducing the Ministry’s reliance on individual organizations. Initially funded by the WHO with support from AFD, the financing mechanism for this role has since shifted to the World Bank, with additional contributions from the Global Financing Facility (GFF). Discussions on sustainable co-financing modalities are underway to ensure the role’s longevity.
How is Niger reforming its health financing system?
Before 2020, fragmented resources led to either insufficient or excessive funding for numerous health initiatives, according to Charlotte Pram Nielsen, Senior Specialist in Sexual and Reproductive Health, Rights, and Gender at the GFF. Partners from various sectors often struggled to collaborate effectively. However, the partnership between P4H and the SDG 3 GAP Financing Accelerator has fostered enthusiasm and commitment among partners to support Niger’s health financing goals. This collaboration enables discussions to extend beyond health financing, incorporating broader social protection programs and policies that influence health outcomes, such as those targeting women and children, as noted by Lou Tessier, Health Protection Specialist at the International Labour Organization (ILO).
In 2020, health financing partners in Niger prioritized support for COVID-19 response, domestic resource mobilization, resource optimization, effective development cooperation, and cross-cutting investments. The Government identified the following key priorities:
- Aligning budgetary support with strategic and harmonized health expenditure indicators.
- Reforming the FCS to enhance its fungibility and transition from a management tool to a financing system.
- Implementing strategic procurement with practical support from the National Institute of Medical Assistance (INAM).
- Improving the predictability of technical and financial partners’ contributions and annual activity planning.
Specific objectives to achieve these priorities include:
Harmonizing health financing:
- Conducting a census of donors, funding flows, and health financing channels, alongside a critical analysis of health financing harmonization (with support from the GFF).
- Defining the trajectory and future of the FCS (with support from the WHO/P4H).
- Identifying investment argumentation funding channels (with support from the GFF).
Harmonizing support:
- Conducting a census and critical analysis of technical assistance for health financing.
Financing systems and tools:
- Analyzing the operational frameworks of free healthcare and universal health insurance strategies (with support from the WHO/P4H, AFD, and FCS).
Efficiency and optimization tools:
- Developing and deploying a cost simulation tool to estimate production and financing costs in peripheral health facilities (with support from AFD, FCS, and GFF).
- Conducting a census of strategies to improve and reform healthcare delivery from the ground up, identifying and disseminating cost-effective innovations across different contexts (with support from AFD, FCS, and the Global Fund).
Mobilizing domestic resources and optimizing health spending:
- Engaging with the International Monetary Fund (IMF) to include health expenditures, such as vaccination and nutrition, as indicative targets in its programs.
- Advocating for increased allocations to primary healthcare and vaccination during high-level missions and meetings with signatories of the SDG 3 GAP alongside the Government.
Additional support is required to analyze the rationalization and reorganization of the Ministry of Health’s technical committees as part of the budget program reform, along with policy proposals to enhance national financing systems and expenditure efficiency.
Though still in its early stages, this collaborative health financing strategy aligns with Niger’s national priorities and is expected to improve healthcare service delivery. For example, the GFF employs a resource optimization method to track and prioritize funding, ensuring targeted interventions that maximize impact. Moussa Bizo of the WHO Niger Office notes that this approach helps “avoid duplication and enables more focused interventions, ultimately improving the lives of more people.” The method also allows organizations like the Global Fund and Gavi to invest more strategically in HIV, tuberculosis, malaria, and vaccination services. As free healthcare policies encompass these programs, financing reforms will further operationalize INAM, reducing out-of-pocket expenses for vulnerable populations.
Challenges, lessons, and future prospects
Joint focal points embedded within the Ministry of Health and sustainably funded add significant value by facilitating coordination and alignment of partner support with Government priorities. This is particularly crucial in a country where a substantial portion of health sector financing comes from external sources.
Despite the enthusiasm surrounding this initiative, challenges remain. Focal points from participating organizations face significant workloads, which could threaten the initiative’s sustainability. Ensuring dedicated time for these roles within each organization is essential.
Another critical issue is clarifying long-term funding modalities for the national focal point role, a cornerstone of these efforts. The GFF has extended its funding by six months, and Gavi is currently engaging discussions with other partners keen to enhance the sustainability of health financing in Niger.
The lessons learned from this pilot partnership will be shared with other countries and partners to address the demand for joint focal points and more harmonized, coordinated health financing support.
Understanding the SDG 3 Global Action Plan
The SDG 3 Global Action Plan for Healthy Lives and Well-being for All is a commitment made by 13 key organizations in health, development, and humanitarian action. Its goal is to help countries accelerate progress toward health-related SDG targets through joint measures and coordinated support that align with nationally led plans and strategies. Updated in October 2021 with an equitable and sustainable recovery strategy following the COVID-19 pandemic, the plan aims to achieve health-related SDG targets.
The case studies associated with the plan aim to track its implementation at the national level.
