Strengthening health financing and partnership in Niger
Collaborative efforts to enhance health system financing in Niger
The Republic of Niger, a landlocked West African nation, has faced persistent challenges including armed conflicts and recurrent droughts. These crises have severely strained the country’s health system, contributing to some of the highest maternal and infant mortality rates globally. In response, the Government of Niger has prioritized universal health coverage (UHC) as a cornerstone of its health strategy, building on lessons learned from earlier attempts to expand access to essential health services.
In 2006, amid alarming health indicators, the government launched a bold initiative offering free healthcare services. This policy provided complimentary reproductive health and family planning services to women and comprehensive care for children under five. Early progress was promising, but insufficient funding soon undermined the initiative’s impact. By 2011, only half of the required resources had been mobilized, leading to unpaid medical bills and disrupted service delivery. Additionally, the policy’s focus on women and young children left other patients facing high out-of-pocket expenses. According to the World Health Organization, direct payments accounted for over 40% of total health expenditures in Niger at the time.
Despite these challenges, health spending in Niger fluctuated over the years. Between 2007 and 2011, health expenditures declined from 5.4% to 4.9% of GDP. A modest increase occurred from 2016 to 2018, with spending rising to 5.6% of GDP, before stabilizing at around 5.7% between 2018 and 2020.
Evolving health financing partnerships
Long before the 2006 free healthcare policy, Niger recognized the critical importance of coordinating health financing efforts. In 2006, the Ministry of Health, the French Development Agency (AFD), and the World Bank established the Health Common Fund (HCF) to support Niger’s health development plan. By 2020, the initiative had grown, with additional partners including UNICEF, UNFPA, Gavi, and the Spanish Agency for International Development Cooperation (AECID) joining the funding coalition. However, challenges in funding allocation and resource planning highlighted the need for systemic reforms to ensure sustainable financing for UHC and other Sustainable Development Goal (SDG) 3 targets.
P4H Network and Global Action Plan for SDG 3: A pathway to sustainable health financing
Faced with fragmented external health financing and the urgent need to expand free healthcare coverage, Niger embarked on ambitious reforms to strengthen its health financing system. One key strategy was to enhance coordination among health partners by leveraging the Providing for Health (P4H) global health financing and social protection network, which has been active in Niger since 2018. In 2021, P4H members and signatories of the Global Action Plan for Healthy Lives and Well-being for All (SDG 3 Action Plan) joined forces to appoint a national focal point. This position was designed to support the government in coordinating health financing and aligning partner efforts with national priorities.
The recruitment process, including the validation of shared objectives and the development of a clear mandate, was led by Gavi in collaboration with all health financing partners in Niger. By January 2022, the national focal point officially assumed the role of co-rapporteur for health financing partners under the P4H network and the SDG 3 Action Plan. Based within the Ministry of Health, the focal point serves as a vital interface between the ministry and technical and financial partners. Its primary function is to help coordinate partner support for health financing and project implementation, aligning efforts with national health priorities. This shift enables the Ministry of Health to adopt a more integrated, less donor-driven approach.
The funding mechanism for this new role, previously managed by the World Health Organization with AFD support, has since transitioned to the World Bank, with additional financial backing from the Global Financing Facility (GFF). Discussions are underway to establish predictable co-financing arrangements for the position. These efforts lay the groundwork for a more harmonized and collaborative support system, helping Niger achieve its ambitious UHC vision.
Key pillars of Niger’s health financing reforms
Before 2020, fragmented health financing in Niger led to either underfunding or overfunding of initiatives, according to Charlotte Pram Nielsen, Senior Specialist in Sexual and Reproductive Health, Rights, and Gender at the GFF. Historically, partners from different sectors struggled to collaborate effectively. However, through the partnership between P4H and the SDG 3 Action Plan’s financing accelerator, many partners are now more engaged and committed to supporting the government’s health financing goals. This collaboration enables discussions to extend beyond health financing, incorporating broader social protection programs and policies aimed at expanding fiscal space for health outcomes, such as social protection for women and children, explained Lou Tessier, Health Protection Specialist at the International Labour Organization (ILO).
In 2020, health financing partners in Niger prioritized support for COVID-19 response, national resource mobilization, resource optimization, effective development cooperation, and cross-cutting investments. The government identified key priorities for partner support, including:
- Aligning budgetary support with strategic and harmonized health expenditure indicators.
- Reforming the HCF to enhance 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 partner contributions and annual activity planning.
Specific objectives were set to achieve these priorities:
Harmonization of financing:
- Conducting a comprehensive survey of donors, funding flows, and health financing channels, followed by a critical analysis of financing harmonization (supported by the GFF).
- Assessing the trajectory and future of the HCF (with support from WHO/P4H).
- Analyzing investment case financing channels (supported by the GFF).
Harmonization of support:
- Surveying and critically analyzing technical assistance for health financing.
Financing systems and tools:
- Analyzing operational strategies for free healthcare and universal health insurance policies (with support from WHO/P4H, AFD, and HCF).
Efficiency and optimization tools:
- Developing and deploying a cost simulation tool to estimate production and financing costs in peripheral health facilities (supported by AFD, HCF, and GFF).
- Identifying and disseminating cost-effective innovations in health service delivery through bottom-up health system reforms (supported by AFD, HCF, and the Global Fund).
National resource mobilization and improved health spending allocation:
- Engaging with the International Monetary Fund (IMF) to incorporate health expenditures, such as vaccination and nutrition, into indicative target lists within its programs.
- Advocating for increased allocation of resources to primary healthcare and vaccination during high-level missions and meetings of the SDG 3 Action Plan signatories with the government.
Additional support is needed to analyze and rationalize the reorganization of technical committees within the Ministry of Health, in alignment with program budget reforms, and to propose policies that enhance the national financing system and expenditure efficiency.
While the collaborative health financing strategy is still evolving, it is expected to significantly improve health service delivery. For example, the GFF employs a resource optimization approach that involves tracking and analyzing funding flows to identify what each partner finances. This prioritization method helps avoid duplication and enables targeted interventions, ultimately benefiting more people, noted Moussa Bizo of the WHO Niger Office. The approach may also yield additional benefits, such as enabling the Global Fund or Gavi to invest more strategically in HIV, tuberculosis, malaria services, and vaccination programs. Since these services are covered under the free healthcare policy, financing reforms will help operationalize INAM more effectively, reducing out-of-pocket expenses for vulnerable populations.
Challenges and future directions
Joint focal points embedded within the Ministry of Health and sustainably funded are adding tangible value by facilitating coordination and alignment of partner support to the government. This is particularly crucial in a context where a significant portion of health sector financing comes from external sources.
Despite the enthusiasm surrounding this ambitious initiative, challenges remain. Focal points from participating organizations are often stretched thin, which could jeopardize the sustainability of the effort. Ensuring that staff have adequate time to dedicate to this role is essential. Another critical issue involves clarifying long-term funding modalities for the national focal point position, which is central to these efforts. The GFF has extended its funding for six months, and Gavi is currently facilitating discussions with other partners eager to enhance the long-term sustainability of health financing in Niger.
Lessons learned from this pilot partnership will be shared with other countries and partner organizations to address the demand for joint focal points and more harmonized, coordinated health financing support.
Understanding the SDG 3 Action Plan
The Global Action Plan for Healthy Lives and Well-being for All (SDG 3 Action Plan) is a collective commitment by 13 key health, development, and humanitarian agencies to help countries accelerate progress toward SDG health targets. The value of the SDG 3 Action Plan lies in its ability to strengthen collaboration among agencies, enabling joint action and more coordinated support aligned with nationally led plans and strategies. The plan was updated in October 2021 with a recovery strategy to ensure equitable and sustainable progress toward SDG health targets in the post-COVID-19 era.
Case studies are used to monitor the implementation of the SDG 3 Action Plan at the national level.
