Strengthening health financing and partner coordination in Niger

Enhancing health financing and partner collaboration in the Republic of Niger

The Republic of Niger, a landlocked country in West Africa, has faced persistent armed conflicts and severe droughts, severely impacting its healthcare system. With maternal and infant mortality rates among the highest globally, the Government of Niger has prioritized Universal Health Coverage (UHC) as a national objective. This commitment followed earlier efforts to expand access to essential health services, which had shown promising results but were undermined by insufficient funding.

In 2006, to address rising health crises, the Government launched a bold initiative offering free healthcare services for women—including reproductive health and family planning—and children under five. While this policy initially succeeded in reducing mortality rates, financial shortfalls crippled progress. By 2011, only half of the required funds had been mobilized, leading to unpaid medical bills and service disruptions. Additionally, the policy excluded other vulnerable groups, forcing them to bear disproportionate out-of-pocket expenses. The World Health Organization (WHO) reports that Nigerians spend over 40% of total health expenditures directly at the point of care.

Between 2007 and 2011, health spending declined from 5.4% to 4.9% of GDP. A slight recovery occurred between 2016 and 2018, with spending rising to 5.6% of GDP, but it plateaued around 5.7% from 2018 to 2020.

Aware of the need for better coordination among health partners, the Government of Niger established the Health Common Fund (HCF) in 2006 with the Ministry of Health, the French Development Agency (AFD), and the World Bank. By 2020, the HCF expanded to include UNICEF, UNFPA, Gavi, and the Spanish Agency for International Development Cooperation (AECID). However, funding challenges persisted due to misaligned priorities and insufficient resource allocation, highlighting the urgent need for systemic reforms to secure sustainable health financing and advance Sustainable Development Goal 3 (SDG 3).

The Government’s ambition to achieve UHC required addressing fragmented external health financing. Leveraging existing collaboration frameworks, Niger turned to Providing for Health (P4H), a global health financing and social protection network active in the country since 2018. In 2021, P4H network members 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, aimed to strengthen coordination among health partners and align technical and financial support with national health priorities.

The recruitment process, facilitated by Gavi in collaboration with health financing partners, culminated in January 2022 when the focal point—initially funded by WHO and AFD—transitioned to the World Bank under the Global Financing Facility, with co-financing modalities under consideration. This role serves as a bridge between the Ministry of Health and international partners, enabling more efficient and predictable health financing and reducing administrative burdens on the Ministry.

Key reforms in Niger’s health financing system

Prior to 2020, fragmented funding resulted in inconsistent resource allocation, with some areas receiving excess funds while others faced critical shortages. Charlotte Pram Nielsen, Senior Specialist in Sexual and Reproductive Health at the Global Financing Facility, notes that sectoral partners often worked in silos. The partnership between P4H and the SDG 3 GAP accelerator has fostered greater collaboration, integrating health financing discussions into broader social protection strategies and expanding fiscal space for health outcomes such as maternal and child protection.

In 2020, health partners prioritized support for COVID-19 response, domestic resource mobilization, resource optimization, and cross-cutting investments. The Government identified key priorities for alignment and reform:

• Harmonizing budget support with strategic and standardized health expenditure indicators.
• Reforming the HCF to enhance fungibility and transition from a management tool to a sustainable financing mechanism.
• Implementing strategic procurement with the support of the National Institute of Medical Assistance (INAM).
• Improving the predictability of partner contributions and annual activity planning.

Specific objectives were set to achieve these priorities:

Financing harmonization:

• Mapping donors, funding flows, and health financing channels, and analyzing alignment efforts (supported by the Global Financing Facility).
• Defining the future trajectory of the HCF (supported by WHO/P4H).
• Developing investment case financing channels (supported by the Global Financing Facility).

Support harmonization:

• Mapping and critically reviewing technical assistance for health financing.

Financing systems and tools:

• Analyzing operational models of free healthcare policies and universal health insurance (supported by WHO/P4H, AFD, and HCF).

Efficiency and optimization tools:

• Developing and deploying a cost simulation tool for health service production and financing at the periphery (supported by AFD, HCF, and Global Financing Facility).
• Identifying and scaling low-cost innovations in primary healthcare systems through bottom-up reforms (supported by AFD, HCF, and the Global Fund).

Domestic resource mobilization and health expenditure allocation:

• Engaging with the International Monetary Fund (IMF) to integrate health spending—such as vaccination and nutrition—into indicative targets in national programs.
• Advocating for increased allocations to primary healthcare and immunization during high-level meetings and SDG 3 GAP signatory sessions with the Government.

Further analysis is needed to streamline technical committees within the Ministry of Health as part of program budget reforms and to propose policies that enhance national financing efficiency and expenditure effectiveness.

While still in development, this collaborative financing strategy aligns with Niger’s health priorities and is expected to improve service delivery. The Global Financing Facility, for instance, uses a resource optimization method to track and prioritize funding, reducing duplication and enabling targeted interventions. “This approach ensures that partners invest where needs are greatest, ultimately improving health outcomes for more people,” says Moussa Bizo of WHO Niger. It also allows strategic investments by partners like the Global Fund and Gavi in HIV, tuberculosis, malaria, and immunization services, which are covered under the free healthcare policy. Reforming health financing is projected to enhance INAM’s operational efficiency, further reducing out-of-pocket expenses for the poor and vulnerable.

Challenges, lessons learned, and future outlook

The integration of joint focal points within the Ministry of Health has proven valuable in aligning partner support with national health strategies—especially critical in a country where external financing constitutes a large share of health sector funding. However, challenges remain. Focal points face heavy workloads, risking the sustainability of these efforts. Ensuring adequate staffing and dedicated time within partner organizations is essential.

Another critical challenge is securing long-term funding for the national focal point position, a cornerstone of this initiative. The Global Financing Facility has extended its support by six months, and Gavi is leading discussions with additional partners to secure sustainable financing for health in Niger. Lessons from this pilot will be shared with other countries and organizations to promote the adoption of joint focal points and more harmonized, coordinated health financing support.

What is the SDG 3 Global Action Plan?

The SDG 3 Global Action Plan unites 13 leading health, development, and humanitarian agencies to accelerate progress toward health-related SDG targets. Its core value lies in fostering collaboration among agencies to deliver coordinated support aligned with nationally led health strategies. Updated in October 2021 with a recovery strategy, the plan aims for equitable and sustainable post-COVID-19 recovery to meet health SDG targets.