Niger’s health financing reforms and partner coordination
The Republic of Niger, a landlocked nation in West Africa, has faced prolonged armed conflicts and severe droughts, significantly straining its healthcare system. With maternal and infant mortality rates ranking among the highest globally, the Government of Niger has prioritized universal health coverage (UHC) as a national goal. This commitment stems from lessons learned in earlier efforts to expand access to essential health services.
In 2006, Niger introduced an ambitious free healthcare policy, offering free reproductive health and family planning services to women, along with a wide range of healthcare services for children under five. While initial progress under this initiative was promising, insufficient funding hampered its full potential. By 2011, only half of the required resources had been mobilized, leading to unpaid medical bills and disrupting service delivery. Additionally, the policy’s focus on women and young children left other patients burdened with high out-of-pocket expenses. The World Health Organization (WHO) reports that direct health expenditures exceed 40% of Niger’s total health spending.
Over the years, Niger has struggled to increase its health budget, with healthcare expenditures fluctuating from 5.4% of GDP in 2007 to 4.9% in 2011, rising again to 5.6% by 2018, and stabilizing around 5.7% from 2018 to 2020.
Even before implementing the free healthcare policy, Niger recognized the importance of coordinating 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 support Niger’s health development plan. By 2020, four additional international partners joined: UNICEF, UNFPA, Gavi, and the Spanish Agency for International Development Cooperation (AECID). The funding challenges tied to the free healthcare policy highlight the need for reforms to ensure sustainable financing for UHC and other Sustainable Development Goal (SDG) 3 targets.
A mother cuddling her baby in the village of Soki, central Niger. © UNICEF/Dejongh
P4H Network and Global Action Plan for SDG 3: A pathway to sustainable health financing
Faced with the urgency of achieving free healthcare and UHC in Niger, the Government has pursued bold reforms in health financing. A key challenge was the fragmented nature of external health funding, necessitating better coordination and alignment among partner organizations. Building on earlier initiatives like the FCS, Niger has leveraged networks such as Providing for Health (P4H) since 2018. In 2021, members of the P4H network and signatories of the Global Action Plan for Health and Well-being (SDG 3 Action Plan) collaborated to appoint a national focal point. This role, supported by the Government, aims to streamline health financing coordination and evidence-based collaboration.
The recruitment process, including the validation of shared objectives and mandate development, was facilitated by Gavi in partnership with all health financing partners in Niger. By January 2022, the focal point’s role as an official “co-rapporteur” for health financing partners was assumed by the national focal point of the P4H network’s financing accelerator and the SDG 3 Action Plan. Within the Ministry of Health, this focal point serves as a critical interface with technical and financial partners, helping align health support with national priorities and reducing reliance on individual organizations. Previously funded by WHO with AFD support, the financing mechanism for this position has since transitioned to the World Bank, with additional funding from the Global Financing Facility, and discussions on predictable co-financing modalities are underway. These efforts lay the groundwork for more harmonized and collective support to help Niger achieve its UHC vision.
Key components of Niger’s health financing system strengthening
Before 2020, fragmented resources led to either insufficient or excessive funding for numerous initiatives, as noted by Charlotte Pram Nielsen, Senior Specialist in Sexual and Reproductive Health, Rights, and Gender at the Global Financing Facility. Health partners from non-health sectors often lacked effective collaboration. Thanks to the P4H network and the financing accelerator of the SDG 3 Action Plan, many partners are now more engaged in supporting the Government’s health financing goals. Lou Tessier, Health Protection Specialist at the International Labour Organization (ILO), highlights that this partnership helps integrate health discussions into broader social protection programs and explore budgetary strategies to improve health outcomes for women and children.
In 2020, health financing partners prioritized support for Niger in areas such as COVID-19 response, domestic resource mobilization, resource optimization, effective development cooperation, and cross-cutting investments. The Government identified the following key priorities for support:
- 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 purchasing 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 were set to achieve these priorities:
Harmonized financing:
- Mapping donors, health funding flows, and channels, along with a critical analysis of financing harmonization (supported by the Global Financing Facility).
- Assessing the FCS’s trajectory and future (supported by WHO/P4H).
- Developing investment argumentation for financing channels (supported by the Global Financing Facility).
Harmonized support:
- Mapping and critically analyzing technical assistance for health financing.
Financing systems and tools:
- Analyzing operational strategies for 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 care production and financing costs in peripheral areas (supported by AFD, FCS, and the Global Financing Facility).
- Mapping strategies to improve and reform the health system from the bottom up, identifying and scaling low-cost innovations across contexts (supported by AFD, FCS, and the Global Fund).
National resource mobilization and better allocation of health spending:
- Engaging with the International Monetary Fund (IMF) to include health spending in indicative targets, such as vaccination and nutrition.
- Advocating for increased resources for primary healthcare and vaccination during high-level missions and SDG 3 Action Plan meetings with the Government.
Additional support is needed to analyze the rationalization and reorganization of the Ministry of Health’s technical committees as part of the program budget reform. This includes proposals to enhance national financing systems and spending efficiency.
While this collaborative health financing strategy is not yet fully operational, it is expected to significantly improve healthcare service delivery. For example, the Global Financing Facility’s resource optimization approach involves tracking and mapping resources to identify what each partner finances. This prioritization helps “avoid duplication and target interventions more effectively, ultimately improving the lives of more people,” says Moussa Bizo of the WHO Niger Office. The method could also enable the Global Fund and Gavi to invest more strategically in HIV, tuberculosis, and malaria services, as well as vaccination programs—all of which fall under Niger’s free healthcare policy. By reforming financing, Niger aims to enhance INAM’s operational efficiency, reducing out-of-pocket expenses for vulnerable populations.
Challenges, lessons learned, and future outlook
Joint focal points embedded within the Ministry of Health and sustainably funded add value by facilitating coordination and alignment of partner support to the Government. This is particularly crucial in a country where a significant portion of health sector funding comes from external sources.
Despite the enthusiasm for this ambitious initiative, challenges remain. Focal points from participating organizations face significant workload pressures, which could threaten the initiative’s long-term sustainability. Ensuring dedicated time for these roles within each organization is essential.
Another hurdle is clarifying long-term financing modalities for the national focal point position, a cornerstone of these efforts. The Global Financing Facility has extended its funding by six months, and Gavi is leading discussions with other partners eager to enhance the sustainability of health financing in Niger.
Lessons from this pilot partnership will be shared with other countries and partner organizations to meet the demand for joint focal points and more harmonized, coordinated health financing support.
What is the Global Action Plan for SDG 3?
The Global Action Plan for Health and Well-being (SDG 3 Action Plan) is a set of commitments made by 13 key health, development, and humanitarian agencies to help countries accelerate progress toward SDG 3 health targets. Its added value lies in strengthening collaboration among agencies to take joint actions and provide more coordinated support aligned with nationally led plans and strategies. Updated in October 2021 with a recovery strategy, the SDG 3 Action Plan aims to support equitable and sustainable health recovery in the wake of the COVID-19 pandemic and achieve health-related SDG targets.
Case studies on the implementation of the SDG 3 Action Plan at the national level are ongoing.