Reforming health funding in Niger through partner coordination

The Republic of Niger, a landlocked nation in West Africa, has faced persistent armed conflicts and severe droughts, placing immense strain on its healthcare system. These challenges contribute to Niger having some of the highest maternal and infant mortality rates globally. In response, the Nigerien government has prioritized achieving Universal Health Coverage (UHC), building on lessons learned from earlier efforts to expand access to essential health services.

In 2006, amid alarming health outcomes, the government introduced a bold free healthcare policy to provide no-cost reproductive health services and family planning for women, along with comprehensive care for children under five. While early progress was made, the initiative stumbled due to insufficient funding—by 2011, only half of the required resources had been secured. Over time, unpaid medical bills accumulated, preventing healthcare providers from delivering consistent services. Additionally, since the policy exclusively covered women and young children, other patients faced prohibitively high out-of-pocket expenses. According to the World Health Organization (WHO), direct payments account for over 40% of total health expenditures in Niger.

Between 2007 and 2011, health spending declined from 5.4% to 4.9% of GDP. A modest recovery occurred from 2016 to 2018, with spending rising to 5.6% of GDP, but it plateaued at around 5.7% between 2018 and 2020. Long before the free healthcare policy, Niger recognized the critical need for coordinated health financing. 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 the initiative: UNICEF, UNFPA, Gavi, and the Spanish Agency for International Development Cooperation (AECID). Inadequate funding for the free healthcare policy stemmed from misaligned priorities and insufficient resource allocation, highlighting the urgent need for sustainable reforms to fund UHC and other targets outlined in Sustainable Development Goal 3 (SDG 3).

global partnerships and coordinated health financing in Niger

Given the urgency of implementing free healthcare to advance UHC in Niger, the government launched ambitious reforms to restructure health financing. A major hurdle was the fragmented nature of external health funding, which demanded stronger coordination and alignment among partner organizations supporting health financing and technical assistance. Building on past experiences with the FCS, the country has intensified efforts to enhance coordination through Providing for Health (P4H), a global network for health financing and social protection active in Niger 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 Global Action Plan) collaborated to establish a national focal point within Niger’s Ministry of Health. This role, supported by Gavi and all health financing partners, aims to streamline coordination, mobilize resources, and align health financing with national priorities. Since January 2022, the focal point has served as an official “co-reporter” for health financing partners, acting as a bridge between the Ministry and technical/financial partners. The position, initially funded by the WHO and AFD, has transitioned to the World Bank, with potential co-financing mechanisms under review by the Global Financing Facility (GFF). These steps lay the groundwork for a more unified and predictable health financing framework to support Niger’s UHC ambitions.

key reforms in Niger’s health financing system

Prior to 2020, fragmented funding led to either underfunding or overfunding of health initiatives, as noted by 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 P4H network and the SDG 3 Global Action Plan accelerator, many stakeholders are now more engaged in supporting the government’s health financing goals. This partnership fosters discussions on integrating health programs into broader social protection frameworks and expanding fiscal policies that influence health outcomes—such as social protection for women and children—says Lou Tessier, Health Protection Specialist at the International Labour Organization (ILO).

In 2020, health financing partners in Niger prioritized support in areas including COVID-19 response, domestic resource mobilization, resource optimization, effective development cooperation, and cross-cutting investments. The government identified key strategic priorities for support:

• Aligning budgetary support with harmonized health spending 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 were set to achieve these priorities, including:

harmonizing health financing

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

harmonizing support

• Mapping and critically analyzing technical assistance for health financing.

financing systems and tools

• Analyzing the operational strategies of the free healthcare policy and universal health insurance (supported by the WHO/P4H, AFD, and the 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, the FCS, and the GFF).
• Mapping bottom-up health system improvement strategies to identify and scale cost-effective innovations across contexts (supported by AFD, the FCS, and the Global Fund).

national 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 meetings with signatories of the SDG 3 Global Action Plan alongside the government.

Further analysis is needed to streamline and reorganize technical committees within the Ministry of Health as part of the budget program reform, as well as to develop policy proposals to enhance national financing systems and spending efficiency.

While still in the implementation phase, this collaborative financing strategy aligns with Niger’s key priorities and is expected to improve healthcare delivery. For instance, the GFF applies a resource optimization method to track and prioritize funding, ensuring each partner’s contributions are clearly mapped. This approach minimizes duplication of efforts and enables targeted interventions that ultimately improve lives, notes Moussa Bizo from the WHO Country Office in Niger. The method also allows partners like the Global Fund or Gavi to invest more strategically in HIV, tuberculosis, malaria services, and vaccination programs. Since these services fall under the free healthcare policy, financing reforms will enhance the operational capacity of INAM, reducing out-of-pocket expenses for vulnerable populations.

lessons, challenges, and future outlook

Joint focal points embedded within the Ministry of Health and sustainably funded add significant value by improving coordination and alignment of partner support to the government. This is particularly crucial in a country where a substantial share of health sector funding comes from external sources.

Despite strong enthusiasm for the initiative, challenges persist. Focal points from participating organizations often face overwhelming workloads, which could jeopardize the sustainability of the effort. Ensuring dedicated time and resources for these roles is essential. Another critical issue is securing long-term funding for the national focal point position, a cornerstone of these efforts. The GFF has extended its funding by six months, and Gavi is leading discussions with other partners eager to bolster the 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 global action plan

The Global Action Plan for Healthy Lives and Well-being for All (SDG 3 Global Action Plan) is a collective commitment by 13 key agencies in health, development, and humanitarian action to help countries accelerate progress toward SDG 3 health targets. Its value lies in strengthening collaboration among organizations to take joint action and provide more coordinated support aligned with nationally led plans and strategies. Updated in October 2021 with a recovery strategy, the plan aims to support an equitable and sustainable recovery from the COVID-19 pandemic while advancing SDG 3 health targets.

The case studies aim to track the implementation of the SDG 3 Global Action Plan at the national level.