Strengthening health financing and partner coordination in Niger

The Republic of Niger, a landlocked West African nation grappling with armed conflicts and persistent droughts, faces severe challenges in its healthcare system. The country records some of the world’s highest maternal and infant mortality rates, prompting the Government to prioritize Universal Health Coverage (UHC). This commitment builds on earlier efforts to expand access to essential health services.

In 2006, Niger launched a bold initiative to provide free healthcare, targeting women with reproductive and family planning services and children under five with a broad range of health benefits. While initial progress was encouraging, financial shortfalls hampered full implementation. By 2011, only half of the required funds had been mobilized, leading to unpaid medical bills and disrupted services. Moreover, the policy excluded older children and adults, forcing them to bear over 40% of total health expenditures—direct payments that remain a significant burden.

Over the years, government health spending fluctuated between 4.9% and 5.7% of GDP, reflecting inconsistent investment and the urgent need for sustainable financing reforms. Even before 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, additional partners—including UNICEF, UNFPA, Gavi, and Spain’s International Cooperation Agency (AECID)—joined the initiative.

The challenges in sustaining the free healthcare policy stemmed from inadequate resource assessments and insufficient funding, highlighting the need for systemic reforms to finance UHC and advance Sustainable Development Goal (SDG) 3 targets.

leveraging global networks to align health financing in Niger

Faced with fragmented external health financing, Niger sought to enhance coordination among partners through the Providing for Health (P4H) network, a global alliance for health financing and social protection 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 Global Action Plan) collaborated to appoint a national focal point. This role supports coordination of health financing and evidence-based decision-making under government leadership.

The selection process, including goal-setting and mandate development, was jointly facilitated by Gavi and all health financing partners in Niger. In January 2022, the focal point’s role as the official co-rapporteur for health financing partners was formalized. Housed within the Ministry of Health, this position serves as a critical interface between the government and technical and financial partners. Its primary function is to coordinate partner support for health financing and project implementation aligned with national priorities, enabling the Ministry to reduce its reliance on individual agencies.

The financing mechanism for this role, previously managed by WHO with AFD support, transitioned to the World Bank, with funding from the Global Financing Facility (GFF) and discussions underway for predictable co-financing modalities. These efforts lay the groundwork for more harmonized and unified support, helping Niger achieve its ambitious UHC goals.

key reforms to strengthen Niger’s health financing system

Before 2020, fragmented resources led to both underfunding and overfunding of initiatives. Through the P4H partnership and the SDG 3 Global Action Plan accelerator, partners have rallied around supporting the Government in health financing. This collaboration expands discussions beyond health programs to include social protection initiatives that influence health outcomes, such as programs supporting women and children.

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

• Aligning budget support with harmonized health expenditure indicators.
• Reforming the FCS to enhance fungibility and transition from a management tool to a financing system.
• Implementing strategic procurement with 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:

harmonizing health financing

• Mapping donors, funding flows, and health financing channels; conducting critical analysis of health financing harmonization (with support from the GFF).
• Assessing the trajectory and future of the FCS (with support from WHO/P4H).
• Developing investment case financing channels (with support from the GFF).

harmonizing support

• Mapping and critically analyzing technical assistance for health financing.

financing systems and tools

• Analyzing the operational strategies of free healthcare and universal health insurance policies (with support from WHO/P4H, AFD, and FCS).

efficiency and optimization tools

• Developing and deploying a cost-simulation tool to estimate production and financing costs at the community level (with support from AFD, FCS, and GFF).
• Identifying and scaling low-cost innovations in health service delivery through bottom-up reform strategies (with support from AFD, FCS, and the Global Fund).

mobilizing domestic resources and improving health spending allocation

• Engaging with the IMF to include health spending indicators—such as vaccination and nutrition—in indicative target lists.
• Advocating for increased allocation to primary healthcare and vaccination during high-level missions and SDG 3 Global Action Plan meetings with the Government.

Additional support is needed to analyze the restructuring of Ministry of Health technical committees as part of program budget reforms and to propose policies that enhance national financing systems and spending efficiency.

While still in the implementation phase, this collaborative financing strategy aligns with the country’s priorities and aims to improve health service delivery. For example, the GFF applies a resource optimization approach to track and monitor funding, enabling partners to avoid duplication and target interventions more effectively. This method benefits programs like HIV, tuberculosis, malaria control, and vaccination services, many of which fall under the free healthcare policy. By reforming financing, Niger can further operationalize INAM, reducing out-of-pocket expenses for vulnerable populations.

lessons learned and future outlook

Joint focal points integrated into the Ministry of Health and financed sustainably add value by facilitating coordination and alignment of partner support—a critical function in a country where a significant share of health funding comes from external sources.

Despite strong enthusiasm, challenges remain. Focal points face heavy workloads, risking the initiative’s sustainability. Ensuring adequate staff time allocation across agencies is essential. Another hurdle is securing long-term financing for the national focal point position, a cornerstone of these efforts. The GFF extended its funding by six months, and Gavi is leading discussions to secure additional support from partners eager to improve health financing sustainability in Niger.

Lessons from this pilot partnership will be shared with other countries and partners to meet the demand for joint focal points and more harmonized, coordinated health financing support.

what is 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 commitment by 13 leading health, development, and humanitarian agencies to help countries accelerate progress toward health-related SDG targets. Its value lies in strengthening collaboration among agencies to take joint action and provide coordinated support aligned with nationally led plans and strategies. Updated in October 2021 with an equitable and sustainable recovery strategy post-COVID-19, the plan aims to meet health-related SDG targets.

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