strengthening cooperation and funding for health in Niger
The Republic of Niger, a landlocked nation in West Africa, has grappled with persistent armed conflicts and prolonged periods of drought. These challenges have severely impacted the country’s healthcare infrastructure, contributing to some of the highest maternal and infant mortality rates globally. In response to this critical situation, the Government of Niger has committed to achieving universal health coverage (UHC), building upon insights gained from previous initiatives aimed at broadening access to essential health services.
In 2006, confronting alarming health indicators, the government launched an ambitious policy to provide free healthcare. This initiative sought to offer complimentary reproductive and family planning services to women, alongside a broad spectrum of health services for children under five. Despite initial successes, the momentum for health improvements was undermined by inadequate funding. By 2011, only half of the necessary resources for full implementation had been secured. Over time, this led to an accumulation of unpaid medical bills and hampered healthcare providers’ ability to deliver services. Furthermore, as this policy exclusively targeted women and children under five, other users of health services incurred substantial out-of-pocket expenses. The World Health Organization (WHO) estimates that direct out-of-pocket payments account for over 40% of total health expenditures in Niger.
Overall, the Government of Niger has struggled to increase health resource allocation, with health spending decreasing from 5.4% to 4.9% of GDP between 2007 and 2011. While it later rose from 4.9% to 5.6% of GDP between 2016 and 2018, it subsequently plateaued around 5.7% from 2018 to 2020.
Even prior to the implementation of the free healthcare policy, Niger recognized the importance of coordinating efforts among health financing partners. In 2006, the Ministry of Health, the Agence Française de Développement (AFD), and the World Bank established the Common Health Fund (FCS) to support Niger’s health development plan. By 2020, four additional international partners—UNICEF, UNFPA, Gavi, and the Spanish Agency for International Development Cooperation (AECID)—were contributing to the fund. The funding shortfalls associated with the free healthcare policy stemmed from poor assessments and insufficient resource provision, underscoring the urgent need for reforms to ensure sustainable financing for UHC and other SDG 3 targets.
P4H Network and the Global Action Plan for SDG 3: leveraging existing collaborative mechanisms for sustainable health funding
Recognizing the critical need to establish free healthcare to achieve UHC in Niger, the government initiated comprehensive reforms of its health financing system. This was partly driven by the highly fragmented nature of external health funding, which necessitated improved coordination and harmonization among partner organizations providing health financing support and technical assistance. Learning from past initiatives like the FCS, the country has intensified its focus on health partner coordination, notably through Providing for Health (P4H), the global health financing and social protection network, active in Niger since 2018. In 2021, members of the P4H network and signatory agencies of the Global Action Plan for Healthy Lives and Well-being for All (Global Action Plan for SDG 3) joined forces to recruit a country focal point. This role aims to support and facilitate health financing coordination and pragmatic research, with leadership and backing from the government.
Gavi, in collaboration with all health financing partners in Niger, facilitated the recruitment process for this country focal point, including validating shared objectives and developing the mandate. Gavi’s national mandate as the official “co-rapporteur” for health financing partners was then assumed by the national focal point for the P4H Network and Global Action Plan financing accelerator in January 2022. Within the Ministry of Health, this focal point serves as a crucial intermediary with technical and financial partners. Their primary role is to help coordinate partner support for financing and implementing projects that align with national health priorities, thereby enabling the Ministry of Health to be “less agency-centric.” The funding mechanism for this new position, previously led by the WHO with AFD financing, has been transferred to the World Bank, with financial backing from the Global Financing Facility. Arrangements for predictable co-financing of the position are currently under consideration. These endeavors are laying the groundwork for more harmonized and collective support, vital for Niger to realize its ambitious vision for UHC.
how is Niger’s health financing system being strengthened?
Before 2020, resource fragmentation often resulted in “many initiatives being under- or over-funded,” as highlighted by Charlotte Pram Nielsen, Senior Specialist for Sexual and Reproductive Health, Rights, and Gender at the Global Financing Facility. In the context of health financing, partners from different areas were not accustomed to collaborating effectively. Thanks to the partnership between the P4H network and the Global Action Plan’s financing accelerator, many partners are now enthusiastic and committed to supporting the government’s health financing efforts. This partnership facilitates “framing discussions within broader social protection programs and considering the expansion of fiscal space policies that impact health outcomes, such as social protection for women and children,” states Lou Tessier, Health Protection Specialist at the International Labour Organization (ILO).
In 2020, health financing partners prioritized supporting Niger in areas such as COVID-19 response, domestic resource mobilization, resource optimization, effective development cooperation, and transversal investments. The government outlined the following key priorities for support:
- Alignment of budgetary support with strategic and harmonized health expenditure indicators.
- Reform of the FCS to enhance its fungibility and transition it from a management tool to a financing system.
- Implementation of strategic purchasing, with practical assistance from the National Institute for Medical Assistance (INAM).
- Improved predictability of technical and financial partners’ contributions and annual activity planning.
Specific objectives were established to achieve these priorities:
harmonizing financing:
- Mapping donors, flows, and channels of health financing, and critically analyzing health financing harmonization (with support from the Global Financing Facility).
- Determining the trajectory and future of the FCS (with support from WHO/P4H).
- Identifying financing channels for the investment case (with support from the Global Financing Facility).
harmonizing support:
- Inventory and critical analysis of technical assistance for health financing.
financing system and tools:
- Analysis of operational modalities for free healthcare and universal health insurance strategies (with support from WHO/P4H, AFD, and FCS).
efficiency and optimization tools:
- Development and deployment of a calculation tool to simulate production and financing costs for peripheral care (with support from AFD, FCS, and the Global Financing Facility).
- Identification of strategies to improve and reform the healthcare chain from the ground up to identify and disseminate low-cost innovations in various contexts (with support from AFD, FCS, and the Global Fund).
domestic resource mobilization and improved allocation of health expenditures:
- Engaging with the International Monetary Fund (IMF) on program design to include expenditures in indicative targets, in areas such as immunization and nutrition.
- Advocating for greater resource allocation to primary healthcare and immunization during high-level missions and meetings of Global Action Plan for SDG 3 signatory agencies with the government.
Further support is needed for analyses on streamlining/reorganizing technical committees within the Ministry of Health as part of budget program reform, and for policy analyses and proposals aimed at enhancing the national financing system and the efficiency of health expenditures.
While not yet fully operational, this collaborative health financing strategy, centered on the country’s key priorities, will ultimately improve health service delivery. For instance, the Global Financing Facility, employing a resource optimization approach, is tasked with inventorying and tracking resources to understand what each agency finances. This prioritization of resources and approaches among various partners helps “avoid duplication and, consequently, allows for more targeted intervention, which would ultimately improve the lives of more people,” notes Moussa Bizo from the WHO Niger Office. Moreover, the resource optimization method could yield additional benefits, such as enabling the Global Fund or Gavi to invest more strategically in financing services for HIV, tuberculosis, malaria, and immunization, respectively. As the free healthcare policy covers these programs, financing reform would contribute to better operationalization of INAM, thereby reducing out-of-pocket expenses for poor and vulnerable populations.
lessons learned, challenges, and future outlook
Joint focal points, integrated within the Ministry of Health and sustainably funded, add significant value by facilitating coordination and aligning partner support with government priorities. This is particularly relevant in a context where a substantial portion of the health sector’s funding originates from external sources.
Despite the enthusiasm surrounding this ambitious initiative, challenges persist. The focal points from participating agencies in this partnership face considerable demands on their time, which could negatively impact the initiative’s sustainability. Therefore, ensuring adequate dedicated time for personnel within each agency is crucial.
Another challenge involves clarifying the long-term funding arrangements for the country focal point position, a central pillar of these collective efforts. The Global Financing Facility has extended its funding for six months, and Gavi is currently leading discussions on securing support from other partners who are keen to enhance 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.
what is the global action plan for SDG 3?
The Global Action Plan for Healthy Lives and Well-being for All (Global Action Plan for SDG 3) represents a set of commitments made by 13 key agencies involved in health, development, and humanitarian action. Its purpose is to help countries accelerate progress towards health-related Sustainable Development Goals (SDG) targets. The added value of the Global Action Plan for SDG 3 lies in strengthening inter-agency collaboration to undertake joint actions and provide more coordinated support, aligned with country-led national plans and strategies. The Global Action Plan for SDG 3 was updated with a recovery strategy in October 2021, focusing on an equitable and sustainable recovery from the COVID-19 pandemic, with the aim of achieving health-related SDG targets.
The objective of these case studies is to monitor the implementation of the Global Action Plan at the national level.
