Reforming health financing and partner coordination in Niger

Transforming health financing and partner coordination in the Republic of Niger

The Republic of Niger, a landlocked West African nation, has faced prolonged armed conflicts and recurring droughts, severely straining its healthcare system. With some of the world’s highest maternal and infant mortality rates, the country has prioritized universal health coverage (UHC) as a national objective. This commitment gained momentum following earlier efforts to expand access to essential health services.

In 2006, Niger launched an ambitious free healthcare policy targeting women’s reproductive and family planning services, along with comprehensive healthcare for children under five. While initial progress was promising, insufficient funding derailed its full implementation. By 2011, only half of the required resources had been mobilized, leading to unpaid medical bills and service disruptions. Additionally, since the policy exclusively benefited women and young children, other patients faced steep 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. Though it rebounded slightly to 5.6% between 2016 and 2018, growth stagnated at around 5.7% from 2018 to 2020.

Prior to implementing its 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 Common Fund (FCS) to support Niger’s health development plan. By 2020, four additional international partners had joined: UNICEF, UNFPA, Gavi, and the Spanish Agency for International Development Cooperation (AECID). However, funding shortages persisted due to misaligned resource allocation and inadequate financial planning, underscoring the need for systemic reforms to ensure sustainable UHC financing and progress toward Sustainable Development Goal (SDG) 3 targets.

Leveraging global health financing networks for sustainable progress in Niger

Recognizing the urgency of addressing healthcare access challenges, Niger pursued ambitious health financing reforms. External health funding had been highly fragmented, prompting the need for better coordination and alignment among partner organizations. Building on lessons from initiatives like the FCS, the country turned to Providing for Health (P4H), a global health financing and social protection network active in Niger since 2018. In 2021, P4H 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, supported by the Government, aims to enhance health financing coordination and evidence-based decision-making.

The recruitment process, including goal validation and mandate development, was facilitated by Gavi in partnership with Niger’s health financing stakeholders. In January 2022, Gavi’s role as the official co-rapporteur of health financing partners transitioned to the national focal point under the P4H network and SDG 3 Global Action Plan. Based within the Ministry of Health, this focal point serves as a critical liaison between the Ministry and technical and financial partners. Its primary function is to streamline partner support for financing and implementing health projects aligned with national priorities, enabling the Ministry to reduce its reliance on individual organizations. Funding for this role, previously managed by WHO with AFD support, has since been transferred to the World Bank, with contributions from the Global Financing Facility and ongoing discussions on predictable co-financing arrangements. These efforts lay the groundwork for more harmonized and collective support to achieve Niger’s UHC vision.

Key pillars of Niger’s health financing system reform

Before 2020, fragmented funding led to “either underfunding or overfunding of multiple initiatives,” according to Charlotte Pram Nielsen, Senior Specialist for Sexual and Reproductive Health, Gender, and Human Rights at the Global Financing Facility. Historically, partners from different sectors struggled to collaborate effectively. However, the partnership between P4H and the SDG 3 Global Action Plan’s financing accelerator has fostered greater enthusiasm and commitment among partners to support Niger’s health financing efforts. This collaboration has broadened discussions to include social protection programs and strategies to expand fiscal space for health, such as social protection for women and children, noted Lou Tessier, Health Protection Specialist at the International Labour Organization (ILO).

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

Harmonizing health financing:

• Mapping donors, funding flows, and channels, and critically analyzing health financing harmonization (with support from the Global Financing Facility).
• Defining the trajectory and future of the FCS (with support from WHO/P4H).
• Developing investment argument financing channels (with support from the Global Financing Facility).

Harmonizing 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 (with support from WHO/P4H, AFD, and FCS).

Efficiency and optimization tools:

• Developing and deploying a cost simulation tool to model healthcare production and financing costs in peripheral regions (with support from AFD, FCS, and the Global Financing Facility).
• Identifying and scaling low-cost innovations in health service delivery chains to improve efficiency across contexts (with support from AFD, FCS, and the Global Fund).

Mobilizing national resources and optimizing health expenditures:

• Engaging with the International Monetary Fund (IMF) to include health expenditures, such as vaccination and nutrition, in indicative target lists within its programs.
• Advocating for increased allocation to primary healthcare and vaccination during high-level missions and meetings with signatories of the SDG 3 Global Action Plan and the Government.

Additional support is needed to analyze the restructuring of the Ministry of Health’s technical committees as part of the program budget reform, as well as to develop policy proposals aimed at enhancing national financing systems and expenditure efficiency.

While still in its early stages, this collaborative health financing strategy centered on national priorities is expected to significantly improve healthcare service delivery. For instance, the Global Financing Facility employs a resource optimization approach to track and prioritize funding, ensuring targeted interventions that avoid duplication. This method enables more strategic investments by organizations like the Global Fund and Gavi in HIV, tuberculosis, malaria, and vaccination services. As free healthcare policies cover these programs, financing reforms will enhance INAM’s operational efficiency, reducing out-of-pocket expenses for vulnerable populations.

Lessons, challenges, and future outlook for health financing in Niger

Joint focal points integrated into the Ministry of Health and funded sustainably 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 financing comes from external sources.

Despite strong enthusiasm for this ambitious initiative, challenges remain. Focal points from participating organizations face heavy workloads, which could jeopardize the initiative’s long-term sustainability. Ensuring dedicated time and resources for focal points across organizations is essential.

Another critical issue is clarifying long-term funding modalities for the national focal point position, a cornerstone of these efforts. The Global Financing Facility has extended its funding for six months, and Gavi is leading discussions with partners eager to enhance the sustainability of health financing in Niger.

Lessons from this pilot partnership will be shared with other countries and partners 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 commitment by 13 key organizations in health, development, and humanitarian action to help countries accelerate progress toward health-related SDG targets. Its added 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 SDG 3 Global Action Plan aims to achieve health-related SDG targets through equitable and sustainable post-COVID-19 recovery.

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