Reforming health financing in Niger through stronger partner coordination

bridging gaps in health financing for universal coverage in Niger

Nestled in West Africa, the Niger faces formidable challenges: recurring armed conflicts and prolonged droughts have strained its health system, pushing maternal and child mortality rates among the highest globally. In response, the Government of Niger has committed to achieving universal health coverage (UHC), building on lessons from past attempts to expand access to essential health services.

In 2006, as health outcomes reached a critical low, the Government launched a bold initiative: free healthcare for women and children under five. This policy provided free reproductive health services, family planning, and a wide range of pediatric care. While the program showed early promise, its progress was derailed by chronic underfunding. By 2011, barely half of the required resources were mobilized, leaving unpaid medical bills piling up and preventing providers from delivering consistent care. The policy’s narrow scope also meant that other patients faced steep out-of-pocket expenses, which the World Health Organization (WHO) estimates now account for over 40% of total health spending in Niger.

Between 2007 and 2011, health expenditure dropped from 5.4% to 4.9% of GDP. Though it rose to 5.6% by 2018, it has since plateaued around 5.7% between 2018 and 2020, underscoring persistent funding gaps despite growing need.

a decade of reforms and evolving partnerships

Long 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 (HSCF) to support Niger’s health development plan. By 2020, the partnership expanded to include UNICEF, UNFPA, Gavi, and the Spanish Agency for International Development Cooperation (AECID). However, systemic funding shortfalls and weak resource allocation derailed early gains, highlighting the need for deeper reforms.

P4H network and global action plan: pathways to sustainable health financing

With the urgency of achieving UHC in mind, the Government launched ambitious reforms to improve health financing coordination. External health funding had been highly fragmented, prompting the need to better align and harmonize partner contributions and technical support. Drawing on the lessons of the HSCF, Niger turned to Providing for Health (P4H), a global network for health financing and social protection active in the country since 2018.

In 2021, members of the P4H network and signatories of the Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP) joined forces to recruit a national focal point within the Ministry of Health. This role was designed to support coordinated health financing, strengthen alignment with national priorities, and facilitate pragmatic research under government leadership. The recruitment process and mandate validation were led by Gavi in collaboration with all health financing partners.

In January 2022, the focal point was officially appointed as the ‘co-rapporteur’ of health financing partners, transitioning from an OMS-led mechanism to one supported by the Global Financing Facility (GFF) and the World Bank, with co-financing under consideration. This position serves as a critical interface between the Ministry of Health and technical and financial partners, helping shift focus from individual agencies to collective, country-led priorities.

strengthening Niger’s health financing system

Prior to 2020, fragmented funding led to inconsistent support—either underfunding or overfunding initiatives. Partners across sectors were not accustomed to collaborating effectively. The partnership between P4H and the SDG3 GAP accelerator has fostered greater enthusiasm and alignment, enabling partners to support the Government in health financing with a broader perspective.

Charlotte Pram Nielsen, Senior Specialist in Sexual and Reproductive Health, Rights, and Gender at the GFF, notes that this collaboration now helps frame health discussions within broader social protection programs and explore policies that expand fiscal space—such as social protection for women and children. Lou Tessier, Health Protection Specialist at the International Labour Organization (ILO), adds that this approach encourages partners to think beyond health-specific interventions and consider systemic reforms that improve health outcomes.

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

• Aligning budget support with strategic and harmonized health expenditure indicators.
• Reforming the HSCF to enhance fungibility and transition from a management tool to a financing system.
• Implementing strategic purchasing with support from the National Institute for Medical Assistance (INAM).
• Improving the predictability of partner contributions and annual activity planning.

Concrete objectives were set to advance these priorities:

harmonizing health financing

• Mapping donors, funding flows, and health financing channels, and critically analyzing harmonization efforts (supported by the GFF).
• Evaluating the future trajectory of the HSCF (with support from WHO/P4H).
• Developing investment case funding channels (with support from the GFF).

harmonizing support

• Reviewing and critically analyzing technical assistance for health financing.

financing systems and tools

• Analyzing the operational models of free healthcare and universal health insurance strategies (supported by WHO/P4H, AFD, and HSCF).

efficiency and optimization tools

• Developing and deploying a cost simulation tool to model production and financing costs at the periphery (supported by AFD, HSCF, and GFF).
• Identifying and scaling low-cost innovations in health service delivery through bottom-up reforms (supported by AFD, HSCF, and the Global Fund).

domestic resource mobilization and better allocation

• 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 care and vaccination during high-level missions and SDG3 GAP meetings with the Government.

Additional support is required to streamline the Ministry of Health’s technical committees under the program budget reform and to propose policies that enhance national financing efficiency and health spending effectiveness.

Though still in its early stages, this collaborative financing strategy aligns with Niger’s national priorities and is expected to improve health service delivery. The GFF, for instance, uses a resource optimization approach to track and align funding, helping avoid duplication and target interventions more effectively. This method could enable strategic investments by partners like the Global Fund and Gavi in HIV, tuberculosis, malaria control, and vaccination services. Since these services are covered under the free healthcare policy, financing reforms could enhance INAM’s operational capacity and reduce out-of-pocket expenses for vulnerable populations.

learning, challenges, and future outlook

Joint focal points embedded within the Ministry of Health and sustainably funded add value by enhancing coordination and alignment of partner support—a critical need in a country where external financing dominates health sector funding.

Despite strong enthusiasm, challenges persist. Focal points in partner organizations are often stretched thin, risking the sustainability of the initiative. Ensuring dedicated time and resources for these roles is essential. Another hurdle is securing long-term financing for the national focal point position, a cornerstone of these efforts. The GFF has extended its support by six months, and Gavi is leading discussions with other partners eager to ensure the sustainability of health financing in Niger.

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

what is the SDG3 global action plan?

The SDG3 Global Action Plan (SDG3 GAP) is a commitment by 13 global health, development, and humanitarian agencies to help countries accelerate progress toward health-related SDG targets. Its value lies in strengthening collaboration among agencies to deliver coordinated support aligned with nationally led strategies and plans. Updated in October 2021 with a recovery strategy, the SDG3 GAP aims to support an equitable and sustainable rebound from the COVID-19 pandemic and advance health-related SDG targets.

The case studies aim to monitor the implementation of the SDG3 GAP at the country level.