Strengthening Niger’s healthcare funding and partner collaboration
Nestled in West Africa, the Republic of Niger faces persistent challenges—from armed conflicts to prolonged droughts—that have strained its healthcare system. These pressures have contributed to some of the world’s highest rates of maternal and infant mortality, prompting the Government of Niger to prioritize universal health coverage (UHC). Building on past efforts to expand access to essential health services, the country is now advancing reforms to secure sustainable funding and improve coordination among health partners.
In 2006, as health outcomes reached alarming lows, the Government launched a bold initiative to make reproductive and family planning services free for women, and a wide range of care accessible to children under five. While early results were promising, insufficient funding hindered progress. By 2011, only half of the required resources had been mobilized, leading to unpaid medical bills and disrupted service delivery. Moreover, the initiative’s focus on women and young children left other patients facing steep out-of-pocket costs. According to the World Health Organization (WHO), direct payments account for over 40% of Niger’s total health spending.
Between 2007 and 2011, health expenditures fell from 5.4% to 4.9% of GDP. A modest recovery followed, with spending rising to 5.6% of GDP in 2018 and stabilizing around 5.7% from 2018 to 2020. Long before the free healthcare policy, Niger recognized the importance of donor coordination. In 2006, the Ministry of Health, the French Development Agency (AFD), and the World Bank established the Health Basket Fund (FCS) to help finance the country’s health development plan. By 2020, four more international partners had joined: UNICEF, UNFPA, Gavi, and the Spanish Agency for International Development Cooperation (AECID). However, funding shortfalls tied to the free healthcare initiative highlighted the need for systemic reforms to ensure stable financing for UHC and other Sustainable Development Goal (SDG) targets under SDG 3.
Leveraging global networks to streamline health financing
To address fragmented external health funding and strengthen coordination among partners, Niger has turned to the Providing for Health (P4H) network—a global platform dedicated to health financing and social protection. Since 2018, P4H has worked in Niger to harmonize donor support and align technical assistance with national priorities. In 2021, members of P4H 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 within the Ministry of Health. This role supports coordinated health financing, evidence-based decision-making, and stronger government leadership.
The recruitment process—including goal-setting and mandate development—was led by Gavi in partnership with Niger’s health financing stakeholders. By January 2022, the position had been formally integrated into the Ministry, serving as a bridge between technical and financial partners. Its primary function is to streamline donor contributions, align them with national health priorities, and reduce administrative burdens on the Ministry. Initially funded through WHO with AFD support, the mechanism’s financing was later transferred to the World Bank, with cofinancing from the Global Financing Facility (GFF) under discussion. These steps lay the groundwork for a more unified and predictable funding approach to support Niger’s UHC ambitions.
Key pillars of Niger’s health financing reform
Charlotte Pram Nielsen, Senior Specialist in Sexual and Reproductive Health and Rights at the GFF, notes that before 2020, fragmented funding often led to overlapping or underfunded initiatives. Thanks to the P4H and SDG 3 Global Action Plan partnership, many partners are now more aligned and committed to supporting Niger’s health financing goals. This collaboration helps integrate health discussions into broader social protection frameworks and supports policies that expand fiscal space for health, such as programs targeting women and children.
In 2020, health financing partners focused on critical areas: COVID-19 response, domestic resource mobilization, resource optimization, development effectiveness, and cross-cutting investments. The Government identified key priorities for donor support:
- Aligning budgetary support with strategic and harmonized health spending indicators.
- Reforming the FCS to enhance fungibility and transition from a management tool to a financing system.
- Implementing strategic procurement practices with support from the National Institute of Medical Assistance (INAM).
- Increasing the predictability of partner contributions and annual activity planning.
Specific objectives were set to advance these priorities:
Harmonizing health financing:
- Mapping donors, funding flows, and channels, and analyzing the harmonization of health financing (supported by the GFF).
- Assessing the future trajectory of the FCS (supported by WHO/P4H).
- Developing financing arguments for health investment cases (supported by 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 the FCS).
Efficiency and optimization tools:
- Developing and deploying a cost-simulation tool to estimate healthcare production and financing at the community level (supported by AFD, FCS, and GFF).
- Identifying and scaling low-cost innovations in primary healthcare delivery (supported by AFD, FCS, and the Global Fund).
Domestic resource mobilization and better allocation:
- Engaging with the International Monetary Fund (IMF) to include health spending—such as vaccination and nutrition—in indicative target lists.
- Advocating for increased resources for primary healthcare and immunization during high-level missions and SDG 3 Global Action Plan meetings with the Government.
Further analysis is needed to streamline technical committees within the Ministry of Health as part of budget program reform, and to propose policies that enhance national financing efficiency and expenditure effectiveness.
Transforming health delivery through coordinated action
Though still evolving, this collaborative financing strategy is expected to enhance health service delivery across Niger. The GFF, for instance, uses an optimization method to track and prioritize resources, helping partners avoid duplication and target interventions more effectively. This approach could ultimately improve health outcomes for more people. Moussa Bizo of the WHO Niger Office explains that by identifying what each partner funds, resources can be deployed more strategically—enabling partners like the Global Fund or Gavi to invest more effectively in HIV, tuberculosis, malaria services, and immunization programs. Since these services are covered under the free healthcare policy, financing reform could also help operationalize INAM more efficiently, reducing out-of-pocket expenses for vulnerable populations.
Challenges and future outlook
Joint focal points embedded within the Ministry of Health and funded sustainably add significant value by enhancing coordination and alignment with national plans—a critical need in a country where a large share of health funding comes from external sources. However, challenges remain. The focal points face heavy workloads, which could jeopardize the initiative’s long-term success unless adequate staffing and support are provided.
Clarifying long-term financing for the national focal point position is another hurdle. The GFF has extended its funding by six months, and Gavi is leading discussions with potential partners committed to strengthening health financing sustainability in Niger.
Lessons from this pilot partnership will be shared with other countries and organizations to meet the growing demand for joint focal points and more harmonized, coordinated health financing support. The goal is clear: build a resilient health system that delivers for all Nigeriens.
Understanding the SDG 3 Global Action Plan
The Global Action Plan for Healthy Lives and Well-being for All (SDG 3 Global Action Plan) brings together 13 leading health, development, and humanitarian agencies to help countries accelerate progress toward SDG health targets. Its strength lies in fostering collaboration among partners to deliver coordinated, country-led support aligned with national strategies. Updated in October 2021 with a recovery strategy, the plan supports equitable and sustainable rebuilding in the wake of COVID-19, reinforcing efforts to meet SDG health goals.
Case studies are used to monitor the implementation of the SDG 3 Global Action Plan at the national level, ensuring real-world impact and accountability.
