Coordination and collaboration on health financing in Niger
The Republic of Niger is a landlocked country in West Africa that has faced armed conflicts and constant periods of severe drought. These challenges have negatively impacted the country’s health system, with Niger having among the worst maternal and infant mortality rates in the world. This situation has prompted the Government of Niger to commit to universal health coverage (UHC), drawing upon lessons learned from previous efforts to expand access to essential health services.
In 2006, the Government initiated an ambitious free healthcare policy in response to the worst health outcomes, which consisted of providing free reproductive health and family planning services for women and a wide range of free health services for children under-five. Despite the early achievements of this initiative, the health gains were threatened by insufficient funding as only half of the resources needed for full implementation were mobilized up to 2011. Over the years, this led to the cumulation of unpaid healthcare bills and affected the ability of healthcare providers to deliver services. Additionally, by focusing on women and children under-five, the rest of the population had to bear very high user fees. WHO estimates that out-of-pocket spending accounts for more than 40% of the total health expenditure in Niger.
Overall, the Government of Niger has struggled to increase resources for health, with health expenditure falling from 5.4% to 4.9% of GDP between 2007 and 2011. Between 2016 and 2018, health expenditure increased from 4.9% to 5.6% of GDP, but then stagnated at around 5.7% between 2018 and 2020.
Prior to the operationalization of the free healthcare policy, Niger recognized the importance of coordination between health financing partners. In 2006, the Ministry of Health (MOH), the French Development Agency (AFD) and the World Bank created the Fonds Commun Santé (FCS) to help fund Niger’s health development plan. By 2020, this group had grown to include four additional international partners: UNICEF, UNFPA, Gavi and the Spanish Agency for International Development Cooperation (AECID). The funding challenges associated with the free healthcare policy were due to inadequate assessments and provision of necessary resources, highlighting the need for reforms to ensure sustainable financing for UHC and other SDG3 targets.
A mother cuddling her baby in the village of Soki, in the center of Niger. © UNICEF/Dejongh
P4H and SDG3 GAP: an opportunity to leverage existing collaborations for sustainable health financing
Recognizing the importance and urgency of free healthcare to reach UHC in Niger, the Government has now initiated ambitious health financing system reforms. This is in part because external funding of health was highly fragmented, prompting the need for better coordination and alignment among partner agencies around health financing support and technical assistance. Learning from previous efforts such as the FCS, the country has worked to cultivate a strong culture of coordination among health partners. This is seen through Providing for Health (P4H), the global network for health financing and social health protection, which has been active in Niger since 2018. In 2021, P4H members and agencies of the Global Action Plan for Health Lives and Well-Being for All (SDG3 GAP) Sustainable Financing for Health Accelerator working group joined forces to recruit an in-country focal point to support and facilitate health financing coordination and action research with Government leadership and support.
The recruitment process of the in-country focal point, including validation of common objectives and development of terms of reference, was facilitated by Gavi working with all health financing partners in Niger. Gavi’s mandate at country level as the official “co-rapporteur” of health financing partners was then handed over to the P4H-SDG3 GAP financing accelerator in-country focal point in January 2022. Embedded at the MOH, the focal point provides a key interface between MOH, and technical and financial partners. Its key role is to help coordinate health partners’ support on health financing and delivery on national health priorities, allowing the MOH to become “less agency centric”. The funding mechanism for this new position, previously led by WHO with AFD funding, has been transferred to the World Bank, with funding support from GFF and modalities for predictable co-financing of the position are being explored. These efforts help lay the foundation for more harmonized and joined-up support for Niger to achieve its ambitious vision for UHC.
What does strengthening the health financing system in Niger entail?
Prior to 2020, the fragmentation of resources caused “many initiatives to be underfunded or overfunded”, recalls Charlotte Pram Nielsen, Senior Health Specialist for Sexual and Reproductive Health and Rights (SRHR) and Gender at GFF. A good culture of collaboration between partners in other areas was not present in the case of health financing. Due to the P4H - SDG 3 GAP finance accelerator partnership, many partners are now excited and engaged to support the Government in health financing. The partnership provides an opportunity to “include discussions with the broader scope of social welfare programmes and to reflect on expanding fiscal space policies that influence health outcomes such as social protection for women and children”, says Lou Tessier, Health Protection Specialist at ILO.
In 2020, health financing partners prioritized their support for Niger in the areas of COVID-19, domestic resource mobilization, value for money, effective development cooperation, and cross-cutting investments. The Government has identified following key priorities for support:
- Aligning budget support around strategic and harmonized health disbursement indicators;
- Reforming the FCS to strengthen its fungibility and transition from a management tool to a financing system;
- Deploying strategic purchasing, with support for the operationalization of the National Institute of Medical Assistance (INAM);
- Improving the predictability of technical and financial partners’ contributions and annual activity planning exercises;
Specific objectives have been developed to support the achievement of these priorities:
Alignment of funding
- Mapping of donors, flows and channels of health financing and critical analysis of health financing alignment (supported by GFF)
- Trajectory and future of the FCS (supported by WHO/P4H)
- Financing channels of the investment case (supported by GFF)
Alignment of support
- Mapping and critical analysis of technical assistance for health financing
Financing system and tools
- Analysis of the operating methods of free healthcare and universal health insurance strategies (supported by WHO/P4H, AFD-FCS)
Efficiency and optimization tools
- Development and deployment of a calculation tool to simulate the costs of production and financing of care in the periphery (supported by AFD-FCS, GFF)
- Documenting strategies for improving and reforming the health care supply chain from below to identify and disseminate low-cost innovations in various contexts (supported by AFD-FCS, Global Fund)
Domestic resource mobilization and better allocation of health expenditure by
- Liaising with the IMF on their programme design with the aim of including spending in areas such as immunisation and nutrition in the list of indicative targets.
- Advocating for the allocation of more resources to PHC and immunization during high-level missions and meetings of SDG3 GAP agencies with the Government.
Additional needs for support include analytics on the rationalization / reorganization of MOH’s technical committees within the framework of the program budget reform and analyses and policy proposals to improve the national financing system and the efficiency of health spending.
While not yet fully operational, this strategy for health financing collaboration around the country’s key priorities will ultimately allow for better delivery of health services. For instance, using a value for money (VFM) approach, GFF is responsible for resource mapping and tracking exercises, which would provide a broad view of which agency is financing what. This prioritization of resources and efforts across partners allows for “no duplication of activities and therefore, better targeted interventions, which would eventually improve more lives”, notes Moussa Bizo of the WHO Country Office in Niger. Furthermore, the VFM approach could yield additional benefits, for example, by allowing the Global Fund or Gavi to make more strategic investments in its funding of HIV, TB, malaria services and immunization services respectively. As the free healthcare policy covers these programmes, the financing reform would contribute to better operationalization of INAM, thus decreasing out-of-pocket spending by poor and vulnerable populations.
Learning, challenges and outlook
Joint focal points, embedded in the MOH and sustainably funded, add value by supporting the coordination and alignment of support from partners to the Government. This is of relevance in a context where a considerable portion of the funding for the health sector is coming from external sources.
Despite the excitement around this ambitious initiative, challenges remain. Focal points of agencies involved in this partnership are stretched thin, which might negatively affect the initiative’s sustainability. It is therefore important to ensure that staff time is dedicated to it in each of the agencies.
Another challenge relates to clarifying the long-term funding arrangements for the in-country focal point position, which is one of the central pillars of all these efforts. GFF has extended funding for an additional six months and Gavi is currently facilitating discussions about support from other partners with a strong interest in strengthening the sustainability of health financing in Niger.
Lessons learned from this pilot partnership will be shared with other countries and partner agencies to respond to the demand for joint focal points and more aligned and better coordinated support on health financing.
What is the SDG3 GAP?
The Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP) is a set of commitments by 13 agencies that play significant roles in health, development and humanitarian responses to help countries accelerate progress on the health-related SDG targets. The added value of the SDG3 GAP lies in strengthening collaboration across the agencies to take joint action and provide more coordinated support aligned to country owned and led national plans and strategies. A recovery strategy (Oct 2021) serves as a strategic update on the SDG3 GAP in the context of achieving an equitable and resilient recovery from the COVID-19 pandemic to the health-related SDG targets.
The purpose of GAP case studies is to monitor SDG3 GAP implementation at country level.