TECHNICAL REPORT NIGER HEALTH FINANCING SYSTEM ASSESSMENT ACCELERATING INFORMED DECISION-MAKING FOR UNIVERSAL HEALTH COVERAGE FINANCING Samia Laokri, Laurence Lannes & Patrick Eozenou 14 September 2022 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE ABOUT THE REPORT CONTENTS This report illustrates the efforts of the Projects and conclusions expressed in this work are team in disseminating knowledge to support entirely those of the author(s) and should not LIST OF FIGURES AND TABLES.................................................................................... 4 Niger’s health policymaking. This work is the be attributed in any manner to the WB, to its product of a principal investigator hired as an affiliated organizations or to members of its ACRONYMS AND ABBREVIATIONS............................................................................... 5 independent consultant for the account of the Board of Executive Directors or the countries they World Bank (WB), with co-authors and external represent. EXECUTIVE SUMMARY .................................................................................................... 6 contributors. The findings, interpretations, 1. INTRODUCTION .......................................................................................................... 12 2. COUNTRY CONTEXTS ............................................................................................... 14 2.1 Socio-demographic and human development patterns ........................................................................... 14 2.2 Macroeconomic environment ................................................................................................................... 16 2.3 Political journey towards UHC ................................................................................................................. 17 2.3.1 UHC financing transition ................................................................................................................. 17 ACKNOWLEDGMENTS 2.3.2 Social protection for health, targeted free care and other health protection mechanisms .............. 18 2.3.3 Human resources policy towards quality services .......................................................................... 20 3. HEALTH SYSTEM OUTCOMES ................................................................................. 22 3.1 UHC tracer index and its sub-components .............................................................................................. 22 This paper was prepared by Samia Laokri Switzerland) and Jean-François Caremel (P4H (consultant and principal investigator) under focal point, Niger) during the study process; 3.2 Other health outcomes performance ....................................................................................................... 25 the overall guidance of HNP Senior economists and by Moulay Driss Zine Eddine El Idrissi (WB and team leaders Laurence Lannes and Patrick lead health economist) and Nicolas Rosemberg 4. HEALTH SYSTEM INPUTS ......................................................................................... 28 Eozenou. This work was funded by the WB (WB economist, health) during the final review 4.1 Human resources for health ...................................................................................................................... 28 and Gavi, The Vaccine Alliance as part of the process. We warmly thank all the participants of 4.1.1 National state of skilled health workforce ......................................................................................... 28 technical assistance program on health and a workshop held in Niamey on May 6 - 9, 2022 4.1.2 National stock by occupation and level of care ................................................................................ 30 public finance reforms for improved service during the immunization week. The editing of the delivery in Niger. The authors are grateful for the report was funded by Global Financing Facility 4.1.3 Staff availability and distribution ....................................................................................................... 31 valuable input, discussions and support received (GFF), and nicely performed by Guillaume Musel 4.2 Public infrastructures for basic needs and health – capacity and administration ..................................... 33 from the whole Projects team and collaborators, and team from Pi COMM and Laura MacMahon 4.2.1 Health system architecture ............................................................................................................... 33 including Cedric Ndizeye (WB senior health for the text editing. We are grateful for all the 4.2.2 Health infrastructure ......................................................................................................................... 34 specialist), Blaise Ehowe Nguem (WB country comments and collaborations received. economist), Marc-François Smitz (consultant) 4.3 Health financing information .................................................................................................................... 36 and Loredana Luiza Horezeanu (consultant). FOR MORE INFORMATION : Issaka Kassoum (national consultant) facilitated 5. HEALTH FINANCING SYSTEM .................................................................................. 38 the data collection process and key informants’ • Samia Laokri (consultant) 5.1 Trends in total expenditure on health ....................................................................................................... 38 interviews. The report was also greatly enriched slaokri(a)worldbank.org; samialaokri(a)gmail.com 5.2 Budget execution in health ....................................................................................................................... 40 by the insightful expertise of key contributors from the Ministry of Public Health, Population 5.3 Major health financing agents .................................................................................................................. 40 or and Social Affairs (MoH) and representative 5.3.1 Overview of funding agents mix for health ....................................................................................... 40  ealth, Nutrition and Population (HNP) •H bodies of the major development partners. We 5.3.2 Domestic public financing for health ................................................................................................. 41 acknowledge the government counterpart for the Global Practice 5.3.3 External sources of financing for health ........................................................................................... 43 data sharing, technical meetings, discussions, www.worldbank.org/health and comments provided throughout the study. @WBG_Health 5.3.4 Domestic private financing for health ............................................................................................... 45 We are also grateful for the collaboration of blogs.worldbank.org/health 5.4 Expenditure allocation on health .............................................................................................................. 47 and insights shared by Juliette Puret (Gavi HQ, askhnp(a)worldbank.org 5.4.1 Functional allocation ......................................................................................................................... 47 5.4.2 Healthcare providers ........................................................................................................................ 47 5.4.3 Costing and financing gap in health ................................................................................................. 49 6. ADDITIONAL ENABLERS AND CONSTRAINTS ..................................................... 52 6.1 Covid-19 response plan and opportunities for increased mobilization for health ..................................... 52 Recommended citation 6.2 Human resources as a lever for improved impact of health financing efforts .......................................... 54 6.3 Improving health financing and system efficiency .................................................................................... 54 Laokri S, Lannes L et Eozenou P (14 September 2022), Niger Health Financing System Assessment: 6.4 Budget increase from expanding the fiscal space for health ................................................................... 55 Accelerating informed decision-making for universal health coverage financing, The World Bank, Washington DC 6.5 Efficiency gains for health from improved public finance ......................................................................... 56 6.6 Inefficiencies in PHC financing ................................................................................................................ 58 © 2022 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 7. DESIGNING THE WAY FORWARD ............................................................................ 62 All rights reserved. 8. REFERENCES .............................................................................................................. 66 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE LIST OF ACRONYMS FIGURES AND TABLES AND ABREVIATIONS Figure 1: Forecasted population age pattern and life expectancy in Niger............................................................................................15 AFD French Development Agency HNP Health, Nutrition, and Population Figure 2: Human capital index (HCI) in Niger and focus countries, 2017-2020......................................................................................16 BHCPF Basic Healthcare Provision Fund HTA Health Technology Assessments Figure 3: Expected progress in service coverage over past decades in Niger, 2000-2020..................................................................22 CHE Current Health Expenditure IC Investment Case Figure 4: Tracking UHC progress in service coverage in Niger, 2000-2019...........................................................................................23 CHP/CSU High Level Steering Committee for Universal IDA International Development Association Figure 5: UHC to per capita expenditure on health in Niger against global trendline, 2019.................................................................23 Health Coverage (Comité de haut niveau de IFSA Immunization Financing System Assessment pilotage de la couverture universelle pour la santé) Figure 6: UHC service coverage sub-indexes in Niger, benchmarked against pooled average of peers, 2000-2019........................24 IHR International Health Regulation CHW Community health workforce Figure 7: Niger survey monitoring of RMNCAH-N, 2012-2017.................................................................................................................24 ILO International Labor Organization COGES School Management Committees (Comités de Figure 8: Disability-adjusted life years, causes of death and related shares across age groups in Niger, 2019...............................26 Gestion des Établissements Scolaires) IMF International Monetary Fund Figure 9: T  rends in disability-adjusted life years and deaths for most prevalent conditions in Niger, COSAN Health Committees (Comités de Santé) JEE Joint External Evaluation benchmarked to regional and low-income averages, 1990-2019............................................................................................27 CTN-CSU National technical committee for UHC (Comité LANSPEX National Health and Expertise Laboratory Figure 10: Density of skilled health workers in Niger against income group and peers, latest year..................................................29 technique national de la couverture universelle LMIC Lower-middle-income country Figure 11: Labor force by healthcare provider and staff occupation in Niger, 2020..............................................................................30 pour la santé) LSMS Living Standards Measurement Survey Share of staff employed in the private health sector in Niger, benchmarked to selected peers Figure 12:  CTN/PS National technical committee for social and regional average, latest year 2016-2018............................................................................................................................31 protection (Comité technique national de la M&E Monitoring and Evaluation Protection Sociale) Figure 13: Regional and district-level disparities amongst the health workforce in Niger, 2020.........................................................32 MoH Ministry of Health CTS Technical committee for health (Comité Figure 14: Bed availability in district hospitals in Niger, 2015-2019........................................................................................................35 MoF Ministry of Finance and Budget Technique de la Santé) Figure 15: Trend in total expenditure on health in Niger, 2015-2020.......................................................................................................39 MPA Multiphase Programmatic Approach CPIA Country Policy and Institutional Assessment Figure 16: Major sources of funding for current health expenditure in Niger, 2018-2020.....................................................................41 MMR Maternal Mortality Rate DAH Development Assistance for Health Figure 17: Public budget prioritization for health in Niger, 2015-2020....................................................................................................42 MTEF Medium Term Expenditure Framework DALYs Disability-adjusted life years Figure 18: Trends in health financing prioritization for the Niger Government, 2014-2020..................................................................42 DGS Directorate General of Health Services NCD Noncommunicable disease Figure 19: Amounts and share of external resources for health in Niger, 2018-2020............................................................................44 (Direction Generale de Santé) NHA National Health Accounts Figure 20: Per capita external financing for health in Niger and against peer countries, 2015-2019..................................................45 DHIS District Health Information System OOPs Out-Of-Pocket payments Figure 21:  Per capita domestic private expenditure on health in Niger and its share against DHS Demographic and Health Survey PAA Annual activity plan other sources of funding, 2000-2019........................................................................................................................................46 DHIS2 District Health Information Software 2 PBB Program-based budgeting Figure 22: Current expenditure by healthcare function in Niger, 2011-2020..........................................................................................48 DLI Disbursement Linked Indicator PBF Performance-based financing Figure 23: Current expenditure by care provider in Niger, 2018-2020.....................................................................................................48 DRM Domestic Resource Mobilization PPP Public Private Partnership Figure 24: Annual and overall forecasted costs (multi-year health planning) in Niger, 2017-2021......................................................49 DRSP Regional public health directorate (Direction WFP World Food Program Overall cost and State contribution and financing needs for the implementation Figure 25:  Régionale de la Santé Publique) WHO World Health Organization of the PAN interventions, Niger.................................................................................................................................................51 ECOWAS Economic Community of West African States RAP Annual Performance Reports Figure 26: Covid-19 financing for the 2020 response plan in Niger........................................................................................................53 ENABEL Belgian Development Agency RMNCAH-N Reproductive, Maternal, Newborn, Child and Figure 27:  Comparative values for money as expressed for selected health outcomes against ENV Living Standards Measurement Survey (Enquête Adolescent Health and Nutrition per capita expenditure, 2019.....................................................................................................................................................55 sur le Niveau de Vie des Ménages) STP Permanent Technical Secretary (Secrétariat Figure 28: Niger 2017 PFM assessment: PEFA outputs for 31 dimensions of public finance..............................................................57 FN Fiscal narrative technique permanent) Figure 29: Billing situation of the free healthcare policy in Niger, 2007-2020........................................................................................59 Gavi Gavi, the Vaccine Alliance SDGs Sustainable Development Goals GDP Gross Domestic Product SCI Service Coverage Index GFF Global Financing Facility for Women, Children SDI Service Delivery Indicator Table 1: P  overty incidence in Niger: nationwide and across sub-groups (urban-rural, and Adolescents regions, sector of employment), 2011-2018.................................................................................................................................15 SNIS National Health Information System GFTAM Global Fund to Fight AIDS, Tuberculosis and Malaria SONIPHAR Niger’s Society of Pharmaceutical Industries Table 2: Health structure count by level of care in Niger, 2015-2019.......................................................................................................34 (Société Nigérienne des Industries Table 3: Tentative response to health financing for UHC constraints and challenges in Niger..................................................... 11, 64 GNI Gross National Income Pharmaceutiques) GTN/CSU National working group on UHC (Groupe de UHC Universal Health Coverage travail National de la couverture universelle pour la santé) UN United Nations HCI Human Capital Index UNICEF United Nations Children’s Fund WB World Bank / WBG: World Bank Group HDI Human Development Index WFP World Food Programme HFSA Health Financing System Assessment WHO World Health Organization HMIS Health Management Information System 4 5 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE EXECUTIVE SUMMARY This Health Financing System Assessment Technical sessions involving the Ministry of Although the level of service coverage The national health system performance (HFSA) study comes at an opportune time to health sanitation, population and social affairs remains extremely low, Niger efficiently builds on its inputs (human resources and favor informed policy-making around health (MoH), major development partners (DPs) and started to narrow the gap by deviating from infrastructure), which are confronted with financing for universal health coverage (UHC) experts were organized to feed the process and the bottom threshold trend of low-income a fast-growing population and increased in Niger. In July 2021, Niger authorities initiated discussions. In this attempt, draft material and countries (LICs). Past Government efforts have demand for a quality service for all. Niger’s an ambitious reform to converge towards UHC, a outputs have been reviewed for improvements and paid off as the country improved service coverage health system lacks qualified and well distributed renewal of prior UHC commitment taken in 2012. maintain responsiveness to the policy dialogue in health and even experienced a faster UHC human resources for health. Niger’s health The introduction of the reform will be spread around UHC. Hence, the study faced some path than the average of its peers. Those efforts system was, in 2020, among the bottom ten most over several years since the strategic document limitations, especially with respect to data scarcity, need to be maintained and strengthened to meet understaffed countries. That year, Niger’s density for its implementation and financing, resulting incomplete series, and discrepancies across data the ambitious goals and targets for sustainable of skilled health workers was far insufficient in institutional changes expected in 2022-2023. sources. The analytical phase will be followed development by 2030. As of 2019, Niger’s UHC compared to the minimum threshold set by Evidence base around health financing state, by the dissemination and translation of the study index scored 37.4 out of 100, which lag the levels the WHO standards (2.3) and below the SSA challenges and opportunities was therefore timely results in support to the preparation and ultimately of service coverage reached by several peers sub-regional (1.36) and LICs (1.07) averages. needed. Launched amid the Covid-19 pandemic, implementation of the upcoming reform for UHC. or the region (46.0) and income group (42.2) Besides, there is an untapped potential with the UHC national agenda obviously involves averages. Niger’s UHC is challenged by uneven respect to spatial distribution, and that would additional considerations. Besides bringing Niger health financing reform should count with progress across sub-sectors and territories. For allow rapid progress. The distribution of skilled additional pressure on the path towards UHC, a fast-growing population of 24 million people instance, if service coverage for reproductive, workers across territories (regions and districts) the current context brings new opportunities, with growing health needs, causing growing maternal, newborn and child health averaged is uneven. The health system composes with notably arising from the fact that maintaining financing needs in a context of fragility. Niger’s the pooled performance of peer countries in regional disparities, with higher staffed Niamey and protecting population health has become a population growth indeed puts high pressure on 2019, it was driven by one single indicator (DPT3 (1.4) and Agadez (0.87) against other regions unifying theme at the global level. The design of national decision-makers to meet associated vaccine coverage). Advances in other indicators (below the national average). At-district level, the technical assistance program offers a real growing needs with basic infrastructure or social were insufficient. Service coverage in essential disparities are also important, especially in opportunity to connect interested parties and services, further challenged by epidemiology and services and infectious diseases, and service Niamey and Agadez. drive a dynamic approach based on increased environmental transitions. Niger belongs to the capacity and access are lagging. This indicates evidence use for an informed policy dialogue group of 35 countries categorized as fragile and a substantial margin of progress is still needed. It Niger critical shortages in the health workforce around health system financing in Niger. It was conflicted-affected states. Fragility poses specific also calls for efficient use of available resources put the country off-track from achieving its also an opportunity to reflect on the progress challenges, now dealing within the spectrum of a complemented by adequate financial resource policy goals. Decision-makers are aware of made and further steps needed to implement pandemic that has exacerbated health financing mobilization to successfully transition towards the key issues as the country has developed a more efficient health financing for UHC. challenges. Widespread poverty and limited financial effective UHC. national plan for human resource in health. Yet, protection arrangements for health are combined regarding the threshold required to revitalize The comprehensive assessment of the with displaced and transhumant populations, long Niger also succeeded in improving other PHC services, the country has come 13.0% of national health financing system examined the distances to care and persisting inequities. These health outcomes, although several critical the way, based on country data (PAN) estimates. trends, state, and challenges of financing for contribute to the limitations in access to healthcare areas for improvement have been recognized. Regardless the data source, there is still a long UHC in Niger. Like many systems from the Sub- and use of care services in Niger. Health financing Niger mortality rate has been declining sharply, way to go before meeting the recommended Saharan African (SSA) region, Niger health system challenges ahead are numerous. catching up with WAEMU and SSA’s average threshold to revitalize primary health care and must move forward in its financing transition. mortality rates. The average annual reduction of achieve effective UHC by 2030. Looking at Our aim was therefore to inform not only on the Niger’s health system will inevitably have 4.8% among U5 children over past decades was disaggregated data, Niger’s stock of doctors, strengths and weaknesses, but on constraints and to cope with evolving macroeconomic superior to the average for Sub-Saharan Africa nurses and midwives counts for 0.16, 0.57 and opportunities while embracing a comprehensive challenges, including contracyclical public (3.0%) or LICs (3.4%). Yet, here as well, Niger’s 0.16 per 1,000 inhabitants respectively (country perspective. HFSA is articulated around four areas spending, even if economic growth is expected efforts must be maintained because the country estimates from the 2020 health yearbook). of interest: 1) the country contexts, 2) the health to resume in 2022. The national economy was is still experiencing too many preventable deaths Intranational disparities or skill imbalance divert system outcomes, 3) the health system inputs built on several years of growth with a real annual and ranks low (171 out of 174) in the human workloads across levels of care. In addition, poor and 4) the health financing system. HFSA also GDP growth averaging 6.1% over 2010-2019. In development index. Children born in Niger today working conditions, a lack of motivation and low discussed policy implications and charted a way 2020, Niger was impacted by the global economic will be 32 percent as productive when they grow staff availability constituted other documented forward in the UHC journey in Niger. slowdown of the Covid-19 pandemic, contrasting up as they could be if they enjoyed complete drawbacks. Improved human resources for health with years of economic growth. At first, some education and full health, a poor performance will require high-level commitments as well as Authors applied standardized methods sub-sectors of the economy escaped the direct compared to the SSA region and LICs. In terms the monitoring of existing indicators in multiple collecting a wide range of quantitative and impact of the Covid-19 pandemic. But the of vaccination coverage, which is still largely areas (skilled staff availability, conditions of work, qualitative data to emulate the evidence-base. country did not escape an economic slowdown insufficient, a concurrent study has highlighted distribution, the skill-mix or policy retention and We prioritized country data and reports, often while facing high pressures on public spending. uneven service coverage, partially attributed to workload production matters) . complemented with key informant interviews. Seeking to improve primary health care, Niger’s the weakness of the financing system. Global data repositories and scientific literature policymakers committed to adequately support were searched for cross-cutting and international the health system, for instance setting ambitious comparison and benchmarking purposes. prioritization of health within the general budget. 6 7 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE Government investment led to improved It is obviously demanding the renewal of major per capita in 2020. The situation has improved the MoH in 2020. Health is a human right and health infrastructure however the system still budgetary commitments under increasing since it used to be around US$ 5.4 per capita in should also be understood as being an efficient has to cope with persisting shortcomings in constraints. To date, the health financing system 2015. A need for increased domestic resource driver of development and growth. Health is care delivery. Indeed, service utilization, quality is fragmented in Niger. Out-of-pocket spending mobilization is clear, since the level is well below therefore a competing interest deserving fair of care, drug availability, vaccine shortages, on health remains unacceptably high, continuing the desirable level of US$ 86 per capita per year, piece of the domestic pie. When considering territorial disparities and insufficient general to expose households to financial risk. Increased a threshold that has been established to promote health expenditure in all sectors (including inputs jeopardize the performance of the investments in the national health system are universal access to primary care (1). This desired MoH), the budget prioritization reaches 6.3% in national health infrastructure, despite high-level substantially needed to meet the sustainable level of health expenditure is not even half met 2020 and 6.8% on average since 2015. Budget commitments and investments made. Regarding development goal of UHC by 2030 in Niger. in Niger when considering all sources of funding prioritization on health in Niger however appears health infrastructure, currently half the population Resource mobilization will require increased spent on health. According to health accounts, largely below the aspirational Abuja expectations (50.4%) has access to care services within a 5 km domestic and external contributions. At the Niger’s total health expenditure was around US$ of investing at least 15% of General Government radius. Globally, thanks to capital investments, same time, Niger’s health system should deliver 38.8 per capita per year in 2020, using the World budget on health in African countries. If the 15% the health structure count has improved in care services maximizing value for households Development Indicator exchange rate. Moreover, appears ideal but fails to be met consensual, one the past five years and seems reasonable for and patients. Challenges are therefore the threshold reference of US$ 112 per capita can assume that the national target was not met regional and income group averages for beds multidimensional and include targeting better per year has recently been projected for LICs as either. Budget prioritization on health was indeed per inhabitant at the national level, although efficiency of health spending. necessary total health expenditure to reach UHC below the 10% threshold announced in Niger’s inequalities remain across regions in Niger. by 2030. general policy (i.e., the Niger Renaissance Within available structures, the bed occupancy To raise awareness of these many challenges, program). This calls for future sectoral trade-off rate was 39% suggesting some room for the study looked at the structure of health The financial gap in health is substantial and negotiations in favor of health decision-makers. improvement in infrastructure utilization. Globally financing architecture while trying to may represent, per capita per year, from US$ for Niger, utilization rates and quality of care tend highlight country’s efforts in terms of return 47.2 to US$ 73.2 if endorsing a more ambitious Regardless of the financial arrangements, to remain low. Niger’s health system also copes on investment for key health outcomes. We scenario. The gap is broadly estimated against external financing for health remains an with recurrent drugs and vaccine shortages and documented the level, trend and adequacy the generic $86 and most ambitious $112 (for important pillar in Niger. Niger’s health system insufficient equipment which are linked to the of health expenditure using the most relevant primary care) against available $38.8 in Niger. is fueled by external resources counting for a financing arrangements, preventing better system indicators. We shed light on the major At the current state of knowledge, it could be substantial share, although varying across time. performance. The WHO tracer medicines survey achievements made, the financing gap and the considered as an aspirational goal to be translated Little more than a third (36.8%) of total external conducted in 2015 showed that the tracers were composition of health expenditure. In an attempt by Niger decision makers into progressive national resources are provided on-budget, through public not available in full. First-line hospitals offered to situate Niger’s efforts, we have compared most targets to implement the ongoing UHC reform (2). administration. In 2020, about two-thirds came up to 70.2% of the tracers, public health centers of the indicators against the trends at global, A costing study is underway at the country level from multilateral donors led by the World Bank up to 68.2% whereas health posts only offered regional and peers’ levels. The choice of peer with the intend to provide up-to-date funding gap (WB), the Global Fund, the World Food Program 40.9% of the tracers. In rural areas, less than countries was made using a set of selected that will need to be covered to converge towards and the World Vaccine Alliance (Gavi). In Niger, 22.2% of the tracers were available. These are indicators to determine structural and aspirational UHC. Based on available literature, we found a Common Fund for health has grown since some illustrations of the weaknesses observed comparators. some useful projections, which seem of similar 2006, attracting a higher number of donors. The in the national health system that will be a focus magnitude. For instance, it would represent for per capita external expenditure on health has within the UHC reform. Setting a UHC-specific bottom threshold of Niger an incremental expenditure of about US$ substantially increased since the early 2000s. On percent share of GDP for health in Niger is 76 per capita, according to authors’ calculations average, it represented an annual addition of US$ Along with strengthened capacity building, the needed as the country aspires to UHC. Such made for LICs. Similarly, the WHO also identified 4.5 per capita (in constant 2019 US$) to Niger’s use of health financing data in policymaking is an indicator can be very influential as it does a threshold range of at least US$ 50 to US$ 60 public financing during 2015-2019. Despite crucial and should be further institutionalized not require intersectoral trade-offs. According to that would be required annually and per capita apparent increasing contributions from health to drive change in Niger. The study indeed Niger’s health accounts, total health expenditure to achieve the sustainable development goals DPs, Niger citizens seem not to benefit as much raised the importance of generating reliable data accounted to 6.8% of the GDP on average for agenda for health (SDG3.8.UHC). There are as populations living in peer countries. Indeed, and indicators serving health financing purposes. 2015-2020, passing from 7.7% in 2015 to 6.4% in therefore a range of benchmarks that should per capita, Niger’s external resource mobilization A recent Lancet Commission on financing primary 2020. Niger’s capacity to translate national wealth further guide the targets to be achieved in Niger. strategy ranked as the lowest recipient among health care called countries to make adequate into sustained investments in health remains at Niger’s health system journey to UHC requires its peers. Globally, two considerations can be information available for decision-makers, which risk of declining as it used to be higher (e.g., 8.1% its government to consider investing more highlighted for DPs future commitments in health echoes Niger’s needs in the matter. When of GDP in 2017). It should be recalled that the and better in health. Global recommendations in Niger, which are: firstly to translate their aid into information is lacking, health financing decision- share financed by the Government represented provided by the Lancet Commission on financing a volume per inhabitant that can be benchmarked making is likely to be poor and funding cannot approximately a third of total expenditure (32.3% primary health care recently raised the necessity internationally, and secondly to engage growing be allocated efficiently. Talking about enhancing on average during 2015-2020). This Government to predominantly finance primary health care volumes, not only to cover Niger’s population primary health care in Niger for instance would contribution is clearly below the standard from public revenue (3). Like almost every single growth but to sustain service coverage expansion. need better knowledge of the levels of, and threshold established at 5% of the GDP (1). health system, although to a larger extend in trends in, financial resources. Health financing Thus, even if health expenditure as a share of Niger, health decision-makers cope with too The national health system in Niger is knowledge was shown to be very limited despite GDP in Niger is proven to be above the general limited domestic resources, both in per capita characterized by a heavy reliance on out-of- the prominence of primary health care in political trend when compared globally, the share that the volume and in relative share of total expenditure pocket expenditure. Out-of-pocket expenditure commitments and policy statements. An in-depth Government secures for health does not meet the on health. Moreover, skewed allocation towards represents up to 43.7% of current health knowledge of the ins and outs of the financing threshold needs for UHC. curative spending (including certain activities expenditure in Niger in 2020. On average, over issues appears to be an essential asset to benefiting to a small group of the population) the past decades (2000-2019), per capita private develop in Niger, as it is the main tool to steer In addition, Niger’s GDP is classified as low- further challenge adequacy of funding for PHC. A expenditure was twice as much as the Niger UHC-related needs. income - it does not generate enough financial related WB study on equity offers a broader view Government‘s share over the same period. The resources for health in Niger since domestic of the matter. financial burden of health on private contributors As a result of the above, in Niger, the pressure government expenditure on health averaged has however substantially decreased as it used to to further promote improved population US$ 9.5 per capita per year during 2015-2020. The Government’s effort to finance health is be around 60% until the early 2010s. Converging health and service coverage while targeting Despite an upward trend that could be observed also reflected in the level of prioritization of towards UHC will have to go hand in hand with affordable access to necessary care without in Niger, the level of health spending that is the General Government budget on health, reducing the financial burden on households leaving anyone behind is ever-mounting. funded by public revenue only reached US$ 14.5 estimated at about 4.9% channeled through and the impoverishing effects including factors 8 9 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE associated with catastrophic health expenditure. made, the reform has some limitations. It has Table 3: been shown that for PHC funds were insufficiently Tentative response to health financing for UHC constraints and challenges in Niger executed. A related WB study on health financing The study has raised awareness on the crucial immunization assessment (May 2022) suggests Level of action Tentative response (non-exhaustive) to raised constraints and challenges need to augment health expenditure efficiency, stakeholders in finance and health to align and which must be the highest priority given its communicate efficiently. The report further Health system stewardship  romote and develop a national strategy that is efficient at tackling existing ineffective and/or wasted ▪P scarcity. The search for better performance has documents some of the current challenges health spending, and structurally fight against persisting technical and allocative inefficiencies imposed itself worldwide. It has been documented related to the linkages between the spending to  lan and include consensual and progressive threshold targets/goals for effective UHC, including the ▪P for Niger using comparative analyzes to reflect its targeted outputs, also underlying the need consideration of existing recommendations for LICs on the potential for improved efficiency in health for improved accountability in health policy. An nstitutionalize the use of global and national guidance and studies providing insights on the financing ▪I expenditure. From a global perspective, it has upcoming WB study on public finance should transition for UHC been shown that several indicators – such as help designing future solutions.  stablish a national arrears payment plan to avoid bottlenecks induced by financing issues with side ▪E life expectancy, under-five mortality and service effect to attract increased external funding coverage (assessed by the UHC index) – were Our assessment provides core information and  stablish the use of ready-to-use and country-specific health financing indicators (sector- and sub-levels) ▪E tackling any information gap below the general trend when confronted with data on health financing, serving as a baseline  romote and support health financing capacity building and analytical capacities for the monitoring and ▪P the use of the per capita expenditure on health. for future comparisons. This diagnosis tool aims evaluation of health financing for UHC These results suggest that Niger needs to make to support policy-makers by flagging key concerns,  romote better use of existing data (NHA for analytics and policy-making both at sector and programs ▪P better use of its available financing. According progress and challenges so that health financing levels). Better use relies on data. Moreover, a specific survey might be conducted to map external to the public expenditure review, the impact of decisions for UHC in Niger can be measured up resources on health that are channeled through NGOs, which was highlighted as a limitations. future policies addressing “identified” health over time and against its peers. Greater means ncrease stakeholder coherence and coordination to improve political advocacy around health financing ▪I system inefficiencies was projected in terms of (political, institutional, relational, technical and and UHC fiscal savings and could yield up to 0.23% of financial capacities) are required to meet the  overnance and efficiency in health expenditure weaknesses ▪G GDP in Niger. Potential efficiency gains can also ambitious goals of effective UHC by 2030 in Niger,  educe inequalities and use specific goals to monitor health workforce shortages at decentralized ▪R be expressed as a percentage of current total especially in a post-Covid-19 era. These can be level as part of the human resources for health national plan, mostly in remote areas, and insufficient distribution of skills to meet quality standards public expenditure on health, which could reach found through better, shared knowledge among  etter document and improve allocative efficiency, for instance with a convergence toward increased ▪B an additional budget space of about 13%. Future health and non-health stakeholders. For more share of financing to front-line providers and primary health care health financing strategies should systematically optimized performance, stakeholders require to  trengthening pooled funding and the UHC reform ▪S assess and tackle every dimension of technical take on a holistic approach that addresses existing  trengthening health system resilience and develop flexible health policies to ensure responsiveness to ▪S and allocative efficiency. More value for money challenges and implements health financing evolving needs, especially post-pandemic should be an integral part of the strategy to raise interventions that enhance efficient and equitable  ommunicate on the key health financing tools and documents to all partners (such as the RAP) ▪C more money for health. service delivery. Emulation is expected around the implementation of the UHC strategy, around the Health system financing  onitor future threshold targets set within the ongoing UHC reform ▪M dentify and address implementation bottlenecks, especially those linked to the free policy implementation ▪I Addressing existing bottlenecks in public institutional impulse for ongoing reform and a more  ommit to a sustainable vision for monitoring and evaluating (M&E), by generating national and ▪C finance is needed and can contribute to raise strategic financing approach. Authors questioned intranational evidence resources for health in Niger. Beyond health, available data to bring answers, raise awareness Address the recurrence of financing gaps, arrears and other cash flow weaknesses that are persisting ▪ the overall public finance management context and ultimately support the health financing within certain activities, while other activities that may register a surplus need to be flexible has several shortcomings that lead to missed transition in Niger. We put forward a set of data  obilize adequate financial resources (especially domestic resources) with respect to reaching political ▪M revenues for health. For instance, health budgets driven orientations and recommendations for and strategic goals were not executed in full, leading to substantial both health and non-health decision-makers. This  onitor the adequacy of health financing for UHC, for primary and community care services, for instance ▪M under-execution of both public and external tool for decision-makers aims to offer a reflective using per capita expenditure indicators/targets resources. Low execution is influenced by the approach calling for increased accountability and  etter information is key, inform on the percent and niche of ineffective and/or wasted health spending ▪B quality and timeliness of health planning, which change to meet transformative financing within the  lan, support and perform analytical studies for high-performance health policymaking (including ▪P public financing management assessments to support the financing transition towards UHC, a public involves various weaknesses (e.g. delays in UHC transition. Building health from sustainably expenditure tracking survey to improve budget execution) planning equals delays in budget execution and informed health financing should be valued.  trengthen or decentralize (at the level of the service provider) investment budget execution to improve ▪S related consequences). Therefore, the national technical efficiency in the PFM process skills to enhance the quality of public expenditure There is still a considerable need for future planning, utilization, monitoring and evaluation are research and analytics in Niger to drive Public finance management Address persistence of administrative delays and inefficiencies in the reimbursement of invoices ▪ crucially needed in Niger. The 5th Meeting of the upcoming health financing reforms and Address the financing limitations within the free strategy that undermine its effective implementation ▪ Montreux Collaborative on “Fiscal Space, Public reinforce health system responsiveness. The  stablish flexible, policy-aligned, and accountable budget formulation. ▪E Financial Management and Health Financing necessity lies in Niger to guarantee that everyone, mprove budget execution ▪I public finance” (November 2021) brought to everywhere has access to the health services that Health information  enerate a health financing information mapping and make it available for sector and cross-sectoral ▪G the fore how much performant public finance they need without becoming impoverished. Niger and communication purposes is worldwide needed. Globally, countries are decision-makers should therefore maintain their  apitalize on existing tools, digitalize data and data availability information, starting for instance with ▪C somehow constrained to endorse public finance efforts to strengthen health financing, prioritize a single website to guide stakeholders across multiplicity of data sources on health financing and adjustments, with the intend to provide greater health equitably and plan strategically while innovation, and/or create new tools tailored to decision-making needs financial flexibility and to tailor accountability progressively targeting effective UHC. As a way  evelop and strengthen a communication plan ▪D systems to respond to the unprecedented crisis forward, we concluded with a chart of potential Advocate and build on possible synergies with social determinants and inclusive growth to improve health ▪ of Covid-19. Niger reformed its public finance responses to the health financing for UHC outcome system in 2018 and moved away from inputs- constraints and challenges observed in Niger. This Intersectoral approach to  onverge towards more coordinated actions undertaken by sectors carrying determinants of health, ▪C based financing. Despite adjustments already report can be used as a strategic asset to prepare health (health in all policies) relate to human capital development, population growth and growing needs and youth/aging issues high-level consultations and topical sessions  earn from and take advantage of evolving contexts (post-Covid-19 economic growth sharing, ▪L around health financing for UHC and the upcoming Government prioritization for social and financial protection for health, ...) second health financing strategy.  stablish commitment around health-linked sectors within the National Technical Group for UHC ▪E See table on next page > 10 11 NIGER HFSA | TECHNICAL REPORT WB HNP WB GLOBAL PRACTICE HNP GLOBAL PRACTICE 1. INTRODUCTION Niger’s Health Financing System growth, dominance of the sector of agriculture, This final stage aims to promote evidence- peer countries and regional advances. Assessment (HFSA) aims to assess the country being a commodity exporter (or not); based change and to strengthen or create the Chapter four describes health system inputs national health system and highlight its ii) socio-demographic features such as the necessary links between actors and research by highlighting the current situation of human performances and potential opportunities population count and growth, life expectancy; teams, as well as across interrelated topics. resources for health and system infrastructure to support the policy dialogue around and iii) the geographical situation such as The analytical phase of the study indeed for care delivery. Chapter five delivers a sustainable health financing. The overarching being a landlocked country (or not). The faced several challenges, mostly with respect critical analysis of the health financing aims were to inform strategic decision-making ranking resulted from analysis of the trend to limited opportunities to effectively reach landscape in Niger, in terms of expenditure in health and to serve as a baseline diagnosis and/or average in indicators observed over a field stakeholders as needed, a scarcity trend and structure, resource mobilization to make future universal health coverage (UHC) 3-year period prior to date or to a decade ago. of digital information and a lack of publicly capacity, health financing adequacy and a reality for the Nigerien population. To that Based on the country ranking, selected peers available and validated data in Niger. performance requirements to meet ambitious extent, we implemented a WB standardized were those matching closest to Niger’s rank. Niger is characterized by multi-stakeholder UHC policy goals. Finally, in a sixth chapter, research protocol that we adapted to our study To avoid potential bias induced by the surge data producers that are not systematically authors spark the debate around a series of purpose. To optimize study responsiveness of the pandemic, all indicators referred to the aligned or aware of each other. Itemized discussion points and a perspective overview , we promoted an inclusive approach and pre-Covid-19 situation. Additional comparators and subnational financial data was scarce, on the future challenges in health system interacted with the field through the support of were explored to consider common use of incomplete, not promptly available, poorly financing. Driven by new evidence, we a local focal point from the WB Country office, country comparators as well as neighbored disaggregated, or undocumented. Interrupted formulated a way forward to be considered Niamey, Niger. Our approach attempted to countries (DR Congo, Chad, Nigeria, Mali, series of existing data, data extraction from when implementing the UHC reform. This bring together national decision-makers, mostly Senegal). For the global-level comparative multiple official reports and parallel information diagnosis aims at delivering insights that flag from health and finance, and development analysis, we refer to the standards using systems augmented complexity. Additionally, key concerns, progress and challenges so partners. Data collection was performed the WHO regional and WB income group when information was made available by that health financing advances for UHC can using a mix of methods including document classifications of countries. stakeholders or key informants, the analysts be measured up over time and benchmarked reviews and analysis of existing quantitative were confronted with multiple versions of the against peers and regional achievements. and qualitative data complemented by key The Niger HFSA comes at an opportune same document, sometimes non-validated or Selected components will need to be re- contributor interviews as needed. We primarily time to favor informed policy-making parallel versions, which required successive explored and synthetized, for instance, in used national data, subject to its availability around health financing for UHC, despite data updates and extension of the time a standalone policy note in support to the and quality. We reviewed both published and the emergence of the Covid-19. The dedicated to the analytical phase of the work. development of the country’s second health unpublished evidence of health financing in assessment was timely conducted after Niger To further build on the lessons learned, a financing strategy for UHC. Niger and interacted with key informants. We adopted its second financing strategy for UHC workshop will be organized during in fall searched complementary data repositories, 2030. In July 2021, Niger authorities indeed 2022in support to improved use of health This HFSA report is going to be part of a key websites and international community endorsed the foundations of an ambitious financing data and indicators among program larger program of interconnected analytical references, conducted cross-cutting analyses reform towards accelerated progress in health manager and health decision-makers and work that will help inform the new Niger and compared our outputs to key informants’ equity and coverage. This national agenda for informed intersectoral dialogue around health Health Financing Strategy for UHC. The opinions while using additional material UHC is as a revival of prior UHC commitment financing and the programmatic and policy WB technical assistance on health and public (including meeting notes). taken in 2012. Launched amid the Covid-19 implications. finance reforms for improved service delivery pandemic, it obviously involved additional in Niger embraces a series of five studies are: A benchmarking approach was used to considerations for agile decision-making. This assessment provides core information 1°) a Health Financing System Assessment highlight Niger’s situation against global, Besides bringing a further pressure to UHC- and data on health financing, serving as (HFSA), 2°) a complementary assessment regional, sub-regional, income group related outcomes, the pandemic may help a baseline for future comparisons and of the Immunization Financing System averages, peer countries and/or trends. For introducing health innovation. The current analytics around health financing for UHC assessment (IFSA) (4); 3°) a fiscal space for the country-level comparative approach ,two context shed light on new opportunities, and institutional sustainability for health health narrative jointly elaborated with the sub-sets of structural and aspirational peers notably arising from the fact that maintaining for all. Niger HFSA is a diagnosis tool, Economic update of April 2022 ; 4°) a Health were defined using MTI method: structural and protecting population health has promote shared awareness and evidence- Equity Assessment and; 5°) a Public Finance peers refer to countries that are currently become a unifying theme at the global based practices as the UHC agenda moves Management assessment (upcoming). similar to Niger (Afghanistan, Burkina Faso, level. Our study was designed to enhance forward in Niger. After the introduction, This study series complement prior studies Malawi, Uganda) whereas aspirational peers stakeholders’ participation at all stages. After chapter two provides a situation analysis of conducted in Niger and especially the Niger’s refer to countries that were similar to Niger a period of relatively limited interactions and the socio-sanitary, macro-fiscal contexts and Public Health Review (5). Along with existing in the past but grew much faster than Niger predominantly virtual collaboration due to health policy anchorage for UHC. Chapter assets (health accounts, budget execution over time (Ethiopia and Rwanda). For each the broad context of the Covid-19 pandemic, three focuses on health system outcomes, and other official reports), the study series sub-set of peers, a country ranking was made national stakeholders and partners will be with particular attention to service coverage will be used in future technical assistance, using criteria in several areas related to: i) the invited to step in into a next phase of study and delivery, population health gains and helping with targeted visuals for instance. economy such as the government expenditure results dissemination, knowledge translation Niger’s health system performance against as a share of GDP, per capita real GDP and GDP as well as policy and practice development. 12 13 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE 2. COUNTRY CONTEXTS Figure 1 : Forecasted population age pattern and life expectancy in Niger Source: IHME This second chapter provides a situational expectancy of 62 years old in Niger is aligned analysis of the country contexts focusing on with LICs and SSA averages of 63 years old the socio-economic, demographic, macro- (WDI 2019). It is expected to improve and economic and political aspects relative to possibly reach 83 years old for women and 78 UHC. for men by 2100, which also means growing demand for care. Yet, the broad base of the 2.1. Socio- age pyramid gives Niger the potential for a demographic dividend, linked to the youth of demographic and its population1. Niger has one of the youngest nations in the world, with a median age of 15.2 human development years, a fertility rate of 6.2 children per woman of childbearing age and annual population patterns growth of 3.9%. The age structure is expected to remain pyramidal, dominated by youth (Figure 1). The country has not really begun Niger is a landlocked and climate- its demographic transition since the synthetic impacted Sahelian country with a rapidly fertility index used to be at 7.6 children per growing population that will likely double woman in 2012 (6). Besides, Niger’s population in size every twenty years. In 2021, the total is and will remain disproportionally distributed population of Niger was 24.1 m people. The across regions (7), with about 83.4% in 2020 country will accommodate nearly 10 million living in rural areas. more inhabitants and could reach a total of 34.8 million by 2030, according to WB projections As raised in a past Health Development Table 1: POVERTY INCIDENCE (%) 2011 2014 2018 Poverty incidence (WDI). According to IMF Country reports, Niger Plan (PDS 2017-2021), prevailing and could become the most populous country in widespread poverty contributes to in Niger: nationwide Niger (Total) 48,2% 45,4% 40,8% and across sub- the West African Economic and Monetary limited access to care in Niger. Despite its Rural 54,6% 52,4% 46,8% groups (urban-rural, Union (WAEMU). With 19.9 million in 2015, vast territory and natural resources, Niger regions, sector of Niger used to be the second most populous remains one of the poorest countries in the Urban 17,9% 9,1% 11,8% employment), 2011- country in the WAEMU (after Ivory coast, world with a gross domestic product (GDP) 2018 22.7 million) and the UN estimates project its per capita around US$569.8 in 2021 and Dosso 52,9% 59,4% 48,4% population to double by 2034 and to surpass 41.8% of the population (about 10 million) Source: INS (survey data) Zinder 47,7% 52,9% 47,8% Ivory coast in 2024. If Niger accounts for a living below the $1.9 international poverty Maradi 58,8% 67,2% 46,1% fifth of the WAEMU population, by 2050, the threshold, according to WB Macro poverty country is expected to account for a quarter outlook and most recent country survey Tillabéri 56,0% 41,8% 42,3% of the WAEMU population, according to IMF. (EHCVM 2018). Niger has about 83.6% of Tahoua 47,9% 28,8% 35,7% Niger’s population is expected to further workers in informal employment (2011), with Diffa 34,0% 34,1% 34,0% increase to up to 185 million people by 2100 a ratio of 1.7 of workers in informal versus Agadez 20,7% 9,7% 14,6% (5). Therefore, it should be emphasized that formal employment, similar to Burkina Faso any attempt to produce a country diagnosis or Nigeria (8). Informal workers are largely Niamey 10,3% 6,3% 6,9% for Niger will need to include indicators represented both in non-poor households expressed per capita to better reflect the real (83.9%) and in poor households (96.4%). Public sector employee 6,2% 12,8% 2,8% impact on populations. Beyond representing an important source of Private sector employee 49,8% 51,4% 25,7% employment, the informal sector is also an Niger’s population growth puts high important source of production of goods and Self-employed (agricultural sector) 56,2% 53,9% 48,9% pressure on national decision-makers services. In many countries, the contribution Other self-employed 29,5% 30,5% 27,0% On the long run, the dividend 1 to meet associated growing needs with of informal enterprises to the added value is Unemployed 34,4% 23,8% 34,7% refers to accelerated growth basic infrastructure or social services, significant and its consideration within the in the national economy which are challenged by epidemiology and UHC reform is crucial (75). induced by a change in the over 2020 to 2021 for Sub-Saharan Africa rural areas (46.8%) compared to urban areas age structure of the country’s environmental transitions. The challenges and LICs against +0.2% and +1.0% as pre- (11.8%), with the regions of Dosso, Zinder, population and potentially of epidemiological transition and the risk In Niger, one might expect a decline in leading to augmented labor Covid projections (9,10). Country data from Maradi and Tillabéri and lower education level force, ultimately generating of a “double burden” induced by a rapid its progress towards poverty reduction the ECVMA household survey (2018) should households having the highest concentration The methodology used for the 2 different household surveys a window of opportunity for a development of chronic and environment- that can further challenge existing over the past years in Niger “transition surplus” if effective be considered as a baseline for poverty of poverty (Table 1). In 2018, the sectors of is not homogeneous and policies (through concerted related diseases are well known. Niger’s disparities. From a global perspective, the monitoring and evaluation in Niger2. Pre- activity in which poverty was most significant makes any direct comparison efforts on social and population growth represents a major public regional distribution of the pandemic-induced perilous between the results economic affairs, including pandemic, national indicators of incidence, were agriculture (poverty headcount: 49.5%), produced by the ENBC 2007- health and human capital) are health concern due to the need to not only poor suggests that Sub-Saharan Africa depth and severity of poverty were respectively livestock-forestry-fishing (38.3%), followed by 2008 or QUIBB2005 and implemented to establish the maintain current health standards but to might be hit hardest, with a percent change ECVMA2011-2018 surveys. conditions to capitalize on the 40.8%, 11.2% and 4.3% at national level. The industry (28.6%), commerce and sales (28.6 Institut National demographic dividend. improve health and service coverage.The life respectively forecasted at +2.5% and +2.7% 2018 incidence of poverty was much higher in and 25.3%), and service sector (21.1%). de Statistiques (INS) 14 15 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE Although Niger has made advances in future generations that is exacerbated by strengthen macroeconomic stability and political commitment to the health sector combating poor health and high poverty, the pandemic (11). Niger also has very poor improve governance and transparency, is renewed. The new 2023-2027 health many challenges are ahead. In 2020, Niger performance in: (i) the rate of children not while laying the foundations for stronger and development plan is being prepared and ranked almost last in the Human Capital Index stunted - 42 out of 100 children are stunted, more inclusive growth. The success of the should confirm, or not, a strong commitment (HCI), falling under the regional average for at risk of cognitive and physical limitations program will depend on the implementation on the part of the State. Sub-Saharan Africa (0.40) and peers (Figure that can last a lifetime; (ii) child survival – 80.4 of reforms to generate additional financial 2). This means that a child born in Niger will children out of 1,000 live births die before their support from donors. The country is eligible Niger’s risk of debt distress is qualified be only 32% as productive when they grow fifth birthday; (iii) expected years of schooling for the HIPC initiative (Heavily Indebted Poor as moderate. Niger’s debt mostly owed to up as they could be if they enjoyed complete - a child who starts school at age 4 can expect Countries). In May 2021, Niger developed a external creditors. Multilateral debt concerns education and full health. The situation to complete 5.3 years of school by their 18th mid-term strategy for 2021-2023 that should eleven creditors, the largest of which are could have been further aggravated by the birthday; and (iv) the learning-adjusted years provide the finance needed and cover IDA (46.3% of total external debt), West onset of the Covid-19 pandemic, with a risk of schooling - factoring in what children future payment obligations (18). Further African Development Bank (15.7%) and of a ripple effect across populations and actually learn, is 2.6 years (11). consolidating public finance as a government African Development Fund3 and IMF (11.5%) priority, Niger concurrently strives to revive (20). Bilateral debt also concerns multiple national economy, control the public deficit creditors grouped into: 1°) Paris Club Figure 2: and debt and ultimately create the required members’ creditors representing 26.5% of Human capital index Country progress Progress among peer comparators budgetary space for new investments from bilateral debt and 3.7% of total external debt (HCI) in Niger and 0,5 internal resource mobilization. and 2°) other creditors representing 73.5% HCI index 0,4 of bilateral debt and 10.2% of total external 0,42 0,41 0,40 0,38 0,38 0,38 0,38 0,37 0,36 0,32 0,32 0,30 focus countries, 2017- 2020 0,3 In the long run, Niger’s economic debt (20). The country carried out a Public 0,3180 0,3157 0,3160 0,2 growth could be expected to become Debt Sustainability Analysis showing that a Source: WB Global 0,1 the dominant factor as it helps mobilize public and external debt to GDP ratio, and a statistics (WDI) 0 more resources to finance the budget in Senegal Malawi Afghanistan Uganda Burkina Faso Ethiopia Rwanda Congo (DRC) Nigeria Mali Chad Niger Niger public and external debt service to GDP ratio a sustainable way, amidst competitive met the IMF sustainability threshold and most spending pressures. Yet, the growth turns but not all the WAEMU convergence criteria out not to be sufficient to create the conditions (20). At the end of 2020, Niger’s outstanding HCI 2017 HCI 2018 HCI 2020 for a sustained development. Although debt represented about 44.8% of GDP and Niger’s real economic growth increased public debt service was 1.5% of GDP in 2020 by 166% between 2000 and 2019 (19), the (14,20). According to WB experts (Economic Global ranking of 174 countries (2020) population grew exponentially, resulting in a Outlook), the country endorsed an ambitious low per capita growth rate over the period. fiscal adjustment that is IMF-supported. Such Over the same period, Niger’s population adjustment intends to reduce Niger’s deficit increased by 194% between 2000 and 2019, from 5% of GDP in 2022, which would put 3 FAD–Fonds Africain equivalent to 3.8% annually, on average the debt-to-GDP ratio onto a steady decline. de Développement (WDI). It is projected that a decline in fertility 2.3. Political journey accompanied by increased investment in the human capital of girls and women would 2.2 Macroeconomic security risks, persisting risk of droughts and floods, food insecurity, inflation, local disease increase real GDP per capita by 32% by 2030. Even a modest reduction in fertility towards UHC environment outbreaks, and widespread socio-economic insecurity. Niger belongs to a group of 35 to approach the regional average would result in an 11% increase in GDP per capita 2.3.1 UHC financing transition countries that are characterized by fragility by 2030. A related study on fiscal space The country has built on a period of and conflict situations by the WB’s Fragile, for health concluded that the predominant economic growth but remains challenged In the Renaissance Program Act II (2016- Conflict and Violence group, according to source of increase in government health by uncertainties and a low level of income 2021), the President of the Republic of their financial and security status (12,13). It expenditure should stem from the capacity of (GDP). Until 2020, Niger’s real growth Niger committed to significantly improve remains categorized as a fragile and conflict- the government to mobilize a greater share of In 2019, Niger also adopted 4 hovered at around 5.5% annually. The real Niger population health, recognizing affected country (FCAS) in 2022. LICs make the GDP for its budget. Budget prioritization a National Strategy for growth falls to 1.3% when expressed per the goal of reaching healthy lives and Community Health (PSNSC) up the majority (51%) of the group, many on health within the general budget of the with the aim of contributing capita. The economy is mostly driven by the well-being for all at all ages. The whole are situated in the African region (47%), and State and the economic growth should be of to progress towards UHC. agricultural, mining and petroleum sectors. UHC path appears to be widely recognized In theory, the PSNSC seeks are IDA eligible countries. DPs like the WB equal importance. to build existing CHW- Many components of the economy are and aligned, through several high-level or Gavi use such country classifications with interventions, move away highly vulnerable to climate change, political commitments. Aware of the many challenges from fragmentation of the the primary purpose of ensuring appropriate Besides, if Niger’s public spending has instability, and external aid fluctuations. All ahead, the country materialized its political interventions and standardize, strategic and programmatic focus and increased during the pandemic, it may expand coverage, reduce sectors experienced a significant slowdown support tailored to the diverse challenges not be sustained in the near future. commitments for UHC through several geographical barriers to strategic documents, both at the health access, and improve the due to Covid-19, even if the primary sector faced by these countries. According to recent data analysis (19) , quality of community-based resisted the initial shock. In a global context sector and beyond. At sector level, Niger service delivery. In practice, Niger’s public spending followed a counter- adopted its second decennial National according to key informants, of recession (15) and a sanitary crisis Niger has adopted a multi-year plan for cyclical expansion during the pandemic, with performance may remain low. Health Policy that is implemented in Health impacting the whole African continent (16), economics and finance for 2022-2024. It increased spending in 2020 and in 2021. Niger’s inflationary pressures rose (+2.9% in is drawn up from four strategic documents However, forecasts call for an adjustment in Development Plans (PDS IV 2017–2021 and The expected results of the 5 2020, against +1% in 2018-2020). Inflation i.e., the Renaissance Act II, the results of the medium term, with a reduction in public PDS III 2011–2015). This is accompanied second UHC strategy are threefold: i) better health was fueled by rising food and cereal prices by several strategies (including a national for all, through the lever of the implementation of the Economic and spending per capita for the years 2022 and and tightened domestic markets. As a result strategy community health4 and a newly the determinants of health; Social Development Plan (PDES) 2017- 2023. As a result, in the absence of renewed i) better quality of health of these economic conditions, the number of national strategy for UHC 20305) and services, through an efficient 2021, successive Economic and Financial political commitment, health spending ultra-poor rose (+1.4%), from 9.8 million to reforms that fit well with the UN Sustainable and resilient national health Programs (14–17), and is supported by growth could be expected to slow down in system guaranteeing that 10.5 million people. The economy is expected Development Goals (SDG 2030), the former everyone receives adequate the IMF’s Extended Credit Facility (FEC- the medium term. Another scenario projected care; i) a financial protection to resume growth in 2022. Future economic UN Framework Plan for Aid Development Facilité Elargie de Crédit 2021-2024). A that the health share of the budget could system supported by an growth will be subject to an even higher (UNDAF 2014-2018) and those of the Niger efficient health financing new IMF-supported program also aims to continue to increase substantially if strong degree of uncertainty, due to intensified Strategy for Sustainable Development and system. 16 17 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE Inclusive Growth (SDDCI 2035). Grounded immunization financing, fiscal space for coverage were Senegal 7% (in 2010), Ethiopia pregnant women and U5 children. It was around human capital development, which health, human capital and public financing, 6% (2006), Mali 5.6% (2018), DR Congo 5% developed after the adoption of the primary covers health issues, the latter should aim to inform upcoming high-level agenda. (2013) and Nigeria 2.3% (2018). The remaining health care (PHC) policy (2002). The State materialize through massive investments If political commitments for UHC are four peers had less health coverage, like acts as a third-party payer, reimbursing health in public goods for rural revitalization (21). clearly being made in Niger, leading Malawi 1.8% (2018), Uganda (1.5%), Chad facilities based on flat rates (fixed by legal This strategic document could serve as a stakeholders are progressively building 1.2% (2015) and Burkina Faso 0.9% (2010). texts) – therefore using a financing design reference for domestic actions over the next the path. A national steering entity worked Yet, the contributory systems in place in Niger that is not based on health benefit costing. decade. Health policymaking was also part along with thematic groups to bring a multi- did and still do not protect against all financial This flat-rate pricing offers the advantage of of the Niger Declaration of General Policy sectorial approach to UHC implementation. risks induced by healthcare use, the expenses predictability and cost control but carries a (DPG 2017-2021). For major stakeholders involved in the in drugs and certain medical examinations risk of under-prescription, particularly of drugs UHC journey (Box 1), success factors will and consumables being often excluded and other inputs, this risk being accentuated Ten years after the 2012 national be to maintain and improve communication from the coverage. The agenda for moving if the price does not take into account the strategy for UHC, last June 2021, Niger while building capacity around the UHC towards UHC is therefore essential to improve production costs of the services – as reported created a momentum with its second agenda in Niger. To further implement the financial health protection. It is even a multi- by key informants. Moreover, flat rates should national strategy for UHC , calling for the UHC agenda, several decision-making and dimensional issue requiring cross-sectoral be reevaluated as these were set in 2005- elaboration of a financing strategy for consultation bodies emerged. Yet, these still development. Even if coverage levels are low, 2006, and are now out of date, as indicated UHC (22,23). Major results are expected need to be either strengthened or provided current insurance mechanisms constitute the by a study report on the costs of care services by 2030 and are enshrined in 10 strategic with the tools, procedural arrangements and first steps towards universal protection (25). carried out in 2015. It had also been noted that axes of interventions, including interventions adequate human and financial resources In 2021, the MoH assessed around 6 million part of the reimbursement of the free package for increased efficiency and resilience to fully function, also to potentially take people are covered for social health protection was made in kind (for example in the form of (23). To date, a legal framework for UHC advantage of possible synergies. (under-five children, state employees and the drug donations). This does not allow health implementation is available and the Council retirees) (22). facilities to generate necessary financial of Ministers of 23 September 2021 adopted 2.3.2 Social protection resources for their operation. Besides, the a decree creating a public establishment for Large inequities persist despite the government purchases services based on social protection. Within a 10 years frame, for health, targeted free health existing arsenal of public and private inputs, as well as outputs largely dealing Niger will have replaced the existing free care and other health protection insurance schemes developed in Niger. with infrastructure, direct financing of health Health care policy with a universal health mechanisms Although a National Social Security Fund was services and some incentives to produce insurance (AMU) to which the entire population established by law (in 1965, revised in 2003), certain results (26). The health workers will be subject. This AMU should be managed The existing social protection policy about 4.1% of workers in the formal sector of involved are mostly salaried. It should be by an independent institution in accordance in Niger insufficiently protects the the economy, 1.6% of unemployed individuals raised that important financing issues were with the law. The National Institute of Medical populations from risks of illness. According and 0.9% of informal workers have a pre- reported and are further discussed in a whole Assistance (INAM) is however not functional to key informants, a recent survey conducted payment scheme for health (24). Disparities section on the inefficiencies in PHC financing. to date, as his role and scope should be further by the mutuals mentioned a coverage of 5% were reported across both socioeconomic defined. The implementation of the upcoming of the population. Overall, only 2% of the segments of the population (poorest-richest Several reforms have been put in place to health financing strategy for UHC has been population in Niger were covered by at least 20% gap) and location of residence (urban- meet the challenges of the national health scheduled during 2022 (i.e., PAA-2022/Q4: one health insurance scheme – as reported rural gap). The scheme funded by the State system, including strategic purchasing. drafting of the document) and will likely start in the latest population-based survey 2012 – (100%) aims to cover 80% of hospitalization For instance, Performance-Based Financing during 2023 (according to key informants). which is much lower than the regional SSA costs for public sector employees (Law of (PBF) was initiated through the 2011-2015 New evidence and insights brought by this average of 7.9% (24). Based on these authors, 2007) and, via agreements, for employees health development plan and is relayed in the HFSA, along with other studies on equity, Niger’s peer with better health insurance of the formal private sector (Law of 2012). Niger’s UHC strategy for 2030. PBF in Niger Complementary health mutuals (i.e., mutuelles is envisaged as part of the health financing de santé) operates by sector (such as oil or reform for UHC, referring to the implementation electricity companies), some others are also of motivational measures in all health facilities. geographically-anchored, but in 2017 they A national strategy for the PBF expansion was Box 1: Institutional framework for UHC, an overview on major steering bodies were reported to not be working very well (26). designed in April 2022, and is in discussion The penetration of private health insurance was in the country. The mechanism started with a (1)  UHC High-Level Steering Committee (“CHP/CSU”) is the highest governing body for the estimated at 3% (2017), which is significantly pilot in the Boboye health district (2015). In its implementation of the UHC strategy, under the direct leadership of the Prime Minister. It is embodied lower than coverage through community goal to achieve the sustainable development, by the UHC-related sector ministers, the senior officials of the key development partners (for health mutual funds (26). To our knowledge, the Niger is working to find concrete solutions and social protection). informal employment rate in Niger is estimated to address the health sector shortcomings. UHC National Technical Committee (“CTN-CSU”), under the aegis of the MoH General Secretary, (2)  at 95.4%, which is very similar to Uganda or One of the objectives of MoH is to improve is an intersectoral body acting in close collaboration with its counterpart for social protection (“CTN/ Senegal (24). Only a few private insurance the performance of the national health system PS”) companies exist. Community health mutuals through an integrated free policy and PBF (3)  Permanent Technical Secretariat (“STP”), for the technical and operational aspects of the were established by law in 2008, mostly in instrument. Indeed, as a financing system implementation of the strategic orientations received from the two bodies CHP/CSU and CTN/CSU, rural informal settings. evolves, the common concern is to reduce including support for the CMU and evaluations its fragmentation. The potential scaling up of Permanent thematic groups (e.g., expansion of quality of services, financial protection, public (4)  In addition to contribution schemes, an integrated PBF arrangement remains a finance) under the supervision of the STP. They are made up of executives from sectoral ministries, exemption policies for targeted care focus prerogative of the MoH, and discussions go representatives of the development agencies, and civil society representatives. They act in support on under five (U5) children, pregnant on as the MoH searches for rapid quantitative of both the “CHP/CSU” and “CTN/CSU” bodies and produce work to inform the decision-making and women and groups living with a disability and qualitative improvement in the provision the elaboration of the strategic orientations or illness (HIV-AIDS), vulnerable groups of health care services for all. According to (5) Additionally, a national working group for UHC (“GTN/CSU”) and indigents6. As part of the MDG global key informants, the Enabel’s approach to Fee exemptions apply 6 agenda, the “free” policy was launched departmental insurance schemes is another nationwide covering Source: UHC strategy, June 2021 (p71) in Niger in 2005-2006, providing either area under discussion in Niger. immunization services, care in the event of epidemics, totally free or co-payment arrangements for prenatal consultations, services related to c-sections, treatment of female cancers, contraceptive health, and some preventive care. 18 19 NIGER HFSA | TECHNICAL REPORT WB HNP WB GLOBAL PRACTICE HNP GLOBAL PRACTICE 2.3.3 Human resources policy numbers of healthcare workers available to towards quality services deliver services. Nationwide health workers have been facing a difficult daily workload for a long time, working in a challenging At the political level, several commitments environment with inadequate compensation were made to improve Human Resources (remuneration or career developments) and for Health (HRH) in Niger. Niger recognized little recognition for their efforts (such as HRH as a building block of the health system bonuses or training) (29). To contribute to more than a decade ago, as stated in its PDS improved access to essential services, the 2005–2010, which had put decentralization as national strategy plans to strengthen the a core axis of the national strategy. Niger had community health component in Niger9. A embraced a multi-sectoral approach for HRH peculiarity of the Nigerien system lies in the and was said to be a pioneer in West Africa existence of a growing risk of insecurity, as to take up the UN High Level Commission on reported by the Armed Conflict Location and employment in health and economic growth Event Data Project. Attacks on healthcare (HL Commission) (27). Interventions like providers are a concern in certain regions. For deploying skilled staff nationwide were taken instance, in 2021, two critical incidents were with the intention to deliver quality services reported of health facilities being damaged to all citizens. Particularly, the Niger’s UHC or destroyed and a worker attacked (killed, strategy (2021-2030) has several specific kidnapped or arrested) (30). objectives related to human resources in health that include the goal of reaching 80% This ongoing HR reform in Niger should of health facilities adequately staffed and create greatly improved labor conditions strengthening human resources management to make HR systems more effective. and capacity. Throughout Africa, HR systems are often seen as weak, with low overall capacity To transition from the ten-year HR plan management. As a result, health workers for 2011-2020 (28), Niger envisaged a are often unprepared and unable to meet the National Action Plan (PAN) to sustain high demands placed on them; they may lose national growth, therefore foreseeing motivation, become disengaged, or vacate large investments in the social sector over their posts altogether. In Niger, there used to the next decade. The country intends to be no formal or informal evaluation system, operationalize the ten recommendations of the resulting in a lack of knowledge among HL Commission7 to stimulate and guide the public workers about any potential career creation of new jobs in the health and social advancement opportunities (29). If some sector and reduce HRH shortages. This bold could aspire to career development plans, HR reform is expected to be a game changer they were often unclear or poorly managed. for the sector and the whole of society, and According to key informants, for instance, if is aligned with the Renaissance Program Act performance contracts were signed, they were for Niger. Four MoH divisions are in charge of not evaluated. Thus, employee engagement HRH norm setting (DRSP, DRH and DGSP/ remained low with high risk of low productivity DOS). The PAN national agreement adopted generating disproportionate waiting time for in 2020 by presidential decree seems to the care beneficiaries, regardless of the type of have not yet been implemented as a whole facility. Frequent reassignment of staff, weak strategy. It nevertheless offers a recent supervision systems and weak in-service situation analysis and advances policy goals training of health workers contributed to HRH in the matter. With the ongoing UHC strategy, weaknesses in Niger and could be seen in substantial HR improvements are expected, the Tahoua region (29,31). The USAID HR and have been translated into budgeted improvement project outlined seven actions actions – under a specific sub-program “21710 for increased efficiency and effectiveness HR management” nested in the MoH program among health workers in Niger: “1) detailing 7 UN-High level commission 1. Niger authorities recognized that investing clear expectations and goals; 2) conducting goals at the regional level in health through the health workforce (HWF), for LMICs: the creation of competency development; 3) relaying frequent at least 40 million new jobs both quantitatively and qualitatively, should feedback; 4) providing a fair evaluation; 5) in the health and social make the population more productive and the sector, and reduce the giving rewards and consequences; 6) offering shortage of 18 million health economy more resilient. opportunities for professional advancement; professionals, mainly in low-income and lower-middle and 7) ensuring a safe and adequate working income countries, by 2030 Despite high-level commitments, human environment” (31). Besides, several other ”Goal 3.4 . (source: High resources challenges ahead are diverse Level Commission on Health concerns may remain valid; for instance, the Employment and Economic and sizeable in Niger. The ongoing challenges linked to the trained headcount, Growth, 2016, Commit to reorganization of the sector is set to better, Health and Growth: investing annual recruitment, quality and targeting of in health workers.). and ultimately fully, meet health facilities’ training or task shifting of medical staff and 8 https://www.afro.who.int/fr/ needs. Niger is a country with a very young nurses to more administrative and managerial news/innover-pour-la-sante- population and is not using this workforce to functions, according to key informants. au-niger its full potential8. Several specific targets have Workforce retention, mostly in rural settings 9 Under the patronage of the been defined to expand public supply to rural may also represent an issue in Niger. The MSP, Niger held a validation populations, strengthen reproductive health workshop for the National 2019 SARA survey reminded the need to Strategic Plan for Community services, strengthen links to communities improve and adapt training of HR among Health in Niamey (November through decentralization, build management 4-5, 2019)”Niger Inter”, other recommendations. presse nationale. capacity and reduce gaps in the quality and 20 21 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE 3. HEALTH SYSTEM OUTCOMES Figure 4 : Country improvements for UHC against LICs, 2000-2019 Tracking UHC UHC index by country, progress in service 100 Latest year (2019) coverage in Niger, 2000-2019 80 PRK SYR Source: UHC Global 60 monitoring data RWA 37,4 UGA 40 31,8 34,1 34,2 ERI 16,7 MWI 20 GMB MOZ 0 This third chapter explores the major health the SDG indicator 3.8.1 on service coverage BDI 2000 2010 2015 2017 2019 outcomes, focusing on the service coverage has progressed enough (+20.6 since 2000) to YEM and epidemiological trends and achievements narrow its gap to the LICs trend (+19.9) (Figure LICs Avg score LICs Median Niger TGO In Niger, benchmarked to regional and income 4). Scoring 37.4 out of 100 in 2019, Niger’s LICs Lowest score LICs Highest score SDN group averages and peer countries. efforts remain behind the levels of service BFA coverage reached by several peers such as LBR Overview of LICs countries: UHC index, latest year (2019) 3.1 UHC tracer Burkina Faso or Malawi, and lagged regional MLI (46.0) and income group (42.2) averages SLE index and its (Figure 4). It should be reminded that across 2019 COD Africa, the best-performing system delivering 67,8 ETH sub-components essential health and health-related services to NER the population is only performing at 70% of AFG what is possible (32). Niger’s achievement in GIN Service coverage for health has improved terms of coverage of essential health services 27,3 GNB significantly in Niger, with sustained is also below the 2030 target set at 80. This MDG progress since the country started at a shows the substantial margin of progress CAF comparatively low level of coverage at the and financial resources needed that could be SSD beginning of the millennium. In terms of further expected from Niger during its UHC TCD progress expressed in relative terms between transition journey. To sustain progress towards SOM 2000 and 2019, Niger performed as expected UHC in Niger, domestic revenue mobilization compared to the general trend (Figure 3). efforts must be maintained and strengthened Powered by Bing © Australian Bureau of Statistics, GeoNames, Microsoft, Navinfo, OpenStreetMap, TomTom, Wikipedia 0 50 100 Indeed, as measured by the UHC tracer index, as has been recommended internationally (3) Considering the level of per capita health coverage compared to Niger. Other countries expenditure spent in Niger, achievements in such as Malawi and Uganda reached higher Figure 3 : Niger health service coverage is lower than service coverage while devoting a similar per Expected progress in expected. Niger’s UHC coverage is below the capita spending in health. With that regard, Niger’s service coverage over 7 general trend (Figure 5) which means that other service coverage appears less performant than Average annual change in service coverage index (%) past decades in Niger, countries provide a higher level of coverage for several peers. It becomes obvious that the pursuit 2000-2020 the same-level of per capita expenditure. For of improved health coverage is not solely based on Source: Author’s 6 instance,Ethiopia that devoted a lesser level of per the money spent per capita and that Niger should calculations using UHC capita spending in health reached higher service improve the efficiency of its health expenditure. Global monitoring data 5 Figure 5 : 85 UHC to per capita Niger 80 expenditure on health 4 in Niger against global 75 trendline, 2019 70 Source: WHO Global 3 statistics 65 60 UHC Index Rwanda 2 55 50 1 45 Uganda Malawi Senegal DRC Nigeria Burkina Faso 40 Ethiopia Mali Afghanistan 0 35 Niger 0 10 20 30 40 50 60 70 80 90 100 30 Chad 25 Initial service coverage value in 2000 20 19.4 28.9 44.5 54.4 73.9 110.9 155 260 337.8 515.8 861.3 1,530 Current health expenditure per capita, US$ 22 23 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE Uneven UHC progress across sub-sectors contributed to mixed results, both in the level of UHC, including low access to basic sanitation, hospital beds or health worker 3.2 Otherhealth its peers (such as Chad (172), Mali (176) and the DRC (178)) (33). Due to the lack of skilled terms of achievements reached or pace of improvements. Niger’s service coverage density. To advance UHC, improvements are further needed in all UHC tracers and outcomes services, too many women still die every year while giving birth or during pregnancy. For on reproductive, maternal, newborn and child health (RMNCH) (54) was close to in beyond. A key set of GFF indicators is available to monitor reproductive, maternal, performance years, acute and chronic malnutrition (children 6-59 months) remained above the respective the pooled average of peers while Niger’s newborn, child, and adolescent health and thresholds of 10% and 40%. In 2020 (SMART service coverage on infectious diseases (35) nutrition outcomes (RMNCAH-N), essentially In Niger, maternal and child health survey), 45.1% of U5 children were stunted. and service capacity (0.15) lag (Figure 7). using EDSN-MICS (2012), ENISED (2015) continues to represent a major public The RMNCH tracer was mainly driven by and PMA (2017) (Figure 7). A related study health issue for the country. In 2021, Niger Since 2009, communicable, maternal, improved immunization coverage (DPT3) (4). showed the state of vaccination coverage (4). had an infant and child mortality rate (U5 neonatal and nutritional diseases In contrast, other factors negatively impacted children) of 123 per thousand live (6), which is are predominant in Niger. Niger has a close to the 2012 DHS rate of 127 per thousand predominant share (73%) of its burden and ENISED (2015) of 126 per thousand. of disease coming from communicable, Figure 6: Infant mortality (<1 year children) seems to maternal, neonatal and nutritional diseases UHC service coverage 60% be experiencing a significant increase, since (illustrated in red) (Figure 8) compared the SSA sub-indexes in Niger, 20 it was 51 per thousand live births in 2012 region (56%) and LICs (54%) averages. Non- benchmarked against Pooled and rose to 73 per thousand in 2021 (6). 50% 44 communicable diseases (in blue and purple) pooled average of average 42 According to past survey data, the neonatal Service coverage (%) (2017) and injuries (in green) represent respectively peers, 2000-2019 53 mortality rate did not improve, as the country 40% 22% and 6% of the total burden of diseases Source: WHO Global stagnated with a rate of 24 per thousand live in Niger. Across age groups, infants and U5 statistics 30% 10 births during 2012 (DHS) to 2015 (ENISED). children are disproportionally affected and Niger 40 Maternal mortality rates improved between have the highest rates of diseases and deaths. 20% (2017) 37 2012 and 2015, passing from 535 to 520 per 54 With respect to the health determinants the 100,000 live births in Niger. As in the “safe primary causes of poor health in Niger are 10% motherhood for all” world ranking of Save the malnutrition, followed by water, sanitation, 0 10 20 30 40 50 60 Children, the conditions for the mothers and and hygiene problems (WASH), then air 0% children living In bottom decile countries, of pollution, high blood pressure, etc. Along with 2015 2017 SCA-Service capacity and access which most are from West and Central Africa, the demographic transition, the epidemiologic Niger IDs-Infectious diseases are alarming as it is reported that on average transition is expected to impact both short EUHC-Essential health services 1 woman in 30 dies from pregnancy-related Infectious diseases term and long term volumes and types of RMNCH-Reproductive, maternal, causes and 1 child in 8 dies before his or her Essential health services newborn and child health health services needed in Niger, auguring fifth birthday. Their conditions in 2015 ranked an additional pressure on the health system Service capacity and access Niger 175th out of 179 countries, along with costs (5). Reproductive, maternal, newborn and child health Figure 7: Niger survey monitoring of All Women: Demand for family planning satisfied by modern… 45,0% 40,9% RMNCAH-N, 2012- 2017 Vitamin A supplementation 59,6% indicators using population - based survey RMNCAH - N standard set of coverage Skilled attendant at delivery 39,7% Source: Niger survey data 29,3% Postnatal care for mothers 36,9% 40,8% Oral rehydration salts treatment of diarrhea 44,3% Institutional Delivery 70,8% 29,8% DTP3 vaccine 78,9% 68,1% Careseeking for symptoms of pneumonia 59,3% 53,1% Antenatal care for pregnancy (4+ visits) 38,5% 32,8% 0% 20% 40% 60% 80% Latest year Baseline (2012) 24 25 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE Figure 8: Figure 9: Disability-adjusted life Trends in disability- years, causes of death adjusted life years and related shares and deaths for most across age groups in prevalent conditions Niger, 2019 in Niger, benchmarked to regional and low- Source: Author’s viz. income averages, For Niger using IHME 1990-2019 Source: IHME The persistence of these nutritional problems of 6.2). Overall, 11% of women in union are has been attributed to recurrent food crises currently using a contraceptive method. This and social norms favoring the adoption of latest survey also highlighted a decline in the inadequate dietary practices and several level of use of modern contraceptive methods other issues. It is also attributed to insufficient since the prevalence fell from 12% in 2012 to implementation of nutrition interventions 10% in 2021. within a consolidated multisectoral framework – whereas the management of malnutrition Hoped initially spared, Covid-19 also shook cases improved within the national strategy Niger. According to 2020 NHA (using MoH/ against malnutrition that has directed its efforts DSRE reporting11), since the first reported through nutritional recovery centers for nearly case (mid-March 2020) to the end of 2021, twenty years. To achieve “SDG 2: End hunger, about 62,421 people have been tested, with ensure food security, improve nutrition and 3,327 positive cases out of which 1,825 have promote agriculture”, Niger adopted a new been cured and 104 have died, (a death rate of intersectoral strategy in 2016. The national 3.1%). The situation deteriorated at the end of nutrition policy (PNSN 2016-2025) targets January 2022–- Niger recorded 8,632 cases, the populations most affected by malnutrition, 297 deaths and 7,863 recoveries according to with a comprehensive approach to nutrition global data tracking (JHCHS verified). A total of problems. Malnutrition remains a public health 472 are still reported as active cases. Only one concern and is at the top of the list of risk case was reported as a serious critical case. factors causing high mortality rates in Niger. Per 1 million people, the impact was estimated In addition to several undesired effects of at 337 cases, 12 deaths and 8,474 tests. In malnutrition on the state of health, it greatly the African region (56 countries assessed), affects the development of children (with Niger ranked 54th after Chad and Burundi that respect to psychomotor and cognitive aspects). had respectively 11 and 3 deaths per million Massive progress has been made in Niger capital and economic growth, with about 9% Nationwide, this represents a shortfall in terms people, these top 3 countries belong to the since the early 1990s but the country of GDP lost as assessed at regional level of socio-economic development and growth. group with the smallest number of reported continues to face huge challenges as (Sub-Saharan Africa)10. High prevalence Other risk factors listed as bringing substantial deaths per million people due to Covid-19. In it transitions towards UHC, including levels persist for both acute and chronic burden to Niger’s populations are air pollution Africa, Niger ranked first with the smallest total the double burden of diseases (i.e., co- malnutrition in Niger, with a remaining critical (third risk factor in 2019) and tobacco (ninth number of reported cases per million people, existence of a persistent infectious, maternal proportion of wasted, overweight or stunted risk factor in 2019). before Chad (412), Democratic Republic of and child health challenge, along with a individuals (51.8% in 2019 against 50.4% in Congo (905), or Burkina Faso (944) among growing burden of chronic non-communicable 2009) (34). Furthermore, more than 60% of Due to the youth population, adolescent others. Yet, at least globally, the direct impact diseases). These additional illustrations show children suffer from anemia (34). On average, health is a public health issue in Niger. of Covid-19 on child mortality was relatively the trend evolution of Niger compared to its stunting gradually decreased by 0.5% per The 2021 ENAFEME survey confirmed a high limited (35), accounting for 1.8% of the cases peers with respect to progress made over year between 2000 and 2018 in Niger, while fertility rate (6.2 vs. 7.6 in 2012), low age for and 0.1% of the deaths attributed to Covid-19 a generation (30 years) (Figure 9). Having the pace of stunting reduction at the global marriage (16.6 years old vs. 15.7 in 2012) and (36). Although the long-term trajectory of borne a higher burden thirty years ago, Niger level was four times higher (around 2% per childbearing (19% of 15-19 years old vs. 33% the Covid-19 pandemic remains uncertain has performed well and improved its health year globally.) Undernutrition contributed to in 2012). Early marriage and childbearing are everywhere, immunization services have outcomes, however peer countries such as the U5 mortality rate, which remained high key contributors to high fertility and maternal been disrupted in Niger, depriving thousands Malawi, Afghanistan or Uganda managed to compared to the global average despite a mortality. In 2021, half of the births occurred of people of vaccination (Gavi narrative12). bear a lower burden than Niger. remarkable reduction (from 326 deaths per within an interval of about 2.5 years after the National reporting may 11  1,000 live births in 1990 to 112 deaths in 2012 vary differ from other data previous birth. In 2021, only 6% of women tracking due to methods According to GDB, malnutrition remained and an estimated 77.1 deaths in 2020). In aged 15-49 currently in union want no more used to determine the cases a primary risk factor driving the most death addition, territorial inequalities persist, with and indicators definition. children (or are sterilized). If all unwanted and disability in Niger. Stunting presents a more critical situations for both acute and births were avoided, the average number of “Mutli-stakeholder dialogue 12  WB/IDA PAD–Project 10  appraisal document 4162 for ́ long- significant challenge to the country s chronic forms of malnutrition in the regions children per woman would be 5.9 (instead 2020: Planning for Immunization in the context Niger (23 August 2021) term development, both in terms of human of Zinder, Tahoua and Maradi (NHA 2019). of Covid-19 26 27 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE 4. HEALTH SYSTEM INPUTS achieve UHC, the country has progressed 2.9% and 8.3% respectively. It had been agreed that to enable the progressive annual review of planned activities, Niger’s MoH uses WHO norms to assess its health staff density policy goals (37). Niger’s 2020 achievement of at least 70% of the UHC estimate for the density of health workforce targets, the density requirement for the African is far behind the LMICs average (2.99), region was an estimated 13.4 health workers Sub-Saharan Africa average (1.36), or the (all categories) per 1,000 population (32). If LICs average (1.07) (Figure 10). Moreover, CHW are excluded, the density threshold was against the minimum threshold of health estimated at 10.9 health workers (comprising worker availability in relation to health targets 12 categories) per 1,000 population (32). As in the SDGs (set at 4.1 per 1,000) Niger’s a result, massive increases in the HWF are HWF is even further behind. The latter needed in Niger to attain minimum coverage measurement is worth highlighting as the (set at 70%) of UHC services. No matter the national investment plan aims to revitalize This fourth chapter provides a situational the information or to communicate on the estimates, the path to reach the goals in Niger HR in two sectors (health and social). Another analysis of the national health inputs focusing information channel to be favored for analytical shows the extent of upcoming challenges, aspirational target set at 5.9 per 1,000 refers on the state and challenges in human work such as this. To improve country just to increase the quantity. Weak technical to the minimum threshold to end preventable resources for health, health infrastructure and reporting and international comparison, performance, mastery of care protocols and maternal death by 2035. Ongoing efforts in health financing information. the International Standard Classification of more generally the quality of care provided Niger should be sustained to improve the Occupations (ISCO-08, 24 categories defined are all parameters to be controlled in Niger HRH situation and gradually move towards and without which the effective deployment regional and income group benchmarks and 4.1 Human resources by the International Labor Standards) can be used for future analytics. of HR would not offer a satisfactory quality of aspirational countries such as Ethiopia (0.79 service. per 1,000 in 2018) or Rwanda (1.34 per 1,000 for health Literature provides additional HR As reported above, against the goal set in 2018). The recent regional survey for Africa also reported an average density of health information for Niger, including insights by the WHO and regional and income workers (13 categories, excluding health 4.1.1 National state of skilled on other occupation types like the group benchmarks, Niger’s health system managers and support staff) of 2.9 per 1,000 community health workforce. Firstly, the health workforce 2021 WHO-AFRO survey report revealed that is impacted by the highest needs-based population for the region in 2018 (32). five countries are reporting critical shortages, shortage in skilled health workers. In its Baseline data is hard to ascertain for including Niger and one of its peers Chad, with Niger’s HWF but the observation is clear HWF density of less than 0.5 health workers and the lack of qualified personnel (as Figure 10: per 1,000 population, which is in line with the Density of skilled defined by the WHO) is a major and known estimate of 0.52 by RAP2020 (32). It should health workers in problem in Niger. Several sources (MoH be highlighted that not all occupation types Niger against income 2011-2015 PDS evaluation report, the World are included – for instance, assistant medical group and peers, social protection report 2014 and ILO report doctors or community health workers (CHWs), latest year on social protection 2016) showed that HWF which may underestimate the real total health shortages persisted, despite significant workforce in both country and global reporting Source: Authors’ calculations using global progress (25). We explored the most channels. According to the CH Roadmap, statistics (WHO and WDI) recent data and sources and attempted to however, the community workforce should and national statistics benchmark the density of health staff in Niger. provide a cost-effective resource to countries (Niger’s health yearbook) According to the WHO data portal, Niger’s pursuing UHC, especially given the potential HWF density improved from 0.56 (2012) to to address multiple health needs at community 0.86 (2016, latest year) health personnel per level. In Sub-Saharan Africa, the investment in 1,000 inhabitants – these are medical doctors, CHW would require an additional $2B annually. nurses/midwifes, dentists and pharmacists. Secondly, to our knowledge (Community Country statistics (via the “Carte sanitaire”) Health Roadmap), Niger should have a CHW reported 0.84 (2020) health personnel per registry managed by the Government at 1,000 inhabitants – including only medical the central level, where CHWs are recruited doctors and nurses/midwifes employed in the through a community engagement mechanism hospitals and CSIs by occupation. According that includes a training program but does not to RAP 2020, HWF density was 0.52 (2019) hold accreditation. Data on CHWs should be health personnel per 1,000 inhabitants, which monitored in the surveillance system, and was evaluated below the threshold of 0.7 CHWs themselves supported with a monitoring health personnel per 1,000 inhabitants set by and evaluating (M&E) system and payment the MoH. The above reported estimates are through Government wage bills. According however much higher than the level reported to this global data source, the country has a by Niger officials during the PAN 2021-2023 density of 0.32 CHWs per 1,000. preparation (acted in a concept note), which uses the baseline value of 0.30 (2020) health Facing critical shortages, Niger’s HWF personnel per 1,000 inhabitants – with respect is far from meeting its policy goals or to all types of occupation (but no detail was the necessary threshold requirements to available of occupations included). In line with revitalize PHC or achieve UHC. Regarding the PAN baseline estimate for 2020, Niger’s the threshold required to revitalize PHC national health yearbook indicated a HWF services, the country has come 13.0% or density of 0.42 (2020) health personnel per 37.4% of the way depending on data sources, 1,000 inhabitants – including doctors and respectively the PAN and WHO estimates. nurses/midwifes only. In light these different Similarly, regarding the threshold required to figures, it seems important either to centralize 28 29 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE 4.1.2 National stock by occupation staff (13,366), 12.5% social and development 2019-2023. A network of 18,787 multi-purpose ASCs by end 2019 out of 851 health and staff (5,30), 7.3% medical doctors (2,992), health-related staff hired by local partners, and level of care 7.2% paramedic and technical staff (2,953), community relays (i.e., relais communautaires polyvalents) would represent half of the needs including communities for the benefit of six 5.3% lab workers and biologists (1,631), and covered. They should deliver the “curative”, regions (37). The stock of doctors, nurses and midwives 0.9% public health workers (360). Illustrations promotional and preventive components of should count for 0.16, 0.57 and 0.16 per 1,000 inhabitants respectively (2020 show labor force distribution by care provider the package of services.. In 2016, Niger’s MoH 4.1.3 Staff availability and across health staff occupation (Figure also mentioned a pilot experience targeting estimates from country health yearbook). 11). Niger should improve the skill mix, which the deployment of 5,800 community relays and distribution Niger’s health system uses the national stock will also require investment in professional (rCom) in 30 municipalities of 10 districts, with of 41,152 health workers. They are 34.4% colleges and technical education. scaling-up perspective already discussed in In Niger, a substantial proportion of active nurses/midwives (14,162), 32.5% logistics 2016 (39). The roll-out of RCom is expected health workers remain employed in the to all communities, offering comprehensive public sector, estimated at almost 9 out package of preventive, promotional and of 10 for doctors/nurses/midwifes. Due to Figure 11: curative services for population living more the scarcity of local data and for comparison Labor force by than 5km from a health facility (IMCI), purposes, we report data using the WHO data healthcare provider Second-line (hospitals) Front-line (CSIs) portal on the human workforce. HRH employed and staff occupation according to the national priorities (38). Another data sourcealso suggests a lesser in the public sector represent a share of in Niger, 2020 10.580 84.9% (against Africa average of 70.0%) of stock than the estimated 7,500 CHWs, Source: Niger health card among them one third community agents medical doctors, 86.8% (vs 80.1%) of nursing 2020 8.011 (ASCs) and two thirds community relays personnel, 53.9% (vs 52.6%) of dentists, and (rCom), respectively equivalent to a density 83.0% (against Africa average of 83.0%) of of 0.1 and 0.2 per 1,000 (38). In Niger, to our pharmacists (Figure 12). WHO statistics do knowledge, CHWs have existed since 1963 in not refer to dual practices of staff employed in 4.660 3.900 the rural Maradi region to promote community the public sector. However, according to key 2.786 development, comprising both paid workers informants, at least in urban area, it is very 1.959 common to for a public servant to complement 1.375 1.617 1.230 1.631 994 and volunteers. The annual review of planned with a liberal practice, as authorized. 558 360 activities by Niger’s MoH reported hiring 27 0 Medical doctors Nurses Logistic staff Social & dev. Lab and Public health Paramedic and workers biologists workers tech staff Figure 12: Share of staff employed in the 50% private health sector Total in Niger, benchmarked 45% to selected peers and 40% regional average, latest year 2016-2018 Front-line (CSIs) 35% 30% Source: WHO health workers global database 25% Second-line (hospitals) 20% 15% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 10% Medical doctors Nurses/Midwifes Logistic staff 5% Social & dev. workers Lab and biologists Public health workers 0% Paramedic and tech staff Rwanda (2018) Niger (2016) Ethiopia (2018) Africa avg Medical doctors Nursing Midwifes Dentists Pharmacists Annual growth of HWF stock in Niger is A “curative” component of the package is linked estimated at 7% (all occupation types). to the management of targeted care services Based on the 2005 and 2018 stock by (malaria, pneumonia or diarrhea), and the occupation, the report showed growth rates screening/referral of cases of malnutrition to Availability of health staff is a concern in than in private facilities (41). According to the of about 20% for doctors, 5% for nurses/ health facilities (38). Other components of Niger that can be is explained by multiple African regional framework for HRH, poor midwives, 8% for dentists/technicians, 15% for the package are focused on promotional and factors. I. In Niger, for instance, the national retention of existing HWF and low production pharmacists, and 4% for lab technicians (32). preventive services (i.e., 13 essential family absence rate of 33% in the health sector is of health workers in the African region are practices such as the support for infant and much higher than the 14.8% observed in major drawbacks to building a strong and CHWs complement health staff, however young child feeding). Total stock estimations education (equivalent to 2.2 times higher in effective health workforce in a country (32). the country does not systematically or fully of CHWs varied greatly depending on the data the health sector) (40) but tends to be lesser In Niger, according to key informants, low report their count in the yearbooks, possibly source., with lowest estimates from the WHO- than in other African countries (averaging production may not be a major concern underestimating the real stock and roles. AFRO 2021 survey report (55 workers). . 43%) (41). Latest data from Niger (2015) whereas low recruitment in the public sector A lack of harmonization between practices and diverging from available country estimates. showed that more care providers were absent can be. In Africa, inadequate HRH education definitions was reported and 6 types of relays To cover the whole country, and according to in private facilities than in public ones, which and training capacity, the low number of health were identified (38). The CSIs are responsible the National Strategy for Community Health contrasted with the results from Uganda or training schools, and the persistent weak for the CHWs recruitment and supervision (PSNSC adopted in 2019), about 35,650 Nigeria (41). There are both authorized and leadership and governance of HRH contribute with the aim to ensure continuity of care. community relays are needed and 80% of unauthorized absences, with usually a much to low production of HWF in the country (32). Other types of CHWs seemed less formalized. them should be recruited during the period smaller fraction of unauthorized absences, In Niger, again according to key informants, even if this is more likely prevalent in public the major concern seems to lie in the low 30 31 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE capacity of training (quality of supervision, and districts. The highest density of skilled 10 outpatients in rural areas and below 10 4.2.1 Health system architecture internships). Among the mechanisms that labor force was in Agadez (0.87) and Niamey outpatients a day in urban areas, which seems can be used to improve HWF availability are (1.40) for which the level was above the lighter workload than the average for Africa of The health pyramid system in Niger is working conditions, including remuneration, national average. However, this level remains 13 outpatients per day (41). About 41.5% of shaped by the administrative division protection and incentives and the guarantee low compared to WHO-recommended targets public health facilities had care providers with a of the country and organized across of a right skill mix coupled with appropriate (Figure 11). For future decision-making in caseload below 5 outpatients per day (against the standard 3-level design. Strategic distribution across the regions and districts. HRH, the qualitative work by LASDEL should 86.6% in Nigeria but only 3.4% in Uganda) management is nested at the central level In Niger major reasons for absence were help further understanding the prevailing (41). Situations are diverse depending on and managed through bodies such as the primarily due to outreach or fieldwork (>30%), practices in Niger. many features and settings, but inefficiency of cabinet of the minister, the secretary general secondly to sickness or maternity leave (20%) the health system should also be linked to low (SG), the general directorates (DG) and and thirdly to unauthorized absence (<20%) Niger’s health workload per worker can utilization rate of the health services. Besides, the national directorates (DN); technical while training or meetings and official missions be seen as a normal or light workload it should also be raised that care provider are support to the districts is provided by the were comparatively less reported (41), depending on the subsector. Indeed, in charge of administrative work that could regional health directorates (DRS); and showing a pattern that differs from Nigeria or another way to estimate health staff workload constitute a substantial share of the workload. operational management is done by the Uganda. In 2019, the MoH reported that the is to monitor the number of patients a care Beyond, task sharing and/or task shifting health districts (DS), which are responsible for distribution of the health workforce is uneven provider can see in a day. On average, approaches should be further developed due the implementation of the health policy. Three in Niger, creating disparities across regions Niger caseloads in 2015 were slightly over to low number of medical specialties staff. levels of service provision emerge from this structure: 1) the operational level (districts, municipalities, and communities) – with health Figure 13: Skill imbalances in the health labor force districts overseeing the community level; 2) Regional and district- 0,37 is a persistent concern in Niger. As shown the intermediate level (regions); 3) the central level disparities previously, the provision of care services (national) level. More precisely, the healthcare amongst the health remains hindered by a concentration of medical workforce in Niger, 1,40 supply organization including public and staff (doctors and nurses) in the Niamey private structures is as follows: 2020 0,87 0,08 region, to the detriment of other regions such •at the bottom, the operational or district level 0,41 0,37 0,35 0,34 0,33 0,32 0,06 0,02 0,03 0,02 0,03 0,03 as the highly-populated provinces of Zinder, Source: Authors’ with the District Hospitals (HD) and their calculations using health Maradi, Tahoua or Tillabéri (40). The skill-mix networks of Centers of Integrated Health yearbooks and INS data Niamey Agadez Diffa Dosso Tillaberi Tahoua Zinder Maradi Niamey Agadez Diffa Dosso Tillaberi Tahoua Zinder Maradi in Niger confirms the low numbers of medical (CSI), health posts (CS Cases de Santé), Density of skilled workers (per 1,000) Na�onal average Density of midwifes (per 1,000) Na�onal average staff, especially at the most decentralized cabinets and private treatment rooms; level where only GPs are represented. The •the regional or intermediate level includes workforce is divided into 70.1% front-line Regional Hospital Centers (CHR), Mother 0,28 providers (CSIs) and 29.9% hospital care and Child Health Centers (CSME), Regional 0,75 0,65 providers. Among the medical staff, we found blood transfusion centers (CRTS), polyclinics 32.5% and 100% of general practitioners and clinics; 0,14 0,30 0,30 0,29 respectively at hospitals and CSIs. At hospital •the central level, which guarantees the 0,28 0,26 0,24 0,06 0,05 0,04 0,03 0,04 0,04 level, there are up to 18 medical specialties, supply of third-level referral care, is made mainly obstetrician-gynecologists, emergency up of hospitals, maternity wards and national staff (ambulance drivers) and pediatricians. referral centers. Niamey Agadez Diffa Dosso Tillaberi Tahoua Zinder Maradi Niamey Agadez Diffa Dosso Tillaberi Tahoua Zinder Maradi None of these specialties is represented Density of nurses (per 1,000) Na�onal average Density of medical doctors (per 1,000) Na�onal average at decentralized levels (CSIs). Among the Despite political will, only half (50.1%) nurses/midwifes, we found 6.8% and 12.6% of the population has access to health of midwifes respectively at hospitals and CSIs. centers within a 5 km radius (2017). In Niger, the Government wants all residents As a takeaway, the global strategy for HRH within a 5 km radius of local health centers, to for 2030 recalled that “health systems can ensure every care seeker has access to the only function with health workers; improving minimum care package. As a result, Nigerien 0,21 0,20 0,20 health service coverage and health outcomes care seekers must resort to smaller health 0,16 is dependent on their availability, accessibility, posts located within the villages, offering more 0,12 acceptability and quality.” Campbell et al limited medical services. As health posts are 0,06 revised the WHO UHC cube to show the only sufficient for minor medical care, often 0,03 0,03 remaining HRH gaps to effective UHC and due to being understaffed or lacking medical highlight the importance of the workforce equipment, care seekers are often required Niamey Zinder Tahoua Maradi Tillaberi Dosso Agadez Diffa agenda to reach UHC (42). to travel >5 Km distance to meet their health Percent popupa�on Percent workforce needs. On a regular basis (every month 4.2 Public according to Enabel), mobile health teams come to health posts to offer nursing and infrastructures medical consultations with equipment and medicines – which is the situation observed for basic needs within a specific project ans may not reflect on the general situation. In 2019-2021, 32 and health – capacity field visits and mobile teams were organized through an externally funded project that and administration started in 2019 (43). 32 33 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE 4.2.2 Health infrastructure Center (CHR) of Tillabéry, 56 maternity Figure 14: Bed availability in hospitals or ward, and 587 integrated health 8.000 2,0 district hospitals in According to the Niger Renaissance centers (CSI) including 334 transformed from health posts. In addition, 3 local pharmacies 7.000 1,8 Niger, 2015-2019 Number per 10,000 Program II for 2016-2021, improvements (“pharmacies populaires”) and 30 laboratories 1,6 in access to care and services made since 6.000 Source: Annual Ministry 2011 are the result of improved health were built. The country also renovated existing 1,4 of Planning yearbooks 5.000 1,2 Number infrastructure. According to Niger’s Ministry infrastructure (5 CHR, 3 CSME, 49 HD, 21 of Planning, investment in infrastructure has CSIs, 21 CS, 16 maternity hospitals, 2 ONPPC 4.000 1,0 increased the total number of structures over depots, 13 CRENAS, as well as the Lamordé 3.000 4.143 0,8 the past 5 years, as shown in the table below National Hospital–HNL). Other renovations 3.097 3.097 0,6 2.000 2.928 were carried out, notably the maternity ward 2.678 (Table 2). The Niger Renaissance program 0,4 reflected on recent efforts, highlighting the of Issaka Gazobi in Niamey (for the surgery 1.000 0,2 construction of two national referral hospitals room “bloc opératoire”), the women’s ward for treatment of fistulas at the CSME in Tahoua 0 0,0 that are located in Niamey and Maradi (in 2018- 2019 according to the Ministry of Planning), and various units in the national hospitals of 2015 2016 2017 2018 2019 1 mother-and-child hospital in Niamey and 7 Niamey and Zinder. This information was communicated as part of the review of the District hospital bed (Nb) mother-and-child health centers (CSME) in other regions, 1 national cancer control center Renaissance Program implementation, Inhabitant per hospital bed (Nb) (CLC), 1 obstetric fistula healthcare center, 6 without any timeline indication. District hospital bed per 10,000 pop district hospitals (HD), the Regional Hospital District hospital park, beds per region, 2019 Table 2: HEALTH INFRASTRUCTURE UNIT BY TYPE 2015 2016 2017 2018 2019 Health structure count Tahoua by level of care National hospital 3 3 3 4 5 in Niger, 2015-2019 Maradi 6% 1% Source: Annual Ministry Military hospital 1 1 1 1 1 Zinder of Planning yearbooks 8% 26% Regional hospital (CHR) 6 6 7 7 7 Dosso 10% Private hospital 6 5 5 5 5 Tillabéri 12% District hospital 33 33 34 35 35 24% Diffa 13% Maternity of reference 1 1 1 1 1 Agadez Integrated health center (CSI) 913 954 1.026 1.041 1.106 Niamey (Commune 5) Health post (Case de santé) 2.516 2.507 2.511 2.508 2.422 TOTAL 3.479 3.510 3.588 3.602 3.582 Overall, health infrastructure lacks In Niger, the pharmaceutical market has operational capacity in the delivery of care great heterogeneity, leaving room for non- services, since only 11% and 34% of the negligeable illicit market development that structures meet all tracers’ requirements does not guarantee the affordability of drugs After declining for several years, the If infrastructure availability seems effective for basic comfort and essential equipment. for care users. In Niger, the pharmaceutical infrastructure of district hospitals at first glance, rural-urban divergence This means that the capacity of health structures sector is organized according to two supply and improved in 2019, but with significant persists in Niger. A 2015 survey shed light on to provide general healthcare services do not distribution circuits, one public and the other inequalities between the eight regions of the availability of care services across facility meet the essential requirements in multiple private. The public circuit includes a national Niger. According to the Ministry of Planning, type and within public and private sectors. On areas, including availability of a light source, production unit (SONIPHAR), a national the number of beds available in district average, all facilities were available to clients a weighing scale for children or at the level of supply center and the national pharmaceutical hospitals increased and was estimated to 1.89 for 13.5 hours a day and for 6.9 days a week. communication technology and equipment. products office (ONPPC) relayed by 3 regional per 10,000 population in 2019, against 1.41 WB experts (fiscal narrative) raised that, for The latter may constitute a constraint to depots in Niamey, Tahoua and Zinder, and 44 per 10,000 population in 2015 (Figure 14). the share of the population with less access, improved health information and case pharmacies (25). The private circuit is based Per bed, the number of inhabitants therefore it can be very challenging or even impossible management. With regard to the prevention of on a network of 21 wholesaler-distributors and decreased from 7,086 in 2015 to 5,296 to reach health services during the rainy infectious diseases, only 13% of the structures 108 pharmacies, 80% of which are situated in in 2019. Compared internationally, in the seasons (44). Regarding opening hours, there meet the norms (standards) and 71% of the urban areas (25), possibly to reach middle- availability of hospital beds in Niger appears was no significative difference between health tracers, on average, are available. In terms of class households that are creditworthy. Beyond to be improving as it is above the regional facility type (health posts, health centers and diagnostic capacity, only 3% of structures have these two circuits, there is a community offer, (SSA: 1.5) and income group (LICs: 0.86) hospitals) public or private sector, or between the necessary means. With respect to specific a network of local depots deployed throughout averages. The bed occupancy rates were urban or rural supply. And regarding opening interventions, for instance in family planning, the territory. NGOs are also present and can estimated at around 39% according to the WB hours for outpatient consultations, there was only 37% can rely on the tracer requirements, offer donations and supplies to the structures. fiscal space narrative (44), which suggests a slight variation among lower-level facilities which may explain the low results in sexual The drug supply system is diverse, and its the extent to which use in hospital districts favoring urban residents and public care users. and reproductive health highlighted previously. heterogeneity leads to a certain complexity. can be improved. According to the Ministry In terms of accessing basic and emergency With respect to immunization care services, The difficulties reported in this study pointed of Planning, the range of inhabitants per bed packages, respectively, almost all public only 6% of the health facilities meet the tracer to supply and procurement problems, which was extreme in 2019, with pressure almost hospitals13 (98.4%), but only one health center requirements. Finally, for preventive and was also found in our concurrent study (4), four times higher in Tillaberi (8,422) or Zinder in five (18.9%) and less than 1% of the public curative care services, none of the health but not only, as poor access to essential (8,318) than in Diffa (2152) or Agadez (2,494). health posts offer basic emergency obstetric facilities meet the tracer requirements. The drugs at affordable prices was also raised, Beyond the bed count, other improvements care (40). A comprehensive emergency 2019 SARA survey shed light on a series of encouraging users to turn to the black market. were attributed to the investments made in obstetric care package was only available in challenges at the national level, which can be In Niger, the illicit and informal drug market is Higher-level hospitals were 13  technical platforms and the logistics of health 89.7% hospitals and in 0.2% of private health even more problematic in rural settings or in captured by non-professional operators who not included in the survey. facilities. centers. certain regions. seem to control 75% of drug purchases in the Focus was on health posts, health centers and hospitals. country (25). 34 35 NIGER HFSA | TECHNICAL REPORT WB HNP WB GLOBAL PRACTICE HNP GLOBAL PRACTICE At the national level, all health structures services such as health centers or schools offer insufficient availability of drugs and should be monitored. In 2014, Niger’s roads vaccines, still with a lower local access were assessed as in relatively good condition to tracer medicines. Drug availability was compared with neighboring countries (45). assessed during a WHO tracer medicines 4.3 Health financing survey conducted in 2015 (40). In the public sector, drug availability varied according to the type of structure. First-line hospitals offered up to 70.2% of the tracers, public health centers information up to 68.2%, whereas health posts only offered 40.9% of the tracers. In rural areas, lower drug If the country regularly tracks health availability was shown and estimated to be less information, sources of information are than 22.2% of the tracers. For specific mother dispersed, and the use of health financing and child health (MCH) tracers, about 50% of indicators seems less widespread. Despite the tracers were available, regardless of the the apparent plethora of information, health type of structure. With respect to vaccines, financing is inadequately documented, in 2015, availability was around 44.6%, with consolidated or used in Niger. Moreover, during more sizeable gaps for certain vaccines and our data collection process, we were confronted health posts generally having fewer vaccines with successive and parallel versions of than health centers and hospitals. A related reports, some undated or unvalidated as well study (IFA Niger 2021) suggests that problems as data discrepancies across sources. Yet key with vaccine availability are not solved as country information could be extracted from many stockouts were reported in recent years the following: the thirteenth report of Niger’s (4). The 2019 SARA raised the concern as the national health accounts (46) and the MoH average percent of essential drugs available annual performance report (“RAP – Rapport was 24% in Niamey (lowest score) against annuel de performance”) (47). Niger’s health 37% in Diffa (highest score). budget execution appears to be monitored by the State annually. National annual statistics The use and quality of care in health for health also report on budget execution, services are at a fairly low level. Indeed, the with some discrepancy across data sources rate of service use of curative care in 2021 was for certain years. Financial laws also indicate about 45.2%, the proportion of births attended Government commitment for health, showing by qualified personnel was equivalent to initial and revived budget allocations. 38.8%, fully vaccinated children represented While such variety of information is vital for 52%, and contraceptive prevalence was decision-making, it does not properly inform 13.5% (ENISED/INS 2015). Furthermore, all stakeholders and is not systematically the quality of the services provided by the communicated by officials. It should be healthcare structures faced challenges, raised that although there is effort to produce particularly in terms of hygiene and, as regularly National Health Accounts to inform mentioned above, availability of the technical on health financing decision, the quality of platform or qualified human resources and analytics is weak and some key issues are medicines. For instance, the results of the missing (4). SARA survey (2019) showed that essential and generic drugs were available in 38% of the In Niger, as in many other countries, health facilities surveyed, compared to 41% limited evidence is available on the levels in 2015. Thus, one of the major challenges of, and trends in, financial resources, facing Nige’’s health system is to offer the especially in PHC financing. A related study population quality services with equity and on immunization financing has discussed efficiency. This challenge could not be met the issues (4). A recent Lancet Commission without the establishment of a health system on PHC called for better data collection and that meets the increasingly growing needs of highlighted the importance of including the the population. collection of quality and disaggregated data in ongoing and upcoming reforms (3). It is urgent Niger’s health system copes with low drug to strengthen the collection and use of data availability and insufficient general inputs. on PHC expenditure for better monitoring and The availability of basic equipment has been evaluation. In Niger, the DHIS2 tool constitutes reported as 82% for health structures (Range: a unique digital database for routine health data 63.2%–89.2%). Essential drug availability was from which more synergies should be found. lower, at 41% (range: 20.0%–76.2%). Within Aggregated data informs decisions and actions the public network, 65.3% of the facilities have at four levels that are the three pyramidal clean water, electricity and sanitation (range: levels of the health system administration and 29.0%–83.7%). Health center and health a fourth local community level (at the level of post densities were respectively estimated health areas). Public health facilities at the at 4.97 and 13.98 per 100,000 population operational level process and report the data, (respectively: 0.0–140.69 and 0.02–271.64). with an estimated completeness rate of 80% Besides the above, isolation of rural villages in 2018 according to the new UHC strategy and geographical access to rural social background information. 36 37 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE 5. HEALTH FINANCING SYSTEM This fifth chapter explores the whole situation The lowest level of investment in health (XOF Figure 15: of health financing in Niger, focusing on the 15,707.1 million) occurred in 2017 and the Hausse Baisse Total Trend in total trends and adequacy of health expenditure highest level (XOF 41,787.1 million) was seen 70% expenditure on health 11,9% in Niger, 2015-2020 in Niger and providing insights on the major the following year, in 2018 – a level that was 550 000 100% 60% challenges related to the major revenue maintained in 2019 but that dropped and later 500 000 11,7% Source: Author’s data 450 000 80% 50% sources, budget execution and allocation as halved in 2020. Investments measure the total extracts and calculations 400 000 well as health planning. value of assets that health providers acquired 3,4% from the Health Accounts 350 000 40% 24,1% and used during the fiscal year (minus the total 300 000 60% (Country reports) Million XOF 5.1 Trend and value of assets sales). Although the annual 250 000 30% 40% Note: The System of 200 000 21,2% report did not mention the source, we were 20% Health Accounts (SHA 150 000 adequacy of able to estimate the external contribution to 2011) terminology is 100 000 20% 10% used for health financing investment at 35.7% over the last three years. -9,1% 50 000 aggregates. health expenditure Niger’s general government budget on health, 0 2015 2016 2017 2018 2019 2020 0% 0% 2015 2016 2017 2018 2019 2020 despite improvements, remains insufficient Current expenditure (CHE) In Niger, health sector spending has to either meet the desired minimum Capital expenditure (HK) Share of current expenditure (%THE) increased by an average of 8.9% annually thresholds for UHC or to predominantly since 2015 however it increased to a finance PHC from public revenues. Hausse Baisse Total lesser extent when expressed in volume Regarding the predominance of domestic 25000 15% 45% per inhabitant. The total expenditure on financing within the UHC financing transition, 40% 5,6% Per capita THE (annual change) 20000 4,4% health reached XOF 508,488 million in 2020, this is a recommendation made recently by the 35% 8,4% suggesting an increase of 7.8%, against the Lancet Global Health Commission on financing 10% 30% Per capita XOF 15000 25% level of spending of XOF 469,029 million for PHC (3). Regarding the level needed, the 5,7% 20% 13,9% 19,2% estimated in 2019 (Figure 15). Health threshold target of US$ 86 per capita per year 10000 15% 5% 10% spending has followed an increasing trend, remains a reference used to promote universal 5% although it has not increased systematically access to primary care, and it was not even half 5000 0% every year, since spending fell in 2016 and met in Niger when considering overall spending -5% -18,1% 2017. Per capita, health spending was on health. In 2017, another estimate at US$ 0 0% -10% 2014 2015 2016 2017 2018 2019 2020 2015 2016 2017 2018 2019 2020 Average equivalent to XOF 22,349 per inhabitant in 112 per capita per year on average for total 2020 (equivalent to about US$38.8), which health expenditure (THE) has been projected THE per capita THE as %GDP would correspond to a lower increase since for LICs as a necessary investment to reach the annual growth was only of +4.4%, against UHC by 2030, which could be considered an the level of XOF 21,375 spent per inhabitant aspirational goal by policy makers (2). This in 2019 (US$36.5). Since 2015, annual growth ambitious scenario suggests an additional averaged +8.9% in budget volume while it investment per person equivalent to US$ 76 on only gained +5.6% when considering the average for LICs. According to health accounts, To meet the above, progress in domestic Globally, health expenditure during the per capita expenditure, respectively coming Niger THE per capita per year increased from investment on health would need to be Covid-19 pandemic grew more than in to XOF 326,908 million and XOF 17,643 per US$ 29.8 in 2015 to US$ 38.8 per capita per maintained and strengthened by 2030. previous years. The annual percent change capita in 2015 (US$ 29.8). year in 2020 (using WDI exchange rates), which Indeed, considering the level of health was +8.1% in 2020 against an average of A 2018 WB report (75) showed that, in the stands far below the potential aspirational goal spending that is funded by public revenue, +2.4% in 2016-2019. Little is known about the sub-region, apart from Burkina Faso, real for 2030. Contrasting with our results, the NHA health spending has increased from US$ patterns in LICs as very few countries were health expenditure per capita has not changed country report 2020 referred to a level of total 5.4 per capita in 2015 to US$ 14.5 in 2020, included in the recent comparative study (48). much since the 2000s. Given the economic spending on health of US$ 44.7 per capita in averaging a level of US$ 9.5 per capita for 2015- Nevertheless, like all other countries from growth in most countries, the study concluded 2020, therefore acknowledging having met 2020 (according to WHO data). WHO also this study, Niger’s percentage share of GDP in the existence of a significant but untapped the formerly US$ 44 threshold needed to identified a threshold range of required cost of on health increased during 2018-2020. For potential for mobilizing more resources for cover essential health interventions. Misuse or at least US$ 50 to 60 per capita to achieve countries where “extra” growth was observed health. misinterpretation of existing benchmark within the SDGs agenda for health. As a result, no during 2020, expenditure was mostly driven the NHA poses the need to align the national matter the calculations, Niger’s investment in from higher public expenditure that was spent The bulk of expenditure on health is analytics with the international standard. health per person per year remains behind the through Government and compulsory insurance devoted to current expenditure, reaching Threshold targets should be further discussed conservative target and appears insufficiently financing arrangements, according to early at least XOF 9 for every XOF 10 invested and documented as they focus on a certain domestically funded despite awareness of the evidence pooled from a small group of countries in health annually. In 2020, respectively required level of financing needed to provide a current post-Covid-19 era. analyzed (Niger included)14. In contrast to this current and capital expenditures accounted defined package of health services. Progressive global pattern, Niger faced a positive but for 95.7% and 4.3% of the overall expenditure country-specific targets should be developed in negligeable annual change in the per capita The list only included a few 14  on health. On average, since 2015, they have Niger to realize full implementation of its UHC health expenditure through the Government African countries (Niger, represented respectively 93.2% and 6.8%. reform. (and compulsory insurance financing), far Burkina Faso, Ghana and Senegal), most belong to behind all HICs and LMICs, excepting Chile. the group of high-income countries. 38 39 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE 5.2 Budget execution since the MoH is aiming for a rate of 80%, according to our information. Besides, several Current expenditure on health (CHE) by source funding Figure 16: Major sources of in health informants raised that three to four month of funding for current health expenditure in the year are taken before annual health plans Domestic transfers Niger, 2018-2020 could be validated. Partially attributable to Average Due to the lack of budget execution, Niger’s cumbersomeness of certain procurement Source: Health Accounts health sector faces a shortfall when the procedures and lack of anticipation, such External transfers through (Country reports) financial resources are voted. According critical bottleneck in planning is directly 2020 public adminitsration to Niger’s health yearbook, since 2008, the impacting health financing efficiency. As a Social health insurance (SHI) budget execution rate averaged 66.5% as result, a central issue of the problem linked to 2019 expressed by the total amount engaged the inefficiency of the health system lies in the against total amount voted. Voted budgets are Voluntary prepayments for quality of the annual planning process. During 2018 published every year in the finance laws (49). health the study, our informants reported that health Depending on the year, the execution rate has planning remains weak in Niger, centered Out-of-pocket payments ranged widely, with the lowest execution at (OOPs) 0 0 0 0 0 0 on the budgets made available (potentially 00 00 00 00 00 44.8% to the highest at 91.8%. Focusing on 0. 0. 0. 0. 0. disproportionally centered on external the five past years (2015-2020), on average Direct external transfers 15 30 45 60 75 budgets than domestic ones). In addition, the only half of the health budget (54.9%) was exercise which is carried out and validated MILLION XOF effectively spent, ranging from the lowest at best in the 1st quarter and which results execution of 44.8% to the highest execution in the execution of financing over at best at 61.8%. Regarding the specific data that nine months (and moreover often less than Share by source of funding (%CHE) was transmitted directly by MoH/DRFM, nine months). This delay in planning partly budget execution could average a higher level explains the absence of a half-yearly review (80.0%), however still ranging from 55.1% to Average and/or reallocation, which also explains the 91.0% between 2017-2020 (which relates to poor execution (planning over a year that is the period of the current health development nine months with no possible readjustment 2020 plan), therefore contrasting with those reported during the year). in the Niger health yearbook (53.6% for the same period). As of December 31 2020, the 2019 national budget execution rate was reported at 55.1%, partially attributed to the Covid-19 5.3 Major health 2018 pandemic that resulted in lower credit release than usual (56.30%) (47). financing agents 0% % % % % % % % % % 0% 10 20 30 40 50 60 70 80 90 5.3.1 Overview of funding agents 10 At the health sector level, looking at the degree of achievement of the planned mix for health activities raises concern as health programs are not implemented in full, potentially due Niger’s health system is predominantly 5.3.2 Domestic public financing 2020 against US$ 5.4 per capita in 2015. This to financing difficulties. A related study funded by private out-of-pocket (OOP) for health largely contrasts with the desirable level of US$ 86 per capita per year, a threshold that has focusing on immunization activities has linked expenditure whereas health coverage remains insufficient with respect to UHC been established to promote universal access the financing to vaccines and delivery of care Setting a UHC-specific bottom threshold of goals. Over the past three years (2018-2020), on to primary care (1). These needs are not even disruptions (4). More generally, the technical percentage share of GDP on health in Niger half met in Niger when considering all sources execution of the health programs, which is average, domestic private transfers from user fees is needed (although not sufficient) as the of funding spent on health. According to the obviously linked to budget under-execution, amounted to XOF 198,321.2 million, equivalent country aspires to UHC. Such an indicator health accounts, Niger’s total health expenditure was of 65.5% in 2020 and below the threshold to 37.6% of total current expenditure on health can be very influential as it does not require any was around US$ 38.8 per capita per year in goal set at 75% (47). In 2019, budget execution – according to the most recent health accounts intersectoral trade-off. According to Niger’s health 2020, using WDI exchange rates. The threshold was reported at 87.9%, meeting the threshold (Figure 16). On average, domestic government accounts, total health expenditure accounted transfers amounted to XOF 150,772.4 million, reference of US$ 112 per capita per year has goal of 80% (47). Another source stated, as of to 6.8% of GDP on average for 2015-2020, equivalent to 28.6% of the total. Direct transfers also been projected for LICs as necessary total 31 October 2019, that only 67% the planned passing from 7.7% in 2015 to 6.4% in 2020. It health expenditure to reach UHC by 2030, interventions were actually implemented and from external donors amounted to XOF 98,201.9 should be recalled that the share financed by which could be considered an aspirational goal executed (37). The net physical execution of million, equivalent to 18.6% of the total. It should the Government represents approximately one be highlighted that the significant changes by Niger’s decision makers (2). According to health interventions of the PDS 2017-2021 third of total expenditure, or 32.3% on average observed in external aid, which are not confirmed these authors, such a scenario could represent was reported across programs, averaging for 2015-2020. This level of contribution is clearly by other data sources, reflect on the need for more an incremental expenditure of US$ 76, based on 62% of planned activities executed. Across below the standard threshold established at reliable data and analytics in the health accounts. average calculations provided for LICs. Similarly, programs, health program 3 achieved half 5% of GDP (1). Even if health expenditure as Besides, external transfers that are channeled the WHO also indicated a threshold range of at of activities implemented (54%) while health a share of GDP in Niger is above the general through the central administration averaged XOF least US$ 50 to US$ 60 that would be required program 1 on leadership and governance was trend, the share that the Government secures 55,006.0 million, equivalent to 10.4% of the total. per capita per year to achieve the sustainable better implemented (71%). Across regions, for health does not meet the threshold needs Social insurance and voluntary pre-payments development goals agenda for health. As a result, disparities were reported as it ranged between to progress towards UHC. Niger’s capacity to for health broadly represented less than 2%, on Niger’s health system journey towards UHC 60% (Maradi) to 79% (Tillabéri). These translate national wealth into investments in average. Like many other countries, Niger could would need its government to consider investing results suggest a need to regularly monitor health remains at risk of declining, as it used to make better use of domestic financing levers more in health, both in per capita volume and and evaluate the implementation of planned be higher (e.g., 8.1% of GDP in 2017). to accelerate inclusive economic growth and in relative share of total expenditure on health. activities at a disaggregated level. Not only to reinforce sustainable health financing, with health- Global recommendations recently published by monitor, but also to understand the complexity In addition, Niger’s GDP being low-income, aware fiscal and monetary policies (50). Domestic the Lancet Commission raised the necessity to and find ways to fully apply the planned health the percent share on health does not generate predominantly finance PHC from public revenue activities. resource mobilization for health is, and should enough financial resources since domestic (3). Broadening the fiscal space for health is remain, a pillar strategy to address the remaining government health expenditure averaged coverage gaps in essential health services and to crucial in Niger and has already been discussed Niger must further analyze and address US$ 9.5 per capita per year during 2015-2020. drive high-performance health financing to realize (51). Improving the fiscal space dedicated to the multiple causes of budget under- Despite an upward trend observed in Niger, the UHC as the country renews its commitment to health emerges as one of the challenges of execution in health. It should be highlighted level of health spending that is funded by public accelerate the journey towards UHC. effective UHC in Niger. that achieving 100% execution is not planned revenue only reached US$ 14.5 per capita in 40 41 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE While health has been prioritized in the observed certain years. Health expenditure Using national statistics from various sources External resources coming from these main general government expenditure with prioritization within the general government (NHA, PAP and Health resource mapping), we bilateral partners are generally included in 5.7% on average, the challenges remain expenditure was equivalent to 6.3% in 2020, isolated the health budget that was channeled the finance law and therefore included in significant to sustain increased per capita against 5.3% in 2014 (average: 5.7%). through the MoH. In 2020, MoH received about the General Government budget. Finally, funding. Figure 17 shows the progress made Figure 18 highlights the annual changes in 93.2% of the health sector pie, equivalent to foundations and other private organizations since 2014, as expressed in volumes spent health expenditure prioritization, using 2014 XOF 147.6 billion and 5.9% of the General represent only 3% of the external resources per capita (GGHEpc) and as a percent share as baseline year (index 100). It also reflects Government budget. This shows the effective committed to health in Niger in 2020, these are of the government expenditure (GGHE%). comparative changes against population prioritization of health via the MoH. As a result, usually extra-budgetary. Overall, health expenditure increased in count and national income (GDP), also using the health budget that is not channeled through per capita volumes, while lower levels were 2014 as baseline. the MoH represented less than a tenth of the Volumes of external support, donor share and whole share for health, i.e., 6.8% (equivalent to budget share across financing modalities Figure 17: XOF 10.7 billion) in 2020. According to recent (extra-budgetary and on-budget) tend to vary Trend in per capita data published by the Ministry of Finance (MoF) greatly over the years and are expected to health expenditure 120 000 7,0% in the revised finance law (LR-2021), the MoH further evolve in the coming years. According XOF per capita prioritization and share would represent 5.4%, now counting with to the health accounts, the share of external 100 000 6,0% percent share of the a fourth program in the MoH budget allocations. aid that financed current health expenditure general government 5,0% 80 000 greatly varied in recent years, representing expenditure in Niger, 4,0% Higher prioritization on health could be 25.1% in 2020, 48.3% in 2019 and 11.8% in 2015-2020 60 000 3,0% reached if high-level and aspirational policy 2018 respectively (Figure 19). Similarly, the 6 537,6 5 700,0 5 596,8 5 191,9 5 061,7 4 673,3 4 226,0 Source: Author’s 40 000 2,0% goals were met, and past efforts sustained. percentage of overall external funds channeled calculations using NHA 20 000 1,0% Note that a national target was set at 6.3% through public administration compared to extra- and WDI population for 2020 within the MoH Program 1 under the budgetary also varied, at 22.7% in 2020, 22.9% estimates for per capita 0 0,0% “Action #21708”, according to RAP 2020; which in 2019 and 46.1% in 2018. The recent trend (pc) indicators 2014 2015 2016 2017 2018 2019 2020 is inferior to both the Government commitment suggests that on-budget external aid tends to be of 10% in the general policy of its Renaissance less volatile than extra-budgetary aid. GGEpc(XOF) GGHEpc(XOF) GGHE%GGE program and the Abuja aspirational target of 15%. The lowest engagement in recent years External financing is an important pillar for was identified in 2016, at a level of 4.9%, a health, yet Niger appears to benefit from a reduction from 2007-2009 during which health comparatively lesser level of support when Figure 18: used to receive 9.8% on average, and 8.0% in expressed in relative terms (spending Changes in health 2010 (according to complementary data directly per capita per year). On average, the per expenditure Evolution du budget de l'état et sa partt dans le secteur de la santé transmitted from the MoH (PDS)). Improved capita external contribution for health in Niger using baseline (MSP et autres secteurs) advocacy for health is needed to experience amounted to US$ 4.5 (in constant 2019 US$) year (2014=index 100) compared to 200 7% more favorable periods and attainment of UHC during 2015-2019. It reached US$ 4.8 per capita population and 180 6% goals in Niger. per year in 2019, an increase from US$ 2.9 in national income 160 2010 and US$1.8 in 2000. Considering the full 5% 5.3.3 External sources Base 100 changes, Niger, 2014- 140 period since the beginning of the millennium, it 2020 120 represents an overall addition of US$ 3.0 per 100 4% of financing for health capita every year to Niger’s public financing Source: Author’s calculations using NHA 80 3% (Figure 20). Despite increasing external 60 External support to Niger’s health system contributions, Niger citizens seem to not benefit and WDI population 2% estimates for per capita 40 takes various forms of which 64% is extra- as much as populations living in peer countries. (pc) indicators 20 1% budgetary and 36% on-budget. In 2020, two- According to another data source (IHME), for 0 0% thirds of external funding for health came from 2018, the ratio of development assistance 2014 2015 2016 2017 2018 2019 2020 multilateral donors led by the WB, the Global received for health against Government health Fund, the World Food Program and the World expenditure was estimated at 0.61 in Niger, GGE GGHE Population GGEpc Vaccine Alliance (Gavi) (52). Most multilateral which comes almost last (ahead of Nigeria) GGHEpc Baseline index (2014) GGHE%GGE and private donor fund (e.g., foundations) are compared to structural peer countries, which extra-budgetary (52). Then comes pooled have ratios estimated at 2.38 for Uganda, 2.36 funding from the WB and bilateral donors. for Afghanistan and 1.95 for Malawi. 140 120 100 Base 100 80 60 40 20 0 2014 2015 2016 2017 2018 2019 2020 GDPpc (constant XOF) GDPpc (current XOF) GGHEpc Baseline index (2014) 42 43 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE Interestingly, national key informants level at XOF 168.5 billion (estimated at about Figure 20: have reported that a portion of the off- US$ 280 million), while the official figure on 10 25 Per capita external financing for health Popula�on (million people) Constant 2019 US$ budget external support in Niger is the budget was XOF 68.4 billion (US$ 116 channeled through NGOs and tends to be million) in 2020. This gap suggests that direct 8 20 in Niger and against peer countries, considerably underestimated. The health transfers may almost represent twice much as 6 15 2015-2019 structures that benefit from NGO support budget support. A concurrent study predicted 4 3,0 10 do not measure or report the value of the that actual direct transfers are underestimated Source: WB’s calculations 2 5 using WHO Global health in-kind support (goods) received. Failing to by a factor of 14 (19). As a result, there in declare this to the central government (for Niger a real need to put in place a tracking 0 0 expenditure data Avg 2000-2019 system of health financing. This is for instance 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 instance through the DIHS2 system) leads to underestimated external support. The GFF an aspect insufficiently documented in the recently surveyed all donors regarding their NHA country reports. Per capita external financing for health Popula�on health spending in Niger and assessed their 30 Constant 2019 US$ Figure 19: 25 Amounts and share of external resources for 20 health in Niger, 2018- 350.000 2020 300.000 15 Million XOF Source: National health 250.000 10 accounts (country reports) 200.000 5 150.000 0 100.000 o a an s o na da ria da r i i ad i ng aw al ge op 50.000 ist Fa rki an ge an M Ch Co Ni hi al an Rw Bu Ni Ug M Et DR 0 gh Af 2018 2019 2020 Average 2015 2016 2017 2018 2019 Average 2015-2019 External transfers through public adminitsration Direct external transfers strengthening ownership, alignment, and out-of-pocket payments is associated with harmonization – advancing three of the five an average increase in the proportion of 60% criteria of the Paris Declaration. Where other households facing catastrophic payments of 46,1% countries remain in the theoretical stages, 2.2%” (1,54). 50% Niger has been able to transpose these 40% 30,6% recommendations successfully (53). The FCS The above cited 5% of GDP threshold for 30% 22,9% 22,7% was used to secure more predictable funds. Government spending on health (UHC) should 20% Discussions around its future development be seen as a conservative target. There is continue, with weak institutional capacity indeed an inverse correlation between public 10% to conduct analytical work around result- spending on health as percent of GDP and 0% oriented evaluations generating some percent of THE funded from direct OOP 2018 2019 2020 Average internal differences. However, it has recently payments from households, suggesting that appeared that a new dynamic is emerging and the greater Niger’s public spending as percent Ratio of on-budget to extra-budgetary (external aid) a desire to enlarge a reform on these aspects. of GDP will be, the lower the burden on the On-budget aid (as %CHE) Beyond weak institutional capacity, one can household could be. Finally, in 2017, relevant Extra-budgetary aid (as%CHE) for instance raise weak result monitoring literature raised that a public spending target system which could trigger more buy-in by of about 6% of GDP should be set if OOP other donors. payments are not to exceed 20% of the total amount spent on health care. 5.3.4 Domestic private financing On average over past decades, Niger External support that is pooled through resuming in 2017). The contributing partners for health households tend to have financed twice the Common Fund for health (FCS) is funded around € 91.3 million between 2015 as much as per capita spending by the recognized as a significant stabilizer and and 2019. Several projects or programs such Niger is at an early stage in its transition Government on health. Indeed, according to useful instrument for DPs alignment. as PAPS (WB), GDPN (AFD) and MTN/P towards UHC, with health financing WB calculations using WHO data, Niger per Interest in pooled funding has grown in were funded through the FCS, which became dominated by a large proportion of OOP capita spending during 2000-2019 averaged Niger. Initially supported by the French the preferred funding mechanism for several expenses by care users. Direct payments constant 2019 US$ 13.0 for households Development Agency (AFD) and the WB, donors. More recently the Netherlands joined for health by households amounted to XOF against US$ 6.6 funded by domestic public a multi-donor fund progressively mobilized the FCS, focusing on reproductive and 212,567.4 million in 2020. This amount expenditure. Over a more recent period, external resources from five additional DPs adolescent health in accordance with the corresponds to a large share (43.7%) of the trend remains worrying as, on average, engaged in developing a more collaborative bilateral agreement. It should be highlighted current expenditure on health. The absolute households and the Government have spent approach (53). Additions to the FCS included that not all DPs joined the FCS. volume from the direct payments increased US$ 14.1 and US$ 8.1 respectively during the Spanish Agency for International by 6.5% between 2018 and 2019 and by 2015-2019. As highlighted, Niger’s health Development Cooperation in 2010, UNICEF 7.0% between 2019 and 2020. Engaged in an system is predominantly funded by private and the Gavi Alliance in 2011, and the United During its evolution, the FCS has also attempt to link the relative share of domestic OOP expenditures by households (Figure 21). Nations Population Fund in 2014. After a deviated from its original sector-wide Government expenditure to household Per capita, both the trend and level of OOP in first contribution, the WB suspended its vision, leading to mixed results. It is now expenditure on health, a recent publication Niger reveal a structural reliance on domestic contribution for five years, before becoming expected to return to its original sector- recalled that “a 1% increase in the proportion private contributions for UHC financing, the largest contributor to the Fund (2005-2012 wide approach. The FCS contributed to of total health expenditure provided by despite a strong improvement since the 44 45 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE beginning of the 2000s as the share amounts Globally, financial hardship caused by continue to pay more than 40% of THE. On this Typically, public procurement represents a to 60.5% (against 46.1% in 2019). The slope healthcare use tends to increase over time, matter, as mentioned before, a concurrent study significant part of the budget, its share varying of private contributions in 2015 may suggest it and Niger will need to increase its efforts if should contribute to informing future decision- from 20% to 33% of all government spending. has partially compensated for the slowdown of the country aspires to reduce direct OOP making in this area of the UHC agenda. In Niger, public procurement amounted to US$ the Government’s commitment on public funds payments to 15–20% of THE. As formerly 950 million (XOF 552 bn) in 2019, representing 5.4 Expenditure to health. Since then, the pressure remains stated in the 2010 WHR, it is only when direct 24% of the national budget. For least developed significant on private expenditure since the OOP payments fall to 15–20% of THE that countries such as Niger, public procurement is the incidence of financial catastrophe and allocation on health volume of health expenditure per inhabitant critical to addressing important challenges ton has not decreased and remains at a higher impoverishment falls to negligible levels, which improving the living conditions of the population. level than the historical level (known since could become an aspirational goal for Niger as Improvements in education, health, and food the beginning of the 2000s). Key informants part of UHC reform. Currently, Niger’s reliance 5.4.1 Functional allocation production depend on the quality of investments emphasized the “virtual” nature of free package on OOP was estimated at around >40%. In made by the Government in these areas. In a in the structure of expenditure and in particular Niger, pre-payments for health from voluntary The distribution of current health context of scarce resource monitoring and at the level of the user contribution. schemes remain relatively low and have barely expenditure across care functions in Niger measurement, achieving savings as well as improved since 2018. Voluntary pre-payments remains skewed towards medical goods and improvements in performance as a buyer or a curative care, which represent the primary supplier is critical. Public procurement can also Figure 21: be a powerful tool for supporting and developing Per capita domestic 18 volume of expenses totaling 59.0% (in 2020). Curative care only accounted for about local SMEs and allowing local entrepreneurs to private expenditure 16 on health in Niger and a third of current health expenditure (against invest in sectors that offer opportunities and 14 thus generate jobs and economic growth.” Constant US$ 2019 its share against other 35.9% in 2016, and 41.8% in 2019) (Figure 12 sources of funding, 22). Expenditure on drugs and other medical 2000-2019 10 goods receives the largest share despite the In Niger, PHC remained poorly prioritized, 8 promotion of the use of generic drugs. In 2016, with Government funding at about 34% of Source: WB’s calculations current PHC spending. Investing in improved using WHO Global health 6 expenditure on medical goods came in second expenditure data position, representing another third of current PHC should be at the forefront of UHC reforms, 4 health expenditure (33.1% in 2016, against as recalled by the Lancet Commission on 2 32.2% in 2020). Expenditure on governance Global health. To accelerate progress towards 0 UHC, Niger’s health expenditure structure 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 was the third largest expense, representing up to a fifth of the share (19.2% in 2020, against could be shifted away from curative tertiary care Niger 13.8% in 2015). In contrast, preventive care towards more primary care goods and services, Per capita domestic private expenditure on health Per capita public expenditure on health represents a much lower share of current health as recently highlighted (5). Decisions to orient Per capita domestic public expenditure on health expenditure, estimated at 15.9% in 2020. increased financing towards PHC are influenced 100% by public revenue mobilization; pooling, provider The budget share spent on governance payment, resource allocation flows as well as 90% appears significant in Niger compared the political economy and country contexts (3). 80% Recent guidance by the Lancet Commission on to LICs. According to WHO global data on As a share of CHE 70% expenditure for 2019, LICs have on average PHC suggested that Governments searching to 60% spent less than 10% on governance, which prioritize increased health equity should focus shows that Niger spends more than twice as on delivering quality and affordable PHC for all 50% much as its peers (19). This finding suggests that while focusing on people-centered financing (3). 40% Increased resource mobilization for PHC would more effective governance in Niger could free 30% up health funds that could potentially be directed imply better knowledge of the needs per person, 20% towards advancing PHC. However, before improved pooling would imply the existence of concluding on this, additional analyzes would a pool mechanism, and adapted purchasing 10% be useful. For example, it should be ensured arrangements would imply assigning resources 0% to those PHC needs. distinguish effective governance expenditure 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 from other expenditure that could have been 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 Niger executed by the central administration for 5.4.2 Healthcare providers External health expenditure (EXT) the benefit of decentralized services (group Domestic General Government Health Expenditure (GGHE-D) Domestic Private Health Expenditure (PVT-D) procurement for the benefit of the districts, Healthcare providers capturing the largest hospitals, centers and/or institutes). As share of current expenditure on health was expenditure on Governance seems indeed the group of other medical providers that for health only represent a small share of current Despite the free health care policy covering about very high in Niger, it will be interesting to includes public and private pharmacies as For 24 of the 43 countries 15  expenditure (5.0%, 4.4% and 4.9% of CHE in a third (27.7%) of the population, the financial explore the result in relation to expenditure well as other drug retailers, capturing about in Africa with survey-based estimates available for 2018, 2019 and 2020). Coverage against health protection of targeted populations may have executed by the central administration for a third of XOF 486,606.8 million (32.2% in more than one year i.e., risks by contributory schemes is proven to be worsened in 2017 compared to 2015, a result the benefit of decentralized services (group 2020). The administration and financing of the the Seychelles, Tunisia, Cameroon, Benin, State inadequate among workers in the formal sector that would deviate from the regional trend for procurement for the benefit of districts/hospitals/ system was the second largest share of current of Palestine, Eswatini, and unsatisfactory in the informal sector of the Africa. On average, Nigerien populations further centers/institutes). As raised by Niger PER, health expenditure (CHE) in 2020, capturing a Namibia, Gambia, Djibouti, Chad, Senegal, economy – an observation raised by both WHO impoverished (extreme poverty line PPP $1.9) “effective public procurement systems can fifth of current expenditure on health (19.2%) Kenya, Guinea, Ethiopia, (2019) and Niger authorities (National UHC due to OOP increased by 6% annually while help local governments obtain better value for (Figure 23). Preventive care, hospital care and Madagascar, the Democratic Republic of the Congo, strategy 2021-2030). A 2017 report recalled Africa witnessed a decrease of 1.2% annually15. money, reduce pressure on the Government’s ambulatory care received respectively around Uganda, Sao Tome and that the Government of Niger was exposed to In 2019, private household expenditure on health budget, and effectively manage the private 15% of CHE in 2020. Patient transportation and Principe , Rwanda, South financial difficulties when care seekers (patients) reached 7% of GDP. It ranged between 7% and sector. Well-designed and well-managed lab services represented 5% in 2020. To ensure Africa, Morocco, Ghana, Cabo Verde, Burundi, Egypt, were unable to pay the user fees (26), which was 8% from 2000 to 2010, before lowering to 6% public procurement ensures transparency and the composition is optimal, benchmarking of Mali, Malawi, Sierra Leone, Guinea-Bissau, Liberia, already highlighted in a previous unpublished between 2012 and 2014. Despite the free health efficiency in public spending and can help the volumes and shares should become a Mauritania, Mauritius, document from the MoH in 2011. care policy for targeted groups, households foster citizens’ confidence in their government. common practice. Mozambique, Botswana, Côte d’Ivoire. 46 47 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE Figure 22: 5.4.3 Costing and financing gap in released each year and sets the framework for programming and M&E while informing the 2020 Current expenditure by healthcare function Other services ; 0,9% health “Document de Programmation Pluriannuelle Governance, in Niger, 2011-2020 administration des Dépenses (DPPD)” (56). and financing Curative care ; Health budgets are forecasted over the Source: National health health development plan period (5 years), accounts (country reports) services ; 19,2% 26,8% The biggest budgeted share of the costing complemented by annual programming was due to the implementation of the adjustment. A multi-year costing for 2017- provision of healthcare services (MoH 2021 was estimated at XOF 1,469 billion, with Program 3), which accounted for 59.9% of Rehabilitation annual budgeting averaging XOF 293,845 overall PDS averaging XOF 175,910 million Preventive care care; 0,0% million. The overall budget is distributed across 15,9% annually. As illustrated (Figure 24), the two years in shares ranging from 18.4% to 21.7% other programs accounted for 21.1% and (Figure 26). Budgeted needs vary depending 19.0% share of the overall PDS respectively, for Lab, imagery and on the year of implementation, from the lowest tranportation access to healthcare services (MoH Program 2) allocation in 2020 (XOF 270,710 million) to and governance and leadership activities (MoH services ; 5,0% the highest allocation in 2018 (XOF 318,790 Program 1), with averages estimated at XOF Medical goods; million). The budgeted amounts represented 61,964 million and XOF 55,971 million. MoH/ 32,2% XOF 16,640 per capita per year in 2017 and Programs 1 and 3 have limited support from XOF 17,647 in 2021. The budgeting was donors compared to MoH/Program 3. Since 500.000 done for each of the 3 programs, as well as the activities included in the MoH/Program 2 450.000 by sub-program (28) and action (94). As part 400.000 largely come under regulatory functions (such Million XOF 350.000 of the public finance reform implemented in as steering, sectoral dialogue, monitoring, and 300.000 the WAEMU zone, the country also has an control, etc.), Government contribution is the 250.000 annual budget programming tool (the Annual 200.000 largest of the three programs. Conversely, 150.000 Performance Project – PAP) (55) that is the Government allocates very few resources 100.000 50.000 0 Figure 24: 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Annual and overall forecasted costs Curative care Preventive care Rehabilitation care (multi-year health Lab, imagery and Other services Medical goods planning) in Niger, tranportation services Governance, administration and financing services 2017-2021 Source: MoH/DEP (MTEF data extracts) Figure 23: Current expenditure Current expenditure across care providers by care provider in Niger, 2018-2020 (in billion XOF) Source: National health 2020 accounts (country reports) 2019 2018 0 100 200 300 400 500 Pharmacies, etc. Ambulatory care Administration and financing Preventive care Other Hospital care Auxilary care (patient transportation & lab) 2020 Auxilary care (patient transportation & lab) Other 5% 1% Ambulatory care Pharmacies, etc. 13% 32% Hospital care 14% Preventive care Administration and financing 16% 19% 48 49 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE to the “provision of health care and services 194 billion). Unexpectedly, MoH/Program 2 Figure 25: (MoH/program 3)”. This program 3 is largely recorded a funding surplus, estimated at XOF Annual Overall State contri- Financing Overall cost and State COST OF IMPLEMENTATION OF THE PAN INTER- (linear) funded by partners through their interventions 14 billion in 2020. This surplus was linked to cost %Total bution %State gap 2021- %Gap contribution and VENTIONS OVER 2021-2023 (IN MILLION XOF) estima- in the fight against neglected tropical diseases, certain activities such as skills-building and 2021-2023 2021-2023 2023 tion financing needs for those aimed at improving reproductive health the availability of health products which have the implementation of and their activities in the field of nutrition. Out of experienced significant funding surpluses, Program 1: Strengthening the synergy of the PAN interventions, interventions and operational research on 489,9 0,4% 90,0 18,4% 399,9 81,6% 163,3 the 8 sub-programs identified in MoH/Program respectively of XOF 17 billion and 7 billion. On HR in Health and Social and UHC Niger 3, four sub-programs mobilized almost all the other hand, other activities within Program Source: Country resources (93%) committed by partners and the 2 (sub-programs 2.2 and 2.3), relating to health Program 2:Re-dynamization primary health care and community health with a view to 72.220,8 64,4% 17.951,0 24,9% 54.269,7 75,1% 24.073,6 information State. Reproductive health alone monopolizes infrastructure and mechanisms of protection CSU (PAN 2021-2023) more than 30% of funds, or around XOF 34 against financial risk, had significant financing billion. The bulk of these funds were dedicated gaps (XOF 5 and 13 billion). In fact, similar Program 3: Improving the quality of training and the availability of health and social wor- 3.904,9 3,5% 1.263,9 32,4% 2.641,0 67,6% 1.301,6 to strengthening maternal and newborn health disparities were also found within Program 3, kers, by exploiting the potential of ICT s services (88%) and family planning activities in which significant inequalities also existed (11%). No funding has been recorded for the according to the sub-programs. For instance, Program 4: Rural Pipeline Program (PPR) 7.014,0 6,3% 1.140,0 16,3% 5.874,0 83,7% 2.338,0 fight against non-communicable diseases certain sub-programs (3.1 and 3.4) relating for the Diffa region for 2020. The “health security, epidemic respectively to the fight against communicable Program 5: Rural Pipeline Program (PPR) management, emergency and health disaster” diseases and reproductive health, showed for the Tahoua region 16.045,8 14,3% 5.820,0 36,3% 10.225,8 63,7% 5.348,6 sub-program integrates part of the funds major deficits of around XOF 84 and 42 billion. initially linked to the fight against Covid-19 (at In contrast, another sub-program (3.8) has a Program 6: Rural Pipeline Program (PPR) 12.386,2 11,1% 5.681,0 45,9% 6.705,2 54,1% 4.128,7 least 50%). These funds represented half of funding surplus, which was mainly attributed for the Tillabéri region the resources mobilized in this sub-program, to massive commitments to the fight against TOTAL COSTING 112.061,5 100,0% 31.945,9 28,5% 80.115,6 71,5% which explains its relative size. Covid-19. These different pieces of information suggest that all activities are not in the same Despite joint efforts by all stakeholders boat, probably depending on the financing involved in health, the sector copes with a sources and modalities. This could lead to to monitor the movements of populations financial incentive allocates to volunteers, the substantial financing gap. Overall, available a recommendation to reactivate the semi- or the enumeration of target populations. amount passed to 20,000 XOF, that expected financial resources dedicated to implementing annual “PAA” reviews with the possibility of However, we have seen that these issues to be predominantly funded externally (15% MoH/PDS in 2020 amounted to XOF 251.2 reallocating funds to adjust them to evolving were important in Niger, also raised in a related from DPS and 5% from the Government). billion, revealing a financing gap of XOF 59 needs and levels of commitment. study on the financing of vaccination (4). According to certain information collected but billion (thus 18.9% short). According to the not published, some informants seem to point PAP, the 2020 MoH budget allocation was Niger has a digital tool (Niger health card) To implement the human resources for out the existence of delays in payments and in equivalent to XOF 147.6 billion (XOF 6,372 per that is intended to be strengthened to health plan (PAN 2023), Niger’s authorities the supply of essential drugs, which would then capita), of which XOF 82.7 billion was financed better guide decision-making in health. The aim to cover about a third of required raise the question of the sustainability of this by domestic resources. According to a recent Ministry of Health is committed to identifying resources, which means that about two level of care provision. resource mapping study (2021), the share potential areas for the future establishment thirds will not be funded by domestic of external financing was XOF 168.5 billion, of new health facilities, based on geographic government resources. Planned interventions According to the most common reference whether budgetary or extra-budgetary support. data on the distribution of the population and are scheduled over the period 2021-2023 and thresholds ($86 per capita and $112 per For 2021, as based on projections made by the data from health facilities (DHIS2) in order to were costed at about XOF 112,061.5 million, capita, as previously discussed), the resource mapping exercise, the financing gap produce a mapping of the needs. The country including a State contribution of XOF 31,945.9 financial gap in health towards UHC in should amount to XOF 140.6 billion, confirming uses a digital tool to identify potential sites in million (29%). The PAN implementation will 2030 should range between US$ 47.2 and the recurrence of a substantial financing gap which health coverage must be reinforced as a be the subject of annual reprogramming, and US$ 73.2 depending on the threshold in health. Considering the requirements to priority. Based on this tool, the planner produces also to amendments and validation by all retained. At the current state of knowledge, implement the PDS reform (e.g., construction a 5-year projection. It appears in practice that stakeholders involved. If the targeted regions it could be considered as an aspirational goal of new health infrastructure, rehabilitation and several other variables and trade-offs are are not those with the greatest human resource and potentially translated by Niger decision standardization of existing infrastructures and also introduced into the planning process that deficits, Niger’s authorities will have to redefine makers into progressive targets to implement the recruitment of new personnel to strengthen defines the construction needs for new health the key issues and proceed the necessary the ongoing UHC reform (2). Indeed, a costing hospital technical facilities), our situation structures. Poorly balanced, the process budgetary adjustments. study is underway at the country level to more analysis of health financing in Niger suggests can lead to a significant level of inefficiency accurately determine the funding gap that that the national health system is inadequately in investment expenditure, potentially also Regarding scaling-up community health will need to be covered to converge towards financed and unable to achieve its policy in current and operating expenditure. The in Niger, a costed budget highlighted UHC. Based on the literature already evoked, objectives, resulting in structural incapacity to healthcare mapping attempts to address the the requirements for 2017-2021, with a we found projections of the same magnitude establish sustainable health financing. specific concern of expanding the healthcare projected forecast of US$ 18.4 million for for Niger, which is an incremental expenditure package and possibly to convert certain health 2021. A budgeted scaling-up plan was made of about US$ 76 per capita, according to A retrospective analysis using health posts into integrated health centers (CSIs). The in 2018 (38), and included an increase in the authors’ calculations made for LICs. Similarly, accounts data identified the main funding health card website is hosted for three years coverage target by the CHWs program from the WHO also identified a threshold range gaps, revealing sizeable disparities by Enabel and is implemented by Bluesquare 12% of the national population to 80% by of at least US$ 50 to US$ 60 that would be across MoH programs and activities. For (57). To support and inform health financing 2021 (Kilometer 5 initiative). Forecasts were required annually per capita to achieve the instance, of the three MoH/PDS programs, decision-making, this type of tool offers a based on a monthly financial incentive system sustainable development goals agenda for only the MoH/Program 1 “leadership and set of modeling solutions based on the use allocated to volunteers (XOF 10,000 equally health (SDG3.8.UHC). There are therefore governance” did not have a funding gap, of geographic data to measure the impact of (50%/50%) financed by the Government and a benchmark range that should further conversely it showed a surplus, although investments in terms of the population served. the DPs), a costed promotional and preventive guide the new targets. Niger’s health system on a small scale (52). The largest gap was In the future, this tool could respond better package (XOF 5,000), a cost linked to the journey to UHC requires its government within the biggest budgeted MoH/Program 3 and better to the needs of modeling access to training (XOF 5,000 per day), necessary to consider investing more and better in “provision of services and health care”, which health care services at the most local level, to transport (XOF 2,000) and a few more in-kind health. As a reminder, most recent global has a gap passing from XOF 112 to 152 billion take into account not only the travel distance incentives. The document highlighted that no recommendations by the Lancet Commission between 2017 and 2018. For the year 2020, to a health center but also potentially the travel national budget line had been allocated to on financing PHC recently emphasized the this Program 3 registered a deficit, estimated time required and other relevant parameters. community health. It must be raised that the necessity to predominantly finance PHC from at XOF 83 billion (for a total cost of XOF Such a tool does not currently make it possible situation has evolved by now. For instance, for public revenue (3). 50 51 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE 6. ADDITIONAL ENABLERS AND CONSTRAINTS This final section offers further insights into large share of resources going through the Figure 26: possible enablers and existing constraints Government general budget (64%), and a Covid-19 financing around health financing, with the aim to feed significant financing deficit for the health 0 10000 20000 30000 40000 0% 50% 100% for the 2020 response plan in Niger decision-making and future reforms in health care services program, even though that it financing. This analysis is not intended to be alone accounts for more than 45% of the total OOAS 54,9 38.790 OOAS 0,1% 100,0% Source: Niger Covid-19 exhaustive, nor does it propose any gradation funding allocated to the PDS. Lack of efficiency ENABEL (PASS) 65,4 38.735 ENABEL (PASS) 0,2% 99,9% committee in the severity of each matter dealt with. It in the allocation of resources, with some BID 162,0 38.669 BID 0,4% 99,7% addresses different themes, including those subprograms largely underfunded (protection 38.507 GPDN dominating the global discussions such the mechanisms of financial risk, communicable 262,0 GPDN 0,7% 99,3% 38.245 pandemic. It can be seen as a discussion diseases) compared to others. Inequity in KfW 262,4 KfW 0,7% 98,6% starter that should occupy the minds of high- the allocation of resources at the regional Gavi Alliance 360,9 37.983 level decision-makers, planners, DPs and level was also seen (for example, low level of Gavi Alliance 0,9% 97,9% 37.622 UNFPA 620,3 other actors around the emerging challenges resource allocation per capita in the Maradi 37.002 UNFPA 1,6% 97,0% in Niger. We attempted to document and region, which has one of the highest infant and WHO 1.337,6 35.664 WHO 3,4% 95,4% highlight some additional lessons to be child mortality rates). The upcoming resources WB (Add. funds)/WHO 1.354,4 learned in order to sustainably support health tracking exercise must integrate information 34.310 WB (Add. funds)/WHO 3,5% 91,9% Unicef 1.383,6 financing in Niger. needs into the government budgeting tools 32.926 Unicef 3,6% 88,5% and enable a greater predictability of partners’ WAEMU 1.400,0 31.526 financial commitments.” 6.1 Covid-19 response WAEMU 3,6% 84,9% WB (Add. funds)/Unicef 1.731,0 29.795 The Global Fund 2.026,7 WB (Add. funds)/Unicef 4,5% 81,3% plan and opportunities The Nigerien Finance Minister expressed 27.769 Commun Fund (fungible) 3.133,7 The Global Fund 5,2% 76,8% the commitment of the National Assembly 24.635 for increased to provide a supplementary budget for UE (TeamEurope) 3.272,0 21.363 Commun Fund (fungible) 8,1% 71,6% additional spending on Covid-19 vaccines, WB (Redisse3) 3.871,2 UE (TeamEurope) 8,4% 63,5% 17.492 mobilization for health if needed (58). A crisis plan to cope with this PRU COVID 7.672,5 WB (Redisse3) 10,0% 55,1% pandemic, which is divided into an immediate 9.819 health response and broader economic EIB (European Invest Bank) 9.819,2 PRU COVID 19,8% 45,1% Covid-19 posed unprecedented exogenous and social mitigation, has been prepared in State 25.565,4 EIB (European Invest Bank) 25,3% 25,3% pressures on national health systems Niger. Financial requirements to cover the - 10.000 20.000 30.000 40.000 worldwide, generating extra burden plan’s needs were estimated at 7.4% of GDP 0% 50% 100% and capturing a substantial share of (equivalent cost of US$ 600 million). On May Mobilized funds (mio XOF) Donor share in EXT funds (%) expenditure. To be fully implemented, the 7, 2021, the riposte plan was revised, and was Cumulative external funds (mio XOF) Cumulative donor share (%) riposte plan required significant support from expected to be 18.4% of GDP (equivalent to grants and concessional financial support US$ 1.5 billion). The 2021 budget information from the international community. Throughout on Covid-19 vaccination doses and distribution PRU COVID the crisis, Niger, like many other countries, was not yet available due to the fiscal year WB (Redisse3) responded by reallocating scarce available calendar, which prevented us offering a UE (TeamEurope) Commun Fund (fungible) funds to the crisis response. Greater external broader analysis of the national response to The Global Fund resource mobilization also succeeded in Niger, Covid-19 in Niger. WB (Add. funds)/Unicef with some partners such as the WB extending WAEMU their contribution. The cost of implementation With the support of the WHO and other 60,3% Unicef of the 2020 Covid-19 response plan was development agencies, Niger has WB (Add. funds)/WHO estimated at XOF 167,298 million. At the end implemented several strategies, including WHO UNFPA of 2020, spending to implement the Covid-19 Covid-19 vaccination, to provide sufficient Gavi Alliance plan amounted to XOF 64,355 million, of which collective immunity to populations and 39,7% KfW the Government of Niger mobilized 39.7% and break chain transmission. DPs set up the GPDN development partners 60.3%, as reported by COVAX mechanism. COVAX is co-chaired BID the Niger Covid-19 committee (Figure 26). A by the Coalition for Epidemic Preparedness ENABEL (PASS) EXT-funded very large part of the funds initially allocated to Innovations (CEPI), Gavi–the Vaccine Alliance OOAS GOV-funded Covid-19 came from the Covid-19 emergency and the World Health Organization (WHO) response project supported by the WB (for an working in partnership with UNICEF as key estimated budget of XOF 7.9 billion according implementing partners, alongside developed to the resource mapping exercise). and developing country vaccine manufacturers, the WB, and other stakeholders. This The financing gap amounted to US$ 105 mechanism aims to provide equitable million, equivalent to 18.9% of the total access to quality and affordable vaccines to funds needed for Covid-19 in 2020, as LICs. Niger joined the COVAX mechanism reported by a recent resource mapping in September 2021. To further support the and expenditure tracking. According to purchase and deployment of doses, the WB GFF, the exercise also had shown “a relatively brought additional financing to Niger through 52 53 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE AVATT. In a boost to the African Union’s target expenditure on health should be further Figure 27: to vaccinate 60% of the continent’s population improved. In 2019, Niger’s health expenditure Comparative 100 values for money by 2022, the WB and the African Union are performance to reach higher UHC index value as expressed for partnering to support the Africa Vaccine was inferior to the general trendline (Figure 90 selected health Acquisition Task Team (AVATT)14 initiative, 27), which was already shown in 2017 (Figure outcomes against per with resources to allow Niger and other African 6). Some of its peers, for instance Ethiopia and 80 capita expenditure, countries to purchase and deploy vaccines for the DR Congo achieved higher “UHC value” 2019 up to 400 million people across the continent for money. Similarly, in 2019, Niger’s health 70 (59). This regional effort complements the Source: WHO Global UHC Index expenditure performance to reach higher life health datasets COVAX arrangement while Covid-19 cases are expectancy outcome was also inferior to the 60 rising. Globally, “the WB-financed COVID-19 general trendline. Some of its peers, for instance vaccine operations allow countries to purchase Ethiopia and Malawi, achieved higher “life Uganda 50 vaccines through COVAX, through regional expectancy value” for money. Life expectancy Malawi Senegal Burkina Faso initiatives, and through bilateral procurement should be four years longer given Niger’s Nigeria from manufacturers.” current level of spending in the health sector 40 Ethiopia Mali DRC Afghanistan (5). Another way to incentivize improvement Niger 30 6.2 Human resources could be to highlight that, for the current life expectancy level in Niger, the per capita spending could be lowered by 11% if efficiency 20 as a lever for improved gains are realized (19). Facing it should incite .5 .4 .3 .8 3 25 7 3 5 6 2 7 1 0 5 21 impact of health 10 0. 3. 6. 68 03 80 71 45 27 policy makers to better ensure that resources 18 31 42 65 ,9 18 48 1, 1, 2, 4, 6, 10 are used efficiently. Other indicators could Current health expenditure per capita, US$ financing efforts provide further insights such as mortality rates and primary care coverage (immunization), 85 which has been covered in the related study (4). Domestic mobilization for human resources is needed. The public sector appears attractive Improving health in Niger will require an 80 Life expectancy, in years in terms of remuneration, at first sight, potentially increase in the supply and quality of health providing 13 to 25 times higher rates compared services delivered nationwide. Beyond 75 to the national average income. This result must increasing health, increasing human capital be put into perspective since there are several was also shown as essential for Niger’s 70 types of health staff, with substantial differences long-term development. Given the significant Rwanda Ethiopia Senegal in remuneration levels depending on whether pressures on the government budget, the 65 Malawi Afghanistan the status is contractual or more permanent scope for increasing the priority given to health Uganda (civil servant). Despite “relatively” attractive expenditure will remain limited. This suggests Burkina Faso condition for remuneration, permanent jobs in that one should rely on general economic 60 DRC Niger Mali health only account for 4% of the domestically growth to increase health spending. It is well graduated workforce. A study published in 2018 known that investing in human capital brings 55 Chad Nigeria warned about additional human resources for a high rate of return on investment, and this health needs, also domestic HR mobilization is particularly true for Niger which has yet to 50 to accelerate progress towards UHC (by 2030), benefit from a window of opportunity linked .6 .4 .3 .1 2 0 2 4 6 5 0 21 and advised investing in recruitment training, to the demographic dividend (19). These 4. 30 0. 3. 31 00 45 20 31 42 59 ,9 12 44 85 1, 2, 4, deployment and retention of health worker authors have estimated that GDP per capita 10 policies to address the shortages and reduce will increase by about 30% by 2030. In the Current health expenditure per capita, US$ the threat of non-achievement of UHC goals short term, however, the greatest potential (60). Having a strong and more resilient health health gains lie in efficiency improvements system based on revitalized PHC and UHC within the sector. Simply increasing public quality healthcare, decision-makers can also toward UHC, especially as Niger’s health would require reaching and exceeding the spending in the health sector may not produce consider tracking and resolving budget under- expenditure structure would need to shift away required thresholds for HRH - the system is still the desired health outcomes if the efficiency of execution at all levels, decentralizing investment from curative care (tertiary services). The study 8 to 15 times lower staffed than the required that spending is low. budget execution to the service provider level, also suggests increasing the share of pooled level identified by Niger competent authorities in providing greater individual career-focused funding to reduce the high reliance on OOPs. 2020. The interventions of the PAN for improved A recent study pointed out a wide range of training and mentorship opportunities, and HRH in Niger must significantly improve the necessary efficiency gains that can help increasing supervision of clinical staff. Thirdly, on availability, accessibility, and quality of health personnel, while acting effectively on the other generate increased financing for health. Indeed, several recommendations were recently the use of pharmaceuticals, other options could 6.4 Budget increase from expanding the lie in strengthening the public pharmaceutical pillars of the health system in care-centered formulated to address major health system supply chain and its regulatory bodies to reduce approaches. The information system was also weaknesses (5), these align with our study fiscal space for health the high cost of medicines, introducing more identified among the urgent needs. results and call for more technical efficiency regulations for the private pharmaceutical sector, in health. Firstly, with respect to low workforce conducting a systematic review of the Essential density and uneven distribution of health staff 6.3 Improving health and skills, decision-makers can consider further Medicines List in view of increasing the share of generic drugs and reducing drug prices. Enhanced domestic resource mobilization strategies and opportunities to expand financing and system increasing the number of health professionals the fiscal space for health are needed in (including community health workers) while Beyond the possible technical Niger. Achieving improved health is a costly efficiency focusing on under-served areas and high disease improvements, the above-cited study also endeavor for Niger that has limited budget burden areas, decentralizing HRH management, identified the need to improve the allocative space, as documented previously. HICs and creating more incentives to deploy services efficiency of the health system. As also MICs invest comparatively more in health. 14  AVATT is an initiative of the Against income group trendline for key and operate in remote areas, and fight both African Union Commission, illustrated in this study, investing substantially in “The ability of governments to increase health outcomes (UHC and life expectancy), absenteeism and its root causes (for instance Africa CDC, Afreximbank, PHC should be seen as a cost-effective strategy spending for the sector without jeopardizing the the African Union Special Niger is below expected values for money, using individual career plans and rewards for Envoys for COVID-19, and and an efficient way to accelerate progress government’s long-term solvency or crowding UNECA. suggesting that its return on per capita performance). Secondly, with respect to low- 54 55 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE out expenditure in other sectors needed to implemented in Niger, possibly due to a lack need to move towards increased financing in achieve other development objectives” (61) of sufficient support. A study conducted by The impact of future policies addressing the periphery is confirmed, the country can is covered in a concurrent study. According the World Bank is underway and could shed “identified” health system inefficiencies resort to various mechanisms including the to this fiscal narrative study, Niger’s main more light on the weaknesses and strengths was projected in terms of fiscal savings strategic purchasing approach, but also the engine to increase its public expenditure of the public expenditure chain. A recent focus and could yield up to 0.23% of GDP (5), strengthening of INAM and other insurance on health will likely rely on two mobilization on the PFM adjustments undertaken and the equivalent to some additional financial mechanisms. channels, which are the national economy linkages to both health financing for PHC and resources that could benefit UHC reform. The and budgetary prioritization for health. While opportunities to expand health coverage is potential efficiency gains were also expressed While the system suffers from weaknesses, economic growth could be a dominant factor discussed for Niger and two other countries as a percentage of current total public their root causes have been investigated in the long run, prioritization is vital in the (Burkina Faso and Mali) (74). expenditure on health, about 13%, suggesting and may offer a way forward. Funds that short run. As the financing gaps are known, that the potential gains would be equivalent to were made available to the MoH were not it is important to concurrently resort to all the The Government of Niger has made a bringing Niger to the level of Burkina Faso, for managed effectively from the start of the possible arsenal, and this includes the search strong political and economic commitment, instance, in terms of efficient performance of fiscal year, leading to some accumulation of for better efficiency in public expenditures. placing the performance measurements of essential health services (5). arrears (63). Such situations can be recurrent mobilized budgetary resources and quality in the sector and were highlighted in a related Several (indirect) levers or financing of expenditure flows at the center of its It should also be reminded that less study on immunization financing (4). With channels could be mobilized to meet the concerns. From this sector-wide reform, than 10% of public expenditure is this regard, PEFA 2017 attributed those additional financing health needs in Niger. health stakeholders align with international decentralized, which seems extremely low. shortcomings to the fact that the heads of It will be for instance interesting to explore guidance for meaningful change (62) and As a result, about 90% of public expenditure ministerial departments, not only health, did opportunities around the future role of the expect real transformation of the M&E of is executed at central administration level, not adopt an optimal management method INAM and upcoming reforms of the financing financing systems to ultimately reach the indicating potential room for improved (63). Yet, budget execution monitoring system around the triptych Common Fund, country’s potential to guarantee that health allocative efficiency (5). Given Niger’s level benefits from a satisfactory computerized INAM (free care) / UHC and alignment with providers receive a steady and predictable of income, the burden of diseases and that system, at least in terms of revenue collection health budget support. Make better use of flow of funds. Expected change to achieve the the primary care level is recognized as a key and accountability, and operational control partner’’ willingness to align and strengthen the UHC transition lies on an adequate budget delivery platform for essential cost-effective mechanisms for audits. The limitations may Common Fund for health mechanism seems provision combined with full implementation of interventions, a larger allocation of public come from low resource levels and staff needed. The budget support in Niger can the available budgets. Yet, to our knowledge, expenditure towards PHC (more decentralized capacity, which makes them ineffective in also constitute an opportunity for increased Niger does not provide systematic evidence financing) may contribute to improving the limiting excessive expenditure, especially in resource mobilization in health, in particular by on how well health budgets are implemented allocative efficiency of the health sector. If the the operating budget (63). Historically, several retaining other methods, process indicators, and evidence from this study, and its linked performance indicators (but without particular study on immunization financing, suggests targeting of financial commitments). More investing in improved budget formulation and aligned indicators are needed to better promote execution practices. Figure 28: and monitor improvements of performance Niger 2017 PFM assessment: PEFA and the implementation of upcoming reforms. To finance the transition to UHC, Niger outputs for 31 With respect to immunization financing, must draw on all its resources, including dimensions of public recent discussion around potential support improving public financial management finance from IMF-linked social sector disbursement (PFM). Meeting national health commitments indicator(s) may represent an opportunity to depends on Niger’s public finance system. Source: Author’s highlights using PEFA 2017 address existing funding bottlenecks of the Yet, a series of weaknesses remain. For government’s vaccine co-financing counterpart instance, during the annual budgetary (Gavi meeting note, 2022) (4). Following such controls, the Court of Auditors identified a approach would involve identifying strategic series of non-regularized expenditure and indicators that could be used to feed the non-charged revenue in the appropriate discussions around budget support. budgetary accounts. This situation was described as recurrent and posed a problem 6.5 Efficiency gains for since it did not allow the full execution of the finance laws15. Unfortunately, the budget health from improved control exercise did not provide any detail on the budgets of the different ministries, public finance thus making no recommendations for the health sector. PFM shortcomings were also highlighted in a previous study, which raised 1. Aggregate expenditure outturn 11. Public investment management 22. Expenditure arrears MoH is a leading Ministry in using upcoming challenges in budget preparation, 2. Expenditure composition outturn 12. Public asset management 23. Payroll controls budget programs, yet there is insufficient credibility, expenditure management and 3. Revenue outturn 4. Budget classification 13. Debt management 14.  Macroeconomic and fiscal 24. Procurement Internal controls on nonsalary 25.  information about efficiency and control that have hampered government 5. Budget documentation forecasting expenditure In 2018, overall, execution 15  accountability. In the process of modernizing efforts to reform its PFM system (5). The same 6.  Central gov. operations outside financial reports 15. Fiscal strategy 16.  Medium-term perspective in 26. Internal audit 27. Financial data integrity of the finance law presented PFM, on January 1, 2018, the country shifted way health determinants likely impair health Transfers to subnational 7.  expenditure budgeting 28. In-year budget reports at first sight a surplus result, governments 17. Budget preparation process 29. Annual financial reports it was assessed at XOF away from inputs-based budgeting to outputs- sector performance, other determinants relate Performance information for 8.  18. Legislative scrutiny of budgets 30. External audit 87.16 billion on the basis of focused budgeting (i.e., the program budget). to PFM. Among the key concerns, low budget service delivery 19. Revenue administration Legislative scrutiny of audit 31.  sector account execution, Public access to fiscal 9.  20. Accounting for revenue reports and at XOF 82.34 billion The program-based reform introduces a result- execution has been raised by a task force information Predictability of in-year 21.  after deduction of the oriented approach that should allow linkages for UHC (namely the UHC strategy working 10. Fiscal risk reporting resource allocation execution of special treasury accounts. Nevertheless, between the spending and the achievements group, 2021) as driving under-performance after taking into account made (output targets), as predefined in the in the sector (e.g., insufficient release of expenditures paid without prior authorization and not budget framework. Although the system announced credits, delays in their release, adjusted and the collections has various limitations. According to a key cumbersome procedures for disbursing State of receipts not adjusted, the result became deficit of XOF informant, the program budget remains poorly credits). 64.09 billion. 56 57 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE audit reports of Global Fund grants identified larger volume, estimated at XOF 860.9 billion the quality of care. a series of non-compliant expenditures for 2022, against XOF 795.3 billion in 2021. For some health facilities more than In terms of volumes spent on PHC through and extensive financial irregularities that These figures are projected using available others, the compensation mechanism that the free policy in Niger, it tends to account led to the decision to reimburse the Global information and based on development is supposed to cover operating costs is for the small share of health expenditure. Fund (64,65). The main recommendations partners’ intentions for 2022. All cited amounts not at all effective. Figure 29 shows some In 2020, the cost of the free policy accounted related to the inadequate monitoring of the refer to MoF provisional reports or the initial variability across locations, both considering to 0.3% of the current expenditure on health, quantification and forecasting of the supply financial law (LFI) and are subject to revisions the entire period since 2007 and for a fiscal potentially rising to 1.5% when including of health products, insufficient use of data, during the fiscal calendar. year exercise (2020). In 2020, recovery rates pending and unpaid claims, according to our absence of a national supply chain strategy, across health structures ranged from 0% to calculations using NHA data. In 2020, invoices 6.6 Inefficiencies in quality and coordination requirements, lack of 100%. Most sites if not all stick around zero totaled XOF 7,451.6 million whereas refunds monitoring, transparency or competitiveness refunds, only two sites (e.g, general refence were estimated at XOF 172.5 million. This PHC financing (66,67). hospital) were above 85% of cost recovery. means that, end of the year, pending refunds Regarding the invoices stored at the Financing at MoH/DEP for the year of 2020 amounted Beyond health, the overall PFM context Division of the MoH/DEP, the recovery rates to XOF 7,279.1 million. Over the whole does indeed have several shortcomings The user fees exemptions (“free”) policy ranged from 33.5% to 100% when considering period of 2007-2020, the cumulative amount that lead to missed revenues for health. A that has been in operation for over almost the cumulative period from 2007 to 2020. Our of all invoices sent to the MoH (MoH/DEP) recent global assessment of PFM strengths two decades in Niger underwent several findings shows that central level care providers amounted to XOF 106,075.7 million, whereas and weaknesses (63) resulted in a low score PFM changes towards higher autonomy have higher recovery rates than facilities in the refunds were estimated at XOF 49,415.2 for almost all dimensions, and concluded that to the PHC providers. A recent publication regions. It should be remembered that some million of refunds, leaving XOF 56,660.5 multiple conditions needing budgetary and describes the PFM changes impacting on structures are almost 100% dependent on the million unfunded. According to the above cited financial discipline have not yet been met health financing (74). Along with the user financing from the fee-free services delivered, recent publication (74), Niger monitoring of (Figure 28). This calls for collective action fees policy backdrop introduced in 2006 in in particular the reference maternity unit free care funds happens quarterly. Thanks to at the State level, and PFM advocacy to Niger, the PHC financing combined financial whose activity is closely linked to pregnancy the novel connection brought by the output- improve health expenditure efficiency. From compensation for user fees removal with complications and therefore to the policy of based framework, it should be possible to a general perspective, a lot of progress was changes in the PFM so the funds could be free caesareans. For those facilities or care assess how much is effectively spent and for made as of 2017 compared to the 2012 allocated, channeled to PHC providers (direct units predominantly or entirely funded by the which types of free services delivered (74). baseline assessment. Since, the introduction transfers from MoF), and used with more claims for free care services, any dysfunctional Upcoming changes may occur along with the of a medium-term expenditure frameworks autonomy. Until 2018, health facilities however pattern directly undermines their operations creation of INAM and the ongoing discussion (MTEF) has been recognized as crucial to did not have their own bank accounts and and therefore the satisfaction of care users around strategic purchasing and free care. To improve the functioning of the renovated public funds therefore transited through district bank with regard to the free services offered. enhance the free policy, it will be of utmost procurement system. Among the weaknesses, accounts, with earmarking for specific health importance to address PFM shortcomings, it has also been shown that the budgeting facilities. Starting 2018, funds were made strengthen the monitoring process and, process continued to be based on political available as cash imprest to health facilities. ultimately, conduct an impact assessment of objectives rather than budgetary concerns As a result, health facilities (PHC centers and the successive changes in PFM practices in driven by MTEF. Too little improvements have district hospitals) are financed prospectively this area. been made in the matter. In the health sector, through a provisional budget allocated to for instance, in preparing the UHC reform, health facilities for the fiscal year. Funds are experts have reported that the MoH Annual released upon claim requests from the PHC Action Plans (PAAs) may not be fully aligned providers. Figure 29: Billing situation of the with national priorities and raised the issue of 120% 20.000 free healthcare policy parallel budgeting processes. The free policy however operates under 100% 15.000 80% in Niger, 2007-2020 certain constraints, with “unpaid” claims 10.000 60% Controlling and improving the quality accounting for a substantial share of 5.000 40% Source: National health 0 20% accounts (country reports) of public expenditure as well as the the free care package. The compensation 0% and MoH DF/DEP mobilization of domestic revenue will be mechanism of retrospective reimbursements L FA A EZ O I Y EY ER N Z IG SR D C R D N N ER U N R LC G SS A M IF D H H M D N O H N H R A B N O N C D IA C part of the priority projects according to to facilities, which is based on ex-post claims, H A G A C ZI D TA M N LL A the strategic orientations of the budget poses problems and is associated with TI announced for 2022 (MoF), which thus PFM bottlenecks undermining the free care Cumulative amounts of bills sent for refund (mio XOF), 2007-2020 covers health sector financing. For 2022, the policy effectiveness (25). Several sources Total refunds (mio XOF), 2007-2020 country’s budgetary policy will be specifically have reported the existence of delayed End 2020 pending refunds, 2007-2020 oriented towards the implementation of reimbursements and arrears, of about XOF 50 Recovery rate (%), 2007-2020 actions to revive and transform the economy billion (68–70). Since 2007, overall, barely half in a context marked by the persistence of (46.6%) the reimbursements claimed were security threats and the pandemic, above reimbursed, a situation that is highlighted in 8.000 100% other domestic and sectoral challenges. Niger the health accounts (country report 2020). 7.000 80% 6.000 also announced that the financial resources It should be noted that out of a total of 1020 5.000 60% of the General Government budget should claims (invoices) expected in 2020, 722 4.000 be around XOF 2,888 billion for 2022 (+2.4% (70.8%) successfully reached the Financing 40% 3.000 compared to 2021), of which XOF 1,359 billion Division of the MoH/DEP for refund. The 2.000 (+4.1%) is from domestic resources and XOF remaining 298 invoices (29.2%) were still at 20% 1.000 1,529 billion (+0.2%) from external resources the level of these structures, these remaining 0 0% – all sectors included. Fiscal revenues for unfunded. Overall, as of end year 2020, only L FA A EZ O I Y EY ER N Z IG SR D C R D N N ER U N R LC G SS A M 2022 were estimated at XOF 1,304 million 2.3% of the claims were paid that year. The IF D H H M D N O H N H R A B N O N C D IA C H A G A C ZI D TA M N LL A (+4.3%), complemented by XOF 301 billion current system therefore encounters major TI (+45.1%) from non-fiscal revenues. Budget limitations that do not give the expected Annual amount of bills sent for refund (mio XOF), 2020 support (including program loans) to Niger financial autonomy to PHC providers. Total refunds (mio XOF), 2020 was estimated to XOF 318.7 billion for 2022, Financing bottlenecks caused a lack of cash End 2020 pending refunds (mio XOF), 2020 against XOF 269.1 billion in 2021 (excluding flow, lack of credibility of health facilities and Recovery rate (%), 2020 program loans). The aid per project attracts a drug shortages, with a consequent impact on 58 59 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE reported elsewhere (5), along with complex Several issues can help understand articulation between what the user must pay why the “free” policy does not deliver and what should be delivered free of charge. on all promises. Some implementation In addition, there is also the problem of data weaknesses related to the lack of verification completeness and recurring strikes by health mechanisms, for instance to assess the contract workers that hindered the impact on quality of services. Niger opted for a total health improvements. Yet, a growing body exemption of consultation and medicine fees of evidence indicates that investing in PHC for U5 children, as well as for prenatal care, interventions is a cost-effective strategy to delivery and post-natal care for women. advance UHC (72,73), which should be further It has been raised that the country was sought in Niger decision-making. To monitor ambitious and implemented a costlier policy budget prioritization on PHC, which should than the one implemented in Mali or Burkina include investment in the free policy but not Faso (71). In Niger, the flat rate for c-section only, it is first necessary to measure what is includes, for example, the surgical service, effectively spent (3). hospitalization costs, preoperative exams and products. For U5 children, the package The question of progressing towards includes consultation and medication, but access to care for indigent populations is may vary according to the level of the health an ongoing process in Niger in which it pyramid. Concurrent modalities coexist in is still necessary to define the criteria of Niger. Preliminary (unpublished) results from indigence, to identify the ways and means an ongoing study on health financing system of their care, the future role of INAM. A assessment in Mali suggests that the failure USAID project found evidence of significant of free policy is linked to several components variations in processes to identify indigents and can be induced by the complexity of the within communities (26). This project argued design of the free care package (e.g., coupling that exploring the context of inaccurate target in the same package free care and fee-based population counts could lead to a reduction in care), poor appropriation of the policy by the the incidence of point-of-care fraud and lead to actors of land, confusion over prices leading more effective government funding of indigent users. Another study suggests that parallel health services. This could be something worth systems to the general system based on cost- to understand even though in terms of budget recovery may affect the overall balance of volumes it may not represent a substantial the system. A lack of effectiveness was also share of the financing. 60 61 NIGER HFSA | TECHNICAL REPORT WB HNP WB GLOBAL PRACTICE HNP GLOBAL PRACTICE 7. DESIGNING THE WAY FORWARD Niger committed to UHC and must chart Capitalization on existing assets (situational its own way forward. Tracking progress diagnosis already providing some policy and expenditure efficiency require deep recommendations and outputs and data) and reliable data. For instance, significant should be further strengthened in Niger. variations of external resources channeled Indeed, regarding the presence of the health through NGOs were raised as a limitation to financing deficit in Niger, a recent resource be addressed. Our results lead to the following mapping study has already drawn some recommendations: (i) upcoming Niger’s health policy recommendations, promoting some accounts should be complemented with a reallocations that could be envisaged in the specific survey of international NGOs and (ii) medium term. The recommendations relate to NHA work and resource mapping should be the institutionalization of a resource mapping harmonized as the GFF has done in other study within the MoH, which deserves to be countries in Africa. Once data is available, strengthened. Five key recommendations data use is needed to make the right decisions were made: (i). Strengthen advocacy with towards more effective delivery of quality- relevant stakeholders (MoF, MoH, donors) on care through system responsiveness and the importance of mapping financial health governance. This exercise in mapping out resources; (ii). Ensure the strengthening health financing data in Niger showed the of programmatic management for the new extent to which high-performing health Development Plan for Health. Review and financing relies on essential factors i.e., timely clarify the nomenclature of activities and evidence, reliable data sources, appropriate results in order to facilitate the inclusion of sets of indicators, availability of data and donor interventions in this next plan; (iii). eventually a common approach for improved Ensure the integration of the resource mapping data use. Our study attempted to capture the information needs into General Government complexity of health financing in Niger with the budgeting tools; (iv). Establish an appropriate intend to fill some gaps in guidance. data collection tool (for donor contribution) for regular completion (each year) at the Niger’s economic growth being a major start of the budget cycle in accordance with channel to drive domestic resources for the requirements of the budget-program health will not be sufficient to finance reform (DPPD); (v). Establish an environment the whole journey towards effective UHC conducive to greater predictability of partners’ and cannot be dissociated with efficiency financial commitments. improvements. Niger committed to UHC but challenges ahead are numerous. Also The UHC reform likely requires better recommended for PHC financing by the shared knowledge and enhanced available Commission (3), Niger should consider evidence. Health financing should not only be investing more and better in its health about assessing the sufficiency of resources, system, especially if aspirational goals are but also about how resources are equitably and made for the current decade towards the efficiently raised, pooled, and allocated to make 2030 horizon. Niger’s financing strategy progress towards UHC. It could be beneficial to national development plan for health had growing major role in health financing (e.g., the free care for UHC should become transformational the health sector to carry out an independent interest among the development partners, initiative) but its role is not fully clear to date. for the health financing architecture. The financial audit with the aim of identifying potential despite still having some weaknesses. The reform should ensure separation between Lancet Commission on PHC has raised efficiency gains, additional gains resulting from decision, implementation and control functions the importance of financing arrangements. future synergies and organizational changes. The health financing transition for UHC will for free care policies. A future landscape with Capitation as recommended could be This could be facilitated in various ways to: require greater mobilization driven by multiple two separate bodies to pool funds and purchase considered as part of the equation to enhance i) implement efficient practices for increased means (political, institutional, technical and services (as it is highlighted in the UHC roadmap) PHC in Niger and fit population growth needs, mobilization of health financing (including financial capacities) to ultimately achieve will also bring new challenges. likely complemented by strategic purchasing the search for allocative and technical health effective service coverage for UHC. This approaches. It also should transition away expenditure efficiency); ii) strengthen the involves reinforcing existing policies to accelerate This last section is an attempt to raise from the high reliance on OOP expenditure production and publication of accurate and time- sustainable development. Cash flow issues awareness around the need to respond to to finance health spending. Health should bound digital datasets; iii) democratize the use need to be better understood and eliminated. existing constraints and challenges. These be sustainably prioritized in the general of data in support of evidence-based decision- For instance, the free policy, which is a primary can be considered, discussed, and developed government budget, especially in a context making for sustainable health financing; iv) step of the UHC path, must be fully effective. by each relevant stakeholder in a coordinated of economic slow-down and growing needs. further disseminate monitoring and evaluation Its funding must be based on a sustainable dialogue to maintain and accelerate the Improved and institutionalized accountability results to involved parties and civil society; v) system, with effective mechanisms, predictable progress for effective UHC. A workshop processes are also needed to successfully generate and expand advocacy skills around funds and strong stakeholder engagement and involving health and finance stakeholders monitor health financing flows, ineffective or sustainable health financing. The next step could alignment. Niger’s Government must make a would be an asset to take direct action on wasteful spending and performance gains. be to produce a guidance note deriving from strong commitment to this, which is currently unspent budgets. The following exercise Despite huge progress in the sector, Niger’s these avenues for development. With this intend, happening. The current Niger roadmap towards should be taken as food for thoughts (possibly health system tends to under-perform in a workshop could for instance help generate UHC involves setting up a third-party payment. used as an input material for a workshop) and several areas when compared internationally. both concrete and operational measures for A strategic dialogue on health financing and its should be refined and actualized by Niger The country context remains characterized by development. Innovative health financing fragmentation has been initiated. The expansion health stakeholders to meet requirements of inadequate financing against the UHC goals. arrangements (basket funding) in support of the of strategic purchasing in Niger is discussed. the evolving policy dialogue. The newly created INAM is expected to play a 62 63 NIGER HFSA | TECHNICAL REPORT WB HNP WB GLOBAL PRACTICE HNP GLOBAL PRACTICE Table 3: Tentative response to health financing for UHC constraints and challenges in Niger Level of action Tentative response (non-exhaustive) to raised constraints and challenges Health system stewardship  romote and develop a national strategy that is efficient at tackling existing ineffective and/or wasted ▪P health spending, and structurally fight against persisting technical and allocative inefficiencies  lan and include consensual and progressive threshold targets/goals for effective UHC, including the ▪P consideration of existing recommendations for LICs nstitutionalize the use of global and national guidance and studies providing insights on the financing ▪I transition for UHC  stablish a national arrears payment plan to avoid bottlenecks induced by financing issues with side ▪E effect to attract increased external funding  stablish the use of ready-to-use and country-specific health financing indicators (sector- and sub-levels) ▪E tackling any information gap  romote and support health financing capacity building and analytical capacities for the monitoring and ▪P evaluation of health financing for UHC  romote better use of existing data (NHA for analytics and policy-making both at sector and programs ▪P levels). Better use relies on data. Moreover, a specific survey might be conducted to map external resources on health that are channeled through NGOs, which was highlighted as a limitations. ncrease stakeholder coherence and coordination to improve political advocacy around health financing ▪I and UHC  overnance and efficiency in health expenditure weaknesses ▪G  educe inequalities and use specific goals to monitor health workforce shortages at decentralized ▪R level as part of the human resources for health national plan, mostly in remote areas, and insufficient distribution of skills to meet quality standards  etter document and improve allocative efficiency, for instance with a convergence toward increased ▪B share of financing to front-line providers and primary health care  trengthening pooled funding and the UHC reform ▪S  trengthening health system resilience and develop flexible health policies to ensure responsiveness to ▪S evolving needs, especially post-pandemic  ommunicate on the key health financing tools and documents to all partners (such as the RAP) ▪C Health system financing  onitor future threshold targets set within the ongoing UHC reform ▪M dentify and address implementation bottlenecks, especially those linked to the free policy implementation ▪I  ommit to a sustainable vision for monitoring and evaluating (M&E), by generating national and ▪C intranational evidence Address the recurrence of financing gaps, arrears and other cash flow weaknesses that are persisting ▪ within certain activities, while other activities that may register a surplus need to be flexible  obilize adequate financial resources (especially domestic resources) with respect to reaching political ▪M and strategic goals  onitor the adequacy of health financing for UHC, for primary and community care services, for instance ▪M using per capita expenditure indicators/targets  etter information is key, inform on the percent and niche of ineffective and/or wasted health spending ▪B  lan, support and perform analytical studies for high-performance health policymaking (including ▪P public financing management assessments to support the financing transition towards UHC, a public expenditure tracking survey to improve budget execution)  trengthen or decentralize (at the level of the service provider) investment budget execution to improve ▪S technical efficiency in the PFM process Public finance management Address persistence of administrative delays and inefficiencies in the reimbursement of invoices ▪ ▪ Address the financing limitations within the free strategy that undermine its effective implementation  stablish flexible, policy-aligned, and accountable budget formulation. ▪E mprove budget execution ▪I Health information  enerate a health financing information mapping and make it available for sector and cross-sectoral ▪G and communication purposes  apitalize on existing tools, digitalize data and data availability information, starting for instance with ▪C a single website to guide stakeholders across multiplicity of data sources on health financing and innovation, and/or create new tools tailored to decision-making needs  evelop and strengthen a communication plan ▪D Advocate and build on possible synergies with social determinants and inclusive growth to improve health ▪ outcome Intersectoral approach to  onverge towards more coordinated actions undertaken by sectors carrying determinants of health, ▪C health (health in all policies) relate to human capital development, population growth and growing needs and youth/aging issues  earn from and take advantage of evolving contexts (post-Covid-19 economic growth sharing, ▪L Government prioritization for social and financial protection for health, ...)  stablish commitment around health-linked sectors within the National Technical Group for UHC ▪E 64 65 NIGER HFSA | TECHNICAL REPORT WB HNP GLOBAL PRACTICE 8. 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