Niger, a landlocked country in West-Africa, part of the Sahel region, had a population of over 26 million in 2023. Approximately 25% of its citizens were under the age of 15, coupled with a population growth rate of 3.3%.1 Ranked 188th out of 193 countries on the Human Development Index,2 Niger faces major health challenges, including infectious diseases, maternal and child health, climate-related health-risks, and non-communicable diseases (NCDs). Persistent security threats have further complicated delivery of healthcare,3 particularly since the 2023 coup d’état. Despite these challenges, life expectancy at birth has improved significantly -from 50.2 in 20001 to 61.2 years in 2023.2 However, the leading causes of death remain largely preventable, with communicable, maternal, perinatal and nutritional conditions accounting for 66% of mortality, and NCDs for 24%.1

In Niger, Primary Health Care (PHC) include District Hospitals (DHs), Health Centres (HCs) and Health Posts (HPs). The HCs and HPs staffed by nurses offer a minimum package of essential services (immunisation, maternal and childcare, and curative). The DHs serve as first-level referral for HCs and HPs, with complementary package including emergency obstetric care, surgery and specialist consultations, delivered by general practitioners, specialist doctors, nurses and laboratory-staff. A district medical doctor leads the District Health Management Team (DHMT) including staff responsible for healthcare, pharmacy, health information systems, finance, and administration.

In Niger, specialised healthcare delivery for NCDs, mental health (MH) and ophthalmology used to be incompletely integrated into PHC and addressed through disease-specific vertical programmes, whereas Ear, Nose, and Throat (ENT) care was delivered through targeted campaigns. To address the challenge of this non-integration, since 2018, the Ministry of Health and Enabel (Belgian Agency for international cooperation) conducted action research to integrate these services into PHC in two regions and three departments (Gaya, and Dioundiou in Dosso Region, and Gothèye in Tillabéri Region) covering ~900,000 inhabitants. The new model for integration of specialised services into PHC follows World Health Organization (WHO) guidelines and includes capacity building, equipment and infrastructure strengthening, coordination between vertical programmes and health districts, active community engagement, and targeted digitalisation strategies.

This paper aims to draw lessons from the integration of specialised services into PHC, enhancing synergy between vertical programmes and DHMTs. After identifying enablers, it proposes strategic solutions for further strengthening integration.

KEY INTERVENTIONS

In Niger, Enabel supports the implementation of a “dual anchorage” model which is a crucial enabler to strengthen both national (policy development) and decentralized (project implementation) levels. The project called PASS-Sutura, has core objectives: improved geographical accessibility to basic and specialized health-services, health staff capacity, quality of care, digital health solutions, and maintenance of infrastructure and equipment.4

To support integration of specialised care into PHC, PASS-Sutura strengthened the PHC staff capacity, reinforced basic equipment in HCs, HPs and DHs,5 implemented a Results-Based Financing scheme to improve healthcare supply and fostered coordination between specific vertical programmes and health districts.6

The specialized care on NCD, MH, ophthalmology and ENT was introduced stepwise. First, in 2020, the WHO Package of Essential NCDs (WHO-PEN) and WHO-Mental Health Gap Action Programme (mhGAP) were adapted to include curative services at PHC level in Niger. The adaptation was based on prioritization of diseases based on the epidemiological burden of NCDs/MH, and the capacity of PHC and referral facilities. These protocols aim to capacitate HP/HC health-staff to diagnose NCDs/MH diseases and to refer patients to district hospitals for confirmation. Stable patients are managed at HP/HC level. To address the challenge of limited availability of medical specialists, referral was reinforced by designating paramedics focal points for NCDs/MH at District Hospitals. PHC staff (148 paramedics from HCs and HPs, 99 paramedics and 4 medical doctors from DH) were trained on adapted WHO-PEN/mhGAP protocols. Moreover, 205 community representatives were trained on referral. Second, quarterly health caravans were organized to enhance community engagement and service delivery of NCDs, MH, ophthalmology and ENT. They delivered specialised outpatient consultations, cataract surgeries, and on-site training for PHC staff.7

Various enablers were identified. On the supply-side, in the context of Results-Based Financing, quarterly quality-assurance activities were performed at 44 HPs/HCs including qualitative/quantitative verification, mentoring/coaching, and formative supervisions by DHMTs. To address challenge of health staff mobility, a new cycle of training is scheduled later in 2025. A new digital hospital information system named OpenClinic was introduced in Gaya and Gothèye DH, together with e-learning modules. OpenClinic improved monitoring of service delivery coverage and volume and contributed to an observed 75% increase in facility revenue between 2023 and 2024.8

On the demand-side two interventions contributed significatively. First, a departmental health insurance scheme was established in Gaya Health District in 2022. It aims to improve financial accessibility to healthcare for rural populations by reducing out-of-pocket expenditures. Yet, participation remains voluntary, and coverage is currently limited.5 Second, collaboration between health staff and local populations was strengthened through community health committees – including community representatives – which regularly monitor service delivery and mobilise financial resources for subscribing to departmental health insurance. Involving community was a key enabler for improving access to integrated specialised care.

LOOKING FORWARD

Several opportunities favouring further integration of NCD/MH services at PHC level are foreseen. First, as part of a broader PHC reorganisation, the Ministry of Health in January-2025 expanded the essential and complementary services packages offered at PHC level to include health promotion, palliative and rehabilitation services. Furthermore, the WHO-PEN Plus targeting children affected by NCDs will be included in the third quarter of 2025 in the three health districts. Both are opportunities for improving service delivery of specialised care at PHC level aligned to WHO strategies.

Second, a Computerised Maintenance and Management System was introduced in 2022 in three health districts. It contributes to continuum of care improvement, costs saving, maintenance planning, and capacity building. It is expected to be scaled up nationwide after 2025.9 Furthermore, later in 2025, telemedicine will be implemented at referral hospitals to link PHC consultations with specialised care. Teleconsultations are also expected to significantly enhance clinical decision-making and professional support for continuity of care to overcome specialist scarcity.

POLICY IMPLICATIONS

The integration of specialised healthcare in PHC in Niger has progressed significantly through systemic support from the PASS-Sutura project. This initiative strengthened collaboration in planning, implementation and performance monitoring between vertical programmes and district health teams. Drawing from this experience, five key policy implications have emerged:

1) Continuous capacity building for PHC staff. Sustained support to PHC staff requires regular updates to clinical protocols and strengthened formative supervision. These components will be incorporated into a new training cycle for late 2025, including WHO-PEN Plus.

2) Early and sustained community engagement. Engaging communities from the outset is essential to improving access to specialised services. Initiatives such as health caravans, community health committees, and departmental health insurance schemes have played a pivotal role in expanding healthcare coverage.

3) Strategic Digitalisation. Digital tools, such as the Computerised Maintenance and Management System, have enhanced efficiency and service delivery. However, it is crucial to ensure alignment between digital health platforms, programme objectives, and district-level needs to prevent fragmentation and duplication of indicators within the District Health Information System (DHIS-2).

4) Resource availability and resilience. The availability of essential resources – particularly PHC staff and medicines – is fundamental. Enabel’s “dual anchorage” approach has helped secure these resources. Nonetheless, supply of medicines has experienced disruptions since the 2023 coup d’état.

5) Sustainable financing mechanisms. While PASS-Sutura has provided financial support for integrating specialised healthcare into PHC, this funding is set to end in 2026. To sustain and expand these achievements, new domestic and international financing models of must be explored and mobilised.

CONCLUSIONS

PASS-Sutura contributed to support substantial progress in integrating specialised care into PHC in Niger through capacity building of PHC staff and service delivery coordination between DHMTs and vertical programmes. The number of consultations for specialised care increased from 7,132 over 2017-2021 to 25,275 in 2022-2023. The evolving security context required adaptation to maintain access to healthcare, particularly for vulnerable populations. In pilot health districts, DHMTs have ensured continued provision of care by remote support mechanisms including WhatsApp, Computerised Maintenance and Management System and Microsoft Teams. However, sustainable financing remains an important challenge. The reduction of cooperation budgets from high-income countries poses a significant threat.10 Without adequate funding, progress achieved risks being reversed in the coming years. Strong political support and new financing models are needed to sustain and build upon these achievements.

Acknowledgements

We are grateful to the Niger Ministry of Health, and the health districts of Dioundiou, Gaya, and Gothèye for their engagement in the implementation of the Project PASS-SUTURA.

Funding

This research has received funding from the Belgian government (NER 20P001).

Authorship contributions

Conceptualisation: NOG, DS

Writing original draft: NOG, DS

Reviewing and editing co-author’s contribution: NOG, DS, AY, DBA, DJM, NA, NG, SVB, AL, and EP

Supervision: AL, EP

Editing and approving final version: NOG, DS, AY, DBA, DJM, NA, NG, SVB, AL, and EP.

Disclosure of interest

The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.