Facility demographic data.

Water, sanitation, hygiene, waste management, and other environmental health services are critical for safe health systems, but global access is lacking. Adequate financing is a key barrier, and understanding resource allocation can help identify solutions in resource-limited contexts. We conducted a qualitative case examining resource allocation in rural Niger. Our objectives were to understand resource allocation processes, key actors and their roles, and contextual factors that influenced resource allocation. We interviewed thirty-three healthcare workers, community leaders, and government officials. We found that resource allocation followed formal and informal processes. Formal processes encompassed annual budgets and monthly supplies through government channels, while informal processes depended on healthcare workers’ out-of-pocket expenses, unpaid labor, in-kind community support, healthcare facility revenue, and contributions from non-governmental and United Nations agencies, and the diaspora. Informal resource allocation was critical to fill the gap when formal processes were slow or insufficient. Resource allocation was highly decentralized with minimal influence of national policies and legal frameworks at the local level. Key contextual factors influencing resource allocation included politicization of budgets at the commune level, sometimes leading to inefficiency or inequity. We observed that healthcare facility actors who were most knowledgeable of needs often held the least decision-making power. We concluded that informal processes were complementary to formal processes, not conflicting. In contexts where government funding is severely limited, informal mechanisms may be the only viable short-term option to ensure the availability of services, demonstrating greater flexibility and adaptability. However, ultimately informal processes are an interim solution that should be explored to ensure service delivery without undermining long-term government systems strengthening. We recommend that funders commit to long-term initiatives promoting local government democratic decision-making, account for local actors’ capacities and incentives, and acknowledge dynamic formal and informal resource allocations to optimize investments and trade-offs.