Additional Financing-Health System Performance Strengthening Project

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The proposed project will contribute to Chad’s human capital development by improving the utilization and quality of RMNCAH and nutrition services. The aim of the project is to improve access/utilization and quality of health services which in the long run should result in women and children surviving and remaining healthy. The health services concerned are preventive and curative essential services delivered at primary and secondary level in selected districts with a focus on RMNCAH-N. Access to and utilization of these services will result in reduced maternal and child morbidity and mortality. Provision of nutrition services to mothers and children, in turn, will result in a reduction of malnutrition and stunting. Evidence shows that when children stay healthy, they are ready to attend school and maximize learning opportunities, which allows them to become productive members of the society, thus contributing to the country’s economic development.The proposed project will contribute to improvement in the quality of RMNCAH-N services through: (i) Incentivizing the performance of the health system using PBF payments; (ii) Rewarding improvements in utilization and quality of care through PBF payments; (iii) Subsidizing the poor and the vulnerable to receive free care to ensure equity; (iv) Performance contracting of subnational authorities and directorates of the MPHNS with specific deliverables for each quarter to improve regulation, leadership/stewardship, governance, coordination and separation of functions; (iv) Strengthening health facilities readiness to deliver quality health care services through the procurement of equipment, the local recruitment of health workers and the training of health personnel; (v) Strengthening community platforms and addressing demand-side barriers to the access of health, family planning and nutrition services; (vi) Communication for Development (C4D) and Social and Behavioral Change (SBC) campaigns; (vii) Delivering Technical Assistance (TA) for institutional capacity building, for the production of up-to-date standards and procedures, training of health personnel and for the maintenance of equipment; (viii) Improving HMIS and CRVS for better decision making based on evidence. PBF will be scaled-up to address critical challenges faced by the health system. These challenges include: (i) The low readiness of health facilities to deliver quality health services to the population, especially at the operational level; (ii) The poor distribution of financial resources as well as allocative, technical and administrative inefficiency which result in the low availability and poor utilization of resources at the frontline health facilities; (iii) The concentration of decision making power in N’Djamena, which undermines the autonomy, empowerment and accountability of health facilities, especially at the operational level; (iv) The shortage of qualified health personnel especially in rural areas; (v) The weakness of the health information system and; (vi) The low institutional regulation, poor coordination and lack of transparency and accountability at different levels of the health system. PBF will provide incentives to health facilities in line with their performance on selected indicators. This will enable health facilities to upgrade and improve the functionality of their health centers and district hospitals, as well as to recruit and pay for needed health workers to deliver essential RMNCAH-N services, purchase needed medical equipment and essential medicines, including nutrition and family planning commodities in line with the required delivery standards for RMNCAH-N services.In order to strengthen the health system, interventions included in the proposed project will be integrated to the public health system and contribute to the implementation of government policies and reforms. With regards to the PBF model proposed, this has been designed to align with other health financing interventions implemented by the Government of Chad. For instance, the model will support the implementation of the Free Health Care policy and promote greater efficiency in public health spending by improving the flow of funds to the frontlines and by allocating resources based on the actual utilization of services. As mentioned above, in the absence of funding to compensate for the loss of revenue, facilities continue to charge fees for the delivery of services covered by the policy. Under the proposed PBF model, only services covered by the Free Health Care policy will be delivered for free. This will promote greater consistency between facilities in project-supported areas and other health facilities in the country. For other services, the official government fee schedule will apply. Vulnerable households will be exempted from fees, which is in line with the National UHC Strate gy. In addition, the implementation of PBF will contribute to the implementation of the Free Health Care policy beyond project-supported areas, as the rigorous costing of the PBF model (which covers all services included in the policy) will provide useful evidence to identify the financial resources needed to implement the policy without placing a burden on health facilities. Another element of integration is that only services covered by the government’s benefit package will be covered by the PBF model. Moreover, services incentivized by PBF might vary over time to avoid the prioritization of selected services in the benefit package.To monitor the alignment between the proposed interventions and ongoing government reforms, the project will finance activities linked to the institutionalization of PBF and identify milestones in the consolidation and harmonization of health financing policies. The first of these milestones consists of the establishment of systems and the development of procedures and guidelines to transfer public funds to health facilities. With the support of the grant-funded Program of Health Advisory Services and Analytics for Chad (PHASAC), Public Financial Management (PFM) systems will be reviewed to support the Government in the adaptation of the current financial infrastructure and the development of a roadmap of reforms needed to institutionalize PBF. The second of these milestones will be the establishment of an annual review process, with a particular focus on the harmonization of health financing reforms. The review will be co-chaired by the Minister of Economy, Development Planning and International Cooperation and the Minister of Public Health and National Solidarity and include relevant stakeholders. The third milestone will be the analysis of the Free Health Care policy. The project will support an assessment of the policy, its costing, and the revision of services included, as well as an update of the fee schedule. Finally, the project will support PFM capacity building for facilities officers-in-charge and introduce financial tools to track revenues at the facility levels, including user fees and transfers from the government and development partners. The proposed project will support demand- and supply-side interventions at all relevant levels of the health sector and these will be developed to be consistent and harmonious. Building on lessons learned from the Mother and Child Health Services Strengthening project (P148052) and from other World Bank operations in Chad, supply-side interventions will target the community, primary, regional and central levels. The project will prioritize innovative interventions and identify opportunities to redesign service delivery mechanisms to maximize the project’s impact. In terms of maternal and newborn services, investments will focus on boosting the capacity of health centers to deliver quality ante- and postnatal care, procuring ambulances to refer pregnant women to hospitals, and reinforcing maternity services in hospitals to improve the quality of institutional deliveries. Further, P