The 33 participants of the course.

The first PBF course in Chad took place in the “Centre Etoile” in Ndjamena, with 33 participants coming from the central directorates of the MOH (12x), from the Inter-ministerial Coordination Unit for Universal Health Coverage (5x), INSEED (3x), Project Coordination Unit (UCP) Redisse (5x) and two national NGOs (2x). Representatives of the Ministry of Finance and Budget (5x) and the Ministry of Planning (1x) were also present.

31 participants took the post-test, and four participants obtained a certificate of distinction with a score of 80% or more for the final test of the course, which were Mr. ASSEMAL Alfred, Responsible for monitoring and evaluation of UCP REDISSE; Dr SODJE Hinberka, from the NGO Alerte Santé ; Mr. GOUH PINABEY Nathaniel, from INSEED; Dr NEHOULNE Gaston, from the MSPSN.

The PBF programme 2022-2025 in Chad and its preparations

The results of previous PBF programs showed improvements in some indicators such as for assisted deliveries, children fully immunised and the quality of care. The government of Chad and the World Bank agreed in 2021 on a new project called the “Health System Performance Strengthening Project” (PRPSS), which will cover all districts in eight provinces. The duration of the project is 4 years. The population covered is 6.7 million inhabitants out of 13.2 million inhabitants of the country, or about 51% of the total population. The amount of funding is $ 106.5 million over 4 years.

Preparatory activities are underway, namely the establishment of the PBF Unit (CTN-FBP in French) and the Contract Development and Verification Agencies (ACV in French). The effective start is scheduled for January 2022. For the preparation of the program, the government organises five international PBF courses. These courses are also used for the training of national facilitators, who will then train the different actors of health facilities, provincial and district regulatory authorities as well as other key actors.

Achievements of the PBF program in Chad

• The PBF program is relatively pure in terms of applying the PBF best practices.
• There is willingness adopt the PBF reforms within the government and among development partners.
• Nine working groups developed excellent action plans during the PBF course which, if implemented, will greatly improve the health system in Chad.

Problems identified by participants concerning the PBF pogram

• Health facilities have insufficient infrastructure and equipment
• A study of 17 tracer products showed that on average, a health facility has 7 of the 17 products => availability rate 44%. This is caused by the “input” financing approach with centralized purchasing of inputs for the health system. The consequence is an inefficient distribution of equipment and drugs with an unused surplus in some HFs, and a shortage in other HFs.
• Some policymakers may be reluctant to accept the change from central “input” financing towards direct results-based financing of the health facilities because they may lose certain benefits linked to input financing
• The members of the Health Committees in Chad play a very important role in the day-to-day management of the health facilities including the signing of contracts and bank checks. However, in PBF best practice, the day-to-day management should be done by the permanent members of the HFs (in-charge with his team) This to avoid late payments and the risk that Health Committee members only sign when they receive “something” in return.
• The performance contracts in Chad are signed by several actors instead of just two. This poses problems because with three or more signatories it is no longer clear who is responsible, which can create confusion.
• Poor management of human resources and the presence of unqualified staff. There is an unequitable distribution of health workers in rural and urban health facilities. Waek knowledge and skills of health staff
• There are not yet PBF budget lines in the Finance Law. This may be caused by a lack of clarity regarding the financial and legal procedures required to disburse the government budget through payments directly to peripheral providers and to the population.
• The functioning of the current HMIS is not optimal at all levels of the health pyramid.
• In the previous PBF pilot program, paper invoices for all HFs in the country were centralized at Ndjamena level.

The 33 participants of the PBF course

Recommendations

• Make wider use of the quality improvement bonuses to correct the problems related to poor infrastructure and the lack of equipment
• Allow the health facilities in the 8 PBF provinces to buy essential drugs, consumables and equipment from accredited distributors operating in competition
• Authorize the Central Pharmaceutical Agency to supply drugs to private health facilities.
• Offer performance contracts to all units and departments of the ministries of health and finance, which allows them to obtain competitive remuneration.
• Most participants (79%) said it would be better if the day-to-day management will be done by permanent HF managers, including the signing of bank checks, and managing drugs. However, they also proposed to get the opinions of the participants of the next course who are closer to the field.
• Performance contracts should be signed between two entities (= binomes). Thus, for Chad, it is proposed that the HF contracts be signed between the Head of the Health Center (RCS) and the CDV (ACV) coordinator.
• Advocate at Ministry of Civil Servants and the Ministry of Finance and Budget to decentralize human resources management, supporting according to the regulations in force and increase the PBF subsidies for the decentralized recruitment of contractual staff.
• On the job training and supportive supervision
• Study the possibility of transforming the government budget lines “crédits délégués” into “PBF” budget lines.
• Advocate for the operationalization of DHIS2
• Archive the paper PBF HF invoices at decentralized level. This recommendation means that HFs and the CDV Agency (ACV) each file copies of the PBF invoices. The CDV Agency also maintains the data in an EXCEL file and enters the data into DHIS2.