Photo credit: World Bank/Arne Hoel
PROJECT RATIONALE
Maternal and child mortality remain significant problems in Chad. The maternal mortality ratio is the highest in Central Africa with an estimated 1,100 maternal deaths per 100,000 live births in 2010 (WHO, 2013). Similarly, the child mortality rate is among the highest in the world with 160 deaths per 1,000 live births (World Bank, 2010). Geographic access to health care services is limited, with 30 percent of households requiring more than a two hour walk to access a health facility. Further, heavy reliance on out-of-pocket health expenditures exacerbates economic disparities – for instance, in 2013, 5 percent of women in the poorest wealth quintile delivered in a health facility compared to 45.8 percent of women in the wealthiest quintile (ECOSIT 2013). The health system’s ability to respond to the needs of the population has been mainly constrained by inadequate health sector financing and by inefficient and poorly distributed human resources for health. The combination of poor service accessibility, affordability, and quality has resulted in a very low use of existing health care services, especially at primary level and among women and children (e.g. 0.18 contacts per child per year).
RBF AT A GLANCE
RBF Payments
The Mother and Child Health Services Strengthening Project uses Performance-Based Financing (PBF) to improve facility-based health service delivery. Through this component, the Ministry of Health (MOH) contracts international non-governmental organizations (NGOs) to act as performance purchasing agents (i.e. one NGO per 1 million people). In turn, individual NGOs contract health facilities to expand the coverage and quality of maternal and child health services. Further, to address geographic disparities, an additional equity bonus is provided for health facilities operating in particularly remote and poor areas. RBF payments are made quarterly upon the verification of results.
VERIFICATION
The RBF verification function is led by the Performance Purchasing Agent (PPA). It consists of monthly verification of the reported levels of service provision of each health facility in targeted districts. In addition, the PPA quarterly assesses the quality of services provided using a quantified quality checklist – with increased weights given to process measures –. It also oversees the verification of the quantity of services provided carried out at community level to ascertain the delivery of reported services. It also leads the implementation of client satisfaction surveys. Conversely, an external evaluation agency (EEA) is contracted by the MOH to counter-verify the quantity and the quality of services delivered by health services.
IMPLEMENTATION
Status and achievements – Fiscal Year 2016
The implementation of the Project is impeded by the prevailing security situation. Nevertheless, a training targeting 1,000 community health workers is being planned in collaboration with UN agencies, The Global Fund and GAVI. Further, the Health Country Status Report was shared with the MOH and disseminated through the annual review.
Lessons Learned
The previous pilot did not include an impact evaluation. Having results from a rigorous evaluation could have facilitated the policy dialogue with the Government and development partners during the project preparation phase.
EVALUATION AT A GLANCE
The design of the impact evaluation was finalized in July 2014. Survey implementation has however been constrained by security measures preventing missions outside N’Djamena. A partnership with UNFPA is being explored to leverage their volunteers and extension workers to implement surveys.