PADS - Support Project for the Health Districts in Chad - Phase II

Context
The Ministry of Public Health is committed to improving the health status of the Chadian population through the implementation of sectoral policies, including the National Health Policy 2016-2030 and several important reforms supported by technical and financial partners.
The Swiss Cooperation Strategy for Chad (Swiss Agency for Development and Cooperation - SDC) for the period 2018 - 2021 is in line with the guidelines of Chad's National Development Plan (PND) and follows the Sahel strategic axes of the Swiss Federal Department of Foreign Affairs (FDFA). Therefore, the three FDFA policy instruments are used for the implementation of this strategy: Humanitarian Aid, Peace Policy, Human Security and Development Cooperation. Through this latter instrument, the implementation of the Support Project for the Health Districts in Chad (PADS) is possible within the area of Citizenship, Peace and Violence Prevention.
In this context, the Swiss Agency for Development Cooperation (SDC) has entrusted the SwissTPH-CSSI Consortium with the implementation of the PADS, a partnership between the Republic of Chad and the Swiss Confederation, for a first phase from 2014 to 2018. and a second phase from 2018 to 2022.

Objectives
The objectives for PADS Phase 2 (2018-2022) are defined as follows.

The overall objective of PADS is to contribute to better governance of the health system to improve maternal and child health, universal health coverage and epidemic prevention.

Expected ouctomes:
Expected outcome 1: Health systems resources are better managed at all levels.
Expected outcome 2: The availability and quality of health services are improved in the program areas.
Expected outcome 3: Equity in access to health services is improved especially for women, children and marginalized populations.

Methods / Approaches
Swiss TPH and CSSI have joined forces to form a consortium. While the first phase took place in the two health districts of Yao and Danamadji, the PADS extends to the provincial level for its second. Proximity and systemic support are being pursued with the integration of the multidisciplinary project teams within the provincial health delegation teams and a technical assistance is maintained within two district management teams supported in the first phase.
The project is managed by a coordination team based in N'Djamena and implements its multi-level approach to bring back good experiences and evidence from the periphery to the central level, in order to capitalize on knowledge, replicate certain interventions, and provide consistent work of policy dialogue and advocacy.

Results
The PADS carried out a baseline study in 2015 and an end-of-phase study in 2018 in order to assess the state of play and to see the evolution after implementation of the program in terms of quality (Part 1) and use (Part 2) health services. In addition, an external evaluation has been commissioned by the SDC during the last year.

According to the results of the external evaluation of the program and in the light of the findings of the end-of-phase study, the quality of the service delivery has been significantly improved in the areas supported by the program. On average, in 2018 health centres have 74% of structural elements, compared to 57% in 2015. While the quality of services with regard to structural attributes is better in Danamadji, Yao and Danamadji DSs have shown a considerable change and in the same proportions (+17 points). In-depth analysis of the different components of structural attributes shows that this improvement is linked to significant progress in infrastructure, maintenance and cleanliness and improved availability of basic medical equipment and tracer drugs.
With regard to the availability of human resources, the increase in available staff per capita in 2018 compared to 2015 is still very low and little progress can be observed during the program.
It is important to note, however, the significant improvement in providers' knowledge of antenatal care, delivery and newborn care during the program. In particular, knowledge of newborn care increased by 39 points between the baseline study and the end-of-phase study.

Analysis of process-related attributes, ie the way prenatal care is managed, shows that overall, there has been a significant increase in the quality of antenatal care, especially among technical attributes, ie significant progress is made in history taking, physical examination, diagnosis and health education.

Regarding the use of health services, the results of the end-of-phase study showed an increase in the percentage of pregnant women among the sedentary population who made at least one CPN (CPN1 +) during the program (from 80% in 2015 to 90% in 2019). On the other hand, for the nomadic population, there has been no improvement and the completion rate in CPN remains low (56%). With regard to childbirth and post-natal consultations, the rate of home birth among the sedentary and nomadic population was little changed between the baseline study and the end-of-phase study and was still very high (73% for the sedentary population and 100% for the nomadic population). On the other hand, we found an increase in the percentage of women who went to the post-natal consultation within 3 months of delivery among the sedentary population, with and without children. For curative services, the rate of participants who reported an illness in the last six months, compared to the baseline study, decreased significantly among the sedentary population and slightly decreased among the nomadic population. The proportion of participants who reported a disease and who visited a health facility increased from the baseline to the end-of-phase study, while the rate of non-use of health services during illness decreased (especially for the nomad population). In general, family planning and the use of contraceptive means and methods are very low and have even declined during the program. In 2015, 8% of the sedentary population and 4% of the nomadic population used a method to delay or avoid pregnancy, compared to 7% of the sedentary population and 0% of the nomadic population in 2018.
With regard to vaccination practices, there is a significant improvement between the baseline study and the end-of-phase study in immunization coverage, particularly for the nomadic population. While in 2015, only 2% of Yao's nomadic population and 6% of the nomadic population of Danamadji presented a vaccination card for their last child, in 2018 this rate was 50% and 24%, respectively.

PADS has helped strengthen governance at the peripheral level by streamlining drug and financial management in health facilities and improving the availability of health data. Local governance has been strengthened by the effective implementation of the Health Committees and Management Committees in the two health districts, thus enabling dialogue and participation of the population in health activities. PADS has also helped build staff capacity through formal training sessions and outreach coaching. Through the performance based contracts (COM), the PADS has contributed to good governance, especially on the accountability aspect. In addition, the PADS has enabled the implementation of innovative information management systems (m-health) through the effective start of mobile integrated surveillance in test areas and the installation of openIMIS software at Danamadji’s mutual health insurance, while the use of DHIS2 continues and is being expanded nationally by the MSP being strongly inspired by PADS experience.

Target groups
PADS is active at all levels of the health system in Chad (health center, peripheral, intermediate and central responsibility area), with differentiated support at peripheral levels in the two intervention provinces:
–    "Comprehensive" support according to the activities of the program in the so-called "original" health districts (Yao and Danamadji) as well as their dismemberments;
–    The other districts in each of the two provinces will receive "provincial" support limited to certain activities (Health Information System, Supply and Inventory Management, OneHealth, Information, Education and Communication).

The project beneficiaries are made up of the following groups:
–    Priority target populations: women (+/- 50.6% according to RGPH 2009) and children under 5 years (+/- 20.20%).
–    Marginalized populations: poor (undefined criteria, therefore non-countable), nomadic (+/- 3.5% at the national level), islanders and located in areas of difficult access (not enumerated).
–    The populations of the 2 health districts known as "of origin" and their dismemberments, ie 519,583 inhabitants (2018 projection of the DSIS):
–    The populations of the other districts in the two provinces: 431,681 inhabitants in Batha and 507,265 inhabitants in Moyen Chari.
–    Communities whose role will be strengthened in participation in the management of health facilities at the most decentralized level and in the promotion of health;
–    Health-care workers in health facilities whose capacities will be increased in different ways depending on the intervention zones;
–    Health administration staff (MSP) at the decentralized, peripheral (District management Teams) and intermediate levels (Executive Teams of Provincial Health Delegations and Provincial Supply Pharmacy);
–    Local community-based organizations and other field partners;
–    The government and the technical and financial partners will benefit from evidence and other lessons learned from the project experiences that will feed into the policy dialogue at the central level and influence sectoral policies.

Next steps
The launching and planning workshop organized in N'Djamena in January 2019 formalized the start of phase 2 and refined the programming of activities whose implementation is underway with the support of PADS teams now in place.

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Involved Regions: Africa
Involved Countries: Chad, Switzerland