CHAI - Hållbar hälsofinansiering - allmän sjukvård för alla 2017-2022

In Nigeria, CHAI provided support to deliver on the promise of the National Health Act 2014 reform, reaching 124,529 beneficiaries in Kano and Kaduna State through the roll-out of vulnerable population programs, which entirely subsidize essential services for vulnerable pregnant women and children. Nigeria CHAI has also worked to operationalize the Basic Health Care Provision Fund and implement the Vulnerable Populations Program in Kano State, which has mobilized resources and facilitated access to essential SRMNCH services for rural poor women ad children. Since 2019, CHAI the Kano State VPP program has provided essential SRMNCH services to 20,000 pregnant women and pregnant adolescent girls and children. In Malawi, CHAI worked with District Health Management Teams (DHMTs) who play a critical role in primary and secondary service provision within a system still facing significant challenges in essential SRH service coverage. Working together with the DHMTs, an assessment showed that while funds were reaching facilities, there were service delivery bottlenecks in the management of other key health system pillars, including insufficient recruitment of priority workforce cadres for SRH (such as nurse midwife technicians) and potential leakages in the supply chain for essential commodities (despite 100% utilization of the drug budget). CHAI worked with the DHMTs to develop practical solutions to these challenges, including the strengthened use of data and auditing for improved decision-making. Proposed solutions by the DHMT included strengthened internal audit for the management of SRH commodities, complemented by improved community oversight. This work continued as part of CHAIs support to district health managers and learnings were documented to be leveraged by the national government in work across districts. In Rwanda, the Mutuelles scheme is often cited as an example of success in the region given its far reaching service and population coverage. However, the scheme faces significant challenges for sustainability and timely payment to providers which is critical to avoid disruptions in service delivery. When management of the Mutuelles moved from the MoH to Rwanda Social Security Board (RSSB), CHAI worked with the RSSB to conduct analyses aimed at improving performance in terms of equity of coverage and sustainability. It supported RSSB to mainstream a process for routine monitoring of key performance indicators for CBHI. This included process indicators to promote understanding of how the scheme is being managed and to surface opportunities for greater process efficiencies, including to reduce the time it takes to process claims and make payments to facilities. Addressing delays in payment was a key priority for new RSSB leadership as some facilities had not received payments for several months and were under critical cash flow pressure, which had an impact on continuity of services. In 2020, CHAIs work with the RSSB to improve claims verification led to the clearing of USD 3.13M of unpaid invoices and an increase in timely payments. In 2021, results of the analyses conducted by the CHAI team were leveraged by RSSB leadership to build the case for provider payment reform, with data demonstrating that under the current system, providers at PHC level are experiencing an average delay in payment of 5 months, with high administrative costs associated with claims adjudication and inefficiencies in reimbursement. In Zambia, CHAI helped to strengthen decentralization of financial management to district level by facilitating automation of district action planning that could be integrated with national systems, and then building subnational capacity to use new automated systems for planning and budgeting. This has increased transparency and accountability, allowing health managers at all levels of the system to actively plan and manage their activities and expenditures. CHAI also supported governments to monitor data on equity in coverage and remain accountable to beneficiaries and health insurance scheme performance goals. In Ethiopia and Rwanda, CHAI worked to strengthen the use of disaggregated data from insurance information systems, and in Kano State (Nigeria) to solicit feedback from beneficiaries of the insurance scheme. CHAI also helped to make information more widely available beyond government. For example, CHAI worked with the Ministry of Health in Malawi to make information on health funding flows and financing gaps more easily accessible to the public and donors on the MoH website, facilitating joint planning, transparency, and accountability

The overarching goal of the project is to empower governments in sub-Saharan Africa to accelerate progress towards Universal Health Coverage (UHC) by sustainably and substantially increasing access to and utilization of basic health services for those at greatest need, including women, children and other poor and vulnerable populations. CHAI will work by addressing financial barriers to access and utilization, with a focus on the needs of the most vulnerable. Addressing financial barriers will enable countries to accelerate progress towards UHC and reduce morbidity and mortality. This requires strengthening or reforming health financing systems to address resource gaps and increase financial protection, ensuring that payments for health do not expose households to financial hardship. A one-year cost extension to the end of 2021 with an additional 60 MSEK, decision ZAM-DC35/202 was agreed in 2020. The extension includes amendments to the programmes theory of change and results framework, expansion of the programme to West Africa, in Nigeria, the scaling down of activities in Zambia, and explicit focus of the contribution to Sexual and Reproductive Health in the region in the final year of implementation. The third amendment re-casted the initial five objectives into the following three: 1. Building and sustaining capacity in the region. The last two and half years of the programme has built capacity in ministries of health technocrats in target countries to foster a culture of evidence- based decision making and accountability to rights holders. In the final year of implementation, CHAI will refocus this objective towards more sustainable approaches of capacity building, by engaging local training and research institutions to build linkages with governments and funders to eventually play CHAIs technical role. 2. Strengthening systems for sexual reproductive health. CHAI has been at the centre of supporting domestic resource harmonization and mobilization in target countries. This work will now move towards multi-country bottleneck analyses to identify where additional funding at national level has translated into improved sexual reproductive health services, or not. By systematically assessing financing, management and delivery systems, in the final year of the programme, CHAI will expand its work to subnational level to definitively strengthen systems and demonstrate progress towards SRHR and UHC goals. 3. Regional learning to propagate impact. CHAI has already made much progress in documenting its practical and diverse approaches target countries have taken to achieve the common goal of Universal Health Care. In its final year the programme will increase the reach of non-target countries it engages with lessons from target countries by building bridges with strategic partners in Sidas regional SRHR portfolio and other donors CHAI already has a relationship with.