AMED - Outlining the institutional set up of the AMED scheme along with its functions and operational processes

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Chad Government is engaged in an ambitious reform to make the Universal Health Coverage (UHC) legislation operational with its three pillars defined as follows: a) contribution-based scheme for the formal sector, b) contribution-based scheme for the self-employed (informal sector) and c) non-contributory, tax-funded scheme for the identified poor so-called AMED (Assistance médicale pour les personnes reconnues économiquement démunies).

These three schemes were established by Law 035/PR/2019 passed in August 2019. It is expected that the management of these three schemes will entrusted to the same managing body, the National Health Insurance (Caisse Nationale d'Assurance Santé (CNAS), itself created by Law N°026/PR/2020 of 31 December 2020.

To contribute to this strategy, a mandate is given to a dedicated unit, the CIC (Inter-ministerial Committee) – CSU (UHC), to work on the functional needs of AMED. The first results of CIC-CSU work are the existing official documents about the main orientations towards UHC. Another achievement of the CIC-CSU is the choice made for openIMIS as the management software, if its test is conclusive. AMED is the first step of the UHC progressive implementation process and the government intends to progressively but rapidly initiate it.

The Swiss Tropical and Public Health Institute (Swiss TPH) was commissioned by Gesellschaft für Internationale Zusammenarbeit (GIZ) to conduct the study entitled "Outlining the institutional set up of the AMED scheme along with its functions and operational processes" in order to analyse the AMED scheme that the Chadian government intends to test within the framework of the three components of its UHC plan.

The overall objective of this study is to propose an institutional and organizational configuration as well as to define in general the key operational processes of the AMED scheme that Chadian Government intends to test as part of its UHC three components.

This includes 5 expected outputs:

1. An initial assessment of what is already planned on the institutional side, including stock taking of existing structures’ added value and taking into account that AMED’s setup has to contribute to the overall goals of the UHC system.
2. A review of AMED’s functional needs according to official documentation and ongoing discussions at the level of the CIC-CSU;
3. An AMED institutional building chart, including structures at central and decentralized levels and their general responsibilities considering the evolution towards the National Health Insurance and Solidarity Fund (NHIF); including its oversight mechanisms, stakeholders’ participation and clear accountability and reporting lines,
4. A description of the key procedures for starting AMED: simplified business process description (title, subtitle, objective) for the implementation of all required functions to be mapped against the functions and organizational structure of the scheme;
5. A list and estimated quantity of human resources required for all required system functions.

The strategy implemented was based on two elements: the analysis of the proposals made by the studies already carried out and in progress concerning the topics to be addressed, but also taking into account the realities of the country.

The methodology of the study includes the following key activities:

• The joint validation of the terms of reference and methodology by the CIC-CSU and the mission team, which resulted in an initial report;
• The exploitation of documents and the organization of field surveys in N'Djamena and in the three selected provinces: Mandoul, Moyen Chari, Ouaddaï;
• The production of a synthesis report based on the documentary review;
• The organisation of a workshop to reflect on the paths to be taken, recorded in an intermediate workshop report;
• The search for additional information, including documentary information, in an iterative process between the resource persons and the consultants themselves, followed by the drafting of the interim report.
• CIC-CSU review of the interim report, written response to comments, and discussion of points of clarification during a video conference;
• Drafting of the final report;
• The presentation of the results of the study on site in N'Djamena is envisaged in accordance with the study methodology.

The basic documents used are essentially Law N° 35/PR/2019 on the CSU, Decree N° 4295/PR/PM/2017 on the institutional framework of coordination for the implementation of the National Strategy for Universal Health Coverage and Law N° 026/PR/PM /2020 on the CNAS for which implementing decree is still missing; whereas CNAS is responsible for the implementation of the 3 health insurance schemes. Similarly, all the reports produced on the subject by the Ministry of Health and the various studies carried out by both international and national consultants, which were made available to the team, were extensively used. Because of the missing information, the mission relied heavily on the CIC-CSU team for additional information and to facilitate meetings with government structures. This lengthened the time required to produce the report.

The final report has been validated with majore stakeholders, the study intends to provide materiel to decision makers (Chadian Government with its partners).

Based on the recommendations of the study report, a note has been validated by the UHC Strategy monitoring Comittee which includes 10 decisions to be validated to the High Committee for UHC.

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