Financial Expenditures and Operational Evaluation of a Pooled-Financing Model for Routine Immunization Strengthening in Three Provinces of Chad: A Mixed-Methods Study

Background/Objectives: A multi-year, government and donor pooled-financing mechanism was established to support interventions aimed at strengthening the routine immunization (RI) system in three provinces and at the national level in Chad. Our study evaluated expenditure magnitude, distribution, and trends and assessed the operational indicators of the interventions and the factors that enabled or curtailed implementation. Methods: A mixed-methods study including a retrospective financial expenditure analysis and a cross-sectional operational assessment of implementation indicators was con-ducted. The interventions assessed for RI strengthening targeted leadership and governance, service delivery, supervision, financial management, and demand generation activities. Expenditure data were obtained from a financial management system housing the pooled funds, f for the period 2020 to 2024. Expenditure data were reported in 2023 US$. Operations data were collected through cross-sectional interviews with district and health facility respondents in the three provinces and were analyzed across intervention and thematic areas. Results: Over the 5-year period, approximately US$7.3 million was spent on interventions to strengthen the RI system in the three provinces and at the national lev-el. Expenditure was concentrated on supervision (43%) and service delivery (37%). Ap-proximately 503,000 doses of third dose of pentavalent vaccine (Penta3) were delivered, with year-over-year increases. The average pooled-financing expenditure per Penta3 dose delivered was US$14.53. Operational indicators suggested consistent implementation of activities and government ownership. Service delivery was sometimes hampered by a lack of transportation, while funding shortages contributed to non-conduct of activities. Conclusions: Investments to strengthen the RI system in Chad were accompanied by growth in Penta3 doses delivered and generally favorable implementation indicators.