2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Jean-Benoît Falisse, Bruno Meessen, Michel Bossuyt, Juvénal Ndayishimiye

Renewing Community Participation?

The case of Performance-Based Financing in Burundi.

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

1. Community Participation in Burundi: poor achievements so far.

2. Performance-based financing: an entry point for renewing community participation.

3. (Re-)defining things -clearly: Who is the “voice” of the community? What community agents to deliver

services/care?

Main Messages / Plan

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Context and Rationale

Community Participation: the old ‘magic bullet’. The Bamako Initiative (1987) Based on community/users mobilization. Heterogeneous experiences. Bottom-up process.

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Formal state: the rules. legal and technical documents,

interviews. Actual and expected state: on the

field. interviews in 104 Health Centers. 3 focus groups: Health Committee,

Community-Based Organization, medical staff.

Triangulation to check the data.

Methodology and Data

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Bubanza18 (100%)

Coverage

Rutana20 (67%)

Ngozi20 (38%)

Bubanza20 (63%)

Muramvya17 (76%)

Mwaro9 (61%)

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

A troubled context. Various projects/programmes since the

Bamako Initiative (1987). NGO led (1993-2008 civil war).

Setting up Health Committees around the country.

Community Health Agents in vertical programmes.

Transfer to the Ministry of Public Health (2007)

The Burundian Case: community participation

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Community Health Agents: out of control?. Unknown by health center staffs (>50%)

Health Committees: Almost no official information about them

(neither NHIS nor PBF). Existing guidelines although:

Largely unknown (<20%). Unclear role (‘co’-management?).

The state of Community Participation

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

An under-efficient System?

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Decision Rights… and Conflicts

decision rights of the health committee

full some none conflict

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

PBF: the ‘trendy’ strategy. Based on incentives (for medical staff). Promising experiences so far (Central

Africa).

The PBF system

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Voicing preferences (community as an end). Upward accountability of health centers

(control mechanism). Almost no downward accountability.

Reaching everybody (community as a tool). Back to the rationale of community-health

agents.

PBF: where is the community?

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Improving accountability: “voice”. Health Committees:

Voice in the business plan. Now they have something to manage!

The contracted Community-Based Organisations:

Not truly the “voice” of the population. What utilisation of the data?

The accountability issue

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

PBF: an entry point. Contracting: no cons? Defining the indicators to subsidize:

HIV/AIDS in Makamba. Traditional midwifes in Ngozi.

Re-organisation: Linking to healthcare facilities. Grouping .

Reorganizing Community Health Agents

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Conclusion

Representation (voice)

Healthcare / service delivery

Institutional arrangemen

t

Health committee strong

limited if existent

laws & bylaws

Community health agents

none yes contract possible

Community –based Organisation

instrumental none contract

2nd Conference of the African Health Economics and Policy Association (AfHEA)Saly – Senegal, 15th - 17th March 2011

Thank you! (murakoze cane)