Download Diapositive 1 - African Health Economics and Policy Association

Renewing Community Participation?
The case of Performance-Based Financing in Burundi.
Jean-Benoît Falisse, Bruno Meessen, Michel Bossuyt, Juvénal Ndayishimiye
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Main Messages / Plan
1.
2.
3.
Community Participation in Burundi: poor
achievements so far.
Performance-based financing: an entry point
for renewing community participation.
(Re-)defining things -clearly:
 Who
is the “voice” of the community?
 What community agents to deliver services/care?
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
Methodology and Data

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, CommunityBased Organization, medical staff.
 Triangulation to check the data.
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Coverage
Ngozi
20 (38%)
Bubanza
18 (100%)
Muramvya
17 (76%)
Mwaro
Rutana
9 (61%)
20 (67%)
Bubanza
20 (63%)
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
The Burundian Case: community participation
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)
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
The state of Community Participation

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?).
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
The PBF system
 PBF: the ‘trendy’ strategy.
 Based on incentives (for medical staff).
 Promising experiences so far (Central Africa).
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
PBF: where is the community?

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.
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
The accountability issue

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?
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Reorganizing Community Health Agents
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 .
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011
Conclusion
Representation
(voice)
Healthcare /
service delivery
Institutional
arrangement
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)
2nd Conference of the African Health Economics and Policy Association (AfHEA)
Saly – Senegal, 15th - 17th March 2011