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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