1. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Jean-Benoît Falisse, Bruno Meessen, Michel Bossuyt, Juvénal Ndayishimiye Renewing Community Participation? The case of Performance-Based Financing in Burundi.

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

3. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th 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.

4. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th 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

5. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Bubanza 18 (100%) Coverage Rutana 20 (67%) Ngozi 20 (38%) Bubanza 20 (63%) Muramvya 17 (76%) Mwaro 9 (61%)

6. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th 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

7. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th 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

8. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 An under-efficient System?

9. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Decision Rights… and Conflicts decision rights of the health committee full some none conflict

10. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  PBF: the ‘trendy’ strategy.  Based on incentives (for medical staff).  Promising experiences so far (Central Africa). The PBF system

11. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th 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?

12. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th 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

13. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th 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

14. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Conclusion Representation (voice) Healthcare / service delivery Institutional arrangement Health committee strong limited if existent laws & bylaws Community health agents noneyes contract possible Community – based Organisation instrumentalnonecontract

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