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This study examines the state of community participation in Burundi, focusing on the role of Performance-Based Financing (PBF) as a catalyst for renewal. It explores the challenges faced in defining community roles, accountability mechanisms, and decision-making structures within the healthcare system. Through in-depth analysis of Health Committees, Community Health Agents, and Community-Based Organizations, the research highlights the need for reorganization and clear guidelines to enhance community engagement and improve healthcare delivery.
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Jean-Benoît Falisse, Bruno Meessen, Michel Bossuyt, Juvénal Ndayishimiye Renewing Community Participation? The case of Performance-BasedFinancing in Burundi.
Main Messages / Plan • 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?
Community Participation: the old ‘magic bullet’. The Bamako Initiative (1987) Based on community/users mobilization. Heterogeneous experiences. Bottom-up process. Context and Rationale
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, Community-Based Organization, medical staff. • Triangulation to check the data.
Coverage Ngozi 20 (38%) Bubanza 18 (100%) Muramvya 17 (76%) Mwaro 9 (61%) Rutana 20 (67%) Bubanza 20 (63%)
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)
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?).
Decision Rights… and Conflicts decision rights of the health committee full some none conflict
The PBF system • PBF: the ‘trendy’ strategy. • Based on incentives (for medical staff). • Promising experiences so far (Central Africa).
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.
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 utilisationof the data?
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 .
