At the end of 2003, a countrywide population survey by Médecins Sans Frontières (MSF) revealed that almost a million people in Burundi a fifth of the rural population were excluded from healthcare as a direct consequence of the governments policy of cost-recovery. The survey revealed crude mortality rates and mortality rates for children under five well above the emergency threshold. Poverty was shown to be generalised, with 85% of the population living on less than $1 per person per week (the international line of extreme poverty is $1 per person per day). In such an environment, the Good Humanitarian Donorship (GHD) initiative which was piloted in Burundi in 2004 is unlikely to be effective if its application does not involve a fundamentally different approach to essential and lifesaving healthcare for a large part of the Burundian population.
Access to healthcare in Burundi
Burundis cost-recovery system requires patients to pay for medicines and medical services before receiving care. Some 17% of people did not seek care even when they felt themselves to be very sick. People tended to wait too long before seeking help, or did not seek help at all, mainly due to lack of money. The average price for a simple consultation corresponded to five to 12 days of income, and was out of reach for many; the fact that mortality rates for malaria were twice as high among people who depended on health centres applying cost recovery, compared to those applying a low flat fee, seems to confirm delays in appropriate care. Eighty-two percent of patients consulting health centres take on debt or sell a possession (harvest, land, livestock) in order to pay for care. As for secondary care, reports from hospitals indicated prices for lifesaving treatment that were completely out of reach of most people (a lifesaving Caesarean section, for example, costs $150). Patients have even been held in the health structure until the family was able to pay the bill. In theory, a waiver system should protect those unable to pay, but in practice less than 1% of patients obtained care free of charge. No link could be detected between partial waiving of the fee and vulnerability criteria, such as returnee or displaced status. Price reductions mainly benefit the holders of the health insurance card for state employees.
Donor policies in Burundi
Since the MSF survey was carried out, there has been little improvement in access to care, nor has donor policy changed with regard to user fees. There has been no updated population-based assessment after the MSF survey, and it is not possible to state if mortality has now dropped below emergency levels. Donors provide technical assistance for the further implementation of cost recovery, without any specific efforts to monitor financial accessibility and affordability. WHO and other UN agencies do not challenge the cost-recovery system, and NGOs, despite their large input in terms of in-kind and cash resources, have not succeeded in persuading the Ministry of Health to lower fees or offer free care, even in NGO-supported health structures.
Burundis annual health budget is equivalent to $5 per capita, well below the average $34 per capita that WHO estimates is required to provide a basic package of care. Donors are reluctant to finance recurrent costs, particularly salaries. The new CAP approved for Burundi within the framework of the GHD requests $21 million to finance health projects. With a population of around seven million, this corresponds to about $3 per capita. Even when these extra funds are added to the current national health budget, the level of financing is still well short of what is needed to provide a decent basic package of essential care. Project funds will be spent on infrastructure and equipment, essential drugs and other material, but staff remuneration is not mentioned in the CAP. The average salary of a nurse in Burundi is equal to $23 a month.
The perverse effect this can have is illustrated by an example from Karuzi province. As part of a WHO programme to reduce maternal mortality, an ambulance was purchased and posted in Karuzi province. The ambulance was intended to transport women to the referral hospital in cases where there were labour complications, or a lifesaving Caesarean section or transfusion was required. The running costs and maintenance of the ambulance had to be covered by the health authorities. The authorities first reaction was to propose raising the level of user fees in the health centres to meet these costs. This might indeed fit with cost-recovery logic, but it does not accord with the principle of assured access to essential and lifesaving care. Donors prefer to leave the burden of running costs to local coping mechanisms, even when this means excluding a substantial number of people from the intervention they are funding.
Regarding access criteria, the GHD Needs Assessment Framework used for the preparation of the CAP and the CHAP in Burundi does not explicitly address financial obstacles to access, though it does mention other access problems, such as social and cultural hindrances. That financial access was mentioned in the needs assessment report was due to chance rather than intent. If funding were guided by the assessment matrix, the problem of financial access to healthcare would have to go begging elsewhere. But even though the final version of the 2005 CAP does acknowledge that cost recovery is causing serious access constraints, no concrete measures are proposed in the CHAP to correct the situation. Project descriptions talk of access to basic services for returnees, vulnerable groups and the poor, but there is no indication of how this will be realised through existing health services. MSFs population survey showed that the waiver system does not protect vulnerable groups, even when formally within the eligibility criteria. Without much closer control, waivers for returnees or other vulnerable groups (such as female-headed households or the poor) will remain theoretical only.
Similarly, no explicit reference has been found to the need to suspend user fees in cases of epidemic outbreak, renewed fighting or other crisis situations requiring effective and urgent coverage of peoples needs. During a cholera outbreak in a refugee camp in June 2004, the health authorities resisted the lifting of user fees in the adjacent health centre. At the end of 2004, WFP pointed to the difficulties people were experiencing in accessing basic health services amid food shortages in Kirundu province. Yet no action was taken to abolish or reduce user fees, even temporarily.
The need for an unambiguous donor position
During the GHD pilot in Burundi, NGOs were consulted at different stages, and MSF provided data from its population survey. But the only explicit reference made to the data is in the WHO and UNICEF humanitarian health and nutrition strategy for 2005. Reference is made to MSFs survey and to a survey carried out by Save the Children, and it is explained that both studies recommend a more equitable system by increasing public funding to the health sector, making healthcare affordable. However, the following paragraph states that while somebody has to pay for health provision, the debate over health financing for the most vulnerable and in complex emergencies is ongoing. The same document also states that cost recovery or cost sharing have not shown to be effective in countries in crisis. The clarity of this statement contrasts with the ambiguous indicator retained in the logical framework: curative services provided at a cost commensurate with the beneficiary communitys revenues (reduced to a minimum or if necessary suspended), all preventive services for free.
The regular use of terms like community participation in the CAP for Burundi (or in the GHD principles, which speak of the adequate involvement of beneficiaries) is also a cause for concern. In practice, community participation does not necessarily refer to people taking part in decisions, but rather to financial contributions. In the majority of cases, this translates into user fees. Without any protection for the poor and without any subsidy from the central level (this means government), local solidarity mechanisms will fail to raise sufficient money and will fail to assure cross-subsidy between poorer and richer communities.
It is extremely worrying that the CHAP is supposed to facilitate the transition to longer term rehabilitation strategies and resource mobilisation mechanisms attached to them. As the current resource mobilisation mechanism for health involves charging patients fees they cannot afford, this seems highly inappropriate, and at variance with the objectives of the GHD initiative. Effectiveness and equity of aid rank high in the ambitious GHD agenda, and should remain core principles.
It is our view that donors should include a formal rejection of user fees in any health intervention in humanitarian crises. User fees are rendering health interventions less effective because they reduce coverage and equity; targeting vulnerable groups is virtually impossible through health structures that charge patients fees.
The case against user fees in complex emergencies has been made in previous issues of Humanitarian Exchange. But outside emergency contexts, it is now increasingly recognised that user fees are excluding a significant proportion of patients, are a source of impoverishment and are anti-poor. User fees will never be able to fill the existing health financing gap in poor countries. From other post-conflict contexts we know that mortality can remain well above emergency thresholds many months after the end of the conflict. The same factors of vulnerability remain: overall, people are still destitute, and their living conditions precarious. Informally, most health actors in poor countries acknowledge that cost recovery is not a solution, even in countries where there is no prevailing humanitarian crisis. Where user fees have been abolished at national level, attendance rates have increased, particularly among the poor. Recent recommendations to reach the Millennium Development Goals (MDGs) state that user fees should disappear at the latest by the end of 2006. If a moratorium on fees is desirable in development contexts, the case to abolish them in humanitarian interventions seems self-evident.
We also recommend that donors overcome their reluctance to finance recurrent costs. The main reason cited for not doing this is that it creates difficulties once the humanitarian crisis is over. But this should not take precedence over the humanitarian responsibility to respond adequately, effectively and urgently to the assessed needs of people, as in Burundi today.
The targeting and financial protection of vulnerable people should be monitored closely, and adequate measures of financial exclusion to essential care should be part of evaluation criteria. In order to measure exclusion correctly, population surveys should be carried out since this is the only method that will provide information on the people excluded. The WHO and UNICEF common strategy for 2005 show some openness to monitoring as they foresee mini-population health surveys, which could include financial access criteria.
Under the current cost-recovery scheme in Burundi, one in five people will not receive health services because of lack of money; three in five will put themselves at risk of further impoverishment in order to obtain money for health fees and drugs. At the beginning of 2004, MSF calculated that about 10 million would be enough to replace revenues from patient fees, based on an average attendance rate of around 0.6 consultations per capita per year. At least part of the funds planned for the health sector in Burundi should go towards relieving the burden patients face in paying for essential care.
Mit Philips has worked for MSF since 1985, mainly in Africa. She is currently part of the Access to Health Care unit, providing support for policy analysis and advocacy around access to essential care. Her email address is Mit.Philips@msf.be.
Armand Sprecher was medical coordinator for MSF-Belgium in Burundi from November 2003 until June of 2004. He is currently working as a public health specialist at MSF headquarters in Brussels. He can be reached at Armand.Sprecher@msf.be.
Inma Vazquez joined MSF in 2004 as a liaison point for institutional donors.