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The Financial Access to Health Services Community of Practice through the lenses of an anthropologist

5/29/2014

Workshop in Bamako

Isabelle Lange

The Harmonization for Health in Africa Communities of Practice are today firmly installed in the global health landscape. The Financial Access to Health Services CoP (FAHS CoP) for instance gathers more than 700 experts committed to progress towards universal health coverage through strategies such as user fee removal, health equity funds, health insurance…  In this blog, Isabelle Lange, medical anthropologist at the London School of Hygiene and Tropical Medicine and FEMHealth researcher reports findings of her qualitative research on the FAHS CoP itself.

“[The FAHS CoP online group] is effective for sharing information, for networking, and for the exchange of experiences…. It’s- it’s extraordinary…. First, through the community I discovered, I had the opportunity to exchange with a lot of people and now after the workshop, I think that they are friends… I will try to maintain these relationships despite…. Even if the relationship is there and exists you have to reinforce it and care for it.”
– Policy Maker, North Africa

More and more actors in the global health community are tapping into the growing range of resources to widen their networks and information bases. Communities of Practice (CoPs) fit into this trend, and as they become a more popular tool in today’s information management methods in global health, there is the sense that the utilization of the Internet and strong content can bridge individuals to create or strengthen a community. A CoP then could provide resources for knowledge sharing and potentially also for informed health policy and systems change, breaking the traditional direction of north to south information flow and communication barriers across professional silos. However, achieving this model can be a complex process dependant on many contextual variables; exploring the processes of a particular CoP can shed light on its contribution to health policy as a mechanism for knowledge exchange. This was one of my ‘assignments’ under the FEMHealth project.

The CoP FAHS and the FEMHealth: three years of collaboration

The FEMHealth project was a 3-year multi-disciplinary evaluation of maternal health user fee removal policies in Morocco, Mali, Burkina Faso and Benin. I carried out a semi-external view of FAHS CoP as a part of the health policy research. The health policy analysis aimed to understand the origin of the policies in these countries and why similar measures were taken around the same time period to reduce the financial burden of childbirth costs on women and their families. There we explored whose voices were heard, which agendas were pushed and what evidence was influential in driving these strategies. The FAHS CoP offered an arena to deepen that research by observing the current debates and actors, in addition to serving as its own study area on this mechanism as a
vehicle for knowledge sharing and transfer. It also offered a channel to connect the FEMHealth researchers in with the wider community interested in their topic. As FEMHealth had supported the establishment of the CoP, it was also interested in understanding how well the CoP was meeting its goals of knowledge creation and exchange. In my capacity as anthropologist working on the health policy analysis research, I attended three FAHS CoP workshops (in Bamako 2011, Marrakech 2012 and Ouagadougou 2013) and alongside informal exchanges and observation of the content during those meetings, carried out in-depth interviews with the facilitators and about 25 participants – following up with a selection of them over the years to gain an idea of the value of the CoP within their professional and personal lives.

CoP workshops

According to my informants, the CoP workshops cut across geographic, disciplinary and linguistic boundaries that frequently hamper knowledge exchange amongst different profiles of actors. The magic formula for this was, according to participants: an appropriate participant body – with engaged, knowledgeable actors there to learn and make a difference, not just to collect per diems; dynamic, skilled facilitation; plenty of time for informal exchange (during coffee breaks or on field visits); quality simultaneous translation between French and English; pertinent technical content; and a format that allowed for questions, discussion, learning and problem-solving, not just presentations and “being spoken at.”

A particular wish of participants was to have the beneficiary community voice present in the discussions, based on the feeling that they did not have space carved out to be legitimately heard in the usual pathways of decision-making. “I think that often we meet just amongst us, actors in the ministry of health, or those who implement the program, without taking many things into account because we can’t imagine the perspectives of the user or beneficiaries of the service”, stated a West African policy maker. “They have to be there to tell us ‘what you did like this, should have been done like this instead.” This view was echoed in reference to other stakeholder groups, including health workers and researchers, underlining the absence of meaningful cross-silo exchanges in typical/existing professional structures.

Importance of the online community

These workshops are an important part of the FAHS CoP identity – strengthening the membership and committing to action a core tenet of the knowledge-sharing mandate of CoPs. What was clear, however, was that the CoP workshops had another special component:  the online community that served as a base to these workshops. This group offers a continuity and home to the technical content and face-to-face exchanges that similar conferences did not have. While many of the attendees at the workshops were not CoP members (at the time), the community thread ran through the conference and made its presence:
member participants were asked to summarize debates and presentations which were posted to the 700+ subscribers, who could then continue the discussion via email and feed back to the conference attendees with further thoughts and questions. One workshop participant who is also a community member said, “I see these face-to-face meetings (as) very important. That's what feeds new community members and that feeds the online life to the next workshop. And so there are these two mechanisms – face-to-face - that are then a good trigger for online knowledge movement and communication and discussions.”

In its own right, the online community served as a valuable link to work being done in health financing on a broader scale than many members were involved in their day-to-day professional lives. Access to grey and academic literature, unpublished experiences, and especially the diverse opinions of fellow community
members on these pieces proved to be a reason why the online group was valued and, for some, ‘boosted confidence’ in their own capacity and was considered a unique contribution to the resources available in this field.

Further reflections and future steps

The enactment of policy-relevant knowledge in more dynamic ways – through interactive meetings, continuous facilitation, editorials, and community building, among others – was seen to be a strong point of the community of practice model in providing both personal and professional benefits to members. But questions remain about strategies that can create a lasting impact in a world where many are over-worked and access to a surplus of material and resources can at times seem to be a burden rather than a benefit. The CoP offers a reference point and an organizational component to information, people and networks, which, as one agency participant says, is “the key to the whole thing…. It’s knowledge dissemination, knowledge production, capacity building.” But, he continues, “a community of practice is not just there for the management, but to build something.” Over the past three years we have watched the FAHS CoP grow into a network of more than 700 individuals and as an organization have seen its presence at numerous conferences and affiliation with other professional bodies. Discussions around its ideal future structure emphasize its need to remain non-normative, independent and be member-driven,
not only member-responsive, in order to be able to contribute to shaping an environment that constructively and innovatively brings about positive policy advances through knowledge sharing.

Read the accompanying policy brief for the facilitators’ perspectives on growing a CoP, and don’t hesitate to get in touch with any thoughts or ideas.

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Performance based financing and community health workers: A new breakthrough in Rwanda

5/13/2014

10 Commentaires

Bruno Meessen

You are international health expert and you distrust the strategy of community health workers, hate performance based financing and don’t believe in community participation anymore? Press on the key “Rwanda” for an update!

In August 2013, during a visit in Burundi, I had the opportunity to discover a pilot experience of community PBF. That experience, led by the ONG IADH overcame the reluctances I had so far, as many others, regarding the strategy of community health workers. I knew that this strategy was already applied countrywide in Rwanda, the neighboring country. I benefited from a recent request from the Government of Rwanda and the United States Government’s Integrated Health Systems Strengthening Project (led by Management Sciences for Health) to learn more about it. My conviction was strengthened: we are facing a breakthrough.

Development of community PBF in Rwanda

The Rwanda’s experience in community PBF occurred in two times. The first experience- since 2006- thoroughly played the game of decentralization: the local government had transferred the budget for the community health workers to the local authorities (the administrative district). That approach, the G2G (government to government), to some extent, failed in its early stage. As Dr. Claude Sekabaraga, who I met again in Kigali, reminded me, the money didn’t reach the beneficiaries and was sometimes used by the decentralized administrative structures to fund other activities (infrastructures…) that seemed to be a higher priority. The second experience - started in 2009 - has been funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Because of the donor's rules, the funds for the community health workers have been transferred through the health centres.

The originality of the Rwandan model lies in the organisation of the community health workers (CHWs). The MOH opted for the setting of cooperatives of CHWs. Cathy Mugeni, who leads, since the beginning, the program at the MOH in Kigali, explained that this choice was, among others, due to the national political context: in comparison to an 'association' (like in Burundi), the cooperative is an institutional formula that permits more easily an economic activity, additional to the support to routine community health activities - it was more conform to the country’s objective to progress towards a lesser dependency to external aid for the funding of its health sector.

I was of course curious to discover the strategy on the field. By chance, my stay in Rwanda coincided with that of a delegation of the Lesotho’s Ministry of Health. I was thus able to join them for a visit of the Gikomero health center (1).

Lessons

The community health workers must henceforth be recognized as an integral component of the health system. I say “henceforth” because it was not and is still not the practice in most CHW programs: in many countries, the strategy of CHWs has been impeded for longtime by its fragmentation (each vertical program having its own CHWs); it had also been accused of paving the way for apprentice doctors, uncontrollable once equipped with drugs. I can’t take position for each context, but what I’ve seen in Rwanda, what told me different informants and what I’ve read besides convinced me: ignoring the CHWs is depriving ourselves of a true accelerator for numerous health objectives that are dear to us, especially those under the MDGs 4,5 and 6.

Dr. Michel Gasana, National Director of the National Tuberculosis Control Programme, thus explained me that CHWs played henceforth a key role in the identification and referral of persons suspected of having tuberculosis. They also play a role in the administration of the treatment (DOTS). At Gikomero, the CHWs showed us a lot of their activities, including the integrated management of childhood diseases (fever, diarrhea and pneumonia) at the community level, the promotion of the use of family planning services, the delivery of contraceptive methods and drugs to manage tuberculosis, the behavior change communication, and the community-based nutrition program: all high impact interventions. We also appreciated the quality of their different tools.

As many health system experts, my attention these last years has been drawn to the health facilities. Our first concern was to reinforce them so they may be able to deliver their health package. What stroke me at Gikomero was the very high integration that exists between the activities of CHWs and those of the health center. If the CHWs provide some services (e.g. treatment of diarrhea with ORS and Zinc, treatment of pneumonia, treatment of malaria), a good part of their contribution is the promotion of the use of the health center (they also are permanently in touch with the health center and the Ministry of Health thanks to mobile phones that permit to lead fast interventions to save lives at the community level). The key advantage of the CHW is that he/she lives in the village. He/she is trusted by the community and is thus welcomed in each household. Later, the same day, we visited, in another district, the Rutongo hospital. In the pediatric ward, we were able to interview a mother with her baby who has kwashiorkor. She told us her journey: her notice of a change in the behavior of her baby, her contact with 'her' CHW, the decision to go together to the health center (despite that the anthropomorphic measures were in the “green”), and after the diagnosis of a severe malnutrition by the health center, the immediate referral to the hospital (using an ambulance).

One of the great strengths of the Makamba experience in Burundi and the one from Rwanda is the establishment of a joint entity to all the CHWs of one health center. Firstly, this removes the previous problem of fragmentation of the strategies using CHWs (each program having his). This also greatly facilitates the communication with the health center; this permits for example passing at the scale of a strategy in a quicker way. More fundamentally, the existence of an association of a cooperative permits to pass from a model where the CHW is strictly instrumental to a model that really favors a collective decision- which is, for me, the real stake of the community action.

For that, it was needed to create a stake for collective decision. Our hypothesis is that community PBF, with its injunction of funds into these self-managed entities (associations or cooperatives), creates that involvement. Because if the community PBF envisages that the joint entity will have to remunerate each CHW for its own contribution, the payment by the Ministry of Health is high enough for the group to put a part of its revenue aside. With that money, investment decisions can be made.

At Gikomero, Ms. Concessa Kiberinka, CHW and accounting of the CHWs cooperative, presented us the different activities led by the cooperative: a piggery, a banana plantation, real estate investments… She also told us about their future project: to build a production unit of pork! In business management schools, this is called to move up the value chain…

I asked her if there was no risk that the economic success of the cooperative corrupts the project, whose first finality was health. We could for example imagine that in the future, the candidates to the post of CHW are “opportunists”, mainly interested by the economic gain. She explained me that each village chose, democratically, its CHW, and that criteria were the dedication for the village, the integrity, the ability to gain the trust to visit households… (2). It’s difficult to describe, but during the different oral interventions of CHWs during our visit, all these values emanated from them.

Emergence of a model

So there is a model extremely well designed and structured that emerges: CHWs, democratically elected by the community, trained on an effective health interventions package, working collectively and under the supervision of a health center, locally organized into a cooperative, itself remunerated by a PBF and fostered to launch economic activities, all of that in a context of strong political mobilization.

One can predict that the next Demographic and Health Survey (2015) will confirm the health impact of that global strategy. Some will ask which component will have been the most determinant. Dr. Ina Kalisa Rukundo (School of Public Health of Kigali), who is coordinating a study in the impact of the community PBF funded by the World Bank told me: “Between the baseline and the final assessment, three years have passed. In Rwanda, everything goes very fast. There has been a very strong mobilization of the national and local authorities in favor of CHWs. It is also a small country and the good ideas are quickly shared. Our study tries to isolate the effect of PBF, but we would not be surprised if finally, the study reveals that the different arms of the study have similar results”. It is also probable that the numerous beneficial effects related to that policy (especially in terms of governance and economic impact) will never be well identified. This is the case for societies in rapid transformation.

A renewed vision

One must of course be careful with the experiences from Rwanda and Burundi. Factors like the high density of population, the democracy at the village level, or the high implication of women in the collective action could be elements more difficult to find in other contexts. It is also possible that more that the “what” to do, it is the “how” to do it that matters. It is by the experimentation elsewhere that we will know it.

This shows a more general lesson, surely valid for the academic world engaged in global health: it is greatly time to review some of our dogmas and mental categories. We live in a world in permanent change, in Africa as well. What was unimaginable yesterday can happens tomorrow… and is already occurring in Rwanda! In public health, many of our references are based on a static, or even worse, wrong reading of the societies. As teachers, we must have the humility to recognize that part of our teaching is shaped by our past experiences and determined by analysis frameworks maybe conceptually elegant, but out of phase with the reality.

Notes

(1) Thanks to Health Development Performance and to the School of Public Health for having accepted us as visitors for this visit!
(2) The cooperatives include 2/3 of women; as a man, I see there a very wise decision (moreover, not surprising for Rwanda).

10 Commentaires

Financement Basé sur la Performance et agents de santé communautaire : une percée au Rwanda

5/13/2014

17 Commentaires

Bruno Meessen

Vous êtes expert en santé internationale et vous vous méfiez de la stratégie des agents de santé communautaire, détestez le financement basé sur la performance et ne croyez plus en la participation communautaire ? Tappez sur la touche « Rwanda » pour une mise à jour !

En août 2013, lors d’une visite au Burundi, j’avais eu l’occasion de découvrir une expérience-pilote de FBP communautaire. Cette expérience menée par l’ONG IADH avait vaincu les réticences que j’avais jusqu’alors, sans doute comme beaucoup d’autres, vis-à-vis de la stratégie des agents de santé communautaire. Je savais que cette stratégie de FBP communautaire était déjà mis en œuvre à l’échelle de l’ensemble du pays dans le pays voisin, le Rwanda. J’ai profité d’une récente sollicitation dans le cadre du « Integrated Health System Strengthening Project » du gouvernement du Rwanda et du gouvernement américain (mise en œuvre par Management Sciences for Health) pour en savoir plus. Ma conviction en sort renforcée : nous sommes face à une avancée pleine de promesses.

L’expérience du Rwanda en matière de FBP Communautaire s’est faite en deux temps. La 1° expérience – dès 2006 – s'est faite sur financement public. Elle a joué à fond le jeu de la décentralisation : le gouvernement central avait fait passer les budgets à destination des agents de santé communautaires par les autorités locales (le district administratif). Cette approche – G2G (« government to government ») a, dans sa phase initiale, été un échec relatif. Comme me l’a rappelé le Dr Claude Sekabaraga, que j’ai retrouvé à Kigali, l’argent n’atteignait pas les bénéficiaires et était parfois utilisé par les structures administratives décentralisées pour financer d’autres activités (infrastructure…) qui leur semblaient plus prioritaires. La 2° expérience -à partir de 2009 - s'est faite sur financement du Fond Mondial de la Lutte contre le SIDA, la tuberculose et le paludisme. A cause des règles imposées par le bailleur, les fonds à destination des agents de santé communautaires ont alors transité, non par le district administratif, mais par les centres de santé.(1)

L'originalité de l'expérience rwandaise réside dans l'organisation des agents de santé communautaires (ASC). Le Ministère de la Santé a opté pour la mise en place de coopératives d'ASC. Cathy Mugeni, qui conduit, depuis le début, le programme au Ministère de la Santé à Kigali, nous a expliqué que ce choix était entre autre dû au contexte politique national : la coopérative des ASC est une formule institutionnelle qui permet plus facilement l’activité économique en plus du soutien aux activités de santé communautaire de routine – elle était plus conforme à l’objectif du pays de progresser vers une moins grande dépendance vis-à-vis de l’aide extérieure pour le financement de son secteur santé.

J’étais bien sûr curieux de découvrir la stratégie sur le terrain. Par chance, mon séjour au Rwanda coïncidait avec celui d’une délégation du Ministère de la santé de Lesotho. J’ai donc pu me joindre à celle-ci lors de la visite au centre de santé de Gikomero.(2)

Leçons

Les agents de santé communautaire doivent désormais être reconnus comme une composante à part entière du système de santé. Je dis « désormais » car ce n’était pas gagné d’avance : la stratégie des ASC a longtemps pêché par son morcellement (chaque programme vertical entretenant ses propres ASC) ; elle a aussi été soupçonnée de faire le lit d’apprentis-docteurs, incontrôlables une fois dotés de médicaments. Je ne peux pas me prononcer pour chaque contexte, mais ce que j’ai vu au Rwanda, ce qu’on m’ont dit différents informateurs et ce que j’ai lu par ailleurs m’a convaincu: ignorer les ASC, c’est se priver d’un vrai accélérateur pour de nombreux objectifs sanitaires qui nous sont chers, en particulier ceux repris sous les OMD 4, 5 et 6. Le Dr Michel Gasana, Directeur national du programme national de lutte contre la tuberculose, m’a ainsi expliqué que les ASC jouaient désormais un rôle-clé dans l’identification et le référencement des personnes suspectées d’être infectées par la tuberculose. Ils jouent aussi un rôle dans l’administration du traitement (DOTS). A Gikomero, les ASC nous ont présenté leurs nombreuses activités, notamment :la prise en charge intégrée des maladies de l’enfant (fièvre, diarrhée et pneumonie) au niveau communautaire, la promotion de l’utilisation des services de planification familiale, la fourniture de méthodes contraceptives et des médicaments de prise en charge de la tuberculose, la communication pour le changement et le programme de nutrition à base communautaire) : toutes des interventions à haut impact. On a aussi pu apprécier la qualité de leurs différents outils.

Comme beaucoup d’experts « système de santé », mon attention ces dernières années a été orientée vers les formations sanitaires. Notre premier souci était de les renforcer pour qu’elles puissent prester leurs paquets d’activité. Ce qui m’a frappé à Gikomero c’est la très grande intégration qui existe entre les activités des ASC et celles du centre de santé. Si les ASC prestent certains services (ex : traitement de la diarrhée par SRO-Zinc, traitement de la pneumonie, traitement du paludisme et suivi nutritionnel de l’enfant malade), une bonne part de leur contribution passe par la promotion de l’utilisation du centre de santé (ils sont aussi en contact permanent avec le centre de santé et le Ministère de la Santé grâce à des téléphones mobiles qui permettent de mener des interventions rapides pour sauver des vies au niveau communautaire). L’avantage-clé de l’ASC c’est qu’il réside dans les villages. Il bénéficie de la confiance de la communauté et est ainsi accueilli dans chaque foyer. Plus tard, le même jour, nous avons visité, dans un autre district, l’hôpital de Rutongo. Dans la salle de pédiatrie, nous avons pu interviewer une maman d’un enfant avec un kwashiorkor. Elle nous a raconté son parcours : son observation d’un changement de comportement de son bébé, une prise de contact avec son ASC, la décision d’aller ensemble au centre de santé (en dépit que les mesures anthropométriques étaient dans le ‘vert’) et après diagnostic d’une malnutrition aiguë par le centre de santé, la référence immédiate à l’hôpital (avec recours à l’ambulance).

Une des grandes forces de l’expérience de Makamba au Burundi et de celle du Rwanda, c’est la mise en place d’une entité commune à tous les ASC d’un même centre de santé. D’une part, cela évacue le problème antérieur de la fragmentation des stratégies recourant aux ASC (chaque programme ayant les siens). Cela facilite aussi grandement la coordination avec le centre de santé ; ça permet par exemple des passages à l’échelle d’une stratégie de façon plus rapide. Plus fondamentalement, l’existence d’une entité autogérée permet de passer d’un modèle où l’ASC est strictement instrumental (comme relais des programmes) à un modèle mobilisant réellement la décision collective – ce qui à mon sens, est le vrai enjeu de l’action communautaire.

Pour ce faire, il fallait créer un enjeu pour la décision collective. Notre hypothèse est que le FBP communautaire, par son injection de fonds dans ces entités autogérées génère cet enjeu. Car si le FBP communautaire prévoit que l’entité commune devra rémunérer chaque ASC pour sa contribution individuelle, le paiement par le Ministère de la Santé est suffisamment élevé pour que le groupe puisse mettre une partie des revenus de côté. Avec cet argent, des décisions d’investissements peuvent être prises.

A Gikomero, Mme Concessa Kiberinka, ASC et comptable de la coopérative des ASC, nous a présenté les différentes activités économiques que la coopérative menait : un élevage de cochons, une bananeraie, des investissements immobiliers… Elle a aussi partagé avec nous leur projet futur : construire une unité de production de viande de porc ! Dans les écoles de gestion, on appelle cela progresser le long de la chaîne de valeur…

Je lui ai demandé s’il n’y avait pas un risque que le succès économique de la coopérative corrompe le projet, dont la 1° finalité était sanitaire. On pourrait imaginer par exemple que les candidats au poste d’ASC dans le futur soient des ‘opportunistes’ surtout intéressés par le gain économique. Elle m’a expliqué que chaque village choisissait, démocratiquement, son ASC et que les critères qui comptaient étaient le dévouement pour le village, l’intégrité, l’aptitude à gagner la confiance pour visiter les foyers… (3) C’est difficile à décrire, mais durant la réunion avec les ASC, toutes ces valeurs émanaient des ASC qui ont pris la parole.

Emergence d’un modèle

Voilà donc, un modèle extrêmement bien pensé et structuré qui émerge : des ASC, sélectionnés démocratiquement par la communauté, formés à un paquet d’interventions efficaces, travaillant en coordination et sous supervision du centre de santé, organisés localement en une coopérative, elle-même rémunérée par un FBP et encouragée à lancer des activités économiques, le tout dans un contexte de forte mobilisation politique.

On peut prédire que les données de la prochaine Enquête Démographie et Santé (2015) refléteront l’impact sanitaire de cette stratégie globale. Certains se poseront la question de quel aura été le composant le plus déterminant. La Dr Ina Kalisa Rukundo (Ecole de Santé Publique de Kigali), qui coordonne une étude d’impact sur le FBP communautaire financée par la Banque Mondiale m’a répondu : « Entre l’étude de base et l’étude finale, trois ans se seront écoulés. Au Rwanda, tout va très vite. Il y a eu une forte mobilisation des autorités nationales et locales en faveur des ASC. C’est aussi un petit pays et les bonnes idées sont vites partagées. Notre étude essaie d’isoler l’effet du FBP, mais ne serions pas surpris si au final, l’analyse finale révèle que les différentes branches de l’étude ont des résultats similaires ». Il est également probable que les nombreux effets bénéfiques connexes de cette politique (notamment en termes de gouvernance et d’impact économique) ne seront jamais bien identifiés. C’est le lot des sociétés en transformation rapide.

Une vision renouvelée

On doit bien sûr être prudent avec l’extrapolation des expériences du Rwanda et du Burundi. Des facteurs comme la forte densité des populations, la démocratie au niveau du village ou encore la grande implication des femmes dans l’action collective pourraient être des éléments plus difficiles à retrouver dans d’autres contextes. Il est aussi possible que plus que le ‘quoi’ faire, c’est le ‘comment’ faire qui compte. C’est par l’expérimentation ailleurs que nous le saurons.

Cela indique une leçon plus générale, certainement valide pour le monde académique engagé en santé internationale : il est grand temps de revoir certains de nos dogmes et catégories mentales. Nous vivons dans un monde désormais en changement permanent. Ce qui était inimaginable hier est peut-être envisageable demain… et déjà en œuvre aujourd’hui au Rwanda! En santé publique, beaucoup trop de nos prescrits sont basés sur une lecture statique, ou pire datée, des sociétés. Comme enseignants, nous devons avoir l’humilité de reconnaître que notre enseignement est façonné par nos propres expériences passées et déterminé par des cadres d’analyse peut-être conceptuellement élégants, mais en décalage avec la réalité.

Notes :
(1) Les deux systèmes co-existent encore actuellement. Jusqu'à récemment les fonds publics arrivant au niveau du district administratif étaient utilisés par ce dernier pour couvrir les coûts que l'action communautaire entraînait à son niveau (supervision, réunions...). Suite à une forte réduction du financement du Fond Mondial, les financements publics vont désormais également servir à rémunérer (à la performance) les activités des ASC.
(2) Merci à Health Development Performance et à l’Ecole de Santé Publique de Kigali pour nous avoir accepté comme participant à cette visite !
(3) Les coopératives comptent 2/3 de femmes ; comme homme, je vois là une décision très sage (du reste, peu surprenante au Rwanda).

17 Commentaires

Agahimbazamusyi gashingiye ku musaruro w'abakangurambaga b'ubuzima: umwihariko w'u Rwanda wageze ku ntego zihanitse

5/13/2014

1 Commentaire

Bruno Meessen

Muri impuguke mu buzima mpuzamahanga kandi mufite amakenga n’ingamba zo gukoresha Abajyanama b’Ubuzima, mwaba mwanga agahimbazamusyi gashingiye ku musaruro kandi mwaba mutizera uruhare rw’abaturage ? Kanda ahanditse «Rwanda» kugira umenye uko ibintu bihagaze!

Muri Kanama 2013, igihe nasuraga i Burundi, nagize amahirwe yo gutahura umushinga-fatizo w’agahimbazamusyi gashingiye ku musaruro mu baturage. Ibyagezweho n’umuryango witwa ADHbyari gushira amakenga nari mfite kugeza icyo gihe, birumvikana nk’abandi bose, ku birebana n’ingamba zo gukoresha Abajyanama b’Ubuzima. Nari nzi ko uwo mugambi wo gushyiraho Abajyanama b’Ubuzima wari warashyizwe mu bikorwa ku rwego rusange rw’igihugu cyose mu gihugu gituranye n’u Burundi, ari cyo u Rwanda. Nakoresheje amahirwe y’ubusabe bwa vuba aha mu rwego rw’umushinga wa « Integrated Health System Strengthening Project» ugamije kubaka ubushobozi bw’imikorere ya Guverinoma y’u Rwanda na Guverinoma ya Leta Zunze Ubumwe za Amerika (ushyirwa mu bikorwa n’umuryango witwa Management Sciences for Health) kugira ngo menye byinshi kuri uwo mugambi w’Abajyanama b’Ubuzima. Nyuma yaho narushijeho kwemera no kunyurwa: nta gushidikanya, aho twerekeza haratanga icyizere.

Ibyo u Rwanda rwagezeho mu birebana n’agahimbazamusyi gashingiye ku musaruro mu baturage byakozwe mu byiciro bibiri. Igerageza rya mbere- kuva mu mwaka wa 2006 –: Agahimbazamusyi k’Abajyanama b’Ubuzima kavaga ku ngengo y’imali y’iguhugu kagezwa ku bajyanama kanyujijwe mu nzego z’ibanze za leta, gusa ntibyagenze neza nk’uko byari byifujwe. Nk’uko Dr Claude Sekabaraga yabinyibukije, nkaba naramusanze i Kigali, amafaranga yoherezwaga ntiyageraga ku bagenerwabikorwa ndetse rimwe na rimwe yakoreshwaga n’inzego z’ibanze zegerejwe abaturage mu gutera inkunga ibindi bikorwa (ibikorwa-remezo…) byasaga n’aho byihutirwa kurusha ibindi. Igerageza rya kabiri- kuva mu mwaka wa 2009- Hashingiwe kubwumvikane n’amategeko agenga imikoreshereze y’inkunga “ Ikigega cy’isi gishinzwe kurwanya Sida, Igituntu na Marariya, hemejwe ko agahimbazamusyi k’Abajyanama b’Ubuzima katazongera kunyuzwa mu nzego z’ubuyobozi ahubwo kazajya kanyuzwa ku Kigo Nderabuzima bahuriyeho.

Umwihariko w’u Rwanda ari nacyo gishya ,ushingiye mu kubumbira hamwe Abajyanama b’ubuzima mu itsinda rikorera hamwe ariryo Koperative bisabwe na Ministeri y’Ubuzima. Cathy Mugeni, uyobora kuva mu ikubitiro, iyi Porogaramu muri Ministeri y’Ubuzima i Kigali, adusobanurira ko aya mahitamo cyane cyane yaterwaga n’imiterere ya politiki y’igihugu : amakoperative y’Abajyanama b’Ubuzima ni uburyo bw’urwego ruboneye kurusha izindi rutuma ibikorwa by’ubukungu cyangwa bibyara inyungu biterwa inkunga y’amafaranga ku buryo bworoshye, hiyongereyeho gushyigikira ibikorwa bisanzwe by’Ubuzima rusange – Uburyo bwa koperative buhuza kurushaho n’intego y’igihugu y’inzira yo kwihaza no kwigenga mu by’imari aho guhora igihugu gihanze amaso inkunga y’amahanga mu rwego rwo guteza imbere Ubuzima bw’abaturage.

Mu by’ukuri nari mfite amatsiko yo kumenya uyu mugambi wo kwiyambaza Abajyanama b’Ubuzima mu baturage aho bakorera. Ku bw’amahirwe, igihe nasuraga u Rwanda cyahuriranye n’icy’intumwa za Minisiteri y’Ubuzima ya Lesotho. Nashoboye rero kujyana n’izo ntumwa ku Kigo Nderabuzima cya Gikomero.(1)

Amasomo nungutse

Abajyanama b’Ubuzima bagomba kumenywa nka bamwe mu bagize inzego zose z’Ubuzima. Umugambi w’Abajyanama b’Ubuzima wakoze amakosa igihe kirekire bitewe no gutatanya ingufu zawo (Buri Porogaramu uhereye hejuru ugana hasi yari ifite Abajyanama bayo b’Ubuzima bwite) ; na none kandi, wakekwaga kuba indiri y’abaganga bigiye munsi y’igiti, umuntu atamenya ibyo bakora cyangwa bagakora ibyo bishakiye, igihe bahawe imiti. Sinshobora guhamya no kuvuga kuri buri rwego, ariko ibyo nabonye mu Rwanda, ibyo nabwiwe n’abantu banyuranye bampaye amakuru n’ibyo nabonye ahandi (ugereranije cyane cyane n’ibyo nabonye muri Niger) byanyemeje ko kwirengagiza Abajyanama b’Ubuzima, ni ukwivutsa umusemburo nyakuri wafasha mu kugera ku ntego z’Ubuzima zinyuranye kandi ziduhenda cyane, by’umwihariko intego zivugwa mu Migambi y’Ikinyagihumbi igamije Iterambere ya 4, 5 n’uwa 6. Dr Michel Gasana, Umuyobozi mu rwego rw’igihugu wa Gahunda yo Kurwanya Igituntu, yansobanuriye ko Abajyanama b’Ubuzima bagira uruhare rukomeye mu kurwanya igituntu ku rwego rw’igihugu. Na none kandi bafite uruhare mu mivurire n’imikoreshereze y’imiti. Ku Kigo Nderabuzima cya Gikomero, Abajyanama b’Ubuzima batweretse ibikorwa byabo binyuranye byinshi, cyane cyane : kwita ku ndwara z’abana ku buryo bukomatanjiye (umuriro, impiswi, umusonga) ku rwego rw’abaturage, guteza imbere imikoreshereze ya za serivisi zo kuboneza urubyaro, gutanga uburyo bwo kuboneza urubyaro, n’imiti ivura igituntu, ibiganiro bigamije guhindura imyifatire, na gahunda y’imirire ishingiye ku baturage) ; byose bigira ingaruka nziza zihambaye. Twanashoboye gushima imihurize n’imikoreshereze inoze cyane y’ibikoresho bitandukanye biyambaza.

Nk’umwe mu mpuguke zinyuranye mu « rwego rw’ubuzima», muri iyi myaka ishize nibanze ku bigo by’ubuzima n’amavuriro. Impungenge za mbere zabaye kuzubakira ubushobozi kugira ngo zishobore gutanga urwunge rwa serivisi zabyo. Ibi byarantangaje kuko ku Kigo Nderabuzima cya Gikomero nasanze hari imikoranire yateye imbere ku buryo buhebuje hagati y’ibikorwa by’amavuriro n’Abajyanama b’Ubuzima.Niba Abajyanama b’Ubuzima batanga zimwe muri serivisi (urugero kuvura impiswi bakoresheje imyungu ivura umwuma ya Zinc, kuvura umusonga), igice kinini cy’uruhare rwabo kibanda ku guteza imbere imikoreshereze n’imikoranire n’Ikigo Nderabuzima (na none kandi bahora bakoranira hafi n’Ikigo Nderabuzima hamwe na Ministeri y’Ubuzima hakoreshejwe za telefone zigendanwa zituma batanga amakuru ku buryo bwihuse mu rwego rwo kurengera ubuzima bw’abaturage).

Akarusho k’ingenzi k’Abajyanama b’Ubuzima ni uko baba batuye mu Mudugugu umwe n’abagenerwabikorwa babo. Kandi bakunze kugirirwa icyizere n’abaturage kandi bagahabwa ikaze muri buri rugo, nta kibazo. Nyuma yaho, twasuye, mu kandi Karere, Ibitaro byta Rutongo. Mu cyumba cy’abana, twabajije umubyeyi wari ufite umwana urwaye bwacye. Yatubwiye inzira yanyuzemo: Uko yabonye ko umwana we yahinduye imyifatire, kugana Umujyanama w’Ubuzima, icyemezo cyo kujyana bombi ku Kigo Nderabuzima (n’ubwo ibipimo ku ifishi y’umwana byari mu ibara « ry’icyatsi kibisi ») kandi ko nyuma yo gusuzuma umwana ku Kigo Nderabuzima bagasanga afite imirire mibi ikabije, uwo mwana bamwohereje mu bitaro (bakoresheje imbangukiragurabara/ingobyi y’abarwayi).

Zimwe mu ngufu zikomeye nabonye i Makamba mu Burundi n’ibyo nabonye mu Rwanda, ni ishingwa ry’urwego ruhuriweho n’Abajyanama b’Ubuzima bose ku Kigo Nderabuzima kimwe. Ku ruhande rumwe, iyi mikorere izakuraho ikibazo cyahozeho cyo gutatanya ingamba zitangwa n’Abajyanama b’Ubuzima (Kuko buri porogaramu ifiite abayo). Ibi bizoroshya ku buryo bushimishije ihuzabikorwa hamwe n’Ikigo Nderabuzima; nk’urugero, ibi bizatuma ingamba zateganyijwe zigerwaho ku buryo bwihuse. By’umwihariko, ishyirwaho ry’ishyirahamwe cyangwa rya koperative bizatuma urwego rw’Abajyanama b’Ubuzima ruva ku rwego mpuzamikorere y’inzego (nk’umuhuza wa za Porogaramu) rugana ku rwego rushinzwe ubukangurambaga nyakuri kandi rufata ibyemezo bihuriweho – Dukurikije uko tubyumva, iyi ni yo ntego nyakuri y’ibikorwa bishingiye ku baturage.

Kugira ngo ibi bigerweho, ni ngombwa gushyiraho intego n’uburyo byo gufatira hamwe ibyemezo. Icyo tubitekerezaho ni uko agahimbazamusyi gashingiye ku musaruro mu baturage, bitewe n’uko kagizwe n’amafaranga yoherezwa mu nzego (ishyirahamwe cyangwa koperative) bibyara icyo gikorwa. Kuko niba agahimbazamusyi gashingiye ku musaruro mu baturage gateganya ko urwego ruhuruweho rugomba guhemba buri Mujyanama w’Ubuzima kubera umusanzu we bwite, igihembo gitangwa na Ministeri y’Ubuzima ni kinini ku buryo bushimishije kugira ngo buri tsinda rishobore gushyira iruhande igice kimwe cy’amafaranga binjiza. Bakoresheje ayo mafaranga, bashobora gutangira ibikorwa by’ishoramari.

Ku Kigo Nderabuzima cya Gikomero, Madamu Concessa Kiberinka, Umujyanama w’Ubuzima akaba n’umucungamari wa Koperative y’Abajyanama b’Ubuzima, yatweretse ibikorwa by’ubukungu binyuranye Koperative yabo yakoraga : Ubworozi bw’ingurube, urutoke, ishoramari mu bwubatsi bw’amazu,… Na none kandi yatubwiye undi mushinga bateganyaga mu gihe kizaza: Kubaka ibagiro ry’inyama z’ingurube! Mu mashuri y’ubucungamari, ibi babyita gutera intambwe nyongeragaciro k’ibikorwa byabo…

Namubajije niba bidashoboka ko iterambere rya Koperative yabo y’ubukungu bitazatuma umushinga wabo umungwa na ruswa, kandi intego yayo ya mbere ari uguteza imbere (1°) ubuzima. Ibi bishobora gutuma twibaza ko abandi bantu bazashaka kuba Abajyanama b’Ubuzima bazaba bakuruwe n’indonke n’irari ry’inyungu y’amafaranga. Yansobanuriye ko buri mudugugudu uhitamo Abajyanama b’Ubuzima binyuze mu buryo bwa demokarasi kandi ko ingingo zigenderwaho zikurikizwa ari ukwitangira umudugugudu, ubunyanyamuganyo, ubushobozi bwo kwizerwa n’ingo no kuzisura… (2) Biraruhije gusobanura, ariko mu biganiro twagiranye n’Abajyanama b’Ubuzima, byagaragaye ko barangwaga n’izi ndangagaciro zose.

Ivuka n’Iterambere ry’ubu buryo

Dore rwose uburyo bw’imikorere bwatekerejwe neza kandi bufite urwego ruteye neza bwavutse : Abajyanama b’Ubuzima, batoranywa ku buryo bwa demokarasi, bikozwe n’abaturage, bahugurirwa gutanga urwunge rwa serivisi zikomatanyije zinoze, bakora no ku buryo buhuza ibikorwa byabo kandi bagenzurwa n’Ikigo Nderabuzima, bishyira hamwe ku rwego rw’aho batuye muri Koperative, nayo kandi ikaba iterwa inkunga n’igihembo gishingiye ku
musaruro, kandi ikaba yiyemeje gutangiza ibikorwa bibyara inyungu z’ubukungu, ibi kandi byose bikaba bikorerwa mu rwego rwa politiki
nkangurambaga ihanitse.

Icyitonderwa no Gushimira:
(1) Turashimira Health Development Performance n’Ishuri Rikuru ry’Ubuzima Rusange rya Kigali kuko bemeye kugira uruhare muri urwo rugendo!
(2) amakoperative arimo 2/3 by’abagore ; nk’umugabo, mbona ari icyemezo gishingiye ubushishozi buhanitse, kandi ibi ntibitangaje mu Rwanda).

Translation: Dr Candide Tran Ngoc & Francoise Kayirangwa

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Performance based financing for implementation of national health strategies: a debate to be continued

5/1/2014

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Mathieu Noirhomme

Performance based financing (PBF) approaches were still mainly considered as pilot approaches a few years ago. This is changing fast, however. PBF is now becoming a central tool for the implementation of national health policies and strategies for an increasing number of governments and cooperation agencies. The question of integration and alignment of PBF strategies then arises. This was the subject of a three-day debate in January on the online forum of the PBF Community of Practice. Key elements of the discussion are summarized below. This is a topical debate which deserves more attention, among others in the framework of a recent Alliance for Health Policy and Systems Research implementation research call.

Mathieu Noirhomme (freelance consultant on health policy dialogue and health systems strengthening) started the debate in January. He more specifically zoomed in on the Burundi case as Mathieu was contributing to the mid-term review of the Burundi national health development plan (NHDP) at the time. His question focused on two issues: (1) the integration of PBF in the national health policy and strategy planning cycle; (2) the risks related to the utilisation of PBF for channelling other financing mechanisms (such as reimbursement of fee exemptions).

Mathieu’s question sparked a short but dense three-day debate, mainly on the Burundi situation. However, many of the reflections are also valid for other countries, we feel.

PBF as a tool in the policy and strategy planning cycle

PBF can be a powerful tool for strategic planning, as it allows refocusing interventions according to the evolution of national and local strategic priorities. This requires coherence between main policy documents (including NHDP) and PBF approaches in terms of central orientations and planning bodies and cycles: on the one hand the PBF must reflect national priorities, on the other hand national policies have to provide a concrete role to PBF strategies. However, Mathieu pointed out that in practice, in Burundi (1) PBF is mentioned but not well developed within the NHDP and that (2) a number of actors at central level claim that the PBF national technical committee acts as a parallel planning system at ministry level, and is insufficiently connected with the system-wide ministry of health (MOH) units (planning unit, health unit). There’s an obvious risk that operational planning exercises and PBF-supported orientations will differ.

At this point, Bruno Meessen (facilitator of the PBF Community of Practice) intervened and highlighted similar situations in other countries where PBF holds a central place in national policies but is weakly or not at all reflected in the NHDP. He also asked COP participants about their national situation.

Regarding Burundi, Olivier Basenya (PBF expert, MOH, Burundi) reminded COP members of the fact that PBF constitutes one of the NHDP’s strategic orientations, and is a priority in the strategic framework for economic development and the fight against poverty. He underlined however, just like Bruno, the importance of aligning national strategies and financing mechanisms. Mathieu agreed and brought the debate back to the operational implications. He pointed out that PBF, although present in the NHDP, remains somewhat underdeveloped in the text if one keeps in mind its strategic operational importance. He also reminded participants in the online debate of recurrent practical difficulties in harmonizing NHDP, the PBF technical committee, vertical programs and partner programs.

Rigobert Mpendwanzi (World Bank consultant) emphasized important breakthroughs achieved in Burundi in this respect the last few years. Since 2012, operational planning falls under the authority of the MOH planning unit, and conforms now to the methods set by the unit. According to him, remaining alignment problems are probably related to some misunderstanding at central level on what exactly PBF involves. This is not an issue anymore in the field, though.

Delmond Kyanza (health financing advisor, Management Science for Health, Democratic Republic of Congo (DRC)) offered a similar illustration, elaborating on the DRC situation. PBF is not reflected in the DRC’s NHDP although its strategic importance is now acknowledged. He deplored a similar missed opportunity for the document on health sector financing policy and strategies. This is probably related to changes in level of commitment to the PBF approach - when the NHDP was drafted, commitment wasn’t very pronounced yet. He argued for better consideration of PBF in the future by presenting it as a tool which can facilitate synergies among financing mechanisms. Michel Muvudi (manager, Arcadie consulting, DRC) complemented the analysis with a warning on the risk of fragmentation in zones where coordination frameworks are weak / absent and where PBF is implemented as a pilot approach.

The last intervention on this subject came from Eric Bigirimana (Chief Executive Officer, Bregmans Consulting & Research, Burundi) who provided a critical synthesis and a message for interested countries. Eric insisted on the importance of having sound PBF approaches prior to inclusion into the NHDP, in order to avoid undermining the strategy through weak designs. Main causes of implementation problems are in his view related to unpreparedness and hurry from political authorities. According to him, Burundi has drawn lessons from the past and now takes sufficient time for technical preparatory work for the introduction of the Carte d’Assistance Médicale (CAM) within the PBF. More generally, he confirmed the need for alignment and integration of different financing mechanisms to meet the challenges of health and access to care.

PBF as a vehicle for other financing mechanisms

If an efficient channel exists, it makes sense to add other financing mechanisms to it. There is no doubt about the principle, but Mathieu raised the issue of implementation, and particularly of the need for preparatory work regarding other mechanisms.

In Burundi, payment for user fees exemption (for pregnant women and children under five years of age) has happened through the same channel as PBF since 2010. In a number of health facilities, providers claim that these reimbursements absorb all of the amounts provided, and do not allow to extract additional PBF-specific resources. Other providers have no complaints about it. There are a number of possible reasons for this (design, lump sum estimation hypotheses, effective performance of the health facility) which deserve further discussion. But whatever the causes, a rather worrying conclusion seems unavoidable: merging two mechanisms can lead to a drop in level of commitment of some providers to the PBF system.

Olivier Basenya immediately reacted by (rightly) reaffirming arguments in favour of a synergy of payment mechanisms. He acknowledged, however, that some linked strategies may actually jeopardize the whole financial structure if they are underfunded. He recommended that a rigorous technical preparation precedes the merging of new mechanisms, as is being done in Burundi for the Carte d’Assistance Médicale (CAM). He also reiterated that all mechanisms will be integrated in the forthcoming national health financing strategy.

Mathieu agreed in principle with these comments but underlined operational realities observed, mainly the priority given to reimbursement of exempted services, and in some cases a reduction in the total dotation received. He raised two questions: (1) shouldn’t we ensure a closer involvement of health care providers in determining what a “rational” prescription and the related lump sum are; (2) would there be an interest in earmarking part of the resources to avoid diluting the PBF effect?

Olivier refocused the debate on the second question. According to him, the problem is not related to earmarking (or not) but instead to the question whether the total monthly financial resources received enable the health facility to function properly, whatever the source of funding. Rigobert Mpendwanzi insisted that indeed, the main issue is underfinancing of strategies adopted at national level. “The CAM and the user fee exemption strategy must be rightly designed and adequately funded to avoid reducing the PBF to playing the role of a stopgap, filling holes”.

This does not contradict but instead provides an additional illustration of linked weaknesses, as “everything is connected with everything”: if the amount or the calculation method of one financing strategy is inadequate, it may jeopardize all merged mechanisms, including PBF.

On the first question, Olivier and Rigobert both defended the lump sum calculation methodology applied. In their opinion, actors at operational level are adequately involved. Olivier also specified that the amounts received by health centres are appropriate according to the data collected by the PBF technical committee. The main remaining problem resides at hospital level where health care providers consider the lump sums as insufficient.

Mathieu nuanced this assessment by reminding COP members of rather contradictory observations made in the field, and called for an extension of the debate beyond the Burundi case. Longin Gashubije (Ministry of Health, Burundi) agreed and also introduced a new element in the debate, pointing to irregularities in payments made by the Burundi Government. According to him, this could reduce the interest of health care providers for the PBF scheme and drive them away from good practices. He put again the possibility of earmarking part of the funds for PBF on the table, without proposing a clear technical mechanism to do so, however.

Synthesis of the debate

In a message that proved to be the last of the debate, Mathieu synthesised the exchanges and reminded COP members of the key elements of the issue of merging different financing mechanisms. (1) Yes, there are serious arguments for operational synergies that nobody really contested. (2) In practice, however, some health facilities have seen their PBF resources channelled towards the reimbursement of user fee exemptions. For these, it appears resources are not devoted to paying for performance but to free health care instead. Whatever the causes, the PBF effect probably got undermined. (3) This calls for a careful approach in the design and follow-up of mergers of financing mechanisms. Olivier and Rigobert focused a lot on the issue of available budgets. Other considerations must also be taken into account. It is even more important for countries where PBF is becoming one of the major funding mechanisms.

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The Financial Access to Health Services Community of Practice through the lenses of an anthropologist

Performance based financing and community health workers: A new breakthrough in Rwanda

Financement Basé sur la Performance et agents de santé communautaire : une percée au Rwanda

Agahimbazamusyi gashingiye ku musaruro w'abakangurambaga b'ubuzima: umwihariko w'u Rwanda wageze ku ntego zihanitse

Performance based financing for implementation of national health strategies: a debate to be continued

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The Financial Access to Health Services Community of Practice through the lenses of an anthropologist

Performance based financing and community health workers: A new breakthrough in Rwanda

Financement Basé sur la Performance et agents de santé communautaire : une percée au Rwanda

Agahimbazamusyi gashingiye ku musaruro w'abakangurambaga b'ubuzima: umwihariko w'u Rwanda wageze ku ntego zihanitse

Performance based financing for implementation of national health strategies: a debate to be continued

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