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).

Jean-Benoît Falisse

It will soon be 27 years that the Bamako Initiative was launched and community participation became a core component of health policy in Africa. Through eight interviews, one personal reflection, and your many comments in French and English, what was once the "magic bullet" of community participation turned out to be a complex topic. The debate is certainly not closed but this blog post series is coming to an end. Here is my own (subjective) conclusion; it brings more questions than answers. 

First of all, the series has put the Bamako Initiative in the continuum of International Health (“global health” we would say today) strategies and policies. The inspiration of the Bamako Initiative seemed a little blurry at first, somewhere between the Chinese barefoot doctors and the 1977 Alma-Ata Conference on Primary Health Care. However, the interview with Walter Kessler shows us how, in the early 1980s, Doctors Without Borders had already set up experimental health committees in Chad and Mali. They would soon inspire the Bamako Initiative. Susan Rifkin and Agostino Paganini explain the relative success of the initiative in its early years, with the involvement of UNICEF in the field and under charismatic and dynamic leadership of the duo formed by Dr. Mahler (WHO) and Mr. Grant (UNICEF). As already foreshadowed by Doctors Without Borders' experience with the health stores in the 1980s, the type of community participation advocated at the Bamako conference came along with the introduction of user fees, which states justified by their inability to pay for everything because of the debt crisis. From its inception, the Bamako Initiative had two faces, which even this series that focused on community participation has not been able to totally disjoint. On the one hand, there is community empowerment and self-management; and on the other hand, there is a more expensive access to care. The question that still arises today, which is answered in the negative by Sophie Witter, is whether it makes sense to continue to link the two?

The Bamako version of community participation -with the health committee as a central mechanism- spread like wildfire in Africa. However, the local context was often neglected, and strategies that worked well in some places worked much less so in others. There is no one size fits all, as illustrated by the contrasting experiences of the DRC where the idea of participation was easily accepted, and neighbouring Uganda where the principle of community health management was going against traditional governance. Once past the initial enthusiasm, community participation initiatives, especially when their support by states or international organisations was discontinued, portended a disengagement of the states vis-à-vis the health of their populations. Community participation cannot be imposed. However, to carry on the idea of "health for all", humanize relationships to health-care services, and develop non-technocratic and holistic approaches to health-care, direct and deep community participation remains a promising track. It is in this spirit that the third recommendation of the recent Dakar Conference proposes to strengthen the capacity of the community to make it a “real partner for the analysis of its health problems, and the planning, implementation and evaluation of health interventions.”

As I write this post, the Bamako Initiative is dead. It has been so for a long time already. Its user fees component is roundly criticized. Its (resource-intensive) community participation component, which has often been hijacked by politicians and was much slower than expected to yield visible impacts, has not been the panacea the global health community once thought it would be. Nevertheless, the idea of ​​giving people a more central place in their health-care system continues to live on. In different parts of the globe, new forms of social accountability and direct involvement of citizens in their own health are taking place. In order to work, these must take greater account of local situations and be of direct interest to the people who are getting involved. The community needs to see an interest in participating. This is basically what the IRC officials, who implemented the Tuungane programme, which generalized a participatory approach to rebuilding communities (and their health services) in Eastern DR Congo, and Dr. Canut of Burundi, who explained how community health workers can become important parts of the health system if they are given incentives, were saying. Community participation cannot be improvised; the example of the ASACO in Mali shows that continued investment and a solid organization are needed to sustain community participation. Once past the naive vision of the community that would ex nihilo organise itself for better health-care, the challenge seems to find ways to encourage and induce participation and maintain it without manipulating it.

In this context, research about community participation still seems in its infancy. More studies are needed and they will probably need to use mixed methods in order to reach conclusions that go beyond the description of cases. It is essential to better understand the link between health facilities and their users. How can we build people's participation? How does it lead (or not) to health improvements? If the process is not linear, how should we report about it? 27 years after the Bamako Initiative, we still know very little about the impact of community participation strategies on health and access to health; especially compared to recent and less recent studies on other major global strategies such as (community-based) health insurance, performance based financing, or fee exemption.

The elephant in the room of this series is the question of power. Community participation is fundamentally about power, which is often disputed among medical staffs, medical authorities, and the population (and within the population itself). Community participation (in health) is not limited to questions that are strictly medical. The Malian adventure, the timing of the set-up of community participation mechanisms in Uganda, or the ASACO system in Mali remind us that participation is political. It is a question of governance. If this were not the case, if the dimension of power was removed from community participation, what we would observe is a pastiche of participation, an empty shell that would quickly lose its appeal. Rather than continuing to avoid the issue of power and call community participation a strictly "technical” question, it is essential to recognize that participation involves the redistribution of power and decisions on the organization and definition of health-care services.

Finally, this series reminds us that there is no magic bullet in international public health. Just like performance-based financing, fee exemption, and all the other ‘grand strategies’ in global health, community participation in itself is not sufficient to achieve health for all. The concept needs to take account of field realities and adapt, and even then, it remains only one element to be combined with other strategies to respond to the many different issues of quality universal health care.

Bruno Meessen

In this blog, Bruno Meessen (ITM, Antwerp and facilitator of the PBF CoP) shows how Results Based Financing could be a lever for African governments in the battle for family planning …  and even more so, when other influential actors in society are hostile.

On sticks, carrots and sermons

Whether you are a general, the leader of a gang, the boss of a big company, or a parent desperately trying to maintain authority, you have three main instruments to steer the behavior of your fellows and subordinates: sticks, carrots and sermons.

The metaphor of a ‘stick’ describes the variety of devices you have at your disposal to deter and, if necessary, punish behavior not in line with your objectives.  This is the fine a policeman gives you if he sees you driving without a seatbelt, for example, or the shot in the knee (at best) for the villain who betrays his boss, the non-renewal of a contract for a supplier due to poor service,… 

The ‘carrot’ is of course used as a metaphor for a reward. A medal for a brave soldier, for example, a diploma for a diligent student, the price paid to a baker for his delicious bread and of course, pay for performance, which I’m sure I don’t have to explain on this blog.

By ‘sermons’, we mean all strategies and tools of education and persuasion. Economists will tell you that these aim to change the preferences of economic agents. More prosaically, the aim is a situation where your fellows, convinced by the strength of your discourse, spontaneously adopt behavior aligned with your goals. This usually happens after you have offered convincing arguments, but if you also have a certain moral authority (like the mother has towards her child, the teacher versus his students, or the priest towards the parishioners), you have an additional advantage.

These tools all have their strengths and weaknesses, and need to be assessed in their particular situation. PBF experts, if they believe in the power of ‘carrots’, also know carrots can’t change all behaviors. ‘Sermons’ will be particularly useful when it’s impossible to verify behavior or when behavior that needs to be encouraged is also beneficial for the one adopting the behavior (example: usage of a condom). Note also that the times are changing: our societies cherish more and more individual freedom and responsibility. ‘Sticks’ are thus less and less tolerated and certain forms used in the past are now even prohibited by law.

Let's appreciate the opportunity offered by Results-Based Financing (RBF)

These are thus the three tools available to governments to influence the behavior of their citizens. In this respect, it is clear that RBF, by its very  nature, is a significant enrichment of the toolbox of African governments. But my wish is that they use this instrument in an even more strategic way, more in particular when they face other leaders promoting views contrary to their own vision of development.

Let’s give an example. Imagine a country which faces a serious demographic problem, to the extent that the high birth rate puts more and more pressure on the economy and more fundamentally, undermines the opportunities which could be available to citizens in the future. Imagine that the government has identified family planning by informed parents as a human right, on the one hand, and as a necessity to boost the development of the country, on the other hand. Imagine then that a prominent religious leader promotes a totally different vision … with a sermon, of course.

What should the government do in this case? Should it opt for the ‘stick’ (eg summon the hierarchy of the religious leader, with the threat of a sanction), or for a confrontation of ‘sermon’ (by the president) versus sermon (of the bishop, for example) on the issue at stake? If I were president of this (imaginary) country, I would think twice. If the bishop (for example) has dared to challenge you over this issue, it’s no doubt because he knows that the balance of power is not exactly in favor of you for the moment. At certain times in the life of a politician, a public confrontation on a particular topic can obviously harm his (or her) goals: the church he/she faces can be very powerful; moreover, given the church’s commitment to social sectors (schools, health centers, …) it will remain a partner for the government to work with. So it’s important to choose your battles – but this, we don’t have to tell politicians.

Results-Based Financing: a powerful lever for change

Faced with this situation, are you powerless then? Before RBF, this was probably the case. However, I think RBF now offers new and ‘smart’ opportunities for government action. The first option, if it hasn’t been implemented yet, is to add family planning to the grid of PBF of health centers (i.e. to reward the health centre for each new woman adopting a modern contraceptive method). If family planning indicators are already present, the government could increase reimbursement rates (as it has been done in Burundi late 2012). This may be powerful, but not enough, especially if many health facilities are affiliated to the church challenging your national policy! I supect that the real breakthrough will come from  involving the communities. First, the government could, like in Makamba (Burundi), contract community associations to refer women interested in family planning. But the government could go even further: it could decide to introduce a voucher system which would encourage women to adopt a modern contraception method. To distribute these vouchers in the community, we would mobilize of course the many female community health workers (with a small compensation for every woman they refer to the health center!). Being wives, mothers, sisters, friends and neighbors, I’m sure they would find the right words to convince their peers.  

By mobilizing the women in communities in Africa and tapping a peer-to-peer educational strategy, it seems to be me RBF can mobilize hundreds of thousands of very persuasive agents who can even beat seasoned preachers, if need be! 

Let us forward this message to political leaders of Africa.



Looking for more resources on RBF & family planning? 

Reproductive Health Vouchers: from promise to practice, T. Boler & L. Harris, 2010, Marie Stopes International.
Voucher schemes for sexual and reproductive health services: a Marie Stopes International (MSI) perspective, factsheet.
Can incentives strengthen access to quality family planning services? Lessons from Burundi, Kenya and Liberia, L. Morgan, 2012, Health Systems 20/20, USAID.  

Jean-Benoît Falisse


Dr. Walter Kessler worked for Doctors Without Borders - Belgium (MSF) in the 1980s. Together with Eric Goemaere, he was one of the architects of the of the ‘health stores’ project, an experience that had greatly inspired the Bamako Initiative as the project was based on both cost recovery and community participation. Later on, Walter also worked on the implementation of the Bamako Initiative in Chad. He discusses these two experiences.

Can you start by telling us about the first project in which you were involved in, the “health stores"? What was the idea? In what context did it occur?

In 1984, during an exploratory mission in the sixth region of Mali (Timbuktu) and after several years of drought, MSF discovered a situation that was critical in every respect: socio-economic, sanitary, and food-wise. The decision was then taken to intervene and two things were set up: (1) a supply system of essential medicines for the health system; and (2) feeding centres for malnourished children. The centres were quickly operational and ran rehabilitation and nutrition education programmes. They also integrated other routine activities of the health centres. But it was not enough. Without massive food aid, the situation could only get worse. In a context of persistent drought, the population had exhausted all forms of food reserves, including seeds.

Events then precipitated: the donors came forward and MSF quickly became a major player in the widespread distribution of grains in the form of food-for-work activities. Food was given out in compensation for work that was organised following various community initiatives, such as the repair of water dykes or the rehabilitation of schools and health clinics.

To support food aid and the drug supply system, MSF also implemented a strategy of "health and drought stores". The idea was to create points for the supply of different basic items such as seeds, spare parts for irrigation pumps, or essential medicines for hospitals and clinics. It would then establish a buffer, a capacity of resilience of the supply system. This system had to be sustainable and a cost recovery approach was therefore chosen. "Stores" would sell their products.

What did the health stores bring new?

In fact, there first was a transition from the emergency "health and drought stores" to the "health stores". These structures were supposed to supply dispensaries and hospitals, given that the already existing “people’s pharmacies” could not do that anymore.

Health stores were accompanied by several innovations, at the medical level first:

• The concept of essential drugs was something new. The list of products used was that of MSF. The “people's pharmacy”, which was the traditional supply system, proposed wholesaler packages for some molecules, but shortages were common. Hence the import of stocks of drugs for the 5th and 6th and health region.
• Similarly, trainings on the use of essential drugs (prescription, dosage, etc.) were organized for the medical staffs.
• A system for recording visits was set up and operated at the health facility-level. Indeed, the rationale for the use of drugs should be based on the morbidity encountered.

And what was new in terms of health services management? Did community participation originate in food-for-work activities?

Yes, building on community experiences during the food-for-work emergency phase of 1984, MSF set up the first health committees Mali. In fact, we transformed the food-for-work and nutrition committees into committees around the health centres, each covering a catchment population. The committee was supposed to be involved in the management of the stock of medicines and ensure the proper use of the means available at the health centre-level. It was composed of members of the community.

Community participation was an opportunity created by the extremely precarious situation in which the population was. Food-for-work was addressed to communities and was thought of as compensation against work for the common interest. This approach enabled us to achieve the rapid distribution of a large quantity of food to the final recipients. The flexibility of an organization like MSF has probably improved the efficiency of the system, but at the same time, public structures were partially bypassed. This caused frictions but the inclusion of district chiefs and village health workers in the health committees helped us avoid problems. The involvement of the whole community, including the medical staffs and authorities, in the project allowed everyone to save face.

How did the health store strategy work? How was the idea received by the population?

This system quickly proved efficient in terms of drug supply. The pyramid –one store per region, and then stores at the lower level (the “cercle”) that cater for health centres– was effective, and so was the procurement system that was flexible and required only limited consultation with some suppliers known for their reliability. Through the new system, out of stocks stopped.

On the ground, there was no visible problem with the acceptance of health stores and this especially because of the situation; who would dare to question a program that caters effectively for an entire area in an adverse socio-economic context? Conversely, it is difficult to say whether all the actors really supported the concept. It is likely that the administration of Public Health was divided on the issue: on the one hand because it disavowed the existing system and on the other hand because of the too important place of MSF in the implementation and management.

Obviously, the speed of implementation and the effectiveness of the system aroused the curiosity of other donors and international organizations. Given the situation, the involvement of the population was -among others- opportunistic, but it fit perfectly with the concept of Primary Health Care advocated at the Alma-Ata conference.

Later on, the Bamako Initiative was inspired largely on the "success story" of health stores. Its founders believed that with this strategy, health for all by the year 2000 was at hand. However, we were quickly disillusioned. At the time of the Bamako Initiative, the health stores had not gone through their “sickness of youth” and it was unclear whether the concept as such, partly based on community participation, was actually viable in the medium and long run.

Based on your experience, do you feel that community participation was ‘spontaneous’?

In times of scarcity and famine, when everybody first works for their own survival and the survival of their relatives, community participation could never be spontaneous. Similarly, in a less dire situation but still marked by relative poverty, community participation without an immediate benefit for oneself or one’s family seems illusory.

Community participation had been requested to facilitate the delivery of aid and then organize the management of health activities. I think this participation was neither entirely spontaneous nor completely imposed. It was naturally organized around the revitalization of health facilities. With food-for-work, nutritional rehabilitation, and the supply of drugs, the benefits of participation were immediate and visible.

Let's talk about your experience in Chad. What were the differences with Mali?

MSF had already begun the supply of essential drugs to Chad during the civil war in the 1980s’. Our activities were gradually extended over a large part of the territory until the mid- 90s’ (I left Chad in 1995); there was a very serious shortage of skilled medical staff. Driven by the circumstances, MSF became a major player in the health pyramid, and was completely integrated to it.

The establishment of community participation in the prefecture of Mayo-Kebbi in 1989 took place in the context of a larger project of revitalization of the entire health system that included the rehabilitation and extension of infrastructures, the revitalization of district hospitals, and support in medical supplies and staff training. From the outset, community participation was oriented towards the active participation of the population in the management of health centres. This management was mainly about the revenues generated through curative consultations in order to cover the cost of medicines.

Revenue management was provided by a person designated by the health committee. This system was encouraged and supervised by the head doctor. The remoteness and lack of competence in the field did not allow for other alternative for the management of relatively large amounts of money; direct management by the medical staff was not a credible alternative. Revenue management remained risky because there often was no way to deposit money outside the health facility.

In an interview on this blog, Agostino Paganini declared that the Bamako Initiative died long ago. What is your take on that?

It is impossible for me to know what our projects have become, especially against the background of the tragic circumstances the region is going through. However, it seems that community participation as conceived in this time is fragile and transient. The heavy investment that is needed for community mobilization and voluntary participation to the committees is hard to sustain and inevitably leads to the depletion of the initial enthusiasm. The “bureaucratization” of some positions in the committees, such as treasurer or manager, often announces the beginning of a general decline in community participation.

In situations I have experienced in countries facing socio-economic and / or political stability and security issues, participation is not spontaneous and does not originate in local initiatives. It is rather part of intervention and support strategies, it is genuine good intention but it is not necessarily in phase with the problems of the target population.

Community participation, as long as community mobilization is supported and regular, can be an interesting vantage point to address populations’ need and take action. Yet, the survival of such initiative is directly related to the duration of the projects/interventions.

Jean-Benoît Falisse

Dans le cadre de notre série sur les 25 ans de l'Initiative de Bamako, Jean-Benoît Falisse interviewe le Docteur Canut Nkuzimana, membre de la CoP Financement Basé sur la Performance depuis sa création. Canut a travaillé au Ministère de la Santé du Burundi à la fin des années 1990 avant de rejoindre Cordaid. Il a eu l’occasion de participer à la mise en place des premiers comités de santé (COSA) du Burundi, au développement du financement basé sur la performance (FBP) dans le pays et plus récemment à celui du « FBP communautaire ». Il nous parle de ses expériences.

Jean-Benoît Falisse: Vous avez eu l'occasion de mettre en place des comités de santé dans le sud du Burundi pour le compte de Memisa (futur Cordaid). Comment cela s'est-il passé?

Canut Nkuzimana: En février 2002, quand Memisa me recrute pour piloter son projet de soins de santé primaire à Makamba, la région était encore une zone de guerre. Plus de 40% de la population de la province vivait dans des sites de déplacés intérieurs. Ces sites -des lieux de misère, de maladie et d’abus de toutes sortes- étaient situés autour des centres de santé et des écoles. Certaines de ces institutions avaient d’ailleurs cessé de fonctionner pour n’être plus que des abris pour déplacés de guerre. Dans les centres de santé qui fonctionnaient encore, la gestion était calamiteuse; le staff qualifié avait bien souvent déserté et le personnel gérait le centre comme il l’entendait. Il n’y avait aucun suivi. Mon projet cherchait à relancer les activités dans les centres de santé où la situation le permettait et à mettre en place des postes de soins dans certains sites pour permettre à la population d'avoir un paquet réduit de services: vaccination, planification familiale, services curatifs.

A l’époque, l’OMS et le Ministère de la Santé avaient commencé à promouvoir l'idée d'organiser la population pour qu'elle soit co-gestionnaire des services de santé et le contexte de Makamba nous a fait passer à l’action. La population devait co-gérer l’aide qu’elle recevait. Pour y arriver, des activités de sensibilisation ont été réalisées à l’endroit de l'autorité administrative (pertinence de l'action), de la population (importance de la gestion et de la redevabilité) et du personnel des centres de santé (nécessité de collaborer avec la population). Après ces séances, nous avons organisé, avec l'administration communale et le secteur de santé (district sanitaire: encore secteur de santé dans le temps), une assemblée générale par aire de santé. La population y recevait une explication préalable sur la nature, la mission, la composition et les obligations des COSA avant de l’élire.

Le principe était que chaque colline de l'aire de santé élise elle-même deux personnes (un homme et une femme, de deux flancs différents de la colline) dites intègres, dévouées à leur cause, et qui manifestent la volonté d'être élus pour les représenter au sein du COSA. Une fois les membres élus, ceux-ci mettaient en place un bureau exécutif. Les élections étaient suivies de formations et d’un long processus de suivi. La population était fière de participer à la gestion des centres de santé et cela a été un point de départ pour organiser une participation communautaire effective.

Comment cela a-t-il évolué ?

En 2002, la stratégie de comité de santé est devenue plus évidente et plus facile à mettre en place car (1) la population vivait dans les sites de déplacés et était donc plus facile à réunir, (2) la situation de crise rendait la population particulièrement sensible aux questions de santé et (3) en tant que « bailleur » nous étions plus écoutés par les formations sanitaires et la population. La stratégie communautaire nous permettait aussi de rassembler et de travailler sur la polyvalence et l’intégration des différents agents de santé communautaires qui travaillaient jusque-là en solo, sans financement, et qui n'étaient utilisés que ponctuellement en période d'épidémie. Enfin, en tant que structures de dialogue communautaire, les COSA nous aidaient dans l’identification et le suivi de la prise en charge des personnes vulnérables (indigents) par les centres de santé et les hôpitaux de première référence.

Dès 2006, la gratuité des soins de santé pour les femmes enceintes et les enfants de moins de cinq ans a été mise en place au Burundi. Différentes initiatives de financement basé sur la performance ont également été mises en place à ce moment. Quelle a été la place de la participation communautaire là-dedans?

Sur la gratuité d’abord, le rôle du comité de santé est d'éclairer ces aspects de santé maternelle et infantile et d'informer la population des directives du ministère de santé. C'est le comité de santé qui doit expliquer aux ménages qu'il faut enregistrer les naissances et qu'il faut avoir des documents à présenter au niveau de la structure de santé. Le COSA permet un meilleur suivi, de voir si le système est équitable, si tous sont couverts; il défend les droits du bénéficiaire dans l'aire de santé.

Au niveau du FBP, l’interaction communautaire se fait à trois niveaux. D’abord le COSA est co-gestionnaire et participe à l'élaboration du plan d'action du centre de santé, lequel est l'outil de négociation du contrat. Ensuite, il y a la mise en place d’un système de contractualisation des agents de santé communautaire. Enfin, le système FBP va contracter des associations locales pour participer à l’audit des formations sanitaires (évaluation communautaire).

Aujourd'hui, on parle au Burundi de FBP communautaire, est-ce que vous pouvez nous expliquer ce que c'est?

A l'instar du FBP dit ‘clinique’ qui subventionne les services prestés par les  formations sanitaires, le FBP communautaire subventionne les résultats des agents de santé communautaires organisés. Les activités de ces agents se font sur 3 aspects: la sensibilisation de la population pour l'utilisation des services; la récupération des abandons (vaccination, tuberculose, ARV, etc.) et l'offre de services par les distributions (moustiquaires, méthodes contraceptives, etc.) (voir tableau ci-dessous, taux de change: 1 $ = 1530 FBU).

Est-ce que les limites du bénévolat ne s'appliquent pas aussi pour  les comités de santé ?

Pour les comités de santé aussi, le bénévolat a été en quelque sorte surmonté à travers la mise en œuvre du FBP. Nous avons senti que  si le centre de santé rémunère les prestations des membres du comité de santé, ce comité de santé n'aura plus de valeur représentative pour la population qui l'a élu. Donc, il a été imaginé une formule qui recommande aux structures de santé de contribuer au fonctionnement du comité de santé par un apport de 5% pourcent de ce qu'elles reçoivent en FBP. Le montant qui est donné n’est pas une prime, c’est un apport au fonctionnement. Le COSA peut s’acheter des stylos, du papier, des classeurs pour son fonctionnement. Et s'il faut payer une boisson le jour des réunions, c'est à eux d'apprécier. Les recettes qui sont générées au niveau du centre de santé sont en quelques sortes un apport de la communauté  à son financement et il est donc logique qu’une partie de celles-ci servent au bon fonctionnement de l’appareil de co-gestion communautaire du centre de santé. 

                                                                                                                                                                                                                                                                                    
Est-ce que la participation communautaire dans la santé a un avenir dans la région des Grands Lacs?

Oui, mais ça passe d’abord par la paix. Sans elle, difficile de continuer à travailler avec les communautés dans la durée. Dans le même temps, dans le contexte qui est le nôtre, l’approche communautaire donne une chance de rapprocher les populations, de les unir autour d'une même vision, d'un intérêt commun. A travers le FBP communautaire, il y a même une possibilité d’injecter un peu de fonds et de forme au niveau de la communauté. Une communauté qui est occupée, qui a du travail, qui a un intérêt commun, est beaucoup moins manipulable. La seconde condition est que le système de santé appréhende les besoins et réserve dans sa planification un financement pour ce  niveau. Il faut en effet organiser des formations cadrées pour ces acteurs communautaires.

Jean-Benoît Falisse

We continue our exploration of community participation in Africa, 25 years after the Bamako Initiative. Dr. Canut Nkuzimana is a member the CoP Performance Based Financing since its inception. He worked with the Ministry of Health of Burundi in the late 1990s before joining Cordaid. He had the opportunity to participate in the set-up of the first health committees of Burundi and in the development of performance-based financing (PBF) initiatives in the country. More recently, he has been active in launching a new "community PBF" project. Here I chat with him about his experiences.

You had the opportunity to establish health committees in southern Burundi on behalf of Memisa (future Cordaid). How did that happen?

In February 2002, when Memisa recruited me to pilot its primary care health project in Makamba, the region was still a war zone. More than 40% of the population of the province lived in internally displaced people’s (IDP) sites. These sites where places of poverty, disease and abuse of all kinds; they were located around the health centres and the schools. Some of these facilities had even stopped working in order to shelter those displaced by war. In the health centres that were still functioning, the management was calamitous; qualified staff had often deserted the place and the remaining staff members were running the centre as they liked. There was no follow-up. My project aimed to revive the activities in health centres and to develop nursing stations. The idea was to allow people to have access to a minimal package of services: immunization, family planning, and curative services.

At the time, the WHO and the Ministry of Health had begun to promote the idea of organizing the population to be the co-managers of their health services. The context of Makamba made us act. The population would be the co-manager of the aid it received. To get there, sensitization activities were conducted for the administrative authority (on the relevance of the project), the population (on the importance of management and accountability) and the staff of health centres (on the need to work with the population). After these sessions, we organized a general meeting in each health area, in collaboration with the local and the health sector (soon to renamed health district) authorities. The population received a preliminary explanation about the nature, the mission, the composition and the responsibilities of the health committees before they elected their members.

The idea was that the inhabitants of each “hill” (“colline”: the lowest administrative level in Burundi) of the health area would elect two people (a man and a woman, from two different sides of the hill) on the basis of their integrity, dedication to the cause, and willingness to represent them in the health committee. Once elected, the health committee members would set up an executive office. The elections were followed by training and a long monitoring process. The population was proud to participate in the management of health centres and it was a starting point for organizing effective community participation.

Was it easy to implement? Did it work?

In 2002, the health committee strategy was obvious and easy to implement because: (1) the population was living in IDP sites and was therefore easy to gather, (2) the crisis made the population particularly sensitive to health issues and, (3) as a donor we were influential in the health facilities and population.

The “community strategy” also allowed us to work on the flexibility and integration of various community health workers who had been working in solo and without funding until then and were only used occasionally, during epidemics.

Finally, as structures for community dialogue, the health committees helped us in identifying and monitoring the care of vulnerable people (“indigents”) by health centres and their referral to the hospitals.

In 2006, free health care for pregnant women and children under five was put in place in Burundi. Various funding initiatives based on performance were also introduced at that time. What is the role of community participation in those schemes?

On free health care first; the role of the health committee is to clarify these aspects of maternal and child health and to inform the population of the MoH guidelines. It is the health committee that must explain to the households the need to register births and bring those documents at the health facility. The health committees allow better monitoring to ensure that the system is fair and that everybody is covered. It defends the rights of the beneficiaries in the health area.

Regarding PBF, the interaction with the community is at three levels. First, the health committee is the co-manager of the health facility and participates in its development plan, which is the tool for negotiating the PBF contract. Second, there is the establishment of a system of contracting community health workers. Finally, the PBF system will hire local associations to participate in the audit of the health facilities (community assessment).

There has been a “community PBF” experiment in Burundi; could you tell us what it is?

Like the “clinical” PBF that subsidizes the services provided by health facilities, the community PBF subsidizes the results achieved by community health workers (CHWs). The activities of these agents focus on three dimensions: sensitization for the use of services, the recovery of dropouts (vaccination, tuberculosis, ART, etc.), distributions of nets, contraceptives, etc. (see table below for a list of the subsidised indicators - $1 = BIF1530 ).

Wouldn’t your reflection on the limits of voluntary work equally apply to the health committees?

For health committees, the issue of volunteering was somehow overcome through the implementation of the PBF. We felt that if the health centre pays benefits to the members of its health committee, the health committee may lost its representative dimension (the motivation to be elected would be biased). Therefore, we designed a formula that recommended to health facilities to assist the functioning of the health committee via a contribution of 5% of what they receive through the PBF. The amount that is given is not a premium; it is a contribution to the operation costs. The COSA can buy pens, paper, binders, etc. And whether it wants to pay its member a drink on meeting day, it is up to it. Revenues that are generated at the health centre are in a sense a community input, so it makes sense that some of that money is used for the proper functioning of the co-managing unit of the community health centre.                                                                                                                                                                                              Group of community health workers (Province Makamba) Photo: Korachais     
Does community participation in health have a future in the Great Lakes region?

Yes, but it starts with peace. Without it, it is difficult to continue to work with communities in the long run. At the same time, in our context, the community approach provides an opportunity to bring people together, to unite them around a common vision/interest. Through “Community PBF”, there is even a possibility to inject some funds and organize the community level. A community that is occupied, works, and has a common interest, is much less likely to be manipulated or to return to violence. The second condition is that the health systems understand the importance of the community and plans some funding of this level. It is indeed necessary to organize training for these community actors.

Sophie Witter

Our series related to the 25 years of the Bamako Initiative is slowly approaching its end. We have invited Sophie Witter (University of Aberdeen) to share some reflections on the Bamako Initiative. In the weeks to come, Jean-Benoît will present two last interviews (scoop: we have found one of the unknown fathers of the Bamako Initiative, who by the way, will answer some of the questions raised by Sophie Witter). Jean-Benoît will conclude the series with his own synthesis. 

As the anniversary call says, the Bamako Initiative of 1987 focussed on two ideas: (1) the introduction (or formalization) of user fees and (2) community participation in resource management, including essential drugs which were now sold to users. While charging may have been a necessary response at the time to collapsing public expenditure in the social sectors, there has always been something peculiar to me about the linkage of these two ideas – charging for services, and community participation. 

Over the years and decades which followed, the two seemed to become conflated, such that charging people equated to their participation. If people were not made to pay, they would therefore somehow be denied the right to participate in managing public services, or so the thinking went. But why? I would say that:

1. Management involvement is an independent variable – if you want people to join committees, or influence priorities or join in community activities, go ahead, that is great. Whether they are paying for services has no bearing on that issue. Where services are publically funded, the users are still tax-payers and citizens. They have just as much right to influence the way that services are delivered.

2. If you have to charge for services because you do not have enough funds, say it straight. Recognise that it is a necessary evil, which will hopefully be temporary. Don’t dress it up with some imagined benefits of community participation.

3. If participation is such a good thing, why is it confined to poor areas and poor populations? The Bamako Initiative focussed on rural districts, which essentially were the ones which were not receiving much public funding. So those who could least afford to pay were paying, while urban areas could turn to better funded hospitals, which they were not expected to run.

4. We need also to recognise that getting involved in resource and other management functions has very real costs for the participants. Those who you might most want to be represented have the least time to spare. The poor and especially women are time-poor – struggling to survive, working, trying to finding time to bring up their children.

5. Finally, community participation – which, if done sensitively, can be a valuable tool to increase provider accountability – needs to work alongside proper supervision, regulation, and setting the right incentives for facilities and staff. If the local public health care system is based around making money from selling drugs and charging fees for services, as it was under the Bamako Initiative, then no amount of users’ committees will be able to protect the patients from abuse.

So as we look back on the Bamako Initiative, let’s reflect on some of the muddled thinking that went with it, and be glad that we are moving into an era where there is a greater commitment, nationally and internationally, to move towards universal coverage, with greater public funding of essential health services. Let us also confront the challenges of achieving greater accountability of providers and real participation - not the kind that meant having to pay if you wanted your child to survive.

The second part of our interview with Dr. Agostino Paganini brings us to the evolution of the Bamako Initiative over time and its political feature. Agostino Paganini has an extensive experience of primary health care and emergency health care in Africa, an area in which he has been active for over forty years now.  He was the manager of the Bamako Initiative (BI) Support Unit at the UNICEF HQ. The unit worked closely with African countries that had shown interest in the principles of the BI. In the 1990s’ and 2000s’, he continued to work with UNICEF as a Team Leader for Health in Emergencies and as a country director in Somalia. He has also done senior consultancy work with the World Bank and advises the director of CUAMM (Doctors With Africa).

In retrospect, some people say the Bamako agenda has rarely been properly implemented. In a post on this blog and in an article, Valery Ridde says we me be better abolishing the Bamako Initiative (it is of course a provocation). How do you view the implementation of the Bamako principles until now?

Absolutely. I think this initiative died a long time ago. I think some of the principles are still incredibly valid and some of the problems it was trying to address also still exist. The problem of public accountability and people participation in the management of their health system should be have been better addressed with more democracy but still, it is left unattended in many African countries. The problem of out-of-pocket expenditures with no rules is also still extremely valid. We can call it Bamako Initiative or we can call it the way we want, it does not really matter: some of the problems which the Bamako was trying to address are still there and some of the experiences and principles (some have been applied and some have been badly applied) are still very relevant. But as an initiative, no, I do not think there is such thing as a Bamako Initiative alive at the moment. At least I have not seen anything. 

Would you agree with Susan Rifkin who says that the Bamako Initiative has widened the horizons of community participation? Do you see the current shift from community participation to community accountability as another widening?

Let's be clear, community accountability is accountability towards the community. The difference now is that communities become shareholders. Before they were paying under the table, now they pay and they can ask, what have you done with the money, why have you not done this or that? This is the difference between a vague participatory process and being represented and part of the management of the health unit. And this is something we still need to work on. People have no voice and no exit in low-income countries, except to go to the private sector, but this is not for the poor.

In her recent interview on this blog, Sassy Molyneux insists that we must “carefully consider remuneration and other forms of incentives for community representatives, the challenges of asymmetries between health staff and community representatives in resources and power, and the importance of building trustful relationships”. To me, this sounds a bit like considering the local politics of health. It always struck me how little attention seems to be paid to politics in the BI. We are in a sort of political process, right?

It is political. And not understanding that it is political is the biggest mistake you could do. I think that within the public health community we are sometimes very naïve. We think about supervision and training as the keys to everything but health is political. This is why the US has its health system and this is why Scandinavians have a different health system. Science is science but how science is available as well as the quality of and equity in access to care are political issues. We have to accept it is a though road to get to high quality equitable health care and we are not there yet. There still is a huge asymmetry between the health staff and the people and it is a sign that democracy is not there yet. We need to start from this problem. What I have seen with the Bamako Initiative is a deeply political, not a strictly technical, issue. But of course, people use things and declarations in different ways and they have used this initiative according to their own interests and point of view.

Twenty five years have passed. You have an extensive experience of primary health care in low income countries. According to you, what will be the keys for primary health care in the next 25 years?

What I see coming is more privatisation and more urbanisation. People seem to find in urban areas and even in slums opportunities they do not have in their rural areas. Some countries are growing and establishing health insurance which is an excellent thing I think. At the end of my time working on the Bamako Initiative, we were working on two things (there were two teams). One was community-based monitoring, because data are power. The other was local insurance. Health insurance is a key issue but it is difficult to establish. In many case they start at the national level; yet, in Europe local solidarity mechanisms were the initial insurances.

We need to work on public accountability and equity. These are the two key areas. Are we going in this direction? I am not sure. I think in some countries we are, but in a majority of other countries the private sector is growing as people have more resources and the public sector remains under-financed. What is more, this public sector is very inefficient unless there is public accountability. This is the mixed picture I have. On one side, they are countries progressing, doing very going things. Take for instance the experience of Rwanda with community-based health insurance (French: mutuelles de santé) and new staff remuneration policy. But on the other side, there are many others I think are not going in the same direction.

Any questions I have not asked and you would have liked me to ask or any conclusion you would like to make?

Not really, for me, as I said, it was a fascinating experience. I realised it was also a fascinating debate. Some of the issues are, as I said, very political and some are extremely relevant now. We have to address the relation between the patient, the client and the provider. The current debate of performance-based financing, which is linking financing not to the drugs but to the results, is also extremely interesting. Of course, it will not solve all the problems. I think we should be able to see what the good experiences were in the past and move on, adding on new experiences and new things. Basic public accountability and the role of people is extremely important, good governance of health facilities is very important but result-based financing of health facilities is also very promising if we combine it with other things we have learned. We should not move from fashion to fashion but take the past into account, understand what we have learned and build on it.

Jean-Benoît Falisse


This is the second part of the interview with the huge community-driven reconstruction programme 'Tuungane' of IRC in Eastern DRCongo. We now turn to issues around community participation in health care.

JBF: Let’s now turn to health. If I understand correctly, the communities had the choice of allocating the money coming from Tuungane to the sector of their choice. Was health-care a much sought after sector? Did it emerge as a priority? What were the main challenges?

VQ & FD : On average, health is chosen second most often by communities in the program, after education. Tuungane dedicated over $ 5 million to the health sector in the first phase (2007 to 2010). Schools were often the communities’ first choice because in general the education sector currently receives much less support than the health sector. In addition, the health sector is more regulated than others in DR Congo: health facilities must be registered and most importantly, have qualified staff to operate.

For the rapid impact projects at the village level in phase I, health was chosen third most often with 223 projects put in place and $484,000 invested. Communities most often chose to build, renovate or equip their health center or maternity ward. Among the larger community-level projects, health was chosen more often than at the village level. As a result, 69 major health infrastructures were built with an investment of nearly $ 5 million. Equipment needs were also considered important at this level, and nearly $ 10,000 per centre went into purchase of things like solar panels, and other electrical equipment to ensure a power supply, given that electricity is not common in rural areas.

A challenge that remains in the end is the ongoing management and functionality of these infrastructures. Without drugs, or qualified staff that are properly supervised, the facilities cannot provide quality service.  To work further on this, the current Tuungane design ensures links with line ministry officials, and with other donors and programs working in the area to improve the sustainability of these health-care facilities.

JBF: IRC has also chosen to support health development committees (CODESA), why did you choose this approach? Can the CODESA really work in the context of humanitarian emergency of Eastern DRC?

VQ & FD : The Health Development Committee (CODESA) is really the program’s entry point to understand the real challenges which health care workers faces at the local level. Generally, these challenges are not limited to the lack of infrastructure but also involve problems of financial management and logistics.

Often, the CODESA is not in a position to play the role they are meant to, that of intermediary between the community and the health service providers. Their members lack both the knowledge of their roles and responsibilities and means to fulfill them.  It is not necessarily the humanitarian context is at the root of these limitations, but rather longstanding issues of low levels of education, weak management structures and lack of resources. Even in the Haut Katanga district of Katanga province in the south of the country which is not in a site of humanitarian emergency, the CODESAs are not effectively playing their role.

In principle, the CODESA is supposed to co-manage the health resources meaning: participate in developing planning of health services in the area, monitor and evaluate the health care services, schedule meetings to consult the population and make joint decisions related to service provision. According to its mandate, the CODESA is also supposed to mobilize local resources, develop small-scale projects to improve service provision, ensure public hygiene, and do public education and promotion of key health principles and behaviours.

When the community chooses health as their priority sector, Tuungane works to strengthen the CODESA. Members of the CODESA are integrated into the Village Development Committee (VDC) so that they can provide technical advice, and also benefit from the training provided by the program and liaise between the VDC and the health personnel. As such, they actively participate in identifying implementing and managing the community project. In its second phase, the program provides a grant of $ 24,000 per community. This is divided into two parts. The first 95% is used to rehabilitate and equip existing health infrastructure. The 5% portion of the grant which remains is meant to spent on improving quality aspects of the service, that is, to resolve issues and problems related to the governance and management of the health facility .

JBF: IRC has also using a tool called the community score card. Is this a relatively known strategy of participation? What do you conclude from your experience? What is specific to your scorecard?

VQ & FD : To imbue the relationship between service providers and beneficiaries with accountability, the program first provides communities with information on the norms and standards as defined in country-wide health policies and strategies. Then we introduce a tool for evaluating and monitoring the service as delivered in the community: the Community Scorecard. Through this scorecard process, the community assesses the performance of the service provided in their local school or health center. After the scoring, the services users and service providers work together to develop a joint plan for service improvement. This so-called community scorecard methodology was developed by the World Bank.

Our first experiences with the scorecard mechanism showed that the population and even the health care workers had difficulty assessing aspects not related to the infrastructure, i.e. the non-tangible aspects of the service provision. They focused primarily on the poor condition of buildings and the lack of equipment. There are of course many more elements that come into play to get good health care. Therefore, the program pre-selected four indicators for communities to consider as part of the scoring: (i) access to care, (ii) equity or the fair treatment of all patients, (iii) participation of the Health Development Committee (CODESA ) in the financial management of the infrastructure, and (iv) their overall impression of the quality of care.

Results following use of the scorecard show some initial signs of improvement taking place in communities such as better access to information about health care services, and a greater understanding of the roles and responsibilities among all parties involved. Through the discussions, the community members and the CODESA build an understanding that they are entitled to certain service standards, but they also have a role to play in ensuring quality service. For example, they have a right to access to quality health care, but they also have a duty to behave responsibly in the prevention of epidemics. The CODESA knows it has the right to audit the budget of the health facility, but it also has a duty to report and consult the public on major decisions taken regarding health services in the area.

In addition, the CODESA and representatives of the people realize that they are potentially allies in the seeking service improvements, because they have certain interests in common. Indeed, they realize if external partners were not intervening in the delivery of health care services, the health facilities and their staff would be left to fend for themselves and just do their best to survive with minimal means. To address this, the program help communities and frontline services providers go together to meet with line ministry representatives, such as the Chief Medical Officer and Public Health Inspectors responsible for the jurisdiction. In dialoguing with these higher-level authorities, the community representatives and service providers endeavour to (i) obtain the higher authorities’ approval for the project they have chosen for the sector, (ii) raise awareness of the real problems and challenges facing the community, and (iii) solicit their support in finding joint solutions to improve health services at the village level.

Since 2007 the program has made great strides in terms of engagement with the Congolese administrative and line ministry authorities. It strives to create space for a productive dialogue between government officials and village-level constituents to improve the quality of service provision at the village level..

Jean-Benoît Falisse


Voici la deuxième partie de l'interview avec le programme de reconstruction communautaire 'Tuungane' mené par IRC à l'est de la RD Congo. Nous nous intéressons maintenant plus spécifiquement à la participation communautaire dans la santé.

JBF : Venons-en maintenant à la santé. Si je comprends bien, les communautés avaient le choix de l'allocation de la bourse de IRC. La santé a-t-elle été un secteur beaucoup sollicité? Est-elle apparue comme une priorité? Quels étaient les défis principaux?

VQ & FD : Tuungane I à 2 projets : au niveau du village (projet CDV avec $3,000) et au niveau de la communauté qui est un regroupement plus large des mêmes villages (projet CDC entre $50,000 et $70,000)
La santé est en moyenne le deuxième secteur de choix dans le cadre du programme Tuungane qui y a accordé plus de 5 millions de dollars de 2007 à 2010. L’éducation est souvent le premier choix des communautés notamment parce que ce secteur reçoit à l’heure actuelle nettement moins d’appui extérieur que le secteur de la santé. Ce secteur est aussi plus régulé que les autres en RD Congo : il faut avoir un code d’immatriculation, et plus important, un staff qualifié pour opérer.

Pour les projets à impact rapide de Tuungane 1, la santé occupe la 3ème place avec 223 projets réalisés et 484 mille dollars investis. Les communautés ont donc choisi de construire, de rénover ou d’équiper leur centre ou poste de santé voire leur maternité. La santé a eu une place bien plus importante lors des projets communautaires : 69 projets d’envergure pour un total de presque 5 millions de dollars décaissés.
L’équipement fut particulièrement onéreux avec près de $10,000 par centre de santé. Une bonne partie allait pour l’achat de panneaux solaires, convertisseurs et batteries pour assurer l’alimentation en électricité, toujours absente dans les zones rurales.

Enfin, un grand défi est la gestion et la fonctionnalité de ces infrastructures. Sans approvisionnement en médicaments, sans personnel qualifié et supervisé, un centre de santé ne peut pas fournir un service de qualité. Tuungane s’assure dès lors de faire le lien avec les services techniques et les autres bailleurs pour assurer la pérennité de ces structures de soin.

JBF : IRC a aussi choisi de renforcer les comités de développement sanitaire (CODESA), pourquoi avoir choisi une telle approche? Est-ce que des CODESA peuvent vraiment fonctionner dans un contexte d'urgence humanitaire qui est celui d'une partie de l'est de la RDC?

VQ & FD : Le comité de la santé (CODESA) est véritablement le point d’entrée du programme pour comprendre les réels défis du personnel de santé au niveau local. Généralement, les défis ne se limitent pas au manque d’infrastructure. Généralement, les problèmes touchent tout autant la gestion financière et logistique de ces infrastructures.
Mais le plus souvent, le CODESA n’arrive pas à jouer ce rôle de relais communautaire. Par manque de connaissance de ses responsabilités ou par manque de moyens pour les réaliser.  Plutôt que l’urgence, c’est le faible niveau d’instruction, de supervision et de moyens de ces organes qui limite leur performance.  Même au Haut Katanga, dans le Sud du pays, qui n’est pas dans un contexte d’urgence à proprement parler, les CODESA ne sont pas suffisamment fonctionnels.

En principe, le CODESA est censé cogérer les ressources du centre de santé, participer à l’élaboration du plan de développement de l’aire de santé, faire le suivi et l’évaluation des interventions sanitaires, programmer des assemblées générales avec la population pour prendre les décisions majeures et leur rendre compte sur les décisions des services techniques. Selon son mandat, il doit aussi mobiliser des ressources locales, élaborer des microprojets d’aménagement d’ouvrages, s’assurer de l’assainissement du milieu, et informer, éduquer et communiquer avec la population sur les principes clés de la santé.  Lorsque la communauté choisit de travailler dans le secteur de la santé, Tuungane renforce ces CODESA.
Systématiquement, quelques membres du CODESA sont inclus dans le comité de développement du village (CDV) pour qu’ils puissent apporter leur avis technique, bénéficier des formations dispensées par le programme et faire le lien entre le CDV élu dans le cadre du programme et le personnel de la santé. Ils participent ainsi pleinement à l’identification, au montage et à la gestion du projet communautaire.

Dans sa seconde phase, le programme accorde une subvention de $24,000 par communauté. Celle-ci est divisée en deux parties. La première, 95%, sert à réhabiliter l’infrastructure sanitaire existante. La seconde partie de la subvention, 5%, est consacrée à l’amélioration du service proprement dit c’est-à-dire la résolution des problèmes liés à la gouvernance et la gestion de l’infrastructure.

JBF : IRC a aussi mis en place des cartes communautaires (community score cards) dans la santé. C'est une stratégie de participation déjà relativement ancienne, que tirez-vous de cette expérience? Quelle a été la spécificité de vos cartes?

VQ & FD : Pour insuffler une relation de redevabilité et de reddition de comptes entre prestataires de service et bénéficiaires, le programme se focalise d’abord sur la diffusion d’informations concernant les normes étatiques en vigueur. Ensuite, on introduit un outil d’évaluation et de suivi communautaire : le Bulletin Communautaire de Performance. A travers ce bulletin, la communauté peut évaluer régulièrement la performance du service fourni dans son école ou son centre de santé. Après cette évaluation, un plan d’amélioration du service est élaboré conjointement entre prestataires et bénéficiaires du service. Ceci est la méthodologie dite du community scorecard telle qu’élaborée par la Banque Mondiale.

Nos premières expériences avec cet instrument d’évaluation communautaire nous ont montré que la population et même le personnel de la santé avaient du mal à évaluer les aspects non infrastructure de la santé. C'est-à-dire qu’ils se focalisaient avant tout sur le piètre état des bâtiments et sur le manque d’'équipement. Or, il y a bien plus d’éléments qui entrent en ligne de compte pour obtenir de bons soins de santé. Ainsi, le programme a choisi 4 indicateurs type que les communautés doivent considérer, tels que : (i) l’accès aux soins, (ii) le traitement équitable des malades, (iii) la participation du comité de développement de la santé (CODESA) dans la gestion financière de l’infrastructure, et enfin (iv) leur impression générale sur la qualité des soins.

Suite à l’introduction de cet outil, les premiers résultats montrent un meilleur accès à l’information et une plus grande connaissance des rôles et responsabilités de chacun. La communauté et le CODESA, à travers les discussions, comprennent qu’ils ont des droits mais aussi des devoirs. Ils ont par exemple le droit d’accéder à des soins de santé primaire de qualité mais aussi le devoir d’adopter un comportement responsable pour la prévention des épidémies. Le CODESA comprend désormais qu’il a le droit de vérifier le budget de l’infrastructure sanitaire, mais aussi, qu’il a le devoir de rendre compte à la population sur les grandes décisions prises par l’aire de santé.

Aussi, le CODESA et des représentants de la population se rendent compte qu’ils sont potentiellement alliés parce qu’ils ont certains intérêts en communs. En effet, s’il n’y a pas un partenaire extérieur pour intervenir, les infrastructures et son personnel sont livrés à eux-mêmes et doivent s’organiser pour subvenir à l’essentiel.
En cela, le programme s’efforce de mobiliser les services techniques (Médecin Chef de Zone, Superviseurs en Eau, Hygiène et Assainissement) pour venir rencontrer directement les communautés et échanger avec elles en vue (i) d’autoriser la réalisation du projet dans ce secteur, (ii) de prendre conscience des problèmes et défis réels qui affectent les communautés, et (iii) de trouver des solutions conjointes en vue d’améliorer le service offert au niveau du village.
Ainsi, depuis 2007 le programme a fait des grands progrès en termes d’engagement avec les autorités et services techniques congolais et il s’efforce de créer des espaces de dialogue constructif entre ces représentants du gouvernement local et les populations en vue d’améliorer la qualité des services fournis au niveau du village.