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Incentivizing Respectful Maternity Care - could PBF promote comprehensive change?

5/2/2017

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Shannon McMahon, Christabel Kambala and Manuela De Allegri
The PBF Community of Practice is initiating a collaborative learning program on ‘PBF & Quality of Care’. Health Financing in Africa welcomes testimonies, opinion pieces and presentations of research findings. In this first blog of our series, Shannon McMahon (Heidelberg University, Germany), Christabel Kambala (College of Medicine, Malawi), and Manuela De Allegri (Heidelberg University, Germany)* present findings from two evaluations in Malawi. The authors urge that Respectful Maternal Care (RMC) attracts more attention within the PBF community, and they offer insights into how PBF programming could be used to bolster elements of RMC.

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Respectful Maternity Care: status of the knowledge

Respectful Maternity Care (RMC) can be defined as the provision of dignified care to women. In recent years, the topic has featured prominently in maternal health, public health and human rights research. Literature reviews in 2010 and 2015 delineated what disrespectful care looks like. A 2016 review examined what drives disrespect in sub-Saharan Africa (SSA), and several studies (including Abuya 2015 and Sando 2016) have examined the prevalence of disrespectful care during childbirth. While knowledge of the problem is extensive, insights into a solution remain limited and narrow in scope. With one notable exception, studies detailing comprehensive, system-wide solutions are nearly non-existent.


Within the Performance Based Financing (PBF) community, RMC has scarcely gathered attention. A 2017 review on quality of care in PBF programming has noted that, to date, quality indicators have been focused on equipment and infrastructure with far less attention paid to patient-provider interactions or client perceptions of care, although these latter facets are emphasized in the WHO’s 2015 “Vision of quality for pregnant women and newborns”.

We see the challenge of RMC as an opportunity for PBF, and we urge colleagues within the CoP to consider how an output-based approach might address dilemmas related to disrespectful care.

The RMC community has built a compendium of indicators that could be used to measure disrespectful or abusive care. A sampling of questions (and their broader domains) that capture facets of disrespectful care, and could be incorporated into patient surveys and patient-provider observations are presented in Box 1.

We urge the PBF community to consider whether or how indicators like these could be integrated into

BOX 1 - A sampling of indicators* (and their broader domains)
that could be used to measure Respectful Maternity Care

  1. Did a woman deliver alone (abandonment) Was a woman allowed to move about during labor (freedom of birth position)
  2. Was a woman allowed to have a labor companion of her choice present (birth companion)
  3. Did health providers discuss a patient’s private health information in a way that others could hear (confidentiality)
  4. Did health providers allow a woman to incorporate cultural practices as much as possible (cultural respect)
  5. Was a woman denied care due to race, ethnicity, age, health status, social class etc (discrimination)
  6. Was a woman or her family asked for a bribe or informal payment (bribes)
  7. Was a woman detained due to lack of payment (detention)
  8. Was a woman hit, slapped, pushed, pinched or otherwise beaten during delivery (physical abuse)
  9. Did a provider scold, shout at or insult a woman (verbal abuse)
  10. Did a provider introduce him/herself to a patient (politeness)
  11. Did a provider seek consent before undertaking a clinical procedure (autonomy)
  12. Did a provider explain what was being done and what to expect during labor in a manner that a woman understood (information exchange)

*Source: https://www.k4health.org/toolkits/rmc/indicators-compendium
existing quality tools (whether during community verifications or facility-based observations). Our teams at Heidelberg University and the College of Medicine have begun having this conversation internally in light of our mixed-methods evaluations of two Malawi-based PBF programs across different districts in the country: the Results Based Financing for Maternal and Newborn Health (RBF4MNH) program and the Support for Service Delivery Integration – Performance Based Incentives (SSDI-PBI) program. Each evaluation revealed problems and opportunities in relation to promoting respect in the context of PBF.

Findings from our two evaluations

In terms of documenting the problem of disrespect, our findings reflect existing RMC literature. Across evaluations, women and community leaders described overcrowding and strained or cursory patient-provider interactions that often entailed demeaning, discriminatory or harsh remarks on behalf of providers.

In both evaluations, respondents reported feeling that providers were tired or overworked, and that they looked down upon the clients they served. The RBF4MNH evaluation placed particular emphasis on maternal care during delivery. In that study, women described how providers did not explain or effectively communicate what they were doing during labor and delivery. Women said they felt ignored. In extreme cases, women described giving birth alone or in the presence of an unskilled companion such as a friend, family member, fellow laboring woman, cleaner or security guard; in three instances, women described how their newborns fell to the floor during delivery as nobody was present to catch their baby. For their part, providers described feeling overworked and undervalued.

In terms of solutions, our evaluations also uncovered reasons to feel hopeful. After three years of implementation, respondents in both evaluations described facilities as having more equipment and better infrastructure (including, in the case of RBF4MNH, enhanced visual privacy via screens); being cleaner; and having a more consistent flow of supplies. Women who sought care in RBF4MNH intervention facilities were more likely to report satisfaction with the level of confidentiality and privacy provided to them during labor and delivery than their counterparts in control facilities. Finally, in both PBF programs, respondents described sensing that the program’s inclusion of patient feedback enhanced provider accountability. In RBF4MNH, this took the form of exit interviews wherein clients were asked a series of questions regarding their encounter with providers. In SSDI-PBI, this took the form of meetings where community members and providers could air grievances and discuss solutions. Whether through exit interviews or collective forums, the process of sharing insights and solutions forced health facility staff to recognize that a patient’s experience of care matters. As one provider said, “Look, when you know you are in part being assessed based on what a woman says, you have to be nice.”

Could PBF contribute more to respectful care?

We have debated within our research team whether it may be feasible for future PBF programs to more pointedly address mistreatment, by incorporating indicators that emphasize respectful care into quantity or quality checklists. We have also posed the following question to providers ‘Could an incentive scheme that rewards respectful care spark lasting changes in provider behaviors and attitudes?’ to which providers responded with caution. Several providers noted that within any given facility there is often a “bad apple” who tarnishes the image of the facility and seems obstinate in their disrespectful approach. Other providers described how a change in incentives could lead to workarounds that don’t eliminate disrespect, but merely shift the role of who is undertaking the disrespectful behavior. For example, overstretched facility staff could recruit those who accompany women to facilities-- in-laws, sisters or mothers --to enact verbally or physically abusive behaviors toward an “uncooperative” laboring woman. We envision that there are many more unintended consequences that could erode trust even amid a well-intentioned, respectful care-focused PBF program.

Despite these challenges, we err on the side of optimism. We recognize that the current dearth of interventions addressing respect is likely linked to the fact that this problem is multi-faceted, emotionally-charged, politically sensitive, and it transcends several tiers of the health system while also demanding long-term, cross-sector collaboration. This makes promoting respect a daunting prospect, but such challenges are not new to those working within PBF.

In fact, we see several parallels between the essential ingredients of a RMC-focused program and the historical experiences of PBF programs. Do both PBF and RMC programs demand a seismic shift in the way a health system operates and views itself? Yes. Do both PBF and RMC efforts require stakeholders from across ministries and sectors to work together in heretofore unheard of ways? Yes. Are PBF and respectful care programs likely to be perceived as burdensome or problematic by providers? Yes. Is the PBF community accustomed to questions and critiques regarding sustainability and cost – perhaps more than any other health intervention in recent memory? Yes it is, and the RMC community may need to brace for this too. Finally, must both PBF and RMC programmers consider how to bring about changes that ripple through several target audiences including: individual clients, households, communities, facilities, district health management teams and multiple ministries? Yes, they do. Given these parallels, could the PBF community harness their tacit and explicit knowledge and devise novel ways to address mistreatment of women? We think so.

*The researchers are engaged in evaluations of the RBF4MNH program and the SSDI-PBI program in Malawi. These evaluations were sponsored by donors including: the governments of the United States and Norway through the USAID | TRAction Project at URC, the Royal Norwegian Embassy in Malawi, and the Norwegian Agency for Development Cooperation (Norad).

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Performance Based Financing and Quality of Care: ready for an upgrade?

3/20/2017

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Bruno Meessen
Performance Based Financing (PBF) is now being implemented in a large number of countries. Ensuring that the PBF strategy is continuously improved must get our full attention. In this blog post, I focus on the challenge of quality care. I also present what the Community of Practice intends to do on this key issue. We are currently looking for experts willing to help us organize a first international meeting. Why not you ?
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The fact that PBF aims to increase the production of health services in countries where services are largely underutilized, is well known. It is also easy to understand the logic: if you are paid according to the number of units you produce, as long as your marginal cost of production is lower than the price you are paid, you have an incentive to increase your production.

From very early on, PBF was also introduced as a quality improvement strategy. When it comes to  improving quality, however, the theory of change is more complex, because the channels are multiple and potentially contradictory. Without being exhaustive, here are some important elements.


Paying for volume already has an influence on quality...

A first channel is the 'resources' effect. PBF will inject financial resources into the health facility. With these resources, the manager can make many decisions to strengthen the quality of care or services. For example, he/she may recruit more qualified staff; he/she can also improve the quality of the service (eg transforming a consultancy room to protect the privacy of users). It is my conviction that such improvements happen spontaneously in many health facilities under PBF.

Another channel stems from the fact that certain quality elements are determinants of quantitative performance. By remunerating the latter, staff are also indirectly encouraged to improve these quality elements. For instance, a health center keen on vaccinating more children will try to avoid stock-outs of vaccines; in its desire to attract more users, it will modify its opening hours ... or as it was, with a refreshing honesty, reported to us by a Rwandan nurse during a qualitative study in 2004: "From now on, we smile at our patients ".

But there are also elements of quality of care that are not determinants of volume. This is particularly the case for all quality elements that are not observable by the user (eg sterility of the surgical material) or which are ignored by the staff. A nurse who, due to lack of training, makes a diagnostic mistake in a systematic way will a priori continue to do so, regardless of the number of patients in consultation. Finally, there are situations of perverse incentives where quantity comes at the expense of quality. This is the case of the nurse who, to increase his quantity bonus, rushes through his consultation.

One can then wonder what effect purchasing quantity has on quality. The truth is that we don’t really know. One can suspect that some quality elements are improving – this is probably true for the aspects of quality noticed by the users. But one cannot exclude that on other aspects, quality suffers.


A solution: the introduction of quality checklists

To address this problem, PBF systems quickly introduced quality checklists into the payment system. Those who were in Rwanda at the very beginning of the PBF scheme will remember that this introduction was not straightforward: we discussed it thoroughly (among PBF experts).

The arguments in favor of these checklists were: "As a buyer, I do not want to buy only quantity; I want to make sure that every service I buy is of quality"; "By paying only for the quantity, there is a risk of incentivizing the health facilities to boost their volume, at the expense of quality"; "By paying for quality, we send the signal to the health staff that quality is important".

Arguments raised against these grids were: "Quality is multidimensional; many important elements are difficult to measure; we risk to only incentivize among staff what is easily measurable"; "Many determinants of quality arise from deeper causes, such as the initial training of health care workers; PBF does not address these causes".

As is often the case, there was some truth in both visions. In many countries adopting PBF, the initial level of quality is often very low - it is then relevant to create incentives for the presence of basic equipment and compliance with essential rules. You need an autoclave to sterilize surgical instruments. All health facilities must have clean toilets. Etc. PBF systems thus developed long lists of indicators with a focus on the availability of equipment and inputs. Routine data have shown almost everywhere that health facilities are sensitive to these incentives and that the quality index improves over time.

But those who were concerned about the bias in the measure of quality were also right. Those among you who attended our conference in Dar-es-Salaam will recall the presentation of a review of the lists of quality indicators in PBF systems. It showed that the indicator grids are biased towards what is easily measurable - equipment (hardware, etc.) (this study has now been published here).

The PBF quality checklists ignore important determinants of quality of care (eg knowledge of health personnel) and do not attempt to measure the outcome of the health services (e.g. cure). There is therefore a real risk that what is captured by the quarterly reviews is not enough to guarantee a level of quality that generates health benefits. In short, it is important for the nurse to have a stethoscope and medication, but if he does not know how to do a quality pediatric consultation and neglects to check some key parameters, there is a high risk that the diagnosis will be erroneous or incomplete.

This poses problems of different kinds. But for the sake of brevity, let’s just say that we could end up with a result contrary to our ambition: higher coverage rates, but mortality rates that do not move, simply because the quality of services is too low. 


The battle for quality care is also our responsibility

Questions abound. Have we used all the power of PBF to improve the quality of care? Or, on the contrary, do we not overestimate the contribution that PBF can make? What are the right mechanisms to change the behavior of clinicians? What is measurable and sensitive to an incentive system? How do we boost synergies between PBF and other strategies to improve quality of care (quality assurance circles, accreditation, etc.)? 

These and many other questions should be on the agenda. Some of the questions go beyond the PBF community, clearly. Currently, the whole international health community is concerned about the quality of care problem. A special commission has just been set up by The Lancet Global Health.

However, on the
PBF CoP side, we must also do our fair share in this global learning program. To this end, our CoP will launch a series of activities in 2017. We will proceed step by step as we obviously need to take into account our organizational capacities and resources when investing in this agenda  (if you are a possible sponsor, do not hesitate to contact us!).

Our attention should focus on two points. On the one hand, we must reopen the reflection on the theories of change of PBF. The mechanisms set in motion by PBF are quite complex, much more so than what has been said so far about this. The question of the theories of change is key, also for other purposes, but is particularly important for the issue of quality of care. We have already discussed this point in Dar-es-Salaam; we must now move into high gear. Expect some blogs and articles in the coming weeks and months.

On the other hand, we must also reflect on the quality indicators currently being collected in PBF systems. The time for critical analysis has come. This second project is ambitious (and as long as some checklists, perhaps!) - so we will take it step by step. As a first step, we decided to focus on quality indicators of family planning services. This challenge has the advantage of being well confined. It is also an area in which quality work has already been produced by different groups. Concretely, we have decided to organize an international meeting to which we will invite both family planning experts and PBF experts. Together, they will review existing indicators, identify areas for improvement, and formulate an implementation research agenda.

To support this process, we are currently looking for experts from both disciplines. We have already created a project on our Collectivity platform. The first responsibility for the volunteers will be to help us organize this meeting of experts. If you want to give us a hand, this is the time to apply! The meeting is scheduled for late summer and will take place in the beautiful city of Antwerp. Hope to see you there.
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Results Based Financing “the Messi way”

7/10/2014

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In this blogpost, Bruno Meessen (ITM, Antwerp) shares some of the key lessons he learned from the Argentinian Plan NACER. He compares this experience with the Performance Based Financing schemes that are being developed in Africa. Some interesting lessons...
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My first real encounter with the Plan NACER (now renamed “Programa SUMAR”, since the expansion of the target group and the benefit packages) (1) was in December 2013, at a donor meeting on RBF in Oslo. Martin Sabignoso, the Lionel Messi of Performance Based Financing (see picture), presented the Argentinian experience to us in a very convincing way. I was therefore happy to accept an invitation by the World Bank to attend its annual “Results and implementation workshop for RBF” (25 March – 1 April) in Buenos Aires. It was time to discover the experience in the country itself. Here are my own take home lessons (2).

Commonalities between SUMAR and PBF …

The Programa SUMAR and what we call Performance-Based Financing (PBF) in Africa, have many things in common. For a start, they both seem to work. In Buenos Aires, we had the chance to listen to Paul Gertler (Berkeley University). Paul is a big name in the research community: among many other things, he proved the impact of the Oportunidades scheme in Mexico and of PBF in Rwanda. He shared his findings on the impact of the Plan NACER on several key health outcomes. The figures are impressive: the Plan reduced the number of babies with a low birth weight, by increasing prenatal care use and quality; combined with better care for low birth weight babies, this led to a reduction in neonatal mortality among the scheme beneficiaries. One of the most interesting results is the reduction of the inequity in terms of health status across provinces: the poorest ones have caught up with the average in terms of infant mortality rates. The strategy is also very cost-effective.

Another similarity between NACER and PBF is the transformative power of the strategies – a feature which is growingly recognized as a key strength of such schemes. In Argentina, this could be seen at many levels. For instance, the program accelerated the adoption of ICT in the health system. Another nice example is the fact that NACER transformed the public health subsystem from one to which people were implicitly belonging (free health care) and implicitly covered (no list of health care services) into a system with formalization of the entitlement (people have to enroll in the program) and an explicit package of health services (Plan NACER Health Care Package). This has forced the public subsystem to collect names of people, which is seen as an important step in the development of a close relationship between the system and each eligible household. (3)

More fundamentally, it has demonstrated to the rest of the health administration the importance of focusing on results. During the field visit, I asked Claudio Scalamogna, general coordinator of the Programa SUMAR in the Province of Chaco, whether the new style of management brought by the Plan could one day penetrate other social sectors. He answered “This is my dream”.

A last similarity I want to highlight is the narrative used to present the scheme. When one listens to Martin, you get the impression you’re listening to a PBF champion. This is of course interesting, as both strategies developed in parallel and independently. I asked Martin how he explains this; his answer was straightforward: “Results Based Financing is about human beings, how human beings can improve their work, and how we, as policy makers, can empower the health workers towards a prioritized goal. Our assessment in Argentina was that in order to improve health of the under-covered population, we had to redesign incentives to health facilities, improve work conditions, give autonomy, provide opportunities for training and for greater participation in the health system. We think that is the secret and I am not surprised it applies to other countries as well”.

But the differences are even more interesting…

A first difference: Argentina is a federal state and the Programa SUMAR reflects this reality. The program rests on a two-tier contractual system: there’s one contract between the national level and each province and another one between the province and health facilities. The contract between the central government and the province has two components: 60% is paid on a capitation basis (in 2013, around 2.6 US$ per person who has registered for the SUMAR– but existing enrollees count only if they used at least one health service during the last 12 months), 40% is performance-based using tracer indicators (see below). Initially, the whole funding was coming from the national level (with money from a loan granted by the World Bank). But since 2009, the provinces have also been co-financing the program, up to 15% nowadays. This share is expected to grow further. Martin told us that an efficient trick to keep control over such a two-level system is to use the national funding to remunerate the provincial unit teams. This allows the central level to define the profiles of members of the provincial units and to have a say on recruitment by provincial units.

The national government maintains some key decision rights: it defines the list of health services that are covered under the program (the benefit package) and the categories of costs which can be covered at facility level with the revenue collected from the program. But the rest is under the control of the province. For instance, each province defines the fee to be paid to the health facility for each service. While the program´s rules stipulates that facilities are allowed to allocate to staff incentives up to 50% of the program revenue, it is up to  each province to decide whether that percentage will be 0 or 50. Of course, below the province, the health facilities are also granted key decision rights: thus the facility has the final decision on what to purchase (but with a variable degree of autonomy across provinces, as we could observe during our visit). We were told that in general, health facilities are prioritizing training opportunities, equipment and infrastructure improvements.

A second difference: more complex payment formulae

The National government puts the emphasis on 14 key interventions scientifically proven to have an impact on priority health problems. As quality is key for the effectiveness of these interventions, a lot of stress is put on fulfilling quality conditions. According to this principle, a province receives more resources as long as its performance is above defined targets. For example, if the province manages to give a first prenatal check-up before the 13th week to at least 29% of the eligible pregnant women, it will receive additional resources. The higher the percentage of women with early check-ups, the higher the retribution (It is a continuous payment function). Each tracer has a mandatory set of information regarding the quality of the health service to be reported for every case. For our example, the province must report – along with the name of the woman and her ID number – the  date of the first check-up, the week of gestation, the date of the last menstrual period, the probable date of birth and, of course, the name of the health facility that provided the health care.

The contract between the Province and the facilities is simpler. They are paid on a fee-for-service basis (a price per quantity, as in PBF systems). For a selected set of health services they have also an incentive to match some standards for quality. All of this is subject of ex post verification (see below). Additionally, some provinces are using higher prices for health services that fulfill the quality matrix. In this case, they are extending the sanction scheme post verification in order to penalize the cases that do not match these criteria.

I  discussed this approach with Gyuri Fritsche (World Bank). He reminded me that this approach – to pay for an output only if it has some key attributes of quality – was the initial strategy of the Belgian Technical Cooperation project in Rwanda (except that the BTC verified the fulfillment of quality attributes ex ante). This model had not been adopted for the scale up in Rwanda and elsewhere in Africa, as it was considered too difficult to bring to scale: collecting quantity and quality indicators separately was seen as much easier to implement – the former being collected monthly, the latter quarterly. The Argentinian system is indeed much more demanding in terms of routine data collection, but as we know, there is an ICT revolution going on. This is something we may have to reconsider in the future.

A third difference: allocation of the RBF revenue to individual bonuses is not the dominant model. Only seven out of twenty four provinces allow their facilities to pay incentives to the personnel. Martin told us that several reasons explain this heterogeneity. Some provinces do not want it for legal reasons, others because they don’t think direct incentives to personnel will bring better results; some also doubt they would be able to sustain a bonus scheme in the future. As a matter of fact, in the health centre we visited, the transfer received from SUMAR represented just 4% of the health centre wage bill. Not sure this would be enough to induce a dramatic change.

We were of course curious to know whether there was a difference in performance between the provinces which have allowed facilities to pay a bonus with the funding and those that haven’t. I asked the question to Paul and Martin. Paul explained that the outcome variables he used to prove the effectiveness of the NACER plan were very rare events; the sample sizes unfortunately did not allow to ascertain a possible positive contribution of individual bonuses. He is about to check this possible determinant with another data set. Martin’s assessment was that the main determinant of the surge in performance has been the  expansion of autonomy at facility level: to have resources and be free to allocate them. As he put it nicely: “Health facilities have set up collective management approaches. RBF represents a real change in the culture of the health system, including at health facility level. For the first time health staff are participating in allocation decisions. This is also incentivizing!” The staff of the health centre we visited gave us another (complementary) explanation: the economic crisis of 2001 was really terrible and the health system experienced a collapse. The reinjection of funds brought by the NACER plan and the fact that the health facility staff had decision rights was a relief and created a new dynamic.

A fourth difference: a more important role for external verification. In PBF schemes, external verification is mainly there as a mechanism to reassure sponsors about the reliability of the verification system; it is henceforth called ‘counter-verification’. The External Concurrent Audit in Argentina is more integrated in the general functioning of the RBF scheme. For instance, the information gathered by the external audit firm feeds into the supervision program of the internal auditors. The permanence of the external audit allows the internal audit to focus on supervision, coaching and problem solving. This is something very valuable as this allows the program supervisor not to be perceived as controller. In Argentina, the external audit’s decisions have biding authority: if a discrepancy from the rules is found, no interference by authorities is possible: the penalty will have to be paid. This external audit is costly, but interestingly enough, the fines it charges to health facilities are nearly covering the full cost of doing the external audit.

A fifth difference: the management of Programa SUMAR involves a lot of people. Olivier Basenya (Ministry of Health, Burundi) and I were a bit shocked by the numbers mentioned when we heard them for the first time in Oslo: 150 staff at the national office of the program and 700 for the whole country! Compare:  Burundi’s central level PBF team counts only 7 ministry of health staff and 3 staff affiliated to partners. Are too many people involved in SUMAR management?

As explained by Martin: “Our job is to develop the strategic planning, to provide support and to supervise the 7,000 health facilities involved in the program. We are also administrating the 24 legal performance contracts. Our team is therefore multidisciplinary: we have economists, physicians, lawyers, social psychologists, experts in communication, experts in information technology, accountants… Health progress is multi-causal, so you need to build multiple solutions, multi perspective solutions. We are always fine-tuning the strategy, trying to learn what the reality is saying to us. We are also very committed to training the provincial teams. SUMAR is also a program that integrates all other substantial programs. We are working with more than 30 health programs in our Ministry of Health”.

We also noticed  many medical doctors in the health center we visited (well, most were absent, but they were reported as members of the team). So, it is possible that the relatively large team of the SUMAR program partly reflects a context-specific reality, but we agree that some PBF national units in Africa could be strengthened.

A last difference:  the system is steered more dynamically

A big danger with a PBF system is self-satisfaction:  you set up the system and then you run it more or less in a routine way. At the workshop, I checked with Olivier Basenya about his main take home message, and he duly agreed: “the Argentinian national unit steers its RBF system in a more dynamic way than we do”.

To conclude

Argentina was a refreshing experience for many PBF experts. Let’s keep in mind that RBF is not about implementing a single standard model. Although there are principles and good practices, there might be even better practices out there that we still have to discover. We learned a lot from Argentina during our stay in the country. Conversely, the Argentinian team is also eager to learn from other country experiences, so don’t hesitate to invite Martin.

(1) In this text, I refer to “NACER” when I refer to the initial scheme. I use “SUMAR” when I refer to what is in place today.

(2) I express my sincere gratitude to the SUMAR team, and particularly Mrs Jesica Azar who kindly answered my numerous questions on the way to the health center.

(3) I find this idea interesting and could be considered in some African countries. Let’s illustrate the concept with the case of Burundi. Each child under 5 would still receive treatment for free, but the health centre would be reimbursed by the national PBF scheme only if the health centre can provide for each utilization by a child his ‘free health care’ number. The great benefit of such a model is that it incentivizes health facilities to enroll families in the program, a way to develop a stronger bond with them. I also imagine that our ICT/PBF colleagues could develop solutions to provide information on utilization by enrollees to health centres (lost in follow-up, etc) to improve continuity of care.


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MSF and the Mali ‘health stores’: the genesis of the Bamako Initiative?

10/14/2013

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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.


PictureMSF medical assistants in Chad, 1984
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.


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Maternal Health Fee Exemption Policies in Africa: sharing research results and experiences

5/24/2013

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Yamba Kafando


From November 25-28, 2013, a workshop on maternal health fee exemption policies is being organised in Ouagadougou (Burkina Faso). Its objective is to draw conclusions on such policies through research results and the experiences of key actors. 

For more than a decade now, a number of African countries have been implementing national fee exemption policies targeting certain services (HIV, malaria, deliveries, Caesarean sections, etc…) or specific population categories (children under 5, pregnant women, the elderly, etc…). The objective of most of these policies is to increase chances of reaching the MDGs and also to reduce financial barriers to accessing health care.

If there is one major shortcoming, however, it is that most of these policies were hurriedly implemented, began on a national scale without a pilot phase, and worse, without having designed or put in place any evaluation mechanisms to measure their effects.

Knowledge on fee exemption schemes: much production, but too little sharing and utilisation

Such highly political processes and hasty implementation present clear methodological challenges to those who wish to evaluate fee exemption schemes. And yet, many different research programs have undertaken studies on the subject and their results are now starting to become available. A number of NGOs have documented their fee exemption interventions. Managers of fee exemption schemes and front-line implementers also have important tacit knowledge that should be shared.

One common characteristic of the period in which these policies were implemented (2000-2010), is that there existed no platform in place for exchange and knowledge management among implementing countries. No doubt this at least partially explains why technical and scientific knowledge already available at the time was rarely used to improve fee exemption policies, leading to a cycle of repeating the same avoidable mistakes.

This situation did, however, lead people to realize the importance of creating such a platform for knowledge and experience sharing, and as such, the Financial Access to Health Services Community of practice (FAHS CoP) was launched.

A more scientific workshop

So it is with great pleasure – and we think a fair amount of legitimacy, that the FAHS CoP announces the upcoming workshop in Ouagadougou dedicated to the evaluation of maternal health services fee exemptions in Africa.

Many of you will remember the one held in Bamako in November 2011. With this upcoming, and most likely last CoP workshop on the topic, we feel confident we can close this chapter of knowledge production.The Ouagadougou workshop will be more scientific than Bamako was: it will allow us to highlight and share the knowledge created through studies carried out on maternal health fee exemptions by different research consortiums, including those linked to the FEMHealth project, the University of Montreal and the University of Heidelberg.

The workshop aims to bring together countries implementing maternal health fee exemptions with research teams who have been investigating these policies in Africa. The goal of this workshop will not be to judge the choices countries have made regarding maternal health fee exemptions, but rather to help them to make them more effective and efficient so as to improve the health of their populations.
 
In order to facilitate a maximum of exchange, a call for abstracts covering 10 themes has been issued not only for researchers, but also for managers and implementers of such schemes. We would like to invite you to share your experience on the topic through this blog, and also by submitting an abstract for the Ouagadougou workshop. On behalf of the Institute for Health Sciences Research (Ouagadougou), we look forward to welcoming you to Burkina Faso.

(Translation: Allison Kelley)



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Interview with Agostino Paganini (2/2): "the Bamako Initiative died a long time ago"

4/22/2013

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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.


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A History of the Bamako Initiative (1/2): under the leadership of Mr. Grant (and Dr. Mahler)

4/16/2013

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The next interview of our series on community participation and the Bamako Initiative is with Dr. Agostino Paganini. 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.  He was the manager of the Bamako Initiative Support Unit at the UNICEF HQ. The unit worked closely with African countries that had shown interest in the principles of the Bamako Initiative. In the first part of the interview we publish today, he shares his analysis of the set-up of the Bamako Initiative. Next week, we will discover his analysis of the evolution of the Bamako Initiative principles over time.

Jean-Benoît Falisse: If I am correct, you took part to the Bamako conference. It was the 38th African Regional Meeting of WHO but UNICEF also became involved. What were you doing at that time? Where was the Bamako Initiative coming from?

Agostino Paganini: At that point of time, I was working on a joint UNICEF-WHO nutrition support programme. I was based in New York and technically working for WHO. I was not there in Bamako but my experience of the event is still vivid. I remember quite well the organisational implications and all the fall-outs of this initiative of Mr. Grant. Of course, everything in this conversation could be biased, it is my own experience that I have revisited and understood over the years. At that time, Dr. Halfdan Mahler was the Director General of WHO and Mr. Jim Grant was the Executive Director of UNICEF. Both were extremely charismatic and powerful leaders and they were two major figures in the public health and health development debate. Mahler had a focus on primary health care issues with a global vision and sensitivity to political implications. Grant was much more pragmatic, he believed in that sort of 'cold war vision' where there were little chances for big progresses and therefore he believed in incremental steps, bringing up health in the political arena. After the Harare declaration [on strengthening the district health systems based on Primary health care], Grant came up with Bamako. Not necessarily, as perceived by some, as a declaration antagonistic to Harare's but maybe as a more incremental, less 'visionary', declaration. Of course, for him it was also a way to call for Africa because he wanted more resources for health organisation and child survival in Africa and he saw the declaration as a way to have them. Basically, the relation between the Bamako and Harare declarations could be seen in the context of an intellectual debate between these two giants of developmental issues.

In the context of this intellectual debate, who was pushing for the Bamako Initiative? What were the main points of consensus and divergence between the countries and/or organisations?

Alongside with the African Ministers, UNICEF promoted and lobbied for this kind of declaration – for which WHO was not especially keen. Actually, even some parts of UNICEF were not happy about this. At the policy level, what was obviously the most difficult to accept was the issue of user fees and cost-sharing. UNICEF and Mr. Grant, on the basis of what was happening in Benin and many African countries, realised that the real payer in health was not the government any more, it was not even the donor any more, it was the household. The majority of expenditures were paid out-of-pocket. The issue was therefore 'co-financing'. Yet, some people identified this idea of having people co-financing their health services with the World Bank vision on user fees and the debate became very ideological. In the proposition for the Bamako Initiative, it was suggested that people would pay something out-of-pocket. If donors were helping making the service better in terms of infrastructure, drugs availability, training and supervision of staff and monitoring mechanisms, it would be wrong that people do not contribute to the cost of delivering services (although paying less than the actual cost). However, that money would stay with people who paid, at the health centre level, and it would be controlled by the community. That was the hypothesis. The reaction from the other side was to call this opening the door to privatisation and a way to have people pay for health when health is a basic human right which cannot be sold.

Part of the Bamako Initiative is about community participation. In the interview with Susan Rifkin, she says what sparkled her interest in community participation was the experience of barefoot doctors in China. Was there anything similar in Africa? Something that convinced people in Bamako?

In the unit I was managing in New York, everybody was absolutely convinced that the biggest political change that Bamako initiative was bringing was not the money but the effort to empower the community in controlling their health centres and staff. We had the impression that the health staff had basically privatised the health system. The health system was not functioning any more. It was an unregulated private sector in which you would have to pay for everything without any control on the quality or the use of the money. For us, the Bamako Initiative was a way to strengthen the capacity of people to be part of and take part in the management of the health centre. It was not about the technical management of the health centre but about the ‘governance’ aspect of it. Was it successful? Well, in certain places like in Mali in the beginning it was quite good. Yet, I had the impression that after a while the Bamako Initiative was interpreted/considered by some of the Ministries of Health and staffs as an excuse to charge whatever they wanted with no control by the community on the money.

Community-wise, what was in place at the time of the Bamako Initiative declaration?

In some countries, there were health committees but these health committees never controlled any resource. In these countries, we could start from these committees. However, in other countries such as Guinea after Sékou Touré, there was nothing. The health system had been destroyed and with the Ministry of Health of Guinea, managing committees were set up. It was the beginning of giving substance to community participation through the co-financing and co-management of the health centres. That was the language we wanted to use; not ‘cost recovery’ but ‘community co-management and co-financing’. It was implemented in different countries and under different labels. This is a labour intensive process that requires a lot of assistance at the community-level.

The Bamako Initiative could be described as having three pillars: (1) community participation, (2) self-financing mechanisms and (3) regular supply of drugs. You already touched the first two issues, could you say a word about the regular supply of drugs?

The experience on the ground was that health centres were not used and their utilisation was incredibly low for two reasons: (1) one was linked with the infrastructure and the behaviour of the staff which were perceived as rotten and so the centres were going down and the other (2) was that there were no drugs. Medicine is perceived by the users as the key element in the therapeutic process, and this is basically true wherever you are. People were spending their money on the market, buying drugs in the unregulated market or anywhere else. It was obvious that medicine had to be available in the health centre. The health centre had to become the place not only for preventive care but also for curative services. Do not forget that the main preoccupation of UNICEF at that time was not curative care; it was mainly immunisation and child survival (which are mostly linked to preventive care). However, having people coming to the health centre because of the availability of medicine for their curative needs was an important key for preventive purposes.

I take an example: child survival and malaria were two of Africa’s very obvious problems which were not very well addressed. There were vertical programmes with antibiotics and antimalarial drugs but they were not sufficient. Having a functional health centre was seen by us as a way to move towards a much more comprehensive vision of primary health care. It was a gradual process through which health staffs were trained and health centres improved thanks to investments from donors and the government. The running costs that were not covered by the government were co-financed by the community. The key was to have a committee which would oversee the management of the money so that there was public accountability. Community participation was seen as a way to obtain accountability from the medical and managerial staff. Monitoring was also a pillar in the system because it would allow the managing committee and the staff to have a view on coverage and immunisation, number of visits, number of women who were delivering babies, etc. This way they could set objectives, discuss between the members of the committee and the health staff, find bottlenecks in the system, and eventually improve the durability, access and correct utilisation of health care.

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The population in Burkina Faso is becoming more demanding - the clinician-patient relationship is the central issue

1/30/2012

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Interview with Robert Kargougou, public health physician, Regional Director of Health Midwest in Burkina Faso by Bruno Meessen

 August 31, 2011, a woman died in childbirth in a maternity hospital in Bobo-Dioulasso. The day after her funeral, people expressed their anger at the negligence of the attending midwife by burning the health center. It is not our role to judge this incident or how it was managed by the Government of Burkina Faso. It did, however, seem interesting to interview one of my former students, now director of another health region of Burkina Faso, to try to understand the underlying causes of patients’ frustration (see in particular comments from readers Online portal "The Faso.net" hyperlinks included in above). This interview took place in Limbe, Cameroon, as part of a workshop on Performance-Based Financing (PBF).

BM: Robert, what do you think the main causes are of this exasperation among the population?

RK: I do not want to comment on the specific case of Bobo, since I do not personally know all the details, but it is true that in Burkina Faso, we have begun to experience isolated but violent reactions by the population targeting health facilities.

One hypothesis is that people are becoming more demanding in terms of the benefits available to them and there is a problem of the responsiveness (or lack thereof) of health services. My personal experience suggests that people are now more perceptive about the quality of care, especially in terms of the relationship between provider and patient. As health workers, we were never adequately prepared for this. Our training focused on biomedicine, and the “art” of communication between carer and cared for has never received the attention it deserves. There is a gap between the training providers receive and peoples’ demands to be treated with dignity, and with respect for their needs and suffering.

This suggests a need to review some aspects in the training curriculum for health workers. But in the short term, are there some solutions? In terms of the population, the health workers? What have you done in your region?

I would first like to say that violence is certainly not the answer to the problem. In Burkina Faso, we have a democratic system. It is possible to challenge the government peacefully. Violence is not the most effective way to get more responsiveness from providers.

In my region, we are trying to improve things on both the demand side and the supply side.

On the demand side, we are trying to promote more fora for citizen input. For example, we convened a meeting under the auspices of the regional governor that brought together the various stakeholders at the regional level. From the administration, there was the Governor, provincial high commissioners, and mayors. From the community level, we invited all the traditional leaders - they still have a significant voice in our society. We also involved civil society, including youth groups, women's associations, of course the provincial officials of the Union of Health Workers - a union which is very representative in the health sector - the provincial branch for human rights, and religious authorities. Professional groups, which have an important role in health care regulation, were also involved, including the College of Physicians, the College of Nursing and the Regional Association of Midwives. At the meeting, we communicated the following message: a health worker who is not in a good psychological work setting cannot use his knowledge to provide quality services; we must sensitize people to this; they may challenge providers and ask tough questions, but we must respect the rights, integrity and safety of health workers.

But we also recognize that on the supply side, action needs to be taken to improve the quality of care too. This has become my personal struggle; since my return from the Institute of Tropical Medicine, I am striving to implement what is known as patient-centered approach. We have organized training for management teams. We now need to go to scale with all health personnel.

But we also need to work on the interface between people and health facilities - I think particularly of the health management committees. Through decentralization today, we can work on this axis as well. A new text in Burkina Faso focuses on the establishment of health management committees, and it provides for representation by locally elected leaders. Our regional governor has made an effort to quickly renew management committees, many of which had expired mandates and thus no effective interface with health centers. The government has also taken a multi-sectoral decision whereby several ministries have put in place management committees at the district hospital level. Previously, there had been no interface at this level. The regional governor saw its importance and quickly put this in place at the district level. These moves should improve the quality of dialogue.

The Governor also stressed the importance of holding that general assemblies. Normally, they should be held twice a year. It should be a pivotal opportunity where citizens and beneficiaries make an assessment of the finances and operations of the health center. These meetings are not always held, however, yet even when they are, there is inadequate civic representation. Women's associations, youth groups, and traditional leaders must be more involved. After the meeting, the governor with all the participants, visited a health center to meet with health staff and reassure them. These are some of the solutions that have been adopted at regional level.

I know that your area is one of the pilot regions for performance-based funding (PBF) in Burkina Faso. Does PBF have a role to play in solving this problem?

Yes, PBF can also help, as it focuses on the quality of services. It should enable providers to have better working conditions and to be more responsive: 30% of PBF resources will be reserved for the health center, the rest will be used to motivate health workers. In addition, Burkina Faso intends to involve locally elected leaders in PBF. This should also help improve the quality of relations between users and health services. PBF will free up staff to enable them to provide quality services. Health care providers will certainly be motivated to implement strategies that attract and satisfy the population. Thus, PBF is part of the response to the current problem.

Traduction: Allison Gamble Kelley
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