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

1/30/2012

13 Commentaires

 
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
13 Commentaires
Robert Soeters
1/30/2012 06:21:53 am

This story of a population burning their health centre is striking and sad and many thanks to share this frank story with us. It is of course not only the population in Burkina Faso that is frustrated with the poor quality and low responsiveness of health systems. Many more professionals in the health care system share the same feeling and for me this goes as far back as 30 years having worked in over 30 countries. It was from this frustration that we gradually first developed contracting approaches from the mid 1990s onwards in Asia and later the PBF approaches such as we know them today in 30 plus countries world wide of which at least 25 in Africa. It is great to learn that also Burkina Faso is piloting the PBF approach and they may thereby start preventing the sad incidents such as reported to this forum.

It would be great if the PBF promotors in Burkina Faso exchange as much as possible with other countries the lessons learned and also to learn from the mistakes we made in PBF during the past 15 years. Lessons learned may be to create as many check and balances in the system as possible, which include strengthening the population voice, and the separation of the functions of health provision, regulation, funding and purchasing.

Furthermore a lesson learned is to create enough (political) ownership for PBF to be expressed by adopting PBF budget lines in the national budget, which then gradually replace inefficient input budget lines (drugs, equipment, bed nets, etc). This case according to our experience can be convincingly made to politicians because typically $ 1 PBF dollar transferred directly into the bank accounts of health facilities has the same effect as $ 4 in terms of input dollars. This argument already convinced politicians and decision makers in countries such as Rwanda, and Burundi and recently more such as in Cameroon, Nigeria, and others ...

It is also crucial that we continuously remind ourselves that the efficiency and provision of quality services in PBF is instrinsically linked to autonomous management and decision making at health facility level. PBF is about creating space for innovation, creating flexibility and an attitude of learning and making use of opportunities. This autonomous space includes the decisions where to buy inputs and the negotiation of cost sharing mechanisms (direct payments and / or insurance premiums) with the local population. This space needs to be protected and regulators are encouraged to avoid by all means interfering in the internal "kitchen" of health facilities.

Yet, allowing autonomous space does not mean "lack of transparency" or "laissez faire". PBF therefore proposes management instruments such as business plans, indices management and costing tools. The 500+ participants, who followed the previous PBF courses since 2007 have become familiar with them and I am happy to report that we just finished PBF course number 19 in Mombasa this last Saturday with 26 participants from Afghanistan, Burundi, Ethiopia, Malawi, Mozambique, the Netherlands, Nigeria, South Sudan and Tanzania). May be some of them may also wish to share their experiences and frustrations on this forum. So while protecting the spirit of innovation and flexibility for health workers, health facility managers need also to have access to the tools to improve the health services.

From our experience and evidence collected, most countries that apply the main PBF principles typically witness the quality of care and outputs to improve dramatically and this is what the population seeks in the first place. It is also true that providing quality services with sufficient staff (1 qualified staff per 1500 population) costs money and we estimate that a health centre and a hospital needs to generate $ 3-5 per capita per year to provide services by qualified staff. Thus, a health centre covering a population of 10,000 needs to generate $ 30-50,000 per year and a hospital covering a population of 100,000, $ 300-500,000 per year.

Direct fixed government contributions in cash and PBF subsidies may typically inject 40-60% of this total of $ 3-5 per person per year but for the sake of sustainability and avoiding to become dependant on unreliable external cash flows, it is realistic and crucial to assume that the remainder of the health facility revenues needs to be generated in some form of cost sharing. Thus, for the population to have access to quality care, they also need to contribute whether we like it or not. Ignoring this in most countries implies that Out-of Pocket Health Expenditures will simply go informal in uncontrolled and poor quality health services.

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Bruno Meessen
1/30/2012 12:10:27 pm

An interesting viewpoint by the Minister of Health of Rwanda.

http://www.newtimes.co.rw/news/index.php?issue=14886&article=49493

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Bruno Meessen
1/31/2012 04:19:03 am

An original experience of interface between a Ministry of Health and the population.

http://dr-agnes.blogspot.com/2012/01/direct-democracy-and-health-sector.html

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Nicolas de Borman
2/1/2012 07:12:49 am

Regarding patients expressing their frustration about low quality of care, there are other interesting examples.

The spanish website www.masquemedicos.com allows you to post an opinion about a service provider. Doctors, hospitals, dentists, medical labs are rated by patients. In one year, this website has become very popular in Spain.

An example for the dental clinic of Dr Lopez in Madrid:
http://masquemedicos.com/dentista_madrid/clinica-dr-m-lopez-linares/opiniones/
Would you use that clinic if : "Las limpiezas de boca son un horror!!" ? (The cleaning of the mouth is a
horror!!) ;-)

Another different website is www.curetogether.com. The website allow you to rate your treatment and compare it with alternatives. An example for arthritis : http://curetogether.com/blog/2011/10/18/arthritis.
Massage seems to work much better than Voltaren.

These websites are interesting because they give more power to patients. In that sense, there is a link with RBF. In RBF systems, patients have more decision rights because public funding is directed to the facilities they choose to utilize. In addition, in some countries such as Burundi, the opinion of patients is taken into account in the quality evaluation of the health facility: a higher patient satisfaction leads to higher subsidies for the facility.

One aspect that we still can improve in most PBF systems is the transparency and accessibility of performance data. Reputation is a high powered incentive that is available at no cost. Don't you think Dr Lopez pays more attention to mouth cleaning now?

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