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