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IV. Background: Health, Poverty and Conflict 

Political and socio-economic situation in Burundi: Moving from conflict to post-conflict

The current Burundian government under President Pierre Nkurunziza was elected in August 2005, following a decade of civil war and a long process of political transition. The dominant force in the government was formerly the country’s largest rebel group, the National Council for the Defense of Democracy-Forces for the Defense of Democracy (Conseil national pour la défense de la démocratie-Forces pour la défense de la démocratie, CNDD-FDD). The CNDD-FDD portrays itself as a popular movement addressing the needs of the poor.

Another rebel movement, the National Liberation Forces (Forces de libération nationale, FNL), continued its war against the government, particularly in areas near the national capital Bujumbura. Both FNL and government forces continue to commit serious violations of international humanitarian law (the laws of war), including attacks on civilians.² As of July 2006 the FNL and the government were engaged in peace talks.³ 

The long and violent conflict has had a destructive impact on society, the economy and the health sector. Burundi is now one of the least developed countries (LDC) in the world, ranking at 169 of 177 on the 2005 United Nations Development Programme's Human Development Index.⁴ The yearly gross national income per capita is at U.S.$90.⁵

The health sector in Burundi

During the period of armed conflict, health care deteriorated as shown by such key indicators as maternal mortality, infant mortality, vaccination rate and medical staff per inhabitant. Maternal mortality is at 1,000 deaths per 100,000 live births, and constitutes one of the most acute public health problems in the country, according to the World Health Organization (WHO).⁶ Infant mortality is at 114 per 1,000 live births (11.4 percent), and mortality of children under five is at 190 per 1,000 live births (19 percent)—these are among the highest in the world. The adult prevalence of HIV is 6 percent.⁷ The health system is plagued by a lack of trained staff and resources to pay them, as well as by a lack of medications and modern equipment.⁸ Many skilled medical staff leave the public sector in Burundi for better-paid jobs in international nongovernmental organizations (NGOs) or private health institutions, or in neighboring Rwanda.⁹ 

Access to health care was made more difficult for poor Burundians by the adoption of a cost recovery system in February 2002. Patients, regardless of their means, must pay all medical costs, such as medical consultations, tests, medicines, supplies, and their stay at a hospital.¹⁰ Only five of seventeen provinces operate alternative models of health financing.¹¹

The cost recovery system revived a health policy from before the war that had not been properly put into practice. Before the 1980s, health care services were free of charge in Burundi. In 1988, the government started a policy of reform and decentralization: It introduced a pre-payment system at the community level and established management autonomy in the health structures at the provincial level, which meant that hospitals were running their operations with a degree of independence (autonomie de gestion) and were obliged to raise some of their funds themselves, while still receiving some state subsidy.¹² The 1988 reform also aimed to gradually implement a cost recovery scheme in all health structures, but was halted during the following decade of armed conflict.¹³

Health policies in Burundi are partly the result of the government’s own priorities: the government devotes only a small fraction of the budget to health—in 2005 just 2.7 percent.¹⁴ They are also the result of the World Bank’s policies across Africa during the 1980s and 1990s, which intended to bridge a “health sector resource gap” through user fees. The strategy was given added weight by the Bamako Initiative, developed by the WHO and UNICEF and adopted by African governments in 1987. ¹⁵ The Bamako Initiative aimed at improving access to primary health care through involving communities in managing and financing health care. It was hoped that cost recovery at the community level would increase the revenue of the health sector, promote an efficient use of resources, and increase equity—that is, overcome differences in access to health care.¹⁶ The introduction of user fees was seen as a step towards rebuilding a sustainable health care system, including in countries wrecked by armed conflict.¹⁷

Studies show that the cost-recovery initiatives for health financing rarely had the desired impact. Cost recovery systems in Africa raised less revenue than expected, and there is little evidence that they improved the efficiency of health care systems.¹⁸ In Burundi, access to the health system is limited, with about one million people—17 percent of the population—being excluded from health care altogether.¹⁹ Because of this limited access, hospitals have a low occupancy rate, despite the enormous needs of the population.²⁰ The World Bank no longer promotes cost recovery as the sole option, and donors have moved to a more nuanced position.²¹ Yet, cost recovery is still the most common health financing model in Africa.

Several mechanisms were meant to ease the pressure on the poor in Burundi, but have failed to do so: the indigence card (carte d’indigence),which waives health fees for the very poor; a voucher that waives health fees for displaced people; and the illness insurance card (carte d’assurance maladie, CAM), which can be bought for the equivalent of about $0.50²² and reduces the medical bill by 80 percent. Both in Burundi and elsewhere in Africa, such programs have rarely been effective in expanding access to health care.²³

Availability and access to health care

Burundi is a relatively small country and 80 percent of the population lives within five kilometers of a health center.²⁴ Still, transport—particularly prompt transport—to a health facility poses a problem for those lacking money. For example, 39-year-old Michelle N. could not get transport when she went into labor at night. She lives in Gatumba, about six miles from Bujumbura. She was able to reach the hospital only at 5 a.m. the next morning, by which point her baby had died. She was then unconscious for two days.²⁵

Some patients seeking help find that the nearest facility lacks the staff or equipment needed for appropriate care, and must move on to another hospital.This was the case of 13-year-old Noah B., who injured his ankle while playing football. His father took him to the nearest hospital, at Kayanza, only to be told that the hospital could not perform the surgery Noah needed. They borrowed money for a taxi to Roi Khaled Hospital in the capital.²⁶ Many women in labor whom we interviewed during or following hospital detention were also sent from one hospital to another. Researchers interviewed one woman who while in labor had gone to four health facilities before being admitted.²⁷

The poor may confront the further obstacle of lacking money to pay the fee for admission to a hospital. Most hospitals require patients to pay fees before receiving care. Fees vary according to hospital and according to the evaluation of the case, with large hospitals in Bujumbura charging the equivalent of approximately $10 for simple cases and up to $100 for more complicated cases or ones where surgery will be required.²⁸ Outside the capital the admission fees are lower. At Ngozi hospital, for example, the regular admission fee is approximately $5.²⁹ Anne K. is a woman who could not pay the admission fee at Prince Régent Charles Hospital in Bujumbura at the birth of her second child:

For medical reasons, I cannot give birth normally, so I must have a caesarean delivery. At the birth of my first child, I found a benefactor who took me to the MSF [Médecins Sans Frontières] clinic and I had a caesarean delivery there. This time there was no benefactor. I went to Roi Khaled Hospital but they refused to admit me because I had no money to pay the admission fee. They sent me to Prince Louis Rwagasore Clinic. There, they were reluctant to do the caesarean delivery so soon after the first one. So I went to Prince Régent Charles Hospital. They, too, refused me because I had no money. I thought to myself, “There is nothing else I can do. If I have to die, I will die.” I left, but then the doctor ran after me and said, “I will do it.”³⁰

As the example of Anne K. shows, some persons needing care were admitted even if they lacked money to pay the admission fee. Such decisions, however, were the exceptions to the usual rule.  Gabriel N., a man who suffered two road accidents, was also rejected because he could not pay the admission fee:

On November 22, 2005, I came here to the hospital [Roi Khaled]. The doctors refused to treat me because I could not pay the admission fee. I stayed outside the hospital for a few days, trying to get treatment. One day a man passed by and asked me why I had been there so long. I explained my problem and showed him my injury and he paid the admission fee of 100,000 francs [FBU, $100].³¹

Getting admitted to a hospital is by no means the same as getting medical treatment. Burundi’s hospitals are poorly equipped and staffed, and medical care is often insufficient or inappropriate.³²

Hospital detentions in Africa

The detention of poor patients by hospitals is found in numerous other African countries where the health system is based on a cost recovery system and hospitals try to force insolvent patients to pay their bills. The practice is found in countries including Kenya, Ghana, the Democratic Republic of Congo (DRC), and there has been at least one instance in Zimbabwe, affecting multiple patients.

Wealthy patients in Kenya can get private health insurance, high quality medical treatment and hospital accommodation, but most Kenyans cannot afford such insurance and are relegated to substandard hospitals where they have to pay for services and end up detained if they fail to do so.³³ In Ghana, women who have delivered babies are frequently kept in the hospital until they pay the costs for childbirth. The country is in the process of introducing a flat fee for poor and vulnerable patients but this will not cover high-cost surgery including caesarean deliveries.³⁴ In the DRC, a local human rights organization focused on the situation of young mothers in hospital on International Women’s Day 2006, showing both the growing frequency of detentions of women in hospitals and their rejection by family members who do not want to be forced to pay for them. Among the detained women are rape victims who are completely isolated and unlikely to find anyone to pay for them.³⁵ The detention of patients is not the rule in Zimbabwe, but in one case, 28 mothers and their newborn babies were detained at Harare Hospital. The charges for maternal health care had just risen and the women were unable to pay the bills for childbirth.³⁶

A young mother and her newborn baby, detained at Prince Louis Rwagasore Clinic following a caesarean section.
© 2006 Jehad Nga