Burundi is a tiny landlocked country of approximately 8 million people, comprising
17 administrative provinces and located in the Great Lakes region of Central
Africa. Following over ten years of civil war which ended with democratic elections
in 2005 the health sector has finally been able to take its’ first steps towards
reform, most importantly decentralisation. The country is only now able to put
in place a system of 41 health districts and address the ways and means to achieving
the Millennium Development Goals.
As in other sub-Saharan African nations motivation and retention of qualified
health personnel is a nagging problem which required the Ministry of Public
Health to find quick solutions to the “brain drain”, particularly of doctors,
from rural to urban areas, public to private sector including local and international
organisations and migration abroad. Performance based health worker incentives
or “Pay for Performance” (P4P) were seen as a means of addressing extremely
low and demoralising salaries as well as improving the “performance” of staff
leading hopefully to increased utilisation rates and better quality health services,
including maternity services. Low salaries are seen as one of the most important
factors, among many (Rowe / de Savigny / Lanata / Victoria 2005), influencing
staff motivation and “performance”. Newly qualified doctors receive an average
of 120 USD per month, while enrolled nurses (A2,A3) can expect 65 to 72 USD.
Auxiliary nurses who make up the bulk of staff in rural health centres can receive
as little as 10 to 20 USD per month.
Burundi was particularly influenced by its’ neighbour Rwanda where P4P had
been enthusiastically embraced at national level in 2006 and, most importantly,
supported by bilateral and multilateral donors, including the World Bank. The
Ministry of Health in Rwanda was influenced by the success of two pilot projects
in the southern provinces of Butare and Cyangugu which had been implemented
by the Dutch NGOs HealthnetTPO and CORDAID respectively. These projects, from
20001 onwards, had been successful in increasing health service “productivity”,
particularly in terms of women giving birth at their local health centre rather
than at home and family planning uptake. The incentives also attracted more
qualified staff to work in rural health centres (Soeters / Musango / Meesen,
2005).
Such a results based approach is also seen by some of the proponents of P4P
as being an alternative to traditional input based financing (“donations” of
equipment, medicines etc.; Soeters / Habineza / Peerenboom; 2006) which has
largely failed over the years to improve health systems at the level of the
“workface” or health outcomes, including maternal and neonatal mortality and
morbidity rates which remain unacceptably high in much of sub-Saharan Africa.
Both CORDAID and HealthnetTPO commenced P4P projects in various provinces
of Burundi in 2006, followed by a Swiss Development Agency funded health system
strengthening project in the northern Ngozi province, which introduced health
worker incentives in November 2007. The Belgian Cooperation and the European
Union have also very recently commenced this approach in other provinces. During
2009 it is planned for the rest of the country to be included in the approach
through health sector budget support funding from the World Bank (Health and
Population project), the GAVI Alliance (health system strengthening) and DFID
(lead donor in health).
Implementation
Indicators: Before commencing the approach it is necessary to sensitise the
workforce concerning the aims of P4P, both in the health centres and hospitals
and “negotiate” the verifiable quantitative indicators to be evaluated in terms
of “productivity”, such as numbers of clients for family planning services (necessitating
a well functioning health information system) and the level of payments for
each indicator, for example 1USD for each client consulted.
With regard to safe motherhood indicators, due to difficulties in measuring
maternal mortality rates, certain proxy or process indicators such as “skilled
attendance” at birth are generally used to determine if progress is being made
in reducing mortality with the proviso that “skilled” does not necessarily mean
the same thing in different settings, for example most health centre births
in Burundi are attended by A2 and auxiliary nurses, rather than professional
midwives, whilst doctors carrying out caesarean sections may not have followed
a course of specialist training.
Safe motherhood indicators for basic (health centre) and comprehensive (hospital)
essential maternity care have been a priority in the Ministries’ of Health directives
for P4P in both Rwanda and Burundi. As mentioned previously the main indicator
is the number of women attending health centres and hospitals for skilled delivery
assistance, but specifying also the use of a partograph in Burundi’s case (a
decision making tool which can assist in the timely referral of women to hospital
during labour).
Trained traditional birth attendant (TBA) assisted home births are not regarded
as being desirable in either Rwanda or Burundi as TBA training is now, for a
number of reasons, considered ineffective in reducing maternal deaths.
In Burundi other safe motherhood indicators specified by the Ministry of Public
Health include the number of new and repeat clients attending family planning
services, the number of women referred to hospital for emergency maternity care,
postnatal and ante natal attendance, the latter despite considerable research
which has shown its’ limits in screening for the prevention of maternal and
neonatal deaths (Rooney 1992), apart from tetanus prevention. An additional
indicator is the number of impregnated mosquito nets distributed (for the prevention
of malaria during pregnancy which can be fatal for the mother and/or baby) despite
the fact that this is rather more dependent on the regularity and sufficiency
of supplies rather than health worker motivation. In hospitals safe motherhood
indicators also include the number of caesarean sections and blood transfusions
performed.
Voluntary confidential screening for HIV and the Prevention of Mother to Child
Transmission activities are also approved indicators in those health centres
(very few, due to a shortage of qualified staff and unreliable supplies of the
necessary materials) and hospitals (all) providing the services. Due to a lack
of trained counsellors in outlying provinces uptake of Voluntary Confidential
Counselling and Testing for HIV during pregnancy is actually low (30% in Ngozi),
although up to 70% in the capital, Bujumbura where considerably more trained
counsellors are available.
Meanwhile intermittent prophylactic treatment of malaria for pregnant women,
a proven intervention elsewhere in helping to reduce mortality, is not currently
stipulated in the health policy of Burundi.
The health information system, registers and other records are the tools used
by the health centres and hospitals in order to fill in their quarterly declarations
of productivity for each indicator and by the fund holding body that verifies
the data. The “fund holder” can be an NGO or donor implementing partner or a
local government committee in collaboration with the Ministry of Health (as
in Rwanda) or a health insurance provider.
Quality indicators include waiting times, the satisfaction of service users,
hygiene standards, institutional management and organisation standards and availability
of medical material and medicines. Facility based and household surveys organised
by the fund holders gather data on these indicators with feedback given to the
institutions concerned.
Health promotion indicators, whether in health centres or in the community,
have not been included in either Rwanda or Burundi due to perceived difficulties
for the fund holder in subsequently verifying the data presented.
Level of payments: Determining the level of payments can be quite tricky, particularly
when there are tight budgets. Forecasting the level of “productivity”, although
theoretically based on the catchment area population figures and previous health
information statistics for each individual health centre or hospital, higher
than expected productivity can arise, particularly where population figures
are inaccurate or changing due to the movement of refugees (in Burundi for example
former refugees have been returning in very large numbers from Tanzania) Health
personnel may also have high expectations due to salaries which do not cover
their basic needs. A proportion of the payments are also earmarked to subsidise
running costs, additional activities to increase productivity such as incentives
for the traditional birth attendants to accompany women to the health centre
for ante natal care or delivery, as well as infrastructure investments of the
health centre or hospital. The level of incentives and subsidies paid, although
based on forecasting and estimations of a “fair” incentive to cover the living
costs of staff and running costs of the facility, also inevitably depend on
the total funding budget available and the number of health centres and hospitals
included.
In Ngozi province the level of incentives was on average 50 to 80 USD per month
for qualified nurses and 3-400 USD for doctors during 2008 (this was consistent
with the other Provinces of the country where P4P was being implemented) in
38 health centres and 1 district hospital. The payment levels for each individual
staff member were decided internally in a transparent manner during meetings
of all personnel, as the financial envelopes transferred comprise the payments
for total performance of the particular health centre or hospital. The parameters
used in the internal “scoring” of staff to determine the level of individual
incentive payments included qualifications, numbers of years experience, numbers
of hours overtime worked and the punctuality of individuals.
Percentage reductions in financial envelopes to be transferred can be made
based on quality indicators as well as the veracity of the productivity data
declared by the health centres and hospitals for payment. The earmarked funds
for running costs (average 150 USD per month in Ngozi during 2008, thus insufficient
for large investments in the infrastructure) also varied depending on the “productivity”
of a particular health centre as they comprised a percentage of the total funds
transferred.
Despite the incentives being paid in various provinces a national strike in
September/October 2008 demanding better pay and allowances paralysed health
centres and hospitals, apart from accident and emergency services (including
deliveries) throughout the country for almost two months. This was the second
strike by health workers during 2008 and demonstrates the fact that health workers
need recognition of their contribution to society through adequate remuneration
and the fact that they do not have faith in the sustainability of the incentives
scheme! At the time of writing a further strike is about to commence.
Results
Utilisation of services: Assessing the effects of P4P on safe motherhood indicators
in Burundi is complicated by the fact that childbirth assistance in health centres
and hospitals (and care for the under fives) became free at the point of access
in May 2006 due to a presidential decree to this effect – this had an immediate
positive effect on institutional delivery rates and thus it is now difficult
to disentangle the relative effects of the health worker incentives and the
removal of the financial barrier previously impeding women from accessing maternity
care at the time of delivery.
In Ngozi the subsidy increased health centre delivery rates by up to 400 %
between 2005 and 2006 in Kiremba District (one of three) a particularly isolated
and poor area (4% to 20% coverage). Following 6 months of incentives, in the
same district, a further 95% increase was noted (from 20% coverage to 39%) The
95% increase seen after the introduction of incentives, however, would still
in theory have the subsidy element influencing the result. It would seem from
these figures that financial accessibility has had a greater impact on improving
“productivity” in the delivery rooms of health centres than health worker incentives.
The same patterns of increase were also seen in the two other districts.
The traditional birth attendants had also to be “co-opted” in the form of incentive
payments from the health centres so as to encourage them to bring their clients
to deliver at the health centres, because they were losing their traditional
livelihoods. Public education campaigns concerning safe motherhood were also
undertaken in the community by health promotion staff based in the health centres
prior to the introduction of the incentives.
The increases in obstetric referrals, post natal consultations and family planning
uptake which occurred are also difficult to attribute solely to the effects
of the incentives, as other interventions such as the training of staff in the
use of the partograph, post natal care and more comprehensive family planning
services as well as the setting up of a subsidised functioning referral system
(ambulances and radio communications) could also have had an additional impact.
Three of the four referral hospitals in Ngozi province were already well staffed
medically due to the fixed salary supplements being paid to doctors by other
donors (Catholic Church and Italian Cooperation). One of the three district
hospitals, however, was not functioning in terms of tertiary level services
and the incentives scheme of the Swiss funded project did allow it to provide
complementary essential obstetric care (eg. caesarean section, blood transfusion)
by attracting an additional doctor. An evaluation or audit of tertiary level
care, however, would need to be undertaken in order to ascertain the quality
and appropriateness of care given, as well as outcomes.
The “massaging” of “productivity” data, although initially a problem in Ngozi
and other Provinces where P4P was in operation, was not of undue concern, as
this can and has been fairly easily detected. Of concern, however, is the sustainability
of the funding and developing exit strategies which would allow the government
to take over the management of the scheme countrywide.
Quality of care: In Ngozi province, following the
introduction of incentives the negative effect of the “free” maternity care
initiative on health worker motivation due to the loss of considerable revenues,
“under the table” payments previously demanded from clients diminished, staff
had a more welcoming attitude and health centres were functioning 24/7 which
they were not previously.
P4P in Ngozi also allowed health centres to improve the working environment
and conditions to a certain extent (purchase of cleaning products, phone cards,
plumbing services, stationary, curtains for delivery rooms, small repairs etcetera)
and to develop strategies to increase service utilisation rates, such as public
education campaigns and incentives for the traditional birth attendants. As
in other provinces, however, the infrastructure was not able to properly accommodate
the increasing numbers of women seeking institutional care. Many health centres
are simple dispensaries in terms of the space available. In Ngozi hospital there
are always two to three women occupying the same bed, with five beds taking
up a space normally reserved for three beds maximum. Ante natal patients are
sharing the same beds as post natal patients.
This pressure on beds also led to complaints from hospitals that many of the
women referred to them by the health centres had normal deliveries and should
not have been transferred. One could argue, however, that even if health centre
staff did refer large numbers of women (the partograph is not infallible and
some women may have only needed an augmentation of contractions in order to
deliver normally) if the life of one woman is saved through surgical intervention
then that is all to the good. One can, however, also understand the frustrations
of hospital, as locating a donor willing to build an extension to the maternity
unit at the Ngozi regional referral hospital for example will not be easy. In
a meeting with traditional birth attendants they claimed that in some health
centres they were often left to conduct deliveries after having accompanied
women to the health centres, particularly if it was late evening or at night
thus defeating the objective of “skilled attendant” at birth.
Where P4P cannot reach
It is evident that safer motherhood requires much more investment in interventions
and strategies other than health worker incentives:
Emergency obstetric care and referral systems for obstetric emergencies:
Incentives can have little or no effect on the number of women transferred in
good time for specialist care in case of complication or emergency where functioning
referral systems are not in operation. These require sufficient funds to invest
in and run and maintain ambulances and radio communications systems. Catastrophic
transport costs cause delays and subsequent morbidity/mortality where subsidies
or community solidarity funds to cover these costs are not in operation. In
Ngozi province, due to the support from the SDC funded project the number of
transfers was already increasing before the introduction of incentives due to
such an input, as well as the training of staff in the use of the partograph
which allows staff to make timely referrals whether for maternal or fetal indications,
as well as the management of obstetric emergencies.
Similarly, high standards of emergency care at both the primary and tertiary
levels such as the effective management of pre-eclampsia / eclampsia or post
partum haemorrhage, can only be ensured at the national policy making level
and through basic and continuing education.
Specialised professional midwifery care: Maternity
care is carried out mainly by general trained A2 enrolled nurses and auxiliary
nurses there being no professional midwives in Burundi. The western medical
obstetric model has been handed down to the nurse training schools from the
colonial period and has led inevitably to practices which would not nowadays
be regarded as the ideal in terms of quality, including immobility during labour,
normal deliveries in the supine position in lithotomy stirrups, routine episiotomy
(with no local anaesthesia) for all first time mothers, extreme fundal pressure
to shorten the second stage of labour, regular use of oxytocin drips in hospitals,
routine manual curettage of the uterus following delivery of the placenta, routine
post natal administration of ergometrine, rapid clamping of the umbilical cord,
poor neonatal care including resuscitation techniques, delay in establishing
breast feeding and the exclusion of a supportive relative from the delivery
room. Assessing foetal positions in labour is also problematic due to the limitations
of general nurse training and basic medical training and which can lead to unnecessary
referrals and/or caesarean sections (alongside the latter’s associated risks
for subsequent deliveries when women live far from hospitals). There is also
very little post natal support and information/counselling for mothers, in establishing
breast feeding for example and general care of the newborn, as well as the use
of mosquito nets, child nutrition etcetera for the same reasons of over medicalisation
and lack of the socially based midwifery skills and concerns.
These issues, however, could be addressed in an evaluation of the various nurse
education curriculae which currently do not meet international standards. Some
of the nurse training schools are private, whilst there is insufficient regulation
of both private and public establishments. University based training schools
for A0 nurses (who complete only two weeks practical training in maternity care)
are under the control and supervision of the Ministry of Education whilst the
other schools of nursing, for A2 level nurses, are under the Ministry of Health.
There is also insufficient recognition of the role and importance of the nursing
and midwifery professions. There is no system of registration or regulation
such as a Nursing Council and none of the health directorates at the national
level of the ministry have high level nursing positions. Neither does nursing
have its’ own directorate at this level.
Specialised family planning skills: It is well known
that increased family planning uptake can reduce maternal and neonatal deaths.
Health worker incentives alone, however, cannot overcome the socio-cultural
factors inhibiting uptake of services and inadequate services. In Ngozi province
intensive training was provided to health workers to improve interactions with
clients, placing more emphasis on attending to women’s concerns about perceived
side-effects and specialised practical training sessions and supervision for
IUD insertion, the latter option having been previously unavailable in the majority
of health centres.
Women prefer methods that can be forgotten about (the oral contraceptive pill
is not popular in Burundi) and for cultural reasons, in many cases kept a secret
from husbands. Thus preferred methods are injectables and IUDs. There are obviously
risks of HIV transmission through the use of non barrier methods, but these
have to be weighed alongside the risks of multiple, closely spaced pregnancies.
Meanwhile women are informed that they are not protected from HIV when using
these methods. Thus, in Ngozi, initial and continued family planning uptake
increased due to these initial interventions prior to the introduction of incentives,
the latter acting as a complementary input.
Safe abortion care: It is estimated that unsafe abortion
accounts for considerable mortality in those countries where abortion is illegal
and women are imprisoned for long periods if found guilty of procuring one as
is the case in Burundi.
Geographical and socio-cultural accessibility: Of
those women who have not attended for institutional deliveries despite the free
maternity care initiative it is clear that health worker incentives cannot have
an effect on reaching out to them. Problems of geographical accessibility persist,
particularly for those experiencing a quick labour and especially in a mountainous
country such as Burundi where much effort and energy is required to reach a
health centre in time. Social and cultural factors also have an inhibiting effect
on the use of services. In a recent household survey in Ngozi province some
women for example requested for deliveries to be assisted by female nurses.
There was also evidence to suggest that some clients are treated in a more respectful
manner than others. Women may not feel at ease if they feel that a nurse is
looking down on them, because she is poorly dressed or does not have sufficient
items or clothing for herself and her newborn. Despite education campaigns women
may still regard childbirth as a normal problem free event and the convenience
of giving birth at home outweighs the perceived low risk of developing a problem.
Where health centres do not have sufficient infrastructure women may prefer
to deliver at home, rather than having to perhaps share a small room with other
patients, males included, after the delivery.
Poor working environments: P4P schemes can potentially
improve working environments only if the levels of payments are sufficiently
high to allow investment in the infrastructure (water supply, latrines, medical
equipment etc.). This in turn requires autonomous, transparent and accountable
financial management systems to be in place.
P4P in Burundi as a whole and in Ngozi province has been less successful in
improving indicators in those health centres which are very isolated due to
poor roads and broken bridges, have poor standards of infrastructure including
a lack of staff housing and have below the required numbers of qualified staff.
Additional inputs will be needed to address these factors and in Ngozi province
actions to this effect are planned for 2009 by two SDC funded projects supporting
the heath sector and local government.
Conclusion
Health worker incentives are, needless to say, not the proverbial “magic bullet”
and should be part of a complete package for change in health systems; a package
which allows geographical and financial accessibility to services (whether through
subsidies or client incentives) and the advancement of the nursing profession
through improved education, recognition and professional accountability to a
regulatory body. In order to improve maternal and newborn survival rates much
more planning and investment will be required in nursing and medical education
and career development, in improved pay scales and living conditions and in
addressing the inadequate health infrastructure. Financial accessibility is
no longer a concern in Burundi due to the government subsidies currently in
operation for pregnant women and the under fives, but should continue to be
seen as potentially problematic if government and/or donor funding of the health
sector does not remain stable – similarly for the sustainability of health worker
incentives.
*Judith Cowley, MSc. is a registered nurse and midwife currently working
for the Swiss Centre for International Health of the Swiss Tropical Institute.
She is based in Burundi coordinating the SDC funded Ngozi health system strengthening
project.
Contact: Judith.Cowley@unibas.ch
References
- Rowe AK, de Savigny D, Lanata CF, Victoria CG. How can we achieve and maintain
high-quality performance of health workers in low-resource settings? The Lancet
2005;366:1026-1035
- Soeters R, Musango L, Meesen B. Global partnership on Output based aid (GPOBA).
Comparison of two output based schemes in Butare and Cyangugu provinces with
two control provinces in Rwanda. World Bank. 2005.
- Soeters R, Habineza C, Peerenboom PB. Performance based financing and changing
the district health system: experience from Rwanda. Bulletin of the WHO. 2006.
- Rooney C. Antenatal care and maternal health: how effective is it? A review
of evidence. WHO. 1992.
