Performance-based financing in the context of selective free health-care: an evaluation of its effects on the use of primary health-care services in Burundi using routine data.

BACKGROUND: Performance-based financing (PBF) is an increasingly adopted strategy in low- and middle-income countries. PBF pilot projects started in Burundi in 2006, at the same time when a national policy removed user fees for pregnant women and children below 5 years old. METHODS: PBF was gradually extended to the 17 provinces of the country. This roll-out and data from the national health information system are exploited to assess the impact of PBF on the use of health-care services. RESULTS: PBF is associated with an increase in the number of anti-tetanus vaccination of pregnant women (around +20 percentage points in target population, P < 0.10). Non-robust positive effects are also found on institutional deliveries and prenatal consultations. Changes in outpatient visits, postnatal visits and children vaccinations are not significantly correlated with PBF. It is also found that more qualified nurses headed to PBF-supported provinces. The limited quality of the data and the restricted size of the sample have to be taken into account when interpreting these results. Health facility-level figures from PBF-supported provinces show that most indicators but those relative to preventive care are growing through time. DISCUSSION: The dataset does not include indicators of the quality of care and does not allow to assess whether changes associated with PBF are resource-driven or due to the incentive mechanism itself. The results are largely consistent with other impact evaluations conducted in Burundi and Rwanda. The fact that PBF is mostly associated with positive changes in the use of services that became free suggests an important interaction effect between the two strategies. A possible explanation is that the removal of user fees increases accessibility to health care and acts on the demand side while PBF gives medical staffs incentives for improving the provision of services. More empirical research is needed to understand the sustainability of (the incentive mechanism of) PBF and the interaction between PBF and other health policies.

[Good governance in the Burundi health sector financial reform]. / La bonne gouvernance dans la réforme du financement du système de santé au Burundi.

INTRODUCTION: Burundi introduced free healthcare for children under five and pregnant women in 2006. In 2010, this was linked to the Performance-Based Financing (PBF) approach. This article is designed to identify factors in these health financing reforms that have contributed to good governance in the health sector. METHODS: Six criteria of good governance were used as an analytical framework. Results were derived from official reports and the international literature. RESULTS: The main contributions of these reforms to good governance in Burundi were the separation of functions, transparency in management and a meticulous description of administrative procedures. Scrupulous monitoring resulted in several corrective measures. DISCUSSION: Several unresolved questions remain, concerning the integration of vertical programmes and the sustainability of the system given the considerable costs, since funding is not yet fully ensured by the State and its partners.

Community participation and voice mechanisms under performance-based financing schemes in Burundi.

OBJECTIVE: Community participation is often described as a key for primary health care in low-income countries. Recent performance-based financing (PBF) initiatives have renewed the interest in this strategy by questioning the accountability of those in charge at the health centre (HC) level. We analyse the place of two downward accountability mechanisms in a PBF scheme: health committees elected among the communities and community-based organizations (CBOs) contracted as verifiers of health facilities' performance. METHOD: We evaluated 100 health committees and 79 CBOs using original data collected in six Burundi provinces (2009-2010) and a framework based on the literature on community participation in health and New Institutional Economics. RESULTS: Health committees appear to be rather ineffective, focusing on supporting the medical staff and not on representing the population. CBOs do convey information about the concerns of the population to the health authorities; yet, they represent only a few users and lack the ability to force changes. PBF does not automatically imply more 'voice' from the population, but introduces an interesting complement to health committees with CBOs. However, important efforts remain necessary to make both mechanisms work. More experiments and analysis are needed to develop truly efficient 'downward' mechanisms of accountability at the HC level.