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VIII. Government Measures Aimed to Improve Access to Health Care

The failure of health insurance

The Burundian health system uses mechanisms that are supposed to increase access to health care for the poor. If functioning effectively, these mechanisms could allow some of the poor to pay their medical expenses and avoid hospital detention. An illness insurance card (carte d’assurance maladie, CAM) costs U.S.$0.50 per year and covers 80 percent of some, but not all medical, costs.¹²⁴ The CAM is a voluntary, community-based prepayment scheme that is open to all. It is particularly meant for the poor, and complements a compulsory insurance scheme for civil servants.¹²⁵

In practice, health insurance rarely, if ever, works well enough to keep poor people from detention in hospitals. Recognized as ineffective, the card is little used in most of the country and has been abolished in five of seventeen provinces. The 2005 National Plan for Health Development says that “the population does not have confidence in the illness insurance card (CAM) any more… This card is in the process of disappearing in most parts of the country.”¹²⁶ Only 1 percent of patients surveyed by the MSF study mentioned above had the insurance card.¹²⁷

In our own interviews, we spoke with over 20 hospital detainees who had the insurance card but still ended up in hospital detention. Many patients did not have insurance when they entered the hospital, but obtained it with the help of their family on the day they were hospitalized, or later. Hospitals sometimes rejected the illness insurance card when it was bought at this late date. Claudine N., whose newborn baby needed lifesaving surgery, told us,

I obtained the insurance card after I came to hospital. My husband got it for me at the commune, and it cost 500 FBU [$0.50]. But they did not accept it at the hospital. You are supposed to get it before you come.¹²⁸

Large hospitals like Roi Khaled Hospital and Prince Régent Hospital also excluded medical equipment and supplies from the costs covered by insurance. Dorothée H., mentioned above, needed a hip replacement but was told that her insurance did not cover the $400 cost.¹²⁹ Other hospitals, like Prince Louis Rwagasore Clinic, do not accept the insurance at all.¹³⁰

Some provincial hospitals, like those at Gitega and Ngozi,¹³¹ accepted the insurance and Gitega Hospital even promoted it. Yet even in these hospitals patients were detained if they could not pay the remaining 20 percent of the costs. Such was the case of two women detained at Gitega Hospital after having had surgery for birth complications.¹³²

The failure of the exemption system for the poor

In Burundi, people with no financial means at their disposal, defined as “indigent” by their local administrators, may receive an indigence card (carte d’indigence) that makes them exempt from paying health care costs, as well as from educational and other fees. Since 2003, those who have been displaced by the war may also qualify for a voucher that exempts them from health care costs.

However, criteria for receiving both the indigence card and the vouchers are not officially defined, leaving the process lacking in transparency and open to arbitrary decisions. According to MSF, “the exemption system has become a sectoral and clientelistic practice.”¹³³ These faults in the procedure make it even more likely that the systems meant to provide relief to the poor actually deliver little but token help to a few.

The indigence card

When poor people receive the indigence card, the commune of residence of such persons is then required to pay their medical bills. The government points to the system as proof of its will to assist the needy, but the system rarely provides exemptions for the poor, and simply hides lack of effective government action. A local administrator in Bujumbura-rural province explained to us,

We as communal administrators are charged with handing out the indigence card. We know who is vulnerable: orphans, very old people, people without land, people who live from begging, sometimes people without children to support them. If someone like this gets sick, neighbors take them to the commune. For small things, we can take them to the health center run by GVC and ECHO [Gruppo Voluntariato Civile and the European Commission’s Humanitarian Aid Office, both humanitarian agencies]. But for big things, like an operation, we cannot help them now. Even if I gave them the necessary document, it does not have any meaning. The commune is responsible for paying these bills and we do not have a budget for that.¹³⁴

In its recent National Plan for Health Development (Plan national de développement sanitaire), the government itself admits that most communes do not provide indigence cards any more.¹³⁵

Most hospital detainees we interviewed did not have an indigence card and had not even heard about it. The study by Save the Children, mentioned above, found that only about 10 percent of all people surveyed knew there was a system to exempt the poor from health care costs, and only 4 percent of the poorest households interviewed knew about it.¹³⁶ Our research found that those who did have the indigence card, or tried to get it, encountered difficulties. As noted above, Christian B., an orphan suffering from a chronic skin disease, was told by his local administrator that the card was no longer in use.¹³⁷

Other patients who had the card had it rejected by the hospital. For example, Désirée N., a woman from Bubanza province who came to Roi Khaled Hospital because she was pregnant and had a tumour, gave birth prematurely and the child needed an incubator. As she was destitute, she was detained—four weeks at the time of the interview—and did not get the tumour treated. She said that she had an indigence card but that the hospital had rejected it.¹³⁸ The director of Roi Khaled hospital told us that “the hospital does not accept the indigence card because the state does not reimburse its expenses.” He added that displaced people and returnees could get vouchers until the end of 2005, but not any more.¹³⁹ A nurse at the same hospital confirmed that staff had been instructed not to accept the indigence card.¹⁴⁰ This is also the case for other hospitals.¹⁴¹

The voucher for displaced people

In recent years displaced people and returnees with an indigence card were eligible for vouchers at the National Commission for the Reintegration of the Displaced (Commission Nationale pour la Réintegration des Sinistrés,CNRS). ¹⁴² The CNRS was an agency established under the Arusha Accords to aid “all displaced, regrouped and dispersed persons and returnees.”¹⁴³ Funded by the government and donors, it functioned from mid-2003 to December 2005.¹⁴⁴

Local administrators sometimes handed out indigence cards when they were confident that the CNRS would reimburse them. However, this was not often the case, as a local administrator criticized:

For a while, the CNRS was able to pay some bills. But you had to find someone who could “do gymnastics” to ever get any money there. If I thought a family had someone who could manage to get help from CNRS, I would give them the indigence card and sometimes they could get some money, but often not.¹⁴⁵

Other officials familiar with the process echoed his concern about the “management and money problems” at the agency.¹⁴⁶

The procedure for obtaining vouchers was such a burdensome and complex process that few potential recipients pursued it to the end.¹⁴⁷  If they did obtain a voucher, it could be used at only three hospitals, all in Bujumbura. For a patient to be permitted to leave the hospital at the conclusion of treatment, the hospitals would have to agree to accept the voucher and then transmit the bills to the office of the CNRS to be reimbursed.¹⁴⁸ Poorly designed, the system was also badly managed and some funds, according to officials involved, were misused.¹⁴⁹

The CNRS, a structure of the transitional government, ended when the newly elected government took power, but a government body called PARESI has been created to succeed it, and the Fund for Victims continues to exist, reassigned to the Ministry of National Solidarity, Human Rights, and Gender. According to the chef de cabinet of the Ministry, the fund held 500 million FBU in 2006 ($500,000).¹⁵⁰ The criteria for receiving assistance are unclear, in particular whether only displaced people and returnees are eligible for help or whether other needy persons may also apply. According to an official charged with distributing vouchers, displaced and repatriated people are often better treated and have better access to free medical care than other indigent people. When there is a lot of media attention on a certain case, for example if a woman has triplets, the Ministry will help her, but in general other needy people will be turned away.¹⁵¹

A patient detained at Prince Régent Charles Hospital. © 2006 Jehad Nga

Alternatives to hospital detention

Some hospitals have found ways other than detention to assure payment of bills, though these alternatives can create other problems for patients. Hospitals in Muyinga (northeastern Burundi) and Matana (southern Burundi) keep the identity cards of patients who are unable pay.¹⁵²  Such former patients then feel pressure to pay because security forces frequently ask to see identity cards, and anyone without one may be considered suspicious and even taken as a possible supporter of the FNL rebels. When an indebted patient has a bicycle, the hospital in Muyinga also retains this essential means of transport in order to increase pressure to discharge the debt.¹⁵³

In some health centers staff get former patients to work off their debt by cultivating fields belonging to the health center.¹⁵⁴ Staff of the Prince Louis Rwagasore Clinic allow patients with stable employment to leave once they agree to have the money owed deducted from their salaries and paid directly to the hospital by their employers.¹⁵⁵ This strategy is useful only in urban settings where patients are salaried workers.

Some facilities supported by international NGOs operate a different model of health financing: the patients pay a percentage of the costs, as in Makamba province where they pay 50 percent of the medicine plus cost of treatment, or a flat fee, as in Karuzi, Cankuzo, Bujumbura-rural and Ruyigi provinces, where patients pay an all-inclusive charge ranging from 50 to 500 FBU ($0.05 to $0.50).¹⁵⁶ As a result, detention of patients is unusual in these hospitals. At Buhiga Hospital in Karuzi, where patients pay 300 FBU [$0.30] for out-patient treatment and 500 FBU [$0.50] for hospitalization, there were no detainees at the time of a visit by some of our research team to the hospital in March 2006. According to the financial and administrative director, there were patients who could not pay the flat fee, but they are treated at Karuzi nevertheless.¹⁵⁷ In Bururi province, the Dutch agency Cordaid started a new scheme for indigent patients in January 2006, sponsoring medicine and consultations, and soon after there were no hospital detainees there.¹⁵⁸

Free care for women giving birth and small children: The May 1 presidential directive

On Labor Day, May 1, 2006, President Nkurunziza declared that all maternal health care and treatment for children under five years old would henceforth be free of charge.He also announced pay rises for public service employees, and the creation of an anti-corruption brigade.¹⁵⁹

The ruling CNDD-FDD portrays itself as a popular movement addressing the needs of the poor. Shortly after coming to power, the new government abolished primary school fees and introduced free and compulsory primary education.¹⁶⁰ The government health plan of December 2005 focused on improving maternal and infant health through improved obstetric care at health centers and hospitals; the creation of a fund for caesarean deliveries and complicated births; improved antenatal care; subsidies for medicine for the poor; and health care for children under five years old.¹⁶¹

The introduction of free health care for pregnant women, mothers and small children is part of the government’s self-proclaimed effort to reach out to the poor.¹⁶² Perhaps more importantly, it also aims to show donors the government’s willingness and ability to use funds well. It constitutes concrete progress towards two Millennium Development Goals—reducing child and maternal mortality.Under the Heavily Indebted Poor Countries Initiative, a country’s debt can be reduced if certain economic and social conditions are fulfilled. Burundi is currently getting debt relief on an interim basis, and it is striving to qualify for permanent debt relief. According to one hospital manager, “The government has received debt relief funds, and now they need to be used.”¹⁶³

Some observers have also noted that increased pressure regarding the detention of hospital patients might have played into the decision.¹⁶⁴ Prior to the announcement of the reform, the Burundian government and the World Bank were discussing how to best use the $10 million gained from debt relief, and the release of detained patients was one of the issues that arose.¹⁶⁵

While the directive on free maternal and child health appears to be a very good idea, in practice it has caused serious problems.

An increased burden on the health system

During the first days of May 2006, thousands of pregnant women and parents of sick children made their way to the nearest hospital to benefit from the reform. According to a manager at Prince Louis Rwagasore Clinic in Bujumbura:

Our hospital is overwhelmed with patients, and we have insufficient capacity…. We have four tables for delivery and sometimes ten women arrive at the same moment, so you can imagine the problem. We have sometimes run out of sterilization equipment and sent women elsewhere.¹⁶⁶

At Bururi Hospital, the number of patients in the maternity ward rose from a daily average of 14 a day to at least 40.  At Kayanza Hospital, where there was already an acute lack of medical staff, the single doctor able to perform caesarean deliveries was overwhelmed.¹⁶⁷ Rumonge Hospital ran out of medicine or supplies only days after the presidential directive.¹⁶⁸ Roi Khaled Hospital ran out of essential materials and had to ask suppliers to fill their orders without immediate payment.¹⁶⁹ As hospitals were overstretched, some patients were denied treatment. A woman with a miscarriage died at Roi Khaled Hospital, after medical staff in this and other locations reportedly turned her away.¹⁷⁰

Many ordinary Burundians have expressed enthusiasm for the initiative. However patients have also criticized that hospitals do not always pay for the medicine for beneficiaries.¹⁷¹ The reform foresees free medicine only for those future mothers and small children who are hospitalized; outpatients—those who do not stay at the hospital—have to pay for their medicine themselves.¹⁷²

One of the main problems of the May 1 presidential directive was the lack of preparation for the reform. Hospitals learned of the change on the radio, which meant that they had no chance to prepare in advance for the influx of new patients.¹⁷³ Even the chef de cabinet in the Ministry of Health recognized this problem:  “When the President declared free health care [for women giving birth and children under five], the hospitals were not ready in terms of medicine, equipment, staff numbers and housing capacity. Now we are dealing with these problems.”¹⁷⁴ Many health administrators and hospital managers also criticized the way the reform was launched so suddenly, a sentiment shared by representatives of donor nations as well.¹⁷⁵

According to the World Health Organization, the government and donors decided that about $3 million of the $10 million to be made available in the context of debt relief were to go to essential medicines and health care for children and costs of childbirth. Some of these funds could be used to pay for maternal and child health care¹⁷⁶ and other funds might have an indirect impact on access to health care. But funds would still be insufficient to pay for the new initiative, which were not covered in the regular budget.¹⁷⁷ The Ministry of Health may ask donors for more support but first, said one official, “we have to negotiate with the government itself to show the gap in funding.”¹⁷⁸ By early August 2006, the Ministry had managed to get some additional government funds, but these “are not sufficient at all” and the government continued to seek further funds.¹⁷⁹ In late June hospitals began sending their bills for the costs of the new program to the government, anxious to see whether they would be reimbursed as promised. Bills at Prince Louis Rwagasore Clinic and Roi Khaled Hospital were roughly $20,000 each.¹⁸⁰ By early August they had not been reimbursed.¹⁸¹

The introduction of free maternal and child health care constitutes an important step towards the progressive realization of the right to health, in particular achieving the reduction of the stillbirth rate and infant mortality.¹⁸² But the policy will fail if the government does not urgently take the measures to ensure the program’s sustainability and increase staff, equipment and medicine throughout the country. Furthermore, the government must embed the new, badly prepared change in the context of a larger health policy.

Impact on hospital detentions

The May 1 reform meant that women giving birth and children under five years old are no longer detained in hospitals, thus significantly reducing (by about one third) the number of persons suffering from this abuse. In June 2006, for example, there were no women with birth complications or children under five detained at Roi Khaled and Prince Régent Charles Hospitals.

The presidential directive also spurred other initiatives. The Ministry of National Solidarity, Human Rights and Gender paid about $13,000 to free women with birth complications and children under five who had been detained at Roi Khaled Hospital between January and May 2006.¹⁸³

Yet the majority of detainees have not benefited from the reform as it does not apply to them. Women with problems unrelated to childbirth, children over the age of five, and men continue to be detained. In late June 2006, 36 patients were held at Roi Khaled Hospital and 41 at Prince Régent Charles Hospital.¹⁸⁴ A staff member at Prince Louis Rwagasore Clinic also confirmed that the practice continued at his hospital.¹⁸⁵

Among those held at Roi Khaled Hospital was Jerôme N., a 17-year-old boy who suffered a serious leg infection, and who could not walk. He was detained for almost one month at the time of the interview, and told us,

My mother left here and sold a piece of our land to help pay for the medicine. We had to pay for the medicine up-front before the surgery could even be done, so she sold the land for 300,000 FBU [$300] to pay for the medicine. By the end of March, I felt much better. I have now been completely healed for a month but I cannot leave the hospital because I have the bill of more than 700,000 FBU [$700] for the operation. The doctor came and told me that I am healed but that I cannot leave because I cannot pay. Yesterday they told me to leave my bed so a paying patient could have it, so I slept on the floor on a mat that someone lent me. I tried to escape once but the guards at the gate said that I couldn’t leave and I didn’t have an authorization to leave.¹⁸⁶

Among those held at Prince Régent Charles Hospital was Augustin M., a 26-year old man from Muyinga province who had a car accident. He told a Human Rights Watch researcher,

Two weeks ago, the doctors told me that I was healed, but I could not pay the bill, so I had to stay here. I have no money and no land and no work, and I need another operation to take the metal rod out of my leg. The nurse told me that they might not take out the metal rod if I cannot pay for the first surgery.… I feel like a prisoner here because I cannot leave. I am afraid I will have the metal rod in my leg forever….

The [government] declaration is good but I think that other people should be covered, like those who have no father. He died when I was young and my mother has no money.¹⁸⁷ 

Not surprisingly these and other victims detained expressed hope that the government would extend the reform to their cases as well.¹⁸⁸

Twenty-year-old Albert H. was hurt in a car accident when he went to check on his family’s farm, which they had fled a year earlier. He sustained injuries to his eye and left arm. When he could not pay the bill, he was detained at Prince Régent Charles Hospital in Bujumbura. © 2006 Jehad Nga

Further government plans for health reform

In its National Plan for Health Development, the Ministry of Health says it intends to raise the health budget to about 15 percent of the total annual budget (from about 2.7 percent in 2005¹⁸⁹), in line with a commitment made by African countries in 2001.¹⁹⁰

The plan also acknowledges that the current medical insurance system is not working properly and proposes abolishing it and replacing it with a system of mutuelles. These are voluntary community-based health insurance schemes that function somewhat like a cooperative. The Burundian government proposes to promote these for the population that is active in the informal urban or rural sectors of the economy—that is, large parts of the population. While community-based health insurance is traditionally created and funded totally through a local community, the Burundian government gives the state a more important role, as it is planning to subsidize them.¹⁹¹ Studies have shown that low enrollment is a frequent problem of community-based health insurance. Should the government go ahead with its plan to create mutuelles, it will need to develop a strategy for how to address this problem and make mutuelles viable for the poor who are active in the rural or urban informal economy.

In its national health plan, the government makes a somewhat artificial distinction between those who work in the informal sector and those who are poor. It suggests that there might be difficulties in extending community-based health insurance schemes to the poor and proposes state subsidies to “protect the most vulnerable groups such as pregnant women (all), children under five years of age and indigents.”¹⁹² While the government has, as already discussed, taken steps to improve access to health care for pregnant women and small children, it has not done so for indigents. The Ministry of Health has attempted to create a fund for poor patients but this was rejected during the budget debate in December 2005.¹⁹³ The plan remains vague and does not mention the problem of hospital detentions. In August 2006 the Burundian government was working on the final touches of the country’s Poverty Reduction Strategy Paper (PRSP), the draft of which repeats the same health policy priorities but does not provide any additional detail. It also does not mention hospital detentions.¹⁹⁴