VIII. Government Measures Aimed to Improve Access to Health CareThe failure of health insuranceThe 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 dassurance 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,
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 poorIn Burundi, people with no financial means at their disposal, defined as indigent by their local administrators, may receive an indigence card (carte dindigence) 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 cardWhen 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,
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 detainedfour weeks at the time of the interviewand 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 peopleIn 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:
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 detentionSome 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 directiveOn 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 governments self-proclaimed effort to reach out to the poor.162 Perhaps more importantly, it also aims to show donors the governments willingness and ability to use funds well. It constitutes concrete progress towards two Millennium Development Goalsreducing child and maternal mortality.Under the Heavily Indebted Poor Countries Initiative, a countrys 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 systemDuring 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:
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; outpatientsthose who do not stay at the hospitalhave 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 programs 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 detentionsThe 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,
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,
Not surprisingly these and other victims detained expressed hope that the government would extend the reform to their cases as well.188
Further government plans for health reformIn 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 economythat 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 countrys 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.194 124 Human Rights Watch/APRODH interview with Dr. Julien Kamyo, chef de cabinet, Ministry of Health, Bujumbura, February 13, 2006; République du Burundi, Ministère de la Santé, Plan national de développement sanitaire 2006-2010. There are other insurances for state employees and private business. 125 Save the Children, The Cost of Coping with Illness,p. 1. 126 République du Burundi, Ministère de la Santé, Plan national de développement sanitaire 2006-2010, p. 28. 127 MSF, Access to Health Care in Burundi, p. 49. 128 Human Rights Watch/APRODH interview with Claudine N., Roi Khaled Hospital, Bujumbura, February 11, 2006. 129 Human Rights Watch/APRODH interviews with financial and administrative director, Roi Khaled Hospital, Bujumbura, February 14, and Dorothée H., Prince Régent Charles Hospital, Bujumbura, February 13, 2006. 130 Human Rights Watch/APRODH interview with director, Prince Louis Rwagosore Clinic, Bujumbura, February 14, 2006. 131 Human Rights Watch/APRODH interviews with financial and administrative director, Ngozi Hospital, Ngozi, February 15, and financial and administrative director, Gitega Hospital, Gitega, February 16, 2006. 132 Human Rights Watch/APRODH interviews with Emérite N. and Berthilde N., Gitega Hospital, Gitega, February 16, 2006. 133 MSF, Access to Health Care in Burundi, p. 49. Save the Children, The Cost of Coping with Illness,p. 3. Some interviewees in the Save the Children study alleged that people had obtained indigence cards through bribery rather than based on the official criteria. 134 Human Rights Watch interview with local administrator, Bujumbura-rural province, April 7, 2006. 135 République du Burundi, Ministère de la Santé, Plan national de développement sanitaire 2006-2010. 136 Save the Children, The Cost of Coping with Illness, p. 3. 137 Human Rights Watch/APRODH interview with Christian B., Ngozi Hospital, Ngozi, February 16, 2006. 138 Human Rights Watch/APRODH interview with Désirée N., Roi Khaled Hospital, Bujumbura, February 11, 2006. 139 Human Rights Watch interview with director, Roi Khaled Hospital, Bujumbura, February 14, 2006. 140 Human Rights Watch/APRODH interview with nurse, Roi Khaled Hospital, Bujumbura, February 11, 2006. 141 Human Rights Watch/APRODH interview with financial and administrative director, Prince Régent Hospital, Bujumbura, February 10, 2006. 142 The Accord used the term Sinistré for Displacedin its French and English versions. The word has been translated here for clarity. 143 Arusha Peace and Reconciliation Agreement for Burundi, Protocol IV. The accord also foresaw the creation of a National Fund for Sinistrés. It further stated that The Government shall ensure, through special assistance, the protection, rehabilitation and advancement of vulnerable groups, namely child heads of families, orphans, street children, unaccompanied minors, traumatized children, widows, women heads of families, juvenile delinquents, the physically and mentally disabled, etc. http://www.usip.org/library/pa/burundi/pa_burundi_08282000_pr4ch1.html, (accessed on April 25, 2006). 144 The Fund was financed through the operating budget of the CNRS, the Social and Cultural Fund (which had been previously under the domain of the Ministry of National Solidarity, Human Rights and Gender), UNHCR, and a World Bank project called Credit de Relance Economique. Human Rights Watch interview with Claire Nzeyimana, Volet Affaires Financières et Mobilisation des Fonds, CNRS, May 9, 2006. 145 Human Rights Watch interview with local administrator, Bujumbura-rural province, April 7, 2006. 146 Human Rights Watch interview with representative of PARESI, May 8, 2006. 147 Human Rights Watch/APRODH interview with Dorothée H., Prince Régent Charles Hospital, Bujumbura, February 13, 2006. 148 The three hospitals were Prince Régent Charles Hospital, Roi Khaled Hospital and CMCC Djabe. Human Rights Watch interview with Claire Nzeyimana, Volet Affaires Financières et Mobilisation des Fonds, CNRS, May 9, 2006. 149 On corruption, see section below on transparency. Human Rights Watch interviews with representative of PARESI, Bujumbura, May 8, and with Claire Nzeyimana, Volet Affaires Financières et Mobilisation des Fonds, CNRS, Bujumbura, May 9, 2006. 150 Human Rights Watch interview with Béatrice Ntahe, chef de cabinet, Ministry of National Solidarity, Human Rights and Gender, February 17, 2006. 151 Human Rights Watch interview with representative of the Ministry of National Solidarity, Human Rights and Gender, Bujumbura, May 10, 2006. When we asked the chef de cabinet to explain the use of the funds, she refused to do so: Human Rights Watch interview with Béatrice Ntahe, chef de cabinet, Ministry of National Solidarity, Human Rights and Gender, February 17, 2006. 152 APRODH interviews with financial and administrative director, Muyinga Hospital, Muyinga, March 6, and with chief accountant, Matana Hospital, Matana, March 8, 2006. 153 APRODH interview with financial and administrative director, Muyinga Hospital, Muyinga, March 6, 2006. 154 MSF, Access to Health Care in Burundi, p. 46. 155 Human Rights Watch/APRODH interview with director and financial and administrative director, Prince Louis Rwagosore Clinic, Bujumbura, February 14, 2006. 156 MSF, Access to Health Care in Burundi, pp. 10-12. 157 APRODH interview with financial and administrative director and with nurse, Buhiga Hospital, Karuzi, March 7, 2006. Such models might be easier to practice in smaller hospitals where there are less complex and expensive cases of treatmentthose are often sent to the capital. 158 APRODH interview with director, Rumonge Hospital, Rumonge, March 1, 2006. 159 Burundi: Nkurunziza announces free maternal healthcare, pay rise for workers, IRIN, May 1, 2006, http://www.irinnews.org/report.asp?ReportID=53075&SelectRegion=Great_Lakes (accessed May 3, 2006). 160 UNICEF, Burundi: Free primary education for all children, September 7, 2006, http://www.unicef.org/infobycountry/burundi_28197.html (accessed July 3, 2006). 161 République du Burundi, Ministère de la Santé, Plan national de développement sanitaire 2006-2010, pp. 35-46. The health plan also made other, broader recommendations. See section 5 in this chapter. 162 According to the Ministry of Health, the reform aims to reduce infant and maternal mortality in Burundi. Human Rights Watch telephone interview with chef de cabinet, Ministry of Health, Bujumbura, June 22, 2006. 163 Human Rights Watch telephone interview with financial and administrative director, Prince Louis Rwangasore Clinic, Bujumbura, June 19, 2006. 164 Human Rights Watch telephone interview with diplomat in Bujumbura, June 19, 2006. 165 Human Rights Watch telephone interview with World Bank official, Washington D.C., March 31, 2006. 166 Human Rights Watch telephone interview with financial and administative director, Prince Louis Rwangasore Clinic, Bujumbura, June 19, 2006. 167 Burundi: Side effects of free maternal, child health care, IRIN, June 9, 2006. http://www.irinnews.org/report.asp?ReportID=53836 (accessed July 3, 2006). 168 Announcement on Radio Isanganiro, May 10, 2006. 169 Human Rights Watch telephone interview with financial and administrative director, Roi Khaled Hospital, Bujumbura, June 20, 2006. 170 Announcement on Radio Bonesha, May 22, 2006. 171 Burundi: Side effects of free maternal, child health care, IRIN. 172 Human Rights Watch telephone interview with financial and administrative director, Prince Louis Rwangasore Clinic, Bujumbura, July 27, 2006. Medicine for children under five and women giving birth is paid for at health centers. 173 Human Rights Watch telephone interview with financial and administative director, Prince Louis Rwangasore Clinic, Bujumbura, June 19, 2006. 174 Human Rights Watch telephone interview with Dr. Julien Kamyo, chef de cabinet, Ministry of Health, June 22, 2006. 175 Human Rights Watch telephone interview with Belgian official, June 21, 2006. This was echoed by other diplomats and donors. 176 Figures provided by donor government, Human Rights Watch telephone interview, June 19, 2006. 177 Of $10 million, 14 percent went to the central level, 23 percent went to the intermediate level and 63 percent went to the operational levelthat is, essential medicines, vaccinations, contracts, and essential health care for deliveries and children. The $3 million is part of the funds allocated to the operational level. 178 Human Rights Watch telephone interview with Dr. Julien Kamyo, chef de cabinet, Ministry of Health, June 22, 2006. 179 Human Rights Watch telephone interview with Dr. Julien Kamyo, chef de cabinet, Ministry of Health, August 8, 2006. 180 Human Rights Watch interview with social worker, Roi Khaled Hospital, Bujumbura, June 23, 2006; Human Rights Watch telephone interview with financial and administrative director, Prince Louis Rwangasore Clinic, Bujumbura, June 19, 2006. 181 Human Rights Watch interviews with financial and administrative directors, Prince Louis Rwangasore Clinic and Roi Khaled Hospital, Bujumbura, August 8, 2006. 182 ICESCR, article 12(2)(a). 183 Human Rights Watch interview with head of accounting, Roi Khaled Hospital, Bujumbura, June 23, 2006. 184 Human Rights Watch interviews with staff at Roi Khaled and Prince Régent Charles Hospitals, June 23, 2006. 185 Human Rights Watch telephone interview with financial and administative director, Prince Louis Rwangasore Clinic, Bujumbura, June 19, 2006. 186 Human Rights Watch interview with Jerôme N., Roi Khaled Hospital, Bujumbura, June 23, 2006. 187 Human Rights Watch interview with Augustin M., Prince Régent Charles Hospital, Bujumbura, June 23, 2006. 188 Human Rights Watch interviews with Jerôme N., Roi Khaled Hospital, Bujumbura, June 23, and with Augustin M. and Adèle A., Prince Régent Charles Hospital, Bujumbura, June 23, 2006. 189 Human Rights Watch/APRODH interview with Dr. Julien Kamyo, chef de cabinet, Ministry of Health, Bujumbura, February 13, 2006. 190 Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases, http://www.uneca.org/ADF2000/Abuja%20Declaration.htm (accessed July 31, 2006). 191 République du Burundi, Ministère de la Santé, Plan national de développement sanitaire 2006-2010, pp. 48-49. 192 Ibid. 193 Human Rights Watch/APRODH interview with Dr. Julien Kamyo, chef de cabinet, Ministry of Health, Bujumbura, February 13, 2006. 194 République du Burundi, Cadre Stratégique de Croissance et de Lutte contre la Pauvreté, July 2006, p. 59. |