IX. Government Failure to Address Other Structural Problems of the Health SystemStarving the hospitals: The downside of hospital autonomyWhen hospitals were made autonomous beginning in 1988, they had to assume responsibility for financing most of their activities. If they fail to recover past costs, they must cut future expenses; in many cases this includes staff salaries. The state owes hospitals large sums of money under the medical insurance system. According to management staff at the Prince Régent Charles Hospital, insurance bills from 2004 and 2005 are still outstanding.195 The Ministry of Finance, responsible for paying bills, pays them with less and less regularity as the year goes on and, according to one hospital official, by June the payments stop.196 The overall budget for medical insurance was 180 million FBU (U.S.$180,000) in 2005 and 300 million FBU ($300,000) in 2006.197 The government pays a subsidy to public hospitals, but this support covers only a fraction of their costs. Prince Louis Rwagasore Clinic, for example, receives about 10 percent of its annual budget from the state198 and Prince Régent Charles Hospital about 30 percent.199 Salaries of health personnel are very low, in part because state assistance to hospitals is so limited. The starting salary of a general practitioner in 2004 was 62,980 FBU ($62) per month.200 Lack of transparency in health sector financeThe Burundian health sector is plagued not just by lack of funds but by lack of clear guidelines, as well as fraud and corruption, in how they are used. Hospital staff are uncertain when and how much of their institutions expenses will be reimbursed by the state because the medical insurance and indigence card systems do not work properly. Poor patients are unsure what costs they will have to pay. Hospital staff have themselves been involved in financial mismanagement and corruption. In October 2005, officials at the CNRS found Roi Khaled staff submitting false vouchers and fabricating and selling documents attesting to poverty or returnee status. The supposed organizer of the fraud, an employee of the CNRS based in the hospital, was suspended.201 According to an official in the Ministry of National Solidarity, Human Rights and Gender, cheating and fraud remain a problem at the Fund for Victims.202International agencies that pay hospital bills for some of their beneficiaries have complained of cases of false or inflated bills prepared by hospital staff.203 On February 24, 2006, the finance minister acknowledged in a radio broadcast that one billion FBU ($1 million) had come through the treasury, supposedly for the purchase of medicine, but that he could not account for its use.204 Shortly after, health officials deplored the disappearances of medicine from health centers and expressed concern that there might be deliberate speculating by health center managers in the sale of medicine.205 Among past indications of corruption in the health sector was the 2001 murder of Kassi Manlan, head of the World Health Organization in Burundi, reportedly killed because he had uncovered embezzlement by important Burundian officials of money meant to buy medicines.206 Following the presidents announcement of anti-corruption measures, parliament voted in July 2006 for the creation of an Anti-Corruption Brigade with police powers, despite worries about the constitutionality of the body.207 195 Human Rights Watch/APRODH interview with financial and administrative director, Prince Régent Charles Hospital, Bujumbura, February 10, 2006. 196 Human Rights Watch/APRODH interview with financial and administrative director, Ngozi Hospital, Ngozi, February 15. Similar information was provided by the financial and administrative directors of Roi Khaled and Prince Régent Charles Hospitals. 197 Human Rights Watch/APRODH interview with Dr. Julien Kamyo, chef de cabinet, Ministry of Health, Bujumbura, February 13, 2006. 198 Human Rights Watch/APRODH interview with director and other managers, Prince Louis Rwagasore Clinic, Bujumbura, February 14, 2006. 199 Human Rights Watch/APRODH interview with financial and administrative director, Prince Régent Charles Hospital, Bujumbura, February 10, 2006. 200 République du Burundi, Ministère de la Santé, Plan national de développement sanitaire 2006-2010, p. 26. This sum includes a housing allowance. On the situation of medical staff, see also Niyongabo et al., Burundi: Impact de dix années de guerre civile sur les endémo-épidémies. 201 Human Rights Watch interview with Claire Nzeyimana, Volet Affaires Financières et Mobilisation des Fonds, CNRS, May 9, 2006. 202 Human Rights Watch interview with representative of the Ministry of National Solidarity, Human Rights and Gender, Bujumbura, May 10, 2006. 203 Human Rights Watch interview with humanitarian agency, Bujumbura, February 12, 2006. 204 Radio Bonesha, February 24, 2006. 205 Gitega Santé: Les principaux facteurs qui freinent encore laccessibilité aux soins de santé, Agence Burundaise de Presse, April 21, 2006. 206 Letter from Claude Beke Dassys, Ambassador of Côte dIvoire to the United Nations, Geneva, to President Laurent Gbagbo, September 2002; Human Rights Watch interview with Alexis Sinduhije, Bujumbura, May 10, 2006; Burundi Court Convicts Killers of WHO Official, Mail & Guardian Online, May 4, 2005, http://www.mg.co.za/articlePage.aspx?area=/breaking_news/breaking_news__africa/&articleId=237024 (accessed April 29, 2006); Burundi police killed aid worker, BBC News Online, May 4, 2005, http://news.bbc.co.uk/2/hi/africa/4512263.stm (accessed April 29, 2006); Entrevue avec Me Bernard Maingain, membre du barreau de Bruxelles, avocat et conseiller de la partie civile dans l'affaire Kassy Manlan, Burundi news, June 6, 2005, http://burundi.news.free.fr/interviewavocat.html (accessed April 29, 2006). 207 Burundi/Assemblée Nationale : Pas de quorum pour voter la loi portant création de la Brigade anti-corruption, Burundi Réalités, July 23, 2006, http://www.burundirealite.org/burundi/display_news_f.cfm?loc=1802 (accessed July 31, 2006); Burundi-politique : La grogne sintensifie à lAssemblée Nationale au sein des députés du FRODEBU, de lUPRONA et du CNDD de Nyangoma Burundi Express, July 13, 2006, http://www.burundiexpress.org/article.php3?id_article=128 (accessed August 8, 2006). Critics maintained the proposed anti-corruption brigade will be a police body, separate from the ordinary police. However the constitution stipulates that there can only be one national police force. |