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IX. Government Failure to Address Other Structural Problems of the Health System

Starving the hospitals: The downside of hospital autonomy

When 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 finance

The 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 institution’s 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 president’s 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