In the mid-2000s, health indicators in Burundi were very poor. The quality of service provision was low, and health personnel were poorly motivated with high rates of absenteeism. There were weaknesses in the organization and management of the health care system, and a lack of qualified health personnel in rural areas. In 2006, the Free Health Care policy was introduced, mandating that pregnant women and under-five children should be provided with basic health care for free. Health facilities were supposed to be reimbursed for their costs incurred due to the new policy, but in practice the reimbursement payments came with long delays, or not at all, thus severely hampering the implementation of the new policy. Results-Based Financing (RBF) pilots—where health facilities were paid for results achieved—were started in 2006 in some parts of the country. These pilots showed good results, but were limited in scope.
With substantial technical and financial assistance from the Bank, the existing RBF pilots were scaled-up nationwide, and merged with the Free Health Care program. The new RBF program—financed by several development partners—covers all public and most private nonprofit health facilities nationwide. Health facilities receive cash directly for performance, as measured by indicators of the quality of care provided as well as utilization of a range of health services, mostly for pregnant women and under-five children. All health facilities that are in the nationwide Results Based Financing system have been receiving payments on time, consistently, as seen from payment records of the Burundi Central Bank (BRB). An automated Internet-based system is used to record data and to generate invoices for payment, based on each health facility’s performance. There are several layers of verification of reported service levels, including independent verification teams comprising civil servants and nongovernmental organization (NGO) employees, and an external NGO that conducts ex-post audits on randomly chosen health facilities.
Substantial improvements have been observed with most indicators covered by the national RBF program since it began in April 2010. These include the following changes observed between April-June 2010 (the first quarter of implementation which serves as a benchmark) and the seasonally comparable April-June 2011 quarter:
- births at health facilities up by 25 percent (64,126 to 80,158),
- prenatal consultations up by 20.4 percent (261,672 to 315,161),
- children fully vaccinated up by 10.2 percent (68,128 to 75,060),
- curative care consultations for pregnant women up by 34.5 percent (85,337 to 114,767),
- family planning obtained via health facilities up by 26.9 percent (141,933 to 180,180), and
- average quality score of health facilities up by 52.8 percent.
The above figures are based on data collected and verified monthly via the national RBF program; they are consistent with the data recorded by the national Health Management Information System. The above trends have continued since April-June 2011, although there have been some seasonal variations. Fundamental to the achievement of the above results has been relatively smooth implementation of the national program on the ground, including timely verification and payments.
Measures of implementation performance have shown excellent results, including:
- Percentage of health facilities that received their payments within the agreed period (50 days) up from 48.09 percent (March 2010) to 100 percent (December 2011),
- Percentage of facilities that have had a verification visit in the previous six months up from 36.3 percent (March 2010) to 100 percent (December 2011). For example, verification activities have proceeded in a timely manner, and health facilities have consistently been paid within 45 days.
The total cost of the national RBF program is about US$26 million a year. IDA is the largest external contributor to the program and the second largest contributor after the government. IDA financing is provided through a US$25 million project spanning three years, covering about 32 percent of the total program cost. Further financing from IDA is expected to be approved later this year. IDA has provided intensive technical assistance (TA) throughout—including short-term TA as well as staff and long-term consultants based in country—starting more than a year before the national program began.
The program is co-financed by the government (which finances about half of the total cost), IDA, the European Union, the Belgian government, the Swiss government, the GAVI Alliance, the U.S. government, and several NGOs. Further financing has also now been secured from the Health Results Innovation Trust Fund (HRITF) which is co-financed by the governments of Norway and the United Kingdom, and administered by the World Bank. All partners finance a single national program which is implemented and monitored in the same way nationwide. NGOs and civil society play a key role, especially with verification and technical assistance activities.
Toward the Future
The current project will close in December 2012, but further IDA financing is expected to be approved in fiscal year 2013 (under the new Country Assistance Strategy, which will start in early fiscal year 2013). Financing from the HRITF is also forthcoming. Several other potential financiers are also showing substantial interest since the program uses an innovative Results-Based Financing approach that has generated excellent results in a short period of time. Sustainability is supported by the strong ownership of the government, which raised its contribution to the program from 10.1 million USD in 2011 to 13.5 million USD in 2012. The level of government contribution is expected to remain on an increasing trend through the life of the project.