International University of Africa

Faculty of Medicine and Health Sciences

African Medical Students Association

Health Problems in Africa: Is there any hope left?
10 11 January 2013 AD/ 28 -29 Safar 1434 AH Khartoum - Sudan

Major Health Problems in East Africa

Burundi

Prepared by:

Safari Julius Mubarak,

Level 4 Faculty of Pharmacy (IUA) -47-

COUNTRY BACKGROUND

Burundi is a landlocked Central African country that borders Rwanda to the north, Tanzania to the east and south, and the Democratic Republic of Congo to the west. It is a relatively small country. Burundi is a small land-locked country in central Africa, bordered to the north by Rwanda, to the east and the south by Tanzania and to the west by the Democratic Republic of Congo and Lake Tanganyika, Burundi belongs to the East African community with other 4 member countries. It is home to 8.5 million people, 90% of them living in rural areas. The country averaged a 3.9% population growth rate from 2001 to 2007 of which 46% is less than 15 years of age. Burundis inflation rate is high (23.5% in 2008) and economic growth is low (3.6% real GDP growth in 2007). It ranked 172 out of 179 countries on the UN Human Development Index in 2006. After independence in 1962, the country experienced cyclical

-48-

crises attributed to ethnic tensions. The last civil war lasted 13 years and ended in 2005, though a rebel organization operated until 2008 despite a cease-fire signed in 2006. Burundi is a fragile state in a post-crisis situation, where ethnic issues remain problematic. The constitution was voted in by the population in 2005 and includes a balance of ethnic groups in public employment. Official development assistance to Burundi was US$ 415 million in 2007. The countrys total external debt in 2006 was 208% of GDP. The government contributes less than 50% of total development expenditure in Burundi. In 2006, total expenditure for health was estimated at between US$ 14.5 and US$ 18.5 per capita. Official external aid to the health sector was US$ 60 million, of which US$ 20 million went to the HIV/AIDS sector and US$ 40 million to other sectors. For the same year, total government expenditure for health was US$ 8 million. 5 Use of heavily indebted poor countries (HIPC) funds allowed national health expenditures for health to rise from less than US$ 5 million in 2005 to 33 million in 2009. The current public health system features free health care for women in labor and children under 5 years since May 2006, as part of the governments national objective of reducing maternal and child mortality. Since 2003, Burundi has been approved for US$ 87 million in funding from the GFATM for HIV/AIDS, TB and malaria efforts, of which US$ 62 million has been disbursed. Burundis application to round 8 of the GFATM for HIV-related efforts has also just been approved.7 Health care in the public sector for HIV-infected patients receiving antiretrovirals (ARVs) is provided free of charge, but this is not the case for PLWA who do not receive ARVs. One CSO in Burundi currently provides performance-based financing (PBF) for health care structures to deliver free care to patients not on ARVs. Antituberculosis drugs and TB-related activities are currently provided free of charge in public health facilities. Malaria treatment is free as of May 2009, but the diagnosis of malaria is not.

-49-

The Health System in Burundi

Burundi is in a transition stage between emergency aid and development aid, after a 13-year civil war that ended in 2005. Its institutional capacity in general and in the health sector in particular is very weak; the civil conflict destroyed most of the health-care infrastructure, resulting in high rates of human resources brain drain and the deterioration of health systems. The conflict had a similar impact on the economic situation of the country such that by 2007, the Gross Domestic Product was only $100 per capita. Until 2005, basic health needs in Burundi were supplied by NGOs specializing in humanitarian aid. These NGOs are being progressively replaced by other NGOs with expertise in long-term development, which increasingly receive GHI funding and direct assistance. The traditionally predominant role of NGOs in the country, together with a lack of

-50-

leadership by government, has resulted in a number of uncoordinated activities in the health sector. The main sources of funding for Burundis health system are now GHIs such as the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), GAVI, MAP, PEPFAR and other donors. By 2006, 76% of total health expenditure was externally financed. The GFATM contributes the largest amount, at 37% of the budget, and the rest is from other donors. PEPFAR supports some international NGOs providing HIV services in Burundi. The Ministry of Health (MoH) in Burundi is organized on four levels: a national level, divided into programs and cross-sectoral administration, a provincial level, a district level (currently being developed) and facility level through the primary health care (PHC) centers. Activities including TB, malaria and immunization, are conducted as part of an integrated minimum services package at facility level and coordinated by provincial or district offices. Since 2002, most of the public facilities, from PHC centers to hospitals, are financially independent. In 2004, under pressure from UNAIDS and the WHO, a separate Ministry for AIDS (MoA) was launched. The MoA was directly linked to the presidency, to ensure political visibility in the fight against AIDS and to direct multisectoral interventions. The MoA was transformed in 2007 into a vice-ministry of the MoH in an attempt to integrate activities into the MoH, though a new separation from the MoH occurred in January 2009 for political reasons. The National AIDS Council (NAC) was created in 2002 following World Bank guidelines, to manage HIV-related funds and coordinate multisectoral HIV activities. As a result, each national ministry has an HIV unit that is in charge of HIV-related activities.

Human Resources for Health (HRH) in Burundi.

Burundis political instability had significant negative impacts on the HRH system. No regular national census on total HRH numbers exists, with figures only reflecting the public sector. Government employees at all levels often also hold positions in the private sector. The number of HRH hired by NGOs, donors, or in the private sector, has never been assessed. In 2008,

-51-

the number of health workers in Burundis public sector was insufficient by international norms. An average of 0.2 physicians served every 10,000 inhabitants, with 1.4 nurses for every 3,000 inhabitants, and 68 pharmacists throughout the entire country. 80% of general physicians and 50% of the nurses work in urban areas although 91% of the population lives in rural areas. The capital has a slightly higher rate of physicians, with 1.4 per 10,000 inhabitants. A study conducted by IOM revealed that 150 physicians left the country between 1993 and 2002, because of conflicts, low salary levels and poor working conditions. The distribution of nurses varies according to the level of ongoing insecurity and the unequal level of external donor support to any given province. The training of new health workers cannot replace those leaving the public sector. Staff development is an area of concern in Burundi as it has only one public school of medicine with an annual rate of graduation of around 50 physicians. Trainings in specializations are offered through collaborations with European schools of medicine, but few trained specialists return to work in the country due to poor working conditions. The government is aware of the insufficient number of nurses and has decided to increase the number of students in nursing schools. 800 clinical staff (nurses, laboratory technicians and nurse assistants) graduate each year from six nurses schools, of which two are private, and one unique laboratory technicians school. However, 75% of the nurses graduate with the lowest degree (of two years training after junior high school). Pharmacists are exclusively trained in foreign countries. The annual number of newly qualified clinical staff available for the public sector is routinely depleted by trainings abroad and staff preference for the private or donor-funded sectors. Physicians in Burundi are also often expected to fulfill management roles, to the detriment of clinical work.

HEALTH WORKFORCE FINANCING.

Public structures have an agreement with NAC and the national HIV program that each facility staff receives a sum equal to 10% of that facilitys monthly expenditure, to compensate for any profit lost as the

-52-

result of not charging for ART-related services. This 10% initiative is specific to Burundi. However, for instance in a general hospital, the benefit would represent only US$ 1.75 per month per worker if equally distributed. Salaries at HIV-focused NGOs in Bujumbura are thus approximately four-fold higher than for staff with similar degrees in the public sector and, moreover, are exempted from revenue taxes. The increase of activities at facility-level funded by GHIs has also led to a parallel increase in workloads for public sector employees, but with no related salary increases. 70% of hospitalized patients in the public sector are HIV-positive. As a result, health workers would rather work for GHIs than in the public sector. Inequities in salaries within the public sector have also impacted on supervision. A manager may earn less than his employee or have to supervise a team of people with the same degrees and identical tasks, but who have different contracts and hence earn different salaries. Discrimination can also occur within a team.

Health workforce
The physician to population ratio (per 10,000 population) in Burundi 2000-2009 is < 0,5 The nursing and midwifery personnel to population ratio (per 10,000 population) in Burundi, 2000-2009 is 2

The pharmacists throughout the country are 68

-53-

THE HEALTH INFORMATION SYSTEM (HIS)

Burundis national HIS is not considered reliable as information is often late or incomplete. As a result, most programs bypass it in reporting to donors and use donors own reporting and data collection systems. The GFATMs separate budget for the training, resourcing and implementation

-54-

of HIV and malaria monitoring and evaluation represents more than US$ 8 million. This has led to situations in which one facility with many programs will have numerous reporting mechanisms and requirements, often duplicating each other. The lack of common indicators hence increases staff workloads. At facility level it was also found that the number of required reporting activities also prevented staff supervision. Furthermore, supervision is not coordinated: district or provincial health offices, for instance, will collect data independently of provincial HIV committees. Staff working more than one job or overburdened due to insufficient staff numbers were also less likely to compete routine tasks such as data entry, supervision and evaluation. .

INFRASTRUCTURE, EQUIPMENT, SUPPLIES

In contrast to other countries, in Burundi it does not appear that GHIs have strengthened the supply system. Maintenance of equipment purchased by GHIs is not effective, with frequent breakdowns. Frequent HIV-related pharmaceutical shortages occur (namely ARVs and opportunistic infection medications), as well as for reagents (HIV-testing, CD4 count, viral load) purchased by NAC with MAP1 and GFATM funds. For instance, in 2006 cotrimoxazole was not available for almost a year and HIV-testing reagents have not been available since October 2008. Local stakeholders attribute these shortages to insufficient reporting at facility level and a complex procurement and administrative system. The supply system in Burundi is very complex with 28 different sources of funding and 26 different supply mechanisms.

Service delivery
The decentralization of GHI-related care, particularly HIV-related services, has been clearly hampered by the health systems weakness in rural areas. Insufficient HRH numbers, and the presidential decree of 2006 that children under five and women in labor receive free health care access has led to clear cases of overwork in primary health care centers. (General antenatal services are not free.) The implementation of new activities, such as HIV-related services, has been subsequently challenging. PMTCT

-55-

coverage amongst HIV-infected pregnant women was only 7.8% in 2008 and less than 20% of facilities offered PMTCT services. Health workers do not consider existing GHI-related activities, like immunization, malaria and TB, as time-consuming as HIV-related activities. The lack of coordination means that any problems are exacerbated, as the response often will not reflect need.

Harmonization and alignment processes.

A National Committee for Aid Coordination (NCAC) was created in 2005 to coordinate all external aid to Burundi. The NCAC supervises 13 sector groupings, of which one is concerned with HIV and another with health, reflecting the parallel system of addressing HIV and health at ministry level. The two most efficient grouping are the health and education groups, with recent efforts in the health group concentrated on improving partnerships between government and technical and financial partners. Since 2007, Burundi has also been involved in piloting the International Health Partnership Initiative (IHP+). However, the disbursement of IHP+ funds is low (29% of the first installment, US$ 400,000, from September 2008 to April 2009) due to the heavy demands of administrative procedures.28 The frequent turn-over of senior national MoH officers, removed for political reasons or attracted by institutions offering better salaries, have at times disrupted the ability of the MoH and other bodies to meet targets.

-56-

BURDEN OF DISEASES IN BURUNDI.

-57-

HIVAIDS
Burundi faces a low-prevalence, generalized HIV/AIDS epidemic that continues to be a priority public health threat. National health information systems are weak and provide little reliable recent data on HIV/AIDS. Recent studies include a national HIV survey conducted by the National AIDS Council (NAC) in 2007, and older studies by UNAIDS and the World Bank. People Living with HIV/AIDS (Adults and Children) (2009) 180,000 Adult HIV/AIDS Prevalence Percent (Aged 15-49) (2009) 3.3%

MALARIA
Reported malaria cases include both probable cases as well as those cases confirmed by microscopy or a rapid diagnostic test (RDT). Country data provided only for countries in which malaria is considered to be endemic. NE = 'not endemic'. Estimates of global and regional malaria cases are also provided in WHO's World Malaria Report 2011. TUBERCULOSIS Tuberculosis: A bacterial infection caused by Mycobacterium tuberculosis. The disease usually affects the lungs but can spread to other parts of the body in serious cases. An individual can become infected with TB when another person who has active TB coughs, sneezes, or spits. Not all people who become infected with TB will develop symptoms. Those who do not become ill are referred to as having latent TB and cannot spread the disease to others

-58-

TOP CAUSES OF DEATH

Scarcity/ low motivation of health professionals.
There are no clear strategies for distribution, coverage, and retention of staff in rural areas. Less than 50 percent of health facilities meet the minimum staffing requirements. No human resource (HR) management tools exist, and there are specific HR shortages in medical specialists, pharmacists, and anesthetists. Public sector salaries remain low (and their real value has significantly declined in recent years) and are substantially lower than those in neighboring countries.

Financial barriers to accessing health care.

Public health expenditures are still low (seven percent) compared to World Health Organizations norms. In a country where 67 percent of the population lives below the poverty line, 40 percent of health care expenditures come from households themselves. Data show that about onethird of the population does not seek health care when it is needed, and among those who responded, 80 percent indicated that the prohibitive cost of health services was the main reason.

Poor quality of health services.

Utilization of health services remain low despite 80 percent of the population living within 5 km from a health center, due to the poor perception of the quality of services provided. Systems for quality assurance are weak at all levels of the heath system. Quality assurance policies, strategies, protocols and guidelines are still lacking or not enforced, affecting diagnosis and treatment. The capacity of service providers is weak and needs strengthening.

Poor access to essential medicines throughout the country.

In sufficient resources are available to purchase essential drugs. There is

-59-

an illicit network for essential drugs and the GOB is struggling to eradicate it. Due to limited knowledge and limited guidance, irrational prescription of drugs by service providers prevails. Very often, health facilities suffer stock shortages of essential drugs because the supply chain management system remains underdeveloped.

Weak health information system.

There is no rigorous national health information system in place. An overall monitoring and evaluation results framework is missing. Parallel data collection and monitoring and evaluation systems are still used separately, with each health actor tracking its own indicators. There is weak human resource and research capacity to generate and use information.

CONCLUSION
Despite the Governments tremendous efforts in the promoting health and the already significant support it receives, much remains to be done as it shifts its attention from quantity to quality though we are in scarce of both. Lastly, on behalf of Burundian students in IUA, I extend my special thanks to the entire administration of IUA and to the government of Sudan in general.

RECOMMENDATIONS
The building of health facilities in the country like hospitals, health centers, Medical schools, etc will help address some health problems The provision encouragement of zealous bodies like AMSA, in the form of academic and other form of support will add to the health workforce to solve the health problems

-60-

REFERENCES; 1. Sources: Global estimate available at: UNAIDS, Together We Will End AIDS, 2012: http://www.unaids.org/en/resources/campaigns/togetherwewillend aids/index.html. Country estimates available at: UNAIDS, Report on the Global AIDS Epidemic, 2010: http://www.unaids.org/GlobalReport/Global_report.htm. 2. Sources: WHO, World Malaria Report 2011: http://www.who.int/malaria/world_malaria_report_2011/en/. 3. Sources: WHO, Global Tuberculosis Report 2012, available at:http://www.who.int/tb/publications/global_report/en/index.html. 4. Country estimates available at: UNAIDS, Report on the Global AIDS Epidemic, 2010: http://www.unaids.org/GlobalReport/Global_report.htm. 5. Sources: WHO, Global InfoBase, available at: http://www.who.int/infobase/report.aspx?rid=118 6. The World Bank Group. Burundi Data -a-Glance 2008. 7. WHO. Core Health Indicators: Burundi. World Health Organization Information System; 2008. 8. The World Bank Group. World Development Indicators: Burundi. 2008. Accessed 6 March 2009 9. United Nations Development Programme. Human Development Reports: Burundi 2005. 10. Ministre de la sant et la Banque Mondiale. Rapport sur le financement du secteur de la sant. Burundi, Novembre 2007.

-61-