The COVID-19 crisis offers Burkina Faso the chance to land on a more coherent approach to health financing. All sights are trained on the health system right now because of the COVID-19 crisis, and within the COVID-19 response lies Burkina Faso’s best chance at addressing fragmentation in health financing.
In the past few years, the Ministry of Health (MoH) in Burkina Faso has developed a variety of ambitious health financing reforms. Implementation has been difficult, however, and too often these reforms compete for funding and attention, rather than complementing each other as a coherent whole. Burkina Faso’s COVID-19 response offers an opportunity to combine the best from each to build something stronger.
Burkina Faso’s limited capacity to implement reform has been undermined by insecurity and labor unrest. Trans-national security threats have increased in recent years, leading to widespread disruption and more than half a million people were internally displaced by the end of 2019 . In a response to this challenge, Prime Minister Paul Kaba Thieba and his government resigned in January 2019, signaling a significant realignment of government priorities towards managing the security situation. Labor unrest has further exacerbated challenges to the health sector; a partial public health worker disrupted provision of many non-curative services in public health facilities from May through November 2019.
In the health financing space, a series of reform programs risk being shipwrecked because of competing priorities. A particular area of interest is the way in which the Government allocates pooled funds to providers of health services on behalf of a population, referred to as ‘purchasing’ in health financing circles. Major purchasing reforms currently under way in Burkina Faso include;
Gratuité – In 2016, MoH removed user fees for maternal and child health services through the popular ‘gratuité’ program, replacing these fees with payments from the Government. The program worked well until budget cuts at the end of 2018 caused shortfalls in payments, which continue to challenge facility managers and have led to increasing debts to the central medical store.
Performance-based financing (PBF) – From mid-2018, with support from the Work Bank, MoH has been working to roll-out a new version of a PBF scheme. In the latest iteration, the scheme will reward facilities for meeting quality standards. However, systematically measuring quality in an objective way is difficult, and progress has been slow.
National health insurance – A national health insurance agency, Caisse Nationale d’Assurance Maladie Universelle (CNAMU), was formally established in 2018. CNAMU is mandated to take on the management of several purchasing schemes including gratuité, a plethora of small community-based health insurance or ‘mutuelle’ schemes, and health insurance for the formal sector. CNAMU is building its capacity and is initiating a program to subsidize mutuelle membership for target populations, but transfer of gratuité has yet to happen.
As COVID-19 struck, the Government of Burkina Faso was quick to recognize the need to plan for the health sector response. A critical part of this was figuring out what funds would be needed at front line facilities, how to get those funds there, and how to enable facilities to use and account for the them. Establishing a rational approach was important to counterbalance political interests advocating for funds for their local constituencies.
In the urgency of COVID-19 planning, MoH stepped away from factional interests to identify and combine the strengths of different purchasing schemes. A participatory process led to the agreement of evaluation criteria for options to transfer funds to facilities. The pros and cons of different schemes were weighed up objectively, setting aside narrow departmental interests. A consensus is emerging that the programme d’appui au développement sanitaire (PADS) system used to transfer PBF funds is the most appropriate to channel additional funds for COVID-19, with its use of commercial bank accounts to move funds quickly and directly to facilities particularly important.
Combining this fund transfer mechanism with strong systems drawn from other purchasing mechanisms has the potential to create a streamlined, integrated approach. For example, policy makers are considering whether to build on the ‘e-gratuité’ information system to support monitoring and reconciliation of COVID-19 funds. Established non-governmental organization subcontracts for gratuité data validation and quality control may also be leveraged.
Maintaining the motivation of frontline health workers is a key consideration and finding the best solutions from across existing systems will again have an important part to play. Recent history in Burkina Faso, and lessons from the Ebola epidemic in neighboring countries, highlight the importance of health worker commitment. Health workers who already feel undervalued may be reluctant to put themselves in harm’s way, should the COVID-19 pandemic explode in Burkina Faso. Giving those we rely on the tools and resources they need to do their jobs safely is a necessary, but perhaps not sufficient, step. Additional incentives, including financial incentives, may be required. Gratuité is recognized as a fair way to decide what funds go to which facility, based on performance, whilst PBF has established tools for sharing incentives between workers at a facility. Again, there is potential to combine the best systems from schemes already in place, and stakeholders should seize this opportunity.
The COVID-19 crisis has forced stakeholders in Burkina Faso’s health sector to think outside of their established silos. This is facilitating the rapid development of integrated systems, in purchasing and elsewhere. Integrated systems, and the partnerships created around them, can stand Burkina Faso in good stead for post-COVID-19 health systems development.
Authors: Matt Boxshall (ThinkWell), Pierre-Marie Metangmo (ThinkWell Burkina Faso), Joel Arthur Kiendrébéogo (University Joseph Ki-Zerbo, Ouagadougou, Burkina Faso)
