Burundi: Investing in Safer Births

September 24, 2012

  • The government, in an effort to speed up progress toward MDGs 4 and 5, in 2006 declared all medical care free for pregnant women and children under five.
  • A results-based financing program pays health facilities for the delivery of quality maternal and child health services.
  • Community health agents receive incentives to educate women about safer births at hospitals and risks of birthing at home.

VYEGWA, BURUNDI — The three-kilometer hike to the Kigarama health clinic appears daunting even for those not in labor. The winding red dirt road isn’t friendly to the foot, and it cuts through green hills with banana and coffee trees. At 6 a.m. that day in May 2009, there was still little light in the valley.

Her contractions were intensifying, but Denise Ntakirutimana was determined to make it to the clinic to have the baby. She had given birth three times at home, but they were painful experiences. Her neighbor’s baby died at birth, just a day before Ntakirutimana’s first one was born.

While she labored all night in terror, the traditional birth attendant, who had little training and couldn’t afford gloves, checked on her too often, trying to feel the baby’s position. “They were telling me to push the entire time, even when I wasn’t feeling contractions,” she recalled. “This frightened me so much.” She delivered two more babies at home – one died suddenly at five months – but the fear never went away.

Ntakirutimana first learned about hospital delivery from a friend, Judith Nsengiyandemye, before she became pregnant with her fourth child. There, the nurses had gloves, fetal monitors and other equipment at hand, and they would only ask her to push when the baby was ready to come out.. In case of an emergency, the clinic, unlike traditional birth attendants, would call an ambulance to transfer her to the district hospital. And the delivery would be free.

So when labor started in the wee hours of the morning, Ntakirutimana, who had already made three prenatal visits to the clinic, called her mother to take her to the clinic – on foot. “It was hard for me,” she recalled. “When I felt contractions, I had to stop.”

Burundi an ‘Unlikely Leader’

The fact that Ntakirutimana made the trip at all is a remarkable development for her indigenous Batwa pygmy community, an ethnic minority traditionally with no or little access to health care. The Batwa make up less than 1% of the population in Burundi, a land-locked country in the heart of Africa, with a population of 8.6 million and a size slightly smaller than Maryland. It’s one of the poorest countries in the world, with $160 in gross domestic product per capita. But as Ntakirutimana’s case illustrates, the country has rapidly become an unlikely leader in health care financing.

That transformation began in 2006, just after a 12-year civil war ended. Burundi’s government realized it likely would not reach the UN Millennium Development Goals related to reducing maternal and child mortality by the 2015 deadline. To speed up the progress, the government declared all medical care free for pregnant women and children under five.

With financial and technical support from the World Bank, the governments of Norway, the U.K, and other donors, Burundi revamped its health care system in April 2010. Clinics are now paid based on their performance in delivering a package of essential maternal and child health services. Once each clinic’s results are verified, they are entered into an automated online system for payments.

The results were impressive. Within a year of the program’s launch, health facilities across the country registered 25% more births. Meanwhile, 20% more women received prenatal care and 10% more children were vaccinated. Quality of care also rose significantly.

These changes have helped save the lives of many pregnant women and children, and contributed to a reduction in mortality among those vulnerable groups. In 2010, with results-based financing covering half of the country, Burundi registered 499 deaths per 100,000 pregnant women, down from 615 in 2005. Among children under five, the country recorded 96 deaths for every 1,000 live births, down from 176 in 2005, before the health care reform began.

“The government made a decision to take care of children under five and pregnant women,” said Nicayenzi Dieudonne, deputy to the Burundi health minister and a public health doctor. “Ours is a system of motivating and financing based on performance.”

" I am welcomed. They listen to me. They always give me enough medicine. I see the result of their effort when the child is cured. "

Jacqueline Mbonihankuye

Turning Nurses into Entrepreneurs

Indeed, the new approach has provided autonomy to health centers and turned nurses into entrepreneurs. The volume of services and quality of care determine how much the clinics – and their staff – make. As a result, nurses actively reach out to communities to serve patients better.

“With performance-based financing, we are independent,” said Benigne Nkunzimana, head of the Kigarama health center, which has 12 nurses and nine supporting staff. “We apply customer care to patients.”

The health center serves about 34,850 people in seven communities, or “hills,” in Ngozi province. The size of the staff has remained the same, but the clinic is now open 24 hours a day, seven days a week. The clinic is clean, well organized, and fully stocked with medicine.

“I am very satisfied,” said Jacqueline Mbonihankuye, whose 29-month-old son, Lewis Niyonkuru, was treated for a respiratory infection by two nurses at the clinic one day in August. “I am welcomed. They listen to me. They always give me enough medicine. I see the result of their effort when the child is cured.”

Community Health Agents Reach Out to Women

To attract patients from the Batwa community, who traditionally never came in for preventive services, such as prenatal care or child vaccination, the clinic arranged meetings with local administrators. In Vyegwa, they organized a 15-member health committee and trained them to be special agents to educate women about the dangers of home births. The clinic also gives Batwa patients priority access when they check in.

Those agents, including Ntakirutimana’s friend Nsengiyandemye, were each paid 8,500 Burundian francs a month for bringing in new patients. Standing on the Ntakirutimana’s family farm, which grows beans and sweet potatoes, Nsengiyandemye talked about the risk of postpartum hemorrhage during home deliveries, the importance of family planning, HIV testing, and reproductive health. It helped that she had her two kids at the district hospital, not at home.

“The community agents told us that it’s much better to deliver at the hospital, because you do not get problems – I  understood the advice,” Ntakirutimana said.

The Role of Traditional Birth Attendants

The clinic also struck agreements with community leaders to deter the use of traditional birth attendants. If an attendant takes a pregnant woman to the clinic, she will receive a reward of 500 Burundian francs. That’s more than what attendants would have earned (the birth family pays them in beers, not cash).

As a result, the clinic now provides maternal care to 60 Batwa patients a month, up from 25 a few years ago. The births of Batwa babies at the clinic went from none to five a month, said Nkunzimana.

With her mother’s help, Ntakirutimana, now 26, arrived at the clinic around 7:30 a.m. on May 8, 2009. Two nurses took care of her, and she walked until shortly before baby Isaac was born at 3 p.m. that day.

“I did not experience the same pain as with previous deliveries, such as being touched all the time,” she said. “I delivered in better conditions thanks to the sensitization of the community agents. I realized that they gave me very good lessons (about hospital birth).”

With her fifth child due this fall, Ntakirutimana will make the journey to the clinic again soon. She has already had three prenatal visits. “They told me that the baby is doing well,” she said, smiling.