Using a Balanced Scorecard referring to the financial domain in the Burkina Faso Health sector case study, what would be one measurable SMART indicator that addresses a key aspect of that domain in the Burkina Faso Health sector case study?

Burkina Faso Health Sector Case Study

Burkina Faso, in sub-Saharan Africa, is considered to be among the poorest countries in the world, ranked 172 out of 175 countries on the Human Development Index.1 GNP per capita in 1995 was US$230.2 It is a low-income country with high population growth, high fertility and mortality rates, with over 5% economic growth and a fairly stable currency. Major health, demographic and socioeconomic indicators are presented in Table 1. Burkina Faso has inherited a highly centralized country from the French colonial era. However, since the end of the 1980s, the country has undertaken major reforms towards decentralization, including reform of the health sector. A law passed in August 1998 (Textes dorientation sur la dcentralisation) created two types of decentralized entities: provinces and communes. Although the implementation of the law will take several years, it presents some interesting opportunities for the health sector. Elected local governments (Collectivits territoriales) will be responsible for: (1) the management of health facilities including district hospitals; (2) the procurement and distribution of drugs; and (3) the implementation of local public health programmes. The health care system in Burkina Faso is divided along administrative borders into 11 regions and 53 health districts (population covered varies from 150 to 200 000) with ve levels of care (health post; health centre; district, regional and national hospitals). Over 95% of health facilities and health care providers are in the public sector. Since 1991, the country has initiated important reforms in the health system: National and regional hospitals have been given progressive autonomy in nancial and personnel management. In 1992, 53 health districts were created under the management of district health teams. Since 1992, the central drug procurement and distribution agency (CAMEGi) has been created, with progressive implementation of the system allowing for a better accessibility to drugs in rural areas. In 1993, health centres were allowed to retain funds collected from fees and the sale of drugs. Elected local bodies were responsible for the management of these funds. In 1996, an intermediate level of the Ministry of Health was created at the regional level in order to improve support to health districts. To date only a few health districts are considered fully operational. Less than ve have the required number of doctors (three) and only 17 out of 53 district hospitals are able to perform caesarean sections, because of lack of skilled staff and appropriate equipment. However, the number of health centres increased from 556 in 1987 to 877 in 1996. Precise data regarding the private sector, which has been ofcially allowed since 1990, are difcult to gather. As the opening of a private health facility is subject to payment of taxes, the ofcial gures underestimate the situation. According to Ministry of Health statistics, the number of private health facilities increased from 106 to 155 between 1991 and 1996. During the same period the number of private pharmacies increased from 40 to 69. Eighty-nine percent of private health facilities and 80% of private pharmacies are located in the two biggest cities (Ouagadougou and Bobo Dioulasso). In addition to these ofcial data, there is a growing informal private health sector concentrated in urban areas where nurses and doctors are recruited from the public sector. They practice privately in addition to their ofcial public sector duties. It is thought that the combination of a highly centralized country and a lack of exibility in the management of civil servants leads to a strong imbalance in the distribution of personnel, low levels of motivation and consequently provision of low quality of care. Recently, Burkina Faso started a reform process for the civil service, which aims at more exible management and better performances of personnel. This process, however, is highly controversial and is fought by trade unions, which have a long tradition in the country. Although the Ministry of Healths budget has increased from 1996 to 1998 (up FCFA 2.6 billion), the health budget as a percentage of the total public budget has decreased from 11 to 9%. This trend is explained by a sharp reduction in external aid during the same period; the share of domestic nancing has remained constant at about 10% (see Table 2).3 The question is whether the decreasing foreign investment in the health sector in Burkina Faso is a sign of donor fatigue. The European Union plans to make a major investment in the sector under the Eighth European Development Fund. Most of this aid would be in the form of budget support for institutional development, specic nancing of the decentralization process and the restructuring of the pharmaceutical sector. These funds are welcomed by the government and the donor community, although there is some concern that the funds might support policies which have not proven to be effective in the past as the performances of the health sector are considered poor. A recent study of the education and health sectors noted that what is missing compared with other African countries is not quantity of public investment, but rather quality, i.e. the effectiveness of investments in these sectors.4 Despite the high priority given to the social sector by governments and donors in general, there is growing evidence that in many countries the existing health systems have limited impact on health conditions because they do not reach the majority of women and children, and the quality of health services delivered is often too low to make a difference.5 Burkina Faso is one such country where successive policy measures have been partly or fully implemented over the past 20 years with no positive effects on the utilization of services. To the contrary, utilization and peoples condence are decreasing, as detailed later in this paper. The poor results of the health care system in Burkina Faso have led the authors to look more closely at the reasons for its poor performances and to suggest some directions for the future.