Table 3.

Burundi case report

Theme	Findings
Background	The post-colonial history of Burundi is affected by long periods of autocratic rule (1962–1992), mass killings (1972, 1988, 1993) and a protracted civil war that started in 1993 and only definitely ceased in 2008. Democracy, the outcome of the liberal peace that gradually started with the Arusha Peace agreements in 2000, is still fragile, and the recent years have seen continuous political violence and the control of the political and economic power by a small group of people coming from the ranks of the former main rebel movement CNDD-FDD. Burundi remains a very obvious case of a FCAS. The country ranks at the very bottom of most rankings on health, human development and governance. The war left the health sector in ruins [91]: in the early 2000s, as peace was returning, the WHO estimated that the country had only 2 nurses per 10 000 inhabitants. The last available figure from 2009 is 19 nurses per 10 000 inhabitants.
Institutional capacity	As a 2011 MoH report points out, information on the management of the health workforce at district and health facility levels is still lacking. The WHO-sponsored National Observatory of Human Resources set up in 2012 may help improve the situation by gathering intelligence on HRH and strengthening institutional capacity to manage them. However, in general, public servants’ positions and tasks within the MoH and at the peripheral level are still often not clearly defined in job descriptions [92]. Laws have been passed (notably the 2010 HRH Development Policy) and frameworks have been designed to improve the management of human resources, but in the field, difficulties remain [93]. In 2006, at the same time when user fees were removed for pregnant mothers and children under five, international NGOs started implementing performance-based financing (PBF) mechanisms in order to respond to the challenges of responsiveness and effectiveness of the public servants. PBF has also boosted the regularity of nurses’ payment and their mean income, which now approximates US$ 350–400/month (for a qualified nurse). Yet, PBF has not tackled the issue of the actual salaries remaining low. Overall, PBF and international aid may have augmented the institutional capacity of the MoH, hence possibly contributing to improving service delivery, but have also introduced a degree of complexity that may not be manageable without aid support. Official documents show that the MoH relies heavily on PBF to sort out human resource issues, ranging from incentivization and payment to general management [93].
Effective intersectoral coordination	Until 2010, there existed a Ministry of HIV/AIDS alongside with the Ministry of Health—and the lack of coordination between the two ministers was notorious. The divide of ministries between political parties and “ethnic” groups, with the Ministry of Health not necessarily always falling in the camp of the main political party, also contributed to hampering coordination until around 2010 when the CNDD-FDD established a firmer control over the MoH. Formal mechanisms of coordination remain primarily aid-led. They also suffer from the reluctance of the health sector to collaborate with other sectors that did not move as fast as it did after the war. Indeed, the MoH had a clear advantage over other ministries as (1) it did not face the same challenges of reintegration of part of the workforce as other sectors (see below) and (2) could count on a well-identified workforce whose work was not very different from past regimes. In the recent years, the presidency has established a stronger grip on health issues, but often, decisions are taken without consultation with or agreement of the MoH staff. A very clear example is the introduction of a new insurance scheme in 2013 that many in the MoH viewed as badly designed but was forced by the presidency. The coordination of the different actors, including non-state, involved in HRH management still remains a weakness of the health system [93] and maintains Burundi as an aid-dependant state.
Presence of funded, effective and responsive public servants and CHWs following public goals	Although until recently the Community Health Workers have been largely left out of the PBF scheme [94], PBF has provided a new source of revenue to the medical staff and has possibly increased their responsiveness to the population needs in terms of maternal and child health care [95,96]. The definition of (paid) indicators has also provided clear incentives for the public servants to align with the priorities defined by the MoH. As long as the PBF functions and leads to (even small) improvements in service delivery, it could reinforce the state, but the risk is that this elaborate scheme, which still rests on international money and support [96], eventually crumbles. As of 2014, less than 1% of the MoH staff had had training on human resources management, and the lack of clear terms of reference for positions may put at risk the good accomplishment of public goals
Adequacy and coverage of HRH	This is perhaps the area in which most progress has been made and where the linkage with state-building is the most obvious, although the causality is probably going both ways. The Tutsi autocratic rule and the 1972 mass killings [97], which targeted educated Hutus, led to a clear imbalance in human resources in health (especially at the highest levels of qualification). The discrepancy in service provision has been well-documented, with the province of Bururi, home province of the dictators, being clearly favoured [98]. Post-conflict strategies for human resources in health did try to balance this out, and the change of political power (to the hands of Hutu northerners) also changed the geographical focus of patrimonial flows. The imbalance still partly remains, though, with most resources per inhabitant still concentrated in the west of the country, but it is probably less than before [99]. In the long run, it is, however, unclear whether the true beneficiary of this change is the Burundian state or the ruling party (or both). A recent report on health facilities [99] finds that human resources are still too centralized.
Integration of HRH	During the civil war, most of the health facilities remained, officially, under MoH control, and the state was, with support from international aid, the main provider of health services. At the local level, the post-conflict integration of human resources was much less of a problem in health than in other sectors. At the central level, the ruling party eventually took control of the MoH. There is recent anecdotal evidence of a ruling party-induced politicization of HRH down to the level of health centres’ chief nurses (with chief nurses being asked to join to the party), which may have unclear effects on state-building. At the same time, the wider opening of medical training has certainly contributed to creating a medical workforce that better reflects and integrates the political, “ethnic” and social cleavages of Burundian society. There was only 1 private paramedical school in 2007 after the war, and 4 years later, there are 13. However, some reports and official documents have seriously questioned the quality and adequacy of the training provided by the newly created schools of nursing and medicine [92]. The quality control of the sector tends to be loose.
International context	Burundi has benefited from massive international aid, which still constitutes over half of its planned budget (43% in the 2010–2015 PNDS). As in other countries, humanitarian aid and the early phases of development aid took a toll on the few existing human resources (that were diverted from the public sectors to aid organizations). The phenomenon has not stopped with the country officially coming out of the humanitarian phase, although, fortunately, the total number of nurses and doctors has increased. As Dinnen [72] noted in a different case, the positive aspect of international involvement is an improvement of service delivery, but it comes at the cost of a protracted dependency to aid which may be detrimental to state-building. In the past years, autocratic decisions of the government, political intimidation and abuse of human rights have pushed donors to withhold part of their support, putting the country on the verge of bankruptcy and triggering more instability [100].