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MSF in Burundi, 2003
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The dense forests and lush vegetation of Cankuzo, a remote province in northern Burundi, hide the dangers that the local people face on a daily basis. The hills are hideouts for rebels who roam the area and – in their fight against government troops – rob, rape and kill civilians and destroy farms. Government troops are known to be equally merciless with anyone suspected of supporting the rebels. Every night, people from the hills around Cankuzo come down to spend the night in the relative safety of the town.
MSF supports three health centers in Cankuzo, and runs mobile clinics in three areas. (A nutrition program was handed over to the Ministry of Health in July 2003.) Due to the civil war, health facilities in Cankuzo – and many other provinces – have virtually come to a standstill. The people of Burundi face a chronic lack of health care. Around 50% of the consultations in Cankuzo are for malaria. This parasitic disease is endemic in Burundi, and the number of infected patients regularly swells to epidemic levels. To give just one example: between October 2000 and March 2001, a severe malaria epidemic caused around 3 million cases among a population of 6.5 million people, and many thousands of deaths. More recently, an epidemic that lasted from December 2002 to April 2003 and covered several provinces produced hundreds of thousands of cases. Unfortunately, until now, people affected by malaria in Burundi have been unable to obtain the treatment that is known to work best. Instead, they have been treated with older drugs, primarily chloroquine, which was the . rst-line treatment until 2001, and sulphadoxine-pyrimethamine (or SP, commonly known by its brand-name FansidarÂ®). In many parts of Burundi – and Africa – the malaria parasite has developed alarming levels of resistance to both these drugs.
The treatment that works best right now is artemisinin-containing combination therapy (ACT), which uses a derivative of a Chinese plant in combination with another drug. Unfortunately, its use in Africa is rare, despite the fact that hundreds of millions of people are infected there each year, and that 90% of the 1-2 million people who die from malaria each year worldwide are African, most of them children. ACT is also a costly therapy, currently about ten times more expensive than older drugs. This is the main reason that African ministries of health have hesitated to make ACT the first-line treatment in their countries. Not wanting to treat patients with ineffective medicines, MSF has pushed for introduction of ACT in its own projects in Burundi and elsewhere. MSF has also been advocating for international donors to step in and assist governments in subsidizing the treatment so that it can become available and affordable for people in Africa. For more on the need to implement ACT in Africa, see excerpts of MSF's advocacy report ACT NOW to get malaria treatment that works to Africa.
Confronting reality in Burundi
Burundi was one of the first countries in Africa to decide to use ACT to treat malaria. This decision to introduce ACT by July 2003 was made in July 2002, after intense pressure from organizations such as MSF (who refused to treat malaria patients in Burundi with older drugs that were no longer effective), and after funds were pledged via UNICEF, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the European Community Humanitarian Office (ECHO) and the Belgian government. The government's decision now seems to have been the easy part. Turning it into everyday reality has proven difficult, with actual use of ACT only now being envisaged for sometime in late 2003. Why has it taken so long? Implementation of ACT, after all the effort to lobby for its acceptance, has been slowed by dif. culties in identifying appropriate sources for artesunate and amodiaquine, the two molecules thought to be most effective in Burundi. The government of Burundi asked the World Health Organization (WHO) to identify sources for these two drugs that were as close as possible to the standards used in pre-qualification, a new process at WHO whereby drugs are identified as being of appropriate quality – but which so far has not included any of Burundi's chosen drugs.
Burundi's health budget is much too limited to pay for ACT for all those who will need it. Burundi applied to the Global Fund for money to fund ACT; this money will be forthcoming in 2004. Until then, MSF has agreed to supply ACT in the five provinces where it works; UNICEF will do the same in the other provinces.
The chosen combination, at about US $2-2.50 per treatment from the suppliers selected, is also more expensive than the $1.50 per treatment available from other sources. Because the chosen drugs are more costly than anticipated, donors had to be approached again for additional funds. When funding was finally secured, one of the producers did not have enough of the needed drug in stock nor did it have suf. cient short-term production capacity, further delaying the introduction of ACT. With the new protocol, patients will have to pay a nominal fee for the diagnostic texts (rapid lab tests or microscopy tests) needed to detect malaria, and for the drug itself. While this should be affordable for most people, there certainly will be some who cannot pay. MSF is trying to guarantee access to this treatment as much as possible. Nonetheless, malaria, which once seemed to be Burundi's dark spot in terms of the magnitude of the problem compared with the inadequacy of the solution, may now become one area for which Burundians will have a reasonable chance of getting the care they need at a price they can afford.
Make them pay?
Even as the problem of inadequate malaria treatment is nearing resolution, another threat to adequate health care in Burundi has materialized. In 2001, the government decided to set up a system of cost-recovery in the public health sector. The cost-recovery system requires that health centers and hospitals become financially independent of government support. Patients are supposed to finance all costs of the medicines and the running of health facilities by paying full prices for the drugs they need, plus a fee for all inpatient and outpatient services. In the current climate of con. ict, it is unreasonable to ask the people of Burundi to carry that burden. While the system has been unevenly implemented across the country, its debut has been alarming.
MSF's research indicates that where the system is put in place, it leads to drastic price hikes in health centers and hospitals. The consequences are three-fold: a dramatic decrease of people seeking medical help in clinics and hospitals; an increasing number of patients who fail to pay their bills; and a tendency for patients to buy fewer pills than what is prescribed for them because medicines are priced on a per-pill basis. Not only does this latter phenomenon result in incomplete treatment, but it also contributes to the increasing resistance to drugs seen in the field today.
"For now the system of cost-recovery is not sustainable," says Ellen Rymshaw, a former MSF Head of Mission in Burundi. "Most patients are unable to pay the costs for consultations and inpatient care. It is not feasible for patients, and hospitals cannot possibly manage their costs with such a low number of paying patients. This system not only fails to provide a solution, it actually prevents people from seeking health care in Burundi," she said, pointing out that it is not realistic to expect ordinary Burundians living in up-country settings to pay up to US $60 for such essential surgical interventions as Caesareans.
While advocating for change, MSF has come up with temporary solutions in the hospitals it is currently assisting. Adhering to the MSF principle that its emergency medical aid should be provided at little or no cost, the organization donates the medicines to the hospitals and health centers it supports. In addition, MSF has entered into agreements with provincial health authorities to limit the negative impact of cost-recovery mechanisms: MSF has introduced a low, lump sum fee covering consultation, tests and drugs, regardless of the disease or the real cost of the drug. MSF also has contracts directly with certain health facilities that cover the costs of the services offered (including salaries) in exchange for strict adherence to quality rules. "We want to make medical care again affordable for our target populations," says Ms. Rymshaw. "The longer-term approach to this problem should include lobbying on yet another level," adds Ms. Rymshaw. "These policies are supported by large donor agencies that grant funds on the basis of poverty reduction strategy papers that often contain policies (such as cost-recovery and user fees) that have failed consistently to reach the goals of sustainable health care. The problem with these policies is that they presume the country to be on a development path, or at least in a post-conflict setting. But this is not the case in Burundi! You cannot expect a country that is in its eleventh year of a nationwide civil war to be able to function in a mode of development and sustainability." In addition, financial participation for basic health care should be linked to the real purchasing power of the people, not to the real costs of services.
Although MSF obviously encourages governments to find long-term solutions for problems in their health care systems, the organization is convinced that a costsharing system is for the time being not feasible in Burundi, and instead advocates that the Burundian government and lending institutions make money available to ensure an adequate level of medical care.
MSF in the field
MSF continues to support a number of regional hospitals and many local health centers in the provinces that have been most affected by the civil war, such as Makamba, Ruyigi, Cankuzo and Bujumbura. In addition, MSF runs health centers and mobile clinics in these provinces. In Karuzi province, programs treat and feed children suffering from severe malnutrition. The organization has fought outbreaks of malaria and other infectious diseases, such as meningitis, over the last year. MSF also responded several times to meet the immediate needs of people displaced after fighting had taken place between the army and rebel groups. In the capital Bujumbura, MSF runs a treatment and rehabilitation center for war-wounded civilians from areas around the capital; another surgery program is based in one of the city's hospitals. In September 2003, MSF opened a new center to deal with sexual violence in the center of Bujumbura.