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.”
