4 June, 2013

Smart healthcare reform in one of the world’s poorest nations

Burundi is known as one of the world’s most poverty stricken nations in absolute terms – plagued by war, corruption, and disease. But still, the country can serve as a good example for a specific reform, at least in healthcare. There, the national healthcare system has implemented quality based reimbursements for care providers.

The Burundian government decided several years ago to test a system were quality and quantity of service were closely measured, and bonus reimbursements granted to the best managed care centres. Inspiration for this system came from Rwanda, where similar reforms clearly show these lead to significant improvement.

In Burundi, two Dutch NGOs initiated a pilot project in three provinces in 2006. The innovative system they tested was based on regular quality measurement of care provided in local centres. This included tracking sanitary conditions at each centre. The best managed centres were then granted bonus reimbursements based on the quality and quantity of care provided.

Evaluation of this system by Dutch researchers and the Burundi government, showed that the pilot trials led to substantial improvement. In the three pilot provinces, more people received better care than previously. More children received vaccinations, more women could access contraceptives, and a larger share of births took place at hospital rather than in the home.

Performance-based reimbursement for healthcare provision has now been implemented across Burundi. The new system pays care providers a performance-based bonus of up to 25% on their annual budget if they perform well. Quarterly, random inspections (including public opinion surveys) are conducted at care centres at randomly selected dates. Based on 109 quality indicators, these inspections and surveys provide quality of care measures at each centre. Each local care centres has broad freedom to allocate their bonuses. But one rule of thumb is these should not only go to employees, and rather must also be invested in operations.

Early assessments of this reform in Burundi show wide-spread improvement. Total visits to pre-natal care increased 18% nation-wide. Those receiving family planning assistance and who could give birth at a care facility both increased approximately 25%. Simultaneously, the quality scores for care provision across the country has risen significantly. An assessment by US Aid noted that further improvement is possible with continued development of the system.

Perhaps the experience from Burundi and Rwanda can also be relevant for Sweden? Despite Sweden being on the opposite end of all prosperity measures, there are interesting elements in the systems implemented in these two less developed countries – such as random inspections and using more quality measures to determine care quality. Considering that currently, quality varies significant between the many care providers in Sweden, providing bonus funding is a potentially useful idea to reward the best providers and to incentivise quality everywhere. Regular assessment of results and quality, and rewarding operations and employees providing the best quality are ingredients that could prove useful within the Swedish publically financed sector, as well.

Nima Sanandaji

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Toonen J, A Canavan, P Vergeer och R Elovainio (2009). ”Learning lessons on implementing performance based financing, from a multi-country evaluation”, KIT Royal Tropical Institute.


Busogoro, J-F, och A Beith (2010). “Pay for Performance for Improved Health in Burundi”, USAid.

USAid (2011). “Performance-Based Incentives in Africa: Experiences, Challenges, Lessons”.