Burkina Faso’s efforts to respond to COVID-19 have benefited from considerable national and international solidarity, which has been demonstrated through donations, support and multifaceted assistance. To ensure regular monitoring, transparent and equitable management of the resources received, the Ministry of Health has put in place a system of proactively mapping these resources. This blog post shares Burkina Faso’s experience in this regard.
The first case of COVID-19 was officially registered in Burkina Faso on 9 March 2020 and the first COVID-19-related death on the night of 17th to 18 March 2020, making Burkina Faso the first country in Sub-Saharan Africa to register a case of COVID-19-related death. As a result of this, the Head of State delivered a speech on 20 March during which restrictive measures were taken, alongside messages to the public to adopt preventive measures and hand hygiene (washing, use of hydro-alcoholic gel). In terms of individual freedom, these included a ban on gatherings of over 50 people; the total closure of cinemas, games and entertainment venues and markets; the partial closure of restaurants and bars, the latter being allowed to sell only take-away food or drinks; and introducing a curfew from 7 p.m. to 5 a.m. throughout the country. Local transport also came to a halt, and air borders were closed as part of the measures undertaken to manage the pandemic. On the political front, the biometric registration and issuance of national identity cards for the presidential and legislative elections scheduled for November 2020 were suspended. Other restrictive measures were taken, such as the closure of schools and universities and placing in quarantine towns that had registered at least one case of COVID-19. In his second speech to the nation on 2 April 2020, the President, faced with the consequences of the restrictive measures on living conditions of households, announced several supportive measures concerning all sectors of economic life. These included tax relief, total or partial subsidies, and easier access to bank loans.
In this context, the Ministry of Health developed a response plan worth approximately 178 billion CFA francs. The cost of all supportive measures, including the overall health response plan, was estimated at 394 billion CFA francs, or 4.45% of the Gross Domestic Product (GDP). Because of the economic consequences of the pandemic, it was expected that the growth rate will drop from 6.3% to 2% in 2020 and that government revenue will fall by an estimated 306 billion CFA francs. This represented a budget deficit of 5%.
An appeal for national and international solidarity
Due to this challenging economic situation, the Government of Burkina Faso launched an appeal for national and international solidarity, particularly in support of the health sector, to mobilise the needed resources to finance the health response plan. Indeed, this COVID-19 pandemic came at a time when Burkina Faso’s health system was already facing many difficulties, including underfunding vis-à-vis needs, a shortage of skilled human resources and low availability of equipment as well as medicinal and technical materials. Burkina Faso’s health system did not have enough personal protective equipment for health workers, diagnostic and testing equipment, resuscitation equipment, medicine and consumables to cope with a devastating situation (overstretching health services) related to COVID-19.
The call for solidarity was well received and was evident through donations and other multifaceted support, in kind, in cash or through technical support in the area of research or interventions on the ground. These came from governmental institutions, private initiatives, the public, associations and technical and financial partners. To ensure good visibility and equitable allocation of mobilised funds and material resources, and in the interests of accountability and transparency, the Ministry of Health considered the need for a tool that would help it to manage and regularly monitor these resources, bringing forth the idea of having a dynamic mapping of the resources mobilised for the fight against COVID-19. The Clinton Health Access Initiative (CHAI) international NGO decided to support the Ministry of Health in developing this tool, with financial support from Bill and Melinda Gates Foundation.
What is dynamic mapping?
The idea of introducing dynamic resource mapping existed within the Ministry of Health long before the outbreak of the COVID-19 pandemic. An architectural proposal had been made by the technical staff of the Ministry of Health and presented to technical and financial partners during a scoping meeting on dynamic mapping that was held on 10 December 2019 in Ouagadougou. Dynamic mapping aims to have regular data on the status of distribution of human, material or financial resources at the national level through monitoring of certain specific indicators. It is a decision-making tool that provides a dashboard for monitoring available resources throughout the country, identifying areas where gaps exist, and guiding future interventions or support to ensure an equitable distribution of resources (avoiding duplications or gaps).
The COVID-19 crisis provided an opportunity to implement this idea of dynamic mapping. Specifically, the idea was to develop a tool based on the one designed by CHAI on Excel to record all donations received in the framework of the fight against COVID-19 in Burkina Faso, whether in kind or cash by bank transfer or by cheque. The configuration of the tool took into account the nine components defined in the national health response plan: (i) Disease prevention and control, (ii) Coordination, (iii) Logistics, (iv) Surveillance, (v) Case management, (vi) Laboratory activities, (vii) Communication, (viii) Security, and (ix) Research. Donations are recorded either at the national level or at the decentralised level. At the national level, resources were often allocated by the donor directly to a specific component. At the decentralised level, some partners donated directly to the health facility of their preference. According to the needs of the response, the Ministry allocated resources to areas not specified by the donor. The status of donations received and the distribution of resources was regularly monitored monthly.
Contribution of dynamic mapping to the management and monitoring of mobilised resources
Resource mapping results showed that, for a funding requirement of 178 billion CFA francs (about 300 million US dollars) for the national health response plan, the total funding and donations of equipment received by 5 June 2020 amounted to nearly 67 billion CFA francs (about 118 million US dollars, or 38% of the target amount), 98% of which was targeted (sent by donors to specific areas, e.g. health facilities etc.). The prominent donors were technical and financial partners (64% of the amount raised), the State (33.5% of the amount raised) and private donations (2.5% of the amount raised). State funding was targeted to specific areas, private donations mainly were non-targeted, while donations from technical and financial partners took both forms but mainly were targeted.
However, results from the dynamic mapping showed disparities in funding for the nine components of the national health response plan. Compared to needs, only the “logistics” component had a funding surplus (nearly 44.7 billion CFA francs) budgeted against more than 53.2 billion CFA francs or 119% of resources raised. This was followed by the “communication” component with 47% (nearly 1.4 billion CFA francs budgeted against nearly 646 million CFA francs raised) of the financing needs to be raised, and the “surveillance” component with 21% (more than 5.7 billion CFA francs budgeted against nearly 1.2 billion CFA francs raised) of the needs raised. The least financed areas were “research” with 5% (1 billion CFA francs budgeted against 52.4 billion CFA francs raised) of the financing needs to be raised and “case management” with 2% (more than 57.8 billion CFA francs budgeted against just over 1.03 billion CFA francs raised) of the financing needs to be raised.
Donations of equipment to deal with COVID-19 were also unevenly distributed, particularly among the 13 health regions of the country. For example, as of 11 May 2020, the Centre-North region had received 95 laser thermometers compared to only 5 for the Boucle du Mouhoun region. The Centre-North region also received 511 handwashing units while the Centre-West region received only 2. As for bibs, the North region received 73,293 compared to 1,628 for the Boucle du Mouhoun region. These donations did not take into account the prevalence of the disease in different regions.
A useful but challenging tool to use
Dynamic mapping allows leadership to make decisions transparently and equitably and ensure efficient management of resources meant to combat COVID-19 and other health system challenges. But its implementation poses many challenges.
First of all, in addition to technical assistance and training in its use, this new approach requires full commitment and ownership by all stakeholders in the health system. It would then be necessary to overcome the reluctance and resistance that generally comes with any new process that necessitates changes in the habits of the stakeholders. Strong leadership from the Ministry of Health is indispensable for a full and robust buy-in from all stakeholders. This support is all the more crucial as the added value and effectiveness of this mapping lies in its dynamic nature and the reliability of the data used to inform it, which means that the data must be regularly updated, either manually or electronically, and that all the players involved must be committed to transparency and accountability. The Ministry of health should also put a data quality control mechanism in place to avoid manipulation of the data.
A final challenge is the effective use of dynamic mapping as a tool for planning, equitable distribution of resources, and decision-making. Here, the question of sustainability, and therefore the institutionalisation of the tool is raised, as it is not uncommon for well-designed planning tools not to be used by the players in the health system, which is in line with the need mentioned above for full commitment to and ownership of dynamic mapping by all of these players.
These prospects are specifically related to the institutionalisation of dynamic mapping in the health system. To this end, the Ministry of Health has adopted the strategy of gradually rolling out the use of the tool while working to meet the challenges mentioned above. In the immediate short term, the Ministry of Health is considering developing a platform with secure online mapping and the possibility of making certain information accessible to the general public. The Ministry should create access for all the stakeholders concerned with the use of the platform to enable them to make regular updates so that the status of resource availability and distribution is shared in real-time. This would make it possible to quickly identify areas where gaps or, conversely, duplications exist and provide guidance on allocations. This would also respond to civil society’s concern that the government should take “the necessary steps to ensure transparent management of the resources raised and to facilitate access to information on all donations received and their use for citizen monitoring”. 
Apart from the dynamic mapping process that is specific to COVID-19, the Ministry of health could gradually integrate all the financial, material and human resources data into the system. Concerning financial and material resources, the dynamic mapping should allow, for example, adjustments to be made during the budget year and reallocations to be made according to the principles of the programme budget. Concerning human resources, the use of dynamic mapping would be combined with the use of the WHO Workload Indicators of Staffing Need (WISN) method to ensure adequate recruitment and distribution of health personnel in health facilities. In addition, regular production, for example, quarterly, of a feedback newsletter on coverage levels and indicators is planned to evaluate and facilitate monitoring of actions taken concerning dynamic mapping. The successful implementation of dynamic mapping will be decisive for the success of the “one plan, one budget, one report” approach, another project that the Ministry of Health has launched in preparation for the new 10-year health development plan 2021-2030.
S Pierre Yaméogo is a medical doctor, public health specialist, Technical Secretary in charge of Universal Health Coverage and One Health at the Ministry of Health in Burkina Faso. He is a member of the Covid-19 National Crisis Management Committee chaired by the Prime Minister and supports monitoring activities to fight against COVID-19 in Burkina Faso. In addition, he supports the effective coordination of the interventions of technical and financial partners in this fight within the Ministry of Health.
Orokia Sory is a research assistant at RESADE (Ouagadougou, Burkina Faso). She is a macro-economist by training and an expert in public health, specifically health policies and systems.
Yamba Kafando is a health geographer, expert in health financing, health policy and systems analysis. He is currently Director of Operations and Researcher at RESADE.
Charlemagne Tapsoba is a researcher at the Centre de Recherche en Santé in Nouna (Burkina Faso) and an associate researcher at RESADE (Ouagadougou, Burkina Faso). His main field of interest is health policy and systems research. He has conducted several studies in the field of strategic purchasing.
Issa Kaboré is a medical doctor and research assistant at Recherche pour la Santé et le Développement (RESADE) (Ouagadougou, Burkina Faso). He was a front-line worker in the fight against COVID-19 in Burkina Faso.
Joël Arthur Kiendrébéogo is a doctor, health economist, lecturer at the Joseph Ki-Zerbo University and associate researcher at RESADE (Ouagadougou, Burkina Faso). He is currently doing a PhD thesis in public health at the Institute of Tropical Medicine (ITM) in Anvers (Belgium) and the University of Heidelberg (Germany) on learning processes in health financing policies and, more specifically, strategic purchasing in Burkina Faso’s health sector.