Authors: Issa Kaboré, Orokia Sory, Charlemagne Tapsoba, Yamba Kafando, Joël Arthur Kiendrébéogo
Following the adoption of decentralization as the preferred method of territorial administration under the Constitution of 2nd June 1991, Burkina Faso introduced the General Code of Territorial Authorities in 2004, which defines eleven (11) areas of authority to be transferred to territorial authorities. With regard to the health sector, the transfer took place in 2010 and covers two areas of authority: (i) Construction, standardization and rehabilitation of basic health facilities; (ii) Coverage of recurrent costs of basic health facilities, including (a) Fuel for medical evacuations, (ii) Gas for the cold chain, (iii) Other sources of energy, (iv) Office supplies, (v) Maintenance equipment and products, (vi) Protective equipment, (vii) Small medical and technical equipment, (viii) Specific printed material, (ix) Medicines and medical consumables, (x) Vehicle maintenance, (xi) Maintenance and repair of buildings.
From 2010 to 2020, a total sum of 49,796,980,605 CFA francs (about US$90 million) has been transferred to local authorities to fund these two areas of responsibility. Between 2017 and 2020, the local authorities used transferred resources to build and develop infrastructures, including 63 health centres, 167 maternity units, 328 housing units, 338 latrines, 119 boreholes, 127 pharmaceutical depots and 191 incinerators, all at a cost of 13 528 920 897 CFA francs (about US$24 million). At the same time, many basic health facilities were upgraded. A decade after the effective transfer of powers and resources by the Ministry of Health to local authorities, this report takes stock of the achievements and difficulties in the implementation of the transfer of powers and identifies prospects for improving the process.
Noble goals at the beginning…
The objective of the transfer of authority and resources from the Ministry of Health to local and regional authorities is to provide accessible health services that are adapted to the needs of the local population. This measure is intended to give local elected leaders, who are in direct contact with the community, the opportunity to effectively identify the priority health infrastructure and equipment needs of their localities, to enable fair and effective investment of the allocated resources. The measure also makes it possible to evaluate in real time the needs of health facilities in terms of equipment and consumables and to purchase them in order to avoid stock-outs that could compromise the quality of care offered to the people.
The transfer of authority to local and regional authorities also aims at increasing people’s participation in decisions affecting their health and reducing barriers in the implementation of certain investments. Indeed, it is not uncommon for local communities to contest the choice of a site for the construction of a health facility, or to refuse to go to a health facility because they were not involved in the choice of the site, which is sometimes a sacred site. Since the local elected leaders come from the same area and have a good understanding of the socio-cultural realities at the community level, it is possible to anticipate these contestations and therefore find a way of reducing their occurrence. Similarly, involving the public in the implementation would secure the investments more and encourage good will to support community-based actions. Such support could, for example, take the form of community work, in-kind or cash contributions for the construction of infrastructure and or for the acquisition of medical equipment and consumables. For example, in several localities within the country, local communities are constructing and equipping health facilities in support of local authorities.
In addition, the resources transferred to local and regional authorities should be subject to rigorous monitoring and control to ensure compliance with procurement standards for construction and procurement of equipment, thus reducing waste of resources and preventing fraud and corruption. Indeed, the administrative, economic and financial accountability of local elected leaders is cited as a guiding principle of the national decentralization policy.
… but difficulties in strategic purchasing implementation
Frequent delays in the implementation of activities due to poor knowledge of public expenditure procedures and poor project management skills. In reality, funds often arrive late to local authorities, leading to failure to meet the deadlines set in the implementation of the health component of their action plans and late allocation of resources to health facilities. In fact, the transfer of authority to local authorities has not always been accompanied by the provision of qualified human resources or capacity building of stakeholders for public expenditure procedures and/or project management. This has led to delays in procurement procedures and purchase of insufficient and/or substandard equipment and consumables, as well as construction of infrastructure that does not meet minimum standards. This in turn results in poor availability and quality of services offered to the people.
Lack of flexibility in the budget lines. Credit transfers meant for health facilities reach local and regional authorities through a passive mechanism. In fact, these credits arrive in form of predefined budget lines that are rigid and can be redirected towards the priority needs of the health facilities. In reality, the amounts of these credits are fixed by an inter-ministerial decree of the ministries in charge of the economy and finance, territorial administration and decentralization, and health. The criteria for distributing these credits are not spelled out, but all health facilities located in urban areas receive the same amount, as do all health facilities located in rural areas. Thus, the allocation of resources does not take into account the performance of health facilities, but only their location in urban or rural areas, which could be equated with the search for equity.
Low level of involvement of all stakeholders in the process, leading to problems of accountability. There is often a low level of involvement of local health players in the management of the transferred funds e.g. the health facilities are unable to express their needs and the management teams of the health districts have little say in the project management of activities relating to the transferred resources (e.g. purchasing of equipment, sites for construction of new health facilities, priority investments). Moreover, local civil society is not always sufficiently equipped to ensure monitoring of the use of allocated resources by citizens, which could lead to irregularities in the management of these resources.
Some suggestions for strengthening transferred credits in terms of strategic purchasing
In view of the difficulties associated with the exercise of the functions transferred to local and regional authorities, appropriate solutions must be found to address this problem, with a view to improving the performance of healthcare providers and the efficiency of the transfer policy.
With regard to the performance of providers, the Ministry of Health could develop performance criteria for the allocation of resources to health facilities in conjunction with local authorities. This would make it possible to reward the best health facilities and perhaps encourage some competition between providers. These performance criteria could be based, for example, on the quality and quantity of services provided such as immunization, antenatal consultations and/or family planning. This continuous focus on performance would encourage providers to make greater efforts to provide quality care to the public.
To improve the efficiency of the transferred funds, strategies to strengthen the stakeholders’ capacities, more flexible payment modalities that take into account the performance of health facilities, and better involvement of key stakeholders would ensure diligent processing, better allocation and optimal management of resources. This would ensure that goods and services purchased for the benefit of health facilities meet their standards and real needs, and that efficiency gains are achieved through improved productivity.
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.