Side effects of free maternal, child healthcare

A new policy of free medical care for Burundian mothers and children was intended to improve their lives; instead it has cripple the nation's health system. Public hospitals in Burundi have recorded double, sometimes triple, the number of patients since a presidential directive for free paediatric and maternal health services was implemented on 1 May. Overcrowded wards, a shortage of doctors and other medical staff, as well as patients' inability to afford prescribed medications are some of the challenges health officials are now facing. The situation in rural health centres is particularly desperate. In one case, four heavily pregnant women with health complications were referred from a rural clinic to a larger and better-equipped city hospital. However, the facility turned them away because of overcrowding. After local media reported that the women had not been admitted, a senior Ministry of Commerce official ordered that they be taken to a private clinic. Unfortunately, it was too late for one patient: She died as she was being taken there. The woman's death could have been avoided had procedures been in place to ensure the proper implementation of the directive, health officials said. The public health system was ill prepared to cope with the resultant increase in patients, and subsequently, patients have been let down. The poor services patients were accustomed to paying for may now be free, but the quality of care has declined even further because of the increased caseload and an acute shortage of doctors. An unmanageable caseload Aline Bigirimana has brought her child, who is shivering with a high fever, to the Prince Regent Charles Hospital in the capital, Bujumbura. "Mothers who brought their children for treatment today are many, and by midday, the paediatrician will tell us to come back later," she said. "But when we return in the afternoon, we will find the doctor has left. I am worried because today is Saturday. If I go home without my daughter being treated, I fear she may not be alive by Monday, when I'm supposed to come back." Although implementing free maternal and child healthcare has been plagued with difficulties, many Burundians, including Bigirimana, have largely welcomed the initiative.

Women with their children wait to see a paediatrician at the Prince Régent Charles Clinic

"Previously, I paid 700 Burundi francs [US$7] for consultation, but now I don't have to pay a thing," she said, as she inched along the long queue of patients waiting to see the only paediatrician on duty at the hospital. Many patients said the government should have included free prescriptions in its initiative. "Free healthcare, to me, should include free medicine," said Adidja Nsengiyumva, another mother seeking treatment for her child at Prince Regent Charles Hospital. Before the directive, many pregnant women simply could not afford to give birth in hospital and delivered their babies at home, despite the health risk. "I delivered my nine children at home for lack of hospital fees," said a woman at Kayanza Provincial Hospital in the central part of the country. Her tenth child would be born in hospital because "the service is now free of charge", she said. Administrative woes The large number of women and children seeking free healthcare has overwhelmed most institutions. Hospital administrators nationwide have complained about congestion in paediatric and maternity wards. "We saluted the measure, but it seems the government did not plan mechanisms to successfully implement it," said Tharcisse Nzeyimana, director and gynaecologist at the Prince Louis Rwagasore Clinic in Bujumbura. "Before the decision to provide free healthcare, our hospital received a daily average of seven women wanting to deliver," Nzeyimana said. "The hospital now receives between 15 and 20 women per day." Crowding at the clinic, which caters to rural and urban residents, peaks at the weekend. A similar situation prevails in other health institutions, such as the provincial hospitals of Kayanza, Bururi and Gitega. A shortage of bed space has forced the two overworked nurses at Gitega Hospital to put patients along corridors. Mothers must be discharged on the day they give birth to make room for others. The nurses complained of working long hours, an average of 10 hours daily, seven days a week. At Bururi Hospital in the south, the maternity ward receives between 40 and 66 patients per day, according to the provincial health director, Onésime Ndayishimiye. Prior to the initiative, the daily average was 14. Lack of equipment and expertise Free healthcare for women and children has made Burundi's lack of qualified medical staff and specialists even more keenly felt. "Kayanza Hospital has only one doctor for the many C-section cases," Firmin Ruberintwari, the hospital's administrator, said. Like many of his colleagues at other facilities, Ruberintwari worried that the hospital would run out of medicines and other equipment. "Of three gynaecologic [delivery] tables needed, only one is in a good state," he said. At the Ruyigi Hospital in the southeast, there is a shortage of beds, mattresses, operating tables and even basics like surgical gloves. The hospital, which already struggles to pay its staff, now has the additional burden of funding the free services. Government unable to pay medical bills Before the 1 May directive, the government paid the medical bill for sections of its employees who sought treatment in public health institutions, including the police and the army. It also paid for the medical care of destitute people. For example, the government owes Kayanza Hospital the local equivalent of at least $60,000. This, in turn, has led to hospitals in Cankuzo, Bubanza, Cibitoke, Ruyigi and Rutana provinces being unable to pay their suppliers, a situation that can only impact negatively on patients. "Suppliers are reluctant or just refuse to provide drugs and equipment, since the hospital is incapable of paying its bills," Ruberintwari said. Kayanza Hospital already owes its suppliers some 50 million Burundi francs ($40,000) and is fast running out of drugs. The situation is identical at the Gitega Hospital. Hospital administrators have demanded the government take urgent corrective measures. Nzeyimana, the administrator of Prince Louis Rwagasore Clinic, said the government should increase medical staff, compel all health centres to remain open 24 hours and reinforce weekend teams to cope with the growing influx of patients. In addition to recruiting more staff, the government needed to increase salaries in order to stem an exodus of doctors from government service, he said. Ministry of Public Health officials say they are aware of the implementation problems and are looking for ways to resolve them. "First instalments of the amounts to be paid [to hospitals and clinics] are available at the Finance Ministry," said Cyprien Baramboneranye, managing director for resources at the Ministry of Public Health. However, he said the ministry was waiting for facilities to invoice the government before clearing its bills. This instalment, he added, would enable hospitals and health centres to function normally. The principal private secretary in the Ministry of Public Health, Julien Kamyo, said the government was providing $2 million to settle the issue of medicine shortages. In addition, foreign donors would give at least $8 million to the health sector this year. However, he said, it would take more than a year to solve all the problems associated with the directive.