When information is not power: Community-elected health facility committees and health facility performance indicators

Abstract

Health Facility Committees (HFCs) made of elected community members are often presented as key for improving the delivery of services in primary health-care facilities. They are expected to help Health Facility (HF) staff make decisions that best serve the interests of the population. More recently, Performance-Based Financing (PBF) advocates have also put the HFC at the core of health reform, expecting it to hold HF staff into account for the HF performances and development. In Burundi, a country where PBF is implemented nationwide, a randomised control trial was implemented in 251 health facilities where the HFC had been largely inactive in recent years. A random sample of 168 HFCs was trained on their roles and rights, with a subset also given information about the performance of their HF (using PBF indicators) and the PBF approach in general. The interventions, taking place in 2011-2013, made the HFCs better organised but largely failed to generate any effect on HF management and service delivery. Nested qualitative analysis reveals important tensions between nurses and HFC members that often prevent further change at the HF. In the HFs that received both the training and information interventions, this tension appeared exacerbated: the turnover of chief nurses was significantly higher as the HFCs exerted pressure to remove them. This situation was more likely to happen if the HFC had already received training before the interventions, thereby suggesting that repeated training empowers committees. Overall, the results provide rare rigorous evidence on HFCs, suggesting that more attention needs to be paid to the socio-economic and cultural contexts in which they operate. They also invite to caution when discussing the role of HFCs as a possible watchdog in PBF schemes.

Citizens Committees and Local Elites: Elite Capture, Captured Elites, and Absent Elites in Health Facility Committees

“…The interventions were motivated by health financing reforms that had given HFs more direct control over their resources (Falisse 2019) and reiterated that the pre-existing HFCs are a core mechanism to ensure that such resources are spent in the population's best interest. The reform, however, had done very little to reinforce the committees (Falisse and Ntakarutimana 2020). The present study and research protocol were informed by (1) preliminary qualitative fieldwork on what could be done to strengthen the HFCs, carried out with HF staff, HFC members, local leaders, and health authorities in 48 sites; as well as (2) the discussion of the preliminary results and suggested interventions with academic researchers, NGOs, HFC and HF representatives, and the Burundian authorities.…”

“…The first intervention (henceforth, training intervention) consisted of the training of HFC members on their role as per official guidelines, the functioning of the HF, and the way for them to access and visualise information on the activities and finances of their HF (Falisse and Ntakarutimana 2020). It lasted for two days and was followed, in the subsequent months, by two follow-up re-cap sessions.…”

“…It was, however, not formally registered. In another paper(Falisse & Ntakarutimana, 2020), we look at cases where only part of the training intervention mentioned in this paper is delivered. In the present paper, we mainly compare the HF/HFCs that benefited from the full training set with those that benefited from this full set and the joint meeting.…”

Do Anti-Corruption Messages Improve Public Service Delivery? Insights from a Lab-in-the-Field Experiment in Burundi

“…In the context of institutional fragility of Burundi, public servants find themselves having to make decisions about who is prioritised in accessing services and, during frequent shortages, who receives goods such as medicine and school equipment. Public servants typically enjoy quite some de facto autonomy in making such decision: the governance framework and informal practices promoted by the ruling party are quite permissive of corruption at all levels (Nicaise, 2019), (social) accountability mechanisms are very limited (Falisse & Ntakarutimana, 2020), and -as the survey data we will soon present shows -control by line managers is limited, especially for teachers and court clerks.…”

The Value of Integrating Governance and Sector Programs: Evidence from Senegal

“…10 Yet, integration at the programmatic level has often proven challenging in practice. 11,12 Even when sectoral and governance investments are combined, limited empirical evidence exists on the results of integrated governance on service outcomes, hampering further adoption of integrated program designs.…”