Although a ceasefire was agreed at the end of 2003, in certain areas of Burundi peace still remains a hope rather than a reality and the effects of war are still very much present.1

The country's civil war has compounded the economic crisis, and severely damaged the health sector. The government's capacity to invest in the health sector is limited. Medical staff are lacking, infrastructure has been destroyed, and ongoing insecurity in certain regions has increased the inaccessibility of health care for many.2

At the same time, infectious and parasitic diseases, especially malaria, remain huge health problems.

Despite the beginnings of political stability in Burundi, the mortality rates are alarming and well above those associated with even an emergency situation.3 The violence has led to a scarcity of goods and services, supply and transport problems, an increase in violence and the destruction of family belongings causing generalised vulnerability of the population.

The link between poverty and health is now well known, and health is recognised as an essential requirement for economic development.4 Yet there are hundreds of thousands of Burundians who have no access to basic health care as a result of their inability to pay for it. This is because since February 2002, the Burundian government have implemented a policy of cost recovery for health services.

In Bujumbura, a health centre run by MSF in the Kamengue district where people with cholera and malaria are treated as well as those wounded by war. Some 40% of those wounded by war are women and children. Here a young boy wounded in the war is looked after by his older brother.

The cost-recovery system is part of a revived health reform planned before the war. It aims to mobilise extra resources for health care. Faced with only a small part of the national budget allocated to the health sector, the Ministry of Health had no other choice but to impose the burden of healthcare costs on the patient. The costrecovery system means that the patient has to pay the full price for medicines as well as tests and medical consultations. The system has been applied in 12 of 17 rural provinces — covering five million people. In some areas non-governmental organisations (NGOs) subsidise essential care and user fees are lowered for some 750,000 people.

The average price for a basic consultation at a primary healthcare centre under the costrecovery system is around. This is equivalent to about 12 days pay for a Burundian. No effective system exists to protect the destitute, or those unable to afford treatment.

In spite of high levels of vulnerability, less than 1% of households obtain a full waiver of the fees.

We met Simeon — a man with no money, no job, and a family to feed. He presented to the clinic with a young girl, age 3 years, with second degree burns: 'I was very worried and I brought my little girl to the health centre in my district in the south of Bujumbura. But the nurse wouldn't see us as I didn't have any money to pay for the consultation. So I had to take my girl back home without having received any care. Then I had no choice but to borrow 2000F (Burundian francs)from my neighbours for the consultation. I also bought a few medicines on the black market. Every day I pay back 150F of the 250F that I earn every day carrying bags. I have 100F left to feed my family. It's not a lot.'

Increasingly, humanitarian relief agencies have expressed their concern over the introduction of cost-sharing mechanisms in complex emergencies or post-conflict situations such as in Burundi. It seems unfair to many that a population struggling to survive in a war situation should have a further financial burden imposed on them.

In Gihogzi, MSF doctors and nurses who treat the locals for malaria, at the same time take basic health statistics that determine malnutrition - height, weight.

According to Poletti,5 the rationale for introducing cost-sharing in complex e m e rgencies has not been well articulated, and the arguments in favour of it are large l y ideological. Although the introduction of user fees is seen by donors as a necessary step in building a sustainable health system, there is sufficient evidence to date to suggest that user fees should not be introduced in complex emergency settings as they can have a dramatic effect on the health and social status of the population.5

Against the background of the precarious situation of the majority of Burundians, Médecins Sans Frontières (MSF), who has worked in Burundi since 1992, initiated a nationwide retrospective epidemiological survey from November 2003-January 2004, to assess the effect of nearly 2 years of the cost-recovery system on the Burundian population.3

The results of the survey were alarming: 17% of the population said they had no access to a straightforward consultation, with 82% of these sick people stating that the reason for this was because they didn't have any money to pay. Our findings from the survey translate to almost 1 million people in Burundi, like Simeon, being excluded from basic health care at this time.

In order to pay for health care, 81.5% of patients consulted said they were obliged to go into debt or sell a proportion of their harvest, land, or livestock. Running up a debt with a health centre is a common practice in Burundi. In order to recover debts, centres confiscate identity papers, or some of the patients' belongings. Another measure reported by MSF was the imprisonment of patients, which may leave them inside the health centre, but with no care. Some NGOs and other civil bodies have been known to reimburse all or part of the debt contracted in order to obtain the patients release.

18-year-old Clémentine, from a desperately poor area called Cibitoke, had recently given birth in the health centre.

'After the delivery I was presented with a bill for 30 900F. I didn't have money enough to pay that much. I am an orphan ... [My husband] left me when he learned that I had to pay 30,900F for the delivery. As I didn't have anything to pay that amount of money, I was imprisoned in the health centre ... I remained there for a week, in detention, without care and without food. It was the other women in the room who shared their food with me and helped me to wash. I was suffering from anaemia and my baby had respiratory and digestive problems.'

Besides the exclusion and the risk of further impoverishment, the delays in attending a consultation for a health problem are a concern. Since the introduction of the system, the survey highlighted that attendance rates at the health centres have fallen off sharply. Mainly for financial reasons, most households postpone seeking health care. This means that patients may be presenting later to services, possibly to the detriment of their health. This practice could be one of the factors explaining the significantly higher mortality rates for malaria that have been observed in regions a ffected by the cost-recovery system.

The population of Burundi is living in extreme poverty and the expenditure on health care is further exacerbating this precarious state. To impose a cost-recovery system on a population emerging from 10 years of civil war is unjust. It is imperative that an effective and free healthcare system is urgently restored in Burundi, and that services are accessible to all. The human price of this cost-recovery system must provoke a reaction among the relevant bodies, with dialogue needed around alternative ways of financing health services to avoid exclusion.

During a Westminster Hall debate on Burundi,6 in response to questioning on whether appropriate exemptions from the cost-recovery scheme could be made for vulnerable elements of the Burundian population, the Parliamentary Undersecretary of State for International Development stated that DFID's priority was, 'to ensure that the poorest of the poor are able to access medical services and for the moment the best way to achieve that is through health services being provided free of charge'.6 MSF is currently in dialogue with DFID Africa Desk to review alternatives to the cost-recovery system in a humanitarian situation.

Burundi today faces a great many challenges. In addition to the real difficulties in guaranteeing access to health care due to the high cost of consultations in public health facilities, aid agencies are still having major di fficulties reaching the most vulnerable people. Aid agencies are also searching for ways to handle the massive return of refugees expected later this year.