In the capital, Bujumbura, MSF treats war wounds and manages a health center while it also runs a medical and surgical program in a local hospital. In 2003, MSF opened a new center in Bujumbura to address sexual violence which is an enormous problem in the country. In addition, we operate nutrition programs and fight outbreaks of infectious disease.

The country's civil war has severely damaged the health sector. Insecurity in certain regions has increased the inaccessibility of health care for many. Medical staff is lacking, while the supervision and motivation of health staff is poor. The economic crisis caused by the war has reduced the government's capacity to invest in the health sector.

A decentralization plan and a cost recovery policy have been implemented nation-wide. MSF believes this new policy will have a negative impact on people's access to health care as a national epidemiological survey conducted by MSF during the final quarter of 2003 revealed that approximately one million people had no access to health care and three million people had to use extreme measures to gain limited access.

Caring for survivors of rape

Because sexual violence is widespread in Burundi, MSF started a program for survivors of rape in Ruyigi Hospital in February 2003. The staff sees an average number of 10-15 patients a month. Fortunately, almost all these patients come to the hospital within 72 hours of the rape. This allows them to benefit from MSF's post-exposure protocol which includes administering the "morning after" pill, prevention of HIV and treating possible sexually transmitted infections (STIs).

If requested, the survivor can also be tested for HIV/AIDS. MSF also works closely with representatives from local associations who tell women about MSF and raise their awareness on sexual violence. MSF's primary health teams also talk about sexual violence with patients in the health centers before carrying out consultations. Counseling is offered alongside medical treatment and a MSF staff member records each survivor's story.

In November 2003, MSF started treating survivors of rape in Kinyinya Hospital in the rural Moso area. In January, a similar program started in Makamba Hospital. Two months earlier, MSF had also opened a health center for women in Bujumbura Mairie that deals with sexual violence and health issues, as well as family planning and STDs.

By providing medical and psychological care in addition to working in collaboration with Avocats Sans Frontières (which provides legal follow-up support), this center has received an increasing number of patients. In fact, the number of cases rose from 40 in September 2003 to 150 in March 2004.

A message against sexual violence elaborated by MSF is broadcast once a month on Burundi's two main radio stations. Hospitals and health centers around the country which are run by MSF are included in the message so that survivors can learn where they can receive medical care.

Other region-specific programs

Karuzi is a geographically isolated province in northern Burundi which has an estimated 300,000 inhabitants. MSF helps the local population here by providing health care, nutritional programs and responding to emergencies.

At present, we support the Buhiga Hospital and ten health centers by providing medicines, training staff, supervising medical activities and coordinating management committees. At the same time, MSF has implemented nutritional activities including supplementary feeding programs at the MSF-supported health centers which now assist about 3,000 people.

There is an additional therapeutic feeding program in Buhiga that can care for 250 severely malnourished children. MSF also carries out epidemiological surveillance across a total of 13 health centers, while continuing to distribute impregnated mosquito nets and spray houses and health structures to prevent malaria.

MSF has been providing assistance to the population in and around Bujumbura since the army razed the region.

The MSF center for war casualties is situated in Kamenge, one of the capital's neighbourhoods. In operation since 1995, the center is regularly filled to capacity with about 200 patients. Since 2001, a health center located in the northern suburb of Kinama has been providing primary health care to an average of 5,000 patients a month.

Approximately 300 people are transferred for hospitalization (medicine, surgery, obstetrics) through MSF's partnership with two private, local hospitals in the city.

In Ruyigi province, MSF operates seven outpatient health centers that target more than 120,000 people. MSF provides medicines, waste management, health education, supervises the care and management at health-center level and works to improve the local health care providers' diagnostic and treatment skills.

MSF staff also give direct patient care to supplement the work carried out by Ministry of Health staff in the health centers. MSF also runs two hospitals in Ruyigi and Kinyinya, supplying staff, medicines, sanitation, laboratory services, a blood bank and sexual violence programs. In Bujumbura rural, MSF staff provides basic medical care to the health sector of Rwibaga.

The most common illnesses treated by MSF here are respiratory infections, diarrheal diseases and malaria. Special attention and support is being given to the health center of Karinzi, providing health care and hospitalization facilities to an estimated population of 50,000 people living in a very insecure area. MSF supports the sector's various health care structures by providing training, medical assistance, supervision and drug and material supplies.

Since the beginning of 2004, emphasis has been placed on maternal health through the health facilities and 180 traditional birth attendants. In addition, a mobile clinic at the camp for internally displaced persons in Kivoga provides first and second level medical care to approximately 10,000 displaced people.

In Makamba province, MSF supports the provincial hospital by running all of the medical services including medicine, pediatrics, surgery, obstetrics/gynecology and emergency care.

MSF also reinforce the hospital's current human resources with international volunteers. MSF supplies all of the medicines and offers pay incentives to the Ministry of Health staff. In this way, the costs of accessing care are kept low and consultation fees remains affordable for everyone.

MSF also runs a mobile clinic that operates throughout Makamba province granting free primary health care to people who are internally displaced or who are recently returned refugees. In response to a number of malaria epidemics, MSF has launched a large-scale emergency program ensuring both curative and preventive measures related to the disease.

In 2003, the team helped change the national malaria protocol to artemisinin-based combination therapy (ACT). MSF now supports training of medical personnel and supervises implementation of the new protocol. MSF also launched several cholera interventions.

In early 2002, cholera treatment centers were opened in the districts of Kamenge and Ruziba. More than 600 cases have been registered and almost all could be cured. The most recent intervention occurred in March 2004 in Rubiza.

Challenges ahead

Burundi faces many challenges. The MSF team is searching for ways to handle the massive return of refugees that is expected this year. This influx of people triggers concerns about health care and adequate shelter. All the available land has been redistributed and there is little room in this small country to accommodate these new inhabitants. There are also real difficulties in guaranteeing access to health care due to the high cost of consultations in public health facilities.

Due to insecurity, MSF and other aid agencies have difficulties reaching the most vulnerable people, especially in the province of Bujumbura rural. Limitations on MSF's movements hinder effective assistance and the prevention of epidemics and malnutrition. Finally, AIDS has become a very serious concern in the country which will have to be confronted in the future.