Ethnic war leaves Burundi's health sector in ruins

Abstract

The central African nation of Burundi is struggling to resuscitate a health sector destroyed by 13 years of ethnic war. But shortages of funds and health workers, and in some instances the heavy presence of landmines, are severely hampering progress. Wairagala Wakabi reports.With the maternal mortality rate at 1000 per 100 000 livebirths per year and infant mortality 114 per 1000 livebirths, Burundi has some of the worst health indicators in Africa. The UN Children's Education Fund (UNICEF) says 60% of primary school-aged children have iodine deficiency in the tiny central African nation of 8 million people.Health authorities blame the prevalence of malaria, diarrhoea, pneumonia, and HIV/AIDS and the effects of the war—which has claimed 300 000 lives since 2003—for these appalling health indicators. And now, a shaky peace agreement between the government and the last remaining rebel group, the Forces for National Liberation (FNL), is under threat of collapse. The UN is worried that fighting could resume in the country, worsening the humanitarian situation. “We still have many challenges in the area of peace and security”, foreign minister Antoinette Batumubwira told The Lancet. “We are trying to negotiate with FNL with the help of regional states. We need peace to get our people out of poverty and stop the suffering they endured during the war.”Although most Burundians live on less than US$1 a day, efforts by the government to raise $1·3 billion from donors to fund a 3-year poverty reduction plan have consistently been rebuffed in the past. Donors have said that, although they are willing to help the country recover from the devastating effects of the war, they would like a firmer commitment to peace and democracy before they release vast sums of development assistance.Burundi's first democratically elected president was assassinated in 1993, and a civil war fought along ethnic lines followed. A new president, Pierre Nkurunziza, was elected in 2005, after insurgent groups agreed to a power-sharing government in internationally brokered talks. A truce was signed with the FNL rebel group in September, 2006, but in April this year it withdrew from the ceasefire pact, claiming Nkurunziza had flouted the agreement. “It is essential that this final phase of the peace process be successfully concluded without delay so that all Burundians can focus on the urgent national reconciliation and reconstruction tasks that lie ahead”, UN Secretary-General Ban Ki-moon said on May 21, 2007.Jean-Claude Kavumbagu, proprietor of the private Net Press news agency says that donor support is needed to fund social sector programmes, noting that a year-old presidential directive on free medical assistance for children less than 5 years of age and pregnant mothers, would fail unless donors dramatically changed their stance towards the country.With a per head income of just under $100, hospitals often detain patients who are unable to settle their bills. Tea and coffee account for 90% of this hilly country's export earnings, but the crops often fail because of bad weather or infestations by pests, says social analyst Sadi Niyungeko. Most people are thus kept in perpetual poverty, and with the public-health services highly corrupt and poorly funded, it means many cannot afford to pay their medical bills.Since the government decided to provide free birth delivery and child care services, families have had some relief from user fees. This move was marked by the launch of a new policy Road Map for the Reduction of Neonatal and Maternal Mortality in February, 2006, which seeks a 75% reduction in maternal deaths and a 50% reduction in neonatal mortality by 2015. The UN Population Fund, UNICEF, WHO, and the World Food Programme helped draw up the policy.In a statement on May 21, 2007, Human Rights Watch (HRW) said Burundi was currently receiving debt relief and had used some of the funds to eliminate user fees for maternal and paediatric health care. “But apparently reflecting the relatively little importance given to health questions by the government, the budget for health care has actually been reduced from the US$15 million called for in 2006 to US$11 million set for 2007”, it said.The organisation added: “Resolving the issue of detention of insolvent patients in Burundi requires measures both to protect individuals from human rights abuses and to establish effective, equitable and transparent methods of financing health care. In both cases, it is the responsibility of the Burundian government to take action, but it is also incumbent upon the international community to apply pressure on the government of Burundi to do so, and to support efforts in that direction.”In 2006, WHO said more than half the population went into debt or sold an asset to pay for health care. Among Burundi's key health concerns are HIV/AIDS, which was exacerbated by the conflict and the late government response to the epidemic. UNAIDS says HIV prevalence in Burundi stands at 6%, among the highest in the world. Shortage of drugs, rising numbers of orphans, and stigmatisation, are among the challenges the country faces in fighting HIV/AIDS.But malaria remains the major killer; acute respiratory illness and diarrhoea are other leading causes of morbidity. Health officials say these are related to overcrowding and poor housing conditions, inadequate sanitation, and unsafe water: less than half the population has access to drinking water.Since 2005, primary education in Burundi has been free, allowing thousands of children, including those returning from refuge in neighbouring countries, to enrol. The peace has allowed government to allocate a larger share of its budget to elementary education, but the failure of the peace agreement with FNL threatens these gains. Ban Ki-moon is encouraging the country to reach an agreement with the UN to establish a Truth and Reconciliation Commission as well as a Special Tribunal. “Durable peace will also depend on how Burundians reconcile themselves with the consequences of their tragic past and forge a shared future”, he said.The FNL rebels are still out of the ceasefire deal, claiming that government forces have not been withdrawn from areas under their control and angry that they have not been given posts in government.In late April, 2007, efforts to reconcile the country were dealt a blow when Hussein Radjabu, ex-leader of the ruling party to which Nkurunziza belongs, was arrested and remanded in jail over accusations of recruiting and arming a militia group to destabilise Nkurunziza's government. He denies the charges, but warns that the regime's intolerance to divergent views is sliding Burundi back towards its dark past. Critics also note that Nkurunziza has failed to live up to his party's promise to respect constitutional provisions that the main opposition party gets five ministry posts.Since the beginning of this year, 3152 Burundian refugees have returned to their homeland but about 150 000 others are still in camps in Tanzania, Uganda, and the Democratic Republic of Congo. The UN refugee agency UNHCR says about 320 000 refugees have been repatriated to Burundi since the agency started assisting their return in 2002.But Francoise Niyonsaba, who works with the non-governmental Centre for Research and Initiatives for Dialogue, told The Lancet the presence of landmines and unexploded remnants of war continue to dog efforts to resettle people who were displaced by war. Burundi has a high population density, and many of the returning refugees are finding themselves with no land to till. Both government and rebel groups used landmines in the war.The Stamm Foundation, a local civil society agency supported by UNICEF, says the war has left behind 823 000 orphans, at least 20 000 of whom are currently living on the streets. Between 2004 and 2006, UNICEF helped to disarm and resettle more than 3000 child soldiers, but other UN agencies and local human rights groups say others remain in government and militia ranks.Meanwhile, a national watchdog says human rights violations, including executions by armed bandits and sexual violence against women and children, have continued in Burundi despite an improvement in the political landscape. Jean-Marie Vianey Kavumbagu, head of the human rights organisation Ligue Burundaise des Droits de l'Homme (ITEKA), says continuing circulation of weapons among civilians and the slow reintegration of demobilised fighters into society have this year led to daily reports of armed banditry. ITEKA recorded an alarming increase in sexual violence cases last year to 1930 cases. “What is of concern is that most of the victims are children younger than 12”, Kavumbagu says.“In the last year, the government has shown little political will to prosecute such grave abuses as the killing of 31 civilians in Muyinga province in July and August, 2006, or the use of torture by agents of the intelligence service”, HRW said in May, 2007. Burundi has also been blamed for failing to make any progress in negotiating transitional justice mechanisms with the UN. The central African nation of Burundi is struggling to resuscitate a health sector destroyed by 13 years of ethnic war. But shortages of funds and health workers, and in some instances the heavy presence of landmines, are severely hampering progress. Wairagala Wakabi reports. With the maternal mortality rate at 1000 per 100 000 livebirths per year and infant mortality 114 per 1000 livebirths, Burundi has some of the worst health indicators in Africa. The UN Children's Education Fund (UNICEF) says 60% of primary school-aged children have iodine deficiency in the tiny central African nation of 8 million people. Health authorities blame the prevalence of malaria, diarrhoea, pneumonia, and HIV/AIDS and the effects of the war—which has claimed 300 000 lives since 2003—for these appalling health indicators. And now, a shaky peace agreement between the government and the last remaining rebel group, the Forces for National Liberation (FNL), is under threat of collapse. The UN is worried that fighting could resume in the country, worsening the humanitarian situation. “We still have many challenges in the area of peace and security”, foreign minister Antoinette Batumubwira told The Lancet. “We are trying to negotiate with FNL with the help of regional states. We need peace to get our people out of poverty and stop the suffering they endured during the war.” Although most Burundians live on less than US$1 a day, efforts by the government to raise $1·3 billion from donors to fund a 3-year poverty reduction plan have consistently been rebuffed in the past. Donors have said that, although they are willing to help the country recover from the devastating effects of the war, they would like a firmer commitment to peace and democracy before they release vast sums of development assistance. Burundi's first democratically elected president was assassinated in 1993, and a civil war fought along ethnic lines followed. A new president, Pierre Nkurunziza, was elected in 2005, after insurgent groups agreed to a power-sharing government in internationally brokered talks. A truce was signed with the FNL rebel group in September, 2006, but in April this year it withdrew from the ceasefire pact, claiming Nkurunziza had flouted the agreement. “It is essential that this final phase of the peace process be successfully concluded without delay so that all Burundians can focus on the urgent national reconciliation and reconstruction tasks that lie ahead”, UN Secretary-General Ban Ki-moon said on May 21, 2007. Jean-Claude Kavumbagu, proprietor of the private Net Press news agency says that donor support is needed to fund social sector programmes, noting that a year-old presidential directive on free medical assistance for children less than 5 years of age and pregnant mothers, would fail unless donors dramatically changed their stance towards the country. With a per head income of just under $100, hospitals often detain patients who are unable to settle their bills. Tea and coffee account for 90% of this hilly country's export earnings, but the crops often fail because of bad weather or infestations by pests, says social analyst Sadi Niyungeko. Most people are thus kept in perpetual poverty, and with the public-health services highly corrupt and poorly funded, it means many cannot afford to pay their medical bills. Since the government decided to provide free birth delivery and child care services, families have had some relief from user fees. This move was marked by the launch of a new policy Road Map for the Reduction of Neonatal and Maternal Mortality in February, 2006, which seeks a 75% reduction in maternal deaths and a 50% reduction in neonatal mortality by 2015. The UN Population Fund, UNICEF, WHO, and the World Food Programme helped draw up the policy. In a statement on May 21, 2007, Human Rights Watch (HRW) said Burundi was currently receiving debt relief and had used some of the funds to eliminate user fees for maternal and paediatric health care. “But apparently reflecting the relatively little importance given to health questions by the government, the budget for health care has actually been reduced from the US$15 million called for in 2006 to US$11 million set for 2007”, it said. The organisation added: “Resolving the issue of detention of insolvent patients in Burundi requires measures both to protect individuals from human rights abuses and to establish effective, equitable and transparent methods of financing health care. In both cases, it is the responsibility of the Burundian government to take action, but it is also incumbent upon the international community to apply pressure on the government of Burundi to do so, and to support efforts in that direction.” In 2006, WHO said more than half the population went into debt or sold an asset to pay for health care. Among Burundi's key health concerns are HIV/AIDS, which was exacerbated by the conflict and the late government response to the epidemic. UNAIDS says HIV prevalence in Burundi stands at 6%, among the highest in the world. Shortage of drugs, rising numbers of orphans, and stigmatisation, are among the challenges the country faces in fighting HIV/AIDS. But malaria remains the major killer; acute respiratory illness and diarrhoea are other leading causes of morbidity. Health officials say these are related to overcrowding and poor housing conditions, inadequate sanitation, and unsafe water: less than half the population has access to drinking water. Since 2005, primary education in Burundi has been free, allowing thousands of children, including those returning from refuge in neighbouring countries, to enrol. The peace has allowed government to allocate a larger share of its budget to elementary education, but the failure of the peace agreement with FNL threatens these gains. Ban Ki-moon is encouraging the country to reach an agreement with the UN to establish a Truth and Reconciliation Commission as well as a Special Tribunal. “Durable peace will also depend on how Burundians reconcile themselves with the consequences of their tragic past and forge a shared future”, he said. The FNL rebels are still out of the ceasefire deal, claiming that government forces have not been withdrawn from areas under their control and angry that they have not been given posts in government. In late April, 2007, efforts to reconcile the country were dealt a blow when Hussein Radjabu, ex-leader of the ruling party to which Nkurunziza belongs, was arrested and remanded in jail over accusations of recruiting and arming a militia group to destabilise Nkurunziza's government. He denies the charges, but warns that the regime's intolerance to divergent views is sliding Burundi back towards its dark past. Critics also note that Nkurunziza has failed to live up to his party's promise to respect constitutional provisions that the main opposition party gets five ministry posts. Since the beginning of this year, 3152 Burundian refugees have returned to their homeland but about 150 000 others are still in camps in Tanzania, Uganda, and the Democratic Republic of Congo. The UN refugee agency UNHCR says about 320 000 refugees have been repatriated to Burundi since the agency started assisting their return in 2002. But Francoise Niyonsaba, who works with the non-governmental Centre for Research and Initiatives for Dialogue, told The Lancet the presence of landmines and unexploded remnants of war continue to dog efforts to resettle people who were displaced by war. Burundi has a high population density, and many of the returning refugees are finding themselves with no land to till. Both government and rebel groups used landmines in the war. The Stamm Foundation, a local civil society agency supported by UNICEF, says the war has left behind 823 000 orphans, at least 20 000 of whom are currently living on the streets. Between 2004 and 2006, UNICEF helped to disarm and resettle more than 3000 child soldiers, but other UN agencies and local human rights groups say others remain in government and militia ranks. Meanwhile, a national watchdog says human rights violations, including executions by armed bandits and sexual violence against women and children, have continued in Burundi despite an improvement in the political landscape. Jean-Marie Vianey Kavumbagu, head of the human rights organisation Ligue Burundaise des Droits de l'Homme (ITEKA), says continuing circulation of weapons among civilians and the slow reintegration of demobilised fighters into society have this year led to daily reports of armed banditry. ITEKA recorded an alarming increase in sexual violence cases last year to 1930 cases. “What is of concern is that most of the victims are children younger than 12”, Kavumbagu says. “In the last year, the government has shown little political will to prosecute such grave abuses as the killing of 31 civilians in Muyinga province in July and August, 2006, or the use of torture by agents of the intelligence service”, HRW said in May, 2007. Burundi has also been blamed for failing to make any progress in negotiating transitional justice mechanisms with the UN.