Reaching out to young people in Burundi with quality health services
Single mothers preparing to educate other young people at Ceru health centre
In an ideal world, health services are of high quality and are eagerly sought out by users, including youth. With this ideal in mind, Burundi’s Reproductive Health Programme has been actively promoting both sides of this equation, associating Systemic Quality Improvement in health centres with Community-Based Networking for adolescent and youth health.
At Ceru health centre in Gitega Province, Vivine and Germaine (not their real names) are a bit nervous. They are about to share their life stories as young single mothers (a status harshly stigmatised in Burundi) with a group of curious high-school students attending the health centre’s weekly ‘open house’ for young people. They are reassured by each other’s presence and the kindly introduction of the school director who has accompanied them to this event. The young women keep their poise as they explain how they became pregnant and were obliged to leave school. They answer all the students’ questions and give them practical advice: ‘Girls, don’t accept boys’ gifts of peanuts or sweets if they seem to expect something in return!’
Vivine and Germaine are members of a single mothers’ association that is part of a network of local stakeholders reaching out to youth in the catchment area of Ceru health centre. The idea of the network is to get different structures that deal with young people – schools, churches, community organisations etc. – to work together on improving their access to quality health services and information.
When Burundi’s National Reproductive Health Programme introduced its concept of Community-Based Networking for Adolescent and Youth Health, it found a supportive partner in the Projet Renforcement des structures de santé dans le domaine de la planification familiale et de la santé et des droits sexuels et reproductifs (‘SDSR Project’ for short), implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ). Starting in 2014, the project helped Burundi’s National Programme put its concept into practice in the provinces of Gitega, Mwaro and Muramvya. Today, Ceru is one of 29 health centres with an active community network in their respective catchment areas promoting adolescent and youth Sexual and Reproductive Health and Rights (SRHR) without external support.
Local structures for young people join forces for youth SRHR
Laetitia Nzitonda is Head of the project component for working with Civil Society. She is familiar with all the reasons that keep young people from seeking sexual and reproductive health services:
Young people are often shy about using health services, so our challenge was where and how to reach them.Laetitia Nzitonda
This is why she and her colleagues work with a Community-Based Networking approach. Community-based networking takes advantage of the variety of structures and resources working with youth that exist in a health centre’s catchment area – and gets them to work together under the coordination of the health centre (see brochure ‘Community-based networking for young people’s health’). Main actors are the public and parochial schools, but also various youth clubs and associations, as well as the health centre’s own group of community health workers, to reach young people who are no longer in school. This makes for a significant number and variety of facilitators and peer educators promoting youth sexual and reproductive health and rights plus the 13 members of the network committee, who are elected each year by the different categories of participating structures. The network functions with organised activities for youth that also regularly bring them into the health centre for education and confidential, quality SRHR services.
According to Laetitia Nzitonda, community and school competitions engage young people in creating songs, poems and plays on reproductive health and rights. The diverse channels make it possible to treat sensitive topics such as sexual and gender-based violence. Each network has a Single Mothers’ Association like Vivine and Germaine’s. Reinforced with training and educational tools developed with project support, single mothers share their stories and encourage young people to come to the health centre for their SRHR needs (see brochure ’Single mothers’ associations’).
The networks also aim to improve access of vulnerable and marginalised youth to SRHR information and services. This has led them to reach out to the Batwa minority group – a historically landless indigenous community who live in extreme poverty – and to the Union des Personnes Handicapées du Burundi, an umbrella organisation that promotes the well-being of people living with a disability (see brochure ‘Protecting the health and rights of young people with disabilities’). Health-service providers have received training and equipment to better respond to the special needs of these individuals.
Getting religious leaders on board
The biggest challenge, according to Laetitia Nzitonda, was working with religious leaders, who have a strong influence on Burundian society, including on youth in parochial schools and associations:
‘Many religious leaders frown on sexuality education for young people.’ She explains that the project reached out to the Réseau des Confessions Religieuses pour la Promotion de la Santé et le Bien-Etre Intégral de la Famille (RCBIF), a structure which brings together the major religious denominations for a faith-based family health concept (see brochure ‘Partnering with religious leaders to increase young people’s access to SRH’). Through a patient and mutually respectful dialogue, they jointly developed an educational tool, ‘Jeunesse victorieuse’, that introduces all aspects of SRHR in a language acceptable to the religious leaders. This tool is broadly disseminated and used in faith-based schools and associations, which means that many more young people now have access to accurate information on sexual and reproductive health and rights.
In informal conversations with project staff, education professionals share their impression that the number of schoolgirl pregnancies has diminished in the catchment areas of the community-based networks. Studies show that knowledge levels among youth on topics such as sexually transmitted infections, HIV/AIDS and gender-based violence have greatly improved. According to some observers, the open communication practised in and by the networks, including through the testimony of single mothers, has helped to reduce the taboo on talking about sexuality between young people and their parents, and with religious authorities.
Health centres with resources to attract youth
In line with the National Programme’s concept of ‘youth-friendly’ health centres, Ceru has made space for a ‘youth room’ with information materials on SRHR, where young people can interact with each other and the centre’s health promoters. Ceru health centre also offers the ‘Ideas Cube’ programme sponsored by the NGO ‘Bibliothèques sans frontières’ – a digital library that fascinates young people and their educators alike.
‘Ever since we started using the Ideas Cube kit,’ explains Fidèle Mbonabuca, the In-Charge of the Ceru health centre, ‘we’ve had a huge number of young people coming to use it – and the young people seem to feel at home here.’ With the local community network, the health centre organises awareness-raising activities such as quizzes and soccer matches. And they have begun to schedule clinics at times that allow young people to use their services discreetly for their health problems.
We have to offer quality services to meet young people’s expectations. Their health matters to us – they are the ones who will replace us one day!Fidèle Mbonabuca, In-Charge of Ceru Health Centre
Ceru is one of 90 health centres in the provinces of Gitega, Mwaro and Muramvya engaged in a process of Systemic Quality Improvement of their health services.
Moving towards sustainable Quality Management in health services
‘Obviously,’ says Dr Marie-Claire Ryanguyenabi, Head of the project component on Accessibility and Quality, ‘if we want young people to come to the health centres, we need to ensure that they will receive quality services.’ When the project started in 2014, her team and their Ministry partners were interested in the Systemic Quality Improvement – or ‘Concours Qualité’ – approach developed by German Development Cooperation in Guinea and then tried out in several countries without becoming a permanent part of their health system. They liked the motivational aspect of positive competition between health structures and the strong accent on self-assessment and responsibility of the individual teams. But on the other hand, they wanted to avoid the administrative burden that made it difficult to pursue the approach elsewhere. As a result, the partners opted for a ’light’ form of the Concours Qualité: only between health centres rather than on all levels of the health hierarchy, and they started out with just two themes – hygiene and accessibility – and only two quality dimensions for each, rather than an exhaustive assessment of all elements of healthcare provision.
In the course of three cycles of the Concours Qualité, the approach was refined: Themes related to SRHR were integrated into the quality competition, with the operational level partners – the Provincial Health Offices and the District Health Teams – progressively taking over responsibility for all aspects of the process. At least as important as the organisation of the competition itself were quality elements such as use of the ‘Deming Wheel’ for planning and self-assessment, strengthening competence through coaching, feedback and self-reflection, and active community participation in planning and implementing the improvements.
Ultimately, it is these day-to-day practices that make for a sustainable, integrated Quality Management approach. The Concours Qualité gave the initial boost to the process, but is no longer necessary.Dr Marie-Claire Ryanguyenabi
Going beyond the Concours Qualité
According to Dr Emile Nzoyisaba, District Medical Officer of Kibumbu Health District, district teams greatly benefitted from the German support, with increasing ownership in the course of the three cycles of the Concours Qualite. ‘We focused on real problems, brainstormed on their solutions and took responsibility for implementing them – and after each sequence we evaluated ourselves. This has created real team spirit both in the health centres and on the part of the District Health Teams.’ The project is now supporting these partners in a process of deploying and adapting tools that they used for the Concours Qualité to sustain a quality culture in the health services.
Ceru health centre’s In-Charge, Mr Mbonabuca, is enthusiastic about the Concours Qualite experience: ‘We were awarded an examination table, a medical thermometer and other useful equipment. But what is even more valuable is seeing improvements in planning and implementing activities, not just in the health centre but also in everyday life.’ He appreciates that the approach has improved team spirit and enables them to offer quality services to their clients, ‘to meet all their needs without discrimination or stigmatisation.’
Even though the project is ending, we are determined to continue this approach. To make sure we don’t fall behind, we will include these activities in the health centre’s yearly action plans and budget.Fidèle Mbonabuca
A scientific evaluation of the Quality Management approach and its impact singled out the use of coaching and the accent on teamwork as particularly motivating aspects conducive to significant quality improvement. It concluded that the positive dynamic of continuous quality improvement which the project launched and supported can be sustained at little extra cost without external support.
Looking back on 10 years of the SDSR Project
After 10 years of operation, the Burundian-German SDSR Project is coming to its end. Ursula Schoch, Head of the project, sums up its guiding philosophy: ‘Both in integrated quality management and in community networking for youth SRHR, our central aim has been our partners’ autonomy. A project can give a temporary boost to something that already exists, to hopefully improve its functioning long-term. In each project component we have focussed on supporting our partners to advance without our support.’
Our central aim has been our partners’ autonomy.Ursula Schoch, Head of project
Six District Health Teams, three Provincial Health Offices and 90 health centres have been supported to pursue improvement of service quality; and the project leaves 29 active community-based networks functioning under the responsibility of their respective health centres, which include their activities in the health facility budget.
The Project has developed two toolboxes based on its many lessons learned (French only):
Promoting health of young people in Burundi through community networking
Promouvoir la santé des jeunes au Burundi par un réseautage sociocommunautaire
From Quality Contest to Integrated Quality Management
Du ‘Concours qualité’ à un Management intégré de la qualité
Dr Mary White-Kaba