8144188922

7

services. The 1992 Survey shows that perceived ąuality of services is one of the most important determinants of level of utilization and willingness to pay. Perception of poor ąuality stems largely <Tom the unavailability of affordable drugs and health workers' attitudes which are often perceived as arrogant. In addition, important and expensive vertical programs, established in the early 1980s (vaccination, family planning, MCH care, diarrhea management, etc.), which depend on donor support have declined in ąuality due to donor budgetary cutbacks.

2.23    Health Workers Attitudes. According to the Survey, health workers’ attitudes depend on: (i) the population's understanding of health problems and Solutions; Cu) community participation in health center management; (iii) health workers' knowledge of the areas under their responsibility; and (iv) supervision and monitoring of health workers. There is little sense of "ownership* vis-i-vis the health faciiity among the communities of the health zonę. Health workers seldom visit the surrounding village communities to sensitize the population as to health problems and the benefits of modern medicine. The lack of supervision of CSPS personnel by provincial/dlstrict authorities induces feelings of isolation and demotivation among health providers.

2.24    Staff Shortages. As the need for a larger, morę effective health care delivery system increases, Burkina is also experiencing serious staff shortages. About 30 rural CSPS were recently estimated to be closed, largely due to lack of personnel. One important factor has been the overconcentration of staff in the two provinces containing Burkina Faso's two major urban centers. Although they account for only 15% of the total population, these two provinces have almost half of the MSASF's personnel. This includes 67% of the midwives, 33% of the trained birth attendants, 40% of the nurses, and 60% of the doctors, pharmacists and medical technicians. Two underlying factors for the shortage in many rural areas have been inflated staff norms and the strong attraction of the two cities.

2.25 Lack of Affordable Drugs. The absence of an effective drug policy has affected the entire health system. Essential generic drugs have been almost nonexistent, and hospitals and other public health facilities have relied upon specialty drugs which, based upon a sampling study in February 1993, have been shown to be approximately six times morę expensive than their generic equivalent and unaffordable to the majority of the population. The Govemment's parastatal SONAPHARM was catering to the interests of local pharmacists and to its own profit margins by focusing on imports of high cost brand-name drugs while showing little interest in generic drugs. Progress has been madę sińce 1992 towards the establishment of an esseutial drug policy. The Government legally established, in May 1992, the Centrale d'Approvisionnement des Mćdlcaments Essentiels et Głn£riques (CAMEG), and this new organization is currently being set up. Legislation allowing peripheral health facilities to retain the funds they collect from the sale of drugs and provision of medical services, which was a condition for appraisal of the proposed project, was approved and signed in January 1993. Nevertheless, it must still be implemented. Successful cost recovery in the health sector under the proposed project, will depend largely on the Government's abilłty to keep the cost of drugs down through reliance on generic drugs. Fuli cost recovery on drugs alone would be a major step forward for the public health system as it would alnost certainly increase utilization of health services by enhancing drug availability.

2.26 Weak Referral System. There is an insufficient distinction between first linę and referral levels, in terms of functions and resources. In particular, the CMs without surgical activities and laboratories do not play their role of first referral. Referral where surgical activities are first offered is at the level of the regional hospitals (CHR) and the national hospitals (CHN). There are nine regional hospitals and two national hospitals—too few for first level referral. Moreover,