Q&A: Burkina Faso’s social movement for universal health coverage

This Q&A is the second piece in a series to document how Burkina Faso’s prominent civil society is paving the way for the advancement of universal health coverage (UHC) in the country. It highlights the pivotal work of RAME, a leading civil society organization (CSO) in Burkina Faso and institutional partner of the African Collaborative for Health Financing Solutions (ACS) project as well as the impact of COVID-19 on the country. RAME, in collaboration with the Health Democracy Citizen Involvement Platform (DES-ICI Platform) created a coordinated response to mobilize communities to combat COVID-19 and are now transitioning their advocacy toward building a social movement for UHC in Burkina Faso. Please find the first blog, “Civil society as an engine of reform,” in this series.

In this post, Katherine Matus, a program officer for the African Collaborative for Health Financing Solutions (ACS), interviews Simon Kaboré, executive director of Réseau Accès aux Médicaments Essentiels (RAME), a Burkinabé civil society organization.

Why is UHC a critical issue for you, personally, as well as for RAME?

Simon: I’m a health activist. I’m in this fight for every individual in society, regardless of their socio-economic status, to have access to care. Currently, there are economic and geographic inequalities in access to health services due to poor governance of the health system. That’s why we’re fighting for universal health coverage (UHC). One shouldn’t have to be rich to have access to health services because health is a fundamental human right.

RAME was created and remains committed to fighting for equal access to quality health services for all. I’m the Regional Executive Director as well as the founder of the organization. My duty is to maintain the light and the fight, to inspire, and to influence politics related to health. I also oversee the implementation of our organization’s work on the ground, by ensuring that our vision and ideology are integrated into our work and by strengthening our team’s capacity to carry out our projects.

What has been the impact of COVID-19 on Burkina Faso’s health system?

Simon: Economically, socially and politically, COVID-19 has paralyzed the country. Socially, the measures taken to prevent the virus were contradictory to some African social norms because human contact is fundamental to our culture. Economically, quarantine complicated livelihoods. If people can’t go out to work and earn money every day, they won’t have an income. As a result of the quarantine measures, many households were exposed to hunger.

COVID-19 also highlighted the weakness of the technical capacity of health centers in the country, the limited capacity of hospitals and the inability to diagnose illnesses. In addition, a travel ban early in the pandemic prevented people from traveling even to receive care. These weaknesses in the system instilled a fear of being infected in health centers, which deterred some from seeking services. 

Right now, UHC is not well understood in the country. There’s a lot of work that needs to be done in order to mobilize people to insist on a higher level of quality care. In Africa, people aren’t very demanding when it comes to healthcare, but without strong pressure from the population, the system won’t change. People must first become aware of their rights and then increase and sustain pressure on decision-makers. Without these two factors, nothing will actually happen. Our job is to make people aware of their right to demand quality health services as well as to empower them to claim their health rights. It’s time to rebuild the whole system. It has been noted that there is a disconnect between the health system and everyday life. On a daily basis- at home, in the markets, and in the schools- the virus forced people to look holistically at the situation to understand that health is at the center of everything because it has paralyzed everything. COVID-19 has made people aware that health is a priority.

Health is at the center of everything because it has paralyzed everything. COVID-19 has made people aware that health is a priority.”

Civil society has always played a pivotal role in Burkina Faso. How was civil society mobilized in the co-creation and implementation of the COMVID COVID-19 movement?

Simon: Initially, the goal of the movement was to bring together different actors around shared values to support a social movement for UHC. When COVID-19 happened, we had to pivot our initial approach. Although addressing the virus was not our final objective, it has been a concrete step towards creating the movement for UHC through citizen engagement.

Co-created with the Health Democracy and Citizen Involvement Platform (DES-ICI), the COMVID COVID-19 movement (translated as “Communities are engaged in ending COVID-19”) immediately encouraged people to become engaged and own this movement. It’s important the movement reflects society, and society isn’t only composed of health workers; it’s composed of all the people who work in different sectors and play various roles. Community members are critical to this fight, and through their engagement, we built citizens’ health watch cells (CCVS) to ensure that people take responsibility for activities in their local community. The movement’s multi-sectoral approach ensures that everyone’s contribution is taken into account. Ultimately, collaboration is key to finding sustainable local solutions to our health challenges.

What have been the movement’s biggest challenges and successes?

Simon: The biggest challenges are maintaining the commitment of the volunteers and actors in the field. In the aftermath of COVID-19, we need to determine how to handle and improve health in general and to push the movement towards UHC. The poor management of COVID-19 in Burkina remains an obstacle. People think that those involved in the fight against COVID-19 are receiving money from the government. The issues surrounding communication of COVID-19 from influential people and the mismanagement of finances is a substantial concern.

In terms of important results of the movement, the fact that we were able to put in place 84 CCVS in Ouagadougou and Bobo Dioulasso with 1,260 representatives (at least 15 per CCVS) with limited resources is incredible and worth highlighting. So far, the CCVS have sensitized more than 47,231 people from remote areas in Ouagadougou and Bobo Dioulasso on protective measures against the virus and have mobilized financial and material resources to support vulnerable populations.

Radio and TV programs were also produced so that the information could reach and sensitize an even larger population.

It’s also critical to highlight how we gained legitimacy at different levels. We were selected by the Prime Minister to be a part of the Management Committee in charge of the COVID-19 crisis. At the regional level, we’re a member of the Regional Management Committee against COVID-19. Additionally, it has been helpful that RAME is in good standing at the national level, which has facilitated the mobilization of large national organizations like the permanent secretary of NGOs (SPONG) and the national council of CSOs (CNOSC) to participate in the movement. Fighting COVID-19 must happen at every level.

How does the movement hold all stakeholders involved accountable?

Simon: The movement is a community dynamic that’s leading activities at the local and national level. We work on the basis of transparency. At different levels of the movement, we ensure that there are independent actors so that no one group or individual is imposing their demands. For example, the secretariat worked with DES-ICI members to draft the terms of reference for the movement as well as the procedures for the creation of the CCVS. Although the secretariat is free to make decisions based on the movement’s goals and the CCVS have the autonomy to make decisions based on their community’s needs, the decisions are mutually shared.

Additionally, the CCVS mobilize resources at the local level and propose local solutions to the secretariat, who then mobilizes resources at the national level. The secretariat also supports with trainings and teaching technical skills that are needed to implement the movement’s activities (i.e. awareness raising techniques, precautions to take during outreach activities, etc.). By being transparent and letting all units have autonomy, we are feeding information to each other and everyone feels that they are a part of the solution.

What about decision-makers? How does the movement hold them accountable?

Simon: At the national level, the secretariat of COMVID COVID-19 uses media, social networks and direct communication with the Ministry of Health to analyze the country’s national COVID-19 response to ensure transparency of information and resources. In fact, the secretariat of COMVID COVID-19 and members of DES-ICI were the first to hold accountable the country’s national COVID-19 response plan which initially lacked CSO involvement. Additionally, the Réseau National de Lutte Anti-Corruption (REN-LAC), a member of the DES-ICI platform, is responsible for monitoring the resources mobilized by government institutions while the Centre d’Information, de Formation et d’Etudes sur le Budget (CIFOEB) conducts analyses to identify the economic impact of the crisis to guide national actions. Advocacy and accountability are methods through which the movement draws attention to decision-makers on the possible misuse of mobilized funds.

As a dynamic and growing CSO, your organization has a unique perspective that bridges the community with national actors while working at both levels. What key lessons can you share about how to be effective in such a position? How do you remain independent and represent community voices while also establish legitimacy at the national level?

Simon: RAME plays an integral intermediary role between communities and decision-makers. Our objective is to understand the needs of the population and to share those needs with decision-makers to influence policy. We also play a role in demystifying and translating health policies and scientific knowledge so that people can take ownership. Lessons learned include the need to emphasize one’s credibility. This ensures that people know that you share reliable data and that your messages are targeted, and that you won’t say disrespectful things about the authorities or the population. Respect of all parties must be gained because we are partners in the same fight for health. 

In terms of how we remain independent while representing the community, I think about it in terms of the lessons I’ve just shared. Despite our proximity to the authorities, we never forget our community base. We strive to remain accessible to the community and to the critics, while reporting to and informing the community of our activities. This is the only way to remain both independent and legitimate.

We also have an internal accountability mechanism with the Executive Board of RAME, who oversees our activities and holds us accountable to our mission. We must also be open to the opinions of our global community, to hear their feedback to further ensure our independence and legitimacy. For example, when we created this movement, a Facebook page was established to share the activities of the CCVS to allow people to comment and send us direct messages. We’ve also done interactive radio shows to share our activities and receive feedback to better implement our work and how we engage with the community.

What is the value add of the African Collaborative for Health Financing Solutions (ACS) project in the movement’s COVID-19 response?

Simon: The flexibility of ACS’ response allowed for quick adaptation to our activities, which is in contrast to many projects where implementation is specific and rigid. For this social movement, it is difficult to anticipate how things will develop and evolve, and one must always be ready to adapt to take advantage of an opportunity or adjust when there is a threat. This is the great value add of ACS.

Another added value is the ability to partner with the Burkina Faso-based research organization, Recherche pour la Santé et le Développement (RESADE), who is documenting and drawing lessons from our activities. Through RESADE’s partnership, it allows us to remain focused on our objectives as well as to share RAME’s contributions towards UHC in Burkina. RESADE released a report that assessed our progress, reflected on needed adjustments, and how to advance and capitalize on our activities. Our hope is for our activities to support other countries in implementing similar social movements. Finally, the level of regional exchange with other partners from outside of Burkina Faso that ACS has convened has allowed us to share and receive consistent feedback, which has been critical to improving the movement’s activities to meet its objectives and goals.

What steps has the social movement taken to pivot its activities toward UHC?

Simon: We have established a partnership with a network of socio-anthropologists to create a communications strategy to bring awareness of COVID-19 and health to the public. Because COVID-19 has impacted the social, economic, cultural and political spheres of Burkina, we want to formulate UHC messaging that incorporate these aspects, which will also be used to transition from COVID-19 to UHC.

The social movement for UHC will not necessarily be a formal movement, but rather more diffuse, more informal, and not necessarily led by RAME. It will be led by the adherence to a concept around UHC: everyone should take ownership of the concept and initiate it themselves. This means that a group of people should be able to come together in a neighborhood to demand better quality of care in their health center. Our role as an organization is to nourish and support the movement and to share accurate and targeted messaging to strengthen the capacity of people to organize and fight for their rights.

As part of the movement’s transition process, we recently organized a radio program on Radio Omega in French and Morré to raise public awareness on UHC and its implication for citizens. Additionally, an introductory UHC training, which included members from the DES-ICI platform and CCVS, as well as new actors and leaders from regions in Burkina Faso not yet implementing the social movement, was held in early November. The training was opened by country office representatives from the World Health Organization (WHO) as well as the Technical Secretariat of UHC from the World Bank, each of whom presented modules on UHC. The training also served as an opportunity to engage CSOs and empower them to take ownership of this movement.

As someone who has been a key ally and contributor to the ACS project from the beginning, can you talk about what you hope RAME’s partnership with ACS supports at a regional level in West Africa and beyond?

Simon: ACS is considered a strategic partner because of its participatory and co-construction approach. We feel that we are a stakeholder in ACS’s investment. ACS is not a funder who comes in with its own vision of what should be done in our country, but rather is a strategic partner who supports us in determining our path and walks alongside us on that journey. We also look to ACS for support at the regional level as RAME moves to extend its activities outside of Burkina and into the broader region. We recognize ACS as a partner who can amplify the voices of sub-Saharan communities at the international level to ensure that local realities in different communities are the driving force for any activity implemented in a country. ACS knows that there’s a more sustainable way to move development work forward, away from vertical programs and toward a reality where civil society, multi-lateral and bi-lateral organizations work side-by-side with the population.

What do you hope other countries learn and carry forward from the social movement for UHC?

Simon: There cannot be a real evolution of a health system towards UHC without feedback and listening to the voices of the population, and in turn, receiving a commitment from the population for UHC. If we only let those in charge set the priorities, there will always be conflicts, barriers and a lack of resources used as a reason not to fight for UHC. Countries must understand the necessity of their populations’ interest in health, in making demands for health and in raising health requirements. Without community voices for UHC, it will never be a priority for decision-makers.

Finally, it is imperative to find the right entry point to mobilize. For us, COVID-19 was our entry point, and although the virus has caused a catastrophic situation in Africa, we’ve turned it into an opportunity. We hope that this momentum will continue beyond COVID-19 to support our country’s movement towards UHC.

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About ACS
The African Collaborative for Health Financing Solutions (ACS) is a five-year, USAID-funded project that supports sub-Saharan African countries to advance their UHC agenda. Learn more on the ACS web page.