Title: The progression of Burundi and the United Nations Sustainable Development



Goal three, Target two

Safe health practices and providing accessible health care has been observed to producing a positive outcome in reducing morbidity and mortality rates in children globally. In many African countries the healthcare provision is poor due to the lack of resources such as finance, infrastructure and a qualified workforce (Rudasingwa, Soeters, & Basenya, 2017). Burundi is unlikely to reduce under-five mortality to at least as low as 25 per 1000 live births by 2030 because of the increased poverty, low access to clean food and water and recent civil conflicts.

Burundi, officially known as the Republic of Burundi, is a country in Central-East Africa. It shares its borders with Tanzania, Rwanda, the Democratic Republic of Congo, and Lake Tanganyika (Central Intelligence Agency, 2019). The current population is around 11.8 million, and are occupied by the ethnic groups; Hutu, Tutsi, Twa, Europeans and South Asians (Central Intelligence Agency, 2019). Children under-five contributed to 14% of the population (Zuniga et al., 2013). Increasing population growth, decline in land availability and poverty leaves Burundi at risk of food crisis and insecurity.

Over 90 percent of the population is working in agriculture related jobs, with 40 percent of the gross domestic product coming from agriculture (Central Intelligence Agency, 2019). Burundi is ranked 185 out of 189 countries in the 2018 Human Development Index scale, an index developed by the United Nations to measure a country’s overall achievement in its social and economic dimensions (United Nations Development Programme, 2018). The low development in health, education and income on the demonstrates that Burundi is unlikely to achieve the sustainable development goal by 2030.

Historical factors

Burundi was governed by an ethnic minority Tutsi monarchy before the colonisation of Germany in 1923 (Caprile, 2007). Burundi became independent in 1962, still preserving its monarchy under King Mwambutsu’s rule (Caprile, 2007). Burundi has faced a series of violent political crisis’s, involving numerous coups, rebellions, massacres and genocide after its independence. The Burundian civil war lasted from 1993 to 2005 and was a result of the conflict between ethnic divisions, which involved the ethnic groups, the Hutu and the Tutsi (Chi, Bulage, Urdal, & Sundby, 2015).

The civil conflict caused the Burundian population to seek refuge in neighbouring countries including Tanzania and the Democratic Republic of Congo. In 1999, an estimated of 470 000 Burundian refugees were estimated to be in Tanzania due to the civil war (Chi et al., 2015). Two million people were estimated to be internally displaced, with up to 90 percent relocating to internally displaced persons camps (Chi et al., 2015). By 2003, an estimated 281 000 people were living in internally displaced persons camps in Burundi and Northern Uganda (Chi et al., 2015).

The civil conflict greatly impacted Burundi’s economy, from 1994 the poverty rate was 48 percent and by 2006, it had increased to 67 percent (UNICEF, 2003). The conflict also contributed negatively to the health system, primarily due to limited access and poor quality of health services. Although certain parts of Burundi were not involved in the civil conflict, the existing state of insecurity prevent pregnant woman from seeking health services (Chi et al.).

The Burundian civil conflict caused the destruction of health facilities, looting of medical supplies and equipment, and targeted killing and abduction of health providers (Chi et al., 2015). Political instability and civil conflict influenced maternal, newborn and children health outcomes for Burundians (Moise, 2018). The civil conflict resulted in “increased maternal and newborn morbidity and mortality; high prevalence of HIV/AIDS and SGBV; high levels of prostitution, teenage pregnancy and clandestine abortion; and high levels of fertility” (Chi et al., 2015).

Cultural factors

The civil war between the major ethnic group Hutu and minor ethnic group Tutsi resulted in targeted killings of health providers based on their ethnic group. With the already limited access and poor quality of health services being provided during the conflict, health providers were also only providing service to patients based on their ethnic group (Chi et al., 2015).

Traditional birth attendants rose to prominence during the civil conflict as primary birth attendants due to the disruption of the health care system (Chi & Urdal, 2018). Traditional birth attendants assist women during their pregnancy, labour and birth and after childbirth. They are more common in developing countries and rural communities. With limited to no access to health facilities during the civil conflict, traditional birth attendants were provided training and basic supplies to assist in childbirth by non-governmental organisations and the Ministry of Health (Chi & Urdal, 2018).

After the civil war, the Burundian government provided free health care to pregnant women and children under-five nationwide. The government discouraged the use of traditional birth attendants and even prohibited them from attending deliveries (Chi & Urdal, 2018). Traditional birth attendants are now part of the health care in Burundi, they are appointed a new role as birth companions and promote maternal health to the community (Chi & Urdal, 2018).

Structural factors

The decrease in maternal mortality rate and children under-five in Burundi is due to the implementation of performance-based financing schemes from the Ministry of Health and the non-governmental organisations (Bonfrer, 2014). The Burundian government funds 52 percent of the performance-based financing scheme, with 28 percent by the World Bank and the remaining 20 percent from other donors (Bonfrer, 2014).

The performance-based financing scheme was piloted in 2006 in the three provinces of Bubanza, Cankuza and Gitega, and then subsequently implemented in 2010 nationwide (Rudasingwa et al., 2017). The performance-based financing scheme in a healthcare provision, is to improve the performance of healthcare providers with financial incentives to achieve targets based on performance measures of quantity and quality services (Bonfrer, 2014). During the pilot period of the performance-based financing scheme, the Burundian government provided free birth care, caesarean sections and care for children under-five nationwide (Zuniga et al., 2013).

The performance-based financing scheme resulted in an increased use of health facilities for maternal health issues, from 1.68 consultations in 2009 to 2.2 consultations in 2012 (World Health Organization, 2015). In the last two decades, the neonatal mortality rate has decreased from 38.9 deaths per 1000 live births in 1997 to 22.1 deaths per 1000 live births in 2017 (United Nations Inter-agency Group for Child Mortality Estimation [UNIGCME], n.d.). Infant mortality has also decreased by over half, from 103.8 deaths per 1000 live births in 1997 to 42.5 deaths per 1000 live births in 2017 (UNIGCME, n.d.). The under-five mortality rate has also seen a significant decrease from 171.60 deaths per 1000 live births in 1997 to 61.2 deaths per 1000 live births in 2017 (UNIGCME, n.d.).

Most of the population live in rural areas and only 13 percent of people live in urban areas (World Population Review, n.d.). Health centres is the preferred option in Burundi due to the lower costs and accessibility compared to hospitals. Most institutional deliveries will be assisted by nurses, with one nurse per 1,395 people compared to one physician per 18 355 people (Rudasingwa et al., 2017).

Critical factors

Contributing factors that resulted in the decrease of neonatal mortality, infant mortality and mortality of children under-five is due to the introduction of free health care and the performance-based financing scheme.

The three leading causes of death for children under-five in Burundi is pneumonia, diarrhea and preterm birth complications (Moise, 2018). The three causes of morbidity for children under-five were malaria, tuberculosis and diarrhea (Moise, 2018). Malaria was the leading cause of death in children under-five and accounted for more than half of the mortality rate. In the northern parts of Burundi, children were more likely to be exposed to malaria due to the higher elevation and the surrounding environment being of warmer and wetter (Moise, 2018).

Poor access to clean water, inadequate hygiene and basic sanitation are common causes of diarrhea related deaths in Burundi. An estimated 64 percent of Burundi’s population has access to clean drinking water and 32 percent has access to adequate sanitation (UNICEF, 2003). Many of the illnesses, diseases and causes for deaths of children under-five, were easily preventable and treatable. Access to basic sanitation for people in Africa has barely increased from 35 percent in 1990 to 40 percent in 2010 (Alemu, 2017). Due to inadequate food and malnutrition, lack of knowledge in infant feeding practices and poor household management of childhood diseases, it is reported in 2005, that an estimated 53 percent of children under-five suffered from stunting as a result (UNICEF, 2003).

To be able to see a higher reduction in the mortality of children under-five, it is recommended that the government should implement basic preventative measure such as introducing clean water and sanitation, adequate food and providing free education.

Although Burundi has decreased their children under-five mortality by over half in the last 20 years, it’s unlikely that they will achieve the sustainable development goal by 2030. The Burundian government has taken preventative actions to decrease the mortality rate of children under-five, by providing free health care to pregnant women and children under-five. The prolonged conflict in Burundi, has caused adverse effects on the current health system and due to the increasing population, poverty, food insecurity and inaccessibility to clean water, mortality of children under-five remains high.

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