08 February 2010

Looking for Explanations

We hit rough weather thirty minutes out from Bujumbura. A jolt and I could suddenly feel the speed at which we were hurtling through the sky—was suddenly aware that there was nothing beneath us but miles of air.

The man sitting next to me, with whom I’d exchanged pleasantries before take off, saw me clutch my seat and gasp. He looked at me, and feeling his gaze I turned, biting my lip.

—Do you believe in God? he asked. His eyes were as still as the ocean floor.

I shot back instantly: Don’t ask me that, please! And then I turned my head towards the window so he wouldn’t see my tears.


I had just left the central African nation of Burundi where I spent a week at a global health conference. The theme was performance-based financing (PBF), a new(ish) idea for improving health in poor countries by, in the case of Burundi, awarding bonuses to health facilities that achieve certain results, such as increasing the number of children they immunize. This is in contrast to the traditional approach of paying for inputs such as equipment and medicine and hoping that better health will automatically follow. It hasn’t always done so. Despite decades of effort and billions of dollars (and some great successes), some health woes persist. Burundi’s maternal mortality rate, for example, continues to hover at about 1,100 per 100,000 live births—one of the highest maternal mortality rates in sub-Saharan Africa.

There are all sorts of ways to explain tragedies like this. PBF says that the reason so many are still sick and dying is that health systems are weak, and health workers underpaid, under-motivated and unaccountable. The answer is incentives: a modest bonus, along with scrutiny of their work, will enable/force health workers to act on the motivation they already have, or inspire motivation if it is lacking.

A small group of young, mostly European men presided over the PBF workshop. They are old friends mostly, who like to talk about their early days in the “trenches” working for Medicins Sans Frontiers in places like Cambodia. There is a lot of camaraderie among them, a lot of shared excitement about their work. None of them would say PBF is full-proof, a silver bullet, but they were confident (almost Certain), that these programs can and will work.

“Evangelists,” is what one observer called them. Just like the man who sat next to me on the plane, they have an answer.


Burundi is emerging from a 12-year, ethnic-based civil war. When Hutu president Cyprien Ntaryamira was killed in 1994 alongside the president of Rwanda when the plane they were travelling in was shot down, violence ensued. More than a half million were killed and many more fled to neighboring countries (including Tanzania, where I live). South Africa mediated peace talks and a power-sharing government was set up in 2001. Most of the rebel groups agreed to a ceasefire, and the country has enjoyed several years of relative calm.

But there is a ripple, just below the surface, of uncertainty, a sort of brace for what might happen. You can feel it in the torn up streets, sudden road blocks, the industrial wasteland feel of parts of the city.

Because it is a post-conflict environment, we had to travel with an armed United Nations security detail on our visit to a rural health clinic. The convoy—a small pick up truck packed with bored Burundian men carrying Kalashnikovs, and us following in a Landrover—felt intrusive, menacing on the simple dirt roads. Especially when we passed a procession of mourners carrying a coffin down a steep jungle hill. They pulled close to the edge of the ravine as we passed, including the somber old man who was leading them. He had a small wooden cross in his hand, raised up to the sky.


There are other wars too. One broke out just before the conference when one of the attendees, a long-time public health expert, decided not to come, citing, in an email sent to all his colleagues, philosophical objections to PBF. Financial incentives, he said, commercialize health care, induce cheating, and create distrust of and among health workers. And dissent is not welcome—the club of proponents are single-minded, arrogant, and rarely willing to admit the limits of their own theories.

There was a flurry of response. Recriminations, a hardening of views and marshalling of evidence. The cc’d list ballooned, and the Burundian Minister of Health even chimed in.

Then came an email with a decidedly different tone. The writer, a Bujumbura-based donor representative, began his note with the usual formalities, but then he summoned a quote from St. Augustine:

“Hope has two beautiful daughters, anger and bravery. The anger at such things and the bravery required for change.”

The author of the email then said that though he did not endorse the charged comments and personal attacks of the PBF dissenter, he admired his bravery, his willingness to speak up, and suggested that such anger could be constructive, if it is channeled toward more useful enterprises.

It was just a small word of calm, a small word of credit to a man who feels besieged, and it reminded me of another quote, this one from Shakespeare’s Richard III:

“O momentary grace of mortal men, which we more hunt for than the grace of God.”


Our wars are low-level—fought amidst the banality of power point presentations, cocktail parties, and networking lunches. But the stakes are high. Our lives might not be in danger, but our reputations are—the way we are viewed by our peers, which affects what conferences we get invited to, what panels we are asked to speak on, what journals we can write for. And through this, our professional success will be judged. And we will judge ourselves too: did what I committed to actually do any good? Did my career matter?

One morning I asked one of the “evangelists”: do you think criticism or doubt ever get drowned out at events like this? He was thoughtful: yes, he said, we should talk more about the limits of PBF, but "look, for years there was no progress, and now something is actually working…and I don't think we should let doubt get in the way of at least trying this. If someone has a better idea of what we should do, fine, but until then, we need to do this, we can’t wait."


I got to the conference hall early one morning. It was quiet out, cool. Some attendees were seated around a table watching a televised church service that was being projected on the wall. A choir was singing:

Hallelujah, Hallelujah, He is risen, He is risen

Some say belief in God is comfort for the suffering, order within the disorder, a port in the pitiless storm. Maybe that is part of what belief is about.

But if that’s all it is about then we are bound to be disappointed. And what I had really wanted to say to the man on the plane was that God, whatever that means, is not responsible for tragedy. Nor does the idea that our lives are guided, that everything is part of a Plan, make me more willing to swallow suffering and grief. Belief like that is bound to be sentimental and fragile.

And new gods like PBF can be fragile too (even war-inspiring). A community tired from years of inadequate solutions to massive problems is in danger of holding on too tightly, moving too quickly, and glossing over details that must be addressed carefully if these programs are going to really succeed.

Everyone knows this. No one needs to be told that caution and careful consideration are needed. Despite the confidence we often project, for most of us, there are moments of serious doubt. But there are moments when we really believe too, when, despite our real differences, a common hope is felt—that even though we may not be able to explain tragedy, there are things we can do to fight it.

That's why most of us got into this business in the first place: Because we want people to live. We want people who are poor not to be poor anymore, or sick. We want life to be more fair than it is.


  1. Nice post, very poetic, but I think you meant Richard III (Shakespeare never wrote a play about Henry III)

  2. Wonderful to hear from you. Amazing post, as usual.

  3. Nice blog Lindsay! It is a fact that those that are proponents of PBF have mostly practiced the art, and that those who are against, without exception, have never designed or managed such programs. Having said that..it is slightly discomforting to be called an evangelist, whilst we are only practitioners who have learned a new technique, fundamentally a health financing method with some specificities, and are trying to learn more from each other on how to do this better. The experienced public health specialist that you refer to in your blog...is an example of a person who has never designed such a program, and has never managed one either. A frustrated old colonialist, rigid in his convictions that he is right, he is the real evangelist out there, whilst we, the real practitioners, gather to learn from each other in an open fashion. Are we convinced that PBF works? Yes we are, and we are also convinced that it saves lives, and that the old dogma of input financing, by the 'inputists', does not work. PBF, if well designed and implemented, is more efficient, and more effective. The 'young Europeans' who have organized this workshop, for the African colleagues, to enable South-South collaboration, knowledge gathering and scientific debate, should be applauded for their efforts. The workshop was a tremendous success and South-South collaboration got a great jolt. The fundamental purpose of this workshop was to enable practitioners who work in far and destitute locations, such as South-Kivu, to engage with like-minded folks. The glass is more than half full. Keep on blogging!

  4. Dear Gyorsan,
    Before writing these kind of baloneys it is sometimes most suitable to think long and hard. The old frustrated colonialist as you call him has unfortunately completely redesigned the PBF program for the EC projet in Burundi and is the first who has analysed the weaknesses of the implementation, weaknesses that have been confirmed by external audit from then on. Fortunaltely, there is some good points in terms of implementation of the PBF component in the EC project and the public health expert is also the first to recognize that. Thus next time, I will recommand you to read first the Sun Zi's book : The Art of War (probably not the best choice in term of title ;-) ) and particularly the chapter 13 in order to be better inform before utter these kinds of comments that finally reinforce the evangelist vision that some people might have. Otherwise, I agree with you on the fact that "PBF, if well designed and implemented, is more efficient, and more effective" than Input approach but have to be also well supported by additional measures and reforms.

  5. Thanks to you both for your comments. Sounds like there's some agreement between you actually -- that PBF is a good approach on the one hand, but that it must be implemented carefully, on the other. I guess everybody knows this, including the conference attendees, who, during the Q&As, asked hard hitting questions that got to to the heart of the many potential pitfalls of PBF.

    I'm writing a story for the Bank on PBF in Burundi, and so when I interviewed people, you included Gyuri!, I think there was a tendency to talk it up a bit, which always happens because people involved want to shape the story, make it positive. Fair enough. I'd like to hear what you and others think when no one is around. Because this issue is a little like ralking about religion -- fraught with politics and our own egos, mine included!

    Anyway, I'm excited for the potentials, Gyuri, and excited to see people who've been in the business a while excited. Let's see what happens!

  6. You sound so diplomatic Lindsay ;-))!! Have you ever visited any medical scientific gathering, for whatever topic? I guess if you would have gone to a meeting of opthalmologists, in say Honolulu, and would have spoken to those present, that you would have observed quite the same as you did when talking to PBF practitioners, in Bujumbura! When you go to a PBF conference, we talk PBF. Keep blogging!

  7. Dear Lindsay, Pierre, Daniel, Gyuri and next visitors,

    Could we try to avoid caricaturing and offending each other? Could we recognise the value of others' contribution? Could we try to pull together in the same direction? Could we avoid unnecessary controversies, but focus on those which really matter? Could we also be a bit cautious when we take the pen? It would be a pity that a few 'flashes of wit' or nice written formulaes undermine the trust we have to build to overcome the next challenges.


  8. Hello Lindsay,

    Nice blog. Interesting to read what your perception of the workshop is.

    Evangelists? Not yet. I think we have a lot to learn from them : collective songs, miracles, and making the attendance pay ! Will you still come if we do that? ;-)

    Evangelists? Maybe. I would prefer motivation. I believe that people organizing health systems in LIC have a moral responsability to deliver more services with the resources that are available. And there is a lot of room for improvement. PBF contributes to that change. My motivation comes from that moral responsability.

    A colleague of mine, french consultant, ~60 years old, laugh at me about my involvement. "Ah Young people... Go ahead with your PBF, but don't hope it will make a difference". I always wonder why optimism is suspect in Africa, and why there are so many powerfull cynics around.