When information is not power: Community-elected health facility committees and health facility performance indicators

Health Facility Committees (HFCs) made of elected community members are often presented as key for improving the delivery of services in primary health-care facilities. They are expected to help Health Facility (HF) staff make decisions that best serve the interests of the population. More recently, Performance-Based Financing (PBF) advocates have also put the HFC at the core of health reform, expecting it to hold HF staff into account for the HF performances and development. In Burundi, a country where PBF is implemented nationwide, a randomised control trial was implemented in 251 health facilities where the HFC had been largely inactive in recent years. A random sample of 168 HFCs was trained on their roles and rights, with a subset also given information about the performance of their HF (using PBF indicators) and the PBF approach in general. The interventions, taking place in 2011-2013, made the HFCs better organised but largely failed to generate any effect on HF management and service delivery. Nested qualitative analysis reveals important tensions between nurses and HFC members that often prevent further change at the HF. In the HFs that received both the training and information interventions, this tension appeared exacerbated: the turnover of chief nurses was significantly higher as the HFCs exerted pressure to remove them. This situation was more likely to happen if the HFC had already received training before the interventions, thereby suggesting that repeated training empowers committees. Overall, the results provide rare rigorous evidence on HFCs, suggesting that more attention needs to be paid to the socio-economic and cultural contexts in which they operate. They also invite to caution when discussing the role of HFCs as a possible watchdog in PBF schemes.