Violent clashes between demonstrators and security forces in Burundi sent tens of thousands of people fleeing both inside and beyond the borders of the central African state. These displacements were only one consequence of the crisis in the capital that stretched the capacity of an already-strapped health system: demonstrating a need for flexibility in resourcing in so-called challenging operating environments. “Health centers have been confronted with an increase in demand for drugs and treatment, without being prepared for it,” said Ferdinand Niyonzima, deputy head of the health promotion program for Caritas Burundi: a principal recipient of Global Fund resources for malaria and a sub-recipient for HIV. “Others are taking refuge in the interior of the country, and the same problem is presenting itself in those health centers. Fortunately we have a small stock of ARVs and drugs for opportunistic infections. Once the situation calms down, we will re-stock.” The situation in Burundi illustrates the need for flexibility in Global Fund grants, in order that implementers are able to adapt rapidly in the case of crisis. A 2014 report from the Fund’s TERG (article here) provided a series of recommendations for flexibility in grantmaking to ensure that service providers – like Caritas Burundi – are able to respond to, rather than be compromised by, changes in the prevailing political environment in their countries of operation. Burundi’s crisis, though short, was a textbook example of how a system can be compromised in an instant by an acute shock. In the capital, health workers fearing violence stayed home rather than go to work, leaving facilities understaffed and patients deprived of access to their medications. In order to prevent a widescale problem, demonstrators and the health ministry collaborated to ensure that no harm would come to personnel trying to access hospitals and health facilities. When necessary, vehicles were made available to transport employees to and from home, said Thaddée Ndikumana, director of the national TB program (PNLT). In a report sent to the Global Fund, the national AIDS commission (CNLS) also said that efforts were being made to ensure continuity of service when conditions permitted, although staff were at times blocked at home in neighborhoods where demonstrations were being held. Some staff didn’t make it to work; others arrived late. Outreach and prevention activities that were planned for secondary schools and universities were postponed and work that was to have been done with local media partners was also delayed, since some of the media houses were shuttered, the CNLS report said. The crisis also had an impact on disbursement of Global Fund grant money. “We have been waiting since March for around $2 million, but when the crisis erupted, the Fund told us that a decision was made to limit the amount being disbursed to principal recipients,” said Ignace Bimenyimana. Several epidemiological studies that were to begin in April were also postponed, including a nationwide facility-level study of the effectiveness of anti-malarial drugs, as well as another demographic health survey (DHS) measuring key malaria indicators. “Study investigators have had difficulties going to work, organizing planning meetings and preparing for field work. Some of our international partners have also repatriated their expatriate staff, which also complicates things,” said Bimenyimana. Fortunately, however, there were no stock-outs of the drugs used to contain the epidemics, and the health system, despite delays and staff shortages, continued to function. Noted Ndikumana of the TB program, only three of the 45 health districts in Burundi are in the capital. The supply chain to other parts of the country, too, continued to function. While one route out of the capital towards the south normally passes through the troubled Musaga neighborhood, which remains a flashpoint for confrontation between demonstrators and police, it was possible to avoid the area and continue trucking medicine elsewhere in the small country. Stock orders continued without noticeable interruption; 75 of the 90 facilities that were to make orders in May for HIV-related commodities were able to do so, the CNLS report said, and all deliveries were made on time. Burundi remains locked in poltiical crisis – and the continued lack of dialogue has evoked concerns. Niyonzima said that all of the Burundi PRs are warning of the same potential consequences: “if the situation persists, the health system will be affected – especially if the crisis reaches the interior provinces,” he said. “This will have consequences on access to health, and medical stocks.”