[Inclusion of hepatitis B vaccination in the Expanded Program of Immunization: feasibility study in the medical region of Kolda (Senegal)]. / Inclusion de la vaccination contre l'hépatite B dans le programme élargi de vaccination: étude de faisabilité dans la région médicale de Kolda (Sénégal).

Hepatitis B is highly endemic in Senegal. The prevalence of hepatitis B antigens in the population was estimated to be 10 to 12% in 1982. According to the WHO recommendations, a hepatitis B vaccination program (HBV) was launched in 10 medical centers in the Kolda medical region to assess the feasibility of including HBV in the EPI. The epidemiological impact of HBV was also investigated by comparison of the vaccinated zone (VZ) to a control non vaccinated zone (NVZ). HBV coverage had a pattern similar to that of DPT-IPV, but at a lower level: the overall coverage with HBV was only 37.5%, and the drop out rate for HBV1-3 was only 34.4%. In addition, the coverage of the under one year age group was insufficient: 45% for HBV3 as compared to 78% for DPT3 (p < 0.0001). Routine vaccination records in the medical centers in the VZ were consistent with the findings of cluster surveys. Hepatitis B markers were less prevalent among vaccinated that non vaccinated children (8 versus 18.5%, p < 0.001). HB antigenemia was significantly less frequent in the VZ than the NVZ (3.9 versus 10.9, p < 0.0001), and the difference was even larger for all hepatitis markers (7.4 versus 23.7%, p < 0.0001). This study therefore suggests that the inclusion of HBV in the EPI should be continued and strengthened in less accessible regions by an adapted social mobilization program. HBV could then be extended to the whole medical district of Kolda in association with regular epidemiological and serological surveillance.

[Evaluation of the financial participation of the users of 102 health services in 3 districts of Senegal]. / Evaluation de la participation financière des usagers dans 102 postes de santé de trois districts au Sénégal.

Primary Health Care (PHC) financing is today one of the major concern of public health system managers in developing countries. Their governments never allocated appropriate and sufficient resources to the sector of PHC. The external donors' funds are mostly allocated to short term PHC projects. They stop with the end of the projects. The undesirable consequences of that situation are well known. They are mainly related to a persistence of high rate of mortality and morbidity due to preventable diseases. To better address that situation the health ministers of the WHO african region adopted in September 1987 in Mali the Bamako alternative, to the country economical situation, for PHC services financing. It permitted to finance up to 80% of the recurrent costs of health system of Pikine department in 1980. In the three pilot districts where the Bamako initiative strategy has been tested: Podor, Matam and Bignona, all of the one hundred and two (102) health posts are self financed for their recurrent costs, since 1992.

Primary health care: from aspiration to achievement.

A review is presented of Senegal's response to the Bamako Initiative, aimed at strengthening primary health care. The experience gained is of broad interest since the basic principles involved are the same everywhere. Of particular importance are users' financial contributions and improved organization and management.

PIP: The 1987 Bamako Initiative tries to rectify the major gaps and inadequacies in implementing primary health care (PHC). In Senegal, people living near health units elect health committees which collect and manage health facilities and their income. Each patient contributes some money each time he/she uses a health service. The proportion of funding allocated to priority health care activities is very inadequate. Problems of public health services in Senegal range from chronic shortages of essential drugs to the people having lost faith and having abandoned public health services. Medical personnel in the public sector question the PHC strategy. So Senegal has developed a medium-term plan for social and health development for each health district and medical region. It has also redefined district and regional level management structures and their roles and responsibilities. Private pharmacies sell most of the 3000 medicines authorized to treat infectious diseases, deficiency diseases, and congenital diseases. They sell the more expensive brand name drugs. They controlled the sale of 13-14,000 million CFA francs worth of drugs out of the 15,000 million CFA francs worth of drugs sold in Senegal in 1991. An expert committee on essential drugs of the Ministry of Public Health and Social Action's Human Resources Development Project has revised essential drug lists to include generic names. It has distributed different lists to health huts, health posts, health centers, and regional hospitals. Another committee has determined the initial amount of money needed for essential drugs for each level of the health system. It has identified various sources of funding with Switzerland contributing enough money to cover drugs for health posts and health centers. Senegal has reorganized the supply and distribution system by decentralizing the National Supply Pharmacy. New management tools are registers of incomes and outgoings, stock cards, inventory cards, order books, and receipt books. Private pharmacists objected to full implementation of the Initiative. Physicians also resisted it.