[Impact of a targeted technical assistance to improve vaccine coverage in Cameroon, Côte d'Ivoire, and Mauritania in 2014]. / Effets d'une assistance technique ciblée pour l'amélioration de la couverture vaccinale au Cameroun, en Côte d'Ivoire et en Mauritanie en 2014.

Within the framework of its strategic goal of vaccine coverage (VC) improvement, GAVI, The Vaccine Alliance has entrusted the Agence de médecine préventive (agency for preventive medicine, AMP) with technical assistance services to Cameroon, Cote d'Ivoire (Ivory Coast), and Mauritania. This support was provided to selected priority districts (PDs) with the worst Penta3 coverage performances. In 2014, PDs benefited from technical and management capacities in vaccinology strengthening for district medical officers, supportive supervisions and technical assistance in health logistics, data management and quality. We analyzed the effects of the AMP technical assistance on the improvement of the cumulative Penta3 coverage, which is the key performance indicator of the expanded programme on immunization (EPI) performance. We compared Penta3 coverage between PDs and other non-priority districts (NPDs), Penta3 coverage evolution within each PD, and the distribution of PDs and NPDs according to Penta3 coverage category between January and December 2014. Technical assistance had a positive effect on the EPI performance. Indeed Penta3 coverage progression was higher in PDs than in NPDs throughout the period. Besides, between January and December 2014, the Penta3 VC increased in 70%, 100% and 86% of DPs in Cameroon, Côte d'Ivoire and Mauritania, respectively. Furthermore, the increase in the number of PDs with a Penta3 coverage over 80% was higher in DPs than in NPDs: 20% versus 8% for Cameroon, 58% versus 29% for Côte d'Ivoire and 17% versus 8% for Mauritania. Despite positive and encouraging results, this technical assistance service can be improved and efforts are needed to ensure that all health districts have a VC above 80% for all EPI vaccines. The current challenge is for African countries to mobilize resources for maintaining the knowledge and benefits and scaling such interventions in the public health area.

Affordability, cost-effectiveness and efficiency of primary health care: the Bamako Initiative experience in Benin and Guinea.

Since 1986 two West African countries, Benin and Guinea, have been actively reorganizing their peripheral health systems according to strategies subsequently called the "Bamako Initiative". Two preceding articles described the strategies implemented and the increased effectiveness of primary health care (PHC) witnessed over a period of six years. This article presents an analysis of cost and coverage data from biannual monitoring sessions between 1988 and 1993 in approximately 200 health centres in Benin and 214 in Guinea. In order to assess affordability, the total and per capita recurrent costs for operational health centres are analysed and then compared. The cost analysis reveals a mean total cost per health centre per year of slightly over US+11,000 in Benin and nearly US+9,000 in Guinea. The median cost per capita per year is approximately US+1.0 in Benin and between US+0.60 and US+0.80 in Guinea. Comparisons of these costs between regions, health centres and over time (as coverage levels evolved) show very little variation in either country. Cost-effectiveness is estimated by allocating these costs to immunization, antenatal and curative care and comparing them to the coverage achieved with these interventions. First, the cost-effectiveness of the Bamako Initiative (BI) system as a whole is analysed. The cost per fully vaccinated child is calculated at US+10.9 in Benin and US+8.8 in Guinea. The cost per woman receiving at least three antenatal visits is US+7 in Benin and US+4.7 in Guinea. For curative care, cost per full treatment is US+1.6 in Benin and half this amount in Guinea. Cost-effectiveness is variable between regions, health centres reveals that these differences in cost-effectiveness are mainly caused by the coverage levels achieved, since total costs are relatively stable. Finally the efficiency of drug management and prescriptions as well as of outreach for the expanded programme of immunizations (EPI) is estimated by relating specific drug and outreach activities costs to the number of beneficiaries. The average cost of drugs per treatment is around US+0.5 in Benin and around US+0.3 in Guinea. Cost analysis of outreach activities undertaken for EPI in Guinea revealed a similar average cost per child completely vaccinated for health centres with different intensities of outreach (approximately US+10) and an additional cost per child vaccinated attributable to outreach of US+1-2.

Local cost sharing in Bamako Initiative systems in Benin and Guinea: assuring the financial viability of primary health care.

The fourth in a series of five, this article presents and analyses data on cost recovery and community cost-sharing, two key aspects of the Bamako Initiative which have been implemented in Benin and Guinea since 1986. The data come from approximately 400 health centres and result from the six-monthly monitoring sessions conducted from 1989 to 1993. Community involvement in the financing of local operating costs in the two national scale programmes is also described. In Benin and Guinea, a user fee system generates the community financed revenue with the aim of covering local operating costs including drugs. Health worker salaries remain the responsibility of the government and donor funding covers vaccine and investment costs. Village health committees manage and control resources and revenue. The community is also involved in decision making, strategy definition and quality control. In Benin in 1993, community financing revenue amounted to about US$0.6 per capita per year and generally covered all local recurrent non salary costs except vaccines and left a surplus. Although total costs and revenues were slightly lower in Guinea for the same period, over-all user fee revenue (around US$0.3 per capita per year) covered local recurrent costs (not including salaries or vaccines). A comparison of costs and revenue between regions and individual health centres revealed important differences in cost recovery ratios. In Benin, some centres recovered more than twice the local costs targeted for community financing. Twenty-five per cent of centres in Guinea did not manage to cover their designated local recurrent costs. The longitudinal analysis showed that the level of cost recovery remained stable over time even as preventive care (and especially EPI) coverage rose significantly. To better understand the most important characteristics affecting cost recovery levels, best performing health centres in terms of cost-recovery levels in 1993 were compared to worst performing centres. This analysis showed that the size of the target population of the health centre is a key determinant of cost-recovery in both countries. In addition, in Guinea the utilization of curative care linked to geographical access and in Benin the average revenue per case linked to the number of deliveries proved to be additional factors of importance. In best performing centres, financial viability improved over time in both countries between 1990 and 1993. Finally, the implications of these conclusions for the planning of health centre revitalization in West Africa are discussed.

Health seeking behaviour and household health expenditures in Benin and Guinea: the equity implications of the Bamako Initiative.

Curative and preventive care utilization in Bamako Initiative health centres in Guinea and Benin increased significantly. Service based data and household survey results are compared and interpreted to evaluate the equity aspects of the Bamako Initiative programmes in these settings. Improvements in the use of preventive services are shared by the richer and poorer groups of the population. Inequities are more apparent regarding curative area. An important part of the population is not using Bamako Initiative Health Centres for financial reasons. However, the poor were found to use these Health Centres relatively more than richer socio-economic groups. Challenges of the future are identified and recommendations made as to how to tackle the problem of true indigence.

[The Bamako initiative: hope or illusion? Observations on the Benin experience]. / L'initiative de Bamako: espoir ou illusion? Réflexions autour de l'expérience béninoise.

In various countries in Africa, community financing has become the main source of finance for health services. In Benin, the "Bamako Initiative" experiment started in 1988 for many health structures and has subsequently been greatly expanded. After three years experience, the authors try to answer some important questions about community financing: To what extent does payment of fees have an influence on the use of health services? How are the funds collected and used and is embezzlement a serious problem? The question of equity is also considered as well as cost recovery, allowing an economics-based assessment of the Bamako Initiative which suggests that it has a promising future in Benin.

[Integration of the Expanded Program on Immunization into primary health care: examples of Benin and Guinea]. / Intégration du PEV aux soins de santé primaires: l'exemple du Bénin et de la Guinée.

Since 1986, two West African countries have been delivering immunizations within the framework of reorganized peripheral health systems. This revitalization is based on strategies which are implemented by an increasing number of African countries under the name "Bamako Initiative". It aims at providing universal access to a minimum package of maternal and child health priority interventions starting with immunizations, pre and perinatal care, oral rehydration for diarrhoea, treatment of malaria and acute lower respiratory infections. Within this package, immunization has been given high priority. Several strategies aimed at improving immunization coverage have been implemented: services have been reorganized so that any child or woman making contact with the health system receives immunization if needed. Health information systems have been revised so as to allow for active individual follow up and better management of health centre resources. Health staff have been given training in management and a biannual monitoring/microplanning process at health centre level has been introduced. The goal of monitoring is to enable health personnel to identify the obstacles to attaining optimum coverages with the priority interventions and to select locally appropriate corrective strategies. Health centres have also been provided with a motorcycle allowing for regular outreach activities. To cover the running costs of the services (mainly restocking of drugs, running and maintenance of the cold chain and the motorbike, and staff incentives), financial contribution from local communities have been sought through a fee-for-treatment system. Prices have been set at an affordable level by limiting the number of drugs to a minimal list purchased under generic names by international tendering procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

[Enlarged program of vaccination and community participation in Benin]. / Programme élargi de vaccination et participation communautaire au Bénin.

The lack of financial resources to make function health services and non implication of community in the management of the system is one of the major constraints to the improvement of health african populations. Within the EPI and to sustain its results, community financing has been implemented in order to focus on the resolution of the health problems of mother and child. The present analysis of the results of community financing in 166 health centers confirms the hope placed on this system which is one aspect of community participation. The cost recovery level of peripheral health services remains globally satisfactory. A better immunization coverage is noticed in the centers that benefit from this system compared to the others.

[Missed opportunities in vaccination. A survey in an urban milieu in Cotonou (Benin)]. / Occasions manquées de vaccination. Enquête en milieu urbain à Cotonou (Bénin).

The authors report the results of a survey on missed opportunities for immunization. The exit interview surveys were carried out at seven clinics in Cotonou (Bénin). Missed opportunities show a level from 15% among children and from 21% among attending women. The authors are insisting about the "daily immunization" for the whole country.