External influences over Senegalese health financing policy: delaying universal health coverage?

Senegal has long sought solutions to achieve universal health coverage (UHC). However, in a context dependent on international aid, the country faces multiple external pressures to choose policy instruments. In this commentary, we propose an analysis of this influence. The empirical material comes from our involvement in analysing health reforms for 20 years and from many interviews and observations. While studies have shown that community-based health insurance (CBHI) was not an appropriate solution for UHC, some international actors have influenced their continued application. Another global partner proposed an alternative (professional and departmental CBHI), which was counteracted and delayed. These issues of powers and influences of international and national consultants, established in a neo-liberal approach to health, have lost at least a decade from UHC in Senegal. The alternative now appears to be acquired and is scaling up at the country level, witnessing a change in the current policy paradigm.

Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.

[Health Statistics in Senegal: between political stakes and role playing]. / Production des statistiques sanitaires au Sénégal : entre enjeux politiques et jeux d'acteurs.

INTRODUCTION: Many countries have developed disease surveillance systems to deal with epidemics, but although health information systems have existed for more than two decades, constraints and biases in data collection limit the relevance of policy decisions and strategies in the field of health, as priority has been given to education and health in developing countries. Donor support has led to the development of systems for the production of statistics, designed, among other things, to more clearly target interventions in terms of educational objectives, action and credibility and enable health systems to continue to benefit from external funding. METHODS: We used a classical anthropology approach based on observations and in-depth interviews with local and national health system actors. RESULTS: The aim of this article is to analyse the real effects of the production of health statistics in health care systems and to determine the relevance of these figures in the context in which they apply. DISCUSSIONS: Health priorities defined by international organizations and technical and financial partners focus on diseases considered to be ?priorities? to the detriment of neglected diseases, which are perceived as being more important at the local level due to their impact on the already limited health systems. We describe how health actors within healthcare structures adjust and adapt to public health requirements.

Acceptability and Feasibility of Delivering Pentavalent Vaccines in a Compact, Prefilled, Autodisable Device in Vietnam and Senegal.

BACKGROUND: Prefilled syringes are the standard in developed countries but logistic and financial barriers prevent their widespread use in developing countries. The current study evaluated use of a compact, prefilled, autodisable device (CPAD) to deliver pentavalent vaccine by field actors in Senegal and Vietnam. METHODS: We conducted a logistic, programmatic, and anthropological study that included a) interviews of immunization staff at different health system levels and parents attending immunization sessions; b) observation of immunization sessions including CPAD use on oranges; and c) document review. RESULTS: Respondents perceived that the CPAD would improve safety by being non-reusable and preventing needle and vaccine exposure during preparation. Preparation was considered simple and may reduce immunization time for staff and caretakers. CPAD impact on cold storage requirements depended on the current pentavalent vaccine being used; in both countries, CPAD would reduce the weight and volume of materials and safety boxes thereby potentially improving outreach strategies and waste disposal. CPAD also would reduce stock outages by bundling vaccine and syringes and reduce wastage by using a non-breakable plastic presentation. Respondents also cited potential challenges including ability to distinguish between CPAD and other pharmaceuticals delivered via a similar mechanism (such as contraceptives), safety, and concerns related to design and ease of administration (such as activation, ease of delivery, and needle diameter and length). CONCLUSIONS: Compared to current pentavalent vaccine presentations in Vietnam and Senegal, CPAD technology will address some of the main barriers to vaccination, such as supply chain issues and safety concerns among health workers and families. Most of the challenges we identified can be addressed with health worker training, minor design modifications, and health messaging targeting parents and communities. Potentially the largest remaining barrier is the marginal increase in pentavalent cost--if any--from CPAD use, which we did not assess in our study.

Effectiveness of a strategy to improve adherence to tuberculosis treatment in a resource-poor setting: a cluster randomized controlled trial.

CONTEXT: Poor adherence to treatment remains a major obstacle to efficient tuberculosis (TB) control in developing countries. Innovative strategies to improve access and adherence to treatment are needed. OBJECTIVES: To assess the effectiveness of a contextualized intervention strategy aimed at improving patients' adherence to treatment and to evaluate its impact on TB control in a resource-poor country in Africa with prevalent TB infection. DESIGN, SETTING, AND PATIENTS: A cluster randomized controlled trial, conducted between June 2003 and January 2005, at 16 government district health centers in Senegal. Patients older than 15 years with newly diagnosed sputum smear-positive pulmonary TB were randomly assigned to the intervention or control group. INTERVENTION: The intervention strategy included reinforced counseling through improved communication between health personnel and patients, decentralization of treatment, choice of directly observed therapy (DOT) supporter by the patient, and reinforcement of supervision activities. In the control group, the usual TB control program procedures remained unchanged. MAIN OUTCOME MEASURE: Proportion of patients successfully completing the 8-month course of treatment and the proportion of patients defaulting from treatment. RESULTS: A total of 1522 patients were recruited into the study. Treatment was successful for 682 (88%) of 778 patients recruited in the intervention group, and for 563 (76%) of 744 patients recruited in the control group (adjusted risk ratio [RR], 1.18; 95% confidence interval [CI], 1.03-1.34). The proportion of patients defaulting was reduced in the intervention group to 5.5% (n = 43) compared with 16.8% (n = 125) in the control group (adjusted RR, 0.43; 95% CI, 0.21-0.89). CONCLUSION: The intervention package based on improved patients counseling and communication, decentralization of treatment, patient choice of DOT supporter, and reinforcement of supervision activities led to improvement in patient outcomes compared with the usual TB control procedures. This approach may be generalized in the context of TB control programs in resource-poor countries. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00412009.