Perceptions of the usefulness of external support to immunization coverage in Guinea-Bissau: a Delphi analysis of the GAVI-Alliance cash-based support

INTRODUCTION: Although many countries have improved vaccination coverage in recent years, some, including Guinea-Bissau, failed to meet expected targets. This paper tries to understand the main barriers to better vaccination coverage in the context of the GAVI-Alliance (The Global Alliance for Vaccines and Immunisation) cash-based support provided to Guinea-Bissau. METHODS: The analysis is based on a document analysis and a three round Delphi study with a final consensus meeting. RESULTS: Consensus attributed about 25% of the failure to perform better to implementation problems; and about 10% to governance and also 10% to scarce resources. The qualitative analysis validates the importance of implementation issues and upgraded the relevance of the human resources crisis as an important drawback. The recommendations were balanced in their upstream-downstream focus but were blind to health information issues and logistical difficulties. CONCLUSIONS: It is commendable that such a fragile state, with all sorts of barriers, manages to sustain a slow steady growth of its vaccination coverage. Not reaching the targets set reflects the inappropriateness of those targets rather than a lack of commitment of the health workforce. In the unstable context of countries such as Guinea-Bissau, the predictability of the funds from global health initiatives like the GAVI-Alliance seem to make all the difference in achieving small consistent health gains even in the presence of other major bottlenecks.

Unaffordable or cost-effective?: introducing an emergency referral system in rural Niger.

OBJECTIVES: An important investment was made in two health districts in Niger to organize an emergency referral system. This study estimates its impact and cost-effectiveness in relation with external determinants. METHODS: After installing a solar radio network in the health centres, emergency calls and related data were monitored over 7 years and investment and recurrent costs for the system were estimated. RESULTS: The number of emergency calls increased significantly in both districts. In 2003, the total yearly cost for the district amounted to US dollars 14,147, the cost per useful and successful call was US dollars 49 and the cost per inhabitant and per year was about US dollars 0.06. CONCLUSION: The impressive and immediate impact on the health system, the relatively low recurrent cost and the minimal management requirements for the health service make the investment very worthwhile. Organizing emergency evacuation systems should be a priority for any health district in the world.

Pilfering for survival: how health workers use access to drugs as a coping strategy.

BACKGROUND: Coping strategies have, in some countries, become so prevalent that it has been widely assumed that the very notion of civil services ethos has completely - and possibly irreversibly - disappeared. This paper describes the importance and the nature of pilfering of drugs by health staff in Mozambique and Cape Verde, as perceived by health professionals from these countries. Their opinions provide pointers as to how to tackle these problems. METHODS: This study is based on a self-administered questionnaire addressed to a convenience sample of health workers in Mozambique and in Cape Verde. RESULTS: The study confirms that misuse of access to pharmaceuticals has become a key element in the coping strategies health personnel develop to deal with difficult living conditions. Different professional groups (mis)use their privileged access in different ways, but doctors diversify most. The study identifies the reasons given for misusing access to drugs, shows how the problem is perceived by the health workers, and discusses the implications for finding solutions to the problem.Our findings reflect, from the health workers themselves, a conflict between their self image of what it means to be an honest civil servant who wants to do a decent job, and the brute facts of life that make them betray that image. The manifest unease that this provokes is an important observation as such. CONCLUSION: Our findings suggest that, even in the difficult circumstances observed in many countries, behaviours that depart from traditional civil servant deontology have not been interiorised as a norm. This ambiguity indicates that interventions to mitigate the erosion of proper conduct would be welcome. The time to act is now, before small-scale individual coping grows into large-scale, well-organized crime.