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1.  Monitoring the performance of the Expanded Program on Immunization: the case of Burkina Faso 
Background
The greatest challenge facing expanded programs on immunization in general, and in Burkina Faso in particular, lies in their capacity to achieve and sustain levels of immunization coverage that will ensure effective protection of children. This article aims to demonstrate that full immunization coverage of children, which is the primary indicator for monitoring national immunization programs, is sufficient neither to evaluate their performance adequately, nor to help identify the broad strategies that must be implemented to improve their performance. Other dimensions of performance, notably adherence to the vaccination schedule and the efficacy of the approaches used to reach all the children (targeting) must also be considered.
Methods
The study was carried out using data from surveys carried out in Burkina Faso: the 1993, 1998 and 2003 Demographic and Health Surveys and the 2003 national Survey of Immunization Coverage. Essentially, we described levels of immunization coverage and their trends according to the indicators considered. Performance differences are illustrated by amplitudes and maximum/minimum ratios.
Results
The health regions' performances vary according to whether they are evaluated on the basis of full immunization coverage or vaccination status of children who have not completed their vaccinations. The health regions encompass a variety of realities, and efforts of substantially different intensity would be required to reach all the target populations.
Conclusion
Decision-making can be improved by integrating a tripartite view of performance that includes full immunization coverage, adherence to the vaccination schedule (timely coverage), and the status of children who are not fully vaccinated. With such an approach, interventions can be better targeted. It provides information on the quality and timeliness of vaccination and identifies the efforts required to meet the objectives of full immunization coverage.
Abstract in French
See the full article online for a translation of this abstract in French.
doi:10.1186/1472-698X-9-S1-S12
PMCID: PMC3226231  PMID: 19828056
2.  System-level determinants of immunization coverage disparities among health districts in Burkina Faso: a multiple case study 
Background
Despite rapid and tangible progress in vaccine coverage and in premature mortality rates registered in sub-Saharan Africa, inequities to access remain firmly entrenched, large pockets of low vaccination coverage persist, and coverage often varies considerably across regions, districts, and health facilities' areas of responsibility. This paper focuses on system-related factors that can explain disparities in immunization coverage among districts in Burkina Faso.
Methods
A multiple-case study was conducted of six districts representative of different immunization trends and overall performance. A participative process that involved local experts and key actors led to a focus on key factors that could possibly determine the efficiency and efficacy of district vaccination services: occurrence of disease outbreaks and immunization days, overall district management performance, resources available for vaccination services, and institutional elements. The methodology, geared toward reconstructing the evolution of vaccine services performance from 2000 to 2006, is based on data from documents and from individual and group interviews in each of the six health districts. The process of interpreting results brought together the field personnel and the research team.
Results
The districts that perform best are those that assemble a set of favourable conditions. However, the leadership of the district medical officer (DMO) appears to be the main conduit and the rallying point for these conditions. Typically, strong leadership that is recognized by the field teams ensures smooth operation of the vaccination services, promotes the emergence of new initiatives and offers some protection against risks related to outbreaks of epidemics or supplementary activities that can hinder routine functioning. The same is true for the ability of nurse managers and their teams to cope with new situations (epidemics, shortages of certain stocks).
Conclusion
The discourse on factors that determine the performance or breakdown of local health care systems in lower and middle income countries remains largely concentrated on technocratic and financial considerations, targeting institutional reforms, availability of resources, or accessibility of health services. The leadership role of those responsible for the district, and more broadly, of those we label "the human factor", in the performance of local health care systems is mentioned only marginally. This study shows that strong and committed leadership promotes an effective mobilization of teams and creates the conditions for good performance in districts, even when they have only limited access to supports provided by external partners.
Abstract in French
See the full article online for a translation of this abstract in French.
doi:10.1186/1472-698X-9-S1-S15
PMCID: PMC3226234  PMID: 19828059

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