Implementing a Basic Package of Health Services in post-conflict Liberia: perceptions of key stakeholders.

Recovery of the health sector in post-conflict countries is increasingly initiated through a Basic Package of Health Services (BPHS) approach. The country government and partners, including international donors, typically contract international and local NGOs to deliver the BPHS. Evidence from routine data suggests that a BPHS approach results in rapid increases in service coverage, coordination, equity, and efficiency. However, studies also show progress may then slow down, the cause of which is not immediately obvious from routine data. Qualitative research can provide insight into possible barriers in the implementation process, particularly the role of health workers delivering the BPHS services. The aim of this study was to explore perceptions of health service providers and policy makers on the implementation of the BPHS in post-conflict Liberia, using SRH services as a tracer and Lipsky's work on "street-level bureaucrats" as a theoretical framework. In July-October 2010, 63 interviews were conducted with midwives, officers-in-charge, and supervisors in two counties of Liberia, and with policy makers in Monrovia. The findings suggest health workers had a limited understanding of the BPHS and associated it with low salaries, difficult working conditions, and limited support from policy makers. Health workers responded by sub-optimal delivery of certain services (such as facility-based deliveries), parallel private services, and leaving their posts. These responses risk distorting and undermining the BPHS implementation. There were also clear differences in the perspectives of health workers and policy makers on the BPHS implementation. The findings suggest the need for greater dialogue between policy makers and health workers to improve understanding of the BPHS and recognition of the working conditions in order to help achieve the potential benefits of the BPHS in Liberia

L’utilisation de l’approche CTC: quel impact sur la couverture vaccinale lors de la campagne préventive de vaccination contre la méningite A avec le MenAfriVac au Togo en 2014?

Introduction: Une campagne de vaccination contre la méningite A avec le vaccin MenAfriVac a été organisée dans les quatre régions septentrionales du Togo du 28 novembre au 07 décembre 2014. L'approche CTC a été utilisée pour la première fois à une grande échelle pour la campagne de vaccination dans dix districts sanitaires du Togo. L'objectif de cette étude était d'estimer la couverture vaccinale et, de déterminer l'effet de l'utilisation de la Chaîne à Température Contrôlée (CTC) sur ces couvertures vaccinales.Méthodes: L'enquête s'est déroulée du 9 au 14 mars 2015, soit environ 3 mois après la fin de la campagne de vaccination dans ces quatre régions. Le sondage en grappe à deux degrés stratifiés selon les régions a été utilisé. Dans 10 districts, le Togo a fait le choix d'utiliser le vaccin MenAfriVac en CTC.Résultats: Au total, 2707 ménages ont été enquêtés et 9082 personnes âgées de 1 à 29 ans ont été interviewées. L'âge moyen des personnes enquêtées était de 11,8±7,7 ans et le sex-ratio (H/F) de 1,01. Le nombre moyen de personnes par ménage était de 5,7 et celui des personnes de 1 à 29 ans ciblées par la campagne était de 3,4. Sur les 9082 personnes enquêtées, 8889 (98%) étaient vaccinées. En analyse multivariée, les facteurs associés à la couverture vaccinale avec le MenAfrivac étaient la résidence dans la zone au moment de la campagne (aOR = 4,52 ; 95%IC = [4.07 - 4.97]) et le fait d'être informé de la campagne avant son démarrage (aOR=2,42 ; 95%IC = [2.05 - 2.80]). Par contre, la couverture vaccinale n'était pas différente selon la zone ayant utilisé l'approche CTC ou non (aOR=0,09 ; 95%IC = [-0,27-0,45]). Deux cent sept personnes interrogées (2,3%) ont déclaré avoir eu une Manifestation Adverse Post Immunisation (MAPI) après l'administration du vaccin. Il s'agissait surtout de MAPI mineures à type de fièvre,  d'abcès et de gonflement au point d'injection.Conclusion: Les résultats de cette enquête montrent que l'utilisation de la CTC dans un pays à ressources limitées comme le Togo n'a pas eu un effet négatif sur les couvertures vaccinales. En effet, il n'y avait pas de différence entre la couverture vaccinale dans les zones CTC et celles non CTC. Il importe de capitaliser l'expérience acquise pour l'utilisation des vaccins du Programme Elargi de Vaccination avec l'approche CTC surtout dans les pays à ressources limitées confrontés à la disponibilité de la chaîne de froid.Mots clés: Meningitis A, MenAfriVac vaccine, CTC, immunization coverage, TogoEnglish Title: Impact of Controlled Temperature Chain (CTC) approach on immunization coverage achieved during the preventive vaccination campaign against meningitis A using MenAfriVac in Togo in 2014English AbstractBackground: a vaccination campaign against meningitis A using MenAfriVac vaccine was implemented in the four regions of northern Togo from 28 November to 7 December 2014. CTC approach was first used on a large scale in a vaccination campaign in ten health districts in Togo. This study aims to estimate the immunization coverage and to determine the effect of Controlled Temperature Chain (CTC) approach on these immunization coverages.Method: we conducted a survey from 9 to 14 March 2015 (for approximately 3 months) after the end of the vaccination campaign in these four regions. Interviewees were selected using two stages cluster sampling stratified according to the regions. MenAfriVac vaccine in Controlled Temperature Chain (CTC) was used in 10 districts, in Togo.Results: a total of 2707 households were surveyed and 9082 people aged 1-29 years were interviewed. The average age of the individuals surveyed was 11.8±7.7 years and sex-ratio (H/F) was 1.01. The average number of individuals per household was 5.7 and that of persons aged 1-29 years targeted in the campaign was 3.4. Out of 9082 people surveyed 8889 (98%) were vaccinated. Multivariate analysis showed that the factors associated with immunization coverage using MenAfrivac vaccine were: habitual residence in the area at the time of the campaign (AOR = 4.52; 95%CI = [4.07 - 4.97]) and level of information about the campaign before it starts (AOR=2.42; 95%CI = [2.05 - 2.80]). By contrast, there were no differences in vaccination coverage between the areas based on whether the CTC approach was used or not (AOR=0.09; 95%CI = [-0.27 - 0.45]). Two hundred and seven respondents (2.3%) reported that they had Adverse Event Following Immunisation (AEFI) after the administration of the vaccine. These were usually minor AEFI involving fever, abscesses and swelling at the injection site.Conclusion: survey results show that the use of CTC in a country with limited resources such as Togo doesn't have a negative impact on immunization coverage. Indeed, there was no difference between immunization coverage in CTC and non-CTC areas. It is important to capitalize on the experience gained in order to use vaccines by Expanded Program of Immunization in CTC approach especially in countries with limited resources in terms of cold chain availability.Keywords: Meningitis A, MenAfriVac vaccine, CTC, vaccine coverage, Tog

Countries’ interest in a hepatitis B vaccine licensed for the controlled temperature chain; survey results from African and Western Pacific regions

Chronic hepatitis B infection can be prevented by hepatitis B vaccine birth dose (hepB-BD) given within 24 h after birth, followed by two hepatitis B vaccinations within the first year of life. Yet nearly half of World Health Organization (WHO) Member States do not provide a hepB-BD. Barriers are primarily attributed to vaccine storage and transportation, as well as high rates of home births. Delivering the vaccine outside the cold chain could potentially increase coverage. To do this, WHO recommends vaccines be licensed for use in a “controlled temperature chain” (CTC), which requires a given product to tolerate temperature excursions up to at least 40 °C for a minimum of three days. To date, no hepB vaccine is labelled for CTC. To inform dialogue with manufacturers, WHO conducted a survey among countries in the African and Western Pacific Regions (AFR and WPR) to assess demand for a hepatitis B product licensed for use in a CTC. Twenty-five (44%) countries responded, with 8 of 11 (73%) from the WPR and 17 of 46 (37%) from the AFR. Of these responding countries, 5 in AFR and all 8 in WPR have introduced universal hepB-BD. Seventy-two percent indicated that CTC would facilitate the provision of hepB-BD. While no overall difference in responses was detected between countries either providing or not providing hepB-BD, countries that already introduced hepB-BD but had low hepB-BD coverage were particularly interested in CTC. Irrespective of hepB-BD policy, responding countries suggested that a CTC-licenced product would be beneficial, though the price of such a vaccine would influence procurement decisions. This survey was beneficial to inform the CTC agenda. However, countries' lack of experience with HepB-BD as well as with CTC and the fact that countries were commenting on a product that is not yet on the market should be acknowledged