Implementation: How Great Expectations in Washington Are Dashed in Oakland; Or Why It's Amazing That Federal Programs Work at All . By Jeffrey L. Pressman and Aaron B. Wildavsky. (Berkeley: University of California Press, 1973. Pp. xviii, 182. $7.50.)

Editor – I am moved by Professor Allan's elegy to bygone NHS virtues of ‘calm caring and gentle pace of clinical life… and all the time in the world to deliver compassionate care' ( Clin Med October 2009 p 407). One's immediate instinct would be to say ‘Ah, but times have changed' – only

Quality of care.

Introduction WHO recommends that all children receive one dose of bacille Calmette-Guerin vaccine (BCG), three doses of diphtheria--tetanus-pertussis vaccine (DTP), three doses of either oral polio vaccine (OPV) or inactivated polio vaccine (IPV), three doses of hepatitis B vaccine, and one dose of a measles virus-containing vaccine (MVCV), either anti-measles alone or in combination with other antigens (1-9) It also recommends three doses of vaccine against infection with Haemophilus influenzae type b (Hib) (10) To boost immunity at older ages, additional immunizations are recommended for healthcare workers, travellers, high-risk groups and people in areas where the risk of specific vaccine-preventable diseases is high (11) Immunization coverage levels and trends are used (i) to monitor the performance of immunization services locally, nationally and internationally; (ii) to guide strategies for the eradication, elimination and control of vaccine-preventable diseases; (12-14) (iii) to identify areas of immunization systems that may require additional resources and focused attention; (15,16) and (iv) to assess the need to introduce new vaccines into national and local immunization systems (17) Models of vaccine-preventable disease burden frequently include immunization coverage levels among their components (18-20) Coverage levels for measles vaccine and DTP are indicators of health system performance frequently considered by funding agencies when reviewing applications for financial and technical support (21-24) Measles immunization coverage is one of the indicators for tracking progress towards Millennium Development Goal 4, to reduce child mortality (25) Furthermore, trends in immunization coverage are used to establish the link between immunization service delivery and disease occurrence and to provide a framework for setting future coverage goals (26) Trends in immunization coverage While some countries had routine immunization systems in place before 1980, major national and international development of routine, universal infant immunization systems did not begin until the late 1970s In fact, it was not until the 1980s that dramatic improvements in immunization coverage were achieved, along with an increase in coverage with the third dose of DTP vaccine (DTP3) from 20% in 1980 to 75% coverage in 1990 While some countries reported significant declines in coverage after 1990, global coverage levels remained fairly constant and began rising slowly but steadily in 2000, until DTP3 coverage worldwide had reached 81% in 2006 In 1980, fewer than 10% of the world's children lived in 20 of the 167 countries with DTP3 coverage levels greater than 80%; 84% of the world's children lived in countries where coverage was less than 50% By 1990, 108 countries (43% of all children) had DTP3 coverage levels greater than 80%, and fewer than 10% of children lived in countries with under 50% coverage Although national coverage levels can "mask" sub-national geographical or sociological pockets where coverage is much lower, in 2006, 57% of children lived in countries with greater than 80% DTP3 coverage Still, that year approximately 263 million children who reached their first birthday did not receive DTP3, but 162 million (62%) of them lived in China, India, Indonesia or Nigeria At the time this report was prepared, there remained seven countries where fewer than half of the children were vaccinated with three doses of DTP3: Angola, Central African Republic, Chad, Equatorial Guinea, Gabon, Niger and Somalia" WHO and UNICEF publish annual estimates of national immunization coverage; (27-30) such estimates have been available by country since 1980 at http://wwwwhoint/immunization_monitoring/en/globalsummary/ wucoveragecountrylistcfm and http://wwwchildinfoorg/immunization_countryreportshtml Additional analyses can be found at http://wwwwhoint/immunization_monitoring/data/en/and http://www …

WHO and UNICEF Estimates of National Infant Immunization Coverage: Methods and processes/Estimations Par l'OMS et l'UNICEF Des Couvertures Vaccinales Des Nourrissons Par Pays : Methodes et procedures/Estimaciones De la OMS Y El UNICEF Sobre la Cobertura Nacional De Vacunacion De Los Lactantes: Metodos Y Procedimientos

To do or not to do.

In Africa, user fees constitute a financial barrier to access to health services. Increasingly, international aid agencies are supporting countries that abolish such fees. However, African decision-makers want to know if eliminating payment for services is effective and how it can be implemented. For this reason, given the increase in experiences and the repeated requests from decision-makers for current knowledge on this subject, we surveyed the literature. Using the scoping study method, 20 studies were selected and analysed. This survey shows that abolition of user fees had generally positive effects on the utilization of services, but at the same time, it highlights the importance of implementation processes and our considerable lack of knowledge on the matter at this time. We draw lessons from these experiences and suggest avenues for future research.

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A scoping review of the literature on the abolition of user fees in health care services in Africa

INTRODUCTION: To reduce financial barriers to health care services presented by user fees Burkina Faso adopted a policy to subsidize deliveries and emergency obstetric care for the period 2006-2015. Deliveries and caesarean sections are subsidized at 80%; women must pay the remainder. The worst-off are fully exempted. METHODS The aim of this article is to document this policys entire process using a health policy analytical framework. Qualitative data are drawn from individual interviews (n = 113 persons) and focus groups conducted with 344 persons in central government three rural districts and one urban district. Quantitative data are taken from the national health information system in eight districts. RESULTS The policy was initiated in all districts concurrently before all the technical instruments were ready. The subsidy is paid by the national budget (US$60 million including US$10 million for the worst-off). Information activities implementation and evaluation support have been minimal because of insufficient funding. Health workers and lay people have not always had the same information such that the policy has not been uniformly applied. Coping strategies have been noted among health workers and the population but there has been no attempt to impede the policys implementation. At the time of the study fixed-rate reimbursement for delivery (output-based) and overestimation of input costs were financially advantageous to health workers (bonuses) and management committees (hoarding). Very few of the worst-off have been exempted from payment because selection processes and criteria have not yet been defined and most health workers are unaware of this possibility. The upward trend in assisted deliveries since 2004 continued after the policys introduction. CONCLUSIONS This ambitious policy expresses a strong political commitment but has not been adequately supported by international partners. Despite relatively tight administrative controls health workers have figured out how to take advantage of the system. Some of the policys instruments should be reviewed and clarified to improve its effectiveness.

The national subsidy for deliveries and emergency obstetric care in Burkina Faso.

Background:To contend with the risk of exclusion created by user fees, those implementing the Bamako Initiative (BI) were asked to organise exemption schemes for the indigent. But those exemption schemes were never put in place in Africa due to difficulties identifying the indigent. An action research was implemented to test the hypothesis that a community-based process for selecting beneficiaries of user-fee exemptions in an African environment of BI organisation is feasible. Methods:This study was carried out in 10 primary health centres (CSPS) in Burkina Faso. Village selection committees (VSC) made lists of those worst-off, and the lists were validated by village chiefs, mayors, and health committees (COGES). A process evaluation was implemented using documentation analysis, accounting calculation, focus groups and in-depth interviews. Results:The 124 VSCs selected 566 persons. The 10 COGESs retained 269 persons (48%), ie 2.81 per 1000 inhabitants. Except for one CSPS, the annual profits from the user fee schemes could support on average six times more indigents than the mean number selected by the VSCs. Conclusions:In the rural African context, villagers are capable of selecting those who should be exempted from user fees according to their own perspective. Thanks to the BI, health centres have a certain financial capacity to take care of the indigent. In a community-based targeting approach using endogenous resources generated from BI profits, local perceptions of the health centres’ financial viability, coupled with the hierarchical social context, led to a very restrictive selection of candidates for exemption.

https://jech.bmj.com/content/jech/64/01/10.full.pdf

A community-based targeting approach to exempt the worst-off from user fees in Burkina Faso

Seasonal malaria chemoprevention (SMC) for children < 5 is a strategy that is gaining popularity in West African countries. Although its efficacy to reduce malaria incidence has been demonstrated in trials, the effects of SMC implemented in routine program conditions, outside of experimental contexts, are unknown. In 2014 and 2015, a survey was conducted in 1,311 households located in Kaya District (Burkina Faso) where SMC had been recently introduced. All children < 72 months were tested for malaria and anemia. A pre-post study with control group was designed to measure SMC impact during high transmission season. A difference-in-differences approach was coupled in the analysis with propensity score weighting to control for observable and time-invariant nonobservable confounding factors. SMC reduced the parasitemia point and period prevalence by 3.3 and 24% points, respectively; this translated into protective effects of 51% and 62%. SMC also reduced the likelihood of having moderate to severe anemia by 32%, and history of recent fever by 46%. Self-reported coverage for children at the first cycle was 83%. The SMC program was successfully added to a package of interventions already in place. To our knowledge, with prevalence < 10% during the peak of the transmission season, this is the first time that malaria can be reported as hypo-endemic in a sub-Sahelian setting in Burkina Faso. SMC has great potential, and along with other interventions, it could contribute to approaching the threshold where elimination strategies will be envisioned in Burkina Faso.

Impact Evaluation of Seasonal Malaria Chemoprevention under Routine Program Implementation: A Quasi-Experimental Study in Burkina Faso.

User fees were generalized in Burkina Faso in the 1990 s. At the time of their implementation, it was envisioned that measures would be instituted to exempt the poor from paying these fees. However, in practice, the identification of indigents is ineffective, and so they do not have access to care. Thus, a community-based process for selecting indigents for user fees exemption was tested in a district. In each of the 124 villages in the catchment areas of ten health centres, village committees proposed lists of indigents that were then validated by the health centres' management committees. The objective of this study is to evaluate the effectiveness of this community-based selection. An indigent-selection process is judged effective if it minimizes inclusion biases and exclusion biases. The study compares the levels of poverty and of vulnerability of indigents selected by the management committees (n = 184) with: 1) indigents selected in the villages but not retained by these committees (n = 48); ii) indigents selected by the health centre nurses (n = 82); and iii) a sample of the rural population (n = 5,900). The households in which the three groups of indigents lived appeared to be more vulnerable and poorer than the reference rural households. Indigents selected by the management committees and the nurses were very comparable in terms of levels of vulnerability, but the former were more vulnerable socially. The majority of indigents proposed by the village committees who lived in extremely poor households were retained by the management committees. Only 0.36% of the population living below the poverty threshold and less than 1% of the extremely poor population were selected. The community-based process minimized inclusion biases, as the people selected were poorer and more vulnerable than the rest of the population. However, there were significant exclusion biases; the selection was very restrictive because the exemption had to be endogenously funded.

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Abel Bicaba

Papers

The national subsidy for deliveries and emergency obstetric care in Burkina Faso.

A community-based targeting approach to exempt the worst-off from user fees in Burkina Faso

Impact Evaluation of Seasonal Malaria Chemoprevention under Routine Program Implementation: A Quasi-Experimental Study in Burkina Faso.

Low coverage but few inclusion errors in Burkina Faso: a community-based targeting approach to exempt the indigent from user fees.

Removing user fees in the health sector in low-income countries: a multi-country review