Without strong political commitment, immunisation programmes often fail to live up to early expectations.
This has, however, not been the story in Burkina Faso. Free access to immunisation was introduced by President Thomas Sankara in 1987, and continues to this day. "The President’s commitment," explains Professor Nicolas Meda, Burkina Faso’s Minister of Health, "is tangible in the fact that healthcare for children under five and for pregnant women has been free since 2015, and in that the 2018 budget will be 5 billion CFA francs [US$ 8.9 million], compared to scarcely 2 billion in 2015.” The Minister of Health intends to continue to increase this budget allocation year-on-year.
Capitalising on this high-level support for child health, Burkina Faso’s health sector is harnessing immunisation programmes as a platform for other interventions. "Vaccination is a great gateway to healthcare!" says Delphine Sandwidi, the nurse in charge of the Expanded Programme on Immunization (EPI) at the Dassasgho Centre for health and social advancement (Centre de santé et de promotion sociale, or CSPS) in Ougadougou, Burkina Faso. Sandwidi, who has been working at the CSPS for 23 years, speaks enthusiastically about the broader impact that vaccination has had in terms of improving access to healthcare.
Vaccination clinics provide health workers with the ideal opportunity to identify children, parents and caregivers who are in need of other health services. "Every day, during weighing and measuring, I take advantage of children's visits to refer them to other services if necessary – especially those suffering from malnutrition," Sandwidi explains.
For many pregnant women, vaccination clinics are their first interaction with health services. When an expectant mother brings her older children to be vaccinated, nurses and doctors can make use of this point of contact to provide advice, medical examinations and any necessary vaccinations, and to encourage her to come back for follow-up visits. "If they like the welcome they get at the health centre, they will feel confident about coming back," says Sandwidi.
Discussions prior to vaccination sessions also provide an opportunity to inform parents about health issues beyond immunisation. In Burkina Faso, where nearly half of all medical consultations and a quarter of hospital admissions in 2017 were due to malaria, pre-vaccination discussion sessions can be a means of disseminating information on ways to prevent this devastating disease.
EPI: a platform for health
While the EPI is by its very nature focused on providing vaccination, it does not operate in isolation. It requires some level of health infrastructure to be in place if it is to be effective and efficient, including a supply system that can transport vaccines from central stores to the most remote villages and trained healthcare staff who can deliver those vaccines. This system can be, and in virtually all countries is, used as a platform to deliver other primary healthcare services.
The EPI is well established in Burkina Faso. Says Dr Anne Vincent, UNICEF's representative in the country: "By building on the EPI’s maturity, we can achieve success in other parts of the health system. The EPI is instrumental in establishing and strengthening the health system, and it allows other programmes to be bolted onto it."
The integration of the EPI and the broader health system is particularly evident in rural parts of the country. Here, community nurses or midwives are typically in charge of all aspects of healthcare. "We really encourage health workers to take advantage of every contact opportunity in order to provide maximum health care and to take a holistic view of the child," explains Dr Alimata Jeanne Diarra-Nama, WHO’s representative in Burkina Faso. "We incorporate activities that have proved to be worthwhile, such as vitamin A supplementation, seasonal chemoprophylaxis and other essential interventions. It has to become part of the culture."
This approach is not restricted to health centres, but is also very much part of the ethos of many small community-based organisations. In Tanghin-Dassouri, a rural area some 50 kilometres outside of Ouagadougou, the nurse in charge of the EPI, Albert Sekoué, works closely with ALAVI, an AIDS association founded in 1995. In addition to their core programmes, which are focused on increasing access to healthcare among the most vulnerable, ALAVI organises awareness sessions on HIV, malaria and immunisation with the help of its community-based health workers.
Pooling resources to reduce duplication
Abdoul Karim Ouedraogo is the coordinator of the Programme d'Appui au Développement Sanitaire (PADS), an organisation responsible for ensuring a coherent allocation of international funds to the health sector. According to Ouedraogo, in 2017 the Global Fund to fight AIDS, Tuberculosis and Malaria financed the operation of 263 CBOs and paid part of the salaries of 17,688 community-based health workers.
The work of these community-based organisations and health workers is by no means restricted to the three diseases covered by the Global Fund. For example, one organisation is helping to identify and register all children who do not yet have a vaccination booklet.
In the same way, EPI motorbikes, which are financed by Gavi to facilitate immunisation outreach, are being used for a range of other interventions. In isolated rural health clinics, which need to cover large geographical areas, it is important to be mobile enough to reach people who themselves have no means of transportation.
This pooling of resources is unanimously welcomed. As Abdoul Karim Ouedraogo points out: "It optimises the management of funds provided by our international partners."
For Dr Issa Ouedraogo, Director of Vaccination Prevention, pooling assets has benefits in terms of greater equity in the allocation of resources. “The duplication we used to come up against is avoided, and it has had an immediate impact in the field. More people are benefiting, access to health facilities is easier and the quality of healthcare has improved."
Increasing levels of interagency collaboration is also delivering benefits at the administrative level. The newly-established strategic EPI management exchange committee, chaired by Burkina Faso’s Minister of Health, brings together a wider group of partners with a diverse skillset.
Says Jean Nouboussi, country portfolio manager for Burkina Faso at the Global Fund: “We have always planned things together with Gavi to avoid duplication of resources, but our collaboration now goes much further. We work closely together to coordinate support, field missions and capacity building.”
Joining hands to modernise the supply chain
Cross-agency collaboration has led to a new initiative to replace old electric fridges with modern, solar-powered ones – an investment that will benefit the wider health system. "For us, the switch to solar energy is a no-brainer," explains Abdou Diallo, nursing officer in charge of the Tanghin Dassouri Medical Centre. "It will lead to greatly improved preservation of vaccines, for one thing, and it will also benefit our entire structure. Although the initial investment is substantial, the savings we will make over the long term are beyond doubt."
Diallo’s view is shared by the Minister of Health, who stresses that while Burkina Faso has 90% vaccination coverage, it does not yet have 90% vaccine effectiveness. "We have a cold-chain problem, which we are working with Gavi to solve by replacing the whole system.” UNICEF is highly involved in the project, providing technical support and procurement assistance thanks to its expertise in cold chain equipment.
Meanwhile, collaboration with the Global Fund is at the heart of a project which uses digital tablets to collect data on childhood diseases and immunisation. Ahawo Komi M. Alain, Gavi’s senior country manager for Burkina Faso, describes how the initiative was conceived: “Last February I visited a health centre in Ouahigouya together with my counterpart at the Global Fund to watch a demo of mHealth tool being used to collect data on childhood illness. It targets the same age bracket as immunisation. As we watched, we had the idea that the same tool should be used to collect vaccination data.”
This collaboration is fundamental to Burkina Faso’s efforts to strengthen its health system. As Diallo points out, the benefits are immediate: "Thanks to vaccination and a more efficient health system, children no longer miss school and parents can maintain their level of income. Together we are fighting poverty."