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Originally produced for UNICEF
“When vehicles broke down there were insufficient funds for repair or even to buy all the fuel we needed. The freezers were getting old and no longer worked so well. Worst of all, many health workers were becoming demoralized. They were paid so little that they could hardly support themselves and their families.” In Senegal, as in many other countries, the success of achieving major Immunization goals in the early 1990’s was followed by rapid decline as the system began to fail
Bernadette Ndiaye and Oumar Ba work in the Division of Disease Prevention. Bernadette is an animated, engaging woman who has spent more than 20 years working in various capacities with the Ministry of Health – one official called her Senegal’s “walking memory of immunization.” Oumar is responsible for health logistics. The two have worked together for years. “She knows everything about my job and I everything about hers,” said Oumar, with a laugh “we are interchangeable!”
Bernadette and Oumar plunged eagerly into the history of Senegal’s immunization service, which got a kick-start from the drive towards Universal Child Immunization (UCI). Launched by UNICEF and WHO in 1985, UCI set an ambitious goal of immunizing at least 80% of children under age one, in all countries by 1990 against the six diseases.
“It was a great period for us. A lot of enthusiasm and creativity went into immunization, “ said Bernadette. “For example, there was the “immunization adoption” project, which had support from UNICEF. School children in grades 3 and 4 ‘adopted’ newborn babies in their communities and tracked them through their immunization cycle. The children kept record books and used to go and tell the mothers when their infants were due for another visit to the clinic to get an immunization.
“We also worked with women’s groups because if you do not involve the women you cannot get anywhere. We talked with them first about measles because measles was a big killer in Senegal. People even thought of it as a kind of milestone in their child’s life because almost every child got the disease. We had a measles season twice a year – the main one was between February and April, just before the long rains.
“After we started immunizing against measles, people could see that those epidemics were not happening so often. Measles vaccine became very popular. It was the door that opened the way for all the other vaccines.”
Between 1985 and 1988, Senegal’s basic immunization rates rose from less than 20% to almost 60%, which was an outstanding achievement, but then progress slowed. In part this was due to the emphasis placed on increasing self-sufficiency as immunization became part of routine health services provided by governments. From 1996, through the Vaccine Independence Initiative, Senegal began paying for its own vaccines (although UNICEF continued to act as the shipping agent.) Important advances were being made, yet there were still difficulties in ensuring that immunization services worked well, and reached all children.
Oumar Ba picked up the story. “After 1990 there were fewer funds for immunization. The adoption project that we ran in the schools gradually faded away because there were insufficient funds for the record books the children kept, or for training and motivating the teachers. When vehicles broke down there were insufficient funds for repair or even to buy all the fuel we needed. The freezers were getting old and no longer worked so well. Worst of all, many health workers were becoming demoralized. They were paid so little that they could hardly support themselves and their families.”
Things came to a head in 1996 when the health workers called a data strike. They still came to work and served their communities, but they didn’t send in any information about what they were doing or about the health conditions of the people. The strike lasted for five years, and as months slipped into years, many health workers did not just withhold data; they stopped recording health information.
“We had little information about the distribution and need for vaccines in different parts of the country,” says Oumar, “and so the vaccine supply became irregular. Health posts sometimes ran out of vaccine. Mothers who may have walked for miles to bring their children for immunization, sometimes had to return home without being able to give their children the protection they needed.”
There seemed to be an increase in the incidence of some vaccine preventable diseases, but the data strike made it difficult to tell what was happening on the ground.
In 2001, an agreement was reached with the health workers and the strike came to an end. The health service was restructured, and a stronger emphasis was placed on prevention. Senegal’s Minister for Health, Awa Marie (Johana) Coll-Seck, pointed out, “We have renamed ourselves the Ministry of Health and Prevention. Of course health services are always about prevention but we are giving it stronger emphasis. It is as important as our curative role.”
In this climate, immunization rose higher on the national agenda, and one of the first priorities was to end the frequent vaccine shortages.
In November 2000, Dr Pap Cumba Faye had become the manager of immunization services. Faye had more than a decade of experience working in remote areas of Senegal – he knew what it took to reach the hardest to reach communities – but, as he says, “I was less informed about how to manage the national vaccine supply!” He gladly accepted an invitation from UNICEF to join a team from Senegal to go for a week’s training in Copenhagen at the agency’s Supply Division.
“It was an eye-opening experience for us,” Faye says now. “That week in Copenhagen changed our ideas about so many things. I hope our immunization service will one day have that same level of efficiency.”
Asked what he learned in Copenhagen, Faye says the most important lessons were that to protect the vaccine supply Senegal needed reliable forecasts of the amount of vaccine needed and the ability to place firm orders and guarantee advance payments. “It sounds simple but it was a challenge in a country like this.”
“We looked for solutions across the board,” says UNICEF Senegal Representative Ian Hopwood. “While helping to solve problems of the timely ordering and payment for vaccines, we also helped to strengthen the cold chain by replacing refrigeration equipment, and providing motorbikes for some key hard-to-reach districts. We helped to train health workers in injection safety, in community mobilization and monitoring. We worked with many partners in these efforts – with WHO, USAID, with the African Development Bank and JICA (Japanese Aid) among others – but as always it was the commitment of the Ministry of Health and Prevention and the health workers on the ground who made the difference.”
The results: “In 2001, we did not run out of vaccines in any of the ten regions!” says Faye.
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