INTEGRATION DU PEV AUX SOINS DE SANTE PRIMAIRES: L'EXEMPLE DU BENIN ET DE LA GUINEE

Since 1986, two West African countries have been delivering immunizations within the framework of reorganized peripheral health systems. This revitalization is based on strategies which are implemented by an increasing number of African countries under the name 'Bamako Initiative'. It aims at providing universal access to a minimum package of maternal and child health priority interventions starting with immunizations, pre and perinatal care, oral rehydratation for diarrhoea, treatment of malaria and acute lower respiratory infections. Within this package, immunization has been given high priority. Several strategies aimed at improving immunization coverage have been implemented: services have been reorganized so that any child or woman making contact with the health system receives immunization if needed. Health information systems have been revised so as to allow for active individual follow up and better management of health centre resources. Health staff have been given training in management and a biannual monitoring/microplanning process at health centre level has been introduced. The goal of monitoring is to enable health personnel to identify the obstacles to attaining optimum coverages with the priority interventions and to select locally appropriate corrective strategies. Health centres have also been provided with a motorcycle allowing for regular outreach activities. To cover the running costs of the services (mainly restocking of drugs, running and maintenance of the cold chain and the motorbike, and staff incentives), financial contribution from local communities have been sought through a fee-for-treatment system. Prices have been set at an affordable level by limiting the number of drugs to a minimal list purchased under generic names by international tendering procedures. Standardized flow charts for diagnosis and treatment have helped to decrease further the cost of treatment. A major element in the sustainability of the system is active community participation, through management committees, in the decision-making process for choice of strategies and management of financial and other resources. Around 60% of health centres in Benin and 80% in Guinea are currently operating these strategies. Immunization coverages have been steadily increasing in both countries reaching, for DTP3 in 1993, 75% in Benin and 63% in Guinea. There are among the best performances in Africa. Although some issues remain to be addressed such as quality of the services, continuing underutilization of services, depreciation of local currencies, these two countries seem to have succeeded in creating solid foundations for a revitalized and viable peripheral health system. Using this approach, the attainment of the EPI mid-decade goals and end-of-the century world summit goals seem feasible.