Background
Large-scale mobilization of the international community has helped improve immunization coverage and reduce vaccine-preventable mortality [
1]. Progress has been rapid and tangible [
2], particularly in sub-Saharan Africa, where national programs have greatly benefited from measures to reinforce the capacity for intervention [
3]. However, inequities to access remain significant, large pockets of low vaccination coverage persist, and coverage varies considerably across regions [
4], districts [
3], and health facilities' catchment areas [
5]. In Burkina Faso, the most recent national survey of vaccination coverage showed a 41 percentage point disparity (31%-72%) between health regions with the lowest and highest complete vaccine coverage rates and a 35 percentage point disparity (58%-93%) for diphtheria, tetanus, polio and pertussis vaccine (DTPP3). Heterogeneity is also found at the district level, where coverage can vary considerably among and even within districts. There were gaps of more than 50 percentage points between the extremes of the districts in Burkina Faso and an average gap of 28 percentage points between districts within regions.
This paper focuses on district-level factors that can explain these disparities. Thus far, much less attention has been paid to district-level factors than to "micro-level" factors that might determine the propensity to have children vaccinated, either in relation to the demand side (characteristics of families, mothers and children [
6]), or the supply side (characteristics of services provided locally). For example, studies in Africa, southeast Asia, and South America [
7‐
15] have shown that immunization services' utilization is related to the acceptability, accessibility, quality, and affordability of the services provided by the health facilities and front line staff. Low vaccination coverage has been associated with lack of continuity in services (vaccine shortages, staff absenteeism, and irregularly held immunization sessions and outreach activities), poor accessibility (charges for vaccines or cards, excessive travel distance, long waiting time, and language barriers), unsuitable immunization sessions (insufficient numbers, inconvenient sessions, inappropriate schedules, and late arrival of personnel), and dissatisfaction with providers' attitudes (unfriendly behaviours, limited information transmitted to mothers, and lack of compassion/concern about the child's health).
Beyond these locally determined influences, we know little about why some districts perform better than others. Indirect evidence suggests district performance is directly related to the availability of resources required for regular supplies [
15], proper functioning of the cold chain [
16], and service continuity. One survey suggests that territories' vaccine coverage improves as the density of health facilities increases [
17]. High turnover of senior management staff [
18], restricted staff mobility [
13], poor inter-sectoral collaboration [
19], and faulty service organization were presumed to be related to non-performing districts. Health districts' vaccine coverage performance has also been associated with their reactions to events requiring mobilization of local capacities that could divert health workers from routine activities. These events include disease outbreaks and immunization days (IDs), about which contradictory effects have been reported [
5,
6,
13,
20,
21]. Finally, health personnel motivation and attitudes [
19,
22] and management leadership have been identified as factors affecting the sustainability and quality of health and immunization programs [
9,
13,
19,
22,
23].
Suspected managerial breakdowns in the districts are also a key focus of the Reaching Every District (RED) approach proposed by WHO to improve vaccine coverage in low-coverage areas. The RED approach targets five immunization functions: regular outreach services; supportive supervision; community links with service delivery; monitoring and use of data for action; and improved management capacities [
3,
24]. Others also recommend developing new strategies to improve the performance of vaccination activities [
25] and training all mid-level immunization program managers in supervisory techniques and management [
26].
Can performance gaps between districts and process inefficiencies at the district level be explained ultimately by outside contingencies, poor choice of intervention strategies, inappropriate organizational modalities, or suboptimal resource allocation? The answers are not clear and, to our knowledge, no systematic approaches have been undertaken to identify the determinants of these disparities. Most of the literature is based on fragmented and limited evidence and examines factors associated with vaccine coverage in only one district of a country.
This paper presents the results of a study exploring district-related factors that may account for variations in district vaccine coverage in Burkina Faso. Six districts with contrasting outcomes participated in this study. Discussions with decision makers allowed us to preselect a number of district-related factors seen as potentially influential. Based on the literature review, the research team then translated these factors into seven research hypotheses. The first four, which are focused on resources, were that,
all else being equal, immunization coverage should be higher or moving forward in districts where:
1.
donor-supported projects provide resources for routine vaccination activities;
2.
the creation of new health posts has improved service accessibility;
3.
health posts meet the staffing standards;
4.
there is no discontinuity in supplies, nor cold chain failures.
The remaining three hypotheses refer to circumstances that are management-focused:
5.
the management has introduced immunization strategies to complement the usual EPI-recommended activities;
6.
the team copes appropriately with events such as outbreaks and IDs that could disrupt routine activities;
7.
the District Medical Officer (DMO) demonstrates a high level of dynamism and commitment.
Discussion
Recent studies have advanced our understanding of system-related sources of disparities in coverage among countries, and of macro-level effects that are potentially attributable to human resources allocation [
17], vaccine prices [
6,
28], decentralization [
20], institutional performance [
6], or aid received, whether technical or financial [
2,
3,
28,
29]. Given health districts' growing autonomy, this study is an attempt to contribute, with earlier studies [
5,
6,
19], to better-developed factual bases to explain performance variations in vaccine coverage among districts of the same country, i.e., among territorial entities in comparable political, economic, and institutional environments. This process is all the more interesting because vaccine coverage is particularly sensitive to local health care systems' performance and constitutes a relevant marker of efficacy and good operation [
15].
Four of the hypotheses refer to the potential impact of resource allocation on vaccination services efficacy and vaccine coverage progression. First, the results of our study show no unequivocal relation between the presence of a project or of external partners and the performance of districts in terms of coverage. TFPs, whether external aid organizations or cooperation projects, are currently present in nearly all the districts. However, their number, the scope of their interventions, and the types of support they provide vary considerably. Several comparative studies have demonstrated the impact on vaccine coverage of countries' access to transnational initiatives or to various forms of development aid [
2,
3,
28,
29]. Second, vaccine coverage is sensitive to district logistics, and, in particular, the cold chain. This is not surprising, given the extent to which immunization activities are contingent upon the continuous availability of the vaccines. It confirms what has been largely demonstrated [
15,
16], including in Burkina Faso [
8]. Third, immunization coverage did not change much in districts where geographic access improved during the period of observation. As in most prevention services, there is evidence that vaccination demand is sensitive to the efforts consumers must expend to receive the services, and vaccine coverage is closely linked with geographic accessibility [
7,
9,
10,
30]. While this study does not allow us to draw clear conclusions, we nevertheless believe this should not call into question the necessity of maintaining, as a matter of common sense, strategies for developing primary health care resources in both heavily populated and relatively remote areas, as well as outreach programs to cover geographically dispersed populations. Fourth, the level of staffing in the districts' health facilities was not a key determinant of the districts' performance. The results of our study do not correspond with the expectations of decision makers and field staff, who, as mentioned, tend to consider that inadequate staffing levels are an important constraint on activities. They are also inconsistent with the results of a large comparative study [
17]. However, the results did not surprise the research team, for whom it is clear that the link between human resources availability and health system effectiveness in Burkina Faso is very tenuous at both the macro and micro levels [
31,
32].
Two hypotheses deal with the districts' ability to cope with destabilizing situations. Seasonal epidemics and IDs habitually mobilize an important part of the districts' resources and require considerable exertion, and it has been suggested they might negatively affect routine vaccination activities. On the whole, districts seemed to adapt well and were able to adjust their vaccination activities. The seasonal epidemics did not show a tangible impact. These results tally with those of the comparative analysis of 82 countries carried out by Gauri and Khaleghian [
6]. This conclusion must nevertheless be qualified because examination of the evolution of coverage at the national level shows that national performance in vaccination may be sensitive to country-wide epidemics. It may be that districts' coping capacity is limited and dependent on national directives and on the scale of the epidemics, such that they are able to adapt when faced with episodes of low or medium scale. Finally, while the study introduces factual data into the current controversy on the potentially negative impacts of IDs on routine activities, it does not resolve it. Contrary to what has been reported in India [
21] and Pakistan [
13], for example, neither IDs nor vaccination campaigns seem to have any measurable impact on the performance of routine vaccination services.
The core finding of our study is the primordial role of the DMO's leadership in strengthening vaccine coverage performance. Our starting hypothesis, according to which the DMO's dynamism and commitment could positively influence the overall performance of vaccination teams and services, is verified. We also found that a strong and committed leadership promotes effective mobilization of teams and creates the conditions for good district performance, even when these districts have only limited access to support from external partners.
In Burkina Faso, leadership skills are not a criterion for a DMO's appointment, nor are they fostered as a part of an institutionalized supervision of the DMO under the health region's responsibility. The choice of DMO is made at the central level without clear, standardized criteria. As a consequence, a newly appointed DMO might have little experience or technical knowledge of management, and may scarcely be interested in public health matters. Supervision and training that should be assured by the regional medical office is generally lacking. Our results suggest that leadership skills should receive more attention when a DMO appointment is considered, as well as throughout a DMO's mandate, through adequate support and supervision.
Some studies show that immunization services and, more generally, the performance of health districts are linked to the professional and ethical practices [
5,
19,
33,
34], commitment, efforts, and motivation of health personnel [
13,
19,
22]. Deficiencies in these qualities arise largely from poor managerial skills and inadequate leadership of the health districts [
35]. However, the role of the human factor in local health care system performance remains largely unexplored; it is virtually absent in the technical and administrative institutional discourse and is usually totally obscured by decision makers and development agencies [
35]. Preferred strategies such as the RED approach refer to them only indirectly, either in terms of improving governance [
3,
24] or strengthening the management capacities of mid-level managers [
26]. Even if things seem to be slowly progressing, the discourse around factors that determine the performance or breakdown of local health care systems in lower and middle income countries (LMICs) remains largely concentrated on technocratic and financial considerations, targeting institutional reforms, resource availability, or health services accessibility.
Initially, the study was not planned to be an in-depth analysis of DMO leadership and neither the specification of study variables nor the analysis could have been based on a leadership framework developed a priori. It is therefore difficult to ascertain precisely and measurably the leadership qualities of the different DMOs who served in the six districts during the period under consideration, and this is definitely a limitation of our study.
Empirically, from interviews with the field teams, the idea emerged that certain qualities of the DMO could play a key role in the performance of vaccination teams and services. These qualities are presented in Table
2. Given the limitations mentioned earlier, this list is provided for illustration purposes only, with no assumptions regarding its validity outside the context of this study. More in-depth studies are required to identify clearly the key elements of leadership in the context of managing district teams and to document the impacts, still not well understood, of the human factor on district performance.
Table 2
Elements of leadership that could affect the performance of vaccination teams and services.
Qualities most often mentioned by field staff during focus groups were: |
(1) Exercising authority:"leadership" authority, personality, charisma, ability "to keep on top of things" |
(2) Managing teams: taking care to transmit and share information, listening, holding regular meetings, motivating staff, encouraging staff participation in decision-making |
(3) Ability to create a good working environment |
(4) Professionalism, voluntarism: able to analyze situations; volunteering; able to innovate and look for new solutions; undertaking new approaches; responding well to unanticipated situations; able to have his decisions recognized at the central and regional levels |
(5) Diligence: being always present in the district |
(6) Transparency in the management of resources |
Because of the relatively exploratory character of our approach and its setting in the reality of Burkina Faso, one limitation of the study is the extent to which the results may be generalized. Also, the local context and the participative process led us to concentrate on a relatively limited number of exogenous and endogenous factors to explain differences observed in the degree and progression of coverage in only six districts. Large-scale studies might make it possible to explore further the different mechanisms of causality and the means by which external environments, the human factor, available resources, and institutional elements determine the efficiency and efficacy of district vaccination services.
Competing interests
The authors declare they have no competing interests.
Authors' contributions
SH and AB are the principal co-authors and contributed equally to this work. They took part in every phase of the study and, as principal investigators, are responsible for the scientific aspects of this article. All the authors were involved in the preparation of the research project, the analyses, and the drafting of the article. MK and ET were responsible for relations with decisions makers and stakeholders. MF supervised the data analysis and the formulation of results. GC contributed to the literature review and data analysis. PF provided scientific support throughout the project. All authors provided feedback on, and made revisions to the manuscript.