BRIEFING - July 2003
In the hot seat: the view from the health ministry
Last November in Dakar, Senegal, at the GAVI Partners' Meeting, health ministers expressed a desire to see a forum for exchange of experiences and information on immunization. Here, we begin by asking four health ministers to describe the key challenges and issues they currently face.
Anna M. Abdallah, Minister of Health, Tanzania
ANNA M. ABDALLA, MINISTER OF HEALTH, TANZANIA
"It all starts with political commitment. Even a poor man has priorities. We made a commitment to the people of our country at the time of independence that the government would prioritize fighting diseases. In Swahili we say, 'Kinga ni bora kuliko tiba', which means, prevention is better than a cure. That is why immunization is such an important part of our health programme.
We have found it is very easy to work with NGOs. In fact we are working very closely with private providers of health services -- especially mission hospitals and clinics. We have a programme in which we give `bed-grants' to help pay for personnel costs. We contract with not-for-profit organizations to provide essential services such as immunization.
We just launched a programme to combine immunization with malaria prevention. We bought one million insecticide treated nets and we give them to mothers when they bring their children in for their third dose of DTP. And we give them out when we do polio house-to-house campaigns for National Immunization Days.
When there have been negative rumours about immunization we have been able to turn around attitudes by working in districts to mobilize community leaders, including traditional healers, to spread the facts about immunization.
One challenge is that in some local governments they do not appreciate what primary health care is about. So we are looking to reform the system so that at the local level there is stronger commitment to primary health care.
LESLIE RAMSAMMY, MINISTER OF HEALTH, GUYANA
"The challenge of buying the vaccines themselves is now being met, through GAVI's assistance and our own increasing investment. What we need now is to develop the capacity to deliver them. Like many developing countries, this is currently our biggest challenge. We need to address several issues.
First, the cold chain. Electricity is not available for many of our hinterland communities. With the help of GAVI and the Pan American Health Organization, PAHO, Guyana has completed a survey of its cold chain. We are addressing the problems, but we will need help. Building a better cold chain has become a priority for us, along with the need for central refrigerated storage facilities.
A second issue is human resources. To have proper coverage, you need a well trained, and fairly large, staff. But we are training people and losing them to the rich countries. We must confront this. Our entry requirements for the health sector are very rigid, and we may have to change them. People in our communities may be able to participate in delivering healthcare even if it means breaking some well established rules. Some workers in an immunization programme need not be trained nurses.
A third issue is to convince parents of the benefits of immunization. We haven't done enough to show them the dangers of vaccine-preventable diseases. I am building community partnerships, producing magazines showing people what these diseases can look like, and working with doctors.
And finally, the government still needs to commit more money to immunization. Remember, GAVI's support covers only a part of our national programme. It's a cash-strapped country. We need to sensitise people at all political levels to the dangers of preventable diseases that can return at any time.''
MARIN KVATERN I K MINISTER, REPUBLIC OF SRPSKA MINISTRY OF HEALTH AND SOCIAL WELFARE, BOSNIA & HERZEGOVINA
"Right now the biggest challenge we face is the effects of the extensive health reforms we have been undergoing in Bosnia and Herzegovina (BiH). Currently, we have two ministries of health, one that serves the Republic of Srpska and another that serves the BiH Federation, and they have different organizational structures. As civil administration is reformed, these problems will diminish.
The first reform affected primary health care. Before the conflict in our country in the 1990s, under the public health insurance system, patients were allowed to go directly to specialists. Now they must first go to a `gatekeeper' -- a family medicine physician. Since this has affected the specialists' practices, some medical professional associations have opposed this, drawing resources away from serving the public to dealing with conflicts.
Now we are in the second phase of reforms -- modifying the health insurance fund, developing a master plan for hospital reform and reorganizing the ministry of health itself. We face classical management problems, such as managing consultants. After the conflict we had 150 agencies offering advice to the health ministry. Now we have 20 separate national coordinators for specific health issues -- immunization, TB, HIV, diabetes, cardiovascular, reproductive health, tobacco, and so on. We will be modifying this system so that coordinators are accountable and responsible for advising the ministry.
The good news is that we are on the right track to making the system run more smoothly."
Pagbajabyn Nymadawa, Minister of Health, Mongolia
©2003 The Vaccine Fund
PAGBAJABYN NYMADAWA, MINISTER OF HEALTH, MONGOLIA
"Reaching the unreached children in our country presents us with some tough physical challenges. First, Mongolia is very large, but sparsely populated. Its surface area is more than 1.5 million square km, (almost as big as France, Germany, Spain, Portugal, Belgium and the Netherlands combined) with a population of only about 2.5 million. This means on average that every square kilometre has about 1.5 people on it. The climate is also harsh. Much of the country is at high altitude and temperatures vary between 40° C and 25° C. But vaccines must still be given to babies at the right times, kept cool in summer and not frozen in winter. Our immunization services are relatively costly to run.
In fact, our immunization history is good. We eliminated smallpox in 1939, four decades before the world as a whole. We also have relatively high immunization coverage for the vaccines available under the Expanded Programme of Immunization, at 90%. We introduced hepatitis B vaccine back in 1991, despite economic difficulties, and in that time we have protected more than 300,000 children from contracting the disease.
We are a low-income country. We used to receive support from the former communist countries. After that era ended, we had two or three very difficult years when the vaccines didn't arrive. From 1995 to 2000, we had a lot of support from Japan, including all vaccines and some training. Mongolia's policy is to invest in preventive medicine, and we have been successful -- for example, during the diphtheria outbreak in the Russian Federation during the 1990s, we remained unaffected. We need more sophisticated hospitals, but instead we try to spend government money on disease prevention. We now have an immunization law which has articulated the government's responsibility to vaccinate all children. However, we need more resources to reach nomadic children and to switch to combination DTP+HepB vaccine. This would save us 150,000 unnecessary injections every year and the same number of visits to nomadic families. We have applied to GAVI and the Vaccine Fund for support for this project, but because our national coverage and performance is relatively good, we get less support than some countries with lower coverage rates. I think good performance should be rewarded.''
Interviews conducted by Lisa Jacobs and Phyllida Brown
Immunization Focus July 2003 - Contents