Disease Eradication in the 21st Century: Implications for Global Health

17. The Impacts of Measles Elimination Activities on Immunization Services and Health Systems in Six Countries

17 The Impacts of Measles Elimination Activities on Immunization Services and Health Systems in Six Countries Piya Hanvoravongchai, Sandra Mounier-Jack, Valeria Oliveira Cruz, Dina Balabanova, Robin Biellik, Yayehyirad Kitaw, Tracey Koehlmoos, Sebastião Loureiro, Mitike Molla, Ha Trong Nguyen, Pierre Ongolo-Zogo, Umeda Sadykova, Harbandhu Sarma, Maria Gloria Teixeira, Jasim Uddin, Alya Dabbagh, and Ulla Kou Griffiths Abstract Measles is a prime candidate for global eradication. Explicit goals to control or eliminate the disease have already been agreed upon by many countries and regions. One of the key concerns in determining the appropriateness of establishing the measles eradication goal is its potential impact on routine immunization services and the overall health system. To evaluate the impact of accelerated measles elimination activities (AMEAs) on immunization services and health systems, a study was conducted in six countries: Bangladesh, Brazil, Cameroon, Ethiopia, Tajikistan, and Vietnam. Primary data were collected through key informant interviews and staff profiling surveys. Secondary data were obtained from policy documents, studies, and reports. Data analysis used mainly qualitative approaches. The study found that the impact of AMEAs varied, with positive and negative implications in specific immunization and health system functions. On balance, the impacts on immunization services were largely positive in all six countries, particularly in Bangladesh, Brazil, Tajikistan, and Vietnam; negative impacts were more significant in Cameroon and Ethiopia. Although weaker health systems may not be able to bene fit sufficiently from AMEAs, in more developed health systems, disruption to health service delivery is unlikely to occur. Nevertheless, in none of the six countries was there an explicit objective to use AMEAs to help remove health system bottlenecks and 236 P. Hanvoravongchai et al. strengthen system capacity. Opportunities to strengthen routine immunization services and the health system should be actively sought to address system’s bottlenecks so that benefits from the measles eradication activities as well as other health priorities can be optimized. Introduction Measles is the prime target as the next disease for a global eradication campaign . Its biological characteristics and effective intervention make it a feasible disease to eradicate at the current point in time (de Quadros et al. 2008). Considerable progress has already been achieved toward the global goal of a 90% reduction in measles mortality by 2010 (Dabbagh et al. 2009). In fact, five of the six WHO regions have already adopted a measles elimination target. Consequently, at the 2010 World Health Assembly, milestones toward measles eradication were endorsed (WHO 2010a). One of the key concerns in determining the appropriateness of measles eradication is its potential impact on routine immunization services and the overall health system. Experiences from previous eradication efforts have shown that eradication activities tend to be conducted using a vertical approach, due to their targeted and time-limited nature. The debate around vertical versus horizontal modes of delivery has long been part of the public health literature (Bradley 1998; Cairncross et al. 1997; Frenk 2006; Mills 1983; Walsh and Warren 1979). Whereas some authors take the view that a horizontal or more integrated approach is preferable, since it includes contributions from other sectors and is more sustainable (Rifkin and Walt 1986), others argue that a more selective or vertical approach is required in view of resource constraints (Walsh and Warren 1979). There are also questions on potential synergies between priority disease programs and the health systems, and how these disease programs can contribute to health systems strengthening. Although many reasons have contributed to the delays in achieving the eradication targets for guinea worm and poliomyelitis , one common factor is that residual transmissions take place in countries with extremely weak health systems (Wakabi 2009; Wassilak and Orenstein 2010). According to an independent evaluation of the polio eradication initiative , this program needs to contribute more systematically to immunization systems strengthening if interruption of the virus is to be accomplished in the remaining endemic countries (Mohamed et al. 2009; Global Polio Eradication Initiative 2010). With the substantial increase in the aid volume to combat diseases in developing countries, the debate on priority diseases and health systems has gained new momentum, and the term “diagonal” approach has been coined to argue that resources earmarked for a particular disease (e.g., HIV/AIDS) can serve to spearhead improvements in health systems (Atun et al. 2010; Ravishankar et al. 2009). Impacts of Measles Elimination Activities 237 Lessons from polio eradication activities can help us understand the potential impacts...