This study shows that complete vaccination coverage of children increased significantly between 1998 and 2003 and disparities in coverage between districts diminished. The factors that continued to have the greatest impact on these coverage rates were poverty, with its various dimensions, and the utilization of healthcare services.
Increase in vaccination coverage
The significant increase in complete vaccination coverage seen in 2003 raises certain points for discussion:
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The addition of financial resources into the healthcare system has the effect of increasing vaccination coverage when it is low [5]. In fact, the authors showed that GAVI support helps to increase DTP3 coverage in countries where the rate of coverage is below 65% [30]. As can be seen in Table 3, between 1997 and 2001 new initiatives to support vaccination were implemented every year. It seems logical to consider the cumulative impact of these interventions, coming one after the other and leading to a significant increase in vaccination coverage. In fact, the positive impact on children of vaccination initiatives is widely recognized. The major difficulty is in sustaining them, as is illustrated by the statement of a person who had worked at all levels in the system (peripheral, regional and central): "The challenge continues to be in maintaining the level of vaccination coverage, because these initiatives come along, create an increase in vaccination coverage, and when they are gone, coverage falls back again."
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The decentralization of the healthcare system and of EPI management, which introduced changes in practice, could have improved both the technical and perceived quality of healthcare services [31]. In fact, an analysis of healthcare services utilization from 1986 to 1997 had indicated the need for in-depth reform of Burkina's healthcare system, particularly in the areas of human resources, funding policy and management (sectoral approach instead of the project approach, communication). The authors saw decentralization as an opportunity to improve the healthcare system [13]. Because the focus for some time was on the sectoral approach, with the revival of the Inter-agency Coordinating Committee and the implementation of decentralization by creating communes and involving the population in the management of health centres via management committees, we would expect to see an increase in the use of services, including vaccination services [see Table 3]. In fact, after an overall decrease in the rate of healthcare services utilization observed between 1984 and 1998 that led the authors [14] to conclude the reforms had failed, an increasing trend was observed from 1998 on, suggesting that the increase in the rate of child vaccination over the same period is not an isolated case.
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Measures were taken to ensure the safety of injections, thus reducing post-immunization reactions. One decision-maker at the central level observed: "The staff is well trained and qualified, and Burkina is one of the few countries where the cold chain meets WHO standards."
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There were nevertheless reservations expressed regarding improving the quality of services, particularly the perceived quality [32]. Assurances about the quality of training provided to vaccination workers are nuanced at the regional level. In fact, the districts plan training sessions for their new workers (coming out of school) to prepare them to carry out vaccination strategies. This is illustrated by the statements of a regional administrator in response to a question about the late arrival of various funds allocated to the health districts: "Yes, for example, this year there are districts that had planned training sessions for their new vaccinators. So, these workers will not be trained. They came out of school because this is not often offered in the school's courses. So they won't be trained."
Reduction in vaccination coverage disparities
Differences between health districts in relation to complete vaccination of children tended to lessen between 1998 and 2003. In fact, even though the healthcare system was decentralized after the creation of health districts in 1994 [33], with district management teams being given a certain amount of autonomy, the central authority at the Ministry of Health retained a major role in decision-making. Among the domains kept at that level were the supply of vaccines and consumables, funding, equipment for the cold chain and rolling stock, and, to a lesser extent, the regulation and distribution of development partners whenever possible, as was revealed by the various actors in the individual interviews. It must be noted that vaccination is funded within a normative framework, based on action plans developed by the health districts. The functioning of this regulatory framework for funding vaccination activities in health districts is recognized and accepted by all actors in the healthcare system (central, regional and district levels, NGOs). This is illustrated by the statements of various resource persons. One NGO representative explained: "At the beginning of the year, we inform the health districts and the regional health administrations which activities will be funded. This way, people know what activities to put into their action plans to get them funded." A manager at the district level spoke along the same lines: "Our action plan is based on a planning framework (directives) from the central authority. These directives tell us that this year, for vaccination, here's how much you can put in as activities that are in accordance with national policy. Then it is adopted by the board of the health district." He added that, "the funding agencies, through a concerted action framework, are already in agreement with the central authority, and when they come to the resource allocation session, there isn't much discussion."
This involvement of the central government has the benefit of making the districts comparable in terms of funding and supplies of material resources and, to a lesser extent, in terms of organization. On the other hand, decisions taken at the central government level, by means of the planning framework sent to the health districts and the specifications imposed by development partners regarding activities they are prepared to fund, leave little room for each district to resolve specific local problems, which will not be included in the health districts' action plans because they are not targeted by funding agencies. Over time, this situation can discourage actors at the operational level from developing any initiatives. For example, if there is a delay in receiving funding, actors in the field have no alternative but to adjust their action plans, even if they would be able to pre-finance the activity concerned, as is recounted by one actor at the regional level: "The Ministry of Health no longer allows pre-financing, which means the districts have to revise their action plans. This affects the morale of the workers and also, indirectly, vaccination, and especially its quality." Another case in point is the fight against meningitis; a person at the central level told: "It was recommended that the regions and health districts should be able to include, in their action plans, a certain number of activities related to fighting meningitis epidemics. These epidemics had become so frequent that they were listed as priority issues in all the districts. Unfortunately, this still hasn't been done, but we continue to ask for these activities to be included in the health districts' action plans so that they can benefit from some funding sessions." In fact, the resolution of problems that are specific to each district in general, and to the area of each CSPS in particular, is the responsibility of the health centres' management committees; as was said by a regional administrator, "the operational funding of vaccination is local." It seems reasonable to assume that the remaining differences between health districts could be explained, in part, by the community's involvement in these districts' health centres and by whether or not the management committee, which in principle reflects the community, functions well.
Poverty
Both in 1998 and in 2003, our results confirm that poverty and resource constraints are an impediment to complete vaccination of children in rural areas [34]. Independently of poverty, in 2003, we found a link between the number of children aged five and under in the household and the probability of being vaccinated. It may be that in five years the situation has become more worrisome [35], such that despite vaccination being free [20], households have become more careful about the use of family resources, which affects the priority given to children and increasingly takes into account the opportunity costs related to wait times, missed appointments, and absence from work in the fields and in the market. Continued poverty would motivate households to ration resources more carefully as the number of children grows [36].
Experience of healthcare services utilization
The experience of healthcare (maternity) services utilization by the mother appears to be the most stable and strongest explanatory factor for complete vaccination of children. Mothers' loyalty to vaccination services depends on the quality of that experience. In fact, it was this concept of loyalty that led to using the DTP3 rate to assess the performance of vaccination services and thus their capacity to retain their users [37].
Education
In this study, factors related to education did not appear to play a fundamental role in complete vaccination of children. In 1998, the community's level of education appeared to be an explanatory factor for complete vaccination in children, but this was no longer the case in 2003. Our observation differs from what has been reported in other contexts [38–42]. This reflects an increasing popularization of vaccination in a population that is becoming more organized into associations that deal with specific issues and, at the same time, become useful channels of communication. In addition, vaccination's benefits and positive effects are widely recognized. People attribute the drop in cases of measles and poliomyelitis to vaccination, and when they speak, for example, of poliomyelitis, they refer to cases of paralysis in the past, noting that these have become rare thanks to the drops that children receive. The following statements from resource persons illustrate this. According to a decision maker at the central level, "Before, when you entered many homes, you saw poliomyelitic children dragging along, and this was frequent. But the disabled persons we encounter today are of a certain age, they are no longer the very youngest ones; that has become the exception. Measles was very common. In our region, there was an adage that if your child had not yet had measles, he was not yours. It was even said that, if you hadn't had measles by the time you died, you would get it in your tomb--all to say, measles was inevitable. But we have seen that with vaccination, it is avoidable, and its impact in terms of morbidity and mortality has greatly diminished. All these observations have been made in recent years." An administrator at the regional level said, "I had both pertussis and measles, because I wasn't vaccinated. But today our children don't know what pertussis is, and measles has become sporadic." In such a context, it seems reasonable that a mother's ability to decide for herself to use curative medical services creates a favourable situation for vaccination, which, moreover, has been declared a free service [20].