Global health strategies versus local primary health care priorities--a case study of national immunisation days in Southern Africa.

Building on the successful eradication of smallpox, the World Health Organisation, together with other agencies, is now moving quickly to the eradication of poliomyelitis, originally aimed for the year 2000. Plans for the subsequent global eradication of measles are in an advanced stage. Eradication of both polio and measles incorporate as a fundamental strategy high routine coverage, surveillance and special national immunisation days (NIDs), which are supplementary to routine vaccination services. There has been a lively debate on whether poor countries, with many health problems that could be controlled, should divert their limited resources for a global goal of eradication that may have low priority for their children. From a cost-effectiveness perspective, NIDs are fully justifiable. However, field observations in sub-saharan Africa show that NIDs divert resources and, to a certain extent, attention from the development of comprehensive primary health care (PHC). The routine immunisation coverage rates dropped on average since the introduction of NIDs in 1996, which is contrary to what was observed in the western Pacific and other regions. The additional investment to be made when moving from disease control to eradication may exceed the financial capacity of an individual country. Since the industrialised countries benefit most from eradication, they should take responsibility for covering the needs of those countries that cannot afford the investment. The WHO's frequent argument that NIDs are promotive to PHC is not confirmed in the southern African region. The authors think that the WHO should, therefore, focus its attention on diminishing the negative side-effects of NIDs and on getting the positive side-effects incorporated in the integrated health services in a sustainable way.