INTRODUCTION: Although many countries have improved vaccination coverage in recent years, some, including Guinea-Bissau, failed to meet expected targets. This paper tries to understand the main barriers to better vaccination coverage in the context of the GAVI-Alliance (The Global Alliance for Vaccines and Immunisation) cash-based support provided to Guinea-Bissau. METHODS: The analysis is based on a document analysis and a three round Delphi study with a final consensus meeting. RESULTS: Consensus attributed about 25% of the failure to perform better to implementation problems; and about 10% to governance and also 10% to scarce resources. The qualitative analysis validates the importance of implementation issues and upgraded the relevance of the human resources crisis as an important drawback. The recommendations were balanced in their upstream-downstream focus but were blind to health information issues and logistical difficulties. CONCLUSIONS: It is commendable that such a fragile state, with all sorts of barriers, manages to sustain a slow steady growth of its vaccination coverage. Not reaching the targets set reflects the inappropriateness of those targets rather than a lack of commitment of the health workforce. In the unstable context of countries such as Guinea-Bissau, the predictability of the funds from global health initiatives like the GAVI-Alliance seem to make all the difference in achieving small consistent health gains even in the presence of other major bottlenecks.

Health sector workers respond to inadequate salaries and working conditions by developing various individual "coping strategies" - some, but not all, of which are of a predatory nature. The paper reviews what is known about these practices and their potential consequences (competition for time, brain drain and conflicts of interest). By and large, governments have rarely been proactive in dealing with such problems, mainly because of their reluctance to address the issue openly. The effectiveness of many of these piecemeal reactions, particularly attempts to prohibit personnel from developing individual coping strategies, has been disappointing. The paper argues that a more proactive approach is required. Governments will need to recognize the dimension of the phenomenon and systematically assess the consequences of policy initiatives on the situation and behaviour of the individuals that make up their workforce.

Los trabajadores del sector de la salud responden a los sueldos y condiciones de trabajo precarios desarrollando diversas estrategias de afrontamiento, algunas de las cuales, pero no todas, tienen carácter abusivo. El documento examina los conocimientos actuales sobre estas prácticas y sus consecuencias potenciales (menor dedicación de tiempo, fuga de cerebros y conflictos de intereses). En términos generales, los gobiernos rara vez han tomado la iniciativa para hacer frente a esos problemas, debido sobre todo a su renuencia a abordar la cuestión abiertamente. Los resultados de muchas de estas respuestas poco sistemáticas, en particular los intentos de prohibir que el personal desarrolle tales estrategias, han sido decepcionantes. Se señala en el artículo que es necesario adoptar un enfoque más proactivo. Los gobiernos han de reconocer la dimensión del fenómeno y evaluar sistemáticamente las consecuencias de las iniciativas de política en la situación y el comportamiento de los individuos que constituyen su fuerza laboral.

Les personnels du secteur de la santé répondent à l'insuffisance de leurs salaires et de leurs conditions de travail en développant diverses stratégies individuelles d'adaptation dont certaines, mais pas toutes, s'exercent au préjudice du secteur public. Le présent article fait le point des connaissances concernant ces pratiques et leurs conséquences potentielles ("détournement" du temps de travail, fuite des cerveaux et conflits d'intérêts). Dans l'ensemble, les pouvoirs publics ont rarement pris les devants pour faire face à de tels problèmes, surtout par réticence à aborder ouvertement la question. L'efficacité de nombre de réactions ponctuelles, notamment de tentatives visant à interdire au personnel de développer des stratégies individuelles d'adaptation, s'est révélée décevante. L'article souligne la nécessité d'une approche plus préventive. Les pouvoirs publics devront reconnaître l'ampleur du phénomène et évaluer systématiquement les conséquences de diverses politiques sur la situation et sur le comportement des membres de leur personnel.