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Comprehensive Analytical Profile: The Gambia

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This analytical profile provides a health situation analysis of the Gambia and, coupled with the Factsheet, it is the most significant output of the African Health Observatory. The profile is structured in such a way to be as comprehensive as possible. It is systematically arranged under eight major headings:
1. Introduction to country context
2. Health status and trends
3. Progress on the Health-Related MDGs
4. The Health System
5. Specific Programmes and Services
6. Key Determinants
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Statistical profile
Introduction to Country Context

The Republic of the Gambia is one of the smallest countries in Africa and is surrounded by the Republic of Senegal with the river as its dominant geographical landmark. The swamps and creeks that cover about one third of the surface area of the country serve as breeding grounds for mosquitoes that transmit malaria, making the Gambia an endemic malaria country.

The country is divided into five administrative regions (Western, Lower River, Central River, Upper River and North Bank) and two municipalities (Kanifing and Banjul). The decentralization of health services closely follows these divisions for ease of administration and this supports the decentralization process.

Health Status and Trends

The health status of the population of the Gambia has improved in recent years. Life expectancy increased from 59.3 years in 1993 to 64 years in 2006. This improvement could be due to health-related factors, including the improvement of physical access to health care, the presence of doctors in major health facilities and community-level clinics as well as to non-health factors, including improvement in transport, road networks, education and access to portable water.

There was a decline in crude death rate from 30 per 1000 population (1983 census) to an estimated 16 per 1000 population (1993 census). Infant mortality rate also declined from 167 per 1000 live births in 1983 to 75 per 1000 live births in 2003. It is important to note that 30–40% of the infant mortality in the Gambia is attributable to perinatal events. This implies that many challenges need to be addressed in the delivery of obstetric as well as neonatal care.

Progress
Progress on SDGs
The Health System
Health system outcomes

The overall health system status in the Gambia has improved in various areas, including the availability of trained personnel, infrastructure and coordination. This is evidenced by the construction of new heath facilities through African Development Bank funding; increased staff being trained at the University of the Gambia as well as postgraduate training for health personnel through bilateral cooperation with some countries.

The major achievement of the sector is the high immunization coverage rate of 97%, which has led to a decline in childhood diseases.

Leadership and governance

The Government of the Gambia provides about 70% of the country's health needs for fairly low fees. Over the years these fees have become unrealistic, leading to a very low recovery for sustaining the services. Communities are involved in health care through the Bamako Initiative, as well as working with private and nongovernmental organization health providers.

There are about 15 nongovernment organizations involved in the delivery of health services in the country, through the signing of a memorandum of understanding with the Ministry of Health and Social Welfare. A few nongovernmental organizations, mainly faith-based organizations, provide social services such as institutional housing, feeding, and care for orphans and vulnerable children.

Community ownership and participation

In the Gambia, one of the guiding principles of the health policy is "changing for good" community participation and empowerment. The Bamako Initiative was implemented in some health facilities where the community were given the opportunity to manage their facilities. No legal framework exists in this regard but in Bamako Initiative facilities, communities have a major say in the running of health facilities in matters relating to financial accountability, purchasing of medication and the state of the facility.

Although there is no documented study on patient satisfaction, complaints received generally concern intermittent shortages of medications and staff attitude, especially during labour and delivery. In contrast, in non-Bamako Initiative facilities communities have little say in the running of their facilities and sometimes do not have a way of expressing their needs.

Partnerships for health development

Local and international partners make a significant contribution to the health sector in the Gambia, providing an estimated 66% of funding. However, the priorities of the different actors often differ and this results in vertical health programmes, inefficient utilization of health services and lack of coordination at the implementation level. In order to maximize effectiveness of partners, there needs to be a policy on partner/donor coordination.

There are positive moves at the intersectoral level, especially within the education sector, through health programmes and the recently established multisectoral Health and Nutrition Committee by the Ministry of Education.

Health information, research, evidence and knowledge

In the Gambia, the emergence and growth of information societies, together with the role of information and communications technologies, has led not only to rapid universal access and utilization of health information but also to enhanced effective monitoring of trends in health status of communities, especially towards achieving the health-related Millennium Development Goals by 2015, the Programme for Accelerated Growth and Employment,[1] and Vision 2020.

Generation of evidence and knowledge through research, including sharing and exchanging health information with many stakeholders across geographical boundaries through multiple channels including the Internet, libraries, seminars, conferences and workshops, and other information centres, is critical for making informed decisions at all levels.

Health financing system

Over 66% of the total health funding in the Gambia comes from international health development partners, raising issues of sustainability and predictability of funding to the sector.[2] Between 2010 and 2011, about 10–11%[3] of the Government's budget was allocated to the health sector, basically for recurrent and development costs, which is still below the Abuja target of 15%.[4]

The cost of providing health care continues to rise owing to increasing demand, changes in diagnostic and therapeutic technologies, inflation and currency fluctuations.[5] This requires that current funding levels be increased to enable the Ministry of Health and Social Welfare to deliver quality services to the population. There is a need to advocate for the funding of the health sector to be increased to at least the 15% Abuja target.

Service delivery

Public health services in the Gambia are delivered at fixed points. These are hospitals and health centres, with monthly visits to communities known as trekking stations. Trekking stations are an important strategy in bringing immunization and maternal services closer to the population. Health messages and new strategies are often introduced to the communities through these visits.

Although there are several Acts that regulate service delivery, most need to be updated for proper alignment with recent developments in the sector, particularly with the advent of a university and medical school.

Health workforce

In the Gambia, the Human Resources Unit comes under the Directorate of Planning and Information. A Human Resources for Health Policy, 2004 and a matching Human Resources for Health Strategic Plan, 2005─2009, have been elaborated to serve as a guide in dealing with human resources for health issues that continuously impact on the health system performance. Human resources for health distribution in the Ministry of Health and Social Welfare is guided by staffing norms and standards where feasible.

The norms provide guides as to cadre, the numbers and services provided at any facility, as well as bed capacity. Inadequate numbers of trained personnel lead to distribution problems, resulting in hospitals being allocated around 75% trained staff. The numbers of trained personnel on April 2011 are shown in the table. According to the Human resources for health country profile 2009[6] most of the public and private health workers (66%) are within the Greater Banjul area.

Medical products, vaccines, infrastructures and equipment

Management of medical supplies in the Gambia is under the National Pharmaceutical Services and covers essential medicine supply, legislation and regulation, quality control services, and planning and management. A Medicines Board, chaired by the Director of Health Services, is responsible for reviewing import as well as the distribution and sale of pharmaceuticals in the country.[7]

Quality regulation is carried out by the quality control department, which is minimally functional due to human and material resource constraints. Procurement of medicines for the public sector is centralized and is mainly from WHO-certified companies. The lack of manufacturing companies in the Gambia sometimes results in delays in receipt of orders. Therefore the need to utilize medicine judiciously is recognized by the National Pharmaceutical Services, which regularly conducts in-service training on the rational use of drugs.

General country health policies

Decentralization is the major cornerstone of the Government of the Gambia's Poverty Reduction Strategy 2007–2011[8] to improve service delivery to the poor. Decentralization involves the creation of regional health teams, which currently are headed by directors. Regular meeting between the regional teams is an entry point to revitalize primary health care in the regions.

Public health policies have been formulated by the Ministry of Health and Social Welfare to engage all disciplines for effective management of the population`s health and well-being. The National Health Policy serves as the basis for all other policies in the health sector. The Health is Wealth 2011–2020 Policy covers areas of health system strengthening as well as new inputs resulting from gaps identified in the previous policy.

Universal coverage

In the Gambia, the mission of the health sector as stated in the National Health Policy 2012–2020 is to "promote and protect the health of the population through the equitable provision of quality health care". The private sector, nongovernment organizations and faith-based organizations also play a vital role in the delivery of health services with a view to complementing the Government of the Gambia's effort in this direction. These joint efforts result in increased access to health services in nearly every community in the country.

The health and health-related laws and acts are designed to regulate or influence outcomes in service delivery. Enforcement of these regulations often poses a challenge due to lack of delineation of functions between the Ministry of Health and Social Welfare and the various professional councils.

Specific Programmes and Services
HIV/AIDS

It is estimated that 28 000 people are living with either HIV-1 or HIV-2 in the Gambia and over 3000 people have developed the advanced stage of AIDS.[9] A national sentinel surveillance system was initiated by the Government of the Gambia with the assistance of the Medical Research Council in 2000. Recent estimates show a decline in HIV-1 prevalence from 2.8% in 2006 to 1.4% in 2008, whereas HIV-2 prevalence declined from 0.9% in 2006 to 0.4% in 2008.[10] This decline is a result of a concerted effort between the Government, the private sector and development partners.

In 2001, the Gambia acquired US$ 15 million funding from the World Bank, which scaled-up the national response to HIV/AIDS. A National AIDS Council and National AIDS Secretariat have been established under the Office of the President, with His Excellency the President of the Gambia serving as Chairman of the National AIDS Council, showing commitment at the highest level.

Tuberculosis

The annual burden of all forms of tuberculosis (TB) in the Gambia is estimated to be 4415 (TB incidence of 257 per 100 000 populations), including 1893 (113 per 100 000 population) smear-positive TB cases.[11] In the past 5 years (2005–2010) with the support of a Round 5 grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GMB-506-G03-T), the total TB case notification in the Gambia increased by 5%. This is, in part, due to an increase in sensitization through both print and electronic media, with the support of the Global Fund.

The number of diagnostic sites increased countrywide from 11 in 2006 to 31 in 2011. Diagnostic sites also serve as places for TB/HIV surveillance. DOTS, the basic package that underpins the Stop TB Strategy, has been scaled-up through the use of primary health structures comprising networks of village health workers, community health nurses and community volunteers.

Malaria

Malaria has remained a major cause of morbidity in the Gambia although it is on the decline. In 2001, 39% of under-five visits and 5% of antenatal consultations at child and reproductive health clinics were due to malaria with mortality rates of 3.6% and 2.3%, respectively.[12] Malaria accounted for 78% of all outpatients visits and 58% of all inpatient admissions in 2003.[13]

Policies on malaria control cover preventive as well as curative aspects of malaria control, with emphasis on partnerships as an important component. The current policy builds on the principle of scaling-up for universal access. Thus all those at risk of the disease, with particular emphasis on young children and pregnant women, will have access to the most suitable combinations of preventive and curative measures against malaria. Implementation of the National Malaria Control Programme is at four levels, namely central, regional, health facility and community levels. Each of these levels has functional structures and responsibilities.

Immunization and vaccines development

The reduction of morbidity and mortality due to vaccine-preventable diseases (particularly childhood diseases) through the effective and efficient delivery of the Expanded Programme on Immunization and related services has been a long-term priority for the Government of the Gambia's Ministry of Health and Social Welfare.[14] However, in order to attain this goal, the Ministry endeavoured to provide a vaccination schedule for children for all antigens (see table).

The percentage of the target population vaccinated by antigen in 2010 in the Gambia is shown in the table.[15] The Expanded Programme on Immunization in the Gambia comprises components such as communication, logistics, data management and surveillance. These programme components work very closely in the delivery of the Expanded Programme on Immunization and related services in the country.

Child and adolescent health

According to the Gambia Multiple Indicator Cluster Survey 2005–2006 (Round 3), the under-five mortality rate was 131 per 1000.[16] This figure represents a fall in mortality compared with the Gambia multiple indicator cluster survey 2000–2001 (Round 2), which reported a mortality rate of 141 per 1000.[17] Many factors related to the improvement in health services and social determinants of health have contributed to this success.

Malnutrition among children continues to be a major public health problem in the Gambia. Children aged under 5 years are vulnerable owing to poor feeding practices, inadequate care and increasing exposure to infection, with poor environmental sanitation being a major contributing factor. Although breastfeeding is a universal practice in the Gambia, exclusive breastfeeding practice stands at 41% and protein energy malnutrition is more prevalent among children aged under 5 years.[18]

Maternal and newborn health

The national maternal mortality ratio in the Gambia declined from 1050 deaths per 100 000 live births to 730 deaths per 100 000 live births between 1990 and 2001, a reduction of about 30.5% in 11 years. Levels in rural areas are twofold greater than in urban settlements. Given that it took 11 years to attain a 31% reduction, it is very unlikely that the country will attain the Millennium Development Goal 5 target of below 262 deaths per 100 000 live births in 7 years. Furthermore, met need for obstetric services such as caesarean section is very low and estimated at 2.1% nationally and 0.6% in rural areas.

While neonatal and perinatal mortality rates are estimated at 31.2 and 54.9 deaths per 1000 live births, respectively, in 2001, the under-five mortality rate has in 2003 declined to 99 deaths per 1000 live births. Currently, there are 35 prevention of mother-to-child transmission sites across the country, providing HIV counselling and testing services at antenatal clinics. There is an urgent need to expand services for improved national coverage. All pregnant women who are infected with HIV are either on antiretroviral prophylaxis or treatment, according to their disease stage.

Gender and women's health

In the Gambia, there are continuing efforts to pay special attention to the girl child. The Ministry of Basic and Secondary Education has a policy objective that includes:

  • free education for girls in rural areas
  • allowing pregnant girls to go back to school after delivery
  • encouraging girls and women to pursue science and technology courses.[19]

This may have contributed to gender parity and the fact that the Gambia is on track to achieving the Millennium Development Goal for education.

Epidemic and pandemic-prone diseases

The Gambia, like the rest of the world, is confronted with emerging and re-emerging potential epidemic diseases that may increase disease burden with their economic implications.

In the absence of modern disease forecasting equipment, the Gambia depends on a robust integrated surveillance system with capacity to timely and adequately respond to disease epidemics/outbreaks and public health events of national and international concern.

Integrated Disease Surveillance and Response guidelines recommend two types of thresholds: an alert threshold and an epidemic threshold. The thresholds described in these guidelines represent the continuum of recommended practices and are used to describe where action is recommended.[20]

Neglected tropical diseases

The prevalence of neglected tropical diseases has increased over the years in the Gambia, mainly due to lack of Government-coordinated community-based intervention programmes, poverty at household level and related social determinants. Currently, there is no evidence-based information determining the extent of the burden of neglected tropical diseases on families, communities and the state.

Contributing factors may be related to inadequate coordination and management of data and information from the public, nongovernmental organization and private facilities and institutions. According to data from public health facilities, including the Department of Social Welfare, the burden of these diseases far exceeds that of infectious diseases. Efforts are underway to increase awareness and expand data sources through the Integrated Disease Surveillance and Response framework, which will also include private and nongovernment organization data.

Non-communicable diseases and conditions

As in some developing countries, noncommunicable diseases such as diabetes and cardiovascular disease are on the rise in the Gambia.[21] Unhealthy diet, lack of exercise and obesity are the risk factors that predispose to noncommunicable diseases in the Gambia. These account for most of the health care resources used and present a significant economic burden in the country.

The Government of the Gambia's 2009 Health management and information system report[22] showed that noncommunicable diseases such as hypertension account for 35.56% and 43.64% of diseases in males and females, respectively. Diabetes affected 1.78% and 1.87% of males and females, respectively.

Key Determinants
Risk factors for health

A study conducted in the Gambia in 2008 by WHO and a local nongovernmental organization, the International Organization of Good Templers, shows a 24.5% prevalence rate of smoking among 13–15 year olds. The results of the 2010 WHO STEPwise survey on noncommunicable disease risk factors also shows a 31.3% prevalence rate of smoking among people aged 25–34 years. The banning of cigarette advertisements and public smoking shows the Government`s commitment to reducing ill health among the population, especially in the young population.

The 2010 WHO STEPwise survey also reveals that about 2% of the adult population aged 25–64 years drinks alcohol.

The physical environment

Significant progress has been registered in the areas of malaria control through indoor residual spraying and environmental sanitation.

Environmental factors such as indiscriminate building and dumping of waste into waterways have led to floods in some urban areas. Rains have destroyed homes and displaced families over the past 5 years, prompting a disaster management team to be established to mitigate the effects of these weather-related disasters.[23]

One of the main environmental issues facing the Gambia is waste management, especially in urban areas. This is exacerbated by indiscriminate disposal of wastes from households and small industries, poor collection and inappropriate disposal practices.[21] Waste management, especially in urban areas, and the safe disposal of excreta, the management of landfills, and monitoring of surface and ground water are the major challenges in terms of sanitation.

Food safety and nutrition

Groundnuts continue to be the main income-generating cash crop in the Gambia. Rice is the staple food but its production in the Gambia is limited by a variety of factors, especially salinity, causing the country to import significant quantities of the grain.[24]

Groundnuts and groundnut products, fish and fish products, and horticultural products are the main exports, mainly to the European Union.[25] The re-export trade in rice, sugar and wheat flour, mainly to Guinea, Guinea-Bissau, Mali and Senegal, is estimated at about 30% of total imports of these commodities.[25]

The largest international trade activity is the import of food (especially rice), machinery, transport equipment, manufactured goods and fuels. Some of these imports are re-exported to neighbouring countries.

Social determinants

The population growth rate in the Gambia is 2.74%, with a crude birth rate of 46 per 1000 population and a total fertility rate of 5.4 births per woman. The Gambia is one of the most densely populated countries in Africa.[21] The youthfulness of the population (63% below 24 years) puts a strain on health service delivery. Average life expectancy at birth is 64 years overall. Rapid population growth and high levels of fertility are a challenge for poverty alleviation efforts as well as for improving quality of life of the people.

The Government of the Gambia has introduced free primary education, hoping to empower women in the future to become more involved in their reproductive health. This will contribute to improving some of these indices and lead to improved quality of life for the population.



References
  1. Program for Accelerated Growth and Employment (PAGE) 2012–2015 (pdf 3.96Mb). Banjul, Government of he Gambia, Ministry of Finance and Economic Affairs
  2. National health accounts 2002, 2003, 2004 (789.53kb). Banjul, Government of the Gambia, Department of State for Health and Social Welfare, 2007
  3. Ministry of Health and Social Welfare estimates 1998─2011 (Government local funds only). Banjul, Government of the Gambia, Directorate of Planning and Information, Health Financing Unit, 2010
  4. Health Financing Policy, 2009. Banjul, Government of the Gambia, Ministry of Health and Social Welfare, 2009
  5. World health report 2007. A safer future. Global public health security in the 21st century (pdf 3.96Mb). Geneva, World Health Organization, 2007
  6. Human resources for health country profile. The Gambia (pdf 356.18kb). Africa Health Workforce Observatory. Global Health Workforce Alliance and World Health Organization, 2009
  7. The Gambia National Drug Policy. Banjul: Government of the Gambia, Ministry of Health and Social Welfare; 2007
  8. Final report of the mid-term review of the Poverty Reduction Strategy Paper (PRSPII) 2007–20011 (pdf 580.60kb). IMF Country Report No. 11/27. Washington DC: International Monetary Fund, International Development Support Services; 2011
  9. Banjul, Government of the Gambia, National AIDS Secretariat, 2008
  10. Report. Banjul, Government of the Gambia, National Statistical System, 2008
  11. WHO global surveillance report 2009. Geneva, World Health Organization, 2009
  12. Malaria situational analysis report, 2002
  13. Banjul, Government of the Gambia, Ministry of Health and Social Welfare, 2004
  14. The Gambia National Expanded Programme on Immunization. Desk review, final report. Banjul, Government of the Gambia, Expanded Programme on Immunization, 2006
  15. National Expanded Programme on Immunization. Routine data. Banjul, Government of the Gambia, Expanded Programme on Immunization, 2010
  16. Gambia Multiple Indicator Cluster Survey 2005–2006 (Round 3). Gambia Bureau of Statistics, Department of State for Finance and Economic Affairs
  17. Gambia Multiple Indicator Cluster Survey 2000–2001 (Round 2). Gambia Bureau of Statistics, Department of State for Finance and Economic Affairs
  18. National Nutrition Policy, 2000–2004. Banjul, Government of the Gambia
  19. The Gambia National Gender Policy, 2010–2020. Banjul, Government of the Gambia
  20. Integrated disease surveillance, the Gambia. Banjul, Government of the Gambia, Ministry of Health and Social Welfare, Disease Control Unit, 2008
  21. 21.0 21.1 21.2 WHO Country Cooperation Strategy 2008–2013, Gambia (pdf 426.64kb). Brazzaville, World Health Organization Regional Office for Africa, 2009
  22. Health management and information system report. Banjul, Government of the Gambia, Ministry of Health and Social Welfare, 2009
  23. UNICEF in the Gambia: making life in the Gambia fit for all children, 2007–2011. United Nations Children’s Fund, 2011
  24. Gambia National Agricultural Investment Programme 2010–2015. Banjul, Government of the Gambia, Ministry of Agriculture and Ministry of Trade, Industry and Employment, 2009
  25. 25.0 25.1 The Gambia Trade Policy 2010. Banjul, Government of the Gambia, Ministry of Trade, Industry, Regional Integration and Employment, 2011