In any health system, good health services are those that deliver effective, safe, good-quality personal and non-personal care to those that need it, when needed, with minimum waste. Services – be they prevention, treatment or rehabilitation – may be delivered in the home, the community, the workplace or in health facilities.
Although there are no universal models for good service delivery, there are some well-established requirements. Effective provision requires trained staff working with the right medicines and equipment, and with adequate financing. Success also requires an organizational environment that provides the right incentives to providers and users. The service delivery building block is concerned with how inputs and services are organized and managed, to ensure access, quality, safety and continuity of care across health conditions, across different locations and over time.
Attention should be given to the following:
- Demand for services. Raising demand, appropriately, requires understanding the user’s perspective, raising public knowledge and reducing barriers to care – cultural, social, financial or gender barriers.
- Package of integrated services. This should be based on a picture of population health needs; of barriers to the equitable expansion of access to services; and available resources such as money, staff, medicines and supplies.
- Organization of the provider network. This means considering the whole network of providers, private as well as public; the package of services (personal, non-personal); whether there is oversupply or undersupply; functioning referral systems; the responsibilities of and linkages between different levels and types of provider, including hospitals.
- Management. Whatever the unit of management (programme, facility, district, etc.) any autonomy, which can encourage innovation, must be balanced by policy and programme consistency and accountability. Supervision and other performance incentives are also key.
- Infrastructure and logistics. This includes buildings, their plant and equipment; utilities such as power and water supply; waste management; and transport and communication. It also involves investment decisions, with issues of specification, price and procurement and considering the implications of investment in facilities, transport or technologies for recurrent costs, staffing levels, skill needs and maintenance systems.
This section of the health system profile is structured as follows:
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.
The package of care for each of the levels in the health sector has been elaborated and requires the provision of human and material resources in order to minimize referrals that contribute to delay in service provision.
Primary care services are delivered by volunteers, namely village health workers and traditional birth attendants under the supervision of trained community nurse attendants. The primary level is an important entry point for many health programmes targeted at communities.
The secondary level comprises major and minor health centres, which are run mainly by experienced nurse midwives or general nurses, who are the major service providers due to the small numbers of doctors in the health sector. However, there is enthusiasm that this situation will soon be remedied with the yearly graduation of doctors from the medical school in the Gambia.
Chronic care services are provided by the Government of the Gambia at no cost to patients. Home-based care and palliative care have been delivered mainly by nongovernmental organizations, especially Hands On Care, a local nongovernmental organization. However, under the Global Fund for AIDS, Tuberculosis and Malaria, the Government will incorporate home-based and palliative care as a vital component of chronic care. This will free up much-needed beds in the country`s only teaching hospital.
Specialized services such as dental and rehabilitative eye care are run as vertical programmes. The eye care programme is well funded, with donors such as Sight Savers International and the Sheikh Zayed Foundation contributing significantly to its budget. Dental services on the other hand are relatively underfunded, with only four qualified dentists in the public sector. Advocacy for the introduction of dentistry in the university curriculum should be taken up at the level of the Ministry of Health and Social Welfare.
Although mental health services are very centralized in urban areas, where the country`s only psychiatric hospital is located, services are also provided at both facility and community levels through visits to communities by the community mental health team. Traditional mental health healers are supported by the community mental team in an effort to give quality care and remove myths surrounding mental illness.
Primary care services in the country are patient centred due to the shared cultural, religious and social values that exist within the community in which the service provider resides. This is often lacking in other levels of care.
There is no formalized system for the sector to regularly monitor quality of service. However, the Ministry of Health and Social Welfare has identified quality issues as a challenge to work on within its new policy. The Gambia has a well-structured system in place and, given its small size, it is potentially able to deliver quality services to match the improved access.
Organization and management of health services
Package of services
Public and private health care providers
Person-centredness and characteristics of primary health care services
Quality of health services
Priorities and ways forward
Endnotes: sources, methods, abbreviations, etc.
- ↑ Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
- ↑ Framework and standards for country health information systems, 2nd ed (pdf 1.87Mb). Geneva, World Health Organization and Health Metrics Network, 2008