Public Health Nursing Vol. 31 No. 2, pp. 126–133 0737-1209/© 2013 Wiley Periodicals, Inc. doi: 10.1111/phn.12057
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LIFESPAN: CASE STUDIES
Making Basic Health Care Accessible to Rural Communities: A Case Study of Kiang West District in Rural Gambia Edward Saja Sanneh,1 Allen H. Hu,1 Modou Njai,2 Omar Malleh Ceesay,3 and Buba Manjang4 1
National Taipei University of Technology, Institute of Environmental Engineering Technology, Taipei, Taiwan; 2Integrated Management of Childhood Illness (IMCI), Ministry of Health and Social Welfare, Banjul, The Gambia; 3Health Promotion and Development Organization (HePDO), Kanifing Municipal Council, SereKunda, The Gambia; and 4Regional Health Management Team, North Bank Region, Farafenni, The Gambia Correspondence to: Allen H. Hu, Professor, National Taipei University of Technology, Institute of Environmental Engineering Technology, No.1, sec. 3, Chung-Hsiao East Road, Taipei 10643, Taiwan. E-mail: [email protected]
ABSTRACT This study focuses on lack of access to basic health care, which is one of the hindrances to the development of the poor, and subjects them to the poverty penalty. It also focuses on contributing to the Bottom of the Pyramid in a general sense, in addition to meeting the health needs of communities where people live on less than $1 a day. Strengthened multistakeholder responses and better-targeted, low-cost prevention, and care strategies within health systems are suggested to address the health burdens of poverty-stricken communities. In this study, a multistakeholder model which includes the government, World Health Organization, United Nations Children Emergency Fund, and the Medical Research Council was created to highlight the collaborative approach in rural Gambia. The result shows infant immunization and antenatal care coverage were greatly improved which contributes to the reduction in mortality. This case study also finds that strategies addressing health problems in rural communities are required to achieve Millennium Development Goals. In particular, actual community visits to satellite villages within a district (area of study) are extremely vital to making health care accessible. Key words: access, bottom of the pyramid, multi-stakeholder, partnership, poverty penalty.
The delivery and availability of health goods and services are critical to national development and poverty alleviation (Marter-Kenyon, 2005). Many complications in maternal and child health in the developing world are believed to be partly due to the differences in the availability of, and access to, health services (Navaneetham & Dharmalingam, 2002). Every year, approximately 10 million children under 5 years of age die throughout the world, mostly in developing countries (Murray, Laakso, Shibuya, Hill, & Lopez, 2007), due to lack of access to basic health care. Poor people in developing countries tend to suffer from a phenomenon known as the poverty penalty (the additional cost paid for goods and services by the poor relative to the more affluent), a term popularized by C.K. Prahalad
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(2004) in his publication, The Fortune at the Bottom of the Pyramid. The works of several other authors (Hammond, Kramer, Katz, Tran, & Walker, 2007; Van den Waeyenberg, 2006) have brought this subject to the attention of the academic community. In sub-Saharan Africa, the under-five mortality rate decreased from an average of 180 per thousand live births in 1990 to 129 per thousand live births in 2009 (Zere, Kirigia, Duale, & Akazili, 2012). The under-five mortality rate of the Gambia is 109 per thousand while the infant mortality rate is 81 per thousand (The Gambia Bureau of Statistics (GBOS), 2011) and continues to be a problem in developing countries. The fourth ‘Millennium Development Goal’ (MDG) is to reduce child and infant mortality
Sanneh et al.: Access to Basic Health care rates around the world, two thirds by the year 2015. However, current estimates suggest that at least 44 developing countries have less than a 20% chance of achieving this goal (Murray et al., 2007). Factors contributing to the mortality of children under 5 years old have been attributed to inadequate access to basic health services (distance from medical facilities), the cost of traveling to reach a health facility, and family/household income (Rutherford, Dockerty, & Jasseh, 2009). According to the United Nations Population Fund, 99% of maternal deaths are preventable, yet every minute a woman dies from pregnancy-related causes (World Health Organization [WHO], 2011a). When health care is needed but is delayed or not obtained, people’s health worsens, which in turn leads to lost income and higher health care costs, both of which contribute to poverty (Narayan, Patel, Schafft, Rademacher, & Koch-Schulte, 2000). In 1978, the historic declaration of Alma Ata was adopted to promote primary health care, endorse health as a basic human right, and offer a set of values, principles, and approaches aimed at the promotion of global health (Chan, 2008). After its adoption of a Primary Health Care system as the basis of national health policy, Gambia developed several health programs in the early- to mid-1980s. These programs included health education, water and sanitation improvement, reproductive and child health care, immunization, control of endemic diseases, treatment of simple illnesses and injuries, as well as provision of essential drugs (Ministry of Health [MOH], 1998). The influence of a local maternal care access study on improving service delivery and organization has previously been demonstrated in Mali (Guindo, Dubourg, Marchal, Blaise, & De Brouwere, 2004). It is estimated that 41–72% of new born deaths in developing countries can be avoided through adequate coverage of current health care interventions (Haines, Sanders, & Lehmann, 2007). Access to health care is a key determinant for the survival of infants and mothers during pregnancy, birth, and the days following birth, particularly when complications arise. Until the late 1970s, Gambia had one of the highest childhood mortality rates in the world, a result of low immunization coverage, poor access to health services, lack of safe drinking water, poor sanitation, and low nutritional status. (Cole-Ceesay, Cherian, & Sonko, 2010), based on
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Gambian situation, stated that contributing factors to access to health care are multiple and include low literacy levels of women, high attrition rate, low morale of skilled health workers, and poverty. This case study presents solutions for poorly resourced communities such as Kiang West of Gambia. It highlights a multistakeholder collaboration approach for required meaningful and effective interventions that influence access to health care. The partnership between stakeholders strengthens health care delivery systems, thereby enabling access.
Health Care System of the Gambia The 2007–2020 National Health Policy Framework of Gambia, referred to as “Health is Wealth,” seeks to address common health desires through a number of initiatives in both preventive and curative health services. Figure 1 shows the primary health care modeled health care system, which is organized into primary (Village Health Services), secondary (major and minor Health Centers), and tertiary (Hospitals) levels of service delivery. Major health centers are staffed by doctors, state registered nurses, assistant public health officers, stateenrolled nurses, and other technical staff. Minor health centers have similar staff profiles, but are without medical doctors and laboratory services. Nurses provide the majority of clinical care at all levels of health service, while community health nurses are largely employed in community work. Assistant public health officers are responsible for
Figure 1. Structure of the Gambian Health care (Source: Department of state for health, Banjul the Gambia. Health Policy Framework 2007– 2020)
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health promotion and protection, including environmental hygiene and sanitation, immunization, and other preventive health measures at various levels of the delivery system. At the tertiary level, there are 10 hospitals while at the secondary level there are 35 health centers comprising 6 major and 29 minor Health Centers. In addition to the health centers, there are numerous village health service or “trekking” posts where Maternal and Child Health services are provided to communities without Health Center. The major health center is the first point of referral for the minor health center. Major Health Centers have laboratories and perform minor surgeries which are not present in minor Health Centers. The village health service was established to provide primary health care services. Communities are involved through Village Development Committees and Catchment Area Committees, including traditional birth attendants and village health workers.
Making Health Care Accessible in Rural Areas- Kiang West Methodology Kiang West is located in the Lower River Region (LRR) of Gambia, approximately 150 km from the capital, Banjul (Figure 2). It is bordered to the west and north by the Gambia River and on the south
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by a large tributary. The area has a 50% poverty rate and a population of approximately 30,000 people per Primary Health Care facility. This district is comprised of approximately 30 villages in sparse settlements. There is little or no meaningful economic activity in the district due largely to inadequate infrastructure and unpaved roads thereby making the area inaccessible, especially during rainy seasons. Its dispersed settlement characteristic of most rural areas elevates health care accessibility to a position of primary importance (Joseph & Moon, 2002). Several interventions were initiated by the health sector and stakeholders in Gambia to make health care more accessible and affordable for its citizenry. The appropriate interventions included improved staffing at the Karantaba Health Centre, which entailed the employment of traditional birth attendants and village health workers through Primary Health Care activities by community health nurses (Rayco-Solon, Moore, Fulford, & Prentice, 2004). The Expanded Program on Immunization, funded by the World Health Organization, Global Alliance for Vaccines and Immunization, and United Nations International Children Emergency Fund, aims to prevent infant mortality by providing vaccines for “childhood” diseases. Providing young children with two high doses of Vitamin A annually (at 6-month intervals) is a safe, cost-effective, and
Figure 2. Map of Kiang West District in Rural Gambia System
Sanneh et al.: Access to Basic Health care efficient strategy for eliminating Vitamin A deficiency and improving child survival. The purpose of this multistakeholder case study is to formulate an operational description of personal access to health care in a rural community. Figure 3 shows the multistakeholder case study model the authors created to analyze the collaborative interventions in Kiang West by the government, Medical Research Council, World Health Organization, and United Nations International Children Emergency Fund. The World Health Organization and other stakeholders support various government programs in terms of funding depending on target health needs. The government as a recipient, plans, organizes, and coordinates the implementation of programs to solve health issues in the Gambia. Research institutions like the Medical Research Council generate the much needed information for planning. Nongovernment organizations have clinics and provide health care services especially in areas where the government cannot afford to do so. This supports government efforts in providing basic health services to communities in rural areas like Kiang West. Stakeholder’s collaboration in making basic health care accessible will help in achieving the millennium development goals and international commitments in terms of health. Figure 4 shows access to health services in relation to poverty and population in Gambia. The LRR is shown in the figure as having the lowest percentage of population with access to Primary Health Care coverage. The two main providers of formal health care in Kiang West are the government and the Dunn Nutrition Unit of the Medical Research Council. In 1995, the Baby Friendly Community Initiative was piloted in 12 communities in
Figure 3. Multistakeholder Collaboration Model of Gambia Government, MRC, WHO and UNICEF in Kiang West
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the LRR (which includes Kiang West) of Gambia. This led to the expansion of the initiative to 293 communities across the country (The Gambia National Nutrition Agency [NaNA], 2009). The WHO has acknowledged the involvement of these systems by challenging global communities to improve standards of living through better access to health care (World Health Organization [WHO], 2011b). In all other divisions, the coverage is less than 50% of their population, the worst population to health center ratio is to be found in the URR and the NBR. Regional health management teams are established in all health administrative areas (World Bank, 2005). Every month, the staff of the Kiang West government health center conducts community visits to satellite villages. Infant immunization is conducted by the assistant public health officer while a midwife provides antenatal and maternal health care. During these immunization sessions, Bacille– Calmette–Guerin, oral polio vaccination, diphtheria, pertussis, tetanus, tetanus toxoid, yellow fever, hepatitis B, and measles vaccines are administered to infants (this was conducted by the first author from 2001 to 2003). In 2009, pneumococcal and pentavalent vaccines were added to the immunization routine. During community visits, sick people living in villages far from health centers are attended to, thus forestalling the villagers’ need to travel long distances to receive medication. The Medical Research Council also conducts similar community visits to other villages. Although their interventions are research based, they operate an outpatient department, offer nutrition supplementation, and support the health center in Karantaba by posting a
Figure 4. The Gambia, Poverty Versus Population Coverage of Basic Health Facilities by Division
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midwife there and helping to provide resources for the facility.
Discussion of the Kiang West Methodology Health issues challenge development in many developing countries, including Gambia. With a goal of improving the health of all Gambians with a per capita income of US$ 1,500 by 2020, the National Health Policy Framework’s mission is the promotion and protection of health through equitable access and affordable services. International organizations, such as the World Health Organization and the United Nations International Children Emergency Fund, act as decisive bodies of oversight and governance for broad goals, ‘Millennium Development Goals’, as well as Global Fund against Tuberculosis and Malaria programs. All of these efforts aim to ease the health burden in developing countries. Strengthened multistakeholder response, as shown in Figure 3, implemented within health systems with better-targeted, low-cost prevention and care strategies are suggested as the best interventions initiated for health care accessibility. Gambia’s Reproductive and Child Health Services have been expanded, in addition to having well-trained staff overseeing case management of common childhood illnesses/conditions under the Integrated Management of Neonatal and Childhood Illnesses strategy. Evaluation of Integrated Management of Child Illness interventions concluded that high risk and poor populations require proximal health services to improve health outcomes (Bryce, Boschi-Pinto, Shibuya, & Black, 2005). The primary health care strategy adopted by the Gambia government has paved the way for decentralization and near-target population management to improve the efficiency of national programs. Strategies for active surveillance of infectious diseases, particularly those affecting children, have been developed and strengthened at both national and community levels. The target diseases have either been eliminated or are in the process of being eradicated (for example, poliomyelitis, measles, and neonatal tetanus). These results were facilitated by the collaborative multistakeholders approach, as shown in Figure 3. Improved childhood vaccination coverage is a key indicator for the country’s health policy objectives. As availability increases, addressing
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issues of demand and timely schedule completion will be solved. Vaccinations conducted by public health officers at outreach stations will boost the immune systems of infants, protecting them from disease and curtailing infant mortality (70.14 deaths out of 1,000 live births, according to year 2007 estimates). As a result of the combined efforts of the World Health Organization, United Nations International Children Emergency Fund, as well as other partners, the immunization coverage for Diphtheria Pertussis Tetanus, Bacille Calmette Guerin, measles, and polio vaccines is currently at 80% or more (as shown in Figure 5), compared with approximately 30%, 20 years ago. Infant mortality has been curtailed as a result (67.49 out of 1,000 live births, according to year 2010 estimates). Services provided by midwives help reduce maternal mortality (540 out of 100,000 live births). A survey on antenatal care delivery, coverage, and access in Gambia (Reproductive and Child Health, Department of State for health [DoSH], The Gambia & Center for Innovation Against Malaria (2007), revealed that 99.2% of pregnant women used formal antenatal services, 67% received antennal care at a health center, 24% received antennal care at an outreach post, 90% visited four or more times, and 96% were satisfied with the services received. Coverage of antenatal care by skilled personnel (doctor, nurse, or midwife), is relatively high in Gambia, with 97.8% of women receiving antenatal care at least once during their last pregnancy. This validates the effectiveness of the multistakeholder collaboration and community involvement through the training of Village Health Workers and Traditional Birth Attendants, in making health care accessible. Vitamin A is critical to child health and immune function. As such, it is critical to the achievement of the fourth ‘Millennium Development Goal’: a twothird reduction in the mortality of children under five by 2015. Giving Vitamin A to breastfeeding mothers helps protect their children during the first months of life, and helps replenish the mother’s health as well. The Multi Indicator Cluster Survey study has shown that Vitamin A supplementation coverage in Gambia is lower in urban areas (77%) than in rural areas (82%) (GBOS, 2011). In the final analysis of this case study, no single organization, sector, nor approach can provide answers for underdevelopment, poverty, and ill
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Figure 5. Immunization Coverage of the Gambia from 2000 to 2008 health. There is little or no meaningful economic activity in Kiang West, where households live below the poverty line and thus cannot change their situations by themselves. Lack of communication services and public transport make the situations of impoverished communities more difficult. Women struggle to take sick family members to health facilities. Some even walk long distances just to receive basic health care. This situation, however, is
not unique to Kiang West, as many other places in the developing world face similar difficulties. We believe that the multistakeholder model used in this area is feasible, appropriate, and can be replicated in other communities. The barriers identified during the case study such as poverty, access to basic health services due to inadequate transportation and communication, impacted heavily on the health and well-being of
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the residents of Kiang West. The inadequate number of health personnel deprives communities’ access to timely health care. Effort to address these barriers by government and other stakeholders was the application of the primary health care strategy where health providers traveled to communities to provide basic health services. We recognize the importance of visiting villages far removed from health centers to provide reproductive and child health care services. This model eases the health care burden for isolated communities located 30 km away from health centers. Addressing the underlying determinants of health is a key factor in achieving MDGs and ensuring sustainable development. The importance of cooperation, both within a specific sector and across sectors, cannot be stressed enough. Progress should be made in forging closer ties between the health sector and other sectors, particularly through local, national, and multistakeholder development plans. This case study suggests that health systems should be oriented toward the needs of the poor, giving greater attention to redressing inequities and closing in on gaps in research. Further study of medical access, specifically in terms of health care delivery system, availability of resources, perceived morbidity and mortality of communities at risk should be a priority.
Acknowledgments The authors are grateful to the Gambia government Ministry of Health, Expanded Program on Immunization and the Integrated Management of Neo Natal and Childhood Illnesses Offices and thank the reviewers for their helpful comments.
References Bryce, J., Boschi-Pinto, C., Shibuya, K., & Black, R. E. (2005). WHO estimates of the causes of death in children. Lancet, 365(9465), 1147– 1152. doi:10.1016/s0140-6736(05)71877-8. Chan, M. (2008). Return to Alma-Ata. Lancet, 372 (9642), 865–866. doi:10.1016/S0140-6736 (08)61372-0. Cole-Ceesay, R., Cherian, M., & Sonko, A. (2010). Strengthening the emergency healthcare system for mothers and children in The Gambia. Reproductive Health, 7(1), 21.
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Guindo, G., Dubourg, D., Marchal, B., Blaise, P., & De Brouwere, V. (2004). Measuring unmet obstetric need at district level: How an epidemiological tool can affect health service organization and delivery. Health Policy Plan, 19 (Suppl. 1), i87–i95. doi:10.1093/heapol/ czh049. Haines, A., Sanders, D., & Lehmann, U. (2007). Achieving child survival goals: Potential contribution of community health workers. Lancet, 369(9579), 2121–2131. doi:10.1016/ s0140-6736(07)60325-0. Hammond, A. L., Kramer, W. J., Katz, R. S., Tran, J. T., & Walker, C. (2007). The next 4 billion. Innovations: Technology, Governance, Globalization, 2(1–2), 147–158. doi:10.1162/itgg. 2007.2.1-2.147. Joseph, A. E., & Moon, G. (2002). From retreat to health centre: Legislation, commercial opportunity and the repositioning of a Victorian private asylum. [Historical Article]. Social Science and Medicine, 55(12), 2193–2200. Marter-Kenyon, J. (2005). Bridging the divide: A third-sector approach to health and development. Greener Management International, 51, 53. Ministry of Health (MOH). (1998). Department of state for health & social welfare on national household poverty survey report, 1998, Banjul, The Gambia. Murray, C. J., Laakso, T., Shibuya, K., Hill, K., & Lopez, A. D. (2007). Can we achieve Millennium Development Goal 4? New analysis of country trends and forecasts of under-5 mortality to 2015. [Research Support, Non-U.S. Gov’t]. Lancet, 370(9592), 1040–1054. doi:10.1016/S0140-6736(07)61478-0. Narayan, D., Patel, R., Schafft, K., Rademacher, A., & Koch-Schulte, S. (2000). Voices of the poor: Can anyone hear us? New York: Oxford University Press: World Bank. Navaneetham, K., & Dharmalingam, A. (2002). Utilization of maternal health care services in Southern India. Social Science and Medicine, 55(10), 1849–1869. Rayco-Solon, P., Moore, S. E., Fulford, A. J., & Prentice, A. M. (2004). Fifty-year mortality trends in three rural African villages. [Research Support, Non-U.S. Gov’t]. Tropical Medicine and International Health, 9(11), 1151–1160. Reproductive and Child Health, Department of State for health (DoSH), The Gambia & Center for Innovation Against Malaria. (2007).
Sanneh et al.: Access to Basic Health care Annual Report: Study conducted by CIAM and DOSH. Rutherford, M. E., Dockerty, J. D., & Jasseh, M. (2009). Access to health care and mortality of children under 5 years of age in the Gambia: A case-control study. [Research Support, Non-U.S. Gov’t]. Bulletin of the World Health Organization, 87(3), 216–224. The Gambia Bureau of Statistics (GBOS). 2011. The Gambia multiple indicator cluster survey 2010, final report. Banjul, The Gambia. The Gambia National Nutrition Agency (NaNA). (2009). NaNa Working with the communities for better health and nutrition: Annual Report December 2009, Banjul, The Gambia. Retrieved from http://www.nana.gm/ reports/NaNAAnnualReportfor2009.pdf Van den Waeyenberg, S. (2006). Which business strategy do multinational corporations need to successfully enter the markets of less developed countries? Lodz, Poland: International Trade and Finance Association. World Bank. (2005). Health and poverty in The Gambia: A background report to the
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National Poverty Reduction Strategy Paper. Africa Region Human Development, Working Paper Series: Human Development Sector, Africa Region, The World Bank - Key Health Indicators for The Gambia, Banjul, The Gambia. World Health Organization (WHO) (2011a). UNFPA and World Bank (2010) Trends in Maternal Mortality: 1990–2008; Estimates developed by the WHO, UNICEF. Retrieved from http://www.who.int/reproductivehealth/publications/monitoring/9789241503631/en/# World Health Organization (WHO). (2011b). CLOSING THE GAP: Policy into Practice on Social Determinants of Health: Discussion paper. Proceedings at the World Conference on Social Determinants of Health (Rio de Janeiro, Brazil 19-21 October, 2011). Zere, E., Kirigia, J., Duale, S., & Akazili, J. (2012). Inequities in maternal and child health outcomes and interventions in Ghana. BMC Public Health, 12(1), 252.
POPULATIONS
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LIFESPAN: CASE STUDIES
Making Basic Health Care Accessible to Rural Communities: A Case Study of Kiang West District in Rural Gambia Edward Saja Sanneh,1 Allen H. Hu,1 Modou Njai,2 Omar Malleh Ceesay,3 and Buba Manjang4 1
National Taipei University of Technology, Institute of Environmental Engineering Technology, Taipei, Taiwan; 2Integrated Management of Childhood Illness (IMCI), Ministry of Health and Social Welfare, Banjul, The Gambia; 3Health Promotion and Development Organization (HePDO), Kanifing Municipal Council, SereKunda, The Gambia; and 4Regional Health Management Team, North Bank Region, Farafenni, The Gambia Correspondence to: Allen H. Hu, Professor, National Taipei University of Technology, Institute of Environmental Engineering Technology, No.1, sec. 3, Chung-Hsiao East Road, Taipei 10643, Taiwan. E-mail: [email protected]
ABSTRACT This study focuses on lack of access to basic health care, which is one of the hindrances to the development of the poor, and subjects them to the poverty penalty. It also focuses on contributing to the Bottom of the Pyramid in a general sense, in addition to meeting the health needs of communities where people live on less than $1 a day. Strengthened multistakeholder responses and better-targeted, low-cost prevention, and care strategies within health systems are suggested to address the health burdens of poverty-stricken communities. In this study, a multistakeholder model which includes the government, World Health Organization, United Nations Children Emergency Fund, and the Medical Research Council was created to highlight the collaborative approach in rural Gambia. The result shows infant immunization and antenatal care coverage were greatly improved which contributes to the reduction in mortality. This case study also finds that strategies addressing health problems in rural communities are required to achieve Millennium Development Goals. In particular, actual community visits to satellite villages within a district (area of study) are extremely vital to making health care accessible. Key words: access, bottom of the pyramid, multi-stakeholder, partnership, poverty penalty.
The delivery and availability of health goods and services are critical to national development and poverty alleviation (Marter-Kenyon, 2005). Many complications in maternal and child health in the developing world are believed to be partly due to the differences in the availability of, and access to, health services (Navaneetham & Dharmalingam, 2002). Every year, approximately 10 million children under 5 years of age die throughout the world, mostly in developing countries (Murray, Laakso, Shibuya, Hill, & Lopez, 2007), due to lack of access to basic health care. Poor people in developing countries tend to suffer from a phenomenon known as the poverty penalty (the additional cost paid for goods and services by the poor relative to the more affluent), a term popularized by C.K. Prahalad
126
(2004) in his publication, The Fortune at the Bottom of the Pyramid. The works of several other authors (Hammond, Kramer, Katz, Tran, & Walker, 2007; Van den Waeyenberg, 2006) have brought this subject to the attention of the academic community. In sub-Saharan Africa, the under-five mortality rate decreased from an average of 180 per thousand live births in 1990 to 129 per thousand live births in 2009 (Zere, Kirigia, Duale, & Akazili, 2012). The under-five mortality rate of the Gambia is 109 per thousand while the infant mortality rate is 81 per thousand (The Gambia Bureau of Statistics (GBOS), 2011) and continues to be a problem in developing countries. The fourth ‘Millennium Development Goal’ (MDG) is to reduce child and infant mortality
Sanneh et al.: Access to Basic Health care rates around the world, two thirds by the year 2015. However, current estimates suggest that at least 44 developing countries have less than a 20% chance of achieving this goal (Murray et al., 2007). Factors contributing to the mortality of children under 5 years old have been attributed to inadequate access to basic health services (distance from medical facilities), the cost of traveling to reach a health facility, and family/household income (Rutherford, Dockerty, & Jasseh, 2009). According to the United Nations Population Fund, 99% of maternal deaths are preventable, yet every minute a woman dies from pregnancy-related causes (World Health Organization [WHO], 2011a). When health care is needed but is delayed or not obtained, people’s health worsens, which in turn leads to lost income and higher health care costs, both of which contribute to poverty (Narayan, Patel, Schafft, Rademacher, & Koch-Schulte, 2000). In 1978, the historic declaration of Alma Ata was adopted to promote primary health care, endorse health as a basic human right, and offer a set of values, principles, and approaches aimed at the promotion of global health (Chan, 2008). After its adoption of a Primary Health Care system as the basis of national health policy, Gambia developed several health programs in the early- to mid-1980s. These programs included health education, water and sanitation improvement, reproductive and child health care, immunization, control of endemic diseases, treatment of simple illnesses and injuries, as well as provision of essential drugs (Ministry of Health [MOH], 1998). The influence of a local maternal care access study on improving service delivery and organization has previously been demonstrated in Mali (Guindo, Dubourg, Marchal, Blaise, & De Brouwere, 2004). It is estimated that 41–72% of new born deaths in developing countries can be avoided through adequate coverage of current health care interventions (Haines, Sanders, & Lehmann, 2007). Access to health care is a key determinant for the survival of infants and mothers during pregnancy, birth, and the days following birth, particularly when complications arise. Until the late 1970s, Gambia had one of the highest childhood mortality rates in the world, a result of low immunization coverage, poor access to health services, lack of safe drinking water, poor sanitation, and low nutritional status. (Cole-Ceesay, Cherian, & Sonko, 2010), based on
127
Gambian situation, stated that contributing factors to access to health care are multiple and include low literacy levels of women, high attrition rate, low morale of skilled health workers, and poverty. This case study presents solutions for poorly resourced communities such as Kiang West of Gambia. It highlights a multistakeholder collaboration approach for required meaningful and effective interventions that influence access to health care. The partnership between stakeholders strengthens health care delivery systems, thereby enabling access.
Health Care System of the Gambia The 2007–2020 National Health Policy Framework of Gambia, referred to as “Health is Wealth,” seeks to address common health desires through a number of initiatives in both preventive and curative health services. Figure 1 shows the primary health care modeled health care system, which is organized into primary (Village Health Services), secondary (major and minor Health Centers), and tertiary (Hospitals) levels of service delivery. Major health centers are staffed by doctors, state registered nurses, assistant public health officers, stateenrolled nurses, and other technical staff. Minor health centers have similar staff profiles, but are without medical doctors and laboratory services. Nurses provide the majority of clinical care at all levels of health service, while community health nurses are largely employed in community work. Assistant public health officers are responsible for
Figure 1. Structure of the Gambian Health care (Source: Department of state for health, Banjul the Gambia. Health Policy Framework 2007– 2020)
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health promotion and protection, including environmental hygiene and sanitation, immunization, and other preventive health measures at various levels of the delivery system. At the tertiary level, there are 10 hospitals while at the secondary level there are 35 health centers comprising 6 major and 29 minor Health Centers. In addition to the health centers, there are numerous village health service or “trekking” posts where Maternal and Child Health services are provided to communities without Health Center. The major health center is the first point of referral for the minor health center. Major Health Centers have laboratories and perform minor surgeries which are not present in minor Health Centers. The village health service was established to provide primary health care services. Communities are involved through Village Development Committees and Catchment Area Committees, including traditional birth attendants and village health workers.
Making Health Care Accessible in Rural Areas- Kiang West Methodology Kiang West is located in the Lower River Region (LRR) of Gambia, approximately 150 km from the capital, Banjul (Figure 2). It is bordered to the west and north by the Gambia River and on the south
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by a large tributary. The area has a 50% poverty rate and a population of approximately 30,000 people per Primary Health Care facility. This district is comprised of approximately 30 villages in sparse settlements. There is little or no meaningful economic activity in the district due largely to inadequate infrastructure and unpaved roads thereby making the area inaccessible, especially during rainy seasons. Its dispersed settlement characteristic of most rural areas elevates health care accessibility to a position of primary importance (Joseph & Moon, 2002). Several interventions were initiated by the health sector and stakeholders in Gambia to make health care more accessible and affordable for its citizenry. The appropriate interventions included improved staffing at the Karantaba Health Centre, which entailed the employment of traditional birth attendants and village health workers through Primary Health Care activities by community health nurses (Rayco-Solon, Moore, Fulford, & Prentice, 2004). The Expanded Program on Immunization, funded by the World Health Organization, Global Alliance for Vaccines and Immunization, and United Nations International Children Emergency Fund, aims to prevent infant mortality by providing vaccines for “childhood” diseases. Providing young children with two high doses of Vitamin A annually (at 6-month intervals) is a safe, cost-effective, and
Figure 2. Map of Kiang West District in Rural Gambia System
Sanneh et al.: Access to Basic Health care efficient strategy for eliminating Vitamin A deficiency and improving child survival. The purpose of this multistakeholder case study is to formulate an operational description of personal access to health care in a rural community. Figure 3 shows the multistakeholder case study model the authors created to analyze the collaborative interventions in Kiang West by the government, Medical Research Council, World Health Organization, and United Nations International Children Emergency Fund. The World Health Organization and other stakeholders support various government programs in terms of funding depending on target health needs. The government as a recipient, plans, organizes, and coordinates the implementation of programs to solve health issues in the Gambia. Research institutions like the Medical Research Council generate the much needed information for planning. Nongovernment organizations have clinics and provide health care services especially in areas where the government cannot afford to do so. This supports government efforts in providing basic health services to communities in rural areas like Kiang West. Stakeholder’s collaboration in making basic health care accessible will help in achieving the millennium development goals and international commitments in terms of health. Figure 4 shows access to health services in relation to poverty and population in Gambia. The LRR is shown in the figure as having the lowest percentage of population with access to Primary Health Care coverage. The two main providers of formal health care in Kiang West are the government and the Dunn Nutrition Unit of the Medical Research Council. In 1995, the Baby Friendly Community Initiative was piloted in 12 communities in
Figure 3. Multistakeholder Collaboration Model of Gambia Government, MRC, WHO and UNICEF in Kiang West
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the LRR (which includes Kiang West) of Gambia. This led to the expansion of the initiative to 293 communities across the country (The Gambia National Nutrition Agency [NaNA], 2009). The WHO has acknowledged the involvement of these systems by challenging global communities to improve standards of living through better access to health care (World Health Organization [WHO], 2011b). In all other divisions, the coverage is less than 50% of their population, the worst population to health center ratio is to be found in the URR and the NBR. Regional health management teams are established in all health administrative areas (World Bank, 2005). Every month, the staff of the Kiang West government health center conducts community visits to satellite villages. Infant immunization is conducted by the assistant public health officer while a midwife provides antenatal and maternal health care. During these immunization sessions, Bacille– Calmette–Guerin, oral polio vaccination, diphtheria, pertussis, tetanus, tetanus toxoid, yellow fever, hepatitis B, and measles vaccines are administered to infants (this was conducted by the first author from 2001 to 2003). In 2009, pneumococcal and pentavalent vaccines were added to the immunization routine. During community visits, sick people living in villages far from health centers are attended to, thus forestalling the villagers’ need to travel long distances to receive medication. The Medical Research Council also conducts similar community visits to other villages. Although their interventions are research based, they operate an outpatient department, offer nutrition supplementation, and support the health center in Karantaba by posting a
Figure 4. The Gambia, Poverty Versus Population Coverage of Basic Health Facilities by Division
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midwife there and helping to provide resources for the facility.
Discussion of the Kiang West Methodology Health issues challenge development in many developing countries, including Gambia. With a goal of improving the health of all Gambians with a per capita income of US$ 1,500 by 2020, the National Health Policy Framework’s mission is the promotion and protection of health through equitable access and affordable services. International organizations, such as the World Health Organization and the United Nations International Children Emergency Fund, act as decisive bodies of oversight and governance for broad goals, ‘Millennium Development Goals’, as well as Global Fund against Tuberculosis and Malaria programs. All of these efforts aim to ease the health burden in developing countries. Strengthened multistakeholder response, as shown in Figure 3, implemented within health systems with better-targeted, low-cost prevention and care strategies are suggested as the best interventions initiated for health care accessibility. Gambia’s Reproductive and Child Health Services have been expanded, in addition to having well-trained staff overseeing case management of common childhood illnesses/conditions under the Integrated Management of Neonatal and Childhood Illnesses strategy. Evaluation of Integrated Management of Child Illness interventions concluded that high risk and poor populations require proximal health services to improve health outcomes (Bryce, Boschi-Pinto, Shibuya, & Black, 2005). The primary health care strategy adopted by the Gambia government has paved the way for decentralization and near-target population management to improve the efficiency of national programs. Strategies for active surveillance of infectious diseases, particularly those affecting children, have been developed and strengthened at both national and community levels. The target diseases have either been eliminated or are in the process of being eradicated (for example, poliomyelitis, measles, and neonatal tetanus). These results were facilitated by the collaborative multistakeholders approach, as shown in Figure 3. Improved childhood vaccination coverage is a key indicator for the country’s health policy objectives. As availability increases, addressing
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issues of demand and timely schedule completion will be solved. Vaccinations conducted by public health officers at outreach stations will boost the immune systems of infants, protecting them from disease and curtailing infant mortality (70.14 deaths out of 1,000 live births, according to year 2007 estimates). As a result of the combined efforts of the World Health Organization, United Nations International Children Emergency Fund, as well as other partners, the immunization coverage for Diphtheria Pertussis Tetanus, Bacille Calmette Guerin, measles, and polio vaccines is currently at 80% or more (as shown in Figure 5), compared with approximately 30%, 20 years ago. Infant mortality has been curtailed as a result (67.49 out of 1,000 live births, according to year 2010 estimates). Services provided by midwives help reduce maternal mortality (540 out of 100,000 live births). A survey on antenatal care delivery, coverage, and access in Gambia (Reproductive and Child Health, Department of State for health [DoSH], The Gambia & Center for Innovation Against Malaria (2007), revealed that 99.2% of pregnant women used formal antenatal services, 67% received antennal care at a health center, 24% received antennal care at an outreach post, 90% visited four or more times, and 96% were satisfied with the services received. Coverage of antenatal care by skilled personnel (doctor, nurse, or midwife), is relatively high in Gambia, with 97.8% of women receiving antenatal care at least once during their last pregnancy. This validates the effectiveness of the multistakeholder collaboration and community involvement through the training of Village Health Workers and Traditional Birth Attendants, in making health care accessible. Vitamin A is critical to child health and immune function. As such, it is critical to the achievement of the fourth ‘Millennium Development Goal’: a twothird reduction in the mortality of children under five by 2015. Giving Vitamin A to breastfeeding mothers helps protect their children during the first months of life, and helps replenish the mother’s health as well. The Multi Indicator Cluster Survey study has shown that Vitamin A supplementation coverage in Gambia is lower in urban areas (77%) than in rural areas (82%) (GBOS, 2011). In the final analysis of this case study, no single organization, sector, nor approach can provide answers for underdevelopment, poverty, and ill
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Figure 5. Immunization Coverage of the Gambia from 2000 to 2008 health. There is little or no meaningful economic activity in Kiang West, where households live below the poverty line and thus cannot change their situations by themselves. Lack of communication services and public transport make the situations of impoverished communities more difficult. Women struggle to take sick family members to health facilities. Some even walk long distances just to receive basic health care. This situation, however, is
not unique to Kiang West, as many other places in the developing world face similar difficulties. We believe that the multistakeholder model used in this area is feasible, appropriate, and can be replicated in other communities. The barriers identified during the case study such as poverty, access to basic health services due to inadequate transportation and communication, impacted heavily on the health and well-being of
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the residents of Kiang West. The inadequate number of health personnel deprives communities’ access to timely health care. Effort to address these barriers by government and other stakeholders was the application of the primary health care strategy where health providers traveled to communities to provide basic health services. We recognize the importance of visiting villages far removed from health centers to provide reproductive and child health care services. This model eases the health care burden for isolated communities located 30 km away from health centers. Addressing the underlying determinants of health is a key factor in achieving MDGs and ensuring sustainable development. The importance of cooperation, both within a specific sector and across sectors, cannot be stressed enough. Progress should be made in forging closer ties between the health sector and other sectors, particularly through local, national, and multistakeholder development plans. This case study suggests that health systems should be oriented toward the needs of the poor, giving greater attention to redressing inequities and closing in on gaps in research. Further study of medical access, specifically in terms of health care delivery system, availability of resources, perceived morbidity and mortality of communities at risk should be a priority.
Acknowledgments The authors are grateful to the Gambia government Ministry of Health, Expanded Program on Immunization and the Integrated Management of Neo Natal and Childhood Illnesses Offices and thank the reviewers for their helpful comments.
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