THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Caitlin Noonan · Latifat Okara · Marwa Ramadan · Manuela Villar Uribe THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Caitlin Noonan · Latifat Okara · Marwa Ramadan · Manuela Villar Uribe July 2023 © 2023 The World Bank Group 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org and www.ifc.org SOME RIGHTS RESERVED This work is a product of the staff of The World Bank and the International Finance Corporation (the World Bank Group) with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank’s Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the information included in this work. 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DISCLAIMER — PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any specific partner organization. Content Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Key findings from the VSP assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Inputs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Population health and facility management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Appendix A. Performance Domain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Appendix B. Capacity Domain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Appendix C. PHCPI Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Appendix D. Recommendations Based on The Gambia VSP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Appendix E. Implications of the Recommendations for Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Appendix F. Progression Model Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Appendix G. Progression Model Documents Reviewed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Appendix H. Project Development Objective (PDO) Indicators, The Gambia Essential Health Services Strengthening Project (P173287) . . . . . . . . . . . . . . . . . . . . . . . . . . .78 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 List of figures Figure 1. Top 10 causes of deaths per 100k in 2019 and rate change 2009–2019, all ages combined . . . . . . . . . . . . . . . . . 17 Figure 2. Barriers to care-seeking among women in The Gambia (2013–2020) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Figure 3. Geographic and financial barriers to care among women in The Gambia by urban rural residence (2013–2020) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Figure 4. Childhood nutrition indicators by local government area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Figure 5. Proportion of facilities providing NCD, infectious disease, and maternal and child health services by service type (2019–2020) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Figure 6. Disparities in RMNCH service coverage by mother’s education level, 2019–2020 . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Figure 7. Variation in PHC coverage indicators in The Gambia by local government area . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Figure 8. Changes in health expenditure by revenue source in The Gambia, 2000–2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 List of TABLes Table 1. Service coverage of RMNCH, infectious diseases, NCDs, and nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Table H.1 Project Development Objective (PDO) indicators and targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 List of BOXes Box 1. A focus on adolescent women’s health care in The Gambia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 6 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Acknowledgements This report was written by a World Bank (WB) team led by Manuela Villar Uribe, Jaime Bayona, Latifat Okara, Caitlin Noonan, and Marwa Ramadan. Dawda M. Joof contributed extensively to data collection and contextualizing The Gambia’s health care system. Revision and feedback were provided by the larger WB team, including Cameron Feil and Jose Gutierrez. Ousman Ceesay, The Gambia MOH focal point, provided invaluable guidance and support throughout data collection. The team is also extremely grateful to the WB task team leader for The Gambia, Samuel Lantei Mills, as well as the key informants interviewed, the PHC assessment Steering Committee members, and the participants of the validation workshop held in November 2021 (see list of names in Appendix F). The team at the Primary Health Care Performance Initiative also supported this work. The authors would like to thank Lucy Hartshorn and Hannah Ratcliffe at Ariadne Labs for their review and contributions to data analysis and validation of the findings highlighted in this report. L IST OF ABBREVIATIONS 7 List of Abbreviations ANC Antenatal Care CHW Community Health Worker DALY Disability-Adjusted Life Year DHIS2 District Health Information Software 2 DPT3 Diphtheria-pertussis-tetanus, third dose DRF Drug Revolving Fund GDP Gross Domestic Product GGHE General Government Health Expenditure HMIS Health Management Information System IDSR Integrated Disease Surveillance and Response IHME Institute for Health Metrics and Evaluation MOH Ministry of Health NCD Noncommunicable Disease NGO Non-Governmental Organization OOPS Out-of-Pocket Spending ORS Oral Rehydration Salts PHC Primary Health Care PHCPI Primary Health Care Performance Initiative PPP Purchasing Power Parity RMNCH Reproductive, Maternal, Newborn, and Child Health TB Tuberculosis UHC Universal Health Coverage VSP Vital Signs Profile WHO World Health Organization 8 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Executive Summary 9 Executive Summary 10 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT The Vital Signs Profile (VSP) exercise provides an opportunity to assess the state of the primary care system in The Gambia. This report presents the findings of the VSP exercise conducted by the Primary Health Care Performance Initiative (PHCPI) of the WB in collaboration with The Gambia Ministry of Health (MOH). The assessment highlights areas of strength and challenges through the lens of the PHCPI framework, which organizes five domains of primary care service through a logic model approach. The PHCPI methodology encompasses the traditional inputs and outputs of primary care systems but also places a strong focus on the processes of service delivery and performance of the primary health care (PHC) system (1). PHCPI recognises the role of social determinants of health and intersectoral health promotion and prevention efforts as chief factors influencing population health, although the VSP is primarily focused on aspects of health service delivery. Although The Gambia’s PHC system has experienced significant improvements, many challenges persist. Geographic and financial access to care is a persistent problem for the population, as 26 percent of women face barriers to receiving care when in need because of distance, and 27 percent face barriers due to a lack of funds (2). These barriers are greater for more vulnerable populations as evidenced by large disparities in access to services by wealth quintile: forty-six percent of women in the lowest wealth quintile report facing financial barriers to access compared to only 13 percent of women in the highest wealth quintile. Barriers to accessing PHC are compounded by gaps in coverage for infectious disease, reproductive, maternal, newborn, and child health (RMNCH), and noncommunicable disease (NCD) services, despite significant improvements in coverage indicators from 2013–2020. Notably, for infectious diseases, the percentage of TB cases detected and treated with success declined by 12 percentage points from 62 percent in 2013 to 50 percent in 2019. Other declines in infectious diseases include a 15-percentage point decrease in children under 5 with diarrhea receiving ORS, while the percent of people living with HIV receiving anti-retroviral treatment and the population sleeping under Executive Summary 11 insecticide-treated nets (ITNs) have remained low. When patients access facilities, specific services are often unavailable; The Gambia performs well in the availability of maternal and child health care services, but the provision of infectious and NCD services is relatively low across PHC facilities. This is particularly important as the country faces a large burden of communicable diseases, with 52 percent of deaths attributable to communicable diseases and 21 percent of premature deaths due to NCDs (3). The capacity of the PHC system in The Gambia—including measures of governance, the availability of inputs, and population health and facility management—demonstrates important strengths as well as areas for improvement. Governance involves assessing policies, quality management infrastructure, social accountability, and the system’s ability to adjust to population health needs. The Gambia has strong policies and plans in place for PHC, and the private sector, civil society, and non-governmental organizations play a large role in health care service delivery. The National Assembly of The Gambia enacted into law The National Health Insurance Bill, 2021 (Ministry of Health, 2021), which establishes a mandatory National Health Insurance Scheme (NHIS) that will include a package of essential health care services delivered at varying levels of care and will pay for the cost of health care services to NHIS members. However, the private sector has minimal involvement in planning and monitoring PHC policies. Inputs are measured to identify resource gaps and required resources for timely, appropriate, and high-quality PHC services. There is significant variation between facility types and local government areas in terms of the availability of essential medicines and supplies, and less than one-third of PHC facilities have all basic tracer items for diagnosing disease. The Gambia has made major investments in the establishment of a Health Management Information System (HMIS), but further digitalization of the system’s data collection methods at facility level is needed. The Gambia’s surveillance 12 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT system also requires improvements, including strengthening data quality and interoperability between electronic systems. The Gambia’s PHC system has a shortage of skilled health professionals, with only 5.9 allocated per 10,000 population, compared to the WHO target of 4.45 physicians, nurses and midwives per 1000 population. However, the country has implemented mechanisms such as stringent accreditation processes to ensure a minimum quality of care for graduating health workers. Population health and facility management evaluates the effectiveness of managing population health and the contribution of facilities to achieving this goal. Proactive population outreach is a strength of The Gambia’s PHC system, with a strong cadre of community health workers (CHWs) providing outreach for various services, while the PHC system in The Gambia has made significant progress but still faces challenges, highlighting the need for continued investment and improvement. The Gambia’s prioritization of PHC funds ranks among the top sub- Saharan countries, with 71 percent of total health expenditure allocated to PHC in 2019, compared to a median of 64 percent for sub-Saharan countries with available expenditure data. Although The Gambia prioritizes PHC funding over other levels of the health system, it ranked the fourth lowest among sub-Saharan countries in terms of per capita expenditure on PHC in 2019 at US$16 among 37 countries with available data. From 2000–2019, government health spending and out-of-pocket expenditure remained static, while the contribution of international sources in health expenditure fell markedly, resulting in an overall decrease in health spending per capita. Low funding levels highlight the need for continued investment to address the availability of essential medicines and supplies and the shortage of skilled health professionals. The results of the assessment point to four policy recommendations to address challenges related to governance, availability of medicines and supplies, comprehensiveness of services, and ability to deliver adolescent Executive Summary 13 sexual and reproductive health (ASRH) services and promote universal and effective PHC coverage in The Gambia: 1. Establish a PHC-specific policy focused on improving coordination across governmental and non-governmental actors, quality of care, and monitoring and evaluation. The report recommends establishing a comprehensive PHC policy in The Gambia, along with a coordinating authority to monitor and implement it. This policy should focus on improving coordination between government and non-governmental actors, promoting a focus on quality, and establishing key indicators for measuring PHC performance at all levels. The report emphasizes the need for increased data collection and better informatics at every level of the health system to guide the implementation of PHC-related activities. 2. Increase the availability of medicines and supplies by leveraging existing purchasing mechanisms and strengthening supply chain management. To achieve this, The Gambia can support the National Health Financing Strategy and conduct an audit of the Drug Revolving Fund (DRF) to improve transparency and control over DRF operations. Furthermore, a needs-based resource allocation formula could be developed, and investments in the existing Electronic Logistics Management Information System (eLMIS) could be made to strengthen supply chain management. 3. Implement a people-centered model of PHC focused on delivering comprehensive infectious and NCD services. An empanelment system could be established to improve continuity in care and promote team-based care. Establishing an empanelment system would entail identifying the population, assigning population members to specific facilities or providers, and periodically reviewing and updating based on demographic shifts. Multi-disciplinary teams for health service delivery can also be employed, including CHWs and community health nurses (CHNs), to improve continuity of care between 14 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT households and health facilities. At facilities, ensuring that providers have the skills and competencies to provide a comprehensive range of services is critical to improving patient outcomes and reducing spending. This is particularly important as The Gambia faces new health system pressures caused by an increasing burden of NCDs and infectious diseases. 4. Increase capacity for adolescent sexual and reproductive health service delivery. The Reproductive, Maternal, Neonatal, Child, and Adolescent Health (RMNCAH) policy and national strategic plan (2017- 2026) recognizes this need and recommends the integration of ASRH services into the existing public health system. The WHO’s 2017 Global Accelerated Action for the Health of Adolescents (AA-HA!) guidance provides a systematic approach for developing comprehensive adolescent health strategies, which could be implemented in The Gambia. Evidence-based strategies include strengthening access to ASRH training for health care providers, integrating ASRH services within existing sexual and gender-based violence one-stop centers, providing financial support for ASRH service delivery at youth- friendly sexual and reproductive health community centers, and engaging religious and traditional leaders in ASRH communication. The development of an explicit adolescent health and development service policy and strategic plan is recommended to coordinate ASRH- related activities. Introduction 15 Introduction 16 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Health outcomes in The Gambia have steadily improved in recent decades. Regarding child health, the under-five mortality rate decreased from 166 to 49 deaths per 1,000 live births from 1990 to 2020 (4), while the prevalence of stunting among children under 5 decreased from 24.5 percent to 17.5 percent, and wasting decreased from 11.5 percent to 5.1 percent between 2013 and 2020 (2). Life expectancy at birth increased from 59 years in 2000 to 66 in 2019 (3). Additionally, the maternal mortality ratio decreased by 69 percent from 2000 to 2020, from 932 maternal deaths per 100,000 live births to 289 per 100,000 live births (2). This decline in maternal mortality is attributable in part to increased access to high-quality maternal health services. For example, the proportion of births attended by skilled health personnel increased from 44.1 percent in 1990 to 57.2 percent in 2013 and to 83.8 percent in 2020 (2). Despite recent progress, The Gambia is undergoing an epidemiological transition characterized by a rising burden of NCDs alongside persistent high rates of infectious diseases. Communicable, maternal, neonatal, and nutritional diseases remain the leading causes of mortality, although their proportion of the total disease burden generally decreased from 2009 to 2019 (Figure 1)(5). NCDs represent a larger proportion of the disease burden in recent years. Between 2009 and 2019, deaths per 100,000 population due to ischemic heart disease increased by 4.6 and stroke increased by 1.6 (Figure 1). NCDs can often require continuous, life-long, and often expensive treatment, leading to higher levels of health expenditure, which is an important consideration as the country transitions to higher rates of NCDs. Introduction 17 Figure 1. Top 10 causes of deaths per 100k in 2019 and rate change 2009–2019, all ages combined Communicable, maternal, neonatal, and nutritional diseases Non-communicable diseases Cause 2009 rank 2019 rank Change in deaths per 100k, 2009–2019 Lower respiratory infect 2 1 −15.8 Ischemic heart disease 5 2 +4.6 Neonatal disorders 1 3 -37.2 HIV/AIDS 3 4 −20.7 Stroke 8 5 +1.6 Tuberculosis 7 6 −8.9 Malaria 4 7 −37.9 Diarrheal diseases 6 8 −18.3 Liver cancer 10 9 +1.5 Cirrhosis liver 11 10 −0.3 Source : Institute for Health Metrics and Evaluation (IHME), 2020. The Gambia’s health care delivery system includes primary, secondary, and tertiary levels of care. Each tier refers patients to the next higher tier of services. The primary tier consists of village health services (VHS) and community clinics for promotive and preventive health care. The VHS are staffed by village health workers (VHW) and community birth companions (CBC). The community clinics are run by CHNs or midwives. The secondary tier includes minor and major health centers that serve as referral facilities for the first tier. Minor health centers deliver up to 70 percent of the basic health care package, including basic emergency obstetric and neonatal care. When cases are beyond their capacity, they refer patients to major health centers. Major health centers provide minor surgeries, comprehensive emergency obstetric care, and radiology and laboratory services, among others. Hospitals comprise the tertiary level of care; the highest-level referral facility is the teaching hospital in the capital city Banjul. 18 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT The Gambia adopted a three-tier hierarchical health care system to implement PHC. The PHC strategy establishes a comprehensive basic health care package of services (integrated health promotion, disease prevention and curative health care services), which are delivered at village health services, community clinics, minor and major health centers, and hospital outpatient departments by trained health workers (CHWs, CHNs, registered nurses, midwives, and doctors). The services in the comprehensive package of services include reproductive, maternal and child health care services (vaccination and growth monitoring), antenatal care (ANC) services, deliveries, minor surgeries, diagnosis and treatment of common diseases (such as malaria, diarrhea, pneumonia, other childhood diseases, communicable diseases, NCDs, STIs, TB, and HIV/AIDS), and injury treatment. Other services in the package include nutrition and social services, hygiene education, and basic sanitation. Government policies and strategies in the health sector support universal health coverage (UHC) by ensuring access to quality essential health care services without creating financial hardship. Both The Gambia National Health Policy (GNHP) 2021–2030 and The Gambia National Health Strategic Plan (GNHSP) 2021–2025 aim to accelerate provision of quality services and UHC. There is an existing Health Financing Policy (2017–2030) to ensure that adequate financing is made available to achieve the national health strategic plans. The Gambia National Health Financing Strategic Plan 2019–2024 operationalizes The Gambia National Health Financing Policy 2017–2030 and provides a pathway for health care reform in The Gambia. Furthermore, the Financing Strategic Plan lays the foundation for the development of a National Health Financing and Payment Mechanism with a view to ensuring security and protection for the rights of health care services for the population. Further, The Gambia National Development Plan (2023–2027) calls for the establishment of a social health insurance scheme. The NHIS was passed by parliament in 2021 and is being prepared for launch in September Introduction 19 2023. The mandatory NHIS will pay for the cost of health care services to members of the scheme and includes a proposed package of essential health care services to be delivered at each level of care (village health services, community clinics, minor and major health centers, general/ district hospitals, and the teaching hospital). Once finalized, the package will be used to develop standards for infrastructure and equipment and to update the list of essential medicines, quality-of-care checklists, and staffing standards for public and private facilities. Using information from household and facility surveys and key informant interviews, the VSP identifies the strengths and areas for improvement of The Gambia’s PHC system to provide the foundation for actionable policy recommendations. The results are presented using the five core dimensions of PHC as identified by the PHCPI VSP: coverage, access, equity, capacity, and financing. Each domain’s performance is measured through a collection of best-practice indicators derived from selected qualitative and quantitative data sources. The results and recommendations can be used by policymakers, donors, advocates, and citizens to better understand and ultimately improve PHC in The Gambia. 20 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Key findings from the VSP assessment 21 Key findings from the VSP assessment 22 The Gambia Draft Primary Health Care Vital Signs Profile FINANCING CAPACITY PERFORMANCE EQUITY 11 GHED 2019 Primary Health Care Progression Model PHC spending: Governance Access Index Access: % with perceived barriers Demographic and Health Survey (DHS) (2019-2020) due to cost, by wealth quintile $16 DHS (2019-2020) 1.7 74 Per capita HIGHEST LOWEST 0 100 0 100 13 46 Prioritization of PHC: Quality Index12 Overall health spending8 Inputs SARA (2019), DHS (2019-2020), WHO TB Country Coverage of RMNCH13 services, Profile (2021), Patient Satisfaction Survey (2018) 71% on PHC by mother’s education DHS (2019-2020) 1.8 67 Government health spending9 0 100 NONE SECONDARY + 70% on PHC 0 100 67 71 Sources of PHC spending: Service Coverage Index Population Health & Facility Outcomes: Under-five 40% Government10 DHS (2019-2020), WHO TB Country Profile (2021), Management UHC Global Monitoring Report (2021) mortality, by residence DHS (2019-2020) 50 URBAN RURAL 2.3 0 100 60% Other 0 100 51 66 COUNTRY CONTEXT AT-A-GLANCE GDP per Living in Government Life Maternal Neonatal Premature Causes capita1 poverty2 health spending expectancy mortality4 mortality5 NCD mortality6 of death 37% Non-Communicable (PPP int’l dollars) (Under $2.15 int’l as % of GDP3 at birth (Per 100,000 live (Per 1,000 live births) (Probability) WHO est. (2019) Diseases WDI (2021) dollars / day) (Years) births) WHO est. (2020) WHO est. (2019) WHO GHED (2019) WHO est. (2017) WDI (2015) WHO (2019) 52 % Communicable and $2,434 13% 1% 66 597 26 21% Other Conditions7 10% Injuries Note: Indicator values presented here may differ from country data sources due to the use of standardized categories and 1. Country provided value: $2231, BGoS 2021 7. Communicable, maternal, perinatal and nutritional conditions methods to enhance international comparability. See Indicator Description Sheet for details. 2. Poverty data expressed in 2017 Purchasing Power Parity (PPP) prices, reflecting the recent change in the World Bank 8. Current PHC expenditure as % of Current Health Expenditure (CHE) estimation and reporting methodology 9. Domestic general government PHC expenditure as % of domestic general government health expenditure Note: Scores for the Capacity, Performance, and Equity domains are color-coded to reflect good (green), medium (yellow), 3. Domestic general government health expenditure as % of gross domestic product. Country provided value: 1.7%, 10. Domestic general government PHC expenditure as % of current PHC expenditure and poor (red) performance, where comparable data are available. Cut-offs can be found in the Indicator Description Sheet. National Health Accounts 2017 11. The PHC Progression Model uses mixed methods to assess foundational capacities of PHC on a scale from 1 (low) to 4 (high) 4. Country provided value: 289, Demographic and Health Survey 2019-2020 12. Because different data/indicators are used in each country, composite index values may not be comparable across countries. Scores based on data from non-comparable sources are colored gray. Finance indicators are not color-coded because these 5. Country provided value: 29, Demographic and Health Survey 2019-2020 See page 2 for the specific indicators used in this VSP. indicators lack common targets. Last updated 12/2022 6. Probability of dying between ages 30 and 70 from cardiovascular diseas, cancer, diabetes, or chronic respiratory disease 13. The composite coverage index is a weighted score reflecting coverage of eight RMNCH interventions along the continuum of care A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA Key findings from the VSP assessment 23 Performance PHC performance refers to the ability of a PHC system to provide high- quality services to populations in need without financial or geographic barriers. In the PHCPI framework, the performance domain consists of three sub-domains: access, coverage, and quality. The access sub-domain includes measurements of financial barriers to care and geographic hardship due to distance. The coverage sub-domain reflects the proportion of the population in need of services who receive them based on a broad range of clinical services related to RMNCH, infectious diseases, and NCDs. The quality sub-domain is organized around core principles proven to impact the quality of PHC service delivery, including the comprehensiveness of care, continuity of care, person-centeredness, provider availability and competence, and safety practices. Access The access domain in the PHCPI framework captures whether individuals can receive appropriate PHC without undue financial or geographic barriers. Access to care is an important dimension of PHC performance, as PHC cannot be considered high-performing if patients are faced with barriers to accessing care, regardless of service quality. Reducing real and perceived barriers to accessing care is typically an important priority for policymakers seeking to improve PHC performance. Almost half of women aged 15 to 49 years in The Gambia reported facing obstacles when accessing health care for themselves when sick, according to the 2019–20 DHS. The most cited reasons were financial constraints with getting money for advice or treatment (27 percent) and the distance to health facilities (26 percent) (Figure 2). These challenges vary widely across residence, with rural women experiencing higher barriers related to financial constraints (38 percent) and distance to health facilities (41 percent) than their urban counterparts (23 percent and 20 24 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT percent, respectively) (Figure 3). Furthermore, disparities exist across local government areas, with 47 percent of women in Janjanbureh facing financial barriers, compared to just 7 percent in Banjul. These findings indicate that the financial and geographic barriers to health care services perceived by women aged 18–49 remain persistent, with similar trends observed since 2013. Figure 2. Barriers to care-seeking among women in The Gambia (2013–2020) Barriers to care seeking among women in The Gambia (2013-2020) 100 80 60 Percent (%) 40 29.7 27.1 28 25.5 20 14.2 9.8 5.3 4.7 0 Getting permission Getting money Distance to health Not wanting to go for treatment for treatment facility to go alone DHS 2013 DHS 2019-20 Source: DHS 2013, DHS 2019–2020. Figure 3. Geographic and financial barriers to care among women in The Gambia by urban rural residence (2013–2020) Geographic and financial barriers to care among women in the Gambia by urban-rural residence 2013-2020 60 50 43 40 41 38 Percent (%) 40 30 23 22 20 20 16 10 0 Urban Rural Urban Rural Financial Geographic DHS 2013 DHS 2019-20 Source: DHS 2013, DHS 2019-2020 Key findings from the VSP assessment 25 Coverage PHCPI aims to measure coverage by assessing the effectiveness of service delivery on RMNCH, NCDs, and infectious diseases. Table 1 presents the VSP indicators selected to measure the coverage of PHC services in The Gambia and that are fundamental in measuring UHC. For this report, four additional indicators were included to capture the coverage of nutrition services: the prevalence of stunted, wasted, and underweight children under 5 years and the prevalence of anemia among women 15–49 years. The Gambia has made significant improvements in the coverage of PHC services from 2013–2020; however, there are still gaps in the coverage of RMNCH, infectious disease, and NCD services. Table 1 outlines the coverage of services for RMNCH, infectious diseases, NCDs, and nutrition using data from the most recent household surveys and monitoring reports. Appendix H includes additional coverage indicators that were measured as part of the Project Development Objective (PDO) for The Gambia Essential Health Services Strengthening Project funded by the World Bank Group. The VSP assessment team opted to use coverage indicators from the DHS 2019–2020 due to varying methodologies between the PDO indicators and globally comparable indicators from the DHS. 26 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Table 1. Service coverage of RMNCH, infectious diseases, NCDs, and nutrition Percent Percent Percentage Point Indicator Source (2013) (2019-2020) Change RMNCH Demand for family planning satisfied with 23.8 39.6 ↑ 15.8 DHS modern methods ANC coverage (4+ visits) 77.6 78.5 ↑ 0.9 DHS Coverage of DPT3 vaccination 83.8 93.0 ↑ 9.2 DHS Percentage of children under 5 with symptoms of acute respiratory infection, 71.2 70.3 ↓ 0.9 DHS for whom advice or treatment was sought Infectious diseases WHO TB TB cases detected and treated with success 62 50 ↓ 12 Country Profile UHC Global People living with HIV receiving 24* 31** ↑7 Monitoring antiretroviral treatment Report Children under 5 with diarrhea receiving 59.2 44.3 ↓ 14.9 DHS oral rehydration salts (ORS) Population slept under ITN the night 36.9 37.8 ↑ 0.9 DHS before a survey NCDs UHC Global Non-elevated blood pressure prevalence 42* 38** ↓4 Monitoring Report Nutrition Child under 5 stunting prevalence 24.5 17.5 ↓ 7.0 DHS Child under 5 wasting prevalence 11.5 5.1 ↓ 6.4 DHS Child under 5 underweight prevalence 16.2 11.6 ↓ 4.6 DHS Anemia among women aged 15–49 60.3 44.3 ↓ 16.0 DHS prevalence Note: DHS = Demographic and Health Survey; DPT3 = Diphtheria-Pertussis-Tetanus, Third Dose; NCDs = noncommunicable disea - ses; RMNCH = reproductive, maternal, newborn, and child health; TB = tuberculosis; ITN = insecticide-treated nets. * UHC 2017 report based on 2015 estimates. ** UHC 2021 report based on 2019 estimates. Key findings from the VSP assessment 27 The VSP assessment in The Gambia shows that effective coverage of RMNCH services has had notable improvements since 2013, but challenges remain. Notably, DPT3 immunization coverage increased from 83.8 percent in 2013 to 93.0 percent in 2020. Over the same period, the coverage of ANC services remained the same with a slight increase in the percentage of women receiving four or more ANC visits, from 77.6 percent to 78.5 percent. There has also been little change in the percentage of children with symptoms of acute respiratory infection for whom advice or treatment was sought; it dropped by one percentage point from 2013 (71.2 percent) to 2020 (70.3 percent). Demand for family planning satisfied with modern methods increased by nearly 16 percentage points from 2013 to 2020, from 23.8 percent to 39.6 percent. However, there is still an opportunity for substantial improvement in the coverage of family planning services, as more than 60 percent of women did not have their family planning needs met with modern contraceptives. The low coverage of infectious disease services (including for HIV, malaria, and TB) poses a significant challenge in The Gambia. Based on the 2021 UHC Global Monitoring report, a relatively large proportion of the population is not receiving HIV and malaria prevention services. For example, 31 percent of people with HIV received anti-retroviral treatment, and only 38 percent of the population slept under insecticide-treated nets (ITN) for malaria prevention. In addition, coverage for TB and diarrhea services has regressed since 2013 as half of TB patients were not successfully treated, and only 44 percent of children with diarrhea received ORS in 2020—a 15-percentage-point drop compared to 2013 DHS estimates. The coverage of NCD services, including the diagnosis and treatment of hypertension, requires attention as the prevalence of this condition increases. The 2021 UHC report estimates that only 38 percent of the adult population in the country had normal blood pressure compared to 42 percent in 2017 (2019 UHC report)—an issue that warrants improved and greater service provision to patients with cardiovascular illnesses in primary care. 28 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Childhood nutrition coverage improved in The Gambia between 2013 and 2020; however, variation remains across local government areas. From 2013 to 2020, the proportion of children who are stunted declined from 24.5 percent to 17.5 percent, wasting declined from 11.5 percent to 5.1 percent, underweight children declined from 16.2 percent to 11.6 percent, and women (aged 15–49) with anemia declined from 60.3 percent to 44.3 percent. However, disparities exist across local government areas (Figure 4(i)), and local government areas such as Kuntaur and Basse continue to face challenges, where one quarter (25 percent) and one fifth (21 percent) of under-five children are stunted, respectively. Figure 4. Childhood nutrition indicators by local government area i) Percent of stunted children Kuntaur Kerewan Banjul Basse Janjanbureh Mansakonko Brikama Children stunted 10.1% - 13.2% 13.21% - 17.2% 17.21% - 19.4% 19.41% - 20.8% 20.81% - 25.2% Kuntaur Kerewan Banjul Basse Janjanbureh Mansakonko Brikama Children underweight 7.8% - 9.2% 9.21% - 12.1% Children stunted Brikama 10.1% - 13.2% Children stunted 13.21% - 17.2% 17.21% 10.1% - -13.2% Key findings from the VSP assessment 19.41% 19.4% 20.8% 13.21% - 17.2% 29 20.81% 25.2% 17.21% --19.4% 19.41% - 20.8% 20.81% - 25.2% ii) Percent of underweight children Kuntaur Kerewan Kuntaur Banjul Basse Kerewan Banjul Basse Janjanbureh Mansakonko Janjanbureh Brikama Mansakonko Children underweight Brikama 7.8% - 9.2% Children underweight 9.21% - 12.1% 12.11% - 14.1% 7.8% - 9.2% 14.11% 14.7% 9.21% --12.1% 14.71% 15.2% 12.11% - 14.1% 14.11% - 14.7% 14.71% - 15.2% iii) Percent of wasted children Kuntaur Kerewan Kuntaur Banjul Basse Kerewan Banjul Basse Janjanbureh Mansakonko Janjanbureh Brikama Mansakonko Children wasted Brikama 2.4% - 3.9% Children wasted 3.91% - 4.7% 2.4% --3.9% 4.71% 5% 5.01% 6.4% 3.91% - 4.7% 6.41% 6.5% 4.71% - 5% 5.01% - 6.4% 6.41% - 6.5% Source: DHS 2019–2020. 30 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Box 1. A focus on adolescent women’s health care in The Gambia Adolescent women in The Gambia continue to face significant barriers to comprehensive health care. Nearly half of adolescent women aged 15–19 (48 percent) report serious problems in accessing care when they are sick. Based on the 2019–2020 DHS, the leading barriers are related to getting money for advice or treatment (28.2 percent), distance to the health facility (26.8 percent), and not wanting to go alone (22.8 percent). From 2013 to 2020, the percentage demand satisfied by modern contraceptive methods among adolescent women aged 15–19 remained relatively stable, increasing from 10.9 to 13.0 percent, and is still below the national average for all currently married women of reproductive age (40 percent). Looking at adolescent pregnancy, from 2013 to 2020, the percentage of women aged 15–19 who have had a live birth declined slightly from 14.3 percent to 10.6 percent. In the same period, knowledge of HIV prevention methods declined among both adolescent women and men. Specifically, 46 percent of adolescent women and 39 percent of adolescent men aged 15–19 still lack appropriate knowledge on HIV prevention methods in 2020 compared to 38 percent and 36 percent, respectively, in 2013. These results highlight the need for increased access to health care, including family planning and health education, among adolescents in The Gambia. Adolescent health indicators in The Gambia Indicator Percent (2013) Percent (2019–2020) Percentage Point Change Problems in accessing health care when sick, 43.9 47.9 ↑ 4.0 women aged 15–19 Family planning demand satisfied by modern 10.9 13.0 ↑ 2.1 methods, women aged 15–19 Knowledge of HIV prevention methods, 61.5 53.8 ↓ 7.7 women aged 15–19 Knowledge of HIV prevention methods, men 63.6 61.2 ↓ 2.4 aged 15–19 Source: DHS 2013, DHS 2019–2020. Key findings from the VSP assessment 31 Quality The overall quality index score of 67 for PHC in The Gambia indicates room for improvement across all six quality subdomains. In the PHCPI framework and the VSP, PHC quality encompasses not only clinical quality, but also core principles of service provision that have been shown to impact PHC quality; these include comprehensiveness, continuity, and person-centeredness of service delivery as well as aspects such as provider competence and safety. The Gambia performs well in three quality dimensions: comprehensiveness of RMNCH service, competence of providers when delivering ANC, and continuity of infectious disease services. Areas for improvement include the availability of RMNCH providers, the comprehensiveness of infectious disease and NCD services, as well as patient safety. RMNCH services are considered comprehensive in The Gambia, meaning PHC facilities provide holistic and appropriate RMNCH care across a range of health problems, age groups, and treatment options within a single facility. However, in regard to infectious diseases and NCDs services, PHC services are not as comprehensive. In the VSP, comprehensiveness of care is measured through the availability of tracer services for infectious disease, NCD, and RMNCH. Higher scores in these indicators are associated with more efficient PHC systems and better patient experiences. A closer look at available indicators for comprehensiveness shows that in The Gambia, the provision of infectious disease services is relatively low for TB and HIV. According to the 2019 SARA survey, 94 percent of facilities offer STI services, but less than half offer TB services (38 percent) and HIV care and support services (18 percent) (Figure 5). Service availability for infectious disease also varies widely by local government area and facility type. For example, the percentage of facilities that offer TB services ranges from 49 percent in the North Bank West Region to 15 percent in the North Bank East Region, while the mean number of medicines, basic equipment, and diagnostic supplies for TB service readiness ranges from 90 percent in 32 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT general hospitals to 29 percent in community clinics. Overall, the provision of services for NCDs is also low, with 62 percent of facilities providing services. Breaking this down by disease, 70 percent of facilities offer services for cardiovascular disease diagnosis/management, 69 percent for diabetes, and 48 percent for chronic respiratory disease (Figure 5). Service availability for maternal and child services is higher, with 71 percent of facilities offering basic services, including 92 percent of facilities providing family planning and sick child services, 75 percent providing ANC services, 53 percent providing vaccination, and 44 percent providing PMTCT (Figure 5). However, similarly to infectious diseases, there are significant disparities in service availability by local government area and facility type, with 54 percent of facilities in the Lower River Region offering ANC services compared to 88 percent in Western Region 1, and 86 percent of general hospitals offering ANC services compared to 59 percent of community clinics. Figure 5. Proportion of facilities providing NCD, infectious disease, and maternal and child health services by service type (2019–2020) Proportion of facilities providing NCD, ID and MCH services by service type 2013-2020 100 94 92 92 90 80 75 70 69 70 60 53 Percent (%) 48 50 44 38 40 30 18 20 10 0 STIs TB HIV CVD Diabetes CRD FP Sick child ANC Vaccination PMTCT ID NCDs RMNCH Source: SARA 2019. Note: STIs = Sexually Transmitted Infections; TB = Tuberculosis; HIV = Human immunodeficiency virus; CVD = cardiovascular disease; CRD = Chronic Respiratory Disease; FP = Family Planning; ANC = Antenatal Care; PMTCT = Prevention of Mother to Child Transmission of HIV. Provider competence scores indicate strong provision of ANC services, with room for improvement in family planning. Provider competence Key findings from the VSP assessment 33 means that providers have and demonstrate knowledge, skills, abilities, and traits to successfully and effectively deliver high-quality services. In The Gambia, provider competence is measured based on patient-reported components of ANC and informed choice for family planning. Almost all women in The Gambia who received ANC for their most recent birth in the past five years (98 percent) report having received the required components of care in at least one ANC visit. These components include blood pressure and weight measurement and blood and urine sample collection. Competence was not uniform across all aspects of RMNCH, as only 58 percent of women using modern contraceptive methods were informed about side effects or problems of the method used, management of side effects, and other methods of contraception. In The Gambia, provider availability was low, as only 26 percent of RMNCH visits lasted for more than 10 minutes. Provider availability is defined as the presence of a trained provider at a facility when expected, who provides the services as defined by his or her job description. Availability is important because, while there are often shortages in human resources, deployed providers are frequently inappropriately absent or, when present, are not actively delivering health care because they are engaged in other duties. Some success in the continuity of infectious disease services suggest that The Gambia has the potential to strengthen the quality of NCD services and other areas of PHC. Continuity refers to the long-term healing relationships between a person and his or her primary care providers over time. It can also be thought of as a consistent and coherent approach to the management of a health condition that is responsive to a patient’s needs. DHS data show significant improvements have been made in continuity of care. For example, only 7 percent of the 98 percent of children who received their first DPT3 vaccination did not receive a third, and 90 percent of TB patients completed their treatment. PHCPI uses two measures to determine patient safety at health facilities: adequate infection prevention and control and adequate waste 34 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT disposal. According to the 2019 SARA survey, 79 percent of facilities had rooms where all infection prevention control items were present (soap and running water or hand disinfectant, storage for sharps waste, gloves, and surface disinfectant). The same 2019 survey also demonstrated that 60 percent of PHC facilities adhered to and had guidelines available for the disposal of medical and hazardous waste. Equity Equitable PHC coverage and access are essential for reducing disparities in health outcomes across populations. The VSP measures equity by disaggregating coverage, access, and outcome indicators by socioeconomic status, mother’s education, and place of residence. Equity in access aims to identify differences in financial and geographic barriers to care between the highest and lowest wealth quintiles. Equity in coverage examines the difference in effective coverage of maternal and child health care services by a mother’s level of education. Equity in outcomes examines the differences in mortality of children residing in urban and rural areas. In addition to the indicators featured in the VSP, we also examined the coverage of selected RMNCH, infectious disease, and childhood nutrition services by wealth quintile and local government area. Data from the DHS 2019–2020 show large disparities across socioeconomic status when accessing health services. For example, 46 percent of women in the lowest wealth quintile reported financial constraints when accessing health facilities when sick compared to only 13 percent of women in the highest wealth quintile. Similarly, 48 percent of women in the lowest quintile reported a perceived barrier in distance to health facilities compared to 11 percent of women in the highest quintile. Slight disparities between households with educated versus non- educated women were found in the coverage of RMNCH services. However, overall, there was low coverage of RMNCH services for women Key findings from the VSP assessment 35 across all education levels. Specifically, 71 percent of mothers and children in households where the mother completed secondary or more education received a complete basic package of RMNCH services, compared to 67 percent of mothers and children in families where the mother has not completed primary education (Figure 6). Figure 6. Disparities in RMNCH service coverage by mother’s education level, 2019–2020 99 100 100 91 92 93 90 91 90 81 80 80 77 77 71 70 66 67 60 48 46 Percent 50 43 39 40 30 20 10 0 FP ANC4 SBA BCG DTP3 Measles ORT ARI RMNCH No Education Secondary + FP: Family planning demand satisfied by modern methods; ANC4: Four or more ANC sisits; SBA: Deliveries by skilled birth attendants; BCG: BCG vaccine coverage in the first year of life; DPT3: Coverage of the third dose of diphtheria, pertussis and tetanus vaccine in the first year of life; Measles: Measles vaccine coverage in the first year of life; ORT: Oral rehydration therapy and continued feeding; ARI: Care-seeking for acute respiratory infections (pneumonia) among under-five children by health facility or provider; RMNCH: Reproducti- ve maternal, newborn and child health services composite coverage index. Source: DHS 2019–2020. Substantial variation can be seen in the coverage of RMNCH, infectious disease, and childhood nutrition services between the highest and lowest wealth quintiles. Advice or treatment was sought for only 59.5 percent of children under five with fever in the lowest wealth quintile, compared to 70.1 percent of children in the highest wealth quintile. There are also inequalities in nutrition outcomes across wealth quintile; for example, 23 percent of children in the poorest wealth quintile are stunted, 36 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT compared to 15 percent in the wealthiest quintile. Similar disparities are observed in the proportion of under-five children with ARI symptoms who sought care from a health facility or provider (66.8 percent in the lowest to 77.2 percent in the highest). Coverage of vitamin A supplementation and demand for family planning satisfied with modern methods are relatively equitable across levels of wealth, although coverage is low for both indicators. In all, 44 percent of children in the lowest wealth quintile received supplementation in the last six months compared to 40 percent in the highest, and the demand for family planning satisfied with modern methods is slightly higher among women in the poorest quintile (38.5 percent) than women in the highest quintile (40.5 percent), reflecting relatively equitable access to family planning services. The extent of PHC service coverage varies among the different local government areas in The Gambia. The proportion of children with ARI symptoms who sought health care ranged from 80 percent to 62 percent across local government areas, with Mansakonko reporting the lowest rate.1 The demand for family planning satisfied with modern methods ranged from a low of 21 percent in Basse to a high of 48 percent in Janjanbureh. The coverage of children receiving a third dose of DPT vaccines and the treatment of diarrhea with ORS display more limited variation between local government areas (Figure 7). 1 Note that the DHS did not provide information for Janjanbureh for this indicator Key findings from the VSP assessment 37 Figure 7. Variation in PHC coverage indicators in The Gambia by local government area i) Care-seeking for ARI Kuntaur Kuntaur Kerewan Kerewan Basse Banjul Basse Banjul Janjanbureh Janjanbureh Mansakonko Mansakonko Brikama Brikama ARI ARI 0% - 61.9% 0% - 61.9% 61.91% - 64.3% 61.91% - 64.3% 64.31% - 69.5% 64.31% - 69.5% 69.51% - 76% 69.51% - 76% 76.01% - 79.6% 76.01% - 79.6% ii) Coverage of family planning demand satisfied by modern methods Kuntaur Kuntaur Kerewan Kerewan Basse Banjul Basse Banjul Janjanbureh Janjanbureh Mansakonko Mansakonko Brikama Brikama FP FP 20.5% - 35.4% 20.5% - 35.4% 35.41% - 37.3% 35.41% - 37.3% 37.31% - 44.4% 37.31% - 44.4% 44.41% - 45.5% 44.41% - 45.5% 45.51% - 47.8% 45.51% - 47.8% Kuntaur Kuntaur Kerewan Kerewan Basse Banjul Basse Banjul Janjanbureh Janjanbureh Mansakonko Mansakonko Brikama FP 38 20.5% - 35.4% THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT 35.41% - 37.3% 37.31% - 44.4% 44.41% - 45.5% 45.51% - 47.8% iii) DTP3 coverage Kuntaur Kerewan Banjul Basse Janjanbureh Mansakonko Brikama DPT 86% - 87.9% 87.91% - 91.7% 91.71% - 94.1% 94.11% - 96.8% 96.81% - 98.3% iv) ANC4 coverage Kuntaur Kerewan Banjul Basse Janjanbureh Mansakonko Brikama ANC4 75.6% - 76% 76.01% - 80.5% 80.51% - 82.2% 82.21% - 83.6% 83.61% - 84.9% Kuntaur Kerewan Banjul Basse Janjanbureh Mansakonko Brikama ANC4 Key findings from the VSP assessment 75.6% - 76% 39 76.01% - 80.5% 80.51% - 82.2% 82.21% - 83.6% 83.61% - 84.9% v) Coverage of ORS for treatment of diarrhea Kuntaur Kerewan Banjul Basse Janjanbureh Mansakonko Brikama ORS 37.2% - 39.1% 39.11% - 40.4% 40.41% - 43.3% 43.31% - 52.7% 52.71% - 61.2% ARI: Care-seeking of acute respiratory infections (pneumonia) among under-five children by health facility or provider; DPT3: Coverage of the third dose of diphtheria, pertussis and tetanus vaccine in the first year of life; ANC4: Four or more ANC visits. Source: DHS 2019–2020. Significant disparities by residence in mortality of under-five children were also reported in The Gambia; specifically, a 16 percentage-point difference in under-five mortality rates between urban and rural residence was found based on the latest 2019–2020 DHS. These findings highlight the challenges faced by the PHC system, particularly in rural areas. Capacity The VSP capacity domain assesses the ability of the health system to deliver high-quality PHC services. In the PHCPI framework, the capacity domain consists of three sub-domains, namely: governance, inputs, and population health and facility management. The governance sub-domain includes an assessment of PHC policies, quality management infrastructure, and social accountability as well as the ability of the system to appropriately 40 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT adjust to population health needs. The inputs sub-domain reflects the availability, equitable distribution, and quality of essential service delivery inputs, including drugs, supplies, workforce, facility infrastructure, information systems, and funds at the facility level. The population health and facility management sub-domain includes an assessment of how well population health is managed, including activities such as community outreach and local priority setting. This section also examines facility organization and management—including management capability and leadership, information system use, performance measurement, and team- based care. Governance The Gambia’s health system is making its way towards UHC. The National Assembly of The Gambia has enacted into law The National Health Insurance Bill, 2021 (Ministry of Health, 2021), which establishes a mandatory NHIS that will pay for the cost of health care services to all members of the scheme. This NHIS includes a proposed package of essential health care services to be delivered at each level of care (village health services, community clinics, minor and major health centers, general/district hospitals, and the teaching hospital). When finalized, the package will be used to develop standards for infrastructure and equipment and to update the list of essential medicines, quality-of-care checklists, and staffing standards for public and private facilities. The Gambia has a wealth of health policies and strategic plans that operationalizes policy objectives. At the time of the assessment, The Gambia was in the process of finalizing the 2021–2030 National Health Policy rooted on the principles of PHC as the basis for the design of health services. Meeting the majority of health needs guides health service delivery in its facilities. The National Development Plan 2018–2021 includes plans and set targets to monitor the delivery of services. In addition to the National Health Policy and National Development Plan, The Gambia maintains a National Key findings from the VSP assessment 41 Health Financing Policy 2017–2030 and a National Health Financing Strategic Plan 2019–2024, which operationalizes The Gambia National Health Financing Policy 2017–2030 with the overarching goal of achieving UHC and ensuring that adequate financing is made available to achieve the national health strategic plans in the 2021–2025 GNHSP. The forthcoming National Health Policy 2021–2030 was developed from a wide range of evidence: Assessment reports of the various health system building blocks, health-related studies from The Gambia and other West African countries, and the WHO Standard Guidelines for Health Policy Development. It was created with participation from across ministry directorates and other ministry programs, with some (albeit limited) input from non-governmental sources and non-health perspectives. There may be further opportunities to ensure the policy captures broad stakeholder needs, preferences, and input and supports an environment of accountability to deliver on its policies. The policy is not embedded in a formalized legal framework, although it is signed by the Minister of Health, which conveys a degree of authority and respect. There are efforts to revisit the Public Health Act and other regulations to support the Ministry’s ability to leverage law and regulation to translate the policy into action. The policy includes some of the fundamentals, such as a defined service package. It does not include a monitoring and evaluation framework but does point to strategic plans with their own “built-in monitoring” and the results-based financing monitoring platform. The Gambia has established a strong sentinel and integrated disease surveillance and response (IDSR) system to support the PHC system’s ability to adjust to changing population health needs, but further efforts are needed to translate information from these systems. The MOH is currently tracking key disease metrics through sentinel surveillance and IDSR strategies to monitor disease burden and detect diseases that have the potential to become epidemic or pandemic. Despite data availability, routine data analysis remains a challenge at regional levels 42 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT due to inadequate and aggravated mobile network difficulties. Collecting and recording data has little use without mechanisms in place to detect incidences or trends of issue, identified communication channels to report to, trained staff with the necessary expertise, and processes to investigate and respond to these incidences or trends. Interviewed experts agreed that areas for improvement of the surveillance system include strengthening data quality, further digitalization of the system’s data collection methods at the facility level, and interoperability between the electronic systems (IDSR and DHIS2). Data on the population’s health generated through the various mechanisms mentioned is occasionally translated into information necessary for the definition of priorities in the PHC system; however, these priorities are scarcely included in government health budgets. A key aspect for adjusting to changing population needs is the availability of systems that enable innovation and learning, having a system, organization, and culture in place that allows for flexibility and adaptation to modify behavior, practice, priorities, and policies to reflect new knowledge and insights from within or outside the country. The Gambia’s mechanisms to recognize, evaluate, and scale successful innovations are quite nascent and often dependent on individual donor-sponsored projects. There is no formalized and systematic way for the government to recognize, evaluate, and routinely incorporate new evidence from successful projects, current research, and discussion of progress and challenges so that lessons from past events are identified and can be used to predict and/or improve response to future threats or changing health needs. PHC experts noted that even when projects are successful in The Gambia, they are rarely scaled up. A key example is the conditional cash transfer intervention deployed in three regions in The Gambia (North Bank River-West, Central River Region, and Upper River Region) that is yet to receive the operational capacity to scale. Key findings from the VSP assessment 43 Inputs The availability of essential drugs and supplies in The Gambia is low, particularly among community clinics. According to The Gambia Service Delivery Survey in 2019, only 2 percent of facilities have all essential medicines and consumable commodities available. The service delivery survey specifically evaluated 20 essential medicines, a portion of the broader essential medicines list defined for The Gambia. A key informant indicated that the medicines list has more than 300 items, making it difficult to know the number of primary care facilities with all essential medicines and consumable commodities consistently available. The Logistics Management Information and Supply Chain Assessment Report 2018 showed that, on average, stock out of essential medicines was 50 percent and was highest among the input categories assessed. The report suggests variation in availability of different medicine types, with the average stock out of medicines and consumables for malaria at 19 percent, 21 percent for HIV/AIDS, and 5 percent for TB. This suggests that the supply chain responsible for efficiently handling the planning, coordination, procurement, inventory management, transportation, distribution, storage, and data collection and reporting of essential medicines and consumable commodities operates in distinct ways. It varies for different categories of medicines and facility types across the country. This means that, at the facility level, PHC services can treat or manage certain conditions (those with medicines and consumables in stock) better than conditions where medicines are unavailable. Evidence suggests that there are challenges in the equitable distribution of available medicines, with significant variation in the average availability of essential medicines between regions and facility types, according to The Gambia Service Delivery Survey. General hospitals had high average availability (90 percent), whereas community clinics had on average 30 percent of the essential medicines available. There were also 44 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT differences between which regions had more essential medicines available, with the highest average availability in Western Region 1 (62 percent) and the least in North Bank West Region and Western Region 2 (31 percent). While the variation compares average availability of medicines (as opposed to proportion of facilities with all medicines available), this functions as an effective proxy to indicate whether there are challenges in ensuring inputs are equitably available and distributed across The Gambia’s health facilities. The availability of diagnostic supplies was also minimal across facilities. Adequate diagnostic infrastructure is vital to tackle the burden of infectious diseases such as HIV/AIDS, malaria, and TB, yet facilities are ill-integrated into the diagnostic and care delivery process. In The Gambia, only about half (46 percent) of facilities were equipped with at least one functional adult scale, child scale, thermometer, stethoscope, blood pressure apparatus, and light source. There was also significant variation in equipment availability between local government area and facility types. Health experts in The Gambia suggest that even though diagnostic equipment is available in facilities, reagents are rarely available, making it challenging to conduct basic laboratory tests and early disease detection. Some facilities such as the Bansand and Bwiam hospitals, Bundung Maternal Child Clinic, and Serrekunda hospital often end up purchasing their own reagents which are either expensive or difficult to access. While The Gambia has made major investments in establishing an HMIS in all public facilities, the interoperability and use of the health information collected from the HMIS leaves significant room for improvement. The Gambia uses HMISs to collect and store data in DHIS2 across all public facilities. Although the systems can produce vast amounts of essential information for decision-making related to PHC, these systems face significant challenges, which include the continued use of paper-based data collection in many lower-level facilities. The lack of interoperability between existing systems and the exclusion of private and urban facilities in the HMIS systems make it challenging to integrate and utilize the Key findings from the VSP assessment 45 information generated from the HMIS system. Another area of opportunity across The Gambia’s health system is the use of longitudinal personal care records. According to interviews with key informants, The Gambia does not have a unique person identification that will enable facilities and health care providers to maintain a history of referrals and have efficient access to clinical data. Maintaining longitudinal personal care records has the potential to improve patient engagement and coordinate health care continuity. The Gambia’s sub-optimal supply of skilled health care workers limits the PHC systems’ ability to provide timely and high-quality PHC services. As of 2019, The Gambia Service Delivery Report showed that only 5.9 skilled health professionals are allocated per 10,000 population, which is well below the target of 44.5 per 10,000 population. Nonetheless, The Gambia is recognized for having created a strong cadre of CHWs that provide care and outreach services to the population to mitigate the scarcity of more highly qualified medical personnel. The Gambia has reformed the system’s capacity to assess and guarantee PHC workforce capacities. The Gambia recently reformed its tertiary and higher education institutions and established a National Accreditation and Quality Assurance Authority (NAQAA) in April 2015 to promote quality professional assessment and improve harmonization and benchmarking of accreditation and quality assurance practices. The regulatory body delivers quality accreditation services for the provision of a workforce that is competent, certified, innovative, and beneficial to the continual development of The Gambia. This reformed process of accreditation in The Gambia guarantees that the PHC workforce has the required qualifications and fulfils the requirements to provide patients with the minimum quality of care. 46 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Population health and facility management Although a substantial amount of health data is collected by health facilities and workers across the country, this data is seldom translated into priorities for service delivery at the local and community levels. Population health management refers to activities and strategies to proactively track and address a population’s health. It includes activities such as health worker outreach services and community participation in local priority settings. Although regional health directorates collect and document data on the health system’s annual action plans and budget reports for the MOH, key stakeholders report that the data are hardly ever used to define priorities for service delivery at the local and community levels. Documents reviewed and experts interviewed suggest that decisions are often made at the national level. Across rural areas, various committees (such as the catchment area committees, health sector management committees, and village development committees) exist as community participation platforms with minimal influence in shaping service delivery offerings. The experts agreed that facility-level community group members often need to be aware of their roles and responsibilities for holding facility management and staff accountable for providing high-quality health care. The MOH could, however, leverage the existence of the local catchment area committees to integrate community priorities in national policies and service delivery strategies. Proactive population outreach is a strength of The Gambia’s PHC system and can be built upon to improve coverage and quality and to reduce health inequities. The Gambia’s strong team of CHWs is recognized for providing care and outreach services to the population to mitigate the lack of more highly qualified medical personnel. Over 75 percent of sub-regional units provided proactive outreach services throughout the country. Specifically, maternal and child health services are provided to at- risk mothers and malnourished children by deploying maternal and child health mobile teams. CHNs occasionally follow up with patients with HIV, Key findings from the VSP assessment 47 TB, and NCDs, ensuring sustained patient care. In addition to providing health education through regular household visits, these health workers supply TB drug refills and medication to patients and follow up on people referred to or discharged from the hospital to the community. Although The Gambia does not have a system of empanelment— the process whereby individuals and families are assigned to a specific health facility whose providers are responsible for their health— the clinics maintain registers of sick patients and refer them to CHNs for home- based care, e.g., HIV patients. CHNs are attached to a facility and report monthly to the facility and regional health directorate. With extensive coverage of households in the country, the use of the different cadres of CHWs has great potential as a source of information and management of patients suffering from NCDs and improvement in the continuity of care, as well as care coordination. An area of opportunity lies in facility organization and management, which are the systems and processes in place to effectively manage the provision and performance monitoring of team-based care and facility management capability. Interviews with key stakeholders report that managerial responsibilities in the facility are assigned based on experience or political appointment. Facility managers are not trained in management skills and typically lack certifications or degrees in management before being given the responsibility to manage facilities, limiting facilities’ ability to strategically distribute work across providers or provide team-based care. Across PHC facilities, poor management and leadership capabilities are an important barrier to improved facility and service delivery performance. Further interviewees confirmed that even though facilities are not optimally managed, health workers work very well together as a team with clearly defined job descriptions and responsibilities that allow them to effectively deliver the services at their designated levels of service. Health services have been decentralized to districts and health sub- districts which play key roles in the delivery and management of health 48 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT services. The MOH developed an evidenced-based staffing norm (staffing standard) using the WHO’s Workload. Each health facility is headed by an officer in charge and support staff to deliver effective and efficient health care across the country. Each health facility has incorporated accountability mechanisms by conducting monthly team meetings with all members of the health facility to analyze their work patterns and take steps to improve efficiency. Financing In The Gambia, health financing plays a critical role in the overall performance of the PHC system. Health financing is connected to nearly every aspect of PHC system performance and refers to how resources are generated, collected, and re-distributed across the PHC system. The health expenditure in 2020 was 2.6 percent of GDP, which is lower than the average of 3.9 percent for low-income countries. Similarly, the domestic general government health expenditure was 1.4 percent of GDP compared to an average of 1.5 percent for low-income countries. The country spent $55 (PPP int$) per person/year on health in 2020, with $28.6 (PPP int$) coming from the government, $5.9 (PPP int$) from international sources, and $12.9 (PPP int$) from out-of-pocket expenditure(6). Over the last two decades (2000–2020), both government health spending per capita (PPP int$) and out-of-pocket expenditure per capita remained nearly the same, while the contribution of international sources in health expenditure decreased markedly from $150.6 (PPP int$) per capita in 2000 to $5.9 per capita in 2020. This decrease in health spending per capita in The Gambia highlights the need for greater investment in health financing to improve the PHC system’s overall performance. Key findings from the VSP assessment 49 Figure 8. Changes in health expenditure by revenue source in The Gambia, 2000–2019 250 200 Current International $(PPP) 150 100 50 0 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 Year Current health expenditure per capita, PPP (current international $) Domestic general government health expenditure per capita, PPP (current international $) External health expenditure per capita, PPP (current international $) Out-of-pocket expenditure per capita, PPP (current international $) Source: World Bank Development Indicators 2019. Precise measures of financing for PHC can be estimated using the System of Health Accounts 2011. Specifically, four indicators were used to understand the amount of PHC spending and whether PHC spending is being prioritized: (1) PHC expenditure per capita in US$; (2) Current PHC expenditure as a percent of current health expenditure; (3) Share of domestic government health spending allocated to PHC; and (4) Domestic government PHC spending as a percent of current PHC spending. Despite having a low per capita expenditure on PHC, The Gambia is one of the leading sub-Saharan countries in prioritizing PHC funds. The Global Health Expenditure Database ranks The Gambia among the top 11 sub-Saharan countries in terms of high PHC prioritization, among 37 countries with available PHC finance data. In 2019, The Gambia spent 71 percent of its total health expenditure on PHC, higher than the median of 64 percent in sub-Saharan countries with available data. The government also 50 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT allocated 70 percent of its health spending to PHC, compared to the median of 56 percent for other sub-Saharan countries. Additionally, domestic government PHC spending in The Gambia was 40 percent of its total PHC spending, compared to the median of 29 percent for sub-Saharan countries. Despite its high PHC prioritization, The Gambia’s per capita expenditure on PHC was only US$16 in 2019, the fourth lowest of sub-Saharan countries with available data. As a comparison, the median per capita expenditure on PHC for sub-Saharan countries with available PHC financing data was US$33 in the same year. While The Gambia prioritizes PHC funding, there is still a need to increase overall funding of PHC services. Recommendations 51 Recommendations 52 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT 1. Establish a PHC-specific policy focused on improving coordination across governmental and non-governmental actors, quality of care, and monitoring and evaluation. Effective governance strategies enable the key functions of PHC: accessibility, continuity, comprehensiveness, coordination, and patient-centered care (9). At present, The Gambia does not have a singular, comprehensive PHC- specific policy or a coordinating authority for PHC strengthening activities. The country would benefit from the formulation of a comprehensive PHC policy with an accompanying national body to coordinate, monitor, and implement PHC policy at national, regional, and community levels. The policy could explicitly focus on three dimensions: (1) coordination for planning and execution of PHC policies; (2) quality management; and (3) continuous measurement. 1.1. Establish a coordination mechanism between government and non-government actors: While governments are the primary drivers of policy making, non-state actors are critical in making sure that health systems achieve goals of improved health status, improved health system responsiveness, and reduced financial risk for users (7). In The Gambia, there is substantial room to improve coordination among non-state actors involved in the provision of primary care. The Progression Model revealed that policies around PHC were primarily led by ministry directorates and specific programs with limited involvement from external partners. Additionally, there is no formal joint review process to monitor progress made toward PHC-related policy objectives. These results are echoed by a USAID report which found that although there was coordination between stakeholders within specific programs or activities, cross-cutting mechanisms for coordination of programs within the MOH were absent (8). Creating a shared vision for PHC across government, private for-profit, private non-profit, and civil society organizations is needed to promote equitable access to high-quality PHC. The WHO recommends Recommendations 53 six governance actions to effectively engage the private sector: (1) building a shared understanding through shared collection and analysis of data; (2) fostering relationships to achieve shared objectives; (3) enabling stakeholders by recognizing their autonomy and strengths; (4) aligning organizational structures to align with policy objectives; (5) nurturing mutual trust among all actors; and (6) delivering a coordinated health strategy (9). For example, when Nigeria developed its 2016 National Health Policy, the Federal Ministry of Health built consensus with non- governmental actors by involving private sector representatives in a technical working group. The group met over a period of two years to analyze progress made on previous health policies and to chart a new way forward (10). Institutionalizing the participation of stakeholders at national and subnational levels makes it more likely for them to be positively engaged with the government to achieve policy goals. A similar opportunity exists in The Gambia to improve coordination between the government and NGOs through the health sector’s joint annual review forum. 1.2. Ensure an overarching focus on quality within the PHC plan: The development of national policies and strategies to improve the quality of care can help clarify the structures, roles, and responsibilities within national quality efforts, support the institutionalization of a culture of quality, and secure buy-in from health system leaders and stakeholders. Developed in 2001, Kenya’s Quality Model for Health provides an example of a policy to promote awareness-raising of health managers and providers to the notion of quality and the benefits a quality focus could have in their work and patients’ outcomes. The policy includes a training course to guide health staff and managers in strengthening the focus on quality management from service delivery to health policy development (11). Nationally, the MOH anchors quality improvement methodology and regulation 54 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT processes for facility licensing. To receive and renew licenses, facilities must provide evidence of quality improvement processes, such as the establishment of improvement teams, demonstration of clinical audits, and regular feedback loops (12,13). Similar recommendations could be valuable in The Gambia where there is no external accreditation of Primary Health Care Units, and there are no systems to share experiences in quality improvement across levels of the health system. 1.3. Establish key indicators for measuring the performance of PHC at national, state, and facility levels: Many countries lack comprehensive data to drive improvements, support civil society and citizens in holding leaders accountable, and evaluate how health systems are functioning. Ethiopia’s first Health Sector Transformation Plan (HSTP-I) implemented from 2015/16 to 2019/20 provides an example of a comprehensive national plan focusing on continuous measurement (14,15). HSTP describes a policy framework accompanied by a strategic assessment, objectives, and performance measures including community scorecards. It features plans for annual regional-level equity analyses to describe access and uptake of health services. Underpinning the plan is a push for increased data collection and the demand for better informatics at every level of the health system (16). Prepared based on a performance evaluation of HSTP-I, Ethiopia’s second Health Sector Transformation Plan (HSTP-II) was implemented in 2020 with an updated set of targets to measure its objectives and performance. Targets are translated to the district level through annual operational plans and implementation is observed regularly through an established monitoring framework. It will be important for the MOH to incorporate continuous measurement to guide the implementation of all PHC-related activities. Recommendations 55 2. Increase the availability of medicines and supplies by leveraging existing purchasing mechanisms and strengthening supply chain management. Ensuring facilities have medicines and supplies is imperative to delivering high-quality PHC services and achieving the Sustainable Development Goals. Effective financing mechanisms and information systems are two necessary components for improving procurement and distribution of medicines and supplies. 2.1. Effective financing mechanisms: The financing of The Gambian health system has relied heavily on donor sources and out- of-pocket (OOP) spending; in 2019, 45 percent of current health expenditure in The Gambia came from external health expenditure and 23 percent came from OOP expenditures (17). To promote more sustainable forms of financing to increase funding for health, the country approved the National Health Financing Strategy 2019–2024 (NFHS). The Gambia can support the existing NFHS, which outlines financing reforms that are necessary for expanding access to quality PHC services, including improving use of resource-pooling mechanisms and needs-based resource allocation for medicines and supplies. 2.1.1. Improving use of pooled resources through the Drug Revolving Fund: The National Treasury manages the Drug Revolving Fund (DRF), the centralized fund for most user fees collected at public facilities. Funds from the DRF are intended to be used by the MOH to purchase pharmaceutical products. However, utilization of the DRF remains a major challenge. The DRF established in 1989 in Sudan represents an example of a successfully managed fund. Established to improve access to essential medicines in the Khartoum state in Sudan, key components of the DRF’s success included strong management, monitoring, and reporting mechanisms. Applying a commercial business-oriented management 56 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT approach that promoted transparency resulted in better control over DRF operations. Supervision teams regularly reported on DRF activities in accordance with an agreed list of performance targets. They also collected revenue and monitored the financial status of each RDF pharmacy. These strategies promoted a well-functioning DRF that the increased availability of affordable medications in a sustainable way (18).    To prioritize improvement strategies from existing DRF models, an audit of The Gambia’s DRF could be carried out to guide future improvements. In alignment with the USAID’s 2019 Assessment of the Health System in The Gambia, we recommend that the MOH conduct an audit of the DRF at all levels of the health system to map the flow of funds and to propose reforms. This audit would benefit from support by a formal accountability framework that tracks DRF inflows from user fees and outflows to pharmaceutical purchasing. To improve transparency, the fund’s regulatory framework could  also be revisited and updated based on reform priorities (8). 2.1.2. Shift towards a proactive mechanism that distributes drugs to PHC, one that is risk adjusted based on disease burden and demand: The National Health Financing Strategic Plan 2019–2024 recommends that the government implement a needs-based resource allocation formula to prioritize existing and emerging health needs. This formula should consider all available health resources and geographic indicators such as population size, socio-economic characteristics, and supply-side capacity for better distribution of public health funds. Currently, the Central and Regional Store uses stock levels, consumption information, and requests from general hospitals and minor and major health centers to determine the necessary quantity of medicines to supply. However, having Recommendations 57 a resource-based allocation formula would allow for better planning in the distribution of limited resources. The MOH can gradually implement this formula as additional resources become available. 2.2. Capitalize on investments in Electronic Logistics Management Information System (eLMIS) to strengthen supply chain management: An efficient and equitable drug distribution system should maintain a constant supply of medicines by maintaining accurate inventory records and forecasting medicines needs. When properly implemented and resourced, eLMISs can contribute to reducing stockouts of essential medicines and supplies. Currently, the government has partnered with the Global Fund to pilot an eLMIS system in 50 facilities; it is expected to cover all health facilities by July 2023. While scaling up coverage of the eLMIS, The Gambia can consider successful innovations other countries have implemented. To overcome supply challenges, Senegal’s Ministry of Health and Social Action and the National Supply Pharmacy worked with partners to develop a nationwide supply distribution scheme that uses real-time data to manage supplies and direct health commodities through routine stock management. Third-party distributors make monthly deliveries of health products directly to facilities, where they evaluate current stock and enter data into an online platform, alowing their logistics managers to track consumption trends and forecast future needs in real time. This strategy lifts the burden of logistics and operational tasks off overburdened health facility staff and shifts the financial risk away from facilities to ensure that monetary constraints do not impede a clinic’s ability to provide essential commodities. Transferring supply chain management to trained logisticians has reduced inefficiency and improved data quality, availability, and visibility 58 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT by ensuring that those responsible for recording stock information and forecasting have the requisite expertise to complete these tasks (19). Building on Senegal’s successful implementation, the eLMIS strategy in The Gambia could consider public-private- partnerships to improve overall efficiency in stock monitoring and forecasting. 3. Implement a people-centered model of PHC focused on delivering comprehensive infectious disease and NCD services. Although The Gambia has made tremendous improvements in maternal and child health, the country faces a double burden of disease. While the health system must still respond to high prevalence of infectious disease, the aging of the population is driving an epidemiologic transition toward an increasing burden of NCDs, including chronic conditions. The successful treatment of NCDs benefits from continuity of care and robust patient management systems that facilitate access to specialized care and essential medicines. Implementing a system of empanelment to support team-based care would allow the country to adapt to its evolving health needs, enable effective utilization of care, and promote high-quality care. 3.1. Establish an empanelment system to improve continuity in care: A robust system for population empanelment allows health workers to better understand the population in their catchment area and contributes to first contact as well as care continuity (20). Empanelment establishes a point of care for individuals and simultaneously holds providers and care teams accountable for actively managing care for a specific group of individuals; it also forms the backbone of integrated health service delivery networks. Systems of empanelment generally entail three processes: the identification of the population, their assignment to specific facilities or providers, and periodic review and update (21). After a population is empaneled, providers can shift their focus towards Recommendations 59 proactive care and health management. Ideally, all people would receive proactive care within their communities, but it can be more feasible to start with specific populations (for example, people with diabetes mellitus or hypertension) that would benefit from receiving coordinated care from a multidisciplinary team of providers. The MOH could empanel the population by building on existing catchment areas of minor health centers. Countries with a strong emphasis on PHC such as Brazil, Costa Rica, and Ghana depend in part on PHC teams’ knowledge and understanding of their catchment areas, which is built up over time through strong empanelment systems. Beginning as a pilot in 1990, Ghana’s Community Health Planning and Strategy (CHPS) program was implemented to address large geographic disparities in access to health care. The program reoriented care to the community level through geographic empanelment of care teams for 4,500–5,000 individuals. Clinical nurses delivered community-based care to their panel through proactive population outreach during home visits. They were supplemented by trained volunteers who provided support for oral rehydration, family planning, ANC, and immunization services. The program resulted in dramatic increases in health service utilization (20). An empanelment system implemented in The Gambia could serve as the basis for strong team-based care providing comprehensive, community-based services. 3.2. Employ multidisciplinary teams for health service delivery: Team-based care refers to groups of providers with diverse training, education, and capabilities who work together to provide comprehensive, coordinated, and efficient primary care to patients. With a critical health care workforce shortage in The Gambia, multidisciplinary patient care teams including CHWs can enable various cadres of health workers to provide 60 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT specific sets of health services while reporting and referring to providers with more extensive training. For example, in Costa Rica, PHC teams including a doctor, nurse, CHW, vital registry data clerk, and pharmacist provide care for 75 percent of all health consultations. The team’s data clerk collects routine surveillance and census data to help identify the health needs and gaps in the assigned population and to improve team performance. Teams are supported by clear roles for each member and consistent communication (22). CHWs visit each household within their assigned empaneled population annually to assess health needs, following specific guidelines for the prioritization of visits. They routinely collect information on each member of the household’s history, vaccinations, and determinants of health that is integrated with the country’s electronic health record system (23). In The Gambia, existing team-based models could be strengthened by increasing the involvement of CHNs and CHWs. Services provided by maternal and child health mobile teams could be scaled up to improve continuity of care between households and health teams at health facilities. As in Costa Rica, linking CHW household outreach activities, including annual household visits, data collection, and post-discharge follow- up, with facility health teams can be a meaningful innovation in improving coordination and continuity of care. To achieve this, the MOH can establish policies that fully integrate CHWs as members of facility-based teams and provide them with appropriate remuneration, such as stipends, performance- based incentives, and professional development opportunities. Adequate remuneration for CHWs’ work improves performance and enhances CHW participation in community activities. 3.3. Ensure that PHC facilities provide a comprehensive range of services including RMNCH, infectious disease, NCD, nutrition, Recommendations 61 and adolescent services. When patients access care in facilities, they should be able to receive a wide range of preventive, promotive, chronic, behavioral, and rehabilitative services. More comprehensive systems are associated with reduced spending, better patient experience of care, and reduced inpatient services utilization (20,24). As The Gambia faces new health system pressures caused by an increasing burden of NCDs, the country is still facing infectious diseases, including lower respiratory infections, neonatal disorders, and HIV/AIDS, as a major cause of death (25). Analysis of country data demonstrates the critical need to improve access and availability services, specifically for NCDs and infectious diseases. To address the dual burden of communicable diseases and NCDs in Malawi, the country worked with Partners in Health to build on the successes of an HIV program to improve NCD outcomes by establishing the Integrated Care Cascade. The pilot program integrates HIV and NCD community- and facility-based screening and treatment through a coordinated care and referral network and demonstrates how integrated models can be implemented to improve the comprehensiveness of care (26). In The Gambia, similar integrated care models can be developed to improve NCD screening and the efficient use of resources. 4. Increase demand and coverage for ASRH services. The RMNCAH policy and national strategic plan (2017–2026) recognize the need to expand ASRH services. To further enhance progress in adolescent health, the MOH should develop an adolescent health and development service policy. This policy can integrate youth-friendly services into the health system while increasing demand for and expanding existing services. 4.1. As part of the policy, the MOH can build on the progress made by the country’s participation in the Sahel Women’s Empowerment 62 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT and Demographic Dividend Project (SWEDD), a collaboration between Sahel countries, the United Nations (UN) system, and World Bank Group. SWEDD focuses on creating demand for RMNCAH services and commodities, increasing access to qualified health personnel, and supporting policy dialogue. In The Gambia, SWEDD focuses on improving the socioeconomic integration of women aged 15–24 in the economy by facilitating their engagement in income-generating activities. 4.2. To ensure that the policy is evidence-based and comprehensive, The Gambia can also draw inspiration from the WHO’s Global Accelerated Action for the Health of Adolescents (AA-HA!) guidance. This guidance outlines a systematic approach for understanding adolescent health needs, prioritizing evidence- based interventions, and planning, implementing, monitoring, and evaluating those programs. Sudan’s National Strategy of Adolescent Health and Wellbeing 2018–2022 is an example of a comprehensive strategy that utilizes AA-HA! guidance. The strategy was developed in collaboration with multisectoral actors, including UN agencies and civil society organizations, with adolescents’ engagement throughout the process. It prioritizes ASRH through several interventions, including provision of adolescent-friendly PHC services, community and school outreach, and comprehensive ASRH education. In The Gambia, similar evidence-based strategies could be implemented and adapted to the country’s specific context. These strategies include: (1) improving ASRH training for health care providers; (2) integrating ASRH services within existing sexual and gender-based violence one-stop-centers; (3) providing financial support for ASRH service delivery at youth-friendly Recommendations 63 community centers; and (4) involving religious and traditional leaders in promoting ASRH communication. 64 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Conclusion The VSP provides an overview of the state of PHC in The Gambia. The above recommendations are grounded in the PHCPI framework and informed by the findings from the quantitative and qualitative VSP. The MOH can use these recommendations as an opportunity to engage with partners with the ultimate aim of strengthening PHC services. Appendix 65 Appendix 66 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Appendix A. Performance Domain PERFORMANCE DOMAIN: DETAILED VITAL SIGNS PROFILE INDICATORS The Gambia SCORE PERCENTAGE SOURCE YEAR ACCESS 74 Financial Perceived access barriers due to treatment costs* 27% DHS STATcompiler 2019-2020 Geographic Perceived access barriers due to distance* 25% DHS STATcompiler 2019-2020 QUALITY 67 Comprehensiveness Avg. availability of 5 tracer RMNCH services 71% SARA 2019 Avg. availability of services for 3 tracer communicable diseases 50% SARA 2019 Avg. availability of diagnosis & management for 3 tracer NCDs 62% SARA 2019 Continuity DTP3 dropout rate* 6% DHS report 2019-2020 Treatment success rate for new TB cases 87% WHO TB country Profile 2021 Person-Centeredness** Percent of the clients reporting that the nurse/doctor explained their condition to them very clearly 75% Patient Satisfaction Survey 2018 Proportion of clients reporting Provider was respectful/ very respectful 67% Patient Satisfaction Survey 2018 Provider availability Percent of clients reporting a consultation time of more than 10 minutes 26% Patient Satisfaction Survey 2018 Provider Competence** Antenatal quality based on patient reported components of antenatal care 98% DHS Report 2019-2020 Family planning quality based on methodological information index (informed choice) 58% DHS Report 2019-2020 Safety Adequate waste disposal 60% SARA 2019 Adequate infection control 79% SARA 2019 SERVICE COVERAGE 50 Reproductive, Maternal, Newborn and Child Health Demand for family planning satisfied with modern methods 40% DHS STATcompiler 2019-2020 Antenatal care coverage (4+ visits) 79% DHS STATcompiler 2019-2020 Coverage of DTP3 immunization 93% DHS Report 2019-2020 Care-seeking for suspected child pneumonia 70% DHS STATcompiler 2019-2020 Infectious diseases Tuberculosis cases detected and treated with success 50% WHO TB country Profile 2021 People living with HIV receiving anti-retroviral treatment 31% UHC Global Monitoring Report 2021 Use of insecticide-treated nets (ITN) for malaria prevention 38% DHS STATcompiler 2019-2020 Children under 5 with diarrhea receiving ORS 44% DHS STATcompiler 2019-2020 Non-Communicable Diseases (NCDs) % of population with normal blood pressure*** 38% UHC Global Monitoring Report 2021 *Indicators where lower values are preferable were transformed before inclusion in the index. The modified indicator was defined as 100-X, where X is the original percentage shown in this table. **Country-specific (proxy) indicator, used in absence of globally comparable survey data. ***Percentage of adult population with normal blood pressure is based on age-standardized estimates. These distributions are rescaled to provide finer resolution before inclusion in the index. Rescaled indicator = (X-40)/(100-40)*100, where X is the prevalence of normal blood pressure. For more details see Tracking UHC: 2021 Global Monitoring Report. Note: Summary scores for the domains of Access, Quality, and Coverage are calculated by taking the average of indicator values within each subdomain, and then taking the average across subdomain scores. Source: Authors’ calculations based on multiple data sources as noted in diagram. Appendix 67 Appendix B. Capacity Domain CAPACITY DOMAIN: DETAILED VITAL SIGNS PROFILE INDICATORS The Gambia SCORE GOVERNANCE 1.72 Governance and Leadership 1.4 Measure 1: Primary health care policies (1/2) Y Y Measure 2: Primary health care policies (2/2) R Measure 3: Quality management infrastructure Y Y Measure 4: Social accountability (1/2) R Measure 5: Social accountability (2/2) R Adjustment to Population Health Needs 2.0 Measure 6: Surveillance Y Y Measure 7: Priority setting Y Y Measure 8: Innovation and learning Y Y INPUTS 1.8 Drugs and Supplies 1.0 Measure 9: Stock-out of essential medicines R Measure 10: Basic equipment availability R Measure 11: Diagnostic supplies R Facility Infrastructure 1.7 Measure 12: Facility distribution Y Y Y Measure 13: Facility amenities R Measure 14: Standard safety precautions and equipment R Information Systems 2.0 Measure 15: Civil Registration and Vital Statistics R Measure 16: Health Management Information Systems Y Y Y Measure 17: Personal care records Y Y Workforce 2.5 Measure 18: Workforce density and distribution R Measure 19: Quality assurance of primary health care workforce Y Y Y Measure 20: Primary health care workforce competencies G G G G Measure 21: Community health workers Y Y Funds 2.0 Measure 22: Facility budgets R Measure 23: Financial Management Information System R Measure 24: Salary payment G G G G POPULATION HEALTH AND FACILITY MANAGEMENT 2.3 Population Health Management 1.5 Measure 25: Local priority setting R Measure 26: Community engagement R Measure 27: Empanelment R Measure 28: Proactive population outreach Y Y Y Facility Organization and Management 3.0 Measure 29: Team-based care organization G G G G Measure 30: Facility management capability and leadership R Measure 31: Information system use Y Y Y Measure 32: Performance measurement and management (1/2) Y Y Y Measure 33: Performance measurement and management (2/2) G G G G Source: Authors’ calculations based on multiple data sources. 68 Appendix C. PHCPI Framework A System B Inputs C Service Delivery D Outputs E Outcomes A1. Governance B1. Drugs & Supplies C1. Population C3. Access C5. High Quality D1. Effective E1. Health Status & Leadership Health Management Primary Service Coverage B2. Facility Infrastructure a Financial Health Care E2. Responsiveness a Primary health a Local priority Setting a Health promotion to People care policies b Geographic a First Contact B3. Information Systems b Community Engagement Accessibility b Disease prevention E3. Equity b Quality management c Timeliness Infrastructure B4. Workforce c Empanelment b Continuity c RMNCH E4. Efficiency C4. Availability B5. Funds of Effective c Social accountability d Proactive population C Comprehensiveness d Childhood illness E5. Resilience of PHC Services outreach Health Systems A2. Health Financing a Provider availability d Coordination e Infectious disease C2. Facility a Payment systems Organization and b Provider e Person-Centered f NCDs & mental health Management Competence b Spending on g Palliative care primary health care a Team-based c Provider motivation care Organization c Financial coverage d Patient-provider b Facility management respect and trust A3. Adjustment capability and leadership to Population e Safety Health Needs c Information Systems a Surveillance d Performance measurement and b Priority setting management c Innovation and learning Social Determinants & Context (Political, Social, Demographic, Socioeconomic) Source: Veillard et al. 2017. A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA Appendix 69 Appendix D. Recommendations Based on The Gambia VSP Resources Time horizon from Difficulty of Potential impact, required, from impact (short, Main PHC Recommendation execution, from low from low (+) to high low (+) to high medium, or long dimension affected (+) to high (+++) (+++) (+++) term) 1. Strengthening PHC governance Quality, access, equity Establish a PHC-specific policy + ++ +++ Long Governance and leadership Improve coordination across Quality, coverage government and non- + ++ ++ Short Governance and governmental entities leadership 2. Increasing the availability of medicines and supplies Improve use of pooled Access, quality, resources through the Drug ++ +++ +++ Long and equity Revolving Fund Health financing Access, quality, Implement needs-based and equity ++ ++ +++ Long resource allocation formula Health financing Capitalize on investments Access, quality in electronic Logistics Facility ++ ++ ++ Medium Management Information organization and System management 3. Implementing a people-centered model of PHC focused on delivering comprehensive infectious and non-communicable disease services Access, coverage Establish empanelment ++ ++ ++ Medium Population health systems management Coverage Employ multi-disciplinary Workforce teams for health service ++ ++ ++ Medium delivery Facility organization and management Capacity, coverage Improve comprehensiveness of ++ ++ +++ Long Population health services management 4. Increase capacity for ASRH services Coverage, access, Expand ASRH services and equity integrate adolescents and ++ ++ ++ Medium Adjustment to youth-friendly services into the existing public health system population health needs Source: Prepared by the authors. Note : low = +; medium = ++; high = +++. 70 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Appendix E. Implications of the Recommendations for Stakeholders National Regional or Service delivery Patients and Recommendation government and divisional health Academia providers citizens health authorities authorities 1. Strengthening PHC governance Establish a PHC-specific policy F, E, M, P F, M, P D I I Improve coordination across government and non- F, E, M, P M, P P P I governmental entities 2. Increasing the availability of medicines and supplies Improve use of pooled resources through the Drug F, E, M, P P D I I Revolving Fund Implement needs-based F, E, M M, P P I I resource allocation formula Capitalize on investments in electronic Logistics F, E, M M, P P I I Management Information System 3. Implementing a people-centered model of PHC focused on delivering comprehensive infectious disease and NCD services Establish empanelment F, E, M M, P P I P, I systems Employ multi-disciplinary teams for health service F, E M, P F, M, P I I delivery Improve comprehensiveness F, E, P, D P P P P, I of services 4. Increase capacity for adolescent sexual and reproductive health services Expand ASRH services and integrate adolescents and youth-friendly services into F, E, M, P M, P D I I, D the existing public health system Source : Prepared by the authors. Note: F = provide financing or financial incentives; E = establish strategic direction, norms and policies; M = manage the pro - gram; P = participate in the implementation of the program or support it; I = stay informed on the program activities; D = make informed or strategic decisions. MOHFW = Ministry of Health and Family Welfare; OOPS = out-of-pocket spending; PHC = primary health care. Appendix 71 Appendix F. Progression Model Participants Key Informants • Dr. Mustapha Bittaye – Director of Health Services, MOH • Momodou Ceesay, Health Economist, WHO • Dr. Omar Manjang, Director of Nursing, MOH • Mariama Janneh, UNICEF • Alieu Jallow, Program Manager, The Gambia Network of AIDS Support Societies (GAMNASS) • Sana Sambou, EDC, MOH • Alhaji Sankareh, Regional Director West Coast Region 1 • Gibril Jarjue, Director of Planning and Budget • Sainey Sanneh, Director of Research, MOH • Jainaba Sey Sawo, University of The Gambia • Babanding Sabally, Directorate of National Pharmaceutical Services, MOH • Ousman Badjie, Director National AIDS Secretariat • Sheriffo Jagne, Director, National Public Health Laboratory • Lamin B Fatty, Program Manager Births and Deaths, MOH • Regional Data Manager WCR • Abdoulie Bah, HMIS, MOH • Alhaji Director of Human Resources for Health, MOH • School of Nursing Midwifery, Lamin Suwareh • Mafugie Bojang, Nurses Council, New Street, Banjul 72 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT • Mr. Lamin Suwareh – Head school of Nursing and Midwifery, Marina Parade, Banjul • Joanna Mendy, Catholic Relief Services • Zandac Jarjue Regional Public Health Nurse WCR1 • Senior CHN Tutor, WCR 1 • Health Facility Management Team • Alhaji Sankareh, Regional Health Director WCR 1 • Members of Hospital Management Board • Abdoulie Bah, HMIS • Data Manager, WCR 1 • Nicolas Njie, Quality Assurance Unit • Monitoring and Evaluation Officer, DPI PHCPI Steering Committee Members • Dr. Momodou Lamin Samateh, Hon. Minister of Health, Ministry of Health • Mustapha F Yarbo, Permanent Secretary, PS Office of the President • Muhamed L Jaiteh, Permanent Secretary, PS Ministry of Health • Abdoulie Jallow, Permanent Secretary, PS Ministry of Finance and Economic Affairs • Ousman Ceesay, Deputy Permanent Secretary, Ministry of Transport, Works and Infrastructure • Dr. Mustapha Betaye, Director of Health Services, Ministry of Health • Bakary Jallow, Executive Director National Nutrition Agency, Office of the Vice President Appendix 73 • Samuel Lantei Mills, World Bank Task Team Leader for The Gambia, World Bank • Shahid Mahbub Awan, Emergency Coordinator, UNICEF • Dr. Kassa Muhammed, Health System Strengthening Adviser, WHO • Alhagie Kolley, National Prog. Officer RH & HIV/AIDS, UNFPA • Lamin Cham, World Food Programme • Cherno Jallow, Programme Director, Riders for Health • Abdoulie Mam Njie, Project Coordinator, MOH, PCU • Bai Ebrihima Cham, Executive Secretary, CCM • Ousman Ceesay, Focal Person PHCPI – The Gambia, MOH Validation Workshop Participants (November 1-2, 2021) • Dr. Momodou T Nyassi, Deputy Director of Health Services, MOH • Dr. Mustapha Bittaye, Director of Health Services, MOH • Momodou Ceesay, Health Economist, WHO • Ousman Ceesay, Programme Manager, PHC Unit, MOH • Alhagie Sankareh, Regional Director of Health Services, Western 1, MOH • Fatoumata Jallow, Programme Officer HMIS, MOH • Sainey Sanneh, Director of Health Research, MOH • Dr. Mamady Cham, CEO Bwiam General Hospital, Bwiam General Hospital • Fatou Sagar Jagne, Operation Manager, PCU, MOH • Dr. Musa Marena, Programme Manager, RMNCAH, MOH • Alhagie Saine, Director of Human Resources for Health, MOH 74 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT • Mariama Janneh, Health Specialist, UNICEF, UNICEF • Joana Mendy, Program Manager Migration, Peacebuilding and Partnership, Programming, Catholic Relief Services • Babanding Sabally, Directorate of National Pharmaceutical Services, MoH • Bai Ebrihima Cham, Executive Secretary, CCM • Dr. Kassa Muhammed, Health System Strengthening Adviser, WHO • Babagalleh Jallow, Programme Manager, RBF Unit, Ministry of Health • Alhagie Sankareh, Regional Director of Health Services, Western 1, MOH • Abdoulie Bah, Programme Manager HMIS, MOH • Dr. Omar Manjang, Director of Nursing, Ministry of Health • Alieu Jallow, The Gambia Network of AIDS Support Societies (GAMNASS), CBO • Amadou Wuri Jallow, Ag. Program Manager, EDC, MOH • Gibril Jarjue, Director of Planning and Information and Budget, MOH • Sheriffo Jagne, Director National Public Health Laboratory, MOH • Ousman Badjie, Director National AIDS Secretariat, NAS • Lamin B Fatty, Program Manager, Registrar Births and Deaths, MOH • Lamin Suwareh, Head School of Nursing and Midwifery, School of Nursing & Midwifery • Mafugie Bojang, Registrar Nurses and Midwife Council, Nurses Council • Abdoulie Kujabie, Senior CHN Tutor, WCR 1, MOH • Zeandac Jarjue, Regional Public Health Nurse RHD WCR 2, RHD WCR 2 • Nicolas Njie, Quality Assurance Officer, MOH Appendix 75 • Lamin Jawla, Monitoring and Evaluation Officer, DPI, MOH • Dr. Abba Hydra, Chief Executive Officer, Sheikh Zayed Regional Eye Care Centre • Mr. Momodou MK Cham, Director, CIAM • Dr. Adama Sallah, CEO Lamtoro Medical Centre, Lamtoro Clinic • Abdoulie Jallow, Permanent Secretary, MoFEA • Dr. Momodou Kabir Cham, Registrar Gambia Medical & Dental Council, GMDC • Beatrice Prom, Manager, Communications & Advocacy, Chamber of Commerce & Industry • Muhammadou L Jaiteh, Permanent Secretary, MOH • Samuel Lantei Mills, World Bank Task Team Leader, World Bank 76 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Appendix G. Progression Model Documents Reviewed 1. Gambia NPHL Policy 2018 2. Gambia Essential Medicines list 3. Gambia 2013 DHS 4. Gambia HIS ME Assessment 5. GMIS 2017 Report 6. Health Facility Assessment on Maternal Newborn and Child health 7. HRH for Health Workforce Strategic Plan 2012 8. HRH Assessment report 2018 9. IBBS Gambia 2017 Final report 10. M&E Plan National Health Strategic Plan 2014 11. MoFEA Core Financing Commitment 2021-2023 12. 2016 BSS Final Report December 2016 13. A survey on prevalence and knowledge of family planning 14. Client Patient Satisfaction survey final report 15. Draft health policy 2021–2030 16. Gambia NHA FY2015 report 17. Gambia projected Pop 2014–2025 18. Final health technology assessment report 2018 19. Final MOH population projection 2020–2025 20. Family planning policy 2019–2026 Appendix 77 21. Gambia health financing strategy 22. Gambia health system assessment 2020 23. Gambia Village health workers training manual 24. Community birth companion manual 78 THE PRIMARY HEALTH CARE SYSTEM OF THE GAMBIA A PRIMARY HEALTH CARE PERFORMANCE INITIATIVE ASSESSMENT Appendix H. Project Development Objective (PDO) Indicators, The Gambia Essential Health Services Strengthening Project (P173287) The Gambia Essential Health Services Strengthening Project is a Word Bank Group-financed project to improve the quality and utilization of essential health services in The Gambia (27). The indicators in Table G.1 have been collected at the project’s midpoint by the MOH Directorate of Planning and Information as part of the results framework. The VSP assessment team opted to use only the coverage indicators collected from the DHS 2019– 2020 due to the varying methodologies between the PDO indicators and globally comparable indicators from the DHS. Table H.1 Project Development Objective (PDO) indicators and targets PDO Indicator Baseline Mid-Term Endline Improve quality of essential health services Target 75.0 85.0 Health Facility Quality Index (percentage) 69.0 Actual 86.87 Improve utilization of essential health services Essential health services coverage index (geometric means Target 49.78 56.38 45.9 of tracer indicators, on a scale of 0–100) (percentage) Actual 52.78 Target 22.00 33.00 Contraceptive prevalence rate (percentage) 17.1 Actual 21.10 Target 81.00 84.00 ANC, four or more visits (percentage) 78.5 Actual 86.90 Target 85.00 88.00 Delivery in a health facility (percentage) 83.7 Actual 89.70 Fully immunized children (percentage of children who Target 86.00 90.00 at age 12–23 months had received all basic vaccinations) 84.6 (percentage) Actual 88.30 Children aged 6–23 months who received minimum Target 16.00 19.00 14.0 acceptable diet (percentage) Actual 16.40 Under-five children for whom advice or treatment was Target 73.00 77.00 sought for symptoms of acute respiratory infection 70.3 (percentage) Actual 90.80 Appendix 79 References 1. 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