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1.00 INTRODUCTION

1.01 Location, Size and Climate

The Gambia is located on the West African coast and extends about 400 km inland, with a population density of 97 persons per square kilometre. The width of the country varies from 24 to 28 kilometres and has a land area of 10,689 square kilometres. It is bordered on the North, South and East by the Republic of Senegal and on the West by the Atlantic Ocean. The country has a tropical climate characterised by 2 seasons, rainy season June-October and dry season November-May.

1.02 Demographic Characteristic

According to the Demographic profile 2000,the population is estimated at 1.4 million and by the year 2005 it is estimated to reach 1.7 million, holding the 4.2% (1993 Census) annual growth rate constant (see Appendix A). About 60% of the population live in the rural area; and women constitute 51% of the total population. The crude birth rate is 46% per 1000 population while the total fertility rate is 6.04 birth per woman. The high fertility level has resulted in a very youthful population structure. According to the 1993 Census, nearly 45% of the population is below 15 years and 19% between the ages 15 to 24. Average life expectancy at birth is 60 years overall, with 58 and 59.3 for male and female respectively.

1.03 Health Services

The public health service delivery system is three tier based on the primary health care strategy. Presently services are provided by 3 hospitals, 36 health facilities at the secondary level and 492 health posts at the primary level. There is also one hospital under construction and another planned for construction in 2001. The public health system is complemented by 34 private and Non-Governmental Organization clinics. The public sector has 1477 beds, 211 doctors and dentists, 8 Pharmacists, 261 Registered nurses, 250 Enrolled nurses, 144 community nurses, 122 public health officials and 8 laboratory technologist.

The Gambia has an Infant Mortality Rate of 84/1000 live births, 60% of which is attributable to malaria, diarrhoeal diseases and acute respiratory tract infections. The main causes of mortality in infants (0-12 months) are neonatal sepsis, premature deliveries, malaria, respiratory infections, diarrhoeal diseases and malnutrition. For child mortality, main causes are: malaria, pneumonia, malnutrition, and diarrhoeal diseases. The Maternal Mortality Ratio is estimated at 10.5/1000 live births, with regional variation of 9/1000 in the urban areas and 16/1000 live births in the rural areas, the majority of which are due to sepsis, haemorrhage and eclampsia.

40% of total outpatient consultation in 1999 was due to malaria, while diarrhoeal diseases and acute respiratory tract infections constitute about 25%`.

The HIV prevalence rate is 2.2% (1.7% HIVI and 0.5% HIVII) in the general population and 1.7 % in antenatal clinic attendance (1991). A sentinel surveillance study result in one of the sites shows that the prevalence of HIV1 has significantly increased from 0.6% in 1995 to 0.9% in 2000.

There has been a decline in national coverage for fully immunized children to a present level of 68.6% for under 1 year and 76.0% for the under 2 year in 2000. (See Appendix A)

Malnutrition continues to be a major public health problem in The Gambia. A 1998 national anthropometrics study of children under five conducted in the dry season indicated 16.8% stunting, 6.8% wasting and 17.1% underweight. Diabetes Mellitus is estimated to affect about 1% of the population while a study found that about 16% of urban women are obese compare to only 1% of rural women.

Safe water is an essential pillar of sustainable health for rural and urban population. Access to safe water (1996 MICS) is 69% of the overall households; with 79.9% urban and 64.9% rural and access to proper sanitary facilities are not encouraging thus limiting to only 37% (1998) for the entire country. This percentage is unevenly distributed between urban areas (83%) and rural areas (17%).

In 1998, the Household Poverty Study indicated that the proportion of the extremely poor population has increased significantly from 15% to 51% (See Appendix B)

Considerable progress has been made in the areas of: EPI Coverage, expansion of health facilities and in recruitment of trained health personnel. Success has been registered in the implementation of the Baby Friendly Community Initiative and the Bamako Initiative. Also, relevant policy documents were developed including: Nutrition Policy, Drug Policy, and many others at various stages of development.

As we highlight the progress made in health, it is worth mentioning the significant support and contributions made to the health sector by the NGOs and by both Bilateral and Multilateral partners.

Although considerable progress has been made, a lot more remains to be done. The implementation of the Health Action Plan 1999-2003 is constrained by several factors including:

- All the major health centres are not fully functional, the main supporting units of the major health centres, i.e. laboratory, radiological services and operating theatres are still not equipped and staffed.

- Acute shortage of medical, nursing and other health staff at all health facilities.

- Inadequate staffing of all Divisional Health Management Teams

- Poor conditions of services including inadequate staff houses have made it extremely difficult to retain staff particularly in rural areas.

- Supervisory schedules for both Divisional Health Management Teams and Health Centre Teams are seriously compromised due to inadequate transport, fuel and spare parts.


- Communication difficulties between the Village Health Services and Basic Health Services and between the later and the divisional and central levels prevent the relaying of information for timely interventions.

- Inadequate capacity at all levels to select and process relevant data in timely manner has hindered planning and management of health care delivery.

- Centralisation of responsibilities and resources has seriously affected implementation of activities at the operational level.

- Central level supervision generally was inadequate

1.04 Policy Environment

There is a pressing need to improve the delivery of health services in order to better the health of the population and reduce the unacceptable prevailing morbidity and mortality rates. These rates are influenced by many factors among which is the uncoordinated delivery of services within different programme areas and at different levels of the health care system.

The need to review the current health policy has been influenced by the following factors:

· Proposed local government decentralisation programme. This exercise demands the decentralisation of government services, including health services to the divisions. The devolution of authority, responsibility and resources to the divisions has to be directed by a policy.

· Proliferation of donor agencies each operating in their own way in the same health care system. There is therefore urgent need for better co-ordination of donor activities.

· The declining, though still high, incidence of infectious diseases and the emergence of new diseases - non-communicable and communicable- need to be addressed in our service delivery packages.

· Formulation of other sector policies impacting on the organisation and the delivery of health services

· The disparity in the demand of services at different levels of delivery as a result of rural-urban drift

· Progressive decline in funding of the primary and secondary tiers of the PCH system

· Experience from the implementation of certain health projects/programmes like PHC, BI and DRF to improve financing of health services

· The need for a new partnership in the health sector among the donors, NGOs, private sector and the community in delivering health services to the population

· The absence of a co-ordinated monitoring and evaluation system to measure performance and plan for improvements

· The limited collaboration between the traditional healing system and the formal health sector

 

1.05 Problem Statement

The health sector has over the years been under great pressure due to a number of factors: the high population growth rate, inadequate financial and logistic support, shortage of adequately and appropriately trained health staff, high attrition rate and lack of efficient and effective referral system. Poverty and ignorance have led to inappropriate health seeking behaviours and contributed to ill health.

The preceding factors have seriously constrained efforts to reduce morbidity and mortality rates and as a result health care delivery throughout the country has not lived up to expectation.

The frequent changes in top management positions at The Department of State for Health has hampered continuity, institutional memory and policy follow through. The need to have a clear direction to improve quality of care and reduce the high morbidity and mortality rates requires a supportive organisational and management framework with a strong flexible and knowledgeable leadership, able and willing to take informed risks.

2.00 VISION AND MISSION


2.01 Vision

Attainment of accessible quality health care for the Gambian population that would be a model in the Africa Region by the year 2020

 

2.02 Mission Statement

Provision of quality health care services within an enabling environment, delivered by appropriately and adequately trained, skilled and motivated personnel at all levels of care with the involvement of all stakeholders to ensure a healthy population.


3.00 GUIDING PRINCIPLES

3.01 Equity

Accessibility to quality services at point of demand especially for women and Children, for the marginalised and underserved, irrespective of political, ethnic or religious affiliations; rational expansion of health services

3.02 Gender Equity

The planning and implementation of all health programmes should address gender sensitive and responsive issues including equal involvement of women in decision-making; eliminating obstacles (barriers) to services utilisation; prevention of gender based violence.

3.03 Ethics and Standards

Respect for human dignity, rights and confidentiality; good management practices and quality assurance of service delivery.

3.04 Client Satisfaction

Accessibility to twenty-four hour quality essential services especially midwifery and blood transfusion services; reduced waiting time; empathy in staff attitudes; and affordability of services; adequate staffing in health facilities.

3.05 Cultural Identity

Recognition of local values and tradition; use of traditional structures e.g. Kabilos, kaffos, traditional healers.

3.06 Health System Reforms

Devolution of political and managerial responsibilities, resources and authority in line with the Government decentralisation programme; capacity building for the decentralised structures (institutions).

3.07 Skilled staff retention and circulation

Attractive service conditions (package); job satisfaction to encourage a net inflow of skills.

3.08 Partnerships

Community empowerment; active involvement of the private sector, NGOs, local government authorities and civil society; effective donor co-ordination.

4.00 POLICY ISSUES

Noting the challenges confronting the health sector, and having conceived the vision, mission and guiding principles, a number of key result areas were identified that would collectively have potential for maximum impact on the health status.

4.01 Essential Care Pakage

Preamble

Morbidity and mortality rates due to both communicable and non-communicable diseases and other factors are unacceptably high, especially among infants, children and women.

Essential Care Package will aim at addressing the common causes of morbidity and mortality, especially for women, children, the underserved and the marginalised. The package will also take care of the emerging communicable and non-communicable diseases. For each level of care, a package of essential services will be developed.

The Essential Care Packages will have implications for the planning, resource requirements and implementation of other policy issues


FIVE YEAR STRATEGIC GOAL
:

Improve access to and ensure provision of essential care packages at all levels of health care delivery system:

Objectives

a. To develop sustainable Essential Care Packages for all levels of the health care delivery system.
b. To provide required resources for efficient delivery of the essential care package
c. To implement delivery of essential care packages at all levels

Strategies

- Determine essential care package for each level
- Strengthen, expand and increase funding for PHC
- Improve effectiveness of the referral system
- Strengthen and expand Primary Health Care countrywide
- Ensure that the required pharmaceuticals and other medical supplies are continuously accessible at all levels of care.
- Institute mechanism for effective monitoring and supervision
- Revitalise the school health programme.
- Research in health seeking behaviour

4.02 Organisation And Management

Preamble

Management of resources for health care, both human, financial and material, still remains centralised at the health headquarters. Divisional health systems are weak with no clear operational linkages with the central level, the community and the other providers in the private and traditional healing systems.

There is need for improving efficiency and effectiveness in the organisation and management of the health sector through (a) Management reform (b) creation of popular structures (i.e Hospital board and local public Health committees ) for re-enforcing community participation in decision making, and (c) devolution of responsibilities, authority and resources to the Hospital and Divisional Health Management Teams and village development committee. Linkages between and functions of all the management structures should be clearly defined to ensure harmony, promote self-management (autonomy) and re-enforce the decentralisation process.


FIVE YEAR STRATEGIC GOAL
:

Ensure effective and efficient management of a decentralised Health Service

Objectives

a. To decentralise responsibility, authority and resources to Hospitals, Divisional Health Management Teams, Basic Health Facilities and Village Development Committees.

b. To improve organisation and management of the health care delivery system.

Strategies

- Management Capacity Building for Divisional Health Management Teams. Program Managers, Basic Health Facility Managers, Hospital Management Teams and Village Development committees.

- Selective transfer of authority responsibility and the required resources and management of these resources to Divisional Health Management Teams, Hospitals, Basic Health Facilities and Village Development Committees in line with the government decentralisation programme.

- Establish implementation mechanism for the health reform process.

4.03 Human Resource Development

Preamble

The demand for health care is increasing and this has led to the expansion of the health care delivery services.

Expansions create a demand for more staff and this is aggravated by the inadequate output from the training institutions. Inadequate staff training and high attrition rates among staff continue to affect health services delivery negatively.

The incentives, including pay package, provided to the health staff are not attractive enough, to retain skilled health staff and to attract others into the service.

Postings and transfer should be driven by the needs of the community for health services, taking into account the social needs of staff especially the young females. Transfers and postings driven by punitive measures and favouritism, demotivates staff and may contribute to the high attrition rate.

There is a need for rational utilisation of the available trained human resources and improvement of the service conditions of the health care workers

A Human Resource Development Plan will be formulated that will address the whole range of personnel functions, i.e. recruitment, pre and in-service training, deployment, promotion, transfer, leave, grievances procedures, pay and non-monetary benefits.


FIVE YEAR STRATEGIC GOAL
:

Ensure appropriate and adequate human resource for the health Sector.

Objectives

To meet the human resource needs of the health sector

Strategies

- An attractive remuneration packages for staff

- An operational human resource development plan including postings and transfers.

- Expand and upgrade the capacity of the training institutions for health service providers.

- Ensure core staff team at all health facilities and Divisional Health Teams.

- Building a positive image of the health sector


4.04 Infrastructure And Logistics

Preamble

Currently, infrastructure and logistics available in the health sector are inadequate and not regularly maintained. There was no operational maintenance policy available in the health sector until September 2000.

The requirements for infrastructure and logistics for health care delivery at each level of care will be influenced largely by the increasing population and the content of the Essential Health Care Package that has to be delivered at that level. Considerations of equity of access, speedy access to emergency and essential care and quality in diagnosis and treatment will entail planned expansion and regular maintenance of facilities and the selective adoption of innovations in diagnostic and therapeutic technologies.


FIVE YEAR STRATEGIC GOAL
:

Adequately address the infrastructure and logistic requirements of
the health services on a sustainable basis

Objectives

a. To provide the necessary infrastructure and logistics for health service delivery

b. To provide the preventive maintenance of infrastructure, equipment and vehicles.

c. To meet the fuel requirements at divisional, health facility levels and hospitals.

d. To replace equipment, vehicles and motorcycles on timely basis

Strategies

- Operationalise the Maintenance Policy 2000.

- Rationalise expansion of health services, using the Health Mapping Study Report as guide.


4.05 Essential Drugs, Vaccines And Other Medical Supplies

Preamble

Government budgetary allocations for drugs and dressings in real terms have not been in the increase. Also there has been a major increase in demand due to the increased number of clienteles and the rapid expansion of service delivery facilities. The procurement process is long and cumbersome and the storage capacity of Central Medical Stores is another major constraint. These factors contribute to the sporadic shortages of drugs and other medical supplies.
Pharmaceuticals are associated with quality services and their shortage has negative effects on communities' perception of the service delivery.

Vaccines supply was to a large extent supported mainly by UNICEF up to 1996, and that helped maintain the level of fully immunized children above 80%. However, with diminishing support of the traditional donors to the EPI programme, immunization coverage began to fall and that trend has continued up to 2000. Other problems affecting immunization include limited storage capacity and an over-aged cold chain system.

Gambia is now a party to the European Union supported Vaccines Independent Initiative and it is anticipated that the country will qualify for the Global Alliance Vaccine Initiative(GAVI).

Improved access to essential drugs, vaccines and other medical supplies contributes to improvement in quality and increase in utilisation of services


FIVE YEAR STRATEGIC GOAL:

- Ensure continuous availability and accessibility to essential drugs, vaccines and other medical supplies.

Objectives

- To make essential drugs, vaccines and other medical supplies and accessible to the population

- To improve immunisation coverage

Strategies

- Improve efficiency in the management of drugs, vaccines and other medical supplies.
- Strengthen the cold chain system
- Review and operationalise the National Drug Policy to make it consistent with the demands of the Essential Health Care Package.

4.06 Health Information

Preamble

Health information is a crucial element and a vital tool for effective management of health service delivery. It is also important for evidence base planning, informed decision making, monitoring and evaluation of all health development activities.

The current weaknesses in the Health Information System (HIS) include the limited capacity at all levels to collect, analyse and use information effectively. There is inadequate disease surveillance system and an out-dated health database. This policy will ensure that HIS provide an effective framework to facilitate planning, budgeting, monitoring and evaluation of the health care delivery system.
The Department of State for Health does not have a strong research base to generate data for management. Also, the findings of some researches conducted in the Gambia are not easily accessible, let alone used in health management.

There is a need to establish a Health Research Unit that will promote, co-ordinate and evaluate all research activities in the country, and to ensure they are relevant and safe.


FIVE YEAR STRATEGIC GOAL:

Timely availability of relevant information for effective planning, implementation, monitoring and evaluation of health services

Objectives

a. To strengthen information generation for effective planning, monitoring and evaluation at all levels.

b. To make research relevant and useful to the needs of the health sector.

c. To make research findings available to relevant stakeholders


Strategies

- Strengthen the Health Management Information System.
- Institute a mechanism for scrutinising research proposals, monitoring research activities and sharing findings with relevant partner.
- Strengthen training for research methodologies in all heal;th training institutions.


4.07 Referal System

Preamble

Timely evacuation of patients from one level of health care to another still faces serious difficulties due to an ambulance fleet most of which are unroad worthy, insufficient and not satisfactorily maintained. This is aggravated by the fact that fuel supplies are grossly inadequate and the facilities receiving these referrals lack the capacity to manage most of them effectively. Late referrals and unsafe methods of evacuation of patients especially at community level contribute to unnecessary deaths.

The desired referral system will aim at ensuring speedy and safe evacuation of patients and also address the capacity of the receiving facilities to manage these referrals effectively. This will ensure continued care of patients from one point to another.

FIVE YEAR STRATEGIC GOAL:

Ensure an effective and sustainable referral system at all levels.

Objectives

a. To ensure timely referral of patients.

b. To improve the safety and comfort of the patient during evacuation to the referral point.

c. To guarantee timely access to required care at the referred point

d. To rationalise the use of services provided in the health facilities.

Strategies

- Make all health facilities fully operational in line with established standards
- Develop standard protocols for referrals
- Develop and implement sustainable referral systems within communities
- Provide sustainable and effective communication linkages between Divisional Health Management Teams, Hospital, health facilities and key villages.


4.08 Health Financing

Preamble

Cost of providing health care continues to rise due to increasing demand, changes in diagnostic and therapeutic technologies, inflation and currency fluctuations.

A Cost Recovery Program was started in 1988, which established the Drug Revolving Fund and the introduction of user fees as a form of health financing. Bamako Initiative was introduced in 1993 as a further development on the Cost Recovery Program. Some successes were registered with both
financing strategies, greater success with Bamako Initiative.
Financing health care requires collaboration of Government, donors, other partners and the beneficiaries.

Government percentage budgetary allocation to the health sector should be raised significantly. The Department of State for Health and Social Welfare will develop other financing schemes, paying attention to equity concerns, and ensure a judicious allocation of resources and their use.

FIVE YEAR STRATEGIC GOAL:

Ensure a sustainable and adequate financing of health services

Objectives

a. To secure the required financial resources for the health sector

b. To improve the management of available financial resources in the health sector.

c. To decentralise budgetary allocation to the divisions.

Strategies

- Develop a Social Insurance scheme.

- Mobilise additional financial resources from external sources.

- Rationalise allocation of financial resources.

- Promote effective and efficient management of financial resources.

4.09 Legal Framework

Preamble

There are many health and health related Acts of parliament which seek to regulate health and health related activities in The Gambia. Some of these Acts are outdated and do not reflect current development in health care. In the light of these circumstances, it is necessary to create a legal environment which will be conducive for the protection and the safety of health care consumers, service providers and the environment.


FIVE YEAR STRATEGIC GOAL:


Ensure an enabling legal framework for the promotion and maintenance of established health standards.


Objectives

a. To update all health and health related Acts to be in conformity with the strategic direction of the health sector.

b. To formulate new legislation inorder to cater for developments in health.


Strategies

- Improve on health and health related Acts and Regulations.

- Establish mechanisms for enforcing the Acts.


- Advocate for health concerns to be adequately reflected in other acts relating to other sectors of government.

4.10 Community Participation

Preamble

Communities, the end beneficiaries of services are rarely involved in the decision making process for the provision of such services. Consequently they continue to see themselves as passive recipients of services rather than as stakeholders. This has a negative impact in ensuring continuity and sustainability for most community targeted programmes.

Community supported health interventions such as Bamako Initiative, Baby Friendly Community Initiative with proven health benefits should be scaled up and extended to national coverage. Others will be reviewed to make them more relevant and effective.

For the desired sustainability and continuity to be realised, the need for effective community involvement in the planning and implementation of these programmes is paramount.


FIVE YEAR STRATEGIC GOAL:

Empower communities to be active partner in the management of their health.

Objectives

a. To create an enabling environment for communities take ownership of their health

Strategies

- Adequate representation of communities in Hospital Management Board and local public health committee.


- Strengthen village health development structures such as VDC, VHC


- Use of traditional community structures in the provision of health care.

- Promote community income generating activities

 

4.11 Partnerships

Preamble

The traditional partners in health contribute significantly to financing health, but their inputs have been dictated by the specific mandate within which they operate. This has to a large extent compromised the strategic interests of the health sector resulting in vertical health programmes and inefficient utilisation of resources. The private sector, Non- Governmental Organisations and other Government Departments have comparative advantage, which the Heath Sector could harness

To promote a sector-wide approach to health, an enabling environment will be created that would allow for effective participation and co-ordination of efforts among all partners to maximise the rational use of available resources.

Partnerships will be based on consensus with partners on the strategic interest of the health sector and the “common basket” approach will form the basis for donor funding in health. Either a “basket of health services” to be funded from a “basket of pooled financial resources” or a “basket of services” which individual donors and partners select to finance through negotiated arrangements.

To facilitate co-ordination, Non Governmental Organisations will be required to enter into a Memorandum of Understanding with Department State for Health and will be encouraged to work through the framework and structures of existing Health Institutions to avoid confusion and duplication of efforts.

FIVE YEAR STRATEGIC GOAL:

Involve partners, (donors, local and international agencies, interest groups and private sector) in the Planning and Implementation of Health Services.

Objectives

a. To encourage stakeholders’ participation in health.

b. To co-ordinate donor, NGO and private sector inputs into health effectively.

Strategies

- Institute mechanisms for regular consultations with all partners in health
- Institute mechanisms for co-ordinating donor, NGO and private sector inputs.
- Encourage private sector participation in health


4.12 Traditional Medicine

For most communities, the first point of contact in seeking care for patients is the traditional system of care and this can be exploited for the benefit of the health of the community. As the communities believe in and use the traditional system of care, there is need to establish partnership with traditional healers. Some of the traditional methods of care have proven to be effective and need to be promoted, while others may be potentially harmful and may require further research

The traditional Healing System is a community based, self sustaining health care service and therefore can complement the public health service. Traditional Healers such as Herbalists, Birth Attendants, Spiritualists, Diviners and Bone Setters have their own support systems and infrastructure already in place. Their system of charging for their services is community friendly.

There is a growing tendency to move long term care from hospitals to home based (or community based) care. This is especially so with regard to TB, HIV/AIDS and psychiatric patients.

There would be benefits if Traditional Healers were adequately sensitised and utilised to complement the Village Health Services.

FIVE YEAR STRATEGIC GOAL

Integrated traditional medicine into the formal health sector

Objectives

a. To utilise traditional health practices effectively in the formal health care system

b. Sensitise Traditional Healers to provide home based care for long term care patients

c. Sensitise Traditional Healers to support community based health initiatives such as the Impregnated Bed Net strategy


Strategies

- Integrate traditional health practitioner into the formal health care system.

- Patenting and trade marking traditional knowledge and medicines.

- Promote operational research in traditional medicine

5.00 HEALTH PROGRAM AREAS AND PACKAGES

Preamble

The current public health care system is characterised by an ineffective inter –program linkages and an array of fragmented programs, which tend to be unduly influenced by donor preferences.


There does not seem to have been deliberate effort to focus on satisfaction of the clientele and on convenience in the provision of health services.
For micro planning especially at primary level, there is need for baseline information on disease burden. It is anticipated that the Community Needs Assessment and Epidemiological Disease Profile Studies will be conducted as precursors to designing the Essential Health Care Packages and in realigning health programs.

5.01 Program Areas

(i) Child Health
(Adopt IMCI – ARI, CDD, Malaria, Nutrition, EPI)

(ii) Reproductive Health
• Maternal Health
• Adolescent Health
• Family Planning

(iii) Nutrition

(iv) Malaria

(v) STI-HIV/AIDS

(vi) TB/Leprosy

(vii) Non –Communicable Disease

(viii) Epidemiology and Disease Surveillance

(ix) Eye Care

(x) Mental Health

(xi) Oral Health

(xii) EPI

(xiii) Environmental Health (include clinical waste management)

(xiv) Health promotion

(xv) Pharmaceutical Services

(xvi) Laboratory services

(xvii) Blood transfusion services

(xviii) Occupational Health

(xix) Geriatric health

(xx) Rehabilitation care

(xxi) Ear Nose and Throat care

(xxii) Radiological diagnosis services

5.02 Health Packages

New Born/infant/child

• Appropriate curative/preventive care for the newborn/infant child
• Immunization
• Proper hygiene practices
• Promotion of Early Child Care and Development
• Exclusive breast feeding for up to 6 months and continued breast feeding for 24 months
• Adequate complimentary feeding and adequate micro-nutrient supplementation (particularly in Vitamin A and iodized salt and iron)
• Appropriate home care for sick child, and timely treatment
• Adequate care for the HIV/AIDS child (infected and affected)
• Malaria treatment and prevention including promotion of impregnated mosquito bed nets
• Prevention, screening and treatment of childhood illnesses, injury, abuse and disability
• Community support for child care, even in schools, including deworming, dental care, screening and correction of poor vision/ eye sight and skin infections

Adolescent

• Promotion of adequate nutrition
• Prevention of HIV/AIDS infection (IEC)
• Prevention and treatment of sexually transmitted infections (STI)
• Prevention of unwanted / early pregnancies (IEC and FP)
• Control of substance abuse (IEC)
• Promotion of appropriate life-skills and health practices for adolescents
• Promotion and support for activities related to poverty alleviation
• Appropriate care for mental health
• Protection against violence and abuse (IEC)
• Prevention and management of disabilities
• Psychosocial needs assessment and support
• Post abortion and abortion complication care


Women

• Antenatal care focusing on major problems (Malaria, HIV/AIDS, anaemia, eclampsia, STIs)
• Maternal Immunization for neonatal tetanus control (including education)
• Skilled attendance at birth
• Emergency obstetric care for complications
• Promotion of optimum nutrition and iron supplementation especially during pregnancy and lactation
• Promotion of exclusive breast feeding for up to 6 months and continued breast feeding up to 24 months
• Promotion of household consumption of iodized salt
• Promotion of Family planning
• General counselling services (when to seek help)
• Protection from violence
• Prevention and response to epidemics/ education on disease causation
• Appropriate care for mental health
• Education on proper hygiene practice and environmental sanitation
• Prevention and control of mother to child transmission of HIV
• Prevention and treatment of common and endemic diseases
• Provision of post natal care
• Psychosocial needs assessment and support
• Promote breast feeding at work place
• Promote the use of labour saving devices
• Appropriate care for infertility, cancer screening and management
• Counselling services for menopausal and post menopausal women


Men

• Prevention of HIV/AIDS and STIs
• Prevention and treatment of common illnesses and endemic diseases
• Prevention and control of substance abuse (alcohol, tobacco)
• Prevention and response to epidemics/ education on disease causation
• Appropriate care for Mental health
• Promotion of and sensitization on Family planning
• Education of men on the importance of optimum nutrition for women, especially during pregnancy, and girls especially in Vitamin A and iron supplementation
• General counselling (when to seek help)
• Education on proper hygiene practice and environmental sanitation
• Psychosocial needs assessment and support
• Counselling services for androposal men

Note: The package to be delivered at different level will be determined.


6.00 IMPLEMENTATION AND MONITORING MECHANISM

The implementation of the Policy Framework and the Health Sector Investment Programme (or the Health Master Plan or the Five Year Health Development Plan) will be fraught with both risks and opportunities – risks to loose momentum for reform and opportunities to innovate and make a positive difference. A system for tracking performance and implementation has to be put in place to guard against risks and take advantage of opportunities. The Department of State for Health will be involved in several complex activities on a daily basis. Given the above statement, implementation of the Policy and of the Investment Programme cannot be left to chance or to the vulgarise of administrative goodwill.

The goal is to provide an implementation and monitoring mechanism that would move and direct the Policy and the Health Sector Investment Programme
The specific objectives will include;
(i) To institutionalise implementation and monitoring functions.
(ii) To provide for a Forum and modalities for regular consultation among Senior Managers, Programme Managers, Donors, NGOs Community Interest Groups and other Government Departments.


6.01 Implementation

The Department of State for Health will have the overall responsibility for implementing the Policy.
The Policy provides for the creation of autonomous Hospital and Divisional Health Boards, which will have Hospital and Divisional Health Management Teams correspondingly.
There will be devolution of responsibilities, authority and resources from Central level to Hospitals and Divisional Structures. The Management teams under each level will be responsible for implementation at that level.
And their functions will include the following:
Central Level
a) Policy formulation, setting standards, and quality assurance.
b) Resource mobilisation and allocation
c) Capacity development and technical support.
d) Provision of nationally co-ordinated services, e.g Epidemic control
e) Co-ordination of health research.
f) Legislation
g) Monitoring and Evaluation of the overall sector performance
h) Advocacy/Partnership

Divisional Level
a) Implementation of the Health Sector Investment Program
b) Planning and management of divisional health services
c) Provision of disease prevention, health promotion, curative and rehabilitative services, with emphasis on the Essential Care Package.
d) Control of Communicable Diseases of public health importance to the division.
e) Vector Control.
f) Health Promotion
g) Encourage provision of safe water and environmental sanitation
h) Health data collection, management, interpretation, dissemination and utilisation
i) Health Research
j) Community partnership
Autonomous Hospitals
(a) Planning and Management of Hospital Health Services
(b) Provisional of hospital Health Packages
(c) Training of professional staff
(d) Referral facilities for specialist care
(e) Hospital data collection, management, interpretation, dissemination and utilisation.
(f) Clinical research
(g) Professional support to the primary and secondary levels.


6.02 Monitoring And Evaluation

The monitoring and evaluation modalities will be required so as to enable policy makers and managers determine whether activities as planned are being carried out and are achieving the set objectives.
The monitoring and evaluation tools should provide linkages at operational level and timely dissemination of information to stakeholders.

To achieve the above, the Department of State for Health will ensure;

a) The creation of a full-time Health Programme Monitoring Unit.
• The unit will be headed by a Director responsible to the Permanent Secretary
• The remuneration package for staff in the Unit will be met from programme funds as will be negotiated with donors and partners
• The Unit will have authority to request information from Program Managers and Divisional Health Managers

The functions of the Unit to include;
- Monitoring of the implementation of the Policy
- Organising meetings for the Health Consultative Forum
- Preparation of progress reports based on information from Program Managers and Divisional Health Managers

b) The creation of a Health Consultative Forum.
• To provide a medium for regular consultation between Senior Staff of the Department of State for Health , donors and partners.
• The Forum will discuss progress reports from donors as well as the Monitoring Unit, and to make recommendations accordingly.

The Forum will compose of:
- Department of State for Health
- Other Government Departments (Finance, Education, Agriculture, Local Government, Works and Communication)
- Donors
- Private sector (Insurance Institutions, Pharmaceutical Proprietors, Gambia Chamber of Commerce, Commercial Banks, Non Governmental Organisations
- Medical and Dental Association
- Nurses Association
- Midwives Association
- Pharmaceutical Society of the Gambia
- Medical Research Council
- Faculty of Medicine and Allied Sciences
- Public Health Officers Association
- Medical and Dental Council
- Nurses and Midwives Council
- Traditional Healers Association
- Medical laboratory Association

QUALITY ASSURANCE
To ensure client satisfaction a quality assurance system will be developed. The following structures will be developed to monitor service delivery in order to maintain quality and standards in health care.
Medical and Dental Council
This will be re-organised and strengthened to better monitor:
- Registration of medical and dental officers
- Medical and dental practice
- Training of medical officers(Provide guidelines for training)
Nurses and Midwives Council
This will be re-organised and strengthened to better monitor:
- Registration of nurses and midwives
- Nursing practice
Pharmacy Council
This will be established to monitor:
- Registration of pharmacists
- Pharmacy practice
Provision would be made for the establishment of other regulatory bodies e.g. Medical Laboratory Technologist/Scientist Council
Clinical Audit Units
Clinical audit units to be established in all the hospitals and at divisional levels to strengthen routine assessment of adherence to set standards.
BOARD OF HEALTH
The Board of Health to be established by an Act of Parliament and to comprise of representatives of the Councils, Clinical Audit Units, policy makers of Health and to include other experienced health professionals outside the Department of Health.
The Board will have the following functions:
- To review the health standards
- To monitor quality of health services
- To certify health facilities for service delivery

APPENDIX A

PROJECTED POPULATION

Year Projected Population Corresponding Population Density
2000 1,384,625 130
2005 1,700,868 159
2010 2,089,341 195
2015 2,566,539 240
2020 3,152,728 295
2025 3,872,800 362


Source: Demographic Profile 2000 by CS D.

PERCENTAGE IMMUNIZATION COVERAGE: EPI PRORAMMES.

1996 1997 1998 1999
BCG 99.6 99.2 99.0 96.3
OPV3 87.0 98.5 95.2 87.8
DPT3 95.9 96.2 96.7 87.5
TT3 75.7 86.7 96.8 70.6
Measles 93.8 91.6 91.9 87.9
Yellow Fever 94.6 91.8 90.8 85.6
%< 1yr fully Imm.
82.9 86.9 79.8 64.1
% < 2yr Fully Imm. 87.8 83.7 87.7 78.6

Source: EPI, DOSH


APPENDIX B

Percentage Distribution of Persons in Poverty Categories 1992 and 1998

Year / Poverty Category National Rural
Greater Banjul

Other Urban

1992 EXTREMELY POOR   23% 5% 9%
POOR 18% 18% 12% 31%
NON POOR 67% 59% 83% 60%
1998 EXTREMELY POOR 51% 71% 21% 42%
POOR 18% 9% 33% 20%
NON POOR 31% 20% 46% 38%

Other urban refers to areas like Farafeni, Soma, Basse and the likes

SOURCE: 1992 AND 1998 Poverty Report

-END.