POPULATIONS AT RISK ACROSS THE LIFESPAN: CASE STUDIES

Making Basic Health Care Accessible toRural Communities: A Case Study ofKiang West District in Rural GambiaEdward Saja Sanneh,1 Allen H. Hu,1 Modou Njai,2 Omar Malleh Ceesay,3 and Buba Manjang41National Taipei University of Technology, Institute of Environmental Engineering Technology, Taipei, Taiwan; 2Integrated Management ofChildhood Illness (IMCI), Ministry of Health and Social Welfare, Banjul, The Gambia; 3Health Promotion and Development Organization(HePDO), Kanifing Municipal Council, SereKunda, The Gambia; and 4Regional Health Management Team, North Bank Region, Farafenni,The Gambia

Correspondence to:

Allen H. Hu, Professor, National Taipei University of Technology, Institute of Environmental Engineering Technology, No.1, sec. 3, Chung-Hsiao

East Road, Taipei 10643, Taiwan. E-mail: allenhu@ntut.edu.com

ABSTRACT This study focuses on lack of access to basic health care, which is one of the hindrancesto the development of the poor, and subjects them to the poverty penalty. It also focuses on contributingto the Bottom of the Pyramid in a general sense, in addition to meeting the health needs of communitieswhere people live on less than $1 a day. Strengthened multistakeholder responses and better-targeted,low-cost prevention, and care strategies within health systems are suggested to address the health bur-dens of poverty-stricken communities. In this study, a multistakeholder model which includes the gov-ernment, World Health Organization, United Nations Children Emergency Fund, and the MedicalResearch Council was created to highlight the collaborative approach in rural Gambia. The result showsinfant immunization and antenatal care coverage were greatly improved which contributes to the reduc-tion in mortality. This case study also finds that strategies addressing health problems in rural commu-nities are required to achieve Millennium Development Goals. In particular, actual community visits tosatellite villages within a district (area of study) are extremely vital to making health care accessible.

Key words: access, bottom of the pyramid, multi-stakeholder, partnership, poverty penalty.

The delivery and availability of health goods andservices are critical to national development andpoverty alleviation (Marter-Kenyon, 2005). Manycomplications in maternal and child health in thedeveloping world are believed to be partly due tothe differences in the availability of, and access to,health services (Navaneetham & Dharmalingam,2002). Every year, approximately 10 million chil-dren under 5 years of age die throughout the world,mostly in developing countries (Murray, Laakso,Shibuya, Hill, & Lopez, 2007), due to lack of accessto basic health care. Poor people in developingcountries tend to suffer from a phenomenon knownas the poverty penalty (the additional cost paid forgoods and services by the poor relative to the moreaffluent), a term popularized by C.K. Prahalad

(2004) in his publication, The Fortune at theBottom of the Pyramid. The works of several otherauthors (Hammond, Kramer, Katz, Tran, & Walker,2007; Van den Waeyenberg, 2006) have broughtthis subject to the attention of the academiccommunity.

In sub-Saharan Africa, the under-five mortalityrate decreased from an average of 180 per thousandlive births in 1990 to 129 per thousand live birthsin 2009 (Zere, Kirigia, Duale, & Akazili, 2012). Theunder-five mortality rate of the Gambia is 109 perthousand while the infant mortality rate is 81 perthousand (The Gambia Bureau of Statistics (GBOS),2011) and continues to be a problem in developingcountries. The fourth ‘Millennium DevelopmentGoal’ (MDG) is to reduce child and infant mortality

126

Public Health Nursing Vol. 31 No. 2, pp. 126–133

0737-1209/© 2013 Wiley Periodicals, Inc.doi: 10.1111/phn.12057

rates around the world, two thirds by the year2015. However, current estimates suggest that atleast 44 developing countries have less than a 20%chance of achieving this goal (Murray et al., 2007).Factors contributing to the mortality of childrenunder 5 years old have been attributed to inade-quate access to basic health services (distance frommedical facilities), the cost of traveling to reach ahealth facility, and family/household income(Rutherford, Dockerty, & Jasseh, 2009). Accordingto the United Nations Population Fund, 99% ofmaternal deaths are preventable, yet every minute awoman dies from pregnancy-related causes (WorldHealth Organization [WHO], 2011a). When healthcare is needed but is delayed or not obtained, peo-ple’s health worsens, which in turn leads to lostincome and higher health care costs, both of whichcontribute to poverty (Narayan, Patel, Schafft,Rademacher, & Koch-Schulte, 2000).

In 1978, the historic declaration of Alma Atawas adopted to promote primary health care,endorse health as a basic human right, and offer aset of values, principles, and approaches aimed atthe promotion of global health (Chan, 2008). Afterits adoption of a Primary Health Care system as thebasis of national health policy, Gambia developedseveral health programs in the early- to mid-1980s.These programs included health education, waterand sanitation improvement, reproductive andchild health care, immunization, control of endemicdiseases, treatment of simple illnesses and injuries,as well as provision of essential drugs (Ministry ofHealth [MOH], 1998). The influence of a localmaternal care access study on improving servicedelivery and organization has previously been dem-onstrated in Mali (Guindo, Dubourg, Marchal,Blaise, & De Brouwere, 2004).

It is estimated that 41–72% of new born deathsin developing countries can be avoided throughadequate coverage of current health care interven-tions (Haines, Sanders, & Lehmann, 2007). Accessto health care is a key determinant for the survivalof infants and mothers during pregnancy, birth,and the days following birth, particularly whencomplications arise. Until the late 1970s, Gambiahad one of the highest childhood mortality rates inthe world, a result of low immunization coverage,poor access to health services, lack of safe drinkingwater, poor sanitation, and low nutritional status.(Cole-Ceesay, Cherian, & Sonko, 2010), based on

Gambian situation, stated that contributing factorsto access to health care are multiple and includelow literacy levels of women, high attrition rate,low morale of skilled health workers, and poverty.This case study presents solutions for poorlyresourced communities such as Kiang West ofGambia. It highlights a multistakeholder collabora-tion approach for required meaningful and effectiveinterventions that influence access to health care.The partnership between stakeholders strengthenshealth care delivery systems, thereby enablingaccess.

Health Care System of the Gambia

The 2007–2020 National Health Policy Frameworkof Gambia, referred to as “Health is Wealth,” seeksto address common health desires through a num-ber of initiatives in both preventive and curativehealth services. Figure 1 shows the primary healthcare modeled health care system, which is orga-nized into primary (Village Health Services), sec-ondary (major and minor Health Centers), andtertiary (Hospitals) levels of service delivery. Majorhealth centers are staffed by doctors, state regis-tered nurses, assistant public health officers, state-enrolled nurses, and other technical staff. Minorhealth centers have similar staff profiles, but arewithout medical doctors and laboratory services.Nurses provide the majority of clinical care at alllevels of health service, while community healthnurses are largely employed in community work.Assistant public health officers are responsible for

Figure 1. Structure of the Gambian Health care(Source: Department of state for health, Banjulthe Gambia. Health Policy Framework 2007–2020)

Sanneh et al.: Access to Basic Health care 127

health promotion and protection, including envi-ronmental hygiene and sanitation, immunization,and other preventive health measures at variouslevels of the delivery system.

At the tertiary level, there are 10 hospitalswhile at the secondary level there are 35 healthcenters comprising 6 major and 29 minor HealthCenters. In addition to the health centers, there arenumerous village health service or “trekking” postswhere Maternal and Child Health services are pro-vided to communities without Health Center. Themajor health center is the first point of referral forthe minor health center. Major Health Centers havelaboratories and perform minor surgeries which arenot present in minor Health Centers. The villagehealth service was established to provide primaryhealth care services. Communities are involvedthrough Village Development Committees andCatchment Area Committees, including traditionalbirth attendants and village health workers.

Making Health Care Accessible inRural Areas- Kiang WestMethodology

Kiang West is located in the Lower River Region(LRR) of Gambia, approximately 150 km from thecapital, Banjul (Figure 2). It is bordered to the westand north by the Gambia River and on the south

by a large tributary. The area has a 50% povertyrate and a population of approximately 30,000people per Primary Health Care facility. This dis-trict is comprised of approximately 30 villages insparse settlements. There is little or no meaningfuleconomic activity in the district due largely to inad-equate infrastructure and unpaved roads therebymaking the area inaccessible, especially duringrainy seasons. Its dispersed settlement characteris-tic of most rural areas elevates health care accessi-bility to a position of primary importance (Joseph& Moon, 2002).

Several interventions were initiated by thehealth sector and stakeholders in Gambia to makehealth care more accessible and affordable for itscitizenry. The appropriate interventions includedimproved staffing at the Karantaba Health Centre,which entailed the employment of traditional birthattendants and village health workers through Pri-mary Health Care activities by community healthnurses (Rayco-Solon, Moore, Fulford, & Prentice,2004). The Expanded Program on Immunization,funded by the World Health Organization, GlobalAlliance for Vaccines and Immunization, and Uni-ted Nations International Children EmergencyFund, aims to prevent infant mortality by providingvaccines for “childhood” diseases. Providing youngchildren with two high doses of Vitamin A annually(at 6-month intervals) is a safe, cost-effective, and

Figure 2. Map of Kiang West District in Rural Gambia System

128 Public Health Nursing Volume 31 Number 2 March/April 2014

efficient strategy for eliminating Vitamin A defi-ciency and improving child survival.

The purpose of this multistakeholder case studyis to formulate an operational description of per-sonal access to health care in a rural community.Figure 3 shows the multistakeholder case studymodel the authors created to analyze the collabora-tive interventions in Kiang West by the govern-ment, Medical Research Council, World HealthOrganization, and United Nations InternationalChildren Emergency Fund.

The World Health Organization and otherstakeholders support various government programsin terms of funding depending on target healthneeds. The government as a recipient, plans, orga-nizes, and coordinates the implementation of pro-grams to solve health issues in the Gambia.Research institutions like the Medical ResearchCouncil generate the much needed information forplanning. Nongovernment organizations have clin-ics and provide health care services especially inareas where the government cannot afford to do so.This supports government efforts in providing basichealth services to communities in rural areas likeKiang West. Stakeholder’s collaboration in makingbasic health care accessible will help in achievingthe millennium development goals and interna-tional commitments in terms of health.

Figure 4 shows access to health services inrelation to poverty and population in Gambia. TheLRR is shown in the figure as having the lowestpercentage of population with access to PrimaryHealth Care coverage. The two main providers offormal health care in Kiang West are the govern-ment and the Dunn Nutrition Unit of the MedicalResearch Council. In 1995, the Baby Friendly Com-munity Initiative was piloted in 12 communities in

the LRR (which includes Kiang West) of Gambia.This led to the expansion of the initiative to 293communities across the country (The GambiaNational Nutrition Agency [NaNA], 2009). TheWHO has acknowledged the involvement of thesesystems by challenging global communities toimprove standards of living through better accessto health care (World Health Organization [WHO],2011b). In all other divisions, the coverage is lessthan 50% of their population, the worst populationto health center ratio is to be found in the URRand the NBR. Regional health management teamsare established in all health administrative areas(World Bank, 2005).

Every month, the staff of the Kiang West gov-ernment health center conducts community visitsto satellite villages. Infant immunization is con-ducted by the assistant public health officer while amidwife provides antenatal and maternal healthcare. During these immunization sessions, Bacille–Calmette–Guerin, oral polio vaccination, diphtheria,pertussis, tetanus, tetanus toxoid, yellow fever, hep-atitis B, and measles vaccines are administered toinfants (this was conducted by the first author from2001 to 2003). In 2009, pneumococcal and penta-valent vaccines were added to the immunizationroutine. During community visits, sick people livingin villages far from health centers are attended to,thus forestalling the villagers’ need to travel longdistances to receive medication. The MedicalResearch Council also conducts similar communityvisits to other villages. Although their interventionsare research based, they operate an outpatientdepartment, offer nutrition supplementation, andsupport the health center in Karantaba by posting a

Figure 3. Multistakeholder Collaboration Modelof Gambia Government, MRC, WHO and UNICEFin Kiang West

Figure 4. The Gambia, Poverty Versus PopulationCoverage of Basic Health Facilities by Division

Sanneh et al.: Access to Basic Health care 129

midwife there and helping to provide resources forthe facility.

Discussion of the Kiang WestMethodology

Health issues challenge development in many devel-oping countries, including Gambia. With a goal ofimproving the health of all Gambians with a percapita income of US$ 1,500 by 2020, the NationalHealth Policy Framework’s mission is the promotionand protection of health through equitable accessand affordable services. International organizations,such as the World Health Organization and the Uni-ted Nations International Children EmergencyFund, act as decisive bodies of oversight and gover-nance for broad goals, ‘Millennium DevelopmentGoals’, as well as Global Fund against Tuberculosisand Malaria programs. All of these efforts aim toease the health burden in developing countries.

Strengthened multistakeholder response, asshown in Figure 3, implemented within health sys-tems with better-targeted, low-cost prevention andcare strategies are suggested as the best interven-tions initiated for health care accessibility. Gambia’sReproductive and Child Health Services have beenexpanded, in addition to having well-trained staffoverseeing case management of common childhoodillnesses/conditions under the Integrated Manage-ment of Neonatal and Childhood Illnesses strategy.Evaluation of Integrated Management of Child Ill-ness interventions concluded that high risk andpoor populations require proximal health servicesto improve health outcomes (Bryce, Boschi-Pinto,Shibuya, & Black, 2005). The primary health carestrategy adopted by the Gambia government haspaved the way for decentralization and near-targetpopulation management to improve the efficiencyof national programs. Strategies for active surveil-lance of infectious diseases, particularly thoseaffecting children, have been developed andstrengthened at both national and community lev-els. The target diseases have either been eliminatedor are in the process of being eradicated (for exam-ple, poliomyelitis, measles, and neonatal tetanus).These results were facilitated by the collaborativemultistakeholders approach, as shown in Figure 3.

Improved childhood vaccination coverage is akey indicator for the country’s health policyobjectives. As availability increases, addressing

issues of demand and timely schedule completionwill be solved. Vaccinations conducted by publichealth officers at outreach stations will boost theimmune systems of infants, protecting them fromdisease and curtailing infant mortality (70.14 deathsout of 1,000 live births, according to year 2007estimates). As a result of the combined efforts of theWorld Health Organization, United Nations Inter-national Children Emergency Fund, as well as otherpartners, the immunization coverage for DiphtheriaPertussis Tetanus, Bacille Calmette Guerin, measles,and polio vaccines is currently at 80% or more (asshown in Figure 5), compared with approximately30%, 20 years ago. Infant mortality has beencurtailed as a result (67.49 out of 1,000 live births,according to year 2010 estimates).

Services provided by midwives help reducematernal mortality (540 out of 100,000 live births).A survey on antenatal care delivery, coverage, andaccess in Gambia (Reproductive and Child Health,Department of State for health [DoSH], The Gam-bia & Center for Innovation Against Malaria(2007), revealed that 99.2% of pregnant womenused formal antenatal services, 67% received anten-nal care at a health center, 24% received antennalcare at an outreach post, 90% visited four or moretimes, and 96% were satisfied with the servicesreceived. Coverage of antenatal care by skilled per-sonnel (doctor, nurse, or midwife), is relatively highin Gambia, with 97.8% of women receiving antena-tal care at least once during their last pregnancy.This validates the effectiveness of the multistake-holder collaboration and community involvementthrough the training of Village Health Workers andTraditional Birth Attendants, in making health careaccessible.

Vitamin A is critical to child health and immunefunction. As such, it is critical to the achievement ofthe fourth ‘Millennium Development Goal’: a two-third reduction in the mortality of children underfive by 2015. Giving Vitamin A to breastfeedingmothers helps protect their children during the firstmonths of life, and helps replenish the mother’shealth as well. The Multi Indicator Cluster Surveystudy has shown that Vitamin A supplementationcoverage in Gambia is lower in urban areas (77%)than in rural areas (82%) (GBOS, 2011).

In the final analysis of this case study, no sin-gle organization, sector, nor approach can provideanswers for underdevelopment, poverty, and ill

130 Public Health Nursing Volume 31 Number 2 March/April 2014

health. There is little or no meaningful economicactivity in Kiang West, where households live belowthe poverty line and thus cannot change their situa-tions by themselves. Lack of communicationservices and public transport make the situations ofimpoverished communities more difficult. Womenstruggle to take sick family members to healthfacilities. Some even walk long distances just toreceive basic health care. This situation, however, is

not unique to Kiang West, as many other places inthe developing world face similar difficulties. Webelieve that the multistakeholder model used in thisarea is feasible, appropriate, and can be replicatedin other communities.

The barriers identified during the case studysuch as poverty, access to basic health services dueto inadequate transportation and communication,impacted heavily on the health and well-being of

Figure 5. Immunization Coverage of the Gambia from 2000 to 2008

Sanneh et al.: Access to Basic Health care 131

the residents of Kiang West. The inadequate num-ber of health personnel deprives communities’access to timely health care. Effort to address thesebarriers by government and other stakeholders wasthe application of the primary health care strategywhere health providers traveled to communities toprovide basic health services. We recognize theimportance of visiting villages far removed fromhealth centers to provide reproductive and childhealth care services. This model eases the healthcare burden for isolated communities located30 km away from health centers.

Addressing the underlying determinants ofhealth is a key factor in achieving MDGs and ensur-ing sustainable development. The importance ofcooperation, both within a specific sector andacross sectors, cannot be stressed enough. Progressshould be made in forging closer ties between thehealth sector and other sectors, particularly throughlocal, national, and multistakeholder developmentplans. This case study suggests that health systemsshould be oriented toward the needs of the poor,giving greater attention to redressing inequities andclosing in on gaps in research. Further study ofmedical access, specifically in terms of health caredelivery system, availability of resources, perceivedmorbidity and mortality of communities at riskshould be a priority.

Acknowledgments

The authors are grateful to the Gambia governmentMinistry of Health, Expanded Program on Immuni-zation and the Integrated Management of NeoNatal and Childhood Illnesses Offices and thankthe reviewers for their helpful comments.

References

Bryce, J., Boschi-Pinto, C., Shibuya, K., & Black, R.E. (2005). WHO estimates of the causes ofdeath in children. Lancet, 365(9465), 1147–1152. doi:10.1016/s0140-6736(05)71877-8.

Chan, M. (2008). Return to Alma-Ata. Lancet, 372(9642), 865–866. doi:10.1016/S0140-6736(08)61372-0.

Cole-Ceesay, R., Cherian, M., & Sonko, A. (2010).Strengthening the emergency healthcare sys-tem for mothers and children in The Gambia.Reproductive Health, 7(1), 21.

Guindo, G., Dubourg, D., Marchal, B., Blaise, P., &De Brouwere, V. (2004). Measuring unmetobstetric need at district level: How an epide-miological tool can affect health service orga-nization and delivery. Health Policy Plan, 19(Suppl. 1), i87–i95. doi:10.1093/heapol/czh049.

Haines, A., Sanders, D., & Lehmann, U. (2007).Achieving child survival goals: Potential con-tribution of community health workers. Lan-cet, 369(9579), 2121–2131. doi:10.1016/s0140-6736(07)60325-0.

Hammond, A. L., Kramer, W. J., Katz, R. S., Tran,J. T., & Walker, C. (2007). The next 4 billion.Innovations: Technology, Governance, Glob-alization, 2(1–2), 147–158. doi:10.1162/itgg.2007.2.1-2.147.

Joseph, A. E., & Moon, G. (2002). From retreat tohealth centre: Legislation, commercial oppor-tunity and the repositioning of a Victorian pri-vate asylum. [Historical Article]. SocialScience and Medicine, 55(12), 2193–2200.

Marter-Kenyon, J. (2005). Bridging the divide: Athird-sector approach to health and develop-ment. Greener Management International,51, 53.

Ministry of Health (MOH). (1998). Department ofstate for health & social welfare on nationalhousehold poverty survey report, 1998,Banjul, The Gambia.

Murray, C. J., Laakso, T., Shibuya, K., Hill, K., &Lopez, A. D. (2007). Can we achieve Millen-nium Development Goal 4? New analysis ofcountry trends and forecasts of under-5 mor-tality to 2015. [Research Support, Non-U.S.Gov’t]. Lancet, 370(9592), 1040–1054.doi:10.1016/S0140-6736(07)61478-0.

Narayan, D., Patel, R., Schafft, K., Rademacher, A.,& Koch-Schulte, S. (2000). Voices of thepoor: Can anyone hear us? New York: OxfordUniversity Press: World Bank.

Navaneetham, K., & Dharmalingam, A. (2002). Uti-lization of maternal health care services inSouthern India. Social Science and Medicine,55(10), 1849–1869.

Rayco-Solon, P., Moore, S. E., Fulford, A. J., & Pre-ntice, A. M. (2004). Fifty-year mortalitytrends in three rural African villages. [ResearchSupport, Non-U.S. Gov’t]. Tropical Medicineand International Health, 9(11), 1151–1160.

Reproductive and Child Health, Department ofState for health (DoSH), The Gambia & Cen-ter for Innovation Against Malaria. (2007).

132 Public Health Nursing Volume 31 Number 2 March/April 2014

Annual Report: Study conducted by CIAMand DOSH.

Rutherford, M. E., Dockerty, J. D., & Jasseh, M.(2009). Access to health care and mortalityof children under 5 years of age in the Gam-bia: A case-control study. [Research Support,Non-U.S. Gov’t]. Bulletin of the WorldHealth Organization, 87(3), 216–224.

The Gambia Bureau of Statistics (GBOS). 2011. TheGambia multiple indicator cluster survey2010, final report. Banjul, The Gambia.

The Gambia National Nutrition Agency (NaNA).(2009). NaNa Working with the communitiesfor better health and nutrition: AnnualReport December 2009, Banjul, The Gambia.Retrieved from http://www.nana.gm/reports/NaNAAnnualReportfor2009.pdf

Van den Waeyenberg, S. (2006). Which businessstrategy do multinational corporations needto successfully enter the markets of lessdeveloped countries? Lodz, Poland: Interna-tional Trade and Finance Association.

World Bank. (2005). Health and poverty in TheGambia: A background report to the

National Poverty Reduction Strategy Paper.Africa Region Human Development, WorkingPaper Series: Human Development Sector,Africa Region, The World Bank - Key HealthIndicators for The Gambia, Banjul, TheGambia.

World Health Organization (WHO) (2011a). UNFPAand World Bank (2010) Trends in MaternalMortality: 1990–2008; Estimates developedby the WHO, UNICEF. Retrieved fromhttp://www.who.int/reproductivehealth/pub-lications/monitoring/9789241503631/en/#

World Health Organization (WHO). (2011b). CLOS-ING THE GAP: Policy into Practice on SocialDeterminants of Health: Discussion paper.Proceedings at the World Conference onSocial Determinants of Health (Rio deJaneiro, Brazil 19-21 October, 2011).

Zere, E., Kirigia, J., Duale, S., & Akazili, J. (2012).Inequities in maternal and child health out-comes and interventions in Ghana. BMCPublic Health, 12(1), 252.

Sanneh et al.: Access to Basic Health care 133