4.2.1 Health service providers
In The Gambia the government is the major provider of health services, but there are also a lot of other actors involved in the health care, both in providing services as well as contributing with economical assistance. As seen from Table 4- 1, 24.3% of the total health expenditures are covered by external resources. Even though the government is the major provider of health services, people have to cover most of their health related expenditures themselves; 52.1% of the national expenditures on health are private expenditures (see Table 4- 1).
2007 data The Gambia Norway
Total expenditure on health of GDP 5.5% 8.9%
Private expenditure on health of total expenditure on health 52.1% 15.9%
General government expenditure on health of total government expenditure
11.6% 18.3%
External resources for health of total expenditure on health 24.3% 0 Per capita total expenditure on health at average exchange
rate
22 US$ 7,354 US$
Table 4- 1 Health expenditures statistics (World Health Organization 2010)
Vertical actors
In an interview the head of the Gambian HMIS was asked whether or not there were many vertical actors in the Gambian health care. He answered rather briefly that there used to be more of them earlier but that there still exist some. The ones he pointed at were the tuberculosis control program and to some extent some HIV/AIDS programs. Some of the HIV/AIDS programs are integrated in the Gambian HMIS.
At a DHIS 2 training session in Lower River Region the director of regional health gave a speech in which he complemented the HMIS head’s views and pointed to the fact that there exist many donor driven programs in The Gambia that want something in return. He mentioned malaria and tuberculosis programs as well as National Aids secretariat (NAS) and said that there are so many indicators to deal with that it is totally confusing. He claimed that about 40% of the Gambian health workers’ time is spent on filling in forms and registers. The time would be better spent providing health services to the population, he stated.
4.2.2 Poor communication
During my stay in The Gambia I experienced that the communication within the ministry of health (MOH) could have been better. In autumn 2009, an employee in the MOH came in touch with International Health Partners (IHP) and was introduced to a project called SMS for health. IHP and their partners were given permission to roll out their project by people who did not bother either consulting the IT office at MOH or the HMIS head before signing
36 the contracts. At the presentation the representatives from IHP and their partners held February 23rd we could state that SMS for health and DHIS 2, with DHIS Mobile, have many similarities. By rolling out SMS for health a lot of duplicate work will thus be done in the future, as MOH is planning to roll out DHIS Mobile application as well.
4.2.3 High mortality rates
Compared to the industrialized country Norway, The Gambia has got some very high mortality rates. The World Health Organization (WHO) states for instance that the maternal mortality ratio (MMR) is unacceptably high, being 730 per 100,000 live births in 2001 (World Health Organization 2009). Table 4- 2 shows that the MMR is down to 690 per 100,000 live births in 2008, but that is still extremely high. The WHO writes that “*t+he main causes of maternal mortality are haemorrhages, eclampsia, anaemia, malaria in pregnancy and postpartum sepsis. Poor maternal nutrition contributes to complications during pregnancy and delivery, and shortage of skilled birth attendants further exacerbates the problem”
(ibid). As seen from Table 4- 2 only 57% of the 2008 births were attended by skilled health personnel. Table 4- 3 throws more light on this topic as it shows that only 43% of the births in rural areas are attended by skilled health personnel while the same number for urban areas is 83%.
2008 data The Gambia Norway
Children aged < 5 years underweight: 15.8% ...
Under-five mortality rate 106/1,000 3/1,000
Measles immunization coverage among 1-year-olds 91% 93%
Maternal mortality ratio (2005 data) 690/100,000 7/100,000
Births attended by skilled health personnel 57% …
Antenatal care coverage 98% ...
Prevalence of HIV among adults aged 15-49 years 0.9% 0.1%
Malaria mortality rate (2006 data) 106/100,000 ...
Tuberculosis mortality rate among HIV-neg. people 44/100,000 0.4/100,000 Population using improved drinking-water sources 92% 100%
Table 4- 2 Some health statistics for Gambia and Norway (World Health Organization 2010)
2006 data Place of residence
Rural Urban
Births attended by skilled personnel 43% 83%
Measles immunization coverage among 1-year-olds 93 91
Under-five mortality rate 150 96
Table 4- 3 Gambian health inequities statistics (World Health Organization 2010)
37 4.2.4 Health workforce
The lack of health personnel at all levels is a big obstacle in the Gambian health care. Table 4- 4 shows that the Gambian health workforce is pretty weak; for instance: The relative number of physicians is more than 78 times lower than in Norway.
Data from the 2000-2009 period The Gambia Norway
Physicians < 0.5/10,000 39/10,000
Nursing and midwifery personnel 6/10,000 163/10,000
Dentistry personnel < 0.5/10,000 9/10,000
Pharmaceutical personnel < 0.5/10,000 7/10,000
Environment and public health workers < 0.5/10,000 …
Community health workers 1/10,000 …
Hospital beds 11/10,000 39/10,000
Table 4- 4 Health workforce statistics (World Health Statistics 2010)
4.3 Summary
The Gambia is the smallest country on the Gambian continent. The Mandinka population of the country dates back to the 13th century. The country was subject for slave trading and was controlled by France and the United Kingdom before it became independent in 1965.
Infrastructures are poor, and so are the ICT knowledge and the health care situation in the country.
38
5 Results and findings
In this section I will present the results and findings of my research. I start with presenting the data collection procedure before DHIS 2 was implemented. Further I go on to introduce how DHIS 2 was implemented and describe the first data collection trek after the DHIS 2 data quality for the 2009 and 2010 data, and in section 5.9 I explain how the SMS for health project contributes to fragmentation. Finally, in section 5.10 I present some of the recent activities in The Gambia.