101505 Maternal and Child Nutrition and Health Results Project Technical Brief: The Gambia December 2015 Health, Nutrition, and Population Global Practice Impact Evaluation Baseline Report: Health System Key Messages: •• Inadequate infrastructure, combined with laboratory, drug, and equipment shortages, undermined health workers’ capacity to provide services. •• Health worker density varied from a high of 1.4 health workers per 1,000 population in North Bank Region-West (NBR-W), to a low of 0.5 health workers per 1,000 population in the Central River Region (CRR). •• Insufficient staffing, poor resourcing, and low salaries contributed to high levels of dissatisfaction and absenteeism among health workers. •• Relationships among staff, as well as those between providers and patients, were strong and an important driver of health worker motivation. •• More than 25 percent of staff were less than satisfied with the quality of management and nearly 20 percent expressed some degree of dissatisfaction with opportunities to discuss work with their immediate supervisor. •• Most regional health directorates (RHDs) and health facilities reported an acute shortfall in funding that limited their ability to operate. Introduction Quantitative and qualitative data were collected The government of The Gambia is implementing on three regions: CRR, NBR-W, and Upper River the Maternal and Child Nutrition and Health Region (URR). Its purpose was to establish a Results Project (MCNHRP) to increase the baseline against which project performance will use of community nutrition and primary be assessed in the future. This technical brief maternal and child health services. In collabora- summarizes the baseline report findings related tion with the government, the World Bank is to the health system. conducting an impact evaluation to assess the project’s impact on key aspects of maternal Health Facility Infrastructure and child nutrition and health. The MCNHRP Acute infrastructure challenges exist across the baseline evaluation was conducted between three regions, especially at major and minor November 2014 and February 2015. health centers. The main inadequacies This series of policy briefs was produced in direct This brief was prepared by a core team comprising Laura Ferguson (Principal Investigator, University of Southern response to a request from the government of The California), Rifat Hasan (co-Principal Investigator, Health Specialist, World Bank), and Chantelle Boudreaux based on the Gambia to share the findings of the Maternal and Impact Evaluation Baseline Report produced by Laura Ferguson, Rifat Hasan, Guenther Fink, Yaya Jallow, and Chantelle Child Nutrition and Health Results Project Impact Evaluation Baseline Survey. Boudreaux. The Impact Evaluation Baseline Report benefited from substantial inputs from the Gambia Bureau of Statistics, Mariama Dibba, Halimatou Bah, Momodou Conteh, Sering Fye, Alexandra Nicholson, Hannah Thomas, and Steven Strozza. The team benefited from the general guidance of Vera Songwe (former Country Director), Louise Cord (Country Director), and Trina Haque (HNP Practice Manager). Helpful comments were received from the Project Implementation Committee led by Modou Cheyassin Phall (Executive Director, The Gambia National Nutrition Agency) and comprised of Haddy Badjie, Abdou Aziz Ceesay, Ousman Ceesay, Modou Lamin Darboe, Malang Fofana, Catherine Gibba, Bakary Jallow, Musa Loum, Lamin Njie, and Matty Njie and Menno Mulder-Sibanda (Senior Nutrition Specialist, World Bank). The work was made possible by support from the Health Results Innovation Trust Fund. 1 Figure 1. Health Facility Infrastructure by Region in The Gambia 100 80 60 Percent 40 20 0 Working toilet for Separate toilets for Access Phone Incinerator patients men and women to ambulance Health Facility Infrastructure Central River Region North Bank Region West Upper River Region mentioned by health workers were: insufficient space were complaints among health staff ward space and consultation rooms, lack of and clients alike. This situation compromised basic drugs and equipment, inadequate privacy and other aspects of the quality of electricity supply, lack of incinerators, poor staff care. Nearly half of health workers reported quarters, inadequate waiting areas, and feeling that the quality of care was con- “For us, lack of materials is our insufficient vehicles. There was wide concur- strained by the facility’s working conditions. problem. Sometimes when you rence from clients, among whom the most need to do something the often reported shortcomings were: lack of basic Availability of Supplies, Drugs, Equipment, materials are not available drugs and equipment, inadequate electricity and Services and some of these materials supply, inadequate waiting areas, and insuffi- While the drugs Paracetemol, Fansidar, and ­ patients cannot buy them espe- cient vehicles for evacuations and referrals. Coartem were generally available, stockouts cially if we have an emergency While all facilities had access to an ambu- of other drugs were widespread and, despite case like Hydralazine [drug used lance, availability of other basic amenities was the existence of guidelines on essential drugs to treat hypertension in preg- much lower (figure 1). More than half of the 24 for health facilities, insufficient resources left nancy] is not available, catheter health facilities reported a power outage in many health managers unable to meet is not available. Sometimes it’s the seven days preceding the survey and minimum standards. The tuberculosis drug just crazy, to be candid enough, almost two-fifths of the facilities had water Rifampin and the antibiotic Amoxicillin, in outages over the same time. Qualitative data particular, were frequently unavailable. There this is just crazy. Cord scissors, highlighted the effects of limited hours of was significant regional variation in supply, no not available. We ask the electricity as well as shortages of the neces- with stockouts least common in NBR-W. women to go and buy razor sary equipment and staff, which restricted the Health facilities in CRR were the least able blades. It’s just crazy actually… availability of laboratory and other services. to perform basic laboratory services while it’s crazy… if I want to work, Chronic underinvestment in maintenance, facilities in NBR-W reported the best I want the materials.” overcrowding, poor sanitation, and a lack of equipped laboratories (figure 2). – Health worker, URR “I always go with the expec- Figure 2. Laboratory Test Availability by Region tation that I will get some 100 medicine like even Paracetamol 90 80 but it doesn’t materialize. The 70 last time I went with my son Percent 60 who was having chest pain, but 50 40 there was no ­ medicine available. 30 I was referred to [a ­different] 20 10 health center to buy the drugs, 0 what a waste of time!” Hemoglobin Malaria Syphilis Pregnancy Blood sugar Stool test for – A woman who had delivered in estimation smears testing testing parasite the previous six months, CRR Central River Region North Bank Region-West Upper River Region 2 Human Resources for Health nearly one in four staff was absent without Insufficient staffing has important implications permission. When authorized absences are for the provision of care. While the government also considered, only approximately six out of has formally increased the quota of health every ten health staff were on duty in CRR worker spaces available, a substantial propor- and URR on the day of the survey. tion of positions remain unfilled, resulting in a Some authorized absences are unavoid- very low health worker density. Estimates vary able. For example, in-service training is a from a high of 1.4 health workers (defined as critical part of ensuring that the health doctors, clinical officers, or nurses) per 1,000 system remains responsive in a dynamic population in NBR-W, to a low of 0.5 health environment. Of the 94 staff participating in workers per 1,000 population in CRR. the survey, 85 (90 percent) perceived a need Shortages cut across all cadres including for additional training, with training related to doctors, nurses, lab technicians, pharmacists, the integrated management of childhood and data clerks. Many health workers noted illnesses (IMCI), tuberculosis, postnatal care, ­ that this labor gap created day-to-day and nutrition being the most in demand. challenges and had an impact on the avail- Perceived need varied greatly by facility type— ability of services. Health information activities and the quality of data collected while only 9 percent of major health center staff reported a need for training in antenatal 65% of health workers interviewed may have been particularly affected by these care, twice this proportion requested training would prefer to work at shortages, as data was rarely used for at hospitals. Focus group discussions high- lighted a broader range of training needs, ­ nother health facility a internal planning or performance assess- ments. Qualitative data suggests that data including communication, data management, recording is a particularly marginalized task financial management, fundraising, informa- and that quality is compromised when staff tion technology, management, monitoring are busy. and evaluation, and results-based financing. Some health workers considered time constraints to be a barrier to consistent and Health Worker Satisfaction appropriate client care—nearly 20 percent of Health workers reported generally high health workers reported not having time to satisfaction with specific components of their appropriately deal with clients. Community job (for example, 97 percent stated that their members’ perceptions of health worker job made them feel good about themselves attitudes were mixed, with some describing and 80 percent were satisfied with the positive experiences and others citing poor available opportunities to use their skills on attitudes and neglect of patients as problems the job). Relationships at health facilities— in some health facilities. both intra-facility and facility-community— The generalized staff shortage is exacer- are strong. Health workers also emphasized bated by high rates of absenteeism, both a client-oriented approach, including being sanctioned and not. Although self-reported friendly and polite to all clients and allowing absenteeism was low, the percentage of clients to ask them questions. workers absent on the day of the survey was At the same time, however, many health high (figure 3). In URR, where there was only workers reported high levels of frustration one health worker for every 1,000 population, with their work. Satisfaction with remunera- tion and benefits was particularly low, as 81 percent reported dissatisfaction with their Figure 3. Absenteeism at Health Facilities salary and 77 percent were dissatisfied with their benefits. Overall, 65 percent of health 50 workers reported that they would prefer to 40 work at a different facility. Percent 30 Leadership and Management 20 There was relatively little formal supervision 10 at health facilities, limiting the opportunity for feedback to staff. In the six months preceding 0 the survey, two-thirds and three-quarters of CRR NBR-W URR Hospital Major Minor health health staff had spoken about their performance to center center an internal or external supervisor, respectively. Percent of workers Percent of workers Nearly one-quarter were less than satisfied absent on day of absent on day of with the quality of internal supervision, and survey (authorized) survey (unauthorized) 41 percent were less than satisfied with the 3 Figure 4. Budgets and Workplans at Health At the levels of both the RHD and health Facilities by Region facility, respondents articulated a desire for budgetary autonomy, explaining that they 100 were best situated to understand their own 80 needs and as such should be able to act accordingly. While most administrators 60 Percent reported being able to assign tasks and 40 activities to staff, a substantial number reported not having sufficient authority to 20 obtain the resources needed in their facility and not being able to choose which health 0 services are provided at facilities. Central North Upper Average River Bank River across Region Region Region three Health Care Financing “We don’t procure ­because West regions Most RHDs and health facilities reported an we don’t have any money Budget in place Workplan in place acute funding shortfall that limited their to ­procure.” ability to operate. Some health facilities – Officer-in-charge, CRR reported having no ability to procure needed quality of external supervision. More than 25 items due to a near total lack of funds. percent of staff were less than satisfied with User fees are among the few revenue-­ the quality of management, and nearly 20 generating options open to facilities, and percent expressed some degree of dissatis- most facilities reported using the govern- faction with opportunities to discuss work ment-sanctioned fees for services. Some with their immediate supervisor. facilities appeared to be charging higher fees Budgeting and planning were generally as a way of increasing their income. Fees weak across health facilities. With substan- were generally coupled with exemption tial regional variation, only 21 percent of policies (especially for children under the age facilities reported having a budget in place of five and pregnant women). However, and just 30 percent reported having a despite the availability of these waivers, workplan (figure 4). Notably, even when approximately 20 percent of households budgets were compiled, formal tracking of reported having a significant health expense— budgets remained weak. Few major health defined as one higher than could be afforded centers and no minor health centers were with the household’s usual income—in the able to provide official reports on financing. previous 12 months. © 2015 International Bank for Reconstruction and Development / The World Bank. Some rights reserved. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. This work is subject to a CC BY 3.0 IGO license (https://creativecommons.org/licenses/by/3.0/igo). The World Bank does not necessarily own each component of the content. 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