National Health Policy 2021-2030: Building Partnerships for Quality Health Care for All

Objectives

The 2021–2030 National Health Policy seeks to achieve a healthier and more productive population through Universal Health Coverage, enabling quality, affordable, accessible, equitable, integrated and responsive health services and prevention measures for everyone in The Gambia.[1][2]It is aligned with the National Development Plan and Sustainable Development Goals, with a particular focus on reducing financial hardship arising from ill-health.[3]

• Provide quality, affordable and accessible health care for all, strengthen financial risk protection and reduce out-of-pocket expenditure.[3][2][4]
• Improve equity, gender equity, community ownership, accountability, people-centred care, evidence-based practice, climate resilience, decentralisation and domestic resource mobilisation.[2][5]
• Deliver equitable essential services through primary, secondary and tertiary care, with primary health care as the cornerstone and an effective referral system linking service levels.[5][6][7]
• Reduce maternal, stillbirth, neonatal, child and adolescent mortality; expand reproductive, maternal, newborn, child and adolescent health services; and address malnutrition, adolescent pregnancy, unmet contraceptive need and gender-based violence.[8]
• Reduce the prevalence, incidence, risk factors and impact of non-communicable diseases, injuries and their leading causes of Disability Adjusted Life Years, while eliminating or controlling malaria, tuberculosis, HIV/AIDS, other sexually transmitted infections and hepatitis.[9][10]
• Strengthen preparedness for epidemics and public health threats, including surveillance, laboratory capacity, points of entry, emergency operations and a One Health approach.[11][12]
• Improve health promotion, environmental health, food safety, water, sanitation and hygiene, social determinants of health, climate-related health-risk management and healthy behaviours.[2][13][14]
• Build resilient health systems through an adequate workforce, reliable medicines and technologies, effective infrastructure, integrated health information, research, governance, partnerships and sustainable financing.[2][11][12][13]
• Establish a National Health Insurance Scheme, a Primary Health Care Fund and a health emergency fund to support financial risk protection, equitable access and sustainable resource mobilisation.[14][4]

Implementation

Implementation is to be guided by the health sector strategic plan and National Development Plan through decentralised, multisectoral and partnership-based delivery.[15][7]The Ministry of Health leads policy, regulation, priority-setting, financial management, budget execution, audits, research and mobilisation of sector support, while delivery is organised across primary, secondary and tertiary levels and progressively decentralised to regions, facilities and communities.[16][6][7]

• Deliver tailored essential health services incrementally through primary, secondary and tertiary facilities, based on disease burden and available needs, while expanding access irrespective of nationality, age or socioeconomic status.[5]
• Strengthen primary health care through village health workers, Community Birth Companions, Community Health Nurses, community clinics, health posts and minor health centres, alongside prevention, health promotion and social and behavioural change communication.[17][6]
• Expand emergency obstetric and newborn care, skilled birth attendance, antenatal care, immunisation, nutrition, family planning, post-abortion care, elimination of mother-to-child transmission and early infant diagnosis.[8]
• Integrate adolescent- and youth-friendly services through a one-stop-shop model within the public health system, address barriers to contraceptive use and involve relevant authorities in preventing gender-based violence.[8]
• Implement the Primary Health Care Revitalisation Roadmap, improve referral linkages, redesign service delivery according to need and strengthen community participation and community-based surveillance.[11]
• Develop regulations, standard operating procedures and protocols; assure quality through accreditation and licensing of public and private facilities and providers; and strengthen professional health councils’ capacity to enforce provider regulation.[5][18]
• Improve infrastructure, laboratory, radiology, biomedical engineering, blood-transfusion, pharmaceutical supply-chain, storage, inventory-control and quality-control capacity.[11][12]
• Operationalise public health emergency preparedness through a National Public Health Laboratory, strengthened points of entry, Public Health Emergency Operations Centres, cross-border collaboration and compliance with International Health Regulations.[11][12]
• Establish an integrated health information system and data warehouse, move progressively from paper-based to computerised records, harmonise programme monitoring systems and support ethical, credible and sustainable health research.[12][13]
• Delegate authority and resources to Regional Health Directorates, establish Regional Top Management Teams and Facility Management Committees, and develop standard procedures for central, regional and facility governance.[19]
• Coordinate partnerships through a Health Policy Advisory Group and collaboration among government, local authorities, United Nations agencies, development partners, civil society, academia, professional bodies, private providers, communities, traditional leaders, traditional healers, religious leaders and the media.[6][20]
• Review operational action plans annually, hold National and Regional Health Conferences, publish The Health of the Gambian People, undertake health-sector performance reviews and use joint annual, mid-term and end-term reviews to support implementation and improvement.[19][21]
• Mobilise domestic and external resources, harmonise aid with national priorities, improve equitable allocation between regions and pursue innovative financing, including taxes on tobacco and sugar-sweetened beverages.[10][4][19]

Monitoring & Evaluation

The policy establishes a broad performance, information and accountability architecture, combining routine health-data systems, surveillance, periodic reviews, reporting obligations, quality assurance and governance controls. It does not, however, provide a consolidated indicator framework, indicator definitions or a single evaluation design for the 2021-2030 policy.[12][13][21]

• Monitor service availability, readiness, access, utilisation, facility and workforce density, regional disparities, tracer medicines, diagnostics, equipment, water, sanitation, communications and internet access using health-system assessment evidence.[18]
• Track service-specific availability measures, including family planning, antenatal care, child immunisation, malaria services, HIV care, surgery, blood transfusion and diagnostic services.[22]
• Use outcome and impact measures covering life expectancy; maternal, infant, under-five and neonatal mortality; water and sanitation; premature non-communicable disease mortality; risk-factor prevalence; and deaths from road traffic crashes and workplace injuries.[2]
• Strengthen surveillance and case management at all levels, including sensitive community-based surveillance, to detect, investigate and control epidemics and other public health threats.[10][11]
• Require mandatory, timely and complete reporting from public and private health facilities under a proposed legal framework.[13]
• Integrate programme-specific monitoring and evaluation systems, replace paper-based records progressively with computerised and automated systems, and establish an integrated health-information system and data warehouse.[12][13]
• Use District Health Information Software 2, the Logistics Management Information System, human-resources information, financial management systems, electronic medical records and civil registration and vital statistics systems to improve the completeness, accuracy and timeliness of routine information.[23][24]
• Compile regular disaggregated monthly, quarterly and annual reports, while strengthening regional capacity to compile health-information reports.[1]
• Conduct annual health-sector performance reviews at facility, district, regional and central levels, assessing progress against work plans, the National Health Sector Strategic Plan targets and the health-system building blocks.[21]
• Undertake National Joint Annual Reviews, a Mid-Term Review and an end-term evaluation of the National Health Sector Strategic Plan with Ministry of Health partners.[21]
• Hold annual National and Regional Health Conferences to review achievements, identify challenges and agree improvement undertakings, and publish The Health of the Gambian People annually.[19]
• Assign direct monitoring and evaluation functions to the Directorate of Planning and Information Monitoring and Evaluation Unit, while retaining ultimate Ministry of Health responsibility for implementation.[21]
• Strengthen accountability through accreditation, licensing, regulations, standard operating procedures, protocols, risk management, transparency, control mechanisms, citizen involvement and community oversight.[5][12][21]

Hospitals are expected to provide patient-usage data to Regional Health Directorates, although some semi-autonomous hospitals are not supervised by those directorates.[16]Operational action plans are to be reviewed annually at all health-system levels, and reporting procedures are envisaged from facilities to regions and from regions to the centre.[19][7]

Costing & Financing

The financing direction is to advance universal health coverage through greater financial risk protection, domestic resource mobilisation, pooled prepayment and more equitable allocation of resources. The policy identifies major reliance on out-of-pocket payments and external funding, but does not specify a comprehensive policy budget, costed implementation plan, financing projections or economic appraisal methodology.[3][2][14][4]

• Reduce out-of-pocket expenditure and financial hardship, including catastrophic expenditure, through the National Health Insurance Scheme and tax-based and non-tax-based prepayment mechanisms.[3][14][4]
• Establish a Primary Health Care Fund and a health emergency fund, and formulate an equitable resource-allocation strategy.[4]
• Purchase services from registered and accredited public, private, non-governmental and traditional providers through capitation, fee-for-service and results-based financing.[14][4]
• Mobilise sustainable domestic resources through innovative financing and proposed levies or taxes on tobacco, alcohol, hazardous products, fuel and sugar-sweetened beverages.[10][14][4]
• Increase health financing, workforce investment and efficient resource allocation, while coordinating development-partner support with national priorities to reduce duplication, wastage and unpredictability.[2][19][6]

Health financing is described as imbalanced, with budget allocations favouring tertiary care and central-level activities; only 20% of health expenditure was allocated to basic health services in the 2020 Public Expenditure Review.[16]The Basic Health Care Package had a funding gap of 4.5 billion Gambian Dalasi, equivalent to 40% of full implementation requirements, in 2017.[22]

Per-capita health expenditure was 23.38 United States dollars in 2016 and 25.84 United States dollars in 2017.[22]Out-of-pocket expenditure accounted for 24.55% of total health expenditure in 2017, while donor funding represented 28.83% in 2016 and 45.49% in 2017.[22][14]Government health spending was between 7% and 11% of the national budget during 2015-2020, below the 15% Abuja target.[22][14]

Direct out-of-pocket payments do not pass through pooling or risk-sharing mechanisms, and the limited success of the Drug Revolving Fund constrains public-fund pooling.[25]Affordability remains a barrier where people cannot pay the 25 Gambian Dalasi consultation fee and associated charges.[1]