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

Objectives

The 2021–2030 National Health Policy, framed as “Building partnerships for quality health care for all”, seeks a healthier and more productive population through Universal Health Coverage (UHC), aligned with the National Development Plan and Sustainable Development Goals.[1][2][3]Its overarching goal is quality, affordable and accessible health care for everyone in The Gambia by 2030.[3][4]

• Provide Ministry of Health leadership and an enabling framework for integrated, quality, effective and responsive health services and prevention measures that improve physical, mental and social wellbeing.[3][5]
• Deliver a tailored essential health-service package incrementally to all people regardless of nationality, age or socioeconomic status, using primary health care as its cornerstone.[6]
• Reduce morbidity, mortality, health risks and environmental exposures, while promoting healthy lifestyles, financial risk protection and equity.[7][8]
• Reduce the prevalence, incidence, impact and risk factors of non-communicable diseases and injuries, covering cardiovascular disease, diabetes, cancers, chronic respiratory disease, mental health conditions, substance-related harms, eye health and oral disease.[9][10]
• Reduce premature mortality from non-communicable diseases, including mental health conditions, by one third; reduce tobacco use, unhealthy diets, harmful alcohol use, physical inactivity and indoor air pollution; and strengthen prevention and treatment of substance abuse.[5]
• Control communicable diseases, including malaria, tuberculosis, HIV/AIDS, sexually transmitted infections and hepatitis, so that they no longer constitute major public health problems.[10]
• Strengthen maternal, child, reproductive and nutrition services, health promotion, environmental health, social determinants of health, research, health information, governance and partnerships.[11][12]
• Build a resilient health system through revitalised primary health care, functional referral systems, adequate infrastructure, workforce capacity, reliable medicines and supplies, and public health emergency preparedness and response.[10][13]

Guiding principles include equity and gender equity, human dignity and confidentiality, accountability, collaboration, community ownership, responsiveness, people-centred and culturally appropriate care, evidence-based practice, climate resilience, decentralisation and domestic resource mobilisation.[5][6]The framework seeks to increase life expectancy from 65 to 75 years, although the supplied material does not provide a complete results framework for all policy priorities.[5]

Implementation

Implementation combines a decentralised, multi-level health-service model with Ministry of Health policy leadership, regional and local delivery structures, community participation, multisectoral action and partnerships.[14][6][12]Public services are organised across primary, secondary and tertiary levels, with referral from village and community providers through health centres and regional hospitals to general, teaching and specialised hospitals.[14][12]

• Implement the health-sector strategic plan and primary health-care revitalisation roadmap through functional linkages across service levels, skilled primary-care personnel, community participation and community-based surveillance.[15][13]
• Tailor and refine the Essential Health Care Package in response to epidemiological and social change, and use demand- and supply-side interventions to reduce inequities in access.[6]
• Strengthen referral, redesign service-delivery models according to need, standardise quality through accreditation and licensing, and develop relevant regulations, standard operating procedures and protocols.[6]
• Expand prevention and health promotion through communication, social mobilisation, advocacy, social dialogue, healthy settings, physical-activity facilities and action on environmental and social determinants of health.[8]
• Coordinate action on non-communicable diseases, injuries and zoonotic threats through intersectoral collaboration, advocacy, partnerships and resource mobilisation, including private-for-profit and private-not-for-profit providers.[10]
• Strengthen medicines and technology systems through procurement, regulation, local production, supply-chain management, storage, inventory control, donations oversight and quality-control laboratories.[13]
• Develop emergency, laboratory, blood-transfusion, trauma, training and regional blood-bank capacity, supported by a functional public health emergency system, a National Public Health Laboratory, One Health coordination and strengthened points of entry.[13][16]
• Establish national and regional stewardship structures for laboratory, radiology, biomedical engineering, infrastructure, transport and estate-management services, with trained technical personnel and quality-management arrangements.[16]
• Build integrated health-information architecture by computerising records, improving connectivity, harmonising programme monitoring systems, integrating logistics, human-resource, finance and medical-record databases, and strengthening civil registration and vital statistics.[17][18]

The Ministry of Health sets policy and regulations, mobilises resources, manages finances, executes budgets and conducts audits, while Regional Health Directorates oversee national-programme implementation and primary and secondary services within their regions.[14][12]Governance arrangements include central and regional management teams, Facility Management Committees involving staff and community representatives, decentralisation of authority and resources, and standard operating procedures for administration, management and reporting.[19][4]The policy envisages an autonomous service-delivery institution while the Ministry acts as regulator, although the supplied text does not confirm a timetable for this reform.[20]

Implementation involves government, local authorities, communities, civil society, academia, professional bodies, United Nations agencies, multilateral and bilateral partners, non-governmental organisations, the private sector and the media.[21][22][20]Development partners are to be coordinated through a memorandum of understanding and a Health Policy Advisory Group, while stakeholder participation, public-private partnership and health-in-all-policies action are promoted.[4][22]

Performance management is to use facility, district, regional and central reviews across the health-system building blocks, annual health-sector performance reviews against work plans and strategic-plan targets, national joint annual reviews, a mid-term review and an end-term evaluation.[20][23]The Directorate of Planning and Information monitoring and evaluation unit has direct monitoring and evaluation responsibility, with routine quarterly, twice-yearly and annual monitoring and timely dissemination to stakeholders.[23]Annual national and regional health conferences, publication of The Health of the Gambian People, transparent procurement and audit responsibilities provide additional accountability mechanisms.[19][4]

Financing measures include a National Health Insurance Scheme, mixed prepayment mechanisms, social health insurance, tax-based and non-tax-based financing, a Primary Health Care Fund, a health emergency fund, improved aid coordination and innovative financing for non-communicable disease prevention through tobacco and sugar-sweetened beverage taxation.[10][24]The policy calls for sustainable domestic resource mobilisation and equitable allocation, but does not specify a total policy budget or costed implementation plan in the supplied material.[5][4]

Monitoring & Evaluation

The policy establishes a layered performance and accountability approach based on an integrated health information system, routine service data, harmonised monitoring and evaluation, periodic performance reviews, and reporting across facility, regional and national levels. It seeks to use evidence for policy, planning, quality improvement and equitable service delivery.[16][17][20][23]

• Strengthen a national monitoring and evaluation system by harmonising programme-specific systems, improving standards and capacity, and institutionalising health-sector performance and appraisal reviews.[16][17]
• Require complete and timely reporting by public and private facilities under a health-information legal framework, supported by an integrated data warehouse for storing and harmonising sector data.[16][17]
• Review health-system performance across the six building blocks at facility, district, regional and central levels through internal and multi-stakeholder processes.[20]
• Conduct annual health-sector performance reviews against work plans and National Health Sector Strategic Plan targets, complemented by national joint annual reviews, a mid-term review and an end-term evaluation.[20][23]
• Assign direct monitoring and evaluation functions to the Directorate of Planning and Information monitoring and evaluation unit, while retaining overall Ministry of Health responsibility for policy implementation.[23]
• Monitor progress and outcomes routinely on quarterly, twice-yearly and annual cycles and disseminate information to stakeholders in a timely manner.[23]
• Review operational action plans annually at all system levels to coordinate actors and assess progress towards policy objectives.[12]
• Use annual national and regional health conferences to review achievements, identify challenges and agree commitments for improvement, alongside annual publication of The Health of the Gambian People.[19]
• Support accountability through transparent procurement, adherence to policy and guidelines, community participation, social accountability and progressive decentralisation.[15][19][4]
• Strengthen community-based surveillance, case management, antimicrobial-resistance surveillance and emergency detection and response at all levels.[10][13]
• Track health inequalities and standardise quality through accreditation and licensing, while applying workforce performance management and medicines and vaccine quality-control functions.[6][13]
• Improve Health Management Information System data quality and completeness, addressing missing electronic records on human resources, community sensitisation, transport, patients and budgets, as well as untimely, incomplete, inaccurate and duplicate reporting.[23]
• Use paper registers and monthly facility returns alongside electronic regional and central systems, including District Health Information System 2, MyChild Solution and the Vaccine Visibility System.[23]
• Integrate logistics, human-resource, financial, electronic medical-record and civil-registration information systems, including integration of the Project Coordinating Unit financial system into the Integrated Financial Management Information System.[23][18]

Quantified results include raising life expectancy from 65 to 75 years; reducing premature non-communicable disease mortality by one third; and reducing risk-factor prevalence for tobacco use, unhealthy diets, harmful alcohol use, physical inactivity and indoor air pollution.[5]Additional targets cover maternal, infant, under-five and neonatal mortality, access to safe drinking water, and sanitation.[5]Service-readiness monitoring includes facilities, beds, workforce, utilisation, medicines, diagnostics, equipment, amenities and obstetric and newborn functions; reported non-communicable disease service availability was 69% for diabetes, 71% for cardiovascular diseases, 49% for chronic respiratory diseases and 14% for cervical cancer.[25][26]The supplied material does not provide a complete indicator dictionary, detailed evaluation methodology, universal reporting format or fully specified accountability schedule.[16][17][4]

Costing & Financing

The policy prioritises financial risk protection, sustainable domestic resource mobilisation, equitable allocation and more efficient use of resources, but the supplied material does not provide an overall policy budget, costed implementation plan, programme allocations or quantified financing target.[5][6][19][4]

• Increase health financing through sustainable and innovative domestic resource mobilisation, prudent investment planning and efficient allocation of available resources.[5][6]
• Establish a National Health Insurance Scheme and reduce out-of-pocket payments through mixed prepayment mechanisms, including social health insurance and tax-based and non-tax-based financing.[8][24]
• Purchase services from registered and accredited public, private, non-governmental and traditional providers, using input-based payments, capitation, fee-for-service and results-based financing as appropriate.[24]
• Establish a Primary Health Care Fund and health emergency fund, coordinate external aid, and develop an equitable resource-allocation strategy.[24]
• Mobilise innovative financing for non-communicable disease prevention and management through taxation of tobacco and sugar-sweetened beverages.[10]
• Mobilise resources and coordinate development partners so that support aligns with national priorities and is more predictable.[4]
• Maintain a core health-finance database within the Directorate of Planning and Information, using financial and budgeting data from the Ministry of Finance and Economic Affairs to inform planning, resource management and financing analysis.[18]

Available evidence indicates substantial resource constraints. Per-capita health expenditure was United States dollars 23.38 in 2016 and United States dollars 25.84 in 2017, while the estimated gap for full Basic Health Care Package implementation in 2017 was 40%, equivalent to 4.5 billion Gambian dalasi.[26]Only 20% of Ministry of Health funds were devoted to basic health services, and allocations were described as skewed towards tertiary and central-level activities.[14][26]Government health expenditure represented 7% to 11% of the national budget during 2015-2020, below the 15% Abuja target, while total health expenditure represented 4.97% of gross domestic product in 2016/2017.[11]External funding accounted for 28.83% of total health funding in 2016 and 45.49% in 2017, and out-of-pocket expenditure was 24.55% in 2017.[26]Direct payments lack pooling and risk-sharing arrangements, and some people cannot afford the Dalasi 25 consultation fee and associated charges.[11][3]

Funding shortages affect infrastructure, supplies, equipment, trained personnel, research, monitoring and evaluation, mental-health services and information-system capacity.[2][9][16]No dedicated non-communicable disease budget, detailed costing methodology, monetary allocation for proposed funds, external funding commitment or economic assumption is specified.[26][10][24]