NATIONAL HEALTH ACCOUNTS - World Banksiteresources.worldbank.org/INTHSD/Resources/376278...National Health Accounts (NHA) is a tool for health sector management and policy development

NATIONAL HEALTH ACCOUNTS

1


Financial year 2002, 2003 and 2004

REPUBLIC OF THE GAMBIA

DEPARTMENT OF STATE FOR HEALTH & SOCIAL WELFARE THE QUADRANGLE

BANJUL, THE GAMBIA

NOVEMBER 2007


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Table of Contents Page

Table of Contents (i)

List of Tables (ii)

List of Figures (iii)

Abbreviations and Acronyms (iv)

Foreword (v)

Acknowledgements (vi)

Executive Summary (vii)

Chapter 1: Introduction

Chapter 2: Background

Chapter 3: Methods and Sources of Data

Chapter 4: Main NHA Findings

Chapter 5: Recommendations

Chapter 6: Conclusion

Chapter 7: Further Analysis of Current Health Financing System

References [End of each chapter]

Annexes

Matrix I

Matrix II

Matrix III


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List of Tables Page

Table 1: Number of various types of health facilities in The Gambia

Table 2: Distribution of health workers in ECOWAS countries

Table 3.1 Breakdown of the categories


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List of Figures Page

Figure 2.1: ECOWAS Member States

in 2006 (Population in Million)

Figure 2.2: Adult literacy rate and combined enrolment ratios for primary,

Secondary and tertiary schools in ECOWAS

Figure 2.3a: Value added by Type of economic activity – millions of Dalasis

Figure 2.3b: Value added by type of economic activity in 1999/2000

Figure 2.3c: Value added by type of economic activity in 2004/2005

Figure 2.4: Life expectancy at birth among ECOWAS countries in 2004

Figure 2.5: Under-5 mortality rate (per 1000LB) for ECOWAS countries in 2004

Figure 2.6: Adult mortality rate per 1000 among ECOWAS countries

Figure 2.7: Maternal Mortality Ratio per 100 000 live births (in year 200)

Figure 2.8: Stillbirth rate and neonatal mortality rates per 1000 in ECOWAS

Figure 3.1: How NHA Presents Financing Flows and Links to Health

Policy Decisions

Figure 4.1a: Total Health Expenditure by Sources

Figure 4.1b: Per capita total health expenditure for ECOWAS countries (US$)

Figure 4.2a: Health financing by source in The Gambia (year 2002)

Figure 4.2b: Health financing by source in The Gambia (year 2003)

Figure 4.2c: Health financing by source in The Gambia (year 2004)

Figure 4.2d: Per capita government expenditure on health in ECOWAS

Figure 4E: Government Expenditure on health as % of total government

Expenditure

Figure 4F: Private expenditure on health as % of total expenditure on health

in ECOWAS

Figure 4g: Out-of-pocket spending as % of private expenditure on health

in ECOWAS

Figure 4.2I: Private prepaid plans as a % of private expenditure on health

in ECOWAS

Figure 4.2h: External resources for health as a % of total expenditure on


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health

Figure 4.3: Percentage of total health expenditure by financing agents

Appendix Table: General NHA Summary Statistics (2002, 2003, 2004)


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Abbreviations and Acronyms

NHA National Health Accounts

NGO Non-Governmental Organisation

DOSH Department of State for Health & Social Welfare

DOSFEA ` Department of state for finance and Economic Affairs

DOSFA Department of State for Foreign Affairs

DOSI Department of State for Interior

DOSE Department of State for Education

DOSD Department of State for Defence

LGA Local Government Authorty

GBoS Gambia Bureau of Statistics

UNDP United Nation Development Programme

GDP Gross Domestic Product

HDI Human Development Index

WHO World Health Organisation

OOPs Out-of –pocket payments

THE Total Health Expenditure

TGHE Total Government Health Expenditure

TPHE Total Private Health Expenditure

GGHE General Government Health Expenditure

CMH Commission for Macro Economics and Health

CRP Cost Recovery Programme

DRF Drug Revolving Fund

BI Bamako Initiative

FA Fianancing Agent

P Providers

F Functions

FS Financing Sources


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Foreword

National Health Account provides information to guide health policy design especially

the health financing policy. This report is the first to be completed for The Gambia.

Objective of NHA Study in The Gambia

The objectives of The Gambia NHA are:

To trace the sources of health expenditure in The Gambia;

To determine total health expenditure by financing agents and providers;

To examine the distribution of funds by functions e.g. prevention and curative

services; and

To trace the channels of distribution of funds by inputs (line items), e.g. personnel

remunerations, medicines.

The inaugural NHA study was the first step towards The Gambia’s aspiration of

institutionalizing NHA to facilitate DOSH stewardship of the national health system. The

study succeeded in addressing three of its four objectives: (i) to estimate the total health

expenditure from public, private and donor sources; (ii) to determine the total health

expenditure by financing agents; and (iii) to approximate the distribution of funds by

various public health functions. Due to dearth of disaggregated information, it was not

possible to estimate the amounts of funds spent on various health system inputs.

The NHA evidence contained in this document constitutes a strong basis for developing a

comprehensive health financing policy and a health financing strategic plan using the

Sector Wide Approach (Common Basket Funding) and mapping out how the

Government plans to realize the vision of universal coverage of health services and

universal protection from potentially catastrophic and impoverishing health care

expenditures in the long-term. In order to facilitate the monitoring and evaluation of such

policy documents once developed, it is important to institutionalize national health

accounts. The latter will require boosting of the capacities in the Directorate of Planning

and Information.

An attempt was made to analyse the Cost Recovery Program using selected Bamako

Initiative Operated health centres.

It is the strong believe that these information should provide sufficient information for

the reform of the health services management in The Gambia.

Dr. Malick Njie

Secretary of State for Health and Social Welfare

November 2007


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Acknowledgement

The Department of State for Health and Social Welfare wishes to acknowledge the

immense support provided by the World Health Organization ( principal financier), and

the Fight Against Social and Economic Exclusion Project of UNDP for the financing of

the study. Beyond the financial support WHO provided technical support from the

Regional Office in the analysis and report writing.

We wish to thank the various contributors to the data; public, private, NGO and donor

community for their strong cooperation and support.

The Department acknowledges the strong coordination role of the Directorate of Planning

and Information, and supported by the National Health Account Technical Team in the

development of this report.


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Executive Summary

Definition of NHA

National Health Accounts (NHA) is a tool for health sector management and policy

development that measures total public (all relevant sectors), private (including

households, enterprises, NGOs) and donor (rest-of-the-world) health expenditures. It

tracks all expenditure flows from the sources of funds to financing agents, service

providers, public health functions and inputs.

Objective of NHA Study in The Gambia

The objectives of The Gambia NHA are:

To trace the sources of health expenditure inThe Gambia;



services; and



Dimensions of The Gambia NHA Study

According to the WHO guide to producing NHA [WHO 2003], international experience

in the development and use of health accounts suggests a number of useful dimensions.

a) Financing sources: Institutions or entities that provide funds used in the health

system by financing agents. In The Gambia the financing sources consist of the

Government (DOSFEA), Local Government Area (LGA), parastatals, private

employers, households and donors (rest-of-the-world).

b) Financing agents: Institutions or entities that channel funds provided by financing

sources and use those funds to pay for, or purchase, the activities inside the health

accounts boundary (i.e. all activities whose primary purpose is to promote, restore

or maintain health). In The Gambia the financing agents include: DoSH, DoSE,

DoSD, DoSI, DOSFA, LGA, NAS, NaNA, Parastatals, private insurance,

households, NGOs, and private firms. The sum of the funds channelled through

all the financing agents should be equal to the total amount of money provided by

the financing sources.

c) Providers: Entities that receive money in exchange for or in anticipation of

producing the activities inside the health accounts boundary. Examples of

providers in The Gambia include: Teaching hospital, general hospitals, private

hospitals/clinics, Government Health Centres (Basic Health Services), NGO

health centres, pharmacies, opticians, pharmaceutical companies, administration

of public health, provision of public health services, other (private insurance), all

other providers of health administration, insurance firms, research institutions,

education and training institutions, NGO health related activities, and rest of the


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4world. Ideally, the sum of the funds received by all the providers should be equal

to the total amount of money provided by the financing agents.

d) Functions: Services of curative care, services of rehabilitative care, ancillary

services to medical care, medical goods dispensed to out-patients, prevention and

public health services, health administration and health insurance, and health

related functions. The latter includes: capital formation of health care provider

institutions, maintenance service management, education and training of health

personnel, research and development in health, traditional medicine development,

and provision of overseas treatment.

e) Resource/input costs: The factors or inputs used by providers or financing agents

to produce the goods and services consumed or the activities conducted in the

health system. In The Gambia resource/input cost categories would include:

personnel (remuneration, employers contribution employees insurance, other

conditions); goods and services (travel and subsistence expenses, drugs and

medical supplies, material supplies, transport, utilities, maintenance, property

rental and related charges; education and training (research and development,

nutritional surveillance, water and sanitation, other services and expenses);

subsidies and other current transfers (membership fees and subscription,

government organization, individuals and non profit, public and departmental

enterprise); and development expenditure (furniture and office equipment;

vehicles, operational equipment, machinery).

Beneficiaries: The people who receive those health goods and services or benefit

from those activities (beneficiaries can be categorized in many different ways,

including their age and sex, their socio-economic status, their health status, and

their location).

NHA matrices used to track flow of health expenditures

Each of the NHA tables displays some facet of health expenditure cross-tabulated by two

of the dimensions mentioned below and these include:

a) Health expenditure by financing source and type of financing agent (FS x FA).

This table highlights resource mobilization patterns in the health system. It

addresses the question “where does the money come from” by showing the

financing sources that contribute to each financing agent. It also shows how

prominent a role each source plays in the financing of each financing agent and in

the total spending overall.

b) Health expenditure by the type of financing agent and type of provider (FA x P).

This table describes how funds are distributed across different types of providers,

e.g., what share of total spending goes to referral and district hospitals relative to

hospitals, clinics, health posts, outreach stations.

c) Health expenditure by provider and type of function (P x F). This table shows

how expenditures on different health functions are channelled through the various

types of providers. It provides useful perspective on the contribution of different


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types of providers to the total spending on specific types of services, e.g. public

health programmes vis-à-vis secondary and tertiary curative care.

d) Health expenditure by type of financing agent and type of function (FA x F). This

table shows who finances what types of services in the health system. It can also

highlight the relative emphasis of public and private financing agents with respect

to the various public health functions.

Health expenditure data sources

To determine household expenditure on health for this exercise, two sources were

utilized. In view of the high cost involved in conducting large scale household surveys, it

was decided to largely utilize data from the 2003 Integrated Household Survey (IHS) to

arrive at estimates of household expenditure on health and also to conduct a small scale

household survey in 2006 to address issues of health seeking behaviour which were

largely not covered by the IHS.

For the other health expenditure sources, the lists of organisations (employers, donors,

NGOs, health care providers) were obtained from various registration sources including

the Registrar General’s Department, The Gambia Chamber of Commerce, NGO Affairs

Agency, DoSFA and The Gambia Bureau of Statistics. All identified organisations were

included in the survey.

Except for the house hold survey which was done by GBoS, the rest of the data collection

was done by Account Technicians provided by the Directorate of National Treasury. The

NHA Technical Committee provided the supervision of the data collection.

Main Findings of the NHA Study

The total health expenditure (THE) was approximately D1,185,223,103 in 2002;

D1,395,958,522 in 2003; and D1,682,323,673 in 2004. The THE as a percentage of GDP

in The Gambia was 16.1% in 2002, 13.9% in 2003 and 14.9% in 2004. The per capita

total health expenditure was D895 in 2002, D1026 in 2003 and D1203 in 2004.

Figures 4.1C, 4.1D and 4.1E show the contribution of government/public, households,

private employers and donors to the total health expenditure in the The Gambia during

years 2002, 2003, and 2004.


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Figure 4.1C: Health financing by source

in Gambia (year 2002)

Donors

70% Household

OOPs

12%

Private

employer

0%

Government/

public

18%

Figure 4.1D: Health financing by source

in Gambia (Year 2003)

Private

employer

0%

Government/

public

22%

Donors

67%

Household

11%


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Figure 4.1E: Health financing by source


Household

OOPs

9%

Private

employer

1%

Government/

public

24%

Donors

66%

During the three years over 66% of the total health funding came from donors

(international health development partners). The Government of The Gambia

contribution grew from 18% in 2002 to 24% of the total health expenditure in 2004. The

households, through direct out-of-pocket payments to health care providers, contributed

12% in 2002, 11% in 2003 and 9% in 2004 to the total health expenditure.

Key Recommendations

1) NHA should be institutionalised to ensure that it can be conducted on a regular

and sustained basis.

2) NHA Advisory/Steering Committee (NHASC) should be maintain and the

membership of the The Gambia NHA Technical Working Group should be

expanded to include representatives of all relevant Government Departments (e.g.

DoSFEA, DOSE, DOSI, DoSFA, LGA) and organs (e.g. NAS, NaNA), plus a

representative of the health development partner group in the country.

3) There is need to plan for undertaking the second NHA exercise covering 2005,

2006 and 2007, and thereafter make a decision on the frequency of subsequent

NHA studies.

4) DoSH should consider developing a comprehensive health financing policy and

health financing strategic plan with a roadmap of how the Government plans to

realize the vision of universal coverage of health services and universal protection

from potentially catastrophic and impoverishing health care expenditures in the

long-term. In the process of developing the national financing policy, it may be

informative to refer to the WHO regional strategy for health financing for

inspiration.


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The following important findings should support the development of the health

Financing policy:

Government current per capita health expenditure is below $35 as

recommended by WHO. The financing policy should advocate for

government increase expenditure on health.

Currently Social Security contribution to health is insignificant. The policy

should therefore advocate for increase Social security contribution to

health expenditure.

The out- of-pocket expenditure as a propotion of total private health

expenditure is over 95%. The health financing policy should advocate for

the development of a national social insurance frame work including

health financing safety nets for the poor.

Donor contribution to the total health expenditure is over 65%. For

effective coordination of this input the health financing policy should

advocate for basket funding system.

Conclusion

This is the first National Health Accounts Study in The Gambia and its findings are

important for better understanding of The Gambia health system financing. The evidence

contained in this report will inform health decision-making, including policy and plan

development. In addition, the results of the study will help government identify better

policy instruments to re-orient the way health- finances are to be distributed in The

Gambia, and will hopefully enable policy makers to better understand the flow of

resources in the health system. Furthermore, the results could be used to negotiate with

multilateral and bilateral agencies for additional funding for the health sector. Lastly, we

hope that the NHA evidence will also be of use to non-governmental and private health

stakeholders.


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Chapter 1: Introduction

1.1 What is National Health Accounts?

The scarcity of resources is increasingly forcing countries in the African Region to take

stock of national health resources, review allocation patterns, review how equitably they

are distributed, assess the efficiency of existing resource use, and evaluate health

financing options [1]. Countries for a long-time have relied on Public Expenditure

Reviews (PER). Unfortunately, PER enables countries to know only the monies invested

into health by the government, and not the total investment made by all the stakeholders,

e.g. all relevant government sectors, households, private firms, and donors. Thus, at best

PER is a partial expenditure analysis. Instead, a number of countries in the Region have

employed the National Health Accounts (NHA) tool to take stock of the national health

resource investment, to support health system governance and decision-making.

National Health Accounts (NHA) is a tool for health sector management and policy

development that measures total public (all relevant sectors), private (including

households, enterprises, NGOs) and donor (rest-of-the-world) health expenditures. NHA

consists of a set of tables presenting various aspects of a nation’s health expenditure. Its

distinguishing features include [2:p.2]:

A rigorous classification of the types and purposes of all expenditures and of all

the actors in the health system;

A complete accounting of all spending for health, regardless of the origin,

destination, or object of the expenditure;

A rigorous approach to collecting, cataloguing, and estimating all those flows of

money related to health expenditure; and

A structure intended for ongoing analysis (as opposed to a one-time study).

In principle, NHA tracks all expenditure flows from the sources of funds to financing

agents, service providers, public health functions and inputs. It seeks to answer questions

such as [2]: Who pays and how much is paid for health services? How are resources

mobilized and managed for the health system? Who provides health goods and services,

and what magnitudes of resources do they use? How are health care funds distributed

across the different services (e.g. prevention, treatment, care, rehabilitation),

interventions and activities that the health system produces? How are the health funds

distributed across the different inputs (e.g. human resources for health, pharmaceuticals

and non-pharmaceutical supplies, equipment, buildings, vehicles, maintenance)? Who

benefits from health care expenditure (e.g. by income groups, age/sex, geographical

regions, diseases or health conditions)?

NHA is an indispensable input in Department of State for Health & Social Welfare

(DOHSW) stewardship of a performing health system. It empowers policy-makers

(decision-makers) to effectively execute the stewardship functions of generation of

financial intelligence, formulating sound strategic policy framework (national health

policy, national strategic health development plan, comprehensive health financing policy


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and plan), monitoring programme implementation, ensuring a fit between policy

objectives and available resources, and ensuring accountability in use of all health sector

resources [3]. According to Berman and Cooper [1:p.vii], “NHA are a powerful tool that

can be used to improve the capacity of decision-makers to identify health sector problems

and opportunities for change and to develop and monitor reform strategies”. NHA can

provide some of the important information need for strengthening health system

performance of its functions of stewardship, health financing, input (or resource) creation

and services provision, and ultimately, the achievement of health system goals of health

improvement (or maintenance), responsiveness to people’s non-medical expectations and

fair financial contributions [3,4].

1.2 Development of The Gambia NHA

The Government of The Gambia faces a situation in which it is expected to finance a

growing double-burden of communicable and non-communicable diseases, rationalize

health service delivery, regulate the quality, improve equity in health care delivery and

meet the growing demand for better health care.

National Health Accounts was designed to provide a comprehensive description of the

flow of resources from the source to the ultimate use. This is the first time that the NHA

tool has been used by the DOHSW in The Gambia.

In November 2005, the DOHSW constituted a NHA Technical Working Group (TWG)

comprising of the DOHSW, The Gambia Bureau of Statistics (GBoS), Office of the

Directorate of Treasury, Local Consultant, and Head Department of Economist

University of The Gambia to undertake a comprehensive NHA study for the years 2002,

2003 and 2004. In addition, the DOHSW constituted a NHA Advisory/Steering

Committee to oversee the work of the TWG. The study was coordinated by the

Directorate of Planning and Information, with the support of WHO and UNDP FASE

Project. The launching of the NHA was done by Permanent Secretary Department of

State for Health and Social Welfare on behalf of the Vice President.

1.3 Objectives of The Gambia's NHA Study

The overall objective of this first NHA study was to establish the total health financing in

The Gambia with a view to gather evidence that would inform policy and strategic plan.

The specific objectives were to:

To trace the sources of health expenditure in The Gambia;



services; and




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1.4 Organisation of the remaining chapters

This report presents the analysis of the first of The Gambia’s NHA study for the fiscal

years 2002, 2003 and 2004. Chapter two briefly describes the geography, demography,

socio-economic attributes and the health system in The Gambia. Chapter three describes

the NHA methodology, data sources and limitations of the current NHA exercise.

Chapter 4 reports the NHA findings. Chapter 5 presents the recommendations. Chapter 6

concludes the report.

References

1. Berman P, Cooper DM: National health accounts: Software manual. Ver 1.01.

Boston: Harvard School of Public Health; 1996.

2. World Health Organization: Guide to producing national health accounts: with

special applications for low-income and middle-income countries. Geneva; 2003.

3. World Health Organization: The world health report 2000 – health systems:

improving performance. Geneva; 2000.

4. Murray CJL, Frenk J: A framework for assessing the performance of health

systems. Bulletin of the World Health Organization. 2000, 78(6): 717-731.


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CHAPTER 2: BACKGROUND

2.1 Geographic and Demographic overview

The Republic of The Gambia is located on the West Africa coast and extends about 400

km inland, with a population density of 128 persons per square kilometre. The width of

the country varies from 24 to 28 kilometers and has a land area of 10,689 square

kilometres. It is bordered on the North, South and East by the Republic of Senegal and

on the West by the Atlantic Ocean. The country has a tropical climate characterized by

two seasons, rainy season June-October and dry season November-May.

Demographic characteristics

According to the Demographic profile 2003, the population is estimated at 1.36 million

and by the year 2011 it is estimated to reach 1.79 million, with annual growth rate of 2.74

% (The Gambia 2003 Census). About 60% of the population live in the rural area; and

women constitute 51% of the total population. The crude birth rate is 46 per 1000

population while the total fertility rate is 5.4 births per woman. The high fertility level

has resulted in a very youthful population structure. According to the 2003 Census,

nearly 44% of the population is below 15 years and 19% between the ages 15 to 24.

Average life expectancy at birth is 64 years overall.

The Gambia is one of the 15 ECOWAS member states. In 2004 the ECOWAS had a total

population of 254.5 million people [WHR2006]. The total population of The Gambia was

1.48 million, i.e. 0.6% of the ECOWAS population (See Figure 2.1). The population aged

60 years and above increased from 5.2% in 1994 to 5.9% in 2004. The Gambia had an

annual population growth rate of 3.2%, which was equal to that of Benin and Togo. The

total fertility rate (TFR) decreased from 5.5 in 1994 to 4.6 in 2004; it was lower than the

average ECOWAS TFR of 5.7. The Gambia’s dependency ratio declined from 84 to 79

per 100 persons; which was lower than the average for ECOWAS of 96 per 100

[WHR2006].


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Figure 2.1: Population for ECOWAS in

2004 ('000)

0 50 000 100 000 150 000

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Thousands of people

2.2 Socio-economic overview

2.2.1 Education

Figure 2.2 presents the adult literacy rate (%) and combined gross enrolment ratio for

ECOWAS countries in 2004.


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Figure 2.2a: Adult literacy rate (% ages 15 and

above) in ECOWAS

0 10 20 30 40 50 60 70 80

Cape Verde

Ghana

Togo

Nigeria

Gambia

Senegal

Guinea

Benin

Côte d’Ivoire

Guinea-Bissau

Mali

Burkina Faso

Niger

Sierra Leone

Percentage

Adultliteracyrate2002 Adultliteracyrate2003 Adultliteracyrate2004

The Gambia had an adult literacy rate of 37.8.%. Those statistics were lower than the

average ECOWAS adult literacy rate of 42% [UNDP HDR2006].

Figure 2.2b presents the gross enrolment ratio for primary, secondary and tertiary schools

in ECOWAS. In 2004 The Gambia had the fifth highest gross enrolment ratio, after Cape

Verde, Nigeria, Sierra Leone and Togo.


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Figure 2.2b: Gross enrolment ratio for primary,

secondary and tertiary schools in ECOWAS

0 10 20 30 40 50 60 70 80

Cape Verde

Ghana

Togo

Nigeria

Gambia

Senegal

Guinea

Benin

Côte d’Ivoire

Guinea-Bissau

Mali

Burkina Faso

Niger

Sierra Leone

Percentage

Combinedgrossenrolment2002 Combinedgrossenrolment2003

Combinedgrossenrolment2004

2.2.2 Human Development Index

The UNDP human development index is an indicator of human development that

combines life expectancy, education and Gross Domestic Product (GDP) indices. UNDP

use these indices to classify countries either as high human development (with an HDI

ranging from 1.00 to 0.801); medium human development (with an HDI ranging from

0.799 to 0.505); and low human development (with an HDI of 0.499 and less).

Figure 2.3 presents the 2002, 2003 and 2004 HDI for the ECOWAS. Only Cape Verde

and Ghana had medium human development. All the other thirteen ECOWAS countries

are low human development countries.


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Figure 2.3: Human Development Index for

ECOWAS (2004)

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8

Cape Verde

Ghana

Togo

Nigeria

Gambia

Senegal

Guinea

Benin

Côte d’Ivoire

Guinea-Bissau

Mali

Burkina Faso

Niger

Sierra Leone

Human development index

HDI2002 HDI2003 HDI2004

Thus, The Gambia is also classified as a low human development country. In 2004 the

country had fourth highest HDI, after Togo (HDI=0.479), Ghana (HDI=0.532) and Cape

Verde (HDI=0.722). The Gambia’s HDI of 0.479 was slightly higher than the average

HDI for ECOWAS of 0.436 and the global average HDI for low human development

countries was 0.427 [UNDP HDR2006].

2.2.3 Economy

The real gross domestic product for The Gambia in 1980 was $213 million. By 2004 it

had more than doubled ($484 million). Between 2000 and 2004 the country experienced a

real GDP growth rate of 3.2%, which was mainly attributed to growth in the industry

(7.2% between 2000-2004) and service sectors value added (5.9% between 2000-2004).

Over the same period the agricultural sector experienced a small growth in value added of

0.2% [World Bank, 2006].


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0 50 100 150 200 250

Value added ($ millions)

Year2002

Year2003

Year2004

Figure 2.3: Gambia Agriculture-, industry-, and

service value added ($millions)

Agriculture Industry Service

In 1980 and 2004 the real GDP per capita was $327 [World Bank, 2006]. Figure 2.4

shows that the real GDP per capita for The Gambia was higher than those of Burkina

Faso, Ghana, Guinea-Bissau, Liberia, Mali, Niger, Sierra Leone, and Togo. However, per

capita GDP being an average measure, hides the inequalities in GDP distribution among

the population. For example, the Gini Coefficient for The Gambia was 50.2 in 2004

[World Bank 2006].


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Figure 2.4: Real GDP Per Capita ($) in ECOWAS

0 200 400 600 800 1000 1200 1400

Benin

Burkina Faso

Cape Verde

Côte d’Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Dollars per person

GDPPC2002 GDPPC2003 GDPPC2004

2.3 Health Profile

Figure 2.5 presents the life expectancy at birth among ECOWAS in 2004. The 2004 life expectancy of The Gambia (57 years) was equal to that of Ghana. It was

the second highest among the ECOWAS after that of Cape Verde (70 years). The life

expectancy in The Gambia was 7 years higher than the average life expectancy for

ECOWAS, which was 50 years. In The Gambia, the life expectancy for males was 55

years and females was 59 years.

Figure 2.6 presents the probability of dying (per 1000 live births) below the age of 5

years (i.e. under-5 mortality rate) for the ECOWAS . The under-5 mortality rate (for both

sexes) in The Gambia was 122 per 1000, which was second lowest in ECOWAS, after

Cape Verde. The Gambia under-5 mortality rate for males (129 per 1000) was higher

than that of females (115 per 1000). The under-5 mortality rate in The Gambia was lower

than the average for ECOWAS of 178 per 1000 (male=183/1000 and female=168/1000).

Figure 2.5: Life expectancy at birth for

ECOWAS (2004)

0 20 40 60 80

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Life expectancy in years


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Figure 2.6: ECOWAS under five mortality per

1000 live births (2004)

0 50 100 150 200 250 300

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Deaths per 1000 live births

Figure 2.7 shows the probability of dying per 1000 between ages 15 and 60 years (adult

mortality rate) for ECOWAS.. The adult mortality rate for The Gambia was 304 per

1000, which was lower than that of all the other ECOWAS , except for Cape Verde. The

average adult mortality rate for ECOWAS was 410 per 1000 and the median was 441 per

1000. The Gambia adult male mortality rate was 344 per 1000 and that for females was

263 per 1000.


26

Figure 2.7: Adult mortality rate in 2004

0 100 200 300 400 500 600 700

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Deaths per 1000

Male adult mortality rate Female adult mortality rate

Figure 2.8 presents the maternal mortality ratio (per 100,000 live births) for the

ECOWAS countries in year 2004. The maternal mortality ratio for The Gambia of 540

per 100,000 live births was the second lowest among the ECOWAS, i.e. after Cape

Verde. It was far much lower than the average MMR for ECOWAS of 905/100,000 (and

median of 800/100000).


27

Figure 2.8: Maternal mortality ratio in ECOWAS

0 500 1000 1500 2000 2500

Cape Verde

Ghana

Togo

Gambia

Senegal

Nigeria

Guinea

Benin

Côte d'Ivoire

Chad

Guinea-Bissau

Burkina Faso

Mali

Sierra Leone

Niger

Maternal deaths per 100,000 live births

Reported MMR2004 Adjusted MMR2000

The Gambia has an Infant Mortality Rate of 75/1000 live births(2003 census), 60% of which is attributable to malaria, diarrhoeal diseases and acute respiratory tract infections. The main causes of mortality in infants (0-12 months) are neonatal sepsis, premature deliveries, malaria, respiratory infections, diarrhoeal diseases and malnutrition. For child mortality, main causes are: malaria, pneumonia, malnutrition, and diarrhoeal diseases (HMIS). The Maternal Mortality


28

Ratio is estimated at 730/100000 live births, the majority of which are due to sepsis,

haemorrhage and eclampsia.

About 40% of total outpatient consultation in 1999 was due to malaria, while diarrhoeal

diseases and acute respiratory tract infections constitute about 25%.

The HIV prevalence rate is 1.1% for HIV1 and 0.6% for HIV2 (sentinel surveillance

2005).

Tuberculosis remains a disease of public health importance in The Gambia. Through

intensified case finding, the proportion of smear positive cases identified has increased

from 56% in 2004 to 66.7% in 2005.

There has been an increase in national coverage for fully immunized children to a present

level of 79.6 % for under 1 year and 84.9% for the under 2 year (2004 EPI cluster

survey).

Malnutrition continues to be a major public health problem in The Gambia. The MICS

2006 indicated 19% stunting, 6.8% wasting and 17% underweight. Diabetes Mellitus is

estimated to affect about 1% of the population while a study found that about 16% of

urban women are obesed compare to only 1% of rural women.

2.4 Health System Overview

A health system includes all activities whose primary purpose is to promote, restore or

maintain individual’s physical, mental and social well-being [11]. Thus, health system

activities include health promotion, disease prevention, treatment, rehabilitation and

nursing/care (including community and home-based care). According to WHO [12], a

health system performs the functions of stewardship (oversight), health financing,

creating resources/inputs (including human resources for health) for producing health,

and delivering (providing) personal and non-personal services with a view to improving

responsiveness to people’s non-medical expectations, ensuring fair financial contribution

to health systems and ultimately improving health status.

2.4.1 Stewardship

The WHO Report 2000 broadly defines stewardship as “the careful and responsible

management of well-being of the population. Health stewardship focuses on the role of

country’s government, through its health ministry, in taking responsibility for the health

and well-being of the population, and guiding the health system as a whole, in order to

achieve its goals. The domains of stewardship include: generating and using

intelligence/evidence; providing vision and direction for the health system through

formulation of strategic policy framework; ensuring tools for implementation: powers,

incentives, and sanctions; building coalitions/building partnerships; ensuring fit between

policy objectives and organizational structure and culture; and ensuring accountability.


29

In order to exercise its stewardship role, The Government of the Republic of The Gambia

developed the National Health Policy Framework [2001]; to guide health development of

her population. The National Health Policy focuses on improving access to basic health

care and health system strengthening.

2.4.2 Provision of Health Services

According to the World Health Report 2000, this function of health system refers to

combination of inputs within a production process (e.g. hospital, clinic, public health

programme) that leads to the delivery of personal health services (consumed directly by

the individual, whether preventive, diagnostic, therapeutic or rehabilitative) and non-

personal health services, i.e. actions applied either collectivities (e.g. national vaccination

campaigns, mass health education) or to the non-human components of the environment

(e.g. basic sanitation, water, air-pollution control).

The Republic of The Gambia responds to the aforementioned health situation through an

extensive network of public and private health facilities (hospitals, health centres, clinics,

health posts) and traditional healers in the 6 health regions of the country. Table 1

indicates the number of various types of health facilities existed in the country in 2006.

Table 1: Distribution of Health Facilities by type and region in The

Gambia (2006)

Regions Public Health Facilities Private/NGO Health

Facilities

Hospitals Major Health

Centre

(District

Hospitals)

Minor

Health

Centres

Hospitals Health

Centres

Western 1 1 5 0 4

North Bank

West

0 1 3 0 1

North Bank

East

1 0 5 0 1

Lower River 0 1 3 0 0

Central River 1 1 7 0 2

Upper River 0 1 6 0 2

KMC 0 1 2 8 1

BCC 1 0 0 0 0

Total 4 6 31 8 11

Source: DOHSW [HMIS 2006]

Table 1 shows the distribution of health facilities in The Gambia by region and type.


30

The Public Health Facilities are government owned. The rest are NGOs, Private sector

and communities owned and managed.

Public sector

Village Health Services (Community Health Posts)

The lowest level for health service provision is the community health post. This provides

the very basic minimum health package to the village. The service providers are the

Village Health Workers with very minimal training and Traditional Birth Attendants with

limited additional training. The village health provider provides treatment for non-

complicated malaria, diarrhoea, minor injuries, worm infestation and stomach pain. He

charges D0.75 for children and D2.00 for adults.

The village health services are complemented by the Reproductive and Child Health

(RCH) monitoring visits from the health centres. The RCH package includes: antenatal

care, child immunization, weight monitoring and limited treatment for sick children.

Minor Health Centre

The minor health centre is the unit for the delivery of basic health services. The national

standard is 15,000 population for a minor health centre. The minor health centre is meant

to provide up to 70 percent of the Basic Health Care Package needs of the population.

The minor health centre coverage for the rural community is not above 65 per cent, for

the Greater Banjul Area it is below 15 percent.

Major Health Centres (District Hospitals)

The major health centres have a bed capacity of about 100. They serve as the referral

health facilities for minor health centres for such services like, obstetric emergencies,

essential surgical services, and further medical care. Major health centres also serve as

blood transfusion points for the area. The national standard is 200,000 population for a

major health centre and coverage is about 100 percent.

General Hospital

The general hospitals are the regional referral points. They have bigger bed capacities of

up to 250 beds and are to provide additional services not available at the regional hospital

level.

Teaching and Specialist Hospital

This is the most advanced referral health facility in The Gambia. Conditions that cannot

be handled at this health facility have to be referred overseas, the nearest being in

Senegal.


31

Considerable progress has been made in the areas of: EPI Coverage, expansion of health

facilities and in recruitment of trained health personnel. Success has been registered in

the implementation of the Baby Friendly Community Initiative and the Bamako

Initiative.

Also, relevant policy documents were developed including that of Nutrition, Drug ,

Malaria, Reproductive and Child Health , Human Resource for Health , Maintenance ,

Mental Health , HIV/AIDS , Health Management Information System , National Blood

Transfusion , Information Technology , and others such as Traditional Medicine,

National Health Laboratory, Health Research, are at various stages of development.

Policy environment

There is a pressing need to enhance the delivery of quality health services in order to

reduce the high prevailing morbidity and mortality rates.

The need to review the current health policy has been influenced by the following factors:

To keep in pace with the Decentralization and Local Government Reforms which

emphasizes an integrated management of government services, including health to the

regions. The devolution of authority, responsibility and resources to the regions has to

be directed by the policy.

Proliferation of donor agencies each operating in their own way in the same health

care system. There is therefore urgent need for better co-ordination of donor

activities.

The declining, though still high, incidence of infectious diseases and the emergence

and re-emergence of non-communicable and communicable diseases needs

intensification of efforts in our service delivery packages.

Formulation of other sector policies impacting on the organization and the delivery of

health services.

The disparity in the demand and quality of services at different levels of health care.

Experience from the implementation of certain health projects/programmes like PHC,

BI and DRF to improve financing of health services.

2.4.3 Resource Generation

Health systems include a diverse group of organizations that produce health services

inputs, particularly human resources for health, medicines, physical facilities and

equipment, and knowledge [12]. According to Murray and Frenk [17:p.727], “this set of

organizations encompasses universities and other educational institutions, research

centres, and companies producing specific technologies such as pharmaceutical products,

devices and equipment”.


32

2.4.3.1 Human resources for health

Table 2 presents a distribution of health workers in ECOWAS in 2004. ECOWAS had a

total contingent of the following human resources for health: 45,426 physicians, 276,559

nurses, 3,014 midwives, 3,653 dentists, 10,727 pharmacists, 2,348 public and

environmental health workers, 125,891 community health workers, 5,700 laboratory

technicians, 11,981 Other health workers, and 29,464 Health management and support

workers [WHR2006]. Out of those total human resources, 156 (0.34%) physicians, 1,719

(0.62%) nurses, 162 midwives (5.37%), 43 (1.18%) dentists, 14 (0.45%) pharmacists, 33

(1.41%) public and environmental health workers, 968 community health workers

(0.77%), 99 (1.74%) laboratory technologist, 3 (0.03%) other health workers, and 391

(1.33%) health management and support workers were in the Republic of The Gambia.

The densities of doctors and nurses per 1000 population were higher than those of most

of the other ECOWAS.

Table 2: Distribution of health workers in ECOWAS in 2004

Physicians Nurses Midwives Dentists Pharmacists

Country Number

Density per 1000 Number




Density per 1000

Benin 311 0.04 5789 0.84 12 0.00 11 0.00

Burkina Faso 789 0.06 5518 0.41 1732 0.13 58 0.00 343 0.03

Cape Verde 231 0.49 410 0.87 11 0.02 43 0.09

Côte d'Ivoire 2081 0.12 10180 0.60 339 0.02 1015 0.06

The Gambia 156 0.11 1719 1.21 162 0.11 43 0.03 14 0.00

Ghana 3240 0.15 19707 0.92 393 0.02 1388 0.06

Guinea 987 0.11 4757 0.55 64 0.01 60 0.01 530 0.06

Guinea-Bissau 188 0.12 1037 0.67 35 0.02 22 0.01 40 0.03

Liberia 103 0.03 613 0.18 422 0.12 13 0.00 35 0.01

Mali 1053 0.08 6538 0.49 573 0.04 84 0.01 351 0.03

Niger 377 0.03 2716 0.22 21 0.00 15 0.00 20 0.00

Nigeria 34923 0.28 210306 1.70 2482 0.02 6344 0.05

Senegal 594 0.06 3287 0.32 97 0.01 85 0.01

Sierra Leone 168 0.03 1841 0.36 5 0.00 340 0.07

Togo 225 0.04 2141 0.43 5 0.00 19 0.00 134 0.03

SOURCE: WHO [WHR2006].

Table 2: Continued

Public and

environmental health workers

Community health workers

Lab technicians Other health

workers Health management and support workers

Country Number Density per 1000 Number




Density per 1000

Benin 178 0.03 88 0.01 477 0.07 128 0.02 3281 0.47

Burkina Faso 46 0.00 1291 0.10 424 0.03 975 0.07 325 0.02


33

Cape Verde 9 0.02 65 0.14 78 0.16 42 0.09 74 0.16

Côte d'Ivoire 155 0.01 1165 0.07 172 0.01 2107 0.12

The Gambia 33 0.02 968 0.68 99 0.07 3 0.00 391 0.27

Ghana 899 0.04 7132 0.33 19151 0.90

Guinea 135 0.02 93 0.01 268 0.03 17 0.00 511 0.06

Guinea-Bissau 13 0.01 4486 2.92 230 0.15 61 0.04 38 0.02

Liberia 150 0.04 142 0.04 218 0.06 540 0.15 518 0.15

Mali 231 0.02 1295 0.10 264 0.02 377 0.03 652 0.05

Niger 268 0.02 294 0.02 213 0.02 513 0.04

Nigeria 115761 0.91 690 0.01 1220 0.01

Senegal 705 0.07 66 0.01 704 0.07 564 0.05

Sierra Leone 136 0.03 1227 0.24 4 0.00

Togo 289 0.06 475 0.09 528 0.11 397 0.08 1335 0.27

2.4.3.2 Essential Medicines and Laboratory Services

The Central Medical Stores (CMS) is the main source of pharmaceuticals and other

medical supplies for the public sector. Its main depot was located at the Medical and

Health Headquarters in Banjul. Until recently when a new complex was opened in Kotu

in the Kanifing Municipal Area. It has distribution points in four out of the six regions.

Procurement is usually done on an annual basis. A number of private pharmaceutical

importers and wholesalers compliment the public provision.

Laboratory services within the public health system are limited and some times the

results are unreliable. More than 50% of public health facilities in the The Gambia are

without laboratory services, whilst private sector and NGO provision of laboratory

services are few. Although the private laboratories produce reliable results, the services

are not affordable and accessible to a vast majority of The Gambians.

The Gambia continues to depend on laboratories out side for a number of specialized

investigations.

2.5 Health Financing

Health financing has been defined as the raising or collection of revenue to pay for the

operation of the health system [16]. It has three functions: revenue collection from

various sources, pooling of funds and spreading of risks across larger population groups,

and allocation or use of funds to purchase services from public and private providers of

health care [12]. The objectives of health financing are to make funding available, ensure

choice of cost-effective interventions, set appropriate financial incentives for providers,

and ensure that all individuals have access to effective public health and personal health

care [17].

In the Republic of The Gambia, there are various sources of health sector funding.

Firstly, is government tax revenue, allocated by the Department of State for Finance and

Economic Affairs to various financing agents, e.g. Departments of Health, Education,

Defence, Interior and Foreign Affairs. Secondly, the households contribute to health

funding through direct out-of-pocket payments (OOPs) for health goods and services. For

the various charges see table 2 below. The OOPs do not go through any resource pooling


34

and risk-sharing mechanism. Thirdly, some employers provide medical cover for their

employees, either through self-operated health clinics (e.g. GPA Clinic) or paying

premiums into health insurance schemes. Fourthly, the international donors (e.g. bilateral

and multi-lateral agencies, Global Fund for AIDS, Tuberculosis and Malaria, GAVI) also

contribute to health funding in the country. To a lesser extent the Local Government

Authorities also contribute to health financing. Chapter 4 provides more details regarding

the amounts of money actually spent from the different sources.


35

Table 2 Public health services user fees

Services Gambians Non-Gambians

0-

5yrs

6-

15yrs

Adult 0-5yrs 6-15yrs Adult

Out-patient

Hospital

0 1.00 5.00 0 1.00 50.00

Out-patient

Health

Centre

0 1.00 5.00 0 1.00 10.00

In-patient

(per week)

Hospital

0 0 50.00 0 0 600

In-patient

(per week)

Health

Centre

0 0 25.00 72.00

Deliveries

Hospital

25 600

Deliveries

Health

Centre

25 36

Minor

Surgery

Hospital

0 0 25 600

Minor

Surgery

Health

Centre

0 0 25 150

Major

Surgery

0 0 50 1500

Lab.

Services

Category iv

0 0 20 600

X-ray 0 0 50 300

Dental 0 0 25

MCH Clinic

Registration

5 75

Mortuary 25 150


36

cold room

per day

References

1. Drug Revolving Fund Procedures Manual 1988

2. The Gambia Primary Health Care Programme 1980/85

3. Bamako Initiative Procedure Manual 2000

4. Health Services user fee revised list 2002


37

CHAPTER 3: METHODS AND SOURCES OF DATA

3.1 NHA Conceptual Framework

According to the WHO guide to producing NHA [WHO 2003], international experience

in the development and use of health accounts suggests a number of useful dimensions.

Financing sources: Institutions or entities that provide funds used in the

health system by financing agents. These financing sources consist of the

Government (DOSFEA), Local Government Areas (LGA), parastatals (Public

enterprises), private employers, households and donors (rest-of-the-world).

Financing agents: Institutions or entities that channel funds provided by

financing sources and use those funds to pay for, or purchase, the activities

inside the health accounts boundary (i.e. all activities whose primary purpose

is to promote, restore or maintain health). These financing agents include:

DoSH, DoSE, DoSD, DoSI, DOSFA , NAS, NaNA, Parastatals, private

insurance, households, NGOs, and private firms. The sum of the funds

channelled through all the financing agents should be equal to the total

amount of money provided by the financing sources.

Providers: Entities that receive money in exchange for or in anticipation of

producing the activities inside the health accounts boundary. Examples of

providers include: Teaching hospital, general hospitals, private

hospitals/clinics, Government Health Centres (Basic Health Services), NGO

health centres, pharmacies, opticians, pharmaceutical companies,

administration of public health, provision of public health services, other

(private insurance), all other providers of health administration, insurance

firms, research institutions, education and training institutions, NGO health

related activities, and rest of the world. Ideally, the sum of the funds received

by all the providers should be equal to the total amount of money provided by

the financing agents.

Functions: Services of curative care, services of rehabilitative care, ancillary

services to medical care, medical goods dispensed to out-patients, prevention

and public health services, health administration and health insurance, and

health related functions. The latter includes: capital formation of health care

provider institutions, maintenance service management, education and

training of health personnel, research and development in health, traditional

medicine development, and provision of overseas treatment.

Resource/input costs: The factors or inputs used by providers or financing

agents to produce the goods and services consumed or the activities conducted

in the health system. The resource/input cost categories would include:

personnel (remuneration, employers contribution employees insurance, other

conditions); goods and services (travel and subsistence expenses, drugs and

medical supplies, material supplies, transport, utilities, maintenance, property

rental and related charges; education and training (research and development,

nutritional surveillance, water and sanitation, other services and expenses);


38

subsidies and other current transfers (membership fees and subscription,

government organization, individuals and non profit, public and departmental

enterprise); and development expenditure (furniture and office equipment;

vehicles, operational equipment, machinery).

Beneficiaries: The people who receive those health goods and services or

benefit from those activities (beneficiaries can be categorized in many

different ways, including their age and sex, their socio-economic status, their

health status, and their location).

Figure 3.1 shows how NHA tracks financial flows of health resources and its links to

health policy issues and policy instruments.

Figure 3.1 How NHA Presents Financing Flows and links to Health Policy Decisions

Financing Sources

Financing Agents

Providers

Inputs & Functions

How are resources

mobilized? Who pays?

Who finances?

Under what scheme?

How are resources

managed? What is the financing

structure?

What pooling arrangements?

What payment and purchasing

arrangements?

Who provides what

services? Under what financing

arrangements?

With what inputs?

Who benefits? Who receives what?

How are resources

distributed?

Some Key Policy Issues Flow of Resources in Health Financing Some Key Health

Policy Instruments

Resource mobilization/

financing strategies

Pooling arrangements

Cost recovery

Regulation of payers

Financial incentives

Subsidies

Resource allocation

Regulation of providers

Targeting

Redistributive policies

Outcome evaluation


39

Each of the NHA tables displays some facet of health expenditure cross-tabulated by two

of the abovementioned dimensions. By convention, the origin of the funds dimension is

shown as columns and the use dimension is shown as rows. Following this convention,

each cell in the table show the amount of resources used for the row “i” of “use” from the

column category “j” of “origin” (“spent by j on I”) as illustrated in Table 3.1 above. The

three critical dimensions for accurate estimation of total health spending include health

financing agents, providers, and functions. The NHA tables that cross-tabulate these

dimensions include:

Health expenditure by financing source and type of financing agent (FS x

FA). This table highlights resource mobilization patterns in the health system.

It addresses the question “where does the money come from” by showing the

financing sources that contribute to each financing agent. It also shows how

prominent a role each source plays in the financing of each financing agent

and in the total spending overall.

Health expenditure by the type of financing agent and type of provider (FA x

P). This table describes how funds are distributed across different types of

providers, e.g., what share of total spending goes to referral and district

hospitals relative to primary/hospitals, clinics, health posts, outreach stations.

Health expenditure by provider and type of function (P x F). This table shows

how expenditures on different health functions are channelled through the

various types of providers. It provides useful perspective on the contribution

of different types of providers to the total spending on specific types of

services, e.g. public health programmes vis-à-vis secondary and tertiary

curative care.

Health expenditure by type of financing agent and type of function (FA x F).

This table shows who finances what types of services in the health system. It

can also highlight the relative emphasis of public and private financing agents

with respect to the various public health functions.

Cost of resources used to produce health goods and services. This table

illustrates the share of national health expenditure contributed by the value of

labour, pharmaceutical supplies, equipment and buildings, etc. This table

provides a basis for the analysis of the efficiency of production and resource

use.

Health expenditure by age and sex of the population. This table highlights the

distribution of health goods and services among age/sex groups in the

population, e.g. children, elderly, women of childbearing age.

Health expenditure by socio-economic status of the population. This table can

be used to answer the question “Does the composition of financing one’s

health care vary with one’s position in society?” Using data from household

income and expenditure surveys to aggregate the population into quintiles,

health accounts may be used to assess how well specific payers target

vulnerable groups and what share of the burden of spending is being borne by

different groups.


40

Health expenditure by geographic region (e.g. districts).

In the current study, it was possible to obtain expenditure data disaggregated by financing

sources, agents, providers, and functions and resource costs. (See Annex Tables 3.1a,

3.1b, 3.1c,…,3.1n).

3.2 Field Work Methodology

The Gambia NHA study relied on primary and secondary data. A wide range of data and

information was collated from various government publications and other sources. In

addition, data was collected from the following sources:

Government Departments: DoSFEA, DoSH, DoSE, DoSD, DoSI, DOSFA , LGA;

National AIDS Secretariat (NAS);

NaNA;

Parastatals;

Employers;

Insurance;

Non-Governmental Organisations (NGOs involved in health);

Donors (both bilateral and multilateral); and

Health care providers: Public, Private for-profit/ not-for-profit Facilities.

To facilitate the data collection process a National Health Account sensitization

workshop was held in September 2006. Potential NHA stakeholders were invited to a one

day workshop where they were introduced to NHA, the usefulness of NHA and its

relevance to The Gambia.

3.2.1 Sampling Approaches: Household health expenditure and utilization

survey

To determine household expenditure on health for this exercise, two sources were

utilized. In view of the high cost involved in conducting large scale household surveys, it

was decided to largely utilize data from the 2003 Integrated Household Survey (IHS) to

arrive at estimates of household expenditure on health and also to conduct a small scale

household survey in 2006 to address issues of health seeking behaviour which were

largely not covered by the IHS.

Integrated Household Survey (IHS)

The primary sampling unit for the IHS were enumeration areas (EA) which were drawn

from the 2003 Population and Housing Census demarcated EAs. For this survey 240 EAs

were selected consisting of 4 sub-samples of 60 EAs surveyed at each quarter. A sample

of 4800 households was drawn across all Local Government Areas LGA) with the

probability of selecting a household in an LGA proportional to the size of the LGA, in

terms of population. The sampling was done in two levels: enumeration areas (EAs) and

households. EAs were stratified by rural-urban areas (12 strata + Banjul and Kanifing).


41

Training of field workers lasted a week during which both enumerators and supervisors

were trained on how to complete the questionnaires. Since the questionnaires were in

English and not translated to any of the local languages, it was decide to train, first, in

English and later on attempt a translation of all the questions in the three major local

languages (Mandinka, Fula and Wollof). As the majority of Gambians could not

complete the questionnaires in English the translation exercise was aimed at ensuring a

common understanding of the concepts in the questionnaires and a uniform translation of

the questions.

Enumerators despatched to the field during the data collection began with a household

listing exercise. The listed households served as a sampling frame for the selection of

households for the detail interviews. Households in protected areas were not surveyed

(mostly military, police and prison camps etc.). Six teams made of 6 supervisors and 30

enumerators each were assigned to the different geographical locations. Each enumerator

covered 40 households in two EAs by quarter. Among these 40 households, 20

households were selected (10 per EA) for whom the daily diaries were administered. In

total the enumerators stayed 6 weeks in each EA. The data collection started in January

2003 and ended in May 2004.

For the purpose of collecting data on household expenditure daily diaries were kept for

the selected households by enumerators of the IHS. These diaries were used to keep

records of household expenditure for a period of a month. The data presented in this

report on household expenditure on health was derived from data compiled from these

diaries.

As is common to household surveys, particularly, income and expenditure surveys

reporting is often prone to varying degrees of errors. A limitation identified with the IHS

is the under-reporting of household expenditure attributed to respondent fatigue due to

the long duration of the completion of the daily diaries. This under-reporting of

expenditure might have affected the expenditure figure presented in this report.

Another limitation related to the IHS data is the fact that since the survey was not

specifically designed for the National Health Accounts, the data was not structured to fit

in the NHA tables. For example, to determine how much of health expenditure went to

out-patient services and how much to in-patient services, data on health seeking

behaviour had to be used as a proxy to disaggregate expenditure on health. As health

expenditure was also not disaggregated by service provider, data on health seeking

behaviour had to be used to disaggregate expenditure.

National Health Accounts (NHA) Household Health Expenditure and Utilization

Survey, 2006

The Household Health Expenditure and Utilization Survey conducted in 2006 targeted

1000 households distributed across LGAs. Probability of selecting a household from each

of the LGAs was proportional to the population size of the LGA. For the purpose of


42

selecting the sample EA the country was stratified into urban and rural. For the 38

enumeration areas selected for the survey 18 were in urban areas and the remaining 20 in

rural areas. As was the case with the IHS the EAs in the 2003 Population and Housing

Census were used as the sampling frame. The second stage of the sampling involved the

selection of households for the detail interviews. Upon the updating of the households in

the selected enumeration areas, enumerators selected 25-29 households in each of the

selected households. This selection process involved the use of random number table to

avoid any bias in the selection.

Enumerators were trained on the completion of the questionnaires for an initial period of

3 days. Following this training enumerators and supervisors were despatched to the field

to pre-test the questionnaires for a day. The following day the teams returned to the

training hall for a review of the completed questionnaires and also to share experiences of

the pre-test. Supervisors who reviewed the completed questionnaires commented on them

and identified errors and misconception. During mock interviewers in the course of the

training, the questions were translated into the local languages to enhance interviewers

understanding of the questionnaires.

The questionnaires were designed to collect data on the following areas;

Demographic characteristics

Education

Employment and remuneration of households in the last 12 months

Health Status of members of the household in the last four weeks

Smoking Habits

Presence of chronic illness

Health seeking behaviour

In-patient admission in the last one year; reasons for admission and duration for

admission

Utilization of out-patient and other health related services in past four weeks

Reasons for seeking health care:

Type of the health provider/facility visited and reasons for the choice

Cost of the services received

Availability of prescribed drugs

Perception on the quality of service received

Time and cost of transportation to health provider

Routine health expenses in the last four weeks

Type of the health provider/facility admitted in and reasons for the choice

Reasons for and cost of admission

source of funds for the services received including drugs

Travel time to health facility and cost of transportation (admissions)

Perception of the quality of services at the inpatient facility

Time and cost of transportation to inpatient health provider

Mortality of household members in the last 12 months

Did the deceased consume health services before he/she died?

How much did the household spend on treatment for the deceased?


43

Access to health insurance

HOUSING CONDITIONS

Construction material (walls, floor and roof)

Source of lighting

Cooking facility and fuel

Toilet facility

Source of drinking water

Tenure of accommodation of households

Notwithstanding the array of topics covered in this survey, for the purpose of the NHA,

data was compiled on selected areas which have been presented in this report. Topics

included in this report mainly relate to health seeking behaviour. Further analysis of the

results of this survey could be the subject of further research.

Data Collection, Processing and Analysis

For the data collection 4 teams, each consisting a supervisor and five enumerators, were

constituted. Two officials one from the Central Statistics Department and one from DPI

coordinated the data collection. The data collection lasted 20 days. Following the

completion of the data collection a coding and editing exercise was undertaken after

which using data was entered using the CSPro software. After the entry the data was

cleaned of errors and the tables generated.

3.2.2 Sampling Frame for organizations survey

Seventy-three (73) private firms (companies), 21 private/NGO health facilities, 37 NGOs,

17 donors and 4 insurance companies were identified for the survey. Table 3.1 shows the

numbers and percentages of different organizations contacted and those that responded.

In general the response was good.

Table 3.1: Breakdown of data sources contacted and respondents

Total number

contacted

Number of

Responded

Percentage

collected

Health Care Providers

Public 41 41 100

Private/NGO 21 18 86

Sources

Govt Department 5 5 100

LGAs 8 7 87.5

Donor 17 14 82

NGO 37 20 54

Insurance 4 1 25


44

Employer/Private firms 73 70 96

Households (2006) 1000 1000 100

3.2.2 Employer Survey

The lists of companies and other employers obtained from Registrar General’s

Department, The Gambia Chamber of Commerce and were compared to determine the

sample size and the cut off point (only organisations with more than (20) twenty

employees). All identified were included in the survey. The data collection was done by

Account Technicians provided by the Directorate of National Treasury. The NHA

Technical Committee provided the supervision of the data collection.

The employer survey instrument contained questions on: general information (firm name

and ownership, principal activity, number of full-and part-time employees); whether the

firm provided medical insurance in the year 2002 to 2004; number of employees covered

by insurance; whether the insurance covered dependents; amount of premiums paid by

the firm; amount employees contribute to private health insurance; types of health

services covered by insurance; amount the firm reimbursed employees for medical

expenses incurred; types of health care services (e.g. inpatient, outpatient, drugs) the firm

reimbursed for; amount spent to reimburse for services purchased at private and public

health care facilities; whether the firm provided on-site health services for employees;

amount spent to provide on-site health services (e.g. expenditure on salaries, drugs and

medical supplies, equipment etc); amount of subsidies the government or any other non-

governmental organization make in support of their health facilities; number of health

care facilities owned by the firm and types of services provided; amounts of money

employees pay for services and/or medication offered in these facilities; firm’s annual

expenditure on various public health sector services (See Employer questionnaires in the

Annex section).

3.2.3 Non-Governmental Organizations Survey

The lists of NGOs was obtained from the Registrar General, NGO Affairs Agency of the

Department of Local Government were used to determine the sample size and identified

NGOs involved in health. The data collection was done by Account Technicians provided


45

by the Directorate of National Treasury. The NHA Technical Committee provided the

supervision of the data collection.

The non-governmental organization survey questionnaire gathered information on: NGO

identity; types of health services or activities supported; amount of revenue obtained by

the NGO from cost sharing/user fees, grants from government, and foreign assistance;

types and market value of goods received in kind; organizations that the NGO provided

with funds for health activities and the amounts in 2002 to 2004; and details on the

amount spent on various health service functions (see NGO Questionnaires in Annex..).

3.2.4 Development partners/ Donor survey

The list of donors was provided by the Department of State for Foreign Affairs and all

were contacted. The data collection was done by the NHA Technical Committee.

The donor survey instrument contained items/questions on: identification information

(name and type of donor and contacts); type of health care related activities

provided/supported (financially and/or technically) and dollar value of that support;

grants/loans to other institutions/organization(s) that provide health care or health related

activities. Each donor was also asked to indicate the amount that it spent in the year 2002

to 2004 to support your health or health related activities within its own organization, e.g.

for programme administration, inpatient care, outpatient care, rehabilitative care, drugs

and medical supplies, public health administration of health services, administration of

public health programmes, education and training of health personnel, research, IEC, and

environmental health, among others (See Annex…). Lastly, the donor was asked to

indicate the amount that his/her organization spent in the year 2002 to 2004 to support

her activities (i.e. administration) in The Gambia as well as the amount spent on technical

assistance not included in the earlier amounts, e.g. administration/programme support,

technical assistance, in-kind support, etc (see Donor Questionnaires in Annex…).

3.2.5 Insurance firms survey

The list of insurance companies was obtained from Registrar General Department and all

were contacted. The data collection was done by Account Technicians provided by the

Directorate of National Treasury. The NHA Technical Committee provided the

supervision of the data collection.

The health insurance survey instrument had questions on: general information (e.g. type

of insurance company); type of insurance policies (e.g. health insurance, life assurance,

personal accident, car insurance, education insurance); whether health insurance is

included as part of other insurance, total premiums and health expenses; organisation’s

total revenues (group/company, individual/family); whether the insurance company

offered health insurance coverage for hospital inpatient care, out patient care, maternity


46

/antenatal care services, HIV/AIDs services, TB care services, evacuation to other

country and treatment in public, private, mission, and/or own facility; number of

subscribers to company/employer, group, and individual/family health insurance cover; a

breakdown of the amount of payment/reimbursement made according to various health

service providers; total revenue from own overall business in the period; own total

expenditure on health from overall business for the period; and types of services contract

out to hospitals/ nursing homes and medical expenses reimbursed (see Insurance

Questionnaires in Annex…).

3.2.6 Private practitioners

The Technical Committee had to use their knowledge of the health system to identify the

private practitioners as there was no up to date registration of these institutions. The data

collection was done by Account Technicians provided by the Directorate of National

Treasury. The NHA Technical Committee provided the supervision of the data collection

The health provider survey questionnaires contained items on: provider identification

(name, type and ownership); types and amounts of revenue for health care and related activities/functions from private insurance reimbursement, employer reimbursement, direct user fees, community funds (at public health centres and dispensaries only), individual contributions/premiums, employer/group contributions, volunteer labour, cash and in-kind grants from government, and foreign/NGO assistance-grants/donations/loans; amounts given to other organizations to provide health related services; amounts of money that the

provider spent on various health care functions (see Private Questionnaires in Annex…).

3.2.7 Government Departments/Parastatals Survey

The NHA Technical Committee encountered no difficulty to identify the departments and

parastatals as they were few. All the concerned departments and parastatals were

contacted. The data collection was done by Account Technicians provided by the

Directorate of National Treasury. The NHA Technical Committee provided the

supervision of the data collection

The respondents were asked to indicate the amount of revenue obtained by his/her

institution in 2002, 2003 and 2004 from Cost Sharing Schemes/User fees, Transfers from

Central Government (DoSFEA) in cash and kind, and Foreign assistance (loans, grants

and donations). S/he was also asked to indicate the amount her/his institution spent on the

following activities in year 2002 to 2004, namely: inpatient care services, outpatient care

services, rehabilitative care services, drugs and medical supplies, public health,

administration of health services, administration of public health programs, education and

training of health personnel, research, IEC, environmental health.

The questionnaire also asked for the actual expenditure on the following inputs (in the

years 2002 to 2004) on personnel emoluments (remuneration, employer contribution to

employees health insurance), goods and services (travel and subsistence expenses, drugs

and medical supplies, material supplies, transport, utilities, maintenance, property rental


47

and related charges, property rental and development), education and training (research

and development, nutritional surveillance, water and sanitation), subsidies and other

current transfers (membership fees and subscription, government organization,

individuals and non-profit, public and departmental enterprise), and development

expenditure (furniture and office equipment, vehicles, operational equipment and

machinery) (See Departments questionnaires Annex …).

The Local Government Area survey instrument contained questions on: general

information; amount of revenue obtained from general taxes (utility taxes), grants (cash

and kind) from government, foreign assistance (loans, grants/donations); amount spent on

the following activities Inpatient care services, Adopt and maintain hospital ward,

Outpatient care services, Rehabilitative care services, Drugs and medical supplies, Public

health administration and services, education and training of health personnel, research,

IEC, and environmental health; amounts spent on acquisition of health inputs.

The other departments included DoSFEA, DoSFA, DOSE, DOSD, and DOSI.

The survey instrument for other Departments of State gathered general information;

amount of revenue (from cost sharing schemes/user fees, transfers from DoSFEA, foreign

assistance) obtained by the Department of State in year 2002 to 2004; amount the

department spent on inpatient services, outpatient services, drugs and medical supplies,

public health administration and health services, education and training of health

personnel, research, IEC, and environmental information, among others; and actual

expenditure on the inputs in the year 2002 to 2004.

3.3 Data analysis

After checking for completeness of the questionnaires filled by various organizations, the

data were entered, cleaned and preliminary analysis done using Excel software. This data

was then entered into dummy matrix tables and analyzed using Excel software. The

matrices were built in accordance to the International Classification of NHA to facilitate

international comparison, but customised to the local situation. NHA uses many matrix

tables for analysis, but due to paucity of data, a decision was made to attempt completing

only the following four main matrices:

Financing Sources (FS) to Financing Agent (FA): (FS X FA)

Financing Agent (FA) to Providers (P): (FA X P)

Providers (P) to Inputs (RC): (P X RC)

Financing Agents (FA) to Health Functions (HF): (HF X FA)

3.4 Limitations of the NHA study

a) In the 2006 survey household sample size was very small

b) Poor response from the Bilateral donors and private health care providers

c) Expenditure data from some respondents was not in the NHA questionnaire

format


48

d) The IHS questionnaire was not designed to fulfil NHA

e) Pledged Funding support from other partners was never made available.

f) NAS could only provide the 2004 data

g) Complete expenditure on CISP (Italian Project) was not available

h) Expenditure on utility and telecommunication for DOSH and RVTH were not

available

i) The health insurance data was available in aggregate form and from only one

provider

References

1. WHO NHA Generic questionnaires

2. Kenyan NHA questionnaires

3. Namibia NHA questionnaires

4. Guide to developing NHA (WHO, WB and USAID)


49

CHAPTER 4: MAIN NHA FINDINGS

4.1 Health Financing by Sources

4.1.1 Total health expenditure and per capita total health expenditure

Figure 4.1a provides total health expenditure (THE) by various sources, including the

Department of State for Finance and Economic Affairs (DoSFEA), Local Government

Authorities (LGA), Parastatal Funds, private employer funds, household funds, and the

rest of the world (Donors). The total health expenditure (THE) was D1,185,223,103 in

2002; D1,395,958,522 in 2003; and D1,682,323,673 in 2004. Total expenditure on health

as a percentage of GDP in The Gambia was 16.1% in 2002, 13.9% in 2003 and 14.9% in

2004 (see Appendix Table 1 and 3).1

The per capita THE was derived by dividing THE for each year by respective population

(1 324 393 people in year 2002, 1 360 681 people in year 2003 and 1 397 964 people in

year 2004) estimates from The Gambia Bureau of Statistics (GBS). That yielded a per

capita THE of D895 in 2002, D1026 in 2003 and D1203 in 2004. Thus, there was 41.9%

nominal growth in the per capita THE between years 2002 and 2004.

-200,000,000400,000,000600,000,000800,000,000

1,000,000,0001,200,000,000

Da

las

i

DoS

FEA.

LGA

Parastatals

Private em

ployers

Household

Donors

Sources of funds

Figure 4.1a: Health expenditure in Gambia by sources

Year2002 Year2003 Year2004

Figure 4.1b shows the per capita THE for the 15 ECOWAS countries [WHR2006].

During the three years, per capita THE for The Gambia was higher than that of Guinea-

Bissau, Liberia, Niger, Sierra Leone and Togo, but lower than that of the remaining

ECOWAS countries.

1 The gross domestic product (GDP) in The Gambia was D7,364,000,000 in year 2002; D10,025,934,179

in 2003; and 12,042,000,000 in 2004 (DoSFEA, 2007).


50

Figure 4.1b: Per capita total health expenditure

(THE) for ECOWAS countries

20 40 60 80 100 120

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Per capita THE (US$)


4.1.1 Total health expenditure by source There are broadly four sources of health financing in the Gambia, namely:

public/government, household out-of-pocket payments (OOPs), private employers and

donors (rest of the world). This subsection provides a distribution THE by each of those

sources. Figure 4.1C shows a breakdown of heath financing by source in The Gambia for

year 2002. Out of the THE of D1,185,223,103 in 2002, 70.2% came from donors, 17.5%

from government/public, 12.2% from household OOPs, and 0.1% from private

employers.


51

Figure 4.1C: Health financing by source


Donors

70% Household

OOPs

12%

Private

employer

0%

Government/

public

18%

Figure 4.1D presents an analysis of heath financing by source in The Gambia for year

2003. During that year THE was D1,395,958,522, of which 67.6% were from donors,

21.6% from government/public, 10.7% from household OOPs and 0.1% from private

employers.

Figure 4.1D: Health financing by source

in Gambia (Year 2003)

Private

employer

0%

Government/

public

22%

Donors

67%

Household

11%


52

Figure 4.1E shows an itemization of heath financing by source in The Gambia for year

2004. In 2004 THE was D1,682,323,673, of which 65.9% originated from donors, 24.6%

from government/public, 9.2% from household OOPs, and 0.7% from private employer

funds.

Figure 4.1E: Health financing by source


Household

OOPs

9%

Private

employer

1%

Government/

public

24%

Donors

66%

It is clear that majority of health funds came from the rest of the world (donors).

However, there is evidence that the donor and household funding as a percentage of THE

decreased slightly between years 2002 and 2004. The funding from private employers

remained fairly constant.

4.1.2 Government Health Expenditure on Health

General government expenditure on health (GGHE) includes health expenditure at all

levels (and ministries) of government, including the expenditure of public corporations.

In the GGHE consists of funding from DoSFEA, LGA and parastatals. The total GGHE

was D207,995,042.6 (18% of THE) in year 2002; D301,763,059 (22% of THE) in 2003;

and D409,165,197.14 (24% of THE) in 2004. During the three years majority of GGHE

came from DoSFEA (93%), parastatals (6%), and LGA (1%). Approximately 34.2%,

24.1% and 40.4% of the GGHE was from external loans in years 2002, 2003 and 2004

respectively.

The per capita GGHE for The Gambia was D691 in 2002, D812 in 2003 and D975 in

2004. Figure 4.1F portrays the per capita government health expenditure on health in the

ECOWAS. The WHO Commission for Macroeconomics and Health (CMH)

recommended that governments should spend at least US$34 per person per year on


53

health. During the years under consideration, it was only Cape Verde who met the CMH

recommendation. The per capita GGHE was less than US$10 in Cote D’Ivoire, The

Gambia, Guinea, Guinea-Bissau, Liberia, Niger, Nigeria, Sierra Leone and Togo.

Figure 4.1F: Per capita government health

expenditure on health in ECOWAS

10 20 30 40 50 60 70 80

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Per capita expenditure on health (US$)


The Gambian government expenditure on health as a percentage of total government

expenditure was 11.47% in year 2002, 13.03% in 2003 and 10.86% in 2004. Figure 4.1G

shows the GGHE as a percentage of total government expenditure. In the Abuja

Declaration, Heads of States and Governments of the African Union set a target of

allocating at least 15% of their annual budget to the improvement of the health sector

(AU 2001). In 2004 Cote D’Ivoire, Guinea, Guinea-Bissau, and Nigeria spent less than

5% of their total government expenditure on health. According to the World Health

Report (WHO 2006) it was only Burkina Faso and Liberia that had met the Heads of

State target as at the end of year 2004. This means the 13 ECOWAS countries that spent


54

less than 15% of their national budgets on health will need to take appropriate steps to

honour the commitment made by their respective Heads of State.

4.1G: Government expenditure on health as % of

total government expenditure

0 5 10 15 20 25

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Percent


Social security spending on health: National health accounts guidelines define social

security schemes as “social insurance schemes covering the community as a whole or

large sections of the community that are imposed and controlled by government units.

They generally involve compulsory contributions by employees or employers or both,

and the terms on which benefits are paid to recipients are determined by government

units. The schemes cover a wide variety of programmes, providing benefits in cash or in

kind for old age, invalidity or death, survivors, sickness and maternity, work injury,

unemployment, family allowance, health care, etc. There is usually no link between the

amount of the contribution paid by an individual and the risk to which that individual is

exposed” [WHO 2003, p.302].

In The Gambia, Benin, Cote D’Ivoire, Ghana, Liberia, Mali, Niger, Nigeria, and Sierra

Leone social security did not contribute to the general government expenditure on health.


55

In the remaining six ECOWAS countries social security contributed to health spending.

Social security spending on health constituted over 14% of GGEH in Cape Verde,

Senegal and Togo.

Figure 4.1H: Social security expenditure on health as % of

general government expenditure on health

0 10 20 30 40

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Percent


4.1.2 Private expenditure on health

Private health financing includes spending by private insurance, private households’ out-

of-pocket payment (Oops), non-profit institutions (other than social insurance), and

private firms and employers (WHO 2003). Private financing for health comes from

personal out-of-pocket payments made directly to various providers (e.g. public health

facilities, private practitioners, private pharmacists, and traditional healers), prepayments


56

to private insurance and indirect payments for health services by employers (firms) and

local charitable groups.

The total private health expenditure on health in The Gambia was D145,545,671 in year

2002; D150,610,801; and D165,222,560. Private spending constituted 12.3% of the THE

in 2002, 10.8% in 2003 and 9.8% in The Gambia in 2004.2 These figures are far much

lower than the estimates contained in the World Health Report 2006. Private expenditure

on health as a percentage of THE has not changed much over the three years. This source

consists of primarily Oops and private health insurance (prepaid plans). The per capita

private health expenditure was D128.4 in year 2002, D145.5 in 2003 and D156.7 in 2004.

Figure 4.2I shows private spending on health as a percentage of the total expenditure on

health for ECOWAS countries. This figure was generated from the NHA estimated

contained in the World Heath Report 2006. In that report the private health spending for

the The Gambia appears to have been over estimated.

4.1I: Private expenditure on health as % of total

expenditure on health in ECOWAS

0 20 40 60 80 100

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Percent


2 These figures are far much lower than the estimates contained in the World Health Report 2006.


57

In 2002, out of a total private health expenditure in The Gambia of D145545671, 99.46%

came from household funds and 0.54% from private employers. In 2003 the private

health expenditure on health was Dalasis 150,610,801 – 99.18% from household funds

and 0.82% from private employers. In 2004 the private health expenditure on health was

Dalasis 165,222,560 – 93.32% from household funds and 6.68% from private employers.

Out-of-pocket payments (OOPs): In 2002 household OOPs constituted 99.46% of the

private health expenditure; 99.18% in 2003; and 93.32% in 2004. It is evident that the

households, through direct out-of-pocket expenditures at the point of service

consumption, make a significant contribution to the private health expenditure in the The

Gambia. Figure 4.2J shows OOPs on health as a percentage of private expenditure on

health for ECOWAS countries. Except for Ghana, household OOPs accounted for over

80% of private health expenditure on health.


58

Figure 4.1J: Out-of-pocket expenditure as % of

private health expenditure on health

0 20 40 60 80 100 120

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Percent


Private prepaid plans: Figure 4.1K presents private prepaid plans (which are voluntary

in nature) as a percentage of private expenditure on health. Apparently, The Gambia,

Guinea, Guinea-Bissau, Liberia and Sierra Leone health systems did not receive any

funding from prepaid plans. Contrastingly, the private prepaid plans accounted for more

than 10% of private expenditure on health in Cote D’Ivoire and Niger.


59

4.1K: Private prepaid plans as % of private

expenditure on health

0 2 4 6 8 10 12 14

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Percent


External financing: External resources for health consist of mainly of grants from

multilateral and bilateral aid donors and international nongovernmental organisations

(e.g. Global Fund for AIDS, Tuberculosis and Malaria). Donors made a contribution of

Dalasis 831,682,389 to health in 2002 (70.2%); Dalasis 943,584,662 (67.6%) in 2003;

and Dalasis 1,107,935,916 (65.9%) in 2004. Thus, donors are a majority contributor to

the THE in The Gambia.

Figure 4.1L shows external resources for health as a percentage of total expenditure on

health. The figure has been generated from the World Health Report 2006. Once again it

is clear that donor contribution to THE in The Gambia was significantly higher than

reported in the World Health Report. Donors contribute more than 20% of THE in 8

(53%) ECOWAS countries.


60

Figure 4.1L: External resources for health

as % of total expenditure on health

0 10 20 30 40

Benin

Burkina Faso

Cape Verde

Côte d'Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

Liberia

Mali

Niger

Nigeria

Senegal

Sierra Leone

Togo

Percent


4.2 Health Financing by Financing Agents

There were four categories of financing agents, namely: government (public), private,

and external. Figure 4.2a depicts the distribution of funds between public, private and

external financing agents (see also Appendix Table 2). Clearly the public financing agents

absorbed the majority of health financing over the three year period. It is also vivid that

the funds going into the public health financing agents grew consistently over the period

under consideration. The funding to the private financing agents grew by a small margin.


61

-

200,000,000

400,000,000

600,000,000

800,000,000

1,000,000,000

1,200,000,000

1,400,000,000

Dala

si


Figure 4.2a: Funds received by public, private &

external financing agents

Public financing agents Private agents Rest of the world

4.2.1 Public health financing agents

The public financing agents consisted of DoSH, DoSE, DoSD, DoSI, DoSFA, LGA,

National AIDS Secretariat, NaNA and parastatals. In 2002 the public financing agents

received Dalasi 915,547,949.8; of which 96.03% went to DOSH, 0.13% to DOSE, 0.00%

to DoSD, 0.05% to DoSI, 3.39% to DoSFA, 0.36% to LGA and 0.04% to NaNA (See

Figure 4.2b).

In 2003 the public financing agents received Dalasi 1,104,213,908.12; of which 96.70%

to DoSH, 0.12% to DoSE, 0.00% to DoSD, 0.04% to DoSI, 2.81% to DoSFA, 0.30% to LGA and

0.03% to NaNA (See Figure 4.2c).


62

Figure 4.2C: Gambia funding to public heath

financing agents in year 2003DoSE

D1,269,939

(0.115%)DoSD

D11,659

(0.001%)

DOSFA

D31,072,626

(2.814%)LGA

D3,282,207

(0.297%)

NaNA

D355,470

(0.032%)

DoSI

D416,616

(0.038%)

DoSH,

1,067,805,392 ,

(96.703%)

In 2004 the public financing agents received Dalasi 1,362,716,725.87; of which 88.59%

to DoSH, 0.16% to DoSE, 0.04% to DoSI, 2.81% to DoSFA, 0.32% to LGA, 8.55% to NAS, and

0.06% to NaNA (See Figure 4.2d). .


63

Figure 4.2D: Gambia funding to public health

financing agents in year 2004

DoSE

D2,114,524

(0.16%)

DoSI

D600,369

(0.04%)

LGA,

D4,392,987

(0.32%)

DOSFA

D31,072,626

(2.28%) NAS,

D116,513,010

(8.55%)NaNA

D805,591

(0.06%)

DoSH

D1,207,217,620

(88.59%)

It is evident in Figures 4.2b to 4.2d that majority of health financing that went to the

public health sector were spent by health service providers within the aegis of the

Department of State for Health.

4.2.2 Private health financing agents

The private financing agents included private insurance, household out-of-pocket

payments, non-governmental organizations, and private firms. Figure 4.2E portrays The

Gambia’s funding to the private health financing agents in year 2002. Eighty-five percent

of funds received by private health financing agents were administered by households;

7% by NGOs; 4% by private firms; and 4% by private insurance.


64

Figure 4.2E: Gambia funding to private health


Private

insurance

D6,282,904

(4%)

Private firms

D6,633,064

(4%)

NGOs

D12,374,104

(7%)

Households

OOPs

D144,756,897

(85%)

Figure 4.2F presents The Gambia’s funding to the private health financing agents in year

2003. Seventy-six percent of funds received by private health financing agents were

administered by households; 15% by NGOs; 4% by private firms; and 5% by private

insurance.


65

Figure 4.2F: Gambia funding to private health financing

agents in year 2003

Private firms

D7,359,222

(4%)

NGOs

D30,440,599

(15%)

Private

insurance

D10,770,647

(5%)

Households

OOPs

D149,379,099

(76%)

Figure 4.2G presents The Gambia’s funding to the private health financing agents in year

2004. Seventy percent of funds received by private health financing agents were

administered by households; 18% by NGOs; 7% by private firms; and 5% by private

insurance.


66

Figure 4.2G: Gambia funding to private health


NGOs

D39,632,840

(18%)

Private firms

D15,291,004

(7%)

Private

insurance

D10,018,122

(5%)

Households

OOPs

D154,184,453

(70%)

Evidence contained in Figures 4.2E to 4.2G vividly shows that majority of the health

funds received by private financing agents were used by households to purchase health

services from various service providers in The Gambia.

4.2.3 External financing agent

The external financing agent consisted of rest of the world (donors). Figure 4.2H presents

the total funds received by the rest of the world entities operating within the The Gambia.

The trend has not been consistent across the three year period.


67

Figure 4.2H: Funds received by rest of the world in Gambia

Year2004,

D100,480,528

Year2003,

D93,795,047

Year2002,

D99,628,184

4.3 Distribution of health funds from financing agents to providers

Figure 4.3A presents the distribution of health funds from financing agents to health

service providers in 2002. Out of the total health expenditure of D1185223103,

approximately 53% was spent on provision and administration of public health

programmes, 18% on hospitals, 18% on institutions providing health related services,

10% on health centres, and 1% on rest of the world (see also Appendix Table 4A).


68

Figure 4.3a: Distribution of funds from financing

agents to providers in 2002

HP.3 Providers of

ambulatory health

care

0%

HP.4 Retail sale

and other

providers of

medical goods

0.42%

HP.2 Health

Centres

10%

HP.7 All other

industries

0%

HP.6 General

health

administration

and Insurance*

0.05%

HP.5 Provision

and

administration of

public health

programs

53%

HP.8 Institutions

providing health

related services *

18%

HP.9 Rest of the

world

1%

HP.1 Hospitals

18%

Figure 4.3B portrays the distribution of health funds from financing agents to health






69

Table 4.3b: Distribution of funds from financing

agents to providers in 2003

HP.6 General

health

administration

and insurance

0%

HP.9 Rest of the

world

1%

HP.8 Institutions

providing health

related services

*

16%

HP.7 All other

industries

0%

HP.5 Provision

and

administration

of public health

programs

48%

HP.3 Providers

of ambulatory

health care

0%

HP.2 Health

Centres

11%

HP.4 Retail sale

and other

providers of

medical goods

0%

HP.1 Hospitals

24%

Figure 4.3C depicts the distribution of health funds from financing agents to health






70

Figure 4.3C: Distribution of health funds from

financing agents to providers in 2004

HP.7 All other

industries

0%

HP.6 General

health

administration

and insurance

0%

HP.8 Institutions

providing health

related services *

11%

HP.5 Provision

and

administration of

public health

programs

57%

HP.3 Providers of

ambulatory health

care

0%

HP.2 Health

Centres

10%

HP.4 Retail sale

and other

providers of

medical goods

0%

HP.9 Rest of the

world

1%

HP.1 Hospitals

21%

The above distribution of health funds to providers is quite encouraging. In most of the

other African countries a critical mass of the THE goes to teaching and general hospitals.

Whereas the preferred scenario is where most of the resources are invested in the public

health programmes aimed at protecting majority of the population from the risk of illness.

In The Gambian case, majority of the total health expenditure rationally goes to the

administration and provision of public health services.

4.4 Distribution of funds from health service providers to health functions

Figure 4.3D shows the flow of health funds from service providers to health functions in

2002. Out of the total health expenditure of D1,185, 223,103, approximately 38% was

spent on prevention and public health services, 19% on health administration and health

insurance, 18% on services of curative care, 18% on health related functions and 7% on

medical goods dispensed to outpatients (see also Appendix Table 5A).


71

Figure 4.3D: Flow of health care funds from

providers to functions in 2002

HC.7 Health

administration

and health

insurance

19%

HC.2 Services of

rehabilitative

care

0%

HC.4 Ancillary

services to

medical care

0%

HC.5 Medical

goods

dispensed to out-

patients

7%

HC.6 Prevention

and public health

services

38%

HC.1 Services of

curative care

18%

HCR Health

Related

Functions

18%

Figure 4.3E shows the flow of health funds from service providers to health functions in

2003. Out of the total health expenditure of D1395963523, approximately 44% was spent

on prevention and public health services, 28% on services of curative care, 8% on health

administration and health insurance, 15% on health related functions and 5% on medical

goods dispensed to outpatients (see also Appendix Table 5B).


72

Figure 4.3E: Flow of health funds from providers

to functions in 2003

HC.6 Prevention

and public

health services

44%

HC.7 Health

administration

and health

insurance

8%

HCR Health

Related

Functions

15% HC.2 Services

of rehabilitative

care

0%

HC.4 Ancillary

services to

medical care

0%

HC.5 Medical

goods

dispensed to

out-patients

5%

HC.1 Services

of curative care

28%

Figure 4.3F presents the flow of health funds from service providers to health functions

in 2004. Out of the total health expenditure of D1,682,323,673, approximately 33% on

health administration and health insurance, 29% was spent on prevention and public

health services, 21% on services of curative care, 13% on health related functions, 3% on

medical goods dispensed to outpatients, and 1% on ancillary services to medical care (see

also Appendix Table 5C).


73

Figure 4.3F: Flow of health funds from providers

to functions in 2004

HC.2 Services

of rehabilitative

care

0%

HC.4 Ancillary

services to

medical care

1%

HC.5 Medical

goods

dispensed to out-

patients

3%HC.7 Health

administration

and health

insurance

33%

HC.6 Prevention

and public

health services

29%

HC.1 Services

of curative care

21%HCR Health

related functions

13%


74

CHAPTER 5: RECOMMENDATIONS

Based on the experience garnered in the process of undertaking this inaugural NHA

exercise in The Gambia, the NHA Technical Working Group (NHATWG), would like to

make the following recommendations:

1. NHA should be institutionalised to ensure that it can be conducted on a regular

and sustained basis. According to NHA guidelines (WHO, 2003),

institutionalization is an ongoing process in which NHA activities, structures, and

values become an integral and sustainable part of the government operations.

With institutionalization, a department or unit is designated to house and oversee

the gathering, analysis, and reporting of health expenditure data in a routine and

systematic manner, with full support of the government. The complex process can

take years and multiple estimates before it is integrated fully into the country’s

formal structure, but in order to ensure that NHA remains an effective policy tool

in the future, institutionalization should be a goal from initiation of NHA (see

http://www.who.int/nha). According to the NHA guidelines (WHO, 2003)

institutionalization process entails four steps:

a. Creating demand among policy makers for institutionalization;

b. Determining a location where NHA will be housed;

c. Establishing standards for data collection and analysis;

d. Institutionalizing data reporting requirements for all stakeholders (public,

private and development partners.

In the process of institutionalizing NHA, it will be necessary to: (i) explore the

possibility of integrating NHA data collection within the national health information

management systems; (ii) reinforce the institutional and human capacities of the unit

responsible for undertaking NHA; (iii) include questions on household out-pocket

payments for health care in the national household survey data collection instruments

routinely carried out by The Gambia Bureau of Statistics; (iv) continually involve

GBoS in NHA activities

2. The existence of a NHA Advisory/Steering Committee (NHASC) has proven to

be of value. The government may consider broadening the NHASC to include

permanent secretaries (or directors) from relevant Departments of State. Once

established, it would be necessary to organize a sensitization seminar for the

NHASC members on the usefulness of NHA evidence in health decision-making

(policy and plan development). The creation of NHASC may help to sensitize the

policymakers on the need for undertaking regular NHA exercises and

institutionalizing it.

3. In order to facilitate the process of institutionalizing data reporting, there might be

need to expand the membership of The Gambia NHATWG to include

representatives of all relevant Government Departments (e.g. DoSFEA, DOSE,

DOSI, DoSD, DoSFA, LGA), plus a representative of the health development

http://www.who.int/nha


75

partner group in the country. Once NHATWG membership has been expanded it

would be necessary to organize a technical NHA workshop to ensure there is a

common understanding of the NHA conceptual framework.

4. There is need to plan for undertaking the second NHA exercise covering 2005,

2006 and 2007 and to include HIV/AIDS, TB, Malaria expenditure reviews, and

thereafter make a decision on the frequency of subsequent NHA studies. In

process of those plans, it may be necessary to revise the existing data collection

instruments for use among sources, financing agents, health care providers (plus

functions and inputs).

5. The DoSH should consider developing a comprehensive health financing policy

and health financing strategic plan with a roadmap of how the Government plans

to realize the vision of universal coverage of health services and universal

protection from potentially catastrophic and impoverishing health care

expenditures in the long-term. In the process of developing the national financing

policy, it may be informative to refer to the WHO regional strategy for health

financing for inspiration.

The following important findings should support the development of the

health Financing policy:

Government current per capita health expenditure is below $35 as

recommended by WHO. The financing policy should advocate for

government increase expenditure on health.

Currently Social Security contribution to health is insignificant. The policy

should therefore advocate for increase Social security contribution to

health expenditure.

The out- of-pocket expenditure as a propotion of total private health

expenditure is over 95%. The health financing policy should advocate for

the development of a national social insurance frame work including

health financing safety nets for the poor.

Donor contribution to the total health expenditure is over 65%. For

effective coordination of this input the health financing policy should

advocate for basket funding system.

6. There will be need to develop a Sector-Wide Approach (SWAp) for coordinating

partners efforts in the implementation of the national health policy. In the course

of designing the SWAp there will be need to make study visits to countries that

have been successfully implementing it, e.g. Ghana and Uganda.

7. The will be need for further training for core member of the National Health

Accounts Technical Working Group.


76

CHAPTER 6: CONCLUSION

The inaugural NHA study was the first step towards The Gambia’s aspiration of

institutionalizing NHA to facilitate DOSH stewardship of the national health system. The

study succeeded in addressing three of its four objectives: (i) to estimate the total health

expenditure from public, private and donor sources; (ii) to determine the total health

expenditure by financing agents; and (iii) to approximate the distribution of funds by

various public health functions. Due to dearth of disaggregated information, it was not

possible to estimate the amounts of funds spent on various health system inputs.

The total health expenditure (THE) was approximately D1,185,223,103 in 2002;

D1,395,958,522 in 2003; and D1,682,323,673 in 2004. THE as a percentage of GDP in

The Gambia was 16.1% in 2002, 13.9% in 2003 and 14.9% in 2004. The per capita total

health expenditure was D895 in 2002, D1026 in 2003 and D1203 in 2004. During the

three years over 66% of the total health funding came from donors (international health

development partners). The Government of The Gambia contribution grew from 18% in

2002 to 24% of the total health expenditure in 2004. The households, through direct out-

of-pocket payments to health care providers, contributed 12% in 2002, 11% in 2003 and

9% in 2004 to the total health expenditure.

The NHA evidence contained in this document constitutes a strong basis for developing a

comprehensive health financing policy and a health financing strategic plan mapping out

how the Government plans to realize the vision of universal coverage of health services

and universal protection from potentially catastrophic and impoverishing health care

expenditures in the long-term. In order to facilitate the monitoring and evaluation of such

policy documents once developed, it is important to institutionalize national health

accounts. The latter will require boosting of the capacities in the Directorate of Planning

and Information.


77

Chapter 7: FURTHER ANALYSIS OF THE CURRENT HEALTH FINANCING

SYTEM

COST RECOVERY PROGRAM AND THE DRUG REVOLVING FUND

In August 1988 as part of the Economic Recovery Program pursued by the Government

of the Gambia, a Cost Recovery Program was implemented in the public health sector.

User fees were introduced for the recovery of the cost of medical goods. These include

pharmaceuticals, laboratory consumables, X –ray consumables. User fees were

introduced for some of the services too, and these services include: Attendance at birth,

Admission and dental care and minor and major operations . The main objective of

introducing these fees was to create a Drug Revolving Fund for the re-financing of the

purchase of the medical goods and the management of the supply of the goods.

The Cost Recovery Program was part of the National Health Development Project 1987-

1992

By the end of the Project, an evaluation was done on the Cost Recovery Program

including the management of the Drug Revolving Fund. National cost recovery average

was below 35 % with the major health centres and hospitals performing better than the

minor health centres.

Bamako Initiative Strategy (BI) was piloted in two health centres in 1993. The main

objective of introducing BI was to strengthen both the Primary Health Care Program and

the Cost Recovery Program. With very little study of the pilot phase, the strategy was

hastily implemented in several other health centres. By 1996, BI was implemented in 12

health centres. A quantitative evaluation of the implementation of BI in health centres

showed some increase in revenue generation over the pre-BI phase, about 44% recovery.

But the report also indicated several challenges for sustainability.

What were the differences between a BI and non-BI health centre? These are

essentially managerial and include:

Involvement of the catchment area community in the management of the

health services provision

Revenue generated at health centre is controlled by the health centre

committee and not deposited in the national treasury or with the Drug

Revolving Fund.

But otherwise, the user fees system and charges were the same for both type of health

centres.

Some efforts were made to strengthen the implementation of the BI strategy and also to

expand to other health centres during the Participatory Health Population and Nutrition

Project (1999-2003).

COST RECOVERY TRENDS IN SELECTED PUBLIC HEALTH FACILITIES

As the Cost Recovery Program (CRP) is still the main mechanism for financing health

services to supplement Government budgetary commitments, it was found useful to

review the performance of the CRP in few selected BI facilities. The BI facilities were


78

selected because it was easy to follow their actual deposits of internally generated

revenue in their accounts at the banks.

The public hospitals were also included as they also maintain their own accounts.

Cash deposit trends in selected BI facilities

KUNTAUR

YEAR 2000 60,692.00

YEAR 2001 51,789.49

YEAR 2002 35,706.00

YEAR2003 36,955.00

YEAR 2004 28,405.00

YEAR 2005 17,955.00

YEAR 2006 15,220.00

KAUR

YEAR 2002 20,808.80

YEAR 2003 14,733.50

YEAR 2004 9,980.00

YEAR 2005 1,650.00

YEAR 2006 6,565.00


79

KEREWAN

YEAR 2000 40,495.04

YEAR 2001 38,489.93

YEAR 2002 33,108.90

YEAR 2003 29,603.30

YEAR 2004 8,948.00

NGAYEN SANJAL

YEAR 2003 10,750.00

YEAR 2004 7,675.00

YEAR 2005 11,172.00

YEAR 2006 9,675.00

GUNJUR

YEAR 2002 20,400.00

YEAR 2003 38,137.00

YEAR 2004 40,221.00

YEAR 2005 60,563.00

YEAR 2006 46,075.00


80

SALIKENE

YEAR 2002 23,552.11

YEAR 2003 31,593.13

YEAR 2004 28,153.65

YEAR 2005 43,587.55

YEAR 2006 32,723.15

BURENG

YEAR 2000 16,835.00

YEAR 2001 4,960.00

YEAR 2002 705.00

YEAR 2003 53,859.50

YEAR 2004 34,854.00

YEAR 2005 18,876.00

YEAR 2006


81

15,794.00

HEALTH CENTRES COST OF PHARMACEUTICALS AND OTHER MEDICAL SUPPLIES ISSUED

AND TOTAL BANK DEPOSIT IN 2006 % RECOVERY

HEALTH CENTRE PHARM ISSUED BANK DEPOSIT

SOMA 793,036.03 21,598.00 2.72

ILLIASA 183,438.39 20,641.00 11.25

NGAYEN SANJAL 257,645.67 9,675.00 3.76

KUNTAUR 485,329.51 15,220.00 3.14

KAUR 539,811.22 6,565.00 1.22

MEDINA BAFUL 223,048.44 24,968.45 11.19

ESSAU 646,628.47 450,058.00 69.60

KUNTAYA 224,872.28 9,400.00 4.18

KWINELLA 152812.87 18,854.00 12.34

BURENG 379281.37 19,294.00 5.09

SALIKENE 189771.12 32,723.15 17.24


82

The public hospitals were also assessed on the cost recovery of the medical goods.

PUBLIC HOSPITALS

RVTH

YEAR PHARM & OTHER MED USER FEES

2002 4,350,000.00

3,179,977.30

2003 3,500,000.00

2,909,214.00

2004 8,217,472.28

3,643,720.50

% RECOVERY

2002 78.10

2003 83.12

2004 44.34

BANSANG HOSPITAL

YEAR PHARM&OTHER MED USER FEES

% RECOVERY

2002 3,195,025.00

562,945.00 17.62

2003 1,810,808.00

530,795.00 29.31

2004 1,720,335.41

622,896.00 39.21


83

AFPRC HOSPITAL


% RECOVERY

2002 2,199,896.05

265,000.00 12.05

2003 1,612,180.00

427,000.00 26.49

2004 1,720,335.41

471,000.00 27.38

SJ HOSPITAL


% RECOVERY


84

2004 838,880.00

46,647.00 5.56

It is quite easy to state that the current user fees cannot sustain the re-ordering of the

essential medical goods . Other than RVTH, none of the other hospitals seem to be

recovering even 50% of the cost of medical goods. The situation is not better with the

health centres, majority of which cannot recover beyond 10% of the cost of medical

goods supplied to them.


85

APPENDICES

Appendix Table 1: Total amounts of funds invested into health from various sources (in Dalasi) 2002, 2003 and 2004

Financing Sources Year2002 Year2003 Year2004

Government/public 207,995,042.6 301,763,059.3

409,165,197.1

Private employer 788,774.0 1,231,702.2

11,038,106.5

Household OOPs 144,756,896.6 149,379,098.9

154,184,453.2

Donors 831,682,389.4 943,584,661.8

1,107,935,915.7

TOTAL (Dalasi) 1,185,223,102.6

1,395,958,522.1

1,682,323,672.6

Nominal GDP 7,364,316,460 10,025,934,179

12,042,000,000

THE as % GDP 16.09 13.92 13.97

Current + capital expenditue 1,813,419,479 2,315,352,000

3,769,347,920

GGHE as % TGE 11.47 13.03 10.86


86

Appendix Table 2: Total amounts of funds received by various financing agents in years 2002, 2003 & 2004

Financing Agents Sub-Total (Dalasi) Sub-Total (Dalasi)

Sub-Total (Dalasi)

Year 2002 Year 2003 Year 2003

Government 915,547,949.8 1,104,213,908.1

1,362,716,725.9

HF.1.1.1.1 DoSH 879,180,001.5 1,067,805,392.0

1,207,217,619.6

HF.1.1.1.2 DoSE 1,179,335.0 1,269,939.0

2,114,524.0

HF.1.1.1.3. DoSD 37,992.0 11,659.0 -

HF.1.1.1.4 DoSI 419,429.0 416,616.0

600,369.0

HF.1.1.1.5 DOSFA 31,072,625.5 31,072,625.5

31,072,625.5

HF.1.1.1.6 LGA 3,282,654.8 3,282,206.6

4,392,986.6

HF.1.1.1.7 National AIDS Secretariat - -

116,513,010.1

HF. 1.1.1.8 NaNA 375,912.0 355,470.0

805,591.0

HF.1.2.1 Parastatals - - -

Private Financing Agents 170,046,968.9

197,949,567.0

219,126,418.4

HF.2.1 Private insurance (medical aid schemes) 6,282,904.2

10,770,647.0

10,018,121.5

H.2.2 Households Out-of- Pocket Payments 144,756,896.6

149,379,098.9

154,184,453.2

HF.2.3 NGOs 12,374,104.0 30,440,599.0

39,632,840.2

HF.2.4 Private firms 6,633,064.1 7,359,222.1

15,291,003.5

External/Donors 99,628,183.9 93,795,047.0

100,480,528.3

HF.3 Rest of the world (donors) 99,628,183.9

93,795,047.0

100,480,528.3

GRAND TOTAL (Dalasi) 1,185,223,102.6

1,395,958,522.1

1,682,323,672.6


87

APPENDIX TABLE 3: GENERAL NHA SUMMARY STATISTICS (2002, 2003,

2004)

Indicator Value in 2002 Value in 2003 Value in 2004

Total population 1,324,393 1,360,681 1,397,964

Nominal gross domestic

product (GDP) in Dalasi

7,364,316,460 10,025,934,179 12,042,000,000

Total health expenditure

(THE) in Dalasi

1,185,223,102.60 1,395,958,522.10 1,682,323,672.62

Total government health

expenditure in Dalasi

207,995,042.60 301,763,059.30 409,165,197.10

Total private funds (private

employer+household) in

Dalasi

145,545,670.60 150,610,801.10 165,222,559.70

a) Private employer 788,774.00 1,231,702.20 11,038,106.50

b) Households 144,756,896.60 149,379,098.90 154,184,453.20

Total donor funds in Dalasi 831,682,389.40 943,584,661.80 1,107,935,915.70

Per capita THE (Dalasi) 894.92 1025.93 1203.41

Total government health

expenditure per capita (Dalasi) 157.05 221.77 292.69

Total private health funding

per capita (Dalasi) 109.90 110.69 118.19

Total donor funding per capita

(Dalasi) 627.97 693.47 792.54

Total household expenditure

per capita (Dalasi) 109.30 109.78 110.29

THE as a % of GDP 16.09 13.92 13.97

Total government expenditure

on health as % of GDP 2.82 3.01 3.40

Total private expenditure on

health as % of GDP 1.98 1.50 1.37

Sources of Funds:

Public health spending as % of

THE 17.55 21.62 24.32

Private health spending as %

of THE 12.28 10.79 9.82

Donors as % of THE 70.17 67.59 65.86

Household Spending:


88

OOP as % of THE

12.21 10.70 9.16

OOP spending per capita

(Dalasi) 109.30 109.78 110.29

Financing Agents: % of THE % of THE % of THE

Government

HF.1.1.1.1 DoSH 74.18 76.49 71.76

HF.1.1.1.2 DoSE 0.10 0.091 0.126

HF.1.1.1.3. DoSD 0.003 0.001 0.000

HF.1.1.1.4 DoSI 0.035 0.030 0.036

HF.1.1.1.5 DOSFA 2.62 2.23 1.85

HF.1.1.1.6 LGA 0.28 0.24 0.26

HF.1.1.1.7 National AIDS Secretariat 0.00 0.00 6.93

HF. 1.1.1.8 NaNA 0.032 0.03 0.05

HF.1.2.1 Parastatals 0.00 0.00 0.00

Private Financing Agents

HF.2.1 Private insurance (medical aid schemes) 0.53 0.77 0.60

H.2.2 Households Out-of- Pocket Payments 12.21 10.70 9.16

HF.2.3 NGOs 1.04 2.18 2.36

HF.2.4 Private firms 0.56 0.53 0.91

External/Donors

HF.3 Rest of the world (donors) 8.41 6.72 5.97

Providers: % of THE % of THE % of THE HP.1 Hospitals 18.41 23.55 20.62

HP.2 Health Centres 9.63 11.23 9.51 HP.3 Providers of ambulatory

health care 0.00 0.00 0.00 HP.4 Retail sale and other providers

of medical goods 0.42 0.37 0.31 HP.5 Provision and administration

of public health programs 52.67 48.35 58.15 HP.6 General health administration

and Insurance* 0.05 0.00 0.00

HP.7 All other industries 0.00 0.00 0.00 HP.8 Institutions providing health

related services * 17.66 15.55 10.55

HP.9 Rest of the world 1.15 0.94 0.86

Functions: % of THE % of THE % of THE HC.1 Services of curative care 17.78 27.669 20.94 HC.2 Services of rehabilitative care 0.33 0.064 0.18 HC.4 Ancillary services to medical care 0.22 0.184 0.59

HC.5 Medical goods dispensed 6.94 4.907 3.25


89

to out-patients

HC.6 Prevention and public health services 37.81 44.001 28.95 HC.7 Health administration and health insurance 19.26 8.141 32.73

HCR Health Related Functions 17.65 15.034 13.36


90

APPENDIX TABLE 4A: FINANCING AGENTS TO PROVIDERS IN 2002 PROVIDERS (P) Sub-Total Expenditure

(in Dalasi) % of THE

HP.1 Hospitals 218,235,852 18.41

HP.1.1. Teaching Hospital 110,879,776.95 9.36

HP.1.2. Public General Hospitals 50,759,741.50 4.28

H.P 1.3 Private Hospitals / Clinics 25,523,707.28 2.15

HP. 1.4 Overseas Care Providers 31,072,626.00 2.62

HP.2 Health Centres 114,144,552.95 9.63

HP2.1 Government Health Centres (Basic Health Services) 104,901,166.95 8.85

HP 2.2 NGO Health Centres 9,243,386.00 0.78

HP.3 Providers of ambulatory health care - 0.00

HP.4 Retail sale and other providers of medical goods 4,936,913.00 0.42

HP 4.1.Pharmacies 4,936,913.00 0.42

HP4.2. Opticians - 0.00

HP.4.9 Pharmaceutical companies - 0.00

HP.5 Provision and administration of public health programs 624,279,350.44 52.67

HP5.1 Administration of Public Health Programs 177,490,082.65 14.98

HP5.2 Provision of Public Health Services 446,789,267.79 37.70

HP.6 General health administration and Insurance* 605,490.48 0.05

HP.6.4 Other (private) insurance+A4 - 0.00

HP.6.9 All other providers of health admin - 0.00

HP6.4.2 Insurance firms - 0.00

HP.7 All other industries - 0.00

HP.8 Institutions providing health related services * 209,368,771.38 17.66

HP.8.1 Research institutions 85,976,011.38 7.25

HP.8.2 Education & training institutions 118,428,439.00 9.99

HP 8.3 NGO Health related service providers 4,964,321.00 0.42

HP.9 Rest of the world 13,652,172.62 1.15

Column totals 1,185,223,102.60 100.00

*D605490.48 which was undistributed was included here.


91

APPENDIX TABLE 4B: FINANCING AGENTS TO PROVIDERS IN 2003 PROVIDERS (P) Sub-Total

(in Dalasi) % of THE

HP.1 Hospitals

328,780,804 23.55

HP.1.1. Teaching Hospital

136,297,022.25 9.76

HP.1.2. General Hospitals

130,924,614.25 9.38

H.P 1.3 Private Hospitals / Clinics

30,486,541.00 2.18

HP. 1.4 Overseas Care Providers

31,072,626.00 2.23

HP.2 Health Centres

156,827,081.50 11.23

HP2.1 Government Health Centres (Basic Health Services)

139,913,914.50 10.02

HP 2.2 NGO Health Centres

16,913,167.00 1.21

HP.3 Providers of ambulatory health care

- 0.00

HP.4 Retail sale and other providers of medical goods

5,096,677.00 0.37

HP 4.1.Pharmacies

5,096,677.00 0.37

HP4.2. Opticians

- 0.00

HP.4.9 Pharmaceutical companies

- 0.00

HP.5 Provision and administration of public health programs

675,000,832.60 48.35

HP5.1 Administration of Public Health Program

76,969,631.00 5.51

HP5.2 Provision of Public Health Services

598,031,201.60 42.84

HP.6 General health administration and insurance

1.40 0.00

HP.6.4 Other (private) insurance

- 0.00

HP.6.9 All other providers of health admin

- 0.00

HP6.4.2 Insurance firms

- 0.00

HP.7 All other industries

- 0.00

HP.8 Institutions providing health related services *

217,123,627.00 15.55

HP.8.1 Research institutions

90,660,547.00 6.49

HP.8.2 Education & training institutions

109,817,961.00 7.87

HP 8.3 NGO Health related activities

16,645,119.00 1.19


92

HP.9 Rest of the world

13,134,500.00 0.94

Column totals 1,395,963,523.00

100.00


93

APPENDIX TABLE 4C: TABLE: FINANCING AGENTS TO PROVIDERS IN

2004 PROVIDERS (P) Sub-total expenditure

(Dalasi) % of THE

HP.1 Hospitals 346,845,031 20.62

HP.1.1. Teaching Hospital 115,644,294.31 6.87

HP.1.2. General Hospitals 162,061,395.01 9.63

H.P 1.3 Private Hospitals / Clinics 38,066,716.02 2.26

HP. 1.4 Overseas Care Providers 31,072,625.52 1.85

HP.2 Health Centres 159,988,776.48 9.51

HP2.1 Government Health Centres (Basic Health

Services) 135,455,838.70

8.05

HP 2.2 NGO Health Centres 24,532,937.78 1.46

HP.3 Providers of ambulatory health care - 0.00

HP.4 Retail sale and other providers of medical

goods 5,262,042.00

0.31

HP 4.1.Pharmacies 5,262,042.00 0.31

HP4.2. Opticians - 0.00

HP.4.9 Pharmaceutical companies - 0.00

HP.5 Provision and administration of public health

programs 978,310,027.33

58.15

HP5.1 Administration of Public Health 506,735,443.91 30.12

HP5.2 Provision of Public Health Services 471,574,583.42 28.03

HP.6 General health administration and insurance - 0.00

HP.6.4 Other (private) insurance - 0.00

HP.6.9 All other providers of health admin - 0.00

HP6.4.2 Insurance firms - 0.00

HP.7 All other industries - 0.00

HP.8 Institutions providing health related services * 177,417,783.63 10.55

HP.8.1 Research institutions 85,980,516.00 5.11

HP.8.2 Education & training institutions 73,108,824.00 4.35

HP 8.3 NGO Health related service providers 18,328,443.63 1.09

HP.9 Rest of the world 14,500,012.32 0.86

Column totals 1,682,323,672.6 100


94

Appendix Table 5A: THE GAMBIA NHA:- Flow of health care funds from


FUNCTION

Sub-total

expenditure

(Dalasi)

% of THE

HC.1 Services of curative care 210,762,008.34 17.78

HC.1.1 Inpatient curative 112,260,198.38 9.47

HC.1.3 Outpatient curative 97,768,497.96 8.25

HC.1.3.1 Basic medical & diagnostic services - 0.00

HC.1.3.2 Outpatient dental care 733,312.00 0.06

HC.2 Services of rehabilitative care 3,906,463.00 0.33

HC2.1 Inpatient rehabilitative care - 0.00

HC.2.3 outpatient rehabilitative care 3,906,463.00 0.33

HC.4 Ancillary services to medical care 2,632,388.16 0.22

HC4.1 Clinical lab 386,387.00 0.03

HC.4.2 Diagnostic imaging 528,459.16 0.04

HC.4.3 Patient transport & emergency rescue 1,717,542.00 0.14

HC.5 Medical goods dispensed to out-patients 82,269,117.22 6.94

HC.5.1 Pharmaceuticals & other medical non durables 41,769,117.22 3.52

HC.5.1.1 Medicines - 0.00

HC.5.1.2 Other medical non durables - 0.00

HC.5.2.1 Glasses & other vision products - 0.00

HC.5.2.2 Medico technical devices, including wheelchairs 40,500,000.00 3.42

HC.6 Prevention and public health services 448,189,031.79 37.81

HC.6.1 MCH, family planning & counscelling 49,570.00 0.00

HC.6.2 School health services - 0.00

HC.6.3 Prevention of communicable diseases 447,763,549.79 37.78

HC6.4 Prevention of non-communicable diseases 375,912.00 0.03

HC.6.5 Occu. H. care - 0.00

HC.7 Health administration and health insurance 228,305,331.71 19.26

HC.7.2 H admin & Pvt. H Insurance 7,298,855.73 0.62

HC.7.2 H admin 221,006,475.98 18.65


95

HC.7.2.2 Admin of insurance firms - 0.00

Subtotal: Total current expenditure on health 968,765,484.48 81.74

HCR Health Related Functions 209,158,762.38 17.65

HCR.1 Capital formation of health care provider institutions

170,000.00 0.01

HCR 2 Maintenance Service Management 3,173,166.00 0.27

HCR.3 Education and training of health personnel 119,765,275.00 10.10

HCR.4 Research and development in health 86,050,321.38 7.26

HC.R.5 Traditional medicine development - 0.00

HC.R.6 Provision of Overseas Treatment - 0.00

Total health expenditure 1,185,223,102.60 100.00


96

Appendix Table 5B: THE GAMBIA NHA - Flow of health care funds from


Sub-total

expenditure

(Dalasi)

% of THE





HC.1.3.2 Outpatient dental care 1,207,311.93 0.086

HC.2 Services of rehabilitative care 896,198.00 0.064


HC.2.3 outpatient rehabilitative care 896,198.00 0.064


HC4.1 Clinical lab 428,972.00 0.031


HC.4.3 Patient transport & emergency rescue 1,173,960.00 0.084











HC6.4 Prevention of non-communicable diseases - 0.000

HC.6.5 Occu. H. care - 0.000


HC.7.2 H admin & Pvt. H Insurance - 0.000

HC.7.2 H admin 113,652,298.01 8.141


Subtotal: Total current expenditure on health 1,186,092,132.04 84.966


HCR.1 Capital formation of health care provider institutions 0.082


97

1,145,607.00








98

Appendix Table 5C: THE GAMBIA NHA: Flows of health care funds from


FUNCTION

Sub-total

expenditure

(Dalasi)

% of THE





HC.1.3.2 Outpatient dental care 953,400.80 0.06

HC.2 Services of rehabilitative care 3,041,996.00 0.18


HC.2.3 outpatient rehabilitative care 3,041,996.00 0.18


HC4.1 Clinical lab 9,034,883.84 0.54


HC.4.3 Patient transport & emergency rescue 527,830.00 0.03











HC6.4 Prevention of non-communicable diseases 471,574,583.42 28.03

HC.6.5 Occu. H. care - 0.00


HC.7.2 H admin & Pvt. H Insurance - 0.00

HC.7.2 H admin 550,600,065.24 32.73


Subtotal: Total current expenditure on health 86.64


99

1,457,536,671.98


HCR.1 Capital formation of health care provider institutions 56,596,453.70 3.36








100

Yearly trend of IDSR Priority diseases by Region, The The Gambia

Western Region

Disease 2002 2003 2004 2005 2006 Totals

Malaria 284,822 95033 98044 56668 275776 810,343

Tuberculosis 362 358 360 461 1,541

Pneumonia 56,938 3582 5789 1020 7681 75,010

Diarrhoea 50,116 5661 8712 1641 17024 83,154

Trachoma 28 10 94 168 300

Measles 49 167 0 0 0 216

Meningitis 10 5 17 15 6 53

Cholera 0 0 0 0 0 0

Schistosomiasis 0 0 0 0 3 3

Yellow Fever 0 2 0 0 0 2

Anthrax 2 5 0 0 151 158

Leprosy 2 78 4 0 10 94

Lower River Region

Disease 2002 2003 2004 2005 2006 Totals

Malaria 53,701 14686 24920 29347 34151 156,805

Tuberculosis 0 2 0 28 7 37

Pneumonia 17,793 733 818 1372 2960 23,676

Diarrhoea 10,906 830 782 1883 2998 17,399

Trachoma 0 1 0 19 11 31

Measles 0 0 0 0 0 0

Meningitis 0 0 8 0 0 8

Cholera 0 0 0 0 0



Anthrax 0 0 0 0 8 8

Leprosy 0 0 0 0 0 0

North Bank West Region

Disease 2002 2003 2004 2005 2006 Totals

Malaria 42,242 20965 29395 30413 31094 154,109

Tuberculosis 1 0 37 13 51

Pneumonia 11,869 1365 1346 1579 2334 18,493

Diarrhoea 8,399 861 560 963 1906 12,689

Trachoma 5 0 0 2 7

Measles 35 1 0 0 36

Meningitis 3 6 3 0 12

Cholera 0 0 2 0 2



Anthrax 0 0 0 0 0 0

Leprosy 0 0 0 0 0 0

North Bank East Region


101

Disease 2002 2003 2004 2005 2006 Totals

Malaria 32,276 18595 21263 16390 30468 118,992

Tuberculosis 0 0 1 7 8

Pneumonia 9,673 1581 1971 4148 5039 22,412

Diarrhoea 6,307 1971 1937 3112 2791 16,118

Trachoma 3 3 0 42 12 60

Measles 4 0 0 0 0 4


Cholera 0 0 0 0 0 0



Anthrax 0 0 0 0 0 0

Leprosy 0 1 0 0 0 1

Central River Region

Disease 2002 2003 2004 2005 2006 Totals

Malaria 75,186 56299 37666 29609 4021 202,781

Tuberculosis 24 20 15 36 22 117

Pneumonia 18,926 3078 2146 5560 881 30,591

Diarrhoea 15,463 2900 1516 3672 345 23,896

Trachoma 129 129 37 28 6 329

Measles 23 2 3 0 0 28


Cholera 0 0 0 0 0 0



Anthrax 0 0 0 0 0 0

Leprosy 8 2 2 0 0 12

Upper River Region

Disease 2002 2003 2004 2005 2006 Totals

Malaria 63,077 30077 32497 14991 40340 180,982

Tuberculosis 1 100 5 245 21 372

Pneumonia 11,754 1729 1127 3236 3085 20,931

Diarrhoea 11,593 1020 1893 2145 3425 20,076

Trachoma 0 1 0 0 0 1

Measles 20 1 57 0 0 78


Cholera 0 0 0 0 0 0



Anthrax 0 0 0 0 0 0

Leprosy 1 10 0 0 3 14

DISEASES

NATIONAL

2002 2003 2004 2005 2006 Totals

Malaria 551304 235655 243785 177418 415850 1624012


102

Tuberculosis 1890 1985 1963 1983 1813 9634

Pneumonia 126953 12068 13197 16915 21980 191113

Diarrhoea 102784 13243 15400 13416 28489 173332

Trachoma 160 165 22 153 22 522

STI 1045 2063 6514 1322 1646 12590

Measles 4343 120 68 0 0 4531

Meningitis 305 29 39 174 5 552

HIB 1 4 3 7 5 20

Cholera 0 0 0 52 0 52



Anthrax 2 5 0 22 0 29

Leprosy 11 101 15 15 18 160

HIB

Female Male Total

ADMYEAR

1990 20 26 46

1991 22 32 54

1992 24 26 50

1993 14 14 28

1994 10 15 25

1995 4 4 8

1996 13 15 28

1997 13 14 27

1998 3 7 10

1999 4 1 5

2000 2 2

2001 1 1 2

Total 128 157 285

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NATIONAL HEALTH ACCOUNTS - World Banksiteresources.worldbank.org/INTHSD/Resources/376278...National Health Accounts (NHA) is a tool for health sector management and policy development