By Baturu Mboge, New York, USA.
On December 1st, 2016, Gambians voted for a change that ushered in a new government that is expected to lead the development and political transition based on the rule of law, democracy, and respect for fundamental human rights and freedom. However, that shift must not leave behind reforms in other essential sectors including health. The rapid population growth with a high level of poverty, youth unemployment, and substantial environmental threats cannot make this agenda any more urgent. The country needs to shift from a health system that is reactive to a one that is more proactive. And this change will require a strong and a bold political action to lay the foundation necessary for a robust Public Health Agenda.
In the National Development Plan (NDP), the government identified key priority areas that are all linked to improving health outcomes. But the timeframe of the development agenda is too short to see any significant change in the indicators of progress regarding long-term results. Nonetheless, it does provide a sense of direction in addressing the long-term health needs of the population.
The NDP made a strong argument for Primary Health Care (PHC) as a vehicle for health service delivery in the country. That is indeed a welcome development. The PHC approach does recognize active community involvement and participation in the delivery of health services. And that is a sine qua non for the long-term sustainability of any meaningful health intervention. Hence, the PHC approach should be consolidated to focus on wellness vs. illness; primary care vs. acute care; outpatient vs. inpatient; community well-being vs. individual health; integrated systems vs. independent institutions; and continuum of service vs. service duplication. It merely means championing the new public health agenda, social determinants of health, and health in all policies as propounded by World Health Organization.
The blueprint also mentioned the demographic dividend and the call for multisectoral collaboration with other key stakeholders in the country. Based on this, the government should consider setting up a National Agency for Primary Health Care Delivery. The quasi-government health entities (affiliated agencies or secretariat that works with the Department of Health) are more visible, better managed and well-funded. Therefore, this new office will assume essential PHC duties and help reform and streamlined other directorates including health services, social welfare, health promotion, and public health. Health services directorate should focus on the monitoring of the health policy, strategies, and plans. It should also be concerned with patient safety & rights; organizational efficiency (hospitals, specialty care, laboratory and radiological services); developing clinical guidelines; enforcement of international health regulations; promoting electronic medical records; telemedicine/telehealth; and other ongoing specialized programs.
Therefore, as part of the reform process, the Directorate of Social Welfare should be restructured to make it more functional and responsive to the needs of today’s Gambia. The Ministry of Health and Social Welfare should consider changing to the Ministry of Health and Human Services. The Social Welfare Directorate should drop “Welfare” and call it the “Department of Social Services.” This new department will combine the department of “Social Welfare” and department of “Community Development” (DCD) under the Ministry of Lands and Regional Government. And the new entity will be tasked with the administration of social protection programs (including poverty alleviation, rural and urban development) children services and people with disabilities. DCD is a crucial department but is in a wrong ministry. The newly created office will continue to work with the Ministry of Lands and Regional Government through the local structures in strengthening the delivery of social services.
The reform process will ensure that the existing Community Development Officers (CDOs) and Community Development Assistants (CDAs) will become employees of this newly created entity. They will join the public health workforce (public health nurses, and community health nurses) in addressing economic, social and environmental challenges in our cities, towns, and villages. The department will work closely with Women’s Bureau, National Youth Council, National Environmental Agency, Strategy for Poverty Alleviation and Coordinating Office, and local governments in support of the public health agenda, social determinants, and health in all policies.
At the community level, this workforce under this new entity will be focused on helping the prevention of diseases and promote healthier lifestyles. Supporting health education programs in schools and communities through training and information sharing on essential health risks such as tobacco use, substance abuse, sexual behavior, injury and violence, dietary and hygienic practices, oral health, environmental quality (sanitation) and other sedentary lifestyles.
However, embarking on this transformation will require planning and making sure that the right capacity is developed for the transition. The Rural Development Institute should be transformed to become the School of Social Work and Policy under the University of the Gambia. Specific training modules can be developed and offered to theexisting CDAs on this new public health agenda. The traditional public health workforce will lead the vaccination campaigns, programs on improving health outcomes; and health emergency preparedness among others.
Also, part of the suggested policy change should make continuing education mandatory for all “social or development workers” and not the traditional two or three days workshops. In this continuing education series, the practitioners’ knowledge and skills should be evaluated. And any worker who underperformed in continuing education could technically be out of compliance. Again, this policy should be across the board for all personnel in the field of social service including the civil servants and the employers of nongovernmental organizations.
Today, health insurance coverage in the Gambia is below 4 percent and mostly through employer-based insurance. According to the NDP, the government will design and pilot an innovative universal health insurance scheme based on community-based health financing and social insurance models. It is very pleasing that the government has realized that the present form of funding is unsustainable and thus, requires urgent action.
There are three significant models of health service systems in the world. National Health Insurance (NHI), where the government finances health services through general taxes (single payer) but private providers are contracted to deliver services. Such as in Canada, the government coordinates financing, insurance, and payment arrangements. Under this model, health services ownership is both public and private.
The second model is the National Health System (NHS) otherwise known as the “Beveridge model” in the United Kingdom, and its other variations in Spain and Scandinavian countries. This model is also a single payer system, and the government provides the finances through taxes and manages the delivery of medical services. Under this system, the government operates most of the institutions (hospitals), and most of the physicians are government employees. The system in The Gambia was designed this way but the resource allocation was inadequate to make it work well. NHS model promotes the principles of primary health care with a focus on community health services. In The Gambia we abandon this philosophy instead focused on building more hospitals and increasing medical services as opposed to primary care.
The third model referred to as Socialized Health Insurance (SHI) otherwise known as the “Bismarck model.” In Germany, health services contributions are mandatory for employers and employees. The private providers deliver healthcare, but the government has the overall control. The non-profit companies called “sickness funds” are responsible for collecting contributions and paying physicians and hospitals. Israel has a similar model, financed through taxation with an income-based contribution. France (Couverture Maladie Universelle), Belgium and other countries in Latin America have a similar system. Japan, on the other hand, combined both (SHI and NHI) and achieved universal coverage just like Germany.
There are other countries such as the United States that have a pluralistic system with private ownership. Financing is through voluntary, multi-payer system (premiums or general taxes). The Gambia need a combination all these three models. The government should provide subsidized health coverage for the poor, disabled and the elderly which I call (GAMcaid); mandatory employer-based insurance (GAMcare) and retired employees (GAMshield). GAMcaid will be financed from taxation and contributions from traders and farmers cooperatives to support needy citizens in the informal sector to access health services and help improve their social conditions. And GAMshield will be financed through social security taxes. Furthermore, there are still substantial funding opportunities for vaccination and diseases like malaria, tuberculosis and HIV/AID among others as part of the new global framework (Agenda 2030) mostly from foundations, bilateral and multilateral partners. These funding will cover children and vulnerable or special population groups.
The first step in this process would be to carry a study on the financial feasibility of a combined model (single payer and employer-based insurance scheme); establishment of the legal framework; development of the human resource and the management bodies; and building synergy between the existing health insurance and other health processes. In conclusion, this PUBLIC HEALTH AGENDA will put the focus on the protection of the health of our communities rather than individuals, and the empowerment of individuals and communities to take charge of their change process.
About the Author:
Baturu Mboge is an Independent consultant for the New York State Office for the People with Intellectual and Developmental Disabilities services. Before this, he worked for Westchester Institute for Human Development(WIHD) as a program supervisor on a wide range of social services. WIHD is a University center for excellence on Intellectual and Developmental Disabilities. In The Gambia, he had experience working with West African Rural Development Center, Child Fund International and African Center for Democracy and Human Rights Studies. While in The Gambia, Dr. Mboge participated in many social research projects and was a strong advocate for women & youth empowerment, good governance and people-centered development.
Dr. Mboge’s research interest include health system strengthening in sub-Saharan Africa, female genital mutilation/cutting, and community-based organizations that offer services to vulnerable and underserved populations. He received his Bachelor of Arts(Honors) in Development Studies and Sociology from the University of The Gambia, his Master of Public Administration in Emergency Management at John Jay College of Criminal Justice, City University of New York. He got his Master of Public Health and Doctor of Health Policy and Management at New York Medical College (NYMC). Dr. Mboge is also a recipient of a Graduate Certificate in Global Health from NYMC.