Decline of mortality in children in rural Gambia: the influence of village‐level Primary Health Care

Abstract

Summary Using data from a longitudinal study conducted in 40 villages by the UK MRC in the North Bank Division of The Gambia beginning in late 1981, we examined infant and child mortality over a 15‐year period for a population of about 17 000 people. Comparisons are drawn between villages with and without PHC. The extra facilities in the PHC villages include: a paid Community Health Nurse for about every 5 villages, a Village Health Worker and a trained Traditional Birth Attendant. Maternal and child health services with a vaccination programme are accessible to residents in both PHC and non‐PHC villages. The data indicate that there has been a marked improvement in infant and under‐five mortality in both sets of villages. Following the establishment of the PHC system in 1983, infant mortality dropped from 134/1000 in 1982–83 to 69/1000 in 1992–94 in the PHC villages and from 155/1000 to 91/1000 in the non‐PHC villages over the same period. Between 1982 and 83 and 1992–94, the death rates for children aged 1–4 fell from 42/1000 to 28/1000 in the PHC villages and from 45/1000 to 38/1000 in the non‐PHC villages. Since 1994, when supervision of the PHC system has weakened, infant mortality rates in the PHC villages have risen to 89/1000 in 1994–96. The rates in the non‐PHC villages fell to 78/1000 for this period. The under‐five mortality rates in both sets of villages have converged to 34/1000 for 1994–96. When the PHC programme was well supported in the 1980s, we saw significantly lower mortality rates for the 1–4‐year‐olds. These differences disappeared when support for PHC was reduced after 1994. The differential effects on infant mortality are less clear cut.

Community-Based Interventions for Improving Perinatal and Neonatal Health Outcomes in Developing Countries: A Review of the Evidence

“…272,291,292 The impact of the intervention on IMR also was mixed. 291,293 conclusions. There is strong evidence for the efficacy of ITNs in reducing childhood mortality and morbidity from malaria.…”

The contribution of primary care to health and health systems in low- and middle-income countries: A critical review of major primary care initiatives

“…More recently, several Latin American countries have invested heavily in primary care expansion with impressive results. Furthermore, several of the reforms in Latin America were implemented with a rigorous evaluation component, (Magnani et al, 1996) Niger X X (Pence et al, 2007) Ghana XXX (Hill et al, 2000) Gambia XX (Pannarunothai et al, 2000) Thailand X X X (Vapattanawong et al, 2007) Thailand XX (Wysocki et al, 1990) Southeast Asia X (Withanachchi et al, 2006) Sri Lanka X X (Fernando, 2000) Sri Lanka X X (Jayasinghe, 2004) Sri Lanka X X X X (Nair, 2004) Kerala, India X X X (Nag, 1988) Kerala, India X X (Varatharajan et al, 2004) Kerala, India X X (Aghajanian et al providing strong evidence of their effectiveness ( (Mullan & Frehywot, 2007). The integration of improved child health and chronic disease services as well as HIV diagnosis and treatment with primary care at the community level has been demonstrated to be successful in even the most resource-constrained countries and has resulted in improving geographic availability of life-saving services to rural populations.…”

“…In Afghanistan, where the government and its development partners have been contracting with NGOs to deliver a standardized package of primary care services, under-five mortality has declined from 257 in 2001 to 191 in 2006 (Ministry of Public Health of Afghanistan, 2008). Several additional countries reported positive impacts, generally on underfive mortality, from a range of primary care programs (Brockerhoff & Derose, 1996;Dugbatey, 1999;Hill, MacLeod, Joof, Gomez, & Walraven, 2000;Magnani et al, 1996;Pence, Nyarko, Phillips, & Debpuur, 2007;Perry, Shanklin, & Schroeder, 2003;Perry et al, 1998;Velema, Alihonou, Gandaho, & Hounye, 1991). While it is not possible to unequivocally attribute mortality reductions to primary care alone in these countries, as all of the initiatives involved multiple components, it is likely that the concerted effort to strengthen primary care services was a core contributor to the observed declines.…”

Traditional Birth Attendants in Rural Gambia: Beyond Health to Social Cohesion

“…It includes the classification of primary healthcare key villages based on size and population of 400 or more, so that they receive Community Health Nurses (CHNs) who are trained by the Medical and Health Department and paid from central funds provided by international donors and government. 8,10 CHNs are the link between village-level primary healthcare services and referral services available at dispensaries, health centres and hospitals. Each of the CHNs is responsible for the supplies, supervision and continuing education of the village health workers (VHWs) and trained TBAs in about five primary healthcare key villages.…”