Abstract
According to the World Health Organizations (WHO) family medicine forms the bedrock upon for accessible, affordable and equitable healthcare for any country. The need for family doctors is more acute for low income countries like The Gambia. More so that The Gambian health infrastructure is suboptimal and appropriate health personnel is low. This is worsened by brain drain leading to poor health indices. Despite these challenges and more, the department of Family Medicine was accredited for training in the Gambia with improved infrastructure (at the training centre), with 7 residents. Though there are still challenges there are also opportunities and strengths. There is therefore hope that the right personnel will be produced for an improved Gambian health system.
Keywords: essential health; strengthen; family medicine; journey; Gambia.
Introduction and overview of The Gambia
The Republic of The Gambia is the smallest country within mainland Africa. It is nearly completely surrounded by Senegal, except for its western coast on the Atlantic Ocean. It is home to several ethnic groups, including Mandinka, Fula and Wolof, and has a population of approximately 2.4 million people. Its economy is reliant on agricultural exports and tourism.1,2
The Edward Francis Small Teaching Hospital (EFSTH) located in Banjul (Capital of The Gambia) established in 1894 as Royal Victoria Hospital, transformed into a teaching hospital for the School of Medicine and Allied Health Sciences of the University of The Gambia in 2002. It is the largest referral centre and the only tertiary and teaching hospital in the country.3
The 2021 country statistics shows that the healthcare infrastructure consists of the following: one teaching hospital, one specialist hospital, four district hospitals, six major health centres and 40 minor health centres. The major health centres are equipped to provide comprehensive emergency care, while minor health centres are equipped to provide basic emergency obstetrics and neonatal care. The public sector accounts for 88.97% of the total bed capacity in the country, while private-owned facilities and non-governmental Organisation (NGO) (owned) hospitals account for 11.03% of the bed capacity.4
Background and context
The Gambia has always endured a paucity of doctors. The medical school and several technical assistance programmes that provide doctors have added too few, mainly transient doctors, to make any meaningful impact on primary health care (PHC) delivery. Consequently, nurses lead all district hospitals and health centres. Occasionally junior doctors are posted there without appropriate supervision. The doctors commonly leave The Gambia in search of greener pastures and/or specialist training, which is not available in The Gambia.5
This paucity of doctors could be responsible for the poor health indices of The Gambia as shown by the 2019–2020 Demographic Health Survey: neonatal mortality 29/1000 live births; infant mortality 42/1000 live births; under-5 mortality rate 56/1000 live births; maternal mortality ratio 289/100 000 live births.6 It is noteworthy, however, that these values are an improvement on the indices prior to the 1980s implementation of PHC policies.7
It is obvious that the need for training and retention of doctors within The Gambia cannot be overstated. This need is most acute for family medicine, which provides doctors with the broad array of competences fit for manning regional hospitals. The effort to establish this training was given a boost by the visit of the West African College of Physicians (WACP) to the EFSTH in 2017.
The Establishment of family medicine in the Gambia was not without challenges. More so that it was previously unknown at the institutional level and was not taught at the undergraduate level. There is only one known Gambian who is a Fellow of WACP in family medicine. Hence to establish family medicine training in The Gambia, the EFSTH recruited Prof. Abraham N. Gyuse and two other consultants from Nigeria with the aid of the World Bank. The Department of Family Medicine was established on 21 September 2021 with seven residents amidst severe infrastructural and workforce deficits. Despite these constraints, team guided by Prof. Gyuse led the hospital to attain infrastructural and functional standards worthy of accreditation for training by the WACP in April 2023.
These included a massive infrastructural upgrade of the former polyclinic at EFSTH to serve as the main training complex. The clinical services at the complex are now physician-led and structured to meet global best practices and accreditation standards. The clinical environment has well-furnished consultation rooms, a resuscitation bay, procedure room and an observation ward. The complex also has a seminar room and a resource room (equipped with computers and 24-h internet services). The department also collaborates with the Clinical Service Department of Medical Research Council Unit (MRC) Gambia for further clinical exposure and research.
The advocacy and service delivery efforts of the new department have started yielding some fruit, with increasing awareness of family medicine at the institutional level and in the general Gambian public. Other specialists are also recognising the role of the specialty in healthcare delivery. The allure of the specialty has attracted four junior doctors who recently passed the family medicine primary examination of the WACP, thus can start specialist training.
It is hoped that once the Family Medicine Training Programme begins to graduate family physicians, they will be posted to all district hospitals in sufficient numbers with the needed skills-set to manage this level of the health services. This in turn should translate to improved patient outcomes country-wide, improved referral quality, improved patient satisfaction and consequently health indices. This should further convince policymakers, the medical fraternity and the health-seeking public on the positive role of family medicine in improving and strengthening the Gambian health services.
Challenges, however, still exist and include sustainability of good remuneration for trainers and residents; unrealistic expectations by the health-seeking public, health authorities and other specialists. The rural component of the training has not been provided with the necessary infrastructure for its take-off, and the University of the Gambia has not incorporated family medicine into her undergraduate training. This is summarised in a strengths, opportunities, weaknesses and threats (SWOT analysis) shown in Table 1.8
| TABLE 1: Strengths, opportunities, weaknesses and threats (SWOT analysis) of the current scenario of family medicine, primary care and primary health care in The Gambia according to the World Health Organization’s Four (4) Core strategic levers. |
Conclusion
The Gambian government is on the right trajectory to improving the country’s primary care services through Family Medicine training. It is hoped that this can be sustained and challenges addressed such that in the near future qualified specialist family doctors will be able to manage the district health services and continue with the training of others, leading to an improved primary health care delivery in The Gambia.
Acknowledgements
The Gambia is the smallest country by land mass on mainland Africa with a population of 2.4 million people. The health services are made of the private sector (11.03%) and public sector (88.97%) health facilities across three tiers of health service delivery including one teaching hospital. The country has experienced a paucity of doctors generally and family physicians in particular, resulting in abysmal healthcare indices, thus the need for training and retaining of family physician in The Gambia. The process of establishing a family medicine training programme while on track now was initially faced with challenges including absent faculty and appropriate man power (namely-doctors, nurses, laboratory scientist etc.) mix and infrastructural deficit to mention a few. Despite these challenges, progress has been made leading to the programme’s accreditation by the WACP Faculty of Family Medicine in April 2023. This training has the potential of improving the current health challenges and indices of The Gambia.
Competing interests
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
Authors’ contributions
A.N.G. conceptualised and the led the entire process from drafts all to the final submission. I.T.-A. and O.N. worked on additional literature search and writing, while J.P.M. and H.S. were involved in additional ideas, reflections and proofreading and correction of the article to ensure the accuracy of statement and grammar.
Ethical considerations
This article followed all ethical standards for research without direct contact with human or animal subjects.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
Data sharing is not applicable to this article as no new data were created or analysed in this study.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this article’s results, findings, and content.
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