101504 Maternal and Child Nutrition and Health Results Project Technical Brief: The Gambia December 2015 Health, Nutrition, and Population Global Practice Impact Evaluation Baseline Report: Child Health and Nutrition Key Messages •• Moderate to severe stunting, wasting, and underweight affected 25 percent, 10 percent, and 20 percent of children under five, respectively. •• Of children whose growth was monitored in the previous six months, 45 percent were clas- sified as malnourished; only one-third of them were referred to nutrition services. •• A notable discrepancy existed between mothers who had heard about exclusive breastfeed- ing until the age of six months (92 percent) and those who reported p ­ racticing it (49 percent). •• Care seeking for reported childhood illness was low, particularly for malnutrition and diarrhea. 25% •• The overall coverage of childhood vaccination was high, but coverage of vitamin A supple- mentation and Mebendazole remained low, particularly in the Upper River Region (URR). of children under 5 are stunted •• Only 23 percent of health workers knew when to give standard vaccines. •• Regular stockouts of critical drugs and vaccines hindered care, especially in the North Bank Region West (NBR-W). Introduction regions: Central River Region (CRR), NBR-W, The government of The Gambia is implement- and URR. Its purpose was to establish a ing the Maternal and Child Nutrition and Health baseline against which project performance will Results Project (MCNHRP) to increase the use be assessed in the future. This technical brief of community nutrition and primary maternal summarizes the baseline report findings and child health services. In collaboration with related to child health and nutrition. the government, the World Bank is conducting an impact evaluation to assess the project’s Child Malnutrition impact on key aspects of maternal and child Child malnutrition levels were high. Moderate nutrition and health. The MCNHRP baseline to severe stunting, wasting, and underweight evaluation was conducted between November affected 25 percent, 10 percent, and 20 ­percent 2014 and February 2015. Quantitative and respectively. As can be of children under five, ­ qualitative data were collected on three expected, the prevalence of moderate to This brief was prepared by a core team comprising Laura Ferguson (Principal Investigator, University of Southern This series of policy briefs was produced in direct California), Rifat Hasan (co-Principal Investigator, Health Specialist, World Bank), and Sneha Paranandi based on the response to a request from the government of The Impact Evaluation Baseline Report produced by Laura Ferguson, Rifat Hasan, Guenther Fink, Yaya Jallow, and Gambia to share the findings of the Maternal and Chantelle Boudreaux. The Impact Evaluation Baseline Report benefited from substantial inputs from the Gambia Child Nutrition and Health Results Project Impact Evaluation Baseline Survey. Bureau of Statistics, Mariama Dibba, Halimatou Bah, Momodou Conteh, Sering Fye, Alexandra Nicholson, Hannah Thomas, and Steven Strozza. The team benefited from the general guidance of Vera Songwe (former Country Director), Louise Cord (Country Director), and Trina Haque (Health, Nutrition, and Population Practice Manager). Helpful comments were received from the Project Implementation Committee led by Modou Cheyassin Phall (Executive Director, The Gambia National Nutrition Agency) and comprised of Haddy Badjie, Abdou Aziz Ceesay, Ousman Ceesay, Modou Lamin Darboe, Malang Fofana, Catherine Gibba, Bakary Jallow, Musa Loum, Lamin Njie, and Matty Njie and Menno Mulder-Sibanda (Senior Nutrition Specialist, World Bank). The work was made possible by support from the Health Results Innovation Trust Fund. 1 Figure 1. Growth Monitoring and Referral for Acute Malnutrition in the Past Six Months 100 90 80 70 60 Percent 50 40 30 20 10 0 Nutrition status Identified as Referred after Given nutrition Referred to higher checked in the last malnourished identification of rehabilitation after level after initial 6 months malnourishment initial referral referral Central River Region North Bank Region West Upper River Region Average across three regions severe stunting decreased as wealth Among children whose growth was moni- increased (29 percent in the lowest wealth tored, approximately one-fifth were identified quintile compared to 18 percent in the as malnourished, but only 34 percent highest quintile). CRR had the highest rate of of these children were referred for additional moderate to severe stunting (28 percent), nutritional support; even fewer received compared with URR (23 percent) and nutritional rehabilitation services. Referrals NBR-W (22 percent). were particularly low in NBR-W and URR. Knowledge of the acceptable minimum diet was low, both in terms of minimum meal Breastfeeding frequency and dietary diversity, particularly in Breastfeeding is the best means of providing CRR. Overall, only 11 percent of mothers of infants with all of the energy and nutrients children under 24 months of age could they need during their first months of life and describe the minimum dietary variety, which protects against common childhood illnesses includes food categories such as dairy, such as diarrhea. The World Health 49% grains, fruits and vegetables, legumes, meat, and fortified baby food. In CRR, only 4 percent Organization (WHO) and UNICEF recommend that exclusive breastfeeding be established of mothers report exclusively within the first hour of life and that women of mothers could describe this variety along with breastfeeding their children exclusively breastfeed their children without the appropriate frequency of feeding young until the age of 6 months children. Village development committees noted additional food or water for at least six months. that community gardens are an important There is a notable discrepancy between source of dietary diversity. theoretical knowledge and actual practice. Although 92 percent of mothers reported Uptake of Nutrition Services having heard that infants should only con- Despite these high malnutrition levels, less sume breastmilk until the age of six months, than half of children under the age of five only 49 percent reported having done this. years had received growth monitoring in Furthermore, 45 percent stated that infants the six months before this survey (figure 1). should receive water in addition to breastmilk. Figure 2. Care Seeking for Children Under the Age of Five 100 90 80 70 60 Percent 50 40 30 20 10 0 Care Seeking Care Seeking Care Seeking Care Seeking Diarrhea Cough/Pneumonia Malaria/Fever Malnutrition Central River Region North Bank Region West Upper River Region Average across three regions 2 Figure 3. Vaccination and Prophylaxis Coverage 100 80 Percent 60 40 20 0 At least one At least one dose BCG: all children All three Pentavalent Rotavirus among of Mebendazole among doses among children children age ≥7 weeks children age >1 year age ≥5 months Central River Region North Bank Region West Upper River Region Average across three regions Note: Rotavirus vaccination protects against diarrheal disease. Mebendazole is a deworming treatment recommended for prophylactic use among children aged 12–59 months. Bacillus Calmette-Guerin (BCG) is a vaccine against tuberculosis. Pentavalent vaccine protects against diphtheria, tetanus, whooping cough (pertussis), hepatitis B, and haemophilus influenza type B (which causes meningitis, pneumonia, and otitis). Qualitative data suggest that health care and diarrhea, and especially in URR (figure 2). workers were disseminating information Care seeking for children under the age of widely highlighting that exclusive breast­ five, within the first 24 hours of exhibiting feeding is important to infant health, but symptoms, was higher among women in ­ women’s levels of knowledge as to why this is wealthier households and literate women. critical remained extremely low. Overall, only Caregivers have several available care options: 20 percent of women were able to list at least minor health centers (used by 31 percent), three advantages to breastfeeding infants. major health centers (11 percent), pharmacies (10 percent), and private clinics (8 percent). Childhood Illness Childhood vaccination is an effective tool Reported illness among children under five against diseases such as measles and ­ ffort “It takes a lot of time and e years of age was low. For example, the tuberculosis. Vaccine coverage was relatively to convince them that the child reported prevalence of malaria among high on average, but varied by type of vaccine does not need the ­ water as the children under five was approximately (figure 3). Mebendazole coverage was low; breast milk c­ ontains the water 0.5 percent. This is in line with a recent even in the province with the highest cover- for the baby.” estimate of national prevalence of malaria age (CRR), only 71 percent of children were – Health worker, URR among children aged 6–59 months of given at least one dose of Mebendazole, and 0.2 percent in 2014 (MOHSW 2015). in URR it was only 16 percent. Childhood illness lasted an average of two days with some variation by region and Health workers had low knowledge as to when standard vaccines should be given. 23% wealth quintile. For example, illness among Only 23 percent of nurses and doctors of nurses and doctors children from the lowest wealth quintile could accurately state the age at which the ­ accurately stated the age at lasted an average of 2.6 days compared with BCG vaccination should be  given. which the BCG vaccine should 1.6 days for children from the highest quintile. While 91 percent of children aged 6 to be given 59 months received at least one dose of Care-Seeking and Uptake of Child vitamin A supplementation, qualitative data Health Services indicated that repeat vitamin A supplemen- Care seeking for childhood illness was tation rates were much lower, particularly in relatively low, particularly for malnutrition CRR and URR. Figure 4. Client Satisfaction with Child Health Services a. The health facility is b. The health staff are courteous c. The health workers did a good clean and respectful job of explaining your child’s condition Agree Neutral Disagree 3 Figure 5. Availability of Vaccines at Health Facilities on the Day of the Survey 100 80 Percent 60 40 20 0 BCG Oral Polio Tetanus Measles Pentavalent Rotavirus Pneumococcal Toxoid Vaccine Central River Region North Bank Region West Upper River Region Average across three regions Note: BCG = Bacillus Calmette-Guerin. Only 41 percent of children under five with Figure 6. Availability of Improved Toilets and diarrhea received oral rehydration solution Handwashing Stations with Clean Water and Soap (ORS), with children in URR most likely to 100 receive ORS (57 percent) and those in CRR 90 least likely to receive it (23 percent). 80 Overall, adults were satisfied with cleanli- ness, waiting times, privacy, staff courtesy 70 41% Percentage and staff willingness to explain issues in the 60 facilities (figure 4). 50 of children under 5 who had 40 diarrhea received ORS Barriers to the Uptake of Child Health 30 Services 20 The most common factor affecting choice of 10 health facilities for children under the age of five 0 was proximity to the health facility (54 percent e t nd t th ag es es ird of respondents), followed by the availability ur co gh er w Th Fo Se Lo Av Hi of drugs (18 percent) and quality of care Wealth Quintile percent). Fees did not present a major barrier; (14 ­ Any improved toilet Handwashing station, only 8 percent of respondents overall reported clean water and soap paying to have their children seen and the average cost of those visits was $1.2.1 In URR, 19 percent cited the low cost of services as a childhood diseases. Overall, 35 percent consideration in their choice of health facility. of households reported having an improved Stockouts of essential drugs were toilet, 61 percent reported having an ­ common. For example, on the day of this unimproved toilet such as a pit latrine, and survey, only 33 percent of health facilities 4 percent reported having no toilet facili- had folic acid available for children and only ties. Families in URR were most likely to 8 percent of health facilities had ORS in report improved facilities (42 ­ percent), stock. Only 58 percent of facilities across whereas only 27 percent in CRR reported the three regions reported regular availability improved toilets. In NBR-W, 37 percent of Mebendazole, with availability in URR reported any kind of improved toilet. While (13 percent of facilities) of particular concern. 37 percent of households on average Availability of common vaccines was also reported having a handwashing station, it © 2015 International Bank for Reconstruction low (figure 5). In NBR-W, none of these varied substantially by region: 66 percent and Development / The World Bank. Some rights reserved. The findings, interpretations, vaccines was available at the time of the in URR to 18 percent in CRR. and conclusions expressed in this work do not survey. Disposable syringes and needles were There was a clear socioeconomic gradient necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments available only in two-thirds of facilities. evident across the study area with regard to they represent. The World Bank does not guarantee the availability of improved latrines as well as the accuracy of the data included in this work. This work is subject to a CC BY 3.0 IGO license Sanitation and Hygiene handwashing stations with clean water and (https://creativecommons.org/licenses/by/3.0/igo). Sanitation and hygiene are critical for soap (figure 6). The World Bank does not necessarily own each component of the content. It is your responsibility promoting child health and preventing to determine whether permission is needed for reuse and to obtain permission from the copyright Reference owner. If you have questions, email pubrights@   All fees were originally reported in Gambian Dalasis 1 MOHSW. 2015. “The Gambia Malaria Indicator Survey, worldbank.org. converted at 43 D = US $1. 2014.” Preliminary Report, MOHSW. SKU K8564 4