Bulletin of the World Health Organization

Access to health care and mortality of children under 5 years of age in the Gambia: a case–control study

Merrin E Rutherford, John D Dockerty, Momodou Jasseh, Stephen RC Howie, Peter Herbison, David J Jeffries, Melissa Leach, Warren Stevens, Kim Mulholland, Richard A Adegbola & Philip C Hill


To assess whether traditional measures of access to health care (distance and travel time to a facility) and non-traditional measures (social and financial support indicators) are associated with mortality among children under 5 years of age in the Gambia.


We conducted a case–control study in a population under demographic surveillance. Cases (n = 140) were children under 5 years of age who died between 31 December 2003 and 30 April 2006. Each case was matched in age and sex to five controls (n = 700). Information was gathered by interviewing primary caregivers. The data were analysed using conditional logistic regression.


Of traditional measures of access, only rural versus urban/periurban residence was important: children from rural areas were more likely to die (OR: 4.9; 95% confidence interval, CI: 1.2–20.2). For non-traditional measures, children were more likely to die if their primary caregivers lacked help with meal preparation (OR: 2.3; 95% CI: 1.2–4.1), had no one to relax with (OR: 1.8; 95% CI: 1.1–2.9), had no one who could offer good advice (OR: 23.1; 95% CI: 4.3–123.4), had little say over how earned money was spent (OR: 12.7; 95% CI: 1.3–127.6), were unable to cut spending for health care (OR: 2.5; 95% CI: 1.5–4.2) or had to carry out odd jobs to pay for the care (OR: 3.4; 95% CI: 2.1–5.5). A protective effect was observed when the caregiver had other children to care for (OR: 0.2; 95% CI: 0.1–0.5).


Improving access to health-care for children in the Gambia and similar settings is not simply a matter of reducing travel time and distance to a health facility, but requires improvements in caregivers’ support networks and their access to the financial resources they need.