This study highlights the poor working conditions for Senegalese HWs - exacerbated by the implementation of UHC - especially in rural areas. The frequent delays in reimbursement for UHC-related services, which healthcare facilities pre-finance, was one of the main issues negatively impacting the organization and functioning of healthcare facilities (37–39). Our results highlight that these UHC-related financial issues contribute to the poor HWs’ working conditions in three different ways: i) lack of motivation caused by the late payment of wages; ii) difficulties in providing quality services due to frequent drug and material stock-outs; and iii) patient dissatisfaction with expected UHC-related services, which led to a deterioration of the patient-HW relationship. With regard to the latter point, the patient-HW relationship plays a crucial role in the day-to-day activities of HWs (27, 40), especially in rural areas, where the UHC programs are supposed to help the most.
The deleterious impact of UHC highlighted by HWs from rural areas compounded pre-existing adverse working conditions for them including a lack of medical equipment and a lack of training/knowledge opportunities, factors identified by participants as being important for the retention of HWs in these areas (24, 26, 27, 41, 42). In this context, where structural factors compromise the continuum and quality of care (39, 43, 44), HWs are constrained to make additional efforts to preserve patient trust in the health system. Although HWs who worked in urban areas also highlighted a lack of equipment, the main issue in these areas was the lack of specialized personnel for equipment maintenance. For these professionals, this was a major obstacle to ensuring quality health services. In turn, the consequence was a shorter job tenure, especially for doctors (12, 24). All these results demonstrate that strategies for the improvement of HWs’ working conditions and job retention should consider the specific needs of HWs according to the position of their healthcare structure in the health system pyramid, the composition of the HW staff in the structure and the predominant activities performed there (diagnoses, treatment and/or prevention) (24, 26, 42). Furthermore, our results highlight that HW retention in rural areas also depends on opportunities for training/knowledge acquisition that contribute to the improvement of human capital, and by consequence to the quality of care provided (45–47). Financial issues such as low wages, scarce/inexistent opportunities for complementary income from a second job, and contract insecurity are also factors that must be taken into account in public policies promoting HW retention in rural areas (23, 26, 49, 52). Furthermore, our results demonstrate that improving the working environment as a strategy for HW retention in rural areas should be combined with improving these professionals’ living conditions. Specifically, our results highlight that the distance from one’s family is an important obstacle to retention in rural areas of HWs coming from an urban setting. However, this is not the case for local HWs from rural areas who work in proximity to their family and their community. Working close to one’s loved ones strengthens engagement with the community, which in turn partially counterbalances poor working conditions. For example, our study shows that there is little mobility among CHWs and that their activity is mostly driven by non-financial motivations such as faith, dedication, and recognition. This reflects previous findings (26).
This study has limitations. First, it was conducted in the Fatick and Kédougou regions which host the two main demographic observatories in Senegal. This may have introduced desirability bias. However, the survey was implemented by trained researchers not known to the participants. Furthermore, the fact that the interviews were conducted separately for doctors and non-doctors limited any potential desirability bias due to hierarchical relationships. Second, urban-based HWs all came from only one healthcare structure in Dakar. The elements raised did not reflect the situation of all HWs in that region. Having said that, this structure is one of the biggest in the country, and offers a general overview of the organizational problems which urban healthcare structures in Senegal face. Indeed, given that this important structure faced financial difficulties, and a lack of both equipment and human resources, we can suppose that smaller structures are also confronted with these problems.
Our study provides in-depth information about the situation of healthcare structures in rural areas of Senegal in the context of UHC implementation, and reopens the debate about the need for efficient public policies to retain HWs in rural areas. This includes CHWs, a population who despite indicating their satisfaction with the work they perform, still endure the poor working conditions highlighted by other HWs in our study. More specifically, these policies should consider the lessons learned on the ground about how the engagement of CHWs with their community and their proximity to their family helps the health system to function, despite their working conditions. Moreover, our findings highlight that increasing medical density and improving HW retention in rural areas requires cross-sectoral cooperation (education, housing, transport, etc.) to facilitate the process of families moving to rural areas (8, 27, 32–36). Solving pre-existing issues concerning HWs’ working conditions would appear to be a fundamental step for the continued implementation of UHC in Senegal.