The Republic of Senegal (hereafter referred to as Senegal), is a west African country with a population of 16.30 million in 2019 according to the World Bank [1]. Senegal has been one of Africa’s most stable countries in the past two decades. It is a lower-middle-income country with a gross national income (GNI) per capita and gross domestic product (GDP) slightly lower than Sub-Saharan Africa (SSA) average [2]. Senegal has a very young population and over half of its people live in rural areas [3]. Though basic infrastructure is not robust in Senegal, it outperforms most of the SSA countries in several aspects (Refer to Annex 1 for more political, economic, social and technological analysis of Senegal) [10]. Paralleling with world’s trend, Senegal’s spectrum of disease burden has shifted from infectious diseases to non-communicable diseases while neonatal disorders and undernutrition posing the heaviest disease burden [4]. The nutrition crisis in Senegal is further intensified by the novel coronavirus 2019 (COVID-19) pandemic though Senegalese’s life expectancy is substantially higher than that of other SSA countries [4, 5]. Besides, there are huge gap between rural and urban, higher-income and lower-income populations with regards to their healthcare access and health status [4, 6]. The Healthcare Access and Quality (HAQ) Index of Senegal ranks 175 out of the 195 countries being measured [7].
Senegal is one of the major recipients of international development assistance in west Africa. In 2017, Senegal received $909.8 million oversea development aid (ODA) in total, ranking 27th among countries receiving any ODA worldwide [8]. Health sector is the second largest ODA beneficiary in Senegal—20.5% of the ODA received by Senegal are for health [9]. The key donor agencies providing funds for health activities are the Japan International Cooperation Agency (JICA), Global Fund to Fight AIDS (USAID), Tuberculosis and Malaria (GFATM), the World Bank, The Global Alliance for Vaccines and Immunisation (Gavi), and the United States Agency for International Development (USAID). China has been sending medical teams to Senegal since 1975. In 2018, China supported the construction of the Maternal and Child Hospital in Senegal and additional donation of 634,000 RMB worth of medicines and medical equipment. In 2013, China’s government launched the Belt and Road Initiative (BRI) to strengthen cooperation between countries and international organization along the 21st century Silk Road, with its focus on trade and health assistance. Senegal joined BRI in 2018, becoming the first participating country in western Africa.
With the Forum of China-Africa Cooperation (FOCAC) related preparations taking place in China, the authors conducted a review and analysis of the health situation of Senegal to provide a view on what international assistances can focus and support the Senegal to meet its Sustainable Development Goals (SDGs) of health-related targets. The authors took the references of the Harvard University Health System assessment criteria from the published papers and structured an assessment tool covering the elements of population health, health service, health human resources, health financing, and global health cooperation [10]. the data on this report was obtained from peer review journals and United Nations (UN) Agencies’ websites, as well as interviews of global health experts for this report.
Population Health
Senegalese people’s health development outperforms most of the SSA countries and other countries comparable in economic development. Life expectancy at birth is 67.4 year in 2017, which is higher than SSA average [11]. Life expectancy at birth raised by almost 10 years from 2000 to 2017, and under-five and under-one mortality and premature deaths due to infectious diseases such as lower respiratory tract infections, diarrheal diseases, tuberculosis, malaria and HIV/AIDS have all declined considerably [4].The maternal mortality ratio (MMR), while still high, has steadily declined, from 401 deaths per 100,000 live births in 2005 to 236 in 2017 [12].
However, there are substantial room for further improving Senegalese’ health as most of their burdensome health conditions are preventable [4]. In the past 10 years, neonatal disorders have been the most serious killer of Senegalese—accounting for 8.98% of all deaths and 34.9% of under five deaths in 2017 [4]. In addition, dietary iron deficiency has been the number one cause of disability in Senegal since 2007 [4]. The most dramatic health effects of anemia—increased risk of maternal and child mortality due to severe anemia, have been well documented. Vitamin and mineral deficiencies have been associated with pregnancy complications and poor birth and infant outcomes. And studies have indicated that undernutrition particularly iron-deficient anemia drives the most death and disability combined in Senegal [4].
The Ministry of Health and Social Affairs (MSAS) of Senegal recognizes that maternal and child health and nutrition are its priority [13]. The World Health Organization (WHO) also identified the areas of maternal, newborn, child and adolescent health, particularly nutrition, as a priority for Senegal [14]. In a stakeholder meeting organized by WHO, stakeholders agreed that health system financing and Universal Health Coverage (UHC) as well as maternal and child health were among the top priorities of the health care system [14].
Maternal and Child Health
With neonatal disorders and undernutrition found to be the most burdensome health conditions in Senegal, it is imperative to examine the root cause of these disorders. Among 45 out of 1,000 children not able to survive their fifth birthday in Senegal [15], significant geographic variations exist in various regions in country—the south-east region of Kedougou and Kolda have the highest under-five mortality rates in Senegal while Dakar has the lowest, which is in line with the distribution pattern of Senegal’s health and other resources [4]. Neonatal disorder—the number one cause of under-five children’s deaths in Senegal—accounts for 34.9% of the total under-five deaths. there are three major contributors to deaths (in order of magnitude) of premature birth, birth asphyxia, and neonatal infections [4]. While study specifically on neonatal disorders in Senegal is absent, studies among other populations have shown that high burden of neonatal conditions is associate with the high adolescent birth rate, high prevalence of anemia among women of childbearing age, low proportion of pregnant women have access to antenatal care, low proportion of births attended by skilled professionals, and low rate of postnatal check-up [15]. The statistics on those indicators show that lessening the burden of neonatal conditions and undernutrition need to take an integrated approach to tackle multiple causes in order to reverse the trends in mortality (Table 1) [15].
Table 1
Maternal and Child Health indicators in Senegal, 2018
Indicator name
|
Statistics
|
Adolescent birth rate
|
18%
|
Proportion of pregnant women have access to antenatal care
|
47%
|
Proportion of births attended by skilled professionals
|
68%
|
Rate of postnatal check-up
|
50%
|
Early initiation of breastfeeding
|
34%
|
Exclusive breastfeeding (0–5 months)5 chil
|
42%
|
Continued breastfeeding (20–23 months)
|
40%
|
Proportion of children under 5 years old anemic
|
67.9% (2016)
|
Proportion of pregnant women anemic
|
58.1% (2016)
|
Anemia among women of childbearing age
|
54%
|
Vitamin A two-dose coverage
|
58%
|
Under five children with diarrhea receive oral rehydration salts
|
32%
|
Percentage of households consuming iodized salt (> 0 ppm) among all tested households (%)
|
62%
|
Data source: UNICEF, 2018, Available from https://data.unicef.org/country/sen/ |
In Senegal, nutrition deficiency has caused the most disability among under-five children in Senegal—iron deficiency, Vitamin A deficiency, and neonatal disorders are the top three contributors of under-five children’s year lived with disability (YLD), account for 20.7%, 14.8%, and 13.7% of the total number of under-five children’s YLD respectively [4]. Besides, 18.8% of the children under five years old are stunted; at the same time, 8.8% of the children are suffering from wasting in 2019 [15]. Even though these are lower than SSA averages, the proportion of under five children stunted or wasted have not been decline steadily like most countries do in recent years. Furthermore, almost one fifth of live births in Senegal were born with low birth weight, which jeopardizes critical early childhood development prospects [16]. As poor nutrition has proven to be an important cause of premature death, we believe that undernutrition, as the driver of most death and disability combined, is the most serious health problem in Senegal, especially for children under five years of age. Moreover, the coronavirus disease is exacerbating fragile contexts in West and Central Africa. It was reported by the United Nations Children’s Fund (UNICEF) that Senegal, Burkina Faso, Chad, Mali, Mauritania and Niger are anticipated to suffer from more acute undernutrition in 2020 due the COVID-19 pandemic, with the number of acute undernutrition cases anticipated to jump from 4.5 million to almost 5.4 million [17].
Studies showed that extending nutrition and growth promotion intervention into rural areas through non-governmental organization (NGO) service providers, and that integrating proven nutrition interventions into health programs at community level improved access to and use of antenatal care, delivery services, and postnatal care by women in Senegal [18, 19]. The WHO performed a Community Nutrition Project (CNP) in Senegal. It provided underweight 6- to 35-month-old children of underweight in urban Senegal with growth monitoring/promotion and food supplementation, and education for mothers for a period of 6 months. However, they did not find no impact was demonstrated in their intervention zone and they suggested six months of CNP services may not be sufficient for catch-up growth of severely underweight children, indicating longer term programming is needed [20, 21]. Certainly more research on the effective interventions to the high burden of undernutrition and neonatal disorders is needed,
Health service delivery
The health system of Senegal is governed by MSAS, shouldering the responsibilities for national diseases control and prevention, monitoring the national health and social development progress, conducting national health strategic planning with the support from other local government ministries and international partners, regulating health resources together with the Ministry of Community Development and the National Pharmacy Agency, implementing new policies and programs with support from government and non-governmental organizations locally and internationally.
The health service delivery system in Senegal is a four-level pyramid structure with provision of the services by the public, private, and nonprofit entities [22]. The public sector runs mainly facilities at central and regional level [23]. the private service providers are a significant source of health service for the Senegalese, especially in and around Dakar where 72% of private facilities are located [24]. Private facilities are guided by the same policies and regulations as the general health system. The nonprofit sector plays a small but important role in health service provision in Senegal. This is particularly true in rural and peri-urban areas where NGO clinics fill a critical healthcare coverage gap. The way nonprofit organizations operate hospitals, clinics, and medical practices is similar to those described above in the private for-profit sector. However, different from for-profit facilities, nonprofit networks are closely linked with nearby public sector health structures and often act as reference clinics for public sector clients. These close relationships can include invitations to public sector trainings that take place in areas where NGO clinics are located.
As a lower-middle-income country, Senegal has a well-structured health care delivery system [11]. However, it is facing a severe shortage of health workers. WHO estimated that the physician to population ratio was 0.1 per 1000 people and the ratio for nurses and midwives was 0.3 per 1000 people in 2016 [25]. These figures are lower than SSA averages and countries with a similar economic status [26]. The shortage of health workers is even more severe in rural Senegal. The capital Dakar has 70% of all specialist doctors and 39% of all general practitioners serving only 24% of the population while 76% of the population live outside Dakar [27]. Similarly, while the capital has 2 physicians per 10,000 population, Kolda, Fatick, Kaolack, and Matam regions have less than 0.4 per 10,000 [28]. These circumstances combined with the absence of continued training on medical topics after university education have resulted in a very low motivation and effectiveness of their work.
Severe shortage of health professionals and weak performance of health workers make health human resource capacity building one of the top issues to tackle in Senegal. In short term, having specialized organizations with local experience to conduct continuing training of doctors, nurses, midwives, community health workers (CHWs), and relais (outreach person) in rural villages on skill-based training related in compliances to operation guideline, Child delivery technics in low-resource settings, and management of complications around child birth, etc. In the long run, development partners need to assist Senegal in building its health human resources through training and continuous education. WHO and World Bank can help MSAS to design an effective and sustainable mechanism for health human resource financing. Local NGOs and donors can focus on improving compensation to health workers in rural places should also a priority for global health assistance.
Health Financing
Senegal spends 5.5% of its GDP on health, which is higher than both SSA average and lower-middle-income countries’ average [3]. And health expenditure takes 6.1% of the total government expenditure, which is also higher than the average of its peer lower-middle-income countries [3]. Total health expenditure is estimated at $69 per person per year in 2016 [4]. The major sources of health financing are the government, health insurance funds international development assistance for health, and out-of-pocket expenditures. And while overall health expenditure increases in the past 25 years, out-of-pocket expenditures see the greatest increase compared to other sources of expenditure [4]. Recent data indicates $34 out of the $69 of health expenditure were estimated to be paid by patients out of their own pockets, which is much higher than SSA average [4, 27]. Health expenditure has put great burden on its people—according to the World Bank, nearly 35% of the population faces impoverishment due to the heavy burden of out-of-pocket payments such as user fees [29].
Public healthcare providers are paid on a fee-for-service basis, with the total amount of reimbursement payment dependent on an annual global budget that set by the government. The aim for global budget is to contain the cost of health providers, where healthcare fee exceeding the budget will not be reimbursed by the government.
Recognizing the financial constrains in accessing healthcare services and in order to reduce out-of-pocket expenditure, Senegal launched its UHC program in 2013. The UHC Strategic Plan is funded through a combination of government subsidies, household contributions, and external funding from development partners. In 2016, after the roll-out of the reform, domestic general government health expenditure increased from 27–35% compared to 2013, and the out-of-pocket expenditure decreased from 55–51% [30]. However, despite the efforts from the government to reforming compulsory health insurance, the social health insurance and voluntary health insurance still only accounts for 4% and 5% respectively [31].
Healthcare Access and Equity
Due to long distance to health facilities, limited transportation means, and environmental conditions (sandy or muddy roads), it was reported that only 32% of rural households have regular access to healthcare facilities [32]. Half of the rural residents indicated that health services are too far from their residency or not even exist [33]. Senegal is the same as in most SSA countries, the health resources are concentrated in the capital. As a result, there are vast variations in health care provision and health outcomes between rural and urban residences and between low-income and high-income patient groups. Furthermore, population whose income fall into the lowest 20% of the income distribution, which represents 68% of the population, cannot use maternal and child health services for economic reasons [6]. Studies have indicated that geographic disparity in maternal and child health outcomes are also consistent with the geographic distribution of wealth [33].
Despite that the Government of Senegal has launched initiative to provide free health care services for pregnant women and under-five children, they still have limited access to antenatal and postnatal care due to lack of health facilities, skilled medical personnel, and nutritional resources within reachable distance. Mladovky indicated that Senegal’s UHC system is fragmented and may have contributed to the inefficiency, inequity and ineffectiveness of its ability to reduce poverty and promote health, and interventions to reduce fragmentation of UHC may be missing [34]. By experimenting interventions on both supply- and demand-sides of Senegal’s health systems to examine effectiveness of interventions to reduce inequity, Parmar et al.. found that the rich benefit more from the supply-side intervention (improving the availability of maternal health services) while those living in poverty benefit more from the demand-side intervention (abolished user fees for facility deliveries) [35].
Rural and poorer communities are in dire need of more accessible, equitable, and quality health care, the development research is needed in new models of financial models and tools beyond to make further improvements in access and quality care services for poor.
Global Health Cooperation
The key global players in the field of health assistance in Senegal include UNICEF, WHO, World Bank, Gavi, JICA, GFATM, and USAID. The health assistance approaches adopted by key donor countries or organizations to work with Senegal MSAS can be summarized as: (1) direct budgeted support, (2) direct technical support, and (3) specific strategies and projects implementation by donors.
Yet in practice, the lack of government resources to implement some of the policies and strategies jointly developed poses a risk to the sustainability of results achieved. There are needs to anticipate alternative sources for resource mobilization and the support of partners for the implementation and uptake of these important results of its joint work with local governmental agencies and other partners. In addition, many stakeholders considered that the national context and priorities continued to evolve and advocated for a revitalized strategic planning process marked by more dynamic cycles, incorporating systematic evaluations and increased flexibility to adjust to country needs in a more focused manner. Finally, coordination mechanisms are limited and aid at the regional level is fragmented while external funds finance a substantial share of total health expenditures in Senegal (21%). On the one hand, donors complement each other by supporting different regions, but this contributes to fragmentation, with several systems being used, increasing inefficiencies in uptake by the national government. Furthermore, only 45% of participating development partners have communicated their resources for the next three years to the MSAS, it poses challenges to the MSAS’s own planning and budgeting [36].
In order to achieve more effective use of health resources, it is imperative to build capacity to the local government agencies to take a more active and stronger role in coordinating the distribution of development assistances to their own regions. Another aspect can be considered is incorporating a theory of change that can better frame the pathway for change, including a clear priority-setting process and targets with indicators for both the expected outcome and output levels, and clarify the expected contribution from all levels of the organization in a measurable manner, allowing the monitoring of performance and target achievement.