Healthcare in Senegal

In 2019, there were 1,347 medical facilities in Senegal, including 13 regional hospitals, 5 national hospitals and two university hospitals. The largest number of hospitals was in the Dakar Region. There was no regional hospital in the Kédougou Region.[3]

In 1999, 53% of health funding came from the government, 11% from individuals, 6% from communities, and 30% from international partners. Of a household's health expenditures, 89% is out-of-pocket spending while 11% is in the form of health insurance contributions.[10] Additionally, only 15.2% of Senegalese people have health insurance, most of whom work in the formal sector.[10] On average, a facility charges 2.90 USD for inpatient care for the median length of stay (five days), 0.43 USD for adult outpatient care, and 0.24 USD for children's outpatient care. In terms of expanding health insurance, it seems that policies that will reduce the negative effect of the time lost to seek care by workers, or policies that will increase the accessibility and the quality of care, will be more effective to increase health care utilization than would the introduction of health insurance to those who do not yet have it.[10]

One of the most influential pieces to the transformation of Senegal's healthcare system in the late 1990s was the Bamako Initiative. The Bamako Initiative started in 1987, when health ministers from two dozen African countries met with representatives of WHO and UNICEF to discuss the limited success of health care strategies in Africa and the need for intervention.[11] At the conference, leaders agreed to provide a minimum of health care services with severely reduced social services budgets. As a result of the meeting, major changes to Senegal's health system occurred. The meeting resulted in the decentralization of Senegal's health sector, which some critics believe has brought about chaos in local governments and administration in Senegal.

The Bamako Initiative also led to the establishment of health committees in Senegal in 1992. The committees strive to meet three central goals: to promote health of their community, to mobilize the community around health development, and to improve the quality of services rendered at their health post, clinic, or hospital.[11] In practice, the committees have not been completely representative, and have become problematic to clinic staff and medical personnel. Women have been almost entirely absent from committee elections and seldom are selected for committee boards. Rather, these boards are held by males who may ignore the needs of women, children, and the disadvantaged in their committees. Critics believe the committees have been characterized by mismanagement, mistrust, and a lack of transparency. Despite these issues, there have been significant gains from the Bamako Initiative and health committees. The changes have led to the improved availability of pharmaceuticals, and have also made up for the shortage of health personnel in many instances.[11]

Decentralization began in the late 1990s, following the Bamako initiative. The key goal has been to make the state more responsive and adaptable to local and regional needs, as opposed to when administrative power and responsibility were concentrated more centrally.[11] This has resulted in more accountability and real power on part of local officials. The state funds a significant portion of the local health budget, but health targets, goals, and interventions are determined at the local level. However, because most local officials have no training on how decentralization should work; there has been a vacuum in terms of planning and management, and weak institutional capacity and the few resources to allocate among increasing responsibilities have exacerbated issues.[11] Decentralization has failed in two major ways: the first three years failed to render politics and local government more participatory and more responsive to local communities, and there has been no attention to gender equality and participation. Decentralization has meant that authorities have completely failed to engage with women's situations and concerns. There have been additional issues in creating conflicts between city officials and medical district officers over disbursement of money for the health sector.[12]

In addition to changes with the Bamako Initiative and decentralization, Senegalese healthcare has become privatized. Privatization in Senegal has meant that user fees and the sales of pharmaceuticals finance a significant part of the health sector.[11] The state still funds the health sector by paying salaries of state employees and giving each district a discretionary budget each year that it decides. However, user fees and pharmaceutical sales are only the most evident parts of the privatized health system in Senegal. Now, patients must buy a ticket to stand in line and receive care at a health clinic, which can be particularly problematic for mothers, the elderly, and the poorest of the poor.[11] Moreover, hospitals require even more available cash. The effects of privatization in have especially disadvantaged women, because they typically manage the health of the household. Additionally, many preventable deaths have occurred as a direct result of privatization.

Some of the greatest barriers to health care utilization include lack of information, lack of communication, low number of health care workers, and social and religious barriers. Currently, there is a strong need for strategies to empower and better support the knowledge role of health coordinators and supervisors.[13] Additionally, the lack of access to current, relevant information by health professionals and decision-makers in Senegal has been problematic. Moreover, health workers desire information on ways to motivate men's involvement in reproductive health and to address rumors and religious barriers to family planning, which have hindered women's health care utilization.[13]

Some Senegalese people, particularly in rural areas, face inadequate access to medicines and prescriptions. Improving access to medicine is a priority in developing nations like Senegal.[14] In 2001, Senegal had only 520 pharmacies (1 per 18,320 people) and 731 health centers (1 per 13,032 people). Access to medicine in Senegal may be limited in three main areas: inadequate supply of drugs, including critical drugs missing in health centers and pharmacies; insufficient health infrastructures to cover needs of the entire population; and high costs of drugs, which are sometimes higher than the minimum price, which can be problematic for the poorest of the poor.[14]

Major disparities exist in health care access for those living in urban versus rural areas. Approximately 70% of doctors and 80% of pharmacists and dentists are located in Dakar, the capital city. However, only 42% of the Senegalese population lives in urban areas, such as Dakar, which means that few doctors are available to rural residents.[15] Of every 10,000 women who give birth, 24 will die in urban areas, but nearly 100 will die in rural areas.[5] Additionally, there are major disparities in children's nutrition in urban versus rural areas, with those in rural areas being more heavily disadvantaged.[1] Therefore, great attention may be placed on narrowing the gap between urban and rural healthcare access.

Ambulance in Agnam-Goly, 2006

First local hospital ambulance with driver, Ziguinchor, 1973

Often, distance from health care facilities, rough roads, and improper means of transportation limit healthcare access in Senegal. For 80.5% of households, the poorly equipped health post is the only accessible health facility in an average distance of 4.3 kilometers.[5] The closest high-level provider (i.e. a hospital) is located, on average, 20& km away from the village of the household. The improvement in the accessibility of health facilities through better road quality and better means of transport will have a positive effect on health care utilization.[10] Because of extreme distances and environmental conditions, such as muddy roads, only 32% of rural households have regular access to a health center and thereby access to a medical doctor.[5] There are two times more unpaved roads in Senegal than there are paved roads.[15] Often, there is trouble with transportation and vehicles in that non-governmental organizations, or NGOs, may not have a large enough fleet, or vehicles are inappropriate for terrain and dirt roads.[5] Some health centers have ambulances, but there is no plan for vehicle maintenance and replacement. Additionally, there are issues with the transportation of sick, pregnant women; if ambulances are not available, horse-drawn trailers may also be effective. The most effective avenue is to improve the mobility of health care providers rather than solely focusing on improving the mobility of rural populations, which requires far less structural support and funding than does providing transportation for every household.[5]

Midwife and birthing bed at an island in the Sine Saloum in Senegal, 2006.

Maternal mortality rates in Senegal remain high relative to those of more developed countries. In 2008, the World Health Organization estimated a maternal mortality rate of 450 deaths per 100,000 live births in Senegal.[16] Maternal deaths are typically clustered around labor, delivery, and the immediate postpartum period. One of the most prevalent issues is the regional imbalance in the distribution of health personnel and health indicators, with a disproportionate burden of disease in Eastern Senegal. Expanding coverage of healthcare workers present at birth, in particular midwifery care, can lessen delays, thus minimizing the risk of severe complications and even death. Increased numbers of health workers in a given region is associated with improved outcomes in maternal mortality. Additionally, extreme conservative practices and fundamentalism can limit dispersal of health personnel, especially that of midwives and other female health workers.[16]

In Senegal, gender relations have been largely ignored in processes of decentralization and implementation of community management strategies.[11] One of the key problems resulting in changes to the health sector is that elected officials and health sector personnel have failed to engage with women as potential leaders and participants in community health structures, instead viewing them in some cases as family health managers and targets of health education messages. As household health managers and primary consumers of public health care, women are intimately connected with realities of managing illness and seeking medical treatment. However, in spite of their marginalization, women are not completely passive in the face of disease. As an example, some women have created networks of service providers in the informal sector for the majority of health care needs in the region of Pikine.[11]

Social opposition to women's rights and agency have, as some have argued, barred women from receiving necessary choice and capabilities in regard to family planning, abortions, and sexual health.[17] Health services targeted at women primarily concern childbearing. As a result, diseases like cancer or infertility, or those linked to menopause or violence, may be ignored. In Senegal, a large number of health care providers believe unmarried women should not be given information on family planning methods. Moreover, the Senegalese government has in some cases failed to enforce international human rights treaties it has already signed, some of which protect women's health services and rights. Also, women's groups in Senegal have not made sexual health a priority, as some believe they should.[17]

One of the major proposed solutions to solving issues within the realm of maternal health care is the inclusion of membership in community-based health insurance plans (CBHI). CHBI schemes are voluntary, non-profit health insurance schemes organized and managed at the community level.[18] In developing nations, CBHI plans are seen as a mechanism to meet health-financing needs of rural informal sector households. CHBI has been incorporated into the national health financing strategy in Senegal. CBHI increases facility-based maternal health services by reducing direct payments, thus facilitating timely use of healthcare. It is beneficial in guarding households against unpredictable and potentially catastrophic medical fees associated with pregnancy-related complications. It can also increase women's interaction with the formal health care sector through its coverage of non-maternal health services. The most important element is the inclusion of maternal health care in any CBHI benefits package, which makes the most significant difference. CBHI plans can increase the demand for and quality of maternal care though requiring certain standards in contracts with health facilities.[18] However, membership in a CBHI scheme is not always sufficient in influencing maternal health behaviors.

In some countries, community health workers, or CHWs, act as a bridge between the health care delivery system and the community, and ensure that people receive adequate primary health care.[19] CHWs are part of a larger goal to find appropriate strategies to improve the attraction and retention of health workers in remote and rural areas, which is particularly important in Senegal. CHWs may also empower the community to identify its needs. In Senegalese villages, CHWs are often unable to leave their home community for training and education, which has been a major obstacle for developing effective CHW schemes. Other obstacles include poor transportation, poverty, the need to run families, and the absence of an economic plan for CHW training. In particular, village populations in Senegal do not necessarily recognize in the CHW the skills necessary for outreach activities.[19]