Available via license: CC BY 4.0
Content may be subject to copyright.
Page 1/13
Senegal Health System Analysis and Its Implications to
Global Health Cooperation
Yue Zhang
NSD: Peking University National School of Development https://orcid.org/0000-0001-6984-3047
Jingyi Chen
Harvard University T H Chan School of Public Health
Chunfeng Zhang
NSD: Peking University National School of Development
Lucy Chen ( lucychen@nsd.pku.edu.cn )
NSD: Peking University National School of Development
Research Article
Keywords: Senegal, Global Health, Health System, Undernutrition, Maternal and child health
DOI: https://doi.org/10.21203/rs.3.rs-585164/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full
License
Page 2/13
Abstract
As an active participant of global health cooperation in west Africa, the Republic of Senegal is one of the major
recipients of international development assistance. Yet, funding and actions from different donors and implementing
organizations are fragmented, which is one of the reasons that Senegal is failing to outstand its health performance
disproportionally. This report provides an overview of Senegal’s population health status and health system
performance and pinpoint areas that should be prioritized for focused global health assistance. Undernutrition and
neonatal disorders were found to have posed the highest and most urgent risks on the public health of Senegal. This
is intensied by the severe shortage of health human resources, vast disparity of resources between rural and urban
areas, and unsatisfactory health nancing mechanism. Based on the situation analysis of Senegal’s population health
and health system, this report recommends (1) the Senegal MSAS to take the lead of integrating and coordinating
public, private, and international health programs to reduce fragmentation with a focus on nancing rural health
human resources; (2) to research the root causes of undernutrition and neonatal disorders in Senegal and construct
nutrition and maternal health interventions based on evidence generated; and (3) to conduct continued training of
doctors, nurses, midwives, community health workers with strong focus in Kedougou and Kolda.
Background
The Republic of Senegal (hereafter referred to as Senegal), is a west African country with a population of 16.30million
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 intensied 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 $909.8million oversea development aid (ODA) in total, ranking 27th among countries receiving any ODA
worldwide [8]. Health sector is the second largest ODA beneciary 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 rst 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
Page 3/13
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 nancing, 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-ve 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 ve deaths in 2017 [4]. In addition, dietary iron deciency 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
deciencies have been associated with pregnancy complications and poor birth and infant outcomes. And studies
have indicated that undernutrition particularly iron-decient 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 identied 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 nancing 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 fth
birthday in Senegal [15], signicant geographic variations exist in various regions in country—the south-east region of
Kedougou and Kolda have the highest under-ve 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-ve children’s deaths in Senegal—accounts for 34.9% of the total under-ve deaths. there are three major
contributors to deaths (in order of magnitude) of premature birth, birth asphyxia, and neonatal infections [4]. While
study specically 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 (Table1) [15].
Page 4/13
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 ve 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 deciency has caused the most disability among under-ve children in Senegal—iron deciency,
Vitamin A deciency, and neonatal disorders are the top three contributors of under-ve children’s year lived with
disability (YLD), account for 20.7%, 14.8%, and 13.7% of the total number of under-ve children’s YLD respectively [4].
Besides, 18.8% of the children under ve 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 ve children
stunted or wasted have not been decline steadily like most countries do in recent years. Furthermore, almost one fth
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 ve 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 4.5million to almost 5.4million
[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 nd no impact was demonstrated in their
Page 5/13
intervention zone and they suggested six months of CNP services may not be sucient 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 nonprot entities [22]. The public sector runs mainly facilities at central and regional level [23]. the
private service providers are a signicant 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 nonprot 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 ll a critical healthcare coverage gap. The way
nonprot organizations operate hospitals, clinics, and medical practices is similar to those described above in the
private for-prot sector. However, different from for-prot facilities, nonprot 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 gures 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 nancing. 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
Page 6/13
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 nancing 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 nancial 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-ve 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 ineciency, 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 benet more from the supply-side
intervention (improving the availability of maternal health services) while those living in poverty benet 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 nancial models and tools beyond to make further improvements in access and
Page 7/13
quality care services for poor.
Global Health Cooperation
The key global players in the eld 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) specic
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 exibility 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 nance 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 ineciencies 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.
Conclusion
Senegal has stable political environment and outperforms SSA average in terms of economic and social infrastructure
development. These make Senegal a welcoming place for global health collaboration. However, there are still several
aspects waiting for substantial improvements in order to achieve better population health, where focused research,
undernutrition, maternal health, and health human capacity building should be given priorities. Successful roll-out of
nutrition and maternal health interventions needs local government, experienced technical and operation partners, and
private sector to work together closely. Even though health-focused NGOs and multilateral organizations are active in
Senegal, coordination mechanisms are limited and fragmented, which may have contributed to the inecient and
non-cost-effective health care system. Thus, Senegal MSAS should be the leading institute in coordinating focused
and across-the-board interventions. A good implementation partner is essential in the successful roll-out.
Implementation partners are responsible of proposing and managing program activities, tracking and reporting
program progress, and coordinating among partners and outreach sites. UNICEF Senegal has abundance of
experience in on-the-ground operation of health programs and has close relationship with MSAS, thus is a good
implementation and coordination candidate. Besides, health interventions need better and clearer priority-setting
process, longer project cycle, and systematic data collection of indicators that measure inputs, expected outcome and
output are needed to enable sustainable and ecient effect. Global health donors should also adjust their funding
Page 8/13
allocation based on new evidence and priorities. Finally, relevant technical multilateral organizations such as WHO
and World Bank can help MSAS to design an effective and sustainable mechanism for health human resource
nancing, while local NGOs and donors can be the implementer of the renewed health human resource nancing
scheme.
Declarations
Acknowledgements
We are grateful to all the experts involved in this study who shared their professional experience.
Authors’ contributions
YZ wrote the manuscript and contributed to gathering information and synthesizing evidence. LC contributed to report
structure and analysis. JC and CZ contributed to gathering information. All authors read and approved the nal
manuscript.
Funding
No funding received.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
Not applicable.
Consent for publication
All authors consented to have the paper published.
Competing interests
The authors declare there are no competing interests.
References
1. WB. Population estimates and projections 2021. https://databank.worldbank.org/source/population-estimates-
and-projections. Accessed 30 March 2021.
2. WB. Health, Nutrition, and Population Statistics, 2021. https://databank.worldbank.org/source/health-nutrition-
and-population-statistics. Accessed 6 April 2021.
3. WB. Overview of Senegal 2019. https://www.worldbank.org/en/country/senegal/overview. Accessed 9 Dec 2019.
4. IfHMa. Senegal 2019. http://www.healthdata.org/senegal. Accessed 9 Dec 2019.
5. UNICEF. West And Central Africa: More Than 15 Million Expected Cases of Acute Malnutrition In 2020 2020.
https://www.unicef.org/wca/press-releases/west-and-central-africa-more-15-million-expected-cases-acute-
malnutrition-2020. Accessed 9 Dec 2019.
. WHO. World Health Statistics 2010. https://www.who.int/whosis/whostat/2010/en/. Accessed 9 Dec 2019.
Page 9/13
7. Fullman N, Yearwood J, Abay SM, Abbafati C, Abd-Allah F, Abdela J, et al. Measuring performance on the
Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a
systematic analysis from the Global Burden of Disease Study 2016. The Lancet. 2018;391(10136):2236-71.
. WB. Net ocial development assistance received 2019. https://data.worldbank.org/indicator/DT.ODA.ODAT.CD?
end=2017&locations=SN&most_recent_value_desc=false&start=1990. Accessed 9 Dec 2019.
9. OECD. Aid at a glance charts - OECD 2019.
10. Lomas, M. Getting health reform right: a guide to improving performance and equity. The Journal of the Royal
Society for the Promotion of Health 126(2006).
11. https://www.oecd.org/countries/senegal/aid-at-a-glance.htm. Accessed 9 Dec 2019.
12. WB. Data for Senegal 2019. https://data.worldbank.org/?locations=SN-ZG-XN&most_recent_value_desc=false.
Accessed 16 Dec 2019.
13. Agence Nationale de la Statistique et de la Démographie - ANSD/Sénégal, et ICF. 2018. Sénégal : Enquête
Démographique et de Santé Continue - EDS-Continue 2017. Rockville, Maryland, USA : ANSD et ICF.
https://www.dhsprogram.com/publications/publication-FR345-DHS-Final-Reports.cfm. Accessed 30 March 2021.
14. Ministère de la Santé et des L’Action Sociales. Plan National de Développement Sanitaire,2009-2018.
https://sante.sec.gouv.sn/sites/default/les/1%20MSAS%20PNDSS%202019%202028%20Version%20Finale.pdf
15. WHO. Country Oce Evaluation: Senegal 2019. https://www.who.int/docs/default-source/documents/about-
us/evaluation/coe-senegal-report-english.pdf?sfvrsn=948b91f8_4. Accessed 9 Dec 2019.
1. UNICEF. Senegal Data 2019. https://data.unicef.org/country/sen/. Accessed 9 Dec 2019.
17. UNDP. Human Development Report 2018.
http://hdr.undp.org/sites/default/les/2018_human_development_statistical_update.pdf. Accessed 9 Dec 2019.
1. UNICEF. Acting Now to Avert a Nutrition Crisis across West and Central Africa 2020.
https://www.unicef.org/wca/stories/acting-now-avert-nutrition-crisis-across-west-and-central-africa.
19. Kung'u JK, Pendame R, Ndiaye MB, Gerbaba M, Ochola S, Faye A, et al. Integrating nutrition into health systems at
community level: Impact evaluation of the community‐based maternal and neonatal health and nutrition projects
in Ethiopia, Kenya, and Senegal. Maternal & Child Nutrition. 2018;14:e12577.
20. Alderman H, Ndiaye B, Linnemayr S, Ka A, Rokx C, Dieng K, et al. Effectiveness of a community-based intervention
to improve nutrition in young children in Senegal: a difference in difference analysis. Public health nutrition.
2009;12(5):667-73.
21. Gartner A, Maire B, Traissac P, Kameli Y, Delpeuch F. Determinants of nutrition improvement in a large-scale urban
project: a follow-up study of children participating in the Senegal Community Nutrition Project. Public health
nutrition. 2006;9(8):982-90.
22. Gartner A, Kameli Y, Traissac P, Dhur A, Delpeuch F, Maire B. Has the rst implementation phase of the Community
Nutrition Project in urban Senegal had an impact? Nutrition. 2007;23(3):219-28.
23. USAID. Senegal’s Community-based Health System Model: Structure, Strategies, and Learning 2019.
https://www.advancingpartners.org/sites/default/les/technical-briefs/apc_senegal_brief_508.pdf. Accessed 9
Dec 2019.
24. The Ministry of Health and Social Welfare of Senegal. Sanitary Facilities 2019.
http://www.sante.gouv.sn/politique-de-sante/les-structures-de-sant%C3%A9. Accessed 9 Dec 2019.
25. Attipoe-Dorcoo S, Linder S, Delgado R, Lai D. An overview of costs, utilization, geographical distribution &
inuence of Mobile clinics in rural healthcare delivery in the United States: Doctoral dissertation, The University of
Texas School of Public Health; 2018.
Page 10/13
2. The Ministry of Health and Social Welfare of Senegal. Overview of human resources in Senegal. 2012.
27. WB. World development indicators 2015.
http://documents.worldbank.org/curated/en/795941468338533334/World-development-indicators-2015.
Accessed 9 Dec 2019.
2. Zurn P, Codjia L, Sall FL, Braichet J-M. How to recruit and retain health workers in underserved areas: the
Senegalese experience. Bulletin of the World Health Organization. 2010;88:386-9.
29. Heyen-Perschon J. Report on current situation in the health sector of Senegal and possible roles for non-
motorised transport interventions. Institute for Transportation and Development Policy. 2005.
30. Denis Garand SS, Mark Akanko Achaw. Performance evaluation framework for government-sponsored health
insurance programmes 2019.
https://www.microinsurancenetwork.org/sites/default/les/Health%20Background%20paper_0.pdf. Accessed 9
Dec 2019.
31. WB. Poverty and Equity Data Portal 2019. http://povertydata.worldbank.org/poverty/country/SEN. Accessed 9
Dec 2019.
32. USAID. Senegal Country Development Cooperation Strategy 2015.
https://www.usaid.gov/sites/default/les/documents/1860/Senegal_CDCS_2012-2017.pdf. Accessed 9 Dec
2019.
33. WHO. Global Health Expenditure Database 2019. http://apps.who.int/nha/database/. Accessed 9 Dec 2019.
34. National Bureau of Statistics and Population Statistics of Senegal. Senegal: Population and Health Survey 2018.
https://www.dhsprogram.com/pubs/pdf/FR345/FR345.pdf. Accessed 9 Dec 2019.
35. Mladovsky P. Fragmentation by design: Universal health coverage policies as governmentality in Senegal. Social
Science & Medicine, 2020:113153.
3. Parmar D, Banerjee A. How do supply- and demand-side interventions inuence equity in healthcare utilisation?
Evidence from maternal healthcare in Senegal. Social Science & Medicine 241(2019).
37. Di Lieto A, Catalano D, Pontillo M, Pollio F, De Falco M, Iannotti F, et al. Telecardiotocography in prenatal
telemedicine. Journal of telemedicine and telecare. 2001;7(2):119-20.
3. HERA. Progress in the International Health Partnership & Related Initiatives (IHP+).
https://www.hera.eu/site/assets/les/6044/ihp_report_opt.pdf. Accessed 9 Dec 2019.
39. UNFPA. Senegal Demographic Divided 2019. https://www.unfpa.org/data/demographic-dividend/SN. Accessed 9
Dec 2019.
40. ITU. Statistics 2019. https://www.itu.int/en/ITU-D/Statistics/Pages/stat/default.aspx. Accessed 9 Dec 2019.
41. Yu-Ying W, Chun-Ming C, Fu-Zhen W, Mei J, Ke-An W. Effects of nutrient fortied complementary food
supplements on anemia of infants and young children in poor rural of Gansu. Biomedical and Environmental
Sciences. 2009;22(3):194-200.
42. Smith ER, Shankar AH, Wu LS, Aboud S, Adu-Afarwuah S, Ali H, et al. Modiers of the effect of maternal multiple
micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual
patient data from 17 randomised trials in low-income and middle-income countries. The Lancet Global Health.
2017;5(11):e1090-e100.
43. WHO. World Health Organization recommendations on antenatal care for a positive pregnancy experience.
Geneva: WHO. 2016.
44. Africanews. Senegal's Macky Sall signs decree scrapping post of Prime Minister 2019.
https://www.africanews.com/amp/2019/05/15/senegal-s-macky-sall-signs-decree-scrapping-post-of-prime-
Page 11/13
minister/. Accessed 9 Dec 2019.
45. Global Edge. Senegal: Economy 2019. https://globaledge.msu.edu/countries/senegal/economy. Accessed 9 Dec
2019.
4. Salim R, Dina R. Cities for an emerging Senegal 2016. https://blogs.worldbank.org/africacan/cities-for-an-
emerging-senegal. Accessed 9 Dec 2019.
47. UN. World Population Prospects - Population Division 2019. https://population.un.org/wpp/. Accessed 9 Dec
2019.
4. UNDP. Human Development Report 2019. http://hdr.undp.org/sites/default/les/hdr2019.pdf. Accessed 9 Dec
2019.
Annex
Annex 1: Political, economic, social and technological analysis of Senegal
Political, economic, social, and technological background
Political
Senegal was colonized by France in the middle of the 19th century. After experiencing as a member of
Union française
(A special combination of countries formed by the relationship between France and former French colonial countries
in Africa)and
the Fédération du Mali
(A federal state of west Africa that existed during 1959-1960, the other member is
Sudan)
,
it declared independence as a republic in 1960.
Senegal has been among Africa’s most stable countries in the past two decades. It is a semi-presidential republic, with
a parliament elected by popular vote every ve years. The president of Senegal is the head of state and head of
government of Senegal. In accordance with the constitutional reform of 2001, and since a referendum that took place
on 20 March 2016, the president is elected for a 5-year term, and limited to two consecutive terms. President Macky
Sall is the current President and has been the President since 2012. In April this year, President Sall announced a plan
to abolish the position of the Prime Minster. In May 2019, Senegal’s parliament approved the constitutional reform to
permanently abolish the Prime Minister, and the President will take a more hands-on approach to governing, this
marks an era of more power to the President [41].
Economic
According to the World Bank’s classication, Senegal is a lower-middle-income country with a Gross National Income
(GNI) per capita of $1,410 in 2018—this is $97 lower than SSA average [10]. Its gross domestic product (GDP) in 2018
was US$ 24.1 billion and GDP per capita was $1,522, also slightly lower than SSA average [10]. However, Senegal is
growing rapidly and has made great progress in economic growth. The growth rates of GDP and GDP per capita have
been increasing at higher rates than SSA average. In 2018, Senegal’s growth rates of GDP and GDP per capita are
6.77% and 3.84%, respectively, compared with SSA average of 2.37% and -0.30% [10].
Senegal is an agricultural country, with added value of agriculture accounting for 16.56% of GDP and over half
(58.2%) of the employments in Senegal agriculture-related [10, 36]. Added value of industry accounts for 22.73% of
GDP and service industry takes a dominant role [42]. This is a result of prospering tourism industry and tourism-
related industries such as catering business and airline business. World Bank has an optimistic forecast of Senegal’s
economy, particularly with oil and gas production expected in 2022 [3].
Page 12/13
Senegal’s national poverty head count ratio has been declining. Nation poverty was last measured in 2011 at 46.7%
measured by the national poverty line and 38% using the international poverty line (US$1.9 PPP) [10]. Senegal’s GINI
index was estimated at 40.3 in 2011, which ranks 14th among SSA countries that have GINI estimates available,
indicating that Senegal’s income distribution is more equal than most of SSA countries [10]. World Bank commented
that “
Poverty should begin to fall faster—from 34% in 2017 to 31.2% in 2020 (IPL)—and by 2020, the decline in the
number of poor that started in 2016 should accelerate due to agricultural growth. Under this scenario, poverty
reduction in urban areas would be driven by services, remittances, and public construction.” [3]
Social and demographic
Senegal has a population of 15.72 million, of which 8.37 million live in rural areas, accounting for 52.80% of the
population, lower than the sub-Saharan African (SSA) average of approximately 62% [3]. The growth rate of total
population is 2.78% in 2018, with 3.74% urban growth rate and 1.92% for rural [3]. The urban population is growing at
almost twice the rate of the rural population, which is a sign for higher urbanization level in the future. It was
estimated in 2016 that up to half of its population is concentrated around Dakar and other urban areas in 2020 [43].
The median age in Senegal is 18.2 years old, and almost one fths of the population are under ve years old (17.5%),
over half of the Senegalese aged between 15 and 64 (54.25%) [36]. Fertility rate in Senegal was 4.7 in 2017, close to
the SSA average of 4.8, meaning that women in Senegal will have 4 to 5 children on average in their life time [36].
Senegal’s death rate is at a low rate of 5.8 per 1,000 population, which is 22.7% lower the world average [10]. With
Senegal’s high fertility rate low death rate, its population will likely maintain young and grow quickly. This, on the other
hand, has also resulted in a high dependency rate with children. Senegal has a high dependency ratio of 84.32%, but a
high percentage are with children (78.75%) and only 5.57% are with elderly [44]. Thus, to benet from a demographic
dividend, Senegal needs to accelerate its fertility decrease.
Notwithstanding Senegal’s progress and great potential in economic development, it is classied as a country with
low human development by the United Nations Development Programme (UNDP)—its Human Development Index
(HDI) ranks 166 out of the 189 countries that were evaluated [46]. HDI, created by UNDP, is a summary measure of
average achievement in key dimensions of human development: a long and healthy life, being knowledgeable and
have a decent standard of living. Senegal’s HDI ranking is 12 lower than its GNI per capita ranking, meaning its human
development does not catch up with its economic development [45].
Education situation in Senegal is worrisome—almost half (48.1%) of the people over 15 years old are not literate, and
current primary education completion rate is only 53%, much lower than lower-middle-income countries average of
90.2% and even lower than SSA average of 68.5% [46]. Furthermore, despite the encouraging intergenerational
progress, adult women are systematically less educated than men—about 46% of women aged 15–49 years old
received no education which, together with their lower access to productive inputs and discrimination, weighs heavily
on their agency and access to opportunities [46].
While basic infrastructure is not robust in Senegal, it outperforms most of the SSA countries (Table 2). Reliable
electricity is accessible to 62% of the population, but with a huge gap between rural and urban areas [10]. As for the
communication sector, 46% of the people have used internet in the past 3 months, which is almost twice as much as
SSA average; and there are 104.5 mobile cellular subscriptions per 100 people, also well above SSA average of 77.4
subscriptions per 100 people [37]. Besides, over 80% of the population have access to basic drinking water sources,
and over half of the population are using basic sanitation facilities [36].
Page 13/13
Table 2.
Basic infrastructure coverage, Senegal and SSA average
Senegal SSA average
Assess to reliable electricity (overall) 61.7% (2017) 44.6% (2017)
Assess to reliable electricity (urban) 91.7% (2017) 79.0% (2017)
Assess to reliable electricity (rural) 35.4% (2017) 22.6% (2017)
Individual using the internet (overall) 46.0% (2017) 25.4% (2017)
Mobile cellular subscription (per 100 people) 104.5 (2018) 77.4 (2018)
People using at least basic drinking water services(overall) 80.7% (2017) 61.0% (2017)
People using at least basic drinking water services(urban) 92.3% (2017) 84.1% (2017)
People using at least basic drinking water services(rural) 70.5% (2017) 45.7% (2017)
People using safely managed sanitation services (overall) 51.5% (2017) 30.9% (2017)
People using at least basic sanitation services (urban) 65.0% (2017) 44.9% (2017)
People using at least basic sanitation services (rural) 39.6% (2017) 21.7% (2017)
Source: World Bank, 2019.
Technological
The African Regional Center for Technology, with 30 member states, has its headquarters in Dakar, Senegal. Most
research facilities in Senegal deal with agricultural subjects. Dakar has centers for mining and medical research and a
research institute on African food and nutrition problems. The University Cheikh Anta Diop de Dakar, founded in 1949,
has faculties of medicine and pharmacy and of sciences, and research institutes in psychopathology, leprosy,
pediatrics, renewable energy, applied tropical medicine, applied mathematics, health and development, environmental
science, adontology and stomatology, applied nuclear technology, and the teaching of mathematics, physics, and
technology [46].
