Challenges

While Senegal has undeniably made impressive progress in reducing the mortality rate for children under the age of five, significant challenges remain, especially with equity in coverage and affordability of care.

Economic and regional disparities in coverage

Senegal has had difficulty meeting the World Health Organization (WHO) target of 4.45 doctors, nurses, and midwives per 1,000 residents, with the country’s most skilled health personnel predominantly concentrated in urban areas, especially Dakar .⁸

In addition to this urban-rural inequality, there is a powerful economic component to the human-resource coverage gap. The Composite Coverage Index used by Countdown 2030 shows that there was no significant narrowing of this disparity between 2005 and 2014.¹ For example, skilled birth attendance at delivery in 2014 was 30 percent for the lowest wealth quintile and 86 percent for the highest wealth quintile; the overall national rate was 60 percent.

This persistent divide also shows up in data on antenatal care (ANC) visits. In 2005, the percentage of women in the lowest wealth quintile who attended four or more ANC visits was 29 percent, while for the highest wealth quintile it was 63 percent. By 2016, ANC visitation rates had improved for all economic classes, but the chasm between the poorest and the richest remained quite broad; the percentage of women who attended four or more ANC visits was 35 percent for the lowest quintile and 74 percent for the highest.¹

Continued inaccessibility of health services in many areas

Multiple interviewees mentioned the relative inaccessibility of the southeast as a major factor limiting the coverage and reach of under-five mortality interventions in that area. They reported that the difficult terrain of the southeast led to an unwillingness of partners and health workers to go there.

For example, Kedougou and Tambacounda had the lowest rates among all regions in the percentage of children 12 to 23 months of age who received the prescribed vaccine set (Bacillus Calmette-Guérin tuberculosis vaccine [BCG], measles vaccine, yellow fever vaccine, three doses of pentavalent vaccine, and three doses of polio vaccine).

The 2016 Demographic and Health Survey (DHS) reported that the rate in Kedougou was 47 percent and the rate in Tambacounda was 41 percent. These figures had declined since the 2005 DHS, which found coverage rates of 55 percent in both regions.²

In addition, data quality from the southeast is often subpar, which makes it difficult to monitor and provide services. For example, Kedougou is a gold-producing area that experiences constant fluctuations in population, which affects the targeted health service catchment population for routine monitoring and evaluation of under-five mortality programs, and larger data collection efforts such as the DHS.

Another challenge related to geographic access during the study period was the lingering tension in the Casamance area, the site of intense civil conflict between 1992 and 2001. According to interviewees, continued low-intensity conflict limited the coverage and reach of interventions to reduce under-five mortality in the south and southwest.

Inadequate or unpredictable levels of health financing and rising out-of-pocket costs

One of the key facilitators in reducing under-five mortality in Senegal has been the provision of health funding from the government, donors, and partners, but a gap in financing still impedes further progress.

The main reasons for this gap appear to be Senegal’s status as a lower-middle-income country, and a lack of alignment between the country’s actual disease burden and the priorities of donors and implementing partners.

“Activity can be postponed for several months or even several years,” said one interviewee. “It is true that most needs are funded, but there are some that are not. It is not because they are not important, but sometimes funding is not available and it also depends on the mission of the partners and their priorities.”

Senegal invests a relatively small share of its own national budget in health care, and that percentage has been going down in recent years. In 2016, Senegal’s government health spending was 1.9 percent of gross domestic product (GDP), comparable to the sub-Saharan African average of 1.8 percent.³

Donor funding continued to be used for a significant portion of overall health expenditures, ranging from 11 to 24 percent; the government’s share was fairly stable at around 30 percent of total health expenditure during the study period.⁴

Interviewees mentioned that Senegal’s ongoing dependence on donor funding for much of its agenda to reduce under-five mortality presents some serious problems, such as an inability to bring pilot projects or small-scale projects to a national level even when they have proven effective.

There is also the broader question of what the country’s dependence on donors could mean for the long-term sustainability of programs. One interviewee said, “The first constraint for sustainability of the intervention is once the partner stops their financial support, it is difficult to supervise because the resources used for the supervision are generally given by the partners.”

The government’s per capita spending on health in 2015 was $48 (2018 PPP International $), and donors spent $26 per capita. Meanwhile, out of pocket costs were $83 per capita – more than the total spent by the government and donors combined.⁵

In a country where the extreme poverty rate is still above 30 percent, the result is that the poor may go without care – or they may forego other necessities, like education and healthy food, to pay for health care.

The government has long set its sights on creating a viable insurance option for the poor. Since the 1970s, Senegal has employed risk pooling schemes, including mandatory employer-based insurance.

In the 1990s, Senegal supplemented these offerings with voluntary community-based insurance plans known as mutuelles de santé or simply mutuelles. These were intended to cover informal-sector and rural workers who were not eligible for mandatory health insurance programs.

Even with the mutuelles and various interventions offering free services for women, children, and the elderly, a huge share of the population – especially in rural areas – still did not have access to care because they could not afford the costs.

According to a 2010–2011 study, 94 percent of women and 92 percent of men had no health insurance coverage.⁶ Research conducted the following year found that community-based insurance plans covered only about 14 percent of the targeted population.

In order to address these shortfalls, Senegal announced a five-year universal health coverage strategic plan in 2013. To reduce inequity and vulnerability among the poor, the plan incorporated elements of coverage expansion and risk pooling, along with the elimination of user fees for some services, such as facility-based delivery and ITN distribution.

In 2014, however, only approximately 25 percent of Senegalese had any kind of insurance coverage – and more than half of these were relatively wealthy people participating in mandatory contribution plans through their work.⁷