This research and analysis was conducted by research partners at the Université Cheikh Anta Diop in Dakar, Senegal and the Makerere University School of Public Health.

Introduction and Key Takeaways

Around the world, public health emergencies such as the COVID-19 pandemic can profoundly disrupt the delivery of routine or essential health services  including routine immunization, antenatal care, and chronic care.1 For instance, public health emergencies can reduce the supply of those services by redirecting health workers and resources toward the emergency response. Among other reasons, clients’ fear of infection in public places during a pandemic, especially in health care facilities, can also reduce demand for essential health services and prevent people from receiving the care they need.

Why Did We Study Senegal?

We selected Senegal for this study, alongside three other countries in sub-Saharan Africa (Democratic Republic of the Congo, Nigeria, and Uganda), because together they demonstrate a wide and variable spectrum of COVID-19 response and outcomes, and because they have experience managing past public health emergencies. These four countries have also established strong partnerships between researchers and health officials, which facilitates access to data. All of the countries we studied faced common challenges, and lessons can be learned from how Senegal addressed them. Documenting the country’s response may also inform future preparedness and response efforts.

Key Takeaways

We know that public health emergencies such as COVID-19—and the response to them—can undermine the demand for and delivery of essential health services. In Senegal, the COVID-19 pandemic undermined essential health services, even as all medical regions (the administrative subdivision below the national level) prioritized their continued delivery as the pandemic progressed. Despite an extensive community mobilization campaign to support health service delivery during the pandemic, many people in Senegal were afraid of contracting the virus in health care facilities. As a result, they were reluctant to seek essential health care, such as routine vaccinations and in-facility deliveries.

Starting in 2020, Senegalese officials implemented a variety of interventions to mitigate demand and supply-side barriers to delivering essential health services. These interventions include the following:

  • Regions experienced varied degrees of disruption to continuity of essential health services. To that end, governors chaired subnational epidemic management structures, run by regional incident managers, to track essential health services challenges and report them to health officials at the national level.
  • Health officials performed functional mapping of health facilities to ensure the availability and use of reproductive, maternal, newborn, and child health services.
  • Health districts partnered with private sector players (e.g., corporations and nongovernmental organizations) to maintain essential health services via risk communication and community engagement strategies, such as advocacy and social mobilization.
  • Gavi, the Vaccine Alliance, has supported the continuity of routine immunization in urban settings; Plan International provided continuity of malaria services.
  • Companies facilitated client transfers between health posts and also provided personal protective equipment, rapid diagnostic tests, and disinfectants in a district of Dakar.
  • Private health care facilities, which account for about a quarter of health facilities in Senegal, played a major role in maintenance of essential health services, since they helped treat patients with and without COVID-19.2 Some private clinics were designated as centers for routine treatments for clients without COVID-19 and other key health services. Private clinics did not change their fees for routine health services provided, but care specific to COVID-19 in private clinics was paid for fully by the government.
  • Community health workers distributed antiretroviral and tuberculosis drugs, enabling clients without COVID-19 to avoid health facilities.
  • The Senegalese government provided food kits to people living with HIV/AIDS during the early phase of the pandemic to support treatment adherence amid the lockdowns, mobility restrictions, and curfews.
  • The door-to-door seasonal malaria chemoprevention campaign, which was planned in July 2020 in areas with high endemicity, distributed doses of sulfadoxine / pyrimethamine and amodiaquine to children under five. The campaign also distributed COVID-19 kits (including face masks and hydroalcoholic gel) to caregivers and targeted families.
  • As part of Senegal’s COVID-19 response, FCFA 69 billion ($127 million USD) was spent on providing food kits for 1 million households in poverty throughout the country. The food kit consisted of basic needs (oil, pasta, rice, soap, and sugar) and was distributed throughout the country.3
  • Health care providers monitored patient treatment—particularly the community drug observance strategy (directly observed treatment, short course) for tuberculosis patients—remotely, via WhatsApp video capabilities.
  • Health care providers used text messages and other digital solutions for patient follow-up.
  • Health officials used Zoom and Microsoft Teams for regular communications, meetings, and trainings. These video communication platforms were used to ensure continued delivery of services. They enabled health workers to provide regular family planning services; maternal, neonatal, and child health services; and even surgery assistance.
  • Computerized models were used to aid with Integrated Management of Childhood Illness (ICMI), specifically ICCAT, the ICMI Computer Adapted Training model.
  • Officials recruited community members (e.g., retired doctors and nurses, volunteers from the Red Cross, and employees of nongovernmental organizations) to act as health workers to minimize the pandemic’s impact on essential service delivery.
  • Community actors, religious leaders, and youth associations promoted the use of reproductive, maternal, newborn, and child health services through various communication campaigns.
  • Health officials implemented hotlines to contact health districts to prevent increases in home births and delays in the use of essential health services.
  • Providers doubled down on self-initiation of care (e.g., training clients on self-injection of contraceptives), though women still had difficulty accessing family planning commodities throughout the pandemic.

What Was the Pre-pandemic Context in Senegal?

Senegal’s pre-pandemic context

Various

Pre-pandemic Health System Indicators and Essential Health Services in Senegal

Senegal’s health system has a decentralized, three-tier pyramidal structure. The central or national level creates health policies and mobilizes resources, and it includes the minister’s office, the general secretariat, the directorates general, and national directorates. The intermediate or regional level’s main role is to support the local level’s implementation of national health strategies; it comprises 14 medical regions along with regional hygiene brigades and the regional social action services. Senegal is divided into 79 health districts, and the district or local level is the primary point of contact with the health system for most people. The district or local level implements all health program activities with community participation and includes hygiene brigades and departmental social action services.

Senegal has a ratio of 0.4 health workers (e.g., doctors, nurses, and midwives) for every 1,000 people, well below the World Health Organization (WHO) recommendation of 4.45 health workers for every 1,000 people. These health workers are concentrated in Senegal’s urban centers, especially in its capital Dakar. IHME estimates that there are 3955 hospital beds in Senegal (2.43 hospital beds per 10,000 people) and that there are 35 ICU beds (.021 ICU beds per 10,000 people).4 The ratio of COVID-dedicated beds to non-COVID beds in Senegal during the pandemic was about 3:1.5

According to estimates of universal health care effective coverage, Senegal is in the twenty-fifth percentile of all countries, ranked 148 out of 204 countries in the provision of universal health care.6 Universal health care effective coverage measures a variety of indicators of delivery of essential health services such as reproductive, maternal, newborn, and child health and infectious and noncommunicable disease treatment. In Senegal, total health expenditures—5.2 percent of gross domestic product (2020) and US$74 per capita7 —are substantially below the Abuja declaration of 15 percent and below the WHO recommendation of $86 per capita. In 2020, out-of-pocket (private) health spending was 44 percent of the total,7 much more than experts typically recommend.

Compared with other countries in Africa, Senegal has a relatively strong performance on essential health service indicators such as in-facility deliveries and routine childhood immunizations. By contrast, it has a high rate of maternal mortality.8 Maternal mortality seems to have worsened over the course of COVID despite maintaining roughly comparable rates of in-facility deliveries, but research is still ongoing to determine the exact cause of these spikes in maternal mortality.

COVID-19 in Senegal

Senegal identified its first confirmed case of COVID-19 on March 2, 2020, when a French citizen returning to Blaise Diagne International Airport tested positive for the virus. As of January 31, 2022, Senegal had reported nearly 85,000 COVID-19 cases and more than 1,940 deaths.9 Most of these were reported after December 2020, when the Delta variant was detected in Senegal and the country experienced a more devastating second wave of infections.10 There were reports of vaccine hesitancy among the Senegalese public along with vaccine access issues, contributing to a low vaccination rate. As of the January 31, 2022, less than six percent of Senegal’s population had received both doses of a COVID-19 vaccine.9

In general, Senegal’s extensive experience with previous epidemics made it possible for officials to repurpose preexisting coordination structures for its COVID-19 response. For instance, the National Association of Epidemic Management was inherited from the 2014 Ebola virus epidemic. In January 2020, Senegal’s emergency operations center, (COUS, Centre des Opérations d'Urgence Sanitaire) assessed the country’s pandemic response capacity and used the results of that assessment to further strengthen capacity of actors at all levels. For example, officials adapted existing WHO case management guidelines for influenza-like illnesses. Senegal also had an emergency stock of personal protective equipment in reserve, which has been reinforced through domestic resources and the support of international partners.

Timeline of COVID-19 cases, deaths, and events in Senegal

Various

Nonpharmaceutical interventions to limit the spread of COVID-19, including public health and social measures, have been a key part of Senegal’s pandemic response. These included:

  • Movement restriction and physical distancing

Between March 20 and May 31, 2020, officials suspended all air traffic to and from Senegal and closed all land borders. In March, the president declared a state of emergency, introduced a nationwide curfew to limit movement from 8 p.m. to 6 a.m., and suspended pilgrimages to the holy sites of Islam and Christianity. In early March 2021, mass protests—in part against these restriction measures and their economic consequences—rocked Senegal.11 As a result, on March 19, 2021, Senegal ended the state of health disaster; restaurants, bars, and nightclubs were allowed to reopen and the curfew ended.

  • Strategies to support mask wearing

On April 20, 2020, Senegal’s minister of the interior mandated face masks in public. To enforce this order, the Senegal government procured and distributed 10 million masks. Mask requirements are still in effect as of January 2022 on public and private transit, in government and private offices, and in commercial establishments.

  • Precautionary measures in public places

Classes in schools and universities were suspended from mid-March until early May 2020.

Relative population-level mobility during the COVID-19 pandemic

IHME

Because of these pandemic response measures, mobility in Senegal decreased sharply in the first months of the pandemic. This limited commercial activity, decreased incomes, and blocked economic growth. The pandemic affected various industries, including exports and tourism – real GDP grew at only 0.87% in 2020, compared to 4.4% in 2019 and 6.2% in 2018.12

What Effect Did These Nonpharmaceutical Interventions Have on the Maintenance of Essential Health Services in Senegal?

Along with the COVID-19 pandemic and the unprecedented disruption it caused in the global supply of essential health commodities, the precautionary measures taken in Senegal created supply- and demand-side barriers to the maintenance of essential health services. Disruption to these services was unevenly distributed across the country, however. In general, Dakar, Thiès, and Diourbel experienced more disruptions to essential services than other regions, because the burden of COVID-19 was much heavier there.

The following findings are organized according to the Health Systems Building Blocks framework.13

Barriers to maintenance and delivery of essential health services in Senegal during the COVID-19 pandemic include the following:

Supply-Side Barriers

Several supply-side barriers hindered essential health services maintenance in Senegal—the main barrier being issues with health service delivery. Senegal’s pandemic curfews, which limited transportation to health facilities for patients and health care workers, and the elimination of community health care services at the beginning of the pandemic created substantial obstacles to care. These challenges were further exacerbated by the Senegal Ministry of Health (MOH) and the broader health system’s diversion of both financial and human resources from routine health care services to pandemic response tasks, such as case management and contact tracing. Due to the highly decentralized and multisectoral nature of the COVID-19 response in Senegal, streamlined coordination of essential health service maintenance was difficult to achieve.

The risk of stress-related depression increased, given that psychosocial support dwindled when the pandemic halted community-based outreach to key populations, such as sex workers, men who have sex with men, and drug users. Likewise, community-based tuberculosis prevention, treatment, and follow-up activities stopped, which meant (among other things) that infected children were not given essential drugs such as isoniazid. From the perspective of infrastructure and commodities, the pandemic—and Senegal’s response to it—kept patients from accessing essential commodities and care. Even before the pandemic, access to family planning and maternal care services was especially inequitable in Senegal across wealth quintiles.14 Senegal also faced a shortage of hospital beds, especially resuscitation beds, as well as medical oxygen, which impacted both COVID-19 care and essential health service delivery.15

Senegal’s health information system also faced challenges related to a lack of quality and incomplete data in monitoring essential health service delivery, especially at the start of the pandemic, because resources were heavily dedicated to COVID-19 response.

Demand-Side Barriers

A major barrier to the maintenance of essential health services in Senegal during the COVID-19 pandemic was public reluctance to seek care from health facilities for fear of contracting COVID-19. For example, despite the high concentration of health facilities that remained open in Dakar, hepatitis B and PENTA3 vaccinations there decreased because people were avoiding health facilities.5 Testing for sexually transmitted infections likewise slowed considerably.16

Research findings from the Partnership for Evidence-Based Response to COVID-19 showed that of the households in Senegal whose members needed medical care in the first six months of the pandemic, more than 20 percent delayed or skipped that care. This number held steady through February 2021 but decreased to about 9 percent in September 2021.17 According to the same survey, 21 percent of females were likely to delay care seeking during the pandemic compared with 19 percent of males. Those living in urban areas (11 percent) were also more likely to skip care than those in rural areas (7 percent), and those from low-income backgrounds (12 percent) were more likely to skip care than those from high-income backgrounds (10 percent).

In Senegal, the most frequently cited reason for skipping health care visits was fear of COVID-19 infection, followed by health facility disruptions, increased need to take on caretaker responsibilities, and cost/affordability. The latter issue is not new or specific to COVID-19 given preexisting economic difficulties in Senegal, but has been particularly exacerbated by COVID-related pressures. A recent study showed that two million people having fallen into poverty since the onset of the COVID-19 pandemic, and estimated that 36 percent of heads of households had stopped working, with a third citing COVID-19 as their rationale.18 Routine or general visits were the most common type of care skipped, followed by diagnostic services.

Delay in health care seeking during the pandemic

PERC with Ipsos

Reasons for and types of delayed or skipped health care

PERC with Ipsos

What Interventions Did Senegal Put in Place to Ensure the Maintenance of Essential Health Services?

The maintenance of essential health service delivery was a high priority across Senegal during the COVID-19 pandemic, and health authorities implemented interventions to overcome supply- and demand-side barriers.

The following findings are organized according to the Health Systems Building Blocks framework.13

Supply- and Demand-Side Interventions

Leadership and Governance

  • Community mobilization campaigns

In the early months of the COVID-19 pandemic, Senegal’s Directorate of Mother and Child Health noted an increase in the number of home births, recurrent absences from antenatal consultations, an overall decline in the number of people attending health facilities for family planning and sexual and reproductive health care, and disruptions to the family planning commodities supply chain. In response to this disruption, health officials launched an extensive community mobilization campaign to promote the use of essential health services, especially family planning and sexual and reproductive health care. Media campaigns, operated from community radio stations, were a particularly important aspect of this push.5 In Dakar and in rural areas, community officials coordinated a pool of firefighters, Red Cross workers, and administrative and local authorities to transport and refer patients in labor and patients with obstetric or pediatric emergencies during curfew times. This was achieved through multisectoral coordination and in collaboration with private health clinics and nongovernmental organizations.

  • Contingency plans for essential health services maintenance

During the COVID-19 pandemic, Senegal’s MOH prioritized the specific areas of care needed to save the lives of sick children and adolescents and pregnant women at risk of complications. In May 2020, the MOH published a contingency plan to ensure the continued availability and use of reproductive, maternal, neonatal, child, and adolescent health services in the context of COVID-19, which greatly improved health system functioning.5

  • Risk communication strategies

Based on its experiences with Ebola virus disease and other diseases with epidemic potential, in April 2021, Senegal’s MOH implemented a new strategy for risk communication and community engagement.5 It has three parts: a communication plan for large community gatherings, a work plan for COVID-19 vaccinations, and communication strategy to promote compliance with social distancing, masking, and vaccination rules.

Finances

  • Continued disbursement of essential health service funds

At the beginning of the pandemic, Senegalese officials mobilized a 1,000 billion CFA francs (7 percent of Senegal’s gross domestic product, or US$1.8 billion) COVID-19 Response and Solidarity Fund (Force-Covid-19) to strengthen all affected sectors, including the country’s health sector. Health officials used some of the 120 billion CFA francs that the health sector received to support the maintenance and delivery of essential health services, including national programs to fight HIV, tuberculosis, and malaria and boost maternal and child health.

  • Private-sector and international development partner engagement

The private sector also made substantial contributions to essential health service maintenance in Senegal. For instance, Gavi, the Vaccine Alliance, and Plan International have taken over key services such as vaccination in some districts. Companies in certain health districts have also contributed, including the Societe Generale Senegal bank and Ecobank who provided funding for the Mermoz health post in Dakar.

Health Workforce

  • Task-shifting to community health workers

Health officials in Senegal strengthened the delegation of responsibilities to community caregivers, including midwives and community health workers. For instance, the Integrated Addictions Management Center of Dakar, a drug addiction management and rehabilitation clinic, adapted its typical approach to methadone treatment. Under normal circumstances, drug users come to a health facility to receive treatment; however, to avoid COVID-19 transmission, trained community health workers distributed the medication to patients at their homes. Likewise, community health workers were trained to supervise treatment for tuberculosis patients (directly observed treatment, short course) through video surveillance in their homes rather than at clinics or other facilities.

Networks of community health workers (along with youth associations and religious leaders) initiated communications campaigns on the importance of continuing to access essential reproductive, maternal, neonatal, child, and adolescent health services. Especially in landlocked areas, community health workers delivered medicines to HIV and tuberculosis patients trapped in place by curfews or movement restrictions.

  • Staff redeployment and recruitment

To make reproductive, maternal, neonatal, child, and adolescent health services target staff permanently available, Senegalese officials (with the support of the World Bank) reorganized the recruitment, assignment, training, and support of health workers in regions where human resources for health care are scarce.

  • Virtual trainings for essential health service delivery

Digital platforms, such as Zoom and Microsoft Teams, were used to run virtual trainings for the delivery of various routine services. These services included the Directorate of Maternal and Child Health, which also facilitated training in two regions, Kaolack and Fatick, on reproductive health, specifically on self-injection of contraceptives in 2021.5

Infrastructure and Commodities

  • Triage facilities for COVID-19 screening

Health officials in Senegal established triage facilities with temperature screening, symptoms observation, and the collection of personal health data (e.g., current fever, history of fever, respiratory symptoms, and place of residence) to prevent staff contamination and encourage patients without COVID-19 to seek care at health facilities.5

  • Purchase plan for essential products

Health officials in Senegal developed a Coordinated Purchase Plan for a list of essential medicines, products, and equipment for reproductive, maternal, neonatal, child, and adolescent health, and held monthly meetings to track stock levels for the items on the list. The monitoring of this list and procurement plan became particularly important as services and supply chains were disrupted by the COVID-19 pandemic. The procurement plan was managed at the national level by the National Procurement Agency and has representatives across all regions.

Health Service Delivery

  • Multimonth prescribing

To reduce the frequency of patient visits to health care facilities, care providers in Senegal’s HIV control program began to prescribe and distribute essential drugs to patients with longer periods of time between refills (six months compared with the two- to three-month standard before the COVID-19 pandemic).

  • Adapting service delivery models

Senegal’s tuberculosis, malaria, and HIV programs adapted their service delivery models to the pandemic context. For instance, officials referred patients from designated epidemic treatment centers to other treatment sites to obtain their antiretroviral and tuberculosis medicines; in addition, health care workers observed treatment via video to enable patient self-care. Multiple hospitals, such as Centre Hospitalier National de Pikine and Centre De Santé De Diamniadio, were converted to epidemic treatment centers in the capital of Dakar, while regional hospitals were converted to epidemic treatment centers in the rest of the country.

Officials from Senegal’s National Tuberculosis Control Program monitored indicators and developed strategies to maintain access to tuberculosis services, including community participation and monitoring of home treatment of tuberculosis patients through video communications. Officials also provided small grants for telephone credits and internet passes to tuberculosis treatment centers, AIDS outpatient treatment centers, and other support organizations to facilitate mobile follow-up with patients. Additionally, health workers distributed food kits to people living with HIV/AIDS to support adherence to treatment.

Community health workers performed at-home, follow-up visits for vulnerable patients to avoid exposing them to the risk of COVID-19 infection in health facilities.

Senegal’s National Malaria Control Program combined campaigns for in-home residual spraying and the distribution of bed nets with public sensitization around COVID-19 and infection prevention and control measures, such as the distribution of face masks and hydroalcoholic gel.

Health Information Systems

  • New digital tools

To maintain the delivery of essential health services in Senegal during the COVID-19 pandemic, officials adopted new digital systems and tools. For example, they created free telephone numbers for patients to contact their local health district to prevent increases in home births and delays in care. In addition, officials adopted telephone systems and text messaging for patient follow-up (especially for patients with chronic conditions), family planning, and self-care.

  • Monitoring of essential health service disruption with WHO

Around May 2020, the Ministry of Health (MOH), in collaboration with WHO, ran rapid evaluations of the impact of COVID-19 on essential health service delivery. The findings from this monitoring of service disruptions were presented to health professionals in a workshop in June 2020. Strategies to improve quality of routine data for monitoring maternal health services were proposed coming out of this workshop.

In early 2021, the MOH and WHO started running regular surveillance of essential health services and disruptions from the baseline every three months. This enabled continuity in the MOH’s understanding of essential health service maintenance throughout the rest of the pandemic.

How Did Senegal Perform Across Essential Health Service Indicators During the COVID-19 Pandemic?

The COVID-19 pandemic disrupted Senegal’s essential health services indicators at the national and local levels.

Different indicators can reveal different patterns of disruption to essential health services:

  • DTP3 immunization

This indicator refers to the number of doses of DTP3 (diphtheria, pertussis, and tetanus) vaccine given to children under one year old in a given month. In Senegal, the number of fully vaccinated children decreased from nearly 475,000 to almost 450,000, a decrease of around 25,000 children.

Disruption in DTP3 vaccine doses

Institute for Health Metrics and Evaluation
  • In-facility deliveries

This indicator refers to the total number of women who gave birth in a health facility in a given year. In Senegal, the number of deliveries performed by qualified health care personnel dropped by a little more than 3,000 deliveries between 2019 and 2020, a decrease of about 1 percent. However, it is worth noting that it is not clear whether this is an actual reduction or due to data reporting or completeness issues.

In response to rumors received from the communities about an upsurge in home births, the Directorate of Maternal and Child Health conducted a survey on the number of home births in different health regions. Some regions reported substantial reductions in the number of home births in 2020 compared with 2019, while others reported substantial increases.

  • Maternal deaths

Senegal recorded a considerable increase in maternal deaths in health care facilities in 2020. While research is still ongoing to determine the cause of these spikes in maternal mortality, the quality of labor and delivery care in Senegal may have been negatively impacted by the COVID-19 pandemic. Additionally, data quality and completeness are likely issues in the reporting of data on maternal deaths.

Deaths increased by about 18 percent from March through June 2020 and about 34 percent from July through December 2020, compared with the same time periods in 2019. This lag in the change in maternal deaths could be related to lower antenatal care coverage or delayed health-seeking given the smaller decrease in in-facility deliveries, but this has not been confirmed.

Trends in in-facility deliveries and maternal deaths before and during the pandemic

In-country research partners

What Are the Key Lessons From Senegal’s Efforts to Maintain Essential Health Services During the COVID-19 Pandemic?

In Senegal, the COVID-19 pandemic interfered with the supply of—and especially the public’s demand for—essential health services. To maintain essential health services functioning, Senegalese officials and health care providers implemented interventions designed to boost service delivery and encourage people to access those services safely and confidently.

These interventions included social mobilization and financial support to promote essential health services; service delivery innovations such as pairing the distribution of personal protective equipment for COVID-19 with other public health campaigns (e.g., with antimalarial bed net and drug distribution through verticalized disease programs); at-home drug delivery and remote patient follow-up using video; and redeployment of health care workers to bring essential health services to as many localities as possible.

Recommendations for Other Geographies Based on Learnings in Senegal

  • Employ digital solutions to ensure patient follow-up, especially for patients with chronic conditions.
  • Recruit community volunteers and non-health workers to delegate as many tasks as possible, including drug distribution and treatment supervision.
  • Leverage those with community influence (such as religious leaders and youth organizations) to promote continued use of maternal, newborn, and child health and other essential services.
  • Develop a contingency plan to ensure the continued availability and use of essential health services, with a clear prioritization of care needs.
  • Leverage public-private partnerships to ensure continuity of essential health service delivery.
  • Establish a package of essential services and procurement plans for essential commodities.
Lessons Learned From Research Applicable to Senegal COVID-19 Context
  • Implement strong national and subnational coordination structures to ensure continuity of essential health services.
  • Provide incentives for health workers such as waived taxes and free resources to better ensure service continuity.
  • Establish and communicate clear and consistent guidance on the maintenance of specific essential services.
AUTHORS
Steven N. Kabwama, Suzanne N. Kiwanuka, Ibrahima Seck, Issakha Diallo, Mamadou M. M. Leye, Youssou Ndiaye, Manel Fall, Ndeye M. Sougou, Oumar Bassoum, Thiané G. Diaw, Talla Cissé, Rhoda K. Wanyenze
  1. 1
    World Health Organization (WHO). Maintaining Essential Health Services: Operational Guidance for the COVID-19 Context. Geneva: WHO; 2020. Accessed January 20, 2022. https://www.who.int/publications/i/item/WHO-2019-nCoV-essential_health_services-2020.2
  2. 2
    Senegal. Primary Health Care Performance Initiative website. Accessed January 25, 2022. https://improvingphc.org/senegal
  3. 3
    RPCA The Food Crisis Prevention Network. “Senegal Emergency Food Aid Operation 2020.” Published November 2020. Accessed December 15, 2021. https://www.food-security.net/en/map-library/senegal-emergency-food-aid-operation-2020/
  4. 4
    Institute for Health Metrics and Evaluation. Global Burden of Disease Study 2019 (GBD 2019) Covariates 1980-2019. Published 2020. http://ghdx.healthdata.org/record/global-burden-disease-study-2019-gbd-2019-covariates-1980-2019
  5. 5
    Key informant interviews
  6. 6
    Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 UHC Effective Coverage Index 1990-2019. Seattle, WA: Institute for Health Metrics and Evaluation; 2020. http://ghdx.healthdata.org/record/ihme-data/gbd-2019-uhc-effective-coverage-index-1990-2019#:~:text=Estimates%20from%20the%20Global%20Burden,1990%2C%202010%2C%20and%202019.
  7. 7
    Financing global health visualization. Institute for Health Metrics and Evaluation website. Published 2021. Accessed January 3, 2022. http://vizhub.healthdata.org/fgh/
  8. 8
    UNICEF. (September 2019). Maternal Mortality. https://data.unicef.org/topic/maternal-health/maternal-mortality/
  9. 9
    COVID-19 Data Explorer. Our World in Data website. Published 2021. Accessed January 31, 2022. https://ourworldindata.org/explorers/coronavirus-data-explorer
  10. 10
    World Health Organization (WHO). Coronavirus Disease (COVID-19) Situation Report - SITREP 80 Covid-19. Geneva: WHO; 2021. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200409-sitrep-80-covid-19.pdf
  11. 11
    “Senegal protests: The country is ‘on the verge of an apocalypse.’ BBC News. March 7, 2021. Accessed January 25, 2022. https://www.bbc.com/news/world-africa-56311673
  12. 12
    World Bank. The World Bank in Senegal. Updated September 29, 2021. Accessed February 2, 2022. https://www.worldbank.org/en/country/senegal/overview#1
  13. 13
    World Health Organization (WHO). Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and their Measurement Strategies. Geneva: WHO; 2010.  Accessed January 20, 2022. https://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf
  14. 14
    Ogundele, O., Pavlova, M., & Groot, W. “Inequalities in reproductive health care use in five West- African countries: A decomposition analysis of the wealth-based gaps.” International Journal for Equity in Health. March 27, 2020; 19(44). https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-020-01167-7
  15. 15
    World Health Organization Senegal. “How Senegal prepared for COVID-19 surge.” June 11, 2021. Accessed December 19, 2021. https://www.afro.who.int/news/how-senegal-prepared-covid-19-surge
  16. 16
    Ollivier T. “Coronavirus: Senegal mobilizes to protect people with AIDS.” Le Monde Afrique. May 17, 2020. Accessed January 25, 2022. https://www.lemonde.fr/afrique/article/2020/05/17/coronavirus-le-senegal-se-mobilise-pour-proteger-les-personnes-atteintes-du-sida_6039946_3212.html
  17. 17
    Partnership for Evidence-Based Response to COVD-19. “Finding the Balance: Public Health and Social Measures in Senegal. Addis Ababa, Ethiopia: Africa Center for Disease Control and Prevention; 2021. Accessed January 25, 2022. https://africacdc.org/download/finding-the-balance-public-health-and-social-measures-in-senegal/“
  18. 18
    Barron’s. “After Protests, Senegal’s Virus-battered Economy in Spotlight.” March 18, 2021. Accessed February 7, 2022. https://www.barrons.com/news/after-protests-senegal-s-virus-battered-economy-in-spotlight-01616062805