Challenges

Remaining stunting burden

Despite Senegal’s overall success since the early 1990s, the country’s stunting rate has not changed much in the past decade. This suggests that current nutrition strategies have reached their limit, and it is necessary to find new ways to reach subpopulations that have been missed so far. Ideally, these interventions would also address other nutritional challenges, especially anemia, which affects more than 50 percent of mothers in 10 of 14 regions.¹

It is not just that the stunting rate is stuck at just under 20 percent. It is also that the burden of stunting is not equally distributed geographically. In some regions, the rates are still close to or above 30 percent.

With the exception of 2000, when the stunting rate recorded for Dakar was suspiciously high, Dakar consistently has the lowest rate of stunting in the country. The regions just to the east of Dakar, including Thies, Fatick, and Diourbel, have demonstrated some of the greatest rates of improvement over time; by 2017, those four regions had the lowest stunting rates in Senegal. They also have well over half of the population of the country.

On the other hand, the regions in the southeast, where the climate is most Sahelian, have consistently suffered the highest stunting rates. Kaffrine, Tambacounda, Kedougou, Kolda, and Sedihou have consistently had the five highest stunting rates in the country. In 2017, the stunting rate in those regions was approximately four times higher than in Dakar.

The inequality in Senegal is also visible in analyses of stunting by wealth quintile. In 1992, children from the richest 20 percent of Senegalese families were significantly less likely to be stunted than other children, and children from the bottom three quintiles were all bunched closely together. Over time, the gap between the richest and the middle three quintiles has closed, but the gap between the richest and the poorest has widened. In 2017, the biggest gap is between the bottom quintile and the second-to-bottom quintile. The conclusion is that the growth of children in the bottom 20 percent of the wealth is improving less than the growth of other Senegalese children.

Better targeting of the worst-off regions and those children who are worst off in the better-off regions could help Senegal start driving the stunting rate down again.

Human resources for health

The WHO guideline for the minimum number of doctors and nurses per 1,000 population is 2.3. In Senegal, the number is 0.38. ² Furthermore, doctors and nurses are heavily concentrated in urban areas. But even in the Dakar region, with its 667 doctors, 2,410 nurses, and 449 midwives, the total number of health workers per 1,000 population comes to 1.1 health workers, less than half the WHO’s recommendation. In the semi-urban regions around Dakar, the ratio is lower.³  

In the eight rural regions in Senegal, the shortage is especially severe. There are just 105 doctors, 1,022 nurses, and 260 midwives. That comes to 0.3 health workers per 1,000 population, or approximately eight times less than the WHO’s recommendation. The reasons health workers cite for not working in rural areas include the lack of opportunities for their families to receive good health care and attend good schools and the lack of opportunities for themselves to continue their medical education and training.

The cadre of more than 15,000 community health workers provide many of the services typically provided by doctors and nurses, lessening the impact of the shortage.⁴  Nevertheless, most Senegalese are isolated from caregivers who have the sophisticated training necessary to manage complex cases.

Out of pocket spending

During the African economic crisis of the 1970s and 1980s, many governments struggled to finance their health systems. In response, and at the urging of UNICEF, the ministers of health present at a 1987 regional WHO meeting in Bamako, Mali, launched the Bamako Initiative. This initiative proposed a set of design principles to help countries facing fiscal challenges provide primary health care.⁵

In short, the Bamako Initiative envisioned a decentralized primary care system funded by user fees. Patients would be charged for drugs or treatment, and local health committees would decide how to spend that money to provide the care its people needed.

The advantage of the Bamako Initiative was that it engaged communities in health care, and those communities were closer to the need and able to be more flexible in meeting it. The disadvantage was that it effectively released governments from the responsibility to keep their citizens healthy and gave that responsibility to the citizens themselves, many of whom were unable to pay.

Although the current movement for Universal Health Care represents a rejection of the Bamako Initiative, much of West Africa, including Senegal, is still contending with the initiative’s legacy. Senegal invests a relatively small share of its budget in health care, and that percentage has actually been going down in recent years. In 2001, Senegal spent 9.5 percent of its budget on health. By 2015, that percentage had dropped by more than half, to 4.2 p ercent.⁶ In 2016, Senegal’s government health spending was 1.3 percent of GDP, well below the Sub-Saharan African average of 1.8 percent.

Moreover, patients still bear the burden of funding the system through user fees. The government’s per capita spending on health in 2016 was $32. External partners spent just a little less, $30 per capita. Meanwhile, individuals spent $57, almost equal to the total spent by the government and donors put together, and $44 of that was spent out of pocket.⁷  The result, in a country where the extreme poverty rate is still above 30 percent, is that the poor may go without care or forego other necessities, like education and healthy food, to pay for it.

In recent years, Senegal has tried to help defray some of these costs, eliminating fees for facility-based deliveries in 2005 and for the elderly in 2006.⁸  As a result of these changes, out of pocket spending decreased slightly. The government has also set its sights on creating a viable insurance option for the poor. As of 2014, however, only approximately 25 percent of Senegalese had any kind of insurance coverage, and more than half of them were relatively wealthy people participating in mandatory contribution plans through their work.⁹  Mutuelles, community-based insurance funds for the poor that have existed since the early 1990s, have scaled extremely slowly, with only approximately 5 percent of the population covered.

Decentralized governance

While decentralization policies aimed to enable local governments to better tailor their services for constituents, there have been a number of challenges that have surfaced over time.

One challenge is the “complex web of authority” created by pushing authority away from the center. Senegal tried two methods of government reform simultaneously, decentralization and de-concentration. Decentralization puts more decision-making authority in the hands of the local community. De-concentration keeps decision-making authority with the central government, but moves its representatives away from the center and into the communities. Unfortunately, this has led to confusion and power struggles, because it puts different governing bodies in the same locations without a clear understanding of roles and authority.

For example, according to the 1996 law, communities were supposed to form local health committees, but the law did not specify who should create these committees, so in many communities, they never formed. In those cases, Ministry of Health bureaucrats continued to make decisions and left the local authorities out of the process.

Similarly, the central government was supposed to transfer money to the local governments, but information about that money did not always reach the people in charge locally, regional council presidents or commune mayors. Therefore, despite being legally responsible for spending the money, mayors, and council presidents had to ask (supposedly subordinate) Ministry of Health bureaucrats for basic information about how much funding they were getting and when.¹⁰

A survey in 2000 found that 79 percent of local elected officials said that they do not have sound knowledge of the laws and regulations pertaining to decentralization, and only 22 percent said they had received any training about how to function in the system.¹¹

Another challenge is the mismatch between responsibility and resources. The 1996 law gave local governments responsibility in nine areas: planning, land planning, public land administration, urbanization, health, education, environment, youth, and sports and culture. “Finance, however,” according to the authors of a World Bank report, “did not follow function.” In other words, the central government did not provide these local governments with enough money to carry out their responsibilities.¹²  The transfers from the central government to the local governments account for only about 20 percent of the local budget. The local governments are responsible for raising the rest through user fees for health huts and schools, business licenses and taxes, and other methods. The reliance on user fees especially can be problematic, because those who are unable to pay may lack access to basic services. ¹³

Agriculture and climate

Over the last two decades, the Senegalese agricultural sector has grown steadily. Food exports and imports rose by $216 million and $309 million respectively, and the food production index, which covers food crops, rose by 75 points.¹⁴ Over the same period, the average protein supply increased from 63 to 72 grams per capita per day.¹⁵

Nevertheless, Senegal is highly food insecure. In some regions, children may take in a sufficient number of calories, but from a single source, which provides no dietary diversity. In other regions, particularly in the southeast, there simply is not enough food. As a result, Senegal ranks 66 out of 119 countries in the Global Hunger Index (even so, it has the best ranking among the countries of former French West Africa).¹⁶

One area of growing concern is the increasing frequency of the climate shocks to which Senegal is subjected, especially because the environmental conditions in the country have always been challenging. In the past year alone, Senegal has suffered a major drought and a major flood, bringing the total to three droughts and two floods in the last decade. These disasters affect huge numbers of people. For example, the 2009 flood affected 360,000 people and the 2014 drought affected 850,000 people—see the data visualization below. But savage weather is not the only threat the country faces; it is also vulnerable to invasion by pests, such as the locust infestation that ravaged crops as recently as 2004.¹⁷

For a country where roughly 70 percent of the population works in agriculture, such disasters have frightening ramifications. For example, the 2011 drought cut grain production by 20 percent and groundnut production by 30 percent. As a result of the droughts of the 1960s and 1970s and now the droughts and floods of the past decade, the groundnut basin in the center of the country, which used to provide 20 percent of the world’s peanuts, produces less than two-thirds of the peanuts it did 50 years ago. ¹⁸

The government has made investments for years to try to cope with this challenge. Since 1989, it built several dams and an irrigation system to try to manage droughts and flooding. In recent years, Senegal has worked with donors to launch a series of food security programs, including an early warning system, crop diversification, and a cash transfer program for poor mothers. Unfortunately, these interventions have not been enough to meet the challenge. Senegal, like many countries in Sub-Saharan Africa, needs to invest in agricultural infrastructure, policies, and tools that help farmers thrive in spite of increasingly severe weather. ¹⁹