Context

Senegal is a small, predominantly flat country in West Africa bound by the Atlantic Ocean to the west. Its population, split about equally between urban and rural areas, has more than doubled since 1990. In 2017 the population had grown to 15.9 million, according to United Nations data from that year.

Like other countries in the Sahel – the Sahara desert region stretching from Mauritania to Chad – Senegal is poised for further major increases in population. According to the 2017 United Nations population figures, the country is projected to grow to over 33 million inhabitants by 2050.¹

In 2018, about 3 million people were living in metropolitan Dakar, the capital and largest city.² Located on the Cap-Vert Peninsula at the westernmost point of the African mainland, Dakar was the capital of colonial French West Africa. In 1959, the area constituting modern-day Senegal merged with French Sudan to form the Mali Federation, which gained independence from France the following year.

The federation suffered internal divisions from the start, and lasted only two months. In August 1960, Senegal and French Sudan – now known as Mali – declared their independence as separate countries.

In 1982, Senegal attempted a merger with Gambia, a tiny former British colony that partially bisects the country’s southern tier. The two countries encountered challenges on the way to full integration, however, and reassumed their separate identities in 1989.

This failed consolidation has had lasting effects on the parts of southern Senegal separated from the rest of the country by Gambia. This region, known as Casamance, is a predominantly Christian enclave in a country that is 94 percent Muslim.

In addition, Casamance is home to the Jola ethnic group, which as of 2019 makes up 5 percent of Senegal’s overall population – far less than the Wolof (who constitute 37 percent of the country’s population), Pular (26 percent), and Serer (17 percent) peoples.³ Exacerbating the sense of regional estrangement was a local belief that the economic resources of Casamance were being unfairly siphoned to Dakar.⁴

In the same year that Senegal and Gambia began their short-lived merger, these geographic, religious, ethnic, and economic divisions erupted in what has become known as the Casamance conflict. This struggle, waged between the government of Senegambia/Senegal and the Movement of Democratic Forces of Casamance (known by the French abbreviation MFDC) has so far displaced an estimated 60,000 civilians and claimed approximately 5,000 lives, with most of the fatalities occurring between 1992 and 2001.⁵ While fighting has abated since 2014, interviewees said that irregular combat continues to plague the area.

Other than the Casamance unrest, Senegal’s post-colonial history has been remarkably stable, with only four presidents serving since 1960 – all of them democratically elected. Indeed, Senegal is considered unique in the region for the quality of its democracy and overall governance. Largely because of this political stability, uninterrupted since independence, Senegal is a longtime recipient of significant foreign aid.

Senegal experienced significant economic growth during the 2000–2016 study period. GDP (in Purchasing Power Parity constant 2011 international dollars) rose from $24.8 billion in 2001 to $46.5 billion in 2016.⁶ GDP per capita has also risen, to levels higher than that of regional neighbors like Mali and Guinea.⁶

The rate of extreme poverty in Senegal, defined by the World Bank as US$1.90 per day, declined from 36 percent in 1991 to 12 percent in 2005 before leveling off; the rate stood at approximately 13 percent in 2011.⁷

Senegal’s currency – the multinational, French-backed CFA franc – was devalued in 1994 in an effort to make West and Central African goods cheaper and more attractive on the global market, following a long recession in the 1980s and early 1990s.

The immediate impact of the devaluation was extreme inflation,⁸ with the price of many consumer goods, including food, doubling almost overnight. This initially made devaluation a very unpopular policy, with many citizens protesting that the plummeting CFA franc was driving them toward starvation.⁹ 

Nevertheless, there is strong evidence that the devaluation stimulated the economy and triggered the relative prosperity of the late 1990s and early 2000s. According to one paper, “The devaluation was a clear success from a macroeconomic viewpoint, as it entailed a significant turnaround from low and unstable growth to a sustained boom.”¹⁰

That boom occurred in Senegal’s non-agricultural sectors first, so the impact was more immediate and ultimately greater in Dakar and other cities, but it also eventually reached the rural economy as well. There is still a large economic gap between Senegal’s rural and urban areas, however, and the currency reform has not shrunk it.¹¹

Outside of Dakar, Senegal is highly reliant on farming, which employed approximately 77 percent of the country’s population in 2018, though it generated only 15 percent of national GDP.¹²

Most of Senegal’s agriculture is rain-fed, and much of the country lies within the Sahel, where rainfall is irregular and soil is poor. Climate instability is a growing threat to food security and health in Senegal. In the past decade, the country has suffered three major droughts and two major floods, including one of each in 2018.¹³

Although economic growth and poverty reduction leveled off after the mid-2000s, labor migration and remittances have become an increasingly important safety net for low-income Senegalese families.

In 2003, Senegal received approximately US$500 million in remittances from citizens working abroad. By 2008, that number was approximately US$1.5 billion, and by 2016 it had reached US$2.0 billion (10 percent of GDP).¹⁴ The evidence suggests that the vast majority of remittances are spent on food, education, and other necessities.¹⁵

One hopeful sign for Senegal’s future economic and social progress is a growing access to education, particularly for girls. Between 1992 and 2017, the overall primary school enrollment rate increased from 44 percent to 72 percent, and the gender-parity index (ratio of girls to boys in school) increased from 0.74 to 1.12.¹⁶

In the same quarter-century, women began waiting longer to have children – and having fewer of them. The median age at first marriage for women ages 20 to 49 rose from 18 in 1997 to 19.7 in 2015.¹⁷ Meanwhile, the adolescent fertility rate declined from 105 births per 1,000 women ages 15–19 in 2000 to 77 in 2015,¹⁸ and the total fertility rate dropped from 5.5 births per 1,000 women in 2000 to 4.8 in 2017.¹⁹

Contextual factors contributing to success

In its campaigns to reduce under-five mortality, Senegal benefited from certain contextual factors, some of which are highlighted in this section.

National Leadership and Accountability

Senegal’s national government has consistently set priorities and provided the oversight that enabled organizations from both within and outside the country to generate lasting momentum to reduce under-five mortality.

The national government has been particularly receptive to the recommendations of the international community, for example, following guidance from the World Health Organization (WHO) to issue insecticide-treated nets (ITNs) free of charge. In addition, Senegal’s government is relatively stable, transparent, and democratic²⁰ – all qualities that help establish it as a trustworthy coordinator of resources to address under-five mortality, whether from within or from abroad.

Along with these traits, the Senegalese national government has frequently displayed a willingness and ability to develop detailed strategic plans – and to adapt them as needed. Perhaps the best illustration of this tendency is the country’s persistence in formulating and adjusting its various programs to address the pressing issue of malnutrition.

Significant Levels of Donor and Partner Support

Donor and partner engagement in under-five mortality interventions took many forms. The national government actively consulted with national and international organizations in developing and implementing its strategies. This collaboration enabled Senegal to build broad-based acceptance for interventions, and to gain access to world-class technical expertise.

Examples of how donors and partners aided Senegal’s campaigns to reduce under-five mortality are both numerous and diverse. In 1996, at the national government’s request, WHO organized several meetings to help introduce the Integrated Management of Childhood Illness (IMCI) program into the country.

This led to the development of an IMCI working group supported not only by WHO, but also by UNICEF and the United States Agency for International Development (USAID). Then, when the country implemented facility-based IMCI (FB-IMCI), it arranged harmonization workshops to ensure that donors and partners acted in alignment with the government’s findings and priorities.

Beyond IMCI, Senegal relied extensively on donors and technical partners for the rollout and sustainment of several vital initiatives. Gavi co-funded the rotavirus vaccine and pneumococcal conjugate vaccine (PCV) programs while WHO, UNICEF, and USAID provided technical support.

In addition, the introduction of children’s intermittent preventive treatment interventions against malaria involved the development of policies, guidelines, protocols, and data collection tools with support from the Global Fund, USAID, and UNICEF.

Strong Community-Based Delivery and Treatment System

Senegal has had effective community health worker (CHW) programs since well before the 2000–2016 study period, and has drawn upon those programs in myriad ways to reduce under-five mortality in the country.

The government deployed the various CHW cadres for several vital interventions, enlisting their help with public engagement and direct care delivery. This reliance upon trusted, locally selected CHWs contributed to the popular acceptance and overall efficacy of interventions, and proved invaluable to national scale-up efforts.

Among the many examples of CHWs working to address under-five mortality include the involvement of agents de santé communautaire, relais communautaires, and matrones in various elements of community-based IMCI (CB-IMCI), and bajenou gokhs for community-based maternal and child health care.

Reliable Preexisting Surveillance and Research Programs

Senegal often built new interventions into preexisting systems, saving valuable time and resources. For example, the ITN rollout drew upon broader antimalaria programs that had been in place for years, the PCV campaign benefited from a surveillance system designed to monitor pediatric meningitis, and the measles vaccination campaign similarly leveraged a polio-surveillance network.

In addition, the country had in place the functional capacity to conduct academic research, as represented by such institutions as Albert Royer Children’s Hospital in Dakar and the Cheikh Anta Diop University. This strong national research capacity helped the government assess programs and policies based on reliable data and scientific evidence – as seen in various adaptations of the malaria program.