Challenges

Equity

Over the past 20 years, district-level DTP coverage has improved across Senegal. DTP3 coverage has improved for both urban and rural departments (see first figure below). The percentage of zero-dose children, defined as children under the age of 1 year who do not receive their first dose of DTP, has declined (see second figure below). For both measures, variation between departments has decreased, illustrating improvement in equity at the department level.

Despite this progress, inequalities in immunization persist in Senegal (see figure below). Findings from household surveys reveal that children of more highly educated mothers are more likely to be vaccinated. This correlation has been found in other African settings as well.^1,2,3 Children in the western and central regions of Senegal are also more likely to be vaccinated, which may reflect inequitable access to high-quality health services across regions or regional differences in attitudes toward health care.

After accounting for the main drivers of childhood vaccination (community access, intent to vaccinate, and facility readiness) in Senegal, two additional factors associated with higher odds of vaccination were maternal education and household wealth. The effects of these factors varied more at the regional level, with Thies and Fatick having a much higher odds of childhood vaccination and Kédougou and Tambacounda showing lower odds. Such regional differences likely reflect unmeasured aspects of how maternal education and household wealth ultimately result in children being vaccinated, which could include regional differences in how vaccine sentiments impact vaccination-seeking behaviors, access barriers beyond travel time to services, and differences in catch-up or outreach activities.

These disparities were borne out in our research. Human resources are concentrated in the more densely populated regions in western Senegal.⁴ Mothers observed that being close to health centers is important for access to care:

Populations in rural and remote areas (such as coastal islands) face greater challenges in gaining access to care, and health workers face greater obstacles in delivering services to communities in rural areas. Outreach services are sometimes canceled due to lack of transportation and poor road conditions during rainy seasons. In Tambacounda, in the eastern region, health workers cited a lack of appropriate transportation and infrastructure, including road networks, as a barrier to delivering vaccines to communities.

Recent work toward building a geolocated master list of health facilities, led by the Institute for Health Research, Epidemiological Surveillance and Training and the Ministère de la Santé et de l’Action Sociale (MSAS, Ministry of Health and Social Action), can lend support for targeted service planning for immunization and beyond. For instance, based on currently geolocated facilities, estimated travel times to the closest health facility are much lower in western areas of the country, as well as along Senegal’s northeastern border. In contrast, especially for regions farthest away from Dakar such as Kédougou in southeastern Senegal, estimated travel times to the nearest facility are much longer.^5,6 Having a master list of health facilities can contribute to more targeted immunization service planning and identify areas that may require increased access to services.

Senegal also funds outreach strategies through community health development committees (comités de développement sanitaire), supplemented by resources from external partners. Transportation challenges remain, however.⁷ For example, motorcycles and cars are critical for outreach services and especially mobile strategies (for locations over 15 kilometers away), but they are rarely provided. As a result, mobile immunization sessions are held less frequently and health workers resort to renting vehicles or borrowing cars from community members or political leaders.

Decentralization

Senegal has implemented multiple waves of decentralization since 1972, leading to the transfer of responsibilities for public health, urban planning, education, social development, and other functions from the national government to local government entities. More local governmental levels were also created to bring governance and service delivery closer to the population. Decentralization may enable more targeted solutions for challenges in service delivery. However, subnational entities need sufficient financial resources and technical and managerial capacity, which has not consistently been available. Senegal is now implementing a revision to its Decentralization Act, including national-level structural reforms and capacity strengthening of local governments.^8,9,10

Health systems issues, as reflected in health worker strikes

Doctors, nurses, and CHWs have gone on strike in many low- and middle-income countries due to a lack of adequate funding and infrastructure.¹¹ In Senegal, health workers went on strike four times between 1997 and 2019, with the strikes ranging between one month and three years in duration.

In most cases, striking health workers in Senegal continued to provide essential services, and halted only the reporting of health data. The data was backfilled after resolution of each strike, albeit with predictable declines in quality. Key informants reported that in the most recent strike (2018–2019), family planning, malaria prevention, and vaccination services were also interrupted, and for the last four months of the strike only emergency health care services were provided.

One interviewee referred to the strikes as a “deterioration of the social climate in the health sector.” Grievances included inadequate pay, unsustainable workloads, inadequate training, poor working conditions, electricity and water shortages, and insufficient transportation for field activities.

Striking workers demanded reforms in such areas as the distribution of funds to health facilities and hospitals, compensation, the recruitment and recognition of personnel, and the provision of housing allowances and liability compensation.¹² Although many points have been resolved over time through negotiations between the trade unions and the government, our interviewees still spoke of heavy workloads and inadequate compensation, especially among health facility staff and CHWs.

Challenges sustaining community health worker programs

In spite of its importance, the ACPP program has struggled to attract and retain volunteers. Incentives vary because the MSAS does not allocate sufficient funding for CHW incentives, and each community makes its own decisions about whether and how ACPPs should be compensated for their work. Whenever health posts joined forces with nongovernmental organizations, ACPPs were more likely to receive a stipend, leading to increased retention. Another highly successful incentive was formal recognition of the CHWs’ efforts.

In some cases, communities encouraged workers to continue their duties through monetary payments or the provision of staple commodities such as flour, sugar, or cooking oil. Community members sometimes worked together to help cultivate crops for the CHWs.

In practice, such compensations were spotty and inconsistent, which decreased motivation, contributed to turnover, and limited recruitment.¹³ This situation is reflected in the numbers of bajenu gox and relais. In 2014, there were 7,435 relais and the MSAS estimated that an additional 16,000 relais would be needed to achieve its target of one relais for every 250 people. Similarly, the MSAS estimated that 12,000 bajenu gox would be needed to achieve its target of one “godmother” per 100 households: in 2014, Senegal had only 3,406 bajenu gox.^13,14

In addition, training and supervision of ACPPs is not consistent across the country. This can lead to differences in capabilities and overall quality of service.¹³ Head nurses reported that some ACPPs had not been trained and thus required more feedback and supervision in the field. Relais in Tambacounda reported that they had not had the vaccination training they wanted and needed. Bajenu gox in Dakar said they were unsure of immunization content.

Decentralization has expanded the number and range of individuals involved in health service provision, making it more difficult to establish consistent training systems. Some informants from the regional and district levels believed that greater investment in human resources and technical training for ACPPs would address personnel challenges and create a stronger, more sustainable frontline workforce.