Senegal

Amadou Gallo Diop

Ibrahima Pierre Ndiaye

Introduction

Epilepsy is one the most common neurologic diseases in outpatient and inpatient health management in Senegal, West Africa. It is the same situation in the majority of African and many developing countries, where it constitutes a major public health care problem.¹¹ From newborns to teenagers, childhood are the most stressed group due to several causes of epilepsy including perinatal problems, febrile convulsions, cerebral malaria, and consanguinity, which is a genetic factor.¹^,¹⁹^,²²

Such as in the majority of African countries, the cultural environment is a limiting factor for early diagnosis and treatment of seizures. Interpreted as a subnatural affliction, epilepsy is mainly managed by traditional healers, reducing the chance for Senegalese people living with seizures to benefit from modern drugs and better opportunities to become seizure free. A heavy burden is generated, leading to school withdrawal, nonemployment, and other social discriminations.

Overview of the Country

Senegal is a Western African country of 196,722 km². It is surrounded by Mauritania (at north), Guinea and Guinea-Bissau (at south), Mali (at east), and the Atlantic Ocean (at west). Gambia Republic is situated inside Senegal. Forty-five percent of the population is younger than 15 years old; 53.5% of the population is female, and 52% of the population is rural. The increasing rate for the general population is 2.6% per year. The population of Senegal is estimated to be near 12 million (Table 1). The general life expectancy is estimated at 54 years for males and 58 years for females. The infantile mortality rate is estimated to be 58 of 1,000 births.

The mean population density is estimated at 54 inhabitants per km², but it is very disparate: 3,659 inhabitants per km² are living in the capital city Dakar region, versus eight inhabitants per km² for the region of Tambacounda in the southeastern region, which represents 30% of the surface of the country. This situation can be explained by the large surface of this region, the low-wealth environment, and its aridity. Sixteen ethnic and language clusters are defined, but the main ethnic group and most spoken language is Wolof. It is important to be aware of this diversity because it may be considered in any information and education program, because of specific social and cultural values that are correlated to each. The rate of illiteracy is 43% of 15- to 24-year-old males and 62% of 15- to 24-year-old females. Ninety-two percent of the people in Senegal are Muslim.

Senegal is composed of 11 regions. Regions are divided in departments, themselves divided into districts, then into rural communities. These structures are led, respectively, by governors, prefects, and rural community presidents. Cities are led by a mayor. In their intervention domains are included health in coordination with the ministry of health, education, environment, urbanism, agriculture, youth, sport, and art craft.

Senegal is a low-economy country. The gross national product per inhabitant is estimated to be U.S. $480. The economy is mainly based on exploitation of phosphate, fishing, tourism, and agriculture.

General Data on the Health System

Health Organization and General Data

Senegal guarantees in its constitution that health is a right of every citizen and the duty of the state to provide. The medical and health systems are inherited from French colonization. A recent law is trying to organize traditional medicine, but one can guess how difficult it is to do so because of the secrecy surrounding this mystic and intrafamilial legacy. Despite this legislation, total or partial health insurance or coverage is a reality for about one third of the population represented by public and private workers and their families. The remaining two thirds remain in an informal sector, financing their health fees through their own or indirect supports. The health system is structured like a pyramid constituted from the base to the top by health post (for villages and rural communities), health center (inside cities), regional hospital, and two university hospitals. This represents the following (Table 2):

11 medical regions (led by the regional head doctor)
56 health districts (with one or more doctors and paramedical staff)
59 health centers (with nurses and midwives)
813 health posts (with nurses)
37 private Catholic health posts located in the suburban area of Dakar

The geographic accessibility to a health structure is theoretically 1.2 km for Dakar’s patients, versus 16.2, 12.9, 11.0, and 10.3 km for the regions of Tambacounda, Louga, Saint-Louis, and Kolda, respectively.

In the context of the African continent, Senegal has a very low prevalence rate of HIV/AIDS infection: 0.8%. Heterosexual transmission is the major route. Since the early beginning of the AIDS pandemic, a strong policy of information, prevention, and caring has been developed. Reported AIDS cases increased progressively and remain stable now, estimated to be about 45,000 people. This tendency is attributed to Senegal’s initiative of access to free antiretroviral drugs since 1996.

Table 1 Socioeconomic, Demographic, and Health Indicator Data about Senegal

Population, total	11.9 million
Population growth (annual %)	2.4
Life expectancy at birth, total (yr)	56.1
Fertility rate, total (births per woman)	4.8
Mortality rate, infant (per 1,000 live births)	77.6
Mortality rate, under 5 yr (per 1,000)	136.6
Births attended by skilled health staff (% of total)	57.8
Malnutrition prevalence, weight for age (% of children under 5)	22.7
Immunization, measles (% of children aged 12–23 months)	57.0
Prevalence of HIV, total (% of population aged 15–49)	0.9
Primary completion rate, total (% of relevant age group)	45.2
School enrollment, primary (% gross)	76.0
School enrollment, secondary (% gross)	19.4
School enrollment, tertiary (% gross)	4.9
Ratio of girls to boys in primary and secondary education (%)	89.8
Literacy rate, adult total (% of people aged 15 and above)	39.3
From www.worldbank.org and www.who.int.

Table 2 Health Infrastructures

Medical regions	Hospitals	Health districts	Health centers	Health posts
Dakar	8	8	11	115
Diourbel	2	4	5	70
Fatick	1	6	6	73
Kaolack	1	4	4	72
Kolda	1	4	3	68
Louga	1	5	5	56
Matam	1	3	3	50
Saint-Louis	2	4	4	81
Tambacounda	1	6	5	58
Thies	2	8	9	91
Ziguinchor	2	4	4	79
Total	22	56	59	813

Health Financing

The health annual budget roses to 9% of the global government budget since 2002. But 65% of the budget of the Ministry of Health is dedicated to pay salaries. There is a decreasing participation of the government financing of health and an increase in the population participation. Thirty percent of
credit and expenses are done in the capital region of Dakar. Other sources of finances include development partners and local communities. They contribute in building, training, salary, and daily expenses. But it is difficult to determine their exact contributions. City administrations are also contributing in the health expenses, drugs, and maintenance. Armed forces and police also participate in health expenses of their personnel and families.

Health Personnel

Representing the health personnel are 649 (public and private) doctors and 3,287 paramedical staff (midwives, private nurses, and health agents) (Table 3). The mean general doctor-to-population ratio in Senegal is one doctor for 18,300 inhabitants, one midwife per 6,124 reproductive women and 0- to 4-year-old children, and one nurse for 4,570 inhabitants. The World Health Organization (WHO) recommends one doctor for 5,000 to 10,000 people, one midwife for 300 people, and one nurse for 300 people. There is a wide disparity: 90% of specialized doctors are concentrated in Dakar, the capital. The Dakar region has more than 50% of doctors, pharmacies, surgeons, nurses, and midwives. The national ratio is 11,163 inhabitants per health post. This is not so far from what WHO recommends (10,000 inhabitants).

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