As I normally write about the health situation in the eastern and southern countries in Africa, this time the focus will be on West Africa and mainly Senegal. Recently, after more than 50 years of experience in East Africa, to fill a pressing need, the NGO AMREF opened an office in Dakar, Senegal as a hub for serving several West African countries. The purpose is to replicate successful programmes of the eastern region in the west.
The republic of Senegal exists of 14 regions and has a population of 12.5 million inhabitants. The Senegalese population consists of many different ethnic groups. The main group is the Wolof accounting for 35% of the population. Senegal has a very young population with 15% of persons less than 15 years old; about 64% of the population is younger than 25 years. Although developing fast, the country is still very poor and more than half of the population lives below the poverty line. There are still many deficiencies in the country’s health sector, nutrition and education. This situation leads to many people staying in poverty. About 75% of the population has access to clean drinking water and 33% to sanitation. The percentages in the cities are higher than in the rural areas; here only 17% has access to sanitation.
Health situation in Senegal
The average life expectancy in Senegal is 62 years. The healthcare system in Senegal operates through city and regional hospitals, district health centers and health posts. The condition of rural roads, especially in the rain season, makes it hard for people to reach these medical centers. Therefore people often rely on local leaders and traditional medicines. Also in Senegal, like in many other African countries, there is a lack of sufficient health workers. There is only one nurse available for 2,380 persons and only one doctor for 19,949 persons. Most health workers are situated in the capital city Dakar and its surroundings. Because of this, the rural areas suffer a shortage of medical personnel. Another issue is that the health workers and midwives at the health posts often cope with a shortage of equipment.
The government of Senegal spends nearly 12% of its budget on healthcare. This spending has funded national initiatives to combat malaria and AIDS, as well as an immunization programme for under-fives and family planning. Despite this, nearly one child out of eleven dies before the age of five in Senegal. Due to widespread poverty, many children suffer from malnutrition. This makes it much harder for them to recover from illnesses such as respiratory infections and malaria. The latter is the leading cause of death by infectious disease, though other diseases such as bilharzia, typhoid and yellow fever are also common. With more than 11,000 cases in 2009, tuberculosis is on the rise again.
Success story in HIV prevention
Thanks to state education and treatment programs, HIV/AIDS infection rates are low in Senegal. Actually the prevalence rate of AIDS in Senegal is the lowest in Africa; at 0.9%. Senegal is considered as one of the world’s success stories in HIV prevention. While other sub-Saharan countries are experiencing one of the worst epidemics in the world, Senegal has maintained its low levels since 1997. Senegal’s success at maintaining this low overall prevalence has been attributed to strong political leadership, early involvement and leadership among religious leaders, conservative cultural norms regarding sexual practices, and a comprehensive strategic approach implemented early in the epidemic. To prevent HIV transmission through blood transfusions a way of Safe Blood Supply has been created. Furthermore there exists a mandatory registration and quarterly health check-ups for sex workers. Also the use of condoms is promoted. Another aspect that contributes to the low AIDS prevalence is the selenium-enriched soil. Selenium is an antioxidant effective in metabolic immune support.
Malaria has been a longstanding public health problem in Senegal. In 2005 there were still two million cases of the disease in the county and more than 2,000 deaths occurred because of this disease. Fortunately, thanks to Senegal’s own National Malaria Program (NCMP) the country experienced in 2010 a spectacular decrease of malaria in five years. In one year, from 2008 to 2009 the cases of malaria dropped with 41% with 175,000 cases in 2009. Also the numbers of malaria cases for children under the age of five dropped drastically from 400,000 cases in 2006 to 30,000 cases in 2009. The NMCP exists in Senegal since 1995 but underwent reorganization in 2005. By this year Senegal has established an effective malaria control program based on strong management and well-defined plans. A key element of Senegal’s success in making malaria control accessible to all, including the people in isolated areas, is its home based care program, called PECADOM. Under this program, which started in 2008, trained volunteers visit patients at home; they administer rapid diagnostic tests and offer treatment with artemisinin-based combination therapy (ACT). In 2009, 97% of the patients seen by a home based care provider and diagnosed with malaria were treated at community level with a 100% recovery rate.
In 2010 82% of the Senegalese households owned at least one insecticide-treated mosquito net (ITN), which is a 36% increase in less than 2 years. Furthermore, pregnant women receive free intermittent preventive treatment. In addition many free rapid diagnostic tests and medicines have been distributed. Also 17,000 health workers have been trained to give the tests and the medicines in 2009. About 330,000 household rooms were sprayed with insecticide in the years from 2008-2009.
Senegal also has implanted many innovative strategies to educate its population about malaria, with the involvement of national celebrities, footballers, religious leaders, the private sector, NGO’s and community organizations. For example singer Youssou N’Dour got involved in an information and education campaign to intensify malaria prevention messages. Besides all these good points, there are still improvements to be done in the battle against malaria. One of the issues is that pharmacies often have supply shortages in the anti malaria drugs.
Shortage of trained midwives
In Senegal most women, especially the ones living in remote areas, have no choice but to give birth at home. These women are lucky when all goes well and no complications occur. But if things go wrong help is far away and often comes too late. These women die of conditions such as breech births, hemorrhaging and high blood pressure. Death during pregnancy is in Senegal the main cause of mortality amongst women. About 410 women out of 100,000 die. Also the child mortality numbers are high; about 95 out of 1,000 children under five years die. Unfortunately there is a shortage of trained midwives in the country: only 1 per 500 births. Training of new midwives can save the lives of many women and their children and is therefore urgently needed.
In August 2011 the NGO AMREF expanded its programme to West Africa by opening an office in Dakar. The NGO will focus on combating the biggest diseases like malaria and HIV, mother and child mortality, education of health workers, access to clean drinking water, bettering overall hygiene and sanitation. When successful, it is the intention to expand the programmes to other countries in West Africa.
Programmes in Senegal
On of the four health programmes in Senegal is that of the flying doctors (called: Outreach). The first health mission took place in November. The arrival of the Outreach team was announced per radio in French and the local languages Wolof en Diola. As part of this mission, 50 women with VVF fistulas were operated. VVF stands for Vesico Vaginal Fistula and is an abnormal connection between the urinary bladder and vagina. This can happen during a difficult childbirth. Patients who have VVF leak urine or stool or both continuously and because of this, they smell of urine or stool all the time.
The Outreach programme is improving the long-term ability of twelve remote hospitals to medical services and, more specifically, reconstructive surgery of cleft and lip palate, and treatment of fistula and or cataracts. During these outreach missions local surgeons, medical doctors, clinical officers, nurses, and laboratory workers are trained. Within the program the remote health centers will be visited about six times per year, each visit taking three to four days. The idea is to extend this program of air-assistance in the surrounding countries before 2015.
Then there's E-Learning. Distance learning uses ICT facilities to improve education and to make it accessible for more people at the same time, including vulnerable people in remote rural areas. E-Learning, a part of distance learning, is learning that is facilitated and supported via ICT’s, mainly a computer. Over the last six years E-Learning has been used to rapidly and cost-effectively scale up the production of the health workforce and to upgrade the skills of health workers in Africa to combat the shortage of health workers. The E-Learning programme is flexible; making it possible for the students to learn anytime and anywhere without the need to stop working while they obtain new skills Thanks to this programme the before mentioned NGO wants to train 20,000 nurses by 2015, all specialized in the treatment of major diseases like malaria and AIDS.
The third programme involves PHASE. Between 2000 and 2004 AMREF successfully implemented Personal Hygiene and Sanitation Education (PHASE) in 247 rural schools across Kenya in partnership with the Ministries of Education and Health. Based on the successes of this project in reduction of water borne diseases and school absenteeism, the Government of Kenya incorporated PHASE into its policy framework.
Within this programme, peer educators are trained who in turn train children to be change agents in the community, working with school management committees, and the Ministries of Education and Health. The infrastructures at school will be developed. These include construction of pit latrines, water tanks and drainages; establishment of refuse disposal pits and setting up of child-friendly hand washing facilities. The public message in health is passed on via the media, use of puppetry and organization of social events like sports, drama and poetry competitions to promote PHASE objectives. In 2000 schools still obtained 70% of their drinking water from rivers. These same schools had very unhygienic sanitation or no sanitation at all. Many of these schools now have access to clean water (from a well) and better sanitation, which causes less cases of diarrhea, less sick children and therefore more children at school. The lessons these children learned at school are often copied by their surroundings. This successful project is introduced March this year in Senegalese schools to teach schoolchildren about hygiene with the idea that they will pass on this information to their families and friends.
Lastly, telemedicine is the use of medical information exchanged from one side to another via electronic communications to improve a patients health status. With help of ITCs like internet, satellite connection and mobile phones telemedicine is providing medical consultations, diagnostic services, as well as specialist medical and surgical services, to health personnel working in remote hospitals. To avoid the risk of professional isolation and outdated practices, the project will improve knowledge transfer to rural doctors through the increased use of information and communication technology, such as mobile phones and internet.
Because there is a shortage of medical staff and doctors in Senegal, telemedicine can support a doctor in helping more patients from distance. This also saves transport costs for both doctors and patients. Therefore telemedicine can improve the health situation in remote areas where there are no specialists available.
Many health concerns
Although the Senegalese government is doing a good job to keep its country healthy by means of their strong HIV and malaria programmes, the country still has many health concerns to be tackled. Amongst these are the shortage of midwives and other healthworkers, especially for the people in remote areas. Furthermore improving access to clean water and sanitation and better hygiene can diminish the occurrence of certain diseases. By means of their programmes the NGO AMREF is improving the health situation in Senegal for both patients and healthworkers in remote areas with their outreach missions and telemedicine; also training and education of existing and new health workers and informing the youth about good hygiene by means of E-Learning and PHASE will contribute to better health in Senegal.
* Jacqueline Lampe is director of AMREF Flying Doctors in the Netherlands.