Interning at a clinic in rural Senegal
Poste de Santé in Nioro Alassane Tall, Senegal
By Mathea Pielemeier
Introduction
Senegal has a decentralized health system; hospitals are located in urban centers with clinics dispersed throughout rural areas. The most advanced category includes national and regional hospitals, which provide a range of technical medical interventions. The level below this, the intermediate level, includes centres de santé (health centers), which provide comprehensive medical care without the resources and scale of a hospital. The final level, the peripheral level, includes postes de santé (health posts) and cases de santé (health huts). Postes de santé often employ a nurse and a midwife who serve as primary care providers, treating common illnesses, assisting births, dressing wounds, and referring to more advanced facilities if needed. Cases de santé are the most informal facility; they are often located in small villages where a community member is trained to treat common illnesses, like influenza or mild malnutrition, and identify warning signs during a pregnancy. Despite this public, decentralized system, the accessibility of healthcare is still limited, particularly for the poor; 68% of the poorest in Senegal people cannot use maternal and child health services for economic reasons.
While I was studying away in Senegal over the fall of 2018 through the MSID Senegal program, the government had implemented a policy providing free medical care for children under 5 years of age and pregnant women as part of The Strategic Plan for Developing Universal Health Coverage. Although the premise of the plan is good, my supervisor claimed that the government did not reimburse the healthcare facilities for the free visits, leading to large debts and a strike in the public health system.
Poste de Santé de Nioro Alassane Tall
While in Senegal, I interned at a poste de santé in the village of Nioro Alassane Tall. Nioro is located in the Fatick region in southwestern Senegal, directly above The Gambia. The poste serves four other villages, Keur Mama Lamine, Ndiop Thiarene, Touba Mouride, and Ndao Malick. These villages all have cases de santé, but the poste provides a more advanced health facility in the area. The majority of consultations at the poste were for general, primary care visits. However, the poste also provided pre- and postnatal consultations and malnutrition screenings for infants and children under 5. Occasionally, a patient would seek care for a more serious ailment, such as malaria. As an intern, my role was to observe my supervisor, nurse Ousmane Diba, during consultations, help record data, screen children for malnutrition, and travel to neighboring villages to gather data on medication stocks and morbidity. By attending consultations and travelling with my supervisor, I was able to get an in-depth perspective on the "peripheral" level of the health system.
Strikes: Barriers to Care in the Senegalese Health System
Due to large debts and the underpayment of medical personnel, the public health system was on strike while I was in Senegal. While on strike, the poste de santé employees worked only two days a week. Over these two days there would be long lines of patients waiting for a consultation. If a patient needed to be seen on another day, they would have to pay an extra fee for an “urgent” appointment. In addition to the limited hours of operation, all vaccines were put on hold and birth control was in the process of being phased out to further protest the debt and underpayment of medical personnel. Public health facilities also stopped reporting data to the government, limiting the government’s ability to track morbidity and mortality. As an intern, I was deeply concerned by the lack of vaccinations, limited hours, and decreasing access to birth control. However, I was also sympathetic to the concerns of my supervisor, particularly the huge amount of debt the poste has accrued. I worried that, without vaccines, there could be an outbreak which would endanger the children in the community, including the children in my host family. Additionally, phasing out birth control could undo the work done to normalize and increase access to contraception in the area. Despite these concerns, I struggled to place blame on the medical personnel since many of them sacrificed their own financial security to continue providing care despite the debts.
Conclusion
Given the complexity of the strike, it is difficult to provide a clear conclusion or plan of action. While interning I was deeply worried by the impacts of the strike and frustrated by the lack of action on the part of the government. I wished that the medical personnel on strike had not decided to discontinue vaccination, but I acknowledged their desire to prompt the government to act. The impacts of this strike could lead to lasting problems in the health system, increasing Senegal’s reliance on foreign aid and decreasing self-sustainability. To prevent further strikes, greater government accountability is needed. Of course, this is difficult to achieve, but as one of the strongest democracies in Africa, Senegal has the capacity to enact change.
Sources:
Camara, Mbaye. (2019, April 04). Unions, Social Inequalities and the Senegalese Health System. Population Services International. http://www.world-psi.org/en/unions-social-inequalities-and-senegalese-health-system
Results for Development. (no date). Laying the Groundwork for Universal Health Coverage in Senegal Through Sustainable Financing. https://www.r4d.org/projects/laying-groundwork-universal-health-coverage-senegal-sustainable-financing/
Mathea Pielemeier
I am a International Studies and French double major with a concentration in Community and Global Health from Seattle, WA. My interests lie in global health and health equity, particularly work which focuses on strengthening health systems to increase accessibility and create sustainable change. Outside of my classes I like to go on runs, play ultimate frisbee, bake, and hangout with my housemates' puppy.
After graduation I plan to complete a Masters in Public Health and a career working locally and internationally around health equity. I hope to return to Senegal, whether for work or as a tourist, and visit Nioro and my host family!