key: cord-273805-01b94ids
authors: Paul, Elisabeth; Ndiaye, Youssoupha; Sall, Farba L.; Fecher, Fabienne; Porignon, Denis
title: An assessment of the core capacities of the Senegalese health system to deliver Universal Health Coverage
date: 2020-09-02
journal: Health Policy Open
DOI: 10.1016/j.hpopen.2020.100012
sha: 
doc_id: 273805
cord_uid: 01b94ids

nan

objective. By the end of June 2019, an estimated 45.39% of the Senegalese population was covered by some form of social protection scheme for health [3] . The Senegalese health system has a pyramidal structure with three levels of care and a system of referral. Health facilities comprise various levels of hospitals, health centres, health posts, plus hygiene and social services The administration of the health sector is also structured along three levels: central (Ministry of Health and Social Affairs -MoHSA), intermediate (14 regions ) and peripheral (77 health districts) [4] . The public health care system is complemented (particularly in Dakar, the capital city) by a growing private sector which is estimated to represent nearly 70% of the total provision of health services and which is increasingly involved in the CMU policy [5] . The health sector has experienced a number of reforms in the past decade, notably so as to facilitate the decentralisation policy whose implementation is still lagging behind [4] .

In addition, the coordination of the financial protection arm of UHC has been assigned to a separate CMU Agency. The latter, which was initially created under the responsibility of MoHSA, was transferred to the responsibility of the Ministry of Community Development, Social and Territorial Equity in April 2019. This is meant to enable a separation of purchaserprovider functions and hence a strengthening of the control function, which is judged essential in the development of the social protection policy, as well as to improve the coherence of community development policies.

The concept of UHC is closely linked to that of health system strengthening (HSS). Indeed, HSS comprises the means (the policy instruments, i.e. "what we do"), while UHC is a way of framing the policy objectives (i.e. "what we want") [6] . African countries face particular J o u r n a l P r e -p r o o f challenges with regard to the implementation of UHC because of substantial gaps characterising their health systems [7] . The objective of this paper is to assess the main capacities of the Senegalese health systems to deliver UHC, and as a corollary, to identify possible gaps and requirements in terms of HSS necessary to implement and facilitate progress towards UHC.

Based on a critical review of existing data and documents, complemented by the authors' experience in supporting UHC policy making and implementation in Senegal, we apply the World Health Organisation's conceptual framework based on six health system building blocks (leadership and governance; financing; health workforce; infrastructure, equipment, pharmaceuticals and medical products; health information; and service delivery) [8] , enhanced by an analysis of the demand-side of the health system (characteristics and expectations of the Senegalese populations) [9] . Indeed, this framework is commonly used by practitioners in Francophone African countries, and was utilised to guide the situation analysis behind the elaboration of the recent national health sector development plan [4] . The main question we intend to answer is the following: how far are the core health system capacities in place in Senegal to deliver UHC? To do so, we have focussed on the main foundational and institutional bases facilitating the implementation of the UHC policy and as a corollary, on the bottlenecks hampering progress towards UHC. Foundations are to be understood as the key basic health system related issues (like primary health care workforce, supply chains and diagnostic facilities, essential medicine, a unified information system, local health governance the World Health Organization [9] . For each building block, we discuss a set of key indicators that have been identified by a working group within the World Health Organisation as being critical for health system strengthening, for adequately delivering health services in an appropriate and equitable way, and therefore for contributing to UHC.

At the policy level, Senegal adopted a national health policy in 1989, which recognizes the right to health and entrusts the Ministry of Health with its implementation [11] . It is implemented through a national health sector development plan, the third of which was adopted in 2019 and is called the Plan National de Développement Sanitaire et Social (PNDSS) 2019-2028. It is based on three major axes which are: (i) the governance and financing of the sector; (ii) the provision of health and social action services, and (iii) social protection in the sector. This decennial strategic plan is further declined in multi-annual expenditure programming documents, specific strategic plans and operational plans at various levels [4] . A draft Law aimed at instituting the CMU had been prepared as a specific legal framework. Nonetheless, following the transfer of the CMU Agency to the responsibility of the Ministry of Community Development, Social and Territorial Equity, that draft law will be integrated into a more holistic legislation on social protection (under construction at the moment). It is planned to specify that all residents are entitled to a financial protection regime.

At the institutional level, a number of stakeholder coordination committees meet regularly and provide policy advice to the MoHSA. Other health-related sectors participate in the joint annual review at both the national and regional levels. At the local level, the former (and under-performing) "health management committees" were replaced in 2018 by "health J o u r n a l P r e -p r o o f development committees" which provide a consultation framework between communities and the local elected officials with responsibilities in the field of health [12] . Inter-sectoriality is facilitated at local level because the district working plans are integrated with the (intersectorial) annual local development plans. The district health management teams run monthly district coordination meetings, and communities participate in local health management committees [4] . Health development committees now exist in every health centre and health post.

At the operational level too, a number of institutions are in place to ensure clinical practice and quality control. Standards, norms and therapeutic protocols are in place in various fields, and are regularly updated. In addition, there are mechanisms to authorise, audit, monitor and evaluate providers according to standards. A reflection is led on how to improve the respect of norms and the quality of services provided in private health care facilities in the context of the public-private partnership, which has been developed to enable expansion of the CMU policy [13, 14] . The CMU policy specifies that private health facilities and pharmacies can apply for recognition by the CMU Agency, which may subsequently withdraw or suspend accreditation.

There are mechanisms to represent the interests of patients and the population in general, as well as the interests of providers in the health system, notably a Civil Society Organisation platform (called CONGAD) and trade unions.

Overall, the health sector in Senegal has appropriate policies and institutions in place to allow for good governance and to facilitate progress towards UHCat least formally. However, based on our appraisal of the situation, two important issues weaken the governance of the health and social protection sectors in Senegal: on the one hand, severe disparities in the way in which resources are allocated and managed in the sector and across regions [2, 15] ; and on J o u r n a l P r e -p r o o f the other hand, the fragmentation of the institutions in charge of managing and implementing the various aspects of the overall UHC policy. Indeed, while the MoHSA is responsible for expanding the supply of health services, the CMU Agency is in charge of coordinating the various financial protection regimes. In practice, four regimes coexistcompulsory health insurance, medical assistance, community-based health insurance (CBHI) and commercial health insurance (see below)but they are managed by various organisations without effective coordination to date. Yet, the CMU policy is constantly evolving so as to respond to the emerging challenges, especially to better integrate the various schemes (e.g., transfer of medical assistance schemes to State-subsidised CBHI affiliation) [16] .

Finally, as for the outcomes of the CMU policy, by the end of June 2019, it was estimated that close to 50% of the Senegalese population was covered by some form of social protection regime, with close to 20% of the total population covered by CBHI [3] .

There are important issues and gaps regarding the financing of the health system in Senegal. epidemiological profilefor instance, because insufficient funding (less than 10% of total current expenditure) was dedicated to reproductive health [2] . As regards the pooling of resources, the various health insurance and medical assistance schemes in Senegal are fragmented, each scheme has its own operating mechanism without interconnection [2] , which reduces the overall efficiency of the system. This is compounded by a lack of progressivity of the health financing system and especially, insufficient targeting of the medical assistance systemfor instance, all children under five and all people above 60 are entitled to free healthcare, whatever their socio-economic status [2] . The four major schemes are the following: (iv) Commercial health insurance: These schemes generally cover individuals with a relatively high level of income. Despite the attractiveness of the benefit packages offered and the professionalism of the management, they cover a very small part of the population, so that the fragmentation of the risks covered and the high premium levels limit the potential for private for-profit health insurance to make a significant contribution to extending health risk coverage [2] . UHC through a good supply of qualified human resources throughout the country [21] .

Today, the computerisation of human resource management is a reality, with the appointment of human resource focal points at the district, medical region and hospital levels, and the use of the iHRIS software, although challenges persist in terms of its implementation in Dakar [2, 22] . There have been a few wage delays: according to a survey undertaken in 2013, some 5% of staff reported a delay of at least two months in paying their wages [23].

However, there are also a number of problems in this regard. Human resource allocation is inequitable and does not reflect regional disparities in the burden of disease distribution [2] .

Indeed, Senegal faces major problems with regard to the retention of human resources in disadvantaged areas. Moreover, efforts to produce human resources are not always followed by recruitment [21] . 

The Directorate of Pharmaceuticals and Medicines is the national drug regulatory authority, whose mission is the preparation, implementation and monitoring of policy and programs in the field of pharmacy and medicines (https://www.dirpharm.net/index.php/dpm/presentation).

The Pharmacie Nationale d'Approvisionnement (PNAcentral medical store) is the J o u r n a l P r e -p r o o f wholesale distributor for the public sector, and also supplies the private sector with generic essential medicines. Over the past decade, the PNA has implemented several strategies to make medicines and essential products available and accessible. It has strengthened the territory's network by setting up eleven Regional Pharmacies, sales depots in health care facilities, and piloted innovative initiatives aimed at bringing the services closer to clients and to improving the availability of medical products [2] . [2] . Nevertheless, a service availability survey at the facility level showed that availability is good for certain drugs and essential products (e.g.

antibiotics for adults) but not for others (e.g. antibiotics for children). Many essential drugs J o u r n a l P r e -p r o o f were available in less than half of the health facilities. Among the health facilities that provide infant immunisation services and routinely stockpile vaccines, for instance, 75% of the facilities had all the basic vaccines available on the day of the survey [15] .

Finally, the balance between regulation and autonomy often hampers effective management as well as relationships between pharmaceutical private entities and national authorities. The

Government of Senegal has already taken the necessary preliminary steps to engage the private sector in order to ensure the introduction of new models for collaboration [26] .

The or treatment services (94%) and curative care services for sick children (91%). Antenatal care (86%), family planning (84%) and child growth monitoring services (82%) are available in more than 80% of facilities. However, there is a s lower availability of specific services such as normal delivery and new-born care (75%) [15] .

It has to be noted that in the context of the National Financing Strategy for UHC [2] , publicprivate partnerships were developed in order to extend the range of services offered as a complement to the public health system. For instance, the Senegalese Sovereign Investment (86%) than in hospitals (34%), which is consistent with the national policy [15] .

Note however that health services must be of a sufficient quality to achieve impact. A recent study estimates that the effective coverage of primary health servicesthat is, adjusted to take quality into accountis only 19% on average in Senegal [32] . [15] .

The Senegalese government is aware of the importance of social determinants of health, and reckons that they should be an important part of the UHC policy. Indeed, the DHS shows important disparities in health care utilisation and health outcomes between regions, living environments, education levels, wealth quintiles, as well as according to individual behaviours. Despite the policies implemented to expand health service coverage and improve financial risk protection, 53% of surveyed women aged 15-49 have at least one problem with J o u r n a l P r e -p r o o f access to health care, including financial accessibility (45%), geographic accessibility related to distance (22%), not wanting to go alone (14%) and obtaining permission to seek care (7%) [30] .

Three problems have been identified in this respect: (i) the non-functionality of multi-sectoral frameworks at national level does not significantly mitigate risks related to population health determinants; (ii) the ineffectiveness of health promotion initiatives contributes to increasing individuals' exposure to the effects of behavioural determinants; (iii) the lack of common and inclusive strategies with regard to health system determinants limits efforts to rationalise health expenditures [2] .

Experience worldwide shows that the path towards UHC is context-specific and pathdependent [33] [34] [35] [36] [37] [38] [39] [40] . In particular, there is no generalizable evidence neither as to whether it is preferable to rely on a tax-based or social health insurance system so as to increase compulsory prepayment for UHC; nor as to whether service provision should be based on a national insurance system that purchases services from public and private providers, or on a public delivery system [38, [41] [42] [43] . Moreover, since countries usually adopt mixed financing schemes, it is acknowledged that policies should approach the system as a whole, and not focus on individual schemes [44] . There is no "magic bullet" solution to achieve UHC, and there is no consensus on the effectiveness and feasibility of most individual strategies considered to achieve progress in terms of that objective [45] . has an effect on the overall system"hence the need to view them together when designing policies and monitoring progress towards UHC [9] . For instance, substantial disparities characterise financing resource allocation in the health sector, and health risk protection schemes are highly fragmented (especially CBHIs)which means that the pooling of funds is not carried out at a sufficiently high level to ensure cross-subsidisation and the reduction of financial risk [2] . These "upstream" constraints in terms of governance and resource allocation have negative effects on the rest of the health systemfor instance, on the distribution of the health workforcedown to service delivery and consequently, health outcomes [30] . Moreover, by definition, a system is just as weak as its weakest element, so that the health system should be supported through all its elements. To apprehend the contribution of the various building blocks to UHC, other authors have developed a composite index comprising indicators of health service delivery, infrastructure, human resources, and health expenditures; using such an index, overall service coverage score is estimated at 38.7 in Senegal, compared to 38.3 for Benin, 37.5 for Cameroon, and 26.6 for Côte d'Ivoire [54] .

Health systems comprise an infinity of dimensions. Consequently, this paper has focused on a number of institutional and foundational indicators that have been identified as being critical for HSS and thus for UHC, but which are, by definition, incomplete. The readers may therefore be a bit frustrated not to get more information on each building block. Moreover, although all the authors have long experience in studying and/or supporting the health sector and UHC policies in Senegal and elsewhere, and have tried to make as objective an J o u r n a l P r e -p r o o f assessment as possible, our assessment could have been stronger if shared and discussed with a wider audience.

Despite these limitations, this paper offers interesting insights into a number of policyrelevant issues that may guide the Senegalese authoritiesas well as inspire authorities from other countries with similar contextsin the progressive adaptation of their UHC policy.

Indeed, experience from other countries corroborate the view that similar systemic constraints hamper progress towards UHC. Regarding governance, the literature is quite consistent in pointing to the fact that progress towards UHC needs above all a strong political commitment including pressure from civil society [37, 38, [55] [56] [57] , which then has to translate into sound policy and planning documents, adequate supportive legislation, inclusive coordination mechanisms and intelligence based accountability. The financing aspects of UHC are also very much developed in the recent literature; indeed, a major challenge for many countries is to move away from out-of-pocket payments and develop prepayment and pooling, but also to shift to strategic purchasing and improve financial management systems in such a way as to improve health spending efficiency [33, 58, 41, 44, [59] [60] [61] . Reducing the fragmentation of financial protection regimes has also been identified as important when it comes to reducing disparities, even if difficult to implementindeed, once different pools have been established, it is politically difficult to integrate or harmonise them because integration involves the redistribution of resources across organised interest groups [36, 39, 40, 48] . Human resources for health are necessary for the availability and the quality of health services; yet, many countries facing human resource gaps ought to match their commitment to UHC with their capacity to deliver health services, depending on the availability of a qualified and motivated health workforce [39, 62] . The health information system building block is particularly important when it comes to developing an ability to track equity issues and make sure the

World Health Organization. Primary Health Care on the Road to Universal Health Coverage -2019 Monitoring Report. World Health Organization

Stratégie nationale de financement de la santé (SNFS) pour tendre vers la couverture sanitaire universelle

Performances majeures de la CMU

Ministère de la Santé et de l'Action sociale. Plan National de Développement Sanitaire et Social (PNDSS)

Etat des lieux de l'implication des prestataires privés dans la couverture maladie universelle. SHOPS Plus pour le Ministère de la santé et de l'action sociale et l'USAID

Health systems strengthening, universal health coverage, health security and resilience. Bull World Health Organ

Investing in health systems for universal health coverage in Africa. Bmc Int Health Hum Rights

Everybody's business -Strengthening health systems to improve health outcomes. WHO's framework for action

Systems Thinking for Health Systems Strengthening

Alliance for Health Policy and Systems Research and World Health Organization

World Health Organization. Thirteenth General Programme of Work 2019-2023. Promote health -Keep the world safe -Serve the vulnerable

Ministère de la santé publique. Déclaration de la politique nationale de santé

Ministère de la Santé et de l'Action sociale. Les Comités de gestion se muent en Comités de développement sanitaire (CDS)

Site web du MSAS

Cissé CAT. Identification d'une stratégie d'amélioration de la disponibilité et de l'utilisation des documents de politique, normes et protocoles de soins dans les structures sanitaires privées du Sénégal -SHOPS Plus Sénégal

Identification d'une stratégie pour améliorer la qualité des soins offerts par le secteur privé de la santé au Sénégal -SHOPS Plus Sénégal

Sustaining Health Outcomes through the Private Sector Plus Project

The DHS Program, ICF. Sénégal: Enquête Continue sur la Prestation des Services de

Reforms for financial protection schemes towards universal health coverage

What level of domestic government health expenditure should we aspire to for universal health coverage? Health Econ Policy Law

Cadre de Mesure de la Performance de la Gestion des Finances Publiques au Sénégal -Rapport sur la seconde évaluation du système de la GFP. Rapport final

Senegal -Fiscal Transparency Evaluation

Staff Report for the 2018 Article IV Consultation and Seventh Review Under the Policy Support Instrument and Request for Modification of Assessment Criteria--Debt Sustainability Analysis--Press Release

for-the-2018-Article-IV-Consultation-and-Seventh-Review-Under-the-46553 21. République du Sénégal, Ministère de la Santé et de la Prévention (MSP) D des R humaines (DRH)

Ministère de la Santé et de l'Action Sociale (MSAS). Rapport d'évaluation de la gestion efficace des vaccins (GEV) au Sénégal, 28 septembre au 30 octobre

Senegal Private Health Sector Rapid Assessment

République du Sénégal, Ministère de la Santé, de la Prévention et de l'Hygiène publique (MSPH)

Plan stratégique du Système d'Information Sanitaire du Sénégal

Universal Health Coverage Measurement in a Lower-Middle-Income Context: A Senegalese Case Study

):e000424. 33. World Health Organization. Health Systems Financing -The Path to Universal Coverage, The World Health Report

The impact of universal coverage schemes in the developing world : a review of the existing evidence. Universal Health Coverage (UNICO) studies series

The World Bank

Theimpact-of-universal-coverage-schemes-in-the-developing-world-a-review-of-the-existingevidence 35

Developing Countries Are Implementing Universal Health Coverage Reforms from the Bottom Up

The World Bank

Promoting universal financial protection: evidence from seven low-and middle-income countries on factors facilitating or hindering progress

Health-system reform and universal health coverage in Latin America

Universal health coverage for inclusive and sustainable development : a synthesis of 11 country case studies. Directions in development

Moving towards universal health coverage: lessons from 11 country studies

Toward Universal Health Coverage and Equity in Latin America and the Caribbean: Evidence from Selected Countries. Directions in Development

Anything goes on the path to universal health coverage? No. Bull World Health Organ

Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia

Universal Health Coverage: an Overview and Lessons from Asia. Harv Public Health Rev

Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ

Assessment of Global Health Experts' Confidence in Policy Options

World Scientific Handbook of Global Health Economics and Public Policy

Does progress towards universal health coverage improve population health? Lancet Lond Engl

Report of the WISH Universal Health Coverage Forum 2015. World Innovation Summit for Health

Impact of Health Systems Strengthening on Health

Strengthening health systems for universal health coverage and sustainable development

Reforms for improving the efficiency of health systems: lessons from 10 country cases

No universal health coverage without primary health care. The Lancet

A concise, health service coverage index for monitoring progress towards universal health coverage

The political economy of universal health coverage; Background paper for the global symposium on health systems research 16-19

A critical player: The role of civil society in achieving universal health coverage. Glob Health Gov

Politics and Universal Health Coverage--The Post-2015 Global Health Agenda

Universal coverage of health services: tailoring its implementation. Bull World Health Organ

Raising revenues for health in support of UHC: strategic issues for policy makers. Health Financing Policy Brief n°1

World Health Organization

Purchasing health services for universal health coverage: How to make it more strategic? Health Financing Policy Brief No. 6. World Health Organization

Aligning Public Financial Management and Health Financing -Sustaining Progress Toward Universal Health Coverage

Health sector employment: a tracer indicator for universal health coverage in national Social Protection Floors. Hum Resour Health

Tracking Universal Health Coverage: 2017 Global Monitoring Report

Using evidence to design health benefit plans for stronger health systems: Lessons from 25 countries

Making fair choices on the path to universal health coverage. Final report of the WHO Consultative Group on Equity and Universal Health Coverage

Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage

Priority-setting for achieving universal health coverage. Bull World Health Organ

What's in, What's out? Designing Benefits for Universal Health Coverage. Center for Global Development

How is equity approached in universal health coverage? An analysis of global and country policy documents in Benin and Senegal

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities