Center for Global Health Engagement (CGHE) REBUBLIC OF SENEGAL Health Context Analysis 2017 Table of Contents PART I – THE COUNTRY CONTEXT History……………………………………………………………………………….…………….3 Geopolitics………………………………………………………………………………………5 Politics………………………………………………………………………………………....….7 Security………………………………………………………………………………………….11 Economy………………………………………………………………………………………..13 Environment…………………………………………………………………………….……...16 Infrastructure……………………………………………………………………………….…..19 PART II – SOCIOCULTURAL BACKGROUND Demographics Profile……………………………………………………………………… ..19 Social Structure……………………………………………………………………… ………..20 Culture…………………………………………………………………………………………..21 PART III – HEALTH CULTURE Explanatory Models of Health and Illness………………………………………………....22 Health Seeking Behaviors……………………………………………………………….…...23 Health-Related Stigma……………………………………………………………………....23 Treatment Approaches……………………………………………………………………...25 PART IV – DETERMINANTS OF HEALTH Population Health Profile……………..………………………………………………….…..25 Social Determinants of Health……………………………………………………………...28 Public Health Concerns…………………………………………………………………...…29 PART V – HEALTH SYSTEMS Leadership and Governance……...……………………………………………………….32 Financing…………………………………………...…………………………………………..32 Health Service Delivery………………………………...………………………………….…33 Center for Global Health Engagement (CGHE) PART I – THE COUNTRY CONTEXT History Prehistoric Senegal Evidence of human inhabitance in Senegal dates back to the 3rd century BCE. The Sénégal River Valley was occupied by the Muslim people known as the Fulani and Tukulor in the 11th century.1, 2 The Jolof Kingdom, founded between 1150 and 1350 AD, helped spread Islamic influence throughout the region and a theocratic confederacy was established in the late 18th century.3 Colonial Senegal Portugal established trading centers on Gorée Island at the mouth of the Sénégal River in the 15th century but power was transferred to the Dutch and then the French in the 17th century. French trading companies sold slaves, gold, and gum in the region but British attemts to grow cotton proved to be unprofitable. Trading companies suffered an enormous economical hit when slavery on French soil was outlawed in 1848 by the French government. In 1854 Napoleon III increased the military presence in the region at the behest of local merchants which caused tension between the French and a Tukalor leader. Ultimately there was a military truce that led to coexistance between the two powers. In the late 19th century the French government approved construction of a railway system connecting Saint-Louis with Dakar.3 Independent Senegal In 1959 Senegal was merged with French Sudan and became the Mali Federation, which, under the leadership of the writer and statesmen Léopold Senghor, gained independence from France in 1960. The Mali Federation fell apart after only a few months and Léopold Senghor served as president of an independent, democratic __________________________ 1 "Fulani | People". Encyclopedia Britannica. N.p., 2017. Web. 27 April. 2017. https://www.britannica.com/topic/Fulani 2 "Tukulor | People". Encyclopedia Britannica. N.p., 2017. Web. 27 April. 2017. https://www.britannica.com/topic/Tukulor 3 "Senegal - History | History - Geography". Encyclopedia Britannica. N.p., 2017. Web. 27 April. 2017. https://www.britannica.com/place/Senegal/History#ref516936 Senegal until 1980. Abdou Diouf replaced Senghor as president in 1981 and there was an attempt during his term (ending in 2000) to join The Gambia to form the confederation of Senegambia. This union was ultimately disolved in 1989.4, 5 From 1960 to 2000 Senegal was under the leadership of a Socialist Party. Abdoulaye Wade was elected president in 2000 and again in Center for Global Health Engagement (CGHE) 2007 and during his time in office added over a dozen amendments to Senegal’s constitution to increase his power and weaken the opposition. His attempt to run for a third term in 2012 led to a public backlash and ultimately a new president, Macky Sall, was elected. In 2016 a consitutional referendum was passed reducing the presidential term from seven years to five years with a two term limit.4 Conflict While Senegal remains one of the most stable democracies in Africa, a southern separatist group known as The Movement of Democratic Forces in the Casamance (MDFC) has occasionally clashed with the government.4 The Casamance region is separated from the rest of the country by The Gambia and rebels have been fighting for independence since 1982. The Senegalese government refused to negotiate with the rebels and in 1998 an attempted military coup in Guinea-Bissau involving rebels from Casamance resulted in renewed violence in the area. In 2003, the rebel leader declared the war to be over and a peace agreement was reached in 2004, however, some rebels continued to fight. President Macky Sall, elected in 2012, renewed peace talks with the rebels and in 2014 one faction declared a cease fire in response to negotiation efforts.6 Some sources claim that up to 5,000 people have lost their lives over the past few decades of fighting. There are also lingering landminds in the Casamance region that have reportedly killed 800 people since 1988.7 _____________________________ 4 "The World Factbook — Central Intelligence Agency". Cia.gov. N.p., 2017. Web. 27 April. 2017. https://www.cia.gov/library/publications/theworldfactbook/geos/sg.html 5 "Senegal Overview". Worldbank.org. N.p., 2017. Web. 27 April. 2017. http://www.worldbank.org/en/country/senegal/overview#1 6 "Senegal - Independent Senegal | History - Geography". Encyclopedia Britannica. N.p., 2017. Web. 27 April. 2017. https://www.britannica.com/place/Senegal/Independent-Senegal 7 Negiar, Claire. "Casamance – Harmonious Name, Discordant Reality". GeoCurrents. N.p., 2017. Web 27 April. 2017.http://www.geocurrents.info/geopolitics/insurgencies/casamance-harmonious-name discordant-reality Center for Global Health Engagement (CGHE) Geopolitics Figure 2. Map of Senegal4 Senegal is a west African country, slightly smaller than the state of North Dakota, bordered on the west by the North Atlantic Ocean, on the North by Mauritania, on the East by Mali, and on the South by Guinea-Bissau and Guinea. Senegal surrounds The Gambia on three sides, separating the southern Casamance region from the rest of the nation. The capital, Dakar, is located on the western-most peninsula of the country.4, 8 It is also important to note that Senegal is located in the Sahel region of Africa (12°N to 20°N) which divides North Africa (the Maghreb) or “white” Africa from sub- Saharan black Africa. There is a lot of conflict between these two geopolitical groups.9 Figure 3. Sahel Region of Africa9 U.S. Relations The United States established relations with Senegal after it gained is independence from France and the Mali Federation was dissolved in 1960. Senegal is considered a strong U.S. ally in the region, as well as an economic and diplomatic partner, even contributing troops to regional peacekeeping operations. The U.S. provides assistance to support agricultural development, improve health care, education, and the Senegalese Armed Forces. Senegal maintains an embassy in Washington, DC.10 The U.S. Congress has taken a strong interest in the country because of it’s role in confronting security threats in the region.11 _____________________________ 8 "Country Facts | Senegal". Un.int. N.p., 2017. Web. 27 April. 2017. https://www.un.int/senegal/senegal/country-facts 9 Vulnerabilities And Factors Of Insecurity In The Sahel. Paris, France: Secretariat of the Sahel and West Africa Club/OECD, 2010. Web. 27 April. 2017. West African Challenges. https://www.oecd.org/swac/publications/45830109.pdf 10 "Senegal". U.S. Department of State. N.p., 2017. Web. 27 April. 2017. https://www.state.gov/r/pa/ei/bgn/2862.htm 11 Arieff, Alexis. Senegal: Background And U.S. Relations. Congressional Research Service, 2013. Web. 27 April. 2017. https://fas.org/sgp/crs/row/R41369.pdf International Relations Center for Global Health Engagement (CGHE) Senegal is a member of many internatinal organizations including: the United Nations, the International Monetary Fund, the World Bank, and the World Trade Organiztion.10 Senegal maintains particularly close ties to France and other major trading partners include: Mali, China, India, the United Kingdom, Nigeria, Italy, the Netherlands, and the United States. The country is an active member of the Organization of the Islamic Conference (OIC) and former President Abdoulaye Wade nurtured a relationship with Iran until 2011 when a military investigation showed an Iranian arms shipment seized in Nigeria was destined to be delivered to Casamance rebels in The Gambia.11 Regional Politics Figure 3. Senegal-Mauritania Border Conflict12 There are no major ongoing conflicts between Senegal and it’s neighbors. There are, however, tensions with Guinea-Bisseau and The Gambia over alleged links to Casamance rebels and there is a long-time border dispute with Guinea-Bisseau.11 There were also border and grazing rights disputes along the banks of the Senegal River with Mauritania in 1989 which led to riots and attacks by vigilantes in both countries and the forced expulsion of Senegalese Fulani herders living in Mauritania and black (non- arabic speaking) Mauritanians. This created a refugee crisis along the river with 25,000 to 50,000 people living in camps between 1989 and 1992. Based on a Colonial treaty from 1933, Senegal insisted the northern border of the river be used as the borderline between