Roundtable report: Epidemic preparedness and response in Senegal

On 8 December 2023, SSHAP convened a roundtable discussion on social science research in epidemic preparedness and response in Senegal. The event was organised in Dakar by the Centre Régional de Recherche et de Formation à la Prise en Charge Clinique de Fann (CRCF) based at the Centre Hospitalier National Universitaire (CHNU), and the Centre des Opérations d’Urgence Sanitaire (COUS). It took place in the Conseil National de Lutte contre le SIDA. The objectives were to:

• Share strategic information derived primarily from social science research with the various actors involved in epidemic preparedness and response;
• Help the actors put in place targeted and appropriate interventions for future epidemics; and
• Highlight the roles social science researchers can play in preparing for and responding to epidemics.

This report shares a summary of considerations from the roundtable discussion. The report also includes background information about Senegal’s epidemic preparedness and response system as well as the challenges the system faces. This additional information is based on a review of scientific articles and various public health and social science documents from research and other institutions.

Introduction

On 2 March 2020, the first case of COVID-19 was detected in Dakar, Senegal. Just over a month earlier, on 30 January 2020, the World Health Organization (WHO) declared a public health emergency of international concern in relation to COVID-19. This declaration required the deployment of various response measures on an unprecedented scale.

Senegal has been regularly confronted with epidemics of emerging and re-emerging infectious diseases. Each epidemic has necessitated the implementation of preparedness and response plans. The dynamics of epidemic management were reinforced after the Ebola epidemic of 2014 to 2016, which necessitated new epidemic preparedness and response strategies in line with WHO recommendations.

The COVID-19 crisis reminded national and international health authorities of the importance of better preparing for future epidemics at all levels (social, economic, cultural and political) by adopting an interdisciplinary approach, including the One Health approach, which integrates human, animal, and environmental health. In Senegal, social science research on the experience and effects of COVID-19 has shown that the restrictive and coercive measures put in place exacerbated pre-existing socio-economic vulnerabilities and provoked strong protests at the community level. Inadequacies in the management of the epidemic were revealed, highlighting the lack of preparedness and the failure of government and health institutions to consider the lessons learned from previous epidemics.¹ This report aims to shares key points from the roundtable discussion and contextual information relating to epidemic management in Senegal.

Summary of considerations

• Evaluate the response to COVID-19, considering experience gained in managing previous epidemics. Envisage an objective internal and external evaluation of the response for each epidemic, through the implementation of an organisational audit of the response at all levels of the health system.
• Support the structuring of epidemic preparedness and response with reference to multisectoral approaches. Epidemics require the mobilisation of all sectors. The epidemic preparedness and response system must therefore adopt a multisectoral approach, including and empowering community actors.
• Promote coordination between actors at all levels of the health system. In Senegal, there are numerous response structures at all levels of the health system, from strategic to peripheral. However, the institutional and organisational set-up for epidemic management needs to be reassessed to avoid conflicts of competence and complementarity of missions between coordinating structures. Coordination between all the actors involved in preparing for and responding to epidemics was not optimal during the response to COVID-19.
• Set up a system to contextualise public health measures through participatory approaches. Local populations perceived public health measures (physical and social distancing measures, confinement and curfews) as poorly adapted to the local context. Some populations felt neglected, including rural populations with limited access to healthcare services, populations living in precarious urban neighbourhoods and the most vulnerable populations. Inequalities in the application of the measures were highlighted between high-income earners and disadvantaged social groups. These measures have had a significant impact on the economy, particularly the informal sector, which accounts for a sizeable share. This has led to strong tensions within the population and has reinforced the non-acceptance of public health measures by part of the population.
• Promote transparent, appropriate communication. During the COVID-19 pandemic, communication was perceived as lacking in communities. Communication was seen by researchers as anxiety-provoking, increasing the sense of fear and dread in the face of the epidemic. The multiplicity of sources of information in the media has encouraged the spread of misinformation and rumours. This growth in the misinformation and rumours was due to a feeling of mistrust regarding the information disseminated by health and political authorities on the one hand and social networks on the other. The experts felt that it was necessary to set up a partnership between the various actors in the response to centralise information and transmit reliable messages to the population. To fight the ‘infodemic’, a community feedback mechanism could be set up.
• Strengthen community involvement in the response. Community actors have an essential role in the response. They can pass on messages in local languages and ensure compliance with public health measures. However, they were not involved early enough in the management of the epidemic and lacked financial and technical support. As part of epidemic preparedness, community actors, who are often ill-equipped, should receive training on the emergence of epidemics and their consequences. It is also necessary to facilitate the co-construction of epidemic responses with actors at all levels of the healthcare system. Epidemic management should also be geared towards the most vulnerable. The various forms of vulnerability must be considered to foster an inclusive response.
• Involve the social sciences from the outset. Biomedical responses have shown their limits. Social scientists have been key actors in the management of various epidemics. Social scientists can help analyse the political, social and economic dimensions of epidemics and make it easier to understand global norms and local adaptations.

Background information

Geodemographic context

Senegal is in the extreme west of the African continent (see Figure 1). It is bordered by the Atlantic Ocean to the west, Mauritania to the north, Mali to the east, Guinea and Guinea Bissau to the south, and Gambia, which forms an enclave within Senegal. The country covers an area of 196,722 km² and is divided into 14 administrative regions, 45 departments, 117 arrondissements and 557 communes.

Figure 1. Map of Senegal

Source: Amitchell125: Wikimedia Commons. CC BY-SA 4.0.

The Sahelian climate has a short rainy season between June and October. There are high levels of air pollution, which favour the development of acute respiratory infections and asthma.²

According to data from the 5º Recensement général de la Population et de l’Habitat (RGPH-5): Données de population [5º General Census of Population and Housing (RGPH-5): Population data], published in 2023, the population is estimated at 18,032,473 (49.4% women and 50.6% men), half of whom are under 19 years of age.³ A large proportion of the population lives in the major metropolitan areas. Dakar, the capital city, includes a quarter of Senegal’s population and has a high demographic density (7277 inhabitants per km²) that further favours the spread of epidemics. Senegal ranks 170 out of 189 countries on the Human Development Index; economic, educational and health conditions therefore remain poor.⁴

Health system

The social and health sector is structured in a pyramidal manner and is linked to the administrative division of the country (see Figure 2).

Figure 2. Organisation of the health system in Senegal

Source: Tabitha Hrynick (SSHAP). Created with inspiration from Ministère de la Santé et de l’Action Sociale.

The health system is comprised of the:

• Central level: Draws up policy documents and standards and ensures their implementation.
• Intermediate/regional level: Coordinates the implementation of healthcare policies.
• Peripheral or operational level: The health districts that provide local healthcare services. In rural areas, healthcare is provided within community health infrastructures (health huts, rural maternity units). This level involves community actors, particularly community health agents (community relays, Badienou Gokh). A Badienou Gokh or Matrone is a woman who has received training and is responsible for assisting the mother during pregnancy, labour, childbirth and the aftermath of childbirth (e.g., compliance with prenatal consultations, guiding women to ensure assistance by qualified personnel during childbirth); she also provides preventive and promotional care in a health hut like a community health agent.

Senegal has 79 health districts, 103 health centres and 1,415 health posts, which are further linked to 2,676 smaller health ‘huts’. The public sector also has 36 hospitals and 4 additional facilities. The private sector has 275,410 private health facilities.⁵

Health and epidemiological situation

Life expectancy has risen from 56 years in 1990 to 68 years in 2022, having reached a high of 69 in 2019, and having dipped to 67 in 2020.⁶ There has also been a steady decline in infant and child mortality rates between 2005 and 2019: infant mortality 64 to 29 per thousand, child mortality 64 to eight per thousand, and infant mortality 121 to 37 per thousand.⁷ However, the consequences of the COVID-19 epidemic have reduced vaccination coverage and favoured the resurgence of epidemics linked to childhood diseases, such as measles and polio.

Epidemic management

Epidemic management actors and systems

In Senegal, the Ministry of Health and Social Action (Ministère de la Santé et de l’Action sociale – MSAS) is responsible for coordinating epidemic preparedness and response. In the event of a public health emergency, the President can set up an interministerial unit at the highest level of government. Within MSAS, the Prevention Division is responsible for surveillance and immunisation. The Public Health Emergency Operations Centre (Centre d’Opérations d’Urgences Sanitaires – COUS) coordinates preparedness and response to health emergencies.

For an integrated approach to epidemic management, the strategic directions of the global health security programme are defined by the ‘One Health’ High National Council for Global Health Security. The role of this committee, which was created in 2017, is to ensure collaboration and complementarity between the fields of human health, animal health, environmental health, food and nutritional safety, food safety, public safety and civil security.

The National Epidemic Management Committee, set up within MSAS in 2016 after the Ebola epidemic, has regional and local committees monitoring the evolution of diseases with epidemic potential. This committee oversees preparedness, prevention and response activities. The committee also organises the evaluation of the response to all epidemics in line with WHO recommendations through the International Health Regulations (IHR) – an international legal instrument designed to prevent the spread of disease. An IHR focal point has been set up in addition to a local, departmental and regional epidemic management committee and an incident management system.

The various air and sea ‘entry points’ – Blaise Diagne International Airport and Dakar Autonomous Port – are equipped with a sanitary control system. The airport has drawn up an integrated public health emergency management plan. Land entry points across Senegal’s borders with other neighbouring countries (Mauritania, Mali, Guinea, Gambia and Guinea Bissau) are subject to sanitary control. Simulation exercises in 2018 and 2022 tested the response capabilities of the COUS and then the Service de Santé des Armées.

Thus, Senegal has various strategic plans that can be mobilised in the event of an epidemic including the National Plan for the Organization of Relief in Cases of Catastrophe (ORSEC) which includes contingencies for health emergencies and disasters, a health security plan (2017 -2021) and the COUS strategic plan (2019-2023).

Community-based surveillance

In Senegal, community-based surveillance has been reinforced since the Ebola epidemic. Comités de Veille et d’Alerte Communautaires (Community Watch and Alert Committees) – made up of resource persons chosen by the communities – are tasked with detecting and preventing the occurrence of events of public health importance, particularly diseases with epidemic potential. Members of the committees are trained to notify any cases or health events to the health agents in charge of surveillance, and to follow up alerts.

Community-based surveillance uses two methods. The first method, indicator-based surveillance, involves identifying and reporting events using agreed indicators, the community definition of cases. The second method, event-based surveillance, involves reporting unusual events that could provide an alert about the early stages of an epidemic or other public health threat. Committee members must report and refer the identified case to the nearest health facility. Committee members can also identify contact cases during an epidemic.⁸

Financial resources

The national health budget assigns part of its funds for epidemic preparedness and response.⁹ An annual allocation of public funds for epidemic management and COUS operations has been set up. This allocation is managed by the Prevention Department. COUS itself also has emergency funds that can be mobilised on an emergency basis.¹⁰ International partners also contribute to funding epidemic management. However, roundtable participants acknowledged this funding was inadequate, particularly for preparedness.¹¹

Responding to epidemics in Senegal

HIV/AIDS

The HIV/AIDS epidemic spread rapidly around the world since the first case was reported by the U.S. Centers for Disease Control (CDC) in 1981. HIV/AIDS was declared a global epidemic by WHO in 1988. In response to the global spread, a national AIDS policy was introduced in Senegal. The Conseil National de Lutte contre le SIDA is the body coordinating and guiding the response to HIV in Senegal. This body works with the Senegalese government and international and national nongovernmental organisations to run awareness campaigns and combat the stigmatisation of HIV-positive people. It also aims to make free and confidential screening tests available, and to promote access to antiretroviral treatment.

According to a 2022 report from Conseil National de Lutte contre le SIDA, there has been a gradual decline in seroprevalence in the 15 to 49 years age group, from 0.70% in 2005 to 0.31% in 2022.¹² Anti-retroviral (ARV) drug coverage changed between 2013 and 2022: it rose from 31.2% in 2013 to 80.4% in 2022.

In 2014, UNAIDS launched the Joint United Nations Programme on HIV/AIDS, a global strategy aimed at ending the AIDS epidemic by 2030, including the 95-95-95 initiative, which designates the following three targets by 2025: 95% of people living with HIV know their serostatus; 95% of people diagnosed with HIV are receiving antiretroviral treatment (ART); 95% of people receiving ART have an undetectable viral load. Senegal is on track to achieve these targets. As of 2022, 88% of people living with HIV/AIDS in Senegal know their serostatus, 91% were on antiretroviral treatment and 90% had an undetectable viral load.¹²

The active participation of civil society contributed to the successful management of the epidemic in Senegal.^13,14 The involvement of expert patients in Person Living with HIV (Personne Vivant avec le VIH – PvVIH) associations has been identified by social scientists as essential to the management of the epidemic, thanks to their medical expertise and their active participation in political and clinical decision-making.¹⁵

The social sciences have also played an important role in the response to HIV/AIDS in Senegal, through research that has analysed the social effects of HIV, compliance with biomedical prescriptions¹⁶ and the vulnerability of vulnerable populations such as women, homosexuals or drug users. The social sciences have also made a major contribution to the support of people living with HIV and the provision of antiretroviral treatment.¹⁷

Ebola

The first case of Ebola was identified in Senegal in August 2014. The case was a Guinean patient in Dakar. On 21 August 2014, Senegal closed its borders with Guinea. An active surveillance and follow-up system for contact cases was set up with the participation of community health workers. No new cases were reported, and the end of the epidemic was declared on 17 October 2014.

Social science research during the Ebola epidemic has shown the difficulties faced by stakeholders in juggling care management and compliance with biosafety standards in the follow-up of contact cases.¹⁸ This research has also emphasised the need to humanise care and to organise dignified and secure burials.^19,20 To promote the effective implementation of these recommendations, WHO invited anthropologists to take part in the response.^21,22

Measles

In 2009, the Dakar region experienced a measles epidemic, with 314 confirmed cases. A vaccine response was rolled out in all districts of the region over a 10-day period, using advanced and mobile strategies. No deaths were recorded.²³

In 2019, four districts faced epidemics: Dakar, Pikine, Kédougou and Saraya. Of the people with confirmed cases, 95% had not been vaccinated for measles.²⁴

In 2023, 400 cases of measles were recorded across almost the entire country. The Diourbel region was the most affected, with over 200 cases.²⁵ This upsurge was certainly due to the health system’s underperformance, linked to the impact of COVID-19 that has destabilised routine vaccination. Researchers have observed a considerable drop in vaccination coverage (around 40%) in hospitals.²⁶

COVID-19

On 2 March 2020, Senegal had its first confirmed case of COVID-19. Later that month, on 23 March 2020, the country declared a national state of emergency. This led to the implementation of highly restrictive measures such as confinement, physical distancing, the closure of schools and public places, and the compulsory wearing of masks. These measures have been considered  ‘imported models’ that do not take sufficient account of local realities.¹ The measures have also had a significant economic impact, particularly in the informal sector and among the most disadvantaged populations.²⁷

The COVID-19 epidemic evolved in four waves, with an essentially biomedical response focused on case management and screening. The effectiveness of the COVID-19 control strategies had been affected by difficulties with coordination, communication, funding and adapting resources appropriately at different levels of the health system.²⁷

A study conducted in Senegal showed that community actors already active during previous epidemics, particularly in the fight against HIV/AIDS, were once again mobilised in the face of COVID-19, and new actors emerged (for example, the ‘100,000 students’ initiative, the participation of artists and of the Réseau des Volontaires Communautaires en Appui au Personnel de Santé).²⁸ Despite their expertise, these community stakeholders have not been involved in defining strategies and sometimes in implementing them.²⁸ In a context marked by numerous scientific uncertainties, populations sceptical about the recommended measures used their own experiential knowledge to negotiate the intersecting precariousness linked to the effects of the epidemic.²⁹

A Court of Auditors’ report on the management of the response and solidarity fund against the effects of COVID-19, estimated at CFA 19,740,000 billion, denounced numerous irregularities in the management of this funding.³⁰

Senegal is one of the countries with the lowest COVID-19 vaccination rates, with only 8% of the population vaccinated against COVID-19 at the end of 2021.³¹ While the COVID-19 vaccination campaign began in May 2021, studies have shown that vaccine acceptability varies according to the epidemic wave, because of multiple uncertainties, inadequate training of healthcare professionals and vaccine supply difficulties.^32,33The COVID-19 pandemic was also marked by misinformation in the media and social networks, reinforcing mistrust in the management of the epidemic and the vaccine.^33,34

Roundtable participants and agenda

Speakers

• Adja Ndiaye, Permanent Secretary, Haut Conseil National de la Sécurité Sanitaire Mondiale (HCNSSM)
• Dr Anthony Billaud, Consultant, World Health Organization (WHO)
• Abdou Salam Fall, Lecturer and Researcher in Sociology, Université Cheikh Anta Diop de Dakar (UCAD)
• Karim Diop, Secretary General, Centre Régional de Recherche et de Formation (CRCF)
• Khoudia Sow, Anthropologist, CRCF
• Mrs Marème Soda Ndiaye, Executive Director, Réseau des Volontaires Communautaires en Appui au Personnel de Santé (REVOCAP)
• Mrs Mariam Boyon, Research Assistant, CRCF
• Mr Massogui Thiandoum, Technical Director, Alliance Nationale des Communautés pour la Santé, ANCS Senegal
• Pape Samba Dieye, Executive Director, Centre des Opérations d’Urgence Sanitaire (COUS)
• Tidjane Ndoye, Lecturer and Researcher in Sociology, UCAD

Participants

• Abdourahmane Ndiaye, Health Director, Red Cross
• Aïssatou Niang, Administrative and financial manager, Centre Régional de Recherche et de Formation (CRCF)
• Dr Albert Gautier Ndione, Researcher and Teacher in Sociology, Université Cheikh Anta Diop (UCAD)
• Alioune Badara Gueye, Manager, CRCF
• Amadou Ndiaye, Logistician, Secrétariat Exécutif du Conseil National de Lutte contre le Sida (CNLS)
• Dr Babacar Ndao, Gendarmerie Chief Doctor, Direction de la Santé des Armées (DSSA) / Ministère des Affaires Étrangères (MEA)
• Bakary Sylla, Computer Scientist, CRCF
• Dr Bernard Taverne, Anthropologist, Agence Nationale de Recherche sur le Sida et les Hépatites Virales (ANRS) / Institut de Recherche pour le Développement (IRD) /CRCF
• Camille Giacomel, International Volunteer for the Network in Anthropology of Epidemics, IRD / CRCF
• Christine Sokhna Thiandoum, Trainee Doctor, CRCF
• Diabou Gueye, Logistics assistant, CNLS
• Dr Diambogne Ndour, Head of Planning, Centre des Opérations d’Urgence Sanitaire (COUS)
• El Hadj Baytir Samb, President, Community Relay Network
• Dr Ibra Diagne, Assistant Director, COUS
• Khady Seck Ngom, Program assistant, CRCF
• Dr Khoudia Sow, Researcher, CRCF
• Lamine Bara Gaye, Director, Service National d’Education et d’Information Sanitaire et Sociale (SNEISS)
• Mamadou Sylla Fofana, Accountant, CRCF
• Mame Samba Ndiaye, Computer Scientist, CRCF
• Mame Yacine Mbodj, Research Assistant, CRCF
• Mariam Boyon, Research Assistant, CRCF
• Mariata Delphine Bousso, Research Assistant, CRCF
• Marième Soda Ndiaye, Executive Director, Réseau des Volontaires Communautaires en Appui au Personnel de Santé (REVOCAP)
• Momath Wade, Administrative and Financial Intern, CRCF
• Dr Mouctar Ly, Doctor, Cellule d’Appui au Partenariat (CAP) / Ministère de la Santé et de l’Action Sociale (MSAS)
• Mouhamadou Diallo, Researcher, MSAS
• Moustapha E. Dia, Head of Community Health, Université Alioune Diop de Bambey (UADB)
• Sokhna Badji, Financial Manager, CRCF
• Pr Tidiane Ndoye, Researcher and Teacher in Sociology, UCAD
• Yaly Marame Ngom, Unité d’Appui à la Gestion Administrative et Financière (UGAF) / CNLS
• Dr Youssouf B. Gueye, Operations Manager, COUS

Agenda

References

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12. Conseil National de Lutte contre le Sida (CNLS). (2023). Rapport CNLS 2022. https://www.cnls-senegal.org/wp-content/uploads/2001/01/Rapport-Annuel-CNLS-2022.pdf
13. Delaunay, K. (1999). Le Programme National de Lutte contre le SIDA au Sénégal: Entre prévention et normalisation sociale [The National Program to Combat AIDS in Senegal: Between prevention and social normalization]. In M.-E. Gruénais (Ed.), Organiser la lutte contre le sida: Une étude comparative sur les rapports Etat/société civile en Afrique (Cameroun, Congo, Côte-d’Ivoire, Kenya, Sénégal) [Organising the fight against AIDS: a comparative study on State/civil society relationships in Africa (Cameroon, Congo, Ivory Coast, Kenya, Senegal)] (pp. 101–111). Anrs-IRD.
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16. Sow, K., & Desclaux, A. (2002). L’observance des traitements antirétroviraux et ses déterminants. Analyse qualitative [Compliance with antiretroviral treatments and its determinants. Qualitative analysis]. In A. Desclaux (Dir.), I. Lanièce (Dir.), I. Ndoye (Dir.), & B. Taverne (Dir.) (Eds.), L’Initiative sénégalaise d’accès aux médicaments antirétroviraux: Analyses économiques, sociales, comportementales et médicales [The Senegalese initiative for access to antiretroviral medicines: Economic, social, behavioral and medical analyses]. ANRS – Collection sciences sociales et sida. https://horizon.documentation.ird.fr/exl-doc/pleins_textes/doc34-08/010030322.pdf
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18. Desclaux, A., & Sow, K. (2015). ‘Humaniser’ les soins dans l’épidémie d’Ebola? Les tensions dans la gestion du care et de la biosécurité dans le suivi des sujets contacts au Sénégal [“Humanise” care in the Ebola epidemic? Tensions in the management of care and biosecurity in the monitoring of contact subjects in Senegal]. Anthropologie et Santé, 11, Article 11. https://doi.org/10.4000/anthropologiesante.1751
19. World Health Organization. (2014). Flambées épidémiques de maladie à virus Ebola et Marburg: Préparation, alerte, lutte et évaluation [Ebola and Marburg virus disease outbreaks: Preparedness, alert, control and assessment]. WHO. https://iris.who.int/handle/10665/130161
20. World Health Organization. (2014). Recommandations transitoires: Comment inhumer sans risque et dans la dignité les personnes décédées de maladie à virus Ebola suspectée ou confirmée [Transitional recommendations: How to bury people who have died from suspected or confirmed Ebola virus disease safely and with dignity]. https://iris.who.int/bitstream/handle/10665/149397/WHO_EVD_GUIDANCE_Burials_14.2_fre.pdf
21. Desclaux, A., & Sow, K. (2016). Des anthropologues face à l’épidémie d’Ebola [Anthropologists facing the Ebola epidemic]. Journal des anthropologues, 144–145, Article 144–145. https://doi.org/10.4000/jda.6452
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Authors: This report was written by Khoudia Sow (CRCF) and Mariam Boyon (CRCF).

Suggested citation: Sow, K. and Boyon, M. (2024). Roundtable report: Epidemic preparedness and response in Senegal. Social Science in Humanitarian Action (SSHAP).
www.doi.org/10.19088/SSHAP.2024.034

Published by the Institute of Development Studies: July 2024.

Copyright: © Institute of Development Studies 2024. This is an Open Access paper distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY 4.0). Except where otherwise stated, this permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited and any modifications or adaptations are indicated.

Contact: If you have a direct request concerning the brief, tools, additional technical expertise or remote analysis, or should you like to be considered for the network of advisers, please contact the Social Science in Humanitarian Action Platform by emailing Annie Lowden ([email protected]) or Juliet Bedford ([email protected]).

About SSHAP: The Social Science in Humanitarian Action (SSHAP) is a partnership between the Institute of Development Studies, Anthrologica , CRCF Senegal, Gulu University, Le Groupe d’Etudes sur les Conflits et la Sécurité Humaine (GEC-SH), the London School of Hygiene and Tropical Medicine, the Sierra Leone Urban Research Centre, University of Ibadan, and the University of Juba. This work was supported by the UK Foreign, Commonwealth & Development Office (FCDO) and Wellcome 225449/Z/22/Z. The views expressed are those of the authors and do not necessarily reflect those of the funders, or the views or policies of the project partners.

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