After winning a contentious presidential election in April 2012, Macky Sall promised to bring universal health care to Senegal. In September 2012 Sall’s administration launched a universal health care program and pledged $3.1 million in funds for initial startup costs.

If Senegal wishes to meet the World Health Organization’s standards for universal health care, it must provide a strong, efficient, well-run health system. This new system would require a method for financing health services, access to essential medicines and technologies and finally a sufficient capacity of well-trained, motivated health workers. While many critics doubt the feasibility of providing basic health care access to Senegal’s 13.7 million citizens, proponents and naysayers both agree that the process will be neither quick nor easy.

The beginning of this process will be complicated by the current state of the Senegalese health care system, which leaves ample room for improvement due to both a lack of infrastructure and a lack of funding.

Though Senegal does have a health care system in place for civil servants and other employees in the formal sector, these benefits only reach an estimated 20 percent of the population, leaving the majority of Senegalese to either go without medical insurance or find a local provider. Statistics show that the majority of workers in the informal sector succumb to the former, as just 6 percent of the Senegalese population participates in a community health mutual.

Of the Senegalese population that neither works for the government nor participates in a community health mutual, one half live below the poverty line, meaning they subsist on $1.25 or less per day. For these people, both preventative and emergency medical care is prohibitively expensive, creating wealth gaps in productivity, life expectancy and overall health.

Expanding medical care as a means of closing these health care gaps is a crucial aspect of improving the quality of life in Senegal. While the need to address health care coverage may not be unique to Senegal, this new program may provide a chance for Senegal to become a global front-runner in health care expansion.

Looking to Rwanda

As a guide to this long and difficult process, the Senegalese government has historically turned to another sub-Saharan Africa country: Rwanda. Though the small central African country is perhaps most well-known for its 1994 genocide, Rwanda now boasts one of the largest, most effective health care systems in the developing world.

Peter Droba of Partnership in Health told the New York Times that Rwanda’s “health gains in the last decade are among the most dramatic the world has seen in the past 50 years.” Currently only 4 percent of Rwandans are uninsured and most community health mutuals have adopted a sliding scale of medical costs ranging from 33 cents to eight dollars. Rwandans with insurance are expected to pay at most one tenth of their medical bills, making medical care both affordable and widely used.

In addition to these inclusive financial provisions, the developing health care system has made considerable progress through initiatives targeted at the country’s most vulnerable populations. Such initiatives have raised the percentage of Rwandan births taking place in medical facilities from 20 percent in 2008 to 70 percent in 2013.

This system has created impressive results in its HIV/AIDS programs as well. Eighty percent of Rwandans in need of treatment for HIV are receiving adequate care, a number that far surpasses similar statistics in even developed countries like the United States where only 50 percent of people in need of HIV treatment receive adequate attention.

The success of these initiatives and the Rwandan health care system as a whole may also be attributed in part to the government’s strict adherence to its financing structure and the performance based payment system for health care workers. An organization, domestic or international, looking to work within the Rwandan health care system must prove that it fits into the government’s program, making access to medical care evenly distributed and extensive. Performance based payment has become an important aspect of effective medical care in Rwanda as community health workers are often the first point of contact for diagnosis and treatment before going to a medical facility.

However, while these programs may work in Rwanda only certain aspects of this system can be feasibly applied to Senegal’s emerging universal health care system.

Like Rwanda, Senegal has opted to similarly target its most vulnerable populations with specific initiatives. In July 2013 the Senegalese government, along with USAID launched the “A Promise Renewed” campaign with the goal of saving 10,000 mothers and children from preventable deaths over the following two years.

As part of this program, on Oct. 1, 2013, the Senegalese government announced that children under five were to be guaranteed free health care, including consultation, vaccinations and emergency care. By offering free health care to children the Senegalese government hopes to cut child mortality from 7.2 percent to 4.6 percent by 2015.

Like Rwanda, Senegal will likely also adhere to a strict financing structure. Along with the announcement of universal health care in April 2012, President Macky Sall also pledged to reform the “institutions de prevoyance maladie,” which provide health insurance to government employees in an attempt to spend government money more efficiently.

There is also hope that Senegal increases its health care spending on a nationwide scale so that the government, rather than local health mutual or individuals, can fund more health care infrastructure. In April of 2001, Senegal became party to World Health Organization’s Abuja declaration, which requires countries to pledge 15 percent of the national budget to health care spending.

Currently the Senegalese government allocates 10 percent of the national budget to medical spending, but many are hopeful that the announcement of this new program will result in an increase to the 15 percent budget allocation to which Senegal is already obligated to.

In contrast, community based health mutual will likely remain more common in Rwanda than Senegal even after the implementation of universal health care. Often these mutuals in Senegal are formed through religious or community organizations, making them responsive to individual’s medical needs.

By brokering deals with local hospitals and pooling together money from the community, local health mutuals are able to provide efficient and quick medical care to those who participate in them. However, as previously discussed, these mutuals are currently not very common or large in most of Senegal. With little money to advertise, and even less money to organize, these mutuals will require government assistance to grow and expand their coverage.

International health experts in Dakar are quoted as having reservations about the ability of local health mutuals to organize without state-appointed officials at the head, remarking, “It is as if the community is being asked to do — voluntarily — what cannot be organized at state level.”

Setting their own precedents

As illustrated, though the Senegalese government can draw on important precedents set by Rwanda’s transition to universal health care, many problems remained unresolved at the beginning of this process. After considering the possibility of an influx of immigrants, Senegal has already chosen not to extend its universal health care programs to foreign residents.

Unlike this decisive action, the question of funding for Senegalese universal health care remains ambiguous. Even Rwanda’s effective and expansive medical system is not financially self-sufficient; only about 45 percent of the operating costs of Rwanda’s universal health care comes from medical insurance premiums, and all other costs are paid for through international humanitarian donations.

Should Senegal adopt a similar method of financing universal health care, it will have to ensure that international donations and government subsidies will continue to be available. Ensuring access to affordable health care is a paramount consideration in the expansion of universal health care, but this goal cannot be accomplished without proper funding, an issue that stalls many projects in developing countries.

Furthermore, the strong centralized planning and emphasis on evidence-based policy that has made Rwanda’s health care system will be difficult to implement in a country almost eight times as large geographically. Government-operated medical insurance may be easier to run in cities like Dakar and Saint Louis, but will likely be much more difficult to implement in rural areas like Ziguinchor and Kedougou.

Attention to vulnerable populations, emphasis on centralized implementation and reliance on evidence-based policy will help Senegal to realize its 2017 health care goals. But, regardless of whether or not these specific health care goals are met, how Senegal answers these difficult questions of implementation and funding will provide a valuable precedent for other developing countries looking to expand their health care programs and will save and improve the lives of numerous Senegalese citizens.