Hospital care for pregnant women remains a challenge in Senegal, particularly for financial reasons. How to remedy the obstetrical violence that can result from it?
Senegal is currently in shock following the death of a mother and her 9-month-old unborn baby in the waiting room of a regional hospital. The family of the deceased denounces negligence by the guard team and several midwives are in police custody awaiting final judgment.
Faced with this, health unions are on strike – days without childbirth – to defend their corporation. A suspension of health services that feeds a feeling of social injustice among patients, who on their side organize bereaved family support walks.
The death of this young woman is only the visible part of the health challenges posed by obstetric violence, in Africa and around the world. This terrible event is a revealing example of an often dysfunctional socio-sanitary environment, characterized by the impossible admission of patients to the emergency room for lack of a guarantor, where women in labor or their fetuses can die in ambulances for lack of resuscitation beds after having toured the referenced hospitals.
Despite childbirth humanization projects and free policies in favor of the mother/child couple in force in most public health facilities in West African countries, this drama thus re-emerges the tensions aroused by the fate reserved for very many women in maternity wards in West Africa, and bases the structural questions on the hospitals in these countries.
Develop hospital reception capacities
In 2020, the organization of the response to the Covid-19 pandemic was a high point for the diagnosis of health systems around the world.
In Africa, several initiatives have been undertaken by the States to coping with and strengthening local health systems : increase in reception capacity (construction of hospitals, hospital wards), upgrading of the technical platform (resuscitation beds), recruitment of specialists and deployment in remote areas.
Today, despite these efforts made in times of emergency, difficulties in accessing care persist in West Africa, especially with regard to maternal health. Pregnant women from poor families still die for lack of adequate care (even more so in the Sahel in conflict areas).
Affluent families affiliated with private insurance or mutual health insurance, or those able to pay, turn to local private clinics. Meanwhile, birth at home or assisted by a traditional birth attendant remains a a practice widely shared by the poorest families, but also by some women who have had a prior traumatic experience of childbirth in hospital.
Thus, inequalities in access to care between social classes remain, in Africa as elsewhere. Are we to believe that the enthusiasm for "renewal" aroused by the Covid-19 pandemic ultimately did not allow for in-depth reform, nor the generalization of universal health coverage promulgated by the United Nations in 2015?
It seems to us that the structural determinism of neoliberal reforms is gaining the upper hand over the short-term measures of the response to Covid-19, largely financed from outside.
A neoliberal hospital model?
Since the structural adjustment programs of the 1980s and 1990s, the functioning of health facilities in Africa has been based above all on a neoliberal model.
While most human resources are paid by the State, each health structure (hospital, centre, post) manages its own operating budget, largely coming from paid services (for the official part) of patients (consultation tickets , medical examination costs, sale of medicines). The financial operation of the public hospital is therefore based on a market logic – supply of health professionals and demand from users (patients) – and good financial health ensures the sustainability of the service and care.
In addition to the two stakeholders (providers and customers), there is also the regulatory role of the State, sometimes saving, sometimes destabilizing.
The interventionist policy of the welfare state grants free services to users on paper, as for children and under 5 years of age or caesarean sections. These initiatives with a social vocation based on territorial equity through universal health coverage allow families, including the poorest, to access care at a lower cost and thus increase the users' power to act. Burkina Faso is a fine example of political will and success in this regard.
But the state must repay a posteriori to health facilities the services of the populations recorded in the register of free care policies. This is often where the shoe pinches.
Indeed, delays in reimbursement from the State put health structures under financial pressure to buy inputs and pay the salaries of contract staff. These delays contribute to a breakdown ethics of caregivers which poison caregiver-patient relationships and lead to inappropriate medical practices.
Combined with poor training in the psycho-sociology of care relationships, financial pressure pushes some providers to triage the sick, not according to the medical emergency but according to the ability to pay: “We take patients who pay cash! Patients in need of free services or without a letter of guarantee from the mutual health insurance fund will have to wait”, told us a midwife during an analysis of the barriers to membership of populations in mutual health insurance in Senegal.
Women with low economic (and social) capital are therefore more exposed to obstetrical violence than others.
Violence exercised and contradictory injunctions
Caregivers' negligence and inappropriate practices are daily occurrences; they manifest themselves in hospitals under pressure beset by state injunctions that interfere with their operation. In Africa, hundreds of women are kept in hospitals after giving birth for non-payment of benefits.
The World Health Organization (WHO) had nevertheless asked countries to abolish direct payment for care during the pandemic. Although some WHO economists do not agree with this solution, the journal's health commission The Lancet has just recalled the importance of primary health care being free at the point of service, it being understood that the State must guarantee its financing.
Nevertheless, few are the African countries to guarantee this right to health and respect their commitments to health financing.
Public hospitals in West African countries are more than ever under pressure, especially since the Covid-19 pandemic has brought hospital-centrism back into fashion (in Senegal, hospitals absorb two-thirds of health expenditure ).
Beyond the steady decline in maternal mortality since 1987, to improve this socio-professional climate, the State must absolutely agree to increase its investment in the health sector. In Senegal, for example, only 5% of the national budget is allocated to health. This amount is derisory in view of the many challenges facing the health organization.
The investment plan announced in 2020 of 1 billion CFA francs, of which 400% for infrastructure, until 62 will certainly not be enough. Moreover, less than 5% of the population is covered by a community health mutual fund, the flagship instrument of the universal health coverage program (UHC).
THEuse of profits derived from extractive resources to finance health appears to be a lasting and feasible solution. It could promote the advent of UHC, in particular (but not only) through departmental health insurance units, large-scale and professional, resilient, solvent and dynamic, able to ward off possible hegemonic and counterproductive actions for the proper functioning of the system. And thus participate in the advent of a “better hospital”.
Support for the structure of demand, for the creation of a counter-power where the sick are at the heart of the health system, becomes an emergency to debate and find a solution, together, with the representatives of the healthcare supply. The legalization of health will not be a solution.
For this, the actors will have to reconcile with the health system, by pleading in favor of the effectiveness of harmonious local health governance. including community health actors.
This can go through the creation of local entities that will establish relationships of trust based on constructive and inclusive exchanges in order to achieve "health" not only "by" and "for" the communities, but also "according to them where the patient will be at the heart of decision-making.
Abdoulaye Moussa Diallo, Sociologist, University of Lille; Clemence Schantz, Sociologist, Research Institute for Development (IRD), and Valery ridde, Director of recherche, Research Institute for Development (IRD)