MAXIMIZING POSITIVE SYNERGIES - World Health Organization

Performance-based funding
In 2005, the Global Fund cut malaria grants in Senegal worth $7.1 million over systemic issues that
resulted in poor performance. The Fund later approved a grant proposal for malaria projects
submitted in Round 4.
The GAVI alliance receives yearly proposals and only funds those that show improvements from
the previous years. For every new child vaccinated, US $20 is added to the previous year’s funding.
Financing
GHIs began operating in Senegal in 2002. Until 2004, Senegalese households financed around 50%
of total expenditure on health through out-of-pocket spending at the point of consumption (the
most regressive and inequitable financing mechanism). In 2004, government and donors began
subsidizing access to key health services.
This policy change had a significant impact on equity. Voluntary Counselling and Testing for HIV
(VCT) were free from the outset, but scale-up in a number of sites really took off in 2003. Between
2003 and 2004 sites increased 4.5-fold and between 2004 and 2007, 3-fold; they are now in all
regions in Senegal. Research at the district level showed that in Ziguinchor, - the region and health
district most affected by the HIV epidemic (with twice the national HIV prevalence) - HIV testing in
the district increased nearly 12-fold between 2004 (166 HIV tests performed) and 2008 (1918 tests
performed).
Senegal was the first country in Africa to introduce antiretroviral treatment in 1998. Yet it was only
when ART became fully free of charge (without income-based contributions from users) that the
number of treatment sites and the number of patients on treatment peaked: from 20 sites to 70
sites between 2003 and 2007, and from around 20,000 clients on ARV in 2003 to around 70,000 in
2007 [8].
Service delivery
In 2005, nine sexually transmitted infection (STI) services specifically directed at men having sex
with men (MSM) were created within existing health care services in Senegal. This number rose to
12 in 2006 and 18 in 2007, and now covers 10 out of the 11 regions in Senegal. Syphilis and
Hepatitis B testing are provided free of charge since GHIs (Global Fund and MAP) started
supporting the Conseil National de la Lutte contre le SIDA (CNLS - National Council for the Fight
against AIDS).
This has increased the capacity (equipment, staff) of laboratories all over the country and
supported the scale-up of diagnosis of these illnesses in the country. For example, 1,478 syphilis
tests were performed in 2008 in Ziguinchor (the health district in Senegal with the highest HIV
prevalence); none were performed in 2004. DTP vaccination coverage increased from 52% in the
year 2000, to 87% in 2004 [9] and 88% in 2008. [10] GAVI has supported free DTP3 coverage in
Senegal since 2002.
“Parrainage” or mentoring programmes, whereby Dakar-based “ART mentors” from a tertiary level
treatment structure are responsible for providing technical support to each region in Senegal, was
key in Senegal’s impressive decentralization efforts in ART coverage [11].
Between 2000 and 2004, a household survey with standardized sampling and measurement
methods to compare four countries at two points in time, showed that in Senegal the percentage
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