|Mapping of Ressources - Western Africa
1. General and Epidemiological Data
1.1. General Data
Senegal is a country located at the extreme end of the West African continent. It covers an area of 196,720 km² and shares its borders with Mauritania, Guinea, Guinea Bissau, Mali and the Atlantic Ocean. Its population is estimated at over 9 million inhabitants of which more than 50% are made up of the youth. Roughly 40% of this population live in the urban centres. The population of Dakar, the capital, is already estimated at over 2 million inhabitants.
Neither is the Senegalese economy any brighter at present. It is heavily dependent on agriculture (54,500 km² of land is used for agricultural purposes) and groundnut exports. Unfortunately production has been dependent on the vagaries of the weather and persistently declining world prices. The bulk of State non-farm income is derived from fishery, phosphates and tourism.
The vast majority of the population lives in abject poverty because the economic crisis has been compounded by the devaluation of the CFA Franc in 1994. Unemployment represents roughly 25% of the active population. Despite an unstable internal situation caused by rebellion in Casamance (South of the country), Senegal is host to a relatively large number of refugees from neighbouring countries where there are pockets of tension. It should also be pointed out that Dakar, the Senegalese capital, was also the capital of French West Africa and still maintains today relics of the past: educational facilities, (universities, training schools and institutes...) which attract many students from the sub-region. Dakar also hosts the headquarters of many international institutions which makes it a cosmopolitan city where citizens from all horizons live together.
With regard to religion, Muslims are in the majority and aCCount for over 80% of the population whereas Christians represent barely 10%. The Catholic-Protestant population distribution represents roughly 5% for the former and 2% for the latter (all denominations inclusive). Constitutionally, Senegal is a secular state.
1.2. Epidemiological Data
It was in December 1986 that the first case of AIDS was diagnosed. The latest figures available are those at the disposal of UNAIDS (June 2000 estimates). Of a population of 9,251,000, there are 76,000 infected adult (1,77%) 40,000 of which are women. Infected children are said to represent 3,300. The two types of HIV (HIV1 and HIV2 are found in Senegal). Three years earlier, 2393 cases of AIDS were reported to the WHO, representing 28,8 infected persons out of 100,000 inhabitants.
Just as elsewhere, regional disparities are noted. In the case of prostitutes considered – as one of the high-risk groups for instance, the prevalence rate ranged from 1,2% to 32%, “with a decreasing gradient from South to North”.
It is obvious that emigration, transhumance and prostitution including cultural tourism due mainly to poverty and inadequate natural resources are the main causes of the rapid spread of AIDS. However, in Senegal, excision and levirate, which are common practices among Muslims, also contribute to this rapid spread of the disease.
2. National Control Policy
2.1. Background to AIDS Control
Just like what is happening in other countries of the sub-region, the National AIDS Control Committee (NACP) executes the government's AIDS Control Policy. At the same time, the Senegalese NACP differs from the others because of its novelty: it does not play an implementation role but is involved in advocacy and delegates its power to the local structures aCCording to the capacities of each of them. Senegal is indeed one of the countries where a very strong partnership exists between the government and NGOs which benefit from a favourable environment, even if the government does not generally provide them with any technical or financial support.
There are over 300 NGOs and associations involved in the struggle against AIDS. This general mobilisation which is explained by the natural tendency of Senegalese to community life, has certainly had a positive impact on the prevalence rate which, aCCording to official sources, might be around 1% in the general population.
2.2. Strategy Thrusts of HIV/AIDS Infection Control
With regard to strategy, the NACP which focuses on advocacy actions vis-à-vis the international community, insists on the following points:
· concerning prevention, priority is given to the struggle against STI, safe blood transfusion, epidemiological surveillance (the prevalence rate must be maintained below the 3% level, because beyond this limit, the epidemics becomes uncontrollable).
· with regard to care, the NACP has been striving mainly to ensure reduction in the cost of anti-retroviral (ARV) and its policy is beginning to yield its first results. ACCording to information provided by the National Daily “le Soleil” carried by the PANA News Agency”, “some 670 adults and 200 Senegalese children living with the HIV/AIDS are expected to benefit by 2003 from anti-retroviral (ARV) treatment through the drop in transfer prices decided upon by five pharmaceutical groups which were in negotiation with the NACP under the auspices of UNAIDS. The groups include Bristol Meyer Suibb (BMS), Glaxo Welcome, Merks Sharp and Dohme (MSD), Boehringer Ingelheim and Roche.
Thus, the annual costs of ARVs for adults are 1,000 dollars as against 7,000. Those of children will fall from 1,750 to 425 dollars. This 75% reduction in ARV prices will enable the State to make savings and increase by four at least the number of patients who will be treated.
2.3. Stakeholders Involved In AIDS Control
The stakeholders are the same traditional partners as in other countries: UNAIDS, UNFPA, UNICEF, the World Bank... which provide a multidimensional support to the fight being waged by government's drive to halt the spread of the disease and care for PLWAs. Senegal is also privileged to host international renowned NGOs such as Enda Third World, African Research Network on AIDS which are taking an active part in this struggle. At the national level, there is nothing the government envies about other countries: NGOs and associations involved in this struggle are countless.
Furthermore, one very significant fact is that Senegal is one of the rare countries of the sub-region to use its Churches and religious communities to collaborate closely with the NACP in the struggle against AIDS.
3. Position and Involvement of the Churches
3.1. Perception of the Churches and Religious Communities
Senegal is one of the countries in the sub-region where there is a strong involvement of the religious communities in the fight against AIDS.
As far as the Catholics, Protestants and evangelicals are concerned, AIDS is not “a divine curse meant for only the sick”. Like all other diseases, it forms part “of the long list of evils which have befallen man at one time or the other since his fall from the Garden of Eden”.
In view of the fact that contamination is mainly by sexual means, the Churches advocate “fidelity of couples and sexual abstinence of bachelors as the means of prevention of AIDS contamination through the sexual mode”. The Protestant and evangelical Churches acknowledge the dimension of the “proper use of condoms”. Indeed, they aCCept the use of condoms solely by married couples, whereas this aspect is not explicit among Catholics or Muslims. The latter tend to consider AIDS as a divine punishment and the prophet Mohammed is quoted to support this claim as follows: “where sexual debauchery and all that it entails appears in a society, the latter itself attracts the punishment of God”.
In countries with high Muslim populations, it has been acknowledged that the practice of levirate which requires that the brother of a deceased “inherits” automatically his spouse(s) is a factor of propagation of AIDS. Meanwhile the fight being waged against this practice has not yet yielded the expected results, since the persons concerned feel obliged to honour the memory of the deceased. Meanwhile, a relatively surprising fact has been discovered regarding Muslims in Senegal: in a document published by the Muslim NGO Jamra in conjunction with the NACP and Catholics, it is affirmed that “no religion should impose levirate”.
The general opinion is that Churches and religious communities must be involved in combating the epidemics regardless of the causes.
3.2. Involvement of the Churches and Religious Communities
3.2.1. The Catholic Church
The Catholic Church is structured into 6 dioceses and its faithful represent roughly 5% of the population. It is deeply involved in the socio-economic life and concentrates its efforts in the educational, health and agricultural fields. With regard to health, the Catholic Church has health facilities of various sizes spread across the entire territory. In Senegal, more than elsewhere in the sub-region, the Catholic Church has been an indispensable and effective stakeholder in the process of combating AIDS and the name of the late Cardinal Hyacinthe Thiandoun, Archbishop of Dakar has been associated with it. One understands therefore why the health promotion centre (HPS) inaugurated on last 3 January bears its name.
However, generally, the entire action of this Church has an engine called AIDS-Services, an association which we will discuss under the item “health facilities”.
3.2.2. The Protestant Church of Senegal (PCS)
The PCS is the Presbyterian type of Protestant Church established in Senegal since 1861. It brings together roughly 300 members mainly non-Senegalese. In view of this, the PCS resembles more an international than a national Church. It is also a Church which has a relatively chequered history because of continuous conflicts between the indigenous and other members of the Church.
Despite these problems, the PCS has, besides evangelisation, also “assigned itself a mission of concrete solidarity works in the service of the Senegalese population without distinction of race, sex or religion”. It is to this end that it established a social structure called APES (Mutual Assistance Protestant Association of Senegal) to carry out educational, assistance and scourge control actions... it is this structure which is responsible for the AIDS component.
3.2.3. The Muslim Community
The Muslim community is very active and contributes in more than one respect towards the struggle against AIDS. Two NGOs called “Jamra”and “Anis”are tangible examples of this. They have already initiated several activities and collaborate with the NACP and the Catholic Church. In March 1995, Jamra organised the first seminar on “Islam and AIDS”. Jamra and Anis jointly published a guide on “Islam and AIDS”.
Unfortunately we could not meet the leaders of these two NGOs, because they had relatively tight schedules during this fasting period. However, through the information which we had received from the NACP, we could outline the major thrusts of the AIDS prevention policy of the Muslim community. The policy mainly focuses on information and education because aCCording to the teachings of the prophet, “giving a good education to a child is better for the parent than providing him with food charity everyday."
4. Poverty and Human Rights
In Senegal there has been a more significant perception, a clearer vision of the link existing between poverty, human rights and AIDS. It is one of the rare countries in the sub-region which could develop and support advocacy vis-à-vis the international community for the reduction of the costs of anti-retroviral which remain inaCCessible for PLWAs or their families. It is with great relief that in October 2000, the population welcomed the new drop in prices of anti-retroviral.
The Churches and religious communities play a very active role in the field of the struggle against poverty by automatically associating their evangelisation efforts with development actions, in order to contribute to the well-being of the populations. Through schools, hospitals and health centres, agricultural facilities..., they strive to address the shortcomings of the State.
5. Ecumenical Organisations and Denominational Health Facilities
AIDS Service is the “spearhead”of the Catholic Church in the fight it has been waging against AIDS for several years. The inauguration on last 3 January of its Health Promotion Centre (HPC) has made it a rare reference at the national and community level.
Since its inception in 1992, it has buckled to prevention by choosing as its main target the youth from academic circles and women. In 1995, AIDS-Service also embarked on support and training. In 1996, it organised the first national seminar on “AIDS and religion”which brought together all the bishops of Senegal. Ever since, AIDS-service has increased and diversified its activities as much as possible as follows:
- establishment of branch offices in the six dioceses
- formation of relay communities
- training of peer educators...
Today, the formation of the HPC has crowned a long and exacting job. Initiated by AIDS-Service and the Association of Catholic Private Health Posts (ACPHP), the HPC is meant to be the place for an audience and for psychosociological, medical and spiritual support. It is also an Information-Education-Communication (IEC) unit particularly for STIs and AIDS, a training unit for those who are involved in socio-educational, psycho-sociological and paramedical activities...
Within the particular framework of the struggle against AIDS, the HPC medical test laboratory provides anonymous and free screening services. The support programme has three components namely, psychosocial, medical and spiritual.
· The first component is listening (counselling) and monitoring. Income-generating activities have been planned for the needy who also benefit from medical and nutritional support as the case may be. The HPC organises visits to homes and to the hospital, whether children, orphans or not also benefit from the monitoring.
· The medical component is responsible for the treatment of opportunistic infections, since the HPC does not yet have aCCess to the tritherapy. The consultation is done three times a week and the sick buy drugs or receive them free of charge depending on their financial conditions.
· The spiritual support has an important place. Depending on his wish, the PLWA is entrusted to a Muslim, Catholic or Protestant leader who will assist him in his/her relation with God.
The HPC which carries out between 200 and 250 consultations – all categories inclusive – wishes to extend screening to the sub-region in the future. It should be pointed out that AIDS-Service is also active in Gambia.
5.2. Young Men's Christian Association (YMCAs)
Established on 21 November 1982, the Young Christian Men's Association (YMCAs) developed programmes in relation with the unionist philosophy. Thus, YMCAs initiated micro-enterprise, environmental protection and kindergarten programmes in favour of the youth. The impact of the movement programmes on the youth has been very significant and the Senegalese movement plays the role of leader in Southwest Africa in YMCA circles.
With regard to AIDS, YMCAs policy has been mainly focused on prevention. Very early on, it drew lessons from the experiences of other national NGOs and instead of developing solely an AIDS programme, it preferred to embrace a more extensive field which is that of adolescent reproductive health (ARH). In fact, an initial aborted experience of common programme with other NGOs namely the “Xaal yoon” programme, prompted YMCAs to design and manage its own programme.
The ARH is a programme whose novelty covers peer training. It is the youth themselves who carry the messages to their “peers”, friends, class mates and neighbours, etc... The action of peers is often supported by that of “peer adults or opinion leaders” namely, teachers, heads of workshops or neighbourhoods. The programme motivators support this youth movement and intervene directly from time to time especially in the area of counselling. Roughly 10,000 youths under 35 years were affected by this programme.
The activities which began in 1993 are based mainly on IEC (Information, Education, Communication) sessions organised in the regions of Senegal where the movement is active. These include Dakar, Rufisque, Mbour, Kaoloak, Thiès, Saint Louis, and Fatik.
The programme co-ordination is responsible for the training of trainers, motivators and peer educators. The sessions extend over a one-year period with the same targets and aCCording to an interval determined in mutual agreement with the targets. It is a participatory method which covers both the choice of themes ranging from the anatomy of the genital organ to AIDS including early pregnancies, family planning, STIs...
The novelty of this programme is that it plans henceforth to include the family planning unit by establishing a parent-child dialogue. The studies have shown that the subject of sexuality is not so much of a taboo problem as that of lack of information. Many parents lack fundamental knowledge on sexuality for the initiation of their children. This project which is also to train the parents is therefore at the experimental stage and will soon be extended to other regions.
5.3. The APES and AINDS Control
APES - Association Protestante d'Entraide du Sénégal (Protestant Mutual Assistance Association in Senegal), work of the EPS, is a member of the Council of Non-Governmental Organisations for Development Support (CONGAD - Conseil des Organisations Non-Gouvernementales d'Appui au Développement). It has been involved in combating AIDS since 1996. With the collaboration of the Churches of Holland, APES is undertaking an awareness-raising action in combating STD/AIDS in the centre of the country and the coastal region. The latter is characterised by a concentration of hotels and the very strong presence of sex professionals. The zone is also fish-endowed and attracts many seasonal workers.
APES often organises public events for the general public or with women's groups backed by drama, television, video films, streamers...
APES also collaborates with health posts and its strategy gives priority to youth and women, combines awareness-raising and the distribution of condoms... It also focuses on the training of trainers and relay of motivators.
In the capital, APES has integrated into the programme of its vocational schools, information and awareness-raising sessions on problems relating to sexuality and AIDS with the support of doctors and motivators of the Senegalese Family Welfare Association.
For the future, APES wishes to focus on the following points:
- participating actively in combating drug in its zones of intervention
- Broadening awareness-raising to other diseases
- Reinforcing and providing the various groups with teaching and motivation aids
5.4. The Protestant IADS Co-ordination Commitee (CPLS - le Comité Protestant de Coordination SIDA)
In Senegal there are Protestant and evangelical Churches. The former include the Protestant Church of Senegal, the Lutheran Church, the evangelical Lutheran Church, the Methodist Church. The latter are broadly referred to as “Evangelical Fraternity”. They include the Assemblies of the Church of God, the evangelical Church, the Baptist Church, the independent Churches and missions...
The main objective of the Protestant AIDS Co-ordination Committee (PACC), which was recently established in May 2000, is to “co-ordinate the fight against AIDS within these two families of Churches. The Protestant Churches already have a structure called “Protestant AIDS Control Committee”(PACC) and the Health Department of the “Evangelical Fraternity”has an AIDS component. However, like any child of this age, the PACC is currently undergoing full structuring and there are trial and errors. The collaboration has been hampered by some reservations observed among the evangelicals probably for doctrinal reasons. The establishment of the General Committee which should be an emanation of the two Church groupings has not suCCeeded. However the PACC has already done good work with the assistance of the CRWRC (Christian Reformed World Relief Committee), by publishing a reference document on AIDS titled “Appeal to the Churches: reflection guide and practical advice”.
In anticipation for the resolution of these difficulties, the PACC has been in operation and has outlined some strategies of action as follows:
- training of trainers at the committee and population level
- monitoring of PLWAs
- design of awareness-raising tools
- creation of a welfare centre
- creation of a care centre
The PACC is of the view that the current challenge is to know the real situation in the regions, make people to act together, encourage health and risk-free behaviours...
In concrete terms, the PACC was able to undertake its initial activities during the World AIDS Day, edition 2000, with the assistance of MAP International based in Abidjan (the Ivory Coast). For this purpose, it chose the city of Fatick, situated at 130 km from Dakar where the Lutheran Church is located. Procession through the main streets of the town, photo exhibition, projection of films, lectures-discussions on AIDS were the programme of the day; political figures, religious figures and the entire population were invited.
Unfortunately, the PACC depends entirely on the CRWRC. It therefore needs funds in order to carry out its activities thoroughly.
5.5. The Evangelical Fraternity of Senegal
As we have already emphasised, the fraternity brings together missions, Churches and associations of Churches which total nearly 8,000 Christians of evangelical denominations. Even though each member is autonomous, the fraternity has a health department which has established an “HIV/AIDS Committee”. For two years, the committee organised several seminars in order to inform pastors and gather their opinions on the matter.
It is the wish of the fraternity, which is mainly a Church-based movement, to preserve biblical values in its struggle against AIDS. Their resource person is Dr. Fotso whom we could not meet because he was travelling.
Remark: We felt a certain reticence in the leaders of the fraternity even though officially they are prepared to collaborate with the PACC.
6. Resource Structures
6.1. Enda Third World Senegal
Enda-Senegal is a special partner to be taken in to aCCount in any initiative in the struggle against AIDS at the West-African sub-regional level. The novelty of Enda-Senegal is to be a development agency in the south, based in a Southern country. Created in Senegal nearly 30 years ago, it is present in some twenty countries.
In the field of the struggle against AIDS, Enda can be considered as a pioneer. Its Health Department has designed a multidimensional programme which is in its thirteenth year of implementation.
Since 1986, with the support of a multidisciplinary team, Enda-Senegal has carried out a reflection on AIDS, whose results appeared in a document titled “AIDS and the Third World” and published in 1987. In 1988, Enda-Senegal established a four-component programme in 10 African countries based mainly on prevention as follows:
- stage 1: general sensitisation consisting in sounding the alarm on the danger of AIDS
- stage 2: provision of comprehensive information on the transmission of the disease
- stage 3: individual information or by small groups on screening
- stage 4: actions targeted towards vulnerable groups: prostitutes, long-distance truck drivers, students...
The novelty of Enda is that it has already gone beyond the evaluation stage with relatively alarming results: 80% of the specimen chosen had precise and correct information on AIDS. However the behavioural change did not follow, because ¾ among them still take the risk of unprotected sexual relations.
How can this objective be attained? Solutions proposed include, inter alia, recourse to the “internal police” which is faith. The Churches and the religious communities have been mobilised to activate the internal lever of faith. Enda is working in this regard with the Muslim brotherhood, with Catholic organisations and religious NGOs.
Enda-Senegal is also co-producer, with the European Union and Radio France International of 12 programmes titled “Priorité Santé”(“Health Priority”) and devoted to the struggle against AIDS in 8 African countries.
At the national level, Enda has been working closely with prisoners, prostitutes and PLWAs.
For the year 2001, Enda designed a programme for West Africa relating to migration and STI/AIDS. The work with the migrant communities will be done with specialists who are citizens of their countries of origin.
Enda projects itself as an indispensable ally and is prepared to collaborate with any action initiated by the WCC and the WAYMCA. Enda is a member of several networks of which it is often founder or co-founder, particularly Icaso (International Council of AIDS Control Agencies), Africaso...
6.2. African Research Network on AIDS
Established in 1989, the network brings together 18 countries in West and Central Africa and its main objective is to encourage the collaboration with other structures and work in the field of training with a view to strengthening the operational capacity of its members: initiation to scientific writing. The latter are organised into national networks and have the possibility of resorting to the headquarters to suCCessfully carry out their own programmes namely: financing of research works. The network is also a service provider which carries out, for instance, research activities or studies for all those who request it in different fields: AIDS-related risks in emergencies in the hospitals, immigration and AIDS.
The network which has a sub-regional board of directors is also involved in advocacy activities at the level of governments, local elected persons, religious leaders...
6.3. National Alliance Against AIDS (NAAA)
The mission of the NAAA which is directed by Mr. B. M. Goumbala, is to strengthen and support in the field, associations involved in the struggle against AIDS. The programme of the Alliance began in 1994 and to this day, it has supported in all over three hundred associations and NGOs.
The strategy of the NAAA is to rely on associations and NGOs already established and have them integrate the AIDS component into their programme, if that did not already exist. In the exceptional event where there are no development associations or NGO in the field, the NAAA established one in order to carry out its mission effectively.
The intervention of the Alliance is in the form of technical and (or) financial support. The first component has enabled the NAAA to assist the association or NGO concerned, to better understand the importance of the struggle and to be involved in the prevention with the design of an appropriate programme. When the observation is made that the zone of intervention did not receive enough information, the focus is then put on the IEC techniques (Information, Education and Communication). In the localities where the information problem does not arise, the associations were made to develop specific activities such as participatory approach.
With regard to support, the following points were tackled:
· psycho-social support
· facilitation of screening
· visits to homes or the hospital
· reintegration of PLWAs. In this regard, it should be emphasised that the NAAA has contributed to the creation in 4 regions of Senegal units bringing together the PLWA, doctors, and other stakeholders of civil society.
The second component consists, where necessary, of a non-refundable financial subvention.
The NAAA forms part of several networks of which it is at times the founding member: Icaso, Africaso, Icaso international, national network of PLWAs...
The unique network which is found in Senegal is "the alliance of religious officials and medical experts in response to the AIDS epidemic". Unfortunately, the Protestants and evangelicals do not form part of it. Addressing this shortcoming would further strengthen the action of the Alliance.
In addition to the Alliance, AIDS-Service, while maintaining its own identity, forms part of nearly all the networks which exist in Senegal and which bring together NGOs working in the same field such as Enda Third World, NAAA, ICASO...
With regard to Protestant Churches, the formation of the network has begun, this deserves to be supported and reinforced.
The evangelical fraternity, even if it is very reserved, also provides a framework for network.
The YMCAs forms part of a network which brings together six African countries and the United States.
Without any exaggeration, one can say that Senegal is far ahead of its neighbours of the sub-region in the struggle against AIDS. Even if it is obvious that the situation is still alarming in a number of localities, it should be mentioned that it proves that "with Uganda and Thailand, they are the first developing countries which achieved the best results in AIDS prevention". Not later than the beginning of this year, UNDP which intervenes since 1998 in the financing of the NACP brought men and women of the media from all over the world to Senegal, so that they would be informed about the suCCess achieved by the country in its struggle against AIDS.
It should be pointed out that the prevalence rate is about 1% and the efforts to maintain it at this level are continuing. One of the factors which has contributed to this suCCess is general mobilisation.
Churches and religious communities also set a very good example by their involvement and providing their assistance towards the attainment of the objectives fixed by the government: in fact, a close collaboration exists between the NACP, the Catholic Church, represented by AIDS-Service and the Muslim community. To some extent, this collaboration was facilitated by the consensus found in connection with the condom. The NACP will not request the religious communities which do not wish to do so to undertake the promotion of condoms and the latter will no longer denigrate its policy on the matter.
Senegal also distinguishes itself from other countries of the sub-region by the constructive progress achieved in the Islamo-Christian dialogue. The alliance of religious figures and medical experts, in response to AIDS in Senegal, is one of the precious fruits of this dialogue. Unfortunately, the absence of Protestants and evangelicals in this process should be deplored: a serious shortcoming which should be addressed promptly.
Furthermore, AIDS-Service is on the threshold of prevention and care by the creation of its health promotion centre. These are examples which should be encouraged and reflected on other countries for the reinforcement of the struggle against AIDS.
Senegal is also an example to be emulated within the framework of the "initiative on the aCCeleration of AIDS patients aCCess to care in developing countries", launched jointly in January 2000 by the United Nations, WHO, UNAIDS, the World Bank, UNICEF and UNFPA which has not yet suCCeeded in other countries.
Finally, Senegal has the privilege of hosting important structures for the struggle against AIDS and could, in this respect, play an important role in the sub-region.
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