Strengthening Health Systems at the Community Level in Senegal

We arrived during Senegal's dry season, a time when the air is dusty and there are fewer crops to harvest. As our group traveled through the southern region of Casamance, we took in the flat green vegetation by the side of the road, and beautiful, lush mangroves peppered with white lilies. Woven fences enclosed communal areas where community members worked and children played. 

As we made our way to the village of Abbecouta, we passed through towns with vibrant public art, where sellers sat by wooden tables with spindly legs loaded with pyramids of stacked citrus. Driving through a village called Diagho, our UNICEF driver, Souleymane Diedhiou, beeped and waved to a group of men. He grew up here. He’s been a driver with UNICEF for 20 years and knows the area well.

Community-Led Total Sanitation: a public health success story

Once in Abbecouta, we met up with Hassanha Sow, a community relay who has been a key advocate of Community-Led Total Sanitation (CLTS), an initiative UNICEF launched in 2009, and continues to support, to encourage communities to build latrines, abandon the practice of open defecation and adopt good hygiene practices.

CLTS has reached over 1.8 million people from 4,300 villages to date, employing a simple and highly effective strategy that relies on positive behavior change by emphasizing the connection between open defecation and the spread of disease.

To spur the movement forward, Hassanha ran demonstrations for community members showing how to treat water before use, helping to drive adoption of better hygiene practices in homes and communal spaces. 

Hassanha’s village is one of many that has managed to end open defecation for good. As a result, there have been fewer instances of diarrheal disease and skin disease — and fewer mosquitos, especially during the rainy season, helping to reduce the risk of malaria and other mosquito-borne illnesses.

CLTS has since expanded to tackle other issues, with UNICEF supporting the training of more volunteers like Hassanha to work across other sector areas, such as education and nutrition. Having members of the community lead the charge is important, we're told, as it strengthens community ownership over — and commitment to improving — local health and social outcomes. 

“The needs are great,” Hassanha said. “But we are making progress.”

Related: UNICEF in Senegal: a mission overview

Local health system strengthening in action

In 2021, with UNICEF's support, the CLTS initiative broadened its scope to take on local challenges related to vaccination, prenatal care for expectant mothers and birth registration, a critical step for connecting children to health and social services.

While prenatal visits are widely understood to be important for the health of the mother and baby, the costs of transportation and the visit itself are often prohibitively high, Hassanha explained. He has found success in bringing pregnant mothers’ families into the conversation, specifically speaking with the husbands who can help support the expectant mother. 

During home visits, Hassanha also talks about the importance of civil registration in the form of a birth certificate for the newborn. Introducing the concept before birth makes it more likely that women will get birth certificates for their children, and he is proud to say that every child in his community now has a birth certificate.

By improving hygiene practices across all villages where it has been implemented, the expanded CLTS program has helped reduce cases of child malnutrition as well. Community workers like Hassanha are trained and equipped to help families understand the connection between good hygiene practices and good health, and to guide them toward healthy practices.

Improved hygiene leads to fewer cases of diarrhea, which interferes with nutrient absorption and is a major underlying cause of malnutrition. In Abbecouta, cases of malnutrition have significantly decreased, with only one case reported last year. 

Integrating services to maximize impact

Yves Olivier Kassoka, Chief of the Field Office in Kolda, joined UNICEF Senegal in 2010 as a child protection specialist. In his current position since May 2019, he has been a champion of UNICEF’s approach to integrating services and supports in order to maximize impact for children.

When I asked him what he is most proud of in his work with UNICEF, he said it was how UNICEF works to meet children's needs holistically, citing the expansion of the sanitation project in Abbecouta to encompass other critical interventions and services as a great example.

During a single visit by a UNICEF-trained community health worker, families can get a birth certificate for their child while also accessing vaccinations, nutrition screenings, early education enrollment and maternal health check-ups to help ensure that children not only gain legal identity but also get essential health interventions, improving both child protection and survival rates.

Combining services like this, Yves said, is how UNICEF maximizes impact: reducing barriers to access and strengthening national health and legal systems while maintaining cost efficiency. “Children’s rights are interrelated,” he explained. 

This strategy isn't just for Senegal. UNICEF takes this approach globally, especially in remote rural areas of many other countries where it works. In Bangladesh — where over 90 percent of children under age 5 are vaccinated but only 56 percent have a birth certificate — UNICEF-supported mobile outreach programs now allow parents to register their children’s births when they receive health check-ups and vaccinations, an effort to close that gap.

Improving maternal health care in rural Senegal

In Dinguiraye, we visited a UNICEF-supported health post that serves 9,700 people in the surrounding area, including Abbecouta. There are serious barriers to accessing health care here too. Even buying medication or getting access to specific interventions requires distant — and expensive — travel.

Community members tell us that there was once a hospital nearby with government-subsidized costs, but it has since closed. Now the closest health center is more than 7 miles away and there is only one ambulance for the community, which they share with several other villages.

We heard about a pregnant woman who faced complications during delivery and had to wait more than a day to be transported to the health center for treatment on the other side of the border, in The Gambia. Delays like these can lead to precarious health situations and complications.

Establishing a health post in the village — the smallest type of health facility, with one doctor, one nurse and one midwife on staff — is an effort to overcome the lack of services. Community health workers pitch in, as does the local Bajenu Gox, or neighborhood godmother, a highly respected community member who provides health and social support to children and women. The concept was introduced by the Senegalese government, building on traditional structures where older women mentor younger women in their communities.

As it does for many other villages across Senegal, UNICEF supports the Dinguiraye health post by providing medical equipment and supplies and supporting health worker training. The entire health system in Senegal, in fact, benefits from UNICEF's contributions in immunization and treatment of child malnutrition.

The three-room structure is frequently crowded, and the day we visited was no different. A cold storage chest contains vaccines provided by UNICEF. The health post mostly uses solar power, making night births challenging when stored solar energy gets used up. Community health workers told us about delivering babies by lamplight or the light from a cellphone.

With support from UNICEF, and with community members leading the way, the village's health care workers have made great progress in prenatal care. Women are encouraged to visit the health post early in their pregnancy and have at least eight prenatal visits where they get vitamins and vaccinations, like the TDap. Samba Sow (no relation to Hassanha), the head nurse on staff, prescribes iron as needed to treat anemia and distributes mosquito nets to those who do not have them. 

Samba told us how he discourages home births, explaining to the women in his care that hospital settings have better outcomes, especially in communities where lack of sanitation at home carries risks of infection. At a birthing facility, the newborn can receive timely vaccinations and health workers can monitor the mother for postpartum complications. 

Some women do not seek out this type of care because it is expensive. This is where community mobilizers come in. These individuals, trained by UNICEF, reach out to women and their families to communicate the importance of delivering at the health post, a tactic that appears to be working: In 2024, the community saw 14 home births; so far in 2025, there has been only one.

Dabo Baldé, one of the community mobilizers who also works in the village’s Early Childhood Development center, described how she helps educate new mothers about the importance of exclusive breastfeeding for the first six months. Given the prevalence of waterborne illness in the community, breastfeeding can significantly improve the health of a baby, in addition to giving them the critical nutrients that breastmilk contains.

Other community members spoke of their future aspirations, including getting a second ambulance and creating a nutrition center where they can make enriched flour to support child nutrition. Currently, the health post is the only place to make this type of flour, but sanitation is a key concern. The sole machine is costly to use and requires training. 

“All across Senegal, needs are increasing but we are seeing great progress across all of our programs,” Yves said. “We and our partners are not sure what might happen with funding gaps and changing needs, but no matter what, UNICEF will be here to support children and communities.”

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Angela Duffy is UNICEF USA's Senior Director for Strategic Marketing and Communications.