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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Report No SE Senegal Population Sector Report (In Two Volumes) Volume l: Main Report June 24,1987 Population, Health and Nutrition Department FOR OFFICIAL USE ONLY Documeronof the World Bank This repo7t htas a restrictedistribution and may be used by recipients only ki the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

2 FOR OMCIL USE ONLY SBhL POPULATION SECTO REPORT VOLUME I: MAIN REPORT Table of Contents Page No. FODE RD v EXRCUTIVE SUMMARY * *.. * v. CHAPTERI. DEMOGRAPHIC SITUATION A. Current Data * B. Population Projections C. Implications of Population Growth Effects of High Fertility on Development Prospects Effects of High Fertility on Family Health CHAPTER II. POPULATION POLICY Foundations A. Policy B. Population and Development Planning C. Prospects I CHAPTER III. DETEmINANTS OF FERTILITY AND DEMAND FOR FAMILY PLANNING SERVICES A. Determinants of Fertility B. Demand for Family Planning Services This report is based on the findings of a World Bank mission which visited Senegal in May-June 1985 in conjunction with a UNFPA mission, which collaborated closely with the World Bank and which has prepared a separate report. World Bank mission members included Mr. A. Williams (Mission Leader), Ms. A. Hill (Demographer) and Ms. D. Benjamin (Information, Rducation and Communications Consultant). UNFPA mission members included Dr. Sabwa a Matanda (Public Health Specialist), Mr. M. Mazouz (Demographic Research and Training) and Ms. S. Crapuchet (Women's Issues). A second World Bank mission, comprised of Mr. A. Williams (Mission Leader), Mr. M. Azefor (Demographer) and Ms. D. Vaillancourt (Operations Analyst), visited Seneg-l in March 1986 to present preliminary conclusions of the sector work and to refine its recomuendations. The main sector report has been prepared by Ms. D. Vaillancourt; the technical note in Volume II has been prepared by Ms. A. Hill This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

3 Page No. m= IV. OEGANIZATION AND FUNCTIONING OF POPULATION ACTIVITIES A. Organization B. Description of Population Activities Family Planning Service Delivery Information, Education and Communication (tec) Activities 3. Demographic Data Collection, Analysis and Research. 33 C. Financing CHAPTER V. ISSUES AND REGcEfNDATIONS A. Satisfaction of Unmet Demand B. Stimulation of Latent Demand C. Organization and MAnagement of Population Activities.. 41 D. Financing of Population Acti;ities I. Demographic Data and Research F. Population Policy CI 4 APER VI. ROLE OF THE BANK A. Promotion and Provision of family Planning Services.. 45 B. Institutional Development C. Improvements in Population Research D. Policy and Program Development AMX 1:Statistical Annex T-ENTTABLES 1. Projected Size and Growth Rate of the Population Projected Population Age Structure: Projected Population of Working Age: Projected Cereal Consumption Needs and Required Growth Rates in Cereal Production: Projected Growth Rates of Food Production: Projected Fuelwood Needs: Projected Numbers of Children Aged 7-12 Years: Projected Growth in Potential MCH Clients: Mean Number of Total Children Desired by Education of Women Mean Number of Total Children Desired by Residence Desired Family Size and Extent of Contraceptive Use Among 24 Currently Married Women by Socio-Economic Characteristics 12. External Assistance to the Population Sector for

4 iii - SENEGAL POPULATION SECTOR REPORT VOLUME I: MAIN REPORT Glossary of Acronyms ASAFED : African Association for Development Education ASB8F : Senegalese Association for Family Well-Being BNR National Census Bureau BOPP Protestant Social Action Organization CONAPOP : National Population Commission ebr Crude Birth Rate CDR Crude Death Rate CEDPA Center for the Development of Population Activities CIRST Tnterministerial Council on Scientific and Technical Research RSC National Economic and Social Council DBD Division of Surveys and Demography DRH Division of Human Resources FAFS Federation of Women's Associations of Senegal FP Family Planning iec Information, Education and Communications Activities IFAN Fundamental Institute for Black Africa TPPF International Planned Parenthood Federation IUD Intra-Uterine Device MCR Maternal and Child Health NOPC Ministry of Planning and Cooperation MOSD Ministry of Social Development MOEF Ministry of Economy and Finance MOPR Ministry of Public Health NGO Non-Governmental Organization GRANA Research Group on Africar Food and Nutrition ORTS National Radio and Television Network of Senegal SSD Secretariat of State for Decentralization SFS Senegalese Fertility Survey UNFPA United Nations Fund for Population Ac:t.ivities USAID United States Agency fot International Development TFR Total Fertility Rate WFS World Fertility Survey

5 - iv - Definitions Contraceptive Prevalence : The percentage of married women in Rate reproductive ages who are using a modern method of contraception at any given point in time. Crude Birth Rate Crude Death Rate Dependency Ratio Infant Mortality Rate : The number of births per 1,000 population in a given year. : The number of deaths per 1,000 population in a given year. : The ratio of the economically dependent part of the population to the productive part, arbitratily defined as the ratio of the young (under 15 years of age) and the elderly (those 65 years of age and older) to the working age population (those years of age). : The number of deaths of infants under one year of age in a given year per 1,000 live births in that year. Life Expectancy at Birth : The average number of years an infant will live if the current age/sex-specific mortality trends prevailing at the time of birth were to continue. Maternal Mortality Rate Morbidity Mortality Rate of Natural Increase : The number of maternal deaths per 100,000 live births in a given year attributable to pregnancy and childbearing complications. : The frequency of disease in a population. : The frequency of death in a population. The rate at which a population is increasing (or decreasing) in a given year due to a surplus (or deficit) of births over deaths, expressed as a percentage of the total population. Rate of Population Growth : The rate of natural in'-rease adjusted for (net) migrat.ion, and expressed as a percentage of the total population of a given year. Total Fertility Rate The average number of children that would be born alive to a woman during her lifetime if she passed through her childbearing years conforming to the age-specific fertility rates of a given year.

6 v Foreword Since Independence, the Government of Senegal has moved progressively in addressing major components of Senegal's demographic growth and social development. Significant reductions in mortality have been achieved over the past few decades through interventionsuch as protecting the population against major communicable diseases, providing clean water and raising educational levels and living standards. However, fertility has remained constantly high over the past 30 years. With declining mortality, constant fertility levels have led to increases in the rate of population growth. While very rapid fertility reduction is not likely to occur until the current level of mortality has declined substantidlly, decreased fertility, itself, is not an inevitable, immediate outcome of mortality decline. The time is ripe in Senegal for the Government to complement ongoing programs to reduce mortality with efforts to moderate fertility. The Government of Senegal is becoming increasingly aware of the negative implications of rapid population growth on the socio-economic development prospects of Senegal. It has, on numerous occasions, expressed concern about the current high rate of population growth in Seuegal and has stated its desire to reduce that rate. Family planning services, which, for the past two decades, were only available through a small number of clinics (both private and those supported by non-governmental organizations (NGOs)), are now being integrated into maternal and child health services provided through Government facilities in an effort to moderate fertility as w311 as to improve maternal and child health. The Goverument has, furthermore, prepared a national and spatial development plan concerned with resource management, internal migration and decongestion of highly populated areas. Nevertheless, the Government has yet to elaborate explicitly a cemprehensive population policy and program. While fully recognizing the importance of reducing both mortality and fertility in addressing the population issue in Senegal, this Population Sector Report has focussed more prominently on the objective of fertility reduction through family planning, which would also contribute to improving materna.l and child health. Tt should be highlighted, however, that the Bank attaches equal importance to Senegal's continued efforts to reduce even further inor'tality rates among its population, particularly in light of evidence that mortality is still high, and its decline has slowed down in recent years. The Bank has supported and continues to support Government efforts to imlrove health status through its sector work and the ongoing Rural Hlealth Project., as well as through the clevelopment and implementation of future investments in the health sector, all of which aim at improving the quality an(d accessibility of basic health services.

7 - vi - SENEAL POPULATION SRCTOR REPORT Executive Suumara A. Demographic Situation Current Data 1. According to its only population census to date, carried out in 1976, Senegal's total de facto population then amounted to 4.96 million. World Bank projections estimated a mid-1985 population of 6.6 million. National density in 1976 was 25 persons per km 2, and is estimated at 33 for sid The population is very unevenly distributed across the country. Regional densities in 1976 ranged from 5 persons per kmo in the east to 1,711 in the Dakar area; and urban growth rates continue to be high. 2. The estimated total fertility rate of 7 and crude birth rate of 49 per thousand reveal a high level of fertility in Senegal, largely attributable to young age at first marriage, almost universal marriage, and a low level of contraceptive use. Mortality is also high, but declining. According to World Bank estimates for the period , the infant mortality rate was 124 per thousand, life expectancy was 47 years, and the crude death rate was 19 per thousand, all of which compare unfavorably with other middle-income Sub-Saharan African countries. Poor health status is a result of adverse environmental conditions, endemic, parasitic and communicable childhood diseases, poor hygiene, inadequate food availability and consumption practices and deficiencies in public health services (preventive and curative). 3. Current crude birth and death rates combine to yield a rate of natural increase of 3.0 percent per annum. Including a net annual (international) migration rate of 0.2 percent, population growth is estimated at 3.2 pereent per annum, similar to many other Sub-Saharan Africzi countries. Populat ion Projections 4. Whatever assumption is made about fertility trends, Senegal's total population will increase by over 50 percent diuring the next 15 years. However, a decline in fertility could have a significant impact on population size and rate of growth within the next 30 years. If fertility were to remain const:ant, by the year 2015 the population would be nearly 19 million (3 times its present size), with a growth rate still hx4h enough to ensure further doubling of the population in lz years. Under an assumption

8 - vii - of a gradual decline in fertility after 1990, the population in 2015 would be about 15.6 million (3.3 million less than with constant fertility), with a further doubling time of 32 years. A rapid decline in fertility would result in a population in the year 2015 of 12.3 million (6.7 million less than with constant fertility), and a further doubling time of 50 years. The dependency ratio, currently estimated at 95, will also be greatly affected by fertility trends; by the year 2015 the present level would increase to 103 if fertility were to remain constant, whereas gradual and rapid fertility declinies would result in decreases to 72 and 46, respectively. Implications of Population Growth 5. As illustrated below, rapid population growth adversely affects family health; it will also inhibit achievement of Government socio-economic development objectives in that it will result in enormous growth in consumption needs for 4od, energy, water, sanitation, road systems, and social services such as education and health, while at the same time hampering economic and agricultural growth. 6. Family Health. Maternal mortality in Senegal has been estimated to be well over 600 deaths per 100,000 births during the period , a level which is on the higher end of the range of maternal mortality estimates for other Sub-Saharan African countries. While high maternal mortality is partially attributable to poor health in general and inadequate quality and coverage of health services, it is also greatly affected by maternal age, parity and spacing of births. Risk of maternal mortality is significantly higher if the mother (a) is under age 20 or over age 34; (b) has 5 or more children; and/or (c) has birth intervals of less than 2 years. Similarly, risk of infant and child mortality is much higher if (a) the mother is under age 20 or over age 34 at the time of the birth; (b) the child has a high birth order; and/or (c) a short birth interval precedes or follows the birth of that child. Worldwide data on maternal and infant mortality indicate that dramatic reductions in deaths and illness of mothers and children could be achieved if high risk births were averted. Targetted family planning services, therefore, could make a significant, positive and immediate contribution to improving the health of mothers and children. Ulnfortunately, national debate on population and family planning has not always focussed adequate attention on the health benefits of family planning services. 7. Agriculture and Food Self--Sufficiency. During the past 15 years, Senegal has experienced shortages of rainfall which resulted in significant declines in agricultural output. According to the 1984 Schema National dl'amenagement du Territoirel, annual growth rates over the next 20 years in the production of Senegal's main cashi crops, groundnuts and cotton, are 1/ An analysis of population growth and distribution prepared by the Tetritotial Development Directorate of the Ministry of Plan and Cooperation.

9 - viii - projected at 0 percent and percent, respectively; and a most likely scenario for annual growth rates over the next 20 years for major food crops includes the following projections: 2.0 percent for millet and sorghum, 6.0 percent for rice and 3.8 percent for maize. 8. Efforts to improve agricultural production in Senegal are constrained by several factors. Market prospects for the principal export crops are poor. Current national pricing policies do not encourage farmers to increase production. Total arable land in Senegal amounts to only 3.8 million hectares, approximately, or less than 20 percent of total land surface, of which about 3 million hectares are already being utilized; total land reserves, therefore, amount to less than 1 million hectares, and are likely to be exhausted by the turn of the century. Climatic conditions are adverse. While there is much scope for the intensification of land use and for the development of marginal or irrigated land, the capital costs of raising the currently low level of agricultural technology to increase efficiency and production are extremely high. 9. Over and above these constraints, rapid population growth constitutes an additional obstacle to achieving agricultural development. Deforestation, degradation of soils in over-settled and over-exploited areas of the country and desertification in some areas caused by overgrazing, are all in part results of the adverse effects of population pressure; and these will be exacerbated in the face of continued rapid growth. In such circumstances, any reduction in the rate of population growth could make an important contrit.tion to alleviating these prcblems by reducing the pressure on overexploited soils and providing a longer grace period for redistribution of rural populations and for the developmetn of agricultural technology. Furthermore, rapid population growth will foil Government attempts to achieve food security, as it is likely to outstrip growth rates in food production, which amounted, incidentally, to only 60 percent of food.. consumptio needs in Declines in fertility can make an important contribution to easing the task of satisfying food needs by reducing future consumptio needs and, thus food requirements, to more manageable levels. A reduction in population growth, incidentally, is not likely to cause a shortage of labor needed for development and expansion of agricultural production; even with a maximum fertility decline, the labor force will grow to two and one half times its current size over the next 30 years. J0. Etnergy. Wood is the dominant source of energy (60 percent of national energy use) and is virtually the only source for the rural majotity. Current fuelwood usage is estimated at 4.1 million cubic meters annually and is expected to increase in the next 15 years by well over 50 percent under any fertility assumption. Assuming a continuation in current rates of consumption and constant fertility, demand for fuelwood would exceed supplies in just ovet 15 years; eveni a rapidl decline in fertility would cause demand to surpass fuelwoo(d supplies within 30 years. Programs of reforestation, better resource management, edlucation of the population in resource use and diffusion of more efficient. stoves are clearly essential to solving these problems; but a reduction in the rate of population growth is another vital element of an effective long-term energy strategy.

10 - ix Education. The Government's objective to increase the primary school enrollment rate, estimated to be 48 percent in 1982, will be difficult to achieve in the face of rapid population growth. Under any fertility assumption, the number of children of primary school age will increase over the next 15 years by percent. Fertility trends over the next 30 years, however, will have great bearing on the feasibility of achieving enrollment goals. The number of school-age children, currently 1.1 million, is projected to increase by the year 2015 to between 1.2 million (assuming a rapid decline in fertility) and 3.2 million (assuming constant fertility). Containing costs and reducing the rate of population growth are two key components of a successful education strategy in keeping with the Government's education policies. 12. Health. In the same light, the Government's objective to improve the coverage of health services would be seriously undermined by rapid population growth. Current coverage of the population by health services is low, and public recurent expenditure on health has been declining both as a proportion of the national budget and in real per capita terms. If fertility were to remain constant, the total number of births would almost triple in the next 30 years over the 1985 level of 322,000. Such an implied increase in users would necessitate a large increase in spending merely to maintain the present low coverage. A rapid decline in fertility would reduce the projected number of users of maternal and child health (MCH) services in 2015 by 3.0 million and consequently would ease budget constraints and make the objective of expanded coverage more attainable. 13. In summary, rapid population growth and high fertility will perpetuate the poor health status of mothers and children, and will hamper the socio-economic development of Senegal. It will increase pressure on limited land and forest resources, while the development of agricultural technologies and improvements in productivity are unlikely to be dramatic in the medium term. At the same time, rapid popvlation growth will create enormous increases in consumption needs for food, energy, infrastructure and searce and expensive social services such as education and health. A slowing of population growth through fertility reduction is thus an essential element in a long-term development strategy for Senegal.. Limitation of growth through fertility reduction will decrease the diependency burden and the needs for expensive social services (primarily direct.ed i( warfds the dependent population) and improve the health of mothers and( chil(dren through longer birth intervals and fewer Iiighi-risk pregnancies. B. Government Actions to Date 14. The Government: is becoming increasingly aware of the implications of Senegal's population growth rate, and considers its fertility rate to be too high. Various actiots have been un&drtakent by tht Government, as a consequence, in an effort to address i he p)op)ulation i issue. Demograpl)hi (c research andi national debate on population trends and issues, stimulated by census results, have prompted the incorporat.ion or population objectives into national development plans. The Seventh Development Plan ( )

11 x reflects a heightened awareness of demographic growth and its impact on prospects for future economic and social development, and recommends that family planning information and services, as an integral part of MCH services, be developed and strengthened, for health as well as for demographic reasons. In 1980 colonial legislation prohibiting contraception was repealed thereby opening the way for integrating modern family planning into MCH services provided by Government facilities. Subsequent to the repeal of this law, a Directorate of Family Welfare was created within the Ministry of Social Development and given the responsibility for coordination of family planning activit;es. Family planning services, currently provided in a few public (and private) facilities, are being extended with the ultimate goal of achieving nationwide coverage. Efforts are also underway to inform the population about the availability and benefits of family planning services. A National Population Commission was created in 1979 and given the responsibility to study issues related to population and development and to draft a population policy. Data collection activities, demographic research, and debate on population issues are ongoing. The Government has prepared a national and spatial development plan concerned with resource management, internal migration and decongestion of high density areas; and, at the request of the President, the National Economic and Social. Council carried out in 1985 a study on population and development which lays the basis for development. of a national population policy. The effectiveness of Government actions undertaken to date in the population sector is seriously constrained, however, for several reasons, which are summarized in Section C below. Low Demand, IJnmet Demand C. Issues 15. There is as yet little demand for modern family planning services in Senegal. Low demand is attributable primarily to insufficient knowledge of contraceptive methods and benefits, opposition by husbands, low education and employment opportunities for women, rural residence and a desire for large families (a mean of 8 children according to the 1978 World Fertility Survey). 16. There is, lhowever, st-rong evidence that pockets of demand and unmet need fot family planning services have emerged, particularly among the educated, those employed in theh forma] sector and the urbanized; their fertility preferences are substantially lower, and contraceptive use (traditional and modern) higher than those of their lesser educated and/or rural counterparts, although demand for family planning services in rural areas has also been observed. While urban de.mand is likely to grow steadily, there is evidence that current needs are not being met. ClandesLine abortion, though unquantifiable, is known to be widespread in urban areas and amotng school girls. This, combinied with the incidence of infant:icide, provides a clear indication of the need for sex education and family planning services. Yet, the coverage and quality of modern family planning services and related information, education and communication (lrc)

12 - xi - activities are inadequate. A survey of family planning clients in Dakar revealed that one fifth of first time visitors to 3 clinics had received information, but no contraception. The survey also indicated that when contraceptives were dispensed, they reflected the preference of clinic personnel rather than the needs or preferences of individual clients. Nonetheless, an increase of 4000 new clients in four months following the expansion of service.s through a USAID-financed project demonstrates the existence of the large pool of potential clients willing to make use of quality services once they become available. Institutional/Managerial Issues 17. Population activities are carried out by a multiplicity of governmental and para-governmental institutions, international, bilateral, technical and scientific agencies and Senegalese and foreign NGOs. Among Government institutions, roles and responsibilities are unclear and often overlapping, which has resulted in competition rather than collaboration among the various institutions. While it is reasonable to assign responsibilities for implementation of population activities to various Ministries commensurate with their respective technical expertises, there is presently no mechanism within the present institutional setup to assure overall management and coordination of activities and collaboration among Ministries. Consequently, human and financial resources devoted to the population effort are being used iniefficiently, thus compromising the effectiveness of family planning service delivery, IEC activities and demographi collection and analysis and research. 18. Family planning services are currently beinig provided by the Ministry of Public Health (MOPH) through its new, integrated MCH/FP program, now operating in six regions with eventual extension to all of Senegal's 10 regions. Services are also provided, particularly in urban areas, by nongovernmental organizations (NGOs) and private family planning clinics. The Ministry of Social Development's (MOSD) Family Welfare Directorate is given the overall responsibility for coordination and implementation of all family planning activities (public, private and NGO-sponsored) including policy elaboration and program implementation, monitoring and evaluation and financial managemetnt. However, this Ministry has not been provided with sufficient resources to carry out such responsibilities effectively, nor does il possess a medi cal/technical, advantage- over the MOPH in this respect (o oversee clin.i n. aspects of' the progrum. 19. lec aelivities ar-e undertaken by various institutions, as well, including GovernmenLt. Ministries, NGOs and privale agencies. MOSD in principle carries oul IEC activities through a network of central and regional unit.s and field personnel. including.10 regional coordinators and 489 rur;il social workers. The MOPH carries ouit health education through its regional health eduatlors. MOPH also provides IEC training to midwives, who run the integrated maternal and child lhealth/family plamning (MCH/FP) program, and to other health workers, who *leliver health education messages in clinics, schools mid villages. A communicationis unit has been attached

13 - xii - to the National Population Commission (CONAPOP) for production of IEC program material on population, health and nutrition. The placement of IRC production work within CONAPOP seems inappropriate as CONAPOP is a policy and research body in the Ministry of Planning and Cooperation (MOPC). Its purpose and future financing is currently being reviewed by UNFPA, which initially set it up. Furthermore, some 20 different population IEC programs are being conducted by various private and non-governmental organizations. MOSD has been given the responsibility for coordinating and evaluating all population IEC activities. Presently, however, it is not equipped with the capability to carry out such an assignment effectively. Again, inefficient management of the myriad of IEC activities inhibits the optimal use of scarce resources dedicated so this effort. 20. Likewise, demographic data collection, analysis and research are carried out by several Ministries and institutions without adequate management and coordination. The National Census Bureau, within the Ministry of Economy and Finance (MOEF) is clearly responsible for undertaking the population census every 10 years. In addition, however, numerous demographic surveys and population and development studies are carried out by MORF (Survey and Demography Directorate), MOPC, the Secretariat of State for Decentralization, universities and various other research institutions. A review of the research institutions and studies they have undertaken suggests that the absence of overall management and coordination has seriously compromised benefits derived from research work. Financing of Population Activities 21. Financing of population activities in Senegal has been secured through Government budgetary allocations, semi-public and private, bilateral and multinational sources. Information on the amount of financing available by source and on allocation of financial resources is dispersed, and poor financial management precludes optimal utilization of resources available for population activities. This deficiency is closely linked to t:ie managerial/institutional issues described above. The bulk of expenditure on population activities has been funded by external assistance, which has not been adequately coordinated, due in large part to the absence of a national population program. Another serious concern is the recurrent cost financing of family planning activities over the long term. For the most part, recurrent costs for family planning services provided through the public system are presently being financed by USAID. However, it should be recognized that the financing of such costs will eventually become t;ue responsibility of the Government and users of the program, as USAID funding of recurrent costs should not be assumed to continue indefinitely. Due to a lack of information on financing, as described above, the magnitude of such costs is not readily known. Executing ministries do not systematically budget for population activities for which they are responsible, a task which is admittedly difficult in the absence of a national population program. The Government is currently experieocing very serious budgetary constraints and it is unlikely that the healtlh budget will increase in real terms over the foreseeable future. Therefore, unless steps are taken

14 - xiii - to estimate and plan for the recurrent cost burden and to rationalize services so as to keep recurrent costs to a minimum, family planning activities would continue to be unavailable to the majority of the population, and even the limited existing services would suffer as a result of inadequate financing in the medium and long term. lnadeau. and Low Uti] _ation of Demqgraehic Data 22. In recent years a number of deraographic data collection activities have been undertaken which have contributed to improving the quality and quantity of information on the population of Senegal. These include the 1976 census, the 1978 Senegal Fertility Survey and other national and smallscale surveys. These data, however, have become outdated; and information on demographic trends over the last 10 year3, such as growth rates, migration patterns, distribution and densities, is lacking. A second census, programmed for 1988, is therefore needed to improve knowlcedge about the dynamics of population change since Furthermore, what demographic data are available are not widely disseminated, even within Government, and the implications of popuiation growth and trends on the individual sectors and on overall socio-economic development are not fully appreciated. Absence of An Explicit Policy and Program 24. While the Government's awareness of the implications of Senegal's population growth rate is becoming increasingly acute, and while it supports the provision of family planning services for health as well for demographic reasons, it has yet to articulate a well defined and comprehensive population policy and program. The absence of an explicit, officially promulgated policy with clearly defined objectives contributes to present institutional inefficienicies and perpetuates the dispersion of the numerous population activities and objectives; it is also the cause of weak commitment and inaction on the part of executing agencies, who claim that they lack explicit instructions to carry out activities. It should be noted that the series of actions and decisions taken by the Government to date to address population issues bears witness to the existence of an implicit policy on population, and that these actions lay the foundation for the elaboration of an explicit policy and program. Against, this background, in early 1987 the President of the Republic reiterated his concern about the implications of the rate of population growth for Senegal's development. prospects. As a further manifestation of his personial commitment and leadership on this issue, the President invited the World Bank and other donors to assist Senegal in developing a national population policy and program. An official expression of this commitment was reflected subsequently in the Government's agreement to prepare a national population policy and program by March 1988, in the context of the Government's commitments under the third Structural Adjustmetnt Credit. The World Bank, in turn, has expressed its readiness to provide support through the ongoing Rural Hlealth Project and the proposed (Second) Population and Health Project.

15 - xiv - D. Recommendations Satisfy Unmet Demand for FP Services 25. Efforts to satisfy the apparent unmet demand for family planning services should first concentrate on the improvement and expansion of services in urban areas where demand is greatest. The potential of NGOs in this respect should be exploited as they have valuable experience and have proven to be effective in initiating and implementing programs and providing services. Secondly, the private and parapublic sectors should be encouraged to provide family planning services in maternity clinics and the workplace. Third, the Government should take steps to strengthen the management and service delivery capabilities of MOPH, which is developing an integrated MCH/FP program through its extensive network of maternity and MCH centers. Stimulate New Demand for FP Services 26. An increase in demand for services will occur as a consequence of intensification of IEC activities and improvements in the status of women. INC activities should be stepped up to improve knowledge of contraceptives among the general population. Particular emphasis should be placed on the health benefits of family planning. Messages should be directed at and tailored for different target groups, such as married women, young girls and men, and should be delivered through various channels, including schools, community groups, women's groups, health facilities, radio and television. 27. Because demand is significantly higher among urbanized, educated and/or formally employed women, improvements in the educational, economic, and social status of women would probably lead to an increase in demand for family planning services. Government efforts should therefore be aimed at ameliorating the status of women through improved educational and employment opportunities, which would extend to the rural areas, and through improved health services. The Government should take steps to encourage a later age at first marriage for girls as a means of improving the status of women and moderating fertility. Most importantly, actions to increase demand should be immediately accompanied by the wider availability of quality family planning services. Lift Institutional Constraints to and ImProve Management. of PoDulation Activities 28. The roles and responsibilities of Ministries and other organizations involved in population activities in Senegal must be defined and streamlined, and thc relationships among these various institutions clarified in order to foster collaboration rather tham competition, as often appears at present. Furthermore, all. population activities must be properly coordinated and managed in order to assure that the effectiveness and efficiency of resources devoted to this effort are maximized. The various

16 - xv - management and coordinating responsibilities currently assigned to MOSD and GONAPOP cannot be effectively carried out because neither has explicit authority over others. Furthermore, MOSD and CONAPOP do not have adequate staff and resources to do so. A population coordinating function should therefore be established and placed above Ministry level. 29. Specifically, it is recommended that a Population Council be established and attached to the Presidency. Its role would be to formulate policy and offer guidelines for its implementation. A Secretariat or Institute should be established in the Presidency which would serve as a permarent secretariat for the Population Council and would monitor, evaluate and cuordinate the activities of various line Ministries and organizations engaged in population activities. This Secretariat would also take a lead role in donor coordination and in the drafting of policy position papers for consideration by the Council. Improve Financial Management and Aid Coordination 30. A system of financial management, accompanied by the proper staffing and training, should be established within the above-mentioned central coordinating body to provide comprehensive information on sources of financing, financing needs, allocation of resources and accountability of recipient Ministries or agencies. Such a system would facilitate the achievement of needed improvements in aid coordination and would assure efficient utilization of resources. Financial planning should also be undertaken so that the recurrent c-ost implications of present and future investments in population will be addressed, their costs minimized and their financing assured. Improve Quality of Demographic Data and Research 31. In view of the paucity of data on demographic trends since the 1976 population census, the Government should give high priority to the execution of the second national population census. Thi.s census should be designed to provide maximum information on current patterns of population distribution, mortality, fertility, migration and population growth, and to provide a useful basis for future surveys and studies. In this effort, the Government should develop national capabilities in census and survey work to reduce to the barest minimum the need for external assistance. It, should give greater priority to staff training and development in demographicrelated disciplines, most, particularly data processing, which hais been a major constraint to rapid and quality processing oft census and survey results. 32. In order to refine ongoing ramily planning service delivery and IEC activities and eventually to develop long--term population programs and policies, studies on population should he focused primarily on operational research, drawing from health and family planning service statistics, and on the determinants of fertility. The Government should streamline population

17 - xvi - research efforts through the establishment, within the proposed Population Council, of a population research institute which would coordinate all demographic research. Disseminate Demographic Data and Research Findings and Incor_orate Them into the National Planning Process 33. Demographic data and population research findings should be disseminated among Ministries an.' other Government agencies, which in turn should be encouraged to incorporate them into the planning process. Such action would heighten awareness among Government officials of population issues and would stimulate elaboration of a population policy and development of a population program. Elaborate a Population Policy and Program 34. The elaboration of Senegal's population policy and a program for its implementation, which the Government intends to undertake within one year, should permit a clarification of objectives and facilitate streamlining and efficient management of the myriad of currently dispersed population activities.

18 I. THE DRMOGRAPHIC SITUATION A. Current Data 1.01 Senogal has held only one population census to date (in 1976), although a second is currently planned for In addition, three national demographic surveys have been carried out in , aid 1978 (the latter one of the World Fertility Survey (WFS) series), as well as a 1970 Labour Force Survey which collected data on migration. Several small-scale surveys, chiefly focussed on mortality, have also been held over the past 30 years in various parts of the country, including the Fleuve, Sine-Saloum and Oriental Regions. Another has recently been undertaken in Thies Region, and a series of regional surveys is planned for the future. Vital registration does not exist for practical purposes, except in Dakar, where completeness of registration is sufficiently high to permit some use of the data. Not all of the demographic data collected have been processed, published or analyzed, and its quality is variable. Serious inconsistencies in the results of data collection efforts, both internally and in comparison with other data sources create uncertainty about the demographic features of Senegal, particularly with regard to the levels and trends of fertility and mortality. A technical note presented in Volume rr of this report evaluates and interprets the myriad demographic data available on Senegal and provides the basis for estimates of basic demographic statistics presented in this report. The technical note, furthermore, details the derivation of base levels and patterns of mortality and fertility in Senegal and uses these derivations as a basis for population projections, contained in this report Senegal counts itself among the three-fourths of Sub-Saharan African countries having populations of less than 10 million. The census of April 1976 enumerated the de facto population of Senegal at 4.96 million (including the institutional and floating populations) (Annex 1, Table 1). According to Bank projections, the population had grown to 6.60 million by mid National density in 1976 was 25 persons per km2, and is estimated at 33 for mid This is close to the average for West Africa, but, as is usually the case in Sub-Saharan Africa, conceals a very marked uneveness of distribution across the country. Regional densities '/ in 1976 ranged from 5 to 1,711 persons per km2 (Annex 1, Table 2). Generally speaking, densities increase across the country from east to west, with the highest densities on the coast around Dakar, and the lowest on the east.ern borders Part of this settlement pattern is the result of heavy urbanization, since most large towns are located on or near the coast. Senegal is among the most highly urbanized of African countries, with 32 percent of the population in 1976 living in towns with at least 10,000 inhabitants. This proportion has doubtless risen even higher over the past 10 years. The u'.ban population is, moreover, heavily concentrated in large I/ Data refer to Senegal's former administrative structure of 8 regions which have, since 1984, been divided into the present 10 administrative regions.

19 - 2- cities. In 1976, 1.7 million, or nearly three quarters of urban dwellers, lived in the 3 cities with more than 100,000 inhabitants (Dakar, Thies and Koalack), of which nearly 1 million in Dakar alone. (Annex 1, Table 3). However, even within the rural population the same pattern of heavier densities in the west and very sparse settlement in the east is observable, together with a clustering of population around the Dakar area, in the groundnut basin of the center-west, and along the course.f the Senegal river on the northern border of the country These settlement patterns are largely the result of internal and external migration flows, themselves caused by differentials and trends in climate, water availability, soil conditions, disease patterns, economic opportunities and development, and political or social disturbances. For almost a century the most marked feature was heavy rural-to-rural flows of both seasonal and permanent, internal and international migrants into the groundnut basin (mainly the Sine-Saloum region), attracted by the demand for labor and income opportunities in the flourishin groundnut production areas. However, with the decline in markets for groundnut exports, the progressiv exhaustion of the soils throu<fx over-exploitation and the gradual drying out of the climate, the aigrant streams dwindled away by the 1970s; and these already heavily settled areas are now growing through natural increase alone. Although another small rural-to-rural flow began during the 1960s into the Oriental region, encouraged by Governmentsponsored pioneer agricultural settlement schemes, the dominant stream of economic migration then became, and has continued since to be, the rural to urban flow, particularly into the Cap-Vert region (the Dakar area). Urban growth rates cannot be reliably measured in the absence of more than one cer.us, but are undoubtedly high, both through net immigration and through very high rates of natural increase arising from relatively low mortality, continued high fertility, and a youthful age structure. Movements out of the country, principally to France and to Ivory Coast, have also been important Internal migrants to these economic foci, first the groundnut basin and later the towns and primarily Dakar, come from all parts of Senegal. However, the north, namely Fleuve, Diourbel, Louga and Thies regions, has always been the principal zone of out-migration. The populations of Casamance, Oriental and Sine-Saloum regions have been much less prone to migrate, the two former due to their relative isolation from the rest of the country, and the latter as a result of adequate opportunities within the region until very recently. Externally, the principal sending countries have been th,e neighbouring countries of Guinea and Guinea-Bissau, which together accounted for half of all non-senegalese enumerated in 1976, followed in importance by Mali and Mauritania. Besides the usual economic incentives, reasons for emigration from Guinea-Bissau were in part political; reasons for emigration from Guinea were often of a mixed political and economic nature Levels of and trends in mortality in Senegal are uncertain. Although a plethora of data are available, there are serious discrepancies in the results. Best estimates indicate a level of mortality that is high, but that has been declining over the past years, a characteristic

20 -3 - which is typical of other Sub-Saharan African countries. According to World Bank estimates (see Technical Note in Volume 2 of this report.), the infant mortality rate was 124 per thousand, life expectancy was 47 years and the crude death rate was 19 per thousand during the period The proportion of children dying in the first 5 years of life during this same time period is estimated at 24 percent. These mortality levels compare unfavorably with other middle-income Sub-Sahara African countries (Annex 1, Table 4). It should be remembered, however, that they are very uncertain; mortality in Senegal may in fact be even higher or indeed substantially lower depending on the data chosen. Poor health status is a result of adverse environmental conditions, endemic, parasitic and communicable childhood diseases, poor hygiene, inadequate food availability and consumption practices and low coverage and quality of public health services One very striking and well-established feature of mortality in Senegal, found also in certain other parts of West Africa, is the excess of mortality among young children in their second to fifth years of life. The risk of a child dying between the first and fifth birthday is in fact almost one and a half times as great as the risk of dying in the first year of life. By contrast, the usual pattern found in historial and modern Western countries, and in most modern developing countries, is of a greater risk of death in infancy than in the next four years combined. The reasons for this "West African" pattern of mortality in childhood, though much studied, are not yet entirely clear. However, child feeding practices, particularly during the weaning period, and severe seasonal fluctuations in food availability and epidemic disease imposed by harsh climatic conditions are the factors generally thought to be most important As in the case of mortality, significant discrepancies in data cast some doubt over levels of and trends in fertility in Senegal. Based on analysis of the results of various surveys undertaken in Senegal (see Technical Note in Volume 2), World Bank estimates indicate that the total fertility rate (TFR) has been consistently high at around 7 for the past 30 years. The crude birth rate is currently estimated at 49 births per thousand population. Crude birth rates throughout Sub-Saharan Africa are comparably high and, as is the case in Senegal, F9ve hardly changed at all over the past few decades. High fertility in Senegal is due primarily to a strong desire for many children which is driven by a number of sociological and economic factors, marriage practices (young age at first marriage and almost universal marriage) and a low level of contraceptive use. Proximate determinants of fertility and the socio-economic factors that influence them are discussed in more detail in Chapter ITI As is the case for Sub-Saharan Africa in general, the population of Senegal is youthful, with probably at least 45 percent now aged under 15 years, causing a high dependency ratio of 96 dependents per 100 adults of working age. Since childhood mortality is likely to continue declining faster than fertility, at least in the near future, both the percentage of children in the population and the dependency ratio will probably rise even further over the next decade. The total de facto sex ratio of the population in 1976 is estimated at 97.4 males to every ion females.

21 Senegal's population growth rate during the period is estimated to have been 3.0 percent comprising a rate of natural increase of 2.8 percent and a net migration rate of 0.2 percent. 2/ Due to a decline in mortality over the past ten years (from 20.4 to 19 per thousand population) and a constant level of fertility (CBR of 48.7 per thousand population), Senegal's current rate of natural increase has risen to 3.0 percent and, consequently, its population growth rate to 3.2 percent, assuming a constant migration rate of 0.2 percenit. This growth rate is high by world standards and is at the upper end of the range for contemporary West Africa, though not as high as those in eastern and southern Africa; it implies, if continued, a doubling of the population every years. B. Population Projections 1.11 In order to examine the socio-economiconsequences of rapid population growth, a set of national population projections for Senegal was prepared for the period 1975 to 2015, using three varying assumptions about fertility trends. The first is of constant fertility, with the TFR remaining at 7 throughout the projection period. This variant is intended to illustrate the effects of a pro-natalist population policy and also to provide a benchmark against which to measure the effects of fertility decline. It is not perhaps the most likely scenario for Senegal, given the high and increasing level of urbanization (since fertility almost invariably falls eventually in an urban environment), but is by no means inconceivable. The second variant is of a gradual fertility decline beginning after 1990, with the TFR falling to 3.9 by and replacement-level fertility not reached until , or years from now. This is the standard fertility decline employed in Bank projection methodology 3/ and is based on the accumulated experience of fertility declines in developing countries. It re.presents what could be achieved by moderately strong government involvement in population policy and improvements in the provision of family planning services starting in the near future. The third variant is of a rapid fertility decline also beginning after 1990, with replacement-level fertility reached by , or years from now, and the TFR falling to 2.4 by This rapid decline, also employed as an alternative hypothesis in Bank projections 4/, is based on the experience of developing countries that have undergone rapid falls in fertility. It is not a very realistic scenario for Senegal, but illustrates the maximum decline achievable with immediate, strong government action in population policy and family planning programmes. All of these 2/ Net migration has been estimated on the basis of a recent World Bank study of West African migration patterns at a net original inflow of 10,000 annually in the late 1970s and early 1980s, thus yielding a positive crude migration rate of about.2 percent. 3/ For details, see My Thi Vu: World Population Projections, 1984, World Bank. 4/ See the World Development Report, 1984.

22 - 5 - mortality, migration and fertility assumptions are laid out in Annex 1, Table Population projections based on these assumptions, summarized in Table 1 below, clearly reveal that Senegal will experience massive population growth over the next 30 years -- a period well within the lifetimes of rhildren living in Senegal today. The population size will increase by 50 to 70 percent over the next 15 years and could double, or even almost triple its current size over the next 30 years. While fertility levels and trends will have a minor effect on population size over the next 15 years (population size will vary by less than 10 percent, or between 10 and 11 million), it will have a significant impact on population size and growth rate over the next 30 years. Were fertility to remain constant over the next 30 years, the population size would increase to nearly 19 million by the year 2015 or about 3 times its present size. With a moderate decline in fertility after 1990, the population size would increase to 15.6 million by the year A rapid decline in fertility after 1990 would cause the population size to increase to 12.3 million by the year percent less than the projected size under the constant fertility assumption. Assuming a continued decline in mortality, a constant fertility rate would cause the growth rate to reach 3.8 percent by implying a further doubling of the population over the next 18 years. A moderate fertility decline, however, would reduce growth to 2.2 percent by the end of the projection period, and increase the further doubling time to a minimum of 32 years, while a rapid decline in fertility would cut growth to 1.4 percent, and increase the further doubling period to 50 years. Table 1: Projected Size and Growth Rate of the Population Fertility AssumPtions Population Size Relative Increase (Millions) Constant Fertility Standard Decline Rapid Decline Annual Population Population Doubling Growth Rate Time at (Percent) Growth Rate (Years) 19851/ Constant. Fertility Standard Decline Rapid Decline / Taken, as mean of projected growth rates for the periods and which are 3.17 and 3.31, respectively. Source: See Annex 1. Tables 7 and 8 of Lbis report.

23 The course of fertility also exerts a very strong effect on the future age distribution of the population and thus the dependency ratio as shown in Table 2 below. Table 2: Pro.iected Population Age Structure: Percentage Aged Under 15 Years - Constant Fertility Standard Decline Rapid Decline Percentage Aged Years - Constant Fertility Standard Decline Rapid Decline Percentage Aged 65 Years and Over - Constant Fertility Standard Decline Rapid Decline DeDendency Ratio'1 Constant Fertility = Standard Decline Rapid Decline / Number of child and elderly dependents (those aged under 15 years and 65 years and over) per 100 adults of working age (15-64 years). Source: See Annex 1. Table 10 of this report. If fertility does not fall, the projected mortality decline (with gains concentrated in childhood) will result in an increasinglyouthful population and a rise in the dependency ratio from its current level of 95 to 103 by A decline in fertility, however, would cut the percentage of children in the population and hence reduce the dependency burden from 95 to 72. if the fall were moderate, and to 46 if the fall were rapid. This effect would of course be only temporary. If fertility were to remain low, the percentage of elderly in the population would gradually rise during the course of the next century to compensate for the reduction in the percentage of children. However, even a few decades of low dependency burdens could provide a welcome opportunity for the economy of Senegal to reduce the balance of net consumers to net producers in the society and hence improve rates of saving and capital investment.

24 -7 - C. Implications of Population Growth 1.14 Individual decisions to have many children have negative consequences at both the family and societal levels; yet the demand for large families prevails in Senegal (Chapter III). Given that population is projected t.o increase by percent within 15 years and to double or triple within 30 years, it becomes crucial to examine the implications of such growth on the social and economic wellbeing of the population as a whole, as well as on the family unit, 1. Effects of High Fertility on Development Prospects 1.15 llntil fairly recently, rapid population growth had not been viewed as a problem within Senegal, no doubt because for a decade after Independenceconomic growth was able to keep pace with population growth and yield rising per capita incomes and standards of living. During the 1970s, howevet, economic growth fell below population growth, resulting in declining per capita incomes and living standards. Prospects are not good for any resumption of rapid economic growth in the near future 5/. In such circumstances, the desirability of rapid population growth is bound to come under question. Excellent analyses of the problems of population growth have recently been carried out in Senegal, notably the "Schema National d'amenagement du Territoire", prepared by the Territorial Development Directorate of the Ministry of Plan and Cooperation in the framework of two UN projects (1984), and the "Etude Sur le Senegal Face aux Problemes Demographiques" prepared by the Economic and Social Council in The discussion that follows here draws heavily on these two documents, as well as on the recently prepared Cereals Plan (Ministry of Rural Development, April 1986); it necessarily constitutes only a very brief and superficial review of the principal issues involved, but does incorporate a new element, namely an examination of the contribution that reduction of population growth through reduction of fertility can make to alleviating the problems posed by rapid population growth. Implications For Agricultural Production 1.16 More than 60 percent of Senegalese are still rural dwellers, with subsistence and incomes primarily derived from agriculture; and the basis of the economy of Senegal is still agriculture in the form of domestic food production, cash crops for export, and raw materials for the developing industrial sector. Long-term prospects for economic growth and improvements in income and living standards are, therefore, highly dependent on agricultural performatnce. According to the Cereals Plan, only 3.8 million hectares of Senegail's total land surface of 19.7 million are classified as arable (Annex 1, Table 11). Of this 3.8 million, 2.4 million are already under cultivation. The 1.4 million hectares of arable but not cultivated land comprise 0.56 million hectares of rtesetrves for rainfed farming and / World Bank Count ry Economi c M(morandum, 1984.

25 8 - million hectares of land either required for fallow or too marginal to take into account. In addition, the Plan mentions another 0.24 million hectares of potential irrigable land along the Senegal river that could be developed in the near future and about 50,000 hectares more along other waterways. Total land reserves, therefore, amount to less than 1 million hectares for the foreseeable future, compared to the 3 million or more being utilized. Clearly, Senegal could not support its projected population growth longer than a decade or two through the extension of cultivation alone. Even under the most favorable assumptions, land resources would be exhausted by the turn of the century. However, there is much scope for the intensification of land use. The level of current agricultural technology is still relatively low, and crop yields could be increased substantially through better land use practices and greater use of fertilizer and improved seed Senegal faces the difficult challenge of developing its resources and raising its agricultural production fast enough not only to keep pace with its rapidly growing population but to ensure a continual improvement in incomes and living standards. Rapid population growth will obstruct rather than assist in the achievement of these goals. As clearly illustrated in Table 3 below, shortage of labor is not likely to be a constraint to agricultural and economic development regardless of the fertility trend. The labor force for the next 15 years has in fact already been born and furthermore, even with maximum fertility decline, the potential labor force 30 years from now will have grown to two and a half times its current size. Table 3: Projected Population of Working Ae: Fertility PoDulation Aged Years Ratio of Numbers Assumptions (in Million) to 1985 Numbers= Constatnt Fertility Standard Decline Rapid Decline Source: See Annex 1, Table 12 of this report In fact, most constraints to agricultural development in Senegal over the next couple of decades are likely to be unrelated to population growth in the country, such as poor world market prospects for the principal export crops and related products, high capital costs of developing marginal or irrigated land, world economic trentds, and difficult climatic conditions. Some constraints, indeed, have already resulted from the adverse effects of population pressure, such as local deforestation and degradation of soils in over-settled and over-exploited areas of the country and desertification in some areas resulting from overgrazing. As a consequence of these constraints, the outlook for Senegal's *:hief cash crops, grountlnuts and cotton, is tmpromising relative to the pace of population growth: the

26 - 9 - "Schema National" for example, estimates close to zero annual grotth for groundnut production over the next 20 years and growth ranging frrm less than 1 percent to 2.4 percent for cotton Yet while rapid population growth will afford little or no direct assistance to growth of agricultural production and economic development, it will undoubtedly create massive increases in consumptio needs such as food, energy, infrastructure and comrnmications, housing, sanitation, water supplies, and social services, notably education and health, which themselves are also necessary to improve the quality of the labor force and hence assist economic development. As illustrations, we consider^ the growth in needs for food staples, fuelwood, primary education and maternal and child health services. Effects of Population Growth on Demand ftr Food Staples 1.20 Assuming the most conservatk-ip recommendation for annual cereals consumption per capita of 210 kg (cite& in the "Etude"), total cereal consumption needs in Senegal amounted to 1.39 million tons in Total annual cereals production on the othet hand amounted to 0.75 million tons during the period , falling short of current needs by 46 percent. The deficit to date has been met in part by imports which averaged 0.4 million tons during the same perioti. As shown in Table 4 below, if fertility were to remain constant, total cereals needs by 2015 would almost triple in size to 3.98 million to.as requiring an average annual gr!wth rate in cereals production of 5.1 pereont to achieve the Government's goal of food self-sufficiency. Even a n;pid decline in fertility would result in a virtual doubling of total cereals needs by 2015 requiring that average annual cereal production grow at 3.8 percent per annum in order to achieve food self-sufficiency by Clearly the rate of population growth will pose a formidable challenge to the achievement of both food self-sufficiency and adequate nutritional levels, even when 30 years are allowed for the task. Table 4: Projected Cereal Consumption Needs and Required Growth Rates in Cereal Produc-tion: Fertility Total Cereal Needs Required AveraMe Annual Assumptions (millions of tons) Growth Rate in Cereal Production between and (Percent) - Constant Fertility Standard Decline Rapid Decline Soure: ee nne LTable 13 of this report.

27 The scale of the problem is indicated in Table 6 below, which shows the range of projected actual growth rates in production of selected food items over the next two decades given in the "Schema National". Table 5: Projected Growth Rates of Food Production: TyDe of Food Annual Average Rate of Growth in Production Pessimistic Most Likely Optimistic Scenario Scenario Scenario Millets and Sorghum Rice Maize Cassava Beans Groundnut Beef Poultry Fish (Traditional Sea Fishing) Source: "Schema National d'amenagement du Territoire", prepared by the Territorial Development Directorate of the Ministry of Plan and Cooperation, A vivid illustration of the scale of development necessary to achieve very rapid growth in agricultural production is provided by the recently formulated Cereals Plan. The overall cereal production target is 1.7 million tons in 2000, requiring an annual growth rate of 5 percent I/ from the average production level of the period. To achieve this level of production, the following operational targets are set for the next 15 years: a 40 percent increase in rainfed/flood plain millet and sorghum yields; a 55 percent increase in maize yields; a 267 percent increase in rainfed rice yields; a 25 percent increase in irrigated rice and maize yields and the establishment by 2000 of 72,000 hectares of newly irrigated cereal-growing areas. The share of total cereal production contributed by irrigated areas would almost quadruple, from 11 percent now to 38 percent by Achievement of these operational targets in turn requires over the next 15 years: the commissioning of 2 major dams; effective programs of agricultural research/development/extension, soil conservation, regional development, relocation of rural populations from densely settled to newly developing rural areas, trypanosomiasis and onchocerciasis eradication, agricultural credit and fertilizer distribution; efficient management of cereal demand generation, pricing and marketing; and a total investment 6/ Exponential rate. The geometric growth rate would be close to 6 percent.

28 budget of CFA 258 billion, or over half a billion dollars. Without this Plan, agricultural production is expected to grow at no more than its past annual rate of one percent over the next 15 years Declines in fertility can make an important contribution to easing the task of satisfying food needs by reducing needed growth in cereal production to more manageable levels. Only the "optimistic" scenario for food production presented in the "Schema National" (Text Table 5 above) appears likely to satisfy growth in needs if fertility does not fall. Indeed, even the ambitious Cereals Plan targets, if realized, would be insufficien to meet fully food needs in With any decline in fertility, however, growth in food needs could be met by the "most likely" scenario, without the necessity for the dramatic achievements in the agricultural sector postulated by the "optimistic scenario". If selfsufficiency cannot be achieved, fertility declines could cut the necessary import burden substantially. If, for example, domestic production were to grow no faster than population over the next few decades, so that a shortfall of about 40 percent persisted up to 2015, the amount of imports needed in that year to meet needs would be cut by percent from 1.6 million tons, assuming no fertility decline, to million assuming some degree of fall in fertility. Effect of Population Growth on Demand for Fuelwood 1.23 Fuelwood accounts for 60 percent of Senegal's national energy use and the vast bulk of domestic use, and there are no prospects for a radical change in this situation over the next couple of decades at least. The "Schema National" gives current annual usage as million n 3 and total potential annual production as million n 3. Assuming no change in per capita usage, Table 6 below shows projected fuelwood needs over the next 30 years. Table 6: Projected Fuelwood Needs: Fertiliy Fuelwood Consumption Consumtion as Percentage Assumptions (Millions of ip) of Potential Supply Constant Fertility Standard Decline Rapid Decline 4.1J Source: See Annex 1. Table 14 of this report Clearly population growth is go:ing to create tremendous pressure on forestry resources over the next few decades. Even with maximum fertility decline and minimum population growth, fuelwood supplies would be

29 fully utilized within 30 years at the national level. If fertility does not fall, full utilization would be reached within 15 years, with no margin for further growth in demand. The situation in fact would be even more critical than national-level figures suggest, because of the unequal distribution of fuelwood demand throughout the country, with some areas already experiencing severe shortages. Again, however, the reduction of population growth through fertility decline could make an important contribution towards solving the problem in the longer term. A slower population growth and, hence, level of utilization over the next few decades, would permit a longer grace period for reducing demand on current resources through such measures as improving the efficiency of fiuelwood use, developing additional forestry resources, and gradually switching, in part, to alternative fuel resources. Effect of Population Growth on Demand for Primary Education 1.25 Table 7 below shows projected growth in numbers of primary schoolaged children. Table 7: ProJected Numbers of Children Aged 7-12 Years: Fertility Children Aged 7-12 Years Average Annual Growth Assumptions (in millions) Rate (Percent) Constant Fertility Standard Decline Rapid Decline Source: See Annex 1 Table 15 of this report. Senegal is likely to experience massive growth in the demand for primary schooling over the next 15 years. Whatever the trend in fertility, the number of children of primary school age will increase by about percent at an average annual growth rate of percent. Thus annual expenditure on primary education (mostly financed by the public sector) will have to increase at least as fast in real terms just to maintain current enrollment of around 50 percent. To achieve Senegal's long-term goal of universal enrollment by the year 2000, annual spending will have to grow by an average of percent. Even if there proves to be some scope for reducing the unit cost of primary schooling while maintaining or improving quality, achieving such levels of expenditure would be a formidable task in the face of probably much slower overall growth in GDP per capita and in government revenues. It would almost certainly be necessary to increase the proportion of government expenditure devoted to education.

30 As can be seen in Table 7, reduction of fertility does not have significant impact on the number and growth rate of schoolage children over the next 15 years; in the longer term, however, fertility declines could make a very substantial contribution to containing growth in the need for primary education. If fertility does not fall, the primary school-age population would continue to experience dramatic growth after 2000, with numbers eligible for primary education in 2015 reaching 3.2 million, or 78 percent higher than in 2000 and triple the number today. Needed annual real growth in expenditure on primary education would then average 3.8 percent, or even higher if enrollment had still not reached 100 percent. Just the moderate decline in fertility, however could cut numbers of children requiring primary schooling by a quarter to 2.4 million, reducing needed annual growth in spending to under 2 percent. The rapid decline would actually result in a decline in numbers of children after 2000, with the 2015 total cut by 60 percent from what would be expected with no decline in fertility. Needed annual expenditure would actually fall, allowing surplus funds to be devoted to other needs. Effect of Population Growth on Demand for Maternal and Child Health (MCli) Services 1.27 Table 8 below shows projected growth in two crucial components of the demand for maternal and child health services, namely the numbers of children under 5 years of age and the numbers of women giving birth in a year. Table 8: Projected Growth in Potential MCH Clients: Children Aged Under 5 Years (in millions) Average Annual Growth Rate (Percent) Fertility Assumptions Constant Fertility Standard Decline Rapid Decline Annual Deliveries (in Thousands) Constant Fertility Standard Decline Rapid Decline Source: See Annex 1. Table 16 of this report.

31 Clearly again, massive growth in the need for MCH services in Senegal must be expected if fertility does not fall. With constant fertility, numbers of children under 5 will grow by 74 percent over the next 15 years from 1.2 to 2.1 million and triple over the next 30 years to 3.7 million. Annual deliveries will increase by two thir(s over the next 15 years andi rise to 2.8 times their present numbers within 30 years. Mere]y in order to maintain currenit low levels of MCH services coverage, annual expenditure will have to grow in real terms by an average of more than 3.5 percent. over the entire period from now to Yet current MCH coverage is ver-y inadequate, with, for example, little more than half of women delivering in medical facilities. Significant improvement in the coverage of MCH services would demand much faster growth in health spending, and probably, again, a significantly larger share of total government expenditure Because MCH services are so closely focussed on births and young children, fertility reduction can clearly make a very important contribution to containing growth in needed funding very early on as it will moderate growth in demand for services. As Table 8 shows, even within 15 years from now antd only 5 years after the beginning of fertility decline, the moderate decline would cut numbers of deliveries by 15 percent and of young children by 11 percent from what would be expected if fertility were not to fall. By 2015, the reductions would amount to 48 and 44 percent respectively. Needed annual growth in spending would be less than 3 percent over the next 15 years and less than 1 percent thereafter considerably reducing the pressure on government budgets and allowing more leeway for improvements in health services. With the rapid fertility decline, of course, the cut in demand for MCH services would be spectacular. Annual deliveries would decline over the next 15 years by an annual 1 percent, and thereafter remain at a rather stable low level; numbers of young children would barely increase over their 1985 total by 2000 or thereafter. Annual MCH spending needs would thus change very little over the projection period in real terms, thereby permitting all increases in funds available to be devoted to improvement of health services coverage and quality. 2. Effects of High Fertility on Family Health 1.29 High fertility and closely spaced births have a seriously detrimental impact on the health of mothers and children. While the risks of maternal, infant and child morbidity and mortality are significantly higher in Africa than elsewhere in the world, all are significantly decreased if the mother is between 20 and 35 years old, has had fewer than five children and/or has spaced her births at least two years apart. Selective reductions in fertility, therefore, could have significant, positive impact on maternal and child health, as illustrated below Maternal mortality in Senegal has been estimated to be as high as 700 deaths per 100,000 births during the period (Annex 1, Table 17), a level which is extremely high even among other African countries whose levels are estimated to range from about In addition to poor health in general and inadequate quality and coverage of health services, maternal mortality and morbidity are determined by (a) maternal age; (b)

32 parity; and (c) spacing of births. Numerous studies on maternal age, spanning continents including Africa, have revealed that adiolescents and women 35 or older are at significantly greater risk of dying as a result of pregnancy. WFS data indicate that 36 percent of all births to Senegalese women occur in women of high risk age (Annex 1, Table 18). Studies have consistently shown that risk of maternal mortality also varies with parity, with the risk being particularly high for first births and most particularly so for women having five or more childrer (Annlex 1, Tab]e 19). In Senegal the risk of dying from childbirth is about three times greater for women with eight or nine children than for women with two children. First births are dangerous to mothers because first-time mothers are, on average, very young in Africa. Inadequate spacing of births results in a maternal depletion syndrome whereby women's bodies have not fully regained strength between closely spaced pregnancies Infant and child mortality rates in Senegal are also high (124 and 28, respectively) as compared with averages for other middle-income Sub- Saharan African countries (112 and 17, respectively) and low-income Sub- Saharan African countries (119 and 23, respectively). In addition to poor quality and coverage of health services, infant and child mortality is to a large extent determined by birth order, maternal age and birth interval. WFS data for Sub-Saharan Africa reveal that mortality under age 1 is lowest among second and third order children and among infants born to women in their twenties. In Senegal, babies born to teenage mothers have a 40 percent greater risk of dying than those born to mothers aged WFS data also confirm that a short birth interval adversely affects the health of both the child born at the start of the interval and the one born at its end The effects of poor health of mothers and children are mutually reinforcing: high infant and child mortality is a powerful determinant of high fertility, which in turn causes high maternal, infant and child morbidity and mortality. Efforts to reduce the risks of maternal, infant and child morbidity and mortality through family planning services would clearly make a significant, positive and immediate contribution to improving the health of mothers and children. Data on maternal and infant mortality indicate that roughly one-sixth of maternal deaths could be averted in Africa if all African women whc, want no more children did not in fact have more. Another one-fourth to one-third of maternal deatls could be averted if no woman had a child after the age of 40. Maternal deaths could be reduced by percent if completed family size fell from eight to six children. The potential for reductions in infant and child mortality is equally dramatic; percent of infant doaths in Sub--Saharan Africa could be averted if birth intervals of less than two years were increased to two or more years. Furthermore, longer birth intervals would improve the health of children throughout the first 5 years of life and often result in lower fertility, consequently reducing the number of high-risk births To sum up, rapid population growth will certainly ereate considerable pressure on the resources of Senegal, and will hinder rather than help the process of economic development and improvement, in human welfare. Reduction of fertility can be of only minor assistance to economic

33 development over the next 15 years or so, and problems posed by populazion increase will have to be faced and overcome during that period. Thereafter, however, fertility declines can make a very important contribution to reducing population growth and hence pressure oni resources. Policies and programmes aimed at fertility reduction should therefore be implemented as soon as possible to ensure the earliest and largest possible beneficial effect on the socio-economic development of Senegal. II. POPULATION POLICY 2.01 The Government is becoming aware of the implications of Senegal's population growth rate and supports the provision of family planning services for health as well as for demographic reasons. Yet, it has to articulate a well-defined and comprehensive population policy. Cultural and religious sensitivities are felt to mollify political commitment to articulate a clear-cut policy, even though some Senegalese scholars and national fora have shown that Islam and family planning services are compatible, and demand for and acceptance of family planning services are widespread. The evolution of a population policy is ongoing, however, and has been in process for over 10 years. A historical perspective of the evolution to date and the propects for further evolution are given below. A. Policy Foundations 2.02 Senegal inherited pronatalist legislation from French colonial administration. There was, in fact, little or no official concern about the consequences of rapid population growth until the results of the 1976 census showed a larger population size and higher rate of growth than had been expected. National development plans did not incorporate population objectives until the results of the census stin 1 l'lated greater research interest and national debate on population trendls and development strategies. An important boost to this debate was provided by President Senghor, in his report on general policy to the national political party congress in December 1976, when he warned that if the annual ralte of population growth of 2.9 percent were to continue the country would face serious difficulties in meeting employment, food, education and other needs Prior to this official declaratio no attention was given by the Government to rapid population growth issues except purely from a legal standpoint. For example, the "Code de la famille", adopted in 1973, raised age at first marriage to 16 and improved conditions for marriage and divorce. Actions taken since 1976 have had more direct bearing on the formulation of population policy. On October 29, 1979 the Secretariat of Sitate for Women's Affairs was assigned the responsibility for formulating

34 and executing family planning policy in concert with the Ministry of Public Health. The promulgation of Decree No of October 31, 1979, creating a National Population Commission, reflected increased commitment to address the population issue. Perhaps the most significant reflection of change in official attitude towards family planning was the repeal in 1980 of colonial legislation prohibiting contraception, thereby opening the way for integrating modern family planning into maternal and child health services provided through Government facilities. Subsequent to the repeal of this law, a Directorate of Family Welfare was created within the Ministry of Social Development and given the responsibility for coordination of family planning activities. Other factors which support formulation and implementation of population policy include the e.xistence of a Directorate of Women's Affairs in the Ministry of Social Development, endorsement and application of a primary health care program, and preparation of a national and spatial development plan concerned with resource management, internal migration and decongestion of urban areas and the central groundnut basin In January 1985, a study on Senegal's population problems was carried out by the National Economic and Social Council (ESC) at the request of the President of the Republic. In his speech to the ESC Assembly in March 1985, he stated that he found the report to be excellent. The report laid out the bases for development of a national population policy. The report recognized that although the GOS had not officially promulgated a population policy with clearly defined objectives, the series of actions and decisions taken to date constituted initial steps in the formulation of such a policy The report postulated that, in order to moderate an admittedly high rate of population growth, programs to influence marriage, fertility, mortality and migration should be developed. It recommeded that legislation relating to age at first -arriage should be reviewed, and the law applied more strictly. The report, furthermore, cited and reaffirmed the Government's response to a 1983 U.N. Survey of Governments' perception of the demographic situation in their respective countries. In that survey, the Senegalese Government considered Senegal's fertility rate to be too high, stated its desire to reduce that rate, and confirmed that it actively supported family planning programs and services, in part by integrating them into MCH and other governmental services. Sterilization and abortion were recommended only under exceptional circumstances. The report also recommended: that contraceptive laws be liberalized and family planning program experience to date evaluated; that the prevailing high rate of infant and maternal mortality (associated with high birth rates) be reduced; and that child death rates be lowered through primary health care services and environmental sanitation. The report noted that population growth has in recent years overtakejn economic growth and growth in food production and thus seriously inhibits development prospects for Senegal. The need for population policy to be integrated into Senegal's overall development strategy was emphasized; and, in recognition of the fact that measures affecting population growth and distribution have a long gestation period, the report stressed the urgency of defining and implemenling an official population policy.

35 - 18- B. Population and Development Planning 2.06 Senegal's Seventh Development Plan ( ), conceived in the framework of a medium-and long-term structural aljustment program, reflects a heightened awareness of demographic growth and its implications for future economic and social development. The Plan is pessimistic about prospects for reducing fertility, and points out that the positive effects of urbanization and female education are being neutralixed by a growing abandonment of the practice of prolonged breastfeeding, the consequent sho:iening of intervals between births, and the very low level of modern contraceptive use. 7 / The Plan concluded that the currenit rate of population growth (which they estimated to be 2.9 percent) was likely to increase to 3.2 percent in coming years, and anticipated problems stemming from the upset in the balance between population growth amd economic resources. The food supply and availability problem is perceived1, together with inadequate health services provision, as the most acute concern resulting from rapid population growth. Chapter I of this report highlights these and other equally pressing issues resulting from rapid population growth The Plan makes reference to the direct impact of family planning and MCH services (including treatment for sterility and sexually transmitted diseases) on the prevention of high risk pregnancies, infanticide and clandestine abortions. It recommends that these services be developed and strengthened through information, training, education and community programs which emphasize birth spacing, prolonged breastfeeding, and through increased access to contraceptives and family planning within MCW services. It recommends that development of family planning activities be accompanied by rapid expansion of primary health care services, programs to reduce illiteracy and improve women's status, and the revision of legal provisions affecting population issues. C. Prospects 2.08 It is clear that, despite the absence of a well defined population policy with measurable objectives, the underpinnings of a national population program have been well enunciated. However, the Government's commitment to developing and implementing an explicit policy on population and family planning has been tempered, in part because of anticipated political, religious and cultural sensivities. It is this caution -- amidst an understandable preoccupation with the pressing economic and political issues facing Senegal today -- that has fed the impression, particularly among external donors, that official commitment is ambiguous and weak. Muted support for family planning is credited, on the one hand, with at least allowing thte nascent family planning program to get off the ground without having to face official resistance. On the other hand, extreme caution and perceived weak co mit-nent are viewed as contributing toward 7/ Estimated at 1% in J978 by the WPS and at 3% in 1984 by USAJD.

36 institutional conflict, through occasional ad hoe arrangements for addressing fundamental population concerns The religious factor in Senegalese culture and politics is of paramount importance, and should not be underestimated, hut neither should it be used as a rationalization -for inaction on family planning program and policy development. A seminar organized by The National Population Commission (CONAPOP) and The Senegalese Association for Family We)fare (ASBEF) in 1982 on Islam and Family Planning (in which all the Senegalese Muslim Brotherhoods were represented) affirmed that (a) the Koranic law authorizes family planning if accepted freely and individually; (b) family planning is viewed as a contribution to family well-being, in particular the health of mother and child; mnd (c) contraceptive techniques include natural as well as modern methods as long as they do not endanger health. Government officials must be made more aware of religious and cultural receptivity to family planning and rendered capable of tailoring policy to accomodate such attitudes. This applies most particularly to central level officials, as many at the local level appear to have a more profound understanding of health and demographic problems Against this background, there have been recent developments which favor the formulation of an explicit population policy. During the first half of 1987, the President of Senegal re--emphasized the importance of population as a development issue, and the Government committed itself to prepare a national population policy and program by March To this end, the Minister of Planning and Cooperation convened an interministerial working group (scheduled to meet late July 1987) to begin the process of developing a national population policy. III. DETETMINANTS OF FERTILITY AND DEMAND FOR FAMILY PLANNING SERVICES 3.01 According to 1978 WFS data, the average desired family size expressed by Senegalese mot.hers is even higher, at 8 children, than the estimated TFR of 7. In spite of these high rates, a growing demand for family planning services does seem to be emerging in Sesnegal. This chapter highlights some of the reasons for high fertility and attempts to identify overt and latent demand for family planning services. Desire for Many Children. A. Determinants of Fertility 3.02 The desire for large families in Senegal is driven by several factors. Over and above the pleasure they bring parents in their own right, children are valued highly for their economic contributions (alleviation of

37 mother's work, earning of income, security in old age). These contributions outweigh the perceived costs to the family of raising children which are shared with extended families, oftentimes, and with the Governement. (education and health costs, in particular). Within the family unit, women bear most of the costs of child bearing and rearing in terms of their time and their health. Despite these costs, women are often motivated to have even more children in anticipation of high infant, mortality, although increasing numbers are gradually becoming more aware of the health consequences of high fertility and closely spaced births. It is men, however, who often decide on family size. Clients of three family planning service providers in Dakar named the opposition of husbands as a major reason why so few Senegalese women currently practice contr-aceptiotn Women's low status in society encourages women themselves to want many children. Strong and widespread traditional thought accords higher status to women (and men) having many children and extremely low status to women with no children. An unmarried woman, no matter how successful in her own right, is given low regard. Furthermore, low levels of education and literacy and poor employment opportunities for women limit their potential to pursue economic activities and other interests outside their traditional role, particularly in rural areas. Ninety-eight percent of women over the age of 15 in Senegal are illiterate. While Senegalese law accords the same rights to girls and boys, Senegalese traditional thought does not recognize the value of or need for providing a formal education to girls. In compliance with traditional values, many women do not finish their formal education; they leave school to get married (voluntarily or by their parents' choosing), to work in agriculture or other family economic activity, or because of an unwanted, out of wedlock pregnancy. Furthermore, women do not feel that formal education will assure them a better future, particularly in view o4 the current conjunc:ture and because most women work in the agricultural sector in capacities that do not require a formal education. The proportion of boys to girls in primary school is about 51 percent/49 percent; this proportion deteriorates in secondary schools to about 56 percent/44 percent and again at the university level to 70 percent/30 percent. While the Government in principle encourage schooling for girls, it has not addressed the strong traditional and cultural forces which have caused many girls to abandon their education. Several women's groups and political parties have tried to raise awareness of the importance of female education, but actions thus far have not had substantial impact Data from the 1976 census reveal that women make up a small minority of the professional work force. Prospects for the promotion of women are less favorable than those for men who possess the same qualifications and competence, particularly in the private sector. Civil service regulations forbid employment discrimination on the basis of sex, except for special disciplines and cases: women are excluded from the fields of civil aeronautics, maritime services, geography, customs and firefighting, all of which are open to men only. For reasons of family well-being a husband, as traditional head of the family, can prevent his wife from working outside the home. Despite their low profile in the formal sector, women are major contributors to Senegal's agricultural sector. They are heavily engaged in food production, processing and commercialization,

38 cash crop production, raising of livestock and poultry, and commercialization of dairy products and fish. However, because they have not benefitted from agricultural technical support which has been directed primarily at men, women have been unable to maximize income gained from these activities, which, combined with their responsibilities for child bearing and rearing and all household tasks, constitute a severely heavy workload, causing a serious and perpetual problem of extreme fatigue, among rura] women in particular. Women's prospects for economic independence are further obstructed by inheritence traditions. In traditional Moslem societies the wife (wives) inherit(s) one eighth of her (their) husband's estate; the rest is distributed among his children, the sons receiving twice the amount given to the daughters While consistently high, women's preference for many children varies with certain factors, most particularly education and place of residence. As shown in Table 9 below, WFS data on Sub-Saharan African countries including Senegal indicate that the number of children desired by women seems to dectease with an increase in years of education. Table 9: Mean Number of Total Children Desired by Education of Women Education (Years of Schooling) Ghana Ivory Kenya lesotho Mauritania', Senegal Sudan Coast No schooling / * Total I/ Preliminary data. Class.ification cannot read, less than six years of schoo]ing; six or more years. 2/ 7 or more years; mean calculated from a sample of 14 women. Source: Ascadi and Johnson-Ascadi, De.mand for Children and Spacing in Sub- Saharan Africa, World Bank background paper on Population, November 1983.

39 WTS data presented in Table 10 below also indicate that urban residence seems to have a depressing effect on the number of children desired. Table 10: Mean Number of Total Children Desired by Residence Residence Country Major Other Rural Total Urban Urban Ghana Cote d'ivoire Kenya 5F Lesotho Mauritania'/ Senegal Sudan I/ P.eliminary data. Source; Ascadi and Johnson-Ascadi, Demand for Children and Spacint in Sub- Saharan Africa, World Bank background paper on Population, November Multivariate analyses of WFS data undertaken by Ascadi and Ascadi-Johnson reveal that the moderating influence of urban life appears to be more important thmn that of education in Senegal and Cote d'ivoire while the effect of education was stronger in the other countries studied. Marriage and Childbearing Patterns and Contracegtive Practices 3.06 Most Senegalese women marry for the first time at a young age (a mtean age of 16.4), which results in the commencement of childbearing at an early age and causes a shorter interval between generations. Women continue having children well beyond the age of 35. These two factors, combined with limited and/or unreliable child spacing practices, have a positive effect on fertility levels. Breastfeeding reduces fertility by suppressing fecundity; it also reduces high infant mortality. In Senegal census data reveal that the mean duration of breastfe-eding.is 19 months. It is suspected, however, that tlhe duration ot this practi-e is liminishing as urbanizatioin progresses. Unless contraceptives are used mure widely, fertility will rise

40 as the practice and/or duration of breastfeeding declines. A decline in breastfeeding practices could also have a significant niegative impact on infant and child nutritional status Another contributor to high fertility is the low level of contraceptive prevalence. WFS data on Senegal reveal that in 1978 current use of contraceptive methods among currently married women was 4 percent for all methods and 1 percent for modern methods. According to USAID estimates, modern contraceptive prevalence among currently married fertile women was still under 3 percent in As will be seen below, these low prevalence levels are dlue in part to a lack of sufficient knowledge of contraceptive metnods and benefits and to a lack of family planning services. B. Demand for Family Planning Services Current Users 3.08 While difficult to quantify, pockets of demand and unmet need for family planning services are rapidly emerging in Senegal. Not surprisingly, demand is prevalent among more modernized groups, namely the educated, formally employed, and urbanized. As shown again in Table 11 below, fertility preferences are substantially lower among the educated (5 children for women with more than 3 years of education versus over 8 for women with no schooling at all) and among the urbanized (6 to 7 children for urban women versus nearly 9 for rural women). Table 11 further illustrates that contraceptive use is also substantially greater among these groups, with the differences particuilarly marked for modern methods. For example, 19 percent of the wives of professional and clerical workers had ever used contraception, and 11 percent a modern method. These levels of contraceptive use are significantly higher than those for all other women: only 6-11 percent of all other women had ever used any method of contraception, and 0-2 percent a modern method. Seventeen percent of women with more than 3 years of schooling had ever used a modern contraceptive method, versus only one percent of those with none. Eleven percent of women in wage employment were currently using contraception versus 2-4 percent of all others.

41 Table 11: Desired Family Size and Extent of Contraceptive Use Among Currentl Married Women by Sio-Economic Characteristics Mean Number All Methods'! Efficient Methods'/ of Total Children Desired Percent Percent Percent Percent Ever Current Ever Current Users Users Users Users Years of Schooling / Type of Residence -Major Urban Other Urban Rural Work Status of Women -Not Working NA Family/Self NA Employed Working for NA Others Husband's Occ uations - Agriculture NA Farming =Skilled and NA Unskilled Labour -Sales and NA Services Professional NA and "lerical 1/ Methods classified as "efficient" are the pill, the IUD, condoms, injectables, sterilization (male and female) and female barriers methods (diaphragm, spermici.dal foams, etc.). Methods classified as "inefficient" are thel douche, withdrawal, rhythm, abstinence and country-specific "folk" methods. 2/ 7-9 years only. The sample with 10 or more years of schooling was too small to use. Note. Sample t.oo) small to use (les-s than 30 women). NA : Not Available. Source Senegal Fertility Survey, 1978.

42 Additional supporting evidence on these patterns comes from dati on clients of three Dakar family planning clinics in 1983 (Annex 1, Table 20). They stand out as disproportionately well-educated, with a third to a half having had some secondary schooling, versus only 5 percent of Senegalese women in general. A quarter to a third are in paid employment. They marry 2-3 years later than the nationial average of 16 years, and are much less likely to be in polygamous unions (one quarter, versus the national average of one half). Their fertility preferenices are lower; they want only 5 children compared to the national preference of 8; most did not want their last pregnancy, and a substantial proportion (30-40 percent) want no more children While more prevalent in urban areas, demand for family planning is not limited to these areas. As part of preparation work for a UNFPAfinanced rural development project, surveys conducted in two villages revealed a demand for family planning services among rural residents. Contraceptives are sold by village pharmacies unauthorized to do so, whose small supplies cannot keep up with demand. As a part of preparation work for a family welfare project proposed for financing by UNFPA (para. 4.31), rural Islamic leaders were interviewed and their opinions on family planning matters solicited; they stated that birth spacing is permitted by the Koran and has been practiced for generations, and that, furthermore, they would welcome modern family planning services as a means of facilitating this practice. Unmet and Potential Demand 3.10 There exists already, therefore, a small but significant pool of demand for modern family planning services. This demand is likely to grow fast, moreover, since Senegal is rapidly urbanizing and the Government places high priority on the rapid expansion of educational opportunities. Tn addition to overt demand, there are indications of significant latent demand for family planning services. First, according to the WFS, 7.9 percent of pregnant women queried wanted no more children. This sentiment was particularly prevalent and increasing among the older age groups (14 percent of age group; 28 percent of age group; 31 percent of age group and 40 percent of those over 45 years of age), among women of high parity (Annex 1, Table 21) and among urban residents (11.8 percent of Uajor urban anid 8.3 percent of other urban women wanted no more chldren versus 7 percent of rural women). Current levels of contraceptive use, however, are inconsistent withl and in fact lower than the demand for limitation of family size (Annex 1, Table 22). Those women who wish to limit their family size and who are not currently using an effettive means of contraception clearly represernt a potential demand for family planning services. Second, despite their desire for large families, some Senegalese women recognize the value of chi]dspacing and have traditional.y used breastfeeditig and sexual abstinence to achieve it; breastfeeding, however, cannot be depended upon as a reliable menus of contraception. Furthermore, the practices of brreastfeedinjg and sexual abstinence for relatively lotig periods after birlh seem lo bv wan inrig in the face of urbanization and modernization leaving women more susceptible to closely spaced births.

43 Women interested in spacing births represent a demand for family planning services which would allow them to continue the practice of child spacing in a more effective manner. In addition, a potential demand for services exists among women who are not aware of the health benefits of child spacing and/or of the availability and types of contraceptives which could help them achieve childspacing. Third, the risk of maternal and infant mortality is high when the mother is under age 20 (para 1.30). WFS data reveal that about 19 percent of all births in Senegal occur to women of this age group. In addition, unwanted pregnancies among unmarried teenagers are emerging as a social problem; clandestine abortion, though unquantifiable, is known to be widespread( in urban areas and among schoolgirls. This, combined with the incidence of infanticide, provides a clear indication of the need for sex education. Family planning activities do not seem to address these problems head-on. Both married and unmarried women in the under 20 age group represent a potential demand for family planning services Improvements in availability and quality of modern family planning services are undoubtedly needed to meet both existing overt and latent demand. As is elaborated in Chapter TV, current services are not fully responsive to clients in terms of both quality and coverage, and consequently fall short of satisfying even existing overt demand. According to USAID, a gain of 4,000 new clients during the period March-July 1984 was noted just after new centers were opened and existing centers renovated and resupplied under the USAID-financed Senegal Family Health Project. This, in itself, is a demonstration of the large pool of potential clients ready to use good quality services once they become readily accessible. Furthermore, effective IEC activities to stimulate latent demand, with particular emphasis on expanding knowledge of the types and benefits of contraceptives and on aiddiressing husbands' resistance to utilizing family planning services, are likely to stimulate significant effective demand for services. IV. ORGANIZATION AND FUNCTIONING OF POPULATION ACTIVITIES A. Ortanization 4.01 Population activities in Senegal are carried out by a multiplicity of organizdtions. They comprise approximately 50 governmental and paragovernmenital institutions, international, bilateral, technical, scientific and financial agencies and Senegalese and foreign NGOs. The main instruments of Covernment intervention are (a) the Ministry of Planning and Cooperation; (b) the Ministry of Economy and Finance; (c) the Ministry of Social Development; (d) the Ministry of Public Health; and (e) the State Secretariat for Decent ral.ization.

44 The Ministry of Planning and Cooperation (MOPC). Within the MOPC, the Directorate of Human Resources (DRH) is responsible for coordinating human resource development activities including manpower training and development, employment and related population issues. The National Population Commission (CONAPOP) is established within this Directorate. Presided over by the Minister, himself, CONAPOP is responsible for drafting a population policy and undertaking studies on the interrelationships between population and development. CONAPOP serves as a national forum for various Ministries and for social, political, cultural and religious groups to examine population issues affecting Senegal; it is supported by an executive secretariat ("Unite de Population") set up with UNFPA assistance The Ministry of Economy and Finance (MOEF). Within MOEF's Directorate of Statistics, the Division of Surveys and Demography (DED) conceptualizes and undertakes demographic and socio-economic surveys. The National Census Bureau, within the DED, is responsible for conducting the general populat.ion census and related national surveys The Ministry of Social Development (MOSD). This Ministry was created through a merger of the Secretariats of State for Women's Affairs and for Human Resources Development. It assumed, consequently, the following responsibilities for family planning which were assigned to the Secretariat of State for Women's Affairs in 1979 by the Prime Minister of Senegal, currently the President of the Republic: (i) Conceptualization and definition of family planning policy (objectives and limits, method mix and appropriate interventions); (ii) Policy implementation (including coordination, allocation and management of all financial resources for family planning, in liaison with the MOPC); (iii) Coordination and implementation of family planning activities, in collaboration with the Ministry of Public Health on medical matters; and (iv) Monitoring and evaluation of family planning activities. Four directorates within the MOSD are involved in population activities: they are the Directorates of Women's Affairs, Family Welfare, Rural and llrban Affairs and Social Action and Community Development. The lead Direclorate is Family Welfare, which is responsible for coordinating and evaluating ramily planning and IEC activities and for supervising and supporting NGOs involved in faumily planning activities The Ministry of Public Health (MOPH). The MOPH is responsible for providinig family planning services as am integral part. of its maternal and child health services, which are delivered through the MOPH network of health facilities. In addition, it is responsible for providing technical support to MOSD with regard to the medical aspects of family plaining policy and program development and implementation. The MOPH is also the major proponent of primary health care program activities.

45 The Secretariat of State for Decentralization (SSD). This Secretariat's involvement in population has been through three of its units. The Directorate of Local Collectivities is in charge of vital registration. The Centers for Rural Expansion (CER), which are decentralized community participation and support structures, are entrusted with promoting rural development, through training of outreach personnel in health and sanitation education, functional literacy programs and promotion of improved land management and rural housing. The Directorate of Land Management is responsible for drawing up the national land management plan which gives special consideration to population growth and migration As early as 1968, NGOs, supported mainly by American organizations, started operating low-key family planning and IEC activities. The number of NGOs involved in family planning activities has increased substantially since then. The Senegalese Association for Family Well-being (ASBEF), an affiliate of the International Planned Parenthood Federation (IPPF), provides family planning services including maternal education and counselling of married couples. The African Association for Development Education (ASAFED), the Federation of Women's Associations of Senegal (FAFS), the Center for Development of Population Activities (CEDPA), financed by USAID, and the BOPP Center, a Protestant social action organization, provide family planning services, MCH services and related health education activities. Many other smaller organizations are also involved in population education, family planning services and development schemes for women. These organizations have received financial and technical support from international, bilateral and foreign NGO sources. The private sector also plays a role in the delivery of family planning services, mainly through about 9 private clinics in Dakar which generally serve an elite clientele Among Government institutions, roles and respcnsibilities for population activities are unclear and often overlapping;this situation has resulted in competition rather than collaboration among the various institutions. Assignment of responsibilities to Ministries for implementation of population activities is not always commensurate with their respective technical expertise, and there is presently no mechanism within the present institutional setup to assure overall management and coordination of activities and collaboration among Min 4.stries. The MOSD is given the overall responsibility for' coordination and implementation of all family planning activities (public,, rivate and NGO-sponsored), including policy elaboration and program implementation, monitoring and evaluation and financial management. However, this Ministry has not been provided sufficient resources to carry out. such responsibilities effectively nor does it possess the medical/technical advantage over the MOPH, particularly with respect to family planning services. MOSD has appropriately been given the responsibility for the promotioni of family planning activities. Presently, hwaever, it is not equipped with the capability to implement its own IEC activities effectively *r- to coordinate ano evaluat-e all population IRC activities carried out by Ihel myriad of Gover-rmentt, private atid NGO agencies involved. Demographic data collection, analysis andl research work is carriied out by several Governmen I agencieis (MOEF, MOPC, SSD) and various

46 other research institutions, with overall management and coordination responsibilities vague and lacking. Consequently, resources devoted to the population effort are being used inefficiently, thus compromising the effectiveness of family planning service delivery, IEC activities and demographic data collection, analysis and research. A description of each of these three types of population interventions which follows will further illustrate organizational constraints to effective implementation of population activities. B. Description of Population Activities 4.09 As shown earlier, although the Government has not officially promulgated an explicit population policy, it has been directly involved in or permitted the promotion of population activities for over 15 years. These activities are not tied into a population program but, rather, remain for the most part disparate and isolated; they have comprised public sector and private sector projects and have involved Senegalese and foreign governmental and non-governmental organizations. Because of the nonexistence of a national population program, these activities are not collectively managed, monitored or evaluated, the objectives of these efforts vary and, consequently, the effectiveness and efficiency of scarce resources directed to these efforts are less than optimal. 1. Family Planninzt Service Delivery Public Sector Services 4.10 MOPH operates most health services and facilities, although in cities the private sector plays a significant and increasingly important role. MOPH facilities comprise 16 hospitals, 45 health centers, 82 MCH centers (of which 17 are served by mobile units), 562 health posts and about 300 rural maternities built by villagers in many cases. In addition, there are specialized parallel services including 9 endemic disease control centers, 13 leprosariams and 10 regional hygiene centers. Effective delivery of quality services by these facilities is in part constrained by poor planning and management capabilities within MOPH and inefficient use of scarce personnel and budgetary resources Through this network of facilities the MOPH has been developing integrated MCR/FP services. The family planning activities within this integrated system are still at a nascent stage. Family planning services provided by MOPH have thus far been limited to six of Senegal's 10 regions (Thies, Fatick, Kaolack, Ziguinchor, Kolda and Cap Vert) which were initiated with Pathfinder Fund support and have since 1980 been supported by a USAID Family Health Project. By the end of the first phase of this project, 4CR/FP services are expected to be available in 22 centers in those 6 regions. USAID intends to extend its project. activ:ties eventually to Senegal's remaining 4 regions. Incidentally, UNFPA is financing a project

47 within MOSD which would introduce family planning services rural development in the same 4 regions. as a part of 4.12 Management of MCH services has been extremely weak and is not being strengthened to accomodate the inclusion of family planninlg services nor is the budget for MCH services being increased accordingly. The national MCH service has low status within MOPH; its current staff of I professional and an insufficent budget renider this service incapable of managing the MCH/family planning program on a national scale. NGO and Private Sector Services 4.13 With support from its affiliate TPPF and under the authority of MOSD, ASBEF runs two model clinics (the first opened in 1981) which provide MCH and family planning services. The clinics offer IUD's, contraceptives and barrier methods at a charge to clients. Service statistics are poor and difficult to decipher (Annex 1, Tables 23 and 24) and consequently performance in family planning service delivery is difficult to assess. The two clinics are each staffed by a nurse-midwife supplemented by a gynecologist who is available twice weekly for consultations Nine private clinics offer family planning services in Senegal (Annex 1, Table 25) including contraception, IEC and treatment of sterility and sexually transmitte diseases. They are generally run by doctors or midwives who charge fees for services -- most often beyond the reach of the general population. The oldest of these clinics is the Blue Cross Clinic, opened in 1964 with Pathfinder Fund assistance. Female barrier methods are generally not available in this clinic which is staffed by a nurse midwife; an obstetrician gynecologist may be seen by appointment. Performance of Services 4.15 Number of Acceptors. The record keeping systems of family planning service providers vary widely in quality. There is a need for a standard format that will yield standard measures of performance. Current estimates of acaeptance, continuation, drop-out and prevalence rates must therefore be taken as rough and tentative. The USAID Family Health Project evaluation report estimated that about 25,000 women were using modern contraception in Senegal in 1984; 8,500 through the Family hlealth Project; 7,500 through ASBEF and other private institutions; and 9,000 through pharmacies. This level, represeniting just under 3 percent. of currently married women, indicates an increase over the 1978 prevalence rate of I percent, estimated by WFS. Services do not currently meet. existing overt demand (para 4.16). A profile of family planning clients can be found in Chapter III The quality of family planning services currently delivered in Senegal is inadequate in that services are tiot responsive to the individual needs of the clients. A study of clients of three clinics (public, parapublic and private) undertaken in 1983 by the Division of Demographic

48 Studies, Department of Statistics revealed that nearly one-fifth of the first-time visitors received no method at all, but only information relating to family planning. Rather than tailoring the contraceptive to the particular needs of the client, clinics generally dispensed them according to the mehbod orientation of the respective clinic personnel (ASBEF personnel preferring IUDs and the Medina MCH Center, barrier methods). Factors which constrain the effective delivery of services include: (a) women's inaccessibility to services (there are waits of up to one month to see a midwife; a battery of expensive tests must be taken to receive the pill; and some women must travel into Dakar from a distance to find services); (b) the predominant sentiment among physicians that contraceptiveshould only be provided by physicians and by midwives trained in family planning techniques and not by nurses, which would, in essence, preclude the delivery of these services at the health post level; (c) insufficientraining in family planning of health personnel both in private and public sectors; (d) the low status of the central MCH service and its incapacity to manage activities due to inadequate staffing, training and budget; (e) MOSD's inappropriately assigned responsibility for coordination and design of service delivery activities (para. 4.08); and (f) the absence of a family planning policy and program which would ensure consistency in objectives between and within the private and public sectors and would facilitate management and coordination of activities. 2. Information, Education and Comunmication (IRC) Activities 4.17 There are currently about 20 different population-related IEC activities being conducted in Senegal. Although MOSD has been assigned overall responsibility for IEC policy development and coordination and evaluation of activities, it has not in actual fact undertaken either task. This is due in part to the fact that it is not equipped with the capability or resources to carry out such an assignment effectively. Furthermore, conflicts among the MOSD, MOPH and CONAPOP on questions of division of responsibilities have obstructed coordination and collaboration and have in the past contributed to competion and mistrust. Consequently, the myriad organizations involved in population IRC have mounted their own programs independently without reference to a clear policy or common objectives. Public sector, private sector and NGO/IEC activities are described below. Public Sector 4.18 Within MOSD the Directorate for Family Well-being has primary responsibility for program activities. Other MOSD directorates involved are Women's Affairs, Rural and Urban Affairs, Social Action and Community Development. The MOSD has, with USAID support, established central and regional IEC units and appointed one national and 10 regional IEC coordinators who work with about 489 rural social workers. This personnel is in contact with various village organizationsuch as women's associations, extension agencies, MCH centers and an assortment of NGOmanaged programs. Messages delivered are directed at. women, anld focus for the most part on the themes of birth spacing and maternal and child health.

49 The MOPC, through CONAPOP, was given a dubious and thus far ineffective role in IEC activities. With UNFPA assistance a communications unit was set up within CONAPOP for production of IEC materials on population, health and nutrition subjects for the usf' of the various agencies involved in population activities, and a project coordinator has been appointed. The appropriateness of placing an IEC production unit within a planning ministry is seriously questioned; IJNFPA is currenlly reassessing this unit's role and location and future UNFPA assistance in this regard. Furthermore, CONAPOP's new role of production of IEC material for the agencies involved in population activities appears to be a duplication of the responsibilities of MOSD, which has an explicit mandate to coordinate IEC activities. The MOSD's administrative structure and personnel gives it closer access to and a better understanding of the population, making it the more appropriate agency to develop TEC materials and activities The MOPII has a small network of health educators in each of the country's regions; they organize health education campaignls, train health workers and organize health education programs in schools. With IJSAID support, the MOPH has since 1979 provided training in IEC to over 40 midwives from among its staff Programs developed by various government ministries and units are broadcast by the national radio and television network, ORTS, which works closely with the National Council for Audio-Visual Education and Communication. The frequency of family planning broadcasts seems to have declined in recent years and radio and television authorities apparently remain indifferent to population and family planning issues. Private Sector 4.22 As early as 1968, the private sector, supported by grants from the Pathfinder Fund and other American organizations, has been involved in lowkey family planning and IEC activities. About eight private maternity and family planning clinics run by midwives undertake IRC activities as a means of educating pregnant women and recruiting family planning acceptors. Outreach workers employed by these clinics make home visits encouraging couples (women in particular) to take advantage of the clinics' services: treatment of sterility problems and sexually transmitte disease, contraception for child spacing or family limitation, and protection of the health of children. NGOs 4.23 A few important NGOs complete the collage of groups engaged in IEC activities. NGO activities, in this regard have proven, for the most part, to be effective, and provide a valuable experience in initiating and implementing programs and providing services. NGO activities are briefly described below Through its journal "Famille ei Developpement", ASAFED (L'Association Africaine d'education pour le Developpement) diffuses

50 information on family health and on a variety of population and socioeconomic issues largely to an intellectual and socially influential audience. Financial support and materials provided by IPPF enables ASBEF to maintain a central unit which diffuses IEC materials. ThVc Center for Development of Population Activities (CEDPA/Senegal) is a Washington-based American NGO, financed by IJSAID to provide training for women from developing countries who are interested in managing family planning projects and programs. CEDPA/Washington created CEDPA/Senegal in part to work with urban and village-based women's associations willing to promote fiamily planning. The BOPP Center is a Protestant social action organization involved in women's development including motivating them to make use of MCH and family planning clinics. Other NGOs involved in promoting family planning are the Federation des Associations Feminines du Senegal (FAFS); L'Amicale des Femmes de l'ecole Polytechnique de Thies; I.'Amicale des Assistantes Sociales; L'Amicale des Anciennes de V'Ecole Nationale des Monitrices d'enseignement Technique; Les Maisons Familiales Rurales (based in Thies); Yewu-Yewi (the only Senegalese women's organization to openly advocate women's equality at home, in the work place, contraception and the repression of polygamy); and the Association Nationale des Sages-Femmes du Senegal (the national midwives' association, with about 400 members). Foreign (chiefly Amercian) NOOs include the National Council of Negro Women and l'union Radio et Television Nationale Africaines. 3. Demographic Data Collection, Analysis and Research 4.25 Although knowledge of the demographic situation has improved substantially since 1976, when the first national census was conducted, significant gaps persist, which justify priority attention to population research and the undertaking of a population census. Demographic data collection, analysis and research is undertaken by many Government and parastatal agencies which have wide reaching and often overlapping mandates The Division of Surveys and Demography (DED), within the MOEF, and the National Census Bureau have been individually and jointly involved in research work comprising demographic and socio-economic surveys, the National Census (1976), the Fertility Survey (1978), the Labor Force Survey (1979) and the Infant Mortality Survey ( ). CONAPOP, within the MOPC, has undertaken analysis of demograph4c trends and population policy issues, established a national population research library, undertaken a national survey on infant and child mortality with USAID support, and is developing micro-computer applications for studying interrelationships between population and development. Within The Secretariat of State for Decentralization (SSD) the Directorate for Territorial Development undertakes as well studies on the interrelationsbips between population and development as a part of its national program for territorial development The Center for Applied Economics Research in the University of Dakar undertakes studies on migratiotn and labor force. The Fundamental lnstitute for Black Africa (IFAN) has researched law and population in Senegal, and Senegambian migratiorn; and the National School for Applied Economics under the Ministry of Hligher E1ducation has focussed its research

51 on primary health care, female migration and rural communities. T'he French institution, ORSTOM, has undertaken research on population and health, childhood diseases, urbanization and health, and has in collaboration with l'organisme de recherche sur l'alimentation et la nutritioni africaitnes, ORANA, carried out research on food and nutrition in Africa. Other organisations involved in population research include Societe Nouvelles des Rtudes de Developpement en Afrique, Tnstitut de Technologic Alimentaire, Conseil pour le Developpement et de la Recherche Economique et Sociale en Afrique, Institut Africar de Developpement Economique et. de Planification, Environnement et Developpement du Tiers Monde et Organisation pour la Mise en Valeur du Fleuve Senegal A review of the research institutions and the studies they have undertaken reveal that inadequate management, lack of coordination of the multiplicity of research initiatives, and poorly structured research compromise benefits derived from scarce resources spent on this effort. Research findings are often not utilized by other research institutions nordo they appear to influence Government policy, strategies and progra s. Because there is no coordination of activities carried out by public and private organizations, there has been no attention paid to effective monitoring and evaluation of family planning services and related JEC activities, which would not only stimulate operational research but provide appropriate guidelines for program development Government efforts to stimulate research in population through the creation of the Conseil Interministeriel pour la Recherche Scientifique et Technique (CIRST) appears to have increased the number of research units in the public sector without improving the relevance or utility of population related research. The multitude of national research organisations, bilateral and multilateral institutions listed as research institutions in Senegal impose serious constrairts on the development of ;a multidisciplinary team which can provide better information on such policy relevant subjects as determinants of morbidity, mortality and fertility and the impact of past and poll factors in migratory movements in Senegal. The dispersion of research efforts has led to a duplication of activities and a loss of policy and program objectives in research. Senegal has neither the financial nor the manpower resources to support a large num)er of population-related research institutes. An improvement in this area will require not just an increase in resources but a critical review of the mandate, relevance and effectiveness of existing research institutions involved in population. C. Financing 4.30 As is the case for other African countries, population activities in Senegal receive financing from various sources including the nationa] budget, semi-public, private, bilateral and multilateral agencies. Financial, accounting and management of resources for population activities are rudimentary or non-existent, and coordination of external assistance is inadequate. Consequently, information on the amount of financing available

52 by source, on allocation of financia.l resources and on financial accountability of recipient agencies is meager and dispersed. External Financing 4.31 Trbe bulk of expenditure on population activities bas beeii funded by external assistance. Two principal sources of finaneing are. UNFPA and USAID. Since UNFPA assistance to Senegal has amounted to over 11S$7.7 million equivalent in support of MCH/PP (including a faimily welfare project launched in 1983); population IEC activities (including an TRC project implemented by UNRSCO for the establishment within CONAPOP of a population communications unit); data collection and enalysis (including census and survey assistance and a vital registration project launched in 1985); population dynamics; and policy and program development. The first IINFPA country program in Senegal, approved by the Governing Council in 1979, amounted to US$5.5 million equivalent and covered the period UNFPA's proposed program for the four years beginning in January 1987, estimated at about US$4.0 million equivalent, will continue to address population growth and distribution issues through studies and surveys (including partial funding of the 1987 population census) and the promotion of MC!4/FP and social development, particularly of women USAID has provided about US$2.6 million for a Family Health Services Project whose initial phase ended in June it hlas committed an additional US$20.0 million for a second phase for which an agreement was signed in mid This assistance has included training of national staff in the delivery and management of family planning progrzsam, the organization and equipment of clinical and non-clinical family planning services both within and outside of the MOPH, and the development of TEC activities and monitoring and evaluation activities. USAID also provided US$2.0 mi.llion for the first phase of a Rural Health Services Project completed in June 1985, and has committed and additional US$20.0 million fot- a second phhse. Other sources of external financing include the International Planned Parenthood Federation whose support has been targetted at ASBEF, and Belgium, UNICEF and WHO, which have financed service delivery and IEC activities in support of maternal and child health Financial assistance to the population sector is usually targetted for a period of more than one year. Table 12 below provides an indication of the amount of external assistance disbursed for one particular year: in 1984 total external assistance to the population sector amounted to about US$1.1 million equivalent. In the absence of such data for other years, it is reasonable to assume that annual disbursements of externial assist-ace to the population sector will continue to increase, at least in [lie near term, despite severe cutbacks in contributions to IUNFPA. The recenttly approved US$20 million USAID project, alone, will disburse an average of US$2.8 million annually over its seven-year life (para. 4.30).

53 Table 12: External Assistance to the Po uletion Sector for 1984 Project Source of Duration of' Financing Financig FinanTacj Taret ted for 1984 (IISs) A. Demographic Morbidity + Research for ,831 and Planning Fertility International Activities Differentials Development (Survey) (Canada) Territorial UNFPA ,295 Development Population UNFPA ,794 Unit Subtotal A 124,920 B. Family Maternal WHO / Planning and Child Activities Health Family ITNFPA ,920 Wellbeing Rural Health II USAID ,0001/ (MCH focus) Fami ly USAID ,000 Health I Subtotal B 962,085 GRAND TOTAL: 1,087,005 l/ Represents 1/3 of total project costs, which is amount assumed to finance family planning activities directly. Source: Rapport Annuel sur l'assistance au Developpement, Republique du Senegal, 1984, PNUD As indicated in Table 12 above, an estimated US$962,085 was spent on family planning activities in A significant proportion of' these costs are recurrent in nature. Assuming a current contraceptive prevalence rate of 3 percent among women aged years (USAID estimate), expenditure

54 on family planning activities, amounted to about US$21.50 per active user for 1984, which appears to be reasonable. Effective family planning programs in Africa (together with some basic health care) are estimated to (ost roughly US$20 anrually per active user. 8 1 If USAID's project objective to achieve a 15 percent contraceptive prevalence rate by 1992 were in fact realized, the annual cost of ftamily planning activities would amount to about US$5.7 million equivalent ir' 1992, if the cost per active user were to remain constant. Tn fact, the cost per active user is likely to increase over time as services are gradually extended to less accessible rural areas where thc return on promotional activities (in terms of acceptors recruited) is likely to be smaller. These estimates, although rough, clearly point to the need for additional financing for family planning activities. Government Funds 4.35 Government financing of population activities has been minimal to date. Almost all investments in population activities, ranging from demographic surveys and studies to family planning service delivery and JEC activities, have been largely financed by aid donors. Government recurrent budgets, however, have not expanded nor have they been appropriately reallocated to accommodate consequent increments in expenditure brought about by such investments. Population recurrent costs are also at present largely financed by aid donors. Government counterpart financing of the -1SATD-supported family health project is estimated at about US$7.0 million equivalent, much of which is in the form of existing personnel and facilities assigned to the project. A financing scheme under the USAID project requires that Government gradually assume responsibility for the gasoline costs for project activities. Other recurrent costs associated with project activiti.es have not, however, been addressed and their financing after termination in uncertain at best. While the Government does not1 itntend to introduce cost recovery for family planning services initially in order to encourage potential users, cost recovery could be introduced in the metdium term once demand for and appreciation of family planning services become appreciably stronger and more widespread The public sector health budget which supports, among other thiings, maternal ap- child health services, including family planning, has slowly diminished as a percent of the national budget. MOPH expenditures as a percentage of total Government expenditures declined from 7.8 percent in 1973/74 to the curretnt 5.4 percent in 1985/86. It had been as high as 9.1 percent in 1969/70. The overriding objective of both the Vlt.h and VIIth plans has been to accelerate economic growth by concentrating resources on the directly productive sectors of the economy, making an increase in the health sector's share of the budget unlikely. The composition of the health budget. is largely dominated by personnel cost.s representing 65.5 percent of the 1985/86 budget leaving little resources to finance the balance of operating costs including drugs and maintenance. Each year this meager budget is spread more thinly over a growinig population. Furthermore, health 1J wlaiions Groewthand Pol icies in Sub Saharan Arrica, World Bank, 1986.

55 budget allocations are not commensurate with MOPH policy which emphasizes the provision of primary health care with particular emphasis on mothers and children; rathet they are heavily biased towards tertiary care and administration to the disfavor of MCH/FP services. Prospects for adequate financing of MCH/FP services are encouraging, nonetheless. Cost recovery experience t.o date reveals that there exists a significant willingness among the population to pay for health care as evidenced by the high level of private expenditures on drugs and pharmaceuticals (three to four times the amount spent on public outlay) and financing already mobilized through community development funds and local health committees. The pot.ential for mobilizinig additionial resources among the population is great and warrants priority attent.ion given the scarcity of public funds for health As is the case fot the MOPH budget the MOSD budget was not increased or reallocated to accommodate recurrent costs associated with MOSD's assigned responsibility for family planning or incremental recurrent costs associated with new investments in IEC activities. These are to a large extent financed by external donors within the context of projects. Little or no planning or budgeting for recurrent costs of ongoing projects seriously threatens the sustenance of project activities once external assistance runs out. V. ISSUES AND RECOMMMN1)ATIONS A. Satisfaction of Unmet Demand Issues 5.01 Current demand for family planning services is not being fully satisfied by existing services due to inadequate coverage and accessibility tnd to the poor quality of services. Not only are current services limited primarily to urban areas, their coverage even within urban areas is inadequate as evidenced by the long waiting periods women are subject to (up to one month to see a midwife) and the long distances women must travel in order t:o henefit. from services. A gain of 4000 new clients over a four month period just after completion of USAID-financed expansion of services clearly demonstrat-es the existence of the large pool of potential clients willing to make use of quality services once accessibility improves. Accessibility is also constrained by physicians' insistence that women undlergo a battery of expensive tests before being prescribed the pill, making the services unaffordable lo many; physicians, furthermore, feel strongly as a group that contraceptiveshould be dispensed by physicians and by midwives trained in family plmnning techiniques and not. by nurses, a prospect which cojuldi severely curtail accessibility. Finally, existing demand is nol being sat.isfiecl because the quajity of' services provided is low and not fully responsive to) the needs of clients (para. 4.18). In order

56 to satisfy fully existing demand for family planning, services must be expanded and their quality improved. Recommendations 5.02 In urban areas expanision of services can best be accomplished through exploiting the potential of NGOs and the private sector, which have successful experience in initiating and operating programs in health and family planning. In addition, the network of 17 dispensaries run by the municipality of Dakar, many of which already provide MCH services, would also be an appropriate vehicle for delivering integrated MCH/FP services; the mayor of Dakar has already expressed an interest in developing this capacity. In order to extend services to rural areas, MOPH should proceed with it. strategy of graduially introducing its integrated MCH/FP program into all of its facilities In order to improve quality of services, MOPH should be given overall responsibility for management, coordination and implementation of all family planning service delivery activities, including those delivered by facilities outside MOPH (NGOs, private sector, municipality of Dakar); this would enable MOPH to ensure that these activities fulfill MCH/FP policy which advocates the reduction of fertility and mortality in the interest of maternal and child health protection and promotion. The national MCH service, which would be the appropriate MOPH unit to execute these responsibilities, needs to have its status within MOPH raised and needs to be strengthened in terms of staffing, training and budget. A management inforxmation system for MCH/FP statistics needs to be established (and inilegrated into a health information system), accompanied by the appropriate training, to permit effective monitoring and evaluation of services. Personnel responsible for family planning service delivery should be trained. Family planning should be integrated into the basic training curricula for all levels and types of health personnel and teachers should be sensitized and trained to teach family planning effectively. Training in *'ami.ly planning should be delivered to currently employed health personnel through the inservice training program. Such training should, among other things, address pockets of resistence to effective delivery of family planni ng (physici ans for example). Issues B. Stimulation of Latent Demand 5.04 Dfemandi for modern family plan:imng in Senegal is apparently low at present. This is attributable primarily to a lack of sufficient knowledge of eont raceptive methods and benefits, opposition of husbands, low education and employment opportunities for women, rural residence and widespread desire for kar-ge families for l-easons Of tradition and perceived economic and social lienefits. A significant latent demand for family planning has been observed among certaiin groups of women: those who have expressed a desire for no more children (7.9 percent of pregnant women queried by WFS);

57 those who understand the benefits of and want to practice birth spacing and need to replace breastfeeding and sexual abstinence with more effective means of contraception; and unmarried teenagers who have ulwanted pregnancies. (Abortion and infanticide have been widespread, particularly among this latter group). Recommendations 5.05 Carefully structured TEC activities aimed at different target groups could stimulate demand among women who would benefit from family planning, and could also address the problem of out of wedlock teenage pregnancy through sex education. Special programs for women should cover such information as: the health benefits of child spacing and avoidance of high risk pregnancies; types of contraceptives available to achieve these objectives or the objectives of family limitation; the health and nutritional benefits of breastfeeding; and the concept of parents' right to choose family size and plan births. Special programs for men should emphasize the health benefits of contraceptives; and those directed at youth should, within the context of sex education, aim at reducing the number of out of wedlock teenage pregnancies. In addition, group leaders, decision makers, members of parliament, senior officials and religious leaders should be sensitized about the benefits of family planning in an effort to assist the Government in the promulgation and implementation of a national population policy The place of women in Senegalese society and their determining role in the success of population efforts emphasize the need for a wide range of measures to rehabilitate and give due recognition to their social and economic functions. The Government should take steps to raise the status of women in Senegalese society by placing greater emphasis on the importance of educating girls; supporting and strengthening women's development programs and projects undertaken by MOSD such as functional literacy, economic development and alleviation of women's domestic chores; and improving opportunities for employment of women in the formal sector. Furthermore, programs promoting the health and welfare of mothers and clhildren should be strengthened, with MOSD and MOPI collaborating closely in this regard. The Government should also encourage girls to marry at an age later than the mean (and legal) age of 16. In amdition to the obvious benefits, these activities combined would serve to stimulate further a growing demanid for family planning services MOSD has appropriately been given the responsibility for coordinating and evaluating TEC activities, but has been unable to carry out this assignment effectively because it is not presently equipped with the capability to do so. Tt, therefore, must be given the necessary resources and training and be relieved of inappropriately assigned responsibilities (para. 4.08). It should then proceed to define a population TEC program with objectives, framework and allocation of responsibilities. In otder to implement. such a program, MO1SD should mobilize and orc:hestrate the efforts of and collabotate with other Government, NG2O and private agencies; it should also monitor and evaluate all populationi IRC activities wit31 a view

58 to achieving optimal efficiency and effectiveness. MOSD field staff should be trained and motivated to deliver population and family planning messages through existing social and community groups and organizations. Village health committees, for example, would be most appropriate in addressing MCH/FP issues, as they were initially formed by villages to organize women's activities. Finally, MWSD should be given the support it needs to undertake production of materials, based on research results. Stimulation of demand must be accompanied by extension of quality services to satisfy that demand. C. Organization and Management of Population Activities Issues 5.08 The myriad of human and financial resources devoted to the population effort are being used inefficiently thus compromising the effectiveness of population interventions. This is due primarily to two factors. First, among Government institutions involved in population activities, roles and responsibilities are unclear, often overlapping and not necessarily commensurate with their respectiv expertises, which has resulted in competition rather than collaboration among the various institutions. For example, MOSD's responsibility for coordination and implementation of family planning service delivery gives it authority over MOPH which is technically better equipped to carry out such an assignment; resulting rivalries between MOSD and MOPH obstruct collaboration between these two ministries which is crucial to efficient delivery of services and IEC activities. The location of a communications unit for production of IEC materials within CONAPOP seems inappropriate as CONAPOP is a policy and research body. Policy development has been assigned to two Government units: CONAPOP has the responsibility for drafting a population policy which seems to overlap with MOSD's assignment to conceptualize and define a ffmily planning policy; and the two agencies have not collaborated to this effect. Within MOPC, the Directorate of Human Resources, including CONAPOP, has responsibilities for population research and data collection and analysis, which overlap with those of MOEF (Directorates of Surveys and Demography and Statistics) and SSE (Directorate for Territorial Development) The effectiveness and efficiency of the population effort is also compromised by the absence of a mechanism within the present institutional setup to assure overall management and coordination of activities and Collaboration among Ministries and other agencies. MOSD is responsible for coordination ancd implementation of all family planning activit:ies including policy elaboration, program implementation, monitoring and evaluation and financial manage-ment, but does not have the capability, resources or sufficienitly high status to carry out such a responsibility effectively. CONAPOP was neither given a eoordinating role nor has it aspired to that position since its creation. Its placement within a ministry, instead of above ministry level, weakens its positioin vis--a-vis other actors involved in populationt.

59 Recomendations 5.10 The roles and responsibilities of Ministries and other organizations involved in population activities in Senegal should be defined and streamlined, tmd the relationships among these various institutions clarified in order to foster collaboration rather than competition, as often appears at present. Assignment should be commensurate with the strengths and expertises of agencies: MOPH should be given responsibility for family planning service delivery within Government institutions, including management coordination and implementation; MOSD should be given lead responsibility for IBC activities, and be relieved of its responsibilities for policy evaluation, program implementation, monitoring and evaluation and financial management for all family planning activities; and the proposed new Population Research Institute (para. 5.15) should be given lead responsibility for data collection and research. Furthermore, all population activities must be collectively coordinated and managed in order to ensure that the effectiveness and efficiency of resources devoted to this effort are maximized. Specifically, it is recommended that a Population Council be established and attached to the Presidency. Its role would be to elaborate policy and offer guidelines for its implementation. A secretariat or Institute should be established in the Presidency to serve as a permanent secretariat for the Population Council and to monitor, evaluate and coordinate the activities of various line ministries and organizations engaged in population activities. This secretariat would also take a lead role in donor coordination and in the- drafting of policy position papers for consideration by the Council. Issues D. Financing of Population Activities 5.11 Population activities are financed by semi-public and private, bilateral and multinational soutrces, but receive very little budgetary support from the Government. The introduction of family planning into MCH services was not accompanied by an increase in or reallocation of the MOPH budget in favor of MCH services, which suffer already from underfunding. Similarly, the MOSD budget was not increased or reallocated to accommodate the introduction of extensive responsibilities for family planning. Donor assistance is uncoordinated and does not cover, moreover, all financing needs, particularly thojse with respect to management of popujntion activities. Furthermore, donor finiancing of recurrent costs of population activities (particularly service delivery and IEC activities) should not be expected to continue indefinitely; tilese costs wil.1 eventually become the responsibility of the Government. pue to a lack of information on financing, the magnitude of such costs is not readily known. The Government is currently experiencing very serioujs budgetary constraints and it is unlikely that the health or social development budgets will increase in real terms over t.he foresieable future. Therefore, unless steps are taken to estimate and plait for the recur-renlt cost burden and to rationalize services so as t.o keep recurrent costs to a minimum, population activities are likely to suffer as a result of inadequate finanicintg in the medium and long term.

60 Another serious concern is that no financial accounting or management of resources is carried out for the entirety of population activities, not is it undertaken within ministries responsible for particular population interventions. External aid, which constitutes the bulk of expenditures on population activities, is inot properly coordinated. Information on the amount of financing available by source, on allocation of financial resources and on financial accountability of recipient agencies is meager and dispersed and consequent poor financial management precludes optimal utilization of resources. This deficiency is cl.osely linked to the organizational issues discussed above. Recommendations 5.13 A system of financial management, accompanied by the proper staffing and training, should be established within the proposed Permanent Secretariat for the Population Council to provide comprehensive information on sources of financing, financing needs, allocation of resources and accountability of recipient ministries or agencies. Such a system would facilitate the achievement of needed improvements in aid coordination and would assure efficient utilization of resources. Financial planning should also be undertaken so that the recurrent cost implications of present and future investments in population will be addressed, their costs minimized and their financing assured. While it is unlikely that health and social development budgets will be increased in the near to medium term, improved financial planning and management within implementing ministries would permit identification of needs and ensure optimal allocation and utilization of scarce resources. Issues E. Demograkhic Data and Research 5.14 Demographic data collection activities undertaken in recent. years have contributed to improving somewhat the quality and quantity of information on the popiulation of Senegal. These data, however, are still of mixed quality, due in part to deficiencies in training, and are becoming outdated; and information oni demographic trends over the last 10 years, such as growth rates, migration patterns, distribution and densities, is lacking. A second census, already programmed for April 1988, is therefore needed. What demographic data are available are not widely disseminated, even within the Government; and the -implications of population growth and trends on indiviclual sectors are not fully appreciated nor are they integrated into the planning process. P'opjulation research aclivities have been compromised by inadequate managemenl, lack of coordination of the multiplicity of researeh initiatives and institul.iotos, and poorly structured research. The dispersion of research efforts has led to a duplication of activities and a loss of pol icy and program ob.ject ivyes in resutarch. Furtlermore, research findings are of Len not utiiized3 by othier research I tist i tut: ions ror do they appear to influence Govefrnmelnl policy, strategi.es arnd ptograms.

61 Reconendations 5.15 In view of the paucity of data on demographic trends since the 1976 population census, the Government should give high priority to the execution of the second national population census, planned for This census should be designed to provide maximum information on current patterns of population distribution, mortality, fertility, migration and population growth, and to provide a useful basis for future surveys and studies. In this effort. the Government should develop national capabilities in census and survey work to reduce to the barest minimum the need for external assistance. It should give greater priority to staff training and development in demographic-related disciplines, most particularly data processing which has been a major constraint to rapid and quality processing of census and survey results. Research efforts should be rationalized throutgh the establishment, within the proposed Secretariat for the Population Council, of a Population Research Insitute which would consolidate and coordinate all demographic research and ensure dissemination and utilization of results. In order to refine ongoing family planning service delivery and IEC activities, and eventually to develop long-term population policies and programs, studies on population should be focussed primarily on operational research, drawing from health and family planning service statistics and from an evaluation of experience derived thus far from ongoing population activities. Cultural and religious attitudes must be made the subject of special research that would provide the basis for preparation and refinement of appropriate IEC activities. Issues F. PoDulation Policy 5.16 Whiile the Government's awareness of the implications of Senegal's population growth rate is becoming increasingly acute, and while it supports the provision of family planning services for health as well as for demographic reasons, it has yet to articulate a well defined and comprehernsive population policy and program. Despite Government actions to create institutions and open the- way for the implementation of population activities, the lack of an explicit, officially promulgated policy and program with clearly defined objectives contributes to present institutional inefficiencies and perpetuates the dispersion of the numerous population activities and objectives. Furthermore, executing agencies point to the absence of a clear policy as the reason for their apparent weak commitment and inaction, claiming that they are in need of mote explicit instructions to carry out. activities. Tt should be noted that the series of actions and dlecisions taken thus fart by the Government to a(ldress population issues bears witnesx to the existence of an implicit population policy, and that these actions lay the foundation for the elaboration of an explicit policy and program. In recognition of 1ilie imnd.ieatel need1 ror a clearly deinled population policy and program, diut'ilg itegotiatiott of a third Wotldl Bank Structural Adjustment Credit in April 1987, the Government agreed, as a condition for th-e release of Lihe third tratizhe of funds under this Credit,

62 to prepare by March/April 1988 a document elaborating Senegal's population policy and a program for its implementation. Recommendations 5.17 The Government should take immediate steps to commence elaboration of Senegal's population policy and program, which should permit a clarification of objectives, facilitate streamlining and efficient management of the myriad of currently dispersed population activities and demonstrate Government commitment to population objectives. World Bank assistance in the elaboration and implementation of Senegal's policy and program should be made available through the ongoing first rural health project and through a proposed second project in support of health and family planning. VI. ROLE OF THE WORLD BANK 6.01 Although the Bank Group has not provided direct assistance to the Government of Senegal for population activities, the country has received World Bank support for a health project which includes family planning activities; an IDA credit of US$15.0 million equivalent was approved in December 1982 to finance a rural health project whose objectives include strengthening of primary health care services and the development of health, family planning and nutrition education within an integrated MCH/FP program. A mid-term evaluation of this project was undertaken in early In view of the fact that population activities are financed and implemented by several agencies in an uncoordinated manner, the future role of the World Bank in the population sector should be twofold. The World Bank should (a) assist the Government to coordinate resources and consolidat efforts dedicated to the population sector in order to maximize their effectiveness; and (b) complement the efforts and financing of external donors by providing assistance in vital areas which are presently uncovered. To these ends, the World Bank should focus its assistance to the population sector in Senegal as follows. A. Promotion and Provision of Family Planning Services 6.03 The USAID-financed Family Health and Population Project seeks to satisfy unmet demand and stimulate latent demand by assisting the Government to introduce family planning into existing public MCH srvices and to carry out IRC activities nationwide; it will also provide some support to private sector and NGO population activities. Even with the complement of UNFPA assistance to family planming and IC activities, gaps in efforts and financing still remain. World Bank experience to date in the health sector in Senegal reveals that Government health services, through which family

63 planning services are to be delivered, suffer from strategic, programmatic and managerial deficiencies. Through the ongoing Rural Health Project as well as during the course of preparation and implementation of a second project, the World Bank should assist the Government to define and implement a national strategy for health service delivery, to strengthen, refine and implement health programs, including MCH/FP, amd to strengt hen capabilities within MOPH in planning and management, all of which w)uld be carried out in a decentralized fashion Because of rapid urbanization, large concentrations of urban populations are at present virtually uncovered by MCH/FP services. Furthermore, urban areas are characterized by a younger population than that in rural areas, implying a larger proportion of women of reproductive age, whose demand for MCH/FP services are greater than that of their rural counterparts. World Bank assistance should, therefore, place particular emphasis on improving and expanding MCH/FP services in urban areas where the need is greatest. It should also support IEC activities and women's development activities to stimulate latent demand and encourage local participation in the development, management and financing of MCH/FP services. In these endeavors, World Bank support should focus on developing and expanding Government and municipal services (Dakar, Thies and St. Louis are immediate priorities), and on encouraging NGO and private sector activities. B. Institutional Development 6.05 In an effort to maximize the effectiveness and efficiency of population activities, the World Bank should assist the Government to define and streamline roles and responsibilities of and relationships among the various institutions involved in the population sector. Within these institutions it should support the improvement of capabilities in planning, programming, management, implementation and monitoring and evaluation of population activities. Furthermore, it should assist in the establishment of a financial management system which would ensure financial accountability and encourage and facilitate aid coordination, financial planning, and mobilization and administration of cost recovery efforts. C. Improvements in PoDulation Research 6.06 The World Bank should consider providing assistance to the population census, now planned for April 1988, for which additional financing is currently being sought. It should also assist the Government in the dissemination of census results and in their analysis and incorporation into the planning process. Through its project assistance, operation&l research on and evaluation of family planning services should be supported to facilitate further design and refinement of service delivery schemes.