Mental health is considered an integral part of health and well-being, as reflected in the constitution of the World Health Organization (WHO). And, like other aspects of health, it can be affected by a range of social, cultural, economic, political, and environmental factors. The local context in which certain vulnerable groups, such as families living in poverty, people with chronic health conditions, children exposed to abuse or neglect, minority groups subjected to discrimination and human rights violations, older adults, women, and others, are situated, can significantly increase the risk of suffering from mental health problems.
People with mental disorders are frequently stigmatized and discriminated against in countries with a low level of development. This is due to a lack of education and awareness among the population, a lack of capacity in health centers, harmful therapeutic practices, and the denial of civil and political rights, the right to health, education, and professional development. This leads them and their families to live in poverty, unhealthy living conditions, and physical and sexual abuse. Furthermore, the WHO also reports in its Comprehensive Action Plan for Mental Health that people with mental disorders have disproportionately high rates of disability and mortality. For example, people with major depression or schizophrenia have a 401 to 601 percent higher chance of premature death than the general population, due to physical health problems that often go untreated.
Senegal is a country where mental health has suffered widespread neglect. Despite government efforts to integrate mental health into the health system, the total number of beds is 3 per 100,000 inhabitants, compared to 27 per 100,000 inhabitants in Spain, according to 2019 data from the National Health System's Strategic Plan for Mental Health 2022-2028. The number of psychiatric medical personnel in Senegal is only 1.6 per million inhabitants, according to UNDP figures for 2017. In comparison, in Spain, the proportion of psychiatrists affiliated with public NHS centers in 2018 was 8.6 per 100,000 inhabitants.
In total, the Ministry of Health has registered 14 mental health facilities, but only six are specialized centers; the rest are units within a general hospital. Almost all of these facilities are centralized in Dakar, which houses the only National Psychiatric Hospital Center. In the regional hospitals (Louga and Saint Louis) and certain medical centers with surgical units, psychiatric services are managed by a single individual without resources. According to figures from the Mental Health Division of the Ministry of Health (MSAS), 36 psychiatrists practiced in Senegal in 2018, of which only seven (15, 21, and 30) were assigned outside the Dakar region.
This situation highlights the difficulty in accessing psychiatric care services in the country and the unequal distribution of mental health care. It is undeniable that only a minority of Senegalese people affected by mental disorders benefit from care through health facilities. This generates a series of negative impacts such as delayed diagnosis and treatment, deprivation of access to services for the population, widespread misinformation about various diseases, and the indiscriminate use of traditional practices.
Within this context, there are two specialized mental health centers of the Hospitaller Order of Saint John of God in Senegal: the Dalal-Xel centers in the city of Thiès and the city of Fatick. Both centers are the main centers for specialized mental health in the entire country and are among the only six specialized centers in existence.
The Dalal-Xel Thiès center was the first to be founded and has been operating for more than 20 years. It serves an average of 20,000 people per year, of whom 45% are diagnosed with some type of mental illness. Schizophrenia, acute psychosis, and epilepsy account for 80% of the pathologies treated. To carry out its daily work, the center must be aware of the limitations present in its environment and seek efficient solutions that allow it to operate with a long-term vision. This is also the case for its counterpart, the Dalal Xel center in Fatick, which began operating a few years later in the southeast of the country and supports the Thiès center in the activities carried out in its area of influence.
In the words of the Director of the Thiès Center, Brother Étienne Sené, the main challenges facing the country today are the shortage and discontinuation of psychotropic medication supplies; the lack of healthcare personnel in psychiatric facilities to ensure the prevention, care, and treatment of people with mental illness; decentralizing psychiatric care services to meet the needs of the population not living in the capital or major cities; establishing social reintegration structures; combating the stigma and taboos associated with mental health; and ensuring the availability of a public mental health budget to support research and care for the abandoned, underprivileged population.
Thanks to the Dalal-Xel centers' in-depth knowledge of the context and the connection they have with the people and their environment, and thanks to their vocation as a Hospitaller Order and their commitment to mental health, they have identified for several years that most of the families and companions of the people they care for had to make great financial efforts to cover medical expenses, transportation, accommodation, and food, as they had to travel very long distances. They realized, by identifying the different places of origin, that care could be concentrated in closer, delocalized strategic points, making it more accessible, since the reality they faced often resulted in the abandonment of treatment and medical follow-up due to the physical, economic, and moral exhaustion of the people they care for and their families.
In response to this situation, and since 2013, the Dalal-Xel centers began expanding their activities to the communities where the majority of their patients came from. As these initiatives have become consolidated into projects, the Dalal-Xel centers have attempted to address, to the extent possible, other issues among the population, such as social stigma and gender bias in mental health, given that they are the only institutions in the country that offer this offshore service, through increased training and awareness-raising activities.
Brother Étienne points out that stigmatization is an action or word that turns a person's characteristic, behavior, disability, or impediment into a negative or inferior mark. In Senegal, this translates into families rejecting or denying the reality of these types of illnesses among their relatives; affected individuals having no relationships or social ties and living in very precarious conditions, which can even lead to abandonment on the streets or the situation leading to other illnesses; having difficulty receiving ongoing medical treatment; having difficulty reintegrating into their families once they find themselves in a more stable situation; and, above all, mental health being a taboo subject due to a lack of awareness among the population and traditional beliefs or myths.
It is due to this reality that, from 2019 to the present, the Dalal-Xel center in Thiès, in coordination with Juan Ciudad ONGD and with the support of multiple public and private entities such as the Government of the Balearic Islands, the Parc Sanitari San Joan de Deu Hospital, the Sant Boi de Llobregat City Council, the Carasso Foundation and Farmamundi, is working on a primary mental health care program in four rural towns belonging to regions in the center and north of the country, which revolves around four goals:
1. Facilitate the population's access to mental health care services by reducing or eliminating the geographic, economic, and sociocultural barriers they face daily.
2. Establish and strengthen local intervention networks that support and collaborate with the primary mental health care program.
3. Empower and train beneficiaries, patients, and their families, in the medical and personal care required for the treatment of mental illness, strengthening their knowledge of public and community health.
4. Improve the quality of outpatient medical care services through training of medical personnel, reinforcement of materials, and purchase of equipment.
This intervention has an annual impact on approximately 18,000 people. Three trips a month are made to rural areas strategically chosen as key hubs for the main towns where the people registered by the clinic come from. The primary care medical team is made up of professionals from the Dalal-Xel Thiès Center, who work Monday through Friday at the institution and conduct community visits on Saturdays. It is comprised of four psychiatrists, three of whom are completing their specialization in psychiatry at a leading hospital in Senegal with which the Dalal-Xel Center has an internship agreement. The team also includes two nurses, two nursing assistants, a social worker, a driver, and one volunteer from each town who support them in disseminating the project, contacting people, locating new patients, and translating into local languages. The project works closely with local health centers, other religious institutions, and traditional religious leaders, such as the Marabú, who also help them spread the word and refer people in need to participate in the project and attend consultations.
The project sites are generally schools, where they use the courtyards as waiting and distribution areas to raise awareness among patients and their families and organize appointment times. They use the courtyards for consultations. The program's activities also include the sale of approved medications because, as the center's director mentioned, one of the biggest problems is the shortage of medications in pharmacies and dispensaries, as well as their high cost.
The Dalal-Xel center in Fatick also runs a very similar community health program, but with different outreach logistics, as the center serves fewer patients at its facilities, allowing it to make more visits to more communities several days a week. It currently covers seven communities in south-central Senegal and has received support from the Association for the Assistance of People with Disabilities (AAJIPH), but is currently managing the project, on a limited basis, with its own resources.
Thanks to the testimonies of those served, their families, staff, volunteers, and other stakeholders, it is clear that the project is having a significant impact on the population, with very high levels of participation, and is significantly improving the condition and health of all those served.
But there are still many challenges to face, above all, reducing wait times, reaching many more towns, being able to serve the population in spaces better equipped for healthcare activities, having more medications, a specialized team dedicated exclusively to community health activities in the communities... The goal is to be able to serve more people, with better quality, in a more accessible way, breaking down the barrier of stigma and social rejection, and ultimately improving the health and lives of people in Senegal.
