Written by Kym Craven and Rick Bailey, longtime Mali Health supporters
As donors to Mali Health, we have always felt confident that the organization was using our contributions wisely and that positive change was occurring as a result. The website posts interesting profiles of programs and people, the newsletters keep us current and informed about major milestones, and blogs provide a real-time window of the latest happenings on the ground. We looked at all the pictures and read many reports. We believed we had a full understanding of the extent of the Mali Health programs we were supporting.
We were wrong. Our understanding, it turned out, was wholly incomplete, the good work far exceeding our perceptions from afar. None of what we read and saw prepared us for what we learned firsthand.
In January, we had the chance to travel to Mali, spend time with Mali Health’s staff, and visit program sites. To say that we were inspired and impressed would be an understatement. Standing on the hill in Sikoro, the pressing need for assistance – roads, sanitary facilities, clean water, housing, and schools – was overwhelming, while at the same time the open reception, and the earnestness and dedication on the part of our hosts was heartening (we later learned that this was one of Mali Health’s secret’s to success – identifying the assets within a community).
Upon arrival, we participated in an orientation that provided context to frame our experience – including Mali’s own history, urbanization, current health challenges, and Mali Health’s present work. We learned Bambara greetings and donned Malian names (both, it became clear, were necessities). Staff members from each program explained in detail the objective of each initiative and how each acts as a building block upon the other. Working as a dynamic unit, staff members have navigated the enormity of the challenges present in Sikoro, concentrating resources on the strategies having the most impact on the health of the families living in the area.
During our stay, we had the opportunity to participate in the following:
Clinic and Maternity Ward site visit – Here we met with the doctor, staff, and a member of the community council and learned that community members are making frequent use of the facilities. Improvements, such as the opening of the maternity ward have increased the number of women using the facility leading to births with fewer complications.
Home visits – On foot we traveled from the clinic up the hill to accompany Community Health Workers on home visits. The Community Health Workers each have a large caseload of more than 50 families. Carrying a scale, thermometer, tape measure, and other supplies in a backpack, they visit with each parent or caregiver individually with the child. Treating each child as they were the only patient of the day, the Community Health Workers talked with the family, assessed the child, and, when needed, identified a warning sign to monitor or a trigger that warranted an immediate clinical referral. Firsthand, we saw how this process, focused on early intervention, improves the health and wellness of enrolled children. The consistency of the message provided by the Community Health Workers indicated that the training provided by Mali Health is preparing individuals for their roles. Impressively, the Community Health Workers enter patient information using a phone-based database, reducing paperwork and improving efficiency.
Health Saving – Gathering in a courtyard, 20 women congregated to discuss pressing health needs. We listened as members of the group shared their stories with us on how their participation in the program is improving their quality of life. Then, we watched as the group of women, drawing out small bits of currency and opening two locked boxes, turned into their own small bank. Every woman deposited savings. Some members requested loans; others paid them back (with interest for economic activities, no interest on health expenses). Some even paid fines for being late to meetings. The “accounts” are a safe way to save small amounts of money that, over time, adds up. The access to funds helps when a woman has an urgent expense or needs funds to support any number of their small enterprises. The fellow members are a constant source of support, accountability and, together, help create a stronger standing for women in the community.
Clinic Quality Improvement Program Meeting – In Mali Health’s new partner community, we observed a workshop that used the Kaizen process of continual improvement to improve performance of the local clinic. Over 25 stakeholders – including management, doctors, and patients – crowded together to brainstorm how to improve a patient’s reception upon arrival. After two hours, the participants identified solutions and assigned specific plans to implement, all led by a cross-sectional committee to monitor progress.
Staff Retreat – In modest offices (that experience frequent brown outs and loss of internet) we sat in on the final day of the staff’s planning retreat. Listening to their presentations it was evident that each coordinator is motivated, innovative, and committed. Proof of their efforts came at the end of the day when Executive Director Kris Ansin, showed slides illustrating decreased cases of malnutrition and increased use of the maternity ward, while at the same time finding ways to decrease the cost of services.
Cultural Opportunities – While much of our time was spent in the office or the field, our ventures into the city proved illuminating. From a concert at the French Cultural Center, to the cool air and green grass in Bamako’s National Park, to rich history learned at the National Museum, to negotiating prices for textiles at the Grand Marché, to sampling the local cuisine, there was never a shortage of activities in which to participate. We navigated the congested city thanks to our mobile phone’s camera function (a Hansel and Gretel crumb-dropping tool for the digital age) and the honesty of taxi drivers, often returning the excess cash we accidentally handed over while learning the currency.
Two activities especially stand out: an afternoon with Project Izumi Coordinator Baba Bayoko and his extended family, sharing a Sunday meal and warm conversation (luckily we had translators); and an overnight stay with Community Health Worker Ami Keita and her family in their home in Sikoro, showing us firsthand the lives and way of living for those in the Mali Health family.
A New Perspective
On our first day, Communications and Public Affairs Director Adama Kouyate asked which three words described our impressions of the country. Hot, dusty, and poor summed it up. On our last day, we sought out Adama to change our answers. Yes, Mali is all of those things we mentioned, but those impressions were replaced by stronger emotions – appreciative, welcoming, and empowered – a true reflection of the people we met and came to know.
If a picture is worth a thousand words, an experience is worth a million. We quickly came to love the place as much as the program, the people as much as the project. To know one means to know the other. Despite our surprise at the depths of commitment and the breadth of Mali Heath’s impact, that we left more confident, proud, and humbled was not unexpected. We are more encouraged to share our praise of the program to those who know it already and those yet unexposed. Mali Health achieves its success not by giving handouts, but rather by working with and through community members in training, decision-making, and developing solutions for long-term sustainability.
Given our backgrounds in law enforcement, we would be remiss if we did not note that despite the poverty, lack of services that we take for granted, and a decaying infrastructure, we saw no evidence of crime or illegal drugs. We walked the streets and neighborhoods, day and night, without an escort – never feeling unsafe.
We encourage you to go ahead, see for yourself, and plan a visit to Mali. You will find that the folks there are wonderful hosts and we guarantee it is a life-changing trip.
Aissita Keita (Kym Craven) and Djibril Kouyata (Rick Bailey)
While we have not mentioned every person contributing to the success of our trip in this article, we personally want to thank each and every staff member of Mali Health for their time and hospitality. We learned a great deal more about Mali Health than we knew on our arrival. We appreciate your work and dedication and because of you, we are even more proud to be donors to and supporters of Mali Health.
Written by Kris Ansin, Executive Director
This fall, Mali Health’s staff and board of directors took the time to take stock of our programs, our accomplishments and the strengths we’ve developed, as well as to address those aspects of our program we could do better, and to seriously consider what more we can do with the resources we have gathered. It meant long days in the office as staff members balanced the need to reflect and plan with their full work schedules. It is my pleasure to share the results of this sometimes arduous, but ultimately rewarding and, I believe, vitally important process with you, our supporters. If it sounds a bit jargon-y at times, you’ll have to excuse us, we want you, our supporters, to feel as close to the action as possible, and we’ll try not to sound like a public health vocab lesson:
When Mali Health began its work in 2006, health outcomes in Mali were among the poorest in the world. Of every 1,000 children born, nearly 50 did not survive their first 28 days, another 50 did not survive their first year, and another 75 wouldn’t see their fifth birthday. Maternal mortality also figured at the bottom of international rankings. Today, those figures have improved modestly – neonatal, infant, child and maternal survival have all increased by approximately 20% over that time, though all have fallen short of expectations and the progress made by many of Mali’s neighbors. Other measurements have stayed flat or even regressed, including the percentage of health services paid for out of pocket (over 99%) and access to contraception (under 10%).
Bamako is one of the fastest-growing cities in Africa, and Sikoro, our flagship community, was also growing exponentially, outpacing even other parts of Bamako. Health outcomes in our community, however, were entirely more positive than the rest of the country. Access to care increased, both in geographic and financial terms. Children and women enrolled in our programs – the poorest members of the community – maintained high rates of maternal and child survival. All the while, we were learning our own valuable lessons about achieving impact. Among them:
- Local ownership by staff, partners, and constituents is essential. Sustainability and exit strategies are important.
- Implementing health programs in such a resource-strained setting require a balance of concentrated effort with the understanding that a wide-angled lens is required, innovation is necessary, and systems must be strengthened, not replaced.
- In a decentralized environment like Mali, inclusion in the health system, particularly for the poor, is a massive challenge. To achieve success, we must better identify defined health system levels, strategies, and partners.
- Increasing the financial resources available to the health system is irrefutably necessary, but Mali Health can have a large impact both as a model and as a direct agent of change, by addressing the gap between what people can afford and what the health system currently provides.
In response to these multiple factors – the evolving and the inert health trends, the lessons, successes, and challenges over the past several years, and our current organizational strengths – Mali Health conducted a thorough strategic planning process, led by senior staff and board members, with significant input from our constituents, our donors, and our partners.
The result was not a shifting of gears but a clarification of action. Our mission reflects what we perceive as the biggest health challenge facing Mali and West Africa – access to quality, basic care. Costs remain too high, knowledge and behavior too neglected, quality and management of services too static.
Our DNA remains unchanged. Our interventions focus on strengthening the most important actors and leveraging existing assets within our partner communities (for the time being, the peri-urban populations of Bamako) to improve health. This means working with public clinics to deliver improved care. It means working with communities to support their advocacy efforts for improved services and increased resources. It means working with women so that they can and do take an active role in improving survival for themselves and their children. It means identifying and expanding ways to address the current gap in maternal and child mortality between need and access.
To fulfill our mission, Mali Health has established a set of 6 overarching goals to guide our priorities and progress. They are:
- Improve the management, function, and capacity of primary healthcare centers
- Strengthen the capacity and increase the scope of community health programs
- Increase financial access to care
- Strengthen mobilization efforts to increase resources accessible to the poor at the primary care level
- Demonstrate and communicate our model and work
- Increase organizational efficiency
Our programs, current and future, align well with these objectives. We will measure our success against these goals. And through these efforts, we’re confident we can alter the landscape of healthcare access in peri-urban Bamako, and through low-cost, people-centered programming, ours can serve as a model for innovation and progress in the field of global health.
To continue the conversation, to request more resources, or to more closely measure our progress over the coming months and years, I invite you to contact me directly: firstname.lastname@example.org
Written by Adama Kouyaté, Communications and Public Affairs Manager
As Mali Health enters 2014, we are planning to focus more attention not only on our direct service programs, but on collaborating with the government and other stakeholders to bring positive improvements to the entire health system. We’ve begun introducing this idea to our partners and beneficiaries in Mali already. Through our Health Radio program, we discussed the levels of the health system, and in our community listener groups afterward, we explored the ways in which we as an organization can interact with and influence the health system, and how community members can do the same.
As Mali Health’s Communications and Public Affairs Manager, I have worked as part of the teams leading these efforts. After we launched the health system discussion with our listener groups, Mali Health partnered with three local women’s associations in Bamako’s Commune 1. The associations came together to produce an extensive report detailing the best health system practices in Mali, as well as acknowledging and offering solutions for the biggest areas of improvement within the system. The report clearly identifies which government agencies or other stakeholders should be held accountable for which changes and lays out a roadmap to success. Mah Coulibaly, coordinator of one of the women’s associations, said: “our aim with this document is not to complain once again about our sanitation conditions but rather to contribute to improving them.” I was extremely fortunate to serve as principal liaison between the women’s associations and Mali Health, and I was thrilled to see the whole process of producing this important report.
After the report had been finalized, my team and I organized a public forum on November 14th at the Massaley Hotel in Bamako, to which eighteen different health organizations — including several government agencies — attended. The forum was an opportunity not only to present the report along with the women’s associations who had produced it, but also to give a voice to the poor and to launch discussions about barriers to universal access to health services, something that is not addressed as often as it should be.
I already count the forum as a success. The critical information contained in the report was conveyed to over a dozen organizations, and now we can begin to work together to address the most pressing challenges in the Malian health system. Additionally, this forum raised Mali Health’s profile, bringing us even stronger support from the Malian government and recognition for our commitment and ingenuity. We will use this recognition to continue to build stronger partnerships with local stakeholders and to drive for bigger and more lasting positive change in Mali’s health system.
I am very thankful for my six years of commitment to Mali Health — the good times and the tough ones — because every day, my hope for better days for all gets more and more visible on the horizon.
Written by Djibril Traore, Community Health Workers Coordinator
It happened some months ago, during a routine visit to one of my families. Someone reported that there was a problem that required urgent action. A child named SK had been badly burned in an accident at home. SK’s mother is a young woman named Oumou; she is raising SK alone, and she has very little to eat. She washes clothes for other people to make ends meet. When my colleague told me about the incident, I was deeply worried about the boy, and I quickly took my bike and rode as fast as possible to family’s home.
When I reached the house, I walked inside to see SK lying on a cloth next to Oumou. He was unable to stand because of his injuries. I could not hold back my tears. Oumou was distraught and desperate; she didn’t know what to do for her child. Her eyes were filled with anguish and sorrow as if she were saying goodbye forever, expecting that she would soon lose her son. I got a taxi and told the young woman to prepare to go to ASACOSISOU, the nearest health facility, built by Mali Health. We struggled to carry the boy into the taxi. Once we pulled up to the clinic and the doctor saw us with the child, he rushed out to help get him safely inside and immediately started treating his wounds. After some time, I called my superiors and explained the details of the situation.
That day, the clinic staff changed this family’s life, and Mali Health was part of that effort. We helped SK access the care he needed. After his wounds were dressed, we returned to the house and Oumou fed her son. A health worker continued to provide follow-up care and monitoring after that day to ensure that SK would make a full recovery. Oumou’s face was radiant, so happy and so lively as she fed and talked to her son; she thought she had lost the most precious thing in her life, but then had it returned to her.
Some time into his recovery, the mother and child came to our office, SK walking on his own at his mother’s side. She blessed Mali Health for what it had done for her and her son. I was very happy to see the child standing strong and improving, and we were all happy that he would fully recover.
I am very proud of Mali Health for its bravery, its tenacity, and the support and guidance it provides to people, as exemplified by this case with SK and Oumou. I want to say thank you to Mali Health, to my colleagues, and to our generous donors, who make our work possible. I am proud to be a part of this wonderful organization. Our mission motivates me and gives me the strength to continue on this path.
Written by Dr. Diakardia Traoré, Medical Advisor
It is August 17, 2013. It is 6:30 in the morning when I get in my car in Sebenicoro under a cloudy sky. I smile to myself; I feel I’ve accomplished a lot to help the people of Sikoro-Sourakabougou. Today is the opening of the maternity ward at CSCOMSISOU, the clinic Mali Health helped to build in Sikoro.
After a 45-minute drive, I pull up to the clinic gates. I lift my eyes to the sky and say “Thank you” with a heart full of satisfaction. The president of the ASACO (the local community health committee) Mr. N’faly Dembélé comes over to meet me and tells me, “Doctor, from my heart I thank you, I thank you for your help. What we are doing today, it is important to me not only as president of the ASACO, but as a resident of this area and as a father.”
As we approach the building, we meet Ms. Adam Traore, the matron of the CSCOM; she says to me, “Thank you, Doctor. This building will give us much better conditions in which to work. Women will no longer wait in pain because this new delivery room is much bigger; they will not fear for their privacy because this building is set apart from the others; and they’ll no longer have to rest with their newborn baby in the same room as the sick. As a woman, this maternity ward warms my heart and makes me even more proud to work here at the clinic.”
An old woman then approaches us. She had been looking for someone from Mali Health when she was told I was one of the people who built the maternity ward. In her soft voice, she began, “Dr. Traoré, thank you for your work. I accompanied my beautiful daughters here, just like the other women around us. Four years ago, I lost my grandson when my daughter gave birth at home. It was 3am and there was no clinic here to come to. It was a dangerous area, and we couldn’t find a taxi to take us to the hospital, so my daughter gave birth at home with no professional help. They were atrocious conditions in which to bring a baby into the world, and he didn’t survive. Now, only three months ago, my daughter gave birth again, this time here in the clinic; there were no problems, but she had no privacy either. With this new ward, our daughters are happy that they can give birth safely and privately, and we are just as happy for them. So I say thank you to everyone who made this possible. God bless you.”
I cannot continue on my way because I am stopped at all turns by people who want to greet me and express their thanks. A sense of pride rushes through me. I sit on a bench for a moment, and I start to think about all of the people who made this event possible: our staff, our partners, and the donors from all over the world who contributed to this project, especially the family of Rita Camardo, after whom the ward is named. Without them, I would not be here today receiving all of this gratitude. But I am, so I do it on their behalf; this gratitude is for all of us. Today, August 17, 2013, will forever live in my memory.
It was the last Friday of August 2013. In the meeting room, the health team was in a training on the implementation of mobile health. My office was open. From my desk, I saw the feet of the Chief of the Department of Communication and Public Relations. He has long legs, so while I could’t see his head, I had a good view of his shoes because his office faces mine from across the terrace.
Suddenly, I saw a woman step onto the terrace, a baby on her back, looking for someone to talk to. She had a big gleam in her eyes. It was just after noon. I walked over and invited her to come into my office and sit down. As she did, she took her baby off her back and handed the child to me with a smile on her face, saying, “I have to show you your baby!” It was like she was handing me a trophy. She seemed to have won a battle.
The woman’s name was Djelika Sogore. She had a cheerful air, which I quickly mirrored, as I took the baby from her. “What is our baby’s name?,” I asked. She told me his name is Kassim Coulibaly and he is 18 months old. She added,
I'm not the baby’s mother. I'm his grandmother. His mother died giving birth after a cesarean section, leaving Kassim to me. He is all I have left of my daughter. But he became very ill and very thin and had trouble breathing normally. I thought that misfortune was still knocking on my door and that I would lose what was left of my daughter. That's when officers from Sigida Keneyali (Mali Health’s local name) arrived. They drove my grandson to CSREF (a near-by health center) to be hospitalized, and he received intensive care for a month. I was told that my grandson was suffering from malnutrition and a severe respiratory disease.
After helping us get my grandson the immediate care he needed, Mali Health workers have often visited us to follow-up on his recovery and growth. On Friday, when I took him in my arms, he looked at me with eyes that remind me of my daughter; that look flooded my heart with joy. I thought to myself that I had to share this my happiness with the people who are behind this miracle, the officers of Sigida Keneyali. That's why I'm here!
I looked at the small child, and I too felt the joy deep within me, being a mother, a grandmother (my son has a 5-year-old son of his own), and having also lost my daughter (who would have been 30 years old now). What can I say? That joy, delivered through the eyes of this child, is indescribable and takes your whole being. I couldn't help myself, and I started crying. I invited the Chief of Public Relations from across the terrace to come and also experience the joy of a grandmother who has seen her grandson win the fight against child mortality.
After that day, I really understood why God led me towards Mali Health to be part of this team that is working tirelessly, and in conditions that are never ideal, to do what is vital: saving lives, providing dignity and empowerment, and giving hope to people forgotten by the health system.
This past weekend, the Rita Camardo Maternity Ward opened its doors for the first time, and – literally before the paint was dry – hosted its first delivery, a healthy baby girl, hours before the official inauguration.
The moment – and the whole new maternity ward – was made possible through extensive collaboration. Seattle foundation One Day's Wages and Mali Health's network of committed partners put forward much of the financing necessary. Moreover, local community members orchestrated a successful fundraising drive, the community clinic itself added support, and the government health system and the Malian Red Cross provided equipment.
Certainly, a building is just a building. It alone can't save lives. But the new facility will allow more room for prenatal care and family planning, and offer delivery and recovery space separate from the general ward, where newborns spent their first hours – the most vulnerable – on beds next to the infirm. Given that clinic births have increased nearly 300% since 2010 in Sikoro (one of the fastest growing areas in one of the world's fastest growing cities) we hold high hopes about the immediate and longterm impact of the dedicated maternity ward.
So far, it has paid off. Baby Diakité was born to Safiatou Ba this last Friday – just couldn't wait until the official opening.
Since last year, Mali Health has been working with professors of health economics at Brown University to launch a randomized control evaluation of Action for Health. The multi-year study aims to clarify the impact of free care and community health worker visits on the health of our target children, and provide analysis on health behaviors in similar communities. For us, it’s as much an opportunity to analyze our own impact as it is a chance to contribute to the greater field of international health and development.
The first step in this evaluation was a baseline survey, conducted last August 2012 with over 1,000 families, to measure indicators and conditions before any intervention had taken place. For Mali Health, the results of the baseline offer a clear picture of the financial and health status of our target families. With a focus on income, expenditures and assets, the survey showed that members of our program spend an average of $1.25 per person per day, living directly on the World Bank-defined poverty line.
During the 6-week survey, less than one in five children received care in a facility when sick. The tendency to avoid medical facilities may be related to cost, as families in the survey paid an average of $2.71 for care, whereas the care for a child enrolled in Action for Health costs about $7.00 at a public clinic, indicating a significant gap in what is financially needed and what is financially accessible.
A lack of accessible and timely medical care is one of the primary causes of Mali’s high rate of child mortality and this survey indicates that children are not receiving care when they need it most. But those children enrolled in Action for Health are able to access care; they are much more likely to visit a doctor when needed and much less likely to die from treatable diseases.
The information that Mali Health gained from the baseline will allow us to better plan our programs. But this is just the start. Moving forward, this evaluation will allow us to truly understand the difference our program – and others like it – can make. The families surveyed last August began receiving services through Action for Health in December. Today, we are preparing for the “Year-1” round of surveying in August, with the continued support of Brown University and new partners at the Aga Khan Development Network. As valued partners in our efforts to improve child survival in our own geographic footprint and beyond it, we invite you to stay tuned over the summer and into the fall as we share and build on these important lessons in global health.
To read the full article, click here.
By Devon Golaszewski. Special thanks to Anja Sautmann and Mark Dean, Professors of Economics at Brown University and co-Primary Investigators, and Samuel Brown, Research Assistant.
In the Global South, health systems and health seekers face an unavoidable and constant tension – how to provide quality and accessible care for the poor and how to pay for it. Common and preventable infirmities remain the world’s largest killers, while financial, geographic and knowledge-based barriers keep the indigent from seeking – and receiving – proper and affordable basic care. Simultaneously, health systems in the Global South are under-financed, poorly equipped and inadequately staffed. Where facilities do exist, patients endure long waits, are hospitalized in unhygienic conditions and receive hasty assessments and hurried follow-up directives.
This is a challenge that, while daunting, we hope to shed light on over the next two years. With generous support provided by the Izumi Foundation, a Boston and Japanese institution well versed in tackling some of the greatest global health challenges, Mali Health is developing an expanded health system-strengthening program. Our intent is to increase demand, improve services, and increase affordability at the primary care level.
Mali Health operates in one of the most decentralized countries in the world (one board member called it ‘A libertarian’s dream’), where community adoption and participation is vital to achieving any degree of lasting impact. Given this environment, the project intends to pilot and identify best practices that can be implemented without significant cost or significant long-term support. Working in 5 major areas – patient behavior, operational efficiency, transparency and goal setting, standardization, and financial strategies – the “model clinic” will be a partnership with an existing primary care center. Together, we will aim to achieve the following:
1. Institute a “Goal for Zero” child mortality target objective and culture at identified clinic(s)
2. Improve patient/maternal access to prompt and appropriate care and service delivery satisfaction
3. Strengthen a peri-urban health system’s efficiency, capacity and sustainability
Only now in its beginning stages, the office is busy with brainstorming meetings and planning sessions. We’re grateful to Izumi for the opportunity to collaborate on such an important project, and we look forward to sharing updates in this space as the program develops.
I'm thrilled to announce the hire of Mariam Fofana Diallo to Mali Health's team as the organization's new Programs' Director! The position will oversee all of Mali Health's current and future efforts on the ground.
Mariam is an accomplished leader in the field of global health and international development, having spent the last 10 years directing and growing programs for Population Services, International, as a Project Manager and specialist of strategy and behavior change communication in several posts across West Africa. Before that, Mariam served for several years as Peace Corp's Training Director in Côte D'Ivoire.
Mariam brings incredible experience, energy, and passion to Mali Health. Together with our Medical Director, Dr. Diak Traoré, and the rest of our local team, she will help to expand our programs and deepen our impact over the next several years.
Undoubtedly, she has some large shoes to fill, as current director Devon Golaszewski moves on to pursue a PhD after many years with Mali Health, the last two in this current role.
Thank you, Devon, and welcome, Mariam. And to our closest friends, partners, and longtime supporters to Mali Health, I couldn't be more thrilled to share our news with you.
With excitement and appreciation,