Mali Health has seen its first major victory in the fight against Ebola! A woman who was confirmed to carry the disease has been completely cured. This is a victory not only for Mali Health, but for all of the members of our coalition who are working tirelessly to quash this outbreak. This victory required a tremendous coordination between our Community Health Workers, the staff at the clinic, and our community partners. We are doubly excited to share this news with our community because it proves what we have been advocating for months: Ebola is preventable and curable with the proper care.
While we hope that this is the last case of Ebola that our country sees, we can use this experience to inform our response to the rest of this outbreak. Two important lessons we can take away: 1) It is imperative to call emergency services as soon as a person shows symptoms; if the person must be moved to a health center, it should be done by professionals who have the training and equipment to do it safely. 2) We must educate as many people as possible to combat the stigma around this disease and allow those who are sick to come forward and get the care that they need. Together, we can end this outbreak before it affects any more families.
In September, the Dorothea Haus Ross Foundation generously donated lab equipment to the community health center in Sikoro-Sourakabougou (CSCOMSiSou). It was a request the staff at the clinic had long held; even the best-trained personnel could only provide basic primary care without the equipment necessary to diagnose and then treat many less common diseases. Patients who needed this higher level of care were faced with two choices: remain at CSCOMSiSou, the closest clinic to them, and receive whatever care doctors could provide; or venture much further away, incurring the cost of transportation and time spent, to a clinic that had the equipment necessary to provide full and appropriate care. Until now, patients have largely chosen the latter option, sometimes even bypassing CSCOMSiSou altogether to seek care at other clinics. As a result, CSCOMSiSou saw fewer and fewer patients, and its revenue began to fall dramatically. Those patients who elected to stay and receive treatment at their home clinic often paid a higher price for medication that didn’t always address their condition.
This lab equipment, provided by the DHR Foundation, has already served to better diagnose and more effectively treat patients at CSCOMSiSou. With quicker and more accurate diagnoses, patients receive treatment faster, and doctors are able to prescribe appropriate medications, often resulting in reduced costs at the pharmacy. With the improved ability to provide more advanced care, the center retains more patients, increasing its revenue and therefore the resources to further invest in stocking diverse medications and training its staff in new and more effective consultation and treatment techniques. Mr. N’fally, the president of the ASACO community health committee, and Dr. Diarra of CSCOMSiSou, had this to say about the new equipment and the clinic’s renewed ability to provide more advanced care to its patients:
Written by Danielle Hull, Monitoring & Evaluation Coordinator
Earlier this year, Mali Health proudly announced we’d been awarded our largest grant yet: $100,000 from the Bill & Melinda Gates Foundation to implement a health system strengthening project at four community health clinics on the outskirts of Bamako. The grant, which aims to support bold ideas in global health and development, represents a momentous opportunity for Mali Health to address a problem we’ve confronted time and again through our work: major advances in maternal and child health require strong, resilient health systems, which are lacking in our communities.
Our project aims to support local clinics to better care for their populations though quality improvement and better management strategies. Within the clinic, itself, our approach will focus on the entire patient experience, from the check-in process to follow-up care. We will ensure that every patient receives the highest possible quality of care by working with medical staff to follow a standardized consultation process and to provide all appropriate tests. We will also work to ensure that clinic staff have access to all necessary materials for care provision and that they follow basic hygienic practices. Outside of the consultation room, we will work with medical and administrative staff to reduce patient wait times, improve doctor-patient communication, and identify and eliminate bottlenecks and inefficiencies.
The project – known as “Projet Amélioration de Qualité,” or PAQ (pronounced like “pack,” meaning Quality Improvement Project) – will stretch across four communities and clinics: Boulkassoumbougou, Lafiabougou, Sotuba, and Sikoro-Sourakabougou. In August, we held a three-day training with community health association members, clinic staff, and patient representatives from each of the four communities to cover tools and strategies for continuous quality improvement.
The first day of the training, I must admit I was cautious, even skeptical. Quality improvement and monitoring really aren’t a part of the work culture in Mali’s under-resourced community health clinics. I wondered if participants would be willing to openly discuss problems that exist at clinics. Would they react defensively? Would we be able to meaningfully engage clinic staff and community members, who are often under- or unpaid?”
My anxiety was quickly quelled. After we’d gathered in the meeting room, the patient representatives stood up, introduced themselves, and immediately began to engage their audience, acknowledging the hard work of the clinic staff, all the while respectfully advocating for the concerns of the patients who frequent the clinic. I could tell then that this meeting was a turning point, a significant step in the right direction, the start of an honest and open discussion of how to improve the care available to community members.
Where at first I had feared that clinic staff would be even more reluctant to engage — wishing not to acknowledge problems within their home clinics — I was astounded at their eagerness to speak up and offer their perspective. Our discussion progressed to quality improvement case studies, and doctors, nurses, and midwives from every clinic came forward to volunteer their own stories and acknowledge cases where they and their teams could benefit from a focus on quality improvement.
We are several weeks into this new and long-term project, and it is not without its challenges. Each clinic faces different deficits, whether in terms of supplies, personnel, or management experience. Each community will face individual struggles on the path to improving patient care and services and ensuring clinic self-sufficiency. But in the face of big problems, the key is to focus on small targets and small victories, such as this midwife’s reaction to a new supervision strategy to ensure a complete and standardized approach to prenatal consultations: “I’ve been doing [obstetrics work] for years, but in the past few weeks, I feel that I, myself, have learned so much! I know now that I’m doing quality work and every chance I get, I review the steps so I can improve.”
Written by Diana Vergis Vinh, Mali Health volunteer & champion. All photos courtesy of Diana Vergis Vinh.
Would people still eat pounded millet porridge? and Would they have the same teasing cousins? were some of the questions going through my head as I returned to Mali to work with an American health organization 30 years after serving as a Peace Corps health volunteer. Looking at the old Malian man sitting next to me in his traditional dress and beard I thought, Not much has probably changed. Then he took out two cell phones from his flowing brocade shirt and shook several SIM cards from a used pill bottle into his hand. “Because I am a merchant I travel a lot and have a different card for each country,” he said as he expertly switched out his phones. Hmm, maybe a lot has changed, I thought as the plane touched down in the Bamako airport.
Security measures are much tighter, I observed as a soldier in a glass booth carefully took my fingerprints and examined my passport. Then I walked through the airport doors onto the same tiled patio I had crossed before and the warmth of the sun and the smell of ripe mangos hit me. I saw a cab driver holding up a sign for Mali Health and made my way towards him. As I sunk down into the car, the Bambara language came flooding back and I asked him about his day, his family, his friends and finally his name. When he replied that he was a “Traore,” I informed him with great gusto that he was “not a serious person and that his preferred food was beans.” Surprised, he gleefully replied, “Oh no! Your last name is not Diarra, is it? Walai! You are the bean eater!” One question was answered: the joyful tradition of teasing cousins was still going strong.
I was completely lost as we made our way towards the office; Bamako is one of the fastest growing cities in the world and it is enormous. Happily, the driver knew exactly where to go, and soon I was meeting the skilled and friendly staff at Mali Health. The brightly painted cinder block structure looked familiar, but as I talked with staff I learned that many of the health conditions I had seen — such as guinea worm, cholera, measles, onchocerciasis and leprosy — were much reduced. Maternal and infant mortality were lower as well. Sadly, malaria is still going strong, and it is one of the main things Mali Health is now focused on fighting.
The next morning, I went out to a suburb of Bamako to take pictures and videos of staff and patients at the Mali Health partner clinics. A lesson on water sanitation for the community health workers was being presented via a Powerpoint projection on the plaster wall. Midway through the talk, everyone broke up into small groups to brainstorm and create posters on ways water could be contaminated. I asked the workers about whether people were resistant to treating their water or using the suggested 20-liter containers. “No, they have seen that their children are healthier when the water is cleaner and there are few problems getting people on board,” was their response. This heartening reply was a far cry from my failed efforts at getting people to screen their water to prevent guinea worm.
So what did it feel like to be back after so long? In short, it was wonderful; so many of the things I loved about Mali — the warmth and energy of the people, the beauty of the country and the delicious food (I did have the porridge) — were still there, and now good health practices, such as regular vaccinations, water treatment, and prenatal care, seem to be taking hold as well. There is concern about the revolt in the north and worry about politics in general, but as I got on the plane to fly home, the Bambara proverb, “An orphan is not a person who has lost their parents, but someone who has lost hope,” still seemed to ring true.
(This proverb is a little more genteel than my favorite: “You can’t run and scratch your butt at the same time.”)
This week, Mali Health’s long-standing Health Radio program was named one of the Sustainia100. Sustainia, a Copenhagen-based NGO, recognizes development programs around the world that employ a sustainable approach to improving the well-being of communities.
Health Radio reaches thousands of listeners, broadcasting on Bamako’s most popular radio station. Radio remains the dominant form of media in Africa, and therefore has the potential to reach the highest number of local residents. Crowding, land use, and sanitation have all become increasingly important challenges in the slum communities of Bamako, and Health Radio mobilizes local residents to address these and many other health concerns together.
You can read more about this year’s Sustainia100 here (we appear on page 128). And you can read more about Health Radio and its role in our larger advocacy efforts here.
Written by Danielle Hull, Monitoring & Evaluation Coordinator
At age 28, Fatoumata Diarra is the mother of four young children. However, she only received pre- or postnatal care for one. “For my first three children, I never went to the CSCOM to see the doctor or midwife. I’d stay at home and not talk about my pregnancy” [a common practice in Mali as some women are worried that talking about a pregnancy will lead to bad luck with the pregnancy]. Fatoumata, like many women in Mali, used to give birth unassisted in her home high atop a hill, a difficult walk to the nearest clinic. This lack of geographic access to professional care is one of the reasons maternal mortality remains high in Mali. “It was always a little scary,” she said. “I never really knew what was going to happen, or even supposed to happen, during each birth.”
But that changed with her last pregnancy; by then, she’d been enrolled in Mali Health’s Action for Health program. Her community health worker made regular visits to her hilltop home to monitor her pregnancy. With the help of Mali Health, Fatoumata made all four of the WHO-recommended prenatal visits, where she received counseling and advice from midwives. Also for the first time, she had access to medication to prevent malaria and a vaccine against neonatal tetanus, both life-saving medicines. And when she was ready, she gave birth at Mali Health’s newly-constructed maternity ward with the assistance of trained doctors and midwives.
“There is definitely a difference between my births. Before, it was very scary and my children were small and sickly. The last time, I knew that everything was going to be okay, because I’d gone to prenatal visits and was with doctors, and my baby was born bigger and has stayed healthier.” Too often in Mali, the day a baby is born is the most dangerous in the life of mother and child, and 1 in 28 mothers in Mali will die from pregnancy-related causes. But Fatoumata Diarra will not be one of them.
Today, May 1st, is Labour Day, and I wish each of you a good day of deserved rest.
I know that I am demanding and that I ask the very best of you in everything that you do for Mali Health. I also see that you not only meet, but exceed what I ask of you. You all work tirelessly to advance our mission and to help reduce maternal and child mortality in our communities. You help us to realize our vision of a more just world, one in which everyone has access to quality primary care at a lower cost, one in which everyone’s dignity is valued and preserved. You all should be proud of yourselves and your colleagues because you have chosen to take on this life-changing work each and every day.
The photo below shows the thrush, also known as the Lily of the Valley, a symbol of Labour Day. It is also a symbol of renewal, rejuvenation, which you help bring to the families in our communities every day. Many live in desperate conditions, lacking money, lacking information on how to stay healthy and avoid disease, how to access care when they need it, not knowing how to work in partnership with health professionals to get affordable and effective treatment. You are there to help them bridge those gaps. You are the lily in the valley of the poor.
Thank you, thank you, and thank you again for your work!
And together we thank our donors, without whom, we would not be able to do this important, life-changing work, improving the lives of thousands of mothers and children in Mali. Thank you to all who help to make this world a just place.
Mariam Fofana Diallo
Last year, Mali Health launched its health system strengthening program, Project Izumi (named after our partner, the Izumi Foundation, which provided funding for the program), to work across all levels of the system to improve access to and quality of care for all members of the community.
Improving a whole system is a daunting task if looked at as a whole. That’s why we have adopted the Kaizen Methodology, an approach that helps to simplify the improvement process. Through Kaizen, the ultimate goals for improvement are broken down into small, achievable tasks. Every member of the team is expected to work toward these small tasks every day, enabling continual progress toward the ultimate goals of a more effective and efficient system.
We recently put this method into practice at our partner clinic, CSCOMBoul1. Patients at the clinic had identified issues with communication between themselves and clinic staff. Specifically, patients noted that they had no prior knowledge of what services are available at the clinic and what the services cost, leading to some reluctance to seek treatment and confusion when they did seek help. Therefore, our team at the CSCOM worked with staff to create a sign listing available treatments and services, as well as their cost to patients.
This sign is now prominently posted near the entrance to the clinic so that patients will know what to expect when they meet with the health providers. Informed patients feel empowered and are more likely to seek treatment for their ailments quickly.
This is just the first step in what will be an ongoing process of achieving significant improvement across the health system, but it is indicative of the fact that real, meaningful change is possible. The Deputy Chief Medical Officer of CSCOMBoul1 recently expressed his enthusiasm for the new efforts: “Kaizen sessions have allowed us to be better organized, with a conscious awareness of our staff. We believe we can solve the various challenges the CSCOM faces with Kaizen sessions.”
Outside of the clinic, our Project Izumi team organized a community meeting to promote the importance of prenatal care. Recently, a woman experienced a stillbirth at the clinic. We strive through Project Izumi to reach zero child mortality, so our team worked together to organize this public forum reinforcing the importance of prenatal care for all pregnant women in order to ensure a healthy pregnancy and birth. The forum was well-attended, and it is just the first of many conversations and events that will help to provide better health for the families in our communities.
Written by Dr. Ariel Pablos-Méndez, Assistant Administrator, Bureau for Global Health, U.S. Agency for International Development
This article originally appeared in March 2014 in Impact, the magazine of PSI. Reproduced with permission. www.psi.org. All rights reserved. To read the full issue, please visit www.psiimpact.com. PSI is a partner of Mali Health.
In his State of the Union Address 2013, President Barack Obama set forth a vision for achieving what would be one of the greatest contributions to human progress – eliminating extreme poverty. There are many ways in which the global health community can contribute to this bold vision. The U.S. government has honed in on two goals that we know are within reach, achievable and sustainable, and has fully aligned with the United Nations Millennium Development Goals 4, 5 and 6 – ending preventable child and maternal deaths by 2035, and ensuring an AIDS-free generation. Protecting human life and health is one of the best ways to eliminate extreme poverty.
As a global health community, we have the skills and know-how to accomplish these goals, but we must work together and recognize that the ‘secret ingredient’ that binds all of our collective knowledge, skills and interventions is a strong health system. The Lancet Commission on Investing in Health reported this past year that such goals are indeed feasible and would bring about a grand convergence in life expectancy between poor and rich nations in our lifetime. The required investment would pay off 9 to 20 times in full-income returns, and to succeed, half of the resources should be used to strengthen health systems – from human resources to better governance of the sector’s public and private components.
As an experienced public health physician and former managing director at the Rockefeller Foundation, where I led its global health strategy on the transformation of health systems, I firmly believe that U.S. and host-country investments in health systems strengthening and integration of services will further accelerate an end to child and maternal deaths. In fact, the USAID restructured the Bureau for Global Health in 2012 and created the Office of Health Systems. This new office not only works across all of our technical areas – from nutrition and family planning to malaria and HIV/AIDS – but collaborates with multilateral and bilateral partners to address age-old barriers related to building strong health system infrastructure.
But let’s first clarify what we mean by strengthening health systems. To deliver quality health care, we must look through multiple lenses – that of the host government, the health practitioner, the community health worker and, most importantly, the patient. From the perspective of our host government partners, determining how to finance universal health coverage (UHC) so that essential services are accessible to everyone and no one is thrown into deeper financial hardship because of a catastrophic event is a growing priority. Both the World Health Organization and the World Bank have prioritized UHC as the new frontier for global health and the way to ensure primary care with equity, efficiency and quality. Furthermore, in order to create an enabling environment for UHC, it must be a political priority for the host country, both in word and deed. Increases in country-level investments to augment donor investments will be a critical component for long-term sustainability, and this will be possible in a growing number of countries that are moving from low-income to middle-income status.
From the point of view of a health practitioner, their ability to deliver quality health care is dependent on how well they are trained, and whether they are stocked with proper supplies and equipment, have decent working conditions, and have a manageable workload. Improving medical record-keeping and receiving timely and reasonable pay are also critical components, and we can look to using technology in innovative ways to help the developing world leapfrog to more advanced systems, while simultaneously building deeper partnerships with academia and professional associations to train health practitioners.
Faith-based volunteers and community health workers are the ‘engines’ of health systems in much of the developing world, and are a tremendous asset, as they connect the patient to the system. They are often the patient’s first point of contact, and play an important role in diagnosing, counseling and triaging to what level facility a patient should be sent. With incentives and proper training, they can counsel a pregnant woman to go to her antenatal care visits, ensure that she gets proper nutrition, and is tested and treated for her HIV, and help her arrange transportation prior to delivery at a health care facility by a skilled practitioner – all important steps in preventing newborn and maternal deaths.
Then there are the patients, the whole reason the health system exists in the first place. Patients need to know that they will be treated with respect and care, and as more than just a specific disease or condition. Knowledge is power, and communities and patients can better protect their health and well-being when they are educated and empowered to seek out care. Therefore, we look at strengthening health systems by integrating services, which further maximizes donor and host-country investments.
Developing strong health systems should not be seen as a separate exercise from other technical areas, but rather as a philosophical shift in how we build those technical teams so we are thinking holistically about how to get the best value for money and, ultimately, save the greatest number of lives. Ongoing work should quantify and clearly make links between health systems strengthening investments and their impact on patients, families and society.
Over the past three months, the pilot phase of our Health Savings program drew to a close. Several groups have already started their second cycle, eager to take advantage of the opportunities the savings groups offer to pay for expensive health care costs, as well as providing funding for women’s small businesses. Over 130 women participated in the first cycle of the program, and over these first months, over 100 loans were withdrawn, many of which have helped to change women’s lives. Aicha S., for example, used her loan to expand her business selling earrings, and now she sells many different items, which has raised her income higher than ever before. She and her family will benefit from this opportunity provided through Health Savings. Below, Dramane Diarra, Health Savings Program Coordinator, shares a story of another woman who can attest to the real impact of the program:
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One recent Monday afternoon, I set out for my weekly meeting with one of our groups from the Health Savings program. When I arrived, I discovered that Assan O., one of the group members, was missing. After our meeting, I asked the other members where she was that day, and they informed me that she had been sick for the past five days. I asked if she had taken a loan from the group’s health care fund to seek treatment at the clinic, and they replied that she hadn’t.
After the meeting, I walked to Assan’s home to check in on her. As I approached, I found her resting on a mat outside of her door. I sat down beside her; she was pale and clearly very weak.
I asked her if she’d seen a doctor, and she assured me she had; she’d gone to the CSCOM (clinic) for a consultation at her own expense, and the doctor had given her a prescription. However, she didn’t have the money to purchase it.
Concerned, I asked her why she hadn’t borrowed money from the Health Savings group’s health fund, and she replied, “I’m afraid of taking a loan from the group because right now I’m not able to run my business, and I’m afraid that I won’t be able to pay back the loan on time.”
Because the terms of each loan are set by the group, there is room for flexibility. Once I was able to convince her that we could help her pay back the loan on time, we walked directly to the home of the woman who managed the group’s health fund. Assan took a loan for 5,000 FCFA (about US$10).
Two days later, I stopped by Assan’s house again and found that she had purchased all the medication the doctor had prescribed her and was already feeling much better.
Assan’s health had improved enough for her to attend the next group meeting, where she explained to the group the loan she had taken and why. Her fellow members, understanding her initial reservations, granted her 60 days to repay the loan instead of the normal 30, enough time for Assan to return to her business and generate an income once again.
After the meeting, I asked Assan how she felt about the Health Savings program. She told me, “I was pleasantly surprised by the quick and easy way in which I could access the loan to pay for my treatment. If I couldn’t have gotten it, I would have been really scared. I am very grateful to everyone in the group, but especially to you for convincing me to take the loan. This is very important to the women of this community. With initiatives like this, we will not be afraid to reach out for care for a lack of money because with the health fund, there is hope.”
With her health improving, Assan gradually returned to her business, and she was able to repay her loan within 47 days.
Since then, all of our group members have come to realize that there is no need to be afraid to seek health care for a lack of money. Through the Health Savings program, they can rely on one another and access they care they need.