Carving out a space for poor urban residents in Mali’s national health program

Amidst two national health care programs addressing access for the poor, MHOP focuses its energies on its unique constituency: urban residents.  Devon Golaszewski, Programs Manager and Health Financing Programs Coordinator, weighs in on her work in the research and development phase of an original health financing program with MHOP.   

Starting in 2010, two national programs will dominate Mali’s health care access landscape.  The first, Assistance Medicale Obligatoire (AMO), is similar to social security as known in the United States. This program is primarily for government employees and salaried workers, who relinquish a certain percentage of their salary in return for medical insurance.  The other program designed to overhaul Malian social security is Régime d’Assistance Medicale (RAMed).  The Département National de Protection Social et Économie Solidaire, or DNPSES runs program.  RAMed deals with indigent populations, or individuals lacking the basics of life due to poverty.  The national government will cover 65% of costs for indigent populations, and local governments will cover the remaining 35% of health costs to participants.  The Malian government estimates supporting just 5% of the population through RAMed.  In the past, this five percent has often been dictated more by political connection than need and MHOP is concerned that this will continue to be the case.

Devon Golaszewski, featured left, spearheads MHOP's health financing initiatives

Golaszewski also anticipates other problems with the RAMed baseline percentage model.  “RAMed officials have told us specifically that they predict that certain communities in Mali will have less than 5% indigency and others will have more.  While not stated explicitly, we at MHOP are worried that the naming of a 5% national indigency rate will prioritize rural poverty (which is much easier to measure: do you have electricity, a car, etc) and downplay the effects of urban poverty on access to health care.” 

MHOP is working to establish a strong relationship with the Malian government in the hope of providing a unique model for considering poverty using additional indicators.  Says Golaszewski, “In May, we undertook a survey which links access to health care and financial information with 308 households in Mekin-Sikoro. With the data from this survey, we plan to create a simple and easy-to-use list of criteria which correlate to financial inaccessibility.” Once analysis is fully complete, the model will be offered to RAMed and local government representatives to help identify populations that would most benefit from RAMed enrollment.  Mostly, the model pushes that access to health services be considered in addition to poverty as a qualifying indicator for enrollment.  

An MHOP-government relationship would help address two concerns: 1) How to ensure that the urban poor are included in the program and 2) How to certify that the appropriate people are enrolled in the program?   Defining ‘appropriate people’ – for Golaszewski, “those among the poor who need help accessing health care for financial reasons” – will be the more difficult question to confront.   In this particular project, success will require considerable work and a long-term investment.  “It is important to remember that our partnership is still in its beginning phase, but we are committed to working with the Malian government on this,” says [title my title? I  am currently the Programs Manager and the Health Financing Programs Coordinator]. 

If effective, the new approach could also serve as a lobbying tool for a larger percentage of participants in RAMed.  Golaszewksi shares, “Our goal is to create a program which will address financial access to health care for urban residents. [This] is a much different issue than financial access to health care for Malians – because most poverty in Mali is concentrated in rural, agricultural communities, the tools for improving access to health care are very different for us than for rural communities where 1) inaccessibility is often based on geography and distance 2) there is a much larger non-cash economy.”  

Change in healthcare access in Mali will mirror that of the United States – slow, and incumbent upon dedicated voices.  Golaszewski outlines some short-term benchmarks towards success: “RAMed will be piloted in certain communities starting in 2010. Our survey, and list of correlates linking access to care and financial status [x-noun-x], will be completed in the fall of 2009 and we hope to publish the results in medical or academic journals as well.” 

Asked what you could do to help, Golaszewski stated: “Our relationship with RAMed and the DNPSES takes a great deal of behind-the-scene resources --  the cost of phone calls, transport for staff members, time spent working on our survey, etc. We realize that supporting staff costs and overhead is not exciting! But it is this sort of support which ensures that long-term (and high-impact) relationships are created. $40 pays phone service for our office staff for 1 month; $100 pays one month rent at our office; etc.”

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