Mariam Fofana Diallow is the Programs Director at Mali Health Organizing Project (not Mariam Samessekou, the Community Health Worker profiled in our last report). While she loves her job, it isn’t always easy to face the daunting challenges present in the field of maternal and child health in a developing country. On a day in late August this year, she was reminded of the true importance and meaning of her work.
Mariam was working in her office when a woman stepped into the terrace, looking for someone to talk to. Mariam could see that this woman was brimming with excitement, and invited her inside. The woman, who introduced herself as Djelika Sogore, carried a healthy, smiling baby on her back. As she greeted Mariam, she handed the baby to her, proudly showing off her grandson.
The woman started to talk about the baby, Kassim, an 18-month old boy, her pride visible and contagious. Djelika’s daughter died giving birth to Kassim after a cesarean section, leaving Djelika to care for him in her stead. Djelika, while heartbroken, embraced Kassim as the last remaining link to her daughter and a much-needed inspiration in an otherwise tragic time. Unfortunately, shortly after her daughter’s death, Djelika’s tragedy seemed as if it would soon double as Kassim grew very ill and thin. Djelika said, “I thought that misfortune was still knocking on my door and that I would lose what was left of my daughter.”
Djelika’s luck changed when officials from Mali Health arrived. Kassim was suffering from malnutrition and a severe respiratory disease. He was taken to a hospital where he received intensive care for a month. With the help of Mali Health, Kassim fought for his life and won. When Djelika was able to take Kassim in her arms once again, she was overwhelmed with happiness, telling Mariam, “he looked at me with eyes that remind me of my daughter; that look flooded my heart with joy.” Djelika sought Mariam out in order to share the jubilation she was so thankful for with those who made it possible.
Even though Mali Health faces significant challenges, stories like that of Djelika and Kassim keep Mariam motivated. Looking at the small child, she thought of her own son and late daughter, and began to cry. Kassim’s second chance at life serves as a testament to the power of the fulfillment of Mali Health’s mission. No child’s life should be put in jeopardy by a preventable or curable illness. What motivates Mariam is what motivates Mali Health: “Saving lives, providing dignity and empowerment, and giving hope to people forgotten by the health system.”
Over the last months, Action for Health has achieved impressive numbers. Health Workers conducted nearly 8,000 home visits. 1,217 children completed clinic consultations, made possible by Mali Health’s financial support. At a recent meeting, mothers stood and recounted the progress of their children and their communities with Mali Health’s intervention, met by much applause. As Mariam currently spends two weeks making visits in the US, she is relaying the messages of hope and gratitude from the many like Djelika and Kassim, partners in our progress.
Over the past year, Mali Health has expanded Action for Health to nearly 2,000 children under 5 years old, made possible by a frontline team of local health workers that serve as a vital link between the community and the health system. Mariam Samassekou is one of those health workers, and this month, celebrates one year on the frontlines with Mali Health.
Every day over this past year, Mariam has faced the challenges and rewards that come with working directly with families to improve the health of her community. She regularly visits over 100 children in the poor and isolated community of Sikoro-Sourakabougou, on the outskirts of Bamako. She monitors the health of children – taking their temperature, height and weight, and checking for signs of malnutrition. She consults with the parents about the measures necessary to ensure proper nutrition, sanitation, and health for their children during their most formative – and vulnerable – years. And when a child is sick, she informs the parents of the need to go to the local community health clinic, and accompanies the child to make sure he or she gets fast and appropriate care.
Over the last month, Mariam conducted 150 home visits to families in Sikoro. Among them, she conducted 6 prenatal evaluations, and accompanied 17 children to the clinic. One of these children was Baba.
Last month, during her routine visits, Mariam noticed Baba showing signs of malnutrition, a common yet dangerous problem among young children in Mali. Poor families here often rely on simple meals high in inexpensive carbohydrates and low in protein and other nutrients. If unrecognized or untreated, malnutrition like Baba’s can lead to developmental delays and make other common childhood illnesses in Mali – such as malaria or measles – more dangerous and costly to treat. It can also kill. Luckily for Baba, this wouldn’t be his case. As soon as Mariam spotted the symptoms of malnutrition during her regular visits, she was able to bring Baba to the clinic, where he was seen by a doctor and received immediate treatment. The entire time, Mariam was on-hand to make sure Baba was seen promptly, received appropriate care, and that Baba’s parents understood his condition, what caused it, how to treat it, and how to best prevent it in the future (among them, more high nutrient meals, the theme of recent health worker culinary demonstrations).
Mariam is one of 19 health workers. And Baba is one child of the 1,886 now enrolled. Eight months into this year, Mali Health’s cadre of community health workers have conducted 17,426 home visits, accompanied nearly 900 sick children to the local clinic, and provided prenatal care for 126 pregnant mothers. Local morbidity and mortality rates have dropped, and through a innovative new financing approach, we’ve also seen the average price of these visits (covered by Mali Health) fall from $11.89 to $8.19, a 31% reduction. Currently, we are in the process of evaluating year-1 results of the collective impact of this work, but to Mariam and her fellow health workers, it’s all about one child like Baba, one lifesaving visit, and one family educated and empowered at a time.
In an effort to appease the left brain with the right, please excuse a number-crunching update as we begin to share some important result from an exhaustive study currently being conducted on our programs. Since last year, Mali Health has been working 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 has 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. The average family size is 6 individuals, while half of these families live in just one room. Residing in a semi-urban area, a majority of families have access to electricity and latrines but almost none have running water. Most families get their drinking water from public taps, and close to a quarter drink well water. Additionally, 63% of the parents in our target families are illiterate, and only 15% have education beyond primary school.
Using techniques from behavioral economic research, the baseline explored Malians’ beliefs about health and health care. Here’s an example: “Suppose one day you hear about 10 children from your neighborhood, each with a fever for four days. Of these 10 children, how many do you think would start getting better the next day if their mothers sought x treatment?” In response, women estimated that only 20% would recover with no treatment, but that 75% would recover following a visit to a public clinic. (Mothers also estimated that 49% of children would recover with treatment from a traditional healer and 36% from an unlicensed pharmacy, confirming their confidence in the health system). These results indicate that our program participants see the value of medical treatment in leading to positive health outcomes.
Despite this confidence, however, related behaviors indicate an aversion to the clinic when children get sick. During the 6-week survey, when a child fell ill, nearly one-third failed to access any sort of care, one third accessed informal care, defined as traditional medicine, herbs, or unlicensed pharmacies, and a last third had some form of access to the primary health system. Under 1 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 on average $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 our programs are able to access care; children enrolled in Action for Health 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 already 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.
By Devon Golaszewski, Programs Director. Special thanks to Anja Sautmann and Mark Dean, Professors of Economics at Brown University and co-Primary Investigators, and Samuel Brown, Research Assistant.
Late in 2012, a group of enrolled mothers in Mali Health’s Action for Health formed a women’s association. Earlier this year, they registered in one of our Community Mobilization workshops. The group was guided through a training curriculum that helped them develop their technical capacities to implement needs assessment and participatory research in the community, two techniques designed to identify local assets and challenges. With these learned skills the women identified a community problem (lack of access to clean water), proposed a solution (finish digging a partially-dug well), and organized the process to realize a solution (obtain financial estimates, engage local actors, develop a fundraising plan). Today, this women’s group represents the driving force and the sweat equity towards the community’s improved water access.
In another division of our Community Mobilization efforts, Mali Health’s radio show broadcasts citywide programming that focuses on issues of health and local governance. Last year, our radio show broadcasted a series of minute interactive shows on the Malian Ministry of Health’s Essential Family Practices, including the importance of complimentary feeding for children over the age of 6 months. Several listeners called in to discuss the theme, including representatives from 3 women’s associations. Inspired by the Essential Family Practices broadcast, these 3 associations proposed an educational activity on malnutrition. Mali Health staff responded, implementing a training on how to access nutrient-rich foods in local markets and how to facilitate their own workshops on the topic. Leaders from each group then organized and implemented a training with their own communities, applying their learned capacities and inviting community health workers from local clinics to talk about complimentary feeding for children. The group members also proposed their own monitoring strategy, following up with participating families over time to identify adopted practices. In sum, this activity reached almost 1,000 people.
These two examples exemplify a key element to Mali Health’s work. We don’t stop at providing opportunities for leadership. Rather, we hope individuals will take them. Action for Health, then, is measured for success on multiple levels. Our Community Health Workers labor tirelessly to ensure every child under their watch has the support they need to stay healthy and access care when needed. It is because of them that our program has maintained a mortality rate of less than 1% for the third straight year. But Mali Health, in its current iteration and in its present footprint, won’t exist in perpetuity – our own goals and the many challenges in Mali and in global health deter any making of small plans. Our success then, is measured in the ripple – in diffusion, in collective action, in the internal pull of a community over external push of an organization.
Mali’s many challenges remain exposed as we soon mark one year since a coup d’état toppled a house of cards. Know that, in the midst of this struggle, progress is accessible. Mali Health’s beneficiaries refuse to have it any other way.
Once considered a haven of democracy in an otherwise-volatile region, over the last several months, landlocked Mali has become a state stricken by national, regional, and geopolitical crises. Since March of this year, the country endured a military coup d’état, regional food insecurity, a malleable transitional government, a separatist uprising, and the occupation of the country’s northern half by religious extremists.
Over 350,000 have been forced to flee. Just earlier this week, the Prime Minister was arrested and forced to resign, shedding light on the challenges of civilian rule and the role the military is playing behind the scenes. While claims of Mali becoming the “Next Somalia” or “Africanistan” are largely sensationalist, it's true that acute issues have arisen in a country plagued by chronic conditions of poverty and ill health, creating a more precarious and volatile environment and leaving Mali’s population – most notably its women and children – particularly vulnerable. Many actors engaged in transformational work – in health, economic development, or agriculture – have been forced to closed their doors or indefinitely suspend operations.
As is often the case, it is the poor that suffer most. Jobs are lost, livelihoods endangered. Resources become scarcer and many lack the capacities or networks to find refuge elsewhere. The displaced populations from the north that have arrived where we work on the outskirts of Bamako – some 400 miles from the line in the sand between government controlled and occupied territory – typically have moved in with family members, who share whatever extra space or food they have.
As the unpredictable winds of political fragility, food insecurity, and extremist agendas continue to blow, Mali Health remains committed to carrying out our intended operations – reducing maternal and child mortality via a three-pronged approach of community empowerment, direct services, and system strengthening. Recognizing the position we’re in to offer additional support to the displaced and the shifting situation writ large, we do what we can, maintaining close communications with local governing bodies. We recently hosted a radio show on the experience and health challenges of the displaced, joined by the mayor of Gao, once a commercial center for trans-Saharan trade and now one of three main cities in the north occupied by extremists.
It’s encouraging that we’ve persevered and are growing – after a month-long delay, we’re finally expanding operations to include free care for 1200 more children and holistic support for their families, while we’ve begun to provide technical training to new community groups and have plans to construct a maternity ward in 2013 – but disheartening as well to realize the limits of our own capacities. To some degree there is overlap between the reasons for our existence and the causes that have precipitated the fallout – factors like poverty, weak governance, growing populations, and scant resources.
From the ground it's evident that civil society has an important role to play within the current context. When disaster strikes anywhere, one looks to those closest to them for support – family, friends, neighbors. Social systems within Mali are incredibly strong, a place where nearly everyone is considered an ancestral cousin. Civil society - the development capacity that emanates from within the country, coupled with the generosity of outside states, organizations, and individuals - has the capacity to ease suffering, save lives, and even hold sway over current events. It’s clear that avarice and ego can exploit a power vacuum. With or without dependable systems of state structure, it’s our belief that there remains a responsibility to act, and with it, an opportunity to carve out a stronghold, however small, in that vacuum.
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