In early 2011, Djeneba, a resident of peri-urban Sikoro, became pregnant. Identified as eligible through a local survey, Djeneba was recruited and enrolled in Mali Health’s Action for Health program. Impoverished and isolated, Djeneba would not have had access to vital health services without the help of our program, but through it, she received counsel, education and monitoring by one of Mali Health’s Community Health Workers, Fanta.
That November, Djeneba gave birth to a healthy boy, Ali. Mali Health continued to monitor and aid Djeneba and Ali after birth – Fanta made frequent home visits and ensured Ali was immunized against the preventable diseases that all too often keep Malian children from reaching their fifth birthday.
Six months after Ali’s birth, Djeneba left Sikoro to spend several months in her family’s rural village. Immediately after she returned, Fanta made a visit to their house to check on mother and child and was met with an alarming sight: Ali had lost significant weight during his time away and exhibited signs of severe malnutrition. Fanta took action immediately, rushing Djeneba and Ali to the closest health center.
Through Action for Health, Ali received lifesaving medical care and access to qualified health workers. He remained in the hospital for 10 days, during which time he regained enough weight to be returned to his mother’s care. Though Ali was no longer in immediate danger, Mali Health’s work was far from over, knowing Ali would continue to require close monitoring to ensure his complete recovery.
Even after his release, Fanta observed that “Ali was so weak initially that he could no longer support the weight of his head.” Neither Djeneba nor her husband had jobs at the time, however, so Ali’s recuperation was in jeopardy. In response, Mali Health provided Djeneba with milk, grains enhanced with vitamins, fish, fruits, and legumes for Ali for the next two months. Fanta continued her close care, sometimes visiting Djeneba every day to check on Ali’s progress.
Today, Ali is 3 years old. He is no longer malnourished and lives a happy and healthy life with his mother in Sikoro. Djeneba is enrolled in our Health Savings program, where she can borrow pooled money for future health expenses or to earn a small income. Mali Health’s Action for Health program has helped 2,000 children like Ali, employing community-based solutions that not only provide for short-term health successes but also long-term improvements in education and care. Mali Health believes that everyone has the right to experience childhood without the looming threat of illness or death. Ali’s mother thanked Mali Health, stating, “I think God has sent Mali Health to help poor persons like us… May God accompany those who fund Mali Health’s activities.”
One of the primary reasons Malian families don’t seek care at the clinic is the high cost of treatment. Though we work with the clinic and other partners on initiatives to bring down the cost of a visit, the price remains out of reach for many families. Thus, through Action for Health, we provide free care to nearly 2,000 children under age 5 and subsidized care to over 900 pregnant women. Through the program, these children and mothers receive the care they need when they need it without the worry of financial burden. However, it is also our aim to create models in which families can better support themselves. We want to foster independence so that all families can access the care that they need with or without our assistance. So, in 2013, we launched the innovative Health Savings program.
Through the program, groups of women from across the community come together weekly to learn about preventive health care and financial management. These women also deposit small amounts of money into two collective accounts. In the first, members draw loans to support revenue-generating activities, such as starting a small business. From the second, women access no-interest loans in order to cover health costs at the local clinic. At the end of a cycle, women are returned their savings, along with the dividend through interest earned, and encouraged to make good on initial commitments to allocate funding saved to preventive health products. By removing the burden of cost from a single family, these women can now ensure that they and their children seek treatment as soon as they need it and can afford to follow the treatment as long as necessary.
Assan O. is a recent beneficiary of one of these health loans. When she fell sick, she was unable to carry on her business, and stopped earning an income. At first, she was afraid to take out a loan from her Health Savings group because she feared she wouldn’t be able to pay it back in time. She sought treatment at the clinic with the little disposable money she had, but it didn’t cover the medicines the doctor prescribed. Assan couldn’t afford the medication, and so she went without it for days, her condition worsening.
When the Health Savings coordinator visited Assan, he could see that her health was not improving. When she told him why she didn’t take a loan from the group, he assured her that she need not worry – they would find a way to help her repay her loan. She borrowed enough funds to purchase her medication. Her health improved very quickly after that, and at the next Health Savings group meeting, she explained the situation to her fellow members. They understood her predicament and granted her 60 days to repay her loan, rather than the usual 30, enough time for Assan to return to her business and earn an income once again. After 47 days, she repaid her loan in full.
Asked afterward how she felt about the Health Savings program, Assan said, “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.”
Dozens of women have benefitted from the loans they withdrew from their savings groups since the program began. Some, like Assan, have paid for health costs. Others have used their loans from the general fund to start or expand their businesses. Aicha S. from Bandiagara Coura used her loan to build on her already-successful small business selling earrings. She put the funding toward expanding her collection to include beads, necklaces, bracelets, and makeup kits. With the extra money she has earned from her new products, she paid back her loan within a month and now is earning more than ever.
Health Savings drew its first cycle to a close earlier this year, and group members and non-members alike made it clear they wanted a second cycle to begin immediately. Over 130 women participated in the first round. Between them, they withdrew nearly 75 loans, 17 of which directly subsidized health care costs. Over the course of the first cycle, group members learned not only about managing their money, but also about the importance of seeking early treatment for their illnesses, how to recognize danger signs in children, and what a woman can do to ensure she has a healthy pregnancy.
With International Women’s Day this month (it was March 8th this year), we are reminded of how much power women possess to be change agents in their communities. The health and education of women has a direct and irrefutable impact on the wellbeing of their children, and thus on the future of the entire community. Through Action for Health, we are ensuring that mothers receive the care and education they need so that they can keep their families healthy. And through Health Savings, we will help those same women to build the independence they need not only to support their families, but to have the power and resources to shape and change their communities for the better.
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.
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