One week from tomorrow, the Mali Health office will be full, our new cadre of Community Health Workers reporting for duty for their first days of training, a two week course designed and led by local medical staff and our own Medical Advisor. The hiring of these 12 new frontline field workers is the latest step in a nearly yearlong process of preparing for our next month’s expansion – the organization’s largest in its history. By the end of October, we’ll be supporting 1,600 children under 5 years old with free care for 90% of all childhood infirmities (like diarrhea and malaria), and nearly 8,000 individuals in the Sikoro-Sourakabougou community with subsidized prenatal services, health education modules, and malnutrition prevention programs. Additionally, the upcoming extension will be rolled out in tandem with a rigorous program evaluation performed by Brown University and implementing partner Innovations for Poverty Action (IPA), measuring the effectiveness of our Action for Health interventions through a multi-year randomized control trial, elevating further our excitement – and the potential impact – surrounding this expansion.
As proud as we are to be able to support and develop a population of this size, equally impressive has been the process to arrive at this point, meticulously undertaking a number of steps that ensure Mali Health is reaching the populations we target – the poorest and most vulnerable women and children – and using our resources most effectively.
Preparation for this expansion began months ago, commencing with a meeting with the region’s traditional leaders in January, 2012. Together, we identified a number of potential zones to work in – those poorest and most geographically isolated from access to basic and governmental services. Specifically, criteria for inclusion included:
Having originally identified 8 areas, our general criteria helped us limit it to the following five within the greater Sikoro-Sourakabougou area:
Once the areas were selected, we undertook a massive survey to identify which households and families would be eligible for the expansion. Working closely with Brown and IPA, we to structured the survey carefully to attain the large amount of information we needed, while making it as logistically feasible to administer and keeping reasonable the amount of time each survey took. In the end, we focused on a wealth index that indicated just how much each household spent on food, per person per day. Under a certain amount, and that family would be eligible for program participation
Upon completion of the design of the survey, we hired and trained a team of 12 to implement it within each zone. Trained in specific capacities like GPS systems and obtaining consent while working in teams of two throughout the community, surveyors spent two months undertaking the laborious process of interviewing thousands of families to collect the pertinent consents and household status information, and bringing that data back to the Mali Health team. One supervisor was responsible for monitoring the work, accuracy, and accountability of the team.
Finally, the last phase of the survey was selecting eligible households given all of the data and cases collected. Our analyst calculated the average food costs to determine how much was spent on each person (weighted for age). Any household where the daily food expenses were less than 475 Francs CFA (roughly $0.93) per adult were considered eligible. In the end, over 2,500 households were surveyed with nearly 1,900 children.
Not without challenge, the survey was implemented in the context of one of Mali’s most challenging and uncertain periods. During a coup and its aftermath, that included a bloody counter-coup in downtown Bamako, just miles away, Mali Health’s local staff applied each step with the dedication and rigor necessary to achieve accurate results. As the staff now prepares to welcome into the program the fruits of this labor, requiring a larger team and larger demands on our existing coordinators, the precision of the process itself warrants recognition of those who implemented it, and gratitude to the many contributors that have continued to support us during such a volatile time for the country. It’s only through this dedication on both sides that we stand ready. And ready we are.
Late last year, we introduced to you to our expanded maternal health program, an initiative within Action for Health aimed at empowering women with the critical knowledge and access to services they need to ensure a safe pregnancy, delivery, and recovery, in a country where 1 in 22 women will die from complications during childbirth. After a six-month pilot, our medical coordinator, Dr. Diak Traore took some time to reflect on the current program and where to go next.
In all, 43 women took part in the program. All of them received frequent and focused visits from our team of Community Health Workers, encouraging safe decisions and relaying warning signs throughout the courses of their pregnancy. 84% of women (36) also elected to participate in prenatal consultations at the Clinic. Among these participants, 35 have either completed, or are currently on track to complete, their own individual series of 4 consultations. At this time of Dr. Traore’s report, 12 women had given birth, 8 of whom in a health facility. The entire team was rightly proud of their work, most notably in the case of a woman who experienced complications during labor and delivery but was able to receive the medical care she needed, with her election to deliver at the health center.
Overall, we were encouraged by the participation and impact of the program. The pilot, however, shed light on areas to improve, largely related to restrictive cost barriers. While the program does in fact cover some associated fees, others were left to be financed by the husband, as is customarily the case in our community. However, the 7 women who did not participate in prenatal care cited high clinical costs as a barrier. Further, of the 4 women who gave birth at home, 3 identified related costs of delivery in a health center as a primary deterrence, and one, tragically, experienced a miscarriage.
This summer, we will be doubling the size of Action for Health, and with it, expanding the prenatal care program. We are currently considering the most effective ways to reduce these cost barriers while reaching more women.
As our program grows, so too can your impact. This June, to support our efforts, all funds given will be matched, dollar for dollar. And, through Global Giving’s additional support, this Wednesday, June 13, all donations will be matched a further 50%, turning a $20 gift into $50 for our program. To give, just follow the link below.
Thank you for your continued support as Action for Health grows in both depth and breadth, and I look forward to sharing continued updates of its expansion. I hope you will consider participating, and help us reach more women with this program.
Since May 2011, the 10 members of the Bandiagara Coura Action Group have been hard at work making their hill-side community healthier. Bandiagara Coura is named after the famous Dogon escarpment, and its steep hills and rock-homes evoke Mali's famous tourist destination. Given the difficulty residents have accessing water, electricity, roads and schools, it is also one the most underprivileged parts of the Sikoro neighborhood.
After an intensive training on community activism by Mali Health’s Mobilization Coordinator Dramane Diarra, the Action Group members went to work developing programs to improve the health and well-being of their neighbors. One of their first activities was to conduct a census of the population of Bandiagara Coura. The members of the Action Group realized that without a clear picture of who resided in the neighborhood, and the number of people living there, they would be unable to plan and execute activities. The Action Group surveyed over 1200 families living in Bandiagara Coura and gathered valuable information about the population (such as the fact that certain households essentially as dormitories for people who work in downtown Bamako) and community relations (for example, some residents have a negative view of the sector chief, dating to the time when the land was divided). All of this information will allow the group to effectively plan and implement activities.
Following the census, the Action Group began work on their first community improvement program: paving the three main roads in Bandiagara Coura. Ama, the Action Group president said, "Paving the roads will make it easier to leave Bandiagara Coura. Today, if someone falls ill, they have to climb down the hill, or someone has to carry them down the hill, to the main road before they can find a car or bus, as these vehicles cannot drive up the hill.” In addition to reducing access to health care, the poor road quality means that women and children have limited access to piped water, which is only located in the valley. More than 5 years ago, the sector chief had directed an activity to pave some of the roads, but others remain unfinished. In order to improve access between Bandiagara Coura and the rest of the neighborhood, the Action Group plans to pave 3 roads. In order to make these roads usable for motor vehicles, they have to do everything from dynamiting rock to make the road wider, building retaining walls, and filling in sunken land. To achieve their goal, the Action Group has solicited donations from community members to pay for cement and sand, and youth have contributed labor to the project. This is an ongoing project, but the start has been very fruitful and close to 70% of Action for Health families have participated in the project. The sector chief says: "It has been a dream of mine to see public transport in Bandiagara Coura, and we need good roads for this to become a reality." (Bamia, chef de secteur).
Over 18 months ago, Action for Health launched to address child health by providing free services for children, health education, and opportunities for families to engage in local health projects. Today we’re excited to announce the start of our expanded maternal health initiative, designed to empower women with critical health knowledge and services to ensure a safe pregnancy, delivery, and postpartum recovery.
1 in 22 women in Mali die of maternal health complications (UNICEF). Most of these deaths are caused by preventable and treatable conditions, like hemorrhaging, infections, high blood pressure, and obstructed labor. Under our new maternal health initiative, we are excited to offer enrolled mothers expanded health education, free prenatal consultations, accompaniment, and follow up to connect them with medical providers. The heart of the initiative is our Community Health Worker team, composed of local residents (most of them mothers themselves) with training in health promotion.
Our Community Health Workers work one-on-one with women in their homes, reviewing lessons such as maternal nutritional needs, birth spacing, the purpose of prenatal visits, and recommended breastfeeding practices. Under the new initiative, Health Workers also accompany mothers on prenatal consultations (now free of charge), work with them and their husbands to plan for transportation and logistics of the birth, and are on-call for deliveries. An emergency fund is now available for complex pregnancies requiring specialized services. Executive Director Anna Ninan states: “Health knowledge and agency are infectious: when one women learns to safeguard her health she shares that information with her family and friends, empowering others around her. At the same time, we have to recognize the critical role of health services, especially for those who might not be able to afford them as is the case for much of Sikoro. We’re excited to be breaking down those financial barriers to care by providing free services.”
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While reviewing the patient charts for Action for Health members, Mali Health Community Health Worker Djibril Traore noticed something – the number of cases of diarrhea was increasing sharply. At the Sikoro-Sourkabougou public clinic, the Medical Director, Dr. Diarra, noticed the same pattern. Together, Djibril, Dr. Diarra and other members of the Action for Health team decided they needed to do something to address the increased number of cases – diarrhea is one of leading killers of children under-5 in Mali.
The Action for Health team worked with Dr. Diarra to plan a two-phase response, including education and community action.
On Sunday August 14 over 100 women assembled in the public square of the part of Sikoro known as Bandiagara Coura, one of Action for Health's primary target zones, to take part in an information session on diarrheal diseases. Dr. Diarra led a discussion of the causes, symptoms, preventive measures and curative actions for diarrheal diseases. Women benefited from learning about the need to maintain clean water sources, and to provide lifesaving liquid to their children even before taking them to the clinic. According to Djbril: “The day was a huge success. The population really appreciated the information, and some of our Community Health Workers even asked that we do this sort of education program every month. I think it was really important as well, because of the impact of diarrheal diseases - in Mali we are even being threatened with cholera epidemics in Mopti and Timbuktu, so it is really important to teach people about how to care for diarrhea."
Bandiagara Coura is located on a hillside overlooking the rest of the neighborhood. Although public taps exist in other parts of Sikoro, no taps have been installed in Bandiagara Coura, and women who live here must walk up and down the steep hill to collect water. Given this challenge, many choose to drink well water instead. The months of June-September coincide with the rainy season in Mali and open latrines and other sources of dirty water can easily contaminate these wells. In light of this reality, education about diarrheal diseases is not enough. Our Action for Health team researched the different options, and decided that the most effective response would be to distribute Aquatabs to families in the Action for Health program. Aquatabs, which are similar to the water-purification tablets used while camping (or traveling abroad), disinfect up to 20 liters of water with one pill, providing a source of clean drinking water for children and family members. The distribution of Aquatabs, in conjunction with the education provided on the prevention and treatment of diarrhea, will lead to a decrease in the number cases of diarrhea in Sikoro– a potentially lifesaving intervention for children.
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