Health
 Mali
Project #3185

Action For Health : Empowering Communities in Mali

by Mali Health Organizing Project
Malik, our Community Health Worker
Malik, our Community Health Worker

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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A well of potential
A well of potential

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. 

Well Done!
Well Done!
Malnutrition Prevention
Malnutrition Prevention
Culinary Demonstration
Culinary Demonstration

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Sikoro
Sikoro's Children

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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Training
Training

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:

  • The income of the population in general
  • Inadequate access to drinking water
  • The type of structure that comprised the majority of residences in the area
  • Difficulty of access due to road conditions

Having originally identified 8 areas, our general criteria helped us limit it to the following five within the greater Sikoro-Sourakabougou area:

  • Bangiagara-Coura
  • Sourakbougou-Kouloubleni
  • Papéré
  • Farafinda
  • The “Cemetary 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. 

Meeting with the Chief
Meeting with the Chief
Getting ready for more of this!
Getting ready for more of this!
And this!
And this!
Survey Team
Survey Team

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Health Education Lesson
Health Education Lesson

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.  

Waiting at the Clinic
Waiting at the Clinic

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Organization Information

Mali Health Organizing Project

Location: Cambridge, MA - USA
Website: http:/​/​www.malihealth.org
Project Leader:
Stephen Muse
Operations Manager
Westminster Station, VT United States
$83,547 raised of $150,000 goal
 
1,038 donations
$66,453 to go
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