Since Mali Health began our participatory quality improvement work nearly ten years ago, we have worked directly with 28 community health centers (CSComs) and 11 health districts. Though we focus on overlooked peri-urban communities, we also adapted our approach for use by CSComs in rural communities so they could address the unique challenges that affect healthcare quality in their context.
Not long ago, Mali’s health authorities developed the first national quality improvement plan, which was implemented from 2018-2022. The plan addressed all three levels of the health system – hospital, reference, and community – but the community health system has seen the least amount of progress and implementation.
The plan includes quality improvement standards and tools, which we use in our work, but nationwide there have been challenges with implementation and adoption at the community level. For example, there are standards for the representation and participation of women and youth in different aspects of the community health system, but these standards are rarely followed and there are no mechanisms for assessing them. However, these are all problems that we have been working to solve with our CSCom partners on the ground for many years and our team has been eager to share those experiences with others.
Sharing lessons learned
For the past year, we have been working on plans for how we can extend the reach of our participatory quality improvement approach so that it can be available to more CSComs and communities across Mali. That has meant working closely with the General Directorate of Health and Public Hygiene (DGSHP) and the Sub-Directorate of Health Establishments and Regulations (SDESR).
In September, we were fortunate to participate in the review of the 2018 – 2022 national quality improvement strategic plan, during a national workshop held in Koulikoro. Alongside dozens of representatives from the health system and nearly two dozen NGO representatives, Dr. Bathily participated in an assessment of the implementation of the 2018-2022 national strategy and the development of recommendations to inform the next plan. During this workshop, Dr. Bathily was able to share the successes, challenges, and insights of our partner CSComs working to implement quality improvement plans at the community level.
Charting the path forward for the next national strategy
In October, the National Committee for the Management of the Quality of Health Care and Services, the unit within the DGSHP which is responsible for overseeing the national quality improvement strategic plan, met to discuss the results of the September meeting and to develop the roadmap for the development of the new plan. In this process, our Dr. Sogoba has served as the lead representative for technical and financial partners of the DGSHP. This is not the first opportunity for Dr. Sogoba to be a voice for the community health system at the national level.
This meeting laid out a series of workshops that would comprise the process of developing the new national quality improvement plan. Again, over 20 stakeholders from the nongovernmental sector have worked alongside health authorities to collaboratively develop the new plan. For example, it gives Dr. Bathily and Dr. Sogoba the opportunity to share how our approach aims to monitor and institutionalize the core value of youth and women’s participation in the health system, from the community and CSCom perspective. It also gives us the opportunity to advocate for the inclusion of patient voices and values in the evaluation process, by recommending that a patient satisfaction survey be added as a primary evaluation tool to assess changes in quality at health facilities.
The draft of the new “Strategic Plan for the Improvement of the Quality of Health Care and Services 2024 -2028” will be finalized at a workshop that is scheduled for the end of December. Once validated, the new plan will be shared in early 2024. We remain hopeful about the new additions to the plan, especially those that may be informed by the experiences of our CSCom partners, and look forward to strongly supporting the implementation of the new plan at the community level.
One morning in March, at the beginning of Mali’s hot season, we went to meet Fatoumata to learn more about the activities of the women of Sanankoro, and their cooperative. Despite the blazing heat, 40° C (104° F) in the shade, Fatoumata generously welcomes us under the shade of mango trees, which offer a slight relief.
Sanankoro is a small community in Lassa, which is a quartier that sits high above Bamako on the outskirts of Commune IV. Like many peri-urban communities around Bamako, Sanankoro is remote with very limited infrastructure. The long and winding road to reach it climbs up the hills and cliffs north of the city, and along the way, the terrain changes dramatically. The earth becomes rocky; trees disappear, long ago harvested for charcoal and to clear land for cultivation. At this higher elevation, you feel surrounded by the haze and dust in the sky, and even the sun feels closer.
The women of this community are renowned for their bravery. Their primary livelihoods are related to agriculture, and they mostly raise groundnuts for cooking and groundnut leaves for animal feed, as well as keeping small market vegetable gardens and harvesting mangoes. But because they are so far away from town, they are forced to walk about 10km a day with loads of up to 50 kg on their heads to reach the markets down in the city. But the proceeds they make from selling in the markets are what help them take care of the basic needs of their households, including food, healthcare, and school fees for their children.
Fatoumata shares her experience living in Sanankoro, and how she first started organizing with women in her community:
I am Fatoumata Ballo Doumbia, I have lived here Sanankoro for 18 years now. Sanakoro is an area considered to be part of the Commune of IV of Bamako but it is neglected. There is a lack of health infrastructure, education, and even access to drinking water. We are forced to go to Lassa, at a distance of 6 km, to satisfy these needs.
One day, several years ago when I went to the health center in Lassa, I met women who told me about a social fund system that allowed them to develop and grow their income generating activities (IGAs) and meet their health needs.
When I returned home, I talked to some women in Sanankoro who bought into the idea. We then made the request to Mali Health to be accompanied in the establishment of our groups.
We set up our first savings group of 21 women. For 12 months, each time a member of the group had a need, she was able to take a loan from the either the fund for health needs or the fund for income-generating activities. Six of us were able to expand our activities by setting up a point of sale in town, and eight others were able to expand our space for market gardening. At the end of our savings cycle, when we did the sharing of the amount saved, each of us made an overall profit of 12,500 FCFA (over $20) from the interest on the income-generating activity loans.
With the success of this experiment, almost all women in Sanankoro and those in two nearby communities, Bankoni and Diakoni, have expressed their interest in our program and joining the next cycle.
So we went from one group of 21 women to 13 groups of 264 women! And we are currently in our 6th cycle.
After the success of their savings group activities, the women of Sanankoro, Bankoni and Diakoni asked Mali Health for help in setting up a cooperative. With the strong leadership skills and determination they demonstrated in the savings groups, we readily agreed to partner with them. The name they chose is Coopérative Bènkadi – bènkadi means coming together in Bamanakan.
Fatoumata explains how forming and operating their cooperative went for her and the other women in her community:
We decided that 30 representatives of the 13 groups would join to form a cooperative that produces soap.
In 2021, we received the training and material support necessary to develop our business. We gathered together to do the production regularly, always in the morning under the mango trees, because the soap will get too warm and will not be prepared properly in the heat of the day. We meet in Sanankoro, which is in between Bankoni and Diakoni Many of our members have a long distance to travel, and leave their homes before the sun rises to meet here at the appointed time. But we managed to produce enough to meet the soap needs of our 3 communities.
The income of each member of the cooperative has been increased on average by 35% from 0 FCFA for some to around 2,500 FCFA per week. These benefits are quite important for us for those who know the role of women in communities like ours. She is the one who completes the meal while the husband gives the cereal, she is the one who will have to meet her own health needs and those of her children, she pays for school supplies for the children as well as their clothes.
The soap that members produce is primarily for their own household use and for sale to their neighbors, because before now, soap was a relatively expensive resource that they would have to secure in Lassa, or down in Bamako. After their production activities, women divide the soap between their thirty members. Whatever they do not use themselves, they sell to their neighbors with a slight markup of 50 FCFA over cost, or about $0.10.
The impact of having soap so readily available has been remarkable and has had an immediate impact. Handwashing with soap prevents a significant portion of diarrheal diseases and acute respiratory infections – which are two of the primary causes of under-5 mortality for children in Mali, along with malaria and malnutrition. That’s why we say that soap saves lives – because in these communities, it does.
Other women in the cooperative have joined our conversation. When asked about what changes they have noticed now that they have enough soap, their enthusiasm and relief is clear. They specifically note two differences: that they are able to keep their homes much cleaner, and that there has been a noticeable reduction in illness among their children, and therefore fewer trips to the health center.
In addition, demand for their soap is extraordinarily high. The members of the cooperative use the majority of what they produce, but because of the remoteness of their communities, there is a significant potential market. As the only source of soap within 6km, they could significantly increase their production and sell in all three of their communities. They have already started to think about how to expand their production, but have faced some limitations, including finding a space to locate their expanded operations. The chef du village in Sananakoro offered them space in the community’s mosque, but it wasn’t big enough to meet their needs.
They are encountering some other challenges, too. Despite their results, the demand for their product, and the welcome changes they have noticed in their lives and the health of their families, serious challenges threaten Coopérative Bènkadi’s progress and the future of their business. Inflation has increased the cost of their inputs, including the local shea butter that is the basis of their soaps. So they have cut back on their production in the hope that the prices of their materials might return to where they were – which unfortunately is not likely.
Fatoumata explains their current challenge, but also the opportunity:
Inflation and the high cost of living have dealt a heavy blow to our business; We can no longer produce as much soap as we need for our needs. Revenues have fallen drastically.
Our members are very engaged with this activity and we have more potential to sell our products because we have already been approached by resellers with whom we can collaborate. We need a boost to increase our production in order to satisfy the needs of our 3 communities and to supply the resellers.
If Coopérative Bènkadi could expand their production beyond their own needs and begin selling more of their soap, they could invest in a proper production space, buy more raw materials in bulk at a lower cost, and perhaps even add members to their cooperative – overcoming the obstacles they face, and even growing their operations.
The members of Coopérative Bènkadi prepared a proposal for how they would invest in their cooperative to achieve their goals, and Mali Health would like to help them. Stay tuned while we work on a strategy for supporting them and all the cooperatives with whom we partner.
>> Update: Coopérative Bènkadi will be the recipient of the very first loan from Gaoussou’s Fund, created in honor of our colleague, Gaoussou Doumbia. To learn more and support this women-led solidarity fund, please click here. <<
The following are excerpts written by Adam Aicha Hanne, an MPH – PharmD student who spent her summer practicum working with the Mali Health team in Bamako. She worked on the Gnaman ni Sôrô ni Kènèya project with the Community Capacity Building department.
The goals of the five-year Gnaman ni Sôrô ni Kènèya project are to improve community health by addressing environmental health hazards and creating opportunities for youth and women’s employment through waste collection, composting, recycling, and repurposing.
One of the goals of Gnaman ni Sôrô ni Kènèya project is to turn what is currently treated as waste into a useful commodity. Based on the Sustainable Community Project from GAYO in Ghana, we want to work with peri-urban communities to convert everyday trash into reusable products. But our very first step towards achieving our goal is to conduct research. Our research is composed of five analyses, three of which I am currently working on:
Waste composition analysis
Social norms analysis
Stakeholder analysis
This week we focused on the waste composition analysis as it is the most time-consuming and physically demanding one. Along with our team of investigators, we went into our target communities – Sabalibougou, Sikoro, and Kalabambougou – to physically analyze the waste generated by the homes participating in the survey. Investigators were provided with a spreadsheet that categorized the different types of waste that are typically found in waste sacs.
Teams of investigators were responsible for adequately weighing the waste sacs, identifying and segregating the types of waste, and documenting the weight of each type. The information will be used to used to identify which waste products are recyclable and the total waste per category will be quantified. Through our analyzes, we will understand the types of waste generated by the participating communities, and how their waste can potentially benefit them.
Learning from History
Last week I had an in-depth. fruitful conversation with my aunt and cousin about pre/post-colonial Mali. So, basically, our conversation was about Mali in the 1880s & 1960s. We spoke about how Mali was succeeding with the ruling of President Modibo Keïta. My aunty expressed that around the time of Modibo Keïta, Mali was functioning sustainably and the streets of Bamako were so clean. She emphasized how the community was centered around the culture, and how traditional ways were respected and followed as laws. For instance, people were frowned upon if they littered or did not contribute to community efforts to keep the country up to par. Mali was united regardless of tribalism or religious beliefs. After our conversation, she told me to take a look at Mali’s original constitution. Therefore, I focused on finding Mali’s first constitution right after gaining its independence from the French government.
However, during this research, I learned that Modibo Keïta had ruled as Mali’s leader during colonialism and post-colonialism from 1915 to 1977. But then my main question became who ruled Mali before colonialism in the 1880s? And what was the constitution or constitution-like understanding of the people of that time? I hope that my Bambara teacher who studies the history and social structures of Mali will be able to fill the gaps in the questions I have about Mali and its history. I honestly believe history is important to understand the future. My motto used to be don’t get stuck in the past but focus your energy on the future. That motto has always come in handy for me and has allowed me to advance in many ways in my life. However, as of today I now understand that it is important to look back at the past and analyze for what may have worked for people or communities and utilize those hidden gems in the future. I hope by revisiting the past I can bring to light the gems of the past to the future, and hopefully what I find can be helpful to my Malian communities.
In Mali’s decentralized health system, ASACOs (community health associations) are instrumental to not only the delivery of primary health care services – particularly maternal and child healthcare – but they are also the primary structure that ensures community participation and local ownership.
Created in 1994 by community members in Commune III, ASACO – BAKON serves five neighborhoods (Badialan I, II and III – Kodabougou and Niomérambougou) in Bamako. Though two neighboring communities often collaborate to create an ASACO, and some communities have multiple ASACOs to serve the needs of large populations, it is unique for five communities to come together to do so. But ASACO-BAKON’s leaders recognized the significance of the ASACO’s role and decided to pool their resources to ensure a greater chance of success.
ASACO – BAKON was one of the first community health associations created in Mali. Though it has faced challenges over its nearly 30-year history, in September 2019, a new group of young leaders were elected to lead the ASACO management committee and they have been dedicated to improving the performance of their health center. They began seeking out partners to assist them in their efforts, and four months after the new ASACO chair, Mr. Aboucar Maiga, was elected, he met with Mali Health as their first technical partner.
Through the partnership between ASACO – BAKON and Mali Health, both the health personnel working at the CSCom and ASACO members have participated in Mali Health’s trainings on the elements of our participatory quality improvement approach. The trainings have covered maternal, neonatal, and child health topics, including basic emergency obstetric and newborn care (BEmONC), as well as the role and function of the ASACO and its management bodies. Following these training sessions, both staff and ASACO members report improved confidence and alignment across the health center, which they have not experienced before. The new skills in the health center staff have resulted in improvements in key indicators, which they have maintained every year, as well as increases in consultations and assisted deliveries at the health center.
The ASACO meets regularly and in accordance with the statutes. Each leader understands his or her role. Mali Health was also able to provide some equipment to support the improved quality of the health center’s services, including a microscope so the center can perform lab work and a warming table for newborns.
The vice president of the ASACO, Mahamadou Sissoko, describes the changes that are taking place at the health center: “The partnership with Mali Health has brought a radical change in the practices at our health center. We have made patient satisfaction our absolute priority, and the community now sees us differently. Today, we are having much more success.”
To further support the health of the communities served by the health center, Mali Health is partnering with women in the community through our Women-Led Health Financing strategies, including helping them to organize health savings groups, develop income-generating activities, and become voting members of the ASACO.
In the first quarter of 2022, Bamako recorded nearly fifty suspected cases of measles. Public health officials collected samples and fourteen cases were confirmed at the national reference laboratory. Several of the 14 positive cases were concentrated in Communes I and IV of Bamako. This distribution of cases meant that Bamako had reached an epidemic threshold, which required a response in both communes and the surrounding areas. Measles is extremely contagious, and unfortunately, Mali registered in the top 10 countries for the highest number of cases reported from September 2021 – February 2022.
The primary reason for the measles outbreak is that thousands of children missed their routine vaccinations due to the COVID-19 pandemic, though the exact number of under-immunized and “zero-dose” children is unknown. But Mali is not unique in experiencing a measles outbreak. Just as we saw with Ebola, the interruption of routine primary healthcare caused by the pandemic could be as or more deadly than the coronavirus itself.
In order to support the regional health authorities in containing the epidemic, the Mali Health team initiated and supported a vaccination campaign to reach unvaccinated children in partner communities across Bamako.
The vaccination campaign mobilized more than 200 vaccination teams over a period of five days to vaccinate children age 9 – 59 months. Each vaccination team was composed of three agents including one agent for the mobilization and organization of the community, one agent to conduct the injections, and one agent to maintain the documentation and records. Though we requested 120 000 doses of VAR vaccines, only 45 000 doses were made available, along with 4,000 vaccine registry forms.
A member of the vaccination team completes the vaccine registry
The vaccination campaign included the following activities:
Communication and outreach: The vaccination teams shared health information messages about measles and vaccination throughout 17 communities by working with the ASACOs (community health association) in each community, as well as a network of women leaders to whom we connected through our partners in the Service Local de Développement Social et de l’Economie Solidaire (SLDSES). Some of the concerns among the community included hesitation and misinformation about vaccines in general, as well as mistrust related to COVID-19 disinformation and rumors.
Case identification and management: The vaccination team actively searched for suspected measles cases in each community. Of those suspected, 12 cases were confirmed through the collection and analysis of samples.
Monitoring of adverse events following immunization (AEFI): Some minor AEFIs (fever, vomiting, pain at the injection site in older children) were reported during the campaign, which were referred to the CSCom (community health center) teams, who provided treatment and case management.
Safe waste disposal: The proper treatment of medical waste is one of the many areas we work on in our participatory quality improvement program, but resources can often be limited at CSComs. All injection and vaccine materials during this campaign were disposed of in safety boxes and packaged in waterproof cartons to hold them safely until they could be incinerated.
Sharing results: To ensure transparency and build tryst, Mali Health shared the results of the vaccination campaign with community leaders and community members from the areas served.
Monitoring and field supervision: To support each vaccination team, 5 additional agents in each community (85 total) were deployed alongside them to help support and manage the flow of vaccination activities, ensure the vaccination teams remained fully equipped, coordinate with the community health system (CSCom), and assist in any other needs that arose for the vaccination teams. They monitored results and progress each day and were in the field with the vaccination teams for all five days of the campaign.
During the campaign, Dr. Bathily reviews the day’s progress with a vaccination team
The vaccination teams deployed across 17 communities over five days achieving the following results:
44,685 children vaccinated
16,082 under age 1 (between 9-11 months)
28,603 age 1 – 5 years
94.6% of children under age 1 (15,211) received their first dose of measles vaccine (VAR)
90% of children age 1- 5 years (25,754) received their first dose of measles vaccine (VAR)
Despite these results, we estimate that there are approximately 117,795 children under age 5 across the 17 target communities, leaving tens of thousands of more children in need of vaccinations. Based on the results of this vaccination campaign, it is likely that the majority of these remaining children are also unvaccinated.
While every child enrolled in our community health program received their vaccines on-time throughout the pandemic, and we worked very hard to support our partner health centers in maintaining the continuity of care for women and children in their communities, tens of thousands of children across remain unreached and under-immunized. We hope to continue vaccination activities as we search for more funding to meet urgent needs and as more vaccines are made available.
