Mali Health is happy to announce that we have won a Grand Challenges Explorations (GCE) grant from the Bill & Melinda Gates Foundation. Our proposal, Using Participatory Quality Improvement Methods to Improve Vaccine Timeliness, will bring together maternal care providers, including health center staff, community health workers (ASC) and midwives (matrones), to develop local solutions for improving childhood immunization completion in the Sikasso region, in southern Mali.
Since 2014, we have been developing a participatory, team-based approach that adapts traditional continuous quality improvement tools for use in the community health system. We will bring those participatory quality improvement (QI) methods, created in collaboration with health center partners in peri-urban Bamako, to the Sikasso region in southern Mali, to improve vaccine delivery.
In Bamako, our participatory, community-based QI strategies led to significant improvement in timely vaccine completion. For example, completion of BCG vaccine delivery from 57% to 92% and retention between doses of MMR rose from 38% to 83%. With average completion of childhood vaccines hovering around 20.2% in Mali, there is room for significant improvement, in both rural and urban regions.
Our team is particularly excited about this opportunity because it allows us to continue working with partners in the Sikasso region, where we have worked to implement the Center for Disease Control’s (CDC) post-Ebola Global Health Security Agenda (GHSA). During that work, we observed significant gaps in the health system and integrated some of our quality improvement and governance strategies into the GHSA project. Our participation in that project ended in October 2017, when funding was significantly delayed during the budgeting process. We are glad to renew our relationships with communities and the health system in the Sikasso region, and to build new ones.
Through their GCE program, the Bill & Melinda Gates Foundation “supports innovative thinkers worldwide to explore ideas that can break the mold in how we solve persistent global health and development challenges.” Our project is one of 35 Grand Challenges Explorations Round 20 grants awarded by the Foundation, out of over 1,500 applications received. This is our second GCE grant; the first, a part of Round 12, helped us to develop our QI approach.
Grand Challenges Explorations is a US$100 million initiative funded by the Bill & Melinda Gates Foundation. Launched in 2008, over 1365 projects in more than 65 countries have received Grand Challenges Explorations grants. The grant program is open to anyone from any discipline and from any organization. The initiative uses an agile, accelerated grant-making process with short two-page online applications and no preliminary data required. Initial grants of US$100,000 are awarded two times a year. Successful projects can receive a follow-on grant of up to US$1 million.
As a part of our commitment to strengthening community health systems in Mali, we are always looking for ways to turn control over to communities and existing structures. This year, we are taking big steps forward in integrating the participatory quality improvement methods we have been developing with partners since 2014, into the health system in Bamako.
In March, the Mali Health quality improvement (QI) team hosted a three-day workshop for staff at area CSRefs – the reference hospitals who oversee our partner community health centers, or CSComs. Joining the CSRef teams for the training was a representative from the Office of Community Health at the Regional Health Directorate.
Staff at the CSRef already have tools and protocols which they use to supervise community health centers in their district, so our team explored the similarities between current supervision methods and the tools we’ve created to support CSComs through their quality improvement processes. Over the coming months, we will work together to adapt these tools so that conducting supervision for QI is a manageable process for the CSRef staff, while also ensuring that health centers continue to have sufficient support and supervision for their QI efforts to remain effective.
Participants in the training attended brainstorming sessions and breakout groups, and they analyzed case studies. They learned about the participatory quality improvement techniques that our partner CSComs use, as well as how they can support health center staff in designing, implementing, and monitoring their QI processes. On the third day of the training, the CSRef teams were able to join us at the health centers to participate in meetings with the QI teams and practice what they’d learned over the previous two days.
Though the CSRef is responsible for supervising CSComs, resources are limited and most staff have received little training. For most who attended, this three-day session was their first opportunity to learn about supervision methods. They were excited about having a chance to improve their own knowledge and abilities, and to apply what they learned not only to their supervision of the CSComs, but to other areas of their own operations.
We were thrilled by the enthusiasm that members of the CSRef teams showed for the quality improvement program and for the role they will play in ensuring it continues to benefit communities for years to come. They, and we, share the belief that in order to promote maternal and child health in the long term, we must build effective and sustainable structures and processes within the community health system, led by professionals like them and their colleagues in the CSComs.
We are excited to take this first step into a new phase of our quality improvement work and look forward to increasing local ownership and management of participatory quality improvement methods.
“We have been meeting as a group and saving for small business needs for ten years,” says Mariam Traoré, the president of her savings group ‘Sigida Yiriwa Ton 1,’ which in English means ‘Association for Community Development.’ “Each member contributes CFA 100 [about 17¢] every week. Half of this amount goes into the small business box and the other half goes into the health savings box.” The group meets at Mariam’s house in Sebenikoro, on the front porch under a red tarp to protect the women from the hot sun as they meet.
Savings groups, or tontines, have been around for decades in many West African countries. It is a traditional way for women to form a collective that allows members to pool their money and share it fairly among themselves. It is popular and even essential in situations of economic uncertainty because this type of collective savings can provide financial and social security to group members.
Fatimata Nyere, the group’s facilitator from Mali Health, says, “Mali Health came to Sebenikoro in August of 2016.” She was tasked with approaching existing women’s groups in this community about making some of their savings available to use for health and sanitation needs that the group was facing, rather than just focusing on small business opportunities. “When I arrived,” Fatimata says, “the group asked me if I could teach them how to make soap.* I wasn’t able to do that, so I suggested that the group buy cases of soap to distribute to its members every two weeks. They could use funds from the health savings box to cover the cost.”
Mariam explains, “We need soap because we lack sanitation here in our community and there is a lot of sickness. Right now, there are mostly cases of malaria, but we also have colds and coughs.” Soap won’t stop malaria, but it can help stop the spread of diarrhea, pneumonia, and other respiratory infections that are prevalent in Sebenikoro and that can be life-threatening to young children whose immune systems are still developing. “Soap can be used to clean everything,” Mariam continues. “I clean my children, myself, the clothes, the dishes, and we even wash our hands with soap before we eat.”
The group has decided to buy cases of soap for about $14 every two weeks using the funds the women have contributed to their health savings box. Three bars of soap each are distributed to half of the women during the first part of the month, and the other half gets their soap during the next distribution in the second half of the month.
“Every member of our group is married, with children. We also use the money in the health savings box for doctor visits and medicine when our families get sick, including our husbands, because men and women are the same,” says Mariam. Her savings group is different from most; other groups in Mali Health’s program generally reserve their funds for use solely by group members and their children. In Sebenikoro and other communities around Bamako, family finances are retained and controlled by men, and women don’t typically have the ability to spend money without permission from their husbands. Mali Health’s savings groups are one way of promoting women’s agency and independence by giving them the freedom to spend the group’s savings on important items like soap or medicine without delay or permission.
“Mali Health helps us to share the cost of doctor visits and any medicine we need when our young children are sick,” Mariam says. “They even help some of us who have no money.”
She calls out to the group, “Let’s clap our hands for Mali Health and all the good work they are doing here, and hopefully the good work will stay for years to come!” On Mariam’s command, the group claps once, CLAP, then twice CLAP, CLAP, and finally three times, CLAP, CLAP, CLAP, and the group in unison shouts, “MALI HEALTH,” and they erupt into laughter and smiles.
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* The women in our programs have repeatedly expressed an interest in learning new skills — like how to make soap — that they can use to raise their family’s income and self-sufficiency, which will help to further improve their access to primary healthcare. This year, Mali Health will work with the women from several savings groups on a pilot project to launch small cooperative businesses, giving these women a chance to learn and market new skills. We’ll support and follow the women closely to see whether these cooperatives can help to sustain, or even expand, the health improvements the women have made through their savings groups.
Halfway up the face of a steep and rocky hill in the community of Sikoro lives Fatoumata and her family. Fatoumata, a mother of four, begins to share the story of when two Mali Health community health workers first visited in 2011. Alimata, Fatoumata’s mother-in-law, adds, “the women asked about my son and whether he worked and if that work came with a monthly salary.” She told the women then that her son worked odd jobs, but the jobs didn’t come with a reliable monthly salary – passing prayer beads through her fingers as she recounts the story. With a young toddler in the home and a low, unsteady income – the family was eligible for, and joined, Mali Health’s community health program.
Sonata Cissogo, a friend and neighbor, became their community health worker. Sonata shares, “The family’s first daughter, Amitou, was about three and a half years old in 2011. Since that time, I have been working with this family as it has grown from one to four children. The next three children were all enrolled at birth.” Fatoumata notes, “We have known Sonata for many years. Every day she comes over to greet us and the children. If the children show any sign or symptoms of illness she tells us to take them to the health center immediately.”
Amitou with her mother Fatoumata
Amitou, now a healthy nine-year-old enrolled in school, helps to look after her three younger siblings—a brother, Seydou, age 7, and sisters Aminata, age 5, and Niekoro, age 2. Neither Fatoumata nor Alimata work, leaving Fatoumata’s husband, N’Golo, the sole provider for the family. Alimata reflects on how the family agonized over what to do when their oldest child became ill: “before Amitou was first enrolled, my son would say to buy traditional medicine to treat her illnesses. Traditional medicine is cheaper, but it doesn’t always work. Now, since my grandchildren have been enrolled in Mali Health’s program, my son tells us to take the kids to the health center right away. Now he is content, and he and my daughter-in-law don’t struggle about it anymore.”
Amitou, Seydou and Aminata have grown up with access to basic primary care whenever they needed it – and today, they are strong and healthy. The youngest, Niekoro, is still covered and just recently became ill. Her mother describes her relief at being able to act quickly to take care of her daughter. “As soon as I recognized the signs, my husband and I agreed that I would take her to the local health center just down the hill. I bring the health card that Mali Health gave us and that helps a lot with the doctor. Before, without the card, the doctor would be scared that you would not have enough money to pay. Sometimes you would only have maybe $2 or $4 in hand, and the doctor and the medicine might be $6 – $10, or more. So, we wouldn’t be able to buy the medicine and would have to get traditional medicine instead. Now with the Mali Health card, the doctor is very nice, and he gives us the consultation and medicine, and we don’t have to wait long either.”
The benefits extend beyond just immediate access to healthcare for the Diarra family. “Now, with the money we would have spent on doctors and medicine, we use it to buy good healthy food, decent clothes for the children, and a bit goes to cover their monthly school fees too,” says Fatoumata. As she recounts her family’s story, she points to her daughter, Aminata, who, unprompted, grabbed a bucket and a bar of soap and is washing her hands. “Aminata learned to wash her hands with soap from Sonata. She taught everyone to do this regularly during the Ebola crisis, and Aminata has been doing it ever since.” Aminata turned five years old last June, graduating from the program.
“My son is thankful for Mali Health and for Sonata too,” says Alimata of her grandchildren’s participation in the program and the community health worker it has provided to their family. “We are all thankful.”
The Health Promotion Department recently celebrated Global Handwashing Day, which takes place every year on October 15th. During the celebration, we promote hand washing with soap as an easy and affordable way to save lives by preventing pneumonia, diarrhea, and malnutrition, three conditions that are especially dangerous for children. Mali Health community health workers encourage families enrolled in our programs to wash their hands with soap throughout the year, but Global Handwashing Day is our opportunity to spread this important message to families we wouldn’t normally reach.
The theme for 2017 was “Our Hands, Our Future.” Mali Health recognized the occasion by hosting two public educational events: one on October 14th in Kalabambougou, where hundreds of women participate in our Savings for Health program; and the other on October 20th in Sikoro, where we engage community members in all three of our programs to improve the health of women and children. Between the two events, 1,100 people joined in the festivities.
We focused on promoting hand washing with soap at three critical times: 1) after using the restroom, 2) after changing a child’s diaper, and 3) before touching food. Two of our Quality Improvement coaches, Dr. Sogoba and Dr. Bathily, demonstrated proper hand washing techniques to the crowd, and our emcee Abdou Touré, Mali Health’s media expert, kept the crowd engaged and entertained between activities. Those attending answered trivia questions about hand washing and won hand washing kits, complete with wash basins and several bars of soap.
We were grateful to be joined by representatives from Mali’s Ministry of Women, Children, and Family Affairs and the Ministry of Social Development, Humanitarian Action, and Economic Solidarity; their participation both strengthens Mali Health’s relationship with important actors in maternal and child health in Mali and provides an opportunity for community members to meet and share their thoughts with their government.
Staff at the CSRef already have tools and protocols which they use to supervise community health centers in their district, so our team explored the similarities between current supervision methods and the tools we’ve created to support CSComs through their quality improvement processes. Over the coming months, we will work together to adapt these tools so that conducting supervision for QI is a manageable process for the CSRef staff, while also ensuring that health centers continue to have sufficient support and supervision for their QI efforts to remain effective.
Though the CSRef is responsible for supervising CSComs, resources are limited and most staff have received little training. For most who attended, this three-day session was their first opportunity to learn about supervision methods. They were excited about having a chance to improve their own knowledge and abilities, and to apply what they learned not only to their supervision of the CSComs, but to other areas of their own operations.
Savings groups, or tontines, have been around for decades in many West African countries. It is a traditional way for women to form a collective that allows members to pool their money and share it fairly among themselves. It is popular and even essential in situations of economic uncertainty because this type of collective savings can provide financial and social security to group members.
The theme for 2017 was “Our Hands, Our Future.” Mali Health recognized the occasion by hosting two public educational events: one on October 14th in Kalabambougou, where hundreds of women participate in our Savings for Health program; and the other on October 20th in Sikoro, where we engage community members in all three of our programs to improve the health of women and children. Between the two events, 1,100 people joined in the festivities.
We focused on promoting hand washing with soap at three critical times: 1) after using the restroom, 2) after changing a child’s diaper, and 3) before touching food. Two of our Quality Improvement coaches, Dr. Sogoba and Dr. Bathily, demonstrated proper hand washing techniques to the crowd, and our emcee Abdou Touré, Mali Health’s media expert, kept the crowd engaged and entertained between activities. Those attending answered trivia questions about hand washing and won hand washing kits, complete with wash basins and several bars of soap.