1. Education talks on COVID-19

Since the beginning of the pandemic, our community health workers have continued to visit the families in their care, ensuring both the continuity of maternal and child healthcare and sharing information about COVID-19. They make sure mothers and caregivers understand what COVID-19 is, methods of transmission, how to prevent it, as well as symptoms and how to respond. Since January, they have conducted 2,810 talks in households during their home visits, reaching 4,973 people.

In addition to sharing information during home visits, our team is also sharing information at savings group meeting, which have been able to restart safely. So far, 310 talks during group meetings have reached 4,941 women.

2. COVID-19 Caravan

From mid-May to mid-June, we conducted 13 caravans in communities across all 6 Communes of Bamako, and Mandé:

• Sikoro-Sourakabougou
• Sotuba
• Bakaribougou
• Lafiabougou
• Lassa
• Djicoroni-Para
• Kalabambougou
• Sabalibougou
• Niamakoro
• Yirimadio
• Badialan
• Samè
• Kanadjiguila

The messages shared during the caravan were those developed by the national health authorities, including a definition of COVID-19, its spread, its symptoms, and the risks of infection. The caravans were held in public, accessible locations, including schools, markets, and open fields. We estimate to have reached about 46,000 people during these caravans, including 18,500 women, 10,500 men, and 17,000 school-aged children.

3. Radio programming

We developed and produced two 30-minute radio programs about COVID-19 prevention on two different subjects – how to remain vigilant about COVID-19 prevention and how to manage distancing and contact with someone who is suspected to be COVID-19 positive. We also developed informational radio spots to encourage continued use of barrier measures and to combat misinformation. They also covered three key subjects being encountered in the communities we serve: stigma against recovering COVID-19 patients, protecting vulnerable populations (particularly elders), and how to manage suspected contacts. The spots are being broadcast 180 times on radio stations across Bamako.

A special thank you to IZUMI Foundation, GlobalGiving, and Fonds d’Appui à l’Autonomisation de la Femme et à l’Epanouissement de l’Enfant (FAFE) for their continued support of our COVID_19 response efforts.

The word “access” implies a simple physical opportunity to achieve or attain something. However, access to COVID-19 vaccines has become an equity issue with big and richer nations deciding who gets what and with countries scrambling to purchase or beg for vaccines from wealthy countries.

Fact: 85% of vaccines are being administered in wealthy countries.

On social media, in international conferences, and in diplomatic missions and negotiations, the campaign to get wealthy countries to donate vaccines to low and middle income countries (LMIC) is raging. It circulates among the Twitter-verse through #VaccineEquity and #DonateDosesNow.

Are we hoarding vaccines? Not an unlikely conclusion as we all lived through the early COVID-19 days of hoarding of Personal Protective Equipment (PPE), cleaning supplies, and even oxygen supplies. It seems to be a wealthy country reaction that totally overwhelms any high-minded equity goal — for how can we achieve equity without control of the supply chain?

Waiting for COVID-19 vaccine and supply donations is not the only solution. As countries wait, people are getting infected and dying. There is also a strong link between the COVID-19 and the interruption of routine services such as childhood immunization, antenatal care, and other essential primary health care.

Fortunately, the African continent is moving ahead on several fronts:

1. Fast tracking the upcoming production of vaccines
   Many vaccines are coming online and will be ready to ship soon. COVAX, the Gavi and donor-supported initiatives are accessing many vaccines as I write this. Countries like Mali have prepared National Deployment and Vaccine Plans to receive COVAX shipments, targeting 20% coverage of the population. Mali has received 1,332,000 doses from the COVAX facility and is in line to receive more as they become available.
   
2. Increasing vaccine manufacturing capacity on the continent
   Dr. John Nkengasong of Africa CDC talks about Africa’s ambitions and efforts to “future proof” itself by producing its own vaccines. Last month, the US International Development Finance Corporation (a US Government agency) announced a technical assistance grant to Fondation Institut Pasteur de Dakar, a vaccine manufacturer in Senegal that could serve the entire West African region.
   
3. Addressing vaccine hesitancy
   Even when the COVID-19 vaccine is available, sluggish uptake is a reality in many parts of the world. We need to emphasize the importance of vaccine understanding and acceptance. The role of NGOs and community organizations has already made a significant contribution to successful efforts like the Global Polio Eradication Initiative and reducing disease transmission during the Ebola outbreak. Countries will be leveraging this valuable community capital as we move ahead.

Community mobilization is a significant component of Mali Health’s strategy to serve peri-urban communities in Mali and strengthen local health systems. Our team continues to inform and generate demand for the COVID-19 vaccine, facilitate community vaccine delivery systems, and reduce community transmission of COVID-19. Mali Health will continue to support this historic global vaccination effort until all members of the communities we serve are protected.

Dr. Sogoba has been helping to ensure that the surveillance priorities and strategies being developed are feasible and realistic for health workers, health centers, and partners on the ground. He is relying on our experience during both the Ebola outbreak, and the health security and systems strengthening efforts that followed it, as well as our participatory quality improvement and community health worker programs.

What is community-based epidemiological surveillance?

The Direction Générale de la Santé et de l’Hygiène Publique (DGSHP) explains why an implementation guide for SEBAC is so important :

characterized by the increasing globalization of emergencies and public health events, the evolution of diseases at the epidemiological level underline the importance of community monitoring in order to move quickly from detection to confirmation and response.

The emergence and earliest detection of infectious diseases – like Ebola or COVID-19 – often occur at the community level. The quicker that the community health system can identify and respond, the quicker an outbreak can be contained, and communities can stay safe. A strong response requires a variety of systems to be strengthened, including a trained health workforce, decentralized and accessible laboratory capacity, and clear response protocols at the local, regional and national levels.

A long-term planning process

At the invitation of the DGSHP, Mali Health has been participating as a technical partner in the development of the national SEBAC guide since 2019. First, a draft of the guide was developed at a workshop in Bamako. It was then tested in the Kadiolo health district, in Sikasso region.

At a workshop in Bamako at the end of 2019, Dr. Sogoba had the chance to present our approach to community health to the entire planning group. He also shared our experiences supporting community health partners during the Ebola outbreak and with the following Djomi project, which was a part of the Global Health Security Agenda (GHSA). We are honored by the opportunity to represent the needs of the community health system, and our efforts to support it, in this national process.

The objective of this latest workshop in Fana was to analyze results from the test in Kadiolo district and to develop a final extension plan. The next step is to submit that final plan to the DGSHP for validation and approval, and to identify a donor to finance the extension of the surveillance program. If a donor can be identified, the entire process of disseminating and implementing the plan in all regions of Mali will take 5 years.

A central tenet of our organization has always been to build deep connections to, and within, the communities we serve.  We believe it is the only way we can develop local, long-term solutions. 

That’s why we deploy a team of 50 community-based health agents who can sit across from mothers, listen to them, and answer their questions. They are an essential part of our strategies to improve community health. They are also an essential part of how Mali and the world will achieve universal health coverage, through improved community health.

One of the greatest examples of the local leadership that is changing the face of community health in Mali is our team’s new leader, Dramane Diarra.

Dramane has been a part of Mali Health for 10 years, having joined us in October 2009. He has held multiple roles over the past decade. Beginning as a health promoter, he rose to lead the entire Health Promotion team. Because of his leadership of his department and several other important projects, like our role in the Ebola response and the subsequent Global Health Security Agenda, Dramane became our most senior program leader at the beginning of this year.

Dramane has as much experience and knowledge of Mali Health as anyone, and perhaps more than anyone.

But it is not just his past roles in our organization that position Dramane well to lead our team. Dramane’s role in Sikoro (see more from Sokone below) and his belief in the power of communities to improve community health, make him the ideal leader for the hard work we will do going forward.

We are at a critical time. We want to from collaborating with our community partners to implement effective strategies, to helping them sustain them. We’ve made progress, as with our participatory quality improvement approach, but our goals are immense and long-term. To reach them, we need someone who understands the communities we serve from within. We need someone who knows how to motivate and support other community leaders to join him – and that is Dramane.

Here’s how Dramane sees his work:

” My commitment to community health comes from my firm belief that in every community, there is the power to improve health.

This power, at times, can be disjointed or poorly expressed, or even misunderstood and undervalued. But all it takes is to highlight it and to show communities how to use it; then the results will follow.

Everyone, whatever her level or his position, comes from a community; it is to this community that he or she returns at the end of every day. If every community understands the need to come together, every community can improve health.“

As our work to improve maternal and child health continues, we are recommitting ourselves to strengthening the resources and leaders on the ground – helping them to see and use their power, you might say. In order to build local and resilient community health systems in Mali, we will rely on leaders like the one Dramane was in Sikoro in 2006, and the one he is today. 

The most powerful, dedicated, and impactful community health leaders come from within – and we are just getting started supporting them. Now, we are thrilled that our team is led by one.

Sokone is a community health worker in Sikoro. She’s known Dramane for many years, and here are her thoughts about our new team leader:

” I have known Dramane since he worked at the Sikoro Animation Center before joining Mali Health. He contributed greatly to the development of Sikoro as an educator and by helping families enroll their children in school. That is the work that helped him to become known, respected and solicited by the people of Sikoro. Since his arrival at Mali Health, this son of Sikoro has been steadfast in his commitment to help disadvantaged families have access to quality health information and healthcare.

Like all the community health workers, Dramane helped me a lot personally. He has helped us become knowledgeable, competent actors so that we can inform the families in our community. This constant support of our team has led to dramatic changes in the health of children and families in Sikoro.

Hard-working and courageous, Dramane has always been available for the cause of Sikoro, from his childhood to this day. “

– Sokone Coulibaly

Getting to Lassa requires a bit of a climb. Like Sikoro, it is north of Bamako, where the hills turn into cliffs. It is a different landscape.

On our way to visit a savings group, we started with a call on the village elders. Traveling with more Americans than usual, they received our small delegation graciously in a thatched-roof building that is surely often occupied by important community meetings and discussions.

Seated on the ground on an animal skin, the eldest offered very warm and customary greetings. We offered a traditional gift of kola nuts. Interpreting the exchange for our guests – Bambara, French, English – English, French Bambara – makes it feel more profound and ceremonial. Receptions like these are an honor and a social performance of respect – and I will never tire of them. I’m unsure if Mariam (our Mali Director), or the rest of our team, share my enthusiasm and awe. They always represent Mali Health with the immense Malian graciousness that is gratifying to this Southerner to watch.

Accompanied by two of the elders, we continued a bit farther up the slope. Noting very large piles of firewood (and suddenly realizing the lack of trees), they inform us that the production of charcoal was the primary revenue-generating activity. The informal economy is how most of those living in peri-urban communities, especially women, get by. They tell us that Lassa used to be like a rainforest – a small oasis above the city – but the dust the characterizes the rest of Bamako now seems to dominate here, too.

But as we continued, mango trees began to appear and grow in size. When we turned the corner to where the group was seated, we encountered one of the largest mango trees I’ve seen in Bamako. Mango trees provide very welcome shade here along the edge of the Sahel; thousands of women’s groups meet beneath them across the continent every day. They are amazing trees – thriving in even the harshest of conditions.

Again our small delegation is welcomed graciously, this time with song. We observe the opening ritual of the meeting – the diligent taking of attendance, reporting, counting, and recounting of the amounts saved in their two accounts: one for health expenses and one for income-generating activities.

Then, one at a time, every woman rises and brings her contribution, 100 FCFA, or about $0.18. The status of loans is reported. The funds are counted, recounted, and reported to the group to be held in the collective memory. At the beginning of their next meeting, the group will be asked how much should be in the accounts. The funds will be counted and the numbers will agree.

At the conclusion of their savings activities, the visitors are welcomed to ask questions. This Director, eager to report back to our wonderful supporters, asks a few (rather standard) questions:

• How many of you have used the health fund for yourself or one of your family members? About 80% of hands go up.
   
• What kind of things do you take the non-health loans for?  Women share that here in Lassa, they are gardeners. They buy inputs and tools for their gardens with the loans. Things like fertilizer, small tools, or seeds they don’t save themselves.
   
• What can we as Mali Health do to better support your group?  They want support to form a cooperative too… word travels fast. Though we are testing the cooperatives in only two communities – not at all close to Lassa – the other 5,000 women in Mali Health savings groups are watching closely.
   
• Great – we would love to help you do that. If you had a cooperative, what would you like use the funds for? To send our children to school, they say.

Hmm… no mention of health. I say as much to Mariam and she nods – but she’s already two steps ahead of me. I ask her if I might ask about the health center, how do they find the service there? How is the quality of care? We have worked with the health center here as an advisor to another community project, but we just added the CSCom in Lassa as a full quality improvement partner a few months ago.

Thanks to our partnership with OSIWA, we are expanding our participatory quality improvement approach – this time with a particular emphasis on women’s participation at all levels. These are some of the very women who we will be relying on to provide their feedback and leadership – to participate actively in the improvement of the health center. Mariam knows what is coming, but gives me the go-ahead.

• Could you tell me about your health center here in Lassa? What has your experience been like? What do you think of the quality of the care you receive there? A few women weigh in, saying they are satisfied with the care. Many have taken their children there and have received effective treatment.

I turned to Mariam – are they just telling us what we want to hear? Do they know we want to hear their real experiences? Mariam smiles at me, knowingly, as if my understanding finally catches up to hers. We discuss that the time is late and I say that we can just let it go. But, it would be nice to encourage them to share more. Their experiences are essential for us and the health center to hear and understand. We want them to know how important they are, but is now the best time to have this discussion?

As I discuss with Mariam, the group becomes restless. We have already taken up too much time – they have households to manage, children to mind, and meals to prepare.  Having stopped interpreting our side discussions, I’m worried I’m boring our guests who are not accustomed to the dryness and heat.

But then Mariam turns to Gaoussou, the dynamic Director of our Community Capacity Building department, and says a few things in Bambara. Though her Bambara is excellent, she usually prefers to speak in French and have Gaoussou interpret for her – another process I enjoy. This time, she speaks directly and deliberately to the women in Bambara.

Mariam tells them she knows there are issues at their health center. She explains why they are so important, not only to us, but to their health center and community. She describes our strategies for sharing feedback from women with the health centers and that we need more women to become leaders in the community association that manages the CSCom to help advocate for better care.

Though we have just taken them on as a full quality improvement partner, Mariam knows the center well. She gives the names of all the personnel – including the new director. She conveys to the group that she knows what happens there – she knows what they know.

One of the visiting elders weighs in.

 Listen to her words, she knows your health center perhaps better than you – why don’t you share your experiences?

After a brief pause, one woman starts pouring out her story – sounding more urgent and frustrated with every word. After hearing about the importance of delivering at the health center from her savings group, she was finally able to convince her brother to let her take his wife to deliver at the health center. Despite going into labor in the center, her sister-in-law was never attended to. She delivered, without being touched by a single provider. She vows to never return to the health center.

Other women weigh in with similar stories of neglect, lack of respect, or poor-quality care. They say that when they take loans from their group, they take extra so they can pay for the transportation to take their children to another CSCom nearby. They avoid their own health center if they can.

Throughout their testimonies, Mariam nods, again knowingly. Their experiences are why we started our quality improvement work in the first place. What is the use of helping women overcome the barriers to accessing care if the care they receive does not help them? This is why our approach of addressing both access and quality is so important.

Mariam thanks them for sharing their stories. She says it is because of their experiences that we are now working with their health center to improve. She reinforces once again that they are a very necessary part of the process and that we will continue to support them and the health center until they are truly satisfied.

We close our meeting with exchanges of gratitude all around. We take a group photo under a branch of the grand mango tree.

Though very aware of the time we have consumed, but not wanting to leave them after such an enlightening visit, I very timidly ask Gaoussou if I might just see one of the gardens they mentioned? Maybe take a photograph of one of the cultivators in her element?

We are again graciously ushered up a hill, through the barriers that keep out renegade goats, chickens and children and into beautiful, lush gardens. Yams, peppers, tomatoes – as far as the eye can see. I’m told that nearly every woman in the savings group has a garden and they sell their excess produce in the markets. No more charcoal.

While many families we serve come from rural areas where cultivation is the mainstay, there isn’t much room for gardens in densely-packed peri-urban communities. Lassa, situated along the ridges above town, has a bit more room – so the women are growing.

After more thanks and farewells, I’m still processing the lessons this group taught us, but mostly feeling very proud of our team and their dedication to ensuring women are heard and can lead. As we descend from the gardens, the elders share that instead of cutting trees, the community is now working on replanting them. Between the trees and the gardens, they have already noticed a difference in their climate.

They say the rains, which started to pass over Lassa into the next valley when the trees were all cut, have returned.

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.