Mali Health believes in building on a community’s existing resources. We do not want to replace them, because we want to enhance them. Often, a community’s greatest resource is its residents – people deeply committed to improving life for their families and neighbors.
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. “
Joe (board member) and Tara (US Director) visited Mali in February 2019 and were honored to host a few American guests for an eventful week, including the celebration of our team of community health workers, and their amazing accomplishment of not having lost a single mother or child in their care since January 2014 (read more on that here). Below is another special experience from that trip, written by Tara.
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.
Des Bonnes Mamans savings group in Lassa, with visitors
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.
In November 2018, Mali Health officially became a partner in the WomenConnect Challenge (WCC) – a USAID initiative intended to “bridge the digital gender divide.”
For so many reasons, this was an unlikely place to find ourselves; it was not something we had planned. Partnership, collaboration, and learning can be funny in that sense – they often lead to unexpected places. The journey to become one of nine WCC partners has been enlightening, challenging, and meaningful. It’s a journey that we are fortunate to be on. This is new territory for Mali Health.
Perhaps you are now wondering: what is a digital divide? and what does that have to do with mothers and children, or health? Confusion, and even skepticism, are rational responses. We would be the first to admit that the connections between our community health work, this opportunity in particular, and the fascination with technology/innovation/social entrepreneurship in general, could seem tenuous. This project could be a distraction from our mission.
But, we’re learning so much on this journey – and those concerns do not keep us up at night. Here are four reasons why:
1. We’re focused on women.
Women are the heart of what we do. They are the focus of our daily work because they are at the core of our mission and strategy. Women are the key to improving maternal and child health in Mali because they are the ones who are most affected by access to and quality of care. You’ll remember that access and quality are our two top priorities in community-level maternal and child health. Women are the care-providers to children and the care-seekers for their families. They are the ones who determine where, when and how their family needs to seek healthcare.
As you may have guessed, WomenConnect is also completely focused on women. We all know that women do not have the same opportunities to reach their full potential, but have you thought about what it means for them not to have access to the same technologies? As the world becomes more digital, what does it mean for women to not have equal access to the internet? Could that impact their health and wellbeing? WomenConnect thinks these are questions worth asking and answering (so do we).
And we’re in good company. In their 2019 Annual Letter, Bill and Melinda Gates described nine of their top surprises as they have pursued their philanthropy and work. Guess what #9 was?
“Mobile phones are most powerful in the hands of the poorest women.”
– 2019 Annual Letter, Bill and Melinda Gates
Say that again? We start a project to learn if and how cell phones using a voice-based technology can help the poorest women in Bamako better meet their health needs… and two of the most towering figures in global health are talking about poor women and cell phones?! On the Colbert Late Show?!
If it makes sense to Bill and Melinda Gates, that works for us.
2.This project allows us to use technology and engage in innovation and social entrepreneurship in an appropriate, measured way.
The potential for innovation and solo social entrepreneurs to save the world is another topic for another day – but let’s just say this approach feels overrepresented in our field at the moment. Not every health problem (especially in community and/or maternal and child health) is a challenge just waiting to be hacked or solved by the right technology or business model, which can then be taken to scale to save the world.
However, there are some very amazing engineers and entrepreneurs out there who may very well revolutionize the way the world tackles certain problems. We’re not one of them, and we’re not trying to be one of them. The revolution we seek is to help communities in Mali have full ownership and control of their local health systems so that all mothers and children have access to quality care. But, that doesn’t mean we can’t partner with one of these visionaries (see #3 below) – and work together to find extraordinary solutions.
So we are. As a small community organization, everything Mali Health achieves is through partnerships. With donors, with communities, with mothers and families. This project allows us to build an exciting new partnership, which happens to include technology.
And perhaps it is through partnership – bringing together community expertise and resources, community builders and problem solvers like Mali Health, and the best of technology, innovation or social entrepreneurship like Lenali – that the real potential for transformative change using technology and innovation exists. Even social entrepreneurs need customers. Maybe it is none of these pieces alone, but working together in partnership with the others, that creates success? We’re excited to find out.
3. We are going to learn a lot. In fact, we already have.
Learning from others is very important to us. So important, in fact, that we made learning and data-based decision-making a pillar of our current strategic plan. It’s something we encourage within our team and within our organization everyday.
Participating in this process has already offered many lessons. Perhaps like me, skepticism about the appropriateness of technology to serve women living below the international poverty line, in some of the poorest peri-urban communities in the world, is still lingering in your mind. When we’re simply trying to help women and children prevent basic illness via handwashing with soap, or get to their community health center for prenatal care, malaria treatment, or to give birth – where is the role for technology? I had to learn.
My favorite line about the 9th surprise in Bill and Melinda’s letter is this: “connectivity is a solution to marginalization.” The most important part of that line is the smallest, the article: Connectivity is A solution, it is not THE solution. Perhaps the greatest lesson I have learned so far is that simply using technology should not ever be THE solution. In fact, it’s quite the opposite. Technology for its own sake almost never works. Technology is a tool, like soap or a mosquito net. And it is one that we should not overlook because the women and families we serve happen to be poor.
This lesson is also particularly evident in our baseline study, which was administered by our talented Research, Monitoring and Evaluation Department. Of the 300 women we surveyed in Sabalibougou, 100% reported owning a cell phone. Of those same women, 52% had no formal education and 37% had some primary school education. So, a full 89% of the women we surveyed had extremely limited or no formal education, meaning they are likely to have trouble with literacy and numeracy – but they all had a cell phone.
So, can connectivity be a solution to marginalization in this context? Absolutely, yes.
Our baseline study was full of other surprising results (so much learning!) but I will save those for another day. This project has already challenged my assumptions about technology – what it is, and how it can be used, it’s relevance to the poorest women – and I am ready for other assumptions to be challenged. That’s why learning is so important.
4. We’re part of a supportive WCC community.
In June last year, we had the opportunity to attend a workshop in DC as a part of the WCC application process. Mali Health was the only health organization to attend among the approximately 20 participants. Not only did we meet some fantastic people, we learned a great deal. We learned from the other projects and organizations who attended and collectively we learned together from a community of experts who shared their advice and work. There was a spirit of collegiality, not competition. For anyone who must attend professional workshops or conferences, or who have firsthand experience with USAID “co-creation” processes – you know what a rare experience that is, and can understand how much we appreciated it.
The person who is most responsible for this community is WCC Director Revi Sterling, whom we had the honor of hosting for the community launch of our project in Sabalibougou earlier this month. We are so fortunate that Revi and her vision for WomenConnect landed at USAID when she did – and we wouldn’t be participating in WomenConnect without her.
Mali Health is proud to be a part of WomenConnect – and we will be working very hard to make our colleagues in the WomenConnect community proud of us.
Thoughts of How on earth did we get here? have ceded to thoughts like What an amazing opportunity for our team!
We cannot know if this project will work – it is a pilot, after all. But as we work alongside 400 women in Sabalibougou and listen to what they think of a brand new technology and its relevance to their lives, we do know that we, and our partners, will be learning a great deal along the way.
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.
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.