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.
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.
Every year, 5 May is dedicated to one of the most important professions in the world – the midwife. No matter where you live, the work of midwives is at the very heart of a family’s health. Their roles are multifaceted and comprehensive, but often underappreciated.
No one knows that better than Mme. Kouyaté Haby Koné, midwife at the community health center in Boulkassoubougou. Haby has served as a midwife and taken care of families in her community for more than two decades.
As a woman, I am proud of my job because I witness all day long the role that midwives play in the health of the family. We accompany pregnant women, newborns, mothers, and families during a very sensitive phase of their lives.
– Haby Koné Kouyaté
Though she has been dedicated to caring for mothers, newborns, and families for much of her life, it can still be a daily struggle. She notes that midwives like her often lack access to technical training and ongoing updates on health standards. She wishes they had more resources to advance in the practice of their profession.
The health center where Haby works in Boulkassoumbougou is a part of our participatory quality improvement program, so she does have access to these resources. They make a difference not only in her feelings about the quality of her work, but in the outcomes for her patients. Thanks to her, more mothers are completing all their prenatal care, coming to deliver at the health center, and returning for postnatal care and their children’s vaccinations.
But as she so effectively and kindly takes care of her patients, she still thinks about all her colleagues across Mali and across the world.
Haby counsels a patient on family planning options
For Haby, the more attention that can be paid to the needs of midwives, the better. She believes more needs to be done, urgently:
I appeal to governments, civil society organizations, and partners to commit themselves to improving the technical platform and support for midwives, and to invest in building the capacity of midwives in order to save lives and improve the well-being of pregnant women, mothers, and newborns.
Together, we can hold policymakers to account and show that the numbers on the impact of midwives speak for themselves and that we need to invest in midwives for midwife-led care now and for future generations.
At the end of April, Dr. Sogoba attended a weeklong workshop in Fana. It was the latest meeting for the development of the national plan for the extension of community-based epidemiological surveillance (SEBAC). Dr. Sogoba, the director of our Health Department, is representing the needs of community health systems in this national policy process, alongside international NGOs and regional and national health authorities.
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.
While the fields of public health and medicine (among others) often invoke compassion as a grounding principle, its application to our training and practice as professionals is still developing. We recently had the chance to reflect on compassion and its role in our work, and we realize it a conversation that we want to continue. And we’d love for you to be a part of it. Share your thoughts with us on social media, or send us an email.
In mid-June, we attended the IZUMI Partners Meeting in Boston. We are so fortunate to work with IZUMI and they have been a strong, steady partner as we have developed our approach to improve healthcare quality, governance, and community participation at community health centers.
IZUMI Foundation supports global health around the world and is part of a group of foundations originating in the Shinnyo-en order. Shinnyo-en is a Buddhist denomination originally established in Japan that is grounded in values such as kindness, compassion, and caring for others. In fact, one translation for the Japanese word izumi is “heart of compassion” and in the Shinnyo-en tradition, that is represented by a deep commitment to social awareness and justice.
IZUMI Foundation is driven by the principles of hope, health and compassion and we are delighted that the one thing that stayed with us the most from their meeting was not something we learned about global health or nonprofit leadership, but something far more universal: the role of compassion.
The keynote speaker at IZUMI’s meeting was Dr. David Addiss, an advocate for compassion in global health, and he spoke about its necessity in our sector. Compassion is a familiar value for most of us, but Dr. Addiss differentiated compassion from other values and grounded it clearly in our field. Compassion is not rooted in sympathy or pity – those connote differences in power, even superiority. Instead, compassion is rooted in solidarity and an acceptance of our interconnectedness.
Though some may view it as an unscientific discourse, he noted that compassion is a skill that can be practiced and there is a growing field of neuroscience devoted to understanding it. Compassion can be taught, and learned. Dr. Addiss asked us to consider and interrogate compassion – as the desire to alleviate suffering – as the inspiration and motivation for many of us and as the ground in which our field is rooted.
Though we are now back in the busy day-to-day of our roles, the idea of compassion has remained with us. It has encouraged us to reflect on the role it plays in our organization – and in our partnerships with communities in the US, and in Mali. As a small community organization, we often think of Mali Health as generating so much of our identity from the communities we serve in Mali – the proximity of our team within them and our service to them – and the community in the US who chooses to support that work. But if we take a step back and ask ourselves why that identity has meaning for us – the answer looks much like compassion.
At its best, compassion is about solidarity, about making connections across difference out of a recognition that we are linked. While compassion might stem from conditions of inequality, those we serve are not the objects or recipients of our charity. They are equal partners in eliminating suffering and improving the wellbeing of all.
But sometimes, that distinction isn’t always clear in our sector. There can be a downside to compassion, especially when it comes to examining our motivations and choices as individuals. Helpers of all kinds can burn out and people make poor choices in the name of serving others. At its worst, those operating in the name of compassion insist on maintaining power and agency over others – blind to their own biases and the oppression they perpetuate. And we still watch with concern as the power that exists in our sector not only can allow poor leadership or poor development work, but can incentivize it. Compassion alone is not enough to solve these challenges, nor is it the only value that should direct us. But we wonder if it might not be the kind of guiding, and grounding, principle from which global health as a field, and we as practitioners within it, could benefit.
In Mali, we see many applications for compassion in our daily work. The idea of “compassionate care” in a clinical or medical setting is not a new idea, but compassion is not a term we often use in public health. Our work and the way we train our team is grounded in principles of respect and care, but compassion still seems distinct.
Yet we see it in our community health workers going out each day to tend to their neighbors – doing so out of a sense of improving their communities and protecting the most vulnerable within them. We see it in our office staff, who have a strong sense of service to others and have dedicated themselves to our mission and values.
But perhaps where the idea of compassion resonates most for us is in our work to improve the quality of primary healthcare for the most vulnerable. Within quality improvement, there is a well-defined emphasis on the delivery of respectful maternal care that ensures all mothers are treated with equity and dignity. Interestingly, compassion does not often accompany these principles in the literature. But with its insistence on recognizing the human connection between a provider and a patient, compassion seems inherent in the current quality, equity and dignity (QED) framework in maternal and child health.
But there’s more we’d like to do.
Ethiopia’s Health Systems Transformation Plan discusses the creation of a compassionate, respectful, caring (CRC) health workforce, embedding compassion not only in quality, but also a building block of health systems strengthening (HSS). HSS can be one of the “nameless, faceless” areas of global health that the call for compassion is seeking to humanize – and we’re watching closely.
We are imagining how we might facilitate conversations with our team and our partners about the role of compassion not only for their motivations as individuals, but also within their daily work. We are thinking about what connections we might make between our emphasis on the patient experience in our quality improvement work, and how compassion might further improve our partners’ ability to provide more patient-centered care. Might we help our partners build a compassionate, respectful, caring (CRC) workforce?
Our ideas for how we might integrate compassion into our work are just beginning…
We also know that members of the Mali Health community are motivated from a place of compassion. You have told us time and again that you see solidarity at the heart of our work, and that is why you support us. You share your compassion with women and children in Mali, and us, because you believe that no one should suffer because they don’t have access to quality healthcare. Beyond your participation in our community, many of you are physicians, educators, or helpers of some kind. Your compassion, your desire to alleviate suffering, emerges in all areas of your life.
For us both, reflecting on compassion has led us to some rich and thought-provoking places. We are thinking about its role in our motivations as leaders, in the organization and team we support, and in our field. We wonder if you might have similar insights?
We want to open up the conversation about compassion in our communities – both in the US and in Mali – and we invite you to be a part of it. Let us know your thoughts about the role of compassion in your life – personal and professional. We’d love to hear from you. Send us an email, or leave us a note on social media.
On Wednesday 10 July, Mali Health was honored by the Sotuba community in recognition of our partnership, and the impact it has had on improving community health. While we were the ones being recognized, for us, this event was actually a chance to celebrate the strong leadership in Sotuba, and the community’s investment and ownership of their health, and health system.
Sotuba is a peri-urban community on the eastern side of Bamako and Mali Health collaborates with the health center (CSCom) to improve healthcare quality and governance, as well as supporting community health workers and women’s health savings groups there.
The celebration featured staff from Mali Health, members of the community, and the president of Sotuba’s ASACO (Association de Santé Communautaire), the organization made of community members that oversees the health center. The ASACO serves as a bridge between the health center and the surrounding community, linking the organization and the people.
The ASACO has a key role in helping to improve the health of the community. When a community has an organized and efficient ASACO, the CSCom’s work is tailored to the specific needs of the people it serves, the CSCom becomes more responsive, and the amount of women and children seeking care at the health center increases.
Sotuba is one of the smallest communities with whom Mali Health collaborates. When the partnership began, the ASACO had no structure or organization and it was unclear to the community and the health center what exactly the role of the ASACO was. Unfortunately, most low-resource communities in Mali face the same challenge and one of the most important pillars of the community health system often is not able to fulfill its role of ensuring strong management, accountability and community participation in health centers.
Today, Sotuba’s ASACO is an active group of community members who are fulfilling that essential role – and they are seeing impressive results. On a measurement scale we use for transparency and accountability, Sotuba went from being one of the lowest-scoring partners to one of the highest. Sotuba’s patient satisfaction scores are consistently among the highest, over 95%, and the rates of pregnant women returning to deliver at the CSCom are the highest of any of our partners – sometimes reaching 100%.
As one of Mali Health’s first partners to implement, test, and refine our participatory quality improvement (QI) approach, their hard work speaks for itself. For several years, a QI coach has provided technical support and coaching to a QI team at the Sotuba CSCom and we are now in the process of turning the QI program over to that team, so that they can continue serving their community at this high level.
To support the efforts of the health center and extend the impact of improvements in quality, Mali Health has provided community health workers and free or subsidized healthcare to children and pregnant women with the least access. We also help women in Sotuba access more financial resources that can help them improve their family’s health. By addressing preventive healthcare, hygiene, and budgeting, these strategies aim to advance health in Sotuba by helping women gain more knowledge about their children’s health and increase their ability to act on it.
A mother and savings group member who attended the celebration shared her experience:
Two times a month, Mali Health makes contact with us parents, to see the evolution of the state of health of the children. They are really there for us; we are really grateful. They educate us about the nutrition of our children and hygiene. The savings funds that Mali Health helped us set up helps us a lot to provide hygiene products such as our soaps and other cleaners. I’m so grateful that I have tears in my eyes about Mali Health.
Mali Health’s overarching goal is to support the Sotuba community to improve access to healthcare; the partnership is rooted in the community’s desire for change. Although there is more work to be done, this celebration represented an important milestone and the core of what makes Mali Health’s approach different. While Mali Health can give support to the health center, mothers and community members to improve health and to make change, it is up to them to decide whether to adopt strategies, act on information, and to take ownership of those strategies to sustain that change in the long term.
As the president of the ASACO described it, to the community, Mali Health represents the idea that a different future is possible, and within their reach. During his acknowledgement, the president reflected:
I remember a story that was told to me by one of my teachers: a little boy from a small village became a doctor and became a source of hope for his entire community. This little boy reminds me of Mali Health which has become the source of hope for our community.
Members of the Sotuba community have seen the change they are able to make to improve the health of mothers and children. While Mali Health remains so grateful for their partnership, and their gracious efforts to recognize what our partnership has achieved, we are most excited by the real steps forward that community members in Sotuba are taking to actively participate and take ownership of their health system and its future.
Every community with whom we work will always have our support, but our role is to strengthen their ability to manage and improve health in their communities, so that they can take the lead.
When they are the ones who start giving us the certificates and the chiwaras – then we know we’re all doing something right.
