While malnutrition remains an urgent challenge across Mali, the number of malnutrition cases treated at CSCom Kalabancoro Kouloubleni has been dropping. Just like at ANIASCO in Niamakoro and ASACOS in Sotuba.

Undernutrition contributes to nearly half of the deaths of children under age 5. Child malnutrition increases the risks posed by malaria and other common childhood infections – and it has been rising rapidly across Mali. At the same time, the international aid systems that have long underpinned emergency nutrition treatment are contracting.

As our team noted last year, health centers with whom we partner were left with limited treatment options and rationed their remaining stocks of life-saving nutritional commodities. Those supplies are now gone.

The disruption leaves children at risk and it has exposed a systemic vulnerability in approaches to malnutrition treatment: relying on imported commodities to manage chronic nutrition leaves communities dependent on forces beyond their control. But it also presents an opportunity to reconsider approaches that are dependent on external resources.

What would it mean to instead invest in approaches built on local resources? In ten communities across Bamako, Koulikoro and Kati, our pilot project is demonstrating what that transition could look like in practice.

 

 > The need for change

In the early days of the US foreign aid funding freeze, our team identified two areas where the interruptions would have a significant impact: reproductive healthcare/family planning and malnutrition treatment.

Food insecurity and the severity of malnutrition cases has been increasing steadily in Mali. Malnutrition treatment became a concern because the standard treatment for the most advanced stage of malnutrition – nutrient- and calorie-dense ready-to-use therapeutic foods (RUTF) – is produced and distributed through international aid networks. RUTF was an effective, lifesaving resource that many depended on and it was now in jeopardy.

We cannot produce RUTF locally, and once it became clear this external resource was likely to run out, as it now has, a shift in strategy was needed. We turned to our mission – working with women and communities to develop local solutions.

> Developing a new community-led approach

To create a new strategy that shifts more control over children’s nutrition to families and communities, there were several resources we could draw from.

First are the lessons we have learned from our own community health worker program. Through the deployment of dozens of community health workers who have provided care to thousands of children and their families, we have over 15 years of experience working with community stakeholders to improve child nutrition. Though we have nearly eliminated malnutrition in families enrolled in our program, our task now was to extend the lessons from this work to the community-level, preventing every case of malnutrition in the population.

Partnerships are the best way to achieve that goal. An essential partner has been the Nutrition Division within the Directorate General of Health and Public Hygiene (DGSHP). As experts in the field of nutrition in Mali, they shared several insights that shaped the approach, with special attention to community-led prevention strategies. Since RUTF cannot be produced in Mali, our focus is to supplement the nutrition of children aged 6-59 months using nutritional supplements made from seasonal produce, aligned to local agricultural production, described below.

Health authorities at the regional, district, and community levels are also critical partners in this project, providing technical guidance, feedback and facilitation, especially related to identifying the communities where the pilot project might take place. At the community level, we worked to engage those involved in children’s nutrition – most directly mothers and caregivers, as well as nutrition health providers – in understanding their challenges and designing a pilot project to implement community-led prevention strategies that would address them. Read more about what we learned from the mothers and health personnel we spoke to here.

The approach that emerged is a peer-led malnutrition prevention program, centered around women leaders known as Demba Gnouman. These peer leaders were nominated by their communities and will lead the transfer of nutrition knowledge to mothers and caregivers through weekly nutrition demonstration sessions, expected to reach at least 15,000 women in the first year.

There are also nutritional education sessions organized at community health centers during their vaccination days – when mothers with children aged 6-59 months will already be at their health centers; these sessions should reach at least 5,000 women.  To support this knowledge transfer, there will be close coordination between the Demba Gnouman and the nutrition officers at their health centers and we hope that community collaborations based on solidarity and mutual support will emerge.

Working together, we are aiming to reach at least 20,000 families and achieve at least a 30% reduction in malnutrition cases in 10 communities in the first year.

> Launching the pilot

In ten communities across Bamako and Koulikoro, the pilot launched in December 2025. Our partners from the Nutrition Division took the lead on training both the nutrition officers at community health centers and the Demba Gnouman during intensive workshops focused on the nutrient-dense recipes, complementary feeding practices for infants and young children, food hygiene and WASH practices, and how to use the communication materials developed for the project to ensure comprehension by all participants.

Equipped with this training and all the supplies for their nutrition demonstrations, the Demba Gnouman took this knowledge directly into their neighborhoods. In just the initial weeks, 1088 women have attended 27 sessions facilitated by the Demba Gnouman and 880 breastfeeding mothers participated in 16 sessions at the health center facilitated during routine vaccination days.

Though it is early, partner health centers are already reporting reductions in both moderate and severe acute malnutrition cases. The initial responses from mothers, but especially from children, are promising. After one demonstration, a mother shared her observation:

My child is 10 months old. I give him Vitablé [a vitamin-enriched flour for infants produced in Mali], but he doesn’t drink enough of it. I am very surprised to see him eagerly drinking the porridge prepared by the Demba Gnouman. I will gladly reproduce this recipe at home for my child.

We are also starting to see clear indications of community ownership and local resource mobilization – both of which will be essential to the long-term success and sustainability of the approach.

Read more about what we are learning, and the next questions we’re hoping to answer.

 

During this year’s rainy season, Mali has experienced extraordinary flooding. Several regions were hit hard, including Bamako. Bamako is particularly vulnerable to flooding, particularly communities along the Niger river, like Kalabambougou, and communities with steep terrain and limited infrastructure to support rainwater runoff, like Sikoro. We work in both of these peri-urban communities, and the effects of the flooding have been devastating.

Women in Kalabambougou like Mandy have made so much progress building sustainable livelihoods, and Kalabambougou is one of three sites of our Gnaman ni Sôrô ani Kènèya project.

The video below shares the experience of Tenin Diarra, who participates in one of Mali Health’s savings groups, in her own words:

Tenin Diarra

The video has subtitles in French, which are translated in English below:

I’m Tenin Diarra, I’m from Kalabambougou and I’m a member of a Mali Health savings group.

This year, we really have been hit hard by the flooding. Since I have been in Bamako, I have never seen such a quantity of rainwater.

The river water overflowed, submerging the homes of families living riverside, including ours.

We have suffered two floods.

During the first, we left the house and as soon as the water started to recede, we returned.

During the second flood, we were rescued in the middle of the night by canoe because there was no way out of the house – the water had already completely invaded.

I lost my clothes, my goods, my provisions, everything.

Here is our vegetable garden where we cultivate corn for our use, as well as potato leaves and mint that we sell to support our family.

Today, everything is destroyed and we have lost everything. Even though the damage was enormous, there was no loss of life.

The place is not accessible without a canoe. Nevertheless, we have been staying in an unfinished home, waiting for the water level to drop.

Living conditions were precarious – without doors for protection, without water, electricity or latrines. We had to use the latrines of neighboring families who were not flooded for a month.

Now that the water has decreased, we have returned to our home, but we really need help, because we are going through a very difficult period.

 

Please consider a contribution to Mali Health to support women like Tenin. Resources are scarce and your support will make a difference helping them to rebuild their lives.

 

The Gnaman ni Sôrô ani Kènèya project has entered its third phase. Women and youth in three peri-urban communities are building a local, circular economy designed to create sustainable livelihoods and address environmental health and climate threats.

After extensive data collection and community engagement in Phases 1 and 2, circular economic activities have begun by establishing composting and gardening cooperatives. From our community research, we found that 57% of waste generated in peri-urban communities is organic, and can be composted, turning unmanaged waste products into a valuable resource.

Beginning in January, 180 women successfully formed 4 cooperatives In Kalabambougou, Sikoro, and Sabalibougou and started acquiring skills in gardening, composting, and cooperative management.

Our baseline data collection revealed some interesting findings.

All 180 women participating in the project have been pursuing gardening activities for subsistence and as their primary income-generating activity for at least 5 years. We expected that composting would be a new idea – and only 4 of them demonstrated knowledge of composting. But nearly half of them, 88 of 180, had limited gardening knowledge. This result indicates just how limited resources are for this group of women, validating the significant need for the project, and leading our team to focus more on mastery of basic skills. In addition, twenty women already had strong knowledge of cooperative management.

About 21% of the project participants (38 of 180 women) reported having no income, the monthly incomes for the rest of the group ranged from 3000 FCFA (about $5) to 22826 FCFA (about $38). Of those with some monthly income, only 8 women reported having enough to be able to save and set aside funds for future needs.

Most of the women participating in the project have been participating in our health savings groups, and 80% (144 of 180 women) knew what to do when there was a health need for themselves or their families. Without sufficient funds to act on that knowledge, the ability to make decisions to protect their health can be limited, but fortunately they can take loans from their savings groups to help meet these needs.

One of the most significant and immediate results of the project has been its impact on food security for women and their families. As they cultivate vegetables, women are not only able to generate income through the sale of their products in local markets, but they are also able to provide fresh produce for their households. In communities where access to nutritious food is limited and prices are often prohibitive, access to this resource is having an immediate impact on child and family health.

The composting activities are ramping up, as the cooperatives sort out their collection and distribution systems. They are already collecting organic waste where the majority of it is generated, at the local markets, and they are working out how to manage more widespread collection operations. With their full operations, women will not only have a local source of nutrients to boost soil health in their own gardens, they will also be able to sell their compost to others. Fertilizers are one of the most costly inputs for gardeners and cultivators across Bamako – and their compost will be an affordable alternative.

 

The project is fostering a sense of community and collaboration among the participants, as they work together to manage their cooperatives and share knowledge about sustainable agricultural practices. Their collective efforts are building social capital that not only improves social cohesion but increases local resilience to the economic challenges they face.

As the gardening and composting activities continue to grow, the cooperatives will begin plastic sorting and recycling activities in 2025. From our research, we found that plastic comprised 14% of all waste generated, so diverting it for recycling and reuse is the next step to building a circular, zero-waste economy.

In a very crowded hotel meeting room in Bamako, brimming with dozens of dignitaries and officials from all levels of the health system along with a wide variety of partners, a special award ceremony recognized the winners of a unique competition. 

Organized by the Ministry of Health and Social Development (MSDS), with technical and financial support from USAID’s Country Health Information Systems and Data Use (CHISU) program, this competition recognized health facilities for the quality of the data they submitted to DHIS2, Mali’s national health information system.

Data quality is a central challenge in health systems like Mali’s, which is why it is a key component of our participatory quality improvement (QI) work. Improved data reporting and data quality contribute to improved disease surveillance and informed, timely decision-making. We work alongside both community health centers (CSComs) and reference health centers (CSRéfs) to help them develop and implement data management systems within their contexts that report timely, reliable data to DHIS2.

On this occasion, the winners were being announced for the CSComs, CSRefs and hospitals who submitted the highest quality routine malaria data in 2023. Scoring was based on four indicators including completeness, timeliness, internal and external coherence of their data, as well as and the stock of malaria-related products.

This competition was actually the second organized by CHISU – the first was initiated in 2023 based on the quality of COVID-19 epidemiological data submitted to DHIS2. In that competition, two of our partners were recognized: the Commune IV CSRéf won the CSRéf competition and our partner ASACODJENEKA placed second among CSComs.

This second competition yielded even better results for our partners. The top five scoring CSComs in Bamako were ASACOKA, ASACOS, ASACOMA, ANIASCO, ASACOLABASAD – four of whom are Mali Health quality improvement partners. The Commune IV CSRéf, a partner of ours for ten years which oversees more of our quality improvement partners than any other district in Bamako, placed 2nd among CSRéfs.

The winners were recognized with certificates, a variety of supplies and equipment, and training and capacity-building support. Their efforts were rightly celebrated and the satisfaction of the winners at having their efforts recognized was encouraging.

For us, the highlight of the event was when the winning CSCom and our partner, ASACOKA, was invited to share a presentation on their best practices for improving data quality. ASACOKA, located in Kalabambougou, opened in 2019 and our partnership began in 2021. Their presentation included the processes and protocols that helped them achieve their success and it was gratifying to see how many of those practices were put in place in the context of their quality improvement work. While we helped to provide tools, methods, skills and confidence – the data quality practices, results, and success were entirely theirs.

As the ceremony concluded, other CSCom partners mentioned to our team how the data quality standards and processes they learned and implemented within the context of our QI partnership were factors in their success, as well.

These results are significant not only because of their performance – which is reason enough to celerbate –  but because they have sustained that performance over time, under the leadership of their own quality improvement teams.

The key sustainability strategy of our participatory quality improvement work is local ownership and leadership from the beginning, so that CSCom and CSRef personnel develop the processes and protocols that ensure quality healthcare, or in this case, quality data.

 

Worldwide, we are losing ground on maternal health outcomes. 

Maternal deaths are rising in many parts of the world, and we are not on track to meet SDG 3.1: Reduce the global maternal mortality ratio (MMR) to less than 70 per 100 000 live births by 2030. In February 2023, the WHO released a report indicating that nearly 800 women died every day in 2020 – about one woman every two minutes. 

More importantly, maternal deaths are not distributed equally. On a global scale, most maternal mortality is concentrated in sub-Saharan Africa (69%), particularly West Africa. Pregnancy-related causes are still the leading cause of death among African women aged 15-29. In the US, black women are 2.6 times more likely to die due to childbirth than white women. 

This significant equity challenge is being overlooked; the deaths of mothers deserve more attention and more resources. Within Mali, even though pregnancy is deadlier than armed conflict, the world pays far more attention to military action than the deaths of pregnant women.

At the same time, nearly every maternal death could be prevented. Though there is no standardized global data, studies from sub-Saharan Africa routinely show that over 90% of the causes of maternal deaths could be avoided with access to basic, quality maternal healthcare. In the US, more than 80% of maternal deaths could be avoided.

This contradiction is important and revealing – maternal mortality is mostly preventable, but we are still failing to prevent it. African women, and black women in the US, are dying at significantly higher rates. We must confront this truth, and its origins. We know what interventions work to improve maternal health outcomes. Our focus must stay on why all women and all communities don’t have access to them, and fix it.

Our current systems, strategies, institutions, and financing are not reaching the women most in need, because the women most in need are not represented in our current systems, strategies, institutions, and financing. In our current approaches, marginalized women and communities are usually rendered as passive recipients of services, not as actors with agency who are essential participants in the development of remedies to these deep and historic inequities.

To fix this problem, as Dr. Mary-Ann Etiebet noted, it is not just about what we do. It is about how we do it. We will not fix it by continuing to use the same approaches that have created and are maintaining these gaps in maternal health equity. It won’t be solved from the top-down, which is still how most of the world’s global public health systems work. What’s required is not developing a new technology or innovation.

If we are going to stop and reverse the increasing trend in maternal mortality, the women and the communities most affected must be at the heart of solutions.

If we do not change our approach, the result would be disastrous. By one estimate, if the reduction of maternal deaths continues at its current rate, SDG 3.1 would not be met in the African Region until 2100, after 125 million mothers died from a cause related to childbirth.

So what does it mean to change the how of our sector? What would it mean to dismantle entrenched systems designed to retain power and decision-making in certain hands? How do we prioritize and center the voices, experiences, and knowledge of those whose needs are not being met?

Instead of continuing to operate through our existing institutions and structures, and building interventions around their capacity to deliver or distribute solutions to a population, it means turning our focus to the mother who needs access to those solutions and starting to address the problem from her perspective.

 It requires a complete shift towards a more fundamental question of who is invited to participate in the solving – who is invited to participate in the how.  It means being willing to give up control and to pursue solutions that put power and resources into local hands.

We are trying to put this shift into practice every day. Whether it is adapting traditional quality improvement processes so they can be led by local teams of women and stakeholders, or redefining local health financing to ensure that women have the ability to build and manage their own health-financing resources, we strive to use a women-centered approach in every strategy. We convene and support women, community members, and providers in the community health system to work together to identify and solve obstacles to quality maternal healthcare in their communities.

Ending preventable maternal mortality is a problem that can be solved, but only if we’re willing to change how we try to solve it.

Led by the Frontline Health Workers Coalition and partners, World Health Worker Week (WHWW) brings together advocates, health workers, leaders, and communities calling for more resources to support health workers.

Directed primarily at policymakers and global leaders, the goal of this week is to urge decisionmakers to follow through on global commitments and to invest in, protect, and support the health workforce, especially women.  The 2024 theme is Safe and Supported: Invest in Health Workers.

The case for investing in community health workers is clear and proven, with immense health, social, and economic returns. Though the financial return on investment for the primary health care workforce has been demonstrated to be as high as 10:1, the current funding gap for community health programs is estimated to be $5.4 billion annually.

Across the African continent, there are many contexts in which leaders and decisionmakers have made policy commitments related to investing in health, but have not yet implemented them.  In 2001, African Union countries set a target of allocating at least 15% of their annual national budgets to their health sectors, known as the Abuja Declaration. But achieving this goal has remained elusive. In Mali, before COVID-19 and the latest governance transitions, Mali’s spending on its health sector was around 4%.

How much longer will it take for more countries to be able to reach the Abuja Declaration targets?

While increasing spending on primary healthcare is necessary, investing in health workers cannot simply be a matter of increasing national spending, or increasing international donor funding.

Whatever the cause, it is clear that greater domestic and international investments in health systems and health workers have not been forthcoming. In the Sahel, even with willing policymakers and treasuries, armed conflict and transitional military governments are a growing obstacle to increased national investment in health. Furthermore, in decentralized health systems, increased national investment may not even necessarily reach primary care systems, as community health systems are not principally financed by the national government.

If not policymakers and leaders, who can do the investing in health workers that so many communities desperately need? Are there other strategies and possible investors? Especially in decentralized health systems?

Communities are being overlooked as essential partners for investing in community health programs.

The calls for increased health financing and investment usually end at the national level. Even the terms “local financing” and “domestic resource mobilization” are mostly used to refer to national budgets. But if we end our advocacy there, we neglect possible health financing that is more localized including district, community, household, and even individual health financing. 

Let us also not forget the Bamako Imitative of 1987, whose purpose was to increase the participation of the community not only in the decision making and governance of the primary care health system, but in its financing as well.

For the past several years, Mali Health has been seeking to expand the understanding of who can do the investing and supporting of health workers. In Mali’s decentralized health system, we are seeking to help build community-led solutions for investing in and supporting community health workers.

To be sure, we do not mean to suggest that primary care workers should not be a health policy priority for every national government, as they are in Mali. But as we continue to advocate for greater investment and the fulfillment of the ambitions of the Abuja Declaration, women and children need health workers now, and we can work on local solutions to support health workers now.

For example, there is already a source of health financing that is highly localized, largely due to the Bamako Initiative. In addition to external donor funding and domestic spending, out of pocket payments (OOPs) are a significant source of health financing in most African countries – matching and exceeding other types of spending in many cases. Regrettably, OOPs and user fees are inequitable and burdensome, but they are a critical component to how primary care systems are financed today, especially in decentralized health systems.

But user fees and OOPs represent just one method for community involvement in the financing of health services. As we advocate for replacements to OOPs and user fees, we have an opportunity to reallocate them and other community resources into more equitable, affordable and sustainable strategies that could channel local, community-led resources to invest in the health workforce. Rwanda provides an excellent example for how community-based health insurance can mobilize community and local resources for more equitable access to quality healthcare, alongside national and donor investments.

To improve health equity, meet urgent health needs, and overcome the expected health workforce shortage, we cannot depend alone on increased national budgets or increased donor funding. While part of a solution, they are not the whole solution. As we work with policymakers and leaders, let us also not forget those with proximity to these challenges, and who work hard to support health workers in their community every day. They have valuable perspectives and insights, not simply as the recipients of health worker services, but as investors in them.

Let us begin to think about investment so that all health workers can be safe and supported, not just from the top down, but also from the bottom up.

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.