Dr. Ari Johnson

Designed to Arrive Early: How we can save the lives of millions of children

Today, thousands of doctors – including me – will go to work. And wait. This is how most health systems function: Providers wait for patients to come into clinics or emergency departments seeking our care.

But to solve the global child mortality crisis, we need to stop waiting. To save children’s lives in the world’s poorest communities, we need to break free from this reactive model for health care delivery and turn this mode of operation on its head. We need to reach our patients earlier.

The leading killers of children globally may seem like easy targets. Pneumonia, diarrheal disease, malaria and neonatal illness all have well-proven tools for both prevention and cure. And yet, 6.6 million children died before the age of 5 across the world in 2012.

The challenge is in delivery of these known methods for prevention and treatment. The leading causes of child mortality are diseases that progress and kill rapidly. Hours and days matter. A model in which doctors sit in hospitals and wait for patients to come to them – even if these hospitals possess the necessary commodities and treatments – will fail the most vulnerable patients.

The concept is simple: reach children earlier. However, this simple idea requires a fundamental redesign of health care delivery. The innovations we need to solve the child mortality crisis, even more than new vaccines or new drugs, are innovations in health systems design. We must redesign health systems to reach children within the first 48 hours of the moment they say, “Mommy, I’m sick.” And even better, to reach patients before illness even arises.

For the past eight years in Mali, I have worked with the teams of two NGOs, Muso and Tostan, and the Malian Ministry of Health to do exactly that. Our model reaches patients before it’s too late through:

Active case finding: Community health workers proactively search for patients through door-to-door home visits. Through these visits, they find and connect pregnant women with prenatal care early in their pregnancy, and find and treat sick children within the first days of their illness. When they visit a home where no one is sick, they provide counseling on prevention.

Community organizing for rapid referral: We don’t typically think of community organizers as core to healthcare. But they could play a powerful role in connecting patients with care. We trained a network of community organizers that mobilized families to bring children to their community health workers early for prevention and care services.

Removing user fees: Out-of-pocket fees for doctor’s consultations, diagnostic tests or medicines have been shown to delay and prevent poor patients from accessing care. We redesigned the health system to remove point-of-care fees, to increase early access to care, particularly for the poorest patients.

Solving the upstream cause: Improved access to education, community organizing and employment opportunities help overcome conditions of poverty that cause disease. For example, community organizers in the area of our intervention in Mali successfully lobbied local government officials to improve access to clean water in their communities, and the government responded by installing more than 30 new public, clean water taps.

Last month, a group of researchers from Harvard and the University of California San Francisco published a study tracking rates of child mortality before and after the roll-out of this new model for health care delivery. What they found was surprising: In an area of 56,000 people in Mali, three years after the roll-out of this new model, the number of patient visits increased tenfold, early access to antimalarial treatment nearly doubled and there was a tenfold decrease in child mortality rate.

The study had no control group and therefore cannot make causal conclusions about the results, which could have been due to the intervention, demographic shifts or other factors. It is worth noting, however, that there were no other known interventions in this area during the time period of the study, and that the demographic characteristics of participants that were measured were similar from year to year.

An increasing number of global health institutions – including the Global Fund, the World Bank and the US Global Health Initiative – have identified health system strengthening as a key priority. As we assess the strength of health systems, we will need to work on redesigning them to reach children earlier. We should measure the success of our health systems by how early we reach the most vulnerable child.

This blog originally appeared on dowser.org.

Dr. Ari Johnson is co-founder of Muso, a co-author of the child mortaility study referenced above and a physician at the University of California San Francisco.

Education, Health Care
public health