Stephen Muse

Putting ‘Health’ Back into ‘Health Clinics’: It’s not good, statistically speaking, to be a mother or child in Mali, but new approaches might bring change

How do you build a bridge?

First, it can’t be done alone; you need a patient, skilled and dedicated team, working cooperatively to ensure every detail is attended to.

Second, you need a plan, meticulously designed to meet the needs of the situation. The gap you are trying to span will shape your approach.

Third, you need the materials, the physical stuff of your bridge, ideally sourced locally so that if something breaks after you’ve finished and left, it can be built back up again.

And you have to remember: No bridge stands alone; it is anchored to the strongest points on both sides of the gap, ensuring it will stand for years to come.

In Mali, there is a chasm between health clinics and the communities they serve; Mali Health (where the author serves as operations manager) is working to bridge that gap.

The 1987 Bamako Initiative, intended to increase community participation in local health systems, ultimately relinquished central authority over the nation’s health system so that each health clinic is financed and governed by the community it serves. In theory, this may increase clinics’ accountability to the local population. But in practice, an undereducated and financially-disadvantaged populace leaves the clinics under-resourced, understaffed and underutilized.

This is especially true in the peri-urban slums of Bamako, Mali’s capital and largest city, where the majority of the population lives below the poverty line. Reports from ICF International and Save the Children consistently rank Mali as one of the worst countries in the world to be a mother or child, where morbidity and mortality remain tragically high.

In this context, Mali Health sees communities in need of health care and primary care clinics that are willing but unable to meet their needs. Our model for improving health outcomes builds on the strengths of both sides to bridge this gap between communities and clinics.

Mali Health began in 2006 as a partnership between Brown University students, local government leaders, community-level health officials, local residents and grassroots donors working together to advance sustainable improvements in health care quality and access for people living in impoverished areas of Bamako.

Community members have repeatedly told us that though they often wish to seek care at the clinic, they cannot afford the out-of-pocket costs. So we built the first plank in our bridge, our Health Savings program. In Health Savings, groups of 20-25 women gather weekly to learn about important health and financial topics and to deposit small amounts of their personal savings into two collective accounts. From one, women can access interest-bearing loans to support revenue-generating activities. From the second, they can access no-interest loans to pay for health care expenses. At the end of a predetermined cycle, each enrolled woman receives the sum of her total savings and a share of the interest earned, and they are invited to reinvest in a new savings cycle.

Through these funding mechanisms, we are removing the financial barrier to care-seeking. Since the program began, more than 600 women have utilized health loans to pay for clinical care, and the numbers are rising dramatically. Today, nearly 2,000 women are enrolled in Health Savings.

Ensuring financial access is only part of the equation, though. Families need to be empowered to care for themselves and they need to know when and how to seek professional care. So we built Action for Health. Through this program, a team of highly trained Community Health Workers (CHWs) visits enrolled families periodically to monitor the health and development of children younger than 2, and pregnant women. CHWs are trained in techniques of behavior change communication and spend time each visit educating mothers and caregivers on preventive health practices. And when a child or a new mother is sick, our CHWs help them connect to the clinic to access the care they need.

When families do seek professional care, we must ensure that the clinics are capable of providing the services they need at the quality they deserve. Health system strengthening through continuous quality improvement is the third major plank in our bridge. At each of our partner clinics, we’ve formed Change Teams – comprised of clinic staff, management and patient representatives – and equipped them with the tools to assess and address needs in their clinics. Teams identify opportunities for improvement and work together to implement and evaluate relevant solutions. Through this process, Change Teams are creating more open, effective and efficient clinics, resulting in greater patient attendance and satisfaction.

Mali Health strives always for efficacy and impact, and we recognize that a unidirectional approach won’t get us there. To achieve significant and lasting improvement in health outcomes for the most vulnerable members of these neighborhoods, we must work with both sides – community and clinic. Working with families, we can reduce the incidence of preventable disease. Working with clinics, we can improve the quality, capacity and accessibility of health care. And working with both, we can finally bridge the gap in maternal and child health.

Stephen Muse is the operations manager at Mali Health.

Health Care