Strengthening healthcare systems and patients alike –
The Access Initiative in rural Mali

In order to improve the health situation in poor southern countries, the people there must have access to primary healthcare. This is one of the major challenges faced by communities, health authorities and development partners in Mali; it applies even more to rural areas with poor geographical accessibility, where villages are far apart. In light of this situation, the Novartis Foundation for Sustainable Development, together with its Malian partners, developed an integrated healthcare project in the municipality of Cinzana, between 2001 and 2006. Since 2007, the foundation, in cooperation with the regional authorities for health and social development, extended this five-year pilot project to another 12 areas in the region of Ségou, covering 170,000 people in 210 villages.

Aligning healthcare services and client needs

This new initiative was conceptually based on the best practices, lessons learnt and results achieved during the pilot phase. For its design, an analytical framework developed by the malaria-related ACCESS Project in Tanzania was used. According to this concept, access can only be improved in an appropriate and sustainable way if the local healthcare system and its services are aligned with the needs, expectations and available resources of clients. This degree of cooperation between the healthcare system and clients can be measured in five dimensions:

• Availability and quality of healthcare services
• Geographical accessibility of services
• Client- and health worker-friendly organization of services (adequacy)
• Cultural acceptability of services by both clients and staff
• Affordability of services

In order to improve access, both the supply (healthcare services) and demand (patient) side can be targeted with regard to each of these five dimensions. For instance, affordability can be enhanced through lowering average treatment costs and/or introducing insurance.

Implementation strategy and core activities

The foundation and its partners are convinced that access can only be sustainably improved if local actors are strengthened and are able to “carry” the healthcare system. The decentralization process in the Malian health sector allows for directly strengthening community health associations and insurance management. The foundation cooperated with its partners at regional level to form focal groups including representatives of the district health and social development authorities. They provide training and supportive supervision to healthcare personnel, associations and insurance schemes in their respective district.

Core activities along the five dimensions are:

1. Availability and quality of healthcare services: In the frame of their five-year action plan, community health associations are supported with co-financing for targeted improvements in infrastructure, equipment and medical supplies of their centers. The rule is that each health association has to contribute financially to every activity they have planned. Moreover, healthcare staff is trained in specific clinical and public health areas.
2. Geographical accessibility of services: In the frame of an outreach strategy, basic preventive and curative services are offered in the villages by village health workers (e.g. malnutrition) and healthcare staff. The latter provide regular vaccination, pre-natal consultation and curative services in each village.
3. Client- and health worker-friendly organization of services (adequacy): Opening hours and rates for all treatments are posted on a blackboard in each center, and a shift system has been established that ensures 24-hour emergency service; regular repair and cleaning of buildings have been initiated.
4. Cultural acceptability of services for both clients and staff: Patient-provider communication is being improved through training and monitoring of the latter (e.g. explanation of diagnosis and treatment to patient).
5. Affordability of services: On the supply side, average treatment costs in each health center are monitored and rational drug use promoted. On the demand side, existing insurance schemes are being strengthened with regard to administrative and financial management as well as sensitization of potential members. In order to increase the pool of insured people in the Cinzana scheme, the catchment area is currently being extended to three neighboring health areas and the benefit package revised. Last but not least, women and farmer groups are being supported with access to small loans as well as viable income generation such as jatropha (cash crop for bio-diesel production), poultry and milk production to allow them to pay for health (insurance). In return, the women’s groups conduct sensitization meetings on health issues as some of them are trained village health workers.

The cross-cutting activities are strengthening of management capacity of voluntary personnel leading community health associations. This includes understanding their roles and functions within the organization as well as administrative and financial management. Finally, supportive supervision and monitoring are provided by the Initiative. Central elements are the regular monitoring of quality of care and the performance of the community health associations with the EQOSS assessment tool. Research on specific topics complements these efforts.

Progress to date

A comparison of the performance assessments 2007 and 2008 of the community health associations shows that the Initiative has improved rapidly. For instance, the score for governance, management and support to the health center improved substantially for all the 11 analyzed health associations from 2007 to the second assessment in early 2008. Between the second and third assessment, 55% of the associations further increased their score. Average treatment costs were reduced from USD 4.70 in 2008 to USD 3.80 in 2009. However, the analysis of patient-provider communication revealed that the adequacy of treatment according to reported symptoms of the patient and the diagnosis provided by the healthcare staff is still not always given.

With regard to the health insurance scheme in Cinzana, the number of beneficiaries slowly but steadily increased from 1,151 in 2004 to 2008 in 2009. Since the number seems to stagnate despite solid management and repeated sensitization, insurance management decided to expand the catchment area to neighboring health areas. This will also allow scheme members to benefit from health services in the various health areas. Moreover, the foundation and the Union Technique de la Mutualité Malienne are currently investigating whether those insured are indeed financially better protected than the non-insured.

Finally, the Initiative is providing 20 women’s groups (1,300 women) with loans to invest in small business activities. The first 10 groups accumulated USD 18,000 after having paid back the loan to the Initiative. The return rate was nearly 100%. While 77% of the interviewed women used the loan for productive activities (poultry, sheep, peanut seeds), 23% solved socio-economic problems (i.e. health, education) with it. Average net gain per month for woman is around USD 18. Some groups were now able to obtain bigger loans from banks thanks to their higher capital base. In addition, 240 farmer and 75 village groups planted 250 ha of jatropha and sold their first harvest of 850 kg of the plants in 2008. Demand for these seeds is extremely high in Mali. The main challenge is to raise the survival rate of the young jatropha plants in the arid area of Cinzana. Better maintenance of the fields and effective protection against termites are all the more important given the unequal distribution of seasonal and yearly rainfall.