Improving access to primary healthcare services in rural areas: the Initiative Accès in Mali
One billion people worldwide lack adequate access to primary healthcare. The situation is especially severe in sub-Saharan Africa: in Mali, for example, 1 in 5 children die before reaching the age of 5, mostly due to preventable and treatable diseases. Availability and affordability of safe and efficacious medicines are crucial factors impacting access, which in turn affects the ability to combat diseases, as well as child and maternal mortality. The complexity of the access issue, however, extends far beyond the availability of affordable medicines and even the healthcare system. Many different factors and causes must be targeted.
The Novartis Foundation for Sustainable Development (NFSD) has developed an access to healthcare framework, defined as the degree to which a healthcare system’s services and providers (supply) are aligned with a patient’s resources, needs and expectations (demand). Access to healthcare and medicines can only be sustainable if the local healthcare system and services meet demand.
Drawing on this framework, the Initiative Accès aims to improve access to primary healthcare specifically for children and women in the region of Ségou, Mali. Supported by the foundation as well as the regional authorities in charge of health and social development, the initiative intervenes on both the supply and the demand sides of access.
Aligning supply and demand sides
The obstacles to access to healthcare are especially pronounced in rural areas with large geographical distances, such as for example the region of Ségou in Mali. In light of this situation, the Novartis Foundation, together with its Malian partners, developed an integrated healthcare project in the municipality of Cinzana from 2001 to 2006. Based on the findings and experiences of this pilot phase, the project was scaled up in 2007 to an additional 12 areas in the region of Ségou, covering 200,000 people in 210 villages.
The decentralization in the Malian health sector allows for directly strengthening community health associations and insurance schemes. The foundation cooperates with its partners at district level to form focal groups (pool of trainers) including representatives of the district health and social development authorities in order to provide training and supportive supervision to healthcare personnel, associations and insurance schemes.
The five-year initiative was designed according to an analytical framework developed by the ACCESS project, which aims to improve access to malaria treatment in Tanzania. The framework states that 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 fit between the healthcare system and clients can be measured along five dimensions:
- Availability and quality of healthcare services;
- Geographical accessibility of services;
- Client- and health worker-friendly organization of services
- Cultural acceptability of services by both clients and staff;
- Affordability of services.
The Initiative Accès conducts different interventions to tackle the issue of access in all these dimensions, covering both the supply and the demand side.
Improving the quality of healthcare services
To improve the availability and quality of healthcare services, the Initiative Accès strengthens the infrastructure, management and human resources in health centers. Moreover, healthcare staff are trained in specific clinical and public health areas. To ensure that the services are transparent and adequate for the customers, opening hours and rates for all treatments are posted on a blackboard in each health center. A 24-hour emergency service has been established, and regular maintenance and cleaning of buildings have been initiated.
Annual performance assessments of quality of health services and their management indicate that from 2008 to 2010 the community health associations increased their average score by 10% from 112 to 126 out of 150 possible points. They are especially improved in the areas of internal governance and support to healthcare personnel. A challenge that remains, however, is that of administrative and financial management. This is why the Initiative Accès conducted tailor-made capacity-buildings for the weakest community health associations.
From 2007 to 2010, utilization rates for curative services increased by 10%. During the same period, utilization rates for prenatal consultations increased from 54 to 88%. From 2008 to 2010, average treatment costs in the supported health centers decreased from USD 4.20 (CFA 2,100 CFA) to USD 3.70 (CFA 1,600 CFA). Through training and before-after-evaluation, the competencies of healthcare staff with regard to medical communication between providers and patients, such as the explanation of diagnosis and treatment are being improved.
Bringing healthcare services closer to patients
In the frame of an outreach strategy, health personnel offer vaccinations and prenatal services directly in the villages. In addition, the Initiative Accès trains village health workers to offer basic promotional services for example against child malnutrition in communities.
Strengthening health insurance schemes
To make healthcare more affordable and ensure people seek immediate care in case of illness, the Initiative Accès strengthens existing health insurance schemes, provides grants to women saving groups and supports farmers in setting up viable income generation activities.
The biggest rural health insurance scheme in the area, the Mutuelle de Santé of Cinzana, has almost doubled its number of beneficiaries from 1,151 to 2,212 people between 2004 and 2010. Yet, enrolment rates remain too low. Therefore the catchment area of the Cinzana scheme has been extended to three neighboring health areas in order to increase the pool of beneficiaries. Furthermore, a professional insurance administrator has been employed and the benefit package improved: now 75% of primary healthcare costs and 100% of costs related to birth delivery are covered. Finally, the Initiative supports the scheme in terms of administrative and financial management as well as the sensitization of potential members.
A recently conducted research study on the Cinzana scheme revealed that total average healthcare costs during the 6-months observation period are lower for insured households compared to the uninsured (USD 18 vs. 23). Moreover, increasing healthcare costs were associated with a decreased likelihood of being insured. Households who sold assets to finance healthcare costs were also more likely to be uninsured. These results confirm that insurance coverage does protect people financially.
Micro-credits for women saving groups
The Initiative Accès supports women saving groups with loans to increase their income. Group members can take on small credits to invest in business activities such as poultry, sheep or peanut seed production. The additional income can then be reinvested in education or healthcare for the children.
To date, 2,800 women in 49 groups have access to credits. The repayment rate of the women is nearly 100%. From 2008 to 2010, the groups have increased their accumulated usable resources from approximately USD 26,000 (CFA 12,000,000) to USD 67,000 (CFA 31,000,000). While 77% of interviewed women used the credit for productive activities (poultry, sheep, peanut seeds), 23% solved social problems (health, education). The average net gain per month per woman amounts to around USD 18. The Initiative has developed a monitoring tool to collect data on what kind of business activities the women are conducting as well as whether or how these impact on the health of the family.
In return for the credits, the women groups conduct sensitization meetings on preventive health, many are trained village health workers.
Income-generating activities for farmers
Last but not least, in five health areas farmers are being supported by the Initiative with the setting up of viable income generation such as the plantation of jatropha (used for bio-diesel production) and rubber trees as well as milk production. The Initiative Accès conducts capacity building for plant breeders’ and planters’ cooperatives as well as for planters through technical trainings.
To date, 230 farmers in 47 villages planted 337 hectares of jatropha and 41 hectares of rubber trees. The main challenge in these semi-arid areas remains the survival rate of the young jatropha plants. However, through better maintenance of the fields and effective protection against termites, the rate could be increased from under 20% for the plantations of 2007 to over 70% for those planted in 2010.
The Initiative Accès has been prolonged until end of 2012. The main challenges ahead are, on the one hand, to further improve the quality of medical consultations and communication. At the same time, the performance assessment tool to evaluate the quality of health services should be further promoted in Mali. On the other hand, the number of health insurance beneficiaries must be increased, e.g. through intensified information campaigns and an enhanced benefit package. For instance, two additional health centers will be contracted by the Cinzana insurance scheme in order to widen the beneficiaries’ choice of providers.