How a poor community in Mali became a trailblazer for tackling child mortality

Home to a large number of migrants and an even larger number of babies, Yirimadio is a heaving, ramshackle district on the outskirts of Bamako. Only a decade ago, it was a commune, much like any other on the Malian capital’s periphery. Now, though, it is the unexpected scene of a pioneering healthcare scheme. Child mortality rates here have dropped to the point where they are now the lowest in sub-Saharan Africa – an achievement that may all be down to knocking on doors.

The premise of the scheme, which launched in 2008, is simple: community health workers spend at least two hours, six days a week searching for patients door-to-door, providing free care to whoever needs it. Mali has long struggled to contain preventable infectious diseases such as malaria, pneumonia and diarrhoea. Consequently, the country has the world’s sixth highest under-five child mortality rate, estimated at 115 deaths for every 1,000 births according to the most recent figures available. But by turning conventional healthcare on its head – sending health providers to patients at no cost, instead of requiring them to seek out fee-paying medical attention – Yirimadio achieved a spectacular turnaround. Between 2008 and 2015, the child mortality rate dropped from 154 deaths to seven for every 1,000 live births.

Experts have called the scheme – the findings from which were published this week in BMJ Global Health – extraordinary. They say it offers “very strong evidence” that universal healthcare can be both cost-effective and widely accessible.

“These results are really very impressive,” said Robert Yates, project director at the Centre on Global Health Security. “This is a part of the world where, generally, access to adequate healthcare is very difficult because of distances, costs and poor quality of services. But by removing user fees, providing free services, and going the extra mile by going into communities and treating sick children, the [scheme] has made primary health care extremely accessible.

“It just shows that when poor communities get good, free healthcare, it goes a long way to improving mortality rates. Put simply: kids don’t die.”

At an average cost of $8 (£5.70) a person annually, the price of the intervention is well within what governments in the region are already spending on healthcare, say the report’s authors, who believe that rolling it out more widely could lead to increased child survival rates elsewhere.

Dr Ari Johnson, who co-founded Muso and co-authored the study, said the scheme’s success proved that “these goals aren’t lofty aspirations or unfeasible: they’re imminently achievable”.

“These results are unprecedented. They are extraordinary,” said Johnson. “But that’s not what we want. We want these results to become boring and normal. That’s the real challenge.”

Communities participated in the initiative during a hugely challenging period in Mali that brought a coup d’etat, al-Qaida occupation in the north, and the west African Ebola outbreak. “Amid global efforts for universal health coverage and child survival, these findings reset the goalposts for what be achieved, in even the most challenging settings,” said Johnson.



A community health worker in Mali measures a child’s arm to check for malnutrition. Photograph: Courtesy of Muso

Muso is leading a separate trial in rural Mali, under which communities will either be randomly served door-to-door by medical professionals, or required to take themselves to a community health centre.

“That trial will address a number of questions and limitations that we can’t [currently] address,” said Johnson. “It’s incredibly important that this study be followed up to try to replicate the findings and find further examples.”

In the meantime, Yates is hopeful that other governments will take note of the recent findings and commit to achieving similar results.

“Lessons like this are so applicable in other countries in the region: take Nigeria for example, that’s got a GDP per capita of $2,200,” he said. “It spends 0.9% of its budget on healthcare, but if it spent 2% on healthcare it could get these results. This is very strong evidence for what works. I would argue everyone in global health knows this, and what is lacking in countries across the world is the political commitment to make this happen.”

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