by Quentin Wodon
Some successful pilot interventions in health are implemented without ever being scaled up, so that their benefits for a country’s population as a whole may be limited. This is not the case for the Muso pilot. In addition to implementing and evaluating an innovative model, Muso worked closely from the start with the Malian Ministry of Health as well as other partners to explore opportunities to expand its model nationally. This second post explains how this was achieved.
A Successful Pilot
Recall from the first post in this series that a Harvard/University of California San Francisco study documented a tenfold difference in child mortality rates after the rollout of the Muso model in the program’s catchment area. Muso relied on paid and professionalized community health workers to diagnose illnesses quickly in its catchment area, refer patients to clinics and hospitals as needed, and reduce financial barriers to care for families. One needs to be careful in assigning causality since the evaluation is based on repeated cross-sectional data as opposed to a randomized control trial. Still, the impact appears to have been major and obtained at relatively low cost. The Muso model was recently recognized as a finalist for two major prizes – the GSK Global Healthcare Innovation Award and the Caplow Children’s Prize.
National Expansion: Four Enabling Factors
Last week Mali’s Ministry of Health Division of Community Health Systems announced a five-year strategic plan to scale up professionalized community health workers throughout the country. Just a few years ago Mali’s public health sector had no paid community health workers. Soon, they may be present in every region.
How did this transformation happen? Muso and other partners have been actively working with the Ministry of Health for seven years. The partnership was launched in 2008. The collaboration has been not only operational, but also scientific, with support from university researchers. Though this partnership, Muso has been able to provide technical assistance to help the Ministry develop a national plan for scaling-up the community health worker model.
Four factors contributed to the success of this partnership and to last week’s scaling-up announcement according to Dr. Ari Johnson, the co-founder of Muso. “First, we started the partnership early on. By setting an operational research partnership at the design phase of the project, we were able to ensure that the pilot would focus on the priorities of the Ministry of Health, which meant a focus on child survival and disease-specific targets, including early effective treatment for malaria.”
A second factor for success was the ability to work with other NGOs to test the robustness of the community health worker model in different parts of the country. “The Malian Ministry of Health worked simultaneously with several NGOs on operational research to test community health workers models. This included, but was not limited to Muso with the operational research study in Yirimadjo and Doctors without Borders (Médecins sans Frontières) with another study in Kanbaga. These experiences with multiple partners in several locations provided the Ministry of Health with converging evidence for scaling up paid, professionalized community health workers,” explains Dr. Johnson.
The third factor for success was the support of international organizations. Multilateral and bilateral global health institutions are all trying to strengthen health systems in Africa. In Mali, Dr. Johnson explains that UNICEF and the Global Fund provided important support for the adoption and expansion of the community health workers model by the Ministry of Health.
Finally Dr. Johnson insists that operational research partnerships must be long-term to succeed. “Longitudinal operational research partnerships take time to implement, but over time, they help build relationships between public sector policy makers and hubs of research. These relationships become avenues for translating research into evidence-based policy change at scale.” Dr. Johnson adds that “the long view is critical, and often neglected in global health work. Short-term funding cycles push organizations to move on after a few years and abandon the foundations of a strong partnership. A long term partnership for iterative and ongoing research is crucial to support Ministries in their strategic plans and thereby achieve scale.”
Many questions remain. What should be the health care financing system for community health workers? How can those workers be deployed across both urban and rural areas? How is the supervision of the workers to be worked out? These and other questions will need to be answered. But on the occasion of the launch of the national plan last week, Dr. George Dakono, the National Director of Community Health Systems, noted that “Muso is at the vanguard.” In recognition of the role played by the Muso team, Dr. Dakono invited Muso’s Health Systems Director, Dr. Djoumé Diakité, to present the plan at the Ministry of Health.
Relevance for Ebola
How does all this relate to the Ebola crisis in West Africa? Apart from their role in preventing and treating malaria as well as other common illnesses, community health workers are essential in the fight against Ebola. Last week witnessed the first confirmed case of Ebola in Mali. A two-year-old girl who had traveled with her grandmother from Guinea died. While no other cases of Ebola have been reported to date, many people have been in contact with the girl and more than 40 of those individuals are being monitored. Mali is now the sixth West African country with a confirmed Ebola case.
Why are community health workers so important for the fight against Ebola? They are crucial in part because they tend to be trusted members of their communities. They can not only help in providing information about Ebola and promoting appropriate behaviors, but they can also help to trace and monitor those who have been in contact with the virus. This must be done for at least 21 days – the period during which symptoms do not yet emerge, and it must be continued after that period if individuals become sick. In the other countries affected by the virus – including Guinea, Liberia, and Sierra Leone, community health workers already play that vital role.
As Dr, Johnson explains, “there is huge potential for community health workers to accelerate the effort to stop Ebola across West Africa, by supporting epidemiologic surveillance, contact monitoring, returning traveler monitoring, community engagement, and prevention counseling.”