Malaria, Ebola, and Saving Lives: Part 3 – Funding and Emergency Response

by Quentin Wodon

The first two posts in this series documented how Muso’s community health workers pilot in Mali helped reduce child mortality and the factors that made it feasible for the Malian Ministry of Health to adopt the model nationally. The relevance of the community health worker model for Ebola was also briefly discussed. This last post explains how Rotary supported Muso and, more importantly right now, how Rotarians and others can help those affected by the Ebola epidemic.

Supplies for the Ebola Response from the Monrovia Rotary Club
Supplies for the Ebola Response from the Monrovia Rotary Club

Two Grants for Muso

While Rotary has not been the only supporter of the Muso pilot, it has played an important role in funding it. Rotary has supported Muso through two so-called global grants thanks to Maria Nelly Pavisich from the Rotary Club of Washington, DC and other Rotarians from many clubs. A first grant of $60,000 was approved when Maria Nelly was with the Rotary Club of Capitol Hill. The focus of that grant was on malaria prevention and treatment. The funds were used to buy high quality insecticide bed nets, and provide diagnosis and treatment for more than 3,500 patients. During the course of this first grant, Muso grew tenfold. With new partnerships among others with the Against Malaria Foundation and CHF Muso achieved universal coverage of its interventions in Yirimadjo.

In March 2014 the Rotary Foundation awarded Muso an additional $151,500 grant to expand its work. The new initiative is called Thrive for Five: Improving Child Health and Survival in Mali. It will benefit 13,500 children over two years. Putting the grant together was not easy, because the Rotary Foundation requires clubs and districts to contribute before matching those contributions. As Maria Nelly explained: “We had to create a global coalition of more than 50 Rotarians from Africa, North America, Europe, and Asia. We all worked together to raise funds and provide expertise. Eight clubs and seven Districts agreed to contribute. It took hundreds of emails, multiple reports, conversations, and presentations to get there. You’ve got to have a firm commitment to reach the goal! I guess it is the humanitarian adrenaline that keeps me going.”

The donations for the $151,500 grant by clubs as well as the district (DDF) and Rotary Foundation (TRF) matching funds are visualized in the Figure below. So far, for the two global grants as well as in other ways, a total of 15 Rotary Clubs in 11 Districts, seven countries, and four continents have supported Muso. While putting these grants together was substantial work, it was all worth it according to Maria Nelly: “When you reach the goal, it feels so good! It is extremely motivating to do this work with a reputable, focused and reliable organization such as Muso. And to hear Yirimadjo survival stories from community health workers… Muso does the hard work on the ground, but as Rotarians we contribute as we can, in this case with funding.”

Funding for Second Muso Grant
Funding for Second Muso Grant

Ebola Response

Today, many Rotarians and others are asking how they can help those affected by the Ebola epidemic, especially in Guinea, Liberia, and Sierra Leone. Funding by individuals and clubs may seem small in comparison to contributions by organizations such as the World Bank ($500 million) or the United States Government (e.g., building hospitals). But while small, these contributions still make a major difference in the life of those who benefit from them.

Many Rotary districts are trying to raise funds. In my district (D-7620), the Disaster Relief Committee will fund personal protection equipment for 18 hospitals and health centers in Liberia in partnership with IMA World Health and the Christian Health Association of Liberia. The fundraising is coordinated by Disaster Aid USA and the Rotary Club of Bonds Meadow Foundation. Beyond support right away, given that the needs for assistance in Ebola-affected countries will be there for quite some time, clubs and districts could also consider global grants, as was done for Muso in Mali.  These grants take a bit of time to prepare, but they can be quite powerful.

Rotarians in affected countries are also engaged, as are many other citizens. For example, the Rotary Club of Monrovia in Liberia has established an Ebola Response Committee. The club initially purchased locally a wide range of items including examination and other gloves, mattresses for patients in treatment facilities, infra-red thermometers, boots for health care workers, and so on. The club also carried out awareness campaigns with the Liberian Nurses Association, and it is has been supporting reintegration of patients into the community. With the Ministry of Health and the NGO ChildFund, it launched the first Interim Care Center for children whose parents were in isolation in treatment centers or had been orphaned by Ebola. Right now, the Monrovia Rotary Club is raising funds to attend to the urgent needs of Ebola victims, their families, and caregivers.

When members of our club spoke to members of the Monrovia club, more than three dozen clubs worldwide had already contacted the Monrovia club to provide assistance. But much more is needed. If you, as a Rotarian or otherwise, can support those responding to the Ebola crisis on the ground in the affected countries, please do.


Malaria, Ebola, and Saving Lives: Part 2 – Scaling Up

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.”