Fighting Malaria and Ebola in Mali (Partnerships Series No. 7)

As part of this series of posts on increasing Rotary’s impact through partnerships, innovation, and evaluation, I had to include Muso, a nonprofit that has successfully fought malaria and Ebola in Mali, in part with support from Rotary. As some readers may remember it, I talked about Muso in this blog previously, and this post is based in large part on previous posts. But at the risk of repetition, it is worth emphasizing again that Muso is a great example of an innovative approach that has been evaluated and has the potential of being replicated at scale thanks to partnerships.

Muso2

A Successful Pilot

Muso started in Mali as a project to provide basic care to communities, focusing initially in part on malaria. Two years ago 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 relies on 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 inferring causality between the intervention and the reduction in child mortality since the evaluation was 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.

Support to the Ministry of Health

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 Muso. 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 the model nationally.

In November last year, based in part on the Muso model, Mali’s Ministry of Health Division of Community Health Systems announced a strategic plan to scale up professionalized community health workers throughout the country. How did this transformation happen? As just mentioned, 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.

Factors contributed to the success of this partnership and to the scaling-up announcement according to Dr. Ari Johnson, the co-founder of Muso, who was interviewed last year. “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 progress is being made.

Relevance for Ebola

How does all this relate to the Ebola crisis that recently hit West African countries? Apart from their role in preventing and treating malaria as well as other common illnesses, community health workers can be essential in the fight against Ebola. Ebola arrived in Mali through a two-year-old girl who had traveled with her grandmother from Guinea died.  Mali became 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 explained it, “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.”

Conclusion

Muso has piloted an innovative new model of health care delivery that appears to have contributed to reducing child mortality in its area of intervention. The model has also proved valuable in fighting the Ebola epidemics. Rotary provided crucial support to Muso when the NGO was still small and not as well-known as it is today, with fewer resources. Rotarians and Rotaractors have volunteered with Muso in Mali, and others have contributed to making the project better known internationally.

Today, Muso is scaling up, aiming to raise substantial funds to expand its program. It is also launching a rigorous impact evaluation through a randomized controlled trial to measure its effectiveness. While many organizations and individuals have contributed to Muso’s success, especially the Muso team working on the ground, at times taking substantial risks to help the population as was the case during the Ebola epidemics, Rotary and Rotarians have played a small supporting role as well.

Malaria, Ebola, and Saving Lives: Part 1 – The Muso Pilot

by Quentin Wodon

Two days ago, Mali launched a national strategic plan to scale up Community Health Workers in every region of the country. This initiative has the potential to save tens of thousands of lives. It could also significantly reduce risks related to Ebola.

This post is part of series of three that tells the remarkable story of how this happened, thanks in part to Rotary-funded Muso, a NGO that has been working closely with the Malian Ministry of Health for several years.

Muso baby

Roll back a few years and meet Djeneba, a young girl living in Yirimadjo in Mali (West Africa), one of the poorest countries in the world. Today she goes to school but her life was once threatened. At the time her family was living on less than a dollar a day. Djeneba started getting high fevers but her parents did not have enough money to pay for care. They tried to break the fever by bathing her in herbal remedies and buying unregulated pharmaceuticals but the fevers persisted and became increasingly severe.

Fortunately Djeneba lived in a community were Muso was being implemented. Families could receive healthcare for free or at very low cost. Sira, one of the community health workers trained by Muso became aware of Djeneba’s situation after one particularly nasty fever, and wrapped Djeneba in wet towels to stabilize her fever. She sent Djeneba by ambulance to a large hospital in the capital city of Bamako where she received comprehensive treatment. During the ambulance ride Djeneba lost consciousness and she was diagnosed with advanced cerebral malaria. During the first 10 days of her stay in the hospital she was in a coma. But after three weeks in the hospital and lifesaving medication she was released happy and healthy.

When Djeneba returned home Sira taught her parents how and when Djeneba should take her medication at home. Everyday Sira visited Djeneba to care for her. Two weeks after her recovery, Sira saw Djeneba with a school backpack entering her house. Sira’s diligence and attention towards Djeneba saved her life and got her back on track in school.

Djeneba’s story is not unique. Half of the world’s population is vulnerable to malaria. Every year, 665,000 people die from malaria episodes. Many are children under five. Muso is on the frontlines of providing timely, proactive health care to poor communities and hard-to-reach populations so that the lives of children like Djeneba can be saved.

“Most children killed from malaria die within 48 hours of the moment they say ‘Mommy I’m sick.’ We already have the tools to avert nearly all deaths from malaria, but they are not reaching the children who need them early enough. Our idea is simple but powerful: if we reach every child early, we could avert nearly all child deaths from malaria. But to reach every child early in the world’s poorest communities is a big challenge. To make this happen, we had to challenge the conventions of traditional health systems. Traditional health systems are reactive. Medical providers like me are expected to wait for patients to come to us. Muso’s health system takes a proactive approach, deploying Community Health Workers to search actively for patients door to door”, says Dr. Ari Johnson, co-founder of Muso.

As explained in a previous post on this blog, Muso works in communities through a four-step approach. The first step consists of mobilizing the existing health care delivery system. This includes selecting, training, employing and supervising local individuals who go door-to-door and identify children sick with malaria and other illnesses. These community health workers diagnose malaria in the household and treat simple cases. The second step consists of removing barriers that prevent people from accessing care when needed. By eliminating point-of-care user fees, Muso ensures that even the poorest can benefit from life-saving comprehensive and universal care, whether at home, in community health centers, or in referral hospitals. The third step consists of creating rapid referral networks by training communities in identifying health risks, prioritizing rapid treatment, and navigating the health system. The final step consists of clinical capacity building. As Muso systematically removes access barriers to achieve universal health coverage, it reinforces the ability of the public sector to provide quality care to its patients.

How do we know that Muso has been successful? A recent study published in the peer- reviewed journal PLoS ONE is very encouraging. The study documents a ten-fold difference in the rate of child mortality in the three years after the launch of Muso. At baseline the rate of child mortality was 15.5 percent. After three years, it dropped to 1.7 percent. During the same period, there was a ten-fold increase in the number of patient home and clinic visits in the catchment area, a doubling of the rate of rapid access to malaria treatment for children in need, and a reduction by one third in the share of children becoming sick with fever.

The Muso team has been interviewed among others by the BBC, ABC News, Reuters, and the New York Times and the project recently received two global awards. First, the 2013 GSK Global Healthcare Innovation Award recognized the project as one of five effective new models for better chances of child survival. In addition the Caplow Children’s Prize named the project one of eight finalists for its global award that also identifies some of the world’s high-impact new models for saving children’s lives.

Part of this story was already told on this blog. But the announcement two days ago of the adoption of a national strategic plan in Mali to scale up Community Health Workers is a major new development that warrants telling this story again in more details. The story continues to have relevance for malaria and child mortality, but it also now has relevance in the context of the Ebola epidemic. The relevance of the Muso model for Ebola and the role that Rotary played in supporting Muso will be discussed next.