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.

Organizing Great District Conferences: Lessons Learned

by Quentin Wodon

April-May is a busy time for many Rotary districts as this is often the period during which districts organize their annual conference. How can districts organize great conferences combining learning and fun at an affordable cost for participants? A few months ago, I ran a series of three posts on preparing and evaluating great conferences. The posts were based on a detailed evaluation of the conferences organized by my district over the last three years. The evaluation is available here. Given that we are entering conference season in full swing, let me summarize in this post some of the key points I made in the three-part series on this topic a few months ago (the links to the series are Part 1, Part 2, Part 3).

What Feedback Did Conference Participants Give?

In my district, our evaluations suggested that participants were often fairly happy with most aspects of the conferences. But they also had suggestions. When asked what types of sessions they would like to see more off in future conferences, they suggested having more sessions on successful projects and debates/discussions on Rotary and its future. In terms of the types of speakers, participants would like more motivational and entertaining speakers, as well as more speakers from the business world versus nonprofits. Participants would also like less time spent on award ceremonies.

Participants would like the conferences to be shorter (two days). Shorter conferences would also help reduce the cost of attending the conference, which is often a complaint. This in turn may make it easier to attract more Rotarians to these events, including some of the younger Rotarians for whom cost may be a more serious issue. As to whether it is better to have one or more districts present at a conference, feedback was split between the two options – some participants prefer to have only their own districts, while others like the opportunity to meet members from other districts. Virtually all participants like opportunities for discussions with Interactors and Rotaractors, and would like more such opportunities.

While some of the feedback received in your district may be different, it seems to me that quite a bit of what we learned in my district about what was great and what could be improved in district conferences is likely to apply in many other districts as well.

Is It Difficult to Evaluate Conferences?

It is not. Evaluating district conferences in a serious way is feasible at virtually no cost, as illustrated by the work we did in our district. The surveys for the evaluation were administered through the web and by sending an email to participants a few days after the conferences took place. Using web surveys reduced the time needed to tabulate data, and ensures that there is no waste of information, say from legibility issues often encountered with printed surveys. Participation rates can be strong, so that the surveys are representative statistically. You can even monitor changes in the evaluation of conferences over time – as we did – by fielding similar surveys year after year.

Our latest survey for 2014 survey had a total of 24 questions, some with multiple sub-questions. The questionnaires were designed to take about 15’ to complete, so that substantial information can be captured without taxing too much the time of respondents. Two emails (one initial email and one reminder email) were sent to participants to ask them to fill the survey – this was enough to generate fairly good response rates.

In terms of the structure of the questionnaire, a first set of questions were asked to respondents about their profile (age, gender, Rotary status, length of membership, club affiliation, past attendance at district conferences, attendance rate at club meetings, positions of leadership in the organization, etc.). A second set of questions were asked for participants to evaluate all of the conference sessions to which they participated one by one, as well as their general appreciation of the conference along a number of characteristics and some of their preferences for future sessions. Finally, a last set of questions were open-ended to elicit qualitative feedback on the conferences. The questionnaire of the 2014 evaluation is available in the report on the evaluation.

If your district is one of many that are organizing their conference in the last quarter of the Rotary year, good luck! And if you would like help with evaluating your conference, please let me know by sending me an email through the Contact Me page of the blog.

Preparing and Evaluating Great Conferences: Part 3 – Lessons Learned

by Quentin Wodon

In the first post of this series, a simple argument was made for the importance of evaluating annual conferences – whether for Rotary districts or other organizations. Major investments are made in those conferences in terms of time and money. They are highlights of the life of their organizations, and essential to build friendships and teamwork among members. In the second post, summary results from the evaluation of the latest annual conference of Rotary district 7620 were provided to show how simple evaluations can provide valuable insights. In this last post,  more information is shared on how the evaluations for the last three conferences of the district were designed, and what some of the recommendations of participants were for future conferences.

Rotarians pack meals for the homeless at a district conference session
Rotarians pack meals for the homeless at a district conference session

Design of the evaluations

The questionnaire of the surveys implemented among conference participants were administered through the web (Survey Monkey) a few days after each conference. Using web surveys reduces the time needed to tabulate data, and ensures that there is no waste of information – for example from qualitative feedback – due to legibility issues often encountered with printed surveys.

In 2014, a total of 100 Rotarians responded to the survey, generating a response rate of about 40 percent, which is fairly good for a web survey and is likely to provide a good level of representativeness. Response rates for the two previous surveys for 2012 and 2013 were good as well. However, it may be that Rotarians who respond are those who tend to be more involved in the activities of their clubs and districts.

The conference evaluation surveys have been implemented for three years. Very similar questionnaires were fielded in the three years to maximize comparability. In 2013 and 2014 however, additional questions were added versus 2012 to better capture preferences from participants for future conferences.

The 2014 survey had a total of 24 questions, some with multiple sub-questions. The questionnaires were designed to take about 15’ to complete, so that substantial information could be captured without taking too much time for respondents. Two emails (one initial email and one reminder email) were sent to participants to ask them to fill the survey – this was enough to generate good response rates.

In terms of the structure of the questionnaire, a first set of questions were asked to respondents about their profile (age, gender, Rotary status, length of membership, club affiliation, past attendance at district conferences, attendance rate at club meetings, positions of leadership in the organization, etc.). A second set of questions asked participants to evaluate all of the conference sessions to which they participated one by one, as well as their general appreciation of the conference along a number of characteristics and some of their preferences for future sessions. Finally, a last set of questions were open-ended to elicit qualitative feedback on the conferences. The questionnaire of the 2014 evaluation is available in the report Evaluating Rotary District Conferences: Lessons from District 7620).

Suggestions from Respondents

Key results from the evaluation of the 2014 survey were already provided in the second post in this series. But it may be useful to summarize some of the feedback received for future conferences. As mentioned earlier, while the results are strictly speaking valid only for Rotary district 7620, they probably have broader relevance for other districts and service organizations.

When asked what types of sessions they would like to see more of in future conferences, participants suggested having more sessions on successful projects and debates/discussions on Rotary and its future. In terms of the types of speakers, participants would like more motivational and entertaining speakers, as well as more speakers from the business world versus nonprofits. Participants would also like less time spent on award ceremonies. Having at least one session devoted to a service project – like packing meals for people who are homeless in the picture above, is highly appreciated.

Participants would like the conferences to be shorter (at two and a half days, the 2014 conference was shorter than the 2012 and 2013 conferences, but even shorter conferences would be better). Shorter conferences would also help reduce the cost of attending the conference. This in turn may make it easier to attract more Rotarians to these events, including some of the younger Rotarians for whom cost may be a more serious issue.

As to whether it is better to have one or more districts present at a conference, the feedback was split between the two options – some participants prefer to have only their own district, while others like the opportunity to meet members from other districts. Virtually all participants like opportunities for discussions with Interactors (high school members of Interact clubs) and Rotaractors (young professionals in Rotaract clubs).

Conclusion

Evaluating district conferences in a serious way is feasible at virtually no cost, as illustrated in the case of Rotary district 7620 in this series of three posts. The results suggest that most participants are highly satisfied with the events. The hotels are often great, as is the organization. Yet areas for improvement include the need to hold the cost of the conferences down and to organize the conferences in such a way that more learning on the future of Rotary and successful service projects can take place. Many of these recommendations have been observed for three years in a row in the evaluations of the conferences implemented by district 7620. The good news is that by learning from these evaluations, the district has been able to further increase satisfaction rates with the conferences.

Next year’s district conference promises to be a bit different from the past three – with more of an emphasis on being financially friendly to new members. The goal, as in previous years, will be to have as many new members in the district attend as possible. But the conference committee is exploring – among other ideas – the possibility of relying on the hospitality of Frederick Rotarians to open their homes for an overnight stay for attendees. With about 400 Rotarians in four clubs living in the Frederick area where the conference will take place, this could be very successful.

 

Preparing and Evaluating Great Conferences: Part 2 – A Case Study

by Quentin Wodon

For the past three years, Rotary district 7620 has conducted evaluations of its annual district conferences using web surveys. As mentioned in the first post in this series, conducting such evaluations is important. Millions of hours and tens of millions of dollars are invested every year by Rotarians in attending district conferences, yet these conferences are rarely evaluated thoroughly.

This post shows how such evaluations can be useful by summarizing results for the (highly successful) 2014 conference (the report for all three conferences combined is entitled Evaluating Rotary District Conferences: Lessons from District 7620). The third post will provide lessons learned on what Rotarians would like to see in future conferences. While the analysis is specific to district 7620, it probably has broader relevance as well.

The "See Something Say Something" theater performance was the highest rated session at the conference
The “See Something Say Something” theater performance was the highest rated session at the conference

Success of the Conference

The evaluations of the previous two conferences of the district (in 2012 and 2013) suggested that while participants enjoyed these conferences, they could have been shorter and less expensive with more engaging speakers and more learning opportunities. Conferences should also be fun.

Did the district succeed in organizing a great conference in 2014? To a large extent, the answer is yes. The conference was shorter, and had lots of fun, but its cost for participants remained relatively high. The conference was better attended than in previous years. Most participants were seasoned Rotarians, but many Interactors and Rotaractors participated as well, thanks in part to an Interact Leadership Conference organized as a smaller sub-conference within the main conference.

Almost 60 percent of participants rated the conference as better than previous conferences, which is a major achievement (in the previous two years most respondents rated the conference as on par with previous conferences). A total of 100 Interactors, Rotaractors, and Rotarians responded to the web-based evaluation survey for the conference, which makes its results reliable.

Evaluation by Category and Session

Data on satisfaction rates with the facilities and various aspects of the conference were obtained and are shown in the Figure below. Most of the ratings look great with large shares of respondents rating various aspects as very good or good. The hotel rooms as well as the conference and hotel facilities and the convenience of the location ranked at the top. The organization of the conference and the opportunities for fellowship were also well rated. Even the category on learning about Rotary was well rated, but as in previous years only one in five participants said that they had learned a lot of new information that is likely to be useful to them as Rotarians. Apart from the issue with the quality of the food served by the hotel, the cost of the conference was the category with the lowest ratings. This is in fact an issue that has been identified for three years in a row.

Selected Results from the 2014 D-7620 Conference Evaluation
Selected Results from the 2014 D-7620 Conference Evaluation

The evaluation provided feedback on all conference sessions. For 26 sessions the sample size was large enough to tabulate responses (a minimum of 10 respondents per session was required to assess a session individually). The conference was focused on youth (on Friday and Saturday) and Wounded Warriors (for the Sunday brunch). Nine of the 26 sessions got 60 or more “very good” ratings.

By and large these were the sessions on youth, including the traditional Four Way Test competition for high school students, a See Something Say Something theater performance on bullying by Interactors from North Carolina, a speech by Jack Andraka – the winner of the prestigious Intel high school competition, and a speech by Teresa Scanlan – a recent Miss America and founder of an orphanage in Haiti. Also highly rated were the Interact Leadership Conference and the Mother’s Day brunch with wounded warriors on Sunday. Hospitality suites as always also fared very well.

What Worked, What Could be Improved

For those who did not attend this specific conference, all this may seem a bit abstract. But these data and results are provided to make the point that by evaluating conferences through simple web surveys, you can know exactly which sessions were great, and which ones not so great. This obviously can be useful for preparing future conferences. In addition, for the 2014 conference, it was clear that the focus on youth and wounded warriors was a hit, something to keep in mind.

The evaluation – including feedback from open-ended qualitative questions included in the web survey, also suggested areas for improvement, together with data on preferences regarding the type of speakers to invite, the length and cost of these conferences, and some of their other features. All of this will be discussed in the third and last post on this topic.

Note: Part of the analysis in this post is updated from a section in a book published by the author entitled Membership in Service Clubs: Rotary’s Experience (Palgrave Macmillan, 2014).

Preparing and Evaluating Great Conferences: Part 1 – The Need

Note: This post is the first in a series of three on preparing and evaluating conferences. Part 1 is about the need to evaluate, part 2 about a case study doing so, and part 3 on some of the lessons learned.

by Quentin Wodon

Many organizations, including firms, NGOs, professional associations, as well as service clubs, organize annual conferences. These conferences are essential not only for running the business of the organization, but also for building team work among the members of the organization. It is not clear however whether these annual conferences are evaluated properly.

Past RI President Bill Boyd at the D-7620 2014 conference
Past RI President Bill Boyd at the D-7620 2014 conference

In the case of Rotary, a global service club organization founded in 1905 which has today 1.2 million members, a global annual convention is organized typically in June of each year. But what may matter more are the conferences organized by each of the 530 or so districts in the world. These district conferences are annual events to which Rotarians from the district are invited to participate. They represent the main event where Rotarians from different clubs belonging to a common geographic area can meet each other and exchange their experiences.

It is important for an organization such as Rotary International to pay attention to district conferences not only because they are essential events in the life of clubs and districts, but also because the resources invested in the conferences are substantial, in terms of both time and money. Right now is the time when many Rotary districts are actively preparing their next annual conference, since these events are typically held in April or May before the end of the Rotary year.

This first post in a series of three on preparing and evaluating great conferences provides quick and dirty “back of the envelope” calculations of the potential investments made in district conferences every year. Because this investment is rather large, the conferences should be evaluated seriously.

Investments in Time

Consider first the allocation of time. To provide a very rough estimate of the time that may be invested every year in preparing and attending district conferences, data from the last three conferences organized by District 7620 can be used. The first conference was organized by district 7620 jointly with district 7630 in 2012. Together the two districts cover the states of Maryland and Delaware, as well as the District of Columbia (that is, the capital city Washington, DC). For the second conference, district 7610 in Northern Virginia joined in as well. The third conference was organized solely by district 7620.

The total attendance at the three conferences combined was estimated at about 1,050 Rotarians and guests. If one considers that activities at the conference go on for up to ten hours per day, and if we assume that participants on average spend 2.5 days attending the conferences (including travel time), with 1050 participants this would represent an investment in time of 26,250 hours. Together, the two districts that organized the joint conference in 2012 have about 4,000 Rotarians, and when the three districts are included for the 2013 conference, membership is above 6,000. For district 7620 in 2014, the membership was at about 2,350. Over the three years, this represents a potential attendance at the conference of close to 12,400 Rotarians. Therefore the amount of time allocated on average for the two conferences was then approximately 2.12 hours per Rotarian per year.

Multiplying this estimate by the number of Rotarians in the world yields an allocation of about 2.54 million hours per year for Rotary worldwide just for Rotarians to attend district conferences. This estimate may well be on the low side given that the attendance rate at the two conferences evaluated in this report, at about 8.5 percent on average for the three years using the approach just outlined, may be lower than is typical in other districts.

In addition, one should include the time spent by district leadership teams and conference committee members as well as district executive secretaries in preparing the conferences. It is not unrealistic to suggest that for any given district at least 30 Rotarians will volunteer time to help prepare various aspects of the conferences, including preparing their own presentations. Some of these Rotarians will spend a very large amount of time on the conferences, especially if they are part of the core organizing committee, while others will spend less time.

Just for the sake of the argument, consider an average of 25 hours spent by each of the 30 Rotarians for preparing various aspects of the conference (this is probably a rather low estimate). With some 530 Rotary districts worldwide, this would generate another 400,000 volunteer hours for preparation. Thus, possibly three million hours are allocated to district conferences every year by Rotarians, and this may well be a conservative estimate. The bottom line is that clearly a large amount of time is allocated to prepare and attend these conferences, so that making these conferences a success does matter for all those involved.

Financial Investments

Consider next the question of cost. Most of the costs of district conferences are borne by participants who pay their hotel bill as well as a fee for attending the conference to cover meals and other costs. A typical fee in the United States to attend a district conference will run at a few hundred dollars including meals and hotel rooms.

District conferences tend to be organized in major hotels or resorts, at least in the United States, so that even when special rates are obtained, room fees will typically be in the $100 to $150 per night. Some Rotarians stay for three or more nights, others for only one or two nights, and some just come for a day. Guests are likely to have additional expenses both at the site of the conference and to get to the conference site.

Assume, again for the sake of the argument, that on average the total cost of the conference per attendee is of the order $600 – it will often be  higher for those staying three nights, but it will be lower for those coming just for one day without staying any night in the hotel or resort. Even based on the somewhat low attendance rate of about 8.5 percent mentioned above for the three conferences considered here, with 1.2 million Rotarians worldwide, this would generate a cost of $61 million per year.

This might be too high because the cost of district conferences may be lower in other countries than it is in the United States. But on the other hand, this does not include special costs for the attendance of high level Rotary officials (whether those are paid for by districts or Rotary International) and other invited speakers. This estimate does not include the cost at Rotary headquarters to oversee and monitor district conferences and it also does not include the cost of the annual Rotary convention that typically welcomes more than 20,000 Rotarians from all over the world each year and could in a way be considered as a super district conference.

This cost estimate also does not factor in the opportunity cost of the time allocated by Rotarians to prepare and attend the conferences (that opportunity cost could be very high if estimated as is normal practice at the wage rate of those involved). Overall, the costs of district conferences are likely to be substantial, and could be higher than those indicated here depending on conference participation rates.

Implication

Major investments in time and money are made every year by Rotarians to prepare and attend district conferences. These conferences are the highlight of the Rotary year in each district. They should be evaluated well. The second post in this series will show how this can be done professionally at very low cost with a case study, and the third post will discuss lessons from the evaluation of the last three conferences of district 7620.

Note: Part of this blog post is adapted from a section in a book published by the author entitled Membership in Service Clubs: Rotary’s Experience (Palgrave Macmillan, 2014).

 

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.

Muso2

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.”

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.