Looking to communities to lead malaria fight

Kalifan Keita is a peasant farmer with no medical education, salary or transport other than a wobbly bicycle, yet he is achieving in Mali what the government and decades of Western aid have largely failed to do.

He is saving the lives of hundreds of children infected with malaria, many of whom would otherwise have died after a slow, agonising descent into delirium and unconsciousness.

“It’s not a miracle what I do,” he said. “It’s simple.”

Keita bicycles around the six villages in his area carrying a small white box with a red cross on it. Inside are little white sticks and needles.

When he enters a village, mothers with sick children gather around. Keita takes out a needle and pricks a child’s index finger then smears a drop of blood on the stick which will quickly indicate if the child has malaria or not.

Of 14 tests administered by Keita on the day IRIN met him, 12 had malaria. Keita then handed the mother six Artemisin-based Combination Therapy (ACT) pills and told her to give the child two tablets a day.

Within three days all the children were healthy again.

Keita is a volunteer in one of 18 communities that are part of a pilot project being run by the non-governmental organisation [NGO] Médecins Sans Frontières (MSF) in a malaria-endemic region of Mali.

What is novel about the project is that it takes malaria treatment to people’s homes instead of expecting them to travel to distant health centres - and that it works.

Photo: Nicholas Reader/IRIN

Doctors and nurses need to go out into communities instead of waiting for patients to come to them, according to the results of MSF and Save the Children pilot projects in Mali

The results from both the MSF project and a similar one being run by Save the Children are due to be presented to the government later this year, but the staff of both projects told IRIN that provisionally they have recorded at least a 50 percent improvement in the number of children being treated.

“There have always been issues of access and delivery of medicines in Mali but previous efforts to address it failed because of the poor health infrastructure,” said Dunni Goodman, head of Save the Children in Mali.

“Now the focus is on how to deliver to the grassroots where the bulk of people live. Malaria cannot be eradicated unless it [treatment] is delivered to the doorsteps of people. Working through health facilities and hospitals alone does not work.”

Challenges

These community projects are refreshingly simple. Overheads are as low as the cost of the testing kits and drugs. In Nonanda around 100 villages are receiving malaria coverage for a total outlay of about US$400,000.

The main criticism of them is that they depend too heavily on the motivation of unpaid volunteers, and on the capacity of a central government or health authority to keep the remote and isolated volunteers stocked up. MSF and Save the Children say they have overcome both these problems.

Although the findings are positive for a region that has been losing the battle against this killer, the challenges are still daunting. Mali is a vast landlocked country with thousands of miles of standing water where swarms of giant mosquitoes breed every rainy season. The country has one of the highest prevalence rates of malaria in the world.

Children die more than adults because they have not had a chance to build up resistance to the disease. The UN Children’s Fund (UNICEF) estimates that in at least 30 percent of child deaths in Mali, malaria is a contributory factor.

Photo: Nicholas Reader/IRIN

Child with malaria being treated for free at an MSF-funded government health centre. The cost of seeing a doctor puts healthcare out of reach for most Malians

Currently the system to curb these deaths does not work. Mali’s government and international donors have consistently prioritised decentralised health centres which people are expected to walk up to 100km to reach, rather than sending health workers out into villages.

“In Mali when you say the word ‘community’, officials often understand that to mean the community health centre, which can be far from where large communities of people actually live,” explained Peter Winch, a professor at Johns Hopkins Bloomberg School of Public Health in Washington DC, who has studied community-based malaria schemes in Mali.

“In fact Malians need treatment at the village level because during the rainy season when the disease is at its peak, roads are in a bad condition and most people lack transport.” The situation is especially bad for women who in Mali’s patriarchal society are unlikely to have their own bicycle or donkey to ride to the clinic on.

Cost

Making the community-based system work requires lifting the financial as well as geographical barriers to healthcare in Mali.

Mali’s health system is still based on cost recovery, meaning adults have to pay 400 CFA francs (80 US cents) just for a consultation at a health centre, not including the cost of medicines which for malaria can run to four times that price.

The costs are prohibitive for many rural farmers who often have five or more children to take care of and who mostly barter rather than use cash.

A national policy last year was supposed to make healthcare free for children under five, but in reality many doctors at health centres that IRIN talked to around Mali said most children are still expected to pay. “There’s some confusion about how the policy has been rolled out,” said a foreign healthcare expert in Mali’s capital, Bamako.

Medina Fernandez, head of MSF in Mali, said the MSF pilot project showed that unless consultation fees are removed for children and lowered for adults, and drugs are fully subsidised or made free, community healthcare schemes make no impact at all on the number of people being treated.

“It was only when we made access completely free for children, and a full consultation and treatment 200 CFA francs all inclusive for adults, that we saw a difference,” Fernandez said. MSF also started providing treatment to children diagnosed as sick with illnesses other than malaria.

Photo: IRIN

Map of Mali. The vastness of the country makes providing public services to the predominantly rural population challenging

At the government health centre in the provincial capital Narena, where MSF has covered the cost of consultations and treatment for the last year, attendance rates have more than doubled since the pricing changes, said chief medical official Amaganu Guindo.

“Economic problems are huge in this country. If there has been a change in attendance it’s because the service is now affordable.”

Lack of government funding

Mali’s government has consistently under-funded its national health system, spending just 10 percent of gross domestic product on the health service, instead of the 15 percent recommended by the World Health Organization (WHO).

“Malaria projects especially are mostly financed by international donors,” said Lamine Cissé Sarr, head of WHO in Mali.

According to recent research published by WHO, Mali’s government covers just 2.6 percent of the estimated cost of an effective malaria programme.

The remainder of the funding is supposed to be made up by foreign aid. Both of the most important donors for malaria funding, the US President’s Malaria Initiative (PMI) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, treat Mali as a priority.

Both support Mali’s government with purchasing malaria drugs and diagnostic kits, and training healthcare providers. The Global Fund, which this year committed to spend US$26 million in Mali, also backs a local NGO, Group Evo, helping it with purchasing and distributing insecticide treated nets and educating people about malaria prevention.

Christine Sow, a health official with the US aid agency USAID and president of the national steering committee to oversee how Global Fund money is used in Mali, said the Global Fund would be prioritising funding for the community projects only if the government requested it.

“Clearly, to get the coverage needed to make an impact on mortality it is going to be necessary to get drugs out at the community level,” she agreed.

Capacity to deliver

Johns Hopkins School’s Winch cautioned that the government’s capacity to distribute drugs is likely to pose another challenge to getting the scheme off the ground on a national basis.

...In Mali where there are shortages of management at the central level, even if you have the money you can't necessarily translate it into getting drugs on the ground...

“In Mali where there are shortages of management expertise at the central level, even if you have the money you can’t necessarily translate it into getting drugs on the ground,” he said. “Drug procurement and supply management is complex, and the government needs to get the right drugs in the right quantity to rural areas, and have a transport system in place too.”

Doing better at preventing and treating malaria would nonetheless leave more of the government’s limited health budget for tackling other chronic diseases.

“Most health centres in malaria endemic zones across Africa are overwhelmed by malaria, so there just is not the clinical time to address other diseases,” said Josh Ruxin, a Columbia University academic who works on the Earth Institute’s Millennium Villages project.

“It is only by preventing malaria cases that you can begin to think about making core improvements to the health system.”

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