Imagine a world in which pregnant women and little kids get regular home visits from a health worker — and free health care.
That's the ground-breaking approach that's being adopted in one of the world's poorest countries: the West African nation of Mali.
And it's already underway in a pilot program. Nana Kadidia Diawara is one of many community health workers who do daily rounds through the sprawling, dusty streets of Yirimadio, a neighborhood on the outskirts of the capital city of Bamako.
Wearing a bright blue and white print dress and matching hat, she carries a large green rucksack full of medical equipment like syringes and bandages.
"I know everyone in my area, and it's a system that works very well," she says, while measuring the skinny arm of a child to check for signs of malnutrition. The child lives in a one-story concrete compound that is home to ten families.
A nurse who's joined the country's cadre of community health workers, Diawara visits each of the homes in her designated area, which contains roughly 1,000 people, at least twice a month. She diagnoses, treats and refer patients. It's part of a free door-to-door health-care plan that began in Yirimadio in 2008 as a trial by the government.
When data from seven-year trial was compiled by a team including researchers from the University of California, they found that child mortality for kids under age 5 in Yirimadio dropped by an astounding 95%, according to findings published last year in BMJ Global Health. The population in the study area was 77,132 in 2013. During the seven years of the study, child mortality rates for that demographic fell from 154 deaths for every 1,000 live births in Yirimadio, among the worst in the world, to seven – comparable to the 6.5 figure in the U.S. Mali's overall rate remains very high at 106 deaths for every 1,000 live births in 2017.
And now the program will be extended to the entire country. This spring, President Ibrahim Boubacar Keïta announced a target date of 2022 for nationwide coverage — at a cost of $120 million. This localized, free health care for pregnant women and children under age 5 could help the West African nation meet the U.N. Millennium Development Goals. A key factor will be the provision of community health care workers who'll be trained to do the door-to-door work.
The decision has earned praise from policy experts and patients alike.
"This is long overdue," says Dr. Eric Buch, a medical doctor and professor of health policy and management at South Africa's University of Pretoria, who was not involved in the study."Free health care for mothers and children under 5 is a very effective way of reducing mortality, and it could have a huge impact."
Astan Koné, a 28-year-old mother of two in Yirimadio, agrees. During Mali's hot season last year – which regularly exceeds 100 degrees Fahrenheit – one pregnant relative was diagnosed with stomach ulcers.
"It makes me very happy that the government will do that for the rest of the country," says Koné.
At the time of the announcement Mali's health minister, Samba Ousmane Sow, said the reforms were an attempt to change "[an outdated] health-care system inherited from the French colony which was put together 50 years ago."
"We are trying to make Mali be great again, to improve our health care system and save lives, and we are hoping this will help us reach universal health care with a very powerful, improved system," he added.
For the moment, however, Mali's planned reforms rely on external funding from bodies such as the Clinton Health Access Initiative to supplement government spending. But there is no guarantee this funding source will last in future decades, and Mali will need to find a long-term solution that may involve restructuring its budget.
Robert Yates, an advocate for universal health care coverage at the U.K.-based think tank Chatham House, believes the reforms mark an end to the controversial Bamako Initiative, a cost-cutting move encouraged by the World Bank to make economies more market-oriented. As part of that initiative, African countries such as Benin, Guinea and Mali introduced user fees for primary health care in 1987.
"It formalized health care but was a cataclysmic disaster," says Yates, pointing to the burden on poor communities unable to pay for treatment.
A spokesperson for the World Bank acknowledged the "growing global recognition" that user fees are one of the barriers to universal provision of health care and said it supported countries like Mali that seek to remove some or all of these costs. But the comment from the World Bank stopped short of signaling a rejection of the model in which a user pays for services. "In most developing countries, domestic spending on health is far too low and too inefficient to achieve universal health care," the spokesperson added, "which not only threatens progress on health but also endangers countries' long-term economic prospects and makes them more vulnerable to deadly outbreaks."
The World Health Organization estimates that health costs force 100 million people into extreme poverty each year.
The key to long-term success, according to Yates, will be political support – which Mali already has – and a long-term funding plan. "Clearly countries need more public finances to do it," he says. "But it's perfectly feasible – by allocating a greater proportion of the budget to the health sector."
The cost of the Mali's reforms, averaging $8 per person a year, could reasonably be covered by what the region's governments are already spending on healthcare, Yates believes.
That said, perhaps the greatest challenge in addressing Mali's public health crisis – where more than one in 10 children die before their fifth birthday – is providing a single system that fits both rocketing urban populations (Yirimadio's population has ballooned from 20,000 in 2005 to 200,000) and dispersed, rural communities across the arid Sahel.
This is why community health workers — who in Mali are trained for at least a year and are able to carry out basic medical procedures — are so important.
"The leading causes of maternal, newborn and child death are curable," says Dr. Ari Johnson, a medical doctor and co-founder of Muso. The nongovernmental organization, which aims to end preventable deaths, has supported the trials in Yirimadio with staffing and training. "Diseases like malaria and newborn sepsis can kill within hours of 'Mommy, I'm sick.' But in status quo health-care systems, poor patients face many barriers that delay their access to care: fees they can't afford to pay, distance they cannot travel to the nearest provider."
Back in Yirimadio, one 6-month-old girl in a white dress calmly awaits treatment on her father's lap under the shade of a mango tree. "She is suffering," says Naba Fané of his daughter, who has pain when urinating. Community health worker Diawara writes the family a referral to the local health clinic in a matter of minutes.
But it wasn't always like this. Fané's first wife died some years ago due to complications during childbirth, and the 55-year-old harbors anger and regret over an incident that he put down to a lack of health workers. Fané believes the community outreach that's been a fundamental part of Mali's pilot program has vastly improved the situation.
"It's important that the community plays a part in this, so we can say if we're happy or frustrated with the system," he says, sipping a glass of sugary tea.
Peter Yeung is a freelance journalist who has written for the BBC, The Guardian, National Geographic, Wired and The Los Angeles Times. Follow him on Twitter@ptr_yeung
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