Posted by: kristinej | August 21, 2009

August 21st

For these next few posts, I’m going to take a slightly different route and talk less about my own experiences and more about Project Muso and the work that it does here in Mali, with a special emphasis on the problems that exist here in the community that I’m living in. With the Tony Blair Fellows here, we’ve been having some really interesting sessions on everything from health as a human right to malaria prevention tools to Mali’s health care system. We’ve had speakers from our own team, as well as from the local community health center and the national hospital in Bamako. Even I have helped prepare and give several presentations, including a Bambara lesson, of all things!

First I will briefly describe the structure of the health care system in Mali. At the national level, there are 5 main hospitals, all located in Bamako. Gabriel Touré houses the pediatric ward and sees most emergencies. These hospitals are also where medical students study. At the next level are the regional hospitals, found throughout the country. Below those are the community reference centers, and then the community health centers, or CSCOMS, of which there are over 800 in Mali. This number has increased significantly in recent years, thanks to efforts to reach rural areas that previously lacked any health clinic at all. The CSCOM in Yirimadjo works closely with Project Muso, who helped finance the construction of a new building a couple of years ago. Before the addition, pregnant women in labor were forced to wait outside or even return home while they dilated, since there was only enough room in the clinic for women who were just about to give birth. Now there is an entire maternity building, and the Yirimadjo CSCOM provides better quality care than many other CSCOMs.

There are many barriers that prevent Malians from seeking care when they need it. For some, the nearest CSCOM is still too far for them to walk to, and they cannot afford to take transportation there. Others still place faith in traditional medicines, using those first before going to a health clinic. The doctors here have tried to integrate traditional remedies into their work by including traditional healers in their trainings and by testing traditional medicines for efficacy. Another big problem in Mali is the lack of doctors. The hospitals are severely understaffed, and for some areas of care there is only one specialist in the whole country.

One of the biggest problems, though, and one that disproportionately affects the poor, is the presence of user fees. User fees were implemented in most African countries in the late 1980s, after a conference held right here in Bamako. The idea was that if patients had to pay a small fee for care, they would only seek care for true illnesses and injuries, and that the government could take that extra revenue and use it for quality improvement. In practice, though, the extra revenue generated by user fees was very small, not enough to make significant changes in quality of care, and health clinics saw a marked drop in attendance among the poorest populations. After years of research on the effects of user fees, some African countries have started to remove some or all user fees, and most have seen an increase in attendance, specifically among the poor. Mali, however, still has user fees.

The fee for a visit to the health clinic is about $1, a large sum in country where 72% of the population lives on less than a dollar a day. When patients cannot afford to pay for their care, they wait until the last moment to seek care, until the illness is severe and will cost even more money to treat, if the person even survives. In other instances, the money used to pay for care comes directly from money otherwise used for food, and a family might eat less than normal for a week or two afterwards.

In order to address this problem, Project Muso has worked to remove user fees at the Yirimadjo CSCOM. Their Solidarity Fund is comprised of the very poorest who cannot afford care. These families are enrolled in the Fund, and receive a card with all of their family members’ names. Whenever someone in the family gets sick, the family just has to bring their card to the CSCOM, where they will receive care, with all costs covered by Project Muso. In addition, when our community health workers find patients who need care but who can’t afford it, they too receive free care, even if they aren’t enrolled in the Solidarity Fund.

Project Muso’s Community Malaria Prevention Program has been in existence for almost a year now. We have 20 Community Health Workers (CHWs) who are all graduates of our education program and have been trained in the basics of malaria prevention and treatment, as well as nutrition and other childhood illnesses. These CHWs go out into the community each morning and look for people who are sick. They each have their own zone that they cover, and in this way they get to know the people around them, and the community knows who they are and what they do. My host mother is one of these CHWs, and I followed her around on one my first days here. When a CHW finds someone that is sick, they accompany them to the CSCOM where they see that the person gets proper care and treatment, and that they understand what the doctor has said and how to take their medications. CHWs are on call 24 hours a day, and it is rare that a day passes without a mother or father bringing a sick child to our house. Since it is rainy season, malaria is in full swing, and I have watched many times as my host mother has pricked the finger of a child, getting a few droplets of blood to use in the rapid diagnostic test, which in 15 minutes can tell whether the child tested positive or negative for malaria.

More about malaria in my next post…



  1. Kristine, Amazing. I can see why you are so dedicated. It is a wonderful program and seems very organized. Wow!! I’m impressed. It sounds like the women and children are a top priority as it should be. Keep up the good work. Robby

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