For seven years, HP+ has worked with government and partners across Mali’s health system. Results and accomplishments were highlighted Thursday, June 9 with an end-of-project event in Bamako. Over the last two years, HP+ in Mali focused on health financing, health system strengthening, and health equity. Representatives of Mali’s National Health Insurance Fund and Devolution and Decentralization Support Team emphasized the importance of the in-depth health financing analyses HP+ conducted to support Mali’s health system. Analyses have focused on provider payment systems, health finance flows, and efficiency and equity at all levels, and were completed in collaboration with key partners. Also noted at the event was HP+’s role in advancing advocacy for community health worker (CHW) rights and legal status. These efforts led to the recent adoption of a decree enshrining the formal status and rights of CHWs, marking a transformative step toward making essential community healthcare sustainable and accessible for all Malians. In closing her remarks at the ceremony, Director of Health at USAID/Mali Julia Henn emphasized, “Although HP+ is coming to a close, we are still with you and will continue to support the Malian population.”
The Government of Mali’s Ministerial Council voted to approve a decree formalizing the status of community health workers (CHW) as an official cadre of health personnel. The adoption of this policy is the culmination of seven years of HP+ partnership with Mali’s Ministry of Health and specifically its Devolution and Decentralization Support Unit (CADD). HP+’s support of CHWs began in 2015 with a diagnostic situational analysis and has since included the development of a dynamic GIS data mapping tool, resource mobilization, capacity strengthening, advocacy, and more. This is a transformative achievement which will protect the status and rights of more than 3,000 CHWs across Mali and mandate the payment of CHWs’ stipends with domestic resources rather than external funds. Dr. Baboua Traore, director of the CADD, noted, “This entire process started when your organization [HP+] drew the health department’s attention to the termination of work contracts of this type of personnel [CHWs] in the regions of Kayes and Sikasso.”
In Mali, HP+ has been supporting the Sub-Directorate of Immunization (SDI) of the Ministry of Health to prepare the country’s health system to receive the Pfizer vaccine in March of 2022. As part of this effort, the country recently received 10 pieces of ultra-cold chain equipment from UNICEF/Japan, with distribution managed by SDI. HP+ has been strengthening SDI staff capacity on the management of cold chain equipment and vaccines, bolstering SDI’s resilience against COVID-19 and capacity to effectively deliver routine vaccinations throughout Mali. HP+’s secondee to SDI, Dr. Famoussa Konaté, has played a principal role in Mali’s COVID-19 response and the Expanded Vaccination Program. Read more about lessons learned from his technical support to strengthen SDI capacity, improve processes, and bolster the health system.
HP+ and Mali’s National Health Insurance Fund (CANAM) co-facilitated a workshop in December 2021 for government and parastatal agencies on HP+’s analysis of CANAM’s provider payment system. At the workshop HP+ shared its recommendations, which included improving efficiency through new communications processes, reducing inefficient healthcare provision practices, and adopting performance-based management practices. The workshop included facilitated discussions and sought input from participants representing the National Federation of Community Health Associations, the Union of Community-Based Insurance in Mali, the Malian social mutuality agency, the World Health Organization, USAID, and UNICEF. A representative from USAID/Mali praised the efforts being made to strengthen Mali’s health system and increase health coverage. CANAM’s Director General noted that HP+’s recommendations will significantly improve the provider payment system, which will strengthen CANAM’s provision of health insurance for Malian citizens. HP+ is working with CANAM to prepare its team to implement the recommendations.
A sustainability approach by HP+ is to strengthen the capacity of in-country partners to navigate the complexities of effective policy development, implementation, financing, and governance aligned to country priorities. In Mali, this approach was undertaken partly through seconded staff at the ministry level. A series of three briefs—"Case Studies on Secondments: A Promising Approach to Government Sector Capacity Strengthening in Mali”—explain the process that was undertaken to second staff and strengthen capacity across ministerial-level departments and document lessons learned, recommendations, and future activities. This approach aims to improve the enabling environment for equitable and sustainable health services, supplies, and delivery systems.
Community health workers provide essential healthcare at local levels, but their status and funding are uneven, often sitting outside official health systems. Momentum is building and the case is being made to formalize and fund these essential health service providers as part of national and subnational health systems throughout many low- and middle-resource countries. HP+ teams in Mali and the West Africa Regional office developed videos to support advocacy for formalization and greater investment for this important cadre of health worker. Interviews for The Place and Role of Community Health Workers in Achieving Universal Health Coverage took place during a high-level meeting of health officials hosted by HP+ West Africa in Lome, Togo in 2019, with participation from the World Health Organization, the West African Health Organization, the United Nations Population Fund, and USAID West Africa. In addition, Togolese community health workers provided testimonials on their work in the community. Mali’s video, The Importance of Investing in Essential Care Provided by Community Health Workers, was developed to support stakeholders to advocate for greater support and funding from the Malian government.
Mali has taken a step forward toward ensuring the sustainability of its community health worker program. The country’s inter-ministerial council in March reviewed a draft decree that would formalize CHWs’ status, rights, and responsibilities, and would obligate the government to finance the CHW program. Securing government support for CHWs—particularly the decree’s formal commitment recognizing the CHWs as a health worker cadre—will boost the sustainability of the program, which has historically relied almost entirely on external funding. HP+ Mali has consistently supported advocacy efforts in favor of government recognition of CHWs as a formal cadre, including supporting numerous workshops during which a draft decree was produced, helping draft the roadmap to adoption, and helping to mobilize the Ministry of Health, as well as its subdivisions and partners, to sponsor the decree. If approved by the inter-ministerial council, the decree will move to the council of ministers, over which Mali’s president presides, for adoption. Finally, the decree will pass to the National Assembly for voting. No timetable is set for these steps. Read more about Mali’s CHW efforts.
In a recent report, HP+ examined the policy environment for male engagement in family planning in Nepal, focusing on men and boys 15–24 years of age. The report presents findings on how policies engage men and boys in family planning, how implementation of those policies influences male engagement, and priority policy actions to strengthen a supportive environment for engaging men and boys in family planning programs and services. Recommendations include a call for more evidence around what works for engaging young men and boys in family planning in Nepal, strengthening family planning policies to explicitly engage men and boys in family planning, and increased capacity to develop and implement male engagement policies across all levels of the health system.
Policy implementation requires information, insight, and effective decision making, but if policymakers are unable to digest and act on new information we have fallen short. The community health worker programs in Mali used data visualization to illustrate how community health workers serve rural communities in Mali and how such scarce human resources might be better used. It’s crucial to better understand how these systems do and could work, says HP+ researcher Patrick Pascal Saint-Firmin. “Nearly 60 percent of sub-Saharan Africa’s population lives in rural areas and relies extensively on community health workers; however, the long-term financial sustainability of these programs is in question,” he says. In a Health Worker Week blog, Saint-Firmin reflects on HP+'s work to inform efforts around Mali’s community health worker program and argues that analysis isn’t enough. As data practitioners, how we make the case using data visualization matters.
HP+ has completed a financial gap analysis to accompany the Mali Costed Implementation Plan for Family Planning (2019–2023). The analysis was prepared to help Mali’s Sub-directorate of Reproductive Health better implement its costed implementation plan, understand the extent to which activities and strategic areas have been allotted funding, and advocate for future funding to drive achievement of Mali's family planning objectives and larger development goals. The costed implementation plan, completed in July 2019, is a five-year roadmap designed to help the Malian government achieve its family planning goals.
A recent peer-reviewed journal article by HP+ staff and consultants explains how Mali can reduce its spending on community health workers without sacrificing quality. The article in Global Health Science and Practice concludes that US$13.01 million expended in 2015 for a package of 23 services, including contraceptive injections and oral contraceptives, could have been reduced to US$8.36 million, if standard care protocols were followed. The article also notes that geographic targeting in rural areas is a particularly productive strategy for optimizing service delivery. The analysis appears at a time when 88 percent of funding for Mali’s community health workers is derived from donors and is thus vulnerable to declines in international funding. The publication is part of a 15-article supplement Communities as the Cornerstone of Primary Health Care: Learning, Policy, and Practice, which explores how countries are reinvigorating primary healthcare systems with communities across diverse settings. The supplement’s editorial notes HP+’s innovation in finding efficiencies and geographic targeting to reach underserved communities.
The Mali Ministry of Health has approved plans for reorganizing the country’s health infrastructure, including the creation of a National Center for Immunization. The plans, developed with technical assistance from HP+, are intended to accelerate implementation of Mali’s foundational reform documents, the Health and Social Development Plan and the Strategic Framework for Economic Recovery and Sustainable Development. The Ministry of Health plans describe the restructuring of the General Directorate of Health and Public Hygiene and provide authority for the National Center for Immunization to organize and operate the national immunization program. The next step is the passage of the revised policies by several committees and adoption by the Council of Ministers.
In the first collaboration of its kind, Mali’s workers’ unions and civil society came together recently to support Universal Health Coverage Day December 22. The event in the capital city of Bamako was supported by technical assistance from HP+. It brought together various stakeholders to demand government action on its universal health coverage (UHC) strategy. The Council of Ministers endorsed the universal health insurance plan and national fund for universal health insurance in 2018 as part of Mali’s UHC strategy, but implementation remains slow. To ignite implementation of the plan in 2021, HP+ partnered with the Civil Society Platform for UHC, a civil society group under the Global Financing Facility, to mobilize key stakeholders to push the government to adopt the necessary regulations to fully operationalize the insurance coverage. With support from HP+, the Civil Society Platform developed a UHC call to action and the workers’ unions agreed to sign. Full implementation of plan will contribute to improved health outcomes for Malians.
Mali has joined the Global Financing Facility (GFF), giving the country potential access to development funding from the World Bank and other donors worldwide, and helping to improve financing efficiencies for health. The country took the final step in unlocking access to GFF funding at a December workshop, when it completed its investment case for reproductive, maternal, newborn, child, and adolescent health (RMNCAH). At the same time, Mali finished development of a monitoring framework for its Health and Social Development Plan, which is tied to the RMNCAH investment case. Finalization of these key strategic documents is essential for the social health sectors and Mali’s intention to achieve the Sustainable Development Goals. The country’s GFF investment case seeks an improvement in health outcomes, including a reduction in maternal mortality from 325 to 146 per 100,000 births by 2023 and a reduction of the proportion of women 15-49 years who have experienced gender-based violence from 10.8 percent in 2018 to 2 percent in 2023. HP+ organized the December workshop with the Ministry of Health and other stakeholders to finalize the document and facilitated remote participation of some partners.
A recently drafted law against gender-based violence was the focus of Mali’s “16 Days of Activism” on GBV in November. HP+ Mali provided technical and financial support in the Koulikoro Region to two key organizations—Coordination of Women's Associations and Organizations and Malian Association for the Well-being of Women and Children. Two separate events to advocate for the adoption of law against GBV produced pledges to abandon the practice of female genital mutilation and commitments from the governor of Koulikoro, the mayor of Kati, and local decision makers to support and advocate for the adoption of the law. Youth from the NGO TAGNE (an organization working for the abandonment of GBV) in Kati challenged decisionmakers through a performance of Poetry Slam, requesting they accelerate government actions to support abandonment of GBV in Mali. Koulikoro is the second of seven regions with 15 percent of women reporting having experienced acts of sexual violence at some point in their life.
In Mali, where faith leaders wield significant influence over sociocultural and health matters, the decision of these leaders to speak publicly about ways to end gender-based violence (GBV) is a monumental step. Since committing in early 2020 to join HP+ and other stakeholders in advocating against GBV and promoting a national GBV law, these leaders—both Muslim and Christian, male and female—have formulated faith-specific talking points and are sharing them with their communities. Along with advocating for passage of the law, this public discussion is a critical step in combating GBV in Mali, where 4,617 incidents were recorded in 2019 alone.
A secondee from HP+ embedded in Mali’s Ministry of Health’s Immunization Subdirectorate supported national and district leaders to improve management of cold chain equipment and vaccines by developing, testing, and validating operational tools for monitoring cold chain equipment. Until now, no monitoring tools were available, making coordination among donors challenging. Availability of performance data on a quarterly basis will allow for informed decision making about forecasting cold chain supply and vaccine needs. This, in turn, will improve performance of cold chain equipment, efficiency of vaccine and distribution expenditures, and coordination of the overall system, contributing to the administration of quality vaccines to children throughout Mali.
Malian mayors, community health associations, and communities mobilized over 7,850,000 FCFA (approximately US$13,305) in local resources to support payments of community health worker (CHW) stipends in Mali. The funds, mobilized by local stakeholders in the regions of Kayes and Sikasso between October 2019 and January 2020, enable CHWs to continue to continue providing essential care following the end of funding from USAID via the SSGI Project this past September. CHWs, who reach Malians who live more than five kilometers from community health centers, have contributed to increased modern contraceptive prevalence. According to the 2018 Mali DHS, modern family planning use among married women age 15-29 increased from 10% in 2012-13 to 16% in 2018.
Mali’s Alliance of Muslim and Christian Religious Leaders has expanded their organizational by-laws to include working against gender-based violence (GBV), an important step forward for a country where faith leaders have significant influence over sociocultural practices that impact health. According to Mali’s 2018 Demographic Health Survey, 45% of women ages 15-49 have experienced violence. Following an orientation by HP+ on the types and prevalence of GBV in Mali, the faith leaders felt compelled to act. With the modified by-laws, the alliance joins forces with the National Program to Abandon GBV and other stakeholders to revive efforts to advance a law to combat GBV in Mali.
In Mali, three members of the Association of Malian Municipalities (AMM) are independently facilitating advocacy meetings to mobilize local financing for community health workers (CHWs), following a HP+ training in AFP SMART methodology. The AMM has secured funding from the Aga Khan Foundation to advocate for communes to assume financial responsibility over their CHWs, and two municipalities have signed service contracts with 210 CHWs to ensure stipend support. Increasing domestic financing for CHWs will increase access to services for women and children, particularly those living more than 5 km from a health facility.
The impending completion of the USAID-funded High Impact Services (SSGI) project threatens to leave 799 community health workers (CHWs) in the regions of Kayes and Sikasso without funding. Community health workers are an important lever for increasing access to quality health services in Mali whose work is essential to be sustained, so HP + worked with partners at the national and local levels to mobilize local resources to fill the gap until the nation’s new health reforms go into effect in 2022. As a result of the work done by HP+ and partners, the Decentralization Support Cell of the Ministry of Health and Social Affairs sent a memo at the beginning of August 2019 to the Minister of Health to transfer funds gained from replacing oil refrigerators with those that are solar powered to finance the community health worker program. This commitment and resource gap filling came as a result of meetings with regional and administrative authorities in these regions who identified the cold chain petrol budget line item as an opportunity. HP+ has also garnered support for better CHW job accountability and security by implementing employment contracts between mayors and health workers – as of July 2019, 105 community health workers have signed contracts across 26 municipalities in Sikasso and 105 health workers have done so across 43 municipalities in Kayes.
Mali’s new Minister of Health Michel Hamala Sidibe launched the country’s costed implementation plan (CIP) in Bamako on July 16th, at an event featuring the USAID family planning advisor Patrick Coulibaly and the UNFPA country representative Josiane Yaguibou. Capitalizing on the growth in modern contraceptive prevalence rate between 2012/13 and 2018 (9.9%-18%), the CIP goal is to reach 30 percent by 2023. The CIP was developed with support by USAID through the Health Policy Project, which worked closely with Technical Advisor of the Minister, Dr. Mohamed Berthé, who is also the FP2020 focal point, and who ensured Ministry of Health and Social Affairs leadership throughout the process. Local news coverage of the event featured HP+ policy and advocacy advisor, Rokia Sissoko, who emphasized the collective effort of many stakeholders. Shanda Steimer, the USAID Mali health team lead, also attended the event.
Mali's National Network of Key Population Associations (RENAPOC), which advocates for its members to seek health services, prioritized addressing the barrier of stigma and discrimination to increase health access to HIV prevention and treatment services. All 36 members from Bamako, Kayes, Koulikoro, Sikasso, Ségou and Mopti came together to discuss and approve the contents of the strategic plan and on March 2, 2019, with technical and financial support from HP+ Mali, finalized and adopted a strategic plan. The RENAPOC strategic plan is now accepted as the validated strategic plan of the various key population associations and will allow RENAPOC to operate with a stronger structure and strengthened autonomy. This strategic plan will serve as a reference tool, both for internal and external partners, for the next 5 years.
On April 29 and 30, a caravan of Ouagadougou Partnership donors visited Mali to view progress that has been made in achieving family planning objectives and to understand existing challenges to these efforts. Since February, HP+ Mali has led the process of finalizing the country’s second generation costed implementation plan for family planning (CIP) that includes plans to accelerate modern contraceptive prevalence in the country from 16 percent in 2019 to 30 percent by 2023. The donor caravan deemed the CIP process to be “inclusive” of all necessary actors, highlighting the success of HP+ Mali in convening and executing the planning process. The project is in the process of finalizing the CIP in line with final recommendations from the pilot committee and aims to launch the plan in June 2019.
This year’s annual national campaign for the promotion of family planning in Mali, "Multisectoral commitment to achieving the objectives of sustainable development through family planning," was launched on December 17 under sponsorship of the First Lady of Mali, Keita Aminata Maiga. For the second year in a row, HP+ was recognized by the Minister of Health and Social Affairs as the recipient of a Certificate of Acknowledgement of Family Planning Champions for its technical assistance efforts to provide the country with a consensus-driven costed implementation plan. This campaign is one of the key priorities of the Ministry of Health and Social Affairs aimed at reducing maternal and infant mortality nationwide.
On May 15, during the official launch of Mali’s 2018 National Family Planning Campaign, the USAID-funded Health Policy Plus (HP+) project was awarded a certificate of recognition as a family planning champion by First Lady of Mali, Mrs. Keita Aminata Maiga. The certificate serves as a recognition of HP+’s valuable contribution to the Division of Reproductive Health over the past two years, particularly in capacity strengthening, improving coordination of family planning stakeholders, and in support of the country’s costed implementation plan. At the event, Dr. Boré Saran Diakité, Head of the Division of Reproductive Health said, “HP+ stands out for the relevance of their support, the quality of the products produced with their support, and their partnership with all the [family planning] stakeholders in Mali.” Rokia Sissoko, who accepted the certificate on behalf of HP+, thanked the First Lady for her collaboration in improving the lives of women and children in Mali. The launch—which took place as part of Mali’s annual event to provide family planning outreach and services—attracted approximately 2,500 people, including representatives from USAID, WHO, UNFPA, and various implementing partners.
On December 28, HP+ Mali participated in the presentation of the Segou Declaration, in favor of the essential health care (EHC) package, to the president of Mali's National Assembly. HP+ Mali has been integral to this initiative, conducting a pivotal assessment on the funding of community health workers (CHWs) and leading ongoing advocacy in favor of these workers and the EHC package. HP+ provided technical and financial support for a preparatory workshop to draft the declaration and participated in its official presentation. At the event, the president of the National Assembly welcomed an initiative promoting women and children's health, recognizing the role that CHWs have played in reducing malnutrition and managing cases of diarrhea and upper respiratory infections, and the important potential impact on development that these efforts have had. As a result of the presentation, the president encouraged stakeholders to continue to invest in CHWs to build knowledge and capacity, and urged parliamentarians to prioritize issues pertaining to EHC and CHWs in the upcoming legislative session. This public declaration of support is a critical step in promoting the passage of a community health law to regulate and protect CHWs and the EHC program, which HP+ has spearheaded since 2017.
Mali’s Ministry of Health and Public Hygiene signed the Dakar Declaration on Factoring Key Populations in the Response to HIV and AIDS on December 9, 2016, after months of effort by the USAID-funded Health Policy Plus’s West Africa team. The Declaration stems from an April 2015 regional consultation on key populations and HIV and AIDS, held in Dakar, Senegal, and outlines how ECOWAS members will work to increase access to and use of HIV and AIDS services for key populations. Mali’s endorsement clears the path for HP+ to work with government and civil society stakeholders to develop a roadmap outlining how the Declaration will be implemented in Mali.