Find the child, treat them early: message from Mali

The mortality rate among children under age five living in Yirimadjo, Mali, southeast of the capital, Bamako, decreased by nearly tenfold over three years after the Malian Ministry of Health and NGOs Tostan and Muso introduced a new healthcare model: proactively seeking out patients and treating them early.

A study on the programme, by researchers from Harvard Medical School and the University of California San Francisco (UCSF), published this week in PLoS ONE, found under-five mortality dropped from 155 deaths per 1,000 children to 17 deaths per 1,000.

"The intervention was based on a simple but powerful hypothesis," said Ari Johnson, a researcher at UCSF School of Medicine and co-author of the study. "If we reorganize and redesign the way health systems reach patients early, could it be possible to avert a large number of child deaths?"

While under-five child mortality rates have been declining throughout Mali over the past decade - from an average of 197 deaths per 1,000 in 2002 to 130 per 1,000 in 2012, according to the researchers, this intervention has produced dramatic results.

Johnson said that to get there, the new interventions challenged some core conventions about how health systems work.

"When I see patients [in the US], for example, I'm sitting in a clinic or a hospital waiting for them to come to me," he said. "That's how healthcare generally works in Mali and the US and the rest of the world. It's a reactive system," Johnson said. "But what if instead… the health system deployed providers to proactively search for patients in their homes and then also deployed community organizers to mobilize community members to bring their kids in early - the first day they were sick?"

That was the idea behind the new healthcare delivery system that was rolled out in Yirimadjo.

Redesigning healthcare delivery

Because the primary causes of child mortality - both in Mali and around the world - are so time-sensitive, with many illnesses progressing rapidly following the first symptoms, NGOs Muso and Tostan focused the healthcare redesign on "ultra-rapid access" to care and prevention services. Tostan's founder and executive director Molly Melching said the approach could be described as "proactive doorstep care."

Community health workers were trained to actively seek out sick patients, as well as pregnant women, and connect them with services, either within their own homes or at the local health centre. A network of community organizers also employed a rapid referral network, in which individual households were taught to identify sick children and bring them for treatment at the first sign of illness.

At the same time, education and empowerment programmes worked to teach people to solve the root causes of poverty that cause disease. This means engaging people to understand their rights and responsibilities in terms of health, development and child protection, said Melching.

"Our goal has always been to educate people at the grassroots level, and give them the information they need to make decisions and to make the development of their community their own," she said. "That's how change becomes sustainable."

The programme also involved removing user fees for those who cannot afford to pay, given that user fees are one of the greatest barriers to achieving universal health coverage.

The approach increased the number of patient visits, either in the home or at clinics, tenfold between 2008 and 2011. The rate of early treatment for malaria in children nearly doubled during that same time, said researchers.

While none of the elements of the new healthcare delivery system are new - each had previously been tested, and many are currently operating at scale in some form or another across sub-Saharan Africa - this was the first time an intervention brought together all of these key strategies and redesigned how they work to optimize healthcare delivery, Johnson said.

Proactive approaches

Other NGOs, including Médecins sans Frontières (MSF), have also seen major success in reducing child mortality in Mali by taking a proactive approach.

For instance, at Konseguela health post, in Koutiala District in Sikasso Region, MSF ran a two-year programme giving all children antimalarial tablets - whether or not they had the disease - during the four-month malaria season. The organization also distributed mosquito nets, made rapid malaria tests available and taught community workers how to measure weight loss using arm-circumference measures. As a result, malaria cases went down by 67 percent, malaria deaths dropped by 72 percent, and hospitalizations for all illnesses, including malnutrition, dropped by 63 percent.

For Johnson, the priority now is to get other communities to adopt a proactive approach.

More than 6.6 million under-fives died worldwide in 2012, and many of these deaths were caused by preventable and treatable illnesses, such as diarrhoea, pneumonia and malaria.

"Global institutions are investing millions of dollars to developing countries around the world to reduce the number of child deaths, whether it be [through] antibiotics, rehydration salts, etc," said Johnson. The difference between whether those investments are wasted or effective will be in the speed and delivery of preventive healthcare services and treatment, he said.

All parties involved in the intervention said it is important to note that there are limitations to the study. Most notably, there was no control group, and without that, researchers say it is impossible to attribute the drop in child mortality solely to the intervention. Other factors, such as demographic changes, including immigration, could have affected the decrease.

Researchers say they are now planning a follow-up to further characterize the role of each element of the intervention in reducing child mortality.

"This was an opportunity for us to reimagine what is possible," Johnson said. "So now it's a question of setting our sights much more ambitiously. And I think that, even beyond 2015, we should be aiming toward much closer to zero on the number of global deaths of children under five."