Mali,
one of the world’s poorest nations, is greatly affected by poverty,
malnutrition, epidemics, and inadequate hygiene and sanitation. Mali's health
and development indicators rank among the worst in the world, with little
improvement over the last 20 years. Progress is impeded by Mali's poverty and
by a lack of physicians. The 2012 conflict in northern Mali exacerbated
difficulties in delivering health services to refugees living in the north.
A new
measure of expected human capital calculated for 195 countries from 1990 to
2016 and defined for each birth cohort as the expected years lived from age 20
to 64 years and adjusted for educational attainment, learning or education
quality, and functional health status was published by The Lancet in September
2018. Mali had the fifth lowest level of expected human capital countries with
3 health, education, and learning-adjusted expected years lived between age 20
and 64 years. This was a notable improvement over 1990 when its score was 0,
the lowest of all.
Most of
the population engages in rain-fed cultivation of subsistence crops, but the
country’s climate is harsh and unpredict- able, with an ever-present threat of
drought. The adult literacy rate is less than 20 percent, among the lowest in
the world. Education services are poorly developed, particularly at the primary
level. School enrollment among girls is less than one third
the Sub-Saharan average, and up to 80 percent of school-age children in rural
areas do not attend primary school.
These
indicators are important because poor economic conditions and low incomes
depress demand for health services, and foster conditions that make the
population susceptible to disease and ill health. The low level of education,
particularly among girls, exacerbates health and nutrition indicators for children
and contributes to low contraceptive use and high fertility rates.
As in
most other Sub-Saharan countries, the main health problems are infectious and
parasitic diseases, and the leading causes of death are such preventable
diseases as malaria, measles, tetanus, acute respiratory infections, and
diarrhea. The burden of disease falls dis- proportionately on children and
women of reproductive age, and health indicators are worse in rural areas than
in urban centers. Malnutrition is a severe problem; one- third of children
under age 5 and one-fourth of infants under 6 months of age are stunted. And
the emerging problem that must now be targeted is the spread of the HIV virus,
which currently infects 5 percent of the popu lation, a figure that is on the
rise.
When
the Bank first embarked on health sector operations in Mali 20 years ago, the
country was faced with a centralized health system that was unresponsive to the
population. Government policy was
biased toward urban, curative health care, leaving a splintered and
inaccessible system for the rural majority of the population. A state-owned
monopoly controlled the distribution and cost of drugs, rendering them
inaccessible to all but a few. Although the government in the mid- 1980s ended
guaranteed employment for medical school graduates and opened up the sector to
private practice, it fixed fees at rates that most could not afford, and
created a pool of unemployed practitioners. An added influence was the
prevailing attitude toward health care: the population was accustomed to
tending to its own needs with the guidance of indigenous practices and beliefs.
The
Bank’s assistance in addressing these problems has yielded substantial
dividends, but stubborn obstacles remain. The Bank’s policy dialogue and sector
analysis helped the government develop a national health policy, which
established a framework for expanded access to rural health services and
increased availability and affordability of essential generic drugs. At the
same time, the government still has not let go of its urban bias, and does not devote an appropriate
share of expenditures to primary health care or the rural sector. The Bank’s
lending and project operations also helped the government create a workable
community-based health care system that has extended coverage to rural areas
through a more coordinated network of donors and NGOs, but overall utilization
remains low, and it is difficult for clinics to recruit practitioners and
provide
a clear
career path for health professionals. The Bank, government, and other partners
are well aware of these unresolved issues, and are now engaged in a comprehensive
Sector Investment Program (SIP) to address them.
Statistics
Total population (2016)
|
17,995,000
|
Gross national income per capita (PPP international $, 2013)
|
1,540
|
Life expectancy at birth m/f (years, 2016)
|
58/58
|
Probability of dying under five (per 1 000 live births, 2018)
|
98
|
Probability of dying between 15 and 60 years m/f (per 1 000
population, 2016)
|
279/261
|
Total expenditure on health per capita (Intl $, 2014)
|
108
|
Total expenditure on health as % of GDP (2014)
|
6.9
|
Mali just took a huge step
towards universal healthcare
When
the World Health Organization reports that half the global population does not
have access to essential healthcare, it's easy to be pessimistic about the
chances of giving all of Africa’s children a healthy start in life. But as We
approach World Health Day on April 7, health experts are optimistic that an
initiative announced in Mali to provide basic healthcare to all under fives and
pregnant women may help provide a solution to an intractable problem.
Mali’s
initiative, which is expected to cost $120 million, has the backing of the
country’s major partners and is due to be rolled out in 2022. It aims to
increase the number of healthcare professionals as well as providing free
contraceptives and boosting healthcare for the elderly. Key to its success has
been signing up new funding partners.
Currently,
more than one in 10 of Mali’s children die before their fifth birthday. Latest
estimates from the UN Child Mortality Agency (IGME) put the rate at 106 per
1,000 births. Although sub-Saharan Africa still has the world's worst infant
mortality, death rates among under fives have halved since 2000.
If the
Malian initiative succeeds it is likely to be adopted by other countries in
pursuit of the UN’s Millennium Development Goals covering child mortality,
health in pregnancy and fighting diseases like malaria and HIV.
Schemes
to introduce free healthcare for Africa’s youngest children are not new. In
2010 the African Union and UN called for the introduction of healthcare free at
the point of use for pregnant women and children under five. South Africa
promptly set the pace by abolishing many healthcare charges.
Other
countries followed and a 2016 study of Sierra Leone’s Free Healthcare
Initiative found that, in its first four years, the initiative gave the people
it treated a total of an extra 595,000 years of life at an annual cost of $6.2
per head of population.
Some
countries were less successful. Analysis of projects in Africa in the
development journal Afrique Contemporaine found other schemes were undermined
by multiple factors from rushed implementation and poor organization to
inadequate funding and a shortage of doctors, nurses and drugs.
The
first comprehensive approach to providing healthcare in Africa was set out in
the Bamako Initiative, agreed by African health ministers in 1987. Sponsored by
the UN and WHO, it sought to provide a framework based on a mix of state and
NGO funding with user fees.
Since
then, opinion has turned against charging fees to patients. A study by a team
led by Dr Valéry Ridde of the University of Montreal Hospital Research Centre
argued that, however low, fees discouraged people from seeking help. The study
also said that, if properly planned, free healthcare was affordable and very
effective.
Evidence
that this approach works came last year when a team behind a seven-year project
to bring free healthcare to under fives and their mothers in a suburb of the
Malian capital Bamako reported that they had cut the local infant mortality
rate from 154 deaths per 1,000 births to just seven.
The
World Economic Forum is playing its part in tackling the global challenge to
deliver affordable, quality healthcare. Its Value in Healthcare project
reported last year offering guidance for policymakers on how to transform
healthcare systems worldwide.
The
challenge to deliver healthcare to the expected 9.8 billion world citizens by
2050 is being addressed by the Forum’s Global Future Council of Health and
Healthcare, co-led by former New Zealand Prime Minister Helen Clark and
Francesca Colombo, Head of Health at the Organization for Economic Co-operation
and Development (OECD).
Mali Health System
Mali’s
decentralized health system presents many challenges, and many opportunities.
When we help communities manage their resources to improve the quality and
availability of maternal and child healthcare in their health centers, the
results are astounding. By supporting community members, we help the health
system to function the way it was designed to – with full community
participation and local ownership.
Community Health Workers
Around
the world and in Mali, when trained community health workers provide health
education and rapid referral to health centers, mothers and children are
healthier. Mali Health has 41 community health workers who are paid,
supervised, and continually trained.
Paid
community health workers are not a part of the peri-urban health system in
Mali. Only rural communities have the community health workers known as ASC –
agents de la santé communautaire. There are volunteer health workers known as
relais – but there is no formal system for their training or support.
We
believe that community health workers play an important role in peri-urban
communities and that they are a key
component of a strong, local, community health system that can bring health to
all. Here’s more about them, their work, and their commitment to their
communities.
Women-Led Health Financing
Since
2013, we have helped women in peri-urban communities gather and share their
funds by making loans to one another to pay for healthcare expenses, or for
small income-generating activity. They organize savings groups of 15-20 women,
elect group leaders, and set rules for contributing and borrowing. The average
weekly contribution is about one quarter (25 cents).
“Simply
put when money flows into the hands of women who have the authority to use it,
everything changes.” – Melinda Gates
When
women come together in their communities – they can be an amazing force for
change. They are leading the way in finding local, sustainable solutions to
improve access to care. They are proving that we can remove burdensome user
fees without removing agency.
Quality and Governance
Improvements
Improving
access to basic healthcare is a good first step, but it is not enough. Ensuring
the high quality of maternal and child healthcare, especially at the local level
where most families seek and receive care, is just as important.
To
support partners in improving the quality of health services, we adapt
traditional quality improvement methods based on the Kaizen approach for use by
local teams based at community health centers.
Our
approach is unique because users and providers work together to address quality
issues. Women play an important role in the change teams and by joining and
leading the health center management associations – so their voices are truly
heard. We call our approach participatory quality improvement.
Using
data and feedback collected from patients (usually mothers) and internal health
center sources, change teams make improvements based on needs and evidence,
while measuring the impact of the changes continuously.
Due to
the structure of Mali’s community health system, improving quality also means
improving governance, accountability, and transparency. We also help raise
sanitation and infrastructure standards in health centers when possible.
Health Promotion and Community
Outreach
With
the right information and some confidence, communities can transform health,
and the way it is delivered. We ensure that mothers, caregivers, and community
members have the information they need to maintain good health, or to seek care
when needed.
Given
how essential community participation is to a thriving community health system
in Mali, we help more community members, especially women, engage with their
health system.
Health in urban Mali
Despite
the very low number of physicians in Mali (8 physicians per 100,000 people),
study has shown that most women in Mali seek medical treatment when giving
birth.This was especially prevalent in the urban regions of Mali. Also, a
woman's social indicators, including her status and type of marriage (widowed,
married, or engaged in a male polygyny), her social power regarding other
members of the community, and her connections throughout different regions and
a variety of people were the defining characteristics of her status of health
as well.
There
is a strong correlation between a woman's social status and health status, as
women of more esteemed social status sought more medical treatment and care
than those of lesser status who tried to fight through illnesses themselves.Two
of the most affected groups in terms of social instability (and therefore
health insecurity) were those pregnant with polygamous men and those who have
lost their husbands, directing many researchers to target those women in terms
of aid.
Because
of the nature of Mali's cultural context among women, their relations with
other women (including social networks, conflicts among co-wives, standings in
women's associations) heavily influences their use of contraceptives, number of
children, and child survival. While many women in Mali suffer from sexually
transmitted infections, this area is quite understudied and is lacking in data
Health in rural Mali
There
is a severe dearth of health services in rural Mali, since even urban regions
do not have adequate numbers of physicians. Unlike women living in urban Mali,
women in rural regions tended to depend more on other around them for their
health needs, being influenced by their community and the number of people with
at least secondary education. Delivery (of infants, from pregnancy) remains a
huge issue for those living in rural areas. Poverty and personal problems related
to rural areas also negatively affect the health status of women in these
areas.
One
study that investigated rural villages in Mali revealed that in these areas,
women and families had to decide between cost and efficiency of medical care
because they were too far from medical centers.[52] What was also found was
that qualified staff members in medicine worked few hours and often turned down
clients, forcing those in rural Mali to depend on traditional medicinal
healing. Also, even though the per capita income was less than $200 in the
rural villages, medicines cost more than they are in Western countries.
Life Expectancy
Infant and juvenile mortality
rates:
up to 1
year: 80 deaths/1,000 live births. This has decreased significantly over the
years, by a percentage of around 50% over the last 20 years.
up to 5
years:115 deaths/1,000 children in 2015 (11.5% percent experience death in
their first 5 years). This places Mali at the 8th place in terms of most mortality
rates for children under 5. This number has been decreasing steadily, from 132
in 2011, 127 in 2012, 123 in 2013, and 118 in 2014, then 115 currently.
Life expectancy at birth:
total
population: 54.55 years (2013 est.)
male:
52.75 years (2013 est.)
female:
56.41 years (2013 est.)
Prevalent diseases
The
degree of risk for contracting major infections diseases is very high in Mali.Some
of the most common food or waterborne diseases include diarrhea (bacterial and
protozoal), hepatitis A, and typhoid fever, all of which pose serious threats
to the communities. Malaria and dengue fever is also very common.
HIV/AIDS
– adult prevalence rate: 0.9% (2012.)
HIV/AIDS
– people living with HIV/AIDS: 100,000 (2012.)
HIV/AIDS
– deaths: 5,800 (2007 est.)
Physician availability
There
are three major public hospitals in the greater Bamako region. However, Mali
still lacks a great number of physicians, as there are only .08 physicians per
10 000 citizens.In 2009, there were only 729 physicians in the entire country
of more than 10 million people.
Major Private Hospitals in MALI
·
Sibiry Doumbia Community Memorial
Health
·
Gabriel Toure University Hospital
·
Hospital Women And Children De
Koutiala
·
Seydou Tounkara
·
CLINIQUE DES NATIONS UNIES MALI
·
Libya Mali Azalai
·
Institut Merieux Bamako
·
Humanity First Medical Center
·
Medical Group De Bamako
·
Regional Directorate De La Santé De
Tombouctou
·
Golden Life American Hospital
Estimates of Unit Costs for Patient Services for Mali
The
table on Hospital Costs presents the estimated cost per hospital stay and per
outpatient visit by hospital level1. Unit costs are specific to public
hospitals, with occupancy rate of 80% and representing the "hotel"
component of hospital costs, i.e., excluding drugs and diagnostic tests and
including other costs such as personnel, capital and food costs.
The
table on Health Centre Costs presents cost per visit for primary care
facilities, i.e. health centres, at different levels of population coverage. It
includes all cost components including depreciated capital items but excludes
drugs and diagnostics.
The results are presented in International dollars and local currency units of 2005.
HOSPITAL COSTS
|
|||
Cost per bed day by hospital level*
|
|||
Int $ 2005
|
LCU 2005
|
||
Primary
|
11.33
|
2722.30
|
|
Secondary
|
14.78
|
3551.52
|
|
Tertiary
|
20.18
|
4850.96
|
|
Cost per outpatient visit by hospital level*
|
|||
Int $ 2005
|
LCU 2005
|
||
Primary
|
2.92
|
700.76
|
|
Secondary
|
4.14
|
993.95
|
|
Tertiary
|
6.12
|
1470.35
|
|
HEALTH CENTRE COSTS
|
|||
Cost per visit at health centre by population coverage for a
20 minute visit**
|
|||
Int $ 2005
|
LCU 2005
|
||
50%
|
5.88
|
1412.76
|
|
80%
|
6.34
|
1523.83
|
|
95%
|
9.54
|
2293.71
|
|
* public facility, 80% occupancy rate, excludes drugs and
diagnostics
** public facility, at different population coverage, excludes drugs and diagnostics
** public facility, at different population coverage, excludes drugs and diagnostics
Future Initiatives
◆ Curative
services alone will not improve health outcomes. They must be combined with
appropriate health education and outreach programs, family planning promotion,
and nutritional surveillance and intervention, and they
must be integrated effectively with those offered by NGOs.
◆ The
cost-recovery mechanism of community-based facilities for curative care does
not create incentives for locally based health promotion activities.
Strengthening these activities will be necessary to achieve further improvements
in health and nutritional status.
◆ Incorporating
health sector concerns effectively into macroeconomic and budgetary dialogue
will continue to require regular communication between Bank macroeconomic and
sector specialists, and sufficient sec- tor work to match priorities with
sector budgets and staffing patterns.
◆ The
community-based agenda must move beyond access by targeting continued cost
barriers, inadequate outreach, and preferences for traditional medicine or
self-treatment.
◆ Establishing
a community sector outside government may have made providers more responsive
to commu- nity centers, but uncertain job security and career paths must be
addressed if community-based facilities are to attract and retain a full cadre
of health professionals.
Important Statistical Links:
Essential
health technologies
Health Governance and aid
effectiveness
Mali
Annual Financial Report for Health