On the outskirts of Bamako, the capital of Mali, Tenindie Samake is making the rounds of the Yirimadio neighbourhood.
In the courtyard of a concrete-block house, she measures the arm diameter of a skinny child, determining that he is borderline malnourished. In another compound, housing 11 families, the kids look scrawnier still. One has an eye infection, so Ms Samake advises treatment with eucalyptus leaves or expressed breast milk. In a third house, where there are no obvious health problems, she talks generally about monitoring symptoms, such as fever or diarrhoea, and asks the mother discreetly about contraceptive arrangements.
These recommendations look rudimentary. But their impact has been nothing short of astounding. In the seven years since these interventions started, deaths of children under five have plummeted from 148 per thousand, among the worst in the world, to seven — almost identical to the US.
The key is Ms Samake and hundreds of community health workers like her. A local resident, she has been trained to go door-to-door looking for signs of childhood diseases such as diarrhoea, malaria, and pneumonia. The idea is to act proactively, rather than waiting for children to come to health centres. Sickness is nipped in the bud. Patients are treated at home or referred to clinics. Crucially, treatment is free.
These are early days. The work has not yet been subjected to a randomised control trial. But Ari Johnson, assistant professor at the University of California San Francisco, who is leading this study, thinks it could have revolutionary implications for healthcare worldwide.
One likely impact would be to reduce the number of children women choose to have. Mali has the fourth-highest fertility rate in the world, at six babies per woman. Countless studies suggest that, if mothers know their children will survive, they have fewer.
These theories will now be tested on a nationwide canvas. Mali’s government this week announced it would provide free primary healthcare to all pregnant women and children under five nationwide. It will also offer free contraception and employ community health workers like Ms Samake across the country.
The experiment marks a sharp reversal. Africa, over the past three decades, has seen a relentless shift towards requiring patients to pay “out of pocket” for medical care. Under the Bamako Initiative of 1987, also signed in Mali, governments agreed to charge for primary healthcare. Their decision came as a result of pressure, often external, to slash spending.
For healthcare, perhaps predictably, the results have been tragic. True, people across the continent are healthier and live longer than before. But many studies suggest they would have been healthier still if fees weren’t preventing the poor from accessing healthcare.
Just this month, a 22-year-old Kenyan man won widespread sympathy — as well as a three-month suspended sentence — for smuggling his baby daughter out of hospital in a paper bag because he could not pay his bill. Tens of thousands of Africans are incarcerated in hospitals each year for failure to settle up. The World Health Organization estimates that catastrophic health costs force 100m people worldwide into poverty each year.
What began in Mali may now end in Mali. Robert Yates, an advocate of universal healthcare at Chatham House, the UK think-tank, says the community care initiative could end “the crazy idea that taking money off poor people when they are sick is a good idea”.
So who will pay? The reform, to be phased in over four years, will cost the Malian government an estimated $120m extra a year by 2022. It has committed to increasing the amount it spends on healthcare, but it will also receive funding from bilateral partners and the likes of the Bill & Melinda Gates Foundation.
The need for external funding might suggest the scheme is too expensive — and thus unsustainable. Costs in Yirimadio run at an extra $6-13 per resident a year. But that is amazing value for money if the results can be replicated nationwide. Mali spends only 6 per cent of gross domestic product on healthcare. Fully funding the new scheme would still put healthcare expenditure well below 15 per cent of GDP, the amount that Mali — and all African governments — committed to nearly two decades ago.
It is obvious, but spending on health (and education) is the basis of development. Even Mao Zedong, who imposed many lamentable policies, saw this and championed “barefoot doctors” to bring healthcare to the rural masses. In rapidly urbanising Africa, where people live in ever denser clusters, it should be easier and more cost-effective to provide basic health. Mali’s initiative can — and should be — the start of a new trend.
