Refusing to accept the inevitability of malaria in Mali: putting effective measures in place

25 April 2008

What does MSF want?
MSF would like the results from its project in Kangaba, in the south of Mali, to lead to reflection on free health care as an essential strategy in the fight against malaria in Mali and elsewhere, particularly for the most vulnerable groups, such as pregnant women and children under five years of age.

© Bruno De Cock/MSF

What do the results of the project implemented by MSF show?
The results at the end of 2007 show that it is possible to tackle malaria effectively. They demonstrate the importance of access to effective treatment (ACT + RDT). They show the significance of the financial barrier to access to health care for patients and prove that there is a positive impact on attendance at health centres when this barrier is removed. Finally, they demonstrate the importance of making health care accessible geographically in order to provide better coverage of the population's health needs.

What were the achievements of the project at the end of 2007?
The number of cases of severe malaria dropped from six per cent of all cases of malaria treated to 1.7 per cent between 2006 and 2007 (care provided at an early stage).

The case-fatality rate for malaria was reduced to a tenth of its former level in the CSCOM community health centres between 2006 and 2007. It fell from 0.35 per cent to 0.03 per cent.

The total number of consultations more than quadrupled each year from 2005 to 2007. Pregnant women and children under five years of age were the main beneficiaries. Six times as many children under five came to the centres in 2007 as in 2005.

What measures are being proposed?
MSF, working together with the country's health authorities, is proposing an effective care strategy that is based on three pillars:

Quality health care: In August 2005, MSF began to provide support in the Kangaba district by introducing an effective artemisinin-based treatment (ACT) using a rapid diagnostic test (RDT) in seven community health centres (CSCOMs - first level) and the reference health centre (CSREF - hospitalisation) for the district.

Financial barrier: In order to reduce the financial barrier to access to health care for the population, MSF changed the pricing in the health centres. All care (treatment + consultation) for all illnesses became free of charge for children under five and pregnant women, the most vulnerable populations. Patients over five years of age now only pay a fixed price of 200 CFA (instead of the usual 2000-6000 CFA) for the complete care of feverish illnesses. The loss of income for the health centres is covered entirely by MSF so as to integrate the measure into the existing system.

Geographical barrier: To overcome the problem of distance and the isolation of villages during the rainy season, MSF has set up teams of malaria agents. These agents are members of the community, chosen by the community on the basis of predefined criteria, who are trained and equipped by MSF to carry out rapid diagnostic tests (RDT) and artemisinin-based combination therapy (ACT) in order to tackle simple malaria cases in children under ten years of age.

Why get involved? In 2005, MSF conducted a survey on mortality and health care access in the Bougouni district in Mali's Sikasso region. This region was chosen because it is at the level of the national average in terms of health and poverty indicators. The results observed can be used to implement a project in another region of the country such as the Kangaba district. The results revealed very high rates of mortality and exclusion from health care. One patient out of five did not have access to care in a health system based on cost recovery. Even when patients did have access to care, treatment was still expensive and ineffective.

What is cost recovery? Cost recovery is the keystone of the Bamako Initiative (1987). The community's contribution to costs is intended to ensure the long-term survival of the system. The initial stock of medication is supplied free of charge. After that patients pay for the service and/or the medication, which makes it possible to recover costs (medicines, salary of the person running the pharmacy, maintenance of buildings) and therefore replenish the supply of medication or even finance other health policies if over 100 per cent of costs are recovered.

Why are the malaria agents only active for part of the year - is there no malaria during the other months?
The strategy of the malaria agents is specifically aimed at addressing the problem of geographical accessibility for patients. During the rainy season, access to the CSCOM community health centres is difficult and sometimes impossible. The malaria agents were set up to be able to deal with cases of malaria amongst children under ten in these circumstances. Outside the rainy season patients can get to the CSCOMs more easily.

What impact does malaria have in Mali?
Although the whole population of Mali is exposed to malaria, the disease is particularly endemic in the central and southern regions and has epidemic potential in the north. Malaria is characterised by an intense transmission period during the rainy season, the length of which varies from area to area. Malaria is the major cause of morbidity and mortality in Mali, particularly in children under five years of age.