Baseline Data in ProCCM Trial Highlight Challenges and Hope in Care Delivery
In March 2018, BMJ Global Health published findings showing that peri-urban areas served by Muso’s Proactive Care, or Proactive Community Case Management (ProCCM) health system achieved and sustained a child mortality rate lower than that of any country in sub-Saharan Africa. In the final year of the study, Muso’s Yirimadio site had a child mortality rate of seven deaths per 1,000 live births—on par with the child mortality rate in the United States. Seven years after the rollout of our model, patient access to health care in communities served increased ten-fold. In the lives of our patients, these results are not meaningless numbers: they translate to lives saved and justice for patients that would have otherwise faced extensive barriers as they sought care for conditions with proven and inexpensive treatments.
While this research represents a landmark moment in the global effort for child survival, it faced key limitations. Because the research design lacked a control group and assessed the entire ProCCM intervention as one package, we cannot draw conclusions about the impact of CHWs proactively providing care on reductions in child mortality. For this reason, Muso and the Malian Ministry of Health launched the ProCCM Trial, an extensive Randomized Control Trial in 2017-2020, to answer a critical question: can Community Health Workers save more lives by searching for patients proactively, rather than waiting for patients to come to them? The Trial will provide critical evidence on which CHW workflow has the greatest impact on child mortality and other secondary outcomes, and will determine whether the proactive approach should be replicated and scaled in multiple contexts.
The ProCCM Trial is being conducted in eight rural sites in the Bankass district of eastern Mali. Bankass is located about 600 kilometers east of Bamako, Mali’s capital, along the southern edge of the Sahara Desert. Muso’s research team has recently completed the analysis of baseline data from these communities participating in the three-year study. The findings sketch a demographic and environmental picture of communities with among the lowest rates of access to care and enormous need for a health system that reaches more patients, faster. In 2016, the study area had an estimated population of about 100,000 people. In recent months, Bankass has seen escalating violence from an inter-ethnic conflict fueled by armed extremists. The region’s remote location, climate, and current security situation create barriers to care, which are exacerbated by a lack of critical infrastructure: according to the recently released baseline data, 66% of patients surveyed in the region had no electricity, 46% lacked access to clean water, and nearly 90% had received no formal education.
Muso and our government partners did not choose to conduct the ProCCM Trial in the Bankass region in spite of its challenges, but rather because of them. We bring care to where it is most needed. The baseline indicators show that, prior to Muso’s intervention, women and children in the Bankass region were often not able to access care when they needed it. Only 4% of reproductive age women were using some form of contraception at the time of the survey. Among women who were pregnant, almost two in every five women received no prenatal care. Almost 40% of children under five years old had at least one illness in the two weeks prior to the survey. While these initial data points are bleak, our hypothesis and hope is that rapidly connecting patients to proactive care by CHWs can improve patient health care access and outcomes, even in the most challenging circumstances.
The ProCCM Trial is currently in its final year. Following the study’s conclusion in 2020, and data cleaning and analyses, Muso will share findings with key global partners and decision-making organizations. Our technical assistance team will provide advocacy and strategic advising to support the Malian government’s uptake of evidence-based strategies in accordance with the Trial’s evidence and in service of national community health strategies to care for the country’s 18 million citizens. We will also disseminate ProCCM Trial learnings to key global norm-setting bodies, including UNICEF and the World Health Organization, and provide joint and direct technical assistance to implementers, policymakers, and funders. Should the trial show that proactive case detection saves more lives, Muso will support many government and implementing partners to adapt and adopt proactive case detection within Mali and beyond. As the ProCCM Trial concludes, Muso will accompany global policymaking and implementing partners to use its evidence to inform global best practice, and ultimately drive health outcomes in the lives of tens of millions of patients.