Dr. Amadou Beydi Cissé first heard about Muso when he was working as a medical student in a district hospital in Mali’s capital, Bamako. A Muso Community Health Worker had accompanied a mother and her child to the care facility, seeking treatment urgently for the child. When he heard that Muso was covering payment for the care not only of this one child, but of the population of Yirimadio, an entire community on the outskirts of Bamako, he couldn’t believe it: “How can we commit to taking care of the health care costs for a whole population? It is not possible!” He made a bet with his coworker that in a week or two, Muso would no longer be able to cover the health costs.
Dr. Cissé may have lost his initial bet on Muso, but when he joined our team in 2013, he found the ideal outlet to match his drive to build a health care system that works for its patients. For the past thirteen years, he has served Muso in many capacities, leading at the forefront of many of our greatest challenges and opportunities for growth. When Muso launched services in the Bankass region in 2016, Dr. Cissé was appointed Rural Site Coordinator, overseeing care delivery across the eight sites that would function as Muso’s boldest operational research project to date: the ProCCM Trial. Dr. Cissé’s leadership has been pivotal in ensuring care providers and researchers are able to continue their work safely, as violence and insecurity have threatened patients’ lives and access to care within the Bankass region.
The year 2020, Dr. Cissé explains, brought with it another major challenge: the COVID-19 pandemic. He shared, “Mali, being an underdeveloped country, has no means to face a multifaceted crisis – security, political, and social. It was difficult to imagine the addition of a global pandemic like that of the coronavirus. We were scared. But I was reassured when, together with the team, we decided to tackle solutions to respond to this crisis head-on, with the aim, of course, of protecting our patients as well as our team.”
The proactive, rapid, and patient-centered response deployed to confront the crises of 2020 is core to Muso’s mission and model, and is embodied in Dr. Cissé’s leadership. That is why Dr. Cissé was promoted in 2020 to become Muso’s first Country Director in Côte d’Ivoire. In his current role, he will guide the team forging Muso’s first expansion outside of Mali, supporting the Ivorian government to build systems that cure delay across their national health care system. We asked Dr. Cissé to share his reflections on the extraordinary trials and accomplishments Muso undertook in 2020:
Parts of the interview have been edited for clarity of translation.
Amadou Beydi Cissé (A.B.C.) : My name is Amadou Beydi Cissé, I am a doctor and Country Director of the NGO Muso in Côte d’Ivoire.
Can you tell us a bit about what brought you to Muso, both professionally and personally? What motivated and prepared you to do this job?
A.B.C.: I was still a student when I accompanied the on-call team at the Community Health Center, the CSCOM of Yirimadio. This is how I had my first contact with Muso: through patients who had come to receive services at the Health Center. When I was told it was Muso providing support to these people, I couldn't believe it. I wondered how could be responsible for the entire population's health care. I thought to myself that everyone had to be able to pay. By circumstance, a few months later, I was called by the Director of the Center, who asked me to support the Muso team in the management of referrals and evacuations [by Community Health Workers] to the health center and hospitals. That's how I got to know and then joined the Muso team and since then I haven't left, because I assure you that through Muso I saw changes in the community where I lived that I could not have believed before. Muso really allowed me to see health differently. That’s how I joined the team and ever since I never wanted to leave. And I hope to stay to achieve our goals together.
How many years have you worked for Muso now?
A.B.C.: I first joined Muso as a volunteer between 2008 and 2013. Subsequently, I was in charge of referrals and evacuations and I have stayed with my team for eight years.
What other positions and responsibilities have you had at Muso?
A.B.C.: In 2013, I was in charge of referrals and evacuations. I facilitated the care of patients referred or evacuated from the clinic in Yirimadio to the secondary and tertiary referral structures and hospitals in Bamako. I held this position from 2013 to 2015. In June 2015, a new position was created, that of Rural Site Coordinator in Bankass. I was responsible for coordinating all the actions of the organization at the Bankass district level, managing the human resources of the team, being the NGO representative to community partners. Because I had that background, maintaining communication and proximity with the communities. I also had the heavy task of ensuring the safety of the team within the office and in our areas of operations. Then in June 2020, I was promoted to Deputy Director for Mali and then Country Director for Côte d'Ivoire. This new position is a new challenge that started in February 2021. I am responsible for installing the team in Côte d'Ivoire. Beyond the installation of an office and recruitment, I am also responsible for the selection of the organization's future intervention sites in collaboration with the Ministry of Health. Also, I will provide a lot of technical assistance to the Ivorian government and will serve as the spokesperson for the organization with all our partners.
When did you come to Bankass, what were the goals for Muso and its expansion in the region? What did you and your team try to accomplish?
A.B.C.: I arrived in Bankass with other colleagues as the first in the organization to come to this new Muso implementation site. Our vision was to be able to replicate the actions that we carried out previously on the periphery of Bamako (in particular in Yirimadio). We had to duplicate the model we had in Yirimadio in a rural context. Beyond this mission, the goal is to offer health services in order to save lives in the communities of Bankass. It was this major goal that brought us and led us 800km away from Yirimadio.
Can you talk about the barriers that patients in the region faced before Muso arrived and changes in the model of care in 2016?
A.B.C.: The obstacles faced by patients before our arrival in Bankass were numerous. First, at the community level, there was really this breakdown of trust between the population and the practitioners to the extent that health services were not accessible. There was no geographic accessibility as there is today and the financial barriers were very high. Patients and sick people in the community preferred to see the traditional healers or just stay at home. This resulted, of course, in high rates of child death. The health structures were also not adapted to meet the health needs. When we arrived there was no equipment. I was struck visiting the centers, and not in a satisfactory way. In one clinic, there was only one bed. On this bed, there was only one mat. Women gave birth where others waited for treatment. There were centers that were not fenced and animals mingled with the patients. The challenge was great.
What makes Muso's approach to care unique in overcoming these barriers?
A.B.C.: What makes Muso unique is innovation. We have strategies that really improve access to health services for populations. And we also have this holistic approach that takes into account all aspects of the health system. In the communities, we support the provision of quality health care services. At the health center level, we provide both the necessary equipment and the provision of quality health care services. Whether at the community level or health center level, we are reaching out to patients and we are going very quickly. This is the difference when compared to other models of health service delivery at the community level.
We often share with our partners how we continue to provide care, despite the insecurity and violence in this region. Can you describe how these conflicts add obstacles to accessing care for our patients in Bankass?
A.B.C.: The obstacles induced by insecurity for the population are: the reduction in mobility, which leads to a lack of access to the health service, as well as a drastic drop in the income of the population. It has to be said, and this is important, we were forced to recognize that we were going to lose a lot of patients [because of the violence]. Our innovative approaches mean that we really manage to offer quality health services as close as possible to patients, villages, and health centers, despite existing barriers and those related to insecurity. This is how we manage to overcome them.
On a daily basis, did this mean that you sometimes lacked equipment, medicines, that the CHWs could not provide their visits? How has the continuity of health services been ensured, no matter what?
A.B.C.: Insecurity has, of course, brought all these problems: the problem of supply, problems in the provision of services. But this generally happens in remote and underdeveloped areas. With regard to our intervention sites, these problems arose many times but we always succeed to overcome them. How? First, CHWs are agents who come from the community, they are part of the community, they are closest to the community. So from a strategic point of view, they can provide the services to the populations. Which helped us deal with the insecurity in Bankass in 2020. Second, the transport and supply of medicine has been a challenge. Obviously, there were times when we were unable to get the medicine to the health centers or our CHWs due to an incident. This required the activation of our security management plan. What did we do? We had the forethought to supply health centers with contingency surpluses. These medicines were stored in quantity which made it possible to compensate for the shortage in the event of difficulty of access. When we could not approach a health center, we drew from these stores of medicine. And this was very well followed. The medicines used in these batches, when given either to health centers or to CHWs, were then replaced. This strategy ensured that there was no disruption at the level of health centers, but also at the community level. Our patients have always received services during episodes of insecurity.
Can you tell us about your experience with the Bankass team during the COVID crisis?
A.B.C.: First, it must be said that Mali experienced several major crises during the year 2020. The coronavirus epidemic was one of the very complicated crises to manage. We were not [originally] prepared for such a situation at the Bankass level. Quickly, the team put in place protocols that allowed us to develop a set of strategies to deal with the epidemic while keeping the activities in place within the communities. As the site manager, it was both exciting, because I saw [how] we respond to challenges, but also very, very stressful.
Patients and colleagues were equally exposed. We had to take action to protect everyone in order to come out winners in the face of this pandemic.
It was difficult. The work we have had to do has doubled. It was not easy, but we held on. Not just the Bankass team, but the entire Muso team. We have developed a lot of action plans and strategies in the context of prevention and continuity of services.
Thinking back to the start of the pandemic, were you worried about what it would mean if the virus arrived in Mali?
A.B.C.: From the moment we heard about the coronavirus through the international media, we have been afraid. Mali being an underdeveloped country, which has no means and faces a multifaceted crisis — security which has reached the north and the center, and even the south of the country, which is facing a political and social crisis— it was really difficult to imagine the addition of a global pandemic like that of the coronavirus. We got scared. But I was reassured when together with the team we decided to tackle solutions to respond to this crisis head-on, with the aim, of course, of protecting our patients, and equally, our team.
What were the first actions taken to prepare for the arrival of COVID? Do you think we have been proactive in responding to the crisis?
A.B.C.: The first actions taken in the case of the prevention of the coronavirus disease were developed on several levels: the first was to be informed about the disease. It was important that we knew what this new disease was. The leadership has prepared what was needed so that the whole team can have the necessary information about the disease. Then we had to respond to these two concerns: how to protect the team, while maintaining services at the community level? For that, we put all our efforts into the prevention of the disease. We then looked for PPE for frontline health services providers as well as put in place protection protocols: train CHWs, provide and explain the use of PPE. Everything has been done to be able to maintain the continuity of services.
Can you explain why Muso is providing support to the government to respond to the pandemic and what were the objectives?
A.B.C.: It was important for us to support the government because, in addition to being an underdeveloped country, Mali is facing a multifaceted crisis. The healthcare system we already knew was not fit to cope with this global pandemic. Muso was to provide its management expertise to the Malian government... particularly in the context of tracing and monitoring contact cases. Which I can say has been very well done. This was preceded by a set of training for contact cases. The vast majority of health districts in Mali have benefited from training on tracing and follow-up of contact cases as well as from PPE provided by Muso. We have also supported the Malian government with oxygen. Oxygen is one of the major challenges in the fight against the disease. We have supported the government in acquiring this oxygen allowing it to offer local service, especially in referral health centers [with usually no oxygen access at all]. We have supported the government so that its health services are able to respond to this pandemic.
In your opinion, have Muso and our government partners built a model of healthcare delivery ready to withstand these crises? How does the model directly benefit our patients?
A.B.C.: Affirmative. This is what makes Muso unique. The innovative strategies that we have developed and implemented in Mali, and that we will certainly duplicate in Côte d'Ivoire, are strategies that make it possible to manage ordinary health situations and extraordinary ones like this pandemic. This is what allowed us to implement this proactive contact tracing and monitoring strategy while maintaining our service delivery model already in place. The CHWs were able to continue working and serving the community. This was also the case at the clinic level. Obviously, COVID is an epidemic but we must not forget the other diseases. We had to make the choice to respond and face this pandemic and the diseases existing in these communities. This is why we have established clear and strict protection and detection protocols to ensure that CHWs are not infected and can continue to offer their services to populations in need.
Can you tell us about the organizational goal of expanding Muso to a second country? What is behind this development goal for Muso?
A.B.C.: The objective of our expansion in Côte d'Ivoire is based on our strategic plan. Since its creation, Muso has worked on two sites in Mali, peri-urban and rural.
We have the strong will to bring about a transformation in health on a global level. That is why it was so important that we expand to another country. To do the same, to be able to offer direct care services to populations but also to show that our strategies can be implemented in all contexts. We want to show that these strategies have been successful in Mali and can also be replicated in other contexts, countries, and more globally at the global level. This is what we are going to implement in Côte d'Ivoire.
How does more than a decade of work as an operational research partner in Mali influence our current efforts to establish a strong and lasting partnership with the Ivorian government?
A.B.C.: A decade of research and work in Mali obviously influences the partnership we have with the Ivorian Ministry of Health in our implementation of activities, and at the global level. What is [our partnership], fundamentally? It is about implementing actions and strategies that have been proven to work. But these strategies can only prove their worth based on objective operational research. This is what we did in Mali. We support all the actions we put in place with research in order to clearly see the impact that we have. Prove that we are making a real contribution to strengthening the health system. Research guides our actions and will continue to guide our actions beyond Mali.
What are your hopes in the future for both Muso and our patients?
A.B.C.: There is only one, the hope that we will continue to save lives. We did it in Mali and that is what made my commitment to Muso. We have faced challenges. You have to be in the communities to really see all the poverty, all this lack of infrastructure to offer quality services with the aim of saving lives. I am one of the people who had the chance to be part of this team, to offer my services to the population, to be able to save lives.
Every time someone calls me to tell me that their child is healed, that the fear has disappeared since Muso has been here, I am moved. I am moved, and at the same time, I am proud. I know that if we continue in this way we will succeed, beyond Mali, beyond Côte d'Ivoire, in having a better world. That’s all the hope I have in this work that we do every day.
Thinking back to 2020, can you identify what has been unique about Muso's work over the years that has prepared us for this very difficult year?
A.B.C.: Looking back to 2020, what makes Muso so successful is our close contact with the community. We are part of the community, we work with the community. All of our actions are led by and for the community. This is how we hear more, we are much closer, so we understand their concerns and can respond to their needs. In 2020, we have not failed in this. We listened a lot. All our actions would not have been successful, we could not have succeeded in this context of insecurity in Bankass, the context of COVID-19, the politico-social context in Mali if we were not with the community and if the community was not with us. This has been our great strength and must remain our great strength in all of our actions.
At the start of 2021, what are your goals as Country Director for the weeks or months to come here in Abidjan?
A.B.C.: Establish this partnership with the government as part of the implementation of direct care. We are going to carry out the first actions in symbiosis with the Ministry of Health and will follow these actions with a rigorous research approach. We will continue to assist the Ministry of Health in strengthening health services. We know there are a lot of challenges but we are bringing a lot of hope. We will very soon be offering direct services to the populations and I am telling you, the need and the desire are already present. I have had contact with some communities [here in Côte d'Ivoire] and every time I present what we are doing in Mali, people pray for us to intervene in their community or district. The need is there. Since I arrived, I also quickly learned that the Ministry of Health is engaged. And we need committed government partners. We will, with the Ministry, work to support these populations who are in need of quality services and work to strengthen health centers to meet international standards so they can provide quality care and services. These are our goals for this first year and will extend to future years.
A partnership agreement has been signed with the Ministry of Health. We are in the team development phase, an office has already been secured. We are working to learn and understand how the health system is organized. We are already working to collect the needs of the populations inside the country and developing the criteria to select our future implementation sites.
Is it difficult for you to have to select only a few sites?
A.B.C.: As in Mali, it is difficult for me to serve only part of the community. But that's also why we are doing this work there. Because our ultimate goal is that everyone can have access to health, beyond Mali and Côte d'Ivoire. I would like us to serve as many people as possible with, of course, quality services. That's why our end goal is to show governments the way, accompany them on the path, [so that they can] continue and replicate what we do.
Do you have anything you would like to add?
A.B.C.: The first time someone told me about Muso. I remember that day, it was a Wednesday. I was on call. A woman came with her child, accompanied by a CHW. They came and I was told that they were supported by the NGO Muso and that they had to be taken care of. So I provided the service, I consulted the child. I don't remember my diagnosis at the time but when they left I clearly remembered that I asked my coworker this question: how can we commit to taking care of the health care costs for a whole population? It is impossible! And then we made the bet that in a week or two, Muso would no longer be able to cover the health costs. So much I was convinced that it was just not possible. A few months later, the Director of the Health Center called me to tell me: "Beydi, are you ready to support the NGO Muso? They wish to have someone who can ensure the coordination and facilitate the care of the patients to the district hospital level." I thought about it and said to myself why not. Still, I was not confident. I didn't think what Muso was doing was possible and can last. I started, and it totally changed my vision. I was in this community, but I ignored what was really going on. Through Muso, I learned the realities, really seeing the poverty, and all the lack: physical and financial inaccessibility to care for most of the population of Yirimadio. Since then, I have been able to truly appreciate the actions taken and how many lives were saved through Muso's interventions. It completely changed my perception and guided me to meet these same challenges in Bankass.