Originally published on Open Society Initiative for West Africa’s Newsroom blog
Through over a decade of partnership, The Malian Ministry of Health (MoH) and Muso have collaborated to redesign and strengthen Mali’s health care system towards achieving universal health care. Muso, a community-led non-profit organization (NGO), delivers health services to 350,000 patients in rural and peri-urban Mali by bringing professionalized Community Health Workers (CHW) to patients’ doorsteps, capacitating government-run clinics, and removing user fees. The need for this work is immense: at 101 deaths for every 1,000 live births, Mali has one of the world’s highest rates of under-five child mortality. Working to change these dire statistics, Muso has partnered closely with the MoH every step of the way to design, implement and evaluate its model through rigorous research focused on impact. This partnership is a potential exemplar for other countries hoping to invest in quality national health systems through the adoption of evidence-based interventions. In our experience, this begins with investing in CHW-led health systems, ensuring they have the support necessary to achieve impact at scale and transform child health outcomes.
Community Health Worker-led health systems have the potential to improve access to quality health care by improving maternal and child health indicators and addressing the significant causes of morbidity and mortality in settings such as Mali. Yet the existing body of evidence around CHW programs at scale suggests that these programs do not always produce the desired impact. CHWs are most effective when compensated, continuously trained, supported by a dedicated supervisor, part of a reliable health system, and contributing their data for monitoring and evaluation purposes. To ensure that CHW-led systems can drive global efforts to achieve the SDGs, health system administrators must work to actively improve the quantity, efficiency, and quality of care delivered. One way to advance these goals is through the deployment of dedicated supervision and performance management for CHWs. Currently, most national CHW programs do not provide adequately frequent or rigorous CHW supervision and may rely on already over-extended clinicians who receive no additional training or support to supervise CHWs. Malian CHWs are supervised on paper by the technical director of the nearest primary clinic. However, these directors receive no additional training or guidance around the supervision of CHWs and often lack the time or transport budget to visit CHWs in their communities. In practice, many CHWs receive infrequent to no direction.
To ensure that Mali’s CHWs can meaningfully impact maternal and child health outcomes in their communities, Muso has worked closely alongside the Malian Ministry of Health to develop a system of dedicated CHW supervision. Muso’s experiences providing direct service in Malian communities allowed them to identify the need for innovative models for CHW supervision in the Malian context. Through this process, Muso and the Ministry of Health have worked together to develop 360° Supervision, a strategic, evidence-based model for CHW performance management.
In the 360° Supervision model, a cadre of dedicated supervisors are deployed for the sole purpose of supervising CHWs. The average ratio of Supervisors to CHWs is 1 to 18. The model incorporates four key elements: group supervision meetings, patient feedback audits, CHW shadowing, and one on one feedback. Group supervision consists of monthly meetings between supervisors and their team of CHWs during which they discuss challenges and successes, as well as stock monitoring and resupply needs for each CHW. The Supervisor then visits each CHW once per month to complete the rest of the 360° Supervision process. Supervisors conduct patient feedback audits by visiting patients’ homes without the CHW, randomly selecting 10-12 households in the CHW’s catchment area to ask questions regarding patients’ overall satisfaction with their CHW. CHW shadowing occurs with the supervisor observing the CHW during their proactive home visits. The final step in this cycle is a one on one feedback session in which the supervisor and CHW sit down to discuss strengths and weaknesses, challenges encountered, and areas for improvement, supported by visual dashboard displays of the CHW’s performance.
In a 2018 study published in the Journal of Global Health, Muso and its government partners found that 360° Supervision of CHWs increased quantity, speed, and quality of patient care, compared to baseline data, and that the use of individualized dashboards further improved CHW care overall. In response to these findings, in 2018, the Malian Ministry of Health committed to scaling this supervision model to all of Mali’s existing CHWs. In doing so, the government is modeling a best practice for other countries and investing in quality and impact. Muso is supporting the Malian government in its rollout of dedicated supervision, providing embedded technical assistance to Mali’s National Health Directorate. As part of this effort, Muso is working with their mobile health (mhealth) partner, Medic Mobile, to adapt the Supervisor App for use by this new national cadre of CHW Supervisors. The Supervisor App is a tablet-based application that guides CHW Supervisors through the 360° Supervision workflow and collects CHW performance data in real-time.
Mali currently has just under 3,000 CHWs operating across the country. With financing from the Global Fund, the government is rolling out dedicated supervision to these existing CHWs. One hundred and fifty new dedicated supervisors have been recruited across five regions where CHWs currently operate: Sikasso, Kayes, Koulikoro, Mopti, and Segou. So far, recruitment has been a success. As Muso’s Dedicated Supervision Technical Specialist, Cheickna Hamalla Diawara, put it:
“ These CHWs have never received consistent supervision. For the first time, they will be regularly supported in their work, which should increase their efficiency and job satisfaction.”
Health care is a human right, one that should be accessible to all regardless of patients’ socioeconomic status, geographic location, gender, or cultural-linguistic background. All actors in global health service delivery must work together to diminish underlying barriers that prevent communities from accessing quality health care services; Muso and the MoH’s partnership is based on this shared goal. Collaborations such as this can help pave the way towards universal health coverage. The Malian government has demonstrated its commitment to this vision, and is taking steps towards transforming the way quality health care is provided for Mali’s more than 19 million citizens. As dedicated supervision becomes a reality in Mali, experienced CHWs, adequately supported for the first time, will be equipped to provide quality care to those who need it most when and where they need it most.