Study Signals New Hope for Universal Health Care and Child Survival

Around the globe, more than five million children die each year from preventable diseases. In 2015 world leaders committed to end the child mortality crisis, and achieve universal health care, by 2030.

These commitments have fueled a global debate: Can we deliver health care to everyone? This week, new evidence to answer this question arrived from the West African country of Mali. A new study published March 12 documents how an area of Mali, previously with one of the world’s highest rates of child mortality, achieved and sustained the lowest rates of child death measured in sub-Saharan Africa.

When the study began, 1 in 7 children died before they could celebrate their fifth birthday. Seven years later, child deaths had become rare—only 1 in 142. These communities in Mali were down to 7 deaths per 1,000 live births, a rate comparable to the United States. This drop represents how the Sustainable Development Goals could be achievable, even as many wealthy countries struggle to make progress on the commitments they made at the UN in 2015.

Over the course of the study, published in in BMJ Global Health, the Malian government worked with the global health organization Muso to roll out a proactive approach to health care delivery, with a goal of reaching every patient in the first hours of their illness onset. To reach patients quickly, Community Health Workers searched for patients door-to-door, cared for patients in their homes without fees, and brought patients to strengthened government health clinics. After this new approach to health care launched, the number of patient visits increased ten-fold. The rate of fever among children dropped by 55%. And child death became a rare event in the communities served.

Dr. Henry Perry, Senior Scientist at Johns Hopkins University, who has been engaged for many years in community-based approaches to improving child health, said, “This is a pioneering and path-breaking study because it provides long-term (7 years) evidence that very low under-5 mortality rates can be achieved in resource-constrained settings through (1) proactive and frequent home visitation to identify children with signs and symptoms of serious illness who need treatment and (2) making that treatment readily available. This is the beginning of a new phase of programming and operations research in the movement to end preventable child and maternal deaths – a goal which the global health community and governments have adopted to be achieved by the year 2030. These findings are sufficiently important to justify funding for similar efforts by independent groups in similar settings. The findings are particularly important because they provide long-term evidence of effectiveness. Very few studies of the mortality impact of health interventions so far have evidence beyond 3 years of programming.”

Dr. Ari Johnson, Assistant Professor at the University of California San Francisco and lead author on the study, said “These results moved the goalposts for global health. We already knew that child survival and universal health care are morally imperative. Now we know they are imminently achievable. These are the battles we can and must win. We have the tools we need, today, to make the death of a child rare in every community.” 

Muso’s strategy is remarkable affordable. The approach to universal health coverage, known as Proactive Community Case Management (ProCCM), costs $6-$13 per person per year in addition to pre-existing government spending during the study—affordable for governments and international partners to scale up.

The study has several important limitations. Without a control arm, the study cannot prove that the dramatic decline in child mortality was caused by the proactive care intervention. The study focused on a set of vulnerable peri-urban communities on the outskirts of Africa’s fastest growing city, Bamako, Mali—a particularly important and challenging setting for universal health care as the region rapidly urbanizes. These communities currently number approximately 185,000 people. Based in one area of one country, questions remain on how these results could be applied to an array of other contexts.

To better understand the impact of the ProCCM approach on child mortality and access to health care, a team of researchers across seven academic institutions has together launched a large randomized controlled study, the ProCCM Trial, which will follow 100,000 patients from 2017 to 2020.

As further research on proactive health care continues, these findings offer important indications that an end to the child mortality crisis is well within reach.

 


Cite: Johnson AD, Thiero O, Whidden C, et al. Proactive community case management and child survival in periurban Mali. BMJ Glob Health 2018;3:e000634.

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