Childhood Mortality Plummets as Community Health Workers Go Door-to-Door in Urban Mali

Affordable Intervention Charts a Possible Path Toward Meeting Two of the UN’s Sustainable Health Goals

Sending community health workers door-to-door to look for sick kids in a rapidly urbanizing area of West Africa, and offering them free care, coincided with a dramatic drop in childhood mortality, researchers at UC San Francisco, Tulane University, the University of Sciences, Techniques and Technologies of Bamako and the Ministry of Public Health in Mali have found.

The program, which cost about $8 a year per person to implement, removed barriers that typically prevent people in developing nations from quickly getting care. The researchers said it shows how even in countries with extreme poverty and little access to health care, the sickest young patients can be found in time to prevent them from dying of curable illnesses like malaria, diarrhea and pneumonia.

“It’s an approach that focuses on reaching every child as soon as possible,” said Ari Johnson, MD, assistant professor of medicine at UCSF and first author of the study, published March 12, 2018, in BMJ Global Health. Johnson founded the community health group in Mali, called Muso, that developed the intervention. “The leading causes of child death are curable, but they are exquisitely time sensitive.”

Since the study was not randomized and only sampled households receiving the services, Johnson said the researchers could not draw definitive conclusions that the intervention was responsible for lowering the child mortality rate. But the drop in mortality that occurred over the seven years that the researchers observed communities on the outskirts of Bamako, the capital city of Mali, was striking and could be a way for developing countries to meet the sustainable development goals put forth by the United Nations (UN).

When the study began in 2008, one in seven children in the Bamako region died before the age of five. By 2015, that had fallen to one in 142, which is comparable to the rate in the United States. This level would meet the UN’s goal of reducing deaths among children under five to no more than 25 deaths per 1,000 live births by 2030.

“This shows us how the end to the childhood mortality crisis is achievable, and how universal health coverage could be achievable, even in some of the most challenging settings,” Johnson said. “It resets the goal posts of what we think of as possible.”

The intervention sent health workers to people’s homes to ask about children’s well-being, provided care at the doorstep and triaged the sickest patients to health care facilities. The community health care workers provided counseling, diagnosed malaria for people of all ages, as well as pneumonia, diarrheal disease and malnutrition for children under five. They treated the uncomplicated cases, and referred patients with danger signs or conditions that were outside their scope of practice to primary health centers.

Over the course of the study, the percentage of young children who had fevers was cut in half and the number of patient visits in the home and the clinic increased by ten times.

The workers offered antimalarial treatment, and the number of children with fevers who received antimalarial treatment within 24 hours of the onset of their symptoms more than doubled, from about 15 percent to just over 35 percent.

The intervention also strengthened government primary care facilities with more infrastructure, training, and staff. And workers were on call, in case someone needed their services. They also made follow-up visits to help patients adhere to their therapy, particularly in the case of diarrheal disease, and searched for sick newborns, pregnant women and those who had just given birth and needed care, to evacuate them to primary care facilities for treatment.

The approach, which the researchers called Proactive Community Case Management, cost between $6 and $13 dollars per person, per year, over what the government was already spending on health care.

During the seven years of the study, the childhood mortality rate in Mali was falling, although not by much, and in 2015, it was still among the highest in the world at 114 deaths per 1,000 live births. By contrast, that same year, the area of the intervention had a child mortality rate of 7 deaths per 1,000 live births. The researchers are currently at work on a large-scale randomized trial that will follow 100,000 people at 137 different sites to see if door-to-door home visits by community health workers lowers childhood mortality.

Other authors of the study include Oumar Thiero, MsPH, PhD, of Tulane University and the Malaria Research and Training Centre, at the University of Sciences, Techniques and Technologies of Bamako in Mali; Caroline Whidden, MSc, MPP, Belco Poudiougou, MD, MSc, MPH, Djoumé Diakité, MD, and Fousseni Traore, PharmD, of Muso in Mali; Salif Samake, MD, Diakalia Kone, MD, and Ibrahim Cisse, MD, of the Ministry of Public Health and Hygiene in Bamako, Mali; and Kassoum Kayentao, MD, MPH, PhD, of the University of Bamako.