Historic Decree in Mali: Community Health Workers at the Heart of Health System Reform

In 2011, implementation of the Integrated Community Case Management (iCCM) package began in five regions of Mali: a package offered by Community Health Workers (CHWs) trained and paid by technical and financial partners. A year later, the communities, subsidized by the State, were to take over, but the road was full of obstacles.

It was in February 2019, almost ten years later, that our government partners made a brave commitment as they faced significant challenges related to the security crisis, particularly the considerable burden of this crisis on the national budget. During the high-level workshop on health system reform in Mali, the President announced a historic transformation of the national health system: free care for pregnant women, children, and the elderly, free contraceptives, modernized clinics, and a CHW for every community in the country that would be rolled out to Mali's 19 million citizens over the next four years. This transformation would represent not only an investment in public health outcomes but also in national stability, recognizing good health care as a vector of peace. At the time, the government requested Muso's technical support, and we in turn committed to supporting our partners on this unprecedented reform of the Malian health system.

On April 04, 2022, the government passed a landmark decree that legally recognizes the work of CHWs, opening the framework for the state to be able to start paying CHWs from domestic coffers in the coming years and laying the groundwork for large-scale reforms at the national level.

How?

Over the past two years, Mali has experienced several waves of political instability, notably through two coups in less than 12 months, which has led to changes in leadership and consequently a shift in national priorities. Despite these challenges, advocates within the Coalition Nationale pour les Soins Essentiels dans la Communauté (National Coalition for Community Case Management; CNSEC) never faltered in their determination. Muso provides technical and financial support to the CNSEC, as well as support in regards to advocacy coordination, which has resulted in several brainstorming sessions to develop advocacy strategies geared towards the takeover of CHW salaries by government partners. The Coalition increased its efforts by adopting more proactive strategies with the Malian government, including maintaining close contact with and targeting advocacy messages towards political authorities as well as technical staff at the Ministry of Health. This is evidence of the government's thought leadership in putting population health at the center of its priorities.

The Muso team has consistently undertaken advocacy efforts over time for the inclusion of CHWs as a part of national priorities.

At the beginning of the process, it was noted that key stakeholders, such as the Ministry of Finance and Economy, the Ministry of Public Service, the Ministry of Territorial Administration and Decentralization, the General Secretariat of the Government, and the Office of the Commissioner for Institutional Development had not been involved, which caused delays and even blockages in the evolution of the decree. To enable the various actors to be at the same level of information and to overcome this obstacle, the Ministry of Health, through the Decentralization Support Unit (Cellule d’Appui de la Déconcentration et la Décentralisation; CADD), took the initiative of involving these entities in the validation workshops of the draft decree and other key steps leading up to adoption. This allowed the different actors to have a common understanding of the issue and the payment modalities of CHWs. During this key stage of the process, Muso took a number of steps to support our government partners, such as providing funding for validation workshops and recruiting a consultant to elaborate a first draft of the decree that was submitted to the Ministry through the CADD.

What's Next ?

Community health is experiencing a significant advance [in Mali]. CHWs could soon be the first entry point to the health system for populations. If this process succeeds, the population will have greater access to health, which is a fundamental right recognized by Article 17 of the 1992 Malian Constitution.

By adopting this decree, the Malian government is demonstrating an important commitment, and has announced three ministerial/inter-ministerial decisions to ensure its effective application.

These decisions establish:

The drafting of these texts is currently underway and the Minister of Health has instructed due diligence to finalize them for adoption.

A Collective Agreement in this regard has also been revised by the National Federation of Community Health Associations (FENASCOM), providing details on the salary and profile of CHWs. The process of signing this document is also underway.

Through these various actions, Muso continues to support our government partners. Our team is involved in the process of developing the three ministerial/inter-ministerial decisions, the Collective Agreement for which we are also providing technical and financial support, and other texts related to this decree.

As we celebrate this victory and this major step toward recognizing the important work done by Community Health Workers, we believe advocacy efforts must continue to support our government partners to deliver on the promise of rapid, universal health care.