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Mali's university community health centres: A partnership between communities

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Professors and clinical supervisors are increasingly shifting from an "all-powerful" instructor role to a mentoring and facilitating role.

Project background

First-line services form the basis of Mali's healthcare system. To support the Ministry of Health and Public Hygiene's efforts to improve the offer of high-quality basic services to Malians, the Government of Canada invested in an innovative initiative: the implementation of university community health centres (Centres de Santé Communauté Universitaires [CSCom-U]) in Bamako and in four other regions.

As with other development initiatives, the implementation of CSCom-Us in Mali stemmed from a partnership between individuals that became a partnership between institutions and communities. CSCom-Us are the prime example of a project born from human experience; this initiative was designed and implemented thanks to individuals committed to a shared vision of human development.

Dr. François Couturier

In 1989, François Couturier was a medical student at the University of Sherbrooke in Canada. He was admitted into a non-residential internship at the community health centre in the Banconidistrict of Bamako, Mali. This Canadian student’s immersion in the Banconi CSCom-U and interactions with its director, Dr. Akory Ag Iknane, was a genuine revelation, one that would prove instrumental in forging a partnership between the Banconi CSCom-U and the University of Sherbrooke.

Seven years later, François Couturier became a professor of clinical teaching in the University of Sherbrooke's Department of Family Medicine. Around the same time, he met, through mutual friends, Dr. Albaka Ag Bazet, a Malian doctor who had recently moved to Montréal and who was a close relative of Dr. Akory. The connection was renewed. This chance meeting led to the first international health clinical internship for University of Sherbrooke family-medicine residents at the Banconi CSCom-U, an innovative partnership model between the community and the university health sector.

Since 1996, the links between the University of Sherbrooke and BanconiCSCom-U have remained solid. This collaboration gave rise to the idea of creating university-affiliated community health centres, a promising innovation associated with the healthcare professional training project (DÉCLIC), which currently involves five CSCom-Us in four regions of Mali.

Community health centres

Mali's health policy is built on a pyramid structure. The first level is the CSComs, the second is the reference health centres (Centre de Santé de Référence [CSRefs]) and the third and fourth levels are occupied by regional and national hospitals respectively. CSComs are managed by community health associations, in particular by each association’s management committee.

As healthcare institutions, CSComs draw on the commitment of the local population and are organized within a community health association. In accordance with the decree of June 28, 2005, setting out the conditions for their creation and basic operating principles, CSComs are tasked with providing public health services at the local level, responding effectively and efficiently to the local health issues and offering a minimum of services. More specifically, CSComs are tasked with:

In fulfilling their three-part mandate (curing, preventing and promoting), CSComs seek to promote community participation in managing and handling individual and community health issues.

First- and second-line care

First-line services are the local population's point-of-contact with the healthcare network. These routine services are based on basic infrastructure and may be dispensed in private clinics, health centres or at home. Second-line services are geared towards individuals who are no longer able to remain in their living environment and who must rely on adapted infrastructure and relatively sophisticated technology, such as that typically found in hospitals.

Interestingly, Banconi CSCom is a forerunner of the community health movement. Thanks to its partnership with Dr. Couturier and the University of Sherbrooke, it was initially an experiment for a new doctor training concept based on community-level experience. “We looked to the University of Sherbrooke for the methods for teaching first-line medicine did not exist in Mali,” notes Dr. Mahamane Maïga, a community medicine pioneer in Mali.

In rural areas, a CSCom plays an even more extensive role, given the challenge of access to healthcare. According to Dr. Maïga, community health is difficult because it is primarily geared towards the poor, yet healthcare is not free. It is also very difficult to entice doctors to rural areas because they are strongly attracted to public or private clinics in urban or university settings. However, the regions need doctors, particularly when it comes to improving maternal and infant health.

Having emerged as an urban phenomenon, the movement to create CSComs gradually spread to rural areas, thanks to an unprecedented flourishing of local initiatives. Mali's public health authorities went on to adopt the CSCom model as the cornerstone of the national health policy.

University community health centres (CSCom-Us)

Thanks to the Canada-Mali partnership, made operational via the DÉCLIC project, Malians now have access to university community health care centres. CSCom-Us are certified by the University of Bamako. This attestation is based on criteria, including being a strategic place of training and potentially a research facility for medical students. This model is innovative, as it facilitates the training of healthcare professionals in the community so they may go on to work in first-line care settings and meet local needs. The CSCom-U model draws on the belief that bringing interns into the community and training healthcare professionals from an interdisciplinary approach are key factors in improving primary healthcare services, particularly for women and children who are the CSComs' primary beneficiaries.

Making the transition from being a regular CSCom to a CSCom-U requires a long process of evaluation and analysis. The objective is to examine as systematically and objectively as possible the CSComs that have university potential. Each CSCom must demonstrate that it would be a rigorous and professional partner; university-level status can only be obtained once a CSCom has been certified by the University of Bamako’s Faculty of Medicine as being a strategic place of training and a potential research facility. CSComs must also meet the following criteria:

Partial view of the Konobougou CSCom-U (Ségou region) following its upgrade under the DÉCLIC project.

In Mali, it is thanks to CSCom-Us that the Faculty of Medicine and Dentistry and the national institute of health sciences training (Institut national de formation en sciences de la santé) have been able to carry out their social responsibility of training the professionals needed by Mali's healthcare system by partnering closely with primary healthcare facilities. This practical training model within CSCom-Us favours an alignment and better synergy between training, the services offered and the needs of local populations.

There are five CSCom-Us in Mali: Banconi (Bamako region), Ségué (Koulikoro region), Koniakari (Kayes region), Konobougou (Ségou region) and Sanoubogou (Sikasso region).

Canadian involvement

Creating the CSCom-U and training medical system stakeholders in Mali are the result of numerous contributions by Canadian institutional and government partners. From 1997 to 2000, the University of Sherbrooke's Faculty of Medicine and Health Sciences and the University of Bamako's Faculty of Medicine and Dentistry forged a partnership aimed at reinforcing the skills of Malian doctors working in first-line settings. Various clinical internships in international health were also organized.

Photo of the visit of Canada's Minister for International Cooperation and La Francophonie, Marie-Claude Bibeau, to the Banconi CSCom-U.

From 2001 to 2006, thanks to a one-time support by the Canadian embassy, both universities developed continuing education workshops focusing on malaria, sexually transmitted infections and obstetrics, thereby benefiting hundreds of participants (doctors, midwives and nurses).

From 2005 to 2010, the Centre de coopérationinternationaleen santé et développement (CCISD), a Canadian non-governmental organization, and the CEGEP in Saint-Jérôme (Quebec's equivalent of a post-secondary training institute) founded a consortium with a view to implementing a support project for paramedical training. The expected results for this five-year project include the creation of a national institute for health sciences training (the INFSS) and also paramedical training using a competency-based approach.

Beginning in 2007, the consortium expanded its scope to include the training and reinforcement of Malian medical personnel in the areas of community and family medicine. One related initiative was the creation of the CSCom-U.

One innovative and noteworthy aspect of the project approach is support for the creation of women-user committees. Their mission is to raise awareness and mobilize women and girls with a view to achieving widespread use of CSComs. Women-user committees also play an interface role between local populations and the CSComs, which are then regularly given feedback on service quality.In addition to the partnership between the University of Sherbrooke and the Banconi CSCom, two medical communities, one in Mali and the other in Canada, are now joining forces in reciprocal sharing to improve their knowledge of family, community and international health.

Funded by Canada, the total budget for the healthcare professional training project DÉCLIC is Can$19.1 million (over 8 billion CFA francs). The consortium made up of the CCISD, the CEGEP in St-Jérôme, Quebec and the University of Sherbrooke contributed over Can$465,000 (approximately 200 million CFA francs). Nearly 20% of that amount was specifically earmarked for the creation of the CSCom-Us. The paramedical training support project, benefiting the INFSS from 2005 to 2010, is valued at Can$7.75 million

Involvement of other partners

Photo of a few CSCom-U student interns

The creation of the CSCom-Us and, in broader terms, the training programs for Mali's medical and paramedical personnel stem from solid partnerships involving the government, institutions and civil society. The Government of Mali, via its Ministry of Health and Public Hygiene, has facilitated the proper functioning of CSCom-U activities. Affiliated with the Ministry, the National Health Directorate has fostered and reinvigorated collaboration between decentralized health structures, healthcare training schools and CSCom-Us. In addition, the Ministry of Higher Education and Scientific Research oversees two public training schools for doctors and paramedical personnel involved in CSCom-U monitoring. The INFSS is a signatory to the agreement with CSCom-Us admitting the INFSS's students for internships, while the Faculty of Medicine and Dentistry oversees students enrolled in the specialized studies diploma in community health.

In charge of managing and running CSCom-Us, the community health associations are tasked with pursuing the expected results, with the support of the Faculty of Medicine and Dentistry and the INFSS. As a representative of all the CSCom-Us, Mali's national federation of community health associations fulfills this promotion with its members. The creation of the women-user committees has made it possible to innovate and tailor healthcare to women's and girls' specific needs.

Results obtained

Reinforcing the healthcare offer hinges on improving the clinical environment, as well as strengthening participants' capacities and supervisory activities that contribute to consolidating and improving healthcare professionals' practice. The five existing CSCom-Us have been given the resources to function properly in an environment that is conducive to healthcare interns' learning and medical research, and to offer comprehensive high-quality services to local populations. Currently, 11 doctors and 59 paramedics work at the CSCom-Us, with 26 residents (5 women and 21 men) enrolled in the specialized studies diploma program in family and community medicine. Since 2012, a total of 1,354 National Institute of Health Sciences Training interns (51% women and 49% men) have completed their internships in CSCom-Us.

One of the most noteworthy benefits of this initiative has been to specifically reinforce the recruitment and retention of skilled human resources at the regional level. A number of measures have been taken to encourage training in rural areas in appropriate and safe conditions and environments. These include gender-specific housing, remote living allowances and improved IT and communications aimed at reducing the isolation of certain CSCom-Us and connecting them to network research and teaching activities.

It was important to create regional conditions similar to those found in the urban areas that usually partner with universities in training doctors and healthcare professionals. Thanks to this newfound proximity, medical teaching is better able to accommodate health realities specific to rural areas.

In addition to creating a cutting-edge precedent, this initiative has advanced a major reform in the area of healthcare teaching in Mali. The project's impact has even been felt in the pre-doctoral medical training program.

Another major change has been the introduction of mental health training for general practitioners, a speciality that was up until then absent from medical training programs and thus from the healthcare system.

This measure received positive feedback and certain residents enrolled in the specialized studies diploma in family and community medicine have carried out research projects in the area of mental health. This demonstrates a familiarization with mental health, and thus a greater likelihood that future first-line doctors will consider these issues in their professional practice.

The long-term viability of any development project, regardless of sector, largely depends on its ability to get local people to adopt and operationalize the changes needed to ensure the sustainability of the gains. In this regard, the strength of the Canada-Mali partnership for training healthcare professionals lies first and foremost in how the Malians themselves have taken charge of improving the teaching programs. The professors and clinical supervisors involved in the specialized studies diploma have all received 100 hours of teacher training. A core group regularly organizes educational and clinical development workshops for all CSCom-U staff on the peer supervision of clinical interns. This hands-on philosophy extends to the Faculty of Medicine and Dentistry, and through the CSCom-U, indicating that the community health associations are fully playing their role of supporting the CSCom-U’s teaching vocation.

Ensuring long-term benefits also hinges on accepting change, adopting new attitudes and modifying professional practices. In this regard, an initial major shift in attitude is the active involvement of women at all levels of the decision-making process.

This initiative has indeed strengthened the individual skills of female healthcare staff members, as well as the organizational capacity of teaching institutions and CSCom-Us to take women's and girls' specific needs into account.

Another major change in behaviour has occurred in the relationships between instructors (professors and clinical supervisors) and students. Professors and clinical supervisors are increasingly shifting from an "all-powerful" instructor role to a mentoring and facilitating role. These major changes and the quality of training have boosted CSCom-Us' attractiveness.

This project has also led to greater recognition among healthcare actors of the importance of family and community medicine, and to a different attitude in medicine that encourages professionals to reach out to local populations to better understand their challenges and needs, and therefore to better serve them in partnership with other organizations and local communities.

At Mali's Ministry of Health and Public Hygiene and Ministry of Higher Education and Scientific Research, managers increasingly recognize that CSCom-Us are first-line academic training facilities.

This project has also had a major impact in communities. Via the CSComs, healthcare workers are providing care with adequate conditions for hygiene and cleanliness and tailored to women's and children's specific needs. Staff members have also been made aware of the importance of admitting patients, particularly female users, with hospitality and dignity.

Women's involvement, via micro-projects funded in connection with CSComs, has had a positive impact on disseminating messages about the importance for women’s and infants’ health of prenatal check-ups, assisted childbirth and post-natal follow-ups. This initiative has also increased learning about the harmful consequences of female genital mutilation and early marriage on women's and girls' health and the importance of preventive healthcare.

Challenges

The breakdown in Mali’s socio-political conditions and the deterioration of safety since the 2012 crisis were the main difficulties the project faced. In particular, unsafe conditions made it difficult to hold meetings outside of Bamako and to organize the Canadian missions. All the residents from the family and community medicine program and CSCom-U clinical supervisors were slated to be introduced to Canadian family medicine, thanks to the participation of Canadian interns supervised by professors in the University of Sherbrooke's microprogram in international health.

Rich in discussion and sharing, these internships were held in the CSCom-Us five months of the year starting in 1997. Unfortunately, since 2012, the University of Sherbrooke has been forced to suspend them in Mali, thus depriving the clinical supervisors of important additional support.

Training was supposed to be offered in Mali in November 2015, but was cancelled in the aftermath of a deadly attack. The training of Quebec students in Mali was also suspended due to instability following the coup d'état. “The program continued, however, because we had deep roots in Mali. The team is very strong, very solid,” notes Dr. Couturier, who does not think that withdrawing from Mali would be a good idea, particularly since the main objective was not training students from Sherbrooke. “We've learned a lot. There's a kind of shared humanity as well, that is very important.”

As a replacement measure, the project’s managers have had to rely on communication technologies to hold virtual meetings, as well as on relocating certain activities to Bamako or even outside Mali. Despite certain gaps in the quality of access to communication services, the implementation of the CSCom-Us' communication and information network provides an opportunity to share information, foster discussion and receive support virtually, especially for the four CSCom-Us outside Bamako.

However, Mali's medical community now faces the greatest challenge of all: ensuring the knowledge acquired is not lost. CSCom-Us are no exception, particularly as regards communications between the initiative's various stakeholders, not to mention the administrative burden associated with adopting plans and reports, the unstable political climate and high staff turnover.

Gender equality

Gender equality lies at the heart of the entire initiative, not only because it fosters healthcare improvements, particularly among women and girls, but also because it includes women at every stage of the decision-making process, from project management to actual use.

The development of specific equality initiatives enabled community health associations, women-user committees and other women's groups to raise awareness among local populations. Strategies were tailored to community realities or chosen themes (meetings in community settings, sketches, theme-based activities or broadcasts on local radio stations, etc.). The project supported the CSCom-Us’ community health associations in carrying out various equality-building initiatives and activities on themes as varied as women's and children's health, the importance of perinatal care, family planning, reproductive health, early marriages, female genital mutilation, etc. Thanks to equality-building micro-projects, 52 individuals from the CSCom-Us (32 women and 20 men) are now better equipped to discuss sexual health and reproduction.

“Before the micro-project, very few women were aware of their rights, particularly health-related rights. Today, they can discuss the consequences of early marriage and early pregnancy, clandestine abortions, genital mutilation and the other forms of violence to which women and girls fall victim. Benefiting from the knowledge acquired at the awareness-raising sessions, a number of women are now hosting informal discussion sessions exploring these issues.” – Managers at BanconiCSCom-U.

It has also been noted that the female trainers are significantly more confident in their ability to carry out educational activities and that female users increasingly solicit maternal and child healthcare. “In Kaworibougou, a 54-year-old woman told us that she had never experienced sexual pleasure and that she now understood the cause of her problem. In Kouroune, the president of the women's association said that she felt guilty over her granddaughter’s death, which occurred by hemorrhage several hours after genital mutilation. In Sirado, two women reported their daughters and granddaughters had died for the same reason.” In the past, women were sometimes stigmatized for discussing “taboo” issues, but these have been partly overcome thanks to the awareness-raising activities.

Since 80% of CSCom users are women, girls and children, it is important CSCom professionals fully take sexual and reproductive health issues into account and acquire the necessary skills to meet these needs, in respect for women's rights. In the beginning, men's lack of involvement was noted so strategies were developed to enrol religious and traditional leaders by informing them and raising their awareness of these issues and the potential benefits for their communities. Getting men participating and adopting a concept of equal gender rights is an important, although relative, marker of the DÉCLIC project’s success.

Lessons learned

An innovation-based initiative often brings many lessons; this initiative was no exception. The main lesson was for the need for a strong partnership between teaching institutions, healthcare sector stakeholders and communities.

The project resultedin removing hierarchical barriers between professors and students, getting involved in rural areas,ensuring community-wide commitment to implement CSComs and promoting healthcare that all point to the need for smooth communication and concerted effort between partners.

The project also showed that women's active involvement in decision-making, particularly at the management level, makes it possible to really include women's and girls' realities and concerns in the delivery of healthcare to local populations. Women's participation is convincing proof of their ability to play a constructive role in implementing strategies, thereby valuing and validating them as fully-fledged stakeholders in the management of community affairs.

Thanks to Dr. Couturier's initial impetus, the long history of Canada and Mali's sustainable partnership is eloquent proof of the important role that civil society can and must play in international aid. Governments are involved, to be sure, but so too are community members, each of whom can contribute to enhancing human dignity.

Sources

We would like to sincerely thank the following for their assistance in creating this impact story.

The Impact Stories series of Canadian aid in Mali was produced by the Field Support Services Project (FSSP) and in collaborationwith the above-mentioned stakeholders.

Rue Sotuba/ACI, rond-point de l’ancienne chaussée
Bamako, Mali
Tel.: +223 44 90 44 45
Email: info@psat-mali.org
Note: The FSSP received funding from the Government of Canada.

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