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Designed to Arrive Early: How We Can Save the Lives of Millions of Children

   /   Dec 25th, 2013Health, Opinion


Today, thousands of doctors – including me – will go to work. And wait. This is how most health systems function: providers wait for patients to come into clinics or emergency departments seeking our care.

But to solve the global child mortality crisis, we need to stop waiting. To save children’s lives in the world’s poorest communities, we need to break free from this reactive model for healthcare delivery and turn this mode of operation on its head. We need to reach our patients earlier.

The leading killers of children globally may seem like easy targets. Pneumonia, diarrheal disease, malaria, and neonatal illness all have well-proven tools for both prevention and cure. And yet, 6.6 million children died before the age of five across the world in 2012.

The challenge is in delivery of these known methods for prevention and treatment. The leading causes of child mortality are diseases that progress and kill rapidly. Hours and days matter. A model in which doctors sit in hospitals and wait for patients to come to them – even if these hospitals possess the necessary commodities and treatments – will fail the most vulnerable patients.

The concept is simple: reach children earlier. However, this simple idea requires a fundamental redesign of healthcare delivery. The innovations we need to solve the child mortality crisis, even more than new vaccines or new drugs, are innovations in health systems design. We must redesign health systems to reach children within the first 48 hours of the moment they say, “Mommy, I’m sick.” And even better, to reach patients before illness even arises.

For the past eight years in Mali, I have worked with the teams of two NGOs, Muso and Tostan, and the Malian Ministry of Health to do exactly that. Our model reaches patients before it’s too late through:

Active Case Finding: Community Health Workers proactively search for patients through door-to-door home visits. Through these visits, they find and connect pregnant women with prenatal care early in their pregnancy, and find and treat sick children within the first days of their illness. When they visit a home where no one is sick, they provide counseling on prevention.

Community Organizing for Rapid Referral:  We don’t typically think of community organizers as core to healthcare. But they could play a powerful role in connecting patients with care. We trained a network of community organizers that mobilized families to bring children to their community health workers early for prevention and care services.

Removing User Fees: Out of pocket fees for doctor’s consultations, diagnostic tests, or medicines have been shown to delay and prevent poor patients from accessing care. We redesigned the health system to remove point-of-care fees, to increase early access to care, particularly for the poorest patients.

Solving the Upstream Cause: Improved access to education, community organizing, and employment opportunities help overcome conditions of poverty that cause disease. For example, community organizers in the area of our intervention in Mali successfully lobbied local government officials to improve access to clean water in their communities, and the government responded by installing more than thirty new public clean water taps.

Last week, a group of researchers from Harvard and the University of California San Francisco published a study tracking rates of child mortality before and after the roll-out of this new model for healthcare delivery. What they found was surprising: in an area of 56,000 people in Mali, three years after the roll-out of this new model, the number of patient visits increased tenfold, early access to antimalarial treatment nearly doubled, and there was a tenfold decrease in child mortality rate.

The study had no control group and therefore cannot make causal conclusions about the results, which could have been due to the intervention, demographic shifts, or other factors. It is worth noting, however, that there were no other known interventions in this area during the time period of the study, and that the demographic characteristics of participants that were measured were similar from year to year.

An increasing number of global health institutions—including the Global Fund, the World Bank, and the US Global Health Initiative—have identified health system strengthening as a key priority. As we assess the strength of health systems, we will need to work on redesigning them to reach children earlier. We should measure the success of our health systems by how early we reach the most vulnerable child.

Ari Johnson MD is co-founder of Muso, a co-author of the child mortality study on this model in the most recent issue of PLOS ONE, and a physician at the University of California San Francisco.

Photo courtesy of OpenSourceWay (Creative Commons, Flickr)

2 Responses

  1. Luc Lapointe says:

    Dr Ari Johnson,

    I have read with great interest this article for many reasons. One of them is my work with the Health Care (ill-care) system in Canada and the second is my working experience in Mali and currently Cali Colombia.

    We are currently working on a few interesting projects that have the same objectives as the work you are currently doing. I would be interested to speak to you as we are putting these pieces together.

    I look forward to hear and congratulation for the proactive work that you are currently doing!

    Saludos cordiales….from Cali Colombia!