Bill & Melinda Gates Foundation

What if We Made Health Care Proactive?

December 12, 2013

When I moved to Mali six years ago, a neighbor asked me to visit her one-year-old grandson Ibrahim. By the time I arrived, Ibrahim was severely ill. He had a high fever and sweat soaked through his clothes. He was breathing rapidly and shallowly. We rushed him to the nearest health facility. We were too late. Mourning at Ibrahim’s funeral with his devastated parents and grandmother, we asked, “Why did this happen?”

Ibrahim was killed by a broken health system, a system that couldn’t reach him soon enough. As the global community seeks ways to improve child survival, our success could depend on how early we can reach the most vulnerable children. To achieve early access, we will need to redefine how health systems work.

 What if, instead of waiting for patients to overcome the many obstacles they face to come in for care, health systems were proactive, and went searching for patients door-to-door?
Last year, 6.6 million children around the world died before they could reach age five. Most of these children were killed by diseases we know how to prevent and cure: pneumonia, diarrheal disease, malaria, and neonatal illnesses. These are curable illnesses, but left untreated they can kill quickly. Hours and days matter.

Global leaders are now striving to reduce child deaths rates around the world. Through the fourth Millennium Development Goal (MDG4), global leaders committed to reduce child deaths by two-thirds by 2015. While progress has been made, only 13 of 61 countries with the highest under-five child mortality rates are on track to achieve MDG4.

In an effort to accelerate progress, global health institutions are investing billions of dollars in medicines and other commodities to treat and prevent the leading causes of child death. These investments could save the lives of millions of children. Or they could be wasted.

Commodities alone are not enough. The great challenge is delivery. These tools can only save lives if health systems rapidly get them to the children who need them most.

This is why reaching children faster is crucial. In the world’s poorest communities, many barriers can delay sick children from getting the care they need in time. Families living in poverty may have to travel long distances to see a health care provider and pay fees they cannot afford for a doctor’s consultation, diagnostic tests, or medicines. As a result, children living in poverty often get care too late, or not at all.

To fix this problem, we need to fundamentally redesign how health systems work.  Most health systems are reactive. Doctors, nurses, or health workers generally wait for patients to visit.

What if, instead of waiting for patients to overcome the many obstacles they face to come in for care, health systems were proactive, and went searching for patients door-to-door?

A new model for health care delivery has taken this approach in an area of Mali, which has one of the world’s highest rates of child mortality. The focus? Reaching patients early. A partnership between the Malian Ministry of Health and two NGOs, Muso and Tostan, the model builds demand for health services together with a route to ultra-rapid access.

To reach patients early, Community Health Workers go door to door for hours each day, proactively searching for patients. At the same time, community organizers mobilize social networks to bring patients in for care the first day they get sick. The system brings health care proactively into the home and removes fees that patients often cannot afford. To reach children even before they become ill, the model includes education, community organizing, and employment opportunities so that community members can overcome conditions of poverty that cause disease.

In a study published this week in the journal PLOS ONE, researchers at Harvard, the University of California San Francisco, and the Malian Ministry of Health tracked the rate of child mortality before and after the rollout of this health system in one area of Mali. At baseline, the rate of under-five child mortality in the area was 155/1000. Three years after the launch of the new health system, the rate of under-five mortality was 17/1000: a tenfold difference. The rate of early treatment for malaria—within 24 hours of a child’s first symptom—nearly doubled.

The study has important limitations. Without a control group, it is not possible to conclude whether these results were due to the intervention, demographic shifts, other unknown factors, or some combination of the above. 

In the coming year, the lives of millions of children will hang in the balance. Most of them could survive. We can achieve MDG4 and set our sights even more boldly—if we build the next generation of health systems to reach children like Ibrahim in time.

 
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