Combine local resources and mobile technologies to increase child & mother resort to care in Mali.

Combine local resources and mobile technologies to increase child & mother resort to care in Mali.

Mali
Année de fondation:
2007
Type d'organisation: 
le secteur de la société civile
Phase du projet:
Croissance
Budget: 
$50,000 - $100,000
Sommaire du Projet
Lancement Important

Bref récapitulatif : Aidez-nous à présenter cette solution ! Fournissez une explication en seulement 3 ou 4 phrases.

Mali faces dreadful levels of child & maternal mortality, mostly due to benign pathologies that could however easily be cured locally. Due to cultural, financial and geographical reasons, people resort rarely - and too late - to healthcare. As a result, untreated diseases get complicated and become lethal, while under-used health structures encounter economic difficulties.
Pesinet deploys an innovative home-based monitoring health service, using technologies, that promotes prevention & facilitates early access to basic medical care. Its objectives are to accelerate resort to care and avoid complications of diseases; to improve sensitization to essential health & hygiene practices; and to help primary health centres reconnect with populations and increase their level of frequentation.

Qu'adviendrait-il si... - inspiration : Écrivez une phrase qui décrit la façon dont votre projet ose demander, "Qu'adviendrait-il si...?"

What if all families in Bamako sought medical care for their children starting with the first sign of illness and children no longer died of cur
About Project

Problème : Quel problème ce projet essaie-t-il d'adresser ?

1 out of 5 children in Mali dies before reaching the age of five. 2/3 of these deaths are caused by complications resulting from easily treatable illnesses such as malaria, diarrhea, and respiratory illnesses. Moreover, the local healthcare centers in urban areas dispose of all the necessary means to treat these illnesses if only they are detected in time, yet families often wait too long to access care at these centers.

Solution: Quelle est la solution proposée? S.v.p soyez précis!

Our approach is innovative because: 1.We have a demand-driven approach to improving health services. In the last decades, most health development projects have aimed at bringing additional medical resources. We reckon this is inefficient if those resources are not used by the population. Increasing resort to care is the key to generate a systemic and lasting change. 2.With one simple solution, we address the financial, geographical and cultural barriers altogether. Mutual insurance systems encounter difficulties to develop as they fail to raise awareness on the value of prevention. Through our network of health agents, we reach populations and introduce health directly into the households. 3.Anchored in the local Malian ecosystem, our service strengthens the public healthcare system instead of replacing it. We reinforce the role of community health structures as the key lever for primary health. 4.We use simple technologies to increase medical radius, accelerate detection and families’ warning, and support management of activities. The IT system we have developed enables remote follow-up of children, keeping of medical records, and production of reports and health statistics. 5.We adopt a paying approach, in order 1) to build a sustainable financial model, 2) to be aligned with the Malian health financing policy based on the principle of cost recovery, and 3) to give families a sense of responsibility through a voluntary decision to enroll their children.
Impact: How does it Work

Exemple : Faites nous découvrir comment cette solution fait la différence en utilisant un ou plusieurs exemples concrets ; en incluant aussi ses activités principales.

In partnership with local primary health structures (CSComs), Pesinet implements a service for children under 5 that combines health follow-up, insurance cover & education to prevention and good health practices. It is based on the work of agents in the communities and on technologies. Through frequent monitoring of simple indicators, it enables early-detection and treatment of benign pathologies. It works as follows: •Every week, Pesinet’s agents visit the children at home and collect simple health data (weight, fever, stools…). They also provide nutrition and prevention advice. •Data is transferred to the doctor of the partnering CSCom via mobile and internet technologies. He reviews the data and identifies children at risk. •When children are called in by the doctor, Pesinet covers medical costs (100% examination + 50% medication). •Families subscribe voluntarily. The monthly price for the whole package is 500 FCFA (€0,75) per child. We plan to develop a similar service for pregnant women. Activities are organized in small operational units. In each district, Pesinet works with the referring CSCom, in line with the Malian administrative health zoning. Pesinet’s goal is to generate a cultural change in the health behaviors of populations, and trigger a virtuous cycle for the whole healthcare system of Mali. By detecting diseases and prompting people to treat them early in CSComs, we enable that they remain benign, and that the different levels of health structures are used appropriately. Our service is currently deployed on 1 site in Bamako, in the area of Bamako Coura.

Impact : Quel est l'impact actuel de ce travail ? Décrivez aussi l'impact désiré dans le futur.

A 2011 independent impact assessment of Djantoli’s pilot site showed: - Subscribers seek medical care twice as often as non-subscribing children in case of illness. - The rate of disease detection following a summons by the partnering doctor via the Djantoli system is 93%. - 70% of medications prescribed are purchased at the partnering health center, thus increasing its revenue. - 96% of families are satisfied with the service and 97% deem it “very affordable.” In the last year, Djantoli has extended its service Ouagadougou, Burkina Faso. In the next three years, we plan to: - Have significantly reinforced the capacities of all of our partnering health centers in Bamako and Ouagadougou (10 partners across all sites by December 2015). - Maintain the high rate of recourse to care among a larger pool of beneficiaries (5000 children by December 2015).
Viabilité

Plan de viabilité financière : Quel est le plan de cette solution qui permet un financement durable à cette initiative ?

Djantoli generates enough revenue from the monthly contribution paid by subscribing families to finance a small % of operating costs – a % we are working to increase via a cross-subsidization strategy and strategic partnerships. The remaining operational and structural costs are financed by philanthropy. We have strong relationships with foundations that support us with in-kind donations (baby scales, phones, phone credit) and monetary gifts.

Marché : Qui d'autre adresse les problèmes mentionnés ici ? Comment ce projet diffère-t-il de ces approches ?

- Djantoli makes use of existing medical resources instead of bringing in new ones, which is more efficient and sustainable. - Djantoli addresses multiple barriers to care with one simple solution – barriers that are addressed individually by health cooperatives, or other mobile health services. - Djantoli’s paying approach helps the service to be financially sustainable, in line with the Malian health financing policy of cost recovery, and ensures that families value the service. - The use of simple technologies increases reach and accelerates detection.
Equipe

Histoire de votre fondation

Anne designed the Djantoli service while still holding down a full time job in France. She would often stay late after hours in the office to work on the model. One such night, Anne struck up a conversation with the cleaner, a Malian, whose cousin happened to run a healthcare center in Bamako. The cleaner convinced Anne to meet and talk with her cousin, who was passing through Paris. They met for coffee at Gare du Nord. The cousin thought Anne’s project was perfect for integration into the existing primary healthcare system in Mali. Suddenly Anne realized the full potential of the Djantoli project. By working with the local health centers, she could reach a huge number of children with a simple, life-saving service.
A propos de vous
Organisation:
Association Pesinet
A propos de vous
Prénom

Anne

Nom

Roos-Weil

Twitter
A propos de votre organisation
Nom

Association Pesinet

Téléphone

+336650967512/+33668061775

Adresse

6 avenue des Pavillons, 92270 BOIS COLOMBES

Pays

France

Pays dans lesquels ce projet crée un impact social

Mali, CD

Depuis combien de temps votre organisation opère-t-elle ?

1‐5 années

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Innovation
A quel étape votre projet en est-il ?

En place depuis 1 à 5 ans

Comment décririez-vous la population auprès de laquelle vous travaillez ? Parlez-nous, par exemple, de la situation économique, des structures politiques, des normes et des valeurs, de l'évolution démographique, de l'histoire ou des précédentes expériences d'engagement communautaire.

We currently work with Malian families living in urban areas. Our service is targeting low income populations, mostly living from the informal economy, which constitute the great majority of people in Mali.

Families are large in size: polygamy is frequent and there is no family planning (women have 7 children on average, with pregnancies close together).

Resort to care is weak and populations distrust conventional medicine. They tend to favor family advice, self-medication or traditional medicine. Popular beliefs are strongly anchored and, as the level of education is low (70% of mothers have either no education or just an elementary one), families often do not recognize the symptoms & diseases, or choose inadequate treatments.

In urban setting, the father is responsible for providing food and money to the family, while the mother takes care of the children. As a consequence, mothers are generally the ones to decide to enroll their child into the Pesinet program and then convince their husband to pay for it. The father has limited information about his child health because he is away during the day. The population we target has very little understanding of the benefits of prevention.

To reach this population, we favor working with national staff members. The network of agents that we hire in partnership with the healthcare centers are from the district covered. They are trusted and well-known women in the community. This allows them to work closely with mothers and children, convince them of the added-value of prevention and create a reassuring climate for families.

Racontez l'histoire du fondateur et ce qui l'a inspiré à démarrer ce projet

Pesinet was founded by Pierre Carpentier, Antoine de Clerck and Anne Roos-Weil in 2007. The NGO is currently managed by Anne Roos-Weil.

The history of Pesinet dates back to the early 2000s. The founding concept - detecting simple children diseases through tracking of their weight - was initially developed by a French philanthropic venture capital firm, Afrique Initiatives. A pilot experiment was launched in Senegal, which had to stop by lack of a sustainable economic model.

In 2006, Antoine de Clerck and Pierre Carpentier, former members of Afrique Initiatives project team, enrolled the idea into an academic program held by top French business school ESSEC and engineering school Ecole Centrale. A team of students worked 6 months on a business plan and designed the service as it is now, including use of technologies, self-sustaining economic model, health insurance model. The team was led by ESSEC student Anne Roos-Weil.

Already graduate in Political Sciences, Anne was passionate about development issues. Coming from a family of doctors, she was particularly interested in public health. At the end of the 6 months, Pierre, Anne and Antoine decided to launch a pilot experimentation in Mali, and founded the NGO.

In 2009, after obtaining a grant from the social incubator Antropia, Anne decided to engage full-time in the project and give it the means to reach its full potential. She has been CEO of Pesinet since then. In 2010, the quality of her approach was further acknowledged, as she became Ashoka Fellow. She is currently based in Mali.

Impact social
Décrivez les résultats positifs obtenus par votre projet ainsi que la façon dont ils sont mesurés.

The project is showing very encouraging results.

An impact assessment study was carried out from September 2010 to July 2011 under the supervision of an independent expert, in order to validate the sanitary and socio-economic impacts of our service.

First results demonstrate the positive impact of Pesinet for families and for healthcare structures:

– High level of satisfaction for the service: 94% of global satisfaction rate among subscribing families
– Affordability for low-income populations: 97 % of families deem the service « very affordable », even though 90% have unstable revenues
– Efficient detection system: 93 % of consultations post–summoning have confirmed that the child is sick
– Increase in resort to healthcare: 1 out of 4 subscribing children are seen at least once a month by the doctor (when the average Malian resorts to health facilities only 0,41 times a year)
– Increase in health centre activity: 37% of new consultations of children from the program area can be attributed to Pesinet ; 70% of medication prescribed to Pesinet subscribers is bought directly at the pharmacy of the health center

Though it is too early to provide reliable health statistics at this point, there have been 2 deaths on the 1000 children followed-up by Pesinet, for a national child mortality rate of 191‰.

The first evaluation has demonstrated the effectiveness of the program in improving use of primary healthcare facilities. It is now necessary to provide evidence that this effectively reduces the risk of complication and the need for costly emergency treatments (see Sustainability).

Combien de personnes ont été touchées par votre projet ?

Entre 1 001 et 10 000

Combien de personnes pourraient être touchées par votre projet au cours des trois prochaines années ?

1,001-10,000

Les projets gagnants possèdent un programme solide indiquant leurs prévisions de croissance. Identifiez l’objectif à atteindre au bout de six mois pour accroître vos résultats.

We plan to have 1120 children enrolled in Pesinet, in our 3 operational sites in the Commune 3 of Bamako (Bamako Coura, Dravela and Ouolofobougou).

Tâche 1

Finalize negotiations on operational launch schedule with the Community Health Centers of Dravela and Ouolofobougou.

Tâche 2

Get equipment and install it in the partnering centers (computers, mobile phones, baby-scales, height gauges), hire and train staff (agents and personnel of the healthcare center).

Tâche 3

Promote the service among the populations and enroll children through active communication and social mobilization campaigns.

Identifiez l’objectif à atteindre au bout de 12 mois.

We plan to follow 1440 children in Bamako Coura, Dravela and Ouolofobougou, as well as 330 women in our pregnancy care pilot site.

Tâche 1

Design sanitary, operational and economic features of the pregnancy care service (selection of relevant health indicators, periodicity of visits, price of service).

Tâche 2

Negotiate partnership conditions with potential partners (Community Health Centre of Banconi and partner NGO - the pilot will be launched in partnership with an international NGO).

Tâche 3

Actively promote the service on the new site and pursue communication efforts in the three sites of Commune 3.

Quelle va être l'évolution de votre projet lors des trois prochaines années ?

3 main projects are planned:
-Extension in Bamako: On top of our Bamako Coura site, we plan to open 2 new sites in adjacent areas, Dravela and Ouolofobougou in fall 2011. We have finalized negotiations with the CSComs and are preparing the launch.
-Development of a pregnancy care service: We will first experiment it alone, before combining it with the children service. A pilot is planned for mid-2012 in the area of Banconi (Bamako.
-Test in rural zone: this is key for large scale extension –73% of people live in rural areas– and will require refining of the service to adapt to rural constraints. We plan to launch a pilot in fall 2012, children and pregnancy care combined.
Once the pregnancy care service & the rural processes are ready, we will be able to develop at a large scale.

Viabilité
Quels sont les obstacles qui pourraient entraver la réussite de votre projet et comment comptez-vous les surmonter ?

Relationships with CSComs: We are dependent on the will of CSComs to implement the Pesinet service and work with us. This might be challenging has those structures are run by community-based committees elected for 3 years. Newly elected committees can have a limited understanding of the benefits of Pesinet. To overcome this challenge, we work with the National Federation of Community Health Associations to facilitate buy-in and sustainability of the service in the affiliated Health Centers.

Quality of health services in the CSComs: The quality of Pesinet service is dependent on the quality of health supplied by the partnering CSCom. In many, service quality is poor, notably when it comes to welcoming patients, as staff is under-paid and not properly trained. We expect to help Centres improve their revenues and thus their performance in the long run. In the meantime, we complement our demand-driven approach by reinforcing CSCom capacity through training. We also consider partnerships with organizations focused on reinforcing healthcare supply capacities, so as to multiply the impact on both the demand and the supply side.

Economic model: Our first aim was to achieve 100% local operational self-financing, i.e fees paid by families covering the running costs of the service. Experience shows that, at current price and current level of service, we are able to achieve 50%, while the other 50% are covered by external sources (for the moment, funds raised by the NGO). We have yet to find a sustainable economic model. Several potential solutions are under study (see below).

Quels sont vos différents partenariats ?

Pesinet develops its projects through a double partnership with the Malian health authorities:

o Strategic partnership with the Ministry of Health. The objective of the partnership is to ensure that the Pesinet project contributes to the country’s health policies & strategy. And the Ministry commits to support the large scale development of PESINET’s activities in Mali and to contribute to the evaluation of the project.
o Operational partnerships with the Community Health Centres (CSComs). The perimeter of these partnerships is the area covered by the center. Both parties agree on their respective roles, responsibilities and obligations in the implementation and day-to-day operation of the service. We have an agreement with the Centre of Bamako Coura, and are finalizing agreements with the CSComs of Dravela & Ouolofobougou.

We also have partnerships with several companies and private foundations that bring us financial, material or skills support, on a one-shot or recurrent basis.

Expliquez vos choix.

Families & friends: Pesinet is still a young project, where the personal implication of the members and of their entourage is very important. Our families and friends bring their affection and their financial support as many of them make donations to the NGO. Many also put their skills to good use and easily volunteer to help us.

Individuals: Our approach is acknowledged and supported by several experts in the field of health and/or development. They enrich the project with their knowledge and advice. Some have joined our board of directors or our advising board.

Companies & corporate foundations: So far, most of our funds have come from companies or corporate foundations. This has enabled to preserve the flexibility we needed as a young and small NGO at the stage of experimentation. As we grow, we will start diversifying our financial sources, notably towards national and international public institutions.

NGOs: More and more NGOs are hearing from us and showing their interest for what we do. Several have contacted us, expressed their enthusiasm for the project, suggested common projects or even required our assistance or expertise. For instance, Action Against Hunger in Mali has recently asked for our technical assistance for a nutrition project in which they plan on using technology for health data reporting.

Government: As explained above, the Malian Ministry of Health supports our actions.

Comment pensez-vous pouvoir consolider votre projet au cours des trois prochaines années ?

• Further strengthen relationships with Malian public health authorities: We have associated the Ministry of Health and the FENASCOM (National Federation of Community Health Centers) to the negotiations for the first extension, so as to validate a standard partnership agreement that will facilitate further replication. As a result, we have just signed a partnership agreement with the FENASCOM to cooperate on the development and roll-out of the Pesinet service in Mali.

• Validate a viable economic model: Our aim is to validate a sustainable economic model, based on self-financing maximization complemented by sustainable external sources. Favored ideas currently under study are cross-subsidization, contribution from public national or local authorities, and partnerships with mutual and insurance companies.

• Evaluation: We need to conduct a more thorough evaluation so as to measure impacts on: 1. the reduction in emergency health treatments and the associated savings for private and public organizations involved in healthcare, 2. epidemiological impacts, to demonstrate the effectiveness of the approach in the long run. To do so, Pesinet is looking for financial and technical partners to undergo a 3-year monitoring of the use of healthcare structures and the health spending of two cohorts of people (subscribers and non-subscribers) in order to monetize the benefits of the Pesinet service as well as to define relevant indicators to appreciate the level of gravity in the health status of people resorting to health facilities.

Enjeux
Quels problèmes liés à la santé et au bien-être votre projet tente-t-il de résoudre ?
Veuillez sélectionner trois réponses par ordre d'importance (notées de 1 à 3 par ordre de pertinence).

PRIMAIRE

Changement du comportement sanitaire

SECONDAIRE

Manque d'assurance / d'options de financement des soins de santé

TERTIAIRE

Accès limité aux outils ou aux ressources préventives

Veuillez décrire la façon dont votre projet s'attaque spécifiquement aux problèmes cités ci-dessus.

- Pesinet combines a system of early-detection and families’ warning with ongoing sensitization to prevention in order to generate a cultural change in the health behaviors of populations.

- In Mali healthcare is not free: populations have to pay for medical examination and medication. A social protection scheme is currently being developed, and will concern the highest and lowest layers of the social pyramid only. 80% remain uncovered. Our insurance cover scheme makes primary care affordable.

- CSComs lack resources to develop preventative services on top of curative services. Within the centres, we implement a service that enables them to reach populations and foster a culture of prevention and early resort to care, through a network of agents and through sensitization events.

De quelle façon faites-vous croître l'impact de votre organisation ou de votre projet ?
Veuillez sélectionner trois moyens potentiels par ordre d'importance (notés de 1 à 3 par ordre de pertinence).

PRIMAIRE

Renforcement de l'impact existant grâce à la mise en place de services complémentaires

SECONDAIRE

TERTIAIRE

Influence sur d'autres organisations et institutions grâce à la diffusion de meilleures pratiques

Veuillez indiquer les activités actuellement en place ou devant être mises en place dans un futur proche pour stimuler votre croissance.

In the very short term, we will focus on improving the self-financing rate by exploring opportunities to develop a service targeting a wealthier segment and that could generate enough revenues to subsidize our core service, which we want to maintain as affordable as possible. We will carry out in the fall 2011 a thorough market study to design and price this “premium” package and assess its market potential.

At the same time, we will work on expanding the number of beneficiaries in the two new units in Bamako. Promotional activities are planned in the short term to develop adoption of the Pesinet service within the target areas, through local town criers, local radio, and traditional communicators. The objective is to cover 40% of under 5 children of the district in 18 months.

Êtes-vous en collaboration avec : (plusieurs réponses possibles)

Organisme gouvernemental , une entreprise à but lucratif.

Si oui, dans quelle mesure ces partenariats ont-ils contribué à la réussite de votre projet ?

Our partnership with the Malian Ministry of Health provides support for development of activities, and ensures that we are in line with the country’s health strategy.

Our partnerships with companies have given us the funds, equipment and sometimes competences necessary to develop and implement our activities.

We do not have a dedicated partnership with a university, though we have relationships with several academics. Our evaluation has been supervised by Marie-Pierre Gagnon, professor at Laval University in Canada and expert in evaluation of e-health projects. We also work with Phd students from the INSERM Research Institute in France and the London School of Hygiene and Tropical diseases.

Commentaires

Portrait de jerome colombe

Vous indiquez que vous recrutez des agents, des femmes essentiellement, localement. Comment faites-vous pour les convaincre de devenir agent Pesinet et comment les formez vous ? Merci

Assocation Pesinet has just changed it's name to Djantoli, which means "to watch over" in Bambara, the local language in Mali where we work!

Portrait de Anne Roos-Weil

Bonjour Jérome,

Merci pour ton commentaire. En fait, le taux de chômage étant très élevé au Mali, en particulier chez les jeunes et les femmes, il est souvent assez facile de trouver des candidates. Par ailleurs, nous n’avons pas de pré-réquis en matière d’éducation, si ce n’est un niveau minimum d’alphabétisation. Pour ces femmes, avoir un travail fixe et formel (déclaré) avec un aspect de valorisation sociale fort est assez privilégié, donc les candidates ne manquent pas.

La manière dont nous menons les recrutements est la suivante : nous demandons aux associations de gestion des centres de santé partenaire de nous proposer des candidates parmi leurs personnel bénévole, et nous sélectionnons les profils les plus à même de remplir le rôle d’agent de suivi Pesinet : très bon relationnel, expérience dans le domaine sanitaire, facilité de communication, niveau d’alphabétisation, compréhension du service. Ce sont les associations de santé communautaire qui recrutent administrativement ce personnel et elles sont encadrées techniquement par l’association Pesinet.

Les agents, une fois recrutés, sont formés sur : 1) les procédures et outils du service (carte d’abonnement, bons de convocation, planning, téléphone mobile) ; 2) les pratiques familiales essentielles en santé et l’identification des symptômes clés des maladies de la petite enfance ; 3) les techniques d’animation participative pour organiser des causeries auprès des mamans sur les thématiques de prévention sanitaire ; 4) l’argumentaire de promotion du service.

Voilà, si tu veux découvrir un peu le quotidien d’un agent, je t’invite à regarder le clip vidéo « Pesinet-Portraits of our Agents » dans la section « vidéo » de notre candidature en ligne !

J’espère que cela répond à ta question.

anne

Portrait de Anne Roos-Weil

Hi,
Jerome has posted a question regarding Pesinet's health agents. He was wondering what was the process for hiring and training of local women working as health monitoring agents.

I explained that hiring agents is not really difficult as the level of unemployment in Mali among younq women is very high and the opportunity to have a full-time formal job and a social role as health ambassadors is very much valued.

These agents are hired by community healthcare centers and trained and supervised by Pesinet's staff. Members of the community healthcare centers give us a pool of potential agents taken from their volunteers and we then select those who meet the requirement for this role : great empathy and ability for interpersonal communication, experience in healthcare, good level of understanding of the service, minimum level of literacy.

Agents are trained by Pesinet staff on key elements : 1) procedure and tools (mobile application and paper tools); 2) Essential health practices and idenitfication of key symptoms of child diseases; 3) facilitation techniques to moderate group discussion on health issues with subscribing mothers; 4) mastering key messages to promote the service among families.

For a quick snapshot of our agents' daily work, please have a look at our video "portrait of our agents" in the video section of our online application.

Portrait de jerome colombe

Thanks for that clear reply Anne (and sorry to have used French for my question!) It illustrates an another angle of these local perspectives.

Hi,

I was wondering how you are assessing the impact of the system?
Thanks for answering !

Portrait de Anne Roos-Weil
Dear Gaelle, Thanks for your message. I am glad you ask this question because Evaluation & Monitoring have been a key focus of Pesinet in the past years. We have differents ways of measuring impact and gaining client”s feedback on the service. First, we monitor on a daily, weekly and monthly basis indicators related to the activity. Special features of our technological application enable the local supervisor to do this check-up easily. Here is the list of indicators that we monitor on a recurring basis as part of the activities and the data sources. (1) Number of new subscribers /month : Recorded in real time in the PESINET database (2)Number of people who leave the service /month: Recorded in real time in the PESINET database (3)Number of children data sent / number of children data expected per week: Recorded in real time in the PESINET database (4) Number of days the doctor connected to the web interface for remote analysis/ 5 days per week: Recorded in real time in the PESINET database (5) Collection rate(Amount of monthly fees recovered among families for the current month/ amount of monthly fees due by all active subscribers): Currently recorded in excel spreadsheet by the program supervisor (6) Rate of medication sold at the center (Amount of medication effectively bought at the partnering center/amount of medication prescribed to Pesinet subscribers): Currently recorded in excel spreadsheet on a semester basis Second, we carry out annual evaluations. A first independent evaluation was carried out in 2009-2010 under the supervision of the Malian Ministry of Health. It consisted in assessing understanding of the service and satisfaction among subscribing mothers. Results of surveys carried out among 96 mothers were very positive (96% satisfaction rate, 97% find the service “very affordable”). A new and much more extensive impact assessment study was carried out from September 2010 to July 2011 under the supervision of an independent evaluator, Marie-Pierre Gagnon, Professor at the Faculty of Nursing Sciences at the University of Laval in Quebec and an international expert in evaluation of e-health projects and community healthcare. The study aimed at measuring the sanitary (prevention spreading, detection & treatment of diseases, evolution of clinical pathways…) and socio-economic impacts (population reached vs. population targeted, impact on health spending of families, impact on attendance rates and revenues of Health Centres…) of our service for all stakeholders; as well as the level of satisfaction of subscribing families. The methodology used was the following: 1. the objectives and expected impacts for each type of stakeholders (Beneficiaries, Health Centers, Ministry of Health, local staff, PESINET) were listed; 2. relevant indicators were chosen to assess progress on each goal; 3. data to measure those indicators was collected and analyzed. Data was gathered through the following sources: •Satisfaction survey among a sample of 91 subscribing mothers •Motivation survey among 91 non-subscribing families (but potential future subscribers)living in the district of Dravela/Dravela Bolibana •Socio-economic survey of the 182 families •Survey of the two groups following-up on the use of health structures by 182 families (visit every 2 weeks, for 8 weeks) •Quantitative analysis of data (data extracted from PESINET’s database, crossed with the Healthcare Centre paper records on medical consultation and prescriptions) The evaluation showed very encouraging results in terms of improvement of primary healthcare use and increase in resort to care by families. The results are presented in our application under the section “Social impact”. The last mechanism that we leverage for monitoring activities is a more participative one. The monthly gathering of mothers around PESINET proximity agents which are organized to discuss specific health issues or program issue are opportunities for subscribers to voice their opinion on the program and for the program management team to get interesting inputs and feedback to improve the service. An evaluation mechanism for those gatherings is being put in place. We record the number of participants and check whether they are new participants or already came to a gathering organized in the same district. Evaluation on the level of education on a specific health issue that has been presented and discussed during gathering will also be assessed among participants a few months after they participated. I am passionate about evaluation so if you have any ideas for improving our evaluation methods or know of anyone who could support us in our monitoring efforts, please let me know !

Hi,
I'm really astonished about the great job you are doing with Pesinet. One question : how strong is your relationship with local authorities in Bamako?
Thanks for your answer and I wish all the best.
Caroline

Portrait de Anne Roos-Weil

Hi Caroline,

Since our work is very much anchored in local territories where primary healthcare centers are operating, it is important for us to develop strong relationships not only with the public authorities at national level but also with local authorities.

We engaged the local city hall of the district, the local federation of healthcare community associations in the district (Felascom) and the local social development service in the definition of the "standard partnership agreement" that we will be signing with each new community healthcare center willing to integrate the Pesinet service into its package of activities. The local city hall of the disctrict is also one of the signatory of each of the partnership agreements signed with individual community healthcare centers.

The representative of the city hall in District 3 stated during the launching ceremony of our service in district 3 "The city hall of District 3 of Bamako is committed to accompanying all community healthcare centers willing to integrate the service and meeting the necessary requirements".

We're hoping to strenghten even more our relationships with the local authorities so that they can commit to financially help develop the program.

Great project, great people, Anne and her team are doing a wonderful job on the field.
I'm proud to be part of this journey. Best of luck for the defi "meilleure santé" which in local language Bamanan would perfectly translate into "Ala nogoyakè" !

Portrait de Anne Roos-Weil

Thanks Antoine for the continued support ! Fingers crossed...

Hello,
You'project looks really great...

Have you already studied the opportunity and feasability of replicating your project in other nearby countries ?

BRAVO again

Hello Vincent, thanks for your support and your question!

Replication in other countries is in the DNA of Pesinet. The principle of Pesinet is relevant for all countries with high child mortality rates, under-used primary healthcare structures, poor prevention and resort-to-care culture and political will to tackle the issue of child mortality.

Mali was chosen as the pilot country, but Pesinet would also be applicable in many other Sub-Saharan African countries, starting with neighbouring countries (Niger, Burkina Faso, Guinea, Senegal…) – of course, each time, the model would have to be slightly adapted to fit the local context. Rolling out Pesinet in new countries is clearly part of our mid-term projects.

In the short term, we plan to remain focused on the development of our activities in Mali, therefore we have not yet undertaken any feasibility studies in other countries.

Nevertheless, several NGOs and institutions from other countries have already approached us and expressed an interest in the Pesinet model, opening the path for future partnerships to expand in other countries.

Best of luck to the Pesinet team! This is a wonderful project, very much needed and into which a lot of work and devotion have been poured... I keep my fingers crossed for you and for all those children who would benefit from Pesinet receiving this support!

Portrait de Anne Roos-Weil

Anne-marie, Thanks for your kind message. It is great to have supporters like you!

Hello,
I am really impressed by the quality of Pesinet project which is a real innovative approach of health care in a sustainable model.
Your tangible results and the successful launch of new programs in additional districts of Bamako really need attention. I feel it provides a unique value and I I really wish you to be selected among all these other valuable Changemakers projects.
Congratulation to the team and the positive energy we feel in your action,
Pascale

And thanks for the positive energy YOU brought us during one month!

Pour avoir travaillé moi-même dans le domaine de la nutrition et de la santé publique en Afrique pendant plusieurs années, je reconnais que ce projet est très porteur. Il me semble que votre projet sur la participation des populations à la prise en charge de leur santé, notamment en leur demandant une contribution financière qui, à son tour, permet de faire fonctionner le système de soins: est-ce que j'ai bien compris ? Qu'en est-il des familles qui ne peuvent pas payer ? Est-ce que les médicaments sont inclus dans le prix d'adhésion des familles au projet, ou celles-ci doivent-elles payer en plus pour les médicaments. Dans la présentation du projet, vous mentionnez la couverture médicale, mais qu'en est-il de la qualité des soins. Avez-vous observer une diminution des principales pathologies de l'enfance ou une amélioration de la santé des enfants depuis que vous avez lancer projet. Puisque ce projet a entre une et cinq années, il est possible de faire une enquête d'impact: a-t-elle eu lieu ? Est-ce que la visite du technicien de santé remplace une visite au centre de santé ? Est-ce que le technicien de santé visite systématiquement toutes les familles de la zône, y compris celles qui ne fréquentent pas le centre de santé ? Avez-vous de données sur l'évolution du contact entre les familles et le système de santé locales depuis que votre projet est en place ? Est-ce que le système que vous avez mis en place est conçu de manière à pouvoir, dans le futur, se maintenir de lui-même sans intervention extérieure ? Merci d'avance pour la réponse à vos questions, mais ce que vous dites de votre projet fait qu'il me paraît très intéressant d'où mon flot de questions.

Portrait de Anne Roos-Weil

Bonjour Benoît,

Désolée pour la réponse tardive et merci pour votre commentaire et votre intérêt pour le projet Pesinet.

Je vais tenter de répondre à vos questions:

(1) la contribution financière des familles permet de faire fonctionner le système de soins: est-ce que j'ai bien compris ?

Oui, vous avez très bien compris. En fait, les 500FCFA/mois demandés à la famille pour l'abonnement de l'enfant permettent de couvrir partiellement les charges du service Pesinet (visite à domicile, prise en charge de la consultation à 100% et des médicaments essentiels à 50%) et permettent d'améliorer l'utilisation par les populations des centres de santé primaire, ce qui en retour améliore le système de soin au sens large car cela permet de viabiliser l'activité des centres de soins primaire et de désengorger les structures hospitalières.

(2) Qu'en est-il des familles qui ne peuvent pas payer ?

Il existe depuis cette année au Mali un dispositif permettant aux familles très démunies de bénéficier d'une prise en charge gratuite. Ce dispositif s'appelle le RAMED et cible 5% des familles les plus pauvres. Sa création a accompagné celle de l'Assurance Maladie Obligatoire qui elle cible les 17% de la population qui sont dans l'économie formelle. Notre service ne se substitue pas à ces dispositif public mais vient les compléter pour les 78% de la population qui ne bénéficie d'aucune couverture maladie publique. Pour les familles de Bamako, le service Pesinet est très abordable et constitue un gain financier très clair par rapport à ce que les familles paient en général pour la santé de leur enfant. D'après les études que nous avons faites entre groupe abonnés et groupe témoins, les dépenses en consultation des abonnés sont 60% moindre que celles des non-abonnés au global (toutes structures de soins confondues) et les dépenses en médicaments 40% moins importantes (tous médicaments prescrits confondus).

(3)Est-ce que les médicaments sont inclus dans le prix d'adhésion des familles au projet, ou celles-ci doivent-elles payer en plus pour les médicaments ?

La prise en charge à hauteur de 50% des médicaments essentiels permettant de soigner les pathologies simples est incluse dans l'abonnement, si les médicaments sont achetés à la pharmacie du centre de santé partenaire.

(4) Qu'en est-il de la qualité des soins ?

Très bonne question. C'est un grand enjeu pour toute structure qui cherche à améliorer le recours aux soins que de garantir la qualité des soins. Les évaluations ont ainsi montré que 66% des mamans abonnées se disent satisfaites de "la qualité et l'accueil au centre de soins", ce qui est beaucoup plus faible que le taux de satisfaction sur le suivi à domicile par exemple (98%). Toute la difficulté est que le service s'appuie sur les structures existantes qui ont un certain nombre de faiblesses et qu'il faut travailler à renforcer pour que le système d'incitation au recours aux soins ait l'impact attendu en terme d'amélioration sanitaire. C'est la raison pour laquelle nous mettons en place des mécanismes de renforcement des capacités des centres avec des partenaires locaux, à travers des formations sanitaires, des formations à l'accueil, un appui à la gestion des stocks etc. Le lancement du service est également conditionné à un certain niveau d'offre de soin dans le centre partenaire qui est évalué en amont du lancement. Mais, c'est vraiment le grand sujet pour rétablir pleinement une confiance et un lien entre les structures de soins et les populations, et cela prend du temps...

(5) Avez-vous observé une diminution des principales pathologies de l'enfance ou une amélioration de la santé des enfants depuis que vous avez lancé le projet ?
Nous souhaitons travaillez à renforcer l'évaluation sanitaire et épidémiologique de notre programme. Néanmoins, nous avons déjà fait un certain nombre de travaux dans ce sens. Il est difficile à ce stade de mesurer les pathologies évitées grâce aux messages de prévention relayés par nos agents. En revanche, il est clair que les complications des maladies non-évitées sont en grande partie atténuées puisque les médecins partenaires constatent au cours des consultations que les enfants Pesinet qui se présentent sont dans des états d'avancement de la maladie bien moins importants que les autres. Nous sommes en train de travailler avec une chercheuse de l'INSERM pour essayer de documenter ceci à partir des données enregistrées par les médecins, mais les registres sont assez mal tenus et ne contiennent pas d'indication de gravité. Nous prévoyons de mettre en place un système d'échelle de gravité sur quelques pathologies cibles pour pouvoir mieux mesurer la prévention des complications de maladies. C'est un travail en cours.

(6) Puisque ce projet a entre une et cinq années, il est possible de faire une enquête d'impact: a-t-elle eu lieu ?

Tout à fait. Après une première évaluation simple menée par le Ministère de la Santé en 2009 sur la compréhension du service et la satisfaction des abonnés, une étude plus approfondie a été menée cette année sous la supervision d'une évaluatrice indépendante.

Les principaux résultats sont mentionné dans l'article et dans les réponses à vos questions.

(7) Est-ce que la visite du technicien de santé remplace une visite au centre de santé ? Est-ce que le technicien de santé visite systématiquement toutes les familles de la zône, y compris celles qui ne fréquentent pas le centre de santé ?

Les visites des agents de suivi sanitaire à domicile ne remplacent aucunement la consultation au centre de santé. C'est bien tout le but de Pesinet que d'inciter les familles à se rendre au centre pour une consultation médicale et non de "court-circuiter" le rôle du médecin dans le diagnostic. L'objectif n'est pas pour les agents d'effectuer un diagnostic médical à la place du médecin mais d'avoir un rôle de détection précoce et de référencement vers les centres.

Les agents de suivi (qui n'ont pas tous le diplôme de technicien de santé mais de l'expérience dans le domaine sanitaire a minima) effectuent le suivi de tous les enfants qui se sont abonnés au service, donc pas seulement ceux qui fréquentent le centre. L'abonnement se fait sur une base volontaire et la promotion du service se fait par différents canaux, mais principalement le porte à porte dans le quartier.

(8) Avez-vous des données sur l'évolution du contact entre les familles et le système de santé locales depuis que votre projet est en place ?

OUi, on sait que chez les abonnés Pesinet le taux de contact dans les structures primaires est beaucoup plus élevé que la moyenne Bamakoise (3 contacts par an en moyenne chez Pesinet contre un taux de contact de 0,5 dans les centres les plus utilisés de la zone d'intervention). Les évaluations ont également montré qu'un abonné a recours aux soins (toutes structures confondues) plus de deux fois plus qu'un non-abonné en cas de maladie.

(9) Est-ce que le système que vous avez mis en place est conçu de manière à pouvoir, dans le futur, se maintenir de lui-même sans intervention extérieure ?

Oui, l'objectif du système a toujours été qu'il puisse être porté et auto-géré par les structures de soins locales. Un des enjeux pour cela est la montée en compétence des équipes et associations de gestion des centres sur la gestion du service mais également la validation d'un modèle de financement viable et pérenne.

Sur le premier point, nous travaillons à une appropriation progressive par les centres des activités principales du service. Ce sont eux qui recrutent administrativement les agents de suivi, ce sont leur médecins qui sont responsables de leur formation sanitaire continue et supervision sanitaire, ce sont les équipes du centre qui doivent assurer l'accueil et le recouvrement des cotisations sur site (en plus du recouvrement à domicile par les agents).

Pour le second point, l'objectif était initialement de parvenir à un autofinancement total du système sur les cotisations des abonnés. Le programme pilote a démontré qu'en maintenant le même niveau de suivi et de prise en charge ceci n'était pas envisageable sauf à augmenter le prix de la cotisation, ce que nous ne souhaitons pas faire car l'objectif est que le service soit abordable pour le plus grand nombre.
Nous explorons actuellement différentes pistes pour compléter le modèle de financement : la définition d'une offre plus complète et plus chère destinée aux populations plus aisées qui permettrait de co-financer l'offre à 500FCFA, des partenariats stratégiques avec les mutuelles de santé, pour mutualiser certains coûts et bénéficier de synergies croisées entre les réseaux d'abonnés Pesinet et d'adhérents aux mutuelles, l'engagement des collectivités locales dans le co-financement du service.

Voilà, j'espère que ces réponses vous donnent quelques éléments supplémentaires de compréhension, j'espère surtout que nous aurons l'occasion d'en reparler de vive voix et, si cela vous intéresse, que nous pourrons bénéficier de votre expertise et de votre expérience pour faire grandir le projet !

A très bientôt
anne