After almost a decade in UNAIDS Executive Directorate, Michel Sidibé was appointed Minister of Health in Mali last May. A true defender of social justice, Michel Sidibé is now fully committed to improving the health situation in Mali. Interview.

54 ÉTATS: Could you give an overview of the health situation in Mali? More precisely, what are the dominant pathologies in Mali and what is the maternal and infant mortality rate?

Michel Hamala Sidibé: Mali is facing new types of challenges that require a multisectoral, innovative and coordinated approach.

The security crisis in north-central Mali has been catastrophic for our country with the degradation of health infrastructure, the theft of medical equipment, and death threats on health workers leading to medical deserts. In view of this picture and since taking office, we have been working to restore hope to our populations and strengthen the bonds of trust between the people and the public authorities by making a substantial contribution to the provision of basic essential services and by making health a vehicle for peace and reconciliation.

In addition to endemic diseases such as malaria, which remains the leading cause of death in Mali, and HIV epidemics, tuberculosis and hepatitis, we are still confronted with the problem of emerging diseases commonly known as chronic non-communicable diseases (CNTDs) such as diabetes, hypertension and cancers…. Health indicators in Mali remain of particular concern and contribute significantly to the loss of human capital accumulated by a country where nearly half of the population is under 16 years of age.

After 30 years of steady decline, infant mortality has increased significantly from 95 to 101 deaths per 1,000 live births between 2012 and 2018, and maternal mortality remains one of the worst in the region, at 325 deaths per 100,000 live births in 2018.

54 ÉTATS: Mr. Minister, you have a solid knowledge of public health issues, particularly through your position at UNAIDS. You have been in office since May 2019, what place will you give to the fight against AIDS, related diseases, including tuberculosis and cervical cancer, and their integration into a broader health policy?

Michel Hamala Sidibé: My recent appointment as Minister of Health and Social Affairs in Mali is a great honour for me and allows me to rediscover my country after years of international commitment to the fight against pandemics, especially AIDS and other related diseases.

As far as AIDS is concerned, we have a concentrated type epidemic with a prevalence of more or less 1.1%.

With the emergence of self-tests, we will quickly implement strategies to detect as many of our fellow citizens as possible who remain sero-ignorant. We have already initiated reforms in this direction and made commitments with the creation of an integrated HIV/AIDS/Tuberculosis/Hepatitis program. In addition, given the critical mass of new cases of cervical cancer recorded each day and the increasingly critical access difficulties, we are concurrently implementing advanced and specific strategies to promote early diagnosis of cervical cancer and promote the vaccination of young girls against papilloma virus.

54 ÉTATS: The journey of care for people with cancer remains complex, sometimes chaotic. How can it be simplified and humanized?

Michel Hamala Sidibé: Indeed, following budget cuts, Mali spent only 0.85% of GDP on health care and 4.32% of the revised national budget in 2018, and 0.05% of GDP and 0.2% of the national budget specifically for primary health care. However, as soon as I took office, I asked the competent services of the Ministry to evaluate the path of the cancer patient, and this work demonstrated the evidence of the complex, titanic and above all very expensive path that increases the rate of people lost to follow-up and consequently the rate of cancer-related deaths. The problem is not so much the lack of qualified human resources, but rather the management of a situation of recurrent and growing insecurity in a significant portion of our territory that sometimes disorganizes and disintegrates our health system. The geographical and financial accessibility of populations to health services remains uncertain, thus creating a mismatch between the supply and demand for services. This favours a medical desert in some areas.

54 ÉTATS: What is the status of the social security issue in Mali? How does care work for people who are unable to pay for their care and medical expenses?

Michel Hamala Sidibé: Health financing in Mali remains inadequate with too large a contribution from the population through direct payments and low mutual health insurance coverage. Also, human resources are poorly distributed, insufficient, inefficient and poorly motivated (training, use, motivation).

However, in 2009 Mali took a leap forward with the establishment of its social protection system through the creation of Compulsory Health Insurance (AMO), which is one of the most important reforms in Mali.

It is an insurance for the benefit of civil and military civil servants, members of parliament, workers governed by the Labour Code in active employment or in retirement and their dependants. It is based on the principle of solidarity and risk sharing.

Moreover, in order to ensure access for all, I must remind you that Mali is resolutely committed to the fight against social inequalities.

Our decentralization strategy gives us the opportunity to establish a true health democracy by jointly involving the State services and local authorities (municipalities and circles). This means that the poor are fully covered for their medical care, examinations and check-ups as well as hospitalization costs, with 85% and 15% paid by the State and 15% by the local authorities.

In February 2019, the President of the Republic launched the most ambitious health reform in Mali’s history.

The latter has made primary care totally free of charge for pregnant women and children under five years of age, upgraded the technical platform, deployed and trained tens of thousands of community health workers to work as closely as possible with 18 million Malians, spread over a territory twice the size of France.

54 ÉTATS: And finally, in the absence of qualified human resources, do you think that the future of health in Mali is in telemedicine?

Michel Hamala Sidibé: The Government of Mali’s disinvestment of the primary care sector from health following the Bamako Initiative and the introduction of cost recovery must be rectified.

I remain convinced that telemedicine and e-health in general is a credible and indispensable alternative that must guide and guide our policies and strategies for providing care.

We are now in the middle of an almost successful discussion with partners to develop health innovation through the digitization of health centres at the grassroots level by connecting them together.

This is a project to improve primary health care through the restructuring of approximately 500 Community Health Centres (CsCom) using the digital solution.

This solution will involve the implementation of tele-medicine, tele-assistance and tele-expertise. We want to move towards a resilient digital health ecosystem. The choice of CsComs is not fortuitous because we are convinced that improving the health of Malians requires improving the supply of community-based care, which is the first link in the health pyramid.

Our ambition is to build a strong health system by fundamentally reforming the system while relying on innovation to achieve this. With this interconnection, our vision is to make Mali the first centre of digital excellence in health in Africa. The immediate benefits that could be derived would include:

– Bringing care closer to the people

– Improving the quality of care

– Expand the offer of first level care

– Streamline the management of primary health care structures

– Implementation of an innovative and intelligent business model….

In the coming months, we will organize an international health innovation fair in Mali.

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