Sigida Joli

One of the most urgently needed forms of risk protection in Mali is related to health. Technology could facilitate better access to mutual health organizations and microinsurance that protect the most vulnerable, but mobile and electronic payment systems are not widely used in Mali. Those most in need have not had the opportunity to understand how the payments work, or to build trust in their systems. The difficulty of accessing technology by those without literacy and numeracy skills is a primary contributor to the lack of use. In Mali, the literacy rate is just 35% (UNESCO, 2018). Our solution proposes to adapt a voice-based technology, which we are currently using to improve access to health information in the target population, to increase the understanding and use of technology-based and mobile payment systems to mutual health organizations, which could dramatically increase access to healthcare and protect families from health shocks.

Across West Africa, most health systems require out-of-pocket payments that place an extraordinary burden on the poorest families. With better access to mutual health organizations, or mutuelles, a community-based risk protection mechanism for health, millions of families could be better protected from health shocks.  In decentralized Mali, community-based health insurance programs can be strategic, effective, and impactful for the poorest families, but their ability to enroll and cover the population has been limited.

Despite the existence of a national community-based health insurance (CBHI) strategy and structure (Union Techinique de la Mutualité Malienne - UTM) designed to cover informal-sector workers which was developed in 1998, less than 5% of the population participates in mutuelles, or mutual health organizations (MHOs). Similarly, the social safety net program (Regime d’Assistance Medicale – RAMED) designed to serve the health needs of the poorest families, is largely inoperative. UTM has tested a mobile money payment system for collecting mutuelle membership contributions, but efforts to scale up mutuelles have largely stalled.

Many mutuelles in Mali are struggling and we attribute their challenges to two causes: the quality of healthcare being saved for (value for the money) and ineffective engagement of informal sector workers (unclear value proposition).

We serve thousands of families in peri-urban communities whose only incomes come from informal sector work. They struggle to meet basic needs, especially to access primary healthcare. We also serve their community health centers who, with extremely limited resources, strain to provide accessible, quality healthcare to their communities. We have worked with these two groups for over a decade to understand their needs and to work with them to develop effective solutions. 

Our next step is to develop accessible financing mechanisms that provide missing and needed social and risk protection, while also providing the community health system with the resources it needs to perform well. In the decentralized health system, peri-urban communities are at a disadvantage because they are serving the poorest and most vulnerable populations, who are primarily informal-sector workers and do not have the ability to pay for care. This leaves limited resources available to provide quality services at the community level, while also leaving families exposed to greater risk. Community-based financing mechanisms, like mutual health organizations and other forms of CBHI or microinsurance, could help to fill this enormous gap not only in social protection but in the financing of basic social services.

Nearly all the families we serve in peri-urban communities rely on informal sector work and live well below the international poverty line ($1.90/day). They face significant barriers to accessing and understanding technology, let alone using it to participate in social protection programs. The voice-based solution we propose was specifically designed to include and serve those without literacy and numeracy skills and with limited access to connectivity.

There is little data available about peri-urban communities, but by designing for some of the poorest and hardest to reach communities in the region, our solution will be more inclusive and relevant to all.

Our solution is based on our current work using a voice-based technology to improve access to maternal and child health information and services for mothers in peri-urban communities with limited resources. The technology we are using was developed by Lenali, a start-up based in Bamako and named by Quartz Africa as a Top 30 Innovator. They aim to create an alternative, voice-based social media network because they believe that the low use of social media in Mali (<20%) and across sub-Saharan Africa is not simply a problem of access to telecommunication infrastructures and their costs, but a lack of understanding and relevance of existing services for those who do not read and write easily. Using the innovation they developed to connect users via a social media network, we intend to alleviate poverty by increasing access to health, financial, and risk protection services.

Many of the existing technologies trying to serve this population still require literacy and numeracy skills – users must be able to read an SMS message, or use numbers on a keypad to access an IVR message. Most of the women and families we serve would be excluded from these solutions. However, with a completely voice-based solution, technology finally becomes accessible to them.  In communities that still primarily rely on spoken communication, a technology that can be used completely vocally and in local languages creates a simpler, more understandable, and more inclusive platform.

Our solution has already shown results in helping women to access health information and in helping informal sector workers market their goods and services. It is also altering perspectives about technology itself, and the relevance of technology as a tool for accessing information and services.

The technology we use was created in order to build a voice-based social media network called Lenali, which CNN dubbed “Mali’s homegrown Facebook.” In that application, the technology currently has over 75,000 users. More information about how informal-sector workers are using and benefitting from the technology can be found here: https://www.africanews.com/201... 

We developed and tested a new application for this technology, as we propose to do in this project. During our 18-month pilot project, which was designed to improve access to health information for women with limited resources and literacy, all of the users demonstrated increased knowledge of maternal and neonatal health subjects and reported increase ability to participate in decision-making in their households based on pre- and post-test data. Based on this  pilot project, which consisted of extensive user testing with 400 women in a peri-urban community in Bamako, we believe it could be used a platform to offer more services.

The technology at the core of our solution is easily adapted to a wide variety of contexts and applications. In particular, because it is voice-based and intended to be used in the native language of the user, it can be deployed easily in multiple languages across the region.

Consistent with our approach to working within existing systems, we seek to strengthen the engagement between hard-to-reach communities and the systems and strategies that already exist to serve them. Rather than starting from scratch or creating parallel systems, we seek to optimize existing and underutilized opportunities, which means understanding barriers and adapting to contexts. This solution was developed to have those capabilities. 

Because our entire theory of change rests on developing solutions that can work within existing systems and can be led primarily by communities; they must be simple to administer and simple to access – and this solution is. In Mali, this means that the solution should not only be an integrated financing mechanism for the community health centers and the women in health savings groups whom we serve, but we also intend for it to work within the framework of the existing mutelle strategies and structure as defined by the Union Techinique de la Mutualité Malienne (UTM). We intend to use this context as a starting point and test for integration into other service delivery systems in the region.

Our use of technology is guided by and limited to the needs of women and families we serve in peri-urban communities. We work with them to create resources that would be valuable to them, and improve their lives. Because these communities have limited connectivity and families living in them had limited opportunities to build literacy and numeracy skills and therefore work in the informal sector, this is the context in which we design and develop all our solutions. As our core target population, this innovation is designed for them.

The Mission Billion Challenge aims to serve the same population our organization has been serving since 2006. There continue to be immense needs and challenges faced by these communities, both in Mali and across the region. We believe more solutions, more investment, and more collaboration are needed to solve these challenges. We are participating in this challenge to be a part of the community that is trying to find solutions in West Africa and to ensure that the needs of the most vulnerable populations are represented in that effort.

While our idea for this solution comes from a technology we are already deploying, its use in this particular application remains an idea. We would welcome partnerships to help us design, develop, and test it, partilcularly with a view towards preparing for a regional application of the technology.

We know our community-based collaborators and partners well - those who would be using the solution. We also know the community health system and how financing works, and doesn't work well, within it. We would welcome partners who could help us improve the technology from the perspective of other service delivery systems, particularly regional ones.