A Crisis of Care: Sexual and Reproductive Health Competes for Attention Amid Conflict and Displacement in Mali

By Devon Cone , Alexandra Lamarche | April 15, 2021

Introduction

National healthcare systems rarely prioritize sexual and reproductive health (SRH). This is a challenge for women and girls worldwide, including in Mali. There, nearly a decade of conflict has created a protracted humanitarian crisis, decimating the healthcare system and limiting the availability of SRH services. Meanwhile, political uncertainty following a coup in August 2020 has focused international efforts on addressing security and stabilization, at the expense of humanitarian needs. The lack of donor funding has exacerbated the situation, including the dearth of SRH services. For women and girls who have been forcibly displaced by conflict and instability, the challenges are particularly pressing.

As of March 2021, more than 311,000 Malians were internally displaced, and the country hosted almost 50,000 refugees from neighboring countries. More than 7.1 million people—some 35 percent of the entire population—were in need of humanitarian aid, of which 1.5 million people had experienced gender-based violence (GBV) and 1.8 million people required health assistance. Displaced communities, both internally displaced people (IDPs) and refugees, often do not have the means to pay for SRH or other healthcare services and often cannot travel to health facilities. This is also true for most other women and girls in rural parts of Mali. Furthermore, even if women and girls can afford services and are able to travel to health facilities, many lack comprehensive SRH care.

The COVID-19 pandemic has worsened access to SRH services because women who fear contracting the coronavirus are hesitant to seek care. Moreover, public health efforts advising women and girls on how and when to seek SRH services are limited. Many SRH professionals cannot effectively operate during pandemic travel restrictions, and funding has been redirected to COVID-19 response efforts. The lapse in SRH care will inevitably lead to a cascade of additional health problems, including increases in the number of unintended pregnancies, maternal deaths, and sexually transmitted diseases.

It is important to address the barriers to SRH for the displaced and for other vulnerable populations of Malian women and girls, particularly those in need of humanitarian assistance. The situation in Mali is extremely fragile, marked by an intensification of armed violence and increased intercommunal conflict and the emergence of a new interim government in the wake of a coup. In the midst of this flux, it is essential that the Malian government and its humanitarian partners do not lose sight of the imperative to provide women and girls with access to sexual and reproductive health.

The Malian government is ultimately responsible for providing health services to its citizens. However, the international community will need to support the government’s healthcare efforts, as well as services provided by humanitarian aid agencies. The United States is the largest humanitarian donor in Mali—providing $74.3 million of the $474.3 million called for in the 2020 UN humanitarian appeal. However, that appeal was only 48 percent funded. This is significantly lower compared to neighboring crises. In Niger, the 2020 UN humanitarian appeal was almost 75 percent funded, while in Burkina Faso it was nearly 84 percent funded.

Donors need to move quickly to close the pledging gap between Mali and other crises in the Sahel. As part of this effort, they must also prioritize funding for routine health services like SRH, even as they continue to respond to the COVID-19 pandemic. The UN Office for the Coordination of Humanitarian Assistance (OCHA) has requested $563 million for the 2021 Humanitarian Response Plan in Mali. Of this, health programming amounts to just $26 million, but there is no indication that much, if any would be spent on SRH. Nevertheless, donors have yet to allocate any money for healthcare.

If donors fail to support healthcare in Mali—through humanitarian aid and government services—the consequences will be serious, especially for women and girls. Donor governments and international institutions such as UN agencies must create long-term, flexible funding strategies that prioritize SRH. They need to allocate resources to the government of Mali, but also to local non-governmental organizations (NGOs) and other civil society groups, including those led by women.

Sexual and Reproductive Health Needs in Mali

Sexual and reproductive health needs in Mali—for the displaced and general populations—include four main areas: family planning, prenatal and postnatal care, abortion access, and support for survivors of GBV. Family planning refers to practices that allow a woman to anticipate and determine her desired number of children. It usually refers to the use of contraception, but can also include the treatment of involuntary infertility, or challenges conceiving when one wants to have a child. Structural factors, including insufficient healthcare facilities, and social factors, including young women’s lack of autonomy, often determine a woman’s family planning choices. For example, it is common in Mali for a woman’s husband or mother-in-law to make healthcare decisions on her behalf.

Prenatal, also called antenatal, care refers to all the care a woman and her unborn child receive while she is pregnant, and postnatal care refers to the medical care she and her newborn receive for at least six weeks after birth. Improving access to these types of care is extremely important in Mali, which ranks among the countries with the worst infant and maternal mortality rates in the world. In 2019, there were, on average, 60 infant deaths for every 1,000 babies born. In 2017—the latest year for which data is available—562 Malian mothers died in childbirth for every 100,000 live births. In 2018, less than 50 percent of women received antenatal care, and just over 50 percent received postnatal care. Rates of assisted deliveries in many regions are low, and unassisted deliveries are dangerous—increasing the probability of maternal or infant mortality and birth-related health complications. Indeed, pregnancy-related deaths remain common.

Health care support for survivors of GBV is also lacking. According to the government, approximately 85 percent of Malian women have experienced GBV, including female genital mutilation, forced marriage, beatings, forced pregnancy, and rape. Notably, about two-thirds of these cases occur within family structures. And rates of GBV in April 2019 compared to April 2020 rose by at least 35 percent. Yet, support services are insufficient, and stigma against survivors remains high. Furthermore, some religious leaders opposed a 2019 law drafted by the Malian Ministry for the Promotion of Women, Children and Families focused on preventing, mitigating, and effectively managing GBV in Mali. Due to this opposition, the legislation never reached Parliament. Without legislation outlawing violence against women, it is difficult for women and girls to pursue legal recourse and access protection when harmed. In light of this setback, the Malian government should in the first instance, make health care support to survivors a high priority, while simultaneously support improvements in the legal system to better protect women.

The international community and local civil society also have important roles to play in assisting GBV survivors. They can do so in several ways. First, they need to strengthen referral pathways, which are mechanisms through which service providers communicate and coordinate between one another regarding GBV cases. Second, they should work to improve GBV survivors’ access to psychosocial trauma counseling. Third, they should invest in programs to counter the stigma GBV survivors face.

Healthcare Capacity

The Malian healthcare system is built of public, private, and community-based facilities. While there are three public hospitals in the capital of Bamako, those with financial means usually obtain their healthcare through private hospitals, pharmacies, midwives, and doctors. Those without such means and most people residing outside of the capital, including IDPs, have little choice and rely largely on a network of community health clinics known in French as Centres de Santé Communautaires (CSCOMs). The centers receive government subsidies and funding from NGOs, but they rely on patient fees to cover most of their costs.

The CSCOMs are often the first point of contact for patients, especially for women in rural areas who do not have other options. They also provide care for many lower-income women who cannot afford hospitals or private provider fees. However, CSCOMs are often under-staffed and under-supplied. Individuals might also seek care directly from NGO-run services and in some cases, independent midwives. Even with these various healthcare providers, as of 2018 there were still only 3.14 health professionals per 10,000 people in Mali. The World Health Organization (WHO) recommends that, at minimum, there be seven times that number of health professionals per 10,000 people.

Mali’s prolonged conflict has also extensively damaged the country’s healthcare infrastructure. In the northern and central parts of the country where the conflict has been most acute, as of mid-2018, 17 percent of health structures were no longer functioning in line with national standards. Midwives tend to be concentrated in urban areas like Bamako, Koulikoro, and Segou, leaving other more rural regions without coverage. Overall, the lack of qualified health personnel—particularly those providing SRH care—is significant. As a result, in 2018, 97.4 percent of births in Bamako were assisted compared to only 20 percent in rural areas. It is likely that with increased conflict and the spread of the COVID-19 pandemic, even fewer women receive medical assistance at birth now. In an interview with Refugees International, a physician in Bamako noted how long distances between sparse healthcare facilities in rural regions limit women’s access to family planning services.

In another interview, a Malian midwife indicated that many organizations that offer door-to-door, community-based services or mobile care do not cater directly to IDPs, who often reside with host families or in displacement camps. Furthermore, the cost of procedures and availability of services are often inconsistent between health centers, with many difficult for IDPs to afford. As a result, female IDPs who do not have access to CSCOMs, NGOs, or mobile care, are more likely to self-administer care without adequate supplies or medicine.

To address this discrepancy between rural and urban areas and increase access to SRH services for displaced communities, the government should promote door-to-door services. They should also prioritize community-based services rather than facility-based services in remote areas and to displaced communities, thus reaching some of the most underserved populations. NGOs that provide healthcare should also consider and/or expand their door-to-door service provision and outreach.

On an urgent basis, the government should allocate more funds to train midwives and doctors at the municipal level and ensure they work throughout the country, especially in remote regions. These midwives and doctors should be prepared to work in facilities such as CSCOMs and also conduct community outreach by providing some basic door-to-door services. The government should also train community health workers to conduct awareness raising campaigns and provide basic care. Although some international organizations train healthcare workers, an activist in Mali told Refugees International that “the government directs those trained workers in parts of the country where they are not needed most.” The government of Mali should map out existing services to identify regional gaps and work to address these.

Sexual and Reproductive Health in National Policy

In 2019, Mali’s then-President Ibrahim Boubacar Keïta announced that the Malian government would provide free primary health care to all children under five and pregnant women. The initiative would also provide free contraceptives nationwide. To implement these important and historic commitments, the government planned to increase the number of healthcare professionals. Following through on these commitments would drastically improve the lives of women and make Mali a healthcare leader in Africa. In a press interview at the time, Mali’s former Health Minister, Samba Ousmane Sow acknowledged the scale of the challenge: “We needed to do this a long time ago. Mali is among the top three countries with the highest infant mortality rate. Mali also has very weak health indicators when you talk about malnutrition, poor family planning, poor sexual reproductive health and primary healthcare like pre- and post-natal consultations, simple deliveries, and routine immunizations.”

This Presidential Initiative is already being piloted in some areas of the country. The goal is to provide nationwide coverage by 2022. However, Mali still needs to raise $120 million in funding to fully execute the plan. Donor countries should provide funds to help Mali reach this goal. But even with the requisite financing, implementation also will require additional healthcare personnel. The government must prioritize training healthcare workers and ensure that they are present in rural and conflict-affected areas for this plan to succeed.

Ongoing conflict and instability present another obstacle. In an August 2020 mutiny, Malian soldiers detained the president until he announced his resignation on national television. Now, with a military-backed interim government in power, it is unclear whether realizing the this consequential healthcare initiative will remain a priority. International actors should strongly encourage the interim government to maintain momentum on this policy initiative and provide financial support to encourage full implementation of the plan. As international organizations and donor countries provide funding, they should enforce strict tracking mechanisms, and funding should be contingent on transparent and equitable service delivery. They should also ensure that they align new funding with ongoing humanitarian funding for IDPs.

SRH Awareness and Formal Education

Studies find that higher levels of formal education correlate with improved sexual and reproductive health for women and girls. As women and girls become literate and further their education, they are better able to understand information about SRH. They often have increased confidence that improves their ability to make independent decisions. Unfortunately, although Mali has made progress on female education over the last 20 years, girls still have less access to education than boys. The correlation between education and improved SRH is, naturally, stronger in schools that educate young people about it. Studies from around the world support this observation, including research conducted in rural Uganda where there are similar demographics and socioeconomic issues to that of Mali. However, Mali’s current school system has no formal nationwide SRH curriculum.

Mali is missing a huge opportunity to educate young people about SRH directly through the school system. In fact, in December 2018, the Malian government announced plans to cancel the “Comprehensive Sexual Education” program for primary schools after a proposed sexual education textbook for adolescents evoked opposition from religious leaders.

Knowledge of SRH

There is a significant rural-urban divide in SRH awareness. Public health messages regarding SRH services tend to reach urban, educated, and wealthier women more effectively. This is likely because their access to better education and healthcare enables them to comprehend and follow disseminated information and advice more easily.

Healthcare providers such as doctors and midwives—particularly those in the private sector—have taken on a significant role in educating Malians about SRH. These healthcare professionals inform their patients about SRH and travel to other regions to train community health workers and educate populations, usually at their own cost. However, a Malian midwife told Refugees International that the COVID-19 pandemic has hamstrung these efforts. Fear and lack of funding have significantly reduced their ability to work. This makes educating vulnerable populations such as displaced women particularly difficult.

To ensure all Malians have equal access to information on SRH, it is important that donors and international aid agencies fund and implement initiatives such as mobile or door-to-door education campaigns to increase knowledge in remote areas and include displaced people. They should also provide financial and logistical support to doctors and midwives who travel throughout the country, especially in light of the added challenges caused by the pandemic. This is essential, as more than 50 percent of the almost 20 million people in Mali live in rural areas that have limited internet access and healthcare facilities.

Many individuals—especially those who do not learn about SRH in school or who are not literate—usually instead learn about SRH through informal conversations, television shows, radio, social media, and interactions with health care professionals. The media thus plays an important role in SRH education. Malians use radio, television, and social media to raise awareness about SRH, especially among young people. The popular television show “C’est la vie” is an example of a nationwide program that educates the general public about SRH.

In rural communities where television or internet are more limited, radio is usually the best way to communicate and raise awareness. Radio programs are effective because they are often interactive, and young people enjoy calling in and listening to broadcasts. The radio station “Voix des jeunes” broadcasts evening programs in different local languages featuring health providers from local youth centers discussing themes related to SRH. It is important that radio shows broadcast SRH-focused programs in multiple local languages and that public education initiatives utilize social media and messaging platforms such as Facebook and WhatsApp to reach both rural and urban audiences.

Several private-sector efforts have also focused on promoting SRH education, particularly in rural and suburban areas. For example, the cell phone company VOTO Mobile has been broadcasting SRH information via mobile networks in its service zones. It specializes in delivering interactive voice calls and mobile text messages in local languages. VOTO should expand these efforts, and other companies should replicate these kinds of initiatives, ensuring that they include IDPs and refugees. The Malian government and international organizations should also explore avenues for collaboration between the public and private sector to expand these efforts and reach more people.

While amending the education system and including SRH in school curriculums would be beneficial, the Malian government, UN agencies, NGOs, and private companies should simultaneously support short-term initiatives that focus on strengthening and sharing information outside of schools.

Availability of Contraception

Women’s decisions about the type of contraception to use, if any, are complex. Available forms of contraception in Mali include condoms, contraceptive injections, implants, and intrauterine devices (IUD).

The venue in which a woman receives care can often determine her choice of contraception. According to several midwives the Refugees International team interviewed, most women would prefer long-acting reversible contraceptives (LARCs) such as IUDs because they are effective and do not require much effort after the initial insertion. However, most CSCOMs do not have the equipment or the trained personnel to administer LARCs, leaving women to travel, often to faraway hospitals, or to seek a private provider to get them.

Those options are not accessible to many women, especially IDPs. Thus, despite their preferences, most women who use contraceptives use short-acting ones, such as pills, injections, or condoms, which are cheaper and more readily available. These methods can also be conveniently and discretely picked up during routine trips to the market, for example, making them easier to obtain in light of the stigma around SRH and women’s lack of decision-making power over healthcare decisions. As cost and access to a provider are key determining factors in choice of care, facilities without doctors and midwives should prioritize stocking and distributing short-term methods. Where doctors and midwives are available to administer LARCs, government or NGO programs should subsidize their cost.

Self-Administered Care

A lack of formal healthcare leads many women to self-administer SRH care. Self-care is the practice of an individual, family, or community promoting or maintaining health without the support of a qualified healthcare provider. A midwife explained that it is common for women to attempt to self-administer certain kinds of care, such as injectable contraception, and seek a midwife’s help only if complications arise. In some cases, self-administered SRH care is successful; however, it can be extremely dangerous. For example, women can experience adverse reactions if incorrectly self-administering prenatal care in the form of traditional herbal remedies.

Self-administered abortion is also common because of Mali’s restrictive abortion laws, which prohibit all abortions except in cases of rape or where a pregnancy threatens the mother’s life. According to a private report produced by CARE and the Malian government, in 2017, an estimated 80 percent of abortions in the country were performed outside the formal health system. The unsafe methods used include ingesting dangerous chemicals or high doses of pharmaceuticals; introducing foreign objects into the cervix; or having an unqualified worker perform the abortion. All of these methods are high-risk and extremely dangerous. To reduce unwanted pregnancies in the first place, the Malian government and aid agencies should ensure that public clinics, mobile clinics, and pharmacies are reliably supplied with contraception. In addition, short of legislation to decriminalize abortion, the Malian government, UN agencies, and NGOs need to ensure that women have access to a full range of SRH services and information about their options during pregnancy. In line with current Malian law, these options should include abortion if the woman or girl has been raped, experienced incest, or the pregnancy puts her life at risk.

Effects of COVID-19

The COVID-19 pandemic has severely taxed an already struggling healthcare system in Mali. Movement restrictions, long wait times at hospitals, and financial burdens caused by the pandemic have made it more difficult for women to get care. Moreover, many people do not feel comfortable seeking care from hospitals or other health facilities because they fear they could be infected there. A midwife in Bamako with whom Refugees International spoke explained that these fears, combined with superstitious beliefs that prematurely talking about pregnancy can bring bad luck, have significantly reduced women’s intention to seek SRH care.

This reality underscores the need for aid agencies to better understand the context and concerns of Malians—especially women and girls—when making decisions about funding, service provision, and SRH services. By doing so, organizations can promote appropriate and efficient service provision for all Malian women and girls, including the tens of thousands of female IDPs.

Although many Malians fear approaching health facilities during this pandemic, the government, with the help of NGOs and UN agencies, has taken some measures to protect both healthcare workers and patients against the transmission of COVID-19. For example, as of September 2020, UNICEF had trained more than 4,000 health and community workers on Infection Prevention and Control Measures. The agency has also provided the National Institute of Public Health with 15,000 COVID-19 screening tests together with surgical masks, hand sanitizers, gloves, and other personal protective equipment (PPE). Additionally, as of March 29, 2021, the COVID-19 Action Fund for Africa (CAF)—made up of 30 different organizations—had already delivered or committed to delivering more than 7 million PPE, almost 80 percent of what is needed in the country.

Despite these measures, the government of Mali and other partners working to provide healthcare need to ensure that healthcare providers have accurate information about how COVID-19 spreads and take the necessary precautions to ensure that they and their patients stay safe. This includes consistently using the PPE that organizations have provided to Mali and when possible, practicing social distancing. It also includes effective community surveillance so that if people, especially pregnant women, have COVID-19 symptoms, they can be referred to testing and healthcare facilities if necessary. Government representatives should also conduct site visits to monitor how well CSCOMs and other healthcare facilities are maintaining infection prevention and control measures.

Recommendations

Prioritizing SRH is always important. It is especially crucial in Mali where birthrates and infant and maternal mortality rates are so high. Mali is dealing with overlapping crises including political turmoil and an interim government, conflict, displacement, chronic poverty, and the COVID-19 pandemic. Surely, the Malian government is grappling with competing priorities. However, it is also clear that SRH education is imperative and that most Malian women and girls do not receive the SRH services they want and need. This is especially true of displaced women and girls who often live in hard to reach areas and need targeted outreach. This includes door-to-door SRH education and service provision as well as GBV programs, given their heightened risk. They also need subsidized contraception because they often have less economic opportunities than their non-displaced counterparts, and the pandemic has further impacted their already limited livelihoods. Therefore, the Malian government must incorporate SRH into all COVID-19 response plans. Furthermore, the government—with the assistance of international organizations, NGOs, and donors—must develop plans to improve the quality of and access to SRH in all parts of Mali long after the pandemic subsides.

The government of Mali should:

Provide support to survivors of gender-based violence (GBV) including comprehensive sexual and reproductive health (SRH) care and improve coordination vis-à-vis GBV cases. When women and girls survive incidents of GBV, they almost always need SRH services to mitigate the negative health effects resulting from the violence. Displacement increases the risk of experiencing GBV, therefore it is especially important to include internally displaced people (IDPs) in these efforts.
Promote door-to-door healthcare services and SRH information sharing in remote areas and to displaced communities. Large portions of Malians live in rural areas, especially IDPs. There are few healthcare facilities in these regions, and the ones that do exist are often understaffed and under-resourced. It is important to train and deploy healthcare professionals to engage with people where they are by conducting mobile outreach.
Dedicate more funds to train SRH care providers, including midwives, nurses, gynecologists/obstetricians, and anesthesiologists. Ensure that they work throughout the country, especially in remote, underserved, and conflict-affected areas. To make certain that these trained healthcare providers are working where they are most effective, map out existing SRH and overall healthcare services to identify regional gaps.
Improve girls’ access to school, adopt SRH curriculum, and collaborate with the private sector to educate youth about SRH. Create a public school SRH curriculum and conduct an outreach campaign to religious leaders, encouraging them to support the curriculum. At the same time, build upon the success the private sector has had in information sharing by subsidizing their efforts to educate youth on SRH.
Subsidize the cost of long-acting reversible contraceptives (LARCs) where there are doctors and midwives to insert them. Where there are few doctors or midwives, assign trained healthcare professionals to work in those areas and build local capacity.
Ensure women have access to a full range of SRH services and information about their options during pregnancy, including abortion when appropriate. Although Mali has restrictive abortion laws, the government should allow doctors and midwives to provide information about legal abortion services and provide these services when the woman meets the legal criteria and decides to pursue this option.
Work together with international organizations and NGOs to conduct information campaigns about the importance of SRH; where women and girls can receive SRH services; and what measures health centers are taking to operate safely during the pandemic. Mitigate widespread public fear of seeking care in healthcare facilities during the pandemic by disseminating accurate information on the spread of COVID-19 and the safety precautions being taken in healthcare facilities. All of these information campaigns should explicitly include IDPs.

UN agencies and humanitarian organizations should:

Strengthen referral pathways to facilitate GBV survivors’ access to relevant service providers that provide psychosocial care, clinical management of rape, sexual and reproductive health care, and shelter. Do this by ensuring that service providers meet regularly, appropriately and systematically share case information, and ensure that even if someone is displaced, her case management continues.
Support short-term initiatives that focus on strengthening and sharing SRH information outside of schools. These include outreach by healthcare professionals, television and radio, and social media campaigns spearheaded by private companies. In addition to basic SRH education, they should also complement the government’s efforts by conducting information campaigns about the importance of SRH; where women and girls can access SRH services; and what measures health centers are taking to operate safely during the pandemic.
Provide contraception directly to public clinics, mobile clinics, and pharmacies. Because most women, especially IDPs, receive their care from these providers, it is important to assist the government in ensuring that these locations are fully stocked with short-acting contraceptives.

Donor governments and institutions should:

Fully fund the request from the UN Office for the Coordination of Humanitarian Assistance (OCHA) for $563 million for the 2021 Humanitarian Response Plan in Mali. Immediately fund the $26 million OCHA has requested for healthcare and ensure that at least some of it is directed to SRH.
Allocate financial resources to the government of Mali, but also to local non-governmental organizations (NGOs) and other civil society groups, including those led by women. Local organizations are on the frontlines of healthcare information sharing and provision, especially in rural and conflict-affected areas where most IDPs live. And women-led organizations are likely better equipped to provide SRH services and information because they personally understand the importance of SRH as well as the challenges associated with SRH in Mali.
Provide funding to help the Malian government reach the $120 million necessary to successfully implement the 2019 Presidential Initiative focused on women and children’s health. This will provide free contraception, healthcare to children under five, and healthcare to pregnant women beginning in 2022. If implemented, it will dramatically improve the health and well-being of all Malian women and girls, including IDPs.

Refugees International would like to thank Emma Dorshimer, Jessica Margolis, and Ndeye Radia Mbengue for providing significant research and writing contributions to this brief.

PHOTO CAPTION: A woman carries her daughter behind her back as she receives medical treatment for protein energy malnutrition due to difficult living conditions, at Diolia hospital’s Intense nutrition Unit on November 9, 2016 in Dioila Cercle of Koulikoro region in Mali. (Photo by Xaume Olleros/Anadolu Agency/Getty Images)