Intended for healthcare professionals


Can a low income country move towards universal health coverage?

BMJ 2019; 367 doi: (Published 12 November 2019) Cite this as: BMJ 2019;367:l6198
  1. Sophie Arie, freelance journalist
  1. London, UK
  1. sophiearie{at}

Mali, in west Africa, is where the idea that user fees for healthcare could work in poor countries was established. Sophie Arie finds that the country is now starting down a very different road

Mali is a vast and troubled country. Much of it is lawless Sahara desert, where UN peacekeepers have failed in recent years to root out jihadists and criminal gangs. To the south, where the Sahara ends and the Niger river flows, Malians are living on the front line of climate change, with increasingly extreme floods and droughts. A bloody conflict between rival communities in central Mali became so bad in May that it triggered a change of government. Two thirds of the country is a no-go zone, according to the UK government’s travel advice.1

Yet in the middle of all this, Mali is introducing an ambitious new plan for universal healthcare. “With this programme, we will drive change and move to building a healthy society,” said health minister Michel Sidibé in a telephone interview.

His troubled west African nation of 18 million people is badly in need of better and more accessible healthcare. Malian women have the fourth highest fertility rate in the world (six children per woman on average). The country has some of the worst health indicators, with child mortality at 106/1000 live births and maternal mortality at 587/100 000.2 It is among the 25 poorest countries in the world.3

From hospitals to community care

Under the plans, announced in March and to be rolled out gradually by 2022, there will be a shift from a system focused on hospital services that patients pay for at the point of care to a community healthcare model that is free for pregnant women, children under 5years old, and anyone over 70. Some 27 000 community healthcare workers will go door …

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