It can no longer be morally acceptable for us to wait behind the walls of our clinics and hospitals, as our patients str
2017 ANNUAL REPORT
NO MORE POVERTY DEATHS
REDEFINING OUR MORAL IMPERATIVE Dear Friends, It began with a moral question. As health care providers, when does our responsibility to patients begin? Typically, health care systems define their responsibility as for the patients who walk through their doors seeking care. I, like many of the world’s physicians and health care providers, was taught that I am responsible for providing quality health care for every patient who walks through the door asking for care. But this reactive definition of health care carries an enormous problem with it: every year, hundreds of millions of patients don’t even make it to the door of a health facility. Delayed and arrested by fees they cannot pay and distances they cannot travel, nearly half our world still does not make it to the essential medical care they need and deserve. This may be the greatest moral crisis of our time. So we need to redefine. And we start with our responsibility: for the communities Muso serves, our moral mandate belongs to every patient, and begins the moment someone becomes sick, not the moment they reach the hospital door. It can no longer be morally acceptable for us to wait behind the walls of our clinics and hospitals, as our patients struggle alone to scale the formidable roadblocks on the path to care. From that first symptom, it’s our responsibility to find our patients, and to meet them with care. This radical mandate—health care for everyone, every moment—has forced us to crack open the conventions of how we define health care. We’ve had to redefine where health care happens, who provides health care, and how we measure success. As we’ve built Proactive Care, we’ve learned that some of the world’s best health care providers have never had a chance to go to school. We’ve learned that some of the world’s most important health care can happen in a home on the edge of the Sahara. We’ve learned that our patient is also the homeless nine month old boy, living in a ditch with his mother, and also the nine year old girl spiking a fever from malaria in the middle of a sandstorm more than 17 kilometers from the nearest clinic. We’ve learned that we need to measure our failure or success by whether health improves for everyone, not just the patients who reach us. In 2017, the Muso team and you, Muso’s community of partners, patients, providers, and supporters, have redefined health care. Because of you, Proactive Care now reaches more than 300,000 people across two regions of Mali. Because of you, the Malian government now mobilizes toward connecting more than 3 million of its most marginalized citizens with care. Thank you for rising to meet our patients where they stand in the struggle for health care for all. Ari Johnson, CEO
1
THE CRISIS
NO ONE SHOULD DIE WAITING FOR HEALTH CARE
5,600,000
A SIMPLE IDEA
CHILDREN DIED IN 2016 BEFORE THEIR FIFTH BIRTHDAY
300,000 WOMEN DID NOT SURVIVE PREGNANCY OR CHILDBIRTH
2
PROACTIVE CARE = EARLY CARE = LIVES SAVED 3
REIMAGINING WHAT A HEALTH SYSTEM CAN BE WITHOUT BARRIERS
THE MUSO MODEL PROACTIVE CARE PROACTIVE SEARCH Community Health Workers and community members search for patients through door-to-door home visits, to connect them with care early. Dedicated supervisors provide 360° Supervision to support this process.
DOORSTEP CARE CHWs provide a package of life-saving health care services in the home. These include family planning, pregnancy testing, newborn screening, and treatment for children with malaria, diarrhea, pneumonia, and malnutrition.
RAPID ACCESS CLINICS Muso removes point-of-care fees, builds infrastructure, and trains staff so that government clinics can provide universal, early access to care.
4
5
MEETING OUR PATIENTS WHERE THEY ARE - WITH CARE
CARE DELIVERY IN 2017 1,442,955
99,208
CHW home visits for active case finding, diagnosis, treatment and follow up
Comprehensive and free clinic-based care for vulnerable patients
RAPID ACCESS within 24 hours
within 48 hours
within 72 hours
57%
75%
68%
84%
PERI-URBAN
94%
6%
after 72 hours
RURAL*
79%
21%
*Rural speed is calculated as averages between passive and proactive CHWs. In order for our study team to remain unbiased, we are unable to disaggregate data between the passive and proactive arms of the randomized controlled trial embedded in our rural expansion. We therefore anticipate some indicators will be lower than they might be otherwise, as our seven RCT sites are comprised of half passive CHWs, who are not conducting proactive case detection. 6
7
CARE SINCE 2008 3,259,968 HOME VISITS
379,041 CLINIC VISITS
8
9
EXPANDING OUR REACH TO SOLVE A GLOBAL INJUSTICE
10
11
EXPANSION IN RURAL MALI
THE PATIENTS WE SERVE
In February 2017, Muso launched seven rural health centers in the district of Bankass, in eastern Mali. This expansion provides care to nearly 100,000 of Mali’s most vulnerable rural citizens, and its launch marked the rollout of one of the world’s largest research studies on community health. In partnership with the Malian Ministry of Health, Muso’s expansion and RCT support a historic national scale up of CHWs to remote areas of Mali. Muso’s nine operational research hubs across Mali help guide and innovate on the government’s national scale-up.
350,000
ENDE
KANI BONZON
300,000
MALI
MUSO EXPANSION
BANKASS
Launch of rural sites
DIMBAL
250,000
DOUNDE
SOUBALA LESSAGOU KOULOGON
ENDE
KANI BONZON
DIMBAL
TORI
200,000
150,000
DOUNDE SOUBALA LESSAGOU KOULOGON
YIRIMADJO
1 Peri-Urban Site 175 Community Health Workers 1 CHW per 1,000 people
BANKASS
100,000
TORI
50,000
8 Rural Sites 200 Community Health Workers 1 CHW per 700 people
0
12
2009
2010
2011
2012
2013
2014
2015
2016
2017 13
TOWARD HEALTH EQUITY There is no reason that children born anywhere should have a greater risk of dying because they are poor. No patient should die because they can't access care. Muso conducts rigorous research to create global solutions to global injustices, testing strategies to accelerate the global effort for universal health care and child survival.
After Muso's Proactive Care approach to health care launched, the number of patient visits in study communities increased tenfold. The rate of fever among children dropped by 55%, and child death became a rare event in the communities served. To learn more about the study and its limitations, visit www.musohealth. org/research.
A seven-year study of the area of Muso's intervention was published in BMJ Global Health in 2018.1 When the study began, 1 in 7 children died before they could celebrate their fifth birthday. Seven years later, child deaths had become rare—only 1 in 142. In 2015, these communities in Mali were down to 7 deaths per 1,000 live births, a rate comparable to the United States.
To better understand the impact of the ProCCM approach on child mortality and access to health care, a team of researchers across seven academic institutions has together launched a large randomized controlled study, the ProCCM Trial, which will follow 100,000 patients from 2017 to 2020 (see page 16 for further details).
“
UNDER-FIVE MORTALITY RATE PER 1000 LIVE BIRTHS
UNDER-FIVE CHILD MORTALITY RATES [2015]
14
The drop in childhood mortality is jaw dropping.
150
120
137 114
90
60
45
30
0
- Kevin Starr, Managing Director Mulago Foundation
15 SOMALIA
MALI
INDIA
MEXICO
11 CHINA
7
7
5
2
USA
ProCCM Communities
CANADA
ICELAND
1
Johnson AD, Thiero O, Whidden C, et al. Proactive community case management and child survival in periurban Mali. BMJ Glob Health 2018;3:e000634.
2
http://www.childmortality.org
15
RESETTING THE GOALPOSTS Muso conducts rigorous research because our patients deserve evidence-based health care systems. With more than 40 countries across the world commiting to put Community Health Workers at the front lines of their health systems, the global community is in urgent need of evidence- based strategies to support these efforts. Muso is testing global solutions to support these CHW-led initiatives, to identify what strategies work, what strategies do harm, and what strategies can accelerate the global effort for universal health care and child survival. Muso’s studies don’t set out to prove the validity of our model, but to help us learn, to help us improve, to provide us with evidence to better serve vulnerable communities.
PRENATAL CARE STUDY
Through Muso’s new Proactive Reproductive Health initiative, CHWs provide home pregnancy testing, proactively, door to door. New research efforts are being developed to test whether this approach enables CHWs to find more pregnant patients, earlier, so they can be protected and healthy during their pregnancy.
FAMILY PLANNING STUDY
A new study in development will assess whether communities receiving proactive care have increased access to family planning. Mali's baseline utilization rate of family planning measures is just 10%.
16
CHW DASHBOARD STUDY
Muso, in partnership with Medic Mobile, has prototyped and deployed a cutting-edge CHW Dashboard. A data analytics platform provides personalized feedback for each CHW on the quantity, speed, and quality of the care they provide, to tailor supervision of each CHW to their precise strengths and weaknesses. We have put the CHW Dashboard to the test in a Randomized Controlled Trial. The RCT's findings will be published in 2018.
“
This is the beginning of a new phase of programming and operations research in the movement to end preventable child and maternal deaths. - Henry Perry, Senior Scientist Johns Hopkins University
RANDOMIZED CONTROLLED TRIAL
A 2013 Harvard/University of California San Francisco study brought attention to Muso’s Proactive Care health system as a global model for child survival, but it is important to note that the study had significant limitations. It was not designed to produce causal conclusions on the role of active case finding. That is why investigators from University of California San Francisco, the London School of Hygiene and Tropical Medicine, the University of Bamako, the Malian Ministry of Health, and Muso together launched a large randomized controlled trial. The 2017-2020 RCT will build from the 2013 study's findings by testing the impact of one of the model’s core components: CHW active case finding. The study tests whether CHWs who proactively search for patients will increase early access to treat- ment and decrease child mortality compared to passive CHWs, which is Mali’s current model. The RCT follows nearly 100,000 people in 137 village clusters in rural Mali over the course of three years. The 137 clusters are then randomized to receive care either from a proactive CHW who conducts door-to-door case finding home visits, or from a passive CHW stationed at a health post.
17
ADVANCING CHW PERFORMANCE Dedicated supervisors provide 360° Supervision to support the entire Proactive Community Case Management process. This ensures CHWs have active and regular mentorship for improved performance, including efficiency and quality of care.
OU
P S U P E RV I S
IO
1.
N
GR
1. GROUP SUPERVISION
BA
C 3.
18
HW
S H A D OW
I NG
IE AT
N T F E E D BA C K
A IT
360° SUPERVISION MODEL
2.
NE FEED
UD
4.
ON O
CK
E ON
P
Supervisor leads a group discussion of the common challenges and potential solutions faced by CHWs, reviews and reinforces key competencies and skills, coordinates stock monitoring and resupply for each CHW, and organizes the month's individual monthly supervision sessions.
2. PATIENT FEEDBACK AUDIT Supervisor conducts home visits without the CHW present to receive performance feedback on a monthly basis.
3. CHW SHADOWING Once per month, supervisor directly observes as the CHW provides care during home visits.
4. ONE ON ONE FEEDBACK Supervisor and CHW sit down together to set goals and identify areas of strength and improvement using personalized performance metrics and visual displays.
19
PARTNERSHIP WITH THE MALIAN GOVERNMENT Muso has served the Malian Ministry of Health as an operational research partner for the past decade. We work with the Ministry to develop and test health care innovations with the potential to improve child mortality and early access to care. Muso and the MoH jointly test innovations that are designed for government implementation at national scale. To prepare for government implementation at scale, Muso focuses on redesigning and strengthening existing government health systems: we work through government primary care sites, tap into government distribution channels as much as possible, train and support Ministry of Health clinical staff, and evaluate the impact of these innovations with policy makers. In our years of partnership, the Ministry has adopted several key strategies we have tested together, including paid, professionalized Community Health Workers providing an integrated package of doorstep health care. With Mali’s national national CHW scale-up underway, the Malian government is now working with Muso on further research to increase the impact of this national effort.
TOGETHER, WE WILL WORK TO MAKE THE DEATH OF A CHILD RARE IN EVERY COMMUNITY 20
BY 2020 335,000
PATIENT REACH BY MUSO
3.4M
PERSON IMPACT OF ROLL-OUT IN MALI 21
In the Malian communities Muso serves, a new generation of children is growing up who doesn't know life before universal health coverage and regular home visits from their Community Health Worker.
22
23
2017 FINANCIAL RESULTS 2017*
2016
REVENUE & SUPPORT GRANTS CONTRIBUTIONS
5,135,079
3,314,246
2016
2,297,834
966,536
247,223
258,944
637,000
1,174,000
-
48,642
PREPAIDS & OTHER ASSETS
47,243
39,973
5,382,302
3,621,832
FIXED ASSETS, NET
74,356
37,100
3,056,433
2,217,609
$4,000,000
$3,500,000
CASH AND CASH EQUIVALENTS PLEDGES RECEIVABLE
EXPENSES PROGRAM
2017* ASSETS
IN KIND TOTAL
EXPENSES
TOTAL ASSETS 3,943,075
GENERAL AND ADMIN
259,417
193,047
ACCOUNTS PAYABLE & ACCRUED EXPENSES
270,868
213,759
FUNDRAISING
198,914
170,903
TOTAL LIABILITIES
270,868
213,759
4,742,705
4,307,025
639,597
(685,193)
NET REVENUE
$4,500,000
LIABILITIES AND NET ASSETS
4,284,374
TOTAL
$5,000,000
$3,000,000 NET ASSETS UNRESTRICTED
1,003,911
304,850
TEMPORARILY RESTRICTED
1,781,655
1,699,000
TOTAL NET ASSETS
2,785,566
2,003,850
TOTAL LIABILITIES AND NET ASSETS
3,056,433
2,217,609
$2,500,000
$2,000,000
*Unaudited
$1,500,000 Program
2017 EXPENSES
90%
$1,000,000
General and Admin 6%
$500,000
Fundraising 4%
$0
24
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017 25
SUPPORTERS BOARD OF DIRECTORS
Rebekah Emanuel LLM, MBA, Chair
Business and Policy in Healthcare, Devoted Health
Samantha Barbee MBA
Chief Financial and Operations Officer, Chavez Schools
Jessica Beckerman MD Co-Founder, Muso
Ogobara Doumbo MD
Professor and Chair, Department of Epidemiology of Parasitic Diseases, University of Mali
Ethan S Johnson MBA
Managing Director, Ramius
Annie T Maxwell MPP
President, Skoll Global Threats Fund
Joia Mukherjee MD, MPH
Chief Medical Officer, Partners in Health
Katie Taylor
Executive Director, Pan American Development Foundation
Aissata Sow Thiam PhD, Vice Chair Biophysicist, Information Technology and Telecommunications Consultant
Sangeeta Tripathi MPP
Operations and Strategy Director, HEAL Initiative
Rebecca Weintraub MD
Managing Director, Draper Richards Kaplan
ADVISORY BOARD
Arachu Castro PhD, MPH
Samuel Z. Stone Chair of Public Health in Latin America, Tulane University
Paul Farmer MD, PhD
Chief Strategist and Co-Founder, Partners In Health
Jim Kim MD, PhD
President, World Bank Group
Molly Melching
Founder and Executive Director, Tostan
Jeff Walker
Vice Chairman, United Nations Secretary General's Envoy for Health Finance and Malaria 26
$500,000+
Bill & Melinda Gates Foundation Ray & Tye Noorda Foundation
$250,000-$499,999
Child Relief International Jasmine Social Investments Mulago Foundation Planet Wheeler Foundation USAID Development Innovation Ventures (DIV) Vitol Foundation Anonymous Donor
$100,000-$249,999
DAK Foundation David Weekley Family Foundation Deerfield Foundation Hampshire Foundation Open Road Alliance Peery Foundation Ripple Foundation Sarnat Hoffman Family Foundation Segal Family Foundation Anonymous Donor
$50,000-$99,999
The Asen Foundation Bertha Centre for Social Innovation & Entrepreneurship, University of Cape Town Bohemian Foundation The Campbell Family Fund Cubit Family Foundation Draper Richards Kaplan Foundation Elmo Foundation Jester Foundation Rob and Brooke O'Dea Sall Family Foundation Skoll Global Threats Fund Anonymous Donor
$1,000-$49,999
Norma Altshuler Aryeh Aslan Benjamin Bechtolsheim Jessica Beckerman and Ari Johnson
Daniel Berman Brian and Kathryn Brackney Ann Brouillette BTIG David & Anita Keller Foundation Rebekah Emanuel Fabrangen Tzedakah Collective Adam Fox Scott and Abby Friedman Goldman Sachs & Co. Google Inc. Alan Gordon Andrew and Ann Gore Andrew Granowitz Robert and Mary Grace Heine Elizabeth Daisy Helman Robert and Sarah Hyams The International Foundation Ethan Johnson Albert and Diane Kaneb The Larson Legacy Mark and Becky Levin Ian Linden Annie Maxwell Dana Mazo and Daniel Sharfman Jermaine and Chantal McGill The Merck Foundation Amy Pasternack and Larry Guth Tom Perkins Virginia and Steven Pollack RA5 Foundation Razoo Foundation The Robert and Maurine Rothschild Fund Inc. Rotary Foundation of Friendship Heights Oliver Rothschild Sally Beth Shore Solar Mosaic Anonymous Donors (3)
$1-$999
Alpha Theory AmazonSmile Foundation Julia Appel Jafet Arrieta Daniel and Nikki Ballarin Samantha Barbee Erin Barlage
Donna Barry Jerry and Marilyn Beckerman Abigail Bellows Arun Bhalla Talya Bock Dale Bolton Matthew Bonds Claire Bradley Rachel Braun Elihai Braun and Alyce Thompson Sarah Brodbar-Nemzer Eric Broockman John Burley and Selma Wise Burley Joaquin Carbonell Ellen Cohen Pieter Cohen Carolyn Commons Joan Cone Patrick Cook-Deegan Alison Davis Dhanna Foundation Gregory Donaker William Dumsick Nicholas Eden-Walker Daniel Esterman Jennifer and Kevin Fiori Ezra Fishman Ryan Floyd Marilyn and Alan Fogel Lucas Foglia Linda and Michael Frieze Paula Fuchs Nancy Fuchs-Kreimer Megan Furnari Jane Gehring Pamela Gerrol Robert and Shirley Gerrol Sarah Gershuny Jonathan Gibson and Eliza Mabry Gary Giles Sarah Gioe Ariel Glasner Bruce Goldhirsch Bianca Gonzalez Barbara Gorson Ari Greenberg Reuven Greenvald
Alice Greenwald Anne Grossetete Jocelyn Guyer and Joshua Seidman Harsch Family Charitable Fund Jonathon Hicks Erica Hughes Gina Hurley Alejandra Iberico Marie Iberico SOLIDARITY CIRCLE (GIFTS UP TO $1,000) Lucas Iberico Lozada Ophir Agassi Alice Jacks and David Achtenberg Howard Trudy Jacobson Daniel andand Nikki Ballarin Sylvia Johnson Donna Barry Jeremy and Margie Klein Ronkin Jerry Beckerman Gregory Kobrick Abigail Bellows Michael Kohn EllenBerman Korner Daniel Alan Lavin Arun Bhalla David Lawhead Talya Bock Phuoc Le Kristine Bos Patrick Lee Adam Levy Gershuny Sarah Bracha Charlotte MacAusland Marc and Kelly Manashil Katherine and John Maxwell Lisha McCormick Colin Meade Michelle Mehlhorn Sophia Mena Katie and Evan Metter Marguerite Metzler Barry and Arlene Millman Lonni Millman Bhakti Mirchandani Jayson Morris Karen Napolitano Nan Narboe National Institutes of Health Elizabeth Nelli Lev Nelson Josh Nesbit Network For Good Moshe Newman Katherine O'Leary Vanessa and Peter Ochs Elizabeth Ochs and Taylor Ellowitz Emlen Page
Mark and Ruth Perlis Elizabeth Phung Georges Piette Ira and Marilyn Polon Megan Preovolos Jordana Price Miriam Quintal Gary Reichelsheimer Danny Richmond Carlos Rivera Gerald and Diane Rogell Daniel Rosen Adina Rosenbaum Michael and Patricia Rosenblatt Katrina Rouse Larry Rubinstein Sandra Sabzevari and Joshua Schulman-Marcus San Francisco Prosthetic Orthotic Service Inc Lieba and Daniel Savitt Daniel Schlozman Nathan Schneider Ruth and Aaron Seidman Peter Sharfman and Tina Silber Howard and Nancy Smith Christy Snider Judith and Matthew Sonfield Aissata Sow Thiam Anne St Goar Elizabeth St Goar Margaret Stern Pat and Alan Symonds Isabel Taylor Katherine Taylor Laurie Todd Erin Toolis Erica Trauba Sangeeta Tripathi Cassia van der Hoof Holstein and Peter Albers Mary Virginia Thur and Benjamin Rothermel Marny and Rick Wasserman Lowell Waxman Rebecca Weaver Michael and Roberta Wentworth Calvin Whidden Thomas Wilson Charitable Fund Elaine Zitomer Susan and Alan Zuckerman Anonymous Donors (13) 27
HEALTH CAN'T WAIT
SUPPORT MUSO 3254 19TH ST, 2ND FLOOR, SAN FRANCISCO, CA 94110 WWW.MUSOHEALTH.ORG/DONATE 28
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