The costs and constraints of pandemic response in Mali*

Mali is one of the least developed countries in the world, ranking 184 of 189 on the Human Development Index (United Nations Development Programme 2021). Average per capita income is estimated at US$2,269. Mali's poverty rate (less than US$1.90 per person per day) remains high, falling from 43.3% in 2017 to 41.2% in 2019 (World Bank 2020, 42). Low levels of formal education are also increasing.

Since 2012, Mali has been challenged by high structural insecurity. In 2012, a military coup coupled with the takeover of much of Mali's north by jihadist insurgents created political crisis. Despite democratic elections in 2013 and subsequent peace talks, the north remains insecure, and violence has spread to central Mali. Community self-defense groups have often set off intercommunity violence. Owing to national political instability, travel is dangerous in areas of Mali. Another coup in August 2020 was followed by a transition government of civilians and military in September 2020.

Despite its problems, Mali has maintained a robust public health structure. Many basic health indicators have recently improved. Mali participates in international health activities such as childhood vaccinations and HIV programs. When Mali recognized its first official cases of COVID-19 on March 25, 2020, about three months after the first publicized cases in Wuhan, China, Mali's Ministry of Health and Social Development had already elaborated an action plan against COVID-19. Nevertheless, its ability to respond was hampered by larger international inequalities, internal socioeconomic inequalities, and the microeconomics of everyday life in a poor country.

This essay is based on information I gathered as a member of the scientific commission put into place by the Ministry of Health and Social Development to advise national authorities on the COVID-19 response. My reflections here are my own and based on my experience as a researcher, not as a member of the commission. The commission focused on health guidelines. Nonetheless, the data collected from many actors, including health professionals and community members (the sick and former patients, those in isolation, contacts of patients) provided much additional information. This piece is focused on two major issues: (a) how inequalities affected responses to the pandemic and (b) how the microeconomics of everyday life touched household responses.

Mali's ability to maintain its public health structure has depended in part on access to international programs that provide tangible resources. Certain parts of the structure were also weak, such as diagnostic testing capacity throughout the country. Actions in the Ministry of Health's plan included prevention, epidemiological surveillance, and breaking the transmission chain. Isolation and treatment centers were put into place. International borders were closed for some time. Health personnel were provided gloves, masks, and other personal protective equipment. Key measures were employed to sensitize, inform, and involve the population. People were encouraged to physically distance, wash hands, use hand sanitizer, and wear masks. Curfews, market and school closures, and isolation and quarantine plans were implemented. The cost of the plan was estimated at more than 2 billion CFA francs (US$3,478,260),¹ which was not immediately available. So, Mali requested financial and technical assistance from multilateral and bilateral partners to meet its costs.

Another aspect of the plan was to mobilize the entire society against the epidemic. Community and religious leaders, traditional health practitioners, women's and youth associations, and community health organizations were involved to increase public awareness and disseminate information. However, some of the efforts were stymied because many Malians denied the importance of the disease. People believed that it did not exist or that if it did, it did not affect Africans. Rumors reflected international and domestic inequalities.

Some rumors circulating expressed that the pandemic affected whites; Europeans may suffer from the disease, but it did not exist in Africa. A variation was that the pandemic came from a botched plot meant to exterminate Africans; instead, it attacked the people who planned it. In either case, the pandemic was created by whites. It was a strategy to make money by selling the means of prevention, including masks and hand sanitizer, and eventually drugs and vaccines.

Other rumors focused more directly on the elites within Mali. Some said that the pandemic was a political affair that allowed the powerful, especially national authorities, to make money. For example, the presidential initiative “One Malian, One Mask,” created to increase availability of masks, lacked clear procurement and distribution mechanisms, nor did local industries step in to make affordable masks. These results led some to believe that certain powerful people benefited personally. The pandemic could also enrich those who claimed they were sick. People cited actual amounts that individuals had received. Anecdotes about money given to sick people, to relatives of sick people, or to people who claimed they had the disease but did not fed these rumors. The pandemic would only end when the money for these payments was spent, according to the rumors.

A real program to aid the vulnerable may have enhanced the misinformation. The Malian government soon realized that the pandemic would pose additional expenses to people. It therefore requested that the World Bank use an existing 2013 program, the Emergency Safety Nets Project (Jigiséméjiri in Bamanan), to serve as the executing agency for payments to the most vulnerable. The program provided one-time payments of 90,000 CFA francs (US$157) to identified households; the first transfers, to 62,900 households, occurred in January 2021. To complement the Jigiséméjiri program, the Malian Red Cross created a similar program for the capital of Bamako and its surrounding regions; it targeted people, such as food sellers and taxi drivers, whose work was affected by the pandemic. It offered a single payment of 75,000 CFA francs (US$130).

The pandemic led to higher expenses and loss of income for households in both rural and urban areas. People faced new expenses to buy and use masks and hand sanitizer. Wearing masks seems simple, but many Malians found it costly. One mask cost 500 CFA francs (US$0.87), but many people needed more than one. Given Mali's heat and dust, many needed at least two masks per workday. At home, there was family and social activity, so another mask was required. Three masks per day at 1,500 CFA francs per day (US$2.61) would cost 45,000 CFA francs per month (US$78), more than the legal monthly minimum wage of 40,000 CFA francs (US$70). Many farmers do not even make the minimum wage. One Bamako resident said that even if the price of a mask were only 100 CFA francs (US$0.17), many in his community could still not afford them. The chief of a Bamako neighborhood added that even some residents who had resources did not want to spend money because they did not believe in the impact of the disease. People who did not believe the disease existed did not wear masks. Mask wearing was enforced only in certain institutions, such as health centers and banks. At social events, it was rare for people to wear them.

Although many Malians wash their hands regularly before eating and praying, they do not always use soap and rarely wash for the recommended twenty seconds. Recommended handwashing strategies for COVID-19 required the purchase of more soap. The use of hand sanitizer is rarer and poses greater cost. Handwashing with soap and the use of hand sanitizer were respected only in public places where they were required.

Prevention measures, such as physical distancing, also led to a loss of income. Many Malians make their living from microenterprises that produce food, agricultural products, goods, and services. Many depend on buses and taxis for transit. Even in big cities, minibuses are owned and run by private individuals, and the income of owners and drivers depends on the number of passengers. Taxi and bus capacity was limited to one-quarter to one-third of the earlier numbers of passengers. Some minibus drivers simply refused to respect these requirements. Some taxi drivers said their daily revenues dropped to where they could not cover the price of fuel and food. Limits on participants in social events to fewer than fifty persons led to a reduction of revenues for support personnel, such as caterers, photographers, and videographers. In rural and urban markets, shorter hours led to lower daily receipts. But sellers had to make sales. They rarely required masks, and physical distance was rarely respected.

People in isolation or quarantine could not work. Some lost work when their employers could not pay them. School closings affected private school teachers because they were paid only when they worked. The many vendors near schools also lost their clientele. Thus many people earned lower incomes at precisely the time that they were expected to pay for prevention.

The program of emergency monetary transfers was meant to cover 1 million households impacted by COVID-19. People who received these transfers could use them however they desired. Often, investment in protection was not a priority, especially among those who denied the existence of the disease. People needed basic necessities, including food. The goal was often to feed themselves so that they could continue to breathe, rather than to cover their mouths and noses against the virus. Those who received resources because of their vulnerable situation in regard to COVID-19 often continued to see the resources as a payment against poverty and vulnerability rather than as a payment for protection against coronavirus. Recipients were not monitored to see how they used the cash transfers. It was assumed that COVID-19 grants would be used for prevention against the disease; without monitoring, it is impossible to know if this was the case.

By August 10, 2021, Mali had posted 14,652 official cases of coronavirus and 563 deaths (Ministry of Health and Social Development 2021). Its national economy had suffered. Owing to a drop in revenue, the government faced a deficit of 5.5% of gross domestic product in 2020 (World Bank 2021). There was also a 5% increase in the poverty rate (World Bank 2021). Before the crisis, estimates were that the poverty rate would decrease to 35.6% in 2022; a more pessimistic post-COVID scenario estimated that the rate would be 43.6% in 2022 (World Bank 2020, 42). The combination of health, political, and social crises had increased Mali's poverty rate to earlier levels.

Because individuals needed to physically distance, wear masks, and use more soap and hand sanitizer, the pandemic impacted household microeconomies. Many Malians, including the estimated half of the population in poverty, lacked the capacity to support the cost of prevention, especially when they also lost income. People who had sufficient resources still often invested little in prevention, insofar as many did not believe in the existence of the disease or the strength of its negative consequences.

Long-term results will be uncertain as long as the distribution of responsibilities between people and the state is unequal, with the largest burden placed on individuals. As with any health-seeking behavior (Diarra 2012), individual decisions about the pandemic were affected by multiple factors, including economic issues. The response of Malians to the pandemic shows that the history of international and domestic inequalities was important, as were the everyday microeconomies of household choices. These international and domestic inequalities are unlikely to change in the short term. A successful response to the pandemic needs to be based on a holistic approach that takes into account the possibilities and constraints on individuals and households.