Exploring how social inequalities in health have influenced the design of Mali’s SARS-CoV-2 testing policy: a qualitative study

Abstract

In the fight against infectious diseases, social inequalities in health (SIH) are generally forgotten. Mali, already weakened by security and political unrest, has not been spared by the COVID-19 pandemic. Although the country was unprepared, the authorities were quick to implement public health measures, including a SARS-CoV-2 testing programme. This study aimed to understand if and how social inequalities in health were addressed in the design and planning for the national COVID-19 testing policy in Mali. A qualitative survey was conducted between March and April 2021 in Bamako, the capital of Mali. A total of 26 interviews were conducted with key government actors and national and international partners. A document review of national reports and policy documents complemented this data collection. The results demonstrated that the concept of SIH was unclear to the participants and was not a priority. The authorities focused on a symptom-based testing strategy that was publicly available. Participants also mentioned some efforts to reduce inequalities across geographical territories. The reflection and consideration of SIH within COVID-19 interventions was difficult given the governance approach to response efforts. The urgency of the situation, the perceptions of COVID-19 and the country’s pre-existing fragility were factors limiting this reflection. Over time, little action has been taken to adapt to the specific needs of certain groups in the Malian population. This study (re)highlights the need to consider SIH in the planning stages of a public health intervention, to adapt its implementation and to limit the negative impact on SIH.

COVID-19, equity, design, planning, testing, Mali

Key messages

• This qualitative study reviewed if and how social inequalities in health were considered during the design and planning of the COVID-19 testing policy in Bamako, Mali.

• Despite the efforts of Malian authorities to reduce inequalities across geographical territories, results showed that the concept of social inequalities in health was unclear to the participants and was not a priority during the testing policy.

• Efforts must be continued to put social inequalities in health on the national and global agendas in the design of public health interventions.

Introduction

Like all Western African countries, Mali was hit by the COVID-19 pandemic in 2020, slightly later than Asia and Europe. The first two cases were identified on 24 March 2020: two people of Malian nationality who arrived from France on 12 and 16 March (Toumanion and Giani, 2021). Since then, five epidemic waves have followed one another and seroprevalence studies demonstrate that SARS-CoV-2 has circulated widely in the country (Sagara et al., 2021).

Mali has been confronted with multiple epidemics for several decades, such as Ebola virus disease and HIV, which has resulted in various control and prevention efforts. These efforts and activities have been useful for informing the SARS-CoV-2 response (Sagaon-Teyssier et al., 2020; Gholizadeh et al., 2021), however Mali is considered a fragile country (Ag Ahmed et al., 2021). It has been in a security crisis for many years, with a poorly performing health system (Olivier de Sardan and Ridde, 2015; Touré and Ridde, 2022) whose public health actions are largely dependent on international aid. In 2019, Mali received US$1.8 billion in official development assistance (World Bank, 2021). Thus, the Malian state allocates only 5.4% of its budget to the health sector and 26.5% of health expenditure is financed by official development assistance (World Health Organization, 2021). As with most countries (Tessema et al., 2021), Mali was not fully prepared to deal with a pandemic of this magnitude.

However, as elsewhere in Western Africa (Bonnet et al., 2021), Mali quickly adopted public health measures to tackle the COVID-19 pandemic. For example, schools and universities were closed on 19 March 2020, followed by border closures on 20 March, and a curfew was instated from 26 March (Bonnet et al., 2021; Diarra, 2022). A national action plan for the prevention of and response to COVID-19 was launched in March 2020 with an estimated budget of more than 3.3 billion CFA francs (Diarra, 2022). Testing for SARS-CoV-2 infections is one of the central interventions for controlling the pandemic. The World Health Organization (WHO) has disseminated multiple guides to support countries in their SARS-CoV-2 testing programmes, including settings such as Mali (IASC, 2020). However, equity issues are not well or clearly addressed in these guidelines, beyond stating that ‘equity must be the guiding principle’ according to the WHO (IASC, 2020).

Indeed, the WHO and most countries rarely address inequality issues in their policies or guidelines (Paul et al., 2019; IASC, 2020; Amri et al., 2021). We have known for several years that if population-based interventions do not account for the specific needs of subgroups, the interventions will likely increase social inequalities in health (Ridde et al., 2007). The failure to take inequalities into account when designing and planning interventions has been the status quo, as two recent systematic reviews have shown for population-testing (Ost et al., 2022) and contact tracing (Mathevet et al., 2021).

Few empirical studies have been conducted to better understand if and how social inequalities in health (SIH) have been considered in COVID-19 control and prevention measures in Africa, beyond calls to include SIH (Glover et al., 2020; Marmot and Allen, 2020). We conducted an empirical study in Mali to understand how SIH had been considered in the design and planning of the national SARS-CoV-2 testing programme.

Methods

Positionality of the research team

This qualitative study took place in March and April 2021 in Bamako, the capital of Mali. This work was part of the public health component of the HoSPiCOVID research project, a larger multi-country research programme, which examined the resilience of health systems during the early waves of the COVID-19 pandemic (Ridde et al., 2021). This specific study was conducted by a team of researchers featuring diversity in terms of gender, nationalities (Malian, French, Canadian), experience (junior and senior) and discipline (anthropology and public health). The two researchers who conducted the interviews have been involved in social science research in Mali for many years and several of the other authors are very familiar with the national context. This facilitated access to some of the key stakeholders involved in the management of pandemic response efforts. None of the authors was involved in the public health response to the pandemic.

Sampling

Individual semi-structured interviews were conducted with 26 participants selected using purposive sampling. This sampling approach allowed for in-depth knowledge generation (Patton, 2015). To obtain detailed intervention descriptions, we first targeted a variety of key actors who were involved in planning phases of COVID-19 testing (Mali’s central and local governments, national and international partners). Then, through a snowballing strategy, we were directed to other experts involved in the testing programme.

Participants

We conducted interviews with 2 women and 24 men, the majority of whom were from the Ministry of Health and Social Development (n = 16), including the pandemic response committees (scientific committee, national coordination, crisis committee). Officials from the Ministry of Security and Civil Protection, to which the intersectoral platform is attached, also participated in the study (n = 2). With regard to technical and financial country partners (n = 8), both national and international, we targeted organizations working with vulnerable groups, those that participated in intersectoral meetings and those that played a major role through their material and/or financial support to the authorities (e.g. Malian Red Cross, World Health Organization).

Data collection

The interviews were conducted using a guide developed in collaboration with the teams from the four countries involved in the public health component of the HoSPiCOVID programme (Savard Lamothe et al., 2022) and tested in pilot interviews. The guide was designed based on selected components of the REFLEX-ISS tool (Guichard et al., 2019), as detailed in the next section. The interviews lasted between 30 and 60 min and were conducted in French. The interviews were recorded, if informed consent was provided, and audio recordings were transcribed.

A documentary review of national reports and policy documents complemented the interview data (see the list in the  Appendix). These documents were identified during the course of the study, as our understanding of the context evolved. Some were downloaded from the Internet, others were forwarded by participants. Decrees and ministerial orders were collected from the website of the General Secretariat of the Government of Mali. These documents made it possible to identify the actors involved in the management of this health crisis, the members and the role of each committee created for the response to the pandemic. These texts added to the elements collected during the interviews, helping us to understand the organization and chronology of the pandemic response in Mali.

Data analysis: a theoretical bricolage

The analysis of the qualitative data was carried out following a deductive and inductive approach (Denzin and Lincoln, 2017). The deductive approach was based on a conceptual model built specifically for this study.

Based on prior interdisciplinary works (Jones et al., 2021), a ‘bricolage’ conceptual model was designed by our research team. Combining theoretical and analytical instruments into one (the ‘bricolage approach’ is often recommended in health policy and systems research) allows for a more holistic analysis of the consideration of SIH in the intervention design and planning (Gagnon-Dufresne et al., 2022). Specifically, we combined and adapted components of three tools and theoretical works, which we detail below.

We first considered the REFLEX-ISS tool. Faced with the lack of consideration of SIH in public health interventions (Ridde et al., 2007), the REFLEX-ISS tool was created to support stakeholders in considering SIH. Based on evidence and developed with public health implementers and decision-makers in France and Canada, this tool proposes a reflective, not normative, approach to support public health actors in their consideration of SIH (Guichard et al., 2017; 2018; 2019). It is based on an analysis/reflection grid with a set of questions containing the elements deemed important to carry out actions to address SIH in planning, implementing and evaluating public health interventions. We used this tool’s components relating to planning as a guiding framework in the context of research aimed at understanding how SIH have been considered in health interventions. For example, we have recently used the tool in Montreal, Canada to analyse the consideration of inequalities in COVID-19 testing and contact-tracing programmes (Gagnon-Dufresne et al., 2022).

In addition to the REFLEX-ISS tool, we reviewed and integrated components of seminal theoretical works on public policy design and public health planning from Howlett and Pineault, respectively (Pineault and Daveluy, 1995; Howlett, 2019). The full bricolage framework is available in Table 1. (Source: authors’ own elaboration)

Table 1.

Development of the ‘bricolage’ conceptual model used for this study

Reference	Stages of policy and public health intervention design and planning explored in the literature
Policy design (Howlett 2019)	Synthesis of available evidence	Solution development and evidence-based decision-making	Consideration of diverging stakeholders’ interests	Anticipation of the potential effects of the proposed solutions
Planning of public health interventions (Pineault & Daveluy 1995)	Strategic planning	Tactical and operational planning	(Implicit)	Operational planning
REFLEX-ISS tool (Guichard et al., 2019)	Analysis of problems and needs	Objectives, justification and conception of SIH	Involvement of partners and the population	(Not applicable)
Combined, ‘bricolage’ model	A. Understanding and perception of SIH	B. Strategies and approaches to address SIH	C. Intersectoral collaboration in design and planning	D. Adaptation capacities (accessibility, acceptability, availability)

Second, we applied inductive reasoning, which allowed additional analytical components to emerge that would not have been specified in the a priori analysis model. Indeed, in addition to the three key categories of the REFLEX-ISS tool, a fourth emerged inductively from the interviews.

Coding of the transcripts with MAXQDA software allowed the identification and classification of the most relevant speech extracts. The codes emerged inductively and were categorized thematically according to the REFLEX-ISS categories. Based on our deductive–inductive approach to analysis, and building upon the aforementioned bricolage model, our analytical model features four categories that provide structure to the results section below: (1) designers’ and planners’ representations and perceptions of SIH (which matches Category A of our bricolage model), (2) strategies to address SIH and subsequent adaptations (which matches Category B of the bricolage model and also integrated Category D), (3) governance and intersectoral collaboration in design and planning (which corresponds to Category C) and (4) obstacles to SIH consideration (additional, inductively-built analytical category).

Results

A confused representation of SIH

The majority of responses implied that participants were not familiar with the concept of SIH. There was little specific knowledge about the SIH and they were also not seen as a priority from the outset. A minority of actors, trained in public health, seemed to have a better grasp of the subject.

First, the concept of SIH appeared to be poorly understood:

What do you mean by social inequalities, in relation to COVID? (National coordination)

Well, maybe we don’t use the same terminology when you talk about… Your terminology here is? (Intersectoral platform)

Secondly, for many participants, having SARS-CoV-2 testing open to all, without discrimination, was considered to reflect considering the SIH. Indeed, when the SIH were mentioned, the participants often replied that COVID-19 testing had been egalitarian and universal:

It’s a global strategy so it targets all categories. As it has been done, there is no category that is not targeted. (Scientific committee)

Moreover, the fact that the patients include vulnerable people but also a diversity of profiles shows, according to the participants, that there were no inequalities in terms accessibility to the testing.

If we decipher the typology of cases, there is a bit of everything. (…) Now the professions, all the professions are, the medical profession was also a victim (…). I don’t see how there was any social inequality in the testing. (National coordination)

For some participants, the consideration of SIH was reduced to a single determinant. The fact that the financial aspect (free testing) or the geographical aspect was considered, meant that the SIH were accounted for.

The fact that testing is free, the fact that the rapid response team travels free of charge to take samples, means that social inequalities are considered. (National coordination)

Finally, one respondent felt considering SIH appeared to have ‘no added value’ in the Mali context:

If it’s not the geographical or security constraints, we don’t have this kind of inequality in Mali. Whether you are rich or poor, whether you are intellectual or not, we will have the same service for the whole population. (Intersectoral platform)

A universal approach first, then adapted to needs

A comprehensive response

In the response plan (Ministry of Health and Social Development, 2020), certain subpopulations were mentioned (e.g. children, pregnant women, disabled persons, the elderly) in order to adapt the medical care to these groups. No explicit reference was made in the testing programme, which focused exclusively on symptomatic cases and contacts. Participants confirmed that the notion of SIH was not explicitly discussed at the outset, as limiting the spread of the epidemic was the primary concern of the actors.

I think that this is a reflection that has not been de facto and from the outset in our way of doing things. (…) Personally, I didn’t think about what, all I was interested in was following the evolution, defining strategies to quickly break the evolution of the disease. (International partner)

With a vocabulary focused on equality, there was a form of pride in saying that no one had been left out of the testing:

There has been no discrimination, everyone is equal, whether it is the care, everything, there has been no distinction. (Ministry of Health)

Rationing logic

The choice of restricting testing to those with symptoms was justified by the low material capacities. Despite donations from their partners, the authorities were faced with a lack of inputs (e.g. swabs, lab materials), forcing them to manage testing in a logic of resource rationing and restricting its promotion.

It was only towards the end of 2020 that we started to increase the number of tests because we were afraid to finish the tests (…) We didn‘t have enough tests so we couldn’t do as much, we had to limit. (National partner)

In order not to have a break in testing, we were obliged to limit promotion to ensure that there was no break in testing. (Scientific committee)

Promoting access to testing and information

Three main strategies have been deployed since the beginning of the pandemic to facilitate access to testing and information on COVID-19: free testing, rapid response teams and a toll-free number. The participants often used the example of these strategies to show that efforts have been made to address SIH.

This notion of free access was an approach to facilitate access to SARS-CoV-2 testing. Rapid Response Teams (RRT), part of the Regional Health Directorates, initially went to residences to take samples from suspected cases. They then transported the samples to the National Institute of Public Health, responsible for centralizing samples and test results, and the patients to a treatment centre if necessary. This ‘outreach’ movement and the fact that the service was free, was a strategy to promote geographical access to testing. However, the outreach and the protective equipment worn by RRT team members led to the stigmatization of the families visited. Given these difficulties and the growing number of cases, the teams’ visits to residences were then limited and sampling was concentrated at the reference health centres (district hospitals). The introduction of home-based follow-up also led to a reorganization of the missions of these teams during the year 2020.

Finally, the toll-free number, which was available 24 h a day, was managed by a call centre that reports to the Ministry of Health. Initially, only doctors were recruited but it quickly required other personnel, which included medical students. Between March 2020 and March 2021, nearly 700 000 calls were received, mainly from Bamako. This toll-free number acted as the first contact with the general population; it was a tool used to facilitate access to information while providing input for epidemiological surveillance. Information was collected during the calls (e.g. age of the individual, reason for call), which was used to inform pandemic response measures, such as tools to fight rumours.

Initiatives to reduce geographical inequality

There was geographic inequality between urban and rural areas, given that the four laboratories capable of conducting the RT-PCR diagnostics were located in the capital Bamako. Decentralization of laboratory capacity was a concern of the authorities from the outset and the aim was to facilitate access to the test for rural areas and also to relieve the four Bamako facilities.

The plan to decentralize laboratory diagnostics (Ministry of Health and Social Development, 2021) mainly included aspects related to strengthening the capacities of regional laboratories and also making diagnostic tests available at the various levels of the health pyramid, with the introduction of rapid antigen tests at sanitary cordon and health district level. Three strategies described by the participants would also be implemented among the population to facilitate access to COVID-19 testing and to provide information: mobile laboratory, community health workers-sentinels (CHW-S) and an outreach communication campaign.

The mobile laboratory was deployed for the first time outside of Bamako from 28 May to 4 July 2020, first to Timbuktu and then to Mopti, via funding from Mali’s government and support provided by the UN Stabilization Mission in Mali (MINUSMA). The number of cases of COVID-19 became alarmingly high among MINUSMA staff but also in the community in Timbuktu. Given the difficulty of sending samples from Timbuktu to Bamako, MINUSMA provided logistical support for the transport of the mobile laboratory into the city. Anyone who wanted to be tested could do so, which was well supported by the general population and decreased the transmission in the area, according to the participants. As an increasing number of MINUSMA agents tested positive in the city of Mopti, the team then moved there to replicate the testing outreach programme. But this effort was ultimately unsuccessful, as health workers and the population were preoccupied with preparations for the Tabaski holiday (the Muslim festival of Eid el-Kebir).

The CHW are caregivers who intervene for health purposes within their community where access to health care is precarious. In parallel to these activities, CHW-S were deployed within the framework of COVID-19 at the initiative of the Ministry of Health and its partners, given financing received from the Global Fund and the Global Alliance for Vaccines and Immunization. A total of 564 CHW-S and 32 supervisors were recruited to provide support and awareness at the community level. Between September and December 2020, the CHW-S went door-to-door in the neighbourhoods of the six communes of the Bamako district. In case of suspected COVID-19, the CHW-S referred people to the RRT for testing.

The National Centre for Information, Education and Communication for Health implemented a community communication operation by recruiting 36 volunteers. They travelled through the streets of Bamako between July 2020 and January 2021 to raise awareness of the barrier measures and disseminate information about COVID-19. The awareness caravan was funded by UNICEF.

We used volunteers, who are in tricycles with sound systems and megaphones, the driver drives, and the volunteers pass on messages. When they arrive at the gathering places, they distribute posters. (National coordination)

Governance not conducive to the consideration of SIH

Challenges of intersectorality

The health nature of the crisis meant that leadership fell to the Ministry of Health. This has led to divergent opinions, with some criticizing this leadership while the health sector felt there was a lack of autonomy, especially financial. Indeed, the resources allocated to the management of COVID-19 were divided between several ministries, which did not satisfy the health sector, which felt that funding should be centralized at the Ministry of Health. The example of the ‘1 Malian, 1 mask’ operation launched in April 2020 by the then President Ibrahim Boubacar Keïta was mentioned several times by participants, as the resources for this programme were granted to the Ministry of Industry and Trade.

‘1 Malian, 1 mask’ never saw the light of day, it turned into folklore in reality, I say it and I assume it. (…) It is not the Ministry of Industry and Trade that should be responsible for such a project. It’s absurd! (Ministry of Health)

Some participants also deplored the lack of synergy between the various committees, which undermined the cross-sectoral approach that is necessary to account for SIH.

I must admit that I am bitter about everything that has happened. Because when you have a disease like this, it’s not the right attitude, you go in all directions, you don’t even know who is doing what. (National coordination)

Politicization of decisions

Many of the participants regretted that politics took precedence over technical recommendations. The scientific committee made many recommendations, particularly at the beginning of the pandemic, such as postponing the legislative elections. These recommendations were not always followed. Others also spoke of their discouragement at the lack of feedback that was provided on their technical proposals:

We proposed a lot of things. When we agree, we work on a document for weeks. We agree on it. We send it off and there’s not even any feedback, we don’t know why it was refused. It’s the politicians who decide. (Intersectoral platform)

Fragmentation of partner support

The support of technical and financial partners (WHO, World Bank, UNICEF, USAID, UNHCR, UNDP, etc.) has been substantial and diversified but was not always given in a coordinated manner. This fragmentation of support did not allow for common objectives and actions.

The partners can’t, everyone comes yes yes I have my money I go I pay what I want I bring, no no it’s not like that. If there is a change, that’s where we have to go. (Ministry of Health)

However, the COVID-19 humanitarian plan published in August 2020 was a good example of pooling the activities of humanitarian partners. This plan was largely focused on communities at the centre and north of Mali (UN Office for the Coordination of Humanitarian Affairs, 2020). The idea that vulnerable populations were the responsibility of humanitarians was mentioned several times by respondents.

Obstacles to considering SIH

Urgency and unpreparedness

The context of a health emergency appeared to be an obstacle to considering SIH, forcing an urgent reaction to limit the transmission of the virus. The priority was to understand this new pathogen, understand and learn the different protocols and tools, and organize the different response efforts.

It was a challenge. We had to quickly gather the means and operationalise them so that any suspect case could be diagnosed. It was a new virus, we had to understand everything, we had to know very quickly and act. (National coordination)

Population beliefs

The participants also mentioned the denial of COVID-19 as hindering the population’s perception of the importance of testing. This perception was further reinforced by the asymptomatic cases and the ‘invisibility’ of the disease.

I think that in terms of social inequalities, we see the possibility of having the means to access health care services, but there is a factor that perhaps we don’t pay attention to, which is the cultural factor. What are you going to do with someone who considers that it’s just an illusion, that even if he’s two steps away from the structure he’s not going to get tested? So you see that in this situation social inequality must rather involve the notion of inequality of acceptance and understanding of the phenomenon. (International partner)

The majority of the participants mentioned general fear and mistrust in the population as well as the stigmatization of people affected by COVID-19.

A fragile context

Participants also pointed to the country’s overall political, health, security and humanitarian fragility to explain that the response efforts, including testing, were organized ‘with the means at hand’.

We have been experiencing a crisis for more than 10 years, with all the realities, emergencies, and then the state’s capacities not being up to the task, because responding to many things at the same time was a bit difficult and priorities had to be made. We dealt with this pandemic with the means we had at our disposal. (National partner)

Discussion

Despite the unexpected emergence and rapid spread of SARS-CoV-2, it was foreseeable that the pandemic exacerbated SIH (Marmot, 2015). While data from Mali on SIH within the pandemic context are not yet available, beyond differences related to living in a rural or urban environment (Sagara et al., 2021), studies are beginning to confirm this hypothesis in other countries (Bambra et al., 2020; Bajos et al., 2021; Chung et al., 2021). Several of our study participants, which included public health officials, had limited knowledge of SIH. This lack of awareness likely explains part of the reason why there was not consideration of the differentiated needs between subgroups of the Malian population. Our work in other countries also demonstrates that disregarding SIH within pandemic response measures was not specific to Mali but was in fact pervasive.

Several studies in West Africa have demonstrated that there is a fundamental lack of understanding of the concept of SIH among public health actors (Ridde, 2008; Paul et al., 2019; Rossier and Soura, 2019). Data from this study showed the challenge for participants to differentiate between equality and equity. It is unclear if this lack of understanding, as in Burkina Faso (Ridde and Samb, 2010), is due to a lack of training on SIH and its associated concepts, or whether it reflects in part, a local conception of social justice that is far removed from John Rawls’ maximin principle of giving more to those who have less (Ridde, 2006). The concept of proportionate universalism (Marmot, 2015), beyond its complexity and the challenges of its practical application (Francis-Oliviero et al., 2020), is widely debated in global health but does not yet seem to be part of public health training or discussions in Mali (Gautier et al., 2021). However, there are multiple guides and training courses, including in French, to support these approaches in intervention design, notably the REFLEX-ISS tool (Guichard et al., 2019).

In Mali, the prioritization of efficiency over equity for health policy has been evident, even prior to the emergency context of the pandemic (Touré, 2013; Gautier et al., 2021). Politics also influenced the planning of the testing programme, despite the need for evidence-based decision making. This issue was also cited by street level (health) workers in Mali. Neither the policymakers, who often guide the planning stages of interventions/programmes, nor the ‘front-line’ technicians, who work on implementation but may also be involved in the planning stages (Cohen and Aviram, 2021), seem to have considered SIH. A specific study among these different forms of actors (political and frontline) would be useful to better understand this missed opportunity. Seizing windows of opportunity to act on equity remains an important challenge (Ridde et al., 2007; Farrer et al., 2015).

Pandemic control and response measures in Mali have been largely dependent on international aid and actors, who normally participate in high-level technical or financial planning meetings and activities. Some local Malian perceptions of this suggest that it is a ‘white man’s business’ (Traoré, 2021), and that COVID-19 is an invention of white men. The WHO or World Bank do not have clear strategies in how to address SIH in programmes (Ridde et al., 2018; Turcotte-Tremblay et al., 2018; Amri et al., 2021). Furthermore, the COVID-19 pandemic did not improve the fragmentation of these technical and financial partners in terms of their interventions and support. Intersectorality, which is conducive to taking equity into account (Blas et al., 2016), was not sufficiently mobilized by the government in the design of this intervention, as seems to be the norm worldwide for this epidemic (Rajan et al., 2020).

Finally, the study demonstrated that those who designed the interventions showed a certain amount of reflexivity and attempted to adapt, even redesign, the SARS-CoV-2 testing programme as it was implemented. These actions did not improve the consideration of SIH, as they remained anchored in their egalitarian rather than proportional perception and mainly focused on financial and geographical barriers to testing access. This is not surprising as focusing on financial and geographical barriers have been the main priorities of public health interventions delivered by the Malian health system (Maïga et al., 1999; Touré, 2013). They could have instead acted on the multiple social determinants of health (e.g. education and literacy, social environment) as would have been logical to address the SIH (Gilson et al., 2007; Marmot, 2015).

In terms of methodological limitations, it is worth noting the challenges of meeting with top-level actors during the pandemic, but we were able to obtain a relevant and sufficiently diverse sample of participants. The challenges of obtaining interviews with officials were exacerbated given the politicization of the pandemic in Mali. With regard to our analytical approach, despite some difficulties of REFLEX-ISS tool’s application to the Mali’s context, the adoption, in concert with the wider research team, of a bricolage model (Gagnon-Dufresne et al., 2022) was successful. According to our understanding, the use of the REFLEX-ISS tool was indeed a challenge in Mali where the concept of SIH is not well established in debate and practice, which is necessary to be able to act upon them. The introduction of inductive reasoning allowed for flexibility in the analysis, which greatly facilitated the analysis. As for the other country teams that are part of this research project (Ridde et al., 2021), the level of data collection was a particular challenge too: the participants’ discourse tended to switch quickly to the subject of the implementation of the intervention vs focusing on the design and planning. This was because the data collection took place at a time when implementation had already been underway for several months, making the design and planning processes more difficult to capture given the time delay. As a result, the results presented here focus more on the implementation of the intervention. The REFLEX-ISS grid, originally developed to stimulate reflexivity in terms of considering SIH among teams designing and implementing interventions, has proven to be an excellent starting point for guiding the data collection and analysis for this research in Mali, and also in other contexts.

Conclusion

Given the extensive discussion and reports about SIH by public health (Guichard et al., 2019), including in Africa, and the WHO Commission on Social Determinants of Health (Gilson et al., 2007), it is disappointing that SIH were not at the forefront of the SARS-CoV-2 testing policy in Mali. In the context of Mali, our study confirms the complexity of the factors that explain the absence of equity considerations in the developing and planning of the national SARS-CoV-2 testing programme for the general population. Efforts must be continued to put SIH on the national and global agendas through training, guidelines and/or incentives (Bali et al., 2022). In the context of international aid, donors have an important role to play while respecting the Paris Declaration and country leadership (Gautier and Ridde, 2017).

Abbreviations

CHW-S = community health workers-sentinels,

RRT = rapid response teams,

SIH = social inequalities in health.

Data availability

The data for this paper comprises of policy documentation that is publicly available (see Appendix), as well as confidential interview transcripts that cannot be shared as per the ethics certificate.

Funding

We acknowledge funding from an operational research grant from the Canadian Institutes of Health Research (grant number DC0190GP), from the French National Research Agency (ANR Flash Covid 2019) grant number ANR-20-COVI-0001-01, and from the Japan Science and Technology Agency (JST J-RAPID JPMJJR2011).

Acknowledgements

The authors would like to thank all the interlocutors who spent their valuable time to participate in this study.

Author contributions

V.R., K.Z. and L.G. designed the study.

L.G. developed the theoretical framework for the interview guide and data analysis, in collaboration with the different research teams.

A.C. and P.B. conducted the interviews.

P.B. analysed and interpreted the interview data.

P.B. and V.R. wrote the manuscript.

All authors reviewed the manuscript and provided constructive feedback.

All authors read and approved the final manuscript.

Reflexivity statement

This qualitative study is part of a larger multi-country research programme, named HoSPiCOVID, looking at the resilience of public health systems during the COVID-19 pandemic. Researchers and research assistants from the Miseli association, based in Bamako, Mali, have been actively involved in this programme since its design in 2020.

The initial idea was to conduct multiple case studies in different countries that represent the diversity of four continents and the COVID-19 pandemic. The other explanation for the choice of these countries was the existence of long-standing scientific collaborations with policy makers and researchers. The objective was to make a comparative analysis and generate lessons learned.

Our study constitutes the public health component of this programme. It involved four countries (Mali, Brazil, Canada, France) and involved students, junior and senior researchers. Collaboration between researchers from high-income countries and low- or middle-income countries was maintained throughout the research, from its conception to the writing of the manuscripts, through joint reflection. In particular, the adaptation of a methodological tool for data analysis led to numerous exchanges between the teams.

Living in Bamako at the time of the research, the first author PB joined this programme as a junior researcher to work on the public health component only. AC had already started the interviews in Bamako and PB continued them, since he was already involved in the other part of the research programme as the principal investigator. The analysis of the data was then carried out, as previously mentioned, in collaboration with the other research teams.

Thus, this research was conducted in a spirit of inclusiveness and equity.

Ethical approval

This research has been approved by the National Ethics Committee for Health and Life Sciences of Mali (n°120 MSAS/CNESS). All participants interviewed were informed about the aim of the study beforehand and consented to participate in the study.

Conflict of interest statement

The authors declare no conflict of interest.

Appendix

List of documents used:

Ministry of Health and Social Development. National laboratory strategy for the response to the SARS-CoV-2 pandemic in Mali. Bamako; 2021.

Ministry of Health and Social Development. Decentralization plan for SARS-CoV-2 diagnosis in Mali. Bamako; 2021.

Ministry of Health and Social Services. Action Plan for the Prevention and Response to COVID-19 Disease (COVID-19). Bamako; 2020.

UN Office for the Coordination of Humanitarian Affairs. COVID-19 humanitarian plan, Mali. 2020

Ministry of Health and Social Services. Decision establishing the crisis committee for the management of the coronavirus and crimea congo epidemics. Bamako; February 2020.

Ministry of Health and Social Services. Decision to set up a scientific committee for the management of the coronavirus pandemic (COVID-19). Bamako; April 2020.

Ministry of Health and Social Services. Decision appointing the laboratory focal point for the management of the fight against COVID-19. Bamako; April 2020.

Ministry of Health and Social Development. Global activity report: Community Health Agents-Sentinels (CHA-S) initiative. Bamako; March 2021.

Official journal of the Republic of Mali. Ministerial decree creating the technical committee for crisis management COVID-19. Bamako; April 2020.

Official journal of the Republic of Mali. Ministerial decree on the creation, organization, responsibilities and operating procedures of the national platform for disaster risk reduction in Mali. Bamako; December 2016.

National Institute of Public Health, Ministry of Health and Social Development. Decision to decentralize sampling and COVID-19 tests for travelers. Implementation of active COVID-19 screening. Bamako; October 2021.