A Tale Of 13 Tests

In the district health office in Ifanadiana, Madagascar—home to some 183,000 people—sit 13 rapid antibody tests for coronavirus.

“That is gold,” says Laura Cordier, PIVOT’s country director, during a recent video conference she joined from her home in Madagascar. Still, she says, given the complexity of testing for this virus, the PIVOT team and local health authorities are looking at just how the kits fit into their response in Ifanadiana and other rural districts.

The 13 tests—how they got there, how they’ll be used, and the very role of testing—tell a universal and ever-evolving story of combating COVID-19.

Madagascar has 128 confirmed cases, including a small epicenter in the city of Fianarantsoa, about 67 kilometres from Ifanadiana. The Ministry of Health has dispatched rapid tests from a central stockpile to the country’s 22 regions, which in turn sent tests to district health centers.

Ifanadiana District is where PIVOT has worked alongside the Ministry of Health since 2014 to strengthen the public health system to ensure universal access to effective and sustainable health care.

PIVOT had planned to have thousands of tests ready in the country, but procurement hit a number of roadblocks, similar to challenges many countries are facing.

With this novel virus having effectively shut down the world, health experts from Milan to Detroit to Antananarivo grapple with testing, which is so crucial to controlling the spread. Tests are new, tests are few, false negatives abound; the world is far from the systematic testing that’s needed. Meanwhile, many institutions are studying other surveillance methods that would complement testing.

In Ifanadiana, PIVOT and local health workers are taking measures they know will be vital, irrespective of the number of tests at hand—educating communities, monitoring the check-point on the single paved road that bisects the district, boosting access to soap, and preparing at the village level to isolate suspected cases and contract-trace.

Dr. Herinjaka Andriambolamanana—better known by the community as Dr. Njaka—is PIVOT’s manager of infectious disease. He says one of the greatest challenges is getting information to rural communities who have limited or no access to TV or radio, much less internet. In Ifanadiana District, nearly half of the population lives more than a 10-kilometre walk from the nearest health center.

The dissemination of critical information related to COVID-19, then, falls to frontline community health workers. Fety Randrianarivelo, one of the 172 PIVOT-supported health workers in Ifanadiana District, says that it’s already becoming a challenge to manage people’s fears and reassure them that seeking care for any illness is still the best thing to do.

In a way, the people of Madagascar are uniquely armed for this pandemic. Measles and plague are commonplace, and health workers are well-versed in the prevention of infectious disease. And while it’s too early to say how this will affect COVID-19’s impact, only around 3 percent of Madagascar’s population is over 65, compared to nearly a quarter in Italy.

On the other hand, many of the island nation’s people are immunocompromised due to widespread conditions like malnutrition and tuberculosis. And the country has one of the weakest health systems in the world.

If coronavirus came to Ifanadiana, the government would deploy extra personnel and supplies. Still, all that would take time. And even using the tests on hand is not a simple matter, as Laura Cordier points out.

“Because of the waiting period of either sending a test for PCR in Antananarivo or the risk of a false negative with an antibody test, we really have to focus on isolation,” Cordier says. PIVOT is collaborating with local health authorities to create a quarantine area in every commune. “We want to focus on taking no risks and making sure that those cases are completely isolated.” The idea would be to assume a positive and launch contact tracing straightaway.

“Same here.” That was the gist of Boston-based Dr. Lara Hall’s take on the situation in Ifanadiana during a recent virtual panel session that connected her to PIVOT staff on the ground. In a COVID-19-hit world, rural Madagascar and Boston, a US mecca of medicine and science, are linked as never before.

Dr. Hall is former PIVOT medical director in Madagascar and current board member, and now works on the front lines at Cambridge Health Alliance in Boston. “Where I’m practicing is in some ways resource-greater but in other ways resource-limited similar to Madagascar, and we’re struggling with how to use testing,” Hall says.

Each country, each community is finding its way based on its people, resources, and context. What is clear now more than ever is the need for fail-safe, accessible health care based on sound data. While the need is not new—indeed it is the very basis of organizations like PIVOT—the global community is now acutely attuned to its urgency.

As Matt Bonds, PIVOT co-founder and scientific director, says, responding to the COVID-19 pandemic is “just an extreme version of what we do routinely.”

As a leader in data collection and analysis, PIVOT began tracking health system and population health indicators before they began implementing programs. For six years, PIVOT has been using data to understand which aspects of their programs are working and which are not, and adjusting their approach as needed. All of this is to ensure a system that is strong enough to meet the needs of the population it serves, and that can remain resilient in the face of public health crises such as this one.

Thousands of tests, including the 13 at hand in Ifanadiana District, will be part of the data engine for halting coronavirus. So will Fety, Dr. Njaka, and countless others dauntlessly leading the fight. The richness of PIVOT is that its foundation is people, of and in the communities. And that’s Madagascar’s greatest asset in weathering this pandemic.

 



    • Sign up for our newsletter
      Stay up to date on Pivot’s latest news

    • Molecular Diagnostics

      Pivot has partnered with the Ministry of Public Health and Centre ValBio to develop the first molecular diagnostics laboratory for COVID-19 outside of the capital city.  We additionally have partnered with the Pasteur Institute of Madagascar on novel analysis of dried blood spots from I-HOPE survey for serological analysis of measles, malaria, schistosomiasis, Hep B, and COVID-19.

       

      Learn more: 

      Integrating Health Systems and Science to Respond to COVID-19 in a Model District of Madagascar, Rakotonanahary, R.J.L., et al., 2021, Frontiers in Public Health

      Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

    • Eco-Epidemiological Surveillance

      We collate environmental surveillance data (e.g. vector surveillance) with biomarkers from household surveys (e.g. rapid tests and antibody tests from dried blood spots of participants in the I-HOPE household survey) to inform the spatio-temporal dynamics of infectious diseases.

       

      Learn more:

      Estimating the local spatio‐temporal distribution of malaria from routine health information systems in areas of low health care access and reporting, Hyde, E, et al., 2021, International Journal of Health Geographics

      Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

    • GIS (geographical)

      We use a participatory approach to map over 20,000 kilometers of footpaths and 100,000 structures. These data have been combined with high resolution data on land cover, a digital elevation model, rainfall data, and geolocated data from the IHOPE cohort (see above). These data are used to determine travel times to health care, measure geographic equity, and study geospatial determinants of disease. Accessibility modeling results are available on an e-health platform developed with R Shiny.

    • IHOPE (household-level longitudinal cohort)

      The Ifanadiana Health Outcomes and Prosperity longitudinal Evaluation (IHOPE) cohort was established in 2014 at the start of Pivot’s work in Ifanadiana District. Modeled after Demographic and Health Surveys, it tracks standard international health, demographic, and socioeconomic indicators. IHOPE has the following combination of characteristics that are novel for localized interventions:

      • True baseline
      • True representative sample
      • Sample from inside and outside of the initial catchment population
      • Collection by third party professionals at the National Institute of Statistics who collect identical data nationally
      • Tracks same individuals over time
      • Includes biomarkers such as dried blood spots used for molecular analyses

       

      Learn more: 

      Baseline Population Health Conditions Ahead of a Health System Strengthening Program in Rural Madagascar, Miller, A., et al. 2017, Global Health Action

    • HMIS and Routine M&E

      Health management information systems (HMIS) collect information on health system utilization and care provision at public sector facilities. These data are combined with additional, routine monitoring and evaluation (M&E) data to track over 1000 indicators of health system performance in Ifanadiana District, including rates of treatment and service utilization, quality of care, supply stock-outs, and human resource capacity at every level. These data are accessible via a real-time dashboard.

    • Capacity-Building

      The purpose of Pivot Science is to improve health outcomes over the long-term. Central to this goal is a new capacity building program, which focuses on both increasing research skills among clinicians/implementers, as well as helping researchers better understand and inform clinical priorities. The training includes a series of workshops on understanding clinical priorities, developing research questions, methodology, and dissemination. Trainees include a range of personnel who work within Madagascar’s health sector.

    • COVID-19 and Molecular Diagnostics

      The majority of deaths in Madagascar are due to infectious diseases and most cases go undiagnosed. The COVID-19 pandemic has underscored the need to implement new diagnostic assays in rural health districts. Pivot has partnered with the Ministry of Public Health and Centre ValBio to develop the first molecular diagnostics laboratory for COVID-19 outside of the capital city, which provides both diagnostic capacity as well as a platform for scientific innovation at the intersection of biomedicine and planetary health.

       

      Learn more: 

      Integrating Health Systems and Science to Respond to COVID-19 in a Model District of Madagascar, Rakotonanahary, R.J.L., et al., 2021, Frontiers in Public Health

      Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

    • Eco-Epidemiology & Surveillance

      There have been major advances in the science of infectious disease dynamics. But there is inadequate application of these advances at local scales to inform health interventions. We combine environmental information, spatially granular health system data, and population surveys, with mathematical models to understand and forecast local disease dynamics (such as malaria, measles, schistosomiasis, lymphatic filariasis and diarrheal disease) to improve service delivery. 

       

      Learn more:

      Estimating the local spatio‐temporal distribution of malaria from routine health information systems in areas of low health care access and reporting, Hyde, E, et al., 2021, International Journal of Health Geographics

      Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

      Towards elimination of lymphatic filariasis in southeastern Madagascar: Successes and challenges for interrupting transmission, Garchitorena, A., et al., 2018, PLOS Neglected Tropical Diseases

    • Operational Research for UHC

      Operational research provides insights into how programs are implemented with an emphasis on quality and fidelity to organizational, national, and international standards. Our operational research priority areas include UHC financing, health care quality, patient satisfaction, and health worker performance. This is a high priority area for growth across clinical and data teams at Pivot. 

       

      Learn more:

      Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar, Razafinjato, B., et al., 2020, medRxiv

      Rapid response to a measles outbreak in Ifanadiana District, Madagascar, Finnegan, K.E., et al., 2020 medRxiv

      Networks of Care in Rural Madagascar for Achieving Universal Health Coverage in Ifanadiana District, Cordier, L.F., 2020, Health Systems & Reform

      In Madagascar, Use Of Health Care Services Increased When Fees Were Removed: Lessons For Universal Health Coverage, Garchitorena, A., et al., 2017, Health Affairs

    • Geography & Community Health

      We are advancing new methods that combine granular health system data with a massive GIS dataset containing over 100,000 structures and 15,000 miles of footpaths in the district. This is used to identify geographic barriers and improve the design of the health system to reach everyone. To overcome geographic barriers, we have piloted a model of proactive community health for Madagascar, and are evaluating its impact and feasibility.

       

      Learn more:

      Estimating the local spatio‐temporal distribution of malaria from routine health information systems in areas of low health care access and reporting, Hyde, E, et al., 2021, International Journal of Health Geographics

      Improving geographical accessibility modeling for operational use by local health actors, Ihantamalala, F.A, et al., 2020, International Journal of Health Geographics

      Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar, Razafinjato, B., et al., 2020, medRxiv

    • Population-Level Impact Evaluation

      We measure the impact of our work through the analysis of a district-representative longitudinal cohort. Our quasi-experimental design allows for some of the most rigorously evaluated analysis of health systems change on population health in Africa. These analyses show improvements in nearly every major health indicator, including infant mortality, under-five mortality, vaccine coverage, access to and quality of health care services, and health equity.

       

      Learn more:

      District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018, Garchitorena, A., et al. 2020, BMJ Global Health

      Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar, Garchitorena, A., et al. 2018, BMJ Global Health

      Assessing trends in the content of maternal and child care following a health system strengthening initiative in rural Madagascar: A longitudinal cohort study, Ezran, C., et al. 2019, PLOS Medicine

      Baseline Population Health Conditions Ahead of a Health System Strengthening Program in Rural Madagascar, Miller, A., et al. 2017, Global Health Action

    • Data Systems

      PIVOT is fully integrated with Madagascar’s Health Management information System. By combining many kinds of data – outcomes, programmatic, geographic and more – we gain insights to inform our approaches in an ongoing improvement cycle.

    • Quality of Care

      Care is of no use to our patients’ health unless it is high-quality. We focus on bringing the best possible care to all levels of the health system, whether offered at a patient’s doorstep, at health centers, or at the hospital.

    • Supply Chain & Equipment

      Constant collaboration and integration with Madagascar’s national supply chain helps maintain adequate stocks of more than 40 essential medicines and supplies across all levels of care while steadily closing the gaps on stockout rates and saving lives.

    • Finance

      PIVOT is working with the government’s National Health Solidarity Fund to create a transparent system for patients, providers, donors, and government officials, building on success in removing financial barriers to care through patient reimbursements.

    • HR & Recruitment

      Skilled, well trained and compassionate people are the most vital components of any health system. To meet the unusual challenge of a setting where posting may be truly remote, PIVOT teamed up with the Ministry of Public Health to design and implement a joint recruitment and retention strategy.

    • Infrastructure

      A public health system needs dignified and durable spaces – a difficult task in a mountainous rainforest environment. The district’s most remote facilities are a priority, where partnership with local communities and contractors ensure that rehabilitated spaces are maintained over time.

    • Emergency Transport

      74% of the people in Ifanadiana District live more than a 5-kilometer walk to the nearest health center. Our district-wide public ambulance referral system is the only one of its kind in Madagascar, operating 24/7 since 2014 to bring urgent cases in for treatment at no cost to the patient.

    • Patient Accompaniment

      PIVOT accompagnateurs welcome people into a system that may be unfamiliar. They explain the process, assist in navigating the system,address the need for food and lodging when needed, and check on the kids back home. This service, along with the improved availability and quality of care, has helped quadruple the use of outpatient health services in Pivot’s catchment area.

    • Maternal Health

      Our programs successfully address high rates of maternal deaths among the women in Ifanadiana District, who give birth an average of seven times during their reproductive lifetime, with four in every five deliveries occurring at home. In the first two years of fully supported obstetric services, access to family planning, and facility-based deliveries, the maternal mortality rate dropped by 20%.

    • Malnutrition

      More than half of the children under 5 in Madagascar are chronically malnourished. We are piloting a national program in Ifanadiana District that combines screening, treatment, and prevention across all levels of the health system to address this major cause of child mortality.

    • Tuberculosis

      TB is so prevalent in Madagascar that there are an estimated 500 new cases in our district every year, most undetected and untreated. In partnership with the National Tuberculosis Program,  we launched a program to control TB in 2017 to upgrade basic resources and capacity, and to ensure that diagnosis and treatment are available in Ifanadiana District.

    • Child Health

      Children under 5 are those most likely to die from preventable causes like malaria, pneumonia and diarrhea. We implement protocols for the Integrated Management of Childhood Illness to guide health workers in diagnosis and treatment and to assess nutrition and vaccine status in low-resource settings.