Defining PIVOT’s Commitment To Diversity, Equity & Inclusion

After five years on the US-based PIVOT support team, it was easy to think of our commitment to social justice as implicit. What could be more social justice-oriented than working to prevent needless suffering in a resource-constrained setting like rural Madagascar? On top of that, we were making a concerted effort to do our part in the movement to localize the global health sector, shifting more resources and authority to our Madagascar-based colleagues in an effort to mitigate the growing trend of undue deference given to those of us in the US, furthest from the work.

(For our executive director’s recent piece on PIVOT’s localization efforts, click HERE.)

Indeed, by May of 2020, we felt like we were on the right track. Then, like so many other organizations, George Floyd’s murder catalyzed a long overdue moment of reckoning for our team. The US staff gathered virtually to discuss our response, and it became immediately clear that we were ill-prepared to speak as a collective on racial injustice in the US. Were we, as individuals, unanimously horrified by this and the countless other manifestations of systemic racial violence throughout our country’s history? Absolutely. Were we moved to do something about it on a personal level? Also yes. But did PIVOT, as an organization, have the right or responsibility to speak or act upon this in some way? Disappointingly (to all of us), we weren’t sure.

Having spent many months concertedly thinking and talking about how to strengthen our identity as a Malagasy-led organization, we fumbled for what to do or say in the face of a major social injustice in the US. It took us far too long to decide whether we’d make a statement, let alone what message it should convey. After hours spent on group calls between board and staff members to discuss, the result was the release of the following statement:

Today marks two weeks since George Floyd’s murder. His death – along with that of countless other Black men, women, and children – occurred because the US is riddled with racial inequality, discrimination, and trauma that occurs regularly and systemically to Black and Brown communities. Not all lives are treated equally. As PIVOT board member Paul Farmer has said, “the idea that some lives matter less is the root of all that is wrong with the world.” Only by removing our country’s pervasive structural inequalities can we hope to ensure that every Black life is truly regarded as equal. It is the time for everyone to intensify the fight for justice and equality. We at PIVOT are examining our own actions as an organization to exemplify a more inclusive and just world – here in the US, in Madagascar, and globally.

As a member of the US staff who has been with PIVOT for most of its existence, I left the experience feeling that we lacked a clear path forward in “examining our own actions” – something we are extremely good at when it comes to our program delivery, which is perhaps why this aimlessness felt so stark in comparison. And of course we love Paul Farmer, a lead advocate for social justice in public health, and a member of the PIVOT board. But did we need to elevate another white voice in the conversation around racial disparities? Probably not.

We decided the next step for our US team was to launch an anti-racist reading club. We started with Ibram Kendi’s How to Be an Antiracist, which I think to some degree we believed (or hoped) might guide our path. But it quickly became clear that there was more to be done if we hoped to be able to make an authentic claim that we are organizational allies to marginalized communities in the US. Weekly book discussions weren’t going to cut it. We started thinking about ways to actualize our commitment to antiracism, including opportunities for our site-based colleagues to join the effort, potentially getting involved with antiracist initiatives in Madagascar.

Meanwhile, the PIVOT Science team was onboarding a new member to their team. In September, Dr. Demetrice Jordan joined PIVOT’s research network as a postdoctoral fellow in the Department of Global Health and Social Medicine at Harvard Medical School, having just completed a dual-doctorate in Geography and Environmental Science and Policy. Dr. Jordan, who goes by “Dee,” was introduced to the rest of the team as a health geographer focused on ecological and environmental drivers of vector-borne, parasitic illnesses of sub-Saharan Africa. But we soon also learned that she also had extensive experience in the field of diversity, equity, and inclusion (DEI). While working on her PhD at Michigan State University (MSU), Dee founded the Advancing Geography Through Diversity Program, to address the persistent underrepresentation of African Americans, Latinx Americans, and Native Americans in geography doctoral programs. She is an advocate for creating safe, supportive environments for students of color, and planned and led workshops developed to “engage students, faculty, and the broader MSU community in meaningful dialogues on microaggressions, privilege, cultural sensitivity and diversity.” As a postdoc, Dee developed the Celebrating Black Geographers anthology hosted by the American Geographical Society to highlight the contributions of Black Geographers to the discipline.

(For more on Dee’s DEI work, click HERE).

It was upon joining our group’s regular discussions on Zoom and Slack that Dee pointed out a key nuance that the rest of us had failed to see up to this point: our decolonization work did not undo the fact that we had a US presence, nor did it serve as a replacement for antiracism work.

In the midst of our active push to emphasize Malagasy leadership and reposition the US-based staff as a “support” tier rather than one of direction, we had lost sight of the fact that our presence in the US can’t simply be overlooked. Not only do we have several US staff and board members, but also a community of hundreds of individuals and foundations who support our work, academic institutions we collaborate with, and vendors whose services we invest in – most of whom are American.

As such, consensus has been established in our US team’s DEI working group around the notion that we can’t effectively advance change elsewhere if we aren’t taking an active part in the movement for change at home. As an organization that espouses the crucial importance of advancing health equity, it is our responsibility to take action against threats to human rights and social justice here in the US. 

We are fortunate that Dee arrived on the scene when she did, and even more so that she was willing to take on the work of guiding our DEI journey. We were awarded a grant to support this very work, which enabled us to contract Dee as our DEI consultant for one year starting in January 2021. For the duration of this first quarter, she has been not only sharing her expertise with us, but also her personal lived experience as an African American woman, all in an effort to help PIVOT better define its organizational contribution to the fight for justice in the US.

Though we’re currently a more racially homogenous group than we’d like to be, each of us comes to these conversations carrying extremely different life experiences, with systems of oppression having touched our lives to varying degrees. But, at the end of the day, we are brought together by a desire to eliminate structural violence of the sort that brought PIVOT into existence in the first place. As a junior member of our team and as a queer woman, I have especially found value in the equalizing effect that this process has had on our group. Weekly conversations across board, management, and staff have ranged from enlightening to uncomfortable, and everything between. Under an umbrella of trust, vulnerability, and a shared desire to do better, we are all learning, we are all making mistakes, and – with much grace from one another – we are evolving.

Despite what we may feel about the depth of our long standing commitments to social justice on a personal level, as an organization, we are still early in our journey. And, as Dee puts it, “this work never ends.” We are collectively staring down the path that lies ahead, and the crucial growth we’re experiencing as individuals is making it easier to identify the opportunities PIVOT has to take action for change.

I am happy to be able to share now that we have finalized a social justice positioning statement:

Racism and inequity anywhere, in any form, are counter to PIVOT’s core values. We are deepening our commitment to diversity and fight for justice. We invite you to act with us.

These words are our north star in the DEI space. This, along with the four official pillars of our DEI commitment (which we’ll discuss in writing in the near future), will serve as a measure of accountability for PIVOT, to track our progress in moving our deepened commitment forward.

As a start, we are actively building our strategy to diversify recruitment, creating opportunities for exposure to and involvement in our work among marginalized communities through internship and board apprenticeship programs. We are creating guidelines around intentionality when it comes to the cultivation and engagement of the many who comprise our PIVOT community, examining where our funds come from and which vendors they go to. And we are fully committed to listening and learning with greater consciousness – both internally and externally – when it comes to the intent and impact of our communications.

We know that silence equals complicity, so we are stepping boldly into functional allyship. With the knowledge that we have a great deal to learn along the way, we look forward to sharing more of this journey with you in the months and years ahead.



  • 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.