First-Hand From The Field: Why Expanding Our Reach Is Our Top Priority

On this beautiful day in November, we leave for the far north of Ifanadiana District. We are ready to leave for a week to see the progress of the rehabilitation underway at 4 of the most remote health centers in the district: Analampasina, Fasintsara, Maroharatra, and Ampasinambo. It would take us at least 2 travel days each to reach 3 of them individually. That’s why expeditions like this – most often carried out by members of our community or infrastructure teams – typically combine visits to multiple health centers at once, to optimize time.

On the road to Fasintsara, we come across men, women and even children carrying goods on their shoulders – basic necessities such as rice and oil – taking them to their villages in the commune of Fasintsara. Under a blazing sun, they walk for hours with their big bags. We are told that there are no other means of transport available at this location. This is also the mode of transport used to move medicines and other essential materials to and from the health centers on this axis of the district, including the construction materials we use for their renovation. So, currently, the people who live in this place have to walk at least 60 kilometers to find most of the food they need. Of course, if they have to go to other towns closer to the main road, it takes even longer.

Arriving in Fasintsara, we meet Dieu Donné (above, left), the Chief of Fasintsara Health Center, who shows us around the facility, which is already undergoing infrastructural renovation with PIVOT’s support (above, right).

He explains to us the challenges he and his team have faced every day for the five years he has worked there. In this remote corner of the district, one of the main problems is a lack of staff. There are only 2 health workers to provide care for patients at this health center: one nurse and one midwife. Recently, through collaboration with the USAID ACCESS program, they were able to have the support of a third person, a clinical aid. With the rehabilitation underway, Dieu Donné says he is happy with the new space made available to them for accommodating patients, especially given that, soon, PIVOT will start the implementation of the pilot project for universal health coverage (UHC) at this health center. This will include strengthening the pharmacy and covering costs for all patients, so the Chief anticipates an increase in the number of patients by at least double, hence the urgency of having a complete and qualified staff as well as adequate space to receive them.

Welcoming malnourished children remains a challenge, the staff of Fasintsara Health Center mentions, because support for the program has not yet been implemented here. When faced with cases of malnutrition, health workers can only advise patients’ caregivers on good feeding practices, even when they know that the child needs more in-depth care, or even hospitalization. Parents listen to the advice, but it is difficult for them to follow, since in the majority of cases they have limited means to access the types of foods recommended for balanced nutrition. Even to pay 2,000 Ariary (about $0.50 USD) for drugs or therapeutic foods, many cannot afford it and ask to pay in installments. The start of UHC here will be a great breath of fresh air for these vulnerable families seeking care.

Currently, if there is a complication that requires greater care than this basic health center can provide, the nearest city is Ambositra, 58 kilometers from Fasintsara, requiring a trip that takes a minimum of a day and a half on foot or 6-10 hours on motorbike (even more, depending on the season and the state of the road).

This situation is difficult – Dieu Donné says he sees complicated cases almost every day. One of the stories he told me made my blood run cold. In 2017, a young girl came to the health center to give birth and, there alone, Dieu Donné realized that the woman could not give birth vaginally and needed a C-section. But the nearest facility in the district that can perform this procedure is Ifanadiana District Hospital (about 120 kilometers away) or in Ambositra (outside of the district). Unfortunately, it was too late to take her there because she was already in labor. So Dieu Donné made the heavy decision to perform a craniotomy on the infant in an attempt to save the mother’s life. She survived but, sadly, her baby did not. According to Dieu Donné, this is far from an isolated case. It is typical that pregnant women arrive to the health center too late to be transferred to higher levels of care, and the outcome is sad; the staff too often must make a critical choice in order to avoid losing 2 lives.

The day after our visit to Fasintsara, we continued on to Maroharatra, a town 12 kilometers from Fasintsara, or about 90 minutes by motorbike. Though renovations are underway, a primary challenge here at Maroharatra Health Center (above, left) is that utilization and service delivery are stagnating due to difficulties with the local supply chain.

As we tour around the health center and the renovations it has underway, we meet Aurélie (above, right), a 33-year-old woman from the village of Ampasimadinika, about 7 kilometers from the center. Her left leg has been badly swollen for about a month and a half, which made her journey to the health center even more difficult. She is lying on a mat on the floor with her mother Rasoamananjara, who stays by her bedside. There is only one functional bed in the facility, and it is occupied by an 18-year-old woman who has come to give birth to her first child. Due to lack of space in the health center, hospitalized people and newborn babies are in the same room.

Aurélie explains to us that she has been at the health center for a week and that her case requires a higher level support. To get the care that she needs, she must go to Ambohimanga du Sud Health Center, a health center that has been supported by PIVOT for over a year, where she can receive an analysis on her foot. However, due to lack of funds, she cannot pay the members of her community who have to take her there. Indeed, it is not uncommon to see almost all of the men in a village traveling to bring one single patient to a health center. This is a common part of Malagasy culture that shows the solidarity of the community. In these situations, the “cost” of transport is food for everyone on the trip, so if a patient’s family cannot afford to feed the villagers, the patient cannot travel.

For now, Aurélie’s only option is to remain at Maroharatra Health Center for however much time it takes for her husband (who remained home in the village) to collect enough money to provide food for the group who will take Auriele to Ambohimanga du Sud. But she has asked Aina, a midwife and Chief of Maroharatra Health Center, to do everything possible to cure her here, as she might not ever be able to get to another health center.

The next day, after our visit to Maroharatra, we decided to visit the Ambodimanga Nord Health Center (above, left) as a detour from our route back to Ambohimanga du Sud. This facility is classified as a “Level 1” health center, meaning that the services offered are more limited than the other “Level 2” health centers we have visited so far. When we arrive, we are so shocked to see the state of the spaces that serve as the delivery and hospitalization rooms (above, right), that we wonder how any human being, just like us, can be expected to give life or trust being taken care of in this place. Ranjato, PIVOT’s Head of Infrastructure, explains to us that almost all the remote health centers – and, above all, the Level 1 facilities – are in this state, not only in Ifanadiana District but all over Madagascar.

During our discussion with Lanto (left), the volunteer nurse of this health center, two people arrive: Celestine, an elderly lady, and her grandson Fabrice, age 15, who is ill. Lanto received them and, after assessing his symptoms and posing a few basic questions about the reason for their coming to the health center on this day, she gave Fabrice a rapid diagnostic test for malaria, which came back positive. The nurse proceeded to give them medicines that cost them 1000 Ariary (or about $0.25 USD) – one of the many costs that PIVOT covers for all patients who receive care in the 7 health structures we already support, but for this facility that service won’t begin until 2022.

On the last day of our trip, I realize that – even after working for PIVOT for over two years – this visit to this part of the district opened my eyes to the challenges of my compatriots: millions of men, women, and children in Madagascar who live in these remote areas, still with minimal access to basic health care. Having access to dignified care in a sanitary structure worthy of that name remains difficult, if not impossible, for too many.

The hope I hold on to is that in the next couple of years, as PIVOT expands to these remote corners of Ifanadiana District, anyone I have encountered on this expedition will be able to consider quality health care as a given. Support for healthcare leaders like Dieu Donné and nurses like Lanto is on the way, and I can’t wait to come back here in 2022 to see the difference it has made for thousands of patients just like Aurélie and Fabrice.

 



  • 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.