Impact Update: The First 3 Months Of Our Community Health Pilot

In Ifanadiana District, more than 70% of the population lives more than 3 miles from the nearest health center, which means that most people must walk for hours to access medical care. Community health workers (CHWs) are members of the community who are trained in diagnosis and treatment of common illnesses and provide care where people live, limiting the need to travel long distances to receive primary care services.

PIVOT is a member of the Community Health Impact Coalition (CHIC), which is a network of fellow field-based health organizations that work to catalyze the adoption of high-impact community health systems for rural and poor populations across the globe. Through our participation in CHIC, we work to develop a strong network of professional CHWs who can bring care to Ifanadiana District’s most remote locations.

In October 2020, PIVOT launched a revamped community health pilot program in Ranomafana. The pilot offers a new, two-pronged approach for care delivery in every fokontany (cluster of villages): one CHW remains stationed at a community health site to receive those who come seeking services, while two or more additional CHWs complete a circuit of assigned household visits to proactively identify and provide care. The CHWs attend to sick children under five years of age as well as pregnant women.

PIVOT Community Health Supervisor Berger approaches a community health site for one of his monthly field supervisions of community health workers.  Photo by Peter A. Harris for PIVOT.

The pilot program also uses a new approach to management, including the hiring of additional CHWs who have completed a twelve-day training prior to deployment, monthly field-based one-on-one supervision led by a PIVOT nurse or midwife, monthly group supervision at the health center, and a financial incentive for CHWs that is equal to Madagascar’s minimum wage. The program changes, implemented in partnership with Madagascar’s Ministry of Health, are guided by the World Health Organization’s (WHO) guidelines on optimizing community health worker programs, and by the Community Health Worker Assessment and Improvement Matrix (CHW AIM) framework.

Previously covered by 16 CHWs, Ranomafana now has 28, which helps ensure that there is an adequate number of health workers to meet the demand for services and provide care for the commune, particularly its more remote villages. Within this expanded cadre of workers, nearly half of the CHWs in Ranomafana are women, reflecting a substantial improvement in gender diversity in the health workforce.

In the first three months of the pilot project (October-December 2019), CHWs completed 1,444 consultations with sick children, including 630 via proactive household visits and more than 800 visits at the community health site. This is a nearly three-fold increase compared with the three months preceding the start of the pilot, in which Ranomafana’s CHWs completed 526 visits with sick children.

Community health worker Lemiarina conducts a proactive home visit to assess the symptoms of a child with fever, accompanied by PIVOT supervisor Berger. Photo by Peter A. Harris for PIVOT.

It is not enough, however, to increase the number of visits; CHWs must also be able to provide high quality care. To ensure this, PIVOT’s community health supervisors complete a performance checklist while observing each CHW diagnose and treat sick children. The checklist documents if the CHW provides care consistent with a protocol developed by the WHO and UNICEF. In the three months that the pilot project has been active, we have found that quality of care is nearly as high among Ranomafana’s newly-recruited CHWs as those who were already  employed; both groups have high rates of correct diagnosis and treatment.

In sum, the first quarter of the new pilot program’s implementation has demonstrated positive results, including increased utilization rates and continued high standards for quality of care. In 2020, PIVOT’s research and clinical teams will focus on understanding the impact of the pilot program on service utilization, patient satisfaction, as well as the impact of continuous supervision on quality of care.

 



  • 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.