Meet Our Malagasy Board Members!

One year ago, Pivot had just one Malagasy board member, Senior Advisor and Founding Board Member Dr. Benjamin Andriamihaja. And as truly wonderful as he is (i.e., no one can imagine Pivot existing or persisting without him), Benjamin was one person, one voice, and one perspective on a twenty-member Board of Directors. Being the sole Malagasy member of the board, as well as the only board member currently living in Madagascar, was a huge responsibility and we depended on Benjamin for a lot for our first seven years – from national diplomacy to program design to partner engagement.

For the past year, we have sought to diversify the Pivot Board of Directors with a crucial focus on increasing Malagasy representation to further our commitment to have those closest to the problems authoring the solutions. As of last month, we are proud to have five Malagasy board members!

To mark the occasion, Benjamin gathered the five board members for the first time this month in Tana (Madagascar’s capital city) and I am thrilled to give you a brief introduction to each of them here. With the organization now mature enough to have had incredible former staff – including Tahiry Raveloson, Fara Rabemananjara, and Seheno Randriamanantena – leave Ifanadiana to live in Tana, we have a talented and dedicated group of alumni to call upon. Luc Samison is new to Pivot but has been following our work from the start. As new in-person relationships can be formed again (i.e., in a post-COVID era), we look forward to increasing Malagasy membership further. And in addition to Malagasy representation on our board, we intend to focus on deepened governance by the communities we serve through links with these board members.

To spearhead the deepening of our community relations, new board member Faramalala (Fara) Rabemananjara will draw on her experience as the first leader of Pivot’s social work program in 2014. With a bachelor’s and two masters degrees in social work, Fara has both the training and compassion to build on trusted relationships to more deeply engage the communities we serve in Pivot governance, program design, and project evolution. Fara grew up in a small rural community herself and hiked to the farthest regions of Ifanadiana District during her five years with Pivot, paying home visits to countless patients and engineering solutions to problems one can only see with that sort of proximity. Fara currently lives in Tana where she and her husband Andres, a long-term member of the Pivot Science team, are expecting their first child, Inés, this July.

 

 

 

 

Dr. Tahiry Raveloson joined Pivot as a clinician at Ifanadiana District’s public hospital in 2014 after working in the south of Madagascar on maternal and child health projects with Médecins Sans Frontières (Doctors Without Borders). He went on to serve as hospital team leader alongside the hospital’s chief clinician from the Ministry of Public Health. Tahiry and his wife Ando, a nurse and former Pivot pharmacy manager, both worked for Pivot in our early days and then again after taking a break to have their second child near family in Tana. They are deeply committed to Pivot’s mission and eventually left again only to access higher-quality schooling for their kids (now ages 9 and 6). Given the rural schooling options in Ifanadiana District, retaining professional team members with growing children is a common challenge and one we hope Tahiry will be well-positioned to help solve. Currently, Tahiry serves as Medical Officer for the U.S. Peace Corps.

 

 

 

Seheno Randriamanantena is the newest member to join the Pivot Board, having started her appointment just last month. As a certified accountant with a Masters in Finance from the Institute Management des Arts et Métiers. Seheno was formerly Pivot’s head of finance and will be joining the Board’s finance committee. Before coming to Pivot, Seheno worked for five years as Finance Manager for the Madagascar arm of the Missouri Botanical Garden. While with Pivot, she supervised the finance team, managed the organization’s budget, accounting, and cash flow, and was responsible for the submission of Pivot’s first application to manage the district pharmacy (a role which Pivot plans to revisit in the next year). Seheno currently lives in Tana with her two children (ages 3 and 8) working as Finance Manager for Operation Fistula.

 

 

 

 

Looking further afield than our former staff, we are proud to share that Dr. Luc Hervé Samison, the former Dean of the Faculty of Medicine at University of Antananarivo and current President of the Global Fund Country Coordinating Mechanism, joined the Pivot Board in February 2021. Luc’s background is in internal medicine, surgery, and infectious disease, and he currently serves as Directeur du Centre d’Infectiologie Charles Mérieux. Luc has followed Pivot’s work since the beginning and will play an essential role in our district-level model system informing the national universal health coverage strategy in the upcoming 2024 national planning cycle. A particular passion of Luc’s, and a significant challenge for us and the rest of the country, is the retention of trained clinical staff at very rural health centers, and we look forward to his leadership in that arena.

 

 

 

 

And then there is Dr. Benjamin Andriamihaja. With a doctorate in geochemistry from Kent State University and over 40 years of experience in conservation, Benjamin is a scientist, a humanitarian, and (it must be noted) a loving grandfather. In his early career, Benjamin served as head of the Department for International Relationships for the Ministry of Higher Education and Scientific Research. He was also the first Coordinator for the Ranomafana National Park Project. He currently devotes his attention to the three organizations he helped found and to the inner workings between them: Madagascar Institut pour la Conservation des Écosystèmes Tropicaux, Centre ValBio, and Pivot. He believes that a model health district as home to a national park with an integrated conservation partner is a model for a global future where the environment and health are prioritized for everyone, everywhere. In addition to his role as chair of Pivot’s nominating and governance committee, Benjamin is currently serving alongside Bénédicte Razafinjato as co-interim National Director for Pivot.

 

 

 

LISTEN TO BENJAMIN’S PERSPECTIVE ON THE CRUCIAL CONNECTION BETWEEN HEALTHY PEOPLE AND A HEALTHY NATIONAL PARK.

Together, we are striving toward a model of universal health coverage for the country of Madagascar. For these five Malagasy citizens, (grand)parents, doctors, social workers, finance professionals, and Pivot board members, that means striving to transform their own national healthcare system to reach all 26 million of their compatriots with quality, accessible healthcare. Health is the foundation of everything we face as a global community this century and beyond, from climate protection, to education, to economic development. Just as Ifanadiana District can be a model for Madagascar, together we believe Madagascar has the potential to serve as a model for other countries and communities around the globe facing complex challenges related to healthcare.

I offer my thanks to Benjamin Andriamihaja and Robin Herrnstein, Chair of the Pivot Board of Directors, for the nominations of these essential new board members during this difficult last year, and I look forward to welcoming more Malagasy members in the future. As Benjamin said to me just yesterday,  “As a global health organization supported by many around the world, Pivot is serving as a recognized pioneer in Madagascar for the elevation of local leadership.”

We thank you for your part in the “many.” When COVID is behind us and we can safely travel to be together in Madagascar, I look forward to stepping out of our Zoom boxes and convening the Board of Directors in person and on the ground in Ifanadiana District alongside the family immersion week planned for summer of 2022. All Pivot community members welcome!

READ MORE FROM TARA ABOUT PIVOT’S EFFORTS TO SHIFT THE ORGANIZATION’S “CENTER OF GRAVITY” AND DECISION-MAKING AUTHORITY TO MADAGASCAR.



  • 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.