Staff Spotlight: Dr. Baolova Ratsimbazafy

With the majority of the Ifanadiana District population living a multi-hour walk from the nearest health center, geography can be one of the biggest barriers to care. So it stands to reason that Dr. Baolova Ratsimbazafy, PIVOT’s Deputy Director of Primary Care who oversees clinical programs at the health center level, would name the expansion of primary care activities to health centers in two rural communes among her proudest accomplishments at PIVOT since she began in 2016.

Of the 15 health centers in Ifanadiana District, 11 are located many kilometers beyond what’s reachable by car, which in most cases leaves hours if not days of further travel by foot or motorbike. This means that the process of bringing any one health center up to even the most basic standards outlined by the Ministry of Public Health requires a great deal of logistical coordination. As one of the key strategists in rolling out support to the district’s health centers, Dr. Lova – as she’s known to all who meet her – played a huge part in establishing primary care activities in the rural communes of Antaretra and Ambohimanga du Sud, effectively increasing access to higher-quality for tens of thousands of people.

(Read more about what it looks like to launch activities in remote health centers HERE.)

Of course, the ongoing COVID-19 pandemic has created even more challenges for Dr. Lova and her team, whose plans to expand services have been “turned upside down” during the first half of 2020.

Though Ifanadiana District has confirmed only two COVID cases to date, the plans for expanding primary care to more remote facilities in the district have been slowed while clinicians necessarily shifted their attention to preparing for a local outbreak. With Dr. Lova at the helm, health center personnel have instead been working to establish new protocols for patient triage at facilities and undergoing extensive disease management training in anticipation of the virus’s spread throughout the already-vulnerable population.

Early in the pandemic, Dr. Lova and colleague Lanto, PIVOT’s Sensitization Manager, lays out markers to promote social distancing at Antaretra Health Center.

 

Extolling the work of her colleagues on the sensitization team in the context of COVID and beyond, she emphasizes that “prevention is better than any cure,” and that the promotion of simple health behaviors can be key to preventing the region’s most common illnesses, which too often result in needless death.

This highlights one of Dr. Lova’s favorite aspects of PIVOT’s approach: the close attention to the specific needs of the population we serve.

As she explains it, Dr. Lova had “no notion of the humanitarian world” when she finished medical school in the capital city of Antananarivo and began her search for full-time work. After a few months bouncing between jobs at private clinics, she came across PIVOT’s posting for an attending hospital physician. She admits that, when she joined the team in 2016, she knew little about PIVOT other than that it was an international health NGO, and that her prior impression of such organizations was that their presence was usually transient and their projects short-term. Despite this, she took the leap, moving 11 hours south to start work at the Ifanadiana District Hospital.

Dr. Lova administers a measles vaccine during a mobile vaccination campaign organized by the Ministry of Public Health and supported by PIVOT in response to Madagascar’s early-2019 measles outbreak.

 

Though she hadn’t anticipated staying in the role for very long, she found after one year that she had a “new appreciation for the value of caring for the poor” and was compelled by PIVOT’s “active commitment to [improving] population health” for the long-term. So, when an opportunity to join the leadership team opened up in 2017, she applied and landed the role of managing health center-level programs – a position she served in for the two years that followed.

Today, she is nearing her one-year anniversary as PIVOT’s first Deputy Director of Primary Care, and says she never imagined she’d be fortunate enough to have a job that allowed her to continuously grow and improve her skills as a physician and a leader.

In her four years of work at PIVOT, Dr. Lova has not only risen into a position of leadership, but has also become a mother of two-year-old Soléa, who she names as her greatest inspiration and “motivator for success in life.” She also credits the experience of motherhood with improving her capacity to empathize with and provide better care for the patients PIVOT serves. It has especially strengthened her ability to support mothers in Ifanadiana District, who face the staggering 1 in 14 odds of dying during childbearing years.

(For more from Dr. Lova on motherhood in global health, check out her appearance on one of our virtual panel sessions, HERE.)

Dr. Lova and daughter Soléa join International Women’s Day celebrations in Ranomafana.

 

For having joined the PIVOT team with no prior familiarity with mission-driven work, Dr. Lova’s commitment to advancing health as a human right is especially abundant and inspiring to her colleagues, who describe her as calm, compassionate, and hard-working.

“I’ve had the privilege of working with Dr. Lova for the past four years, and I am constantly amazed by her work ethic and ability to care for patients while also managing clinical programs,” says country director Laura Cordier. “As a leader, she always prioritizes integrating PIVOT’s values into her approach, and effectively shares her skills with her colleagues, ultimately helping build a stronger team.”

For her own part, one of the mottos Dr. Lova lives by says that “to the valiant heart, nothing is impossible.”

The value of this outlook in the context of health system strengthening cannot be understated, given the often slow nature of the work, and speaks volumes about her value as a leader on the PIVOT team. Because if, like Dr. Lova, we persevere through the complex challenges we encounter in this work, we’ve seen that we actually can have lasting impact on population health. And if we can do that in as remote a place as Ifanadiana District, we ought to be able to do it anywhere.

Dr. Lova (far right) joins colleagues from PIVOT and Madagascar’s Ministry of Public Health at the 2019 Women Leaders in Global Health Conference in Kigali, Rwanda.

 



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    • 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.