Staff Spotlight: Laura Cordier

When PIVOT launched at the beginning of 2014, we had a lot going for us: strong partners, seed funding, and the government’s blessing to start work strengthening the health system. From an outsider’s perspective, however, there was little to no evidence that the organization had a good shot at success. “I couldn’t even find a website for PIVOT,” Laura Cordier recalls, “or any sort of online presence, really.”

But it was exactly that opportunity to start something from scratch that compelled her – in what could only be described as a leap of faith – to apply for one of PIVOT’s very first job listings.

Despite the feeling that she may be under-qualified she figured “why not.” Having concentrated her studies in public health and epidemiology, the fact that PIVOT was conducting a baseline survey of the population before beginning work excited her – it was something that set PIVOT apart from other international development organizations, and it drew her in.

From a data standpoint, PIVOT felt like a huge opportunity to contribute to important health delivery and research. On a personal level, her grandparents had lived in Madagascar for several years in their twenties, so she had grown up hearing stories that put the country at the top of her list of places she wanted to spend time.

It wasn’t until Laura had already accepted a different job offer that would have moved her to New York that she heard from Tara Loyd, now PIVOT’s Executive Director, with an offer to move to Madagascar and launch PIVOT’s Monitoring and Evaluation program.

Around that same time, though, the New York offer unexpectedly fell through.

“I believe in things being meant to be,” Laura says. So, before long, she agreed to spend two years in Madagascar as PIVOT’s first Monitoring & Evaluation (M&E) Manager.

She describes her first few weeks on the ground as “hectic, eager, and fast.” But PIVOT’s ambitions matched her own – at 24, she was hungry for a challenge. And, fortunately for Laura, there would be plenty of challenges in the process of building the data systems that have become the lifeblood of PIVOT’s identity.

“Figuring out optimal data flow” is one of her favorite parts of the job, she says. “It’s like a puzzle.”

Laura has worked tirelessly to ensure PIVOT has seamless data feedback loops that our clinical teams and leaders intimately rely on to inform programs and strategy.

In five years, she has formed and trained a 13-person M&E team comprised of data collectors, analysts, and database managers. The M&E team, like much of the PIVOT staff, is young and motivated, which Laura finds inspiring. She invests significant time in building team capacity, ensuring data literacy among her staff, and helping them to hone the skills required to meet her high standard for quality of work. The same goes for her relationship with Ministry of Health officials, who she has supported in the improvement of data quality and reporting, integrating their existing systems with PIVOT’s.

“She is always bringing up new ideas and ways for us to improve our work,” says Benedicte Razafinjato, who has risen from her position as an M&E Assistant to that of Manager during her time working with Laura. Benedicte says Laura has a keen sense for recognizing her team staff’s skills, cultivating them, and celebrating them.

Together over the past year, Laura’s team has worked through the long and meticulous process of building a platform that will grant everyone in the organization access to virtually all of the data her team collects. As clinicians, managers, and leaders eagerly await the conclusion of the platform’s rollout, they look forward to having the fruits of the PIVOT teams’ labor right at their fingertips.

“We are so lucky that Laura has dedicated so many years of her career to working for PIVOT,” says PIVOT National Director Dr. Ali Ouenzar. “Her contribution to the mission is matched by few, and her dedication represents the spirit of the organization.”

Now, as Laura and PIVOT enter their sixth years of work in parallel, she is part of the organization’s Senior Management Team in Madagascar, and serves as Interim National Director whenever Dr. Ali is not present in the PIVOT office. She successfully manages to balance her time between being deep within the details and driving high-level strategy.

Perhaps most importantly, Laura has integrated herself into the local community. Today, a stroll with Laura through the local market would not be complete without a flurry of greetings exchanged with friends, neighbors, and her go-to banana vendor. She credits the market with helping her assimilate in the beginning. She spent a significant amount of time there early on, getting to know members of the local community as well as the culture and the language. Investing time in these things is a priority for Laura – she believes that the better she understands the culture of the people PIVOT serves, the better she is at her job.

For as many joys as come with being a friend and neighbor to many locals, Laura says there are as many challenges. Showing up for celebrations of life events, like new babies and marriages, comes with an equal expectation that she will be present for the harder things, like funerals, of which she says there are simply too many. This motivates her work day in and day out.

On any given day in the PIVOT office, Laura can be heard flowing in and out of conversations in Malagasy, French, and English without skipping a beat.

“When I look back on hiring Laura in 2013, I feel so grateful,” says Loyd. “Five years into the work, our data systems stand out as so exceptional in the field that it looks like that must be the easy part. But I know very well that the incredible foundation and team Laura has built has required commitment and perseverance that comes entirely from within her. She is a part of the fabric of the organization and has integrated into the community in a way that will set the example for anyone we hire for years to come.”

In her spare time, Laura loves painting watercolors, the subjects of which are often interesting-looking doors that have caught her eye (a lifelong “obsession” with vibrant, textured doors is nourished well here). She also plays basketball on a local women’s team – a sport she had never played before moving to Madagascar, but that allowed her to meet some of the people she now considers best friends. And on weekends, it’s likely you’ll catch Laura and her fiancé Haja – a PIVOT chef and local business-owner – on a walkabout with their “zoo” (Rex the dog, Biquette the goat, and Serge the chameleon).

When asked what has compelled her to stay so far beyond the two year initial commitment, Laura replies, “PIVOT has been a never-ending source of interest for me. PIVOT is fascinating and inspiring, and the beauty of it is that it never stops. PIVOT is providing care regardless of how complicated the health system is or how far away the people live from it.”

 



  • 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.