Staff Spotlight: Pauléa Eugénie Rahajatiana

As one of PIVOT’s earliest recruits, Pauléa (“Léa”) Eugénie Rahajatiana joined the team as an ambulance referral nurse in May of 2014, just four months after we launched work. Having spent the two years prior working as a hospital nurse with Médecins Sans Frontières (Doctors Without Borders), Léa, despite her self-proclaimed reserved nature, arrived on the scene with a proactive approach and a crystal clear commitment to doing whatever it takes to meet every patient’s needs. Her compassion for each individual she cared for was tangible, as was her curiosity and desire to learn and grow.

Not long after her start with PIVOT, Léa took the position of Drug Inventory Manager. Having studied nursing in Betroka, in the south of Madagascar, Léa describes the personal experiences that ultimately influenced this particular shift in her career path:

“During my internships in the various health facilities, I witnessed the inability of most of my compatriots to cover their health costs and I myself experienced this inability. I was sick during my studies and it was difficult [for me] to buy the drugs. I asked my family to help me and they were able to do so, but I knew it was just as expensive for them as for the [rest of the] Malagasy population.”

Léa names these experiences – both witnessing patients who were unable to get care for lack of funds, and experiencing a similar struggle personally – as what led her to know she wanted to play a part in the field of humanitarian healthcare delivery. When she heard that a new NGO was starting up in Ifanadiana District that aligned with her passion for the Malagasy population to be able to “access care without suffering from the financial barrier,” she knew PIVOT would be the right fit for her. During her first year with PIVOT, Léa played an integral role in establishing one of our earliest and most important initiatives to ensure health for all: a reimbursement program that enables patients to access care at no cost. She names this as one of her greatest professional achievements, as it addresses the exact matter that sparked her ambition to expand her public health career in the first place.

“When there is a difficult situation, we not only look at the situation but we always look for solutions,” she says, when asked which aspect of her work PIVOT makes her most proud. “PIVOT enables everyone to enjoy their right to health. The organization is there for the entire population without distinction, but above all for vulnerable people.”

Today, with this steadfast commitment to a patient-centered health system still intact, Léa serves as our Deputy Director of Biomedical Services, part of a growing cadre of PIVOT’s Malagasy clinical leadership. As the first person to occupy this new position, she is charged with overseeing all things related to pharmacy, supply chain, laboratory, and facility readiness (including things like equipment and the availability of electricity and water). Léa thinks of her job as one constant, central challenge: to avoid stockouts of all drugs and consumables throughout Ifanadiana District.

As PIVOT’s joint endeavor to establish a model for universal health coverage (UHC) in Ifanadiana District gains more momentum through collaboration with the Ministry of Public Health, Léa’s job has never been more crucial, or more complex. Supply chain is notoriously one of the most complicated components of UHC, relying on multiple stakeholders, vendors, and management systems to work in harmony to ensure hundreds of drugs and supplies are available where and when they need to be. But in practice, any number of issues could disrupt this system – from global shortages of a particular drug, to general mismanagement of stock, to weather conditions slowing deliveries along Madagascar’s national route. The role not only requires responsive problem-solving skills, but also a knack for navigating partnerships effectively.

 

“Since building a system for the population is not just the work of one person, nor of one organization, but of many entities, […] it is often difficult to find a rallying point with all stakeholders.” But ultimately, she continues, “our goal is for all patients to be well taken care of. For this, we participate in capacity-building, thinking together with stakeholders to seek solutions to problems.”

During COVID, of course, many of the existing challenges Léa faces have only become more convoluted. For one, restrictions on movement have affected the supply chain more significantly in Madagascar – where there are few paved national routes – than in many other countries. But as a leader who wholeheartedly embodies the PIVOT values of humility and the pursuit of learning, she has forged ahead fearlessly, leaning into opportunities for support and growth. Thanks to the generosity of the Gould Family Foundation and collaboration with Pharmaciens Sans Frontières (Pharmacists Without Borders), Léa’s learning journey continues on with a biomedical apprenticeship and pharmaceutical management mentorship.

Looking back, Léa says that, when she first joined PIVOT, she was pleasantly surprised by the demeanor of its leaders, and draws inspiration from their approach still today. “Often, we have a stereotypical image of a leader of an organization, but I noticed that at PIVOT the founders were very humble, and that amazed me. When I came here, the organization was still very young, and we were asked for our opinions on how to improve the work together. […] They listened to what we had to say.”

As we look down the road toward expansion into more districts in the years to come, Léa carries this memory with her, and hopes to emulate the kind of leadership she has seen work effectively throughout her six years at PIVOT. Dr. Alishya Mayfield, our Chief Medical Officer, maintains much faith in her ability to do so: “Léa’s focus, dedication, and unwavering commitment to her work have always impressed me,” she says. “She approaches each new challenge with quiet strength and determination, and she is an invaluable asset on our team.”

Léa’s expertise as both a healthcare provider and a manager will play a crucial role in the process of scaling our model for UHC and, once again, greater complexity lies ahead for her role. But her humble outlook remains that “life is always a learning process. You can’t move forward in life if you don’t cultivate yourself.”



  • 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.