Staff Spotlight: Rado Rakotonanahary

Staff Spotlight: Rado Rakotonanahary

It was during a mathematical modeling workshop that Rado Rakotonanahary first learned about Pivot. 

“To tell you the truth, I had never thought about pursuing a career in the humanitarian field,” he recalls. As a scientist, however, he says that he was “directly drawn to the organization” upon learning about Pivot’s public health research agenda. So, when he heard of an opening on the Pivot team, he didn’t hesitate to apply.

Prior to joining the Pivot team, Rado was a laboratory research engineer at the Institut Pasteur of Madagascar (IPM) in Antananarivo, the country’s capital city, where he also grew up and pursued his education. With a doctorate in immunology and training in quantitative methods, his specific research interests include diagnosis and surveillance of infectious diseases. During his time at IPM – which is known internationally for its dedication to the study of infectious disease at the microbiological level – Rado was involved in responding to Madagascar’s 2017 plague outbreak, coordinating diagnostic efforts and advancing research on rodent-borne and other zoonotic illnesses.

When Rado assumed the role of Pivot’s Research Manager in October 2019, the team couldn’t have anticipated the imminent pandemic or how critical Rado’s particular skills and experiences would become as the COVID-19 crisis unfolded. Before that, Rado enjoyed his transition from the hustle and bustle of Antananarivo to the rural tranquility of Ranomafana – something that he says added to the draw of the position. “The environment, the fresh air, and the low-stress commute” are among the aspects of living in Ifanadiana District that he appreciates most.

At the start of his time as Research Manager, Rado’s primary charge was already broad: to oversee the coordination of Pivot’s scientific studies with a focus on supporting and leading operations and clinical research. Considering the central importance of research in Pivot’s overall strategy to model universal health coverage for the country, coordinating even one study – let alone several at once – is no small feat. So he dove right in, getting involved in every step of the research process, managing studies “from their conception [to their] implementation, analysis, publication, and popularization of their results.”

Of these functions, he finds the last to be the greatest challenge. “It can be a bit difficult to communicate the results of a study to our clinical staff,” he explains “because we need to distill the complex explanation into something that our programmatic colleagues can understand well enough to use to strategically improve our intervention on the health system.” 

However, nothing in his two years at Pivot has proven more challenging or exciting than the project that awaited Rado just a few months after starting his new position. With the onset of COVID-19 around the world giving Madagascar – an island nation – some lead time to organize prevention measures, Rado was called upon to oversee the establishment of a reverse transcription polymerase chain reaction (RT-PCR) laboratory in Ifanadiana District. Working in collaboration with Pivot’s founding partner at Centre ValBio (CVB), whose research station sits at the edge of the Ranomafana National Park, and with the Ministry of Public Health (MOPH), Rado’s new charge was to transform CVB’s existing biosafety level 2 laboratory into a regional COVID-19 testing lab.

Fortunately, Rado’s vast experience working in such lab settings had prepared him to rise to this unexpected challenge. He explains that there were a multitude of obstacles that he and his collaborators faced in this endeavor to expand Madagascar’s testing capacity beyond the capital city, especially when it came to procuring the specific equipment and reagents necessary for the lab to function as intended – materials that were only available internationally and in high demand across the globe. The perseverance of Rado and collaborators led to the laboratory’s grand opening in May 2021, just as Madagascar was experiencing a second wave of COVID. Though he says there are still improvements to be made in terms of the lab’s efficiency, the mere establishment of such a facility in a rainforest – the first of its kind outside of the capital – means a great step forward for the country’s capacity to respond to infectious disease crises.

Simultaneously, Rado has been contributing to the Pivot Science team’s development of predictive epidemiological models of the spread of COVID-19, and authored an article that was published in Frontiers In Public Health in July 2021 entitled “Integrating Health Systems and Science to Respond to COVID-19 in a Model District of Rural Madagascar.” In the latter, Rado et. al. outline Pivot’s multifaceted response to the pandemic in conjunction with the MOPH and CVB, and demonstrate how “an integrated platform of strengthened health systems and research” can generate transferable lessons for the prevention of future epidemics in rural Madagascar and around the world.

Balancing his dual roles as Research Manager and de facto lab manager continues to keep Rado busy, but the diversity of the work in which he is involved is what he enjoys most about his job. The fact that he thrives on being involved in the variety of disciplines and methods brought forth by himself and his fellow researchers aligns naturally with his favorite of Pivot’s seven values: the pursuit of learning. “I don’t want to be satisfied with what I already know,” he explains. “I always want to learn and deepen what I know, and to have notions of what I do not yet know.” Even when asked about his hopes for the future of Pivot, Rado names the ways in which he envisions continuing to improve our approach, the evaluations of impact, and the integration of the evidence generated by research with our long term plans.

“Rado’s background and diverse skillset have helped Pivot’s research respond to the global need for a better understanding of disease dynamics and the health system response during a global pandemic,” says Karen Finnegan, Associate Scientific Director. “His leadership of the COVID-19 laboratory has been pivotal in helping diagnose and treat cases in the district and surrounding regions. Rado is tireless in his pursuit of answers to the questions that are central to Pivot’s work.”

Today, Rado has a new appreciation for what it means to leverage his work as a scientist in a healthcare delivery organization at the edge of a peaceful rainforest. “I’m especially proud to support the people,” he says, “especially that, above all, we work to help the poorest of the population.”



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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.