Field Note: “The World Needs To PIVOT, And Now We Know How To Start”

I’m walking deep in the rural countryside of Madagascar with three community health workers and their supervisor. They work with the non-governmental organization PIVOT, who is hosting my visit so that I can provide advice about how to adapt the program. Having started my work in community health in rural southern Mexico almost 15 years prior, I now try to lend what I’ve learned to such programs all over the globe, and make these trips as often as is useful to our colleagues.

But now my hiking boots are full of mud and water – apparently they were better for corn and coffee fields than for rice paddies. We get to a particularly deep part and I look up, helpless. They pause to look back at me, and I can see the pity on their faces. Toky, a cheerful and robust community health worker in knee-high gumboots comes back and hunches in front of me so that I can hop on piggyback. Moments later, I’m across the stream, but not without a dose of pointing, laughing, and picture-taking. Malagasy social media is about to get a hilarious new meme, and I’m enthralled; I may have come to teach, but I’m reminded that partnerships are always about co-learning and humility.

PIVOT is a 501c3 that was started by US donors and leadership, but is now very squarely rooted in Malagasy soil, in Ifanadiana District, next to Ranomafana National Park. Madagascar is famous for being unique in the world, supporting flora, fauna and people found only in this place, but 90% of its original natural wonder is now already gone. Burned, logged, or producing rice for a growing population, you see in Madagascar the timeless question first asked at the dawn of agriculture and civilization: does the land belong to us, or do we belong to the land? We now live in a warming world, and everything is changing. In my time on the planet I’ve seen many examples that show we may be incapable of coming together to confront the problems that cross the lines we’ve drawn, be they national borders, distinctions of race, tribe, gender, class, age, or any of the many other axes of difference we’ve dreamed up. Pandemic viruses, however, remind us that we maintain these dividers at our peril; viruses jump our walls with ease, and only we stay trapped.

So, if we are going to preserve all that we’ve built, we need to pivot, and we need real, viable, ambitious examples of what works. The group I am visiting offers much to meet this need, and I hope it delights you that their name is PIVOT.

In Ranomafana, you can see how a symbiosis between humans and the forest is possible; a UNESCO world heritage site adjacent, the town is booming, fueled by eco-tourism that is mostly for the Malagasy-with-means. I walk through the streets and see how wealth redistribution and environmental protection can follow the flow of delight: a middle-class visitor from the capital tells me with a tear in his eye, “This place is very, very, special. We must not lose it.”

The town is also booming because PIVOT provides high-quality health care with no user fees. Health is wealth, because young people who don’t die needlessly build things as they grow up, if given a chance. Abolishing user fees opens the gates so that all can enter the health system, and if the system can actually meet the demand, then patients will choose to enter over other, more personally expensive options. All over the world, a top cause of further impoverishment is catastrophic spending on healthcare; when the person you love is dying, it is deeply human to want to put out their fire with Champagne if it may save them. For us in the global north, that might be taking out a loan or maxing out a credit card; for the rural poor, after they’ve sold off their possessions and possibly even the roof over their head, the only substantial wealth available to them is the neighboring rainforest. How much illegal logging can be linked back to a worried parent, spouse, or sick child? The inhumane systems we have come to accept as the status quo force people, through their love, to make impossible choices like this every day.

Yet love can also build, and cherishing the details can be holy. You may have heard that there are more cellphones than latrines in the poor world. Well, PIVOT has one of the most ambitious digital health programs I’ve ever seen, utilizing data to inform action and decisions, such as an impressive geo-mapping of the rural paths we walked on my soggy hike. The community case management of childhood illnesses (iCCM – in which community health workers have a small kit of lifesaving medical interventions that they can provide in the most remote and rural places “where there is no doctor”) has rarely been effectively launched at scale. The reasons for this are many, but PIVOT has added a number of innovations that promise to position it as one of the most exciting and promising iCCM programs anywhere. Some of these are based on evidence coming out of programs launched by peer organization, such as implementing the proactive community case management which Mali-based NGO MUSO pioneered. Some are fresh and unseen anywhere else, such as the addition of Paracetamol (a.k.a. Tylenol) to the community health workers’ medicine kits. Why would the addition of a common, non-lifesaving medicine be of any use? Because parents like to see their children without fevers and pain, and for many symptom relief is the proof that a medicine worked. Every sleepless parent knows this: just a spoonful of Paracetamol helps the Artemether/Lumefantrine (antimalarials) go down. I hope that PIVOT’s example changes medicine kits everywhere in the world where such kits exist.

These details alone would make PIVOT an exciting program, in line with worldwide community health ambitions. Zooming out from these details, another picture comes into focus: PIVOT is finding success in all the right pieces of the puzzle, and putting together something very, very different. Some of this they learned from the organization I grew up in, Partners In Health (PIH), likely because some of their leaders have also worked at PIH, and our values are closely aligned. These include: partnership with the government, because public sectors are the best way to reach the poor equitably with “healthcare as a human right”; proper health systems extending care that you would want for yourself and your family; a happily motivated and qualified staff; enough stuff (i.e. the right equipment and a functioning supply chain) to do the toughest jobs; strong infrastructure to receive the increasing volume of patients accessing care, and even a nice space for care providers to see these patients; systems that make the engine hum; and social supports to address poverty and achieve equity of outcomes.

If a clinical outcome is available anywhere, shouldn’t it be available everywhere? For example, if curable diseases are cured in Geneva, shouldn’t they be cured in Amboasary Village too? If your soul sings yes, well, then you’re unfortunately in the minority among global health “experts.” Don’t despair, however, because your people exist, and we are busy putting this aspiration into practice.

Blazing this trail is a group of effective leaders that deserve the accolades they have received. First, I was delighted to learn that over 50% of leadership roles at PIVOT are held by women, including 7 of 12 director-level and 21 of 40 manager/supervisor-level roles. The bravery of these leaders has launched this enterprise into necessary, but uncharted, territory. At a time when PRESIDENT OBAMA HAS REMINDED US that “if every nation on earth was run by women, you would see a significant improvement across the board on just about everything… living standards and outcomes,” I find myself nodding at his words as I observe the deeper truth of that idea in play out here. The mechanisms for this are many, but what I saw firsthand was the ability to deftly balance large clinical ambitions (“let’s go wide and deep in this community”) with that holy attention to critical details (“from whom are we buying our local goods, and are we spreading our disproportionate wealth fairly throughout this impoverished town that hosts us?”).

Also quite impressive was the ability to weather all the slings and arrows inherent in this work: from endless meetings with government partners about contentious questions, to never-ending negotiations pushing against the dominant frameworks imposed by institutions in the global north. Radiating out from the top leadership is a latticework of similarly dedicated social justice warriors, all with their own dose of dedication and resolve. I have yet to meet someone here who yawns during a discussion about how to better reach the rural poor.

As I write this, COVID-19 is spreading rapidly. It is hard to say how long it will last or what will be the ultimate impact. In it, however, we are seeing just how vulnerable we all are, but also that we have no choice but to get through this together. For many in the global north, this is an awakening. But for our colleagues in the countries where PIH and PIVOT work, they have long known this truth: West Africans who saw Ebola, Mexicans in Chiapas who saw Zika, Haitians who see Cholera, Peruvians who see multidrug resistant tuberculosis, the Basotho who see some of the highest rates of HIV infection, and the list goes on. We have had many chances to make the necessary changes to confront such challenges with greater focus and agility, but we still haven’t done enough. In the face of this complexity, this is what we fight for every day to get us out of this seemingly endless cycle of disease and vulnerability: all lives have value, and we must validate those lives by assuring material benefits are available equitably, including education, health care, food, housing, peace, and justice. PIVOT has a mantra that says this well: care for the person, systems for the populations, innovation for the planet.

When you look around today, do you feel that our modern civilization is on the right path? If so, feel free to ignore PIVOT’s example. But if you have even the slightest pang that change will be necessary, sleep well tonight knowing that an iterative yet irrefutable model exists in the deep countryside of Madagascar. And when you wake up renewed, please roll up your sleeves, put on your gumboots, and join us. We have a lot of work left to do.



  • 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.