17 Jun Field Note: PIVOT’s First Steps

Posted at 12:01h in Blog by

I came to Ranomafana after having worked in the south of Madagascar with Médecins Sans Frontières. Ranomafana is like paradise to the eyes after the dry south, hills of green and constant rain much of the year, living in the clouds almost. While being a haven for nature, part of which is protected by the oldest national park set up by Pat Wright, the district, a 10 hour drive from the capital, Tana, presents its own challenges: our first trip out to try to visit health centres was cut short, 10km from our destination. 10km but maybe a 1 to 2 hour drive! We turned back when the car looked like it was about to turn over!

The drivers are more courageous than us!  Some of the health centres are a 3 day walk, and that’s after a motor bike ride as far as the road allows to points more distant than where we turned back from. The health centre we were planning to visit has just one nurse who works alone. As part of their monthly minimum package of activities, she walks a full day to reach some of the more distant sites which are attached to her health centre. Many people understandably prefer to go to the traditional healers or “midwives” and the health centre is the last recourse, often too late. Part of our work is going to be about attracting people into the health centres: good care, free care for those who can’t pay, happy health workers who feel valued and supported and are happy and able to respond; the other part will be about going out to them: walking a few days with the community health workers to reach the furthest villages and support the communities.

That’s what PIVOT is about for me: being side by side with those who need care, side by side with those who face the challenge of providing that care with very little support, being side by side with those who are attempting to facilitate the work from district level and ensuring at each level quality care is available.

We’re starting with 4 health centres to make sure our accompaniment reaches the level of quality care we intend to spread throughout the district, by the end of 2 years we hope to have reached the whole of the district, and we know that will mean being very inventive: setting up ambulance relay points for emergencies from health centres where there is no means of communication, working with communities and traditional healers and leaders in villages which can only be reached by crossing raging rivers, walking through forests where there’s illicit gold mining. Even with all these challenges, we are already getting more and more referrals each week and some from remote health centres, and patients are reaching the hospital or even referred to the regional hospital and kids are starting to shout “Pivot” when the cars go by. We’re the only healthcare NGO based in the district and people are starting the reach out to us as we make services accessible to those in need. And that’s exciting! And we hope PIVOT-al!!!

 




    • JOIN OUR MAILING LIST TO RECEIVE
      THE LATEST NEWS FROM PIVOT!



      First Name

      Last Name

      Email

      (We will never share your data without your permission.)

    • 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.