Report From Community Frontlines

PIVOT’s approach is to strengthen all three levels of the existing district public health system: the district hospital, health centers, and community. In the Ifanadiana district where PIVOT operates, many people cannot travel to the district hospital or health centers for a variety of reasons including long distances between villages and health facilities, lack of roads, and poor conditions of existing roads (see video in this enews).

Creating and supporting a strong network of Community Health Workers (CHWs) is key to our approach. CHWs play a critical role in extending access to health services in the rural and hard-to-reach areas where PIVOT operates. They are often the first to encounter vulnerable patients and can be critical for overcoming barriers to health care.

PIVOT is bolstering the existing system of CHWs through our community health teams. The community health teams in Kelilalina and Ranomafana are hard at work focusing on supervision and on-site training of the CHWs.

(Accompagnateur Communautaire Clinique) visit each Fokontany (village) once/month to provide on-the-ground supervision and training of CHWs.  In the photos above, they review Integrated Management of Childhood Illness (IMCI)-community forms with CHWs.  In the community, we are focusing on children under 5 years old.  Many of these patients live very far from a health center (some > 20-30 km away), so PIVOT is striving to provide CHW training to: (1) recognize and treat some illnesses in the community; and (2) recognize and refer more serious illnesses to the health centers.  There is a Madagascar National Community Health Policy that recommends CHWs, and supervision/training of these CHWs from health center staff.  But health center staff are usually unable to go out to the communities due to lack of funding, time and motivation.  So PIVOT ACCs are working with health centers to fill this gap.

PIVOT Community Health Supervisor Marco visits CHWs in the field, providing training, supervision and patient education skills.  ACCs also provide urgent medical consults when they visit the Fokontanys.

PIVOT ACC midwife Lanto gives a child a polio vaccination during one of the national polio campaigns.

Currently, CHWs do not have a location to see patients or to store their equipment.  Part of the PIVOT community health program includes helping each Fokontany to build a community health site.  These sites are recommended by the Malagasy government as part of their community health program, belong to the communes, and serve as a location for CHWs to evaluate and treat patients.  The communities donate local materials and their time to build, and PIVOT donates roofing materials, nails and construction recommendations.  Above left, a community member works on a community site; above right are PIVOT ACCs Lanto and Marco in front of a completed community site.

Another important part of our community programs are the distribution of “kits” of medications to CHWs.  CHWs are trained in IMCI for community health care workers, i.e., basic training to identify and treat the most common causes of childhood mortality in Madagascar – malaria, diarrhea with dehydration, pneumonia and malnutrition.  Previously, CHWs had to purchase medications and sell them to patients; if the CHWs did not have the money to buy the medications, or if the patients did not have the money to buy the medications, the child would not receive treatment.  PIVOT donates basic medications to the CHWs each month (Amoxicillin to treat pneumonia, rapid malaria tests and malaria treatment, Oral Rehydration Salts and Zinc for diarrhea with dehydration), and the CHWs provide the medications for free to the patients.

The CHWs come to the health centers each month to turn in reports and pick up their supplies of new medications. Above right, CHWs arrive at Ranomafana Health Center to replenish their medication kits and turn in their reports for medication distribution. Above left, PIVOT Community Program Supervisor Marco checks inventories, replenishes kits and reviews medication usage guidelines with CHWs.

An important aspect of the community health medication kits is on-site supervision of medication use and inventory / supply management.  Above, PIVOT ACC Adolphe reviews medication use with a CHW to verify that the medications are correctly administered and appropriately recorded.

Over the past 2 weeks, PIVOT also financed and organized a malnutrition training for CHWs. Over 150 CHWs and community leaders in Ranomafana, Kelilalina, Ifanadiana and Tsaratanana were trained to screen and refer patients with acute severe malnutrition.  This was the community health companion training to the malnutrition training that we completed for health center staff in September.  Trainers included National Ministry of Health (MoH) staff, regional MoH staff and local PIVOT and MoH staff.  CHWs will now conduct mass malnutrition screenings in their communities and refer patients with severe acute malnutrition to health centers for treatment.  CHWs also received training on conducting home visits for patients diagnosed with malnutrition, and patients with malnutrition lost to follow-up.

Below are several photos from the trainings.

The final photo is a sample page from the patient education materials.  These patient education materials were provided to all CHWs. The materials are double-sided.  One side is a pictorial representation of common illnesses, good sanitation and hygiene practices to show to patients and families; the other side is an instructional guide in Malagasy for CHWs that details how to provide the patient education.

 



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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.