Staff Spotlight: Natacha Rajaona

Natacha Rajaona joined the PIVOT team in January 2020, just before the onset of the COVID-19 pandemic. Within weeks of her onboarding as the Deputy Director of Infrastructure and Logistics, an unexpected personnel shift promoted Natacha into the newly formed role of Director of Programmatic Support. Now, almost a year and a half in, Natacha remains one of the two directors of our 70+ person Operations Department, and is boldly heading up the rehabilitation of rural health centers throughout the district as a foundational step to our largest-ever expansion of services. Despite the challenges created by the pandemic and the simultaneous leap into her new role, Natacha has maintained a laser focus on this goal, which is key to executing PIVOT’s strategy to implement universal health coverage (UHC) throughout Ifanadiana District by 2022.

Prior to moving to Ranomafana, Natacha primarily lived and worked in Madagascar’s capital city, Antananarivo. Trained as an engineer, her past professional experiences were exclusively in the private sector, working with for-profit companies dealing in the implementation of telecommunications and solar power in rural communities without electricity. In these roles, she often found herself negotiating with poor communities on behalf of wealthy companies, and it left her feeling conflicted about the true impact of these business practices on the local people and economy.

“There was no justice in what I was doing,” she says, reflecting on these previous chapters in her career. Natacha explains that it was this realization, combined with her faith, that pushed her to seek opportunities in the humanitarian field. “Today I can say that I am working for something where I feel I’m really contributing to the good of the community. And that creates fulfillment and peace.”

When prompted to summarize her role in just a few words, she says it is “to provide support for clinical activities.” And when asked which aspect she loves most about her role, she says simply: “being of service!” Whether it is resolving supply chain issues to ensure all essential medicines are available at the district hospital, or solving a real-time logistical puzzle to free up an ambulance needed for an urgent patient transfer, she loves leading a “department that is designed to support other (clinical) departments,” as she puts it.

Among Natacha’s greatest prides from her time with PIVOT thus far has been the development of strong policies and procedures that were lacking when she assumed the role of overseeing the infrastructure, procurement, and logistics departments. From strengthening the process of contracting with quality local vendors to the establishment of anti-corruption policies, she sees these accomplishments as a direct manifestation of her favorite of the seven PIVOT values: accountability – to our donors and to the communities we serve.

Natacha embodies this value in her approach to leadership as well, with the firm belief that “if something does not work, it [falls to] me first. She says even if it is an error of the department, I will not put the blame on others.” Humility, another of the PIVOT values, shines through in her work. “I don’t know how to do everything,” she says without hesitation, “so I need my team. [They] have good ideas, and our strength comes from our teamwork.”

Of course, leading her team of more than forty people comes with plenty of challenges, but Natacha’s colleagues say that one of her greatest strengths is being an empathetic listener. Even though Natacha would name conflict management as one of the more difficult aspects of her job, she is a firm believer in the power of open communication, and strives to lead by example in this way.

Natacha meets with one of the 45 members of the 3 programmatic support teams (logistics, procurement, and infrastructure) that she oversees.

Amid the pandemic, the everyday sorts of challenges in her job have had to be met with extra adaptability, given the increased demand for both building and medical supplies, for the safe transport of patients and of COVID test samples between labs for diagnosis, and so much more. Even within the parameters of the policies she established soon after joining the team, Natacha has demonstrated a great deal of flexibility and grace in responding to the shifting needs of the organization.

“I have been impressed with Natacha from the moment we started working together in such a tumultuous time, and my respect has only grown since,” says colleague Alexis Moisand, HR & Finance Officer. “Bringing fresh ideas and innovative ways of working from her wealth of prior experience, Natacha has supported her department in breaking through some of the most pressing challenges that have dogged our work for years. In addition to her professional excellence, Natacha has an uncompromisable integrity that has led her to challenge inequities whenever she sees them – even if that means shaking up the way things have ‘always’ been done.”

Natacha sees her function within the organization as one of ensuring PIVOT’s longevity. One aspect that sets PIVOT apart in the field of global health is a focus on improving the health system as a whole; not only ensuring strong, dignified clinical care, but equally as strong and dignified buildings and systems to bolster that care. As a salient example of her effectiveness, over the last six months Natacha has led her teams through the lofty charge of simultaneously rehabilitating six rural health centers – during a pandemic, no less, which means navigating additional layers of challenge with regard to domestic travel restrictions and global supply chain. This is an enormous milestone on the path toward achieving UHC in Ifanadiana District, as quality infrastructure facilitates availability of health services, which in turn dramatically increases access to care.

Natacha visits one of the six health centers to monitor the progress of the rehabilitative infrastructure work she’s overseeing – a key part of PIVOT’s strategy to achieve universal health coverage in Ifanadiana District.

Already faced with a large scope of work tied to PIVOT’s growth, Natacha’s greatest hope for the future of the organization is further expansion. Seeing the impact of the “healing, supporting, and lifesaving” work on Ifanadiana District’s population, she looks forward to playing a part in the process of transforming other districts’ healthcare into systems that serve all, too. In so doing, the importance of teamwork remains at the forefront of her mind at all times. “We need to always focus on the fact that PIVOT is there to really support the [population], and we need everyone to do their part […] for it to work.”

WATCH NATACHA DISCUSS SOME OF THE BIGGEST CHALLENGES WE’VE ENCOUNTERED IN THE PROCESS OF REHABILITATING RURAL HEALTH CENTERS.

Outside of her big and often frenetic job, Natacha finds tranquility in the natural surroundings that Ifanadiana District has to offer. Though she misses being close to family and friends back in Antananarivo (including her husband, who has remained there for work), she says that her 3-year-old daughter, Anoka (who lives with her in Ranomafana), is a constant source of inspiration. On her most difficult days, she reminds herself that she is on the right path because she is serving the needs of the population, which also means she is creating a better future for her daughter.

Natacha and her daughter Anoka, age 3.

 



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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.