Staff Spotlight: Onja Randriamiaranjatovo and Sophie Rasoatsilavina

Prior to uprooting their lives to work for PIVOT in 2015, Onja Randriamiaranjatovo and Sophie Rasoatsilavina had lived, studied, and worked in Madagascar’s bustling capital city of Antananarivo for their whole lives. After some years holding various clinical positions – from volunteering for health organizations to working in private clinics – the couple were ready to relocate to somewhere more remote, where they felt they could use their training to make more of an impact. In 2015, each pursued positions with PIVOT and relocated to rural Ifanadiana District. Onja was hired as a nurse and Sophie as a midwife.

After five months of excelling as a pediatric nurse at a PIVOT-supported health center in Ifanadiana, Onja was assigned to launch the malnutrition program in the even more rural community of Tsaratanana. Getting to Tsaratanana Health Center involves a sharp turn off of the paved national route onto bumpy, muddy terrain – a drive that lasts for about an hour (or more, depending on the vehicle and the season) before your destination emerges in the distance. He was ready for the challenge.

Sophie continued working where she was needed most, as a midwife jointly-supported by PIVOT and the Ministry of Health (MoH) at Ifanadiana Health Center. The pair would spend the next seven months making the trek to see one another when time allowed. Not long after the couple married, an opportunity opened up for Sophie to transfer to Tsaratanana and work as a midwife in the same remote community as Onja – she took it.

Sophie and Onja met while studying to enter their respective clinical fields, and have been together ever since. They shared ambitions of leaving the city to live life at a different pace and, above all, settle down somewhere that their skills and passion for delivering care could make a lasting difference. The contrast between Antananarivo and Tsaratanana cannot be emphasized enough. Onja and Sophie swapped the abundance of products in round-the-clock shops for small, quiet market days where certain products are only available certain days of the week, if ever. They swapped relentless automotive traffic for dirt footpaths and muddy motorcycle routes. And they swapped working in a big city alongside hundreds of other clinicians to instead live in a community where electricity may be scarce, but their voices are heard and taken more seriously among their small team of colleagues.

Since relocating to Tsaratanana in early 2017, they’ve each settled into positions that are well-suited to their professional passions and strengths. Onja leads the program for treatment of malnourished children under the age of five. Sophie, in addition to her role as midwife, has been appointed by the MoH as administrative director of the health center. The couple is unwavering in their commitment to act strictly as colleagues in the workplace (to a point where it took many colleagues months to discover they were married), Onja and Sophie serve as a living example of how PIVOT’s collaborative partnership with the MoH can have a huge impact on population health.

When asked about the aspects of working for PIVOT that make them most proud, their list is long. Sophie says with a laugh that delivering babies is her favorite part of the job (“which is good, because it is my job”), and notes that, beyond that, Tsaratanana Health Center was recognized for having greatest number of safe health center deliveries in the region during her first year. The “incredible drops to maternal mortality” that she’s seen result from PIVOT’s work have inspired her and strengthened her belief in the organization’s mission.

Onja states simply that he’s most proud of the fact that PIVOT focuses on childhood malnutrition, because there are so many children affected by it in Ifanadiana District. He is greatly fulfilled having a role in helping children and their families overcome needless suffering.

Both say that awareness of PIVOT’s presence, purpose, and impact is high among members of the Tsaratanana community. In their years of work there, they’ve seen an increase in understanding and trust in the public health system. They have observed how the removal of fees for patients has been a game-changer when it comes to a person’s likelihood to come to the health center – in a place where patient visits had once been scarce, one of their biggest challenges today is the sheer number of patients who come seeking care each day.

They are pleased to see that people trust the quality of care at the health center enough to come – often walking kilometers at a time to get there – when sick. “And even when we are not equipped to provide care,” Sophie says, “we work with PIVOT’s referral team to transfer patients to higher levels of care where they can get the help that they need.”

Over the past two years, Onja and Sophie have fully embraced the lifestyle changes that came with their move to Tsaratanana, establishing a home where they welcomed their first child. They recognize that their aspirations to live and work in a remote community differ from those of many young Malagasy couples, but they don’t get caught up in comparisons. In the context of both personal and professional endeavors, the couple lives by a Malagasy adage that says, “Do not put yourself in competition with others, but exceed your successes of yesterday.” Their adherence to this philosophy is evident both in their conduct as healthcare providers, and in their commitment to continue serving the community of Tsaratanana. With no plans to relocate soon, both Onja and Sophie exhibit an exceptional level of dedication to helping those who are most in need.

With first-hand observations of the difference a strong, functioning health center can make in a remote community like Tsaratanana, Sophie and Onja are excited by PIVOT’s plans to reach every health center in Ifanadiana District by 2022. For as long as they continue their work in solidarity with patients and communities, we feel fortunate to have these two remarkable clinicians contributing to PIVOT’s mission in Ifanadiana District.

 



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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.