Miller, A.C., Bonds, M.H. (2021). American Journal of Public Health.
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.
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
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.
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.
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:
Baseline Population Health Conditions Ahead of a Health System Strengthening Program in Rural Madagascar, Miller, A., et al. 2017, Global Health Action
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.
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.
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.
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.
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 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.
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
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.
Improving geographical accessibility modeling for operational use by local health actors, Ihantamalala, F.A, et al., 2020, International Journal of Health Geographics
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.
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
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.
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.
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.
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.
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%.
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.
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.