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Strategic Plan 2018-2022

Strategic Plan

2018-2022

CONTENTS

CONTENTS GOAL ONE GOAL TWO GOAL THREE GOAL FOUR Introduction 3 • Mission and Values •
  • GOAL ONE

  • GOAL TWO

  • GOAL THREE

  • GOAL FOUR

 

Introduction

3

Mission and Values

Background and Approach

Create a Model Health District

6

  • I. Health System Readiness

II.

III.

District Hospital

Health Centers • Community Clinical Programs

Child Health (IMCI) • Malnutrition

• Tuberculosis Maternal and Reproductive Health

Emergency Transport • Patient Accompaniment • Future Programs Information Systems

Build a Platform for Science and Innovation

Implementation Science

Scientific Innovation

Planetary Health

Grow Organizational Capacity to Support Long-Term Effectiveness

Organizational Site and Structure

Internal Capacity Building

Health System Strengthening

Development

Strengthen Partnerships

Government

Academic

Local and International

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32

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CONTENTS GOAL ONE GOAL TWO GOAL THREE GOAL FOUR Introduction 3 • Mission and Values •

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INTRODUCTION

MISSION

In partnership with communities in resource-poor areas, PIVOT combines comprehensive and accessible health

care services with rigorous scientific

research to save lives and break cycles of poverty and disease.

VALUES

• Health as a human right • Solidarity • Bias toward action • Sustainability • Humility • Accountability • Pursuit of knowledge

INTRODUCTION MISSION In partnership with communities in resource-poor areas, PIVOT combines comprehensive and accessible health care

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INTRODUCTION

BACKGROUND AND APPROACH

Madagascar is one of the poorest countries in the world with one of the weakest health systems. Ninety percent of the population of 24.9 million lives on less than $2 a day. When PIVOT began operations in 2014, 1 in 7 children in Ifanadiana District died before reaching age 5 and the lifetime maternal mortality rate in the district was 1 in 14.

Most causes of suffering and death are preventable or treatable

with existing knowledge, policies, and technologies that are

affordable at scale. The disparity between existing knowledge and

implementation is a challenge around the world and is referred to

as the global health delivery gap or the “Know-Do” gap.

Integral to solving the “Know-Do” gap are functional health sys- tems that can support clinical programs across the continuum of care. Strengthening health systems requires: trained and dedicated

professionals; working equipment and infrastructure; reliable drugs and supplies; and the ability to refer patients to appropriate levels of care for treatment and follow-up. Improving these health

systems requires modest financial resources, but alignment

between national policies and localized coordination is critical.

The government of Madagascar can fill the “Know- Do” gap by

leveraging resources and capacity among relevant partners — if it can ensure that systems are ultimately aligned at the point of care.

IFANADIANA DISTRICT Madagascar is an island nation located in the Indian
IFANADIANA
DISTRICT
Madagascar is an island
nation located in the Indian

Ocean, off the east coast of

Africa. PIVOT is working in Ifanadiana District in the rural southeast of the country.

In working to fill the “Know-Do” gap, PIVOT’s vision is one of a district — and ultimately a country — where all people can exercise their fundamental right to health care and unnecessary suffering

and death are alleviated. Since early 2014, PIVOT has worked alongside the Ministry of Health

(MoH) with the goal of transforming Ifanadiana District into a model system of universal access to quality health care. Located in the rural southeast of Madagascar, the district has a population of over 200,000 people and borders the Ranomafana National Park (RNP), where Centre ValBio, a key

partner, conducts world-class conservation research and outreach that benefits the surrounding

communities. Through 2017, PIVOT supported a catchment area of 75,000 people with community

health activities that fed into seven government-run health facilities: the district hospital, five

health centers, and the university hospital (for referrals outside of the district). Some district-wide

programs have reached other health centers off of the main tarmac road and will become more

robust through 2022, the timeframe for the current Proof of Concept phase, which will be followed by National Scale-up (see pages 7 and 8 for further explanation).

INTRODUCTION BACKGROUND AND APPROACH Madagascar is one of the poorest countries in the world with one

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INTRODUCTION

In partnership with the Madagascar Institute of Statistics (INSTAT) and Harvard Medical School, PIVOT began a longitudinal cohort study of over 8000 individuals, yielding district-representative estimates of health indicators available both inside and outside the initial catchment population and comparable across the country, with a true baseline before major health interventions. These data are a unique asset in health system strengthening. Combined with data from Health

Management Information Systems (HMIS), we can now show that the first two years of the intervention produced significant population health improvements. Overall treatment rates

quadrupled, and the district saw rapid declines in mortality among vulnerable populations: a

decline in neonatal and under-five mortality of 36 percent and 19 percent respectively, and a

district-wide drop in the lifetime maternal mortality rate from 1 in 14 to 1 in 18.

As we look to the coming five years, 2018-2022, we will go deeper and wider with existing clinical

programs, initiate new programs, and geographically expand the intervention to transform Ifanadiana District into a model health system. In partnership with the MoH and Centre ValBio,

our integrated system of health care and data will provide a platform for entirely new scientific

exploration, technological development, and pioneering solutions for sustainable human and

planetary health. This model system and scientific innovation hold promise for saving lives and

breaking cycles of poverty and disease in Madagascar and beyond.

INTRODUCTION In partnership with the Madagascar Institute of Statistics (INSTAT) and Harvard Medical School, PIVOT began

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Health care for the individual. Systems for the population. Innovation for the world.

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GOAL ONE

CREATE A MODEL HEALTH DISTRICT

Our approach to creating an evidence-based model district is based on the integration of

strengthened “horizontal” systems using the World Health Organization’s Service Availability &

Readiness Assessment (SARA) guidelines, “vertical” clinical programs, and information systems, implemented across all levels of the health system: community health, health centers, and hospital. The model is sustainably aligned with the Ministry of Health, and produces rapid, substantial, and lasting population-level impacts on health care access and mortality rates.

GOAL ONE CREATE A MODEL HEALTH DISTRICT Our approach to creating an evidence-based model district is

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GOAL ONE | Create a Model Health District

Population-Level Key Performance Indicators (KPIs)

Indicator

2014

2017

2022 Goal

Maternal mortality rate

1044/100,000

828/100,000

500/100,000

Under-5 mortality rate

136/1,000

114/1,000

70/1,000

Lifetime fertility rate

6.9

5.5

4

Composite coverage index (CCI)*

46.2%

54.5%

75%

Percentage of district population covered by PIVOT intervention

0%

37%

100%

* CCI is a composite score that represents access to key clinical services, including: treatment for fever, respiratory infection and diarrhea, access to family planning, deliveries in health facilities, and vaccine coverage, among others.

Phase 1: Proof of Concept

During the current Proof of Concept phase,

PIVOT’s model is being tested through the process

of implementation, adaptation, and analysis of inputs and impacts. PIVOT is the main driver of

the Proof of Concept stage, requiring flexible,

private funding to optimize the intervention. We aim for Ifanadiana District to serve as a fully

functioning model health district by the year 2022, with our package of services reaching the

entire district population. As of 2017, we have

begun activities in the district hospital and five health centers (covering 37% of the population)

with the intention of reaching all thirteen level 2 health centers. Consideration will also be given to the smaller level 1 health centers over time. The implementation will be guided by national policy, and by our Key Performance Indicators (KPIs) listed throughout this Strategic Plan. Costs of the model are to be estimated annually, with the most rigorous analysis completed in 2022.

GOAL ONE | Create a Model Health District Population-Level Key Performance Indicators (KPIs) Indicator 2014 2017

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LOCAL ADMINISTRATIVE STRUCTURE

The district health system in Madagascar comprises the following levels, referred to throughout this document:

FOKONTANY: A small cluster of 2-3 villages of approximately 250 households, totaling about

1300 people. In accordance with national policy,

each is assigned two locally elected community

health workers to treat children under five

and pregnant women. Fokontany are the smallest administrative unit of the government, represented by locally elected leaders.

COMMUNE: A group of 8-10 fokontany, totaling 10,000-25,000 people. Each commune (13 in

Ifanadiana) has a primary care government level 2 health center (CSBII), which according to

national policy should be staffed by a doctor,

nurse, and midwife. Communes with a dispersed rural population have an additional smaller level

1 health center (CSBI), which should be staffed by

a nurse and midwife (7 in Ifanadiana).

DISTRICT: There is one hospital that provides higher-level care in the district (119 in Madagascar). The district is the most self- contained administrative unit for managing and scaling up health systems. Ifanadiana District has a population of about 200,000 people.

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GOAL ONE | Create a Model Health District

Phase 2: National Scale-Up

National scale-up will rely on partnerships between the Madagascar government, multilateral institutions, and non-governmental partners, where PIVOT plays a dual role as advisor and implementing partner to the government. The key to the transition from Proof of Concept (Phase 1) to National Scale-Up (Phase 2) is integrating with the MoH from the start, and producing evidence that multiple vertical programs can be locally integrated through strengthened health systems at the point of care. This transition is not binary: early evidence is already contributing to national discourse on key topics, such as Universal Health Coverage. To date, we have enjoyed strong relationships with the local, regional, and national government, and with key national-level partners.

GOAL ONE | Create a Model Health District Phase 2: National Scale-Up National scale-up will rely

Timeframe for Expansion in Ifanadiana District

2017: 37%
2017: 37%

PIVOT currently works in Ranomafana, Ifanadiana,

Tsaratanana, Kelilalina, and Antaretra health centers

and COVERS 37% of the population.

  • 2018 TARGET: 61%

EXPANSION TO Ambohimanga du Sud and Andro-

rangavola COVERS 61% of the district population.

  • 2019 TARGET: 70%

EXPANSION TO Marotoko and Antsindra COVERS

70% of the district population.

  • 2020 TARGET: 85%

EXPANSION TO Ambohimiera and Analampsina

COVERS 85% of the district population.

2021-22 TARGET: 100%

EXPANSION TO Maroharatra and Fasintsara

COVERS 100% of the district population.

GOAL ONE | Create a Model Health District Phase 2: National Scale-Up National scale-up will rely

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Part I: Health System Readiness

Health system "readiness" refers to systems of horizontal capacity. Our standards are adapted

from the World Health Organization’s SARA guidelines with a focus on alignment with national

policies, quality, and access that apply to each level of care within the district. Where needed, PIVOT exceeds MoH norms or pilots interventions that have potential to inform national policies.

Components of Service Availability and Readiness (SARA) Guidelines

PERSONNEL: Medical and non-medical personnel

working in facilities and out in the communities are

trained and supervised.

BASIC AMENITIES AND INFRASTRUCTURE: Health

facilities are set up to provide care with amenities and

infrastructure maintained at an acceptable, consistent

level of quality: includes electricity, water, sanitation,

dedicated private space for patients, communication,

and workspace.

EQUIPMENT: Health facilities have the needed

equipment for all services provided, (e.g. basic medical

technologies such as monitors and scales).

INFECTION CONTROL: Health facilities implement and

maintain standard methods and precautions for infection

control: includes waste management, disinfection, hand

hygiene, patient contact protocol, and sterilization.

DIAGNOSTIC CAPACITY: Health facilities have the

needed tests and laboratory equipment for all services

provided at all times.

MEDICINES AND SUPPLY CHAIN: Health facilities

including community health sites have the needed

medicines for services available to all patients (not

stocked out). Pharmacy systems are functional.

INFORMATION SYSTEMS: Health facilities have the

necessary tools for complete, reliable, prompt, quality

reporting for all services.

ACCESS: Financial, geographic, and social barriers to care

are addressed/removed.

Examples have included:

Hiring clinical staff jointly with the

MoH with PIVOT paying salaries of government clinicians to help meet and exceed norms Placing nurse or midwife Community

Health Worker (CHW) supervisors at health centers with the mandate of supporting CHWs through onsite training and supervision Removing patient user fees at the point

of care (while still directly compensating the facilities for the service and consumables, feeding capital back into the system) Operating emergency transport through

a referral fleet of ambulances and

motorcycles Accompanying patients through their health care experience followed by community outreach after discharge

Part I: Health System Readiness Health system "readiness" refers to systems of horizontal capacity. Our standards

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GOAL ONE | Create a Model Health District

We conduct comprehensive health facility surveys annually to measure the evolution of the

health system’s readiness at all three levels: community, health centers, and hospital. Each level

of the system is monitored with a specific set of KPIs provided in this plan. In addition to tracking

the individual components, composite SARA scores for each level of the health system are under development.

AMPASINAMBO FASINTSARA FASINTSARA MAROHARATRA AMBOHIMANGA DU SUD ANALAMPASINA ANTSINDRA AMBOHIMERA Readiness Map TSARATANANA LEGEND 0 -
AMPASINAMBO
FASINTSARA
FASINTSARA
MAROHARATRA
AMBOHIMANGA
DU SUD
ANALAMPASINA
ANTSINDRA
AMBOHIMERA
Readiness Map
TSARATANANA
LEGEND
0 - 20%
KELILALINA
20
- 40%
PIVOT
40
- 60%
Catchment
RANOMAFANA
Area
60
- 80%
IFANADIANA
80
- 100%
ANTARETRA
This map is a representation of measured health
system readiness at the health center level in
each commune of Ifanadiana District.
ANDRORANGAVOLA
MAROTOKO
GOAL ONE | Create a Model Health District We conduct comprehensive health facility surveys annually to

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GOAL ONE | Create a Model Health District

DISTRICT HOSPITAL

GOAL ONE | Create a Model Health District DISTRICT HOSPITAL When PIVOT arrived in Ifanadiana in

When PIVOT arrived in Ifanadiana in 2014, its hospital — like most hospitals in Madagascar —

was severely understaffed and not always open. It did not have reliable electricity. There were no

systems for infection control and weak systems of clinical supervision. There were no functional laboratory services or emergency room, and no isolation ward for infectious disease. The hospital provided most services nominally, but lacked trained professionals, infrastructure, and medicines to provide needed care. As a result, referrals and utilization were at a minimum, rendering the hospital largely empty, thereby often serving as a last resort for dying patients. PIVOT has begun the process of transforming this district hospital into a model hospital for the country of Madagascar, one capable of providing secondary care for curable diseases, emergency treatment, cesarean sections, and other urgent surgeries. There remains considerable work to be done across all areas, including needed improvements in infrastructure, supply chain, and training.

GOAL ONE | Create a Model Health District DISTRICT HOSPITAL When PIVOT arrived in Ifanadiana in

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GOAL ONE | Create a Model Health District

Service Availability

With greater readiness, the hospital will be able to support the following specific services by 2022,

meeting the National Health Sector Development Plan and following national/international norms. Services in bold indicate programs PIVOT is already supporting with the MoH:

Removal of user fees

HIV testing and counseling, ARV

Emergency care (including ambulances)

prescription and management, PMTCT

Family planning

Inpatient malnutrition

Antenatal care

Chronic care: noncommunicable disease

Comprehensive obstetric care

(NCDs) diagnosis and management

• Vaccinations

Basic and comprehensive surgical care

Malaria diagnosis and treatment

Laboratory capacity

Blood transfusions

Tuberculosis diagnosis and treatment

Social work

Dentistry

Key Performance Indicators: Hospital Service Availability and Readiness

Indicator

Baseline

2017

2022

Goal

 

Data

   

Average monthly availability of tracer medications*

unavailable

82%

95%

Number of beds

19

40

65

Occupancy rate

<25%

54%

80%

Annual number of inpatient admissions

1161

1644

3500

Annual number of emergency room / outpatient visits

3116

5698

7500

Staffing to Ministry norms

< 50%

90%

200%**

*Tracer medications include a list of 15 essential medicines the MoH dictates should be tracked on a monthly basis. **PIVOT expects that the model hospital will require staffing beyond MoH norms and will assess the level to inform national policy in the National Scale-up phase.

GOAL ONE | Create a Model Health District Service Availability With greater readiness, the hospital will

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GOAL ONE | Create a Model Health District

HEALTH CENTERS

GOAL ONE | Create a Model Health District HEALTH CENTERS Health centers are the focal point

Health centers are the focal point of primary care in Madagascar where the majority of preventative and treatment services reach patients. Health centers are supposed to provide ante- and postnatal care, deliveries, family planning, integrated management of childhood illnesses, immunizations, and malnutrition and emergency care, as well as serve as diagnostic and treatment centers for infectious disease.

When PIVOT arrived in 2014, health centers were widely under-supported, under-staffed,

commonly uninhabitable, and (with the exception of "vaccine days") rarely utilized. Through

2017, PIVOT has implemented a core package of support in five health centers, four being the

only readily accessible health centers from the tarmac road in the district. This package includes

all components of readiness: trained and adequate staffing, infrastructure, supply chain, vertical

program support, equipment, and information systems. Notably, through a reimbursement scheme with the MoH, user fees have been removed, contributing to a quadrupling of utilization

in the first two years. By 2022, PIVOT will support all level 2 health centers in the district with our

"model package" and will develop plans for strengthening level 1 health centers.

GOAL ONE | Create a Model Health District HEALTH CENTERS Health centers are the focal point

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GOAL ONE | Create a Model Health District

Service Availability

With greater readiness, health centers will be able to provide the following specific services by

2022, meeting the National Health Sector Development Plan and following national/international

norms. Services in bold indicate programs PIVOT has already begun to support significantly in our current five model health centers:

Removal of user fees

Basic emergency/primary care, link to referral network

Family planning

Antenatal care

Obstetric care

Integrated Management of Childhood Illness (IMCI)

Vaccinations

Malaria diagnosis and treatment

Tuberculosis diagnosis and treatment

HIV testing and counseling

Malnutrition diagnosis and treatment

CHW supervision

Chronic care: noncommunicable disease (NCDs) diagnosis and management

Key Performance Indicators: Health Center Service Availability and Readiness

Indicator

Baseline

2017

2022 Goal

Percentage of health centers district-wide with model package

0%

25%

100%

Percentage of health centers district-wide staffed to

15%

55%

100%

Ministry norms

Average monthly availability rate of tracer medications*

64%

75%

85%

Number of external consultations per capita per year

<0.3

0.72

2.5

*Tracer medications include a list of 15 essential medicines the MoH dictates should be tracked on a monthly basis.

GOAL ONE | Create a Model Health District Service Availability With greater readiness, health centers will

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GOAL ONE | Create a Model Health District

GOAL ONE | Create a Model Health District COMMUNITY Community health is the front line of

COMMUNITY

Community health is the front line of PIVOT’s intervention, responsible for extending the reach

of the formal health system into remote communities. As of 2017, we have an active program in

five communes (covering a population of about 75,000 people) supported by our model health

center package. The Community Health program will scale alongside health center expansion.

Community Health Workers (CHWs) provide treatment for children under five and pregnant

women including routine malnutrition screening, treatment follow-up, and support to discrete community-based health campaigns such as immunizations. Our goal is to have CHWs become increasingly professionalized through training and compensation to support a variety of community-based clinical interventions, such as TB care, family planning, and noncommunicable

disease management.

According to national policies, there should be two CHWs per fokontany who report to the

head of the health center. Using a 'training the trainer’ curriculum for CHW supervisors, PIVOT

exceeds MoH standards by placing CHW supervisors at the health centers who provide onsite

training and supervision. PIVOT provides the CHWs with community health kits of five essential

medicines. We work with communities to construct a community health site in each fokontany where CHWs can see patients.

Once the program is fully functional throughout the district by 2022, we expect to have 400 trained and supervised CHWs actively working in Ifanadiana district. This number aligns with national strategy; however, our CHWs will provide a broader range of services mentioned below.

GOAL ONE | Create a Model Health District COMMUNITY Community health is the front line of

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GOAL ONE | Create a Model Health District

Service Availability

We will add modules of training and supervision until CHWs can deliver the following services. Services in bold are already provided by CHWs in our catchment:

Basic first aid

Severe Acute Malnutrition

Community IMCI

screening and follow-up

Family planning

Referrals

Tuberculosis screening

Home visits for follow-up care

Moderate Acute Malnutrition screening,

Household sensitization

nutritional counseling, prevention

Chronic care: noncommunicable disease

Vaccinations

(NCDs) management

Key Performance Indicators: Community Service Availability and Readiness

Indicator

Baseline

2017

2022 Goal

Percentage of CHWs district-wide trained and super- vised by a CHW supervisor

0%

12%

90%

Average monthly availability rate of tracer medications*

4%

57%

90%

Number of outpatient visits at community health site

Data

   

per child under 5 per year

unavailable

1.3

5

*Tracer medications include a list of 15 essential medicines the MoH dictates should be tracked on a monthly basis.

GOAL ONE | Create a Model Health District Service Availability We will add modules of training

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GOAL ONE | Create a Model Health District

Part II: Clinical Programs

PIVOT partners with the MoH to implement and strengthen key clinical programs, which are prioritized based on needs and strategic opportunities. Key programs include Child Health (IMCI), Malnutrition, Tuberculosis, Maternal and Reproductive Health, Emergency Transport, and Patient Accompaniment. Additional programs will include HIV, Noncommunicable Diseases, and Dentistry.

GOAL ONE | Create a Model Health District Part II: Clinical Programs PIVOT partners with the

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GOAL ONE | Create a Model Health District

Child Health

GOAL ONE | Create a Model Health District Child Health PIVOT’s Child Health Program implements and

PIVOT’s Child Health Program implements and

supports the WHO and UNICEF’s Integrated

Management of Childhood Illness (IMCI) protocols, a systematic approach to diagnosing and treating

illness in children under five. This age group bears

the highest burden of deaths from common illnesses,

such as pneumonia, diarrhea, and malaria. PIVOT supplements clinical staff to fully implement IMCI, offers national training programs with bedside

follow-up, and ensures data is collected and correctly recorded. By 2022, PIVOT will ensure that IMCI protocols are implemented at all health centers and among all CHWs throughout Ifanadiana.

Implementation

Community
Community

CHWs will be trained and supervised to follow the community IMCI protocol, including triage, appropriate antibiotic use, and dietary practices. Future activities

will move to a more proactive, case-finding approach to identify at-risk patients

and refer them to higher levels of care.

Health Centers

Health Centers

PIVOT will work to continuously improve adherence to protocols and improve the triage system with an increasing focus on improving quality of care.

Child Health KPIs

 

Baseline

2017

2022 Goal

Population Health

Under-5 mortality

136/1,000

114/1,000

60/1,000

 

Infant mortality

71/1,000

61/1,000

35/1,000

Access to treatment:

     

Fever

48%

57%

75%

Diarrhea

32%

37%

60%

Vaccine Coverage

35%

43%

65%

Community

Number of outpatient visits at community health

Data

1.3

5

site per child under 5 per year

unavailable

Percentage of children under 5 seen according to

0%

43%

95%

the IMCI protocol

 

Annual per capita under 5 utilization at health

< 0.4

1.05

3.5

Health

Centers

center

Percentage of children under 5 seen according to

0%

87.5%

95%

 

the IMCI protocol

GOAL ONE | Create a Model Health District Child Health PIVOT’s Child Health Program implements and

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GOAL ONE | Create a Model Health District

Malnutrition

GOAL ONE | Create a Model Health District Malnutrition Madagascar has one of the highest rates

Madagascar has one of the highest rates of childhood stunting in the world, and malnutrition is one of the most important underlying contributors to death in childhood. In Ifanadiana District, over half of children are chronically malnourished and more than one- fourth are severely malnourished. PIVOT is working with the MoH to implement national programs to combat severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) through community surveillance, clinical evaluation, and outpatient and inpatient treatment.

 
Community

Community

PIVOT will equip and train CHWs to proactively screen, treat, and refer patients to care and follow up through social workers who support them.

Implementation

Health Centers

Health Centers

As of 2015, all patients diagnosed with SAM are enrolled in weekly outpatient support (CRENAS- centre de récupération nutritionnelle ambulatoire pour

sévères) from PIVOT staff who provide therapeutic food and nutritional

counseling, assess treatment via weight monitoring, and screen for complications. We will continue to train nurses and clinicians in malnutrition protocols with a focus on moderate acute malnutrition.

Hospital

Hospital

PIVOT and MoH launched an inpatient malnutrition program for cases

 

of SAM with complications (CRENI- centre de récupération nutritionnelle intensive) including construction of a malnutrition ward and the hiring and

training of dedicated staff. We will continue the implementation of intensive malnutrition protocols including the provision of therapeutic food.

Malnutrition KPIs

2014

2017

2022 Goal

Community

Percentage of CHWs district-wide trained

0%

12%

86%

and supervised in malnutrition

Percentage of children under 5 screened

     

annually for malnutrition at the community

0%

26%

90%

health site

Health

Centers

Number of CRENAS centers

0

5

14

CRENAS success rate

No existing program

42.5%

80%

CRENAS loss to follow up rate

No existing program

41.5%

<15%

Hospital

Loss to follow up rate

No existing program

<15%

Transfer rate back to health center CRENAS

   

program (success rate)

No existing program

>80%

GOAL ONE | Create a Model Health District Malnutrition Madagascar has one of the highest rates

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GOAL ONE | Create a Model Health District

Tuberculosis

GOAL ONE | Create a Model Health District Tuberculosis PIVOT is partnering jointly with the National

PIVOT is partnering jointly with the National Tuberculosis

Program to deliver and demonstrate comprehensive TB

control in a rural district in Madagascar. The actual TB burden in Ifanadiana District is unknown; the national

incidence is estimated at 236/100,000 (roughly twice that

of the rest of Africa and Asia) with TB prevalence possibly

double the incidence rate. The treatment coverage

nationally is estimated to be 52%. In Ifanadiana, this

means there are likely nearly 500 new cases of TB each

year, most of which are going undetected and untreated.

Prior to the program’s launch, the district lacked basic

capacity and systems for diagnosis and treatment.

PIVOT’s TB control activities were started in 2017 and are

embedded in health system strengthening (HSS) activities in collaboration with the MoH, following and enhancing National TB program policies.

Implementation

Community

Community

CHWs will be trained to screen patients for TB, refer them to the health center for evaluation, and continue facility-initiated treatment in the community. PIVOT will consider a system of financial incentives to CHWs for participation in TB activities.

Health Centers

Health Centers

By 2022, all level 2 health centers will have the ability to screen TB suspects via sputum collection and transport, follow modern diagnostic protocols, and interact with the CDT for implementing and monitoring treatment.

Hospital

Hospital

PIVOT is transforming the district hospital into the primary Center for the Diagnosis and Treatment of Tuberculosis (CDT) for Ifanadiana with state-of-the-art diagnostic laboratory instruments (Xpert MTB/RIF). Focus is on safe hospitalization of sick TB patients, maintaining the district registry, and supervising/managing all TB activities in the district.

Tuberculosis KPIs

2014

2017

2022 Goal

 

District treatment coverage

41%

52%

80%

District-Wide

Treatment Outcomes • Treatment success

55%

61%

92%

Failure

4%

22%

0%

17%

2%

2%

Death

Loss to follow up or no data

18%

22%

4%

Community

Percentage of CHWs trained and supervised in tuberculosis

0%

0%

86%

Health Centers

Number of health centers capacitated as TB Treatment Centers

2

7

14

GOAL ONE | Create a Model Health District Tuberculosis PIVOT is partnering jointly with the National

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GOAL ONE | Create a Model Health District

Maternal and Reproductive Health

GOAL ONE | Create a Model Health District Maternal and Reproductive Health PIVOT’s Maternal and Reproductive

PIVOT’s Maternal and Reproductive Health program aims to reduce maternal and neonatal mortality

and to support female agency, including prevention of unwanted pregnancies. At baseline (2014),

women in Ifanadiana District gave birth an average of 6.9 times over their reproductive lives with

81% of deliveries occurring at home. This contributed to a lifetime maternal mortality rate of

1044/100,000, which fell by 20% in the first two years of intervention. Essential for continuing the decline in maternal death are prenatal obstetric services and dignified spaces for facility-based

deliveries. This creates a positive cycle of infant/child health, as children become enrolled in the formal health system at birth.

Through 2017, PIVOT has focused on horizontal system readiness for Maternal and Reproductive Health, renovating delivery wards at health centers and the hospital, training in ultrasound and emergency delivery care, creating hospital referral systems for complicated deliveries (where c-sections are available), and removing user fees for illnesses related to pregnancy. We have

exceeded MoH norms for nurse and midwife staffing levels at the health centers and hospital,

recruited a hospital surgeon, and provided post-delivery kits for mothers. Through 2022, Maternal and Reproductive Health will grow as a keystone strategic intervention. The horizontal strengthening will be integrated with new vertically aligned clinical activities.

GOAL ONE | Create a Model Health District Maternal and Reproductive Health PIVOT’s Maternal and Reproductive

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21

GOAL ONE | Create a Model Health District

 
Through consultations and home visits, CHWs will provide family planning counseling, deliver oral contraceptives, and refer

Through consultations and home visits, CHWs will provide family planning counseling, deliver oral contraceptives, and refer women to health centers for further care. They will identify and accompany pregnant women through care, encouraging them to

start antenatal care in the first trimester, have a facility-based delivery, and attend

Implementation

Community

all scheduled follow-up visits. Through community-based sensitization, our goal is to increase referral rates to antenatal and postpartum care.

Health Centers

Health Centers

Through training and supervision, PIVOT will support high quality services for delivery including delivery kits and construction of waiting homes for pregnant women. We will continue to support free basic primary care services including immunizations,

IMCI, and antenatal care. For family planning, we will support a supply chain of freely available contraceptives, including injectables and long acting contraceptives (IUDs,

implants). By 2022, we will need to significantly increase staffing to support expected

   

facility-based delivery loads.

Hospital
Hospital

The hospital will provide high quality services for complicated delivery including

cesarean sections, obstructed labor and other obstetrical related emergencies such as

fistulas.

Maternal and Reproductive KPIs

2014

2017

2022 Goal

 

Maternal mortality rate

1044/100,000

828/100,000

500/100,000

Neonatal mortality rate

39/1,000

33.5/1,000

20/1,000

Population Health

Contraceptive prevalence

Data unavailable

36.9%

50%

Percentage of pregnant women attending four prenatal care visits

32.9%

43.3%

60%

Percentage of women giving birth at health facilities

17.5%

27.4%

50%

 

Percentage of women receiving postnatal care by a skilled provider within 48 hours

19%

25.5%

40%

Community

Percentage of CHWs district-wide trained and supervised in reproductive health

0%

0%

86%

Health

Centers

Percentage of health centers with a Maternal and Reproductive health program

0%

0%

100%

Hospital

 

Under development

GOAL ONE | Create a Model Health District Through consultations and home visits, CHWs will provide

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22

GOAL ONE | Create a Model Health District

Emergency Transport

GOAL ONE | Create a Model Health District Emergency Transport As of 2016, 74% of people

As of 2016, 74% of people in Ifanadiana District live more than 5 kilometers from a health

center (primarily without road access). In Madagascar, patients have no government-supported mechanism for transport between health facilities. Since 2014, PIVOT has been implementing the

country’s only public, 24/7, district-wide referral system in order to reduce geographic barriers, rapidly bring urgent cases to treatment, and provide connection across the continuum of care.

By 2020, we will have ten ambulance motorbikes and four ambulance vehicles active in our fleet,

enough to provide coverage where roads can reach.

Emergency Transport KPIs

2014

2017

2022 Goal

Percentage of communes reached by referral program

0%

69%

100%

Percentage of health facilities referring patients to a higher level of care

0%

55%

100%

GOAL ONE | Create a Model Health District Emergency Transport As of 2016, 74% of people

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23

GOAL ONE | Create a Model Health District

Patient Accompaniment

GOAL ONE | Create a Model Health District Patient Accompaniment In Madagascar, patients are expected to

In Madagascar, patients are expected to pay for most of their care. This includes medicines, consumables, bed sheets and blankets for hospitalization, and food. Many patients have never accessed the district hospital and are unfamiliar with ambulances or the process of care.

In order to facilitate quality care and ensure the patients are welcomed into and remain in the

system, PIVOT provides social support in the form of “patient accompaniment.” The PIVOT

accompagnateur explains the care process, provides essentials such as blankets, pays the bill, and supports the food and lodging needs of the accompanying family member(s) in cases when they

cannot provide for themselves. Our goal by 2022 is to broaden the support beyond the hospitals

to include health centers.

Patient Accompaniment KPIs

2014

2017

2022 Goal

Assessment of unmet social need per clinical program for vulnerable populations (e.g. maternal health, tuberculosis)

 

Under development

Percentage of population living in health facility catchment areas where user fees are removed

0%

37%

100%

GOAL ONE | Create a Model Health District Patient Accompaniment In Madagascar, patients are expected to

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24

GOAL ONE | Create a Model Health District

Future Programs

GOAL ONE | Create a Model Health District Future Programs We will launch several new clinical

We will launch several new clinical programs in order to deliver on national standards and ensure needed care

is available to all patients in Ifanadiana. These future programs include:

HIV / AIDS
HIV / AIDS

Largely neglected in Madagascar, reported prevalence

rates are low (<1%). However, inadequate testing

capacity and anecdotal evidence suggests that the

real prevalence may be significantly higher and more

commensurate with rates of other STDs. PIVOT aims to equip the health system for routine testing and treatment at health centers and the hospital. We will also integrate HIV/AIDS into our ongoing family planning and maternal child health activities at all levels, advancing safe sex practices, condom use, and initiatives to prevent mother-to-child transmission.

Noncommunicable Diseases

NCDs represent a significant portion of the burden

of disease in Madagascar with the WHO reporting that the probability of dying between the ages of

30 and 70 from the 4 main NCDs is 23%. These

four major diseases are cardiovascular disease, cancers, chronic respiratory disease, and diabetes. Madagascar has evidence-based national guidelines for the management of major NCDs through primary care. PIVOT aims to implement and strengthen these national guidelines at all health system levels to ensure

continuous and effective NCD care.

Dentistry
Dentistry

National policy in Madagascar requires dental care to be provided at the district hospital. This program is rarely supported. PIVOT will ensure that the district hospital has a trained and equipped MoH dentist.

GOAL ONE | Create a Model Health District Future Programs We will launch several new clinical

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25

GOAL ONE | Create a Model Health District

Part III: Information Systems

PIVOT is a data-driven organization that prioritizes strong information systems to track activities and

evaluate the progression of programs. The monitoring and evaluation (M&E) system currently tracks

848 indicators to measure health system interventions, represented in nine dashboards designed to improve real-time programmatic decision-making. PIVOT data integrates with and supplements existing Health Management Information System (HMIS) data in the district.

Our M&E Approach

We ensure continuous monitoring of all of our activities by integrating the Ministry’s HMIS with

our own routine data collection. We also lead frequent evaluation, using a variety of methods to

objectively measure the results and impact of our interventions. PIVOT’s M&E plan is based on program logical frameworks that present all indicators that are tracked according to the projects’

objectives. Through 2022, we will continue to ensure that all programs have clear logical frameworks

with associated M&E plans.

Objectives of PIVOT M&E

Track the evolution of activities and monitor implementation progress.

Measure the impact of programs at the population and health system level.

Evaluate programs and objectively assess the relevance, progress, efficiency, efficacy and

sustainability of programs. Support program implementation by creating information feedback loops to discuss results, inform adaptations, and allow for midcourse corrections for improvement.

Contribute to institutional knowledge, share knowledge and experience from the field,

highlight successes, and elucidate challenges faced. Support organizational reporting, grounded in our commitment to accountability.

Support higher level strategic decisions by making information available; inform resource allocation.

Create a data platform to serve multiple purposes, from M&E to operational research and

scientific innovation.

GOAL ONE | Create a Model Health District Part III: Information Systems PIVOT is a data-driven

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26

GOAL ONE | Create a Model Health District

Data System and Architecture

PIVOT’s M&E team centralizes all data to

ensure that it is both safe and accessible. By

2020, we plan to rebuild our data system, transitioning from paper-based to a stronger, unique, evolvable data platform. This new

system will allow for remote, offline data entry

using mobile technology and will include a

more advanced and flexible visualization and

reporting platform.

Our data and M&E approach will further evolve

over the next five years as we engage in quality

of care improvement and focus on supporting

the MoH to improve the district level public health information system overall. We aim to align and analyze health facility data with longitudinal cohort data to assess our impact. We will explore new evaluation methods, such

as beneficiary satisfaction reviews and costing.

DATA SOURCES

Internal data on financial and human

resources allocated to programs

Health facility surveys to capture the evolution of the health system service availability and readiness

Health Management Information System

(HMIS) to track the utilization of services

at different levels

Quality assessments to capture the quality of care provided by programs

Beneficiary satisfaction/household

surveys to understand patient experience

Baseline and Longitudinal Demographic Health Surveys to capture district representative estimates of changes in health and socioeconomic indicators

GOAL ONE | Create a Model Health District Data System and Architecture PIVOT’s M&E team centralizes

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27

GOAL TWO

BUILD A PLATFORM FOR SCIENCE AND INNOVATION

PIVOT’s research agenda is broadly advanced across three aims: implementation research, scientific innovation, and planetary health, with primary effort placed on using research for the continuous

improvement of our health care model. Our integrated system of clinical interventions and data provides a platform for science and innovation in global health that can create impact beyond our

physical footprint.

Operating on the edge of the Ranomafana National Park (RNP), a UNESCO world heritage site, and partnering with Centre ValBio (CVB), PIVOT is uniquely positioned to advance an actionable agenda

for planetary health. Founded by Dr. Patricia Wright, who established RNP, and located in the buffer zone of the park, CVB has a 30-year history of providing services to the community and conducting

research on conservation biology and disease ecology; it has world-class research facilities, including a Biosafety Level 2 infectious disease lab.

GOAL TWO BUILD A PLATFORM FOR SCIENCE AND INNOVATION PIVOT’s research agenda is broadly advanced across

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GOAL TWO | Build a Platform for Science and Innovation

Implementation Research

PIVOT’s commitment to integrated data systems and impact evaluation is exemplified by a longitudinal cohort study of 1,600 households in Ifanadiana District, conducted in partnership with

the Madagascar Institute of Statistics and Harvard Medical School. Through this study, district- representative estimates of health and socioeconomic indicators are available inside and outside

our catchment area, prior to PIVOT’s intervention, and are tracked over time.

During our first two years of activities, the rate of deliveries at health facilities as well as treatment

for children with fever have both doubled in our catchment area while remaining stagnant in the

rest of the district. Increased healthcare access has contributed to a 36% decrease in neonatal mortality and a 19% decrease in under-five mortality. The lifetime maternal mortality rate across

Proportion of Febrile Children that Received Treatment

2016 2014
2016
2014
25-29% Model Health Center Health Center District Hospital PIVOT Catchment Area Commune Limit Villages Sampled 50-100%
25-29%
Model Health Center
Health Center
District Hospital
PIVOT Catchment Area
Commune Limit
Villages Sampled
50-100%
40-49%
30-39%
H
20-24%
10-19%
5-9%
0-4%
Household acces
to health care
Legend
2014
2016

Longitudinal cohort data allows for detailed mapping of changes in

health outcomes and access throughout the district. We pair this data

with health system data to assess and improve our programs’ efficacy.

the district has declined from 1 in 14 at baseline to 1 in 18 at the end

of 2016. The composite coverage

index (CCI) increased by 30% in our

catchment area while remaining virtually unchanged outside.

As clinical programs are being improved and scaled, we aim to focus in the next phase of strategic planning on developing and launching a robust implementation science program to publish results on our key programs and impact. Current studies include

quality of care, geographic barriers to care, malnutrition, and the process

of strengthening data quality. Key to

this agenda will be developing the

capacity of both local PIVOT staff

and Malagasy nationals to engage in

scientific research; our agenda will be

achieved through dedicated support for implementation research, data

analysis, and scientific writing.

GOAL TWO | Build a Platform for Science and Innovation Implementation Research PIVOT’s commitment to integrated

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29

GOAL TWO | Build a Platform for Science and Innovation

Scientific Innovation

PIVOT has the data, infrastructure, and local integration to provide a true “ground game” for scientists and innovators looking to improve delivery in remote areas. This innovation relies on strategic partnerships with academic institutions. As one example, we have engaged with scientists

and engineers from Stanford University who have pilioted the use of paper microscopes and centrifuges. This “frugal science” is not only inexpensive and scalable, but also has the potential to eliminate the need for cold-chain capacity for diagnosis of malaria and other diseases. We have

also brought in scientific partners who have piloted the use of dried blood spot (DBS) technologies for diagnosing tuberculosis and other diseases. In the coming years, we aim to meaningfully incorporate effective technologies in our ongoing work and to disseminate our findings to the government, other delivery partners, and the scientific community.

GOAL TWO | Build a Platform for Science and Innovation Scientific Innovation PIVOT has the data,

On the left, bioengineer and MacArthur ‘Genius‘ Dr. Manu Prakash, who joined the PIVOT board in 2016,

demonstrates his new ultra low-cost “paperfuge,” which can provide the same functions as commercial centri-

fuges. On the right, one of 40 PIVOT-trained MoH community health workers tests the paperfuge in Ranomafana.

Scientific partner Jeff Freeman of Johns Hopkins University pilots Dried Blood Spot technology in Ifanadiana District.
Scientific partner Jeff
Freeman of Johns
Hopkins University
pilots Dried Blood
Spot technology in
Ifanadiana District.
GOAL TWO | Build a Platform for Science and Innovation Scientific Innovation PIVOT has the data,

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GOAL TWO | Build a Platform for Science and Innovation

Planetary Health

The ecological context of the region in which we operate presents unique opportunities for exploring drivers of disease at the human-

environment interface. To date, most of PIVOT’s

work in this space has been spearheaded by our co-founder and co-CEO Matt Bonds, a disease ecologist-economist. With academic partners,

he has advanced significant ecological and epidemiological modeling efforts to understand coupled systems of poverty and disease. In the

next phase, PIVOT aims to test these mathematical models in Ifanadiana District to identify and forecast long-term socioeconomic and health impacts of our programs, as well as optimize HSS to account for environmental drivers.

In the next phase of scale, PIVOT aims to build ecological interventions into our HSS work to create a model for planetary health for rural places with deteriorating environments. Based on health and conservation priorities, strategic areas of

What is PLANETARY HEALTH?

Traditionally, medical science is based on systems within the human body. Planetary health broadens health research to include the external systems that sustain or threaten human health. While human health has progressed the depletion of our natural systems threatens our ability to maintain these improvements. Planetary health brings together a wide range of existing disciplines to ensure a healthy and sustainable future.

– The Lancet Planetary Health

interest include food security, environmental reservoirs of disease, and family planning. Initial ideas

will go through a feedback process with the MoH and other partners. The period between now and 2022 will be spent designing and testing a limited set of interventions.

GOAL TWO | Build a Platform for Science and Innovation Planetary Health The ecological context of

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31

GOAL THREE

GROW ORGANIZATIONAL CAPACITY TO SUPPORT LONG-TERM EFFECTIVENESS

As PIVOT moves through the Proof of Concept phase, we aim to build effective and efficient internal staffing and operations systems to achieve our model health system and maximize our impact. We are operating with steadily increasing annual budgets and clean external annual audits, a fleet of more than twenty vehicles, and a staff of nearly 200 people in Ifanadiana District (96% Malagasy)

with a small team working from the U.S headquarters in Boston. Ifanadiana District has no bank or ATM machine and no fuel station, presenting unique opportunities to demonstrate how to run

effective operations in remote areas of Madagascar. With significant expansion anticipated by 2022,

it will be important to track and measure our own internal growth and set the stage for expansion

beyond the district. The following outlines the broad goals for PIVOT’s internal departments.

GOAL THREE GROW ORGANIZATIONAL CAPACITY TO SUPPORT LONG-TERM EFFECTIVENESS As PIVOT moves through the Proof of

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32

GOAL THREE | Grow Organizational Capacity to Support Long-Term Effectiveness

Organizational site and structure

PIVOT aims to optimize the medical team and support team staffing structures to deliver planned programmatic and geographic expansion. We will consider decentralizing staff throughout the district, restructuring PIVOT offices accordingly, and determining the ideal presence of PIVOT staff

at health centers, both at the time of initiating new programs and in sustaining quality program

delivery over time. We aim for continuous improvement of MoH-PIVOT staff relationships. PIVOT will formalize strategies to scale for clinical mentorship, direct observation of facilities, and joint financing mechanisms to support MoH capacity to staff public facilities to norms and compensate employees.

Internal capacity building

PIVOT aims to promote and professionalize strong internal control procedures, including finance and audit procedures across U.S and Madagascar offices, robust local and international procurement processes, enhanced fleet management, and accurate budgeting in a remote and unpredictable environment. We are committed to strong professional development for PIVOT staff, including

management support and formal training, opportunities for clinical exchanges and mentorship, and

defined career path development.

Health system strengthening

PIVOT will explore efficiencies to confront the unique challenges of delivering health care in rural, remote areas. For fleet management, we will explore motorcycle ambulances. For information

technology (IT), we will explore innovative connectivity for rural health centers and communities.

For supply chain management, we will increase direct support to the management of the district’s

public pharmacy. For human resources (HR), we will engage local and community support whenever

possible, working with the MoH to enact strategies for retaining medical staff in remote facilities, including benefits and the consideration of performance based financing plans.

Development

PIVOT will expand and diversify the donor base, gaining foundation and public-sector funding to

provide growth and stability over time. We aim to increase overall giving to provide the flexible

funding necessary to meet strategic objectives and complete the Proof of Concept phase by 2022. We will enhance the number of volunteers and the quality of the opportunities we provide them, with the overall aim of building partnerships, networks, communications, and events that strengthen the

PIVOT community. Over these next years, we will improve systems, processes, and tools that support efficient and effective fundraising including Customer Relationship Management (CRM) database,

Standard Operating Procedures (SOPs), and our Case for Support.

GOAL THREE | Grow Organizational Capacity to Support Long-Term Effectiveness Organizational site and structure PIVOT aims

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GOAL FOUR

STRENGTHEN PARTNERSHIPS

Partnerships are the foundation of PIVOT’s success. The core of our model is working in direct

partnership with the Ministry of Health to strengthen a public health system that can scale.

Beyond the government, PIVOT sees the critical importance of leveraging the contributions of academic, international, and local partners to improve our work, extend our impact, and disseminate our results to local, national, and global audiences. Strengthening and expanding our partnerships will be essential to reaching the goals of this strategic plan.

GOAL FOUR STRENGTHEN PARTNERSHIPS Partnerships are the foundation of PIVOT’s success. The core of our model

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GOAL FOUR | Strengthen Partnerships

GOAL FOUR | Strengthen Partnerships Madagascar Ministry of Health Centre ValBio Government Since 2014, PIVOT has

Madagascar

Ministry of Health

GOAL FOUR | Strengthen Partnerships Madagascar Ministry of Health Centre ValBio Government Since 2014, PIVOT has

Centre ValBio

Government

Since 2014, PIVOT has partnered with the Madagascar MoH to develop protocols, set goals, and build capacity to deliver high-quality health care in Ifanadiana District; in doing so, we have become a recognized, top nongovernmental partner, and now chair the Country Coordinating Mechanism of the Global Fund. This partnership will evolve and grow in alignment with our plans to scale. PIVOT will continue to serve as an implementing partner, reaching the eight additional communes across Ifanadiana District. During the Scale-Up phase, PIVOT will continue as an implementing partner in Ifanadiana while serving as a lead technical assistance partner to the MoH for broader initiatives.

Academic

PIVOT leverages academic partnerships to advance the scientific

and training aspects of our mission; we seek to align research

and training opportunities with an emphasis on capacity

building for our national staff and MoH colleagues. To date,

key academic partnerships include Harvard Medical School,

GOAL FOUR | Strengthen Partnerships Madagascar Ministry of Health Centre ValBio Government Since 2014, PIVOT has

Harvard

Medical School

GOAL FOUR | Strengthen Partnerships Madagascar Ministry of Health Centre ValBio Government Since 2014, PIVOT has

Partners In Health

Stanford University, Johns Hopkins, Brigham and Women’s

Hospital, Madagascar Institute of Statistics, and Institut Pasteur Madagascar.

Local and International

PIVOT partners with local and international nongovernmental

and multilateral organizations to maximize the efficiency of resources and leverage expertise to fight poverty and disease

on multiple fronts. Key partners to date include Centre ValBio at Stony Brook University and Partners in Health (PIH), both central to the founding story of PIVOT and to the future of the organization. We have emerging partnerships with the United States Agency for International Development (USAID) and United Nations Population Fund (UNFPA) and hope to develop more bilateral and multilateral partners as foreign aid returns to the country in the coming years. We also aim to build our partnerships with foundations and corporations as both strategic thought partners and funders to improve and advance our health care and research programs.

GOAL FOUR | Strengthen Partnerships Madagascar Ministry of Health Centre ValBio Government Since 2014, PIVOT has

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