PIVOT Strategic Plan 2018-2022

Strategic Plan
2018-2022
CONTENTS
Introduction 3
• Mission and Values
• Background and Approach
GOAL ONE Create a Model Health District 6

I. Health System Readiness
• District Hospital
• Health Centers
• Community
II. Clinical Programs
• Child Health (IMCI)
• Malnutrition
• Tuberculosis
• Maternal and Reproductive Health
• Emergency Transport
• Patient Accompaniment
• Future Programs
III. Information Systems
GOAL TWO Build a Platform for Science and Innovation 28

• Implementation Science
• Scientific Innovation
• Planetary Health
GOAL THREE Grow Organizational Capacity to Support Long-Term Effectiveness 32

• Organizational Site and Structure
• Internal Capacity Building
• Health System Strengthening
• Development
GOAL FOUR Strengthen Partnerships 34

• Government
• Academic
• Local and International
| Strategic Plan 2018-2022

INTRODUCTION
MISSION VALUES
In partnership with communities in • Health as a human right
resource-poor areas, PIVOT combines • Solidarity
comprehensive and accessible health • Bias toward action
care services with rigorous scientific • Sustainability
research to save lives and break cycles • Humility
of poverty and disease. • Accountability
• Pursuit of knowledge
| Strategic Plan 2018-2022 3

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- IFANADIANA
DISTRICT
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
Madagascar is an island
systems requires modest financial resources, but alignment
nation located in the Indian
between national policies and localized coordination is critical.
Ocean, off the east coast of
The government of Madagascar can fill the “Know- Do” gap by Africa. PIVOT is working in
leveraging resources and capacity among relevant partners — if it Ifanadiana District in the rural
can ensure that systems are ultimately aligned at the point of care. 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
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.
Health care for the individual.
Systems for the population.
Innovation for the world.

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
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

0% 37% 100%
covered by PIVOT intervention
* 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, LOCAL ADMINISTRATIVE STRUCTURE
PIVOT’s model is being tested through the process The district health system in Madagascar
comprises the following levels, referred to
of implementation, adaptation, and analysis of throughout this document:
inputs and impacts. PIVOT is the main driver of FOKONTANY: A small cluster of 2-3 villages of
the Proof of Concept stage, requiring flexible, approximately 250 households, totaling about
1300 people. In accordance with national policy,
private funding to optimize the intervention. each is assigned two locally elected community
We aim for Ifanadiana District to serve as a fully health workers to treat children under five
and pregnant women. Fokontany are the
functioning model health district by the year smallest administrative unit of the government,
2022, with our package of services reaching the represented by locally elected leaders.
entire district population. As of 2017, we have COMMUNE: A group of 8-10 fokontany, totaling
10,000-25,000 people. Each commune (13 in
begun activities in the district hospital and five Ifanadiana) has a primary care government
health centers (covering 37% of the population) level 2 health center (CSBII), which according to
national policy should be staffed by a doctor,
with the intention of reaching all thirteen level 2 nurse, and midwife. Communes with a dispersed
health centers. Consideration will also be given to rural population have an additional smaller level
1 health center (CSBI), which should be staffed by
the smaller level 1 health centers over time. The a nurse and midwife (7 in Ifanadiana).
implementation will be guided by national policy, DISTRICT: There is one hospital that provides
and by our Key Performance Indicators (KPIs) higher-level care in the district (119 in
Madagascar). The district is the most self-
listed throughout this Strategic Plan. Costs of the contained administrative unit for managing and
model are to be estimated annually, with the most scaling up health systems. Ifanadiana District has
a population of about 200,000 people.
rigorous analysis completed in 2022.

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.
Timeframe for Expansion

in Ifanadiana District
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.

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.
Examples have included:
Components of Service Availability
and Readiness (SARA) Guidelines • Hiring clinical staff jointly with the
PERSONNEL: Medical and non-medical personnel MoH with PIVOT paying salaries of
working in facilities and out in the communities are
trained and supervised. government clinicians to help meet and
exceed norms
BASIC AMENITIES AND INFRASTRUCTURE: Health
facilities are set up to provide care with amenities and • Placing nurse or midwife Community
infrastructure maintained at an acceptable, consistent
level of quality: includes electricity, water, sanitation, Health Worker (CHW) supervisors at
dedicated private space for patients, communication,
and workspace. health centers with the mandate of
supporting CHWs through onsite training
EQUIPMENT: Health facilities have the needed
equipment for all services provided, (e.g. basic medical and supervision
technologies such as monitors and scales).
• Removing patient user fees at the point
INFECTION CONTROL: Health facilities implement and
maintain standard methods and precautions for infection of care (while still directly compensating
control: includes waste management, disinfection, hand the facilities for the service and
hygiene, patient contact protocol, and sterilization.
consumables, feeding capital back into
DIAGNOSTIC CAPACITY: Health facilities have the
needed tests and laboratory equipment for all services the system)
provided at all times.
• Operating emergency transport through
MEDICINES AND SUPPLY CHAIN: Health facilities a referral fleet of ambulances and
including community health sites have the needed
medicines for services available to all patients (not motorcycles
stocked out). Pharmacy systems are functional.
• Accompanying patients through their
INFORMATION SYSTEMS: Health facilities have the
necessary tools for complete, reliable, prompt, quality health care experience followed by
reporting for all services. community outreach after discharge
ACCESS: Financial, geographic, and social barriers to care
are addressed/removed.

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 - 20%
KELILALINA
20 - 40% PIVOT
40 - 60% Catchment RANOMAFANA
60 - 80% Area
IFANADIANA
80 - 100% ANTARETRA
This map is a representation of measured health ANDRORANGAVOLA
system readiness at the health center level in

each commune of Ifanadiana District.
MAROTOKO

DISTRICT HOSPITAL
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.

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
• Tuberculosis diagnosis and treatment • Blood transfusions
• Social work • Dentistry
Key Performance Indicators: Hospital Service Availability and Readiness
Indicator Baseline 2017 2022 Goal

Data
Average monthly availability of tracer medications* 82% 95%
unavailable
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.

HEALTH CENTERS
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.

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 • Vaccinations
• Basic emergency/primary care, link to • Malaria diagnosis and treatment
referral network • Tuberculosis diagnosis and treatment
• Family planning • HIV testing and counseling
• Antenatal care • Malnutrition diagnosis and treatment
• Obstetric care • CHW supervision
• Integrated Management of Childhood • Chronic care: noncommunicable disease
Illness (IMCI) (NCDs) diagnosis and management
Key Performance Indicators: Health Center Service Availability and Readiness

Percentage of health centers district-wide with model
0% 25% 100%
package
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

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.

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
Percentage of CHWs district-wide trained and super-

0% 12% 90%
vised by a CHW supervisor
Average monthly availability rate of tracer medications* 4% 57% 90%
Number of outpatient visits at community health site Data

1.3 5
per child under 5 per year unavailable

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.

Child Health 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
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
Community and refer them to higher levels of care.
PIVOT will work to continuously improve adherence to protocols and improve

the triage system with an increasing focus on improving quality of care.
Health Centers
Child Health KPIs Baseline 2017 2022 Goal

Under-5 mortality 136/1,000 114/1,000 60/1,000
Population Health
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%
Number of outpatient visits at community health Data

Community
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
center
Centers
Health
Percentage of children under 5 seen according to

0% 87.5% 95%
the IMCI protocol

Madagascar has one of the highest rates

Malnutrition 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.
PIVOT will equip and train CHWs to proactively screen, treat, and refer
Community
patients to care and follow up through social workers who support them.
As of 2015, all patients diagnosed with SAM are enrolled in weekly outpatient
Implementation
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
Health Centers complications. We will continue to train nurses and clinicians in malnutrition
protocols with a focus on moderate acute malnutrition.
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
Hospital malnutrition protocols including the provision of therapeutic food.
Malnutrition KPIs 2014 2017 2022 Goal

Percentage of CHWs district-wide trained
Community
0% 12% 86%
and supervised in malnutrition
Percentage of children under 5 screened
annually for malnutrition at the community 0% 26% 90%
health site
Number of CRENAS centers 0 5 14
Centers
Health
CRENAS success rate No existing program 42.5% 80%

CRENAS loss to follow up rate No existing program 41.5% <15%
Loss to follow up rate No existing program <15%
Hospital
Transfer rate back to health center CRENAS

No existing program >80%
program (success rate)

PIVOT is partnering jointly with the National Tuberculosis

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.
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
Community consider a system of financial incentives to CHWs for participation in TB activities.
Implementation
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
Health Centers with the CDT for implementing and monitoring treatment.
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
Hospital
in the district.
Tuberculosis KPIs 2014 2017 2022 Goal

District treatment coverage 41% 52% 80%
Treatment Outcomes
District-Wide • Treatment success 55% 61% 92%
• Failure 4% 0% 2%
• Death 22% 17% 2%
• Loss to follow up or no data 18% 22% 4%
Percentage of CHWs trained and

Community 0% 0% 86%
supervised in tuberculosis
Number of health centers capacitated as TB

Health Centers 2 7 14
Treatment Centers

Maternal and Reproductive Health
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.

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
Community all scheduled follow-up visits. Through community-based sensitization, our goal is to
increase referral rates to antenatal and postpartum care.
Implementation
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,
Health Centers
implants). By 2022, we will need to significantly increase staffing to support expected
facility-based delivery loads.
The hospital will provide high quality services for complicated delivery including
cesarean sections, obstructed labor and other obstetrical related emergencies such as
Hospital 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

32.9% 43.3% 60%
four prenatal care visits
Percentage of women giving birth at health

17.5% 27.4% 50%
facilities
Percentage of women receiving postnatal

19% 25.5% 40%
care by a skilled provider within 48 hours
Community
Percentage of CHWs district-wide trained

0% 0% 86%
and supervised in reproductive health
Percentage of health centers with a

Centers
Health
Maternal and Reproductive health 0% 0% 100%

program
Hospital
Under development

Emergency Transport
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

0% 55% 100%
level of care

Patient Accompaniment
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

Under development
vulnerable populations (e.g. maternal health, tuberculosis)
Percentage of population living in health facility catchment

0% 37% 100%
areas where user fees are removed

We will launch several new clinical programs in order to

Future Programs deliver on national standards and ensure needed care
is available to all patients in Ifanadiana. These future
programs include:
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
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.

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.

Data System and Architecture

DATA SOURCES
PIVOT’s M&E team centralizes all data to
ensure that it is both safe and accessible. By • Internal data on financial and human
2020, we plan to rebuild our data system, resources allocated to programs
transitioning from paper-based to a stronger,

• Health facility surveys to capture the
unique, evolvable data platform. This new evolution of the health system service
system will allow for remote, offline data entry availability and readiness
using mobile technology and will include a

• Health Management Information System
more advanced and flexible visualization and (HMIS) to track the utilization of services
reporting platform. at different levels
Our data and M&E approach will further evolve • Quality assessments to capture the
over the next five years as we engage in quality quality of care provided by programs
of care improvement and focus on supporting

• Beneficiary satisfaction/household
the MoH to improve the district level public surveys to understand patient experience
health information system overall. We aim
to align and analyze health facility data with • Baseline and Longitudinal Demographic
Health Surveys to capture district
longitudinal cohort data to assess our impact.
representative estimates of changes in
We will explore new evaluation methods, such health and socioeconomic indicators
as beneficiary satisfaction reviews and costing.

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
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
Model
for children with fever have both Health District:
doubled in our catchment area while remaining stagnant in the
Ifanadiana,
rest of the district. Increased Madagascar
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
Longitudinal cohort study shows proportion
the district has declined from 1 in
of febrile children receiving treatment over time.
Proportion of Febrile Children that Received Treatment 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
Proportion of Febrile Children that Received Treatment 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
2014 2016 quality of care, geographic barriers to
care, malnutrition, and the process
2014 2016
of strengthening data quality. Key to
Villages Sampled 0-4%
5-9%
this agenda will be developing the
Household acces
Commune Limit
to health care
capacity of both local PIVOT staff

10-19%
PIVOT Catchment Area
Legend
20-24%
H District Hospital 25-29%

and Malagasy nationals to engage in
30-39%
scientific research; our agenda will be

Health Center
40-49%
Model Health Center 50-100%
achieved through dedicated support

Longitudinal cohort data allows for detailed mapping of changes in
health outcomes and access throughout the district. We pair this data for implementation research, data
with health system data to assess and improve our programs’ efficacy.
analysis, and scientific writing.

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.
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.

Planetary Health
The ecological context of the region in which What is PLANETARY HEALTH?
we operate presents unique opportunities
for exploring drivers of disease at the human- Traditionally, medical science is
environment interface. To date, most of PIVOT’s based on systems within the human
work in this space has been spearheaded by our body. Planetary health broadens
co-founder and co-CEO Matt Bonds, a disease
health research to include the
ecologist-economist. With academic partners,
external systems that sustain or
he has advanced significant ecological and
threaten human health. While
epidemiological modeling efforts to understand
coupled systems of poverty and disease. In the human health has progressed the
next phase, PIVOT aims to test these mathematical depletion of our natural systems
models in Ifanadiana District to identify and threatens our ability to maintain
forecast long-term socioeconomic and health these improvements. Planetary
impacts of our programs, as well as optimize HSS
health brings together a wide range
to account for environmental drivers.
of existing disciplines to ensure a
In the next phase of scale, PIVOT aims to build
healthy and sustainable future.
ecological interventions into our HSS work to
create a model for planetary health for rural places – The Lancet Planetary Health
with deteriorating environments. Based on health
and conservation priorities, strategic areas of
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 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
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 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
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
Madagascar across Ifanadiana District. During the Scale-Up phase, PIVOT will
Ministry of Health 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
Centre ValBio
building for our national staff and MoH colleagues. To date,
key academic partnerships include Harvard Medical School,
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
Harvard resources and leverage expertise to fight poverty and disease
Medical School 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
Partners In Health
strategic thought partners and funders to improve and advance
our health care and research programs.

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PIVOT Strategic Plan 2018-2022

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Strategic Plan

GOAL ONE Create a Model Health District 6

GOAL TWO Build a Platform for Science and Innovation 28

GOAL THREE Grow Organizational Capacity to Support Long-Term Effectiveness 32

GOAL FOUR Strengthen Partnerships 34

| Strategic Plan 2018-2022

| Strategic Plan 2018-2022 3

BACKGROUND AND APPROACH

Most causes of suffering and death are preventable or treatable

| Strategic Plan 2018-2022 4

Health care for the individual.

Systems for the population.

Innovation for the world.

| Strategic Plan 2018-2022 5

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

| Strategic Plan 2018-2022 6

Population-Level Key Performance Indicators (KPIs)

Indicator 2014 2017 2022 Goal

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

Phase 1: Proof of Concept

| Strategic Plan 2018-2022 7

Phase 2: National Scale-Up

Timeframe for Expansion

PIVOT currently works in Ranomafana, Ifanadiana,

2018 TARGET: 61%

EXPANSION TO Ambohimanga du Sud and Andro-

2019 TARGET: 70%

EXPANSION TO Marotoko and Antsindra COVERS

2020 TARGET: 85%

EXPANSION TO Ambohimiera and Analampsina

2021-22 TARGET: 100%

EXPANSION TO Maroharatra and Fasintsara

| Strategic Plan 2018-2022 8

Part I: Health System Readiness

| Strategic Plan 2018-2022 9

This map is a representation of measured health ANDRORANGAVOLA

system readiness at the health center level in

| Strategic Plan 2018-2022 10

| Strategic Plan 2018-2022 11

• Removal of user fees • HIV testing and counseling, ARV

Key Performance Indicators: Hospital Service Availability and Readiness

Indicator Baseline 2017 2022 Goal

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%**

| Strategic Plan 2018-2022 12

| Strategic Plan 2018-2022 13

Key Performance Indicators: Health Center Service Availability and Readiness

Indicator Baseline 2017 2022 Goal

Percentage of health centers district-wide staffed to

Average monthly availability rate of tracer medications* 64% 75% 85%

| Strategic Plan 2018-2022 14

| Strategic Plan 2018-2022 15

• Basic first aid • Severe Acute Malnutrition

Key Performance Indicators: Community Service Availability and Readiness

Indicator Baseline 2017 2022 Goal

Percentage of CHWs district-wide trained and super-

Average monthly availability rate of tracer medications* 4% 57% 90%

Number of outpatient visits at community health site Data

| Strategic Plan 2018-2022 16