14th Annual

Global Health & Innovation Conference

April 23, 2017

Breaking Down Barriers to Care: PIVOT’s Integrated

Approach to Health System Strengthening in Madagascar

Matthew H. Bonds

PIVOT | Harvard Medical School | Stanford University

Outline

I. The ‘Know-Do’ Gap

II. PIVOT’s Approach to a Model Health District

III. PIVOT’s Data Platform

IV. Our Scientific Future

I. The “Know-Do” Gap

The Know-Do Gap

“Closing this [Delivery] gap… has been a particularly stubborn

global health challenge.

Kruk et al. PLOS Bio (2016)

The Delivery (‘Know-Do”) Gap

“There is a gap between today’s scientific advances and their

application: between what we know and what is actually being done.”

Lee Jong Wook WHO (2004)

10 million deaths can be averted annually

Global Health 2035, Jamison et al. Lancet (2013)

Policy

Implementation

Research

The Delivery (‘Know-Do”) Gap“There is a gap between today’s scientific advances and their application: between what we know and what is actually being done.” Lee Jong Wook, WHO

The Know-Do Gap

Policy

Implementation

Research

The Delivery (‘Know-Do”) Gap“There is a gap between today’s scientific advances and their application: between what we know and what is actually being done.” Lee Jong Wook, WHO

The Know-Do Gap

Policy

Implementation

Research

The Delivery (‘Know-Do”) Gap“There is a gap between today’s scientific advances and their application: between what we know and what is actually being done.” Lee Jong Wook, WHO

The Know-Do Gap

Partners in Health-Rwanda

Partners in Health-Rwanda

Thomson, et al. in review (2017)

Health System Strengthening: Staff, Stuff, Systems, and Space

Partners in Health-Rwanda

Thomson, et al. in review (2017)

Health System Strengthening: Staff, Stuff, Systems, and Space

Partners in Health-Rwanda

Thomson, et al. in review (2017)

Knowledge Gap

• Rwanda is an outlier?

• Broader socio-economic change

• Unique national leadership

• Data Systems were retrofitted

• Small household sample size

at baseline

• Weak health systems data

at baseline

• Convergence ≠ Divergence

Health System Strengthening: Staff, Stuff, Systems, and Space

II. PIVOT’s Approach to a

Model Health District

PIVOT - Madagascar

Why Madagascar?

The Need

Why Madagascar?

Under-5 Mortality Lifetime Maternal Mortality

1 in 6 1 in 14

Per Capita Spending on Healthcare

$14

The Need

1. 30 years of relationships

2. Research capacity

3. Biodiversity:

UNESCO World Heritage Site

The Opportunity

Why Madagascar?

PIVOT’s Aims

Advance agenda for

health as a human

right

1Create a model

health district for

Madagascar

2

3Provide platform for

science and innovation

Health System Strengthening

Health System

Intervention

“Staff, Stuff, Systems, Space”

Partnership with

Ministry of Health

System ‘Readiness’

• Infrastructure

• Equipment

• Staffing

• Supply Chain

Health System Strengthening

Health System

Intervention

“Staff, Stuff, Systems, Space”

Partnership with

Ministry of Health

System ‘Readiness’

• Infrastructure

• Equipment

• Staffing

• Supply Chain

Health System Strengthening

Health System

Intervention

“Staff, Stuff, Systems, Space”

Community

Health Workers

Health Center

Hospital

System ‘Readiness’

• Infrastructure

• Equipment

• Staffing

• Supply Chain

Clinical Programs

• Malnutrition

• Tuberculosis

• Maternal and

• Child Health

Clinical Programs

Health System

Intervention

“Staff, Stuff, Systems, Space”

Community

Health Workers

Health Center

Hospital

III. PIVOT’s Data Platform

PIVOT – Information Loop

Health Management Information Systems

Longitudinal Cohort StudyDemographic and Health Survey

Data Platform

Community

Health Workers

Health Center

Hospital

Health System

Intervention

Health System Intervention

Testing

Treatment

Follow-up

Example: Malnutrition Program

Data Platform

Health Management Information Systems

Longitudinal Cohort StudyDemographic and Health Survey

Results: Utilization Rates

Garchitorena et al Health Affairs in revision (2017)

Utilization Changes

0

200

400

600

800

1000

1200

1400

1600

1800

Ja

n-1

3

Mar-

13

Ma

y-1

3

Ju

l-1

3

Se

p-1

3

No

v-1

3

Ja

n-1

4

Ma

r-1

4

Ma

y-1

4

Jul-14

Se

p-1

4

No

v-1

4

Ja

n-1

5

Ma

r-1

5

Ma

y-1

5

Ju

l-1

5

Se

p-1

5

No

v-1

5

Outside PIVOT Intervention PIVOT Intervention

HospitalHealth Center

$0.6882,712 patients

$266,167 patients

15,251 4,849

Ambulance referrals made

Children under 5 provided comprehensive examinations

Ambulance ReferralsDiagnostics & TrainingInfrastructure & Equipment

2014

PIVOT – Results

Ambulance ReferralsDiagnostics & TrainingInfrastructure & Equipment

2014

PIVOT – Results

2016

Follow-UpTreatmentDiagnosis

2014

PIVOT – Results

Follow-UpTreatmentDiagnosis

2016

PIVOT – Results

Thomson, et al. in prep (2017)

Under-five Mortality

16%

2014 2016

PIVOT – Results

Thomson, et al. in prep (2017)

Under-five Mortality

16%

9.9%

2014 2016

14%

PIVOT – Results

IV. Our Scientific Future

Our Scientific Future

Environmental Determinants of Disease

Pioneering TB Diagnostics (DBS) Frugal Science

Summary

• There is a a need for evidence-based bottom-up health

system strengthening

• PIVOT is partnering with the Madagascar Ministry of

Health to create a model district

• A key to this model is simultaneously strengthening all

levels of the health system in the district, while

establishing rigorous data systems

• Early results indicate population-level change in health

access and mortality rates

Acknowledgments

Ali Oeunzar

Lara Hall

Andres Garchitorena

Ann Miller

Laura Cordier

Tom Gillespie

Manu Prakash

Mark Krasnow

And many more

PIVOT Staff

Madagascar Ministry of Health

Centre ValBio of Stony Brook U

Partners in Health

Fogarty International Center,

National Institutes of Health

James S. MacDonnell Foundation

Jim and Robin Herrnstein Foundation

Madagascar National Institute of Statistics

Pat Wright

Benjamin Andriamihaja

Jim Herrnstein

Robin Herrnstein

Megan Murray

Paul Farmer

Tara Loyd

Michael Rich

Meg McCarty