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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
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