2021 IMPACT REPORT

CONTENTS

Letter from our

2 Board Chair

8 Science & Research

15 Publications

16 Clinical Programs

24 Systems Readiness

30 Coalitions

32 Equity & Justice

Partners &
35 Supporters In partnership with communities in
resource-poor areas, Pivot combines
38 Financials comprehensive and accessible
healthcare services with rigorous
scientific research to save lives and
break cycles of poverty and disease.
 AS WE ENTER YEAR NINE...
A NOTE FROM OUR BOARD CHAIR
Dear Pivot Community,

In Madagascar there is a proverb that reads, “Ataovy toy ny dian-tanalahy, tsinjovina ny eo aloha, jerena ny ao aoriana,”
which means “Like the chameleon, keep one eye on the future and one on the past.” It is with that sentiment that I
welcome you to Pivot’s 2021 Impact Report.

With an eye towards the past, I am amazed by what Pivot has accomplished in eight years.

I think back to the challenges we faced in 2014: pharmacies without medicines, beds without mattresses, and – most
alarmingly – health centers without patients. But what struck me most was the resolute determination of our small
team of Malagasy and expatriate staff to overcome these obstacles. Critically, they understood Pivot wanted to save
lives on a daily basis AND build systems to change things for the long-haul in the region and beyond.

Today, that small team has grown to 247 people (96% of whom are Malagasy), and our programs cover every level of
care, from remote community health posts to health centers to the district hospital. Thanks to the quality of our data,
Pivot’s impact is clear: more than 800,000 patient visits supported, a 19% drop in under-5 mortality, and a facility-
based delivery rate that is rising 1.5 times faster where Pivot works than in the rest of the district. We completed our
fourth collection of longitudinal cohort data for impact evaluation, which included dried blood spot samples that will
enable a first-of-its-kind measure of COVID-19 seroprevalence in a remote population of sub-Saharan Africa. In July,
Ifanadiana was named by the government as a pilot district for universal health coverage (UHC) in Madagascar with
the aim of codifying a model that is truly replicable across the entire country. Each of these milestones represents a
huge step forward for our health and science strategies.

Everything we’ve accomplished in the past year was impacted by the ongoing global pandemic. Pivot’s COVID-19
response this year included establishing the only molecular diagnostic lab outside of the capital, coordinating the
distribution of over 2 million pieces of PPE to 40,000 community health workers across the entire country through a
partnership with the COVID-19 Action Fund for Africa, and driving COVID-19 vaccination campaigns in the district. All
the while, we continued to ensure health centers implemented proper protocols and that prevention messages were
spread, with our teams refusing to allow the pandemic to compromise our established caliber of care.

Like the chameleon, I enter our ninth year with an eye to the future.

Over the next year we are planning to expand at an unprecedented scale for Pivot. First, we are committed to
reaching every last person in Ifanadiana District, which – with an incredibly dispersed rural population and an
extremely limited road system – is no easy task. We’re most of the way there but the last part will be the hardest. We
will use the 20,000 kilometers of geocoded footpath data to maximize efficiency in overcoming geographic barriers,
expand community health services to reach the people farthest from facilities, rehabilitate the health centers we have
not yet reached to ready them for provision of dignified care, and broaden our patient referral network to increase “Ataovy toy ny dian-tanalahy,
access to services from the community level all the way to the capital.
tsinjovina ny eo aloha jerena
Walking hand-in-hand with the new Ministry of Public Health administration, we aim to expand cost-effective
approaches designed to bring high-quality, accessible healthcare from 200,000 people to, ultimately, 28 million. We
ny ao aoriana.”
will start by expanding services to two additional districts, where we expect to reach approximately one million people
once replication roll-out is complete. Our expanded footprint will generate data and lessons of implementation
intended to inform the government’s 2024-2028 national healthcare planning cycle.
“Like the chameleon,
keep one eye on the future
Our staff and board members (in Madagascar and around the globe) are characterized by a shared willingness to
attack complex problems and relentlessly search for solutions. Together with our growing network of partners and
your support, I am confident we will meet the challenges that lay ahead and bring lasting change to Madagascar.

Onward together,
and one on the past.”
Robin Herrnstein
Pivot Co-Founder & Board Chair Malagasy Proverb
2
 IFANADIANA DISTRICT
Total Population: 187,571

WHERE WE’VE BEEN AND

WHERE WE’RE HEADED
When Pivot began in 2014, we knew it would be crucial to operate at a scale
relevant to Madagascar’s national government. With an invitation from the
Ministry of Public Health (MOPH), we set out to transform one district-level
health system into a replicable model for the country. The five years that
followed were focused on refining our approach to ensure accessible, quality
care for all.
H H H
In 2019, in view of the improvements in access to care and quality of services
in Pivot’s intervention area, the MOPH designated Ifanadiana as one of the
districts to pilot UHC for the country and invited Pivot to co-design the strategy.
In the two years since, we’ve further refined and expanded our model in
collaboration with the MOPH to address some of the greatest barriers to care.

In 2021, our co-designed UHC strategy formally launched across the district,
eliminating financial barriers to care for an additional 75,000 residents.
2014 2021 By 2023
This is a critical moment in the history of our partnership with the MOPH. With 100% of the district population
HOSPITAL 187,185 187,571
an abundance of evidence to support our model, and plans for replicating CATCHMENT (100%) (100%) will have access to health
it in additional districts, this is our opportunity to implement the methods services at all levels of care,
tested and lessons learned during our first eight years in new settings. While with no out-of-pocket fees.
HEALTH CENTER 51,203 157,197
Ifanadiana District will forever remain our homebase and testing ground for
CATCHMENT (27%) (83%)
innovative solutions, we are ready to take this step forward, continue honing This will include enhanced
our model, and – ultimately – improve healthcare across all of Madagascar. community health, dignif ied
COMMUNITY HEALTH 82,224 facility-based primary and
CATCHMENT
0 (44%) secondary care, and a patient
referral network, including
– which includes –
transport to overcome
PROACTIVE CARE 12,287 geographic barriers within and
CATCHMENT 0 (7%) beyond the district.

>810,000 PATIENT VISITS

SUPPORTED SINCE 2014
4 5
 “As a nurse, I have a "I’d already
LEADING BY EXAMPLE lot of contact with
patients. I wanted
suffered from
COVID-19, so when
With 93% of our Madagascar-based staff vaccinated, Pivot is to get vaccinated to vaccines arrived in
supporting the Ministry of Public Health to ensure that the Ifanadiana District
protect myself and Madagascar, I didn’t
population is informed about the safety and importance of vaccination.
others.” hesitate."
– Alex – Noro
Referral Nurse Social Work Manager

"I got the vaccine

so that, if I catch
COVID-19, it will be
easier to treat.
This is what I tell
patients, too."
– Clara
Community
Health Worker

"I got vaccinated

to protect myself,
protect those around
me, protect the
organization I work
for and above all to
protect my country."
– Alex
Ambulance Driver

“I’m vaccinated to
protect myself and
my loved ones.
I want to be a model
for those who are
hesitant to do it.”
– Lova
Hospital Lab Manager
 DRIVEN BY VALUES, PRIMARY
RESEARCH
What makes Pivot-supported GUIDED BY SCIENCE DOMAINS:
health workers different?
Research always begins with a question.
They care for people Our research has always been about how to ensure equitable access Population-Level
they’ll never meet. to high-quality healthcare for all. But that was only the starting point.
Today, we’re answering questions that we couldn’t have imagined when
Impact Evaluation
we began work in 2014. This is why we collect data at multiple scales
and engage scientists and practitioners across disciplines: it offers new
insights on how programs address complex determinants of health to
improve health systems design at all levels.

Health systems transformation is complex.

Geography and
We don’t accept the complexity of health systems as an excuse for Community Health
not addressing persistent, fatal health inequity. Curiosity, rigor, and
a commitment to health as a human right have given rise to our
diverse research team, equipped to tackle the seemingly intractable
problems that too often lead to inaction. With a moral commitment to
basic human rights, Pivot’s Science team embraces complexity as an
opportunity to learn, share, and chart new ways of doing science.
COVID-19 and
Science is a tool of human compassion.
Molecular Diagnostics
With Ifanadiana District as a model system and a testing ground for
integrating care delivery and research, we are generating some of the
most rigorous health systems research and analysis in the world. The
goal of Pivot scientists is not to do science – it is to improve health
outcomes.

Eco-Epidemiology
and Surveillance

“I don’t want to be satisfied

with what I already know.
I always want to learn and Operational
Research for UHC
deepen what I know, and
to have notions of what I
do not yet know.”
– Dr. Rado Rakotonanahary
Research Manager
Capacity-Building

8
 UNDER-5 MORTALITY
PARTNER
MOVING THE NEEDLE decreased by 19%, maintaining an overall death
rate that is half that of the rest of the district
SPOTLIGHT
The collection and analysis of longitudinal
cohort data has been foundational to Pivot’s
impact evaluation strategy since the very
beginning.

In 2014, the first round of survey results

established a true baseline of the district
population’s health and socioeconomic
conditions, allowing us to compare changes
in outcomes over time, within and outside of
Pivot’s initial catchment area.

These metrics on impact, which are collected

and analyzed every two years, provide a
uniquely robust data landscape that informs
our clinical and scientific agendas. In
December 2020, the Pivot team’s four-year
VACCINATION COVERAGE
increased at a rate 5.7x faster
impact analysis was published in BMJ Global
compared to the rest of the district
Health.

The study revealed that healthcare coverage

(i.e., a sick person reaching a health service
provider) for children under 5 increased and
Since 2017, Pivot’s collaboration with the Institut de Recherche pour le Développement (IRD) has been helping the mortality rates decreased – at faster rates
advance our research agenda to inform and strengthen local health programs. The partnership is led by Dr. Andres
in Pivot’s catchment area than in the rest of
Garchitorena, Pivot’s Madagascar-based Associate Scientific Director and an IRD-appointed researcher. Our partnership
the district.
is centered around three primary domains: impact evaluation, health geography, and disease ecology.

Through surveys conducted across the same 1,600 households (±8,000 individuals) every two years, we are Equally important, it also revealed new
able to collect and analyze key population-level information to determine the evolution of healthcare challenges to explore: “economic inequalities
access, mortality, and inequalities in the district over time. The process enables us to measure the true in most coverage indicators were reduced,
impact of Pivot’s interventions, comparing outcomes with those of areas that Pivot has not yet while geographical inequalities worsened
reached. IRD provided support for the 3rd (2018) and 4th (2021) rounds of data (MORE ON
in nearly half of the indicators.” Pivot’s work
THIS STUDY)
collection carried out by the Institut National de la Statistique de Madagascar.
is bolstering the health system to meet the
needs of the economically vulnerable, and
Since IRD’s 2018-2019 support of our initiative to map over 100,000 buildings and 20,000 kilometers of footpaths
those who live far from health facilities require
in Ifanadiana District, the resulting data have helped us understand the evolution of geographic access to
care in the district with an unprecedented level of detail. Together with remote sensing analyses carried out in more attention. HEALTH SYSTEM READINESS
a composite metric that measures key service and supply
collaboration with IRD researchers, our geographical data provide the basis for multiple ongoing research projects
availability, readiness improved by 16% in Pivot-
on geographic accessibility to all levels of care. The unique and rigorous methods made possible by our partnership In 2021, the fourth round of cohort surveys
have garnered the attention of international organizations such as USAID, who has funded a new project to apply supported facilities vs. 8% in the rest of the district
included the collection of dried blood spots
this same fine-scale geographic mapping and modeling to achieve a broader understanding of health system for the first time. Introducing serologic
accessibility in additional regions of Madagascar.
biomarkers will deepen our understanding
IRD has also played an integral role in our disease ecology research – an increasingly crucial area of Pivot Science’s of the epidemiology of many diseases and
core work. Most recently, research to improve malaria surveillance and modeling in Ifanadiana District used provide critical insights on dynamics of
innovative methods to enable forecasting and nowcasting of malaria dynamics at very fine spatial scales. COVID-19 in one of the most remote corners of
the world. We will have the results for COVID-19
Additionally, IRD has emerged as one of the leading institutions of the global Preventing Zoonotic Disease seroprevalence in early 2022.
Emergence (PREZODE) initiative, which aims to develop and promote One Health approaches to preventing the
emergence of zoonotic diseases such as COVID-19. Pivot is participating in the PREZODE pilot project, set to launch
in 2022, with the goal of developing a deeper understanding of, and ability to anticipate, zoonotic spillover risk
in Madagascar. Garchitorena, A., et al. (2020). District-level health system
strengthening for universal health coverage: evidence
from a longitudinal cohort study in rural Madagascar, 2014-
2018. BMJ Global Health; 5:e003647.
10
 DISTANCE CAN BE FATAL, BUT DATA CAN SAVE LIVES Pivot Community
Health Supervisor Adoré PARTNER
WE’RE MAPPING SOLUTIONS and Pivot-supported
community health
worker Clara review
SPOTLIGHT
patient registries during
one of their regular
supervision visits.

In 2020, we featured the work of Dr. Felana Ihantamalala, postdoctoral researcher

at Pivot and Harvard Medical School, who led an award-winning study on
geographic accessibility modeling. Using innovative methods to improve the
modeling of healthcare access, her team’s participatory process included the
mapping of over 100,000 buildings and 20,000 kilometers of footpaths in
Ifanadiana District. The results culminated in an online platform called
LALANA (meaning “path” in Malagasy) that, akin to Google Maps, can
estimate the travel time between any two points in the district, even
accounting for complex factors, such as weather or terrain.

In 2021, combining this wealth of geospatial and health system data, Dr.
Andres Garchitorena, Associate Scientific Director, led a study entitled
Geographic barriers to achieving universal health coverage: evidence
from rural Madagascar, which was published in Health Policy and Planning.

The study found that the removal of user fees – a tenet of universal health
coverage (UHC) adopted by Pivot from the start of work in 2014 – has led to
increased utilization of health services among those living within 5 kilometers
of Pivot-supported primary care facilities. However, patients living more than
5 kilometers from the nearest health center are accessing health services at
approximately 1/6 the rate of those who live closer.
Pivot is a member of the Community Health Impact Coalition, which promotes key lessons that informed the World
Health Organization’s 2018 guidelines for professionalizing community health workers (CHWs) through training,
“We found that the geographic reach of facility-based primary care is quite
compensation, equipment, and supervision.
limited, even after fees are removed at the point of service and quality of
services are improved,” explain Garchitorena, et al.
In collaboration with Ariadne Labs, Pivot is developing new tools and protocols for data-informed CHW
How can we improve UHC policy design to reach those at the last mile? And supervision, based on principles of human-centered design and guided by international standards.
how do we capture their information? According to the study, “community
health workers are the main source of health care delivery for children in Through this partnership, Pivot aims to further improve quality of care and close the gap in knowledge about
remote populations, representing 90% of primary care visits for those living how to best implement CHW supervision. By developing, testing, and iteratively improving these new supervision
further than 15 kilometers from a health facility.” guidelines, conducting focus groups with CHWs who receive enhanced supervision, and monitoring the initiative’s
impacts on quality of care and CHW motivation metrics, we aim to generate transferable lessons for optimizing
The study’s outcomes have led to direct action, informing our strategy to community health programs in settings beyond Madagascar.
strengthen the quality and accessibility of healthcare services at the community
level through enhanced training and support to community health workers. CHW Adherence to Protocol

100%
98%
As evidence of the impact that
enhanced CHW supervision
can have on quality of care, 79%
Above: Lines connect the origin of a patient 3 80%
to the public health care center they visited the graph on the right shows
a high rate of adherence to
Annual health center visits

in Ifanadiana District, with line transparency

inversely proportional to the number of visits. protocol where Pivot has 60%
Pivot catchment
2 been piloting an enhanced
Rest of district community health strategy,
To the right: Each dot represents the average
compared with communes 40%
per capita utilization rate for the population
implementing existing
of one fokontany (village cluster) in Ifanadiana
1 community health policy.
District, displaying a clear “distance decay” 20%
trend in population access to care.

0%
0 Existing Enhanced
Community Community
Health Policy Health Strategy
Garchitorena, A., et al. (2021). Geographic barriers to 0 5 10 15 20 Razafinjato, B., et al. (2020). Evaluation of a novel
achieving universal health coverage: evidence from rural approach to community health care delivery in
Madagascar. Health Policy and Planning, czab087. Kilometers from nearest health facility Ifanadiana District, Madagascar. medRxiv.
13
 Rado leads a tour of the
newly-outfitted RT-PCR
laboratory during its

PUBLICATIONS
inauguration in May.

Studies authored by members of the Pivot Science team, published during FY21

Ihantamalala, F., Bonds, M., Randriamihaja, M., Rakotonirina, L., Herbreteau, V., Révillion, C., Rakotoarimanana,
S., Cowley, G., Andritiana, T., Mayfield, A., Rich, M., Rakotonanahary, R., Finnegan, K., Ramarson, A, Razafinjato, B.,
Ramiandrisoa, B., Randrianambinina, A., Cordier, L., Garchitorena, A. (2021). Geographic barriers to establishing a
successful hospital referral system in rural Madagascar. BMJ Global Health, 6:e007145.

Garchitorena, A., Ihantamalala, F., Révillion, C., Cordier, L., Randriamihaja, M., Razafinjato, B., Rafenoarivamalala,
F., Finnegan, K., Andrianirinarison, J.C., Rakotonirina, J., Herbreteau, V., Bonds, M. (2021). Geographic barriers to
achieving universal health coverage: evidence from rural Madagascar. Health Policy and Planning, czab087.

Raojaonarifara, E., Bonds, M., Miller, A.C., Ihantamalala, F., Cordier, L.F., Razafinjato, B., Rafenoarimalala, F.H.,
Finnegan, K.E., Rakotonanahary, R.J.L., Cowley, G., Ratsimbazafy, B., Razafimamonjy, F., Randriamanambintsoa,
M., Raza-Fanomezanjanahary, E.M., Randrianambinina, A., Metcalf, C.J.E, Roche, B., Garchitorena, A. (2021).
Impact of health system strengthening on delivery strategies to improve child immunization coverage and
inequalities in rural Madagascar. medRxiv, 10.1101/2021.07.19.21260640.

Razafinjato, B., Rakotonirina L., Hutchings, M., Finnegan, K. (2021) Application of the CHW AIM tool for high
impact research: a case study from Madagascar. CHW Central.

Rakotonanahary R.J.L., Andriambolamanana H, Razafinjato B., Raza-Fanomezanjanahary E.M., Ramanandraitsiory,

V., Ralaivavikoa, F., Tsirinomen’ny Aina, A., Rahajatiana, L., Rakotonirina, L., Haruna, J., Cordier, L.F., Murray, M.B.,
Cowley, G., Jordan, G., Krasnow, M.A., Wright, P.C., Gillespie, T.R., Docherty, M., Loyd, T., Evans, M.V., Drake, J.M.,
Ngonghala, C.N., Rich, M.L., Popper, S.J., Miller, A.C., Ihantamalala, F.A., Randrianambinina, A., Ramiandrisoa,
B., Rakotozafy, E., Rasolofomanana, A., Rakotozafy, G., Andriamahatana Vololoniaina, M.C., Andriamihaja, B.,
Garchitorena, A., Rakotonirina, J., Mayfield, A., Finnegan, K.E., Bonds, M. (2021). Integrating Health Systems and
TRANSFERRING KNOWLEDGE TO ACTION Science to Respond to COVID-19 in a Model District of Rural Madagascar. Frontiers in Public Health, 9:654299.

Evans, M.V., Bonds, M., Cordier, L.F., Drake, J.M., Ihantamalala, F.A., Haruna, J., Miller, A.C., Murdock, C.C.,
“The central challenge in responding to COVID-19 is that it requires integrating complex health Randriamanambintsoa, M.M., Raza-Fanomezanjanahary, E.M., Razafinjato, B.R., Garchitorena, A. (2021). Socio-
demographic, not environmental, risk factors explain fine-scale spatial patterns of diarrhoeal disease in
systems that incorporate prevention, testing, front line health care, and reliable data to inform Ifanadiana, rural Madagascar. Proceedings of the Royal Society B, 288: 20202501.
policies and their implementation within a relevant timeframe. It requires that the population
Miller, A.C., Bonds, M. (2021). Building “Bridges” to Equity. American Journal of Public Health.
can rely on the health system, and decision-makers can rely on the data,” posits Dr. Rado
Hyde, E., Bonds, M., Ihantamalala, F.A. Miller A.C., Cordier, L.F., Razafinjato, B., Andriambolamanana, H.,
Rakotonanahary and team in our recent publication in Frontiers in Public Health. Randriamanambintsoa, M., Barry, M., Andrianirinarison, J.C., Andriamananjara, M.N., Garchitorena, A. (2021).
Estimating the local spatio‐temporal distribution of malaria from routine health information systems in
areas of low health care access and reporting. International Journal of Health Geographics, 20, 8.
In May 2021, Pivot partnered with the Ministry of Public Health and Centre ValBio to open
the first moderate- to high-complexity RT-PCR testing laboratory outside of Madagascar’s Ballard, M., Westgate, C., Alban, R., Choudhury, N., Adamjee, R., Schwarz, R., Bishop, J., McLaughlin, M., Flood, D.,
Finnegan, K., Rogers, A. (2021). Compensation models for community health workers: Comparison of legal
capital city, in Ranomafana. Rado, above, led coordination of a year-long process to procure the frameworks across five countries. Journal of Global Health, 11: 04010.
necessary materials, develop protocols, and train personnel involved with lab operations.
Arthur, R.F., Jones, J.H., Bonds, M.H., Ram, Y., and Feldman, M.W. (2021). Adaptive social contact rates induce
complex dynamics during epidemics. PLoS Computational Biology 17(2):e1008639; 2021

Our role in bringing molecular testing capacity to southeastern Madagascar also represents
a long-term commitment to ensure access to infectious disease diagnostics and surveillance
in Ifanadiana District and beyond. We view the challenge of launching a state-of-the-art
laboratory on the edge of a protected rainforest as an opportunity to learn – to answer today’s
most pressing questions, and uncover new ones to explore – through the lenses of planetary
health and global health equity.

Watch the national Malagasy news segment about the lab’s

inauguration here and read more about Rado here.
14 15
 REACHING MORE CHILDREN
“Ny fahasalamana
no voalohan-karena.” WITH THE CARE THEY NEED

“Health is the With 1 in 7 children dying before age five when Pivot began
DURING 2021:

first wealth.”
work in Ifanadiana District, there was never a question that a
comprehensive suite of pediatric services would be essential to our
clinical strategy at every level of care. From the community level
to health centers to the district hospital, Pivot-supported health

Malagasy Proverb workers are equipped to provide comprehensive child health

examinations, which include screening for the most common
>68,000
comprehensive
pediatric health threats in Madagascar. health exams provided
to children under 5
In 2021, the start of support to six additional communes included
mass malnutrition screenings and revealed significant case rates in
two of those communes, Marotoko and Androrangavola. In response,
our clinical team accelerated plans for launching malnutrition services
there, expanding treatment access to an additional 4,000 children
under five years old.

With the full malnutrition program now active in 9 of 15 health

>18,000
children under 5
centers, and all of the district’s primary care clinicians having with local access to
completed training on diagnosis and management of acute treatment for
malnutrition, we look forward to rolling out malnutrition care to the acute malnutrition
rest of the district’s primary care facilities in 2022.

Improving vaccination rates has been an area of success since the

early days of Pivot’s implementation. In our catchment area, we
improved vaccine coverage from 38% to 64%, a rate 5.7x faster
than the rest of the district, between 2014 and 2018.
>15,000
When an uptick in polio cases appeared in Madagascar this year, parental education
the MOPH launched a catch-up campaign to vaccinate those who touchpoints on key child
did not receive vaccination at the recommended age, and the Pivot health topics, including
the importance
team mobilized to support. By coordinating logistics and ramping
of vaccination
up sensitization efforts, the collaboration was a success, resulting in
100% polio vaccine coverage in the targeted areas.

Ventsia’s Journey to Healing

When community health worker Letelo visited Ventsia, age 3, and his mother
Céline at their home in Vohimarina, he immediately referred the child
to the health center, and accompanied the family on the 4-hour walk to
access malnutrition treatment. When Ventsia’s condition did not improve,
he was transferred to the hospital, where the clinical team diagnosed him
with tuberculosis (TB), which had been severely compromising his ability to
overcome malnutrition. After a month of intensive inpatient treatment, he was
Mother and daughter arrive
well enough to be discharged from the hospital and return to routine care for
at Ambohimanga du Sud
his ongoing case of TB. “I am delighted with the treatment the doctors have
Health Center for health
consultations. given my son,” Céline remarked. “I see that he is getting more and more
healed, which motivates me to continue bringing him to treatment.”
16
 SUPPORTING EVERY
STAGE OF MOTHERHOOD
DURING 2021:
Maternal and reproductive health has always been one of Pivot’s
foremost clinical priorities. When we began work in Ifanadiana District,
the average woman could expect to experience 7 pregnancies in her
lifetime, and faced a 1 in 14 chance of dying during childbirth.

Since 2014, our integrated efforts to improve these outcomes have led
to a 16 percentage point increase in facility-based delivery rates in
2,530
women newly
our catchment area, compared with a 10 percentage point increase
in the rest of the district.
enrolled in family
planning services
In 2021, observing consistently low facility-based delivery rates led us
to more deeply explore the root of the issue and identify strategies to
motivate women to access care before, during, and after pregnancy.

A series of community dialogues and qualitative surveys were

launched to amplify the voices of those most affected. The results

1,570
signified a need to ramp up efforts to ensure that the population is
aware of the maternal health services available at no cost.

safe,
The feedback also led to an upcoming collaboration with traditional
Malagasy birth attendants, known as matrones, playing an active
facility-based
role in encouraging facility-based care. By formalizing a program to deliveries
compensate matrones for accompanying women to their local health
centers (planned to launch early next year), we are bridging the gap
between the tradition and safe delivery. Vitasoa’s Journey to Delivery

Vitasoa, age 20, lives about an hour’s walk from the nearest health center. When she gave birth to her first

99% child, it was at her home in the village of Ambodipaiso. Though she delivered without complications, she
decided to be more proactive when she got pregnant with her second child, and started by visiting
survival among Kelilalina Health Center to receive prenatal care. The midwives who cared for her over the course of her
pregnancy encouraged her to consider delivering there in the health center.
women delivering
in Pivot-supported So, when the time came, she opted to journey to the facility, accompanied by her grandmother. After a
facilities smooth labor and delivery attended by the health center’s midwives, Pivot’s social work team arrived with
congratulations and a “newborn kit” containing health and hygiene essentials to support the wellbeing of
mother and infant in their initial days after delivery.

Vitasoa confirmed that she was happy with her decision to deliver in a facility. “I really liked giving birth in
the health center. I received social support and, what’s more, I'm in good health.”

We look forward to learning Her grandmother affirmed the positive experience from her perspective as an accompagnateur, saying
more regarding population-
that the good health of both Vitasoa and her newborn are “proof” of the quality service they received at the
level maternal mortality
following the analysis of health center.
data collected in 2021 for our
longitudinal cohort study. Positive experiences like that of Vitasoa play a major part in building communal trust in the health
Information from the study system. Returning home to Ambodipaiso in good condition after giving birth to a healthy newborn means
will help us identify additional that Vitasoa and other like her are spreading awareness to her community about the quality of maternal
approaches to improve healthcare services offered in Ifanadiana District.
women’s health in Madagascar.
18 19
 FIGHTING INFECTIOUS DISEASE

TUBERCULOSIS COVID-19
Tuberculosis (TB) is one of the biggest killers in Madagascar. Prior to Pivot’s start in Ifanadiana District, The COVID-19 experience worldwide is much like the everyday
the case fatality rate was an alarmingly high 17% among patients in TB treatment (well-functioning lived experience in settings such as Madagascar, reinforcing
TB treatment programs have a rate of <5%). In response, we launched support to the Ministry of Public the urgency of focusing on health equity and strong health
Health’s TB control activities in 2017. systems worldwide.

Over the course of 2021, we increased TB case identification and treatment capacity throughout the In April 2021, the government declared a second wave of
district by establishing sputum sample refrigeration and improving systems for transporting samples COVID-19 in Madagascar. With a well-established triage
between facilities. This means that health centers in some of the most rural parts of Ifanadiana District and isolation system already in place and the recruitment
are now able to send samples to the district hospital for testing without having to send the patients of additional temporary clinical staff, the district hospital
themselves. was prepared to save the lives of patients in acute
respiratory distress without disrupting the availability of
As a result, TB patients enrolled in treatment in Pivot’ catchment saw an average successful other lifesaving services.
treatment rate of 94.5%, a case fatality rate of 3.5%, and a loss to follow-up rate that dropped below 1%
by the end of the year. This dramatic improvement is especially notable given geography alone, which In addition to the unique diagnostic capacity established
creates immense challenges both in identifying TB cases in remote communities and in ensuring patients in the district by the opening of the RT-PCR
complete their full course of treatment over time. lab in May (see page 16), the hospital
laboratory’s GeneXpert machine
Our experience, supported by data, has demonstrated that the integration of community health and provides on-site testing capacity.
social support into the TB program is integral to reaching international target outcomes. Having the ability to provide
same-day results to patients and
their accompagnateurs at the
district hospital aids significantly
TB Treatment Outcomes by Quarter
in monitoring the number of active
cases in the district.
100%

90% By May, COVID-19 vaccines began to arrive in Madagascar,

and the then-Minister of Public Health, Prof. Jean Louis
80%
Rakotovao was the first member of the government’s
executive branch to receive his shot. In a setting where
70%
vaccine hesitancy is high, this was an important moment
60% for the nation’s leadership to set an example and
demonstrate the vaccine’s safety.
50%

Following suit, the Pivot team volunteered to be among

40%
the first to receive their doses in Ifanadiana District.
30% With 93% of Pivot staff now vaccinated, the MOPH
and Pivot teams are playing an essential role to reassure
20% the population that vaccination is the most effective
way to overcome the pandemic.
10%

0%
Q3-2019 Q4-2019 Q1-2019 Q2-2020 Q3-2020 Q4-2020 Q1-2020 Q2-2021 Q3-2021 Q4-2021

Above, laboratory technician Dinah Zafimbara conducts

GeneXpert testing. To the right, Bénédicte Razafinjato, during
Success rate Rate of transfer, Death rate her period as interim National Director, set an example as the
loss to follow-up, first Pivot employee to receive her shot.
or abandon

20
 CARING FOR THE WHOLE PERSON
SOCIAL On World AIDS Day, Pivot’s
sensitization and infectious disease
teams collaborated to launch
awareness-raising activities about
HIV/AIDS prevention, offering
free screenings to the population,
Social workers wear many hats, from serving as patient advocates and counselors, to making and engaging young people in
home visits. With their finger on the pulse of the communities we serve, Pivot social workers discussions about safe sex. Here,
bring a crucial human-centered perspective to our clinical strategies, serving as liaisons between Pivot sensitization team member
patients and the health system to ensure a dignified care experience. Victor speaks with a community
member about access to testing.
In 2021, the social work team identified and acted on numerous opportunities to better serve
patients, including:

• launching social support services for patients with HIV, including targeted facilitation of
access to care, connection to psychological health services, and provision of food;

• initiating a new program for addressing gender-based violence in the region following a
disturbing uptick in women presenting at the hospital after violent incidents, established a
One of our social work team’s
safe shelter for survivors of abuse and assault, and initiated trainings on how to identify signs of
primary focuses is identifying
violence;
vulnerable patients. In Ifanadiana
District, that includes mothers
• piloting a process for matching patients with volunteer accompagnateurs to provide and newborns, and families with
support during hospitalization (after observing more patients accessing care without family or malnourished children, all of whom
community accompaniment, a common cultural practice, especially for patients traveling long receive “kits” containing essential
distances to access public health services); goods. Here, Pivot social worker
Felana delivers a newborn kit
• expanding the social work team in order to provide more psychological support to containing clothing, blankets, and
patients in response to an increase in requests from clinicians; and hygiene supplies to support mother
and child in their initial days
• organizing mass awareness-raising campaigns in collaboration with Pivot’s sensitization following delivery.
team, to spread key public health information (ranging in topics from diabetes to COVID-19
prevention), via in-person gatherings and more than 20,000 radio emissions across the district.

As we continue to work in partnership with the MOPH to achieve UHC, we are piloting an
additional layer of social support. By stationing a full-time social worker at 3 of the district’s primary
care facilities, we aim to demonstrate how expanded access to social support services can help
ensure continuity of care, especially for our most vulnerable patients.
Contributing to the fight against
COVID-19, Pivot staff made
DURING 2021:
continuous rounds to high-traffic
areas such as local marketplaces
and schools to disseminate key
public health information about

9,003 747 5,255 preventing the spread of disease.

Here, sensitization team member
patient psycho-social kits of
essential goods Hery Zo delivers a lesson to school
transports sessions
reimbursed provided distributed children about how they can help
keep themselves and their loved
ones protected.

22 23
 ENHANCING COMMUNITY HEALTH
When programs addressing
complex problems are
supported by rigorous In Madagascar, community health workers (CHWs) provide

data and science,

essential health services for sick children and pregnant DURING 2021:
women on the frontlines of their communities. They are not
only healthcare providers, but accompagnateurs, advocates,
good things happen. and our first and best source for information about the
health of rural communities.

In March 2021, CHWs in Ifanadiana District started using 80

the mobile application CommCare, designed to facilitate community
their daily work and report health information in real health posts
time. The launch of CommCare in Ifanadiana District supported
represents a partnership with Dimagi, a technology
company which supports electronic data collection in
many developing countries, and ACCESS, a USAID-funded
program implemented in Madagascar by Management
Sciences for Health.

Historically, CHWs have recorded information on paper 175

forms, aggregated into a summary of their activities and community
submitted on a monthly basis. The CommCare app allows health workers
CHWs to instead store and access patient information from a (CHWs)
smartphone – a total game-changer for both data quality supported
and quality of care in Ifanadiana District.

The app automatically generates monthly activity reports

from the data entered. It also guides the delivery of routine
care for child health exams, malnutrition and TB screenings,
family planning services, pregnancy monitoring, and more.
With care protocols embedded in the application, CHWs are
prompted to ensure that no diagnosis or treatment steps
>32,000
child health
are overlooked, and automatically sends reminders about consults provided
patients requiring follow up visits by the CHW.
by CHWs
Together, we are strengthening the foundation of the public
health system in Madagascar, ensuring greater efficiency
and accuracy in our pursuit of addressing the needs of
patients at the last mile.

Community health worker

Fety demonstrates how the
CommCare application can be
used to manage patient data.

24 25
 DELIVERING PRIMARY CARE AT THE LAST MILE
The physical spaces in which people access health services are foundational to dignified patient care. As a key element
of our strategy to achieve universal health coverage (UHC) in Ifanadiana District, the rehabilitation of 6 additional
remote primary care facilities in 2021 marked an expansion of unprecedented scope for Pivot.
READYING THE
In addition to shoring up rural health center
HEALTH SYSTEM
infrastructure, the 2021 renovation process
These facilities are located beyond routes passable by car, which means materials have to be transported by tractor or included the installation of solar power
on foot. Though local COVID-19 travel restrictions and global supply chain bottlenecks complicated these challenges at 8 of the district’s remote health
even further, the six renovations were completed ahead of the July UHC launch, with these health centers ready to centers. Bringing electricity to these
receive more patients in a dignified manner. rural facilities is a huge step forward.
This is a game-changer for the patient
The logistical challenges faced by the Pivot infrastructure team during the process were significant, requiring experience; particularly for pregnant
adaptation of operations to manage multiple complicated projects simultaneously. This generated important Quality
women, whose motivation to give birth
lessons that we will carry with us as we carry forth future expansion. Inf rastructure
at health facilities has been low in part
due to the lack of electricity.

Ambiabe Health Center

Available
Medicines Pivot and the MOPH jointly recruited 37 new
clinical personnel to bring staffing to (or
beyond) government norms at these
newly-supported health centers. This
includes at least one additional midwife
or nurse at each of the 15 primary care
Trained facilities. The new role of “UHC Agent”
Personnel is also being implemented at each
health center. UHC agents are charged
with welcoming and orienting patients
to facilities, and ensuring that facility

2020 2021
operations are aligned with UHC policy.

Infection
Ampasinambo Health Center Control

Thanks to the DAK Foundation, two of

the most distant health centers in
Ifanadiana District are now equipped
Diagnostic with ultrasound machines. Each a 2-3
Capacity day walk from the nearest paved road,
Ambohimanga du Sud and Maroharatra
Health Centers serve more than 21,000
people in some of the most remote
parts of the district. By building
diagnostic capacity here, it will be
Essential feasible for patients to access a new mode
Equipment of lifesaving care for the first time.

2020 2021 27
 SUPPORTING THE DISTRICT HOSPITAL

As Ifanadiana’s central hub for specialized care, the district hospital

serves the entire district population.

Following a year of major infrastructure updates to the hospital

campus in 2020 (pictured on the left), 2021 hospital work was
all about expanding the services offered, building diagnostic
capacity, and strengthening our network of referral centers for
tertiary care.

With an increasing capacity to identify patients’ needs for services

only offered beyond the district level (e.g., chemotherapy), we are
ensuring that every patient gets access to the best possible care
available in Madagascar.

DURING 2021:

2,468 21,898
diagnostic
496
surgical
>130,000
meals served
1,697
referrals to
EXPANDING OUR NETWORK OF CARE
hospitalizations procedures to patients &
tests perfomed accompagnateurs tertiary care
performed

Distance can be fatal – particularly in a highly DURING 2021:

rural setting like Ifanadiana District, where
the population is geographically dispersed
across mountainous rainforest. For Pivot’s
patient referral team, nothing is more vital
than finding creative solutions to overcome
this challenge. With thousands of miles 3,409
of footpaths between health facilities and patient
patients, an ambulance can only do so much referrals
supported
beyond the paved road.

In 2021, Malagasy tradition inspired a newly

formalized initiative called the “human
ambulance” referral. Designed to maximize
efficiency and minimize the burden on
community members who are frequently 37% 30% 33%
transferred transferred other mode
called upon to carry patients to care, Pivot is by Pivot by taxi brousse of transport
ambulance or private car
working in tandem with community leaders by porteur,
on foot, etc.

to recruit paid porteurs. Traveling in teams

Hospital physician
and rotating shifts, these groups traverse the 100%
Dr. Haingo checks 48%
the X-ray of a child terrain with the patient until they’ve reached of referrals
were for
of patient
transport costs
with a suspected the nearest health center or ambulance meet-
urgent cases were covered

case of tuberculosis.
up point on the main road.
28 29
“Injustice anywhere AMPLIFYING OUR MESSAGE OF CHANGE
is a threat to justice
everywhere.”
The Rev. Dr. Martin Luther King, Jr.
If there’s one thing Pivot knows to be true about global health, it’s that success for one organization is success for
all. We are grateful to have a robust network of partners, peers, and coalitions committed to moving the needle
on health equity together. With a deeply rooted belief in health as a human right and a commitment to social
justice, the collaborative work we participate in – to develop research, advocate for policy change, exchange
lessons of implementation, and more – is how we amplify our message of change across the world.

Climate change poses a threat not only to the environment, but to human health
as well. Worldwide, the regions least culpable for harming the environment are
often the most affected.

Madagascar is among the countries most vulnerable to the impacts of

climate change due to its geographic location and chronic poverty. It is also
one of the richest in biodiversity, with 90% of the species endemic to the
island. It is no accident that Pivot’s work in Madagascar is within a district
that is directly adjacent to the World Heritage-designated Ranomafana
National Park.

In 2021, Pivot became one of four founding members of Climate Accountability

in Development, a new collective of organizations aiming to chart a path for climate accountability in

PPE for All

the development sector. The coalition aims to build upon the awareness of global emissions reductions
during the pandemic with a commitment to “come back better.”

Pivot’s carbon emissions baseline study revealed that we’re responsible for producing 578 CO2e (or the
equivalent of the carbon emissions attributed to 136 average Americans). We strive to be excellent stewards
of natural resources as we strengthen the health system and commit to reducing and mitigating our carbon
The Community Health Impact Coalition (CHIC) exists to make professionalized community health workers
footprint, with the goal of carbon neutrality by 2025.
(CHWs) a norm worldwide. Around the world, CHWs are the first line of response in the COVID-19 pandemic –
conducting case identification, contact tracing, referrals to higher levels of care, and treatment follow-up. As
an essential part of the public health system, they deserve and require adequate protection to ensure not only
their own safety, but also that of their patients and communities.

In 2021, through CHIC, we partnered with the COVID-19 Action Fund for Africa (CAF-Africa) to procure and The global consequences of COVID-19 have revealed the challenges of
pandemic containment and health system response. These approaches do not
distribute PPE for all CHWs in Madagascar, marking the first such national opportunity. The reception of 1.6
include more basic upstream effects, such as preventing zoonotic spillover in
million masks, 1 million gloves, and 33,000 face shields brought representatives of Pivot, the Ministry of Public the first place, which scientists believe caused 6 out of 7 pandemics of the
Health, and other government officials together in the nation’s capital to mark the occasion (pictured above). past century.

Spillover events have accelerated in tandem with accelerating tropical

We are proud to be protecting the country’s frontline workers, and grateful for CAF-Africa’s mobilization deforestation, live wildlife trade, and livestock production. Preventing the
for the equitable distribution of PPE worldwide. As we look to build upon this national-scale progress for next pandemic means addressing these kinds of human activities, which
community health, we will continue to advocate for adoption of CHIC’s Community Health Worker Assessment Harvard researchers recently calculated would require a $20-30 billion
annual investment worldwide –– only 2% of the economic and mortality costs
& Improvement Matrix, endorsed by the WHO, at the national level to ensure that trained, supervised, and of COVID-19.
compensated CHWs are built into future national plans.
In 2021, Pivot joined forces with a new coalition, Preventing Pandemics at the Source, which advocates
for global leaders to invest in pandemic prevention.

Pivot’s experience as a boots-on-the-ground healthcare organization working in close proximity to a

rainforest gives us a unique position to inform both how to detect and prevent spillover events. We look
forward to contributing to the evidence that supports investing in these vital prevention efforts.
PARTNER
SPOTLIGHT
31
 SHIFTING OUR CENTER OF GRAVITY

At the start of 2020, the Pivot team embarked on an essential journey to ensure that those most
proximate to the work are those who hold the most authority. We believe this is crucial to
mitigating inequities in the field of global health and doing our best work possible.

We started with the decision to shift the designation of “headquarters” from Boston to Ranomafana
and closed our central US office (reducing our small US team from 9 to 3 people). The remaining
staff worked to mindfully reframe the way we thought about roles across the organization: those in
Madagascar direct, those in the US support.

Practically speaking, that has involved shifts of decision-making power, management of resources,
and opportunities for professional development. Almost two years into this new dynamic, the Pivot
Science team is publishing papers led by Malagasy researchers, and our clinical program teams are
creating innovative and culturally relevant solutions to complex challenges.

Where things stand at the end of 2021:

Once made up of four expatriates, our Senior Management Team (SMT) is now a thriving cohort
of 11 leaders, 8 of whom are Malagasy and 9 of whom are women. Pivot is investing in their
capacity and their vision for the future of Madagascar’s health system. In the coming year, the SMT
will participate together in a six-month remote executive leadership course they co-designed at the
University of Global Health Equity in Rwanda to further their collective leadership and management
in global health delivery.

During 2021, four new Malagasy members joined our Board of Directors, joining founding
Board Member Benjamin Andriamihaja to establish an expert cadre of proximate organizational
leadership. In September, the group traveled to Ranomafana with their family members –
pictured on the left visiting a Pivot-supported community health post – to deepen relationships
with the staff who are leading the work and (re)acquaint themselves with Pivot’s work in
person. With professional experience ranging from the former Dean of Faculty at Antananarivo’s
School of Medicine, to current President of the Global Fund Country Coordinating Mechanism, a
founding coordinator of Ranomafana National Park, and early Pivot staff members, we believe there
is no better inaugural committee to provide Board-level leadership from within Madagascar.

“As a global health organization supported

by many around the world, Pivot is serving as 247
Pivot staff
a recognized pioneer in Madagascar for the
elevation of local leadership.”
98% 96%
Dr. Benjamin Andriamihaja Madagascar-
Malagasy
based
Founding Board Member & Senior Advisor

32 33
 DEEPENING OUR COMMITMENT TO JUSTICE

PARTNERSHIPS
Racism and inequity anywhere, in any form, are
counter to Pivot’s core values. We are deepening Entities that supported our work, financially or otherwise, during FY21
our fight for justice and commitment to diversity.
We invite you to act with us.

CENTRE
Advocating for change on a global scale often requires identifying and addressing
the need for local change. As a global health organization with a mission rooted in
social justice and an ongoing commitment to elevating Malagasy leadership, we’ve
seen this truth play out during our eight years of work in Madagascar.

It’s taken time for Pivot’s small US-based team to articulate the organizational
VA L B I O
imperative of addressing injustice in all places where we have a footprint, no
matter how small. In the awakening of the United States’ shared consciousness
around racial disparities during the last 18 months, one key truth could no longer Pivot’s work has been possible thanks to the foundational
be overlooked: everyone on our US team is white, and it is our responsibility to support and ongoing collaboration of these three key partners.
leverage our privilege to foster a more racially diverse and inclusive work PARTNER
environment. SPOTLIGHT
The question of how to go about doing so was answered when Dr. Demetrice
“Dee” Jordan was brought onto the Pivot Science team as a postdoctoral fellow IMPLEMENTING PARTNERS INSTITUTIONAL FUNDERS
specializing in health geography research. What none of us knew – until Matt
Bonds, Pivot Co-founder and Scientific Director, got to know her through his role as Dr. Demetrice “Dee” Jordan has a dual Akbaraly Anonymous (2)
her postdoctoral advisor – is that Dee also has a rich background in diversity, equity, PhD in Geography and Environmental
AMADIA Cartier Philanthropy *
and inclusion (DEI) work through her company Bella Academic Consulting, LLC. Science and Policy from Michigan State
Thanks to funding from Kathy and Bob Burke, we were able to bring Dee on board University (MSU). While pursuing her Catholic Relief Services CRI Foundation *
degree, she founded the Advancing Centre ValBio Crown Family Philanthropies
in the additional capacity of our US team DEI consultant.
Geography Through Diversity
Program, to address the persistent Community Health Impact Coalition David Weekley Family Foundation *
Over the course of 2021 Dee has led a critical journey, convening our group
underrepresentation of people of color DAK Foundation IZUMI Foundation
(including Pivot’s Board Chair) every two weeks to align and deepen our in geography doctoral programs.
understanding of antiracism and functional allyship. As a result, we’ve Dimagi Mulago Foundation *
formalized our commitment to DEI through an official social justice statement As a postdoc, Dee co-created and Direct Relief Panorama Global
(above) and the following pillars: co-instructed the first DEI-centered Fondation Mérieux Planet Wheeler Foundation*
Responsible Conduct of Research course
Resilience and Inclusion in Academic
Gould Family Foundation Preston-Werner Foundation
Research for Harvard Medical School Harvard Medical School RA5 Foundation
postdocs. Dee is a Council Member of
Ministère de la Population, de la Ripple Foundation
LISTEN CULTIVATE the American Geographical Society
EVALUATE
+ COMMUNICATE
+ (AGS) and developed the Celebrating Protection Sociale, et de la Sall Family Foundation
LEARN + RECRUIT + Black Geographers anthology hosted Promotion de la Femme T&J Meyer Family Foundation
ENGAGE SHARE online by AGS. She also received the
Ministère de la Santé Wagner Foundation
2020 Enhancing Diversity Award by the
American Association of Geographers. Publique de Madagascar
* Member of Big
Ny Tanintsika Bang Philanthropy
Dee is an advocate for creating
With these pillars to guide our path, we are ready to turn words into action. The safe, supportive environments for Operation Fistula
essential growth we’ve experienced as individuals during this journey has made it students of color, and planned and Partners In Health
easier to identify the opportunities for growth for Pivot as an organization. As Dee led workshops developed to “engage
Pharmaciens Sans Frontières-Canada
so aptly puts it, “this work never ends.” The new initiatives that we plan to launch in students, faculty, and the broader MSU
the coming year won’t be an end point, but experiences to build from. community in meaningful dialogues USAID ACCESS program
on microaggressions, privilege, cultural WeCare Solar
Pivot stands for justice in all places where we have a presence, and we believe sensitivity and diversity.” With her
that our mission in Madagascar is only strengthened by our work to advance expertise in social justice, her lived
experience, and commitment to rights-
DEI in the US.
based science, we are honored to have
Dee as our guide.
34 35
 WITH GRATITUDE TO OUR SUPPORTERS:
Josh and Ariya Lapan Up to $1,000 Christine Jones Katrine Smith
The following reflects cumulative
FY21 giving totals of all who made David and Cynthia Lippe Anonymous (4) Dee Jordan Marilyn Sprung
gifts between October 1, 2020 The Magis Charitable Foundation Danny Abelson Lolita and Steven Keck Craig and Regina Stanton

SPECIAL
and September 30, 2021. Glen and Jennifer Moller Martin and Natalie Anderson Jana Kemp Meg and Sam Steere
Philip Perkins and Margaret Allen Norma and George Andreadis Louis Kemp Sharon Sullivan
$100,000 and up
Anonymous (2)
Walter and Judy Rich
The Svrcek Foundation
Benjamin Andriamihaja
Donna Barry
Travis Knowles
Elliot Leake
Synchrony Corporate
Bill and Patricia Thomas
THANKS:
Cartier Philanthropy Thomas Young Jessica and Ari Beckerman Johnson Michelle and Carl-Johan Lindgren David Thrush
David Weekley Family Foundation Nancy Berg Charles Michael Loyd Jane and Warren Thrush
Stephen Della Pietra and $1,000-$4,999 Julia Berman Herb Loyd and Renata Kinney L. Blair and Sandy Thrush
Pam Hurst-Della Pietra Anonymous (1) Nicole Breazeale Jim and Jennifer Loyd Alena Tschinkel
Vincent Della Pietra and Margaret Archer Jacqueline Brooks Peter Lucey Michael and Katina Tucci
BOARD OF DIRECTORS
Barbara Amonson Ron Basu, on behalf of Morgan Emily Brown Ali Lutz Laura Vaughan
Miriam and David Donoho Stanley Wealth Management Israel and Stephanie Catz Andrew Lynn Amy Voiland Benjamin Andriamihaja
Gates Medical Research Institute Matt Bonds and Molly Norton Melissa Charlton Jen Mackethan Wallace Robinson Fund Bob Hower
Herrnstein Family Foundation Beth and Mike Boonin JC and Jen Coffey Aaron and Julie Mann Kathleen Wetherby and Henry Zenzie
Brittany Powell
Tomislav and Vesna Kundic Valerie Briston and Marko Kleine Carrie Daus Jennifer Marks Merywen Wigley and Kevin Magill
Edward Norton
Colin and Leslie Masson Berkenbusch Linda Delgaudio Duncan and Sheela Maru Gabriel Wilmoth and Catherine Walsh
Paul and Larisa Cuff Amy Donahue and David Matthews Jane B. Winer Faramalala Rabemananjara
Mulago Foundation
The Night Heron Foundation Ophelia Dahl and Lisa Frantzis Shey Nessralla Gigi McDougall Benjamin Wise Jim Herrnstein
Planet Wheeler Foundation Mark Dumont and Lynn Mehlman Tyler Donahue Charlie and Marylou McDowell Patricia Wright Lara Hall
Ripple Foundation David and Barbara Duryea Elaine and Steve Donahue Toi and Wayne McGary Luc Samison
Jim and Marilyn Simons Paul and Didi Farmer James and Jean Donohoe E. Graham McKinley IN-KIND SUPPORT Manu Prakash
Wagner Foundation Peter and Sarah Harris Michael and Nina Douglas Gabby Merill McGraw Dai Ellis Mark Krasnow
James Houghton and The Dowling Family Microsoft Inc. DAK Foundation
Matt Bonds
$25,000-$99,999 Connie Coburn Jacqueline Edwards Ann Miller Gould Family Foundation
Max Herrnstein
Peter Barrer and Judy Nichols Mathilde and Matthew Hutchings Jena Eichinger Ariel and Huxley Miller
Robert and Jacqueline Hutton Dai Ellis Alexis Moisand IN LOVING MEMORY
Michael Rich
Burke Family Foundation
Kathy and Bob Burke Jim and Patty Rouse Charitable Garry Embry Lisa Monke Nancy Jones Gray Patricia Wright
Scott and Yilin Chen Foundation Tsiry Endor Rakoto James Moran Susan Herrnstein Paul Farmer
CRI Foundation Jared Lettieri Kaylee Engellenner Daniel Mungwarakarama Louise Hutton and Lucy Thrush Robin Herrnstien
Crown Family Philanthropies Nathan and Leslie Levenson Marybeth Esposito Murti Nauth Marjorie A. Shedd Seheno Randriamanantena
Robert and Mary Grace Heine Nisha Ligon Randi Ewing Minda Nicolas and Josh Nesbit Oscar the Cat Stephen Della Pietra
Bob and Kira Hower Parke Loyd Camille Ezran Brendan O’Neill
Tahiry Raveloson
Institut de recherche pour le Tara Loyd and James Keck Peter and Caroline Fairley Amber Oberc IN YOUR HONOR
Tara Loyd
développement Regina Malhotra and Karen Finnegan and James Mbabazi Judy Olson Tom Hampton and Katja Koeppen
Miguel Catalina-Gallego Richard and Ellen Finnegan Nancy Palus Jim and Robin Herrnstein
Tyler Saltiel
IZUMI Foundation
Dan and Sara Koranyi James and Mini Mammen Becky Grund Dirickson Dan Pargee Mathilde and Matthew Hutchings Vincent Della Pietra
Robert Lourie and Michael McCrain and Cynthia Agals Jennifer and Kevin Fiori Dilip Patel Tara Loyd
Ivana Stolnik-Lourie Michael and Kimberley Mumford Nicholas Fischetti Danielle Pernicone Dr. Jessie Lucey
William F. Milton Fund - Harvard Susan and John O’Brien Paula Fischetti Sara Peskin Ed Norton VOLUNTEER
University Phil and Betsy Palmedo Trillium and Michael Fox Jody Pesso Jeremy Ratcliff CLINICAL ADVISORS
The Polymath Fund Panorama Global Haley Frazier Pauline and Mark Peters “All of Pivot’s female leaders”
Myles Perkins and Jennifer Furin Sandra Porter “Matt Bonds and his team” Adriane Levin
Kathryn and Steven Puopolo
RA5 Foundation Christina Lindgren Goldman Sachs Matching Gift Brittany Powell “The new Malagasy board members” Alice Bukhman
Sall Family Foundation The Philanthropy Workshop Program Faramalala Rabemananjara and “The Pivot team in Madagascar” Allison Navis
Francesco Scattone and Jonathan and Linda Rich Susan Grekin Andres Garchitorena “The team who set up the RT-PCR Archana Patel
Judith Gibbons Michael Rich Kathryn Grey Seheno Randriamanantena testing facility in Ranomafana” Dayo Fadelu
T&J Meyer Family Foundation Daniel and Judy Richards Jeb Gutelius and Margaret Butler Tahiry Raveloson Gene Kwan
Ted Rouse Anne and Robert Hall Bruce and Sandra Reeves
Heather Brown
$5,000-$24,999 Patrick Sabourin Lara and Patrick Hall Elisa and Bill Richardson
Jason Beste
Anonymous (1) Nimish and Niti Sanghrajka Sally Hallen Pejman, Rebecca & Sophie Rohani
David Shedd Lulie Harry Jennifer Ruglio Jason Frangos
Lalit Bahl and Kavita Kinra
Stanko and Nicole Barle Elizabeth Sheehan Jae Hartzell Donna Sabatino Gist Jeffrey Mendel
Betsy Barton and Robert Beals Simonet Family Fund Justin Haruna Tyler Saltiel Lisa Bebell
Kathleen de Riesthal and Robin Sparkman F. B. Harvey Luc Samison Marla McKnight
Alvaro Begue Craig Spitzer Elizabeth Herman Dan Schwarz and Jafet Arrieta Maurine Achebe
Michael and Stacey Gargiulo Jack and Barbra Thomas Nicole Herskowitz Lamb Joe Shaw Natasha Archer
Robert and Louise Grober Anne and Lanny Thorndike Amy Hettinger Pascucci Mike and Jamie Sileo
Neil Gupta
Max Herrnstein and Danielle Curi Susan Wheeler Jared Amadeo Holstein Harry Siler
Ole-Petter Hamnvik
Susan Herrnstein Bill Wiberg and Lynda Sperry Virginia Humphreys Miriam Silman
W.T. Rich Company Darby Jack Katherine Sims Suha Patel
Sophia Hilton and Jorel Doherty
Donna Hutton Anna Johnson Erika Sky Zahir Kanjee

36 37
 FINANCIALS

EXPENSES FY21 (12mo) FY20 (9mo)

Health Care Delivery Programs

Research
$5,269,080
$489,355
$2,686,617
$323,473
85%
Administration & Fundraising $410,168 $480,492
Health Care
TOTAL $6,168,603 $3,490,582
Programs
$5,269,080

REVENUE 8%
Grants & Contributions $6,624,531 $4,028,355 FY21 Science &
Research
Foundations
Individuals
$3,190,066
$3,434,465
$820,717
$3,207,638
EXPENSES $489,355
In Kind $0 $23,845
Interest & Dividends $1,372 $2,493
TOTAL $6,625,903 $4,054,693 7%
NET REVENUE $457,300 $564,111
Administration &
Fundraising
$410,168
ASSETS
Cash and Cash Equivalent $3,484,005 $3,373,214
Pledges Receivable $657,863 $222,771
Prepaids & Other Current Assets $629,627 $426,533
Fixed Assets, Net $452,798 $379,085
Other Assets $2,862 $2,919
TOTAL ASSETS $5,227,155 $4,404,522

NET LIABILITIES & ASSETS

Accounts Payable $243,231 $184,929
Accrued Expenses $332,900 $187,177
Long Term Debt (PPP Loan) $0 $107,572
TOTAL LIABILITIES $576,131 $479,678

Net Assets, Unrestricted $4,103,938 $3,496,401

Net Assets, Restricted $547,086 $428,443
Research Activities $150,335 $91,755
Community Health $279,722 $232,233
Construction $4,378 $74,043
Infectious Disease $77,059 $0
Staff Support & Development $35,592 $30,412
TOTAL NET ASSETS $4,651,024 $3,924,844

TOTAL LIABILITIES & NET ASSETS $5,227,155 $4,404,522

38
 CELEBRATING THE RIGHT TO HEALTH
ZO HO AN’NY FAHASALAMANA

Community health workers from across

Ifanadiana gather to celebrate the formal
launch of universal health coverage
throughout the district on July 22, 2021.
 K Y O
T H A N A !
A O T R
M I S O U !
N K Y
T H A R A !
S A O T
M I Y O U !
A N K !
T H T R A
I S A O !
M Y O U
A N K !
T H T R A
I S A O !
M Y O U
A N K !
T H T R A
S A O
www.pivotworks.org

M I U !
@pivotmadagascar

Y O
BP. 23, Ranomafana

NK
District d’Ifanadiana 312

75 North Main St. #2075

Randolph, MA 02368