Three Pillars

Mada Clinics provides free medical care to over 15,000 people each year living in rural Northern Madagascar. We are organized and staffed by members of the rural communities we serve. We are the main source of healthcare in the region as other institutions are approximately seven hours away. As we built a system of primary care in this previously unserved area, our experiences, conversations, and input from our patients have taught us metrics crucial to assessing our own performance in addressing the health needs of the communities that we serve.

The largest issues we encountered when developing a primary care system in our region were a lack of basic public health, poor access to care, and poor coordination of care (and follow-up) in the instances when access to care had been achieved by a patient. 70% of community members had never received a vaccine, and all were inadequately vaccinated. No testing or treatment for HIV was available in the region, despite some of the highest rates of syphilis, gonorrhea, and chlamydia in the world. Nearly all patients who presented to us with a previously diagnosed chronic illness had long ago run out of medications. 

This MIT Solve Challenge asks for novel, simple methods to measure improvement in primary care performance in low-income countries. We believe our experience in rural Northern Madagascar positions us well to develop, screen, and share these methodologies. 

To understand the extent of these issues and measure our performance in addressing them, we developed a performance measurement system utilizing three ratios, which is quick and simple enough to be used by healthcare workers at our busy rural healthcare center. These healthcare workers often treat over forty patients per day each, so simplicity is crucial. Our solution is named the "Three Pillars." We believe our solution is applicable to the 17 million people living in rural Madagascar and to the more than 700 million people living in other rural low-income regions.

The three pillars solution is a method for assessing primary care quality utilizing three ratios that can be easily ascertained by healthcare staff at busy primary care centers utilizing patient records or patient interviews. These three ratios assess public health quality, access to medical care, and coordination of ongoing treatment. Healthcare centers utilizing this system to measure their quality of care or the impact of new initiatives should aim to increase each of these ratios over time. 

To assess public health quality, we use the rate of patients adequately vaccinated vs. the rate of patients under-vaccinated or unvaccinated. This ratio can be customized to vaccines deemed most vital to the region or country in which it is being utilized. As public health services reach more members of a community, this rate should rise. 

To assess access to medical care, we use the rate of patients presenting with a known chronic disease diagnosis vs. the rate of patients diagnosed with a chronic disease for the first time. If screening and testing for diseases are poor, or a high percentage of community members cannot access care, this ratio will be low. If community members are able to access screening or testing for chronic diseases on a regular basis, this ratio will rise over time. 

To assess coordination of ongoing care, we use the rate of patients who present for a refill of their prescription before they have exhausted their medications vs. the rate of patients who present for refills after exhausting their prescriptions. If patients struggle to obtain medications on a timely basis, this ratio will be low, and disease management is likely poor. If, as an example, low-resource pharmacies are strategically located to improve access to medications, or community health workers are utilized to bring patients their medications, this ratio would rise, and disease management would improve. 

The strength of the three pillars solution is its simplicity. We anticipate this system being used by nurses and community health workers with little to no training in epidemiology, public health, or quality improvement. Our solution is designed to enable these frontline workers to identify deficiencies in the care they provide and brainstorm solutions to these deficiencies. The system is then used to measure the impact of these solutions. While a pen and paper are the only technologies necessary for this assessment method itself, we will implement a simple software application to monitor ratios, which will allow us to analyze and respond to existing and future health needs more efficiently.

Mada Clinics is working to implement the three pillars solution in rural Northern Madagascar in order to improve the quality of care that we provide to the 15,000 patients that we serve each year. We anticipate that our method of assessing primary care quality will apply to most healthcare institutions working in underserved areas. 

Our patient population consists mainly of rural Malagasy rice farmers and sapphire miners. On average, they earn less than one dollar per day and are amongst the most impoverished people in Madagascar. Most of our patients do not know how to read or write. Most live more than an hour from a road. They utilize rivers and streams for water used for bathing, drinking, and cleaning and practice open defecation as there is currently little to no access to latrines. 

Based on epidemiological data we have collected, two-thirds of our patient population are infected with schistosomiasis. 3.5% have HIV, and greater than 70% are unvaccinated. Many of our patients have lost children to measles and loved ones to diseases such as tuberculosis and malaria, which would have been addressable with a well-functioning primary care system.

We have built schools to provide education and wells to provide clean water for the closest towns to our institution. Utilizing the three pillars system, we have so far observed that there is a critical need to provide vaccination, that the vast majority of cases of hypertension, diabetes, and HIV are undiagnosed, and that patients have not been able to access medications or follow-up care in order to adhere to treatment guidelines even when they have been diagnosed. 

After discussing these deficiencies with patients and local leaders, we have begun working to improve our primary care system by building out solar power to power a refrigerator to provide accessible vaccination. We have also begun screening all patients for HIV and all at-risk patients for hypertension and diabetes.  To address the logistical difficulties patients face in accessing medications, we plan to hire community health workers to deliver prescriptions to more accessible locations. The three pillars metrics will help us understand whether these interventions are efficacious. When combined with discussions with local communities, we anticipate that these metrics will continue to be part of our system of continuous quality improvement.

All of the paid staff on the Mada Clinics team, including senior leadership, consist of Malagasy community members from the same region of the country as our organization's patients and students. Our nurses, teachers, midwife, onsite-director, secretary, and other staff members all come from rural Northern Madagascar and live among the people we serve. They play on the same soccer teams, attend the same festivals and celebrations, and sit at the same town meetings. When we make decisions for our community it is after face-to-face meetings with community leaders and their constituents. 

Our success as an organization comes directly from the trust and relationship we have with the region we serve. When we chose to address HIV, over 99% of patients consented to testing. When we began a schistosomiasis control program, the local communities we serve got together and constructed their own deep water wells and latrines. Our community creates our organization, and for that reason, we are well positioned to understand and meet the public health and primary healthcare needs that surround us. 

The area of rural Madagascar in which we operate faces an enormous burden of vaccine-preventable disease, sexually transmitted infections, and undiagnosed and untreated chronic conditions. Over the past three years, we treated over 400 children for measles and discovered that 4% of the population we serve has HIV, and nearly 70% have schistosomiasis when previously no testing or treatment for these illnesses was available. In addition, over 70% of our patient population is unvaccinated. 

We currently lack the staff and resources needed to adequately address the critical shortage of vaccinations, testing, and medication in our area. This challenge will enable us to build the systems necessary to provide our patients with the care that they need. We are working to install solar power to power a fridge in order to store and provide vaccines to our patients. We will hire community health workers to ensure that our patients can access HIV medications, tuberculosis treatment, and medications for noncommunicable chronic diseases. We will build a road so that patients have easier access to our services and so that we are better able to transport vaccines and prescribed medications to them. 

Over the years, we have been able to demonstrate to the regional government both the severity of health problems in our area and our ability to address those problems. Over time we have received increasing funds from both the regional government and outside institutions by demonstrating that these health issues can be addressed in a highly cost-effective manner.  

The three pillars method is innovative because of its simple yet comprehensive approach to assessing health quality. Community health workers can be quickly taught how to implement the method into existing care practices without the need for additional resources. 

The decision to choose these three specific ratios was decided after significant discussion and reflection between myself, a Mayo Clinic-trained M.D., and Malagasy medical professionals responsible for overseeing everyday patient care. These discussions led to the choice of vaccination, chronic disease diagnosis, and timely access to medications as the most representative measurements for the three pillars of primary healthcare, which are prevention of disease, diagnosis of disease, and treatment of disease. 

We chose these three representative rates because their improvement would require the establishment of processes likely to strengthen all aspects of primary care, including those that are not directly measured.

Within the next 12 months, we aim to accomplish the following three impact goals. We plan to accomplish these by measuring and analyzing the data provided by the three pillar approach to primary care.

1. Improve public health quality by creating the infrastructure and distribution channels necessary to provide critical vaccines to those who desire them
2. Provide timely diagnosis and ongoing, accessible care for patients with chronic and communicable diseases
3. Identify and bring attention to HIV prevalence rates for women, men, and children in our region.

• • Note: this is the next stage of our ongoing HIV research study. Testing children requires special consideration regarding informed consent, which was one reason for not including them during initial screening. Half of the population of Madagascar is under 15 years old, so we are taking the appropriate time to navigate and facilitate pediatric testing. 

On a one-to-five-year horizon, we aim to;

1. Evaluate and scale findings from the three pillars solution that demonstrate clear benefits for community care. 
2. Strengthen our relationships with the government of Madagascar and other aid organizations with the collective goal of improving primary care coverage throughout Madagascar. 
3. Serve as a model for addressing the rapid and exponential increase in HIV infection in Madagascar.
4. Challenge and correct the current understanding of disease burden in Madagascar

We conduct weekly check-ins between administrative and medical staff to discuss testing and treatment progress, which ensures we have an adaptive and agile approach to addressing our community’s needs. Once our software application is in place, we will begin to analyze trends in our findings, establish progress indicators, and track the changes over time. Additionally, by understanding the current state of primary care in our region, we will be able to accurately measure the impact of future health interventions.

If the impact of a primary healthcare system on the critical health needs of a community can be simply and accurately measured, then limited resources can be efficiently invested to scale effective interventions that improve community health outcomes over time.

The three pillars solution is a method of analysis grounded in the most basic healthcare needs of a community. Implementing the three pillars solution requires no technology beyond a pen, a piece of paper, and division. No internet connection or electronic devices are required. However, we will utilize a simple software application in order to make the data more accessible to all organization members in real-time, which should aid in discussions and analysis surrounding healthcare improvement initiatives. The data from each patient case will be logged during that case via simple yes or no answers to each of the three ratios. This should also aid in keeping organization members focused on the core healthcare needs of the community, namely public health infrastructure, access to primary care, and coordination of ongoing care.

Nurses and community health workers collect the data for our solution by checking three yes or no boxes during routine patient visits or when reviewing records. By utilizing our solution, these front-line workers can identify areas for improvement in the current system of care and are empowered to participate in strengthening the health system in which they operate. These workers can also assess the effectiveness of new health interventions more easily and thereby avoid interventions that do not efficiently utilize their time. 

Data is not intended to be collected or managed by third parties, thereby reducing complexity and cost and improving patient privacy. 

The healthcare and educational staff of Mada Clinics come directly from the communities that we serve, which are some of the most impoverished communities in Madagascar. These communities are of Afro-Malagasy decent and are part of a marginalized minority ethnic group in Madagascar that comprises 6% of the population. We proactively gather community input to identify their most pressing health needs and work together to develop practical solutions.

Additionally, the simplicity of the three pillar solution leads it to be accessible to all levels of healthcare staff, inclusive of varying degrees of technical backgrounds and education.

Mada Clinics provides free medical care to approximately 15,000 people yearly in rural northern Madagascar. We provide primary care, treatment for infectious diseases, obstetric care, and treatment of minor traumatic injuries. We additionally refer for and often fund surgical treatment and other higher-level care that we are unable to provide directly. We operate a small pathology lab and also offer ultrasound imaging. We are located over five hours from the nearest healthcare facilities and are therefore able to provide value that is otherwise nonexistent for those living in our region. We regularly receive patients from as far as one hundred miles away.  

Mada Clinics also operates three schools, providing free education from the elementary through the high school level. There was no option for childhood education in the area prior to the establishment of these schools, and much of the adult population in our region is illiterate. These schools follow the Malagasy national curriculum and also offer additional education in English and health sciences. Our schools are now majority funded by the government of Madagascar. 

We additionally provide public health services through community-wide mass treatment in the form of childhood de-worming and schistosomiasis control programs. We have built deep water wells to provide clean water for nearby towns and villages. We are building out infrastructure to provide vaccinations to the area that we serve.

All of our paid staff are Malagasy and we hire local teachers and contract with local workers or village chiefs for all infrastructure projects. This has far-reaching benefits for the local economy and also allows us to reach more patients and construct more critical infrastructure in a cost-effective manner. 

Mada Clinics is currently financially sustainable for the level of care that we provide. A mixture of monthly donor funds and Malagasy government funding pays for 90-100% of staff salaries, medications, and infrastructure maintenance costs. One-time donations and research and grant funding have enabled the purchasing of new medical equipment, community infrastructure projects, and expansion of the quantity and quality of care that we provide. We expect that the number of patients treated each year will expand from 15,000 to 40,000 patients yearly after the construction of a road leading to the clinic. We will continue to seek new monthly donors and operating grants to pay for this expansion in care and seek greater integration within the Malagasy government’s provision of healthcare. 

Mada Clinics was incorporated as a nonprofit in 2018. That year approximately $9000 was raised from international volunteers who traveled to Madagascar to aid and provide training for Malagasy teachers and healthcare providers. 

In 2019, $13,000 was raised via donations, and we obtained our first research grant from Mayo Clinic to study and address schistosomiasis prevalence rates in rural Northern Madagascar. Overall, our funding increased 100% that year.

In 2020, $20,000 was raised via donations, and one grant was obtained from Mayo Clinic, with an additional grant obtained from the Infectious Diseases Society of America to begin addressing HIV in rural Northern Madagascar. Additionally, funding was obtained from the government of Madagascar for educational staff salaries for the primary and secondary schools we built over the preceding two years. Overall, our funding increased an additional 72% that year.

In 2021, $43,000 was raised in donations, and two grants were obtained from Mayo Clinic. We additionally began receiving Malagasy government support for the clinic in the form of medications, disease test kits and a government-salaried midwife. Overall, our funding increased an additional 64% that year, not factoring in the additional government support.

In 2022, we have so far fundraised approximately $65,000 and expect that this year could be an overall additional 100% increase in our funding. This will mean an approximate 1100% increase in yearly funding as compared to four years ago.