When I laid off five of my seven team members in February, I had no idea a global pandemic was about to hit. It was a tough enough decision even without that in the background: There is no pleasure in laying off good people, just as there is no pleasure in recognizing that the way we’ve been doing it—the way I’ve been doing it—runs contrary to PIVOT’s mission.
However, I saw no clearer way to shift our organization’s center of gravity from the United States to Madagascar. No clearer way to shift resources, responsibilities, and authority from the customary hub (here) to the rightful place (there) than by taking this kind of action. Even with 206 staff members in Ifanadiana, Madagascar, and only a handful in the US, undue deference was being paid to the US team—including myself—at the price of the local team’s power, despite anyone’s best intentions (not to mention the budgeted inequity of basic US salaries at five to 10 times those of key national staff). Decisions were too often made by US-based directors and board members, with only the national director representing the team at site, and the imbalance of power affected how meetings were conducted, how communication was handled, and how decisions were made.
It wasn’t hard to understand how it got this way, nor is this kind of problem unique to PIVOT. But “decolonizing global health” is easier said than done. NGO headquarters, academic journals, and decision makers are too often removed from the problems they purport to solve, allowing the field of global health—knowingly or not—to perpetuate patterns of power and dominance that we must instead dismantle. Those living the reality of the problems have, regularly and structurally, been excluded from authoring the solutions. This must change.
To create space for that change within PIVOT, so the leadership team in Madagascar would have the space to lean-in, I asked the team in the US to lean-out, in the most extreme way possible. I believe this will make us more effective as an organization, and ultimately save lives.
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Pivoting PIVOT
PIVOT is a 7-year-old global health organization partnering with Madagascar’s Ministry of Public Health to transform Ifanadiana district into a model of universal health coverage for the country. Since 2014, PIVOT has supported more than 600,000 patient visits to the public health centers and hospital which we work to strengthen through adequate staffing, dignified spaces for service delivery, and a robust supply chain. We’re part of the Community Health Impact Coalition, working to establish fair wages and adequate support for community health workers nationwide. Born of the Partners in Health model of Health Systems Strengthening, we have followed their example, committing to the long haul to effect long-term systemic change as partners to the government. We work in a district that contains the extraordinary World Heritage Site, Ranomafana National Park, and collaborate closely with the local partners who founded it.
As PIVOT’s executive director, I am a well-meaning, comfortably middle class, white American woman. I’ve spent my career entirely in the non-profit sector, with 21 years in tether to rural Lesotho, Malawi, and now Madagascar. As our first employee, I had the pleasure of building the PIVOT team. The Malagasy team grew quickly—from 18 people on opening day, to 64 by the end of the first year, to 206 in early 2020. I was more cautious on the US side, clear that we weren’t delivering programs or advising the government of Madagascar from here. Still, by the end of 2019, we were an eight-person team set to add a ninth in early 2020. I was cognizant that I wasn’t hiring people who had lived in Madagascar or spoke the local language as I grew the US team and tried to make up for it with the international and national team at site.
In retrospect, I wasn’t intentional enough about the size and scope of exactly what I was building toward. We were “building the plane as we flew it,” rather than hiring to execute on a plan, as I believe we are now. The simple fact is that we did not have a single Malagasy team member with a “director” title until almost six years in (lots of Malagasy managers, but no directors). I gave a handful of reasons for that over the years, and PIVOT isn’t unique in this shortcoming, but somewhere along the way, the word ”headquarters” became the way the Madagascar-based staff referred to the US office. By the end of last year, I was too.
My Decision to Act
When the Ministry of Health selected Ifanadiana as one of two districts to implement universal health coverage (UHC), as a model for the country, I had to take a hard look at the numbers. To fund the UHC expansion, I entered our January 2020 board meeting proposing an annual plan that was $400,000 over budget. And here’s where I started to feel really uneasy: The Malagasy national team of 206 people cost less in salary than the 17 people not from Madagascar receiving salary support from PIVOT (eight-person administration team, a few full- and part-time advisors, and the handful expatriates at site). One of my more junior staff members shared the anecdote that his colleagues in Madagascar were curious how many people reported to him back in Boston—40, 80? The answer was zero. But perceptions were hard to counter.
A major shift was called for and it was mine to carry out. The people whose jobs were on the line were people who I knew deeply loved their work, but I could no longer justify or envision carrying their work forward here in the United States. PIVOT would save more lives when power sat clearly and squarely in the hands of the 10-person, majority Malagasy leadership team at site. And so, I resolved to let the majority of the US administration team go, retaining only one junior member from each department (operations and fundraising) to keep things moving.
Once the idea took shape, I had fire in my belly. I was headed to Madagascar for the launch of the new year in February and wanted to be able to report that we had a budget approved with the UHC plan front and center in it. I needed to move fast. I was taking calls in odd places and at odd times, convening board meetings outside of session, and delaying the job offer for the ninth US administration team member as long as I could. I talked to advisors, peers, the two US staff members I knew I had to retain, as well as the team in Madagascar whose jobs would be affected by the shift. Could I pull this off in a way that honored and acknowledged the departing US team members for helping build PIVOT and at the same time let them go? Could that message be communicated to the Madagascar-based staff with enough significance to mean something? What if our long-term commitments made to communities couldn’t be fulfilled with a much leaner US team? What if just telling our Malagasy leadership team that they “had the power” actually didn’t result in people exercising that power? What if we didn’t raise enough money? What if, what if, what if?
The tension created by all these questions was valid and productive. From loyalty to the US team, without whom board members acknowledged the PIVOT we know (of US community and networks) couldn’t have been built, to concern about destabilizing the organization from a decision this drastic, we were also discussing the role of the international community in global health equity. What do long-term partnerships really mean in practice? What roles are there for expertise, training, and labor from outside a country in confronting the challenges of achieving a more equitable and healthier world together? I acknowledged the important debate, emblematic of what it means to wrestle with these problems across the broad global health ecosystem. And I also acknowledged the deepest worry: What if PIVOT failed, failed our patients? Ultimately, I returned to the clarity, that for me to lead authentically, to lead from my gut, this bold and clear action was the best starting point to facing those questions as an organization together.
My green light from the board came February 11. On February 12, I flew to Boston to deliver the news in person. The layoff conversation itself was awful, but the team understood the decision. Nevertheless, they are people with identity wrapped up in our shared work, whose friends and family had supported PIVOT, and in some cases had even visited Madagascar. I offered them all a say in how long they’d stay, requesting a minimum of 2 weeks and offering a maximum of 3 months to wrap up and hand off their responsibilities. The longer departures were the hardest—those extra weeks were sad, hard, and often led me to defend my decision. And when COVID hit, I found myself laying off people in an unimaginably challenging job market, as well as dismissing our chief fundraiser during the most unpredictable funding landscape of our lifetimes.
On each person’s final day, we gathered on Zoom for a group farewell. After the final farewell in May, I set about telling our institutional funders and key individual supporters the news directly. They got it and seemed willing to back the risk. Peer organizations offered encouragement, and I learned about others’ efforts in a similar direction.
Having the Layoffs Mean Something
Though I felt motivated and clear, I began hearing murmurs of people worried they could be next on the chopping block. Some didn’t understand my motivation and approach well enough or had issues with the secrecy of the conversations I had initiated to move the decision through. I got help designing a survey to take the pulse of the organization. The questions asked each person to share their balance of good days and bad days, biggest hopes and fears for the coming year, areas of misalignment and confusion they sensed in the organization, and what could be done to address the hard stuff together. What I planned as a two-part session to talk through the survey responses together became 12 sessions of what we named the Transition Summit.
The Transition Summit is where the healing began to happen and trust was rebuilt. It was more than just the layoffs. People wanted to talk about job descriptions, overworked colleagues, and my long-term plans for PIVOT and the team. They wanted to pause and fully acknowledge the loss of colleagues, the particular pain of a layoff during a pandemic, and the awkwardness of being chosen to stay. I listened and learned. I was vulnerable and yet also resolute. Each week, I kept us on the path to talking despite the world of 2020 swirling around us. And when it was over, I marked the moment and thanked everyone for their willingness to walk through this emotional valley together.
The good news is that we closed our 2020 fiscal year on September 30, and we did raise the money. And most importantly, thanks to the incredible Malagasy national team leaning-in and leading, we landed squarely on our two feet. Whether fundraising credit goes to amazing supporters stepping up during COVID, the direct connections Zoom offers between our donors and our front-line Malagasy staff, the clarity and momentum of the UHC direction for PIVOT, or the way the board showed up to support this decision once it was carried out, I can’t be sure. But I am grateful. To the patients we exist to serve, I believe we owe the commitment to always be evaluating ourselves and correcting course as needed. And for the ongoing work ahead, to realize Ifanadiana district as an evidence-based model of universal health coverage for Madagascar, I believe PIVOT is stronger and more dynamic than ever before.
For Organizations Thinking of Doing Something Similar:
1. Take action and hold on. Holding steady to the layoff decision was made even more difficult when others doubted it, or felt bad that it was happening, both at the outset and throughout the process. But as hard as it was, PIVOT now feels right-sized, -shaped, and -oriented to me. We are designed to do what we set about achieving in the world and that is reinforced to me nearly every day.
2. Communicate directly. I flew to Boston to tell employees in person, and each call with a supporter, PIVOT community member, or peer organization made sure that they were hearing it from me directly. I was managing my own message and keeping rumors or worries from percolating. There were plenty of moments where I would have preferred to send an email but that would not have honored the people, the process, or my role in initiating it.
3. Give everyone time and space to grieve, both for yourself and for the colleagues saying goodbye to their team members. We took time to share old pictures, fond memories, and enjoy the fellowship of each person in their own way as they left, and I am glad we did.
4. Think hard about how to maintain trust. The period between the moment you realize what you need to do and the moment you do it is really hard to handle. I tried to find the balance between seeing advice, enlisting everyone whose support I needed, and warning key people something was coming (but clarifying that it wouldn't affect them) without betraying the people I planned to fire. In retrospect, I told too many people and had too many conversations in secrecy to maintain trust. And then I had to face that reality.
5. Take a deep breath afterward. The people chosen to stay will not necessarily have an easy time either. From perceptions of favoritism to realities of increased workload, their journey is affected by the decision too. Our Transition Summit helped us process and heal and is the basis of what allows us to move forward together now.
The Path to Maintain Our Center of Gravity With the Team in Madagascar Continues
The work is not done. I still hold a position with a title that doesn’t match the reality of what I think I can and should do from my distance. I would like to trade the name executive director in for “ambassador” or something that better conveys the feeling of what I know and what I cannot know. But funders like to talk with the person who seems to be in charge, and as long as we continue to have a primarily American board of directors holding meetings primarily in America, we depend on a role like mine, as a bridge. I used to think of serving as the link to our US funders and the board as helpful ways I could support the team while they managed the complexity and ever-present challenge of moving the work forward, but I realize now that in doing so, I am also robbing them of the power to advocate for their work directly, to put their ideas for change directly, rather than through my voice, on the table. Connecting our funders directly to our staff in Madagascar and having greater Malagasy representation on our board, with more board meetings in Madagascar, are two clear areas we can invite progress.
We keep moving forward. Funders are taking me up on the offer to speak directly to staff, across language and time zones, in Madagascar and in more and more cases inviting that directly. We held the first quarterly board call of FY21 with the Madagascar leadership team present for the first time. There we defined essential work to be driven together through direct and deepening relationships across leadership and board. Our newest board member, a Malagasy former member of our clinical team, opened the meeting with his reflections on how the Malagasy staff and board leadership within PIVOT can truly occupy seats at the decision-making table. He named shifts in communication style and meeting format needed to truly center their voices was his idea, as he and the other Malagasy leaders at PIVOT exercise their power to make change for the better. It feels right. In fact, it feels great.
The Big Picture
As 2020 rages on around us, I am trying to put the pieces together and continue to take the steps I can from where I sit in this world. From the atrocious legacy of colonization and slavery to the unbalanced ravages of climate change, I would much prefer these things had nothing to do with me and my role that I used to see as so clear cut. What I have been trying to confront is that the reality of my life puts power and privilege like mine at the center of anything I do. I hope naming that is a first step. The great pause caused by COVID has forced the world to slow down if not truly stop, and I like the idea that we use the pause as an opportunity to listen deeply to those we may not have previously heard or made time to hear. By truly listening to those closest to the problems, I believe we can collectively move closer to the solutions.
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Read more stories by Tara Loyd.