Haiti - Reconstruction : (IV) Health - Strategic Plan
While donors begin to fulfill their pledges and have difficulty accessing the facts about what is needed most on the ground, many are asking how to prioritize their spending.
The strategic plan presented at the fourth meeting of the IHRC, December 14, 2010 at Santo Domingo in the Dominican Republic, will help guide the project implementers, donors and investors as they guide the disbursement of their pledges for the reconstruction and development of Haiti, and add much needed new funding. Developed jointly by the Commission, international experts and ministry leaders, this plan outlines many of the most important things needed in Haiti by October 2011, the end of IHRC’s mandate.
Each day of the week we'll discover a part of this strategic plan for 2011. Today we cover the health.
The health sector goals outlined in this document are based on recommendations of the IHRC Health team in close collaboration with the Ministry of Health, conversation with other Ministries, input from Donor supported technical assistants, and comments from group or individual sessions with NGO or private sector partners. The targets are consistent with the IHRC Health Team’s overall strategy and approach as follows:
The health sector target outcomes are segmented into two categories. Those that support direct increases in clinical care referred to as “Service Delivery” and those that support the public and social structures in their ability to respond and monitor are referred to as “Institutional Strengthening” with specific intervention areas as follows:
A. Service Delivery:
– Human Resources
– Financing and Access to Care
B. Institutional Strengthening
– Strategic Planning
– Public Sector Capacity Strengthening
– Civil Society Outreach
For each of the six areas mentioned above, the document below lays out targets, rationale, programs and funding requirements.
In addition to the two main categories, this plan also addresses the current situation of the cholera outbreak
Intervention area A: Service delivery
1) Strategically strengthen health infrastructure to cover all major population centers by supporting constructions that rebuild damaged structures, bring new clinical services to the relocation sites of the neighborhood approach and encourage constructions that support the overall regional poles through the completion or launch of 40 hospitals and 75 clinics
2) Create an emergency care network to reduce trauma fatalities by establishing properly equipped emergency rooms and departmental ambulance networks
Restoring and increasing access through hospital and clinic infrastructure:
The earthquake left Haiti’s health infrastructure severely damaged. In the disaster zone, 30 out of 49 hospitals collapsed or became unusable together with the Ministry’s main building. There is a clear need to build and rebuild the infrastructure to a level that is beyond pre-earthquake levels in strategic locations with strong construction norms. Projects should first address the immediate reconstruction needs that remain from the earthquake. Second, infrastructure should support IDP relocation sites according to the Neighborhood Return and Housing Reconstruction Framework. Finally, the long term construction projects should reflect the economic poles as described in the PARDN. This three-step approach will allow reconstructions of health care facilities in a way that responds to current needs, supports social services during relocation and contributes to the long term health care network.
Currently, there are 32 hospitals projects and 57 clinics that are under construction or in the planning stage. While this is an impressive start, this pipeline needs to be expanded to include 40 hospitals and 75 clinics. The IHRC has the following expectations for October 2011:
Specific Goals/Projects Gap Cost ($98m)
10 hospitals built or rebuilt
20 hospitals constructions launched
10 hospitals with construction financing in place
30 clinics built or rebuilt
30 clinics with constructions launched
15 clinics with construction financing in place
Improving disaster response and reducing trauma related deaths by increasing
Emergency Care Network
Haiti’s emergency infrastructure was weak prior to the earthquake with few well equipped hospitals and no publically administrated ambulance system. The Government is targeting the refurbishing and provisioning of 20 hospitals (including all 10 departmental hospitals) and the establishment of an ambulance network administered by coordination centers at the departmental level. Current MSPP and Red Cross ambulances would become part of this network.
Specific Goals/Projects Gap Cost ($6m)
Fully equip 20 emergency rooms (in 10 departmental hospital + 10 Hôpital Communautaire de Référence) $2m
Implement 60 ambulances in National Ambulance Network (public + Haitian RC) $3m
Establish an Ambulance Network coordination centers in each of the 10 departments $1m
In order to successfully coordinate the reconstruction effort across sectors, a Neighborhood Return and Housing Reconstruction Framework with a clear set of recommendations for social support needs to be developed and validated. A key component will be developing a “Carte Sanitaire” (health infrastructure map) that would take into account current service gaps and population movements to guide prioritized areas for health care services, and facilitate the transition from mobile/temporary clinics to permanent service sites. Building codes that take into account multi-disaster risk management and access for those with disabilities will also be needed, in alignment with the overall reconstruction and housing efforts. Lastly, the Emergency Room minimum package of services should be revisited to take into account lessons learned from the earthquake and the cholera epidemic.
Strong human capital is a fundamental component of service delivery and must accompany the infrastructure efforts in order to achieve a well functioning health care system. The earthquake damaged three out of the four accredited medical schools. The largest nursing school was destroyed in Port-au-Prince, tragically killing almost the entire second year class. Four health technical schools were also destroyed. This is a huge setback to an education system that was, even prior to the earthquake, struggling to produce and retain enough health care workers to serve the Haitian population.
For this reason, the IHRC is calling for projects that address the human resource deficit in the health sector, including administrative capacity to serve in central and departmental public offices. Reinforcement projects are listed as follows:
Specific Goals/Projects Gap Cost ($21.5m)
Reinforce 4 medical schools and 10 specialty training programs $10m
Reinforce 4 nursing schools $5m
Launch the training of 4,000 Allied Health professionals $3m
Complete the training of 3,000 Health Agents $3m
Support training of 10 individuals for a Masters in Public Administration $0.1m
Fund 10 scholarships for Masters in Public Health $0.4m
In the context of continued losses of trained physicians and nurses, a reviewed public salary grid should be considered to ensure the long term success of reinforced training institutions. To encourage public sector retention and improve the public sector’s ability to monitor and coordinate the re-designed health care system, professional development of current staff as well as clear career plans for future employees, as suggested by the recent Ministry institutional audit, should also promoted. Allied health professionals will play a major role in the new healthcare system and guidelines about the priority fields (i.e. psychologists, physical therapists) will be needed, along with reflections and recommendations on training and approaches to absorption of newly trained professionals.
Financing and Access to Care
A system-wide health systems financing method to ensure increased access to health care will be needed. There are multiple proposals on how to achieve this goal, yet none has been developed into a comprehensive strategy.
A common approach involves using existing platforms for maternal and child health. Programs such as Soins Obstétriques Gratuits (SOG/free obstetrics care) have benefitted over 60,000 women, out of an estimated 280,000 women who give birth every year. A companion pilot program introduced after the earthquake provided free care in several institutions to children under 5 years old. By October 2011, the IHRC’s aim is to help provide support so that free obstetrics care can be expanded to serve 100,000 women. This will not only require the program to be launched in additional institutions, but will also need continued outreach to encourage women to engage with clinics during and after their pregnancy.
Specific Goals/Projects Gap Cost ($12m)
Maternal and Newborn access to care for 100,000 pregnancies (35% of estimated total) $12m
The Government will work with the IHRC and partners towards a comprehensive strategy for health care financing beyond the SOG and other pilots underway.
A review of current approaches, engagement with the Private Sector and feasibility studies based on projected growth should be considered by the Government and its partners. Moreover, these studies should be completed with the goal of implementing the strategy as part of a larger government social sector plan.
Intervention area 2: Institutional strengthening
In addition to encouraging project submissions, the Government also works with its partners and the IHRC to develop long term strategic planning. This is a critical component of institutional strengthening, as it facilitates government leadership over a more coordinated sector. The goals for October 2011 include:
Specific Goals/Projects Gap Cost ($5m)
Assist in developing and then begin implementing the long term strategic health plan
Develop a comprehensive disaster plan that involves the key government offices affected and addresses the HR, technical and basic logistics needs of an effective public sector response
Support cross sector planning for key policies such as school based health programs, healthcare financing, occupational and employee health, use of technology for public safety and social support for the vulnerable
These strategic documents will need the input of all major ministries and donors. Full cooperation and coordination is critical to the creation and adoption of such plans.
Public Sector Capacity Strengthening
The Ministry of Health’s capacity to both respond and manage the response to the 2010 earthquake and cholera outbreak has been strongly affected by the loss in HR and structures. Current staff has had to work long hours and have had to face new challenges in their efforts at coordinating a significantly higher number of national and international partners. As noted in the Ministry’s institutional audit, career development programs will play a key role in effectiveness and retention. Funds should thus be allocated to support continuing education for public health officials in key areas like leadership, conflict management, epidemiology, supply management, public health forecasting and coordination. In terms of physical infrastructure, the MSPP departmental offices are in great need of upgrades since the facilities lack the basic necessities required for an appropriate work environment capable of supporting the national move towards decentralization. Additionally, the central MSPP office, which is currently housed in a temporary structure, will need to be rebuilt.
Specific Goals/Projects Gap Cost ($7m)
Create continuing education program for public health officials (leadership, coordination, budgeting) $5m
Construct/Refurbish 10 departmental health offices $0.5m
Rebuild MSPP $1.5m
Funding organizations committed to public sector strengthening will be essential partners in reinforcing and expanding the Ministry of Health’s capacity.
Civil society outreach
For effective and grounded policies that ensure responsible local society engagement, reinforcement and, when needed, full support will be required for civil society groups that are able to advocate for communities or vulnerable groups in need. Beyond funding, technical support including IHRC outreach sessions to support target groups, such as the disabled, or rural associations will be considered.
Specific Goals/Projects Cost ($5m)
Provide vulnerable groups access to IHRC and MSPP through information sessions, ministry liaisons and financing $5m
This strategy will need to be coordinated both internally (with the Social Recovery sectors) and externally (with different ministries levels of government) with a clear list of priority target groups. Lessons can be learned from HIV globally and locally programs that enable people living with HIV the ability to provide recommendations to policymakers.
Cholera Response Strategy
As of December 8th, 2010, the MSPP data shows that cholera has killed more than 2,120 people and has sickened at least 90,000 in all 10 of Haiti's departments. Epidemiological modeling carried out by PAHO/WHO and the U.S. Centers for Disease Control and Prevention (CDC) for planning purposes projects an estimated 400,000 cases over the first 12 months, with as many as half those cases occurring in the first three months of the epidemic. The Government of Haiti began an active response and the IHRC Health team joined the effort by providing technical assistance in keeping with its usual 3 areas of work as follows:
Alignment of Stakeholders
Understanding the MSPP and Public Sector needs at the central and local levels
In the emergency phase, the Ministry of Health quickly activated its response mechanism and worked with the media and international partners on the response. As the Epidemic spread, the President‘s office activated the COUN (national emergency response system), and the IHRC health team provided technical assistance to the Ministry and the COUN, as they established a list of most pressing needs to respond to the cholera epidemic. It has been able to determine departments’ needs in terms of installation of clinical services (new Cholera Treatment Centers and Units), outreach, and sanitation, logistics (transport and storage), supplies, human resources and treatment of medical waste.
The Government, with its partners, notably the IHRC Health Team, has taken an active part in coordinating the proper allocation of partners’ resources given departmental needs. Members of the health cluster and interclusters, along with the private sector and country partners, were brought to the COUN, where the barriers they faced towards a rapid response were addressed.
All partners were actively encouraged to align their interventions with the MSPP three-level national strategy and accompany public entities in their response. Since the epidemic is expected to last months, close coordination and leadership by the Government will be essential with partners in academia, the private sector and others on alternative approaches to dealing with the epidemic and minimizing its impact if and when it becomes endemic to the country.
With the epidemiologic projections, the Cholera epidemic will become a major health issue for months to years and represents a true tragedy. Given the many partners involved in the response, the IHRC may decide to encourage submission of projects related to the cholera epidemic in so far as they reinforce the capacity of the Government both centrally and across departments in its ability to manage this or similar outbreaks now and in the future. An emphasis would therefore be on programs that address the essential elements needed to manage outbreaks over time and in reducing the mortality associated with such epidemics, like improvements in water and sanitation infrastructure or support for public sector response.
HL/ S/ HaitiLibre /CIRH