1. Haiti: Building from the Bottom Up
Musleehat Hamadu
Edward Kong
Esther Rojas-Garcia
Julia Shu
Katharine Owers
TSC Consulting
Team 8 · February 15, 2014

2. Background
Fragile infrastructure
Earthquake
Introduction
of Cholera

3. Objectives
Right Wrongs
• Stem cholera epidemic
• Compensation
Support
Development
• Infrastructure
• Personnel
Prevent
Future Harm
• Recommendations for
future UN missions

4. Framework


5. Guiding Principles
Increase
transparency &
accountability
Develop sustainable
systems
Build national
capacity

6. Major Stakeholders
Community
NGOs
Donors
Haitian Haitian
Gov’t People
Private
Sector
UN

7. Building National Capacity
National Volunteer Program
National University Program
Leadership skills
Technical skills
Community Liaisons
Future technical specialist

8. Oversight
Settlement
Fund
MOF
PIU
Independent
Auditor
COM
• Key holder of funds and oversight
• Manages overall program and
disburses funds to communities
• Identifies community needs and
submits funding proposals

9. Monitoring & Evaluation
Clear, realistic
indicators
Real time
evaluations
Open
communication

10. Leveraging Mobile Technology
 95% Coverage Rate
 Cholera Alert Hotline
 Monitoring and Evaluation
 Mobile Banking

11. Budget and Timeline
2014
2015
2016
2017
2018
2019
2020
2021
2022
Funds Distribution (Millions of USD)
Claims
Housing
Water
Sanitation
Health
0
100
200
300
Short
Med
400
Long
500
600
700
2023

12. Compensation Scheme


13. Individual Claims
Set and publicize guidelines
Register victims in-person
Disburse funds through mobile
money

14. Community Claims
Identify eligible
communities.
Vet partner
NGOs and
contractors.
Issue call for
proposals and
disburse funds.
Assess project
impact after
completion.

15. Infrastructure Improvements


16. Priority Infrastructure Sectors
Housing Sanitation
Water
Health
Structure

17. Housing
Short Term
• Prevent Forced
Evictions
• Continue Rental
Subsidies (IOM)
• Provide Basic
Services
Long Term
• Permanent housing for
IDPs
• Support Income
Generating Activities

18. Sanitation
Short Term
• WASH
standards
• Community
Education
• Emergency
response
Long Term
• Strengthened
institutions
• Wastewater
treatment
• Sanitation 90%

19. Water
Short Term
Short Term
Safewaterhaiti.com
Long Term
Long Term
Washfunders.org
85%
Improved
Water
Source

20. Health Structure
Long Term
Short Term
National
Enhance Surveillance
Build Infrastructure
Department
Build CTCs
Generalize CTCs
Community
Support CHWs
Develop CHWs

21. Limitations
Assessing Heterogeneous Community Needs
Building Community Trust
Implementation Challenges

22. Policy Recommendations


23. Peacekeeping Policy Recommendation
Troop
Contributing
Countries
Joint
evaluation
of troop
suitability
for mission
UN DPKO

24. UN Mission Recommendations
Improve
logistical
operations
Improve
community
engagement
• Procurement
• Behavior
• Mobile Technology
• Feedback

25. Thank you

26. Appendices


27. INFRASTRUCTURE
Housing
Cash Grant Subsidies for Rent
Stable home construction / repair
Sanitation
Education and hygiene
Infrastructure
Water
Implementing SODIS
Drilling Wells
Chlorine & Maintenance
Health
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Total
96.0
11.4
72.0
13.1
56.6
15.1
28.8
17.4
14.4
20.0
9.6
23.0
2.9
26.4
1.4
30.4
0.7
34.9
0.4
40.2
282.8
231.7
8.7
6.5
6.9
8.1
5.6
10.2
4.4
12.7
3.5
15.8
3.4
19.8
3.2
16.3
3.1
13.5
3.0
11.2
2.9
9.2
45.0
123.5
20.0
20.0
12.3
26.9
10.0
20.0
22.7
26.9
5.0
20.0
34.0
26.9
0.0
15.0
34.0
26.9
0.0
0.0
34.0
26.9
0.0
0.0
34.0
26.9
0.0
0.0
34.0
26.9
0.0
0.0
34.0
26.9
0.0
0.0
34.0
26.9
0.0
0.0
34.0
26.9
35.0
75.0
307.0
269.0
8.4
55.0
8.4
55.0
8.4
55.0
8.4
55.0
8.4
55.0
8.4
55.0
8.4
55.0
8.4
55.0
8.4
55.0
8.4
55.0
83.5
550.0
ORGANIZATIONAL
Project Implementation Unit
8.0
8.0
8.0
8.0
8.0
8.0
8.0
8.0
8.0
8.0
80.0
Communication Campaign
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
3.0
30.0
10.0
20.0
29.6
29.6
10.0
20.0
27.4
27.4
10.0
20.0
26.7
26.7
10.0
20.0
23.1
23.1
10.0
10.0
19.5
19.5
10.0
10.0
19.3
19.3
10.0
10.0
19.0
19.0
10.0
10.0
19.2
19.2
10.0
10.0
19.6
19.6
10.0
10.0
20.1
20.1
100.0
140.0
223.4
223.4
Total Budget
(in millions)
2,849.4
COMPENSATION CLAIMS
Individual Claims
Community Claims
National Volunteer Program training
University Training
Contingency
Independent Audit

28. Project Implementation Unit
 Manager
 Financial Management Specialist
 Procurement and Contract Management Specialist
 Information Technology Specialist
 Social Development Specialist
 Monitoring and Evaluation Specialist

29. National Volunteer Program
Infrastructure
Projects
Skills Training
Leadership
National
Volunteer
Program
Communication
Settlement
Commission
Community
Liaison
Community organizing
Proposal development
Settlement claims
Link with
health
workers
Education
Campaign

30. National University Program
Ministry
work
Technical Training
National
University
Training
Program
Sector-specific knowledge
Civil service accreditation
Financial management
Intl’
Org
Technical
Specialist
Procurement and contracts
Information technology
NGO
Private
sector

31. Housing Cost Calculations
Two Methodologies:
• 171K IDPs or ~40,000 households remain in 306 camps.
• Target 145K most vulnerable
• Cash grant rental subsidies through IOM: optimal budget 96 million / year for 36k households
• Yearly discounting of budget as more IDPs find permanent housing solutions
Extrapolating From Construction Cost
• At $10,000 per house and five individuals per home = current amount budgeted
• Representative pricing: http://pacificgreeninnovations.com/haiti.html
Based on Prior NGO Work
• Church World Service
• 475K over 3 years at $1700 per person housed
• Reaching 145,000 IDPs: 246million
Sources: Unocha.org & haiti.ngoaidmap.org/sectors/12

32. Cost Effectiveness of Water Interventions
WHO, 2008

33. WHO, 2008

34. Solar Disinfection Worldwide
Successful
reduction in
cholera and
other diarrheal
disease rates in
Kenya, India,
South Africa,
and Cambodia
McGuigan et al. 2012

35. Improving Health Capacity
Capacity Building of Immediate Solutions for Long Term Sustainability
NATIONAL
Hospitals
•
•
•Training programs to increase number of health workers
available at hospitals
•Satellite system of hospitals for specialized care and CTCs for
primary care
Enhancing national surveillance system
Upgrading national hospitals
Stakeholders: government ministries, UN, PAHO, WHO
DEPARTMENTS
CTCs
•Increasing number of CTCs in proportion to
regional burden of cholera
•Using CTCs as point of distribution for all cholera
related initiatives
•Expansion to local health centers to PRIMARY CARE CENTERS
•Equipping CTC staff with training to become HIGHER LEVEL
HEALTH WORKERS (nurses, Pas, and doctors) to staff hospitals
COMMUNES
Community Health Workers
• Equipping COMMUNTY HEALTH WORKERS with
resources to educate community on cholera
treatment and prevention
•Expanding their training beyond cholera to other health issues
•Training experienced CHWs to become CTC staff or
Stakeholders: local and international NGOs, departmental government
Stakeholders: religious groups, schools, NGOs
Building human capital from the bottom up
Long Term
Short Term

36. From CTCs to Primary Care Centers
Current State of CTCs
Decline in number of CTCs and CTUs between
2010 & 2013
Fewer resources
Immediate Improvements
Sustainability
•Increase the number of CTCs
especially in high risk areas (Norde,
Artibonite, Centre, Quest)
•Establish CTUs within preexisting
infrastructure (religious buildings,
schools, community gathering areas)
•Gradually add other basic health care
services to ramp up CTCs to primary
care centers
•Establishing infrastructure for eventual
take over by Haitian authorities
High burden of
cholera remains
Increases Access to
Healthcare
Improved Health
Outcomes
Source: www.unocha.org
Creates Jobs
Economic Prosperity

37. CHW Activity Based on Cholera Seasonality
Cholera Peak
•CHWs focus on prevention
•Community education and sensitization
•Evaluation treatment intervention used during
peak periods
•CHWs meet at CTC and discuss results and
improve interventions and delivery
Cholera Low
Cholera Incidence
•CHWs focus on diagnosis
and treatment
• Distribution of ORS
•Vaccination
Time
Cholera Peak
•CHWs focus on treatment
•Adapt interventions based on results
from evaluation

38. Surveillance System
CTCs
CHWs
•CTCs keep track of cholera cases and trends
and report to head CTC for each Commune
•Distribute cholera materials to CHWs and
can designate CHWs to affected area
•CHWs are assigned to a CTC
•Report cholera cases to CTCs
via SMS
Flow of cholera information
Flow of policy and funds and resources
MSPP
•Head Commune CTC report cholera trends to
Department
•Department reports cholera trends to MSSP
•MSSP uses this to inform policy and allocate funds and
resources

39. Individual Claims: Process Details
- Set guidelines:
- Registration deadline
- Standard of proof: death certificate, NCSS records, witness statements
- ID standards: citizenship card or NGO-issued ID
- Disbursement amount: $75 per illness and $1000 per death
- Register victims in-person:
- Enlist NGO help (MSF, for example) with deploying mobile health units that are familiar with cholera and with the
commune to register victims in an online registry (to be checked against NCSS, although that only runs until 2012).
- When victims register, they’ll note their mobile information or receive one upon registration.
- Disburse funds via mobile banking:
- Yellow Pepper agents and UN-trained support staff will deploy to individual communes when cash transfers through
TchoTcho mobile wallet are made to help residents with technical questions.

40. Community Claims: Process Details
-
Identify communities:
-
-
Each of the 140 communes is responsible for providing the claims commission with a list of all interested communities within the commune.
Vet partner NGOs and contractors:
-
-
This addresses a common criticism of other collective reparations and community project programs, which is that communities lack technical knowledge to write the proposals.
Accomplished either through third party charity/NGO rankings or by having every NGO or contractor we’re interested in evaluate the others on the list (max of 50). These “preferred
providers” will be slotted into categories based on mission, such as housing, health care, or education.
Issue call for proposals:
-
-
Hard submission deadline and funding cap per project.
Submitted by a community-elected management committee that later meets with NGO/contractor counterparts. Committee is accountable for progress reports during and after
project implementation.
Review project proposals:
-
-
-
Criteria: relevant infrastructure area, adherence to our guiding principles, the need/immediate impact/projected impact of the requested project, and how local capacity/resources will
be used.
Disbursement: half initially, the rest according to a pay-for-performance model to reimburse expenditures (in an effort to minimize corruption without disrupting efficiency).
Review periodic progress reports and impact assessments one or two years after completion.

41. Claims Monitoring & Evaluation
Commit to clear, realistic outcome indicators.
• Baseline survey of community expectations compared against monthly progress reports and impact assessment.
• Sustainability: target % of local procurement and local residents employed
• Transparency: distribution of x monthly commission reports in English and French
Evaluate efficiency at multiple points during Commission’s life span.
• Third party (panel of independent experts) audit of fund management
• NGO shadow reports
Create culture of transparency and open communication with communities.
• Use public notice boards, newspaper ads, and radio PSAs.
• Place comment boxes in each commune capital
• Establish formal complaint mechanism for communities and individuals about claims processes

42. References
Barzilay, Ezra J., et al. "Cholera surveillance during the Haiti epidemic—the first 2 years." New England Journal of Medicine 368.7 (2013): 599-609.
Cairncross, S., Ensink, J., & Kahawita, T. (2009). Evaluation of the WASH activities undertaken to prevent and control cholera outbreaks in Guinea-Conakry & Guinea-Bissau Systematic Literature
Review. UNICEF. Londres-Dakar, LSTMH-UNICEF WCARO, 79.
"Cholera Cost Model Methods." Infectious Disease Cost Calculator. UPMC Center for Health Security. Web. 15 Feb. 2014. <http://www.idcostcalc.org/contents/cholera/cost-model.html>.
"Ease of Doing Business in Haiti." Doing Business . World Bank Group, n.d. Web. 15 Feb. 2014. <http://www.doingbusiness.org/data/exploreeconomies/haiti/>.
"Haiti." — MEASURE Evaluation. Web. 15 Feb. 2014.
"Haiti Aid Map." Shelter and Housing -. Web. 15 Feb. 2014.
“Handbook on United Nations Multidimensional Peacekeeping Operations.” Peacekeeping Best Practices Unit. UN DPKO. New York: 2003.
Heinrich, Erik. "Haiti's mobile redemption." Fortune Tech. Web. 15 Feb. 2014. <http://tech.fortune.cnn.com/2013/08/15/digicel-tchotcho-haiti/>.
“Humanitarian crises, emergency preparedness and response: a strategy and options analysis of Haiti.” Overseas Development Institute. London, UK: 2014.

43. References
"PAHO's Interactive Atlas of Cholera in la Hispaniola." PAHO's Interactive Atlas of Cholera in la Hispaniola. 15 Feb. 2014. <http://new.paho.org/hq/images/Atlas_IHR/CholeraHispaniola/atlas.html>.
WHO Report, Public Health and the Environment Group "Water Quality Interventions to Prevent Diarrhoea:Cost and Cost Effectiveness" by Thomas Clasen and Laurence Haller, 2008
McGuigan et al. Solar water disinfection (SODIS): A review from bench-top to roof-top" Journal of Hazardous Materials (2012) 29-46
Case Study: A conceptual design of a new paradigm for the Elimination of Cholera.
http://en.choleraalliance.org/files/Pdf/Guide%20for%20the%20elimination%20of%20Cholera%20GAAC%202011.pdf
Cholera in Haiti: End in Sight
http://www.un.org/News/dh/infocus/haiti/Cholera_Haiti_end_in_sight.pdf
Cholera Toolkit
http://www.unicef.org/cholera/Cholera-Toolkit-2013.pdf
Comprehensive intervention for the cholera epidemic in Haiti
http://thedo.osteopathic.org/?p=72091&page=2

44. References
Digicel Coverage Mao
http://www.digicelhaiti.com/en/coverage_roaming/coverage_map
Haiti Humanitarian Action Plan 2013
https://docs.unocha.org/sites/dms/CAP/HAP_2014_Haiti.pdf
InterAction’s Haiti Aid Map
http://haiti.ngoaidmap.org/sectors/12
National Plan for the Elimination of Cholera in Haiti 2013-2022
http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=20326&Itemid=270&lang=en
The Zimbabwe Health Cluster Cholera Outbreaks: Coordinated Preparedness and Response
http://www.who.int/hac/crises/zwe/zimbabwe_cholera_resp_plan_nov08.pdf