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Team 9

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  • What? Evidence-based, cost-effective combination of prevention and treatment interventions to avert the highest number of cases
    Why? Simultaneously stems cholera spread1, improves awareness2, and builds infrastructure3
    How? Immediate scale-up of most effective programs
    Coordinated, progressive implementation of prevention and treatment interventions
  • http://haiti.ngoaidmap.org/
    -Use “InterAction’s Haiti Aid” map to Assess current areas of greatest need
    -Identify existing services
    -Identify which organizations/infrastructures are currently most effective and support their rapid expansion
  • -Involve communities in intervention placement decisions to ensure investment choices are practical and useful
    -what are rural/urban – decide how
    - Change OCV, L, C, maybe order?
  • Aid coordination for our long-term infrastructure development (which is in conjunction w/ WASH+Vaccine)
    community involvement?
    -Aid Management Platform
    -Integration with surveillance system
    -Performance based financing to NGOs? based on surveillance from GIS
  • Aid coordination for our long-term infrastructure development (which is in conjunction w/ WASH+Vaccine)
    community involvement?
    -Aid Management Platform
    -Integration with surveillance system
    -Performance based financing to NGOs? based on surveillance from GIS
  • Fix ids
    Infrastructure decisions – should be done in a way that benefits the community
  • Include appendix on the specific data
  • Building off Aid Coordination
  • Delivery difficulties associated with 2 doses of vaccine.
    Finite funds indicates cutoff necessary for individual compensation.
    Lack of infrastructure in Haiti can interfere with the rollout of the intervention
    Challenges of coordinating various stakeholders given the current and ongoing reconstruction and stability efforts
  • 2008: cholera most prevalent in Congo, Angola, Zimbabwe  look at AFR E as a comparison for Haiti, because it has a similarly high incidence
    estimated cumulative incidence in Haiti (650,000 cases) = 6.56%
    ~784,000 cases under 15 v. 232 cases over 15  77% of cases in under 15  higher prevalence under 15 than over 15  can’t use age v. life expectancy as metric for compensation, and we need a totally different equation
  • Short term goals:
    TheannualcholeraincidencerateinHaitiisreducedfrom3%toч0.5%
    Ͳ 80% of the population living in areas of the country where there is activesecondary
    transmissionofcholerawashestheirhandsafterdefecatingandbeforeeating
    VIII–MONITORINGANDEVALUATION
    FollowͲup of implementation of the Action Plan will be the responsibility of a Steering Committee
    comprisedofrepresentativesfromtheministriesinvolvedandtechnicalandfinancialpartners.Therole
    of the committee is to facilitate the coordination of policy and strategy. It is desirable to have
    participation by the Ministries of Public Works, Public Health, Education, Communications, the
    Environment, and the Interior and Local Communities. The committee will meet twice a year and
    wheneverelsetherepresentativeofoneoftheexecutingagencies(DINEPA,MinistryofHealth,Ministry
    of Transport and PublicWorks, Ministry ofthe Interior and Local Communities) callsfor convoking a
    meeting.
    OperationalimplementationoftheActionPlanwillbesupervisedbyaTechnicalCommitteemadeupof
    highͲlevel officialsfromDINEPA,theMinistry of PublicHealth,theMinistry of PublicWorks, andthe
    MinistryoftheInterior,aswellasrepresentativesfrominternationalagenciescooperatinginoneofthe
    ActionPlanareas.TheDirectorͲGeneraloftheMinistryofPublicHealthorhisdesignatedrepresentative
    willpresideoverthiscommittee.
    17
  • The platform was introduced in response to the international community’s call for more effective aid management as the Rome and Paris Declarations on Aid Effectiveness and Harmonization synthesized in 2005. However, it has since been implemented in 21 countries, on four continents with the main goal of allowing donors and governments to visually see where aid is concentrated, where it is lacking, and where projects overlap.
    The integrated GIS module leads to the production of maps and promotes the intuitive exploration of available aid. Users can locate specific project locations as x, y coordinates and authoritative data is introduced to provide administrative boundaries for geographic spaces. A database serves as the backbone of an interactive map that displays the locations of the inputted projects. In addition, AMP has four components that aim to increase collaboration among international actors including a monitoring and evaluation dashboard, a national planning dashboard, a data exchange, and budget integration.
    Development Gateway. Mapping Development Assistance. “Geospatial tools in the AID Mangement Platform (AMP). http://www.developmentgateway.org/dg_uploads/pdfs/
    mapping_aid_april_2012.pdf
    Development Gateway Foundation. Aid Management Platform. http://www.mfdr.org/Marketplace/Posters-pdf/DGF_MfDR_Marketplace_Poster_Final_07.pdf
  • Problems: accountability concerns related to pooled funding, donors disagreeing on best practices
  • MINUSTAH = UN peacekeepers in Haiti
    MSPP Plan = UN / Haitian gov’s cholera elimination initiative
    CAED = Framework for Coordination of Foreign Aid for Haitian Development, not implemented because donors have objections to lack of elections in Haiti
  • Transcript

    • 1. Team 9 Emily Briskin, Teresa Logue, Lindsey Hiebert, Justin Mendoza, Karen Zhang, Hye Ryeong Cho (Juli)
    • 2. 2
    • 3. 3
    • 4. 4
    • 5. 5
    • 6. NGO/Aid 1 UN Government 2 3 http://soteriapublishinghouse.com/?p=4524 http://www.digitaltrends.com/computing/un-declares-internet-access-a-human-right/ 3 http://www.mapsofworld.com/flags/haiti-flag.html 1 2 6
    • 7. 7
    • 8. Fung et al. 2013 Aibana et al. 2013 3 Ivers et al. 2012 1 2 8
    • 9. Cholera 1 Treatment Center Cholera Treatment Center InterAction Haiti Aid Map, 2013 http://haiti.ngoaidmap.org/ 1 9
    • 10. 1 Fung et al., 2013 1 10
    • 11. 11
    • 12. 12
    • 13. Internally Displaced Persons training program Education, skills building, IDs, community health worker training Housing, employment, health 13
    • 14. 14
    • 15. 15
    • 16. Low Estimation Moderate Estimation High Estimation Compensation Infection Fatality Period 1 513,340,300 Period 2 266,194,800 Compensation coverage 779,535,100 23,348,000 Subtotal 802,883,100 WASH+Vaccine OCV WASH+ Treatment+Prevention 9,775,207 593,636,040 Extraneous 300,000,000 Subtotal 893,636,040 ID People w/o ID cost per person 2,000,000 2 Subtotal 4,000,000 ORS applicable Unit cost population 0.5 1600000 Subtotal 800,000 Mobile Banking Subtotal 200,000,000 Refugee Program Subtotal 240,000,000 GSI Subtotal 100,000,000 TOTAL 2,241,319,140 Infection Fatality 513,340,300 266,194,800 779,535,100 OCV Infection Fatality 692,986,800 411,231,800 23,348,000 1,104,218,600 31,520,000 802,883,100 1,135,738,600 WASH+ OCV WASH+ 9,775,207 989,393,400 9,775,207 989,393,400 300,000,000 300,000,000 1,289,393,400 1,289,393,400 People w/o ID cost / person People w/o ID cost / person 2,000,000 2 2,000,000 2 4,000,000 4,000,000 Unit cost applicable population Unit cost 1 1600000 1,600,000 applicable population 1 1600000 1,600,000 200,000,000 200,000,000 240,000,000 240,000,000 100,000,000 2,637,876,500 100,000,000 2,970,732,000 16
    • 17. 17
    • 18. Monitor, Evaluate, and Adjust 18
    • 19.  Vaccine delivery  Finite funds  Limited infrastructure  Coordinating various stakeholders 19
    • 20. 20
    • 21. 21
    • 22. 22
    • 23. 23
    • 24. The global burden of cholera  Mohammad Ali, Anna Lena Lopez, Young Ae You, Young Eun Kim, Binod Sah, Brian Maskery & John Clemens  Volume 90, Number 3, March 2012, 209-218A  24
    • 25. 25
    • 26.  Development Gateway announced the AMP to Haiti in November 2012  Began with: ◦ Geocoding the activities of several donors in Haiti (USAID, World Bank, IADB, Canada, EU, etc.) ◦ Enabled an analysis of aid flows in each sector ◦ Trainings of staff and donors 26
    • 27.  Goals: ◦ Increase potable water access to 85% ◦ Increase assess to improved sanitary and hygiene facilities to 90% of population ◦ Strengthen healthcare facilities to care for 80% of the population ◦ Increase solid waste collection to 90% in Port-AuPrine and 80% in secondary cities  Short Term: ◦ Emergency measures: ORT ◦ Community health agents ◦ Vaccinations  The annual cholera incidence rate in Haiti is reduced from 3% to 0.5%  80% of the population washes their hands after defecating and before eating 27
    • 28.  Synergistic effect   Prevents transmission of other diarrheal diseases  ◦ Leading cause of under 5 mortality   Already endorsed in National Plan for Eliminating Cholera Benefits  OCV not 100% effective Time needed to build WASH infrastructure Not enough OCV supplt to vaccinate entire Haitian population Impact of target immunization campaigns not studied Limitations 28
    • 29.  The Inter-agency Real-Time Evaluation of the Humanitarian Response to the Darfur Crisis ◦ launched by the United Nations Emergency Relief Coordinator ◦ found that the 2004 crisis response in Darfur was delayed and inadequate mainly due to the inability of aid agencies to mobilize and coordinate  Improve internal perceptions of aid ◦ . A randomized study of 3,600 Ugandan citizens found that nearly 80% of respondents reported that they had not directly benefited from aid, and nearly two-thirds of participants believed that more than half of aid dollars were not spent as intended. United Nations Office for the Coordination of Humanitarian Affairs. 29
    • 30.  Need for: ◦ Transparency  Preserve integrity of aid ◦ Reduce duplication of projects  Vertically and geographically ◦ Minimize cross-purposes  purposes that undermine the objectives of other projects ◦ Increase value of projects  Prevent fragmentation of aid 30
    • 31.  Double-edged sword of transparency ◦ Privacy Slow down provisioning process  Monopolization of aid  Group dynamic issues  ◦ No one suddenly stepping up to the plate Donor fatigue from extra work burden  Cumulative power gained by aid organizations  31
    • 32. 32
    • 33. create permanent Haitian Development Authority to coordinate, set country-wide strategie  pool funding within existing Haitian gov budget mechanisms  regulate & provide oversight of NGOs  align NGO projects to government priorities and guidances  33
    • 34. Pan-American Health Association, 2013. http://new.paho.org/hq/images/Atlas_IHR/CholeraHispaniola/atlas.html 34
    • 35. The rate of new infections has decreased by 94 percent, from 11,985 cases in week 25 of 2011 to around 645 cases in week 25 of 2013.  UN Cholera Factsheet:  http://www.un.org/News/dh/infocus/haiti/Haiti%20Cholera%20Factsheet%20July2013.pdf 35
    • 36. Price of Vaccine is $1.85 per dose, 2 doses needed, gives 67% efficacy for about 3 years.  http://www.who.int/immunization/sage/SAGE_April _2011_cholera_investment_case.pdf  36
    • 37. Barzilay, et. al. (2013, February 14). Cholera Surveillance during the Haiti Epidemic – The First 2 Years. The New England Journal of Medicine.37 2
    • 38. “Community-based studies in North Jakarta and Kolkata found that cholera cases cost between US$28 and US$206, depending on hospitalization. Patients' cost of illness as a percentage of average monthly income were 21% and 65% for hospitalized cases in Kolkata and North Jakarta, respectively.” http://www.ncbi.nlm.nih.gov/pubmed/21554781 38
    • 39. -Model of most effective combinations of WASH and OCV- yay! -“The rate of intervention coverage extension had the largest effect on cases of cholera averted” -”If in this scenario, effective OCV coverage were allowed to reach 50% at year 5, and then decrease at a constant rate to 5% at year 20, an additional 23,933 (95,519 cases) would be averted (Table 5).” “Over the next two decades, scalable WASH interventions could avert 57,949–78,567 cholera cases, OCV could avert 38,569–77,636 cases, and interventions that combined WASH and OCV could avert 71,586–88,974 cases. Rate of implementation is the most influential variable, and combined approaches maximized the effect.” Fung and Fitter et. al http://www.ncbi.nlm.nih.gov/pubmed/24106189 Murray Model Shows that in refugee camps cost-effective methods would be to use Treatment instead of Vaccine. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2305758/pdf/bullwho00004-0026.pdf 39
    • 40. 40
    • 41. 41
    • 42. -67% efficacy for 5 years -Does not require a buffer and thus much simpler to administer in refugee and post-disaster situations http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(13)702731/abstract 42
    • 43. Aibana et al. 2013 “Cholera vaccination campaign contributes to improved knowledge regarding cholera and improved practice relevant to waterborne disease in rural Haiti.” -Oral cholera vaccination campaigns have been associated with increased awareness and hand washing/ water treating in Haiti. OCV can be paired with education and have increased benefits. http://www.ncbi.nlm.nih.gov/pubmed/24278498 43
    • 44. Ivers et al. 2012: -OCV rollout has benefits to infrastructure : “The capacity of the health system in the region is being reinforced by the cholera vaccination programme through the promotion of the national childhood immunisation campaign; community health workers have been trained to better prevent and, failing that, refer cases; cold chain capacity has been expanded; and a new vaccine has been delivered through the public sector vaccination programme.” http://www.sciencedirect.com/science/article/pii/S0140673612608320 The WASH infrastructure provides a long-term, sustainable solution for prevention of cholera.12 Evidence from Europe and North America over the past two centuries, and more recently from Latin America, demonstrate that as water and sanitation coverage improves, the risk of epidemic or endemic cholera transmission is greatly reduced.12,14,15 WASH also prevents the transmission of many other diarrheal diseases, which in Haiti, as in many developing countries, is a leading killer of children less than five years of age.32,33 The overall benefit of expanding WASH coverage extends far beyond its effect on cholera alone. http://www.ajtmh.org/content/89/4/633.long#T3 44
    • 45. The OCVs should help reduce the burden of cholera while WASH coverage is expanded, given the considerable amount of time required to improve WASH infrastructure (e.g., piped water and sewers). However, an OCV program should not be considered as a long-term alternative substitute for WASH. Implementation of OCVs will present its own challenges. Currently available OCVs are not 100% efficacious, induced immunity wanes over time thereby requiring periodic booster dosing, and today's globally available OCV supply is not sufficient to vaccinate the entire Haitian population with the required two-dose regimen. In addition, evidence from the routine childhood expanded program for immunizations and recent nationwide vaccine campaigns in Haiti has demonstrated varying ranges of coverage.34–37 http://www.ajtmh.org/content/89/4/633.long#T3 45
    • 46. “For every $1 U.S. dollar invested, an estimated $5–46 U.S. dollars in economic benefits results, depending on the particular WASH intervention.34 Haiti's National Plan to eliminate cholera provides an outline of how such health and economic benefits might be achieved: investment, coordination, and capacity building.” http://www.ajtmh.org/content/89/4/665.long 46
    • 47. Hill and Baldwin et. al Vermicomposting toilets, an alternative to latrine style microbial composting toilets, prove far superior in mass reduction, pathogen destruction, compost quality, and operational cost. http://www.ncbi.nlm.nih.gov/pubmed/22658870 47
    • 48. “Oral rehydration, intravenous rehydration and antibiotic therapy were given to 99.5%, 85% and 97.77% of patients, respectively. Only one hospital death was noted. The low case fatality rate was mainly due to the following factors: the high quality of care provided in a center with qualified personnel and available and free of charge treatment kits, protocols based on massive rehydration and appropriate hygiene measures, and patient compliance with the treatment plan. The response was also characterized by good coordination, wide mass and local health promotion, and selective antibiotic prophylaxis, which contributed significantly to reducing the spread of the infection.” http://www.ncbi.nlm.nih.gov/pubmed/22177702 48
    • 49. - “The factors responsible for rapid spread in Haiti include: longstanding water and sanitary inadequacies in Haiti; the further disruptions to water and sanitary systems imposed by the earthquake; above average rainfall; high water and ambient temperatures; and insufficient capacity of the government infrastructure to respond to the crisis.”  Etienne 2013 http://www.ncbi.nlm.nih.gov/pubmed/24106186 49
    • 50. -“As a result of the 2011 earthquake in Haiti, almost 280,000 internally displaced people (IDPs) remain in camps and another 200,000 are living with host families or in informal settlements. Many of the IDPs in these informal settlements have been forcibly evicted from camps. This situation is likely to continue in 2014, while the precarious conditions in the existing IDP camps are bound to pose significant protection risks, particularly sexual and gender-based violence (SGBV).” -as many as 2 million Haitians lack documentation (personal ID papers) and are at risk of becoming stateless upon leaving Haiti UNHCR http://www.unhcr.org/cgi-bin/texis/vtx/page?page=49e491766 50
    • 51. The ten-year cholera eradication plan also envisions a strengthening of the public health sector and of the coordination between NGOs and the government. To this end, the government plans to “integrate their support into the national health system.” Through investments in training, capacity building and by channeling funds through the domestic institutions in charge of each sector, the plan aims to create a stronger public sector overall. This could be especially significant given that aid for the cholera response (and for the overall relief and reconstruction effort) has largely bypassed the Haitian government. According to data from the U.N. Special Envoy, only 2.5 percent of humanitarian spending for cholera went through the Haitian government. As noted in the plan, the “lack of investment coming directly from the country’s fiscal budget represents a threat to the stability of the” water and sanitation sector. http://www.cepr.net/index.php/blogs/relief-and-reconstruction-watch/choleraeradication-plan-announced-but-funding-still-in-question 51
    • 52. AMP software works by replacing the Ethiopian government’s cumbersome collection of faxes, spreadsheets and emails with a virtual workspace where the government, its donors and its agents in the field can share information on aid flows and the activities they support – from planning through implementation, to monitoring and reporting. With simple, web-based technology, AMP also establishes a process for standardizing the data that is loaded into the system and retrieved from it. The consolidated information is managed by the government, enabling detailed analysis and reporting, as well as scenario-building, scheduling and knowledge management.  http://unpan1.un.org/intradoc/groups/public/documents/other/unpan022092.pdf  http://www.undp.org/content/nepal/en/home/operations/projects/democratic_governance/d ceamc/ 52
    • 53. Use digicel, Haitel, and Comcel to host a program like M-Pesa. http://www.un.org/africarenewal/magazine/december-2011/dialing-cash-mobile-transfersexpand-banking 6.095 million people currently use Mobile Phones This would be expanded by the families of those affected by the outbreak. Source: CIA World Factbook, 2014 53
    • 54. • Responding to a request from the UN Special Envoy to Haiti, the Development Gateway has partnered with other organizations to build a system to help with Hatian reconstruction. The joint system, which partially adapts Aid Management Platform technology, will track damage reports and donor funding as well as pledges to Hait • Development Gateway announced extending the AMP to Haiti in November 2012 • They began with: o Geocoding the activities of several donors in Haiti (USAID, World Bank, IADB, Canada, EU, etc.), enabling an analysis of where aid is flowing within Haiti alongside needs in each sector o Training government staff and donors on the Aid Management Platform http://www.developmentgateway.org/news/developm ent-gateway-extends-support-haiti 54
    • 55. Death Amount (USD) High 3500 Moderate Illness Regional Scale Severe 3000 Low 2500 Regional Scale 4000 Severe Cutoff 1 (Wk 25 2011) 1700 Cutoff 2 (Wk 25 2013) 1200 High 1200 700 Moderate 900 400 Low 700 200 55
    • 56. The U.N. historically has addressed the scope of its liability in peacekeeping operations through Status of Forces Agreements (SOFAs) signed with host countries.  The Haitian government signed such an agreement with MINUSTAH in 2004. In this SOFA, the U.N. explicitly promises to create a standing commission to review third party claims of a private law character.  -Yale Global Health Justice Partnership 56

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