1. From Crisis to Opportunity
The U.N.-Haiti Cholera Settlement Fund
Team 5:
Brian Wayda
Amogh Sivarapatna
Ffyona Patel
Fjodor Melnikov
Travis Whitfill
Kevin Nay Yaung

2. Overview
Problem
Plan of Action
Implementation
• Projected burden of cholera
• Root cause analysis
• Phased response
• Supports and enhances National Plan
• Fund oversight and disbursement
• Addressing settlement claims
• Guidelines for UN
2

3. Without intervention, cholera will become endemic
to 2000
Haiti
New cases per week
1500
$22.3
million
in total
costs
Annual burden
1000
$3.7
million in
healthcare
costs
90,000
cases
per year
9000
deaths
500
0
Jan-13
2013
Problem
Jan-14
2014
Jan-15
2015
Action Plan Implementation
Jan-16
2016
Jan-17
2017
3

4. Root cause analysis shows four factors contributing to cholera
V. Cholerae, El Tor
introduced
U.N. MINUSTAH
ENDEMIC
HEALTH
CHOLERA
Problem
Action Plan Implementation
4

5. Root cause analysis shows four factors contributing to cholera
V. Cholerae, El Tor
introduced
U.N. MINUSTAH
HEALTH
Problem
Action Plan Implementation
5

6. Environmental factors contributing to cholera
V. Cholerae, El Tor
introduced
U.N. MINUSTAH
Inadequate
waste disposal
Poor water
supply
Climate/
Geography
Endemic Cholera
Problem
Action Plan Implementation
6

7. Existing National Plan - Environment
Section
2014-2016
2017-2019
2020-2023
TOTAL
$M
Water supply
825
Wastewater
DINEPA
strengthening
468
224
Total $
Problem
$1516M
Action Plan
Implementation
7

8. Enhancements to National Plan incorporate WASH improvements
Section
2014-2016
2017-2019
2020-2023
TOTAL
$M
Water supply
825
Wastewater
DINEPA
strengthening
WASH
improvements
468
224
470
TOTAL $
$1986M
$1 USD invested results in $5–6 USD in economic
1
benefits results, depending on WASH intervention
Problem
Action Plan
Implementation
8

9. Innovative, sustainable WASH solutions
INNOVATIVE TOILET DESIGN:
 Increases efficiency
 Decreases costs
Problem
Action Plan
Implementation
9

10. Social factors contributing to cholera
V. Cholerae, El Tor
introduced
U.N. MINUSTAH
ENDEMIC
CHOLERA
Attitudes toward
healthcare
Poor hygiene
habits
Displaced
population
Problem
Action Plan Implementation
10

11. Existing National Plan - Social
Section
2014-2016
2017-2019
2020-2023
TOTAL
$M
Health promotion
54
Hygiene practices
Institutional
strengthening
19
36
Total $
Problem
$109M
Action Plan
Implementation
11

12. Enhancements to National Plan utilize integrated media
Section
2014-2016
2017-2019
2020-2023
TOTAL
$M
Health promotion
54
Hygiene practices
Institutional
strengthening
19
Integrated media
21
36
$130M
Problem
Action Plan
Implementation
12

13. Targeted media campaigns to reach Haitians
Senegal targeted marketing:
Community communications
• NGO involvement with local
entities
Mass media
• TV, radio, print
• Citizen journalists
Direct to consumer
Wall marketing in Benin:
• SMS/mobile alert (42% of
pop. in 2011)
• Technology
Problem
Action Plan
Implementation
13

14. Health system factors contributing to cholera
V. Cholerae, El Tor
introduced
U.N. MINUSTAH
ENDEMIC
CHOLERA
Lack of
antibiotics, ORS
Poor lab/
surveillance
Shortage of
providers, health
posts
Problem
Action Plan Implementation
14

15. Existing National Plan: health system
Section
2014-2016
2017-2019
2020-2023
TOTAL
$M
Healthcare services
83
Essential medicines
Micronutrient
deficiencies
95
20
$198M
Problem
Action Plan
Implementation
15

16. Enhancements to National Plan apply manpower and technology
Section
2014-2016
2017-2019
2020-2023
TOTAL
$M
Healthcare services
83
Essential medicines
Micronutrient
deficiencies
Health care delivery
innovations
95
20
200
$398M
Problem
Action Plan
Implementation
16

17. Multifaceted, essential roles of Community Health Workers
Employment
• Recruit from
schools and
community
• Target = ~10,500
nationwide, 50% in
rural areas
Problem
Action Plan
• Screening &
referrals
• Home visits
• Case
management
Logistics
Implementation
Administration
• Electronic/ mobile
records
(OpenMRS jr.)
• Monitoring and
evaluation
• Health
education and
communityspecific
demonstrations
Education
17

18. Biological factors contributing to cholera
V. Cholerae, El Tor
introduced
U.N. MINUTSAH
Low pre-existing
immunity
Malnutrition
ENDEMIC
CHOLERA
Problem
Action Plan Implementation
18

19. Existing National Plan: biological
Section
2014-2016
2017-2019
Epidemiological
surveillance
Microbiology
research
Research capacity
building
2020-2023
TOTAL
$M
16
5
11
$73
Problem
Action Plan
Implementation
19

20. Enhancements to National Plan: Vaccination for health
Section
2014-2016
2017-2019
Epidemiological
surveillance
Microbiology
research
Research capacity
building
2020-2023
TOTAL
$M
16
5
11
Vaccines
40
$73
Problem
Action Plan
Implementation
20

21. Lack of vaccine supply is the primary barrier
Supply
Advance commitments
Purchasing consortium
Allocate
Adapt
Problem
Action Plan
Implementation
21

22. Lack of supply is the primary barrier
Supply
Allocate
Vary coverage targets
according to risk
Adapt
Problem
Action Plan
Implementation
22

23. Lack of supply is the primary barrier
Supply
Allocate
Adapt
Problem
Action Plan
Implementation
Update based on real-time
surveillance
23

24. Foreseen barriers to implementation
Lack of coordinated approach
Problem
Action Plan Implementation
24

25. Foreseen barriers to implementation
Lack of coordinated approach
Inefficient funding streams
Problem
Action Plan Implementation
25

26. SWAp maximizes efficiency, accountability, & community involvement
Sector-wide Approaches Program (SWAp)
Sector Coordination Committee
SCC
Forum and Working Groups
• Discuss NGO activities
• Address local issues
• Accept New Organizations • Informal setting
• Approve funding
• Planning and Oversight
• Regular meeting
• Regular Reports
Working
Groups
Direct Interventions
Population
• Community funds
• Quality assurance
• Local interventions
• Local labor
26

27. SWAp integrates national plans with foreign investments
SWAp
Working Groups
SWAp
NGOs
Local
Government
Global Funds
Problem
Action Plan Implementation
27

28. Foreseen barriers to implementation
Lack of coordinated approach
Inefficient funding streams
Lack of political credibility
Problem
Action Plan Implementation
28

29. Justification for Settlements
Right to water
Right to Health
Arbitrary deprivation
of life
Right to Effective
Remedy
Universal Declaration of
Human Rights
Universal Declaration of
Human Rights
American Declaration on
the Rights and Duties of
Man
American Declaration on
the Rights and Duties of
Man
American Declaration on
the Rights and Duties of
Man
Inter-American Court of
Human Rights
Violations:
Universal Declaration of
Human Rights
U.N. Human Rights Council
Human
rights
laws:
General Assembly
U.N. Committee on
Economic, Social, and
Cultural Rights
Negligent oversight of its
own forces‟ waters and
sanitation
Problem
Failing to prevent
introduction of cholera into
Haiti. Lack of infrastructure
Action Plan Implementation
8,100 lives claimed by
epidemic in Haiti
Foreclosed any potential
remedy for Haitians who
contracted cholera
29

30. Cholera Recovery Payment Program (CRPP)
1
2
Apologize to Haitian
people
Form claims commission
to appropriate funds
3
Cease involvement
by Dec. 2017
CRPP
5
Community funds
4
Payments to families of deceased
victims
For adult victims: $5,000
For children victims: $1,000
Problem
Action Plan Implementation
30

31. Community Sustainability Fund: key component of CRPP
1
Cease involvement
by Dec. 2017
Apologize
5
CRPP
2
Claims
commission
Community
funds
4
3
Problem
Payments
Action Plan Implementation
CSF
31

32. Guidelines for UN
1
Actuate
settlements
Problem
2
Restructure
SOFA
agreements
Action Plan Implementation
3
Restructure
U.N.‟s legal
immunity
4
Create a culture of
accountability task
force
32

33. Summary & Highlights
Biological:
$73M
Health
system:
$398M
Environment
Social:
$130M
CRPP:$
407M
• Outcome 1: WASH innovations
• Outcome 2: Increase sanitation coverage to 85% of Haiti
Social
• Outcome 1: Integrated media campaign
• Outcome 2: 75% of population understand hygiene
Health system
• Outcome: Increase primary care access to 60%
Environment:
$1,986M
Biological
• Outcome: Immediate vaccination
CRPP
• Outcome 1: Settlements
• Outcome 2: Community fund
33

34. Thank You!
Mesi!
Questions?
Kesyon?
34

35. Appendices
35

36. Appendix: Risk Analysis
Corruption and
Inefficiency risk
financial losses
Natural Disasters and
Disaster risk
Epidemics
Inadequate funding
Financial risk
Problem
Action Plan Implementation
• International Control
• Personal Exchange
• Local Oversight
• Community Fund
• Improved Infrastructure
• Conduct Guideline
•
•
Long term oversight
Supporting SWAp funds
36

37. All published studies predict sustained cholera transmission
• Five independent studies estimate Ro > 1; this is consistent with sustained (endemic) cholera transmission over the long-term (>10
years)
Estimates of Reproductive Number (Ro) for cholera in Haiti
2.0 (Bertuzzo et al)
2.6 (Chao et al)
1.06 – 1.73 (Chunara et al)
1.04 – 1.51 (Chunara et al)
2.1 – 2.9 (Tuite et al)
(Ro < 1) Elimination
Ro = 1
(Ro > 1) Endemic
• Several experts agree with this conclusion, e.g., “A decline in cholera prevalence in early 2011 is part of the natural course of the
epidemic, and should not be interpreted as indicative of successful intervention.” (Andrews and Basu 2011); “Endemic cholera to
continue for many years…unless a coordinated effort is mounted “ (Sack 2011)
37

38. Derivation of projected cholera incidence
• Based on an assumption of a constant, steady-state level of cholera incidence
• There is a close relationship between access to improved sanitation and cholera incidence, as shown in the graph below. We extrapolate the predicted
cholera incidence for Haiti based on its position on this graph.
Cholera incidence vs. % of population lacking sanitation access for 66 countries with endemic cholera
Annual cholera incidence (per 1000
persons)
6
R² = 0.1703
5
4
Haiti
3
2
1
0
0
10
20
30
40
50
60
70
80
90
100
% of population without access to improved sanitation
• Haiti currently has 74% of the population lacking access to improved sanitation; extrapolating from the curve above, we estimate a base case annual cholera incidence of 1.5 cases per 1000 people
• We use lower bound and upper bound estimates of 1 and 2cases per 1000, respectively; noting that countries of similar sanitation levels fall in this incidence range
• Cholera incidence data from: David Sack. “Cholera Burden of Disease Estimates” http://www.jhsph.edu/departments/international-health/_archive/research/cholera/index.html
• Sanitation estimates from: WHO + UNICEF Joint Monitoring Programme for Water and Sanitation http://www.wssinfo.org/
38

39. Mathematical model for quantifying deaths and costs due to cholera
10%
75%
90%
75%
25%
25%
10%
90%
39

40. Mathematical model for quantifying deaths and costs due to cholera: Assumptions
•
•
•
•
•
•
•
•
Mortality rate : 1%
75% of all infections receive treatment
75% of all requiring treatment are hospitalized
Non-treated and treated cases result in lost workdays, hospitalized days, and ambulatory clinic visits
(see specific assumptions on previous slide)
Number of years of lost life due to cholera calculated as: (0.8 x [country life expectancy – 15]) + (0.2 x
[country life expectancy – 30])
Costs of each hospitalized day to healthcare system: $50.68
Costs of each clinic visit to healthcare system: $9.66
Value of lost life and missed workdays calculated based on per capita annual ($460) and daily
GDP, ($1.26) respectively
Assumptions based on
http://www.idcostcalc.org/contents/cholera/cost-model.html
And
WHO-CHOICE http://www.who.int/choice/country/country_specific/en/index.html.
40

41. Cost-effectiveness and real world efficacy of vaccines in Haiti
Field trials have shown efficacy of 66% (Trach et al; Vietnam), 50% (Thiem et
al; Vietnam), and 67% (unpublished interim analysis; Kolkata, India)
41

42. Elimination will require more intensive intervention in some areas
Estimates of Reproductive Number by department
Mukandavire et al (2013)
42

43. Elimination will require more intensive intervention in some areas
Estimates of Necessary Vaccine coverage to
achieve Ro < 1
Department
Vaccination Coverage Resulting in <1
Haiti[Country]
45.4
Artibonite
79.5
Centre
34.3
Grande Anse
27.2
Nippes
6.9
Nord
44.4
Nord Ouest
36.4
Nord Est
38.9
Ouest**[Ouest]
19.9
Port-au-Prince[Ouest]
60.5
Sud
39.5
Sud Est
18.3
Ouest
54.2
Mukandavire et al (2013)
43

44. Projected shortfall of oral cholera vaccine (internationally)
International Vaccine Initiative. “An Investment Case for Accelerated Introduction of oral cholera vaccine”
http://www.ivi.int/publication/IVI_Global_cholera_case.pdf
44

45. Appendix: Existing Strategies
• National Plan for Elimination of Cholera in Haiti (2013-2022)
• U.S. Embassy partnership framework to support Haiti‟s health
strategy (2012-2017)
• Haitian Ministry of Health Director‟s Plan
(2012-2022)
45

46. Appendix: Haitian Healthcare System Overview
• 7.9% of GDP on health expenditures vs international Abuja target of 15%
•
Major impediments to health care
•
Over 40% lack access to health care
•
Few health care personnel relative to residents
•
Nature of funding – 21% public; 79% private
•
NGO/ INGO/ Bilaterals/ Multilaterals provide services in tandem and sometimes primary to MSPP
•
Mixed format of delivery in rural versus urban areas
•
Geographic, environmental differences in burden of disease and proximity to health care facilities
•
Health insurance, where existent, is mainly private
•
Economics need to shift to allow for sustainable health care system
46

47. Appendix: Overarching health system problems: not just cholera
Cholera is the latest manifestation of the
overarching problems, not the problem itself
47

48. Appendix: Reducing NGO Duplication
•
Currently, few barriers to NGO/ IGO/ etc. entry into Haiti
•
Equal information: Use interactive, real-time mapping to showcase where health care service deficits exist and what
kinds of services are needed
•
Pop. Count
•
Disease prevalence
•
Other key statistics
•
Encourage NGO/ IGO entities to specialize and collaborate
•
•
Rather than 900+ NGO/ IGO entities doing a little bit of everything, simplify stream of major NGOs to those with
long-term, demonstrable successes and stakes in Haiti and incentivize their subcontracting with smaller NGOs to
do specialty work
System of major NGOs will simplify accountability
48

49. Appendix: Targeted geographic intervention
Estimates of Reproductive Number by department
49

50. Appendix: Priority zones for WASH
Intervention
50

51. Appendix: Vaccination is cost-effective
Problem
Action Plan
Implementation
51

52. Appendix: Highlights of current national plan for elimination of cholera
Environmental: Increase water/sanitation
coverage to 85% of population
Health systems: Increase primary care
access to 80% from 46%
Biological: Better epidemiological
surveillance
Social: 75% of population understanding
hand washing importance
• Construction
• Chlorination
• Economic self-sufficiency
• Healthcare facility strengthening
• Oral rehydration points
• Collaborations between public/private/NGOs
•Cholera vaccination campaign
•Compulsory notification system
•Routine microbiological study
• Hygiene practices and national standards
• Multipurpose community agents
• Local community health clubs
52

53. Appendix: Timeline of results for 2022 plan
End of 2014
Annual cholera incidence
rate from 3% to less than 0.5
-Intensify health promotion
-High-level committee carries out monitoring and evaluation
functions, advocate strengthening regulatory/legal frameworks,
admin/management procedures
-Prioritize mountainous rural villages and communities where
there is shortage of health facilities and to protect welfare
(Artibonite, central and western with hotspots such as Western
Grande Anse and Aquin, border areas)
End of 2017
Reduced to less than 0.1%
-Regularly chlorinated/monitored all public water supplies,
-All national research labs functional and generate surveillance
data
End 2022
Reduced to less than 0.01%
-Access to potable water and sanitation at least average level of
Latin America and Carribean
-Strong lab surveillance component
-75% of general population have knowledge of prevention
measures
53

54. Appendix: National Health Plan summary
Areas
Water and Sanitation
Aims by 2022
-Increase coverage of access to 85% of
population
-Collect solid waste to 90% in port-au-prince
and secondary cities to 80%
Current situation/what has been done
-Coverage of water supply (50% in urban and 30% in rural, high leakage
in water supply networks of 90%)
-Certain cities not included in previous reform framework
-No specific legal framework for management of solid waste in Haiti
-Only 8.5% connected to water distribution systems, 32% uses water
from rivers,
-10% of urban defecate openly, 50% of rural defecate in open areas
-Fragmentation difficulties
-Loss of trained and qualified staff to funding providers and NGOs
Measures to solve
-Construct and repair water supply networks, water supply
for rural
-Chlorination of water supplies
-Promote economic self-sufficiency using microcredit funds
Public health access
-Increase % with access to primary healthcare
for 46% to 80%
-Increasing no of physicians and nurses per
100,000 population
-47% of the population has no access to health services and that about
80% has access to traditional medicine
-The public sector represents 35.7% of health infrastructure the mixed
private sector 31.8%, and the private sector 32.5%.
-Treat cholera like all other diseases
-More health care facilities, strong community component
-Oral rehydration points
-Collaborate with pharmacy directorate
-Cholera vaccine campaign by MOH
Epidemiological surveillance
Strengthen epi surveillance for timely
detection
-Strengthened surveillance through biological confirmation
-Steering and coordination role of ministry of public health and
population.
-Rapid response and implementation teams created and stationed
-Compulsory notification system for cholera
-Research on outbreaks, routine collection and analysis for
microbiological study
-Structure implementation for emergency response to all
events (capacity strengthening)
Promotion of health and food
hygiene
75% of general population understand
importance of washing hands after defecating
and before eating
-Operational research
-Build ,maintain and expand by religious orgs, NGOs and youth groups
-Private sector collaboration
-Media, comm. Radio networks
-Hygiene practices, vigilance of population, national
standards
-Multipurpose community agent, one in every 500-1000 in
at-risk areas
-Local community health clubs
54

55. Appendix: Cost breakdown
Section
Environment
Environment
Environment
Environment
Health system
Health system
Health system
Health system
Biological
Biological
Biological
Biological
Social
Social
Social
Social
CDRP
CDRP
CDRP
Action Plan
Water supply
Wastewater and excreta treatment
DINEPA strengthening
Waste collection and treatment
Healthcare services
Healthcare innovations
Essential medicines
Micronutrient deficiencies
Epidemiological surveillance
Microbiology research
Research capacity building
Vaccines
Health promotion
Hygiene practices
Institutional strengthening
Integrated social media campaigns
Settlements
Future settlements/emergencies
Community fund
TOTAL
$M
825
468
224
470
83
200
95
20
16
5
11
40
54
19
36
21
7
100
300
$3B
55

56. Appendix: Towards a better framework for peacekeeping
4
1
STEP
Actuate reparation
1
for victims
1. Appoint claims commissioner per the
2.
3.
4.
5.
requirements of paragraph 55 in SOFA
Create claims commission to pay
victims
Apologize to Haitian people
Create guidelines for claims for future
Community funds and overarching goal
of health
3
STEP
2
STEP
2
Restructure
SOFA
agreements
Ensure that SOFAs are followed in
all following missions
Allow for more accountability by third
parties
3
Restructure
U.N.‟s legal
immunity
Eliminate legal immunity of United
Nations and establish a system of
accountability
4
STEP
4
Establish long-term
accountability
Third-party accountability is
necessary to hold U.N. accountable
56

57. NGOs
Appendix: Implementation stakeholders
Provide supplies and technical support for cholera relief
UNITED NATIONS
Raise funds for MSPP and relief
Appoint claims commissioner and disburse claims
Support Haitian government
Apologize to Haitian people
Ensure peacekeepers are accountable for actions
NATIONAL
GOVERNMENTS
Haiti – Fund and supply treatment centers;
demand claims from U.N.
WHO and Pan-American
Health Organization
United States – Fund treatment and MSPP
plan, manage claims
Aid funding of MSPP
Others – fund treatment and MSPP
Provide assistance to MSPP
57

58. Appendix: Community Building Education-to-Employment Pipeline
01.
RECRUITMENT
02.
ENGAGEMENT
• Via community and
education system, NGOs
recruit qualified Haitians to
work across generalized &
specialized job types
• Scholarships and
fellowships for highdemand talent
• Train-the-trainer model for
long-term capacity building
and sustainability
• Three-year minimum
commitment for
underserved areas
• Employ local experts
whenever possible
• 1:4 target NGO to Haitian
hire ratio (1:10 for highly
specialized jobs)
• Community-oriented, “By
Haitians, for Haitians”
culture
03.
RETAINMENT
• Over time, transfer jobs in
key areas to local
agencies
58

59. Appendix: 182% ROI on Health Care Infrastructure Investments
3% 3%
4%
For every $1 invested in
health care
infrastructure, the Haitian
economy gains $1.82
across multiple sectors.
5%
6%
39%
7%
Rental Housing
Teaching
Manufacturing
Transportation
Food
Commerce
Other Industry
Health
ROI
33%
Source: PIH
http://www.pih.org/blog/investing-in-haiti-the-economicimpact-of-university-hospital
59

60. Appendix: SWAp ensures compliance with international NGO governance best practices
• Ownership requires national development
strategies to be incorporated into operations.
• Alignment entails that aid flows are correlated to
national priorities, aimed at strengthening
capacity and employing local procurement
systems, while avoiding creating parallel
structures.
• Harmonization implies that implementing
agencies use shared analysis and programming
to avoid overlap.
• Management encourages a results based, and
transparent system for assessing progress
against national development goals.
• Accountability ensures that partner countries
implement agreed commitments on aid
effectiveness.
Ownership
Alignment
Accountability
SWAp
Harmonization
Management
60

61. Appendix: SWAp Program in Mozambique management costs
Family and Reproductive Services
Primary Care
Health policy &
admin. management
4
5 Personal Education and Training
3
24%
2
5 STD control
(including HIV/AIDS)
Population policy &
admin. management
1
61

62. Appendix: The Overall Risks are Moderate
3
-Corruption and
1
financial losses
- Natural Disasters
2
and Epidemics
2
3 -Inadequate funding
1
62

63. Appendix: Community Sustainability Fund: supports local projects, builds capacity, and responds to emergencies
1
• Finance public health and medical
training for Haiti Nationals
• Provide direct funding to local project
on the ground
2
• Require public works in Haiti
• Finance grants for local government
projects
• Work to minimize brain-drain
• Support public and private
entrepreneurship
• Improve national labor force
• Build economic resilience and
diminish unemployment
• Empower local communities
CSF
4
• Ensure rapid response in case of
emergencies
• Support local relief efforts
• Respond to extreme weather and
seasonal events
• Provide safeguards against international
mishaps
• Provide a large endowment fund
• Ensure support for long-term projects
• High growth potential with efficient saving
and investment
• Empower local economy in the global
market
• Reduce dependence on foreign donations
63
3

64. References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Haitian Director of Health Plan for 2012-2022, http://mspp.gouv.ht/site/downloads/Plan%20Directeur%20de%20Sant%C3%A9%C2%81…
National Haitian American Health Alliance report on State of Population Health in Haiti (October 2012), http://www.nhaha.org/2012topics/2012018.pdf
Haitian epidemiological map of weekly cholera incidence (1st week, January 2014), http://mspp.gouv.ht/site/downloads/Inc_commune_SE01_14.pdf
PAHO Haiti website, http://www.paho.org/disasters/index.php?option=com_content&task=view&am…
UN Update Report on cholera in Haiti (November 2013), http://www.un.org/News/dh/infocus/haiti/Cholera_Haiti_end_in_sight.pdf
UN Fact Sheet on Cholera in Haiti (December 2013), http://www.un.org/News/dh/infocus/haiti/haiticholerafactsheet-december-2013…
Haitian Epidemiological Map of Cholera incidence (January 2014), http://mspp.gouv.ht/site/downloads/Institution_SE02_14.pdf
Haitian Epidemiological Map of Weekly Cholera incidence by Commune (January 2014), http://mspp.gouv.ht/site/downloads/Inc_commune_SE01_14.pdf
“Electronic Medical Record systems in developing countries,” World Health Organization (2007),
http://www.ehealth.ed.ac.uk/EHR%20Critical%20Issues%20Workshop/Philippe%20Boucher,%20EHR%20Systems%20in%20Developing%20Countries.ppt
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