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From the Ground Up

By Nellie Bristol

Haiti's new health system will guarantee access to quality services for all through a performance-based funding system and large investments in human resources, according to rebuilding plans laid out by the Haitian government. The effort will require an investment of $1.5 billion according to a Post Disaster Needs Assessment (PDNA) developed by the Haitian government and international groups. The estimate of funding "needs" in the document takes into account recovery, reconstruction and re-establishment of the Haitian government.

Stakeholders already have begun meeting to develop specific objectives and goals for the system's development, said Judith Timyan, health program coordinator for USAID's Haiti Reconstruction Task Team. Overall reconstruction initially will be overseen by a Haitian interim commission for recovery led by former U.S. President Bill Clinton in his role as UN special envoy to Haiti and by Haitian Prime Minister Jean-Max Bellerive.

Donor funding will be pooled in trust fund overseen by the World Bank. Auguste Kouame, World Bank Sector Leader for Poverty Reduction and Economic Management and Lead Economist for the Caribbean, said the Bank will serve as a fiduciary agent for the fund. The trust fund will receive and distribute money largely from major international donors, keeping with the priorities of the Haitian government. Kouame said the fund is modeled on a similar structure used to distribute international donations related to the 2004 tsunami and included strict oversight to ensure the quality of the work funded through the program. "It worked beautifully," Kouame said. "If we could replicate and adapt the Aceh model in Haiti it would be great."

The PDNA indicates that 30 out of 49 hospitals have been damaged or destroyed. On the plus side, it says, 90 percent of health centers are intact or suffered only minor damage, providing a platform to launch a community based health strategy. Priorities for a new system include services in maternal and reproductive health and to combat the spread of HIV/AIDS.

The goal is to build a system that is a vast improvement over the pre-earthquake model, which left 47 percent of citizens without access to health care. "The health system is fragmented, highly unfair (6 percent of the poorest women give birth in health-care institutions, compared with 65 percent among the most well-off) and highly inefficient, with expenditure of $32 USD per capita per year and poor health outcomes for expenditure of this level," the PDNA says. It cites fee-for-service arrangements as a major barrier to health-care access.

One of the biggest obstacles to revamping the Haitian health-care system is lack of personnel. "The earthquake has had a major impact on health-care staff, with more than 50 percent living in tents, leading to disorganized service delivery," the report says. Further, most of the country's training facilities and universities were located in the earthquake zone leaving a major gap in that sector.

While all concerned are anxious for the government to take charge of reconstruction efforts, many worry it doesn't have the resources needed. "They're going to need a lot of help," said Timyan. Lindsay Coates, vice president of policy and communication for the NGO umbrella group InterAction, agrees: "The Haitian government is very thin."

"There is a very strong desire to work with the government of Haiti in partnership," she said. "The challenges are around the government's capacity." InterAction received funding from USAID to set up a "coordination cell" that is helping NGOs connect with the UN system.

Coordination of UN activities and program implementers is being overseen by the UN Office for the Coordination of Humanitarian Affairs and representatives of the Haitian government. Souad Lakhdim, a Pan American Health Organization official helping to coordinate UN health activities, said OCHA, government representatives and NGOs are meeting regularly to exchange information and synchronize activities. Despite the effort, some say more is needed to ensure help is reaching those in greatest need and isn't duplicative, particularly as the effort moves from relief to reconstruction. "The problem in responding to the earthquake is not lack of material or coordination, but lack of complete and coherent planning that could be implemented without gaps," said Loris de Filippi, Medecins Sans Frontieres' Haiti operational coordinator.

Creating the local personnel capacity to take charge of the reconstruction and mobilize the many resources to carry it out is a top priority. In the health sector, USAID is offering technical assistance to train health personnel, particularly allied personnel such as pharmacists' assistants, nurse midwives and auxiliary nurses, Timyan said.

Many are seeing the involvement of the Haitian diaspora as a key to ensuring that as many indigenous personnel as possible are part of reconstruction, with the hope that the involvement will make new systems sustainable. The Center for Global Development (CGD) is urging development of a mechanism to support the exchange. "Dozens, even hundreds might be willing to return home for up to two years to help jumpstart and expand the school and health systems, replacing the skills of the huge number of Haitian civil servants who lost their lives," CGD President Nancy Birdsall wrote in a commentary on the group's website. She suggested that USAID could support a group like the Clinton Foundation or the Peace Corps to manage the program, screen the applicants, and to arrange modest monetary support. CGD also is urging flexibility in USAID contracting rules to ensure Haitian NGOs receive priority in contracting for work.

Haiti will need all the help it can get to repair not only earthquake damage, but to escape a history rife with instability and hardship. "It is a plan to create a ‘New Haiti,'" UN Secretary-General Ban Ki-moon said of the reconstruction. "A Haiti where the majority of people no longer live in deep poverty, where they can go to school, and enjoy better health, where they have better options than going without jobs or leaving the country all together."

Nellie Bristol is a freelance journalist, specializing in health policy.