Attachment_P_GOH-USG_Partnership_Framework.pdf

Contents

I. INTRODUCTION

II. PURPOSE AND PRINCIPLES

III. BACKGROUND

a. THE HEALTH SECTOR IN HAITI

b. GOVERNMENT OF HAITI’S RESPONSE

c. THE UNITED STATES GOVERNMENT’S SUPPORT

d. OTHER DONOR SUPPORT

IV. FIVE YEAR STRATEGIC OVERVIEW

V. RESEARCH AND INNOVATION

VI. ROLES AND COMMITMENTS

VII. DEVELOPING THE PARTNERSHIP FRAMEWORK IMPLEMENTATION PLAN

VIII. MONITORING

IX. MANAGEMENT, COORDINATION AND COMMUNICATION

X. SIGNATURES

XI. EXPECTED CONTRIBUTION TABLES

I.

Aligned with the Global Health Initiative (GHI) and PEPFAR Phase Two approach, the United States Government (U.S.G.) and the Government of Haiti (G.O.H.) negotiated a Partnership Framework (PF) throughout 2009 which was overtaken by events: the resignation of the Prime Minister in late 2009, the earthquake in January 2010 and the cholera outbreak in October 2010. The purpose of the PF was to strengthen G.O.H.’s ownership of and the sustainability of the PEPFAR program. To achieve this, the two governments decided to scale up HIV care, treatment and prevention services, to reinforce governance and to undertake the policy reform necessary to facilitate the implementation of these goals. However, with the new priorities and challenges created by the earthquake in January 2010 and the cholera outbreak in October of the same year, there was a need to substantially reassess and redirect resources to rebuild the infrastructure damaged by the earthquake; to respond to existing and emerging health threats; to strengthen Haiti’s health systems, especially in the areas of supply chain management and health information systems; and to support G.O.H.’s coordination role at the central and departmental levels.

These two crises dramatically changed the breadth of assistance in the country, requiring that key tenets of the PF be revised. Building on the pre-earthquake advances and sizable post-earthquake investments for improved health, this PF is more expansive, serving as a framework for a broader, more comprehensive approach to health that integrates and coordinates the HIV/AIDS response with other public health and development needs. It is also aligned with the U.S.G.’s post-earthquake strategy for Haiti and the commitment to support the rebuilding of the country’s health system.

Thus, this PF articulates both governments’ commitment to a set of guiding principles; joint goals and objectives; and relative roles and responsibilities in their partnership to rebuild and strengthen Haiti’s health system. The PF builds upon the foundations laid by the Government of Haiti, civil society, the private sector, NGOs and bilateral and multilateral partners, including existing coordination mechanisms such as the Global Fund Country Coordinating Mechanism. This PF embraces the GHI principles which build on a strong PEPFAR program, expanding the focus on health issues beyond HIV and related diseases, and integrating with other development programs supported by the U.S.G.

In establishing this PF, both governments recognize that their respective resources are limited and that their investments are subject to the availability of funds. They also recognize that achievement of the goals and objectives of the PF requires investments beyond the ability of any one partner. Furthermore, the PF should be reviewed periodically to assess progress against and continued prioritization of the stated goals. This PF is to serve as the basis for a Partnership Framework Implementation Plan (PFIP) that is to be developed collaboratively by both governments. The PFIP is expected to define specific benchmarks and a roadmap to achieve the objectives put forth herein and further articulate expected results.

II.

The purpose of this PF is to refocus the cooperation between the U.S.G. and the G.O.H. and their respective partners on supporting Haiti’s efforts to improve its health system and to reach the Millennium Development Goals (M.D.G.), including promoting maternal and child health and reinforcing the fight against HIV/AIDS and other infectious diseases. This is expected to be achieved through technical assistance, support for service delivery, policy reform, and coordinated financial investments.

More specifically, this PF aims to advance the G.O.H.’s ownership and oversight of an adaptable and self-correcting public health system in Haiti, and to reduce its dependence on donor support over time through the following objectives:

Objective 1: Improve G.O.H. leadership and oversight of the health sector

Objective 2: Increase access to quality integrated health services with a focus on maternal and child health, nutrition, family planning/reproductive health, HIV and other infectious diseases, and disabilities

Objective 3: Improve health information and supply chain management systems

Objective 4: Rebuild health facilities and physical health infrastructure

At the end of the five year period, it is expected that results in maternal and child health, reproductive health, HIV/AIDS, other infectious diseases, and care for disabilities will improve, and that the G.O.H.

should have made significant strides toward assuming primary responsibility for the management and performance monitoring of the overall health system, as well as increasing its financial support.

The principles of the collaboration between the U.S.G. and the G.O.H. are to:

Support Country Ownership: The U.S.G. and G.O.H. plan to ensure that the G.O.H. is at the center of decision-making, leadership, and management of Haiti’s health sector and related systems, and that the PF operational priorities are derived from national priorities.

Increase sustainability through health systems, policy reform and financial accountability: Through the PF, the U.S.G. and G.O.H. plan to emphasize key policies that promote effective and sustainable quality health programs, improve transparency in health financing and promote a unified health budget as well as sound financial and monitoring and reporting systems.

Strengthen and leverage key multilateral organizations, global health partnerships and private sector engagement: Through this PF, the U.S.G. and G.O.H. plan to collaborate to support mechanisms and platforms to leverage and coordinate with other donors, including civil society and the private sector.

Ensure that assistance is comprehensive and integrated: Both governments plan to seek to promote reforms and approaches to integrate services at the point of delivery, and to integrate vertical programs where feasible while supporting effective Ministry of Health oversight at all levels.

Focus on Women, Girls and Gender Equality: Through this PF, the U.S.G. and G.O.H. plan to continue to implement programs centered on women and girls, including adolescent and pre-adolescent girls, and plan to seek opportunities to create policies and reforms to promote gender equity and the engagement of men in the health of their families and communities.

Improve metrics, monitoring and evaluation: The U.S.G. and G.O.H. are committed to advancing their collaboration based on measurable goals, objectives and concrete commitments. The U.S.G. plans to support national, country-owned and harmonized reporting systems to lead to informed decision-making.

Promote research and innovation: Under the PF, the two governments plan to work to identify and support the introduction and successful scale up of technological advances as well as creative and effective new ways of addressing development challenges.

a. THE HEALTH SECTOR IN HAITI

Haiti is facing serious economic challenges. An estimated 55 percent of the country’s approximately nine million people live on less than one dollar a day. On January 12, 2010, the most powerful earthquake in 200 years struck Haiti. The human impact was immense. According to official accounts, more than 200,000 people died and an additional 300,000 were injured. More than 250,000 homes were leveled, causing over 1 million people to move to temporary Internally Displaced Persons (IDP) camps, often referred to as tent cities.

In the face of this catastrophic event, the G.O.H. and its partners (governments and NGOs) committed and invested substantial resources to improve the health condition of the Haitian people. The following public health sector deficiencies were identified as a starting point for these efforts:

According to the M.O.H., only 47 percent of the population gets access to the minimum package of health services the Government committed to providing.

The overall health system is extremely weak: The G.O.H. spends only 5.8 percent (compared to the Abuja Target of 15 percent) of its national budget on public health, and 90 percent of that supports personnel costs1. There is a shortage of health workers, low retention of nurses and doctors, and low skill level and knowledge base at all levels. There are multiple medical commodity procurement and distribution systems to ensure supply of commodities for the health activities that donors support.

Social and community mobilization to adopt healthy behavior and seek services is weak, due to socio-cultural barriers, low G.O.H. investment, limited data to inform promotion strategies, and poor empowerment of individuals and communities.

The health outcomes over the last decade lag far behind the Millennium Development Goals and the national objectives. Although the infant mortality rate has improved over the last 15 years from 80 to 57 per 1,000 children, it is still very high compared to the Americas. Six hundred thirty (630) out of 100,000 pregnant women die while giving birth, and only 25 percent of women deliver in a health facility. With an HIV prevalence rate of 2.2 percent, Haiti’s estimated 135,000 HIV positive individuals constitute the greatest burden of HIV/AIDS care and treatment responsibility in the Caribbean region. According to the M.O.H., 50 percent of HIV infected individuals in need of treatment are currently receiving it. TB incidence, 132 cases for

1 Budget 2010-2011, Depenses Courantes. Excludes Depenses de Capital managed by Ministry of Planning

100,000 inhabitants, is the highest in the Americas. About 60 percent of expected cases are being detected and 60 percent of TB patients are being tested for HIV.

The earthquake and the rapid and large cholera outbreak have added a new dimension of challenges to the health system in Haiti by increasing demand for basic services, creating new demand for specialized post-disaster services, destroying health infrastructure and proliferating an expanded set of health sector actors thus making it harder for the M.O.H. to coordinate and provide leadership.

b. GOVERNMENT OF HAITI’S RESPONSE

The Government of Haiti has been increasing the proportion of its budget that is devoted to health, from 5.8 percent in FY2010-11 to 6.9 percent in FY 2011-12. While this is still far short of the 15 percent Abuja target, it is trending in the right direction. As the economy grows and the overall budget available to the G.O.H. expands, the G.O.H. will be able to take on a greater share of the health financing burden through the Public Treasury and other concessional loans. The G.O.H. is currently developing its strategy for social protection and response to the human right of Haitians to access health services in a sustainable way. The more financing the G.O.H. provides, the greater the control it exercises over the health system and the more Haitians have access to health services.

The G.O.H. has routinely provided overall guidance to the health sector by formulating national health strategic plans. Currently, a unified national health plan, an integrated national budget, national health accounts, and a coordination mechanism within the G.O.H. to manage the whole health sector are all under development. The post-earthquake “Plan Interimaire” ended in 2011 and a new strategic plan 2012-2022 is being developed. The interim plan refocused energy on rebuilding the health system;

maintaining the provision of health services at all levels; improving access to services for vulnerable groups such as women, children and disabled people; strengthening the governance and capacity of the sector to respond to disasters; and promoting public-private partnerships.

The G.O.H. defines similar objectives in its new Health Strategy guidance, which will lead to the development of a new national health plan. In addition, the G.O.H. articulates the need for a single national health information system; the development of a human resources policy including employment, human capacity development, personnel retention, salary scale and career plan; the expansion of intermediary personnel such as nurse practitioners, nurse midwives, and sanitary officers;

and the creation of a unified drug management system.

The development process for a new health sector strategic plan (2012-2022) has been launched. Multi-sectoral stakeholder consultations, the “Etats Généraux de la Santé”, have been completed. The government is also evaluating the previous five year strategic plan (2008-2012) for HIV/AIDS, which focused on the reduction of risk; vulnerability and impact of the epidemic; the promotion of PLWHA (People Living with HIV/AIDS) rights; sustaining HIV/AIDS interventions; and surveillance. This evaluation along with the planned creation of a National Commission for HIV/AIDS will inform the formulation of a new strategic plan for HIV/AIDS. These policy documents will form the basis for the development of this PF’s implementation plan (PFIP).

c. THE UNITED STATES GOVERNMENT’S SUPPORT

The U.S.G. is one of the major donors to Haiti’s health sector, contributing over $100 million in PEPFAR funds annually, plus additional funds for family planning, maternal and child health, and nutrition. In the aftermath of the earthquake and the cholera epidemic, the US Congress also made one-time supplemental funds available for post-earthquake reconstruction, cholera response, and additional support to the public health system. This assistance supports a package of maternal and child health services, including immunization, Integrated Management of Childhood Illness (IMCI), pre- and postnatal care, obstetrical care, reproductive health and HIV/AIDS through a network of more than 300 health institutions (out of 800) that provides service coverage for approximately 50 percent of the population.

Through PEPFAR, the U.S.G. supports comprehensive HIV prevention, care, and treatment activities throughout the country in coordination with the Global Fund. To date, approximately 150 health facilities at different levels of the health care system provide HIV/AIDS care and treatment services, enrolling over 100,000 patients in clinical care (out of 135,000 people believed to be living with HIV/AIDS according to UNAIDS models, but not yet identified) while maintaining 32,000 on ARV treatment (representing half of the people in need of this treatment). An integrated program to provide community and social support to Orphans and Vulnerable Children, People Living with HIV/AIDS and their families has been developed around these care and treatment sites. The new HIV prevention strategy prioritizes expanding sexual transmission prevention activities with a particular focus on prevention with positives and youth as well as on most-at-risk groups.

PEPFAR resources also strengthen the overall health system in Haiti. More than four thousand health professionals of all categories are supported by PEPFAR to provide HIV/AIDS and primary care services.

Pre and in-service training continue to be a major focus of the effort to build a critical mass of health professionals trained in HIV and other infectious diseases. In the meantime, a task-shifting strategy with an emphasis on training nurses and community personnel has been initiated. Efforts to build robust health information and drug supply management systems as well as an improved public health laboratory network are underway.

To respond to the new challenges created by the earthquake, the U.S.G. pledged to help G.O.H. rebuild and strengthen the health system, supporting the priorities identified in the M.O.H. interim plan. The majority of these resources are expected to be concentrated in already identified development corridors where the U.S.G. and G.O.H. have decided to focus most of the U.S.G.’s Haiti reconstruction effort. The U.S.G.’s new strategy is formulated around the following five components:

Develop comprehensive referral networks at the communal and departmental levels within the US development corridors

Continue to support the delivery of a “basic package” of services and targeted infectious disease prevention and management outside the US development corridors

Establish disability care to support G.O.H. and civil society capacity to provide care and rehabilitation services for persons with disabilities

Increase support to the Ministry of Health in strengthening systems and governance

Rebuild and reform management of public health infrastructure

d. OTHER DONOR SUPPORT

Other donors have also played an important role in supporting the Health sector in Haiti, including HIV/AIDS activities. The Global Fund to Fight AIDS, Tuberculosis and Malaria has approved approximately $70 million for the next two years to support HIV/AIDS, malaria and TB activities. The Global Fund coordinates closely with PEPFAR to strengthen care, treatment, and prevention activities.

The Global Fund plays a significant role in ARV drug procurement, tuberculosis and malaria diagnostics and treatment, and support of operational costs for HIV, TB and malaria-related services in Haiti. It is a priority for both the U.S.G. and Global Fund teams in Haiti to improve coordination and oversight of related programming. To that end, the U.S.G. supports efforts to strengthen the Country Coordinating Mechanism (CCM) to oversee the implementation of Global Fund supported activities. Strategies are in development to establish common approaches for planning, budget capture, and commodity quantification.

In the wake of the earthquake, other countries including Brazil, Canada, and France, as well as non-governmental organizations such as the American Red Cross, also pledged significant resources. The World Bank is planning to invest approximately $50 million to support maternal and child health services and reinforce governance over the next five years.

ESTIMATED DONOR FUNDING COMMITMENT

DONORS ESTIMATED FUNDING

UNITED STATES GOVERNMENT $ 1 billion

BRAZIL $ 94.5 million

GLOBAL FUND $ 70 million

WORLD BANK $ 50 million

CANADA $ 40 million

FRANCE $ 30 million

VENEZUELA $ 20 million

AMERICAN RED CROSS $ 10 million

Source: World Bank; Global Fund CCM Haiti; USG; Pledges at the March 31, 2010 Haiti Donor conference; http://www.haitispecialenvoy.org/download/International_Assistance/5-ny-pledge-total.pdf

The PF should provide a platform to support the G.O.H. in a first step toward integrating and/or coordinating all donor contributions in support of one national health plan. The U.S.G. and G.O.H.

should work to confirm these donor resources and commitments as well as the priority activities planned with these resources.

IV.

The goal of this PF is to advance the Government of Haiti’s leadership and oversight of the health sector in Haiti, and to reduce its dependence on donor support over time. The PF lays out the commitments of the Governments of Haiti and the United States and builds upon the contributions of civil society, the http://www.haitispecialenvoy.org/download/International_Assistance/5-ny-pledge-total.pdf http://www.haitispecialenvoy.org/download/International_Assistance/5-ny-pledge-total.pdf private sector, NGOs and bilateral and multilateral partners, including existing coordination mechanisms such as the Global Fund CCM.

Through the PF, the two governments should harmonize efforts to meet the following objectives:

Objective 1: Improve G.O.H. leadership and oversight of the health sector

Objective 2: Increase access to quality integrated health services with a focus on maternal and child health, nutrition, family planning/reproductive health, HIV and other infectious diseases, and disabilities

Objective 3: Improve health information and supply chain management systems

Objective 4: Rebuild health facilities and physical health infrastructure

OBJECTIVE 1: Improve G.O.H. leadership and oversight of the health sector

The G.O.H. has prioritized increased governance and leadership in order to improve health outcomes for all Haitians. The G.O.H. and the U.S.G. are reinforcing their collaboration to reach this objective by 1) improving the M.O.H. capacity to coordinate and manage the entire health sector, including the management of resources from all sources; 2) implementing a financing strategy that involves increased resources and accountability from the G.O.H. and expands access to and the sustainability of health services; 3) developing a plan to support human resources that reinforce the health workforce at all levels and that allows the G.O.H. to fill in serious gaps in the public sector; and 4) coordinating with the Dominican Republic to address cross border health issues.

The G.O.H. is committed to improving oversight of the health system including the coordination and management of public, private, and NGO service delivery. U.S.G. resources are currently being provided directly to the M.O.H. at the central and departmental levels to reinforce management and coordination capacity. The promising results generated by these efforts are being enhanced with plans to develop within the M.O.H., in coordination with other donors such as the World Bank, a new contracting unit and to strengthen the governance functions of the various directorates that already exist within M.O.H.

to carry out oversight functions like priority and norms setting, accreditation and the development and implementation of a unified plan and budget for the whole health sector. Improved financial oversight and planning will support timely and effective procurement of essential goods and services for the health sector. The M.O.H. should continue to receive targeted assistance to support decentralized services, decision-making, and budgeting authority at department and communal levels, according to G.O.H. priorities and policies.

The U.S.G. is contributing to G.O.H. efforts to coordinate with other donors to develop a financing plan for the health sector that reduces donor dependence by bolstering contributions from government, the private sector and other local sources of funding. The approach has examined various cost-recovery models, including public and private health insurance and health procurement models, including performance based contracting. Through these efforts both governments aim to develop: 1) a national budget that includes line items and sources of funding to support capital investment, recurrent costs for health services, and specific program costs in areas such as HIV, TB, Family Planning and Immunization;

and 2) a database of health funding and costs; and conduct various cost benefit analyses to inform policy decisions.

To address the gap in the human resources of the health sector, the G.O.H., U.S.G. and other donors are developing a human resources plan to effectively deploy and retain health workers in the public sector and in high-need locations; to accelerate training of physicians, nurse-midwives, nurses, laboratory staff, allied health professionals and mid-level cadres; to support task-shifting; and to integrate Traditional Birth Attendants and other community health service providers into the health workforce. This approach aligns with ongoing efforts to integrate donor funding and G.O.H. resources to organize all Community Health Workers under the G.O.H. umbrella; to promote a unified and standardized package of health services; and to develop a career path for this group of workers within the public health system. The approach is also strengthening in-service training to support the expansion of critical health services for HIV/AIDS, TB (including MDR TB), maternal and child health, cholera, and other priorities. In addition to clinical staff, the U.S.G. and the G.O.H. are working together to improve the competency of epidemiologists and laboratory staff that are essential for effective diagnosis, surveillance, response, and evaluation of health information and emerging threats to the population’s health.

The G.O.H. is committed to both continuing and expanding its proactive engagement of the Government of the Dominican Republic to strengthen cross-border collaboration on a wide range of health issues.

Collaborative efforts to address cross border health issues are ongoing and have been orchestrated at the level of the Ministries of Health and the U.S.G. agencies from both countries. More specifically, teams worked together to harmonize tools and information systems to address TB issues on both sides of the island. Recently the health ministries from both governments created a joint task force to eliminate cholera from Hispaniola and are also contemplating a new plan to eliminate malaria. Partners at the borders with support from the U.S.G. in both countries have been actively collaborating on PMTCT issues to ensure there is a continuum of services for HIV infected pregnant women across the border. Inclusion of these health issues at a higher level, for example in the agenda of the bi-national commission, could be a precursor to drafting and adopting policies that are critical to strengthening this collaboration. Through the development of the PFIP, both U.S.G and G.O.H. should continue to engage their counterparts in discussions regarding specific benchmarks and indicators for cross-border coordination of TB and HIV- related activities and island-wide control of cholera and malaria.

Illustrative National Indicator and Target

Increased percentage of national budget allocated to health from 5.8 percent to toward the 15 percent Abuja target

Key Reforms

Reform of hospital management including financial accountability and personnel policies

Development and implementation of a human resource plan that includes health workers training and retention, and norms for task shifting

Development and implementation of a national health financing plan with a clear path towards sustainability, including the development of national health accounts and increase of the share of health in the national budget

Extension of key functions (budgeting, financing, surveillance) of the M.O.H. to departmental and local levels

Implementation of policy tracking protocols to analyze progress on these reforms

Permit nurses to be trained to become nurse practitioners with the skills to prescribe ARV

Illustrative Five Year Benchmarks and Measurements of Success

Management and governance of Hôpital de l’Université d’Etat d’Haiti (HUEH) is reformed

A contracting unit is functioning within the M.O.H. that provides a transparent and efficient platform to purchase, manage and coordinate essential health services using G.O.H. systems

G.O.H. personnel policies are reformed to promote competitive staffing, transparent processes, and clear guidance for the support of project funded staff

The G.O.H. increases its financial contribution toward costs of MSPP staff hired by U.S.G. health projects

OBJECTIVE 2: Increase access to quality integrated health services with a focus on maternal and child health, nutrition, family planning/reproductive health, HIV/AIDS and other infectious diseases, and disabilities.

G.O.H. has prioritized improving access to a minimum package of health services that encompass maternal and child health, infectious diseases, disability care, and emergency care. To support this priority, the U.S.G. and G.O.H. have been working together to reinforce and expand a basic package of health services for women and children as well as HIV services, other targeted infectious diseases such as TB, cholera, lymphatic filariasis, and malaria; and disabilities care. Particular emphasis is placed on: 1) scaling up HIV treatment and PMTCT services to reach universal coverage; 2) integrating HIV and TB services with basic care package of services, including services in prison; and 3) integrating the cholera response into regular health services. These efforts expand and reinforce current child survival and HIV/AIDS programs that are delivered through a network of 300 public and not-for-profit health institutions, and are expected to be supported by the expansion of a tiered national laboratory network that improves disease diagnosis and monitoring. Expansion of existing collaborative efforts with other key stakeholders such as the Global Fund, Canada, France, Brazil, UNICEF, and UNFPA should focus on harmonizing approaches to coordinate and support health care services at the facility level.

Currently, the referral system between the primary, secondary, and tertiary levels of the health care system are being reinforced to ensure continuum of care with appropriate systems for management and oversight. This effort should be expanded during the PF period, and should further promote linkages between facility and community services to ensure referral and capture with targeted activities to address loss-to-follow up and engagement into appropriate access points. Referral networks link public facilities with NGOs, where appropriate, based on geographic proximity and service complementarities.

Additionally, to expand access to lab services, a laboratory specimen referral network currently being rolled out for HIV patient monitoring is expected to be expanded to accommodate other specimens and link the network of public health laboratories to the patients who need quality laboratory assessment.

The G.O.H. and the U.S.G. have been collaborating with other key partners to promote healthy behaviors and healthcare seeking behaviors as a means to improve health outcomes. The G.O.H. created a Behavior Change Communication group led by the M.O.H. that includes key stakeholders to harmonize approaches and strategies. A national strategy for health promotion has also been created and reflected in specific departmental plans. The U.S.G. and G.O.H. are leveraging the existing infrastructure set up through the child survival, PEPFAR, and the Water, Sanitation, and Hygiene (WASH) programs, as well as large social marketing programs, to implement activities that promote an enabling community environment for healthy behavior. Throughout the PF period, the stated activities are planned to continue, and particular priority should be placed on the promotion of maternal and child health including accessing available and expanding immunization services and emergency obstetrics care;

sexual prevention of HIV with emphasis on most at risk populations, including commercial sex workers and their clients (“hot spots” where risky behavior takes place have been mapped so that prevention activities can be tailored to these populations); WASH to prevent cholera and other hygiene and water related diseases; gender equity; and the reduction of physical and sexual violence. The G.O.H. intends to increase its participation in social marketing strategies and techniques to reinforce demand for critical maternal and child health services, especially in the areas of nutrition, family planning, and maternal health.

The U.S.G. and the G.O.H. are engaged in a multi-sectoral, joint planning process that is expected to be both continued and expanded in the coming years. For example, the Ministry of Social Affairs, the Ministry of Justice, and the Ministry of National Education, Youth, and Sports are designing and implementing targeted strategies for HIV sexual transmission prevention, especially for positives and youth engaged in multiple concurrent sexual partnerships. The M.O.H. is integrating communication and education interventions for sexual prevention of HIV into other HIV and health services, including intensified risk reduction counseling and STI treatment services. The Ministry of Education is partnering on the integration of sex education into schools while collaboration with the Ministry of Social Affairs is seeking to reinforce and expand programs aimed at risk reduction among commercial sex workers and address sexual violence, stigma, and discrimination against HIV positive women and mothers, and overall sexual violence against women and girls. M.O.H. and Social Affairs are assisting to develop clear standards, accreditation, and monitoring/coordination capacity to meet the needs of people with disabilities, in collaboration with organizations of disabled people and local institutions. The Ministry of Justice is involved in the implementation of health services in prisons, and this relationship should be further strengthened during the PF reporting period.

Illustrative National Indicators and Targets

The implementation of this objective – through the integrated service approach and the focus on women and children – is expected to significantly improve key health outcomes. The U.S.G. and G.O.H.

and their partners intend to put a particular emphasis on the following indicators and related long-term targets in their monitoring and evaluation efforts during implementation:

Reduce the under-5 mortality rate from vaccine preventable diseases by 35 percent

Reduce maternal mortality by 30 percent

Reduce the prevalence of tuberculosis by 25 percent

Virtually eliminate mother to child transmission of HIV

Virtually eliminate the threat of epidemic cholera

Virtually eliminate lymphatic filariasis

Ensure that all eligible HIV+ patients are initiated onto ART (patients are eligible when their CD4 reaches 350, if they have TB and/or are pregnant)

Ensure that 75 percent of Haitians have access to an improved water source or means of treating their drinking water

Key Reforms

While Haiti only invests 5.8 percent of its domestic budget for health, poor public health delivery is also due to lack of implementation of key policies and strategies outlined in the G.O.H.’s official documents, thereby compounding the challenges of the sector, especially in the areas of oversight, governance, access to services, and quality of services. Robust implementation of all G.O.H. adopted policies and strategies for health are a critical goal for this partnership as are the following reforms:

Definition of mechanisms for mutual accountability between the national (central) and departmental health directorates

Enforcement of Minimum Standard of Services and a system of accreditation of health institutions

Implementation of referral and counter-referral networks, including linkages between NGOs and the public sector, and between the community and the facility

Integration of sexual education in school curriculum

Enforcement of law to protect HIV positive individuals against stigma and discrimination

Enforcement of laws to protect women and children from violence

Development of regulations and norms to protect persons with disabilities

Illustrative Five Year Benchmarks and Measurements of Success:

All health facilities in the development corridors are assessed by MSPP for accreditation in order to ensure that key facility readiness benchmarks are met

Service readiness of public facilities are improved

HIV care and treatment services are reinforced and expanded to provide universal access to these services

Active surveillance of lymphatic filariasis informs final strategies for elimination of this disease in Haiti

Objective 3: Improve health information and supply chain management systems

Priorities are to develop a unified health information system; to collect and use appropriate data to support decision making; and to unify and consolidate cost-effective drug procurement and logistics systems; and to use laboratory diagnosis to strengthen monitoring of diseases.

The G.O.H.’s objective is to reinforce its ability to collect, analyze, and use health information as a cornerstone for a robust public health system. The G.O.H. strategy is to reinforce surveillance of disease, laboratory diagnosis to determine etiology, review of health service delivery data, and evaluation of interventions that are essential to increase its capacity to identify, monitor, and respond to health threats and to determine whether interventions provided are broadly available and of high quality. To assess health information effectively, information gathering activities should be available through a robust Health Information System that links surveillance, service provision, and related data sources.

The U.S.G. has supported the effort to build on the tools and infrastructure put in place for the HIV reporting and surveillance system. The U.S.G. is working with the G.O.H. and other donors, particularly the development agencies of Canada, France, and Brazil, and multilateral agencies including PAHO and UNDP to support an integrated health information platform that focuses on quality epidemiology and active surveillance systems. Through this effort, various sources of health information related to family planning/reproductive health, nutrition, tuberculosis, and HIV/AIDS are expected to be integrated into a centrally available platform managed by the G.O.H. The resulting system should facilitate the use of data for decision making. In addition, the U.S.G. should continue to support investments in laboratory diagnosis linked to surveillance and response.

The U.S.G. and the G.O.H. are also working to identify and strengthen efficiencies within the supply chain that currently consists of multiple parallel procurement systems, disjointed distribution networks for drugs and commodities, and poor stock management in the periphery. The system is heavily supported by multiple donors and the G.O.H. plays a limited role in its execution. The G.O.H.’s plan, which is being fully supported by all the donors, is for a gradual shift from multiple vertical supply chain management systems to a single national system. Technical assistance providers are working with the M.O.H. to assess existing drug and commodity management systems, to develop standards for a unified procurement and active distribution system, and to update norms for the operation of the departmental drug warehouses and waste management, including both pharmaceutical and biomedical waste.

Illustrative National Indicators and Targets

Increased percentage of health institutions reporting timely health statistics

Increased number of departmental health directorates submitting aggregate surveillance data in a timely fashion

Increased percentage of health institutions regularly supplied with essential drugs

Key Reforms

Guidelines defining the architecture of the health information systems developed are updated and disseminated

Guidelines regarding drug and commodities procurement and distribution system are updated to reflect the roles and responsibilities at each level of the system

Procedures for the operation of departmental warehouses are updated

Enforcement of pharmaceutical policies related to dispensing controlled substances

Illustrative Five Year Benchmarks and Measurements of Success

A unique consolidated national supply chain is developed

Availability and use of high quality national and sub-national surveillance, health utilization, and access information

Objective 4: Rebuild health facilities and physical health infrastructure:

The U.S.G. and the G.O.H. are working to support the rebuilding of physical health infrastructure in earthquake zone and in the development corridors. Specific health infrastructure projects include:

The rebuilding of the HUEH teaching hospital to reinforce the tertiary level of the health care system and to provide a better environment for training physicians and nurses

Rebuilding of the national Blood Bank

Construction and/or refurbishing of health facilities located in the development corridors based on needs assessments to improve service delivery and build functional referral networks

Construction and/or refurbishing of four warehouses for drugs and health commodities to support the expansion of the drug logistics system

Rebuilding of the Faculty of Medicine and Pharmacy and School of Medical Technology of the State University to strengthen the capacity of human resources for health

Renovation of maternity wards to increase access to emergency obstetrics care

For each infrastructure project, the G.O.H. is developing a plan for maintenance, reinforcement of human resources, and support for recurrent and operating costs. The G.O.H. is taking steps to reserve resources to finance this plan. The G.O.H. and the U.S.G. are also coordinating with other donors to support these infrastructure projects. For example, the HUEH is being rebuilt jointly with the Government of France; and the Canadians are rebuilding the School of Midwifery that will be part of the National Campus for Health Sciences co-located with HUEH. Beyond physical infrastructure, current efforts to establish a national tiered laboratory system that provides high quality diagnosis and disease monitoring throughout the country should be expanded. This should include the national, regional and several departmental laboratories participating in a stepwise accreditation process that improves the ability to deliver high quality laboratory services throughout the country.

National Indicators and Targets:

HUEH hospital is rebuilt and fully functional

Faculty of Medicine is rebuilt

National Blood Transfusion Center is rebuilt and meeting national blood supply needs

Key Reforms:

The G.O.H. makes budget provisions to support maintenance and operational costs to sustain different infrastructure projects

Illustrative Five Year Benchmarks and Measurements of Success:

M.O.H. capacity is reinforced to coordinate and monitor the health infrastructure projects

G.O.H. has a plan for maintenance and operating costs including human resources for each infrastructure project from the G.O.H. health budget

V.

Through the PF, the U.S.G. and G.O.H. intend to work to promote best practices and innovative approaches to improving health outcomes for Haitian families and communities, based on sound studies and evaluation data. The U.S.G. has launched a fund for Development Innovation Ventures to support innovative ideas and research, as well as multiple research agreements with the M.O.H.

VI.

Overall G.O.H. leadership for the PF rests with the Office of the Prime Minister, which oversees all

Ministries of the Government. As a key stakeholder, the M.O.H. designated a PF point person that is a central point for M.O.H. engagement, and who has the capacity to bring in other M.O.H. staff as needed to move the PF agenda forward. The U.S.G has also partnered with the Prime Minister’s Office, which has fully endorsed the PF on behalf of the G.O.H. The G.O.H. has recently completed a diagnosis and a vision of the Health Sector (“Etats Généraux de la Sante”) in Haiti with public and private sectors. The conclusions and priorities are endorsed by the highest level of the government (Prime Minister and the

President) and align with the principles and key benchmarks adopted in this agreement.

In order to ensure a multi-sector approach to the PF, the Prime Minister’s Office is creating a G.O.H.-led steering committee to implement and monitor the PF. The steering committee will include the Ministries of Health, Social Affairs, Education, Youth and Sports, Women’s Affairs, Justice, and Planning.

In addition to this Committee, both governments are facilitating the participation of civil society and other key donors, including the Haitian Chamber of Commerce, the Canadian International Development Agency, the World Bank, the Inter-American Development Bank, the Haitian Medical Association, UNAIDS, and the Global Fund CCM.

The G.O.H., through its various entities, commits to take the necessary reforms and coordination efforts to make the investments in health successful and sustainable. The G.O.H. should continue to engage and maintain constant dialogue with relevant donors to ensure effective and productive coordination among all players around the objective of a unified national health system reinforcing existing coordination platform such as “Table Sectorielle”.

The U.S.G., through its relevant sources of appropriation, existing agreements and agencies operating in Haiti, commits to provide financial and technical resources up to the funding ceiling of these agreements to support the implementation of planned interventions, pending availability of funding. In moving forward, it is expected that G.O.H. contributions will meet host country cost sharing requirements under U.S. foreign assistance programs. Details regarding the G.O.H. financial and in-kind contributions to programs under this PF are to be provided in the PFIP.

A core tenet of US government assistance in Haiti is to support sustainable programming. While the US government has assisted the G.O.H. by directly supporting the delivery of primary health care, HIV/TB and cholera related services, it is the intent of the US government to transfer components of this support to the G.O.H. over time, as central G.O.H. management and financial systems are strengthened.

Shifting the model of support from direct service delivery to technical assistance will allow the G.O.H. to have a more prominent role in the procurement, management and monitoring of development resources, while allowing US government support to be applied through targeted technical assistance.

Following the earthquake in January 2010 and subsequent cholera outbreak in late 2010, the US government provided additional financial assistance to support reconstruction and service delivery efforts. The considerably higher funding levels during these periods were due to one-time supplemental funds related to those natural disasters, and are expected to decline considerably over the life of this PF.

The PF prioritizes the development of benchmarks that will allow activities supported with multiple year strategic planning and budgeting to be strategically transferred to the G.O.H. over time.

VII.

The U.S.G. and G.O.H. intend to develop a PFIP. A joint U.S.G./G.O.H. design team should be created to complete this task. The G.O.H. is taking steps to create a PF Steering Committee to oversee the development of the PFIP and the overall implementation of the PF. The proposed timeline for the development of the PFIP is as follows:

PFIP Development Timeframe table

Week 13 Creation of the G.O.H./U.S.G. design team

Planning of the launching of the PF Steering Committee

Weeks 2 and 3 Launch of the PF Steering Committee

Weeks 4, 5, and 6 Document review

Data collection

Meeting with stakeholders

Consensus on key indicators, targets, benchmarks and reforms

Weeks 7, 8, and 9 First draft of the PFIP

Circulation of the first draft by the design team

Weeks 10 and 11 Presentation of the first draft to the Steering Committee

Integration of Steering Committee comments/inputs into the plan

Weeks 12 and 13 Submission of the final draft of the PFIP

VIII.

Ongoing measurement of progress and evaluation of results will be essential to ensure that investments made through the PF are achieving expected impact. The PF national indicators are based on the 2005- 2006 Demographic Health Survey (DHS) data. The DHS 2012, the 2012 National HIV Antenatal Survey, and the 2012 Violence Against Children Survey will be used as sources to review the PF indicators based on more accurate and updated data. Resources have been set aside to track the progress of implementation closely, to undertake sector evaluations to determine if national goals are being reached as well as micro-level impact evaluations to determine the cost-effectiveness of particular interventions and approaches.

OBJECTIVE I ILLUSTRATIVE KEY

OUTPUTS

EXPECTED CONTRIBUTIONS STEPS REQUIRED

FOR PFIP

DEVELOPMENT

U.S.G. G.O.H. OTHER

Improve G.O.H.’s leadership and oversight of the health sector

Increased percentage of national budget allocated to health from 5.8 percent to closer to the 15 percent Abuja target

Technical assistance to develop an integrated national plan of financing for the health sector.

Technical and financial support for cost studies of the package of services.

Technical assistance to finalize the plan of health workforce development

Financial resources to support the embedding of human resources to reinforce the planning and coordination capacity of the M.O.H. within the assumption that the G.O.H.

intends to progressively pick up these costs.

Technical assistance and financial resources to implement within the M.O.H. a contracting unit

Ministry of Health and Ministry of Finance:

Advocate and plan to progressively increase the percentage of the national budget allocated to health.

Develop national plan to hire, train and retain health workers, including: for new infrastructure projects and to progressively take over the costs for human resources supported by the U.S.G.

Revise the Loi Organique of MSPP to integrate in the MSPP structure a contracting unit

France: support to social protection.

Canada: support to human resources development.

Cuba: deployment of health professionals.

Brazil: training of epidemiologists.

World Bank:

support to the contracting unit.

Refine and complete the list of indicators, key benchmarks and reforms needed.

Finalize the list of policy reforms

OBJECTIVE II ILLUSTRATIVE KEY

EXPECTED CONTRIBUTIONS STEPS

REQUIRED FOR

PFIP

DEVELOPMENT

U.S.G. G.O.H. OTHER

Increase access to quality integrated services with a focus on maternal and child health, nutrition, family planning/ reproductive health, infectious diseases and disabilities

Reduce the under-5 mortality rate from vaccine preventable diseases by 35 percent

Reduce maternal mortality by 30 percent

Reduce the prevalence of tuberculosis by 25 percent

Virtually eliminate mother to child transmission of

HIV

Virtually eliminate the threat of epidemic cholera

Virtually eliminate lymphatic filariasis

Ensure that all eligible HIV+ patients are initiated onto ART

Ensure that 75 percent of Haitians have access to…