Attachment_R_SDSH_I_End_of_Project_Report.pdf

Santé pour le Développement et la Stabilité d’Haïti

(SDSH)

Quality Basic Health Services Support to Haiti

End of Project Report — August 2007 to September 2012 Contract No. GHS-I-00-07-00006-00

Order No. GHS-I-01-07-00006-00

End of Project Report

August 3, 2007 to September 30, 2012

Santé pour le Développement et la Stabilité d’Haïti — Pwojè Djanm Contract No: GHS-I-00-07-00006-00 Order No: GHS-I-01-07-00006-00

Management Sciences for Health 784 Memorial Drive Cambridge, MA 02139 Telephone: 617.250.9500 www.msh.org

Management Sciences for Health – Haiti 27, Frères 31, route de Frères, Delmas 105 En face rue La Pépinière Pétion-Ville, Haiti Téléphone: 509.2510.9901 @ 9902

Website: www.msh.org mshhaiti@mshhaiti.org

Santé pour le Développement et la Stabilité d’Haïti / Pwojè Djanm: End of Project Report, September 30th, 2012. Cambridge MA: Santé pour le Développement et la Stabilité d’Haïti— Pwojè Djanm; Management Sciences for Health, 2012.

This publication has been supported by the United States Agency for International Development (USAID) under Contract No. GHS-I-00-07-00006-00. The contents are the responsibility of SDSH and do not necessarily reflect the views of USAID or the United States Government.

http://www.msh.org/ http://www.msh.org/ mailto:mshhaiti@mshhaiti.org

Table of Contents

Acronyms 4

Executive Summary 6

Introduction 8

Result 1: Reduced Transmission and Improved Treatment of HIV 10 HIV Voluntary Counseling and Testing 10 HIV Palliative Care and Support 11 HIV-Tuberculosis Co-infection 11 Prevention of Mother-to-Child Transmission 11 Antiretroviral Therapy 13

Result 2: Reduced Transmission and Improved Treatment of Tuberculosis 13

Result 3: Contribute to Reduction of Maternal Mortality in Targeted Populations 14

Result 4: Contribute to Reduction of Infant Mortality in Targeted Populations 16

Result 5: Increase Access to and Use of Family Planning Methods 18

Result 6: Strengthen MSPP Public Sector Executive Function 20 Strategic Planning & Decentralization 21 Performance-Based Financing 21 Financial Management 22 Health Information Systems 23

SDSH Responding to Disasters 24 2008’s Hurricane Season 24 January 12, 2010 Earthquake 24

Other Domains 25 Grants Under Contract 25 Strategic Partnerships 26 Infrastructure and Renovation Work 26 Renovation of Four ARV Sites 27

Conclusion 27

Annexes 28

Acronyms

AIDS acquired immunodeficiency syndrome

ART antiretroviral therapy

ARV antiretroviral (medicine)

BCC behavior change communication

CA Contracts and Administration

CBD community-based distribution

CBO community-based organization

CM community mobilization

CONASIS Comité national Comité National d’appui au système d’information sanitaire

CS centre de santé (health center)

DRI Direct Relief International

DTP3 diphtheria, tetanus, pertussis, third dose

FBO faith-based organization

FP family planning

FY fiscal year

GUC grants under contract

HIS health information system

HIV human immunodeficiency virus

MIS management information system

MSH Management Sciences for Health

MSPP Ministère de la Santé Publique et de la Population (Ministry of Public Health and Population)

NGO nongovernmental organization

OFDA Office of US Foreign Disaster Assistance [USAID]

PBF performance-based financing

PCR polymerase chain reaction (HIV test)

PEPFAR President’s Emergency Plan for AIDS Relief

PLHIV People living with HIV

PMP Performance Monitoring Plan

PMS Paquet Minimum de Services

PMTCT prevention of mother-to-child transmission

PNLT Programme National de Lutte contre la Tuberculose

PSPI Paquet de Services Prioritaires Intégrés, RH reproductive health

SADA Service and Development Agency

SCMS Supply Chain Management System (PEPFAR USAID-administered project)

SDSH Santé pour le Développement et la Stabilité d’Haïti

STI sexually transmitted infection

TB tuberculosis

TBA traditional birth attendant

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

USG US Government

VCT voluntary counseling and testing (for HIV)

WHO World Health Organization

WINNER The Watershed Initiative for National Natural Environmental Resources (Project)

ZC Zone Ciblée

Executive Summary

In the past five years, Haiti has endured some of the greatest catastrophes in its history: social and political unrest, hurricanes, mudslides, the devastating January 2010 earthquake, and the cholera outbreak that followed. Throughout, USAID’s flagship health project in Haiti—Santé pour le Développement et la Stabilité d’Haïti (SDSH, Health for Development and Stability in Haiti)—worked toward its goal “to improve the health status of vulnerable populations so that they can become more productive members of society to promote stability within their communities and participate in the economic and social development of Haiti.” To this end, SDSH increased access to basic health care services for nearly half of the national population through a network of 28 local nongovernmental organizations (NGOs) that operate 81 private health facilities and through 79 public-sector sites in 33 geographical areas (target zones) known as zones ciblées (ZCs).

Management Sciences for Health (MSH) implemented SDSH from August 2007 through September 2012 using innovative performance-based financing (PBF) agreements, technical assistance, and integrated health care services rooted in the community. The network—which began and grew under USAID-funded Haiti Health Systems 2004 (HS-2004) and Haiti Health Systems 2007 (HS-2007)—has delivered services to some of Haiti’s most vulnerable people, virtually uninterrupted by the countless challenges the country has faced.

Each year, SDSH has helped an average of 95, 838 people receive HIV tests and learn their status, has made it possible for 12,649 women on average deliver their child with assistance from a facility-based, skilled provider, and has reached an average of 489,338 children with nutrition programs. In the SDSH network, upwards of 89 percent of infants under one were fully vaccinated in four of the program’s five years. In the final project year, SDSH increased the number of sites offering antiretroviral therapy (from 6 to 8) to help mitigate the impact of HIV in Haiti.

To help decentralize health care services and better manage health sector resources, SDSH strengthened the capacity of the Ministère de la Santé Publique et de la Population (MSPP, Ministry of Public Health and Population) at the central and departmental levels to perform critical functions such as strategic and work planning, financial management, and clinical supervision. SDSH mobilized strategic private partners to provide more than US$86 million worth of lifesaving equipment and commodities to the health facilities in the communities served by the US$81.4-million project’s network. Contributions range from biosand filters that provide schoolchildren with potable water to operating room equipment that allows health facilitates to provide women with emergency obstetric care.

SDSH staff and partners suffered personal and professional losses during the unprecedented and devastating disasters that marked the project cycle, but managed to succeed in the face of adversity.

The unusually destructive hurricane season and lingering floods of 2008 left 160,000 without shelter. Although not designed as a relief project, SDSH’s network of facilities and community health agents helped to efficiently deliver donations from small and large relief organizations or agencies to people and areas in need. SDSH also helped the MSPP coordinate its response, including a nationwide epidemiological surveillance plan, water treatment, and the mobilization of disinfection and fumigation specialists to help control vector-borne and waterborne diseases.

The devastating earthquake of 2010 killed more than 230,000 people and displaced more than 1.5 million. SDSH staff quickly resumed project operations from an employee’s home to ensure support to partner NGOs and network sites. Some staff members worked in partner health facilities delivering emergency clinical services, and others mobilized to conduct a detailed post-earthquake needs assessment that provided the basis for SDSH’s contingency plan to reinforce the partners’ capacity. SDSH also received several direct grants from partners to provide health services to displaced persons, support reinforcement of damaged infrastructure, assess health services provision in the camps, and provide badly needed pharmaceutical supplies.

Years of generous support and lasting commitment to Haiti have impacted the lives of some of the country’s most underserved populations. SDSH, its predecessor projects, and the health facility network they supported have been critical to Haiti’s steady and lasting improvements in the health system across public and private sectors.

Introduction

The Santé pour le Développement et la Stabilité d’Haïti (SDSH, Health for Development and Stability in Haiti) Project was USAID’s flagship health project from August 2007 through September 2012. SDSH’s overarching goal was “to improve the health status of vulnerable populations so that they can become more productive members of society to promote stability within their communities and participate in the economic and social development of Haiti.” To this end, SDSH increased access to basic social services for nearly half of the national population. SDSH supported basic health care service delivery in each of Haiti’s ten departments1 through performance-based financing (PBF) subcontracts with 28 local nongovernmental organizations (NGOs) that operate 81 private health facilities, and with the public sector delivery services through 79 public sites in 33 geographical areas (target zones) known as zones ciblées (ZCs).

SDSH helped provide access to the Paquet de Services Prioritaires Intégrés (PSPI, Priority Package of Integrated Services), a basic package of integrated health services, for 4,460,896 million people in Haiti’s ten departments. The project’s first five results areas were developed around components of this services package: improvements in (1) HIV prevention, care, and treatment; (2) tuberculosis prevention, detection, and treatment; (3) maternal health for reduced maternal mortality; (4) child health for reduced infant mortality and malnutrition; and (5) access to and use of family planning, including long-term and permanent methods. Because SDSH worked through private-NGO and public health care facilities, the project’s sixth result area focused on improving the ability of the Ministère de la Santé Publique et de la Population (MSPP, Ministry of Public Health and Population) to function more effectively at the central and departmental levels.

1 Haiti is divided into ten administrative units called departments.

Figure 1: SDSH Results Framework

In support of these results areas, SDSH conducted a number of activities in other domains: grants under contract (GUC) to community-based organizations for grassroots, health-related initiatives; strategic partnerships with private-sector partners to leverage additional resources in pursuit of shared health goals; capacity building to improve financial and administrative systems strengthening at the facility, departmental, and central levels; and infrastructure improvements creating the space for health care delivery and management.

USAID awarded the three-year SDSH project to Management Sciences for Health (MSH) in August 2007. The project was subsequently extended, increasing the life-of-project funding from US$42.5 million to US$81.4 million and changing the completion date to September 30, 2012.

SDSH built on the successes and lessons learned from earlier MSH projects, namely Haiti Health Systems 2004 (HS-2004) and Health Systems 2007 (HS-2007). SDSH was differentiated from earlier projects in part by its heightened focus on public-sector institutional strengthening and capacity building, and its expansion of PBF—a model that has proven successful with private-sector NGO partners—to the public sector.

Result 1: Reduced Transmission and Improved Treatment of HIV

Exacerbated by decades of poverty and instability, Haiti’s HIV prevalence peaked at 3.6 percent in the mid-1990s and has been approximately 2 percent since the early 2000s. The beginning of the millennium brought awareness, education, and affordable treatment through efforts including those of the MSPP, the US President’s Emergency Plan for AIDS Relief (PEPFAR), and various donors. While lower than many countries in sub-Saharan Africa, Haiti’s HIV prevalence is the highest in the western hemisphere and has been devastating to thousands of families across the country.

HIV Voluntary Counseling and Testing

Combating stigma and inadequate access, SDSH expanded facility-based voluntary counseling and testing (VCT) for HIV to supported public and private facilities (at least 29 sites each year and 40 sites in the final project year), and provided testing through mobile clinic outreach and events such as Carnaval and fêtes champêtres (annual celebrations) in cities and villages across Haiti. SDSH-supported providers routinely offered HIV testing during other services such as tuberculosis care and treatment, family planning, and maternal health visits. SDSH made it possible for an average of 95,874 people and 50,662 pregnant women to learn their HIV status every year. In Year 5 alone, 102,305 people and 55,682 pregnant women learned their HIV status. Empowered with this knowledge, individuals could make decisions to protect themselves, their partners, and their children, accessing care and treatment as necessary.

Each site has a lab technician able to perform rapid HIV tests, and who was trained by the USAID-funded Supply Chain Management Systems (SCMS) project to manage stock and medicines. SDSH also supported renovations and provided technical assistance to sites in order to improve overall service organization, patient flow, and resource availability.

Figure 2: Number of people in the SDSH network who received counseling and testing for HIV and received their test results

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HIV Palliative Care and Support

SDSH worked with support groups and other community organizations to reduce HIV-related stigma and discrimination in communities and bring people living with HIV and their children into supportive services such as nutrition, income-generation, and assistance for orphans and vulnerable children. Through networked facilities, patients and families were also linked to psychosocial services and home-visits from social workers, health agents, and other people living with HIV. SDSH facilities provided palliative care to a total of 20,481 individuals at the end of the PY5 period.

During the nation-wide responses to Haiti’s devastating 2010 earthquake and 2010–11 cholera outbreaks, community palliative care and support (including assistance to orphans and vulnerable children) dwindled as providers struggled to meet more immediate patient needs. In June 2011, SDSH re-launched community palliative care interventions. Representatives of 26 partner institutions participated in a two-day workshop to refocus their roles and work, based on lessons learned and taking into account the new context. A training workshop was also organized with the support of Measure Evaluation to enable SDSH partners to use the community-based information system for the monitoring and reporting of their activities.

HIV-Tuberculosis Co-infection

Haiti’s overwhelming tuberculosis burden—one of the highest in the western hemisphere—is particularly concerning given the number of people living with HIV (PLHIV) also infected with tuberculosis or at risk of Co-infection. (WHO estimates that one-third of the PLHIV globally are also infected with tuberculosis) In the first years of SDSH, other donors and programs were expected to provide tuberculosis services and inputs for patients in SDSH-network catchment areas (see Tuberculosis section). These activities did not come to fruition but SDSH tried to make contributions within its mandate.

SDSH network sites integrated testing and treatment referrals for tuberculosis, and their staff were trained in detecting the two diseases. The percentage of tuberculosis patients who were tested for HIV and received their results increased from 47 percent to 66 percent from year one to year five.

Prevention of Mother-to-Child Transmission

Prevention of Mother-to-Child Transmission (PMTCT) challenges in Haiti include those common in most developing countries: human resource shortages (e.g., most health centers do not have a nurse midwife); powerful stigma, taboos, and traditional beliefs associated with HIV;

and logistical and technical barriers to a formal and functional referral and counter-referral system at institutional and community levels. SDSH employed three major strategies to improve

PMTCT in network facilities: (1) strengthen linkages between institutional and community levels to improve follow-up of pregnant and lactating women identified as HIV-positive; (2) increase access to maternal health through outreach such as mobile clinics;

and (3) support MSPP in the update of national PMTCT norms and rolling those out through SDSH-network facilities.

Community health agents and traditional birth attendants (TBAs) were critical in reaching women at the community level, encouraging HIV testing and maternal care (which includes PMTCT), and developing birth and adherence plans for HIV-positive mothers. SDSH network facilities made great strides in helping pregnant women learn their HIV status, particularly through outreach and HIV testing during prenatal visits. In PY5, 55,682 pregnant women learned their HIV status and 795 HIV-positive pregnant women received PMTCT services through the SDSH network. On average, every year 50,662 pregnant women learned their HIV status, and 614 who tested positive received PMTCT services at one of the SDSH network sites. At the end of September 2012, 31 SDSH network sites offered the minimum package of PMTCT according to national and international standards—well above the target of 22.

The project offset the costs associated with prenatal care visits (striving for the standard four appointments) and institutional births by subsidizing transport fees incurred by pregnant HIV-positive women, providing direct support to the birthing institutions, and giving birth attendants a small sum to offset costs they faced—for example, the cost of their time and direct costs associated with referrals and follow-up of the mother and newborn. When HIV-positive women give birth in facilities, providers can help ensure that both mother and newborn receive antiretroviral drugs to prevent HIV transmission.

To reach HIV-positive mothers who gave birth at home, SDSH worked with TBAs to ensure that they could administer antiretroviral medication to HIV-positive mothers and their exposed infants. These matrons also checked on the health of mothers and newborns—regardless of their HIV status or exposure—during visits in the first three days after birth. All HIV-positive pregnant women were strongly encouraged to choose an accompagnateur—a traditional birth attendant, community health worker, family member, or friend—to accompany the pregnant woman to prenatal health center visits, help administer prophylaxis medication to the mother and help bring the newborn in for a follow-up visit no more than 72 hours after birth.

Detecting HIV in Newborns An important aspect of preventing mother-to-child transmission and the first step in improving health outcomes for HIV-positive newborns is early HIV testing for infants known to be exposed to the virus. Since an infant carries its mother’s antibodies for as long as 18 months, a test other than the adult HIV test is necessary for newborns. A partnership between SDSH and Caris Foundation made these infant tests possible at network sites offering antiretroviral therapy and prevention of mother-to-child transmission services.

The project also provided technical assistance to the MSPP to revise PMTCT standards in PY5.

The Direction Sante de la Famille (Directorate of Family Health) is preparing to print and disseminate these standards as of project close-out in September 2012.

Antiretroviral Therapy

SDSH was designed to focus on HIV prevention and care, but the practical advantages of and critical need for comprehensive antiretroviral treatment (ART) were evident by 2012 when the project, with USAID encouragement, expanded its treatment centers from 6 to 9 in just six months. To improve the quality of care —particularly follow-up—network ART patients receive, SDSH collaborated with GHESKIO to provide trainings and refreshers to health providers, and with SCMS to ensure that medicines and related commodities were continuously available to patients. As a result of these combined interventions, 3,429 people received antiretrovirals from SDSH-network facilities at the end of the PY5 period.

SDSH also strengthened referral systems within the network and collaborated closely with community organizations and resources to provide critical services to HIV patients outside of the clinic. Links with assistance included services such as psychosocial care, support groups, income-generation, clean water, or nutrition counseling.

Result 2: Reduced Transmission and Improved Treatment of Tuberculosis

Haiti bears the largest tuberculosis burden of any country in the Caribbean region: in 2010, the prevalence was 314 per 100,000 people (compared to an average regional prevalence of 36 per 100,000).2 PLHIV are particularly vulnerable to contracting the disease. Once contracted, mortality rates among HIV-positive patients are considerably higher than those who are HIV negative. SDSH was designed in 2007 to support DOTS implementation for the Programme National de Lutte contre la Tuberculose (PNLT, the National Program to Fight Tuberculosis) by helping to ensure tuberculosis prevention, detection, and treatment in the SDSH network. PNLT would supply medicine, training, and equipment to network facilities. At the time, PNLT had substantial Global Fund support, but that support ended in 2010 and no stakeholders were able to fill that gap in the remaining project years. (See the HIV-Tuberculosis Coinfection section for other SDSH efforts related to tuberculosis.)

SDSH worked to mitigate the impact of HIV-tuberculosis coinfection by:

training personnel for HIV-tuberculosis detection and case management;

integrating testing and treatment referrals for tuberculosis into supported sites;

2 WHO Country Health Profile: Haiti. http://www.who.int/countries/hti/en/ Accessed 26 September 2012.

http://www.who.int/countries/hti/en/ improving laboratories and the supply system for tuberculosis drugs;

addressing tuberculosis- and HIV-related cultural barriers and stigma using behavior change communications and community mobilization.

To this end, SDSH trained 52 staff to screen for HIV and tuberculosis and 27 providers in

DOTS.

In May 2012, SDSH participated in the joint evaluation of Haiti’s TB program effectiveness in collaboration with the PAHO team. Subsequently and with the support from the MSH Global lead on TB, SDSH worked with PNILT and USAID to review the strategies for TB infection control and developed a plan to address case detection and care in Haiti on TB and TB/HIV in the SDSH network. This plan will inform the work on TB during the SDSH II contract.

Result 3: Contribute to Reduction of Maternal Mortality in Targeted Populations

Maternal mortality in Haiti is 300 per 100,000 live births, as compared to 85 across Latin America and the Caribbean.3 Many factors contribute to this dire reality, including poor maternal nutrition, closely spaced births, and inadequate access to medical care throughout a woman’s reproductive life. Yet a number of cultural and behavioral barriers inhibit many women in Haiti from seeking the care they need before, during, and after pregnancy. SDSH worked to overcome these barriers by (1) improving access to and uptake of prenatal and postnatal care, (2) increasing the number of institutional births and the number of attended home births, and (3) expanding access to emergency obstetric care.

To improve access to and uptake of prenatal and postnatal care, SDSH supported intense community mobilization, improved linkages between community health workers and health facilities, revitalized training activities for traditional birth attendants, and encouraged mobile clinics. From the first to the final project year, the percentage of pregnant women in supported facilities that had their first prenatal visit during their first trimester increased from 28 percent to 39 percent; and the percentage of pregnant women that had at least three prenatal visits during their pregnancy increased from 42 percent to 49 percent. Additionally, an average of 45,249 women every year received a home visit from a community health agent or birth attendant within 72 hours of delivery. During this visit, providers made sure that both

3 Population Reference Bureau. The World’s Women and Girls 2011 Data Sheet.

Meeting the Needs of Expectant Mothers The smallest, seemingly insignificant thing can inform a patient’s life-or-death decision.

When a recent sociological and behavioral survey revealed that many pregnant women said they did not plan to deliver in a health facility because they couldn’t afford the dignity of a clean robe or simple sandals to wear after giving birth, SDSH worked with its partner Direct Relief International to provide both in prenatal kits for expectant mothers. In 2008, total institutional deliveries were at 13%. By September 30, 2012, they reached 15%.

mother and newborn were healthy and received antiretroviral medication if the mother was HIV positive.

Skilled birth attendants can identify delivery complications before they become irreversible and help women in labor seek emergency obstetric care, improving birth outcomes for mothers and their newborns. To this end, SDSH encourages all women to deliver in health facilities with a skilled birth attendant. Ninety-two percent of pregnant women in SDSH network facilities had birth plans (a statement of how the mother would like her birth to proceed) in the last project year, up from 10 percent at the end of the first project year and readily surpassing the PY5 target of 75 percent. More than 63,000 women gave birth with assistance from a facility-based skilled attendant during SDSH’s five years (see Figure 3). Acquired knowledge, social support, and modest stipends to cover travel costs for pregnant women and birth attendants helped increase institutional deliveries for pregnant women under SDSH.

Recognizing that most women in Haiti deliver at home and have limited access to other options, SDSH promoted attended home births as an option for those not able to give birth at a health facility. The program worked with MSPP to recognize the valuable role traditional birth attendants can play in maternal and child health, and helped expand traditional birth attendant skills. These attendants can develop birth plans with pregnant women, recognize signs of a potentially difficult birth, and encourage these women to deliver in health facilities. SDSH also made birth kits available to improve the quality of attended home births. More than 268,000 women had a trained traditional birth attendant present during labor and delivery during the project’s five years.

Physical access to health facilities is an obstacle for many patients across Haiti, yet few patients feel an arduous journey to a health facility as acutely as a mother in a difficult or complicated labor. To improve transportation options for women in need of emergency obstetrical care, SDSH promoted context-specific solutions. In some communities, members with access to a vehicle agreed to share responsibility for transferring mothers in labor to facilities. SDSH also supported the purchase or maintenance of boats for communities on Haiti’s remote islands. In one high-profile example, SDSH, with a special authorization from the Mission Director, procured a rapid boat to provide ambulance services from the very remote Ile-a-Vache public health center to the hospital on the mainland in Les Cayes.

Figure 3: Number of deliveries with assistance of a facility-based skilled birth attendant

Figure 4: Number of deliveries with assistance of a trained traditional birth attendant

Result 4: Contribute to Reduction of Infant Mortality in Targeted Populations

Children in Haiti face a multitude of preventable and treatable childhood diseases such as measles, diarrheal disease, and pneumonia, and the country’s poverty is too often reflected in the poor nutritional state of young children. SDSH promoted and delivered comprehensive under-five immunizations, nutritional counseling and support, and hygiene education.

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Through community outreach programs, SDSH helped train 152,744 caregivers in diarrhea prevention and 152,236 in diarrhea management (exceeding each year’s targets). The project also trained health providers and agents at facility and community levels to prevent, identify, and manage other common childhood illnesses. Network facilities provided antibiotic treatment to thousands of children with pneumonia, surpassing targets in project year two through five*.

The SDSH network also maintained an annual average of 350,860 children under the age of five receiving Vitamin A supplementation.

SDSH inherited HS-2007’s successful vaccination coverage but also brought new facilities into the network specifically because their communities were underserved (the zones ciblées, or targeted zones). This decreased the average in the first project year, but SDSH’s performance-based financing, technical assistance, and strategic partnership support quickly increased vaccination coverage beyond its initial level, and largely maintained it even through the January 2010 earthquake and the cholera outbreak of 2010–2011.

After Year 1, vaccinations for children less than one years of age across the SDSH network were at 89 percent or more through the end of the project.

SDSH interventions made great strides in providing essential child health services such as immunization and IMCI, and strived to maintain those services during the intense cholera response in 2010 that pulled resources and attention from primary child health care. In fact, the community network and the existing knowledge and mobilization around diarrheal prevention and care provided a critical foundation for the cholera response.

Activités Intensives pour la Santé de l'Enfant 2012

To reinvigorate immunization results in 2012, SDSH supported the MSPP in organizing and implementing vaccination campaigns with support from USAID, UNICEF, PAHO/WHO, and CIAD. One highlight of these efforts was the 2012 Intensive Child Health Activities (Activités Intensives en Santé Infantile – AISE-2012) in April/May 2012. SDSH participated in inter-agency consultation meetings and helped organize field activities through Departmental Directorates. The project also mobilized 1,544 community health agents from across the 160-facility SDSH network;

the health agents’ contributions were critical to the planning and provision of services during AISE-2012. SDSH also facilitated the donation of five million syringes through Direct Relief International.

*A target for this indicator was not set in PY1

Figure 5: Percentage of children 0–11 months, fully vaccinated

Result 5: Increase Access to and Use of Family Planning Methods

Across Haiti, women suffer the health risks of narrowly spaced pregnancies and families struggle to provide sustenance and opportunity to their children. Family planning can ease the economic burdens and help improve the health of women and their children. To expand availability and voluntary uptake of family planning, SDSH worked to increase knowledge of and access to modern family planning services through community outreach, behavior change communications, and provider education. The project also made family planning services and commodities more accessible through efforts such as mobile clinics and community-based distribution (CBD). SDSH rolled out CBD to the entire project network, and advocated for health agents to provide injectable contraception, making longer-lasting protection available as close to home as possible.

At health facilities, SDSH improved service quality by building the capacity and knowledge base of providers, integrating services, and helping sites maintain a reliable stock and wide range of family planning methods. The number of network sites that offered at least five modern methods of family planning increased from 16 percent to 51 percent over the five-year course of the project. SDSH coordinated closely with the MSH-implemented Leadership, Management and Sustainability (LMS) program that manages family planning commodities for sites in Haiti. In one measure of retention in Year 5, 93 percent of Depo-Provera clients received their next shot on schedule, suggesting accessible services, informed clients, and reliable supplies.

At the outset of SDSH, NGO facilities (previously supported by HS-2007) had contraceptive use rates four times higher than the public sector sites (new to the network and PBF). By the end of SDSH, the rate in public sites improved, and the entire network provided 289,834 couple-years

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Actual (%) protection and averaged 31 percent contraceptive use, including nine percent of clients using long term or permanent methods.

SDSH supported MSPP production of several posters and technical guidelines on topics relating to family planning side effects, management of obstetric emergencies, PMTCT, and syphilis. The documents were validated by the Department of Family Health as of project close-out.

Posters Initial prenatal assessment

Targeted prenatal consultation

Management of severe preeclampsia

Guideline for the management of preeclampsia

Active management of third stage of labor

Reanimation of the newborn

Management of shock

Protocol for the management of shock

Handling of instruments in the context of infection prevention

Technical Guidelines Sheets Self-breast exam

Spotting under combined oral contraception

Migraine under combined oral contraception

Hypertension under combined oral contraception

Amenorrhea under combined oral contraception

Spotting under oral progesterone contraception

Amenorrhea

Bleeding under injectables

Headache under injectables

Amenorrhea under injectables

Bleeding with implants

Sore head with implants

Amenorrhea under implants

Cramping and pain with intrauterine device

Figure 6: Percentage of people of reproductive age using modern methods of contraception for family planning

Result 6: Strengthen MSPP Public Sector Executive Function

In the years preceding SDSH, social and political instability moved many donors and their projects to work around rather than in collaboration with the Government of Haiti and the MSPP. SDSH predecessors HS-2004 and HS-2007 positioned themselves as technical partners to public and private stakeholders in the health sector and distanced themselves from political parties or administrations. As the political context began to stabilize, SDSH continued and expanded the work of HS-2007 by partnering with the MSPP and providing technical and organizational support to the ministry at central and departmental levels. By strengthening the organizational capacity of the MSPP—in particular its executive functions—SDSH supported health system decentralization and helped to reinforce the ministry’s leadership and legitimacy.

In collaboration with the MSPP and taking into account national priorities, SDSH supported four main areas of MSPP executive function: (1) strategic planning and decentralization, (2) performance-based financing, (3) governance and financial management, and (4) health information systems (HIS). In these domains, the project interventions were carried out at central and departmental levels as described below.

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SDSH Support for National Policy Development SDSH supported MSPP in planning and executing efforts to streamline technical and policy documents such as behavior change communication and community mobilization (BCC/CM) for the National Program to Fight Sexually Transmitted Infections (STIs) and HIV & AIDS, vaccination promotion for the World Health Organization’s (WHO’s) Expanded Program on Immunization (EPI), and contributing to the updated Repositioning Family Planning Framework.

Strategic Planning & Decentralization

Improved departmental-level capacity to manage resources and oversee service delivery at the facility level is a cornerstone of successful decentralization of health services in Haiti. SDSH expanded on HS2007’s “departmental strategy”—an approach to build capacity and offer mentoring to department-level staff—by placing SDSH staff in each of the 10 departmental directorate offices. These staff worked shoulder-to-shoulder with and offered training and technical assistance to their MSPP counterparts in clinical oversight, strategic planning, financial management, and other management areas. The support helped MSPP staff to develop and implement strategic plans, to purposefully coordinate donors and other health providers, and to participate in joint clinical supervision.

Resources and capacity at the departmental level vary greatly, but SDSH saw improvements in most areas by the end of the project in September 2012:

All 10 departments were implementing their operational plan.

Seven (one more than the six originally targeted) health departments had a mechanism to coordinate health-related activities planned by donors in their jurisdiction.

All 10 departments were implementing service-delivery supervision plans for their facilities.

These efforts helped make the most of critical donor resources and are precursors to sustainable delivery of high-quality services throughout Haiti. The SDSH Project also supported key governance activities by the departmental directorates such as work planning sessions, supervision visits, training, and coordination meetings.

As part of institutional capacity building, SDSH procured computers, printers, and copiers for the ten Departmental directorates towards the end of the project, to continue strengthening MSPP’s financial management system at the Departmental level.

Performance-Based Financing

To improve primary health care in a system lacking both resources and the ability to deliver adequate services, MSH piloted PBF in 1999 under the USAID-funded Haiti Health Systems 2004 (HS-2004). Funding for facilities was often inadequate, and many well-intentioned NGOs lacked the capacity to effectively plan and manage their meager resources. Rather than paying for inputs or making grants to institutions with minimal accountability, PBF tied reliable funding to verifiable reporting and actual services delivered. By the end of SDSH in late 2012, the project managed performance-based contracts with 28 NGOs running 81 health care facilities across Haiti’s ten departments. A similar performance-based mechanism was put into place in March 2010 to fund 79 public-sector facilities in the designated zones cibleés.

An independent study commissioned by MSH headquarters confirmed that PBF helped to improve health care delivery in Haiti.4 Examining data (2008 to 2011) from 27 NGO-managed facilities in the SDSH network, the study found that

Performance-based incentives delivered by SDSH increased the quantity of key services by 39 percent more than training and technical assistance alone;

The increase in services for children younger than one year and for pregnant women were statistically significant at a range of 1.7 to 2.2 times baseline rates;

Incentives were more effective and less expensive than training and technical assistance alone.

Over the years, providers and managers noted that PBF influenced a shift in how they approached their work, focusing on results, cost-effectiveness, and accountability, and emphasizing building capacity to maintain a higher level of sustained functioning. PBF helped each site receive the technical and material resources that it needs to deliver crucial results.

Additionally, the collection and careful documentation of patient data required for PBF reporting also helps providers improve care for their patients and supports health information systems.

The MSPP plans to make PBF a national policy and is looking to the SDSH model with increased emphasis on quality.

SDSH staff have become globally respected experts for their work designing and implementing PBF in Haiti. In July 2010, SDSH staff participated in a national conference on PBF organized by MSPP with OMS/PAHO, the World Bank, and USAID. SDSH presented the experiences, alternative models, and lessons learned during more than 10 years of USAID-funded health programs in Haiti. A film on MSH PBF experience in Haiti was presented in September 2010 at a meeting organized by the Clinton Global Initiative (CGI) in Haiti, and also at the CGI annual meeting in New York City.

Financial Management

Decades of underfunding and neglect had left the MSPP with limited systems or skills to effectively manage even modest funds. MSH began providing financial management support to MSPP (central and departmental levels) under HS-2007, and expanded those efforts under SDSH. With improved financial management systems, MSPP will be better positioned to directly receive US government funding and to successfully manage performance-based contracts with public and private health facilities; these are both near-term MSPP goals.

4 Zeng, W., M. Cros, K. Dilley, and D.S. Shepard. “Impact of performance-based financing on primary health care services in Haiti,” Health Policy and Planning (forthcoming).

SDSH helped the MSPP to improve its overall financial systems, to start using appropriate accounting software, and to train staff to better manage and audit funds. The central MSPP office and nine of the ten departments were equipped with modern financial and accounting management software systems (Peachtree and QuickBooks, respectively). Furthermore, the SDSH supported the development of a financial management manual. These investments will help the Ministry of Finance in the process of standardization of financial management systems for the MSPP.

Toward the end of SDSH, the project supported the MSPP to conduct a cost and revenue analysis for the basic package of essential health services in Haiti. This effort was designed to help the MSPP understand the actual costs of basic health services, and to provide a rationale for evidence-based budgeting and financing and management of health care service delivery through performance-based contracting mechanisms. Preliminary SDSH findings revealed a wide variation of data, much of which seemed to be linked to differing and hard-to-predict health uptake in different populations. SDSH gave the data set to MSPP for further analysis. To support MSPP participation in or leadership of future costing exercises, SDSH trained 10 MSPP staff to use the CORE Plus costing tool. Support to the MSPP is expected to continue under the Leadership, Management and Governance (LMG) project that is also funded by USAID and implemented by MSH, and will help the MSPP roll out nationwide PBF and enable the public sector to improve social services through results-based management.

Health Information Systems

To support the MSPP’s health information systems (HIS)—a key component of any functional health system—SDSH worked at central, departmental, and facility levels. SDSH played an important role in the central Comité National du Système d’Information Sanitaire (CONASIS, or Committee for the Support of the Health Information System). The program helped the MSPP to design indicators and tools (for data collection and reporting), reporting plans, and data analysis methods; SDSH also supported MSPP in drafting an HIS manual for Haiti. Within the SDSH network, the project provided program-specific trainings to staff so they could better collect and report data, and make data-driven decisions at site and departmental levels.

In response to changing demographics such as population shifts due to the January 2010 earthquake, SDSH modified the application used to track service delivery results and worked with Departmental Technical Advisors and NGO and zone ciblees partners to adjust Year 5 project plans (targets, payment schedules, etc.) accordingly. The project also collected GPS coordinates for all facilities to accurately map the SDSH

USAID and SDSH conducted a joint data quality assessment in PY5 and observed no major weaknesses that could impact the reliability of SDSH network data. Reliable data helps decision-makers at all levels better serve patients through improved clinical care, site management, supervision, budget allocations, and improved national guidelines and policies.

network. The SDSH network produced high-quality data for the HIS: monthly data reports from each site (required for PBF) fed into the project’s monthly progress reports and into the nationwide HIS. The SDSH network provided nearly half of Haiti’s population with access to health care, so these contributions to the national data set are noteworthy.

SDSH Responding to Disasters

Development work in Haiti requires implementers to plan for the unexpected and respond to the unimaginable. During the SDSH project, three events challenged our work as rarely—if ever— before.

2008’s Hurricane Season

During a few short weeks in Haiti during 2008, four back-to-back hurricanes and tropical storms—and lingering floods—hit Haiti, leaving an estimated 160,000 people without shelter, and severely damaging already-fragile infrastructure. Although not designed as a relief project, SDSH’s network of facilities and community health agents helped to efficiently deliver donations from small and large relief organizations or agencies to people and areas in need.

SDSH also helped the MSPP to coordinate its response, including a nationwide epidemiological surveillance plan, water treatment, and the mobilization of disinfection and fumigation specialists to help control vector-borne and waterborne diseases.

January 12, 2010 Earthquake

January 2010’s devastating earthquake in Haiti killed more than 230,000 people, displaced more than 1.5 million, and affected the entire nation. Already-fragile infrastructure was destroyed and demands for emergency trauma and mental health services placed additional burdens on health facilities. Catchment populations also changed dramatically as displaced citizens moved into camps or migrated outside the earthquake impact zone. The SDSH network was forced to adapt almost overnight to dramatic changes in their patient population and service demands in order to quickly re-establish health delivery systems. USAID was not able to provide additional funding to SDSH specifically to respond to the emergency.

The SDSH office was damaged in the quake and SDSH staff—facing deep personal losses and trauma themselves—quickly resumed project operations from an outdoor porch at one employee’s home to ensure that partner NGOs and network sites would have the support they needed. Some staff members worked in partner health facilities delivering emergency clinical services, and others mobilized to conduct a detailed post-earthquake needs assessment of nearly all SDSH sites. This rapid assessment provided the basis for SDSH’s contingency plan to reinforce the partners’ capacity and by March 2010, the team began to see improvements. SDSH also received several direct grants from partners to provide health services to displaced persons, support reinforcement of damaged infrastructure, assess health services provision in the camps, and provide badly needed pharmaceutical supplies.

Along with the staggering loss, the earthquake also served as a much-needed call to action.

Health care reform could no longer be delayed and needs assessments called for billions of dollars to rebuild infrastructure, strengthen human resources, and secure supply chains. SDSH built—and SDSH II will continue to build—on this vital chance to make change.

Other Domains

Grants Under Contract

Envisioned as small grants (about US$5,000) for community-identified and led initiatives that support health care services and healthy behaviors—and, by extension, strengthen decentralization—the grants under contract initiative built on project community mobilization efforts that reached back as far as HS-2004. The program started slowly while USAID explored mechanisms through which to issue the funds and SDSH worked with communities and MSPP representatives at central and departmental levels to build consensus and raise awareness of this new program. Additionally, the 2010 earthquake put all nonessential activities on hold temporarily. SDSH made eight awards to umbrella organizations (reaching 43 community-based organizations across eight communes) under the first phase (April to September 2011) and 12 under the second (February 2012); as of September 2012, 142 small community organizations in 20 communes participated in the grants under contract program and received a total of

US$532,320.

Popular grant initiatives included efforts to improve access to potable water and sanitation; to make physical improvements at health centers; and to support community education about hygiene and HIV prevention. Unique programs included a cervical-cancer screening program in Corail and the construction of 50 market tables to allow for more hygienic displays in a Petit Trou de Nippes fish market.