Attachment_W_-_SDSH_Annual_Report_2010.pdf

This publication was produced by Management Sciences for Health for review by the US Agency for International Development (USAID).

The views expressed herein do not necessarily reflect the views of USAID or those of the United States Government.

Projet Santé pour le Développement et la Stabilité d’Haïti — SDSH Annual Progress Report — October 1, 2009–September 30, 2010

Attachment W - SDSH Annual Report 2010

PROJECT

Projet Santé pour le Développement et la Stabilité d’Haïti — SDSH is funded by the US Agency for International

Development (USAID), through the US Government’s President’s Emergency Plan for AIDS Relief, and is operated by Management Sciences for Health under Contract No. GHS-I-01-07-00006-00.

Recommended Citation Management Sciences for Health. 2010. Projet Santé pour le Développement et la Stabilité d’Haïti — SDSH Annual

Report, October 2009–September 2010. Cambridge, MA: USAID | SDSH Project.

Abstract This annual report documents the activities of the Projet Santé pour le Développement et la Stabilité d’Haïti —

SDSH (October 1, 2009– September 30, 2010). Key sections highlight the major activities for each strategic performance objective—the activities, results, accomplishments, the implementation challenges, lessons learnt, and recommendations.

The contents and conclusions presented in this publication are the responsibility of Management Sciences for

Health and do not necessarily reflect the views of the US Agency for International Development or the United

States Government.

USAID | SDSH Project

27, Delmas 105, route de Frères, bloc Frères 31

Pétion-Ville, Haiti

Telephone: 509.2510.9901 @ 9904

Management Sciences for Health

784 Memorial Drive

Cambridge, MA 02139-4613 USA

Phone: 617 250-9500 www.msh.org http://www.msh.org/

Annual Progress Report

Projet Santé pour le Développement et la Stabilité d’Haïti — SDSH ii

Table of Contents Table of Contents ........................................................................................................................................................................................................... ii

Acronyms .......................................................................................................................................................................................................................iv

Executive Summary

About the Project: Year Three

NGOs and MSPP Implementing Partners

Success Highlights

Performance-Based Financing Introduced with MSPP

MSPP Department Level Improves Management Functions and Financial Systems

Management Information Systems Strengthened at Central and Departmental Levels

Steady Progress in Maternal Health, but Challenges Remain

Family Planning, Use of Modern Methods within the SDSH Network Attains 30 Percent—Remarkable Progress!

Community-Level Project Plans Developed and Advances Made in Nutrition and Diarrhea Education

Greatly Improved Immunization Rates, Treatment of Acute Respiratory Illness, and Diarrheal Management Capacity Achieved through

Community-Based Services

SDSH Network Combats Malnutrition among Children and Pregnant/Lactating Women

HIV and AIDS and Tuberculosis: Integrated Services Increase

Sustained Results in VCT Provided by 32 NGO Service Delivery Sites

Palliative Care: 14,212 Are Living Positively with Support from SDSH-Supported Sites

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PMTCT Targets Met and Surpassed in SDSH-Supported Sites

Tuberculosis: Overall Results Are Disappointing

After January 12, 2010: SDSH Earthquake Response

After the Earthquake: SDSH Regroups, Responds, and Focuses on Rebuilding

SDSH Focuses on Re-Establishing Functional Health Service Delivery

SDSH Interventions Revitalize the Integrated Basic Package of Services in Project Sites

SDSH Participates in Coordination of Earthquake Response and Support to the MSPP

SDSH Participates in Coordination of Earthquake Response and Support to the MSPP

SDSH Partnerships Provide Resources for More Substantial Project Engagement in Emergency Response and Reconstruction

Annex: Evolution of the Results of the SDSH Project, October 2009–September 2010

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Acronyms

AME-SADA African Methodist Episcopal Service and Development Agency

ART antiretroviral therapy

ARV antiretroviral

BCC behavior change communication

CONASIS Committee of Support for the Health Information System

CYP couple years of protection

DRI Direct Relief International

FP family planning

HIGHER Haiti Integrated Growth through Hurricane Emergency Recovery

IEC information, education, and communication

MIS management information system

MSH Management Sciences for Health

MSPP Ministère de la Santé Publique et de la Population

NGO nongovernmental agency

NSU nutritional stabilization unit

OMS/PAHO Organisation Panaméricaine de la Santé/Pan American Health Organization

PBF performance-based financing

PLWHA people living with HIV and AIDS

PMTCT prevention of mother-to-child transmission

SAM severe acute malnutrition

SDSH Santé pour le Développement et la Stabilité d’Haïti (Project)

TB tuberculosis

TBA traditional birth attendant (matrone)

USAID US Agency for International Development

WFP/PAM World Food Programme/Programme Alimentaire Mondial (UN)

ZC zones ciblées

“Despite the January 12 earthquake, the SDSH Project achieved or surpassed almost all of its project indicators.

Overall, during this project year, results show significant improvements.”

Despite the January 12 earthquake, the SDSH Project achieved or surpassed almost all of its project indicators. Overall, during this project year, results show significant improvements in the following:

family planning skilled deliveries and postnatal consultations child vaccination vitamin A therapy nutritional interventions

HIV counseling and testing antiretroviral therapy (ART) initiation and palliative care total number of individuals receiving antiretrovirals (ARVs) enrollment for prevention of mother-to-child transmission (PMTCT) of HIV

The project also made significant progress in the implementation of integrated communal plans.

However, project targets were not achieved for:

prenatal consultations

HIV-positive women receiving PMTCT prophylaxis

TB testing of HIV-positive patients

ART treatment continuation achievement of the last intervention in a series (e.g., third prenatal visit, second dose of vitamin A)

The earthquake affected all development sectors of the country, including the health sector. Infrastructure damage, loss of life, and loss of staff to evacuation impaired health facilities’ ability to function, even in parts of the country not directly affected by the quake. Significant stress was added to an already fragile network by the demands for post-quake emergency care, the increased needs for handicapped and mental health services, and the additional demands placed on many health facilities by displaced populations living in camps or migrating to communities outside the earthquake impact zone.

After the earthquake, SDSH moved quickly to re-establish health delivery systems in SDSH sites. No additional USAID funding was provided specifically to respond to the emergency. Despite damage to the SDSH office that required staff to work in an outdoor porch, the contracts and finance teams were able to quickly resume operations and renew NGO contracts, providing funds for their continued operations.

Some staff members provided direct assistance to partner health facilities so they could deliver needed emergency clinical services, and the rest mobilized to conduct a detailed post-earthquake needs assessment of nearly all SDSH sites.

This provided the basis for an SDSH contingency plan to reinforce the partners’ capacity. Starting in March 2010, significant improvements were observed.

Simultaneously, SDSH sought out existing strategic partners and developed relationships with new partners to provide a direct response to the emergency. These efforts resulted in

Executive Summary several direct grants from partner NGOs to provide health services to displaced persons, support reinforcement of damaged infrastructure (International Relief Agency, AmeriCares, Containers to Clinics), and assess health services provision in the camps (Organización Panamericana de la Salud/Pan American Health Organization [OMS/PAHO]). In addition, another partner, Direct Relief International (DRI), made massive contributions for the provision of pharmaceutical supplies to SDSH-supported health facilities.

Emergency efforts did not divert attention or resources from the SDSH Project, but rather contributed to SDSH objectives.

In September 2009 the three-year goal had been surpassed for leveraged contributions to the health system from these private sector partners. From October 2009 through September 2010, the total amount of these contributions increased fourfold.

SDSH partnership with the MSPP at departmental and central levels continues to provide the framework for institution building. Preparations for the “Success Fair” scheduled for January 22, 2010 brought together NGO partners and all departments and directorates of the MSPP, strengthening collaboration and communications.

After the earthquake, PBF was introduced to 4 of 10 departments. Financial management and management information systems were strengthened at the departmental level. SDSH has been an active participant in the development of post-quake reconstruction efforts of the MSPP.

In August 2007, the US Agency for International Development (USAID) awarded Management Sciences for Health (MSH) a contract for the implementation of a new three-year task order in line with the 2006–2009 USAID country program for Haiti. The Santé pour le Développement et la Stabilité d’Haïti (SDSH) Project contributes to USAID’s priority objectives, especially that of increased access to quality, basic social services.

The technical assistance delivered under the extended, now five-year, $81.4 million SDSH Project targets approximately 50 percent of the Haitian population in all 10 departments to increase their access to and use of a package of integrated basic health services that includes maternal and child health care; nutrition; family planning; and prevention and control of infectious diseases, including HIV & AIDS and tuberculosis. Demographic targets are (1) children and youth under 25 years of age, (2) women, and (3) special concerns groups, such as persons living with HIV and AIDS (PLWHA) and tuberculosis patients.

Three Areas of Focus

Service Delivery—to increase access to and use of the Government of Haiti’s basic health care package.

The SDSH Project supports public and private, and nonprofit sector health care delivery. MSH implements project activities through performance-based financing (PBF) subcontracts with 26 local nongovernmental organizations (NGOs) operating 72 health facilities and 1,843 community “rally posts,” and through the Ministère de la Santé Publique et de la Population (MSPP) in 31 targeted geographical areas known as zones ciblées (ZC), which include 75 health facilities and 2,098 “rally posts.”

Support to the Government of Haiti—by strengthening the leadership of the MSPP at both central and departmental levels to carry out its executive functions in support of health care services delivery and strategic management of resources for the health sector.

Partnerships with other local and international organizations—to increase program impact by leveraging funding from the private sector and other donors.

The project currently covers 41 percent of the Haitian population, or 4,159,412 people.

Despite the catastrophic earthquake that struck Port-au-Prince on January 12, 2010, the SDSH Project continued to focus on delivery of basic health services throughout its network, quickly helping partners to re-establish services and expand care to meet the needs of displaced populations. The overarching strategies for SDSH Project implementation, however, continue to include:

Producing measurable results and sustainable impact;

Integration of services to provide a continuum of care to all clients;

Health systems strengthening and governance at national and departmental levels through PBF and direct technical assistance;

Mentoring and accompaniment of local partners by SDSH and development of same among partners;

Linkages, synergies, and operational collaboration among public and private sector groups and organizations;

Strategic partnerships that engage stakeholders at all levels.

About the Project: Year Three

Department MSPP / Zones Ciblées (ZC) NGO Partners

Artibonite Gonaïves; Centre de Santé Saint Michel Centre de Santé de Marmelade; Centre de Santé de Grande Saline

Albert Schweitzer Hospital; Hôpital Claire Heureuse;

Pierre Payen Health Center

Centre CS de Belladère; CS Cerca la Source; CS Savanette Save the Children; Medishare

Grand’Anse Centre de Santé des Abricots;

Centre de Santé de Corail

Haitian Health Foundation; Ste Hélène; Léon Coicou H.C.;

AEADMA (Association d’Entr’Aide des Dame-Mariens)

Nippes CS de L’Azile; CS de Petit Trou; CS de L’Anse à Veau None

Nord Centre de Santé de l’Acul; CS de Borgne; CS de Dondon;

Centre de Santé de Saint Raphaël

Comité Bienfaisance de Pignon; Dugué Clinic; Center for Development and Health (CDS); Konbit Santé

Nord’Est CS de Mombin Crochu; CS Ste Suzanne; CS Vallières Center for Development and Health (CDS) Nord’Est

Nord’Ouest CS La Tortue; CS Baie de Henne; CS Anse à Foleur Beraca Medical Center

Ouest Centre de Santé Belle Fontaine; CS Cornillon; CS Aurore du Bel Air; Centre de Santé Saint Martin II; Trou d’Eau/Crochu; Centre de Santé de Tayfer

St. Paul Clinic; CSNRR (Filles Charité); FONDEFH, FOSREF;

Fermathe Hospital; Grace Children’s Hospital; OBCG, SADA, Lucelia Bontemps Health Center; Center for Development and Health (CDS) Ouest, St. Croix

Sud CS Les Anglais; CS de l’Ile à Vache La Fanmy; MEBSH

Sud’Est CS de Baînet Sacré Cœur de Thiotte Health Center

Total : 31 zones ciblées; 75 fixed sites; 1,379,808 population 26 NGOs; 72 fixed sites; 2,779,602 population

NGOs and MSPP Implementing Partners

Indicator Oct. 2008

Result Oct 2009

Result

Oct 2009– Sept 2010

Result

Sept 2010 Target

Number of pregnant women counseled and tested for HIV 40,341 49,196 48,640 40,000

Number of sites furnishing a minimum packet of PMTCT services 19 22 19

Number of HIV positive persons having received palliative care 11,133 14,212 13,000

Number of people tested for HIV and received results 91,494 94,907 92,109 75,000

Number people newly placed on ARV 726 973 712 700

Number of people receiving ART at end of the reporting period 1,595 2,077 2,413 2,650

Tuberculosis (TB) case detection rate (overall) 31% 32% 35%

Number of postpartum/newborn visits in 3-day interval after delivery 27,977 40,019 47,544 45,000

Percent of newborns benefiting from a postnatal consultation within 42 days after birth 33% 34% 35%

Number of prenatal visits completed by qualified personnel 247,889 243,958 245,000

Percent of pregnant women having received 2nd dose of tetanus vaccination 69% 74% 75%

Number of pregnant and lactating mothers who received food supplementation _ 910 1,301 2,000

Percent of children 0-11 months fully vaccinated _ _ 89% 85%

Number of children reached by nutrition programs 431,946 495,552 440,000

Number of children under 5 years who received vitamin A 280,579 314,419 380,318 343,000

Number of children 0–11 months having received DPT3 vaccination 116,451 108,100 99,000

Number of family planning users 201,083 239,394 256,161 249,503

Percent of persons of reproductive age use a modern family planning method 26% 30% 24%

Percentage of sites offering at least 5 family planning methods 41% 55% 45%

Number of MSPP “Targeted Zones” under performance-based financing 0 0 11 12

Success Highlights

Principal Accomplishments Performance-based Financing (PBF) for the public sector was introduced in four departments starting in May 2010, after a four-month delay due to the January earthquake. Subsequent training and orientation sessions were held in all four departments. (North: 4 ZC, North East: 3 ZC, South East: 1 ZC, and Centre Department: 3 ZC). All departments have nearly identical indicators with specific targets determined in collaboration with the departmental directors and site managers. Results will be audited and verified by a group that includes a representative of the departmental hospital, a departmental program manager, and an SDSH representative.

In July 2010, SDSH staff participated in a national conference on performance-based financing, presenting the experience, alternative models, and lessons learned over the past 10 years of USAID-funded health programs in Haiti. The conference was organized by the MSPP with OMS/PAHO, the World Bank, and USAID. This conference was intended to initiate discussions regarding formal adoption of PBF by the MSPP as national policy. A film on MSH PBF experience in Haiti was presented in September at a meeting organized by the Clinton Global Initiative in Haiti, and also at the CGI annual meeting in New York City.

To strengthen the Ministry’s financial and accounting management systems, an orientation session on QuickBooks software was organized in December with staff from departmental directorates (Centre, South, and Nippes) and employees working for the departmental hospital. The subcommittee on financial resources of the Committee of Support for the Health Information System (CONASIS), of which SDSH is a key member, organized a three-day workshop on user fees and fixed asset management at Moulin Sur Mer in December. A second workshop was held for personnel from the South and Centre Departments in August 2010.

The project organized a five-day workshop for SDSH Project and partners’ staff in November, with the objective of calculating standard costs of the minimum package of services. A plan was developed to provide technical assistance to five selected institutions to use the CORE+ tool to achieve this objective. Participants included staff from Save the Children, Fondo de Fomento al Desarrollo Cientifico y Tecnológico (FONDEF), African Methodist Episcopal Service and Development Agency (AME-SADA), International Child Care (ICC), and Ohio Baptist General Convention

(OBCG).

Performance-Based Financing Introduced with MSPP

PBF orientation in Hinche, Centre Department, with MSPP Departmental Director (speaking) and staff.

SDSH central and departmental public health and management staff work closely with their MSPP departmental colleagues. MSPP staff works with SDSH staff to analyze project results, conduct supervision, prepare integrated departmental plans, prepare and manage budgets, and develop strategies to improve performance. In addition to this routine assistance, specific activities were carried out in several departments to strengthen financial and logistics management. These included:

A financial management training organized in the North Department for the MSPP staff based in the departmental directorate to implement a system to adequately manage program income.

A training in the Nippes Department improved skills of departmental staff on the use of Microsoft Excel® software to prepare financial reports and budgets.

The West Department financial advisor participated in the logistics planning of the Hygiene Program managed by the departmental directorate and in the distribution of aid/support received by the department.

In the Artibonite Department, technical assistance was provided to local service providers—including Saint-Nicolas Hospital, Dumarsais Hospital, and Charles Colimon Hospital—to strengthen their accounting and financial management. Participants identified key management weaknesses, including timesheet management, vacation planning procedures, bank reconciliation, and management of program income and equipment and supplies. They then developed plans to improve those areas.

Artibonite departmental staff was integrated with the SDSH team in the disbursement of funds for the department. They signed vouchers, ordered payments, and actively participated in the payroll process. Administrators and site managers now understand the need to create a group responsible for solving health issues in the Department.

MSPP Department Level Improves Management Functions and Financial Systems

To strengthen the reliability and validity of the project’s reported results as well as partner capacity in results information management and reporting, the Project MIS staff introduced an information system, based on the MSPP MIS (SIS National), in all health facilities supported by SDSH. The project “dashboard” was modified to take into account changes resulting from population growth and modifications in project partnerships.

Targeted technical assistance visits were made to the South, Artibonite, and Grand'Anse departments to improve data collection and reporting there. MIS training was provided to 23 individuals from newly integrated project partners (Sainte Croix and Medishare) and the targeted zones (ZC) of Dondon, St.

Raphaël, and Borgne, as well as to nine personnel from the community health programs of Fermanthe Hospital, AME-SADA, and the St. Martin and Bel Air health facilities.

The project supported the operationalization of the Routine Health Management Information System of the MSPP in ZC sites.

The planned training of trainers for this activity had to be postponed because of the earthquake, but financial assistance and on-site technical assistance was provided. Project departmental-level staff organized meetings at the departmental level to review and verify SIS and project results.

SDSH staff continues to participate regularly in meetings of the CONASIS to develop tools, procedures, and training materials to strengthen the national health information system.

Management Information Systems Strengthened at Central and Departmental Levels

The SDSH Project Management Information System (MIS) is based on the

MSPP National Management Information System. Early in the project, a

Data Management Guide that specifies data collection and reporting procedures for all project indicators was developed and distributed to all project partners. In addition, project partners were trained to use the

Project MIS system. Based on internal analysis of the completeness and internal coherence of partner data received, regular field visits are made to verify data collection and reporting procedures and provide technical assistance to help partners improve their MIS process. Regularly throughout the year and prior to the annual publication of project results, data received from partners are analyzed and feedback is provided to partners, who are asked to clarify discrepancies and inconsistencies.

This process allows the project to provide regular updates to donors, partners, and colleagues on project attainment of objectives; to respond to ad hoc requests for specific information; and to document current results for project internal quarterly reviews and monthly project progress reports. The data are also used internally to analyze project progress and as the basis for preparation of quarterly, semiannual, and annual strategic and work plans.

Finally, project results are the basis of the establishment of annual PBF agreements with partners, leading to agreed-upon scopes of work and annual targets. Achieved results, independently verified annually by an outside firm, are used to guide periodic payments to partner institutions as well as to determine annual performance bonuses or withholdings.

Although SDSH attained or surpassed its annual targets in 5 of 10 of its key maternal health indicators, comparison with the results for 2009 show that there has been some slowing of progress this year. This was principally due to the disruption caused by the earthquake, and also to the temporary suspension of its subcontract with JHPIEGO in May, which led to the loss of key project maternal health staff who have yet to be replaced.

Principal Accomplishments

Significant progress this year was made in the revitalization of efforts to upgrade the skills of trained community birth attendants (matrones). SDSH worked closely with the MSPP Division of Family Health (DSF) to review maternal health norms, including the integration of PMTCT at institutional and community levels. Adapted MSPP norms recognize the traditional birth attendant (TBA) as “a community health agent to promote safe maternity within their community and their families.”

Based on this official recognition, SDSH launched the strategy called

Relance des Matrones. Training norms and guidelines were adapted in French and Creole, including tools for program organization and monitoring. As a result, 39 reproductive health program managers in the 10 departments have been oriented and 98 program monitors trained.

In addition, 3,319 TBAs have been trained and certified, and 1,161 more will have their sessions during the next fiscal year.

Perspectives and Challenges in the Coming Year

Dissemination of the maternal health and family planning norms and standards and their use at the facility level.

Use of the emergency obstetrics protocols in some SDSH-supported sites.

Creation of at least one committee for the surveillance of maternal mortality and management of obstetrical emergencies in each project-supported commune.

Strengthening the integration of PMTCT in maternal health while linking community and institutional response.

Steady Progress in Maternal Health, but Challenges Remain

Traditional birth attendants’ graduation in the North-East Department

Indicator Objective Attained Percentage of target attained

Number of postnatal visits at home within 3 days after delivery

45,000 47,544 106%

74.5% of 63,793 deliveries reported

Number of prenatal visits by qualified personnel

245,000 243,958 99.6%

% of pregnant women having received 2nd dose of tetanus vaccination

75% 74% 99%

Number of births assisted by a trained professional

(not incl. TBAs)

12,000 11,893 99%

% of new deliveries benefiting from a postnatal consultation within 42 days after delivery

35% 34% 97%

% of pregnant women having a birth plan 85% 78% 92%

Number of births attended by trained community birth attendants

60,000 51,900 87%

Percent of pregnant women with 1st prenatal visit within 1st trimester of pregnancy

40% 34% 85%

32,991 women seen during first trimester/96,029 women having received at least one prenatal visit

Percent of pregnant women having benefited from 3 prenatal visits

55% 43% 78%

50,030 pregnant women with 3 prenatal visits/ 115,718 expected pregnant women

In September 2007, private sector sites supported by the USAID-funded HS2007 Project implemented by MSH had achieved a contraceptive use rate of 32 percent, with public sector sites attaining only 8 percent. The integration of additional public sector sites into SDSH in 2008 resulted in an overall (public and private sector together) use rate of 21 percent in the SDSH-supported network. In October 2008, utilization of modern family planning (FP) methods had risen to 24 percent within the coverage areas of the public sites within the network (zones ciblées). By October, 2009, SDSH’s intensive efforts to increase access to family planning in public sector sites especially had resulted in an overall (combined public and private)increase in the FP utilization rate of nearly 24 percent (to 26%)compared to the initial rate of 21 percent. . This year SDSH has reached an overall rate of 30 percent, with 10 percent (or 30,234 individuals) using long-term or permanent methods, including 5 percent Norplant and 5 percent voluntary surgical contraception. Over 92.6 percent of Depo- Provera users are receiving their supplies on schedule.

Family planning activities were strengthened by working with nurses to involve them more intensely in departmental- and communal-level planning and by encouraging and supporting them through multiple means of communication: email, phone, and field visits. Factors that contributed to the observed progress included close collaboration with departmental directorates of health, intensive on-the-job training, and mobile clinics to promote and offer services for long-term methods (with the training of an additional 26 long-term method providers). SDSH also expanded access to an increased range of contraceptive methods, with 55 percent of sites now offering at least five modern methods. With fewer stock-outs, this has meant that more women had a greater choice of preferred methods. Finally, the role of the community-based health agents in the provision and resupply of FP methods at the community level, as well as the increased awareness-raising within the community, cannot be underestimated.

A total of 354 providers and FP motivators received training this year, including 137 community agricultural agents who received basic training about the interactions of environment and population growth as well as the role of family planning. Collaboration with this USAID-funded agricultural and watersheds development project has been slower than desired, largely due to the disruptions caused by the earthquake, but will eventually lead to the sensitization of nearly 2,000 agricultural workers and training of 100 or more of them as community family planning promoters and providers (condoms only, with referral to nearby health facilities for other methods) at the community level.

Indicators Objective Results

% of objective attained

# of users of modern FP methods

27% 30% 111%

% of sites offering at least 5 modern methods of FP, including 2 of long term

45% 55% 78 sites

122%

# of people trained 100 354 282%

# of sites offering counseling and family planning services

142 142 100%

CYP 260,000 256,161 99%

Family Planning, Use of Modern Methods within the SDSH Network Attains 30 Percent—Remarkable Progress!

Community members working together

BCC/IEC Materials: Existing behavior change communications (BCC) and information, education, and communication (IEC) materials were distributed in response to specific requests, as supplies allowed. However, plans to disseminate new materials at the Success Fair were pre-empted by the earthquake. This year a brochure on maternal health and PMTCT, and a guide for establishing and training mothers’ clubs have been produced.

Local Health Task Force: As of end of March 2010, 18 community-level organizations were identified to manage grant funding at the commune level and implement community-level health improvement activities. Since then, the identification and selection of umbrella organizations has continued in the departments. Twenty community organizations developed proposals for community health actions and submitted them to SDSH for grant funding. The project reviewed and in some cases revised these proposals. A total of 40 proposals coordinated by the 20 umbrella organizations has been submitted to USAID for approval.

Technical Assistance to the MSPP: This semester, BCC support focused on institutional strengthening at the central level of the MSPP. As a member of the BCC/CM (community mobilization) national cluster, SDSH supported the development of a brochure on maternal health and PMTCT as well as audio spots and guidelines for establishing and training mothers’ clubs. Similarly, SDSH participated in the workshop on National Policy for the Promotion of Health, and the planning, preparation, and organization of the workshop on the standardization of curriculum in interpersonal communication. A concerted effort was made to involve the central technical consultants (CTC) and departmental CTD in coordinating the process of implementation of the Communal Health Councils.

Community-Level Project Plans Developed and Advances Made in Nutrition and Diarrhea Education

The child health package includes immunization, prevention of acute respiratory infection, nutritional surveillance, administration of vitamin A and, finally, diarrhea and dehydration prevention.

Principal Accomplishments

The total number of children 0–11 months in project areas for FY 2010 was 97,844, and SDSH’s objective was to fully immunize 85 percent, or 83,168, of these children. This objective was exceeded by 23 percent, as a total of 102,079 children 0–11 months were fully immunized following norms and standards of the National Immunization Program (DPEV). Given the massive displacement of large groups of the population after January 12, it cannot be concluded that the full immunization rate is 100 percent in SDSH-supported areas, but it is certainly considerably higher than the 85 percent target. This impressive performance in immunization results from key interventions implemented to strengthen the operational capacity of partner institutions. These interventions include:

Increasing vaccines storage sites and placing them as close as possible to community-level immunization sites through our community health agents.

Increasing the number of rally posts and implementing more outreach activities to reach a significant number of children in hard-to-reach areas.

Ensuring routine and daily immunization activities at the institutional level in almost all facilities.

Working closely with MSPP National Program and departmental offices to ensure good cold chain maintenance and improve distribution of vaccines to sites.

Emphasizing follow-up on children’s immunization status.

Knowing that diarrhea and dehydration are primary causes of childhood morbidity and mortality, SDSH community health agents also trained 75,317 mothers and caregivers about diarrhea prevention, safe water, and good hygiene practices. The number of cases of pneumonia treated was more than double the annual objective (15,887 treated versus 7,000 targeted). This may, in part, reflect inaccuracies in diagnosis, however.

Greatly Improved Immunization Rates, Treatment of Acute Respiratory Illness, and Diarrheal Management

Capacity Achieved through Community-Based Services

Vaccination at St. Martin II Health Center, West

All 147 SDSH network sites provide growth monitoring.

However, selected sites supported by the USAID-funded HIGHER (Haiti Integrated Growth through Hurricane Emergency Recovery) Project offered treatment for severe acute malnutrition (SAM) from mid-2009 until September 30, 2010.

From October 2009, the HIGHER Project supported 9 nutritional stabilization units (NSUs), 20 outpatient management sites, 12 nutritional supplementation sites, and 49 community-based satellite sites that identified malnourished children and mothers for referral. The NSUs closed after an April 2010 change of MSPP policy restricted this service to hospitals with a pediatrician.

Other SDSH/HIGHER sites functioned at reduced capacity when UNICEF and the UN World Food Programme/Programme Alimentaire Mondial WFP/PAM were unable to provide needed food and other supplies. Approximately a third of the SDSH/HIGHER continue to function at a lesser level and provide nutritional monitoring and some care. SDSH trained 500 people in child care and nutrition this year (166% of the target).

During this fiscal year, 495,522 children under five years of age were reached by nutrition outreach programs, (113% of the annual objective).

Among these children, 87,878 (17.7%) were screened for SAM. Moderate acute malnutrition was detected in 30 percent of children under the age of five, SAM in 5.4 percent, and SAM with complications in 1.0 percent. A total of 9,720 children under age five with acute malnutrition have received supplemental feeding, surpassing annual objectives by 10 percent. Over 380,000 children under five received vitamin A, again surpassing annual objectives by more than 10 percent; 206,545 of these received a second dose of vitamin A. This second dose is provided four months after the first, and the fact that SDSH only attained 80 percent of its annual target for this indicator reflects the constraints on reaching children for a second dose.

Over 71,000 mother and child caretakers received nutrition counseling services (10% over target). To reduce low weight at birth and newborns exposed to greater morbidity and increased mortality, SDSH enrolled 4,621 pregnant and lactating women in the nutrition program. Among them, 2,618 have received food rations (over 30% in excess of annual target). In collaboration with Feed the Children, SDSH was able to provide 10,243 under children under five with albendazole/pebendazole for deworming.

SDSH Network Combats Malnutrition among Children and Pregnant/Lactating Women

Results attained through the USAID-funded

HIGHER Project in collaboration with UNICEF and WFP/PAM greatly improved the management of cases of severe acute malnutrition among children less than five years old, despite the period of instability created by the January 12 earthquake. By

August 2009, 522 health agents and 160 doctors, nurses, and auxiliaries were trained, and they helped launch the nine first CNAM sites of the network. The package of nutritional care offered included intensive care in an NSU for severe cases with complications, an ambulatory program for children severely affected but without current medical complications, and nutritional demonstration activities for prevention and care of less malnourished children in community-based “Ti

Foyers.”

Over the 14-month course of the program, 97,123 children were monitored, 34,510 of whom had acute malnutrition. Of these children, 2,993 received RUTF (ready-to-eat food) therapy, and 1,228 completed their treatment and returned to health. Insufficient availability of nutritional supplements (F75, F100, and Plumpy Nut) contributed to the relatively low treatment completion rate.

Also, 16,962 pregnant and lactating women were monitored and participated in supplemental feeding programs.

Detection of Acute Malnutrition in Children Less than 5 Years Old at 20 SDSH Network Sites, October 2009 –September 2010

Month

Children

Screened for

Malnutrition

Detecttion

October 09 4044

November 09 4711

December 09 6092

January 2010 5557

February 2010 6938

March 2010 7709

April 2010 9391

May 2010 11675

June 2010 9234

July 2010 8805

August 2010 6212

September 2010 7510

87878

100%Total

56932

SDSH

Detection of Severe Acute Malnutrition in Children less than 5 years old at 20 SDSH network Sites

October 2009 - September 2010

Moderate Acute

Malnutrition

(MAM)Normal

Severe Acute

Malnutrition with

Complication

(SAM/C)

Severe Acute

Malnutrition

(SAM)

25380

64.8% 28.9% 5.4% 1.0%

To expand, organize, and maintain youth-friendly sexual and reproductive health services, four new sites were selected (in North West, North, Centre, and Nippes) from October 2009 to April 2010, in addition to the six sites already enrolled in this initiative. The goal was to provide quality services in sexual and reproductive health, including counseling, family planning methods, and HIV testing and referrals for the continuum of care available throughout the SDSH HIV program. The selected sites are:

1. North West: Centre Médical BERACA, Port de Paix

2. North: Centre Médico-social La Fossette, Cap-Haïtien

3. Centre: Centre de Santé de Belladère

4. Nippes: Centre de Santé de l’Anse-à-Veau

5. West: FONDEF Sainte Elisabeth, Carrefour Feuilles, Port-au-Prince

6. West: FONDEF Martissant, Port-au-Prince

7. Artibonite: Hospital Claire Heureuse, Marchand Dessalines

8. North East: Centre Médico-Social, Ouanaminthe

9. South: Centre de Santé, Les Anglais

10. Grand’Anse: AEADMA, Dame-Marie

Despite the serious difficulties caused by the earthquake, the project was implemented at all 10 sites. A total of 242 received training in youth-friendly communication techniques, offering counseling services in family planning, counseling for voluntary testing for HIV, behavior change communication to promote safer practices regarding health and sexual behavior, and helping their young counterparts to navigate the system to obtain youth-friendly services.

A strong component of youth-friendly sexual and reproductive health services is the anchorage of the youth program within the community. The Haitian NGO FOSREF (Fondation pour la Santé Reproductrice et l’Education Familiale), an SDSH partner, has a strong presence in youth activities and programs throughout the country with the support of its extensive funding portfolio. Indeed, various donors—such as the Bill & Melinda Gates Foundation; the Global Fund; PEPFAR; the Ministry of Youth and Sports; USAID-supported projects MSH/SDSH, MSH/LMS; FYI/CHAMP (Family Health International/Community Health and AIDS Mitigation Project); and others—have given FOSREF the opportunity and ability to conduct several experimental or institutional programs in the 10 departments of the country over the years. The end result is an ad-hoc youth program integration at the field level.

242 Peer Educators Provide Quality Sexual and Reproductive Health Services at 10 Youth-Friendly Sites

Youth training at Les Anglais Health Center

To be effective and sustainable, the next generation of HIV & AIDS services requires a dramatic change in thinking and strengthened health systems in countries most affected by HIV & AIDS. To reverse the HIV & AIDS epidemic in Haiti, the SDSH Project has supported the MSPP in changing how services are designed and delivered.

SDSH is supporting a systems approach to HIV & AIDS programming. This holistic approach creates a strong foundation by focusing all efforts on integration, effectiveness, and sustainability. AIDS programs in the 2010s must be centered on a health systems response, which requires an approach based on a vision of a holistic, high-performing system that builds on six fundamental components working as a unified whole:

1. Leadership, governance, and management

2. Health service delivery

3. Human resources for health

4. Pharmaceutical and laboratory management

5. Health care financing and financial management

6. Health information

The health system must use evidence to guide policies, choose interventions, and develop programmatic strategies. It should work from a vision of the desired impact on health to choose the inputs, processes, and outcomes to achieve measurable results.

MSH’s philosophy is to look at the HIV & AIDS epidemic comprehensively and see the person living with the virus as a “whole,” while recognizing the need for additional, innovative, and varied approaches to the disease. This includes integration with family planning, maternal and child health, and tuberculosis services.

Services specific to the HIV-positive population and HIV prevention are not neglected, but rather made stronger through the integrated approach. The four strategies still found to be effective in the SDSH Project, and implemented throughout the entire network are: (1) voluntary counseling and testing (VCT) “Eclaté,” including an “opt-out” approach to testing and PMTCT, (2) a treatment approach emphasizing patient monitoring and adherence, (3) involvement of all categories of providers, and (4) reduction of stigma and discrimination.

Integration of HIV & AIDS Services with Family Planning Serivces and STI Prevention

MSH’s approach has always emphasized integration of HIV prevention and care with family planning and prevention of other sexually transmitted infections (STIs). This year 264,393 tests for HIV, TB, and syphilis were completed by SDSH-supported laboratories. HIV information and testing is offered systematically now through SDSH-supported family planning programs and sites and starts from the first prenatal contact with a pregnant woman and extends beyond her postnatal follow-up. In addition, SDSH includes complete family planning services in its VCT, PMTCT, and ART services to offer all women, and particularly HIV-positive women, the opportunity to avoid unintended pregnancies and to space pregnancies or plan new births.

HIV and AIDS and Tuberculosis: Integrated Services Increase

The following indicators represent the greatest strides forward this period for the SDSH HIV and AIDS component.

Indicator Result

Year 2008 Result

Year 2009

Annual Target/

PMP 2010

October 2009

– September, # pregnant women counseled and tested for HIV 40,341 49,196 40,000 48,640 (122%)

# pregnant women tested HIV (+) placed on ARVs 434 562 700 613 (88%)*

# people counseled, tested for HIV, and received results 91,494 94,907 75,000 92,109 (123%)

# people HIV (+) having received palliative care 8,398 11,133 13,000 14,212 (109%)

# people HIV (+) newly initiated in ART 726 973 700 712 (102%)

# people HIV (+) having received ARVs 2,120 2,834 3,534 3,513 (99%)

# people on ARVs active at the end of the period 1,595 2,077 2,650 2,413 (91%)

* This result covers the period September 2009–May 2010. After May, the MSPP no longer required health facilities to collect this information.

To strengthen ARV services, on-site refresher sessions were carried out in all sites providing HIV services to enhance health provider knowledge and improve treatment and follow-up strategies. Partners’ budgets have been readjusted to fund the initiation of new support groups. As of March 31, 2010, 3,194 individuals ever received ART, among whom 2,139 are still active, and 381 were newly enrolled in treatment. After the earthquake an urgent effort was launched to reach out to most patients under ART.

From Hospital to Home: SDSH Provides an Unparalleled Continuum of Care

With the exception of HIV/TB, SDSH exceeded nearly all of its HIV-related objectives during this past year. Thirty-two sites provide VCT, surpassing the annual target of 24 sites. This year, three sites began offering PMTCT services with SDSH assistance, bringing the total number of full-service PMTCT sites in the network to 22. Six network sites continue providing ART.

The SDSH Strategic Approach to Voluntary Testing and

Counseling

During this period, SDSH put the highest priority on HIV testing and counseling in high-density areas and targeted the most at-risk populations.