Reflecting Back and Looking Forward

Regional Coalition to Eliminate Cholera from Hispaniola

Achievement Highlights 2012 – 2016

SUMMARY VERSION

Highlights of Achievements of the Regional Coalition to Eliminate Cholera from Haiti

2012 - 2016

In January 2012, the presidents of Haiti and the Dominican Republic joined PAHO, UNICEF, and the U.S. CDC in issuing a “Call to Action” for a cholera-free island of Hispaniola through major new investments in water and sanitation infrastructure. Water and sanitation insecurity is evident in both urban and rural areas in Haiti, and affects the health and well-being of millions of men, women and children.

Six months later, the Regional Coalition for Water and Sanitation to Eliminate Cholera in the Island of Hispaniola was launched. As of September 2016, the Regional Coalition has 23 members. Members have engaged in joint international advocacy, coordination and information sharing and resource mobilization. Spearheaded by PAHO as Secretariat, the Coalition has worked steadily to catalyze organizations within the international community to come together to monitor the trends, build national capacity, provide technical assistance, and share best practices and lessons learned on inter-sectoral approaches to cholera prevention and control in Haiti. While the Coalition has continued to advocate for longer- term solutions to the underlying problems of poor sanitation and vulnerable populations (potable water supply, basic sanitation and improved health behaviors), shorter-term activities that provide immediate care (cholera treatment, vaccines and medical care, combined with the provision of quality household water and health communication to promote healthy behaviors) have been steadily implemented and the results documented.

The Coalition’s key message underscoresthat safe water and hygiene are a basic human right, and the most important public health intervention is to steadily increase water and sanitation coverage together with measures to strengthen the health system and promote healthy behaviors.

Highlights of its achievements since 2012are briefly summarized below:

Under the direction of the Ministry of Public Health and Population (MSPP) and National Directorate of Potable Water and Sanitation (DINEPA), Coalition partners provided steady support to the development of the comprehensive ten-year National Plan of Action to eliminate cholera transmission that was launched in Haiti in late February 2013. Some members have also supported the development of the MSPP Medium Term Plan 2016 – 2018.

In successfully succeeding to bringtogether the Government representatives from the health, water, sanitation, education, public works and finance sectors at various high-level and technical meetings (international and national),the Coalition has demonstrated that such an approach could also be a model for many other diseases.

The Coalition has continued to put a spotlight on Haiti by using advocacy as a tool to sustain the momentum, despite the increase in global humanitarian crises elsewhere. Since 2012, ithas worked steadily to maintain an international awareness and to advocate for solidarity on the issue of clean water, sanitation and better health. The Coalition has consistently noted that If the infrastructures are adequate, Vibrio cholera can be present in the environment with reduced risk of disease transmission. In terms of equity, communities where everyone has clean water to drink and a safe place to go to the toilet are within our grasp. Lives can be saved, productivity increased, security heightened, and health costs diminished.

As part of its endeavours to undertake advocacy and coordination, the Coalition has brought together government policy makers and senior technical officials from the diverse sectors, and international experts to discuss successful national experiences and to share lessons learned from the international arena. Examples of such meetings include: a Symposium organized by the Center for Strategic International Studies (CSIS) and PAHO October 2012, a U.S. Capitol Hill Briefing, October 2013 organized by WASH Advocates and PAHO, and attended by more than 135 persons.
Highlights of the technical assistance and operational activities at country level have been individually reported by Coalition members to the PAHO Secretariat to support the government’s cholera control efforts in support of the health and water sectors between April 2012 and August 2016. These are outlined below.

For the water sector, members of the Coalition have provided support that included, (amongst others):

Establishing a water-quality monitoring system
Strengthening the capacity of sanitary officers from Haiti’s Ministry of Population Health and Population (MSPP) to undertake water disinfection and to manage and distribute water treatment supplies.
Decontaminating water in cholera treatment centers during outbreaks, evaluating the water and sanitation infrastructure in health facilities, and rehabilitating water and sanitation infrastructure in Haitian health centers.
Developing a training package for TEPACS
Providing technical assistance to DINEPA to improve the monitoring and analysis capacity of the data collected by TEPACs
The provision of water supplies in Port au Prince, intermediary cities and rural areas
Improvement of sanitation facilities in schools and markets
DINEPA strengthening at the central level but also in the cities with a strong support to Centers of Technical Operations (CTE) and the rural areas (Water Supply and Sanitation Committees CAEPAs and URD).

Support to the Government of Haiti and DINEPA’s Total Sanitation Campaign that targets 16 communes during a first phase and 35 during the second phase in the departments of Artibonite and Centre.
Construction and rehabilitation of drilled boreholes, shallow wells, spring development and rainwater harvesting structures;
Improvement of service delivery and governance by building the capacity of Water Supply and Sanitation Committees (CAEPA) and Communal Administrative Councils (CASEC); adopting community led total sanitation approaches in accordance with the national Total Sanitation Campaign.

For the Health Sector:

Regularlymobilized international expertise through the Global Outbreak and Alert Response Network (GOARN). The network pools human and technical resources for rapid identification, confirmation and response to outbreaks of international importance.
Ongoing support to the rapid response teams through its NGO partners and the MSPP mobile teams together with operating oral rehydration posts, cholera treatment units and a cholera treatment centers.
The provision of funds for hiring of additional staff, training of support staff and field staff (health, brigadiers and rapid intervention brigades), management training of community leaders, home visits by health agents
Help in the organization of small technical advisory meetings of global cholera experts in Port au Prince lead by the Ministry of Health and DINEPA. Topics to address strategies such as combining oral cholera vaccine with WASH interventions such as household chlorination in targeted rural and urban communities.
Support to the Ministry of Public Health and Population (MSPP) in carrying out a pilot vaccination campaign in urban and rural sites in Haiti using oral cholera vaccine (SANCHOL) between April and June 2012 followed by asecond campaign targeting 200,000 people in 6 communes classified as higher-risk[1] in August and September 2014. The results published in the Lancet in July 2015 show that oral cholera vaccine demonstrates a 66% effectiveness and protected against cholera in Haiti from 4 months to 24 months after vaccination. Another article in the American Journal of Tropical Medicine and Hygiene (AJTMH) describes the impact of OCV in reducing the number of culture-confirmed cases of cholera admitted to GHESKIO Centers from its catchment area’s cholera treatment center between April 2012 and April 30, 2015 shows an overall high efficacy rate.

5. Major Challenges Faced by the Coalition

In order to sustain the gains made and the commitment to the Coalition by its members, it is also helpful to take into account the major challenges that the Coalition has faced in achieving its objectives. These include: the global recession, an increase in humanitarian and health emergencies elsewhere, an inadvertent slow down in the initiative arising from the UN Secretary General’s effort to generate funds for the program, limited human resource capacity in Haiti to operate programs and disburse funds, absence of a designated leader at national level to coordinate the coalition members.

To overcome some of these challenges, in 2014 and 2015, the Millennium Water Alliance (MWA) actively sought to develop a sub-network of its eight WASH NGOs with a strong capacity to support the Government of Haiti through coordinated field activities. While resources have not yet been forthcoming, the MWA effort demonstrates the breadth of technical expertise within the Coalition that goes beyond UN agencies and major development banks.

6.Sustaining the Gains

The Coalition has been a solid platform through which a unique message has beencrafted.Its efforts to date in achieving its objective have been acknowledged by the Government of Haiti and constitute a good legacy. Such a model could be replicated for many other diseases.

Most successful outcomes of the Coalition:

A reduction of the high incidence and prevalence rate of cholera from the 2010-2012 period owing to individual organizational support to MSPP in the affected areas.
Development of National Plans of Action for the long, short and medium terms.
Heightened international awareness of the cholera problem in Haiti.
Involvement of new partners (MWA, CRS, CWWA, WASH Advocates, World Vision, IFRC, PIH, GHESKIO)
Some increase in funding for WASH and health interventions, but insufficient to sustain the gains.
Closer coordination among Government of Haiti ministries and international organizations has occurred owing to ongoing support in this regard.
A national coordination cell has been created under the leadership of Dr. Donald Francois, MSPP. UNICEF has recruited one M&E officer to assist MSPP and DINEPA in the monitoring of the plan implementation, and one Cholera response specialist, both iare embedded at UADS. PAHO/WHO has recruited an alert/response coordinator also embedded at UADS. Logistic support to establish the cell within the office of UADS has been shared between PAHO/WHO and UNICEF. Weekly meetings are now held on each Monday morning.

Least successful outcomes of the Coalition:

Cholera elimination has not yet been achieved; cholera control measures remain only partially effective.
Lack of a consolidated donor approach to cholera programs. External agencies have been unable to develop close coordination on their individual programs.
Coalition NGOs have been unable to organize themselves around a common approach owing to limited funding support (despite efforts to coalesce)

Major Needs Remaining:

Amongst therecommendations for a way forward for Coalition support, partners have proposed the following:

Continuation of cholera control programs in the form of a common platform based upon the Long- and Medium Term Plan 2016 - 2018 to build the bridges and solve the problems. National institutional commitments on the part of MSPP and DINEPA are fundamental for donors’ support to the initiative with additional resources. Continuation of close coordination of health and WASH agencies is also central.

Continued targeting of high priority areas and capacity building in the decentralization of WASH and health services
Continue to provide rapid response & prevention services to markets, public places and remote rural areas etc.
On the ground coordination of all the players within and outside the Coalition is crucial. Members of the Coalition with local offices on the ground should have a more inclusive role (both technical, operational, and potential resource mobilization role) with leadership support from the PAHO and UNICEF Haiti country offices.
Expanded monitoring and reporting of effectiveness of Cholera control programs to allow for timely decision-making.
New funding for WASH (infrastructure, water quality monitoring, community-based technical engagement, behavior change) and health services (OCV, training, rapid response teams, epidemiological surveillance).

7.Conclusion

With support from its multiple partners, PAHO, and UNICEF should be encouraged to re-assume the leadership role within the UN to: i) implement the proven public health interventions, ii) continue its collaboration technically with the MSPP and DINEPA in the form of a program approach, and iii) guide, monitor and coordinate planned activities with the partners. Operations in the field would continue to be coordinated under the direction of MSPP and DINEPA with support from a strong partner organization with good convening powers, and supported by a team working within the framework of the common integrated operational plan.

The role of the members of the Coalition at international and regional level can be to continue to: i) catalyze public opinion and stakeholders to work in coordination toward the common goal of eliminating cholera and promoting the sustainable development of Haiti; and ii) to mobilize human, technical and financial resources to support the nationally lead Plan of Action to eliminate cholera from Haiti. If resources fail to materialize, the Coalition may need to be reassessed.

[1]The campaign lead by the Ministry of Health with support from the partners focussed on the Centre (Lascahobas, Savenette and Section Sarazin of Mirebalais), Artibonite (Ennery and Section Poteaux of Gonaives) and West (Section Delides in Arachie) Departments.