Reflecting Back and Looking Forward

Regional Coalition to Eliminate Cholera from Hispaniola

Achievement Highlights 2012 – 2016

LONG VERSION

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Table of ContentsIntroduction

Highlights of Coalition Achievements 2012 - 2016

1. A spotlight on Haiti - National Plan of Action 2012 – 2020

2. Strengthening Government-lead intersectoral Connections 2014 – 2016

3. A spotlight on Haiti - Advocacy as a Tool to Sustain the Momentumo Lessons Learned from the Europe and the Americaso CSIS-PAHO Symposium mark Global Handwashing Day, October 2012 o U.S. Capitol Hill Briefing, October 2013o Letter of Response to the Editor of the NY Times, April 2014o World Water Days, March 2014, 2015

4. Technical Assistance to the Government of Haiti by Members of the Coalition.

o Health Sector Technical and Operational Supporto Water and Sanitation Sector Technical and Operational Support

5. Major Challenges Face by the Coalition 2012 - 2016

6. Sustaining the Gains

7. Major Needs Remaining to Achieve Cholera Elimination by 2022:

8. Moving Forward as a Collective Entity

ANNEXES. Key events & activities supported by the Coalition 2012 – 2016

List of Declaration Signatories and Members of the Coalition 2016

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List of Acronyms

AECID Spanish Agency for International Development Cooperation

AIDIS Inter-American Association of Sanitary Engineering and Environmental Sciences

AJTMH American Journal of Tropical Medicine and Hygiene

CAEPA Water Supply and Sanitation Committees in rural areas

CASEC Communal Administrative Council CDC Centers for Disease Control and Prevention

CRS Catholic Relief Services

CTE Centers of Technical Operations

CWWA Caribbean Water and Waste Water Association

DINEPA National Directorate of Potable Water and Sanitation

EMIRA Rapid Response Teams

GHESKIO Centers - Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes

GOARN Global Outbreak and Alert Response Network

HWTS Household Water Treatment and Storage

IDB Interamerican Development Bank

MSPP Ministry of Public Health and Population

MWA Millennium Water Alliance

PIH Partners in Health

TEPACS Technical Environmental and Potable Water Community Workers

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Introduction

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. Nearly 40% of the population in Haiti is still without access to improved water sources, and over 70% of the population lacks access to toilets and adequate sanitation and services such as flush toilets, septic tanks, ventilated improved pit latrines, or composting toilets. In addition, 47% of hospitals are lacking either in potable water or sanitation. These conditions led to the rapid spread of cholera throughout the country as a result of open defecation, inadequate disposal of excreta and wastewater, poor personal hygiene and the consumption of contaminated foods and water. Between October 2010 and July 2016, cholera has claimed more than 9,000 lives and sickened more than 776,000 persons.

Six months after the Call to Action, the Regional Coalition for Water and Sanitation to Eliminate Cholera in the Island of Hispaniola was launched. The partners included PAHO, UNICEF and CDC, the Spanish Agency for International Development Cooperation (AECID), and the Inter-American Association of Sanitary Engineering and Environmental Sciences (AIDIS). The Coalition’s consistent message is that 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.

As of September 2016, the Regional Coalition has 23 members. 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.

Haiti still has, after 6 years of cholera interventions, unacceptably high numbers of ongoing cases of cholera. Unless the cholera reservoir is eliminated, or the number of new cases reduced to zero, cholera will continue to be a major disease burden on the people of Haiti and a source of infection threatening the surrounding countries of the region. Since 2010, more than 777,000 cases have been reported, together with more than 9,100 deaths. More must be done.

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Highlights of Coalition Achievements 2012 - 2016

1. A spotlight on Haiti - National Plan of Action 2012 - 2020

Since 2012, members of the regional coalition have engaged in joint international advocacy, resource mobilization, coordination and information sharing. 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.

In revealing the plan, Haitian Minister of Public Health and Population, Florence Guillaume said it reflected “an integrated effort of the entire international community” and called for “continued support from Haiti’s partners to help mobilize the resources needed for its implementation.”

The National Plan for the Elimination of Cholera in Haiti provided a blueprint for increased investments in water and sanitation infrastructure, water-quality monitoring systems and water and sanitation management. It also included health measures for prevention, surveillance, and case management; interventions for community-based behavior change; and vaccination for targeted groups against cholera. The Plan called for investments amounting to $2.2 billion over the next ten years and US$ 485,944 million for the period 2013-2015.

In a message to mark the launch, the Director of PAHO stated, “We will work with coalition partners to implement this plan, and I call on the entire international community to play your part in protecting and promoting the health and well-being of our Haitian brothers and sisters.”

2. Strengthening Government-lead intersectoral Connections 2014 - 2016

This early achievement in bringing together the Government representatives from the health, water, sanitation, education, public works and finance sectors at various high-level and technical meetings (international and national) has continued, and a major message is that such an approach should be used as a model for many other diseases.

At the World Bank High Level Meeting in Oct 2014, DINEPA (Department of Potable Water and Sanitation) authorities acknowledged the importance of leading the coordination with other Government ministries, and liaising more effectively with selected NGOs that are based in the country and able to implement activities in targeted communities. This was considered to be a positive step forward.

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A successful Sectorial Dialogue was organized by DINEPA in Port au Prince on May 24 – 26 2016 with the objective to present the guiding principles and pillars of DINEPA’s sanitation strategy, to showcase national experiences with urban and rural sanitation, and to complement this with international experiences in sanitation. Diverse Government representatives included those from Ministry of Health (MSPP), Environment, Education, and Municipal authorities. NGOs with experience in Haiti presented their work and lessons learned. International representatives from Jamaica, South Arica, Kenya, Senegal, Ghana and Indonesia also attended. National and international examples were presented as a basis for the refinement of DINEPA’s Sanitation Strategy and principles that are presently under development. The MSPP highlighted the importance of good sanitation to the longer-term reduction of diarrheal, water borne, and excreta related illnesses.

In April 2016, a technical health meeting of diverse experts was convened by MSPP with support from the Coalition partners including PAHO, CDC, UNICEF, Zanmi Lasante/Partners in Health, Gheskio Centers and international experts from Africa, Asia. Participants agreed on the importance of:i) Continuing advocacy for WASH measures, and prioritizing increased access to

chlorinated water at home as the most cost/efficient measure. ii) Implementing water, sanitation, hygiene promotion together with vaccination

to ensure household water has been adequately treated and chlorinated in two departments (Centre and Artibonite).

iii) Focusing on remote rural areas that require complete coverage to tackle prevention and control. Sanitation interventions remain essential in 70% of the rural areas where open defection continues as a normal practice. In the urban areas of Bangladesh and Haiti, there is evidence that treated water with vaccination using OCV has been effective in preventing cholera transmission. Resources should therefore be mobilized for oral cholera vaccine to address the short-term needs while the longer term investments in water, sanitation are made.

iv) The institutional capacities of cholera response implementation structures at MSPP and DINEPA level require ongoing strengthening.

3. A spotlight on Haiti - Advocacy as a Tool to Sustain the Momentum

Since its launch in June 2012, the Regional Coalition to Eliminate Cholera has 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 infrastructure is adequate, Vibrio cholera can be present in the environment with reduced risk of disease transmission. 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.

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Lessons Learned from Europe and the Americas

The Coalition points to Europe and the Americas as examples whereby encouraging investments to eliminate cholera transmission and reduce other water-borne illnesses also have had a spin-off effect on national economic development, tourism, agricultural production of fruits and vegetables, and overall productivity arising from improvements in the health of the population in general.

Evidence from Europe and North America over the past two centuries shows that as water and sanitation coverage and hygiene improves, the risk of epidemic or endemic cholera transmission is greatly reduced. In the 1990s, a cholera epidemic in Latin America spread to over 20 countries in its first two years. Between January 1991 and December 1997, 21 countries of the Americas were affected with a total of 1,199,804 cases including 11,875 fatalities. The epidemic was finally controlled after eight years of international public health efforts and massive investments in infrastructure, water supply, and sanitation in the region.

CSIS-PAHO Symposium mark Global Handwashing Day, October 2012

On October 17, 2012, an expert-led symposium co-sponsored by the Center for Strategic International Studies (CSIS) and the Pan American Health Organization (PAHO) gathered in Washington DC to discuss the ambitious efforts of the Coalition to Eliminate Cholera on Hispaniola. Experts participating in the symposium described the opportunities presented by regional collaboration on water and sanitation (WASH) activities, and identified opportunities for greater engagement on cholera elimination by the non-government sector. Partners concurred that “by implementing this strategy, water and sanitation as basic human rights will finally be accessible to everyone.”

The Director of Health Systems Reconstruction Office at the Centers for Disease Control and Prevention (CDC) noted that, “Few countries have declining access on WASH services as Haiti; and the earthquake only made things worse.” A long-term strategy is needed to expand the number of sanitary and environmental health workers, especially to check and recheck the sources of water, for example. The Senior Health and Human Resource Policy Advisor at the World Bank also underscored the importance of capacity building for the Ministry of Health and DINEPA. “Building capacity is something that we need to do all the time and not only for water and sanitation, but in every area,” she added.

U.S. Capitol Hill Briefing, October 2013

On October 24 2013, a briefing in the U.S. Capitol was organized by WASH Advocates and hosted by Rep. Barbara Lee (Calif.), Rep. Dave Reichert (Wash.), and Rep. Betty McCollum (Minn.). Attended by 135 participants, including nearly 50 hill staff members, it was standing room only. The event coincided with the publication of a special section

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in the American Journal of Tropical Medicine and Hygiene, titled “AJTMH and PAHO: Commemorating the 3rd Anniversary of the Cholera Outbreak in Haiti: Invited Papers,” which documented the public health response to the largest national cholera outbreak in modern history. The question and answer discussion was moderated by the executive director of the American Society of Tropical Medicine and Hygiene.

The Director of PAHO and other experts from U.S. Centers for Disease Control and Prevention (CDC), Center for Strategic and International Studies (CSIS), WASH Advocates, and Partners in Health/Zanmi Lasante spoke on the panel. The PAHO Director stated,

“The initiative will require resources. But not taking action is unacceptable. Too many lives have already been lost, and more lives will be lost if we do not act purposefully and decisively.”

The panelist from CSIS noted that Haiti’s national 10-year plan offers “multiple opportunities” for the United States to enhance its support for water and sanitation improvements and contribute to both cholera elimination and the reduction of other diarrheal diseases. Failure to support these improvements would threaten the sustainability of other U.S. development investments in the country in areas including economic development, women’s empowerment, and progress toward democratic governance and participation. A Haitian physician from Zanmi Lasante in Haiti spoke of the high human losses over the past three years, but that “the epidemic has taught us a lot—now we know how to treat cholera. The fight has just started, and we need the support of everybody here.” The CDC representative noted that Haiti had already made meaningful progress in water and sanitation. The National Directorate for Potable Water and Sanitation (DINEPA) had recently trained and deployed 264 technicians that, together with local rural water committees, are “arguably one of the best rural water and sanitation work forces in the world.”

Letter of Response to the Editor of the NY Times, April 2014

On April 25, 2014, in response to an Editorial in the NY Times “Haiti in the Shadow of Cholera,” (23 April, 2014) PAHO, in its role as the Secretariat of the Coalition, and WASH Advocates replied in writing to the Editor. The letter noted that the partners:

“share the frustration with the persistence of Haiti’s cholera epidemic and is working overtime to help the victims and to raise the millions of dollars for the clean water and sanitation that will be necessary to rid the country of the disease. Despite the direness of the situation, we have had successes. For example, under the leadership of the Ministry of Health in Haiti, we have helped to improve Haiti’s system for detecting and rapidly responding to cases. We have trained health-care workers and provided tons of medical equipment. Together with the Department of Potable Water and Sanitation (DINEPA) in Haiti, we have chlorinated water and vaccinated people. But the editor is right: Haiti still needs our help. Full implementation of the 10-year

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national plan would eliminate cholera from Haiti and reduce other waterborne diseases there as well. We appeal to our coalition members and to other donors including the NY Times readers to provide the resources that are needed to save lives in Haiti.”

World Water Days, March 2014, 2015

World Water Days provided an opportunity for the Coalition partners to highlight how critical water and sanitation are in the fight against cholera, while ensuring access to safe water as a basic human right.

To mark World Water Day in 2014, the CEO of WASH Advocates stated,

“We want to go far beyond treating cholera patients. We want to stop the actual transmission of cholera in Haiti and elsewhere, and to get there we need major improvements in water, sanitation and hygiene. Safe water is medicine. Toilets are medicine. Every man, woman and child in Haiti and beyond deserves access to safe drinking water and sanitation. This is not just essential to prevent cholera. It is every person’s basic human right.”

The Deputy Director of PAHO underscored the same point:

“If we stop cholera transmission by investing in water and sanitation, we will also help prevent other causes of waterborne, childhood-killer diarrheal diseases. The secondary benefits will be enormous, not to mention economic growth, higher productivity, and greater national stability in Haiti.”

4. Technical Assistance to the Government of Haiti by Members of the Coalition.

The Coalition is made up of different types of organizations with different roles, mandates, expertise and objectives, ranging from technical assistance, to operational implementation to donors/funders. While there has been an increase in WASH and health programming for cholera control, it has been realized through individual organizations, not among organizations. The following technical assistance activities that have been reported by Coalition members to the PAHO Secretariat during the 57 teleconference calls and summary reports between April 2012 and August 2016 are summarized below.

Health Sector Technical and Operational Support

PAHO/WHO, In addition to serving as the Regional Coalition’s secretariat, has been providing technical cooperation to support the Ministry of Health’s cholera control efforts since the beginning of the epidemic, through its permanent country office in Port-of-Prince and by mobilizing 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

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international importance.

UNICEF and PAHO continue to support cholera the rapid response teams (EMIRA) through its NGO partners and the MSPP mobile teams. However, due to reduced funding, the capacity was reduced in April 2016 with fewer teams responding to alerts. As the risk of a resurgence of uncontrolled outbreaks remains, UNICEF continues to advocate for the need to maintain a response capacity, together with improved community-based surveillance, and capacity of local laboratories to confirm suspected cases, while efforts are focused on improving access to water and sanitation services in priority areas. A network of partners - some of whom are members of the Coalition - include Action Against Hunger, Acted, Oxfam, Solidarites International, the International Federation Of Red Cross and Red Crescent Societies (IFRC) and the French Red Cross (supporting the Haitian Red Cross), and Zanmi Lasante/Partners in Health.

The Centers for Disease Control and Prevention (CDC) has supported MSPP through the provision of funds for hiring of additional staff, training of support staff (health, brigadiers and rapid intervention brigades) in 10 departments, management training of community leaders, home visits by health agents, training of field agents in diarrheal diseases prevention and management; response to alerts in the event of outbreaks and support to Oral Rehydration Points (ORPs). To support epidemiological surveillance, CDC engaged in capacity building to undertake daily verification and weekly analysis of alerts, and to develop tools for surveillance by communities; information technology equipment and materials; logistical support (vehicles, maintenance, and repairs), provision of inputs and reagents, and follow-up on the resistance of Vibrio cholerae to antibiotics. CDC provided input into the health promotion and hygiene component that addressed interpersonal and mass communications, home visits and community meetings, design/production of educational materials, training of community health agents, supervision and follow-up on the network of agents.

Between 2012 and 2016, PAHO/WHO, CDC, UNICEF and the World Bank have helped to organize a number of small technical advisory meetings of global cholera experts in Port au Prince lead by the Ministry of Health and DINEPA. Topics discussed have addressed strategies to combine the use of oral cholera vaccine with WASH interventions such as household chlorination in targeted rural and urban communities (21 – 22 April 2016), and recommended key strategies for the dry and rainy seasons (July 2015). In addition, on 11 April 2014, the World Bank held a small technical meeting on global best practices for cholera elimination, and their application in Haiti. The meeting was held on the margin of the Spring Meeting in Washington DC. Approximately 20 Global Experts from Bangladesh, Peru, UK, US and South Africa were invited. The objectives of the meeting were to gather recommendations for the World Bank’s contribution to the cholera elimination initiative in Haiti.

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The World Bank commitment to the health sector for 2012 – 2013 for cholera control amounted to $15 million, with an additional $20 million for 2014 – 2018 to support the four pillars of the national plan to eliminate cholera in four target departments (Centre, North, Northeast and Northwest) as well as for health services and promotion / prevention in the West Department through two NGOs. As budgets from other sources have declined, the World Bank has extended financing for cholera coordinators in all 10 departments. It will also extend financing to ensure the continuous functioning of EMIRAs (mobile rapid response teams) in six departments that were not previously financed by the Bank. A rapid assessment of water and sanitation conditions in health facilities in the 4 target departments has also been undertaken. Some contingency funding has also been provided to help address emergency outbreaks in cholera.

World Vision’s early technical health sector support in Haiti included partnering with public and private organizations in supplying, staffing, maintaining and running 31 oral rehydration posts, 14 Cholera Treatment Units and 1 Cholera Treatment Center. World Vision also supplied drugs and other health supplies to 12 Government of Haiti hospitals on an ongoing basis, and continuously tracked and fed data into the national cholera surveillance systems. In 2016, as a result of World Vision’s experience with cholera programs, the organization has adopted a new integrated development country strategy for Haiti that focuses on water, sanitation and hygiene, health, and nutrition. The strategy is founded on the building blocks of partnership, church and community mobilization and capacity building, national level advocacy and child protection/survival. The program focuses on household, community and policy levels. Its preventive activities include working through social networks, supporting behavior changes, training of WASH committees and religious leaders in prevention and promotion, and support to citizen voice in action groups, advocating for WASH and Sanitation services.

The International Federation of the Red Cross (IFRC) secured US$ 8.3 million for implementation for the period 2014 -2016 as a result of a special appeal in 2013. The plan of action developed by the IFRC and discussed with the MSPP was presented at a technical meeting in Port au Prince in April 2014 organized by PAHO. Institutional and community based surveillance, Community investigation and interventions in response to cholera outbreaks, hygiene promotion and Community Health Agents’ training have since been implemented by the Haitian Red Cross and seven other national Red Cross societies in Ouest, Centre, Sud-Est, Nord, Nord-Est, Nord Ouest, and Artibonite. Also, these interventions are accompanied by mapping of epidemiological data, which allow for the identification of areas of cholera persistence where targeted actions have been implemented, in particular improvements in access to potable water.

Catholic Relief Services (CRS)CRS’ focuses on training, supporting and deploying community health workers, field agents, teachers, school management committees, WASH Committees, masons, healthcare workers and other professionals, as well as building WASH infrastructure and carrying out community-based hygiene promotion activities in the South and in

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neighborhoods of the selected metropolitan communes of Port-au-Prince, Delmas, Carrefour & Petionville. In the South Department, CRS manages construction and rehabilitation of urban and rural water systems and institutional (school/emergency shelter) latrine blocks.

Zanmi Lasante/Partners in Health (PIH) operates in 11 health care sites. Services provided continue to include comprehensive care, treatment, and prevention activities in cooperation with the Government of Haiti and other partners operating CTCs.

Oral cholera vaccination (OCV) with WASH

The Centers for Disease Control and Prevention (CDC) participated in the vaccine effectiveness study on OCV based on the initial campaign in 2012 undertaken by Zanmi Lasante/PIH and GHESKIO Centers. CDC also completed a study on the costs of OCV and developed training modules for clinicians. During the campaign in September 2014, CDC documented the use of OCV in the prisons.

Zanmi Lasante/PIH and GHESKIO centers supported the Ministry of Health in carrying out a vaccination campaign in urban and rural sites in Haiti using oral cholera vaccine (SANCHOL) between April and June 2012 followed by a second campaign targeting 200,000 people in 6 communes classified as higher-risk1 in August and September 2014. PAHO provided strategic support for Haiti to purchase, store in the warehouse, and distribute cholera vaccines, and to finance, train and equip 370 vaccination teams made up of 1,222 health workers and community agents led by 145 departmental supervisors. Altogether 191, 275 persons were vaccinated following the required protocols and guidelines.

The door-to-door vaccination campaign also undertook complementary activities such as pre-prepared posters and media messages related to sanitation and hygiene promotion. The partners used community health workers to reinforce messages in the weeks and days before, as well as "town criers", t-shirts, radio shows and SMS messages etc. Focus groups were also organized with key community leaders in advance with the same messaging. Every 'contact' was considered an opportunity for education.

The effectiveness of the oral cholera vaccine has been evaluated in a case-control study. 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. Vaccination can therefore be considered to be an important component of efforts to control cholera epidemics while longer-term water and sanitation infrastructure is being installed.http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70368-7/fulltext

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.

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Another article published 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. Since September 2013, no documented cases of cholera have occurred in over 50,000 people who had received the vaccine. Only a few cases of acute diarrhea have been treated among > 70,000 people, a phenomenon which may also be attributed to the distribution of chlorine tablets for household water and constant health education of the population. The overall efficacy rate in this study provides evidence for the effectiveness of OCV as part of an integrated package for the control of cholera in outbreak settings. This larger proof of concept can only be done in Haiti with an ongoing epidemic of cholera and a relatively small population.

Water and Sanitation Sector Technical and Operational Support

PAHO country office together with UNICEF, CDC and some members of the Coalition, have provided technical support that has included:

Establishing a water-quality monitoring system that has been implemented in the health centers and that is being expanded to all of Haiti’s 140 communes. The system uses mobile phone technology to ensure daily water quality surveillance in 56 or more health facilities. The system allows for real time information to be collected directly from the field. If the water quality is identified as poor, trained health personnel send an SMS alert to the national water authority that triggers an immediate investigation and response from UN partners. UNICEF is ensuring the expansion of the system to monitor more than 300 water systems across the country with a focus on health structures

Strengthening the capacity of sanitary officers from Haiti’s Ministry of 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 10 Haitian health centers.

Supporting the operation of hygienists in Health structures caring for a large number of patients.

The Centers for Disease Control and Prevention (CDC) has provided technical cooperation to the Haitian Ministry of Health and DINEPA by:

Developing a training package for TEPACS, and coordinating with other donors such as the World Bank, IDB, and AECID to support the TEPAC program

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Providing technical assistance to DINEPA to improve the monitoring and analysis capacity of the data collected by TEPACs

Supporting DINEPA in the development of a national strategy for household water treatment and storage (HWTS)

Supporting IOM and PSI to stimulate demand for household water products through the private sector;

Undertaking a study on the quality of water in the privately operated water kiosks; the findings demonstrated that most of the water sold is microbiologically safe.

Participating in training activities related to the Total Sanitation Campaign undertaken by the Government of Haiti.

The Inter-American Development Bank’s (IDB) priority support has focused on the water and sanitation sector through a portfolio of USD160 million (7 grant operations) with an emphasis on:

Water provision (construction, rehabilitation, expansion and maintenance of water supply systems) in metropolitan Port au Prince, intermediary cities and rural areas,

Improvement of sanitation facilities in schools and markets, and waste water treatment centers

institutional strengthening of DINEPA 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 sectoral governance to strengthen the coordination and control of the diverse actors engaged in the water sector across the country at central, regional and departmental levels. In addition, IDB has supported the recruitment and financing of procurement officers and sanitation staff, as well as their training.

The World Bank is supporting a $50 million project in WASH as of May 26, 2015 that will target specific localities targeting 3,000 – 10,000 persons in small rural towns.

Water-related activities focus on construction and rehabilitation of water supply systems together with strengthening the local management models by way of CAEPAs or local private operators trained from scratch (using the model tested under IDB/WB financing in the South Region that has proven successful).

Sanitation activities focus on behavior change at the community level, plus sanitation facilities in schools, health centers and public spaces such as markets, etc. Areas selected with DINEPA coincide with communities selected for water supply interventions in the departments of Centre, Sud, Grande Anse and Nippes.

At the institutional capacity building level, the project is supporting the de-concentration process (OREPAS, URDs, TEPACS, and CAEPAS). Specific focus will be applied on supporting local private operators to recover operation and

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maintenance costs for sustainable service delivery in small towns. A shift from a project-based approach to a programmatic approach in under

discussion with DINEPA, with information on WASH across the country and a plan of investments in a particular region. Round table planning is being strengthened.

Capacity strengthening of DINEPA is also a component of the program. The project will be implemented by DINEPA's staff with support from additional consultants, as needed. Responsibility for implementation of sanitation activities at the community level would be delegated to partners to support DINEPA. Activities will also focus on quick repairs of previously constructed infrastructure supported by WB/IDB.

The Sectorial Dialogue organized by DINEPA in Port au Prince on May 24 – 26 2016 to help refine the guiding principles and pillars of DINEPA’s sanitation strategy based upon national experiences with urban and rural sanitation, and to complement this with international experiences in sanitation was supported by the World Bank. The strategy will be presented to partners for financial and technical support. (See section 2)

UNICEF and its partners are presently engaged in technical support to the Government of Haiti and DINEPA’s Total Sanitation Campaign that was launched in July 2014 by the Prime Minister of Haiti and the Secretary General of the UN. The campaign targets 16 communes during a first phase and 35 during the second phase in the departments of Artibonite and Centre.

At the height of the post earthquake cholera outbreak, World Vision undertook preventive activities that included disinfection, repair and rehabilitation of water points, plus the distribution of water purifying gadgets, and hygiene kits. World Vision Haiti presently supports construction of water infrastructure and promotion of water decontamination. Artisans are trained in sales of WASH products or repair, plus maintenance and construction of water facilities. Boreholes have been completed, non-functioning water sources rehabilitated, and households using recommended water treatment technologies and hand washing facilities have increased.

World Vision Haiti is also supporting the Community Led Total Sanitation Project in partnership with UNICEF. As a result of its focus on latrine construction, and hygiene awareness, there have been no cholera cases since 2013 compared with 110 cholera deaths before the project began. Two of the targeted localities have become open defection free (ODF), and 15,035 people now use local structures for defecation, through the construction of unsubsidized family latrines. In addition, rainwater collection systems and water points were installed in several schools while 8500 people have improved access to potable water through the distribution of 400 bio sand filters. And owing to the need for rapid responses, 50 oral rehydration points were installed where over 400 cases of diarrhea were treated.

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The Millennium Water Alliance (MWA has eight member organizations working on Haiti on WASH activities, all of whom have indicated that they are interested in working together with DINEPA on a coordinated program of cholera control in the priority communes identified by the Government of Haiti. On World Water Day 2015, the MWA issued a statement highlighting its members’ work in Haiti, and calling for expanded coordination of NGOs working with DINEPA. MWA members have been actively:

Constructing and rehabilitating drilled boreholes, shallow wells, spring development and rainwater harvesting structures.

Improving service delivery and governance by building the capacity of Water Supply and Sanitation Committees (CAEPA) and Communal Administrative Councils (CASEC). Living Water and FH, to give an example, are active in hygiene promotion by using community care groups and training community health agents. Pure Water for the World (PWW) provides training, capacity building and consultancies to NGOs throughout Haiti. PWW’s area of expertise is in safe water treatment for households.

All MWA members are adopting Community Led Total Sanitation approaches in accordance with the national Total Sanitation Campaign.

In addition, CRS is leading the cholera response in nine private hospitals in five departments in cooperation with the Ministry of Public and Health and Population (MSPP).

CARE is integrating WASH activities into its “Neighborhood Improvement Program”.

The Caribbean Water and Waste Water Association (CWWA) is the joint Secretariat for the Caribbean Water Operators Partnership (Cari-WOP) supported by UN Habitat. Cari-WOP is working to support DINEPA through a twinning arrangement (mentor-mentee relationship). While the focus is on utility management, a common component of the partnership is to strengthen DINEPA's capacity to develop and implement Water Safety Plans (WSPs). CWWA and Cari-WOP are exploring any convergence of interests with PAHO and other partners to advance this water safety initiative with DINEPA. AECID & IDB, as well as the CDB have indicated that resources are available for DINEPA’s capacity development.

Since 2014, a special session on the initiative in Haiti has been organized at the CWWA’s Annual Caribbean Conference and Exhibition in order to continue to raise awareness and garner technical and financial support from the Caribbean. The CEO of DINEPA also participated in the 3rd Global Water Operators Congress in Barcelona Spain to speak at the “Water Resources, Protection and Resilience” panel, and to attend several sessions including the “Strengthening Operators Post-disaster”, and “Multi-Partner WOPs”.

The Multi-WOP for Haiti has advanced significantly in terms of negotiation with DINEPA and the definition of the technical exchanges between Caribbean water Utilities.

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Between 2010 and 2015, the International Federation of the Red Cross (IFRC) spearheaded the collaboration between the American, British, Canadian, French, German/Austrian, Netherland, Norwegian, Spanish, Swiss and Secretariat Red Cross in the areas of health promotion and water and sanitation. Each Red Cross Society focused its activities on specific geographic zones and communes as determined by the Ministry of Health. Their contributions to the improvement and construction of additional water and sanitation systems, waste water treatment and management, and quality of water between 2012 – 2015 has been significant. And to improve the sanitary conditions in the schools and markets, the IFRC and partner Societies constructed and/or repaired and installed latrines for schools in Leogane, Jacmel and Port-au-Prince, Salomon and for the markets in Delmas. From 2013 to 2015, in partnership with other actors, the American Red Cross supported more than 100 camps of Internal displaced population (IDP) which have benefited from water provision projects, construction, maintenance and emptying latrines.

5. Major Challenges Faced by the Coalition

As of September 2016, the Coalition of partners is composed of twenty-three institutions and agencies. The Coalition mechanism provides a constructive space for the members to share information and alternative strategies. Being in a formal group allows these discussions to be structured more productively, and increases the sense that on some issues the members must move in a collective direction with a clear timeline.

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:

Global recession affecting national relief and development assistance budgets.

Increase in the number and scope of humanitarian and health emergencies in other geographic zones, superseding the attention to the cholera crisis in Haiti.

Liaison with UN NY, while maintaining a separate and less prominent identity as an independent body and being complementary to a shared vision. The Coalition should continue to advocate for proven interventions to eliminate cholera, share information, and coordinate its efforts wherever possible.

Limitations on available funds from major development agencies due to donor fatigue following the earthquake relief, and their reluctance to support the UN’s fund raising efforts owing to external legal challenges. The responsibility to mobilize the necessary financial resources to support the Plan of Action had been centralized to the UN in NY. But the Secretary General’s Initiative

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inadvertently caused a slowdown of the initiative. The necessary funds proved slow to materialize.

Limited capacity faced by the Government of Haiti resulting from loss of life in the earthquake and resultant management and personnel difficulties. The limited capacity to disburse also presented roadblocks to further implementation and resource mobilization.

Absence of an effective clearinghouse for cholera-related activities in Haiti.

Absence of a designated leader at national level to pull the coalition members into a more coordinated program.

To overcome some of these challenges, in 2014 and 2015, the Millennium Water Alliance (MWA) actively sought to develop a sub-network of WASH NGOs with a strong capacity to support the Government of Haiti through coordinated field activities. The consultations generated a strong commitment by the eight MWA organizations working in Haiti to jointly scale up their water and sanitation operations in priority departments and communes, and to work in alignment with DINEPA and other agencies of the Government of Haiti. 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

During the September 8 Meeting of the Coalition, the partners concurred that the Coalition has done some notable work in helping to keep Haiti in the spotlight long after the news headlines had faded. The fact that the Coalition has survived as long as it has is a success in itself, and Haiti being back in the news again now highlights the importance of the Coalition. Interest has continued to be strong among the members, with conference calls well attended and lots of participation. And when different people from within and outside the Coalition have been asked if the Coalition should continue, the consensus has been positive.

Most successful outcomes of the Coalition: A reduction of the high incidence and prevalence rate of cholera from the 2010-

2013 period owing to individual organization’s contributions undertaken separately.

Development of National Plans of Action for the long, short, and medium terms between 2012 and 2016.

Heightened international awareness of the cholera problem in Haiti and required solutions.

Involvement of new partners (MWA, CRS, CWWA, WASH Advocates, World Vision, IFRC, PIH, GHESKIO)

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An increase in funding for WASH and health interventions. Closer coordination among Government of Haiti ministries and international

organizations.

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 donor support.

7. Major Needs Remaining to Achieve Cholera Elimination by 2022:

During the annual face-to-face and webinar meeting on September 8 2016, the following recommendations were discussed as a way forward for Coalition support to the Medium Term Plan 2016 – 2018 and beyond to 2022:

Noting that cholera continues to take a heavy toll on the people of Haiti, strong financial and political support is required for the medium-term cholera elimination plan. More specifically:

1. Continue with a multi-faceted integrated approach to the control of cholera in Haiti within a 5-10 year time frame.

1.1 WASH interventions should not be reduced or simplified. The longer-term plan for the installation of improved WASH infrastructure combined with constant messaging on hand washing and food hygiene is a proven approach used in the Americas.

1.2 Continued implementation and steady improvements in water, sanitation and hygiene promotion at the national, community, and household levels is fundamentally important. A medium term response includes: repairing existing networks, protecting wells and water supply systems against fecal contamination through regular technical monitoring, ensuring the control of water quality, improving collection practices, transportation, storage, treatment and usage of water at home.

1.3 Place an emphasis on the Water User Associations at community level, and on increased capacity to manage, monitor and disinfect at municipal level. Use proven human and medical waste disposal technologies (including for excreta disposal), and selected test sites weekly.

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2. The Coalition is also prepared to support the scaling up of OCV with WASH for the short and medium term.

2.1 Design a more aggressive three-to-five year national vaccination campaign using an appropriate mathematical model with cholera vaccine as a key component, and combining household-level WASH interventions, more complex water and sanitation and hygiene measures over time, and ongoing behavior change messages. This would be a Step Wedge design with appropriate indicators to measure impact. For the long term, a national program to enhance the Haitian sanitary infrastructure can be effective and is essential for the health of the Haitian people.

2.2 Support the Coordination Axis One of the Medium Term Plan by creating a National Level Vaccination Group to study more systematically, and to produce better indicators for measures combining cholera vaccination with WASH over a five-year period. If Vaccine Stock becomes more widely available, the Vaccination Group could determine the precise timing and logistics for operationalizing an expansion of OCV with WASH.

2.3 Support the recommendation to ensure that the local multi-task health agents (ASCP-CHW) are mapped and fully integrated across the entire health system (not just for cholera) and that the same CHW protocol applies for every donor-supported program using CHWs. Coordination at the departmental and local level should be strictly operationalized, not just part of the written plan. Also ensure that community based surveillance (SEBAC) continues to be strengthened as a national priority and health professionals employed in the health facilities can become agents of change in their communities.

2.4 Apply the same expectations for DINEPA financed water and sanitation projects. Support a scaled up model that engages local private sector operators and CAEPAS at community level, with DINEPA functioning as a higher-level regulatory agency.

2.5 Help to overlay the mapping of hot spots where partner organizations are present and prepared to support either the longer-term, larger scale WASH infrastructure and repairs, or shorter-term rapid response, preventive and curative care, and behavior change activities.

3. Predictable sources of funding for defined periods of time are essential for sustainability. New funding is also essential for longer-term WASH measures

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(infrastructure, water quality monitoring, WASH security, community-based technical engagement, behavior change) and improved health and prevention services (OCV, training, rapid response teams, epidemiological and community-based surveillance). Explore potential opportunities for establishing public-private alliances to leverage resources.

3.1 Encourage and support the UN Resident Coordinator office in Haiti to take the lead in mapping out the gaps and needs, and tracking funding commitments.

3.2 Agree on a common strategy to support and influence how the UN funding support should be administered and directed. Use the medium term and long term plan and dollar figures as the single tool, and break the components into smaller packages that bilateral agencies could willingly support. That is, make the Medium-Term Plan doable to the international donors’ support (WASH, Governance, Education, Health, OCV rollout design etc.). A steady focus on long-term, sustainable WASH capacity should also be brought to the attention of the donor community.

3.3 A fresh approach could be envisioned at country level that envisages WASH and health in the context of the SDGs 3, 6, 13, 16, 17 and the concept of universality. SDG 3 and 6 particularly refer to ensuring access to universal health services, and to universal safe water, sanitation and hygiene.

3.4 Collectively identify the needs and distinguish clearly between sources of funds for emergency short-term requirements, two-year medium term development requirements, and 15-year horizons for longer-term commitments.

3.5 New thinking should be discussed as to how to raise funds from non-traditional sources; (for example, visa fees, transfers through Western Union, and approaching the diaspora organizations that are members of the Coalition for their systematic support).

8. Moving Forward as a Collective Entity

8.1 The Secretariat might invite other organizations that are active in the cholera elimination work to join the Coalition. Clear criteria for the selection of organizations to be invited could be developed, and an option for organizations wishing to join the coalition to apply should also be made available. At the same time, re-evaluate those that are not active.

8.2 The Coalition’s added value at global and regional level is its advocacy role to continue to: i) catalyze public opinion and stakeholders to work in coordination toward the common goal of eliminating cholera and promoting

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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.

8.3 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.

ANNEX. Key events & activities supported by the Coalition 2012 – 2016

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Launch, Advocacy, Technical Cooperation and Expansion of Coalition

Launch of the Declaration & Coalition in Salvador, Brazil (4 June 2012 ) founding Partners (PAHO, CDC, UNICEF, AECID, IDB, AIDIS)

OAS - PAHO USA launch: (29 June 2012 ) Two new Partners (FUNASA, AMHE Haiti Diaspora Feder’n)

Pan American Sanitary Conference (PASC) Promotional Event for Member Governments (18 September 2012 ) Four new Partners, WB, IFRC, CARICOM, WASH Advocates

National Plans of Action developed over 10 months by Ministries of Health, DINEPA and INAPA with support from PAHO, CDC, UNICEF and some NGO partners (CRS, IFRC, WV) May 2012 – Feb. 2013

Technical Advisory Group (TAG) on Immunization and OCV in Washington DC (August 12 2012) Hosted by PAHO, UNICEF & CDC

Technical Advisory Group (TAG) meeting on WASH in PaP Haiti ( 2 Oct 2012 ) Hosted by

DINEPA/MOH with support from PAHO and CDC

Bi-National Strategic Planning Meeting in Santiago DoR – (8 – 9 Oct 2012) CSIS-PAHO Seminar in Washington DC (12 Oct. 2012) Five new partners (PIH, Zanmi Lasante,

CRS, Veolia, CWWA)

UN Secretary General’s Launch in NY (11 Dec. 2012)

Official launch of the 2 and 10 year Plan of Action, PaP Haiti (Feb 27, 2013)

Millennium Water Alliance (MWA) joins the coalition (18 March, 2013)

First Donor Meeting of Partners at PAHO Hdq (31 May, 2013) $26 million committed

USAID and World Vision join the coalition (28 June, 2013)

Capitol Hill Event (PAHO, WASH Advocates, ASTMH, CSIS, PIH) (23 Oct 2013) 125 attendees and participants

Coalition Partners Meet at PAHO to discuss the way forward (Feb 4, 2014)

World Bank Meeting of Global Experts in Cholera in DC (April 11, 2014) (DINEPA, MOH, PAHO, CDC, Experts, WB)

MOH Technical Meeting in Port au Prince with cholera experts (April 22, 2014)

GHESKIO Centers and Fondation Merieux join Coalition (September 2014)

World Bank High Level Meeting on Hispaniola (9 October 2014) $50 million committed for WASH in Haiti

Caribbean Waste Water Alliance (CWWA) – 23rd Annual Meeting attended by PAHO, DINEPA and Millennium Water Alliance (MWA) 6 – 9 October 2014

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A survey conducted in October 2014, partners summarized the principal successes of the Coalition as being advocacy, coordination, information sharing and dissemination.

WASH Advocates and PAHO promote World Water Day March 2015

CARIWOPS-CWWA mission to Haiti in February 2015. Work Plan developed with DINEPA for peer-to-peer collaboration funded by CDB and the Utilities.

CWWA-AWWA Annual Conference August 2015 included DINEPA Haiti. A subsequent meeting in Argentina approved the workplan.

World Bank $50 million project for WASH is approved in May 2015

GHESKIO Centers, Red Cross, and World Vision continue health care & promotion, vaccination, water and sanitation, chlorination in the communities 2015

PAHO, UNICEF, MOH, PIH, GHESKIO centers collaborate on OCV campaign 2015

IFRC, World Vision, UNICEF, PAHO note that funds expiring in March 2016

WASH Advocates closes its office – December 31 2015

High Level Commission on Cholera meet in Haiti – December 2015 attended by some members of the Coalition. (PAHO, UNICEF, World Bank)

Face to Face Meeting of the Coalition, Washington DC, September 8 2016

University of North Carolina Conference on Water and Health, Side Event, October 10, 2016

Signatories to the Declaration and Coalition Members

PAHO/WHO, UNICEF, CDC – founding partners

(AECID) Spanish Agency for International Development Cooperation (AECID)

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Association of Haitian Medical Physicians Abroad (AHMPA)/ Haitian Diaspora Federation/National Organization for the Advancement of Haitians

Caribbean Community (CARICOM)

Caribbean Waste Water Association (CWWA)

Catholic Relief Services (CRS)

FUNASA (National Health Foundation) of Brazil

GHIESKIO Centers, Haiti

Inter-American Association of Sanitary and Environmental Engineering (AIDIS)

Inter-American Development Bank (IDB)

International Federation of Red Cross and Red Crescent Societies,

Merieux Foundation

Millennium Water Alliance2

Partners in Health / Zanmi Vasant

The World Bank

WASH Advocates

World Vision

USAID

Veolia Environment Foundation

2 There are presently 13 members of the MWA, at least 8 of whom are working in different sites in Haiti. These include: CARE, CRS, Food for the Hungry, Living Water International, Lifewater International, WaterAid in America, Water For People, Water Missions International, Water.org, World Vision, Global Water, Pure Water for the World, , and IRC - International Water and Sanitation Centre (Netherlands).

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