New Details Emerge on Elimination Plan as Cholera Continues to Spread

June 12, 2013

On May 31 the World Bank, PAHO and UNICEF announced $28.1 million in new funding for cholera elimination efforts in Haiti. The new funding was announced following a meeting in Washington, D.C. of the Regional Coalition to Eliminate Cholera Transmission in Hispaniola. In February 2013, a $2.2 billion, 10-year cholera elimination plan was announced by the Government of Haiti, with the support of the coalition. The plan calls for $443.7 million over the first two years. Thus far, however, there have been few details of how the plan will be funded and coordinated.

In announcing the new funding, PAHO noted that UNICEF would “take lead responsibility for the operation of a national trust fund to channel resources to cholera elimination.” While the terms of reference for the national fund are still being worked out, those familiar with the discussions told HRRW that it would be run by a steering committee led by the ministries of health of Haiti and the Dominican Republic. In contrast with previous aid and reconstruction funds that have largely bypassed the Haitian government and Haitian institutions, the new fund would have the ability to directly fund the work of the Haitian government as well as international NGOs.

“Donors are looking for improved international cooperation with Haiti and this is a model they’re looking for,” said Kate Dickson, Senior Policy Advisor at PAHO. Dickson added, “it is a model that allows the respective governments, Haiti and the Dominican Republic, to actually take the lead, accompanied by a coalition at the international level.”

This would represent a significant change from previous efforts, such as the Haiti Reconstruction Fund, which was only able to disburse funds to the U.N., World Bank and Inter-American Development Bank. It also may reflect the influence of Paul Farmer, named the U.N. Secretary General’s Special Envoy on Community Based Medicine and Lessons from Haiti. Under his previous role as Deputy U.N. Special Envoy, Farmer argued that “the way aid is channeled matters a great deal, and determines its impact on the lives of the Haitian people.”

During the meeting between coalition partners and donor groups in late May, Farmer directly addressed this, in an appeal to donors:

By December 2012, only 10% of the total $6.4 billion dollars invested in Haiti had gone through national systems.  We have learned and relearned this lesson in Haiti: unless efforts are made to increase the amount of such resources to and through public institutions, the process of building them is slowed or thwarted. When we say “through”, we mean of course, that there can be local private entities, from contractors to NGOs, that wish to be part of rebuilding… Again, we are here not only to fund the national actions plans, but to do so in a way that strengthens ownership and local capacity, while accompanying local authorities and providers. This requires, as the Americans say, “boots on the ground” – not those of soldiers but of community health workers.

Nevertheless, some traditional donors, reluctant to give up operational control of their aid funds may instead opt to work outside of the national fund. This is already evident. In December, when the U.N. Secretary General announced an initiative to support the cholera elimination plan, he stated that there had already been $238.5 million committed. However, with the recent funding commitments of $28.1 million announced last week, PAHO noted that it “brings the total funds committed to support the national plans to $209.4 million, less than half the amount needed over just the next two years.”

The Secretary General’s announcement, where he pledged to “use every opportunity” to mobilize funding for the plan, included commitments from the IDB and Spanish government for example, to support the water and sanitation sector in general.  Once plans for a national fund emerged, some donors appear to have balked at providing resources through this mechanism rather than through other channels of their choosing.  USAID also reportedly does not favor putting resources into a national fund, though it is apparently interested in coordinating with the coalition. USAID did not respond to a request for comment.

But, as the national fund has yet to formally take shape and the immediate needs on the ground remain pressing, for the time being many donors will continue to fund work in the water and sanitation sector through their existing funds. “Saving lives is a priority,” said PAHO’s Dickson. “We cannot wait on the mobilization of resources for the fund to be set up, we have to move now using existing funding mechanisms to ensure a timely response to any additional outbreaks.” While donors may at first be reluctant to channel resources into a national fund, by working with the coalition the hope is that program activities will be integrated into the scope of the cholera elimination plan. The risk, however, is that aid agencies and donors fall into the same mistakes that have been made in the past, bypassing the Haitian government and failing to coordinate. What is clear though is that with hurricane season beginning, and cholera continuing to spread, the needs are not just long-term but also immediate.

“The situation is worse than it was two years ago,” says Duncan McLean, a health program manager for Medecin Sans Frontieres, adding, “I’m very, very concerned about the state of cholera preparation in Haiti. The situation has become more dangerous than it was before.”

Through the first three months of the year, the number of reported cases was up 83 percent over 2012, while deaths had increased by over 100 percent. Over the last two months cases have diminished, though cholera is still sickening nearly 100 Haitians every day. Part of this decrease is because the spring rains, which led to large increases in the caseload in 2012, have not occurred this year. However, with the hurricane season starting June 1 and the potential for a late rainy season, the expected cholera spike may have just been delayed. As of May 28, over 6.5 percent of the population has been sickened by the disease and at least 8,120 Haitians have died, according to the Health Ministry

Meanwhile, funds for the short-term response have been just has hard to come by as funding for long-term development. “To treat cholera primarily as a development issue is grand, but people are dying now,” McLean told Fox News. The Miami Herald reported last month that the $37 million U.N. appeal for Haiti was just 19 percent funded and that “Water, sanitation and health activities related to cholera are so far the least funded sectors” of the appeal.

The result has been a decreased response capacity on the ground. According to data from the United Nations, the number of cholera treatment centers and treatment units has decreased drastically over the last two years, and has reached a low of just 28 for the entire country as of April 2013, down from over 300 in early 2011.  Haiti’s Ministry of Health, which has struggled to take over for departing NGOs, is sounding the alarm. “The rainy season is upon us. Alas, our resources are not as available as they need to be. We must take urgent and bold steps to meet these needs,” Marie Raymond, director general of MSPP warned.

As Farmer stated to donors last week, “there is much to be done in the immediate term, long before the goal of eradication might be met. The fatality rate among cholera patients in Haiti is still far too high; of course no one should get cholera but no one, once sick, should die from it.”


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