1. Strength in Unity:
Aligning Incentives to
Address and Redress Cholera in Haiti
Team 12
Dennis Wang
Matthew Tran
Michelle Tseng
Mary Germino

2. 2

3. Landscape of the Problem
UN being sued by IJDH
650,000 cases, 8,300 deaths, from cholera
74% lack access to basic sanitation
36% lack access to safe drinking water
3

4. Objectives
Addressing Cholera
1a. Eliminate cholera by 2022.
1b. Halve by 2022 the proportion of the population
without sustainable access to safe drinking water and
basic sanitation.
Redressing Cholera
2a. Set precedents for UN compensation of affected
individuals and communities.
2b. Prevent future incidents.
1a
1b
2a
2b
4

5. 1a. Eliminate Cholera by 2022

6. Lessons from history
John Snow and
“The Ghost Map”
1a
Eliminate Cholera, 2022
1b
2a
2b
6

7. Controlling the epidemic
• Prevention, prevention, prevention
• Earthquake damage was preventable (Haiti)
• Cholera was preventable
• Cholera is preventable (resistance)
• Short term to long term strategy
1a
Eliminate Cholera, 2022
1b
2a
2b
7

8. Secondary and Tertiary Prevention
• Diagnosis: education! signs and symptoms
• Treatment (as prevention): oral rehydration
solution, oral antibiotics, nutrition
supplementation
1a
Eliminate Cholera, 2022
1b
2a
2b
8

9. Primary Prevention
• Five basic prevention measures:
•
•
•
•
•
Water
Hands
Feces
Food
Cleanliness
• Education via radio, schools, etc.
1a
Eliminate Cholera, 2022
1b
2a
2b
9

10. Elimination 2022
• Epidemiology: active (expensive) or passive case
finding
• Compensation as an incentive for cholera
patients (fragmented health system)
• Symptomatics first (passive)
1a
Eliminate Cholera, 2022
1b
2a
2b
10

11. Haitian Human Capacity
• UN will need to interact with cholera cases, main
incentive is $3B, already guaranteed
• For new cases in the Haiti/UN system...
Diagnose (only
in govt. health
centers)
Collect
Epidemiological
Data
Treat
Baseline
Compensation
1a
Eliminate Cholera, 2022
1b
2a
2b
11

12. 1b. Halve by 2022 the proportion of the
population without sustainable access to safe
drinking water and basic sanitation.
1a
Eliminate Cholera, 2022
1b
2a
2b

13. Haitian Physical Capacity
• Retroactive compensation: community level
• For old cases... Use community estimates, create
health centers
• Community compensation goes toward health
centers, training, more sustainable
1a
1b
Water and Sanitation
2a
2b
13

14. Disbursement Guidelines and Oversight
Procedures
A synergistic solution will:
Leverage and unify
the existing
funding, manpower,
and expertise
offered by resident
NGOs
Reinforce the
Haitian
government;
facilitate excellent
civil service
1a
1b
Water and Sanitation
2a
2b
14

15. 2a. Set precedents for UN compensation of
affected individuals and communities.

16. Redressing Wrongs
• Public Apology
• Community Claims
• Individual Claims
1a
1b
2a
Precedents
2b
16

17. Redressing Wrongs
• Public Apology
• Community Claims
• Individual Claims
1a
1b
2a
Precedents
2b
17

18. UN Precedent in Individual Claims
Reasons Against:
• There is a danger of penalizing the wrong parties. Nepal pays an
insignificant amount of the UN peacekeeping budget – the top 10
members contribute 80%.
• Could be difficult to verify deaths due to cholera, non-fatal cases
cover a broad spectrum of severity.
That being said, it would be a commendable gesture for the UN
fund to pay outstanding debt accumulated from funeral and
treatment costs.
18

19. Disbursement Guidelines and Oversight
Procedures
CHALLENGE
CONSEQUENCE
Large number of disparate
organizations involved in
response to cholera outbreak
Poor coordination among
actors, misaligned goals
Haitian government directly
receives only a small fraction
of aid sent to Haiti
Limited government
influence in unifying actors;
little opportunity for
government to gain strength
Most qualified workers are
lured away from civil service
by higher paying NGOs
1a
1b
2a
Precedents
2b
19

20. Disbursement Guidelines and Oversight
Procedures
Preliminary Steps:
• Ensure that every rural region has an active
water committee (CAEPA).
• Use some fund monies to attract talent back to
government agencies as needed by offering more
competitive wages.
• Compose an oversight committee of UN
members, Haitian citizens, and sector experts.
1a
1b
2a
Precedents
2b
20

21. Disbursement Guidelines and Oversight
Procedures
Oversight
Committee
CAEPAs(2)
&
OREPAs(3)
DINEPA(1)
1. Higher-level government organizations
biannually solicit proposals from lowest-level
water committees for local improvements.
1a
1b
1)
2)
2a
Precedents
21
2b
Direction Nationale de l’Eau Potable de l’Assainissement
Comites d’Aprovisionnement en Eau Potable et d’Assainissement
3)
Offices Regionaux de l’Eau Potable et de l’Assainissement

22. Disbursement Guidelines and Oversight
Procedures
Oversight
Committee
CAEPAs(2)
&
OREPAs(3)
DINEPA(1)
1a
1b
1)
2)
2a
Precedents
2. Once proposals are
approved, contracts are
bid on by the public.
NGOs,
potentially
including
local forprofit
contractors
22
2b
Direction Nationale de l’Eau Potable de l’Assainissement
Comites d’Aprovisionnement en Eau Potable et d’Assainissement
3)
Offices Regionaux de l’Eau Potable et de l’Assainissement

23. Disbursement Guidelines and Oversight
Procedures
Oversight
Committee
DINEPA(1)
CAEPAs(2)
&
OREPAs(3)
$
$
NGOs,
potentially
including
local forprofit
contractors
3. Grants will be offered to the best bids.
1a
1b
1)
2)
2a
Precedents
23
2b
Direction Nationale de l’Eau Potable de l’Assainissement
Comites d’Aprovisionnement en Eau Potable et d’Assainissement
3)
Offices Regionaux de l’Eau Potable et de l’Assainissement

24. Disbursement Guidelines and Oversight
Procedures
Oversight
Committee
CAEPAs(2)
&
OREPAs(3)
DINEPA(1)
4. Contractors will be held accountable for
progress by water committees; funding will
be pulled if unsatisfactory.
1a
1b
1)
2)
2a
Precedents
In addition, water committee
must send progress report to
DINEPA in order to enter next
round of proposal approvals.
NGOs,
potentially
including
local forprofit
contractors
24
2b
Direction Nationale de l’Eau Potable de l’Assainissement
Comites d’Aprovisionnement en Eau Potable et d’Assainissement
3)
Offices Regionaux de l’Eau Potable et de l’Assainissement

25. 2b. Prevent future incidents.

26. Updating UN Operating Procedures
CATALYST FOR CHANGE
RECOMMENDATIONS
Cholera-causing bacteria were
transported to Haiti via a
Nepalese UN peacekeeper.
Stricter immunizations and
screening before and immediately
after entry into Haiti; initial screen
is the responsibility of the troopproviding nation.
Presumed cause of cholera
outbreak was poor sanitation
practices in a UN peacekeeper
camp.
Nepali peacekeepers continued
to earn a salary 3-4 times the
average of their home nation,
even when their activities
became harmful.
1a
All UN sanitation facilities are to be
inspected at regular intervals.
Violating nations will be given a
probation period wherein the fixed
compensation per peacekeeper paid
by the UN to the providing nation
will be halved.
1b
2a
2b
Prevention
26

27. Budget
Government Staffing
($80)
(in $mm)
Incentivizing Hospital
Check-ins ($50)
Inspection/screening
costs ($20)
Water Infrastructure
($1000)
Cholera Treatment
($450)
Sanitation
Improvement ($500)
Technical Experts/UN
overseers ($50)
Public Awareness ($30)
Total: ~$2.2bn
1a
1b
2a
2b
Debt payoffs of cholera
victims ($20)
Prevention
27

28. Timeline
Action
YR 1-2
Prime environment, establish gov. structure;
attract partners/funding
YR 3-4
YR 5-6
YR 7-8
X
X
X
X
X
Implement Cholera Treatment
Pilot, learn, refine
Expand to larger regions, refine
Scale up
X
X
Strengthen Infrastructure/Education
Build and create material, pilot
Expand to larger regions, refine
Scale up
X
X
Redress Wrongs/Strengthen Organization
Compensation Scheme
Accountability/mgt system
1a
1b
2a
2b
Prevention
X
X
28

29. The Evaluation Indicators
Alignment with WASH; Cholera Prevalence
KAP survey; increased hand-washing
Attendance at meetings; fewer redundancies
1a
1b
2a
2b
Prevention
29

30. The Summary
Problem:
Liability
Cholera
Access to water and waste
management
Infrastructure
Education
Compensation
Governance
Treatment
Objective:
Eliminate Cholera
Improve access
Set Compensation
Outcome: Reduce mortality
and improve quality of life
1a
1b
2a
2b
30

31. Building Back Better
• Haitians…
• Build health centers, water facilities
• Staff health centers for diagnosis and treatment
• Manage the data for elimination
• Cholera cases become health workers for
prevention
• UN manages the money
1a
1b
2a
2b
31

32. Q&A
Thank you!

33. Appendix

34. Appendix A: Current Funding
Recipients of Relief Aid to Haiti, 2011
1%
5%
6%
Donor's own civil/military entities
34%
UN agencies and NGOs
Other NGOs and private contractors
26%
Unspecified
Red Cross
28%
Government of Haiti
34
1)
http://www.cgdev.org/blog/haiti-doomed-be-republic-ngos

35. Appendix B: Top Contributors to
Peacekeeping budget
Percentage of Assessed Contributions
Top 20 Providers of Assessed Contributions to UN Peacekeeping
Budget
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
35
1)
https://www.un.org/en/peacekeeping/documents/backgroundnote.pdf

36. Appendix C: Water Sources
36

37. Appendix D: Water Committees
“There are hundreds of water committees, called CAEPAs (Comités
d'Aprovisionnement en Eau Potable et d'Assainissement) or simply Comités d'Eau,
in charge of water systems in rural areas and some small towns.[8] They consist of
elected community members. Their degree of formalization and effectiveness varies
considerably. The best water committees meet regularly, closely interact with the
community, regularly collect revenues, hire a plumber who performs routine
repairs, have a bank account and are registered and approved by DINEPA. However,
many water committees fall short of these expectations. There is no national or
regional registry of water committees or water systems and there are no
associations of water committees at the municipal, departmental or national level.”
37
1)
http://en.wikipedia.org/wiki/Water_supply_and_sanitation_in_Haiti

38. Appendix E: Disbursement Guideline
Details
• A template proposal will be provided to all water committees, which
they can submit practically as is if their community does not have
any specialized needs.
• Solicitations will be called for in fixed cycles with fixed budgets, so
that the managing actors can better prioritize. We recommend a
biannual deadline.
• Bids will be ranked by (1) the competency of the bidding group; (2)
the involvement of Haitian citizens in the bidding group; (3) the
amount of additional funds the bidding brings to the table.
38

39. Appendix F: Budget assumptions
Assumptions:
1.
2 weeks salary=$50 ,so compensation per admission will be $50
(remaining $450 goes towards treatment/hospital stay, etc)
2.
1,000,000 hospital admissions in the next 8 yrs based on 500,000
over last 4
3.
8000 deceased already from cholera*1000 per family = 8mil+
doubled for future deaths
4.
10,000 employee costs*8 yrs*1000 workers = 80mil
5.
1.5 bil for water and sanitation, based on numbers from the
Ministry of Public Health
39