It’s been six months since the earthquake, and there’s been lots of talk of progress (or lack thereof) over the last handful of days. In summation, I’d say that the first line of belabored challenges is precisely the obvious:

Rubble: Only 2% of the 26 million m3 of rubble created by the earthquake has been trucked away. There are 300 trucks working daily, but most of Port-au-Prince remains impassable. You can’t build on rubble, and with scarce capital to clear it, we’re looking at a grossly extended timeframe for rebuilding the commercial and political centers.

Housing shortage: The number of people in relief camps has nearly doubled to 1.6 million. Only 5,657 transitional shelters (of a planned 125,000) have been built, and nearly four times as many are awaiting assembly (land and customs clearance are cited as major limiting factors). Hundreds of thousands live in squalid conditions, including the medians of major roadways. It’s untenable, and much more work has to be done to consciously relocate the displaced to more viable sites.

Importing aid shipments: the port’s an arrant Charlie Foxtrot.

The Haitian government is getting a lot of slack for lackluster leadership and the NGO community’s still feeling the heat of deeply imperfect coordination. To be fair, upwards of 30 percent of Haitian civil servants were lost when 28 of 29 government ministries collapsed, and roughly 90% of the NGO community has registered with the Interim Haiti Recovery Commission, co-chaired by Bill Clinton and Haitian Prime Minister Jean-Max Bellerive. Clinton concedes that the paucity of progress is horribly frustrating, and reconstruction remains a pipedream, but promises to be on the phone this week cashing in on the $5.3 billion pledged at the Donors’ Conference back in March. Only about 10% has been delivered to Haiti – most in forgiven debt – which frustrates the commission’s ability to execute programs.

Six-months out, hope remains for the alliterative plan to build back better, but it’s discouraging that something as fundamental as clearing out the rubble isn’t a lower-hanging fruit. Still, theoretically, because of the scale of devastation and the dire situation preceding it, Haiti has a tabula rasa and we know how to bench our expectations.

Grace Children's Hospital and the C2C Plot

There have been a couple delays to the installation schedule, which had a soporific effect on the blog.  The delays came in two broad strokes, most of which was out of any one person’s control, none of which was specifically anticipated, and all of which is par for the course given the context:

1) Getting the clinic cleared through USAID takes a variable – but almost certainly considerable – amount of time.  Because Haiti has entered hurricane season there’s been an influx of aid to the country, and a good deal of it is consigned to USAID.  All the shipping documents, which – we learned the hard way – have to be originals, shift through many offices and get stuck in a fair amount of bureaucratic gook before they’re cleared by the Haitian government.  Far from the break-neck speed with which we thought we’d clear customs, this has truly been a marathon.  The clinic *may* get cleared for delivery later this week, but USAID, the US embassy, and the Haitian customs office are all backed up, and meanwhile, our containers continue to make their unmodified peers feel inadequate:

A clinic moonlighting as a lego in Port-au-Prince. Container 1 is buried a few rows back.

2) Until the end of last week, even if the clinic had cleared, the site wouldn’t have been ready to receive it.  So robust is the NGO support for Grace Children’s Hospital that we too suffer the coordination-snafus plaguing the general aid effort in Port-au-Prince.   It took the better part of my last two weeks in Port-au-Prince to get all parties on board to our vision for the site layout and preparation.  Then there were the added challenges of scarce resources, which [ironically?] includes the “rubble” (the engineers’ word, not mine) with which we’re leveling the land.

Now the land is prepped, the NGO environment mapped, and once the clinic gets the green light from USAID/US Embassy/Haitian customs, it’s full steam ahead…”full steam,” of course, calibrated for a Port-au-Prince speedometer.

I thought people might be interested to hear a little about one of the Haitians currently working with Grace Children’s Hospital and Containers to Clinics.  As a volunteer, I had the opportunity to rub elbows with some of the convivial doctors and hospital management who oversee the clinic’s future home.   I also spent some mornings with the Grace Children’s Hospital’s land preparation team over the last couple of days.  The hospital is independently expanding its infrastructure to replace buildings and offices lost in the earthquake and it is exciting to see the new projects that will work in conjunction with the C2C clinics.

In the many moments I spent escaping the sun, I met Alex, one of the land-prep workers shoveling next to me.   He smiled a big smile and started rattling off some questions that I had a hard time keeping up with as I used my hard hat as a bench and chased my breath.  I think he could tell that I was lost, so he started over, we shook hands, and the conversation began in earnest.  His cadence was quick and it was clear that he knew English very well.  His energy eclipsed mine.  This was not any sort of surprise; this city is rugged but effervescent.  Most of the Haitians I have met are vivacious and expressive.  It’s a city where when Brazil scores in a World Cup match the cheers of their supporters rise across the city to a cacophony that surmounts the walls and windows wherever you are; then lingers.  Alex seems to be one of Port-au-Prince’s own, without a doubt.   

We bantered over the usual opening subjects in Haiti: soccer, the possibility of rain, how long I would be in town.   He asks where I am from and when I mention my mother’s Japanese descent, he is quick to ask for phrases.  We try a few out and he is a quick study, smiling all the while.  He throws some Creole back I try my hand at the amalgamation of streamlined French and some words that seem to lack European etymology.  He jabs with a quick phrase and I fail to see the connection.  Arabic?  Yes, he speaks Arabic, oh, and Spanish.  You don’t?   No, I laugh, I don’t.

As we spend some time talking over his background, I learn about his upbringing with an adoptive Canadian father and supplemental education with various non-profit programs.  At one point, he worked in the office for the UN.  He was born and raised in Port-au-Prince, but educated by people from all over the world.   Alex has a propensity for languages, for sure.  Right now, he seems content to have a well-paying job that also puts his hands into rebuilding the city and country where he grew up.  So we talk some more (he likes to talk), and prepare the land.

Alex with the ICC crew

Port-au-Prince

While our field correspondent reports her adventures from Port-au-Prince, I thought I’d chew on a thought project.  I just got back from a conference in DC that locked all the top public health professionals and academics (and those of us who seek to learn from them) in a confined space, and they’ve set us free again to ask serious questions about how we measure the impact of our work.  This isn’t anything new to C2C’s organizational development discussions, but now that we’re entering the practical phase of our work, the rigor of the discussions and their practical application are a lot more relevant.

Conventional wisdom has it that what goes in, must come out.  Think about everything that’s gone into the C2C project as inputs defined broadly as capital and labor; what, ultimately, will be the outcomes and how, quantitatively, will we measure them?  This is a line of questioning that’s recently been given a lot of attention; recall the chagrin when we all heard there were 10,000 NGOs in a country that kept getting poorer (Haiti).  How does that happen?  To be fair, there are SO many variables, and success never looks the same twice. Still, there’s no doubt that there’s inefficiency in non-profit operations, and we need a way of measuring it so that we might do better.

How do we hold ourselves accountable?  The relative value of money is universally agreed upon (allow me that one generalization), so ideally, we would monetize health outcomes. But that’s tough to do.  Follow a dollar investment into a family planning intervention, which connects a woman with the knowledge and resources to space her pregnancies or have only as many children as she and her partner can afford.  Maybe now that she’s a bit more in control of her health and productivity, she gets a job, which lets us assign a dollar amount to the consequent addition to her family’s wealth.  Actually, you could follow it even further and look at the healthy, not-overstretched mom who’s able to send her kids to school and because of their educations they land solid jobs and move above the breadline.  But because you don’t have an accurate shot of the counterfactual – the “what would have happened” if the family planning NGO hadn’t intervened – you can’t measure a delta in wealth or the dollar outcome of the NGO’s dollar input. There’s no doubt that these are totally over-simplified hypotheticals, but the logic works.  The public health community hasn’t yet come up with a universally agreed upon set of definitions or metrics, and I think that’s something we’ll see a lot more discussion about in the next few years: holding ourselves accountable to efficiency.

Another thought on measurement, while we’re on it: there was also a bit of talk at the conference about “cash on delivery” aid, or cash for improved outcomes.  The idea is for financiers of development projects to espouse a results-based financing model, which would necessarily raise the bar on outcome measurement.  If you pay for proven and improved outcomes rather than talk of inputs and activities, financiers incentivize more innovation and results-oriented interventions, and we more closely align what we get out with what we put it – in other words, funding inextricably tied to accountability . That’s something C2C takes very seriously, and it’s why we’re working so closely with MSH to evaluate the change in capacity and quality of care at Grace Children’s Hospital.  It will be a hybrid quantitative/qualitative evaluation, which is harder to measure, but we’ll learn to understand our outcomes in terms of an agreed upon value system – if that’s dollars, then we monetize quality.

This is something I hope we can come back to on the blog. It fascinates me, and I offer it up as food for thought.  When we design health interventions – just as when we fund them – we must have an eye toward results.