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.

“Football is the opera of the people” -Stafford Heginbotham

Finally, a happy affliction has struck Haiti: World Cup Fever. Since the tournament began last week, Haitians have something to celebrate and they’re doing it with unreserved joy. One and half million people are still living in camps or on the streets, 5 months after the devastating 7.0 magnitude struck Haiti in January. But soccer is bringing people together; cheerful shouting can be heard across Port-au-Prince when the games are broadcast three times each day at 6:30am, 9:30am, and 1:30pm.

Haitians are, by and large, supporting the Brazilian team. It’s hard to miss the thousands of yellow and green Brazilian flags decorating every corner of Port-au-Prince: hanging from the twisted balconies of fallen buildings, decorating cars and utility poles. Across a wide stretch of Port-au-Prince’s central road, Rue de Delmas, fans have gathered thousands of yellow and green plastic bottles and have strung them, criss-crossed, across Delmas like Christmas lights. The Haitian government has teamed up with groups like FimAid International to erect huge viewing screens in the refugee camps. For a little while, at least, displaced Haitians will have the World Cup games to share with each other as a distraction from the grind of daily life.

And in addition to soccer, there’s hockey. Grace Children’s Hospital, where the prototype C2C clinic will arrive on Tuesday, June 22^nd, received a special visit several weeks ago from Canadian NHL player, George Laraque. Of Haitian descent, Laraque lifted the spirits of children awaiting treatment at Grace by bringing hockey sticks and playing a demonstration game. It’s wonderful to see that sports, even in the worst of circumstances, can bring a measure of joy to Haitians.

Across campus at Grace Children’s Hospital, workmen have begun land preparation for the C2C clinic. A cash-for-work program has hired 20 local people to level the land on the northwest corner of Grace’s campus, in anticipation of the delivery of C2C’s container clinic.

Stay tuned in the coming days for more progress on-site at Grace, the installation of the C2C clinic, and soccer dispatches from Haiti.

Following up on yesterday’s meeting with MSH, we met today with Dr. Georges Dubuche, MSH’s Senior Techinical Advisor. Georges brought us to two of their clinics in Port-au-Prince with immediate need for replacement facilities. Of course, immediate need implies severe damage, and the first step is to get MOH permission to hire a demolition crew.

Georges estimates that it will take 1000 trucks 1000 days to clear the rubble in the city, and I’m not convinced that’s hyperbolic. A word on disaster preparedness, which I found interesting: based on historical records, the last earthquake felt in the Port-au-Prince area along the Enriguillo-Plaintain Garden fault was in 1770. At that time, Haiti was still a French colony, and in developing the city after the earthquake, Louis XVI mandated that all buildings were to be constructed of wood (as opposed to concrete blocks). If you look around Haiti today, many of these wooden buildings are still standing. Louis was on to something.

Thirty-two coups and the economy-draining amortization of what in today’s USD would be 21.8 billion in debt to France (which, curiously, the US took to finance the Louisiana Purchase) later, what wasn’t burned (figurative) by politics, was challenged by hurricanes. With the extreme winds and rains, city planners returned to concrete as a primary building material and paid little attention to old building codes. New building norms were set and no one paid much attention to tectonic plates, which was fine…until more than 200 years of built up stress and energy in the earth brought many [concrete] buildings to ground – and with them much of the relative stability the country enjoyed in the last year/two years. Time to rethink building codes. Shipping containers, anyone?

This  doesn’t read like very linear thinking, so let’s loop back: I learned all this driving around with Georges. MSH is an impressive organization, a talented and knowledgeable all-local staff with a wealth of contextual knowledge and a commitment to partnership with and capacity building in the public sector. C2C deeply admires and aspires to the bar they’ve set.

MSH’s approach to clinical programming is an “integrated package of primary health.” Interestingly, a few years ago, USAID encouraged quite the opposite: either you did TB or reproductive health or nutrition or sanitation or malaria, etc. MSH recognized the need to integrate these services in a central community-oriented location; rather than working off the expectation that folks would mobilize between locations for their many needs, MSH clinics offer all the primary care a patient needs in one facility.

They keep both electronic and paper records of community outreach and clinical visits. With two doctors, three nurses, six auxiliary nurses (responsible for the health education and home visits), a full lab, and a radio and bullhorn-disseminated public relations campaign, MSH clinics are quite comprehensive in their planning, scope, reach and reporting. They set the bar for clinic-level health delivery, and C2C and the MSH team will be in close touch in the weeks ahead.

YIKES, it just started to downpour. There are so, so many people in tents…