Non-Governmental Organization Responsibilities for Health Systems Strengthening in the Wake of the 2010 Haiti Earthquake

Written for GH 511 at the University of Washington, Fall 2018

Non-Governmental Organization Responsibilities for Health Systems Strengthening in the Wake of the 2010 Haiti Earthquake
Background and Introduction
On January 12, 2010, Haiti experienced 7.0 magnitude earthquake. The epicenter’s proximity to Port-au-Prince ensured the destruction of the capital, including many government and agency buildings, as well as the loss of over 200,000 lives and displacement of 1.5 million urban residents.(1) In response to the catastrophe, the world sprung to action. Nearly half of all households in the United States donated to earthquake relief, contributing over $3 billion in private aid.(2, 3) Foreign governments and multilateral organizations such as the United Nations (UN) pledged over $9 billion to help with relief and reconstruction.(3) Much has been written examining the international aid response to Haiti’s earthquake in terms of outcomes for housing, economic and political stability, foreign investment, and health. With so many international players descending upon Haiti in the wake of this crisis, the question becomes what responsibility these various actors have within each of their sectors. In terms of non-governmental organizations (NGOs) working in healthcare, this paper argues the following:
Policy Statement: At times of acute humanitarian crisis, such as the 2010 earthquake in Haiti, NGOs have a responsibility to work towards broad health systems strengthening in addition to responding to the health-related demands of the crisis.
In this paper, NGO contributions to the relief effort will be considered separately from the contributions of donor states. Donor states pledged $4.6 billion to Haiti in the months following the earthquake, and the Interim Haiti Recovery Commission (IHRC) was formed to oversee these funds.(1) The UN, World Bank, and Inter-American Development Bank had a hand in forming the IHRC, co-chaired by Haiti’s Prime Minister Bellerive and former U.S/ President Clinton, in an attempt to coordinate resources and avoid duplication of efforts.(3) The priorities of the IHRC and other large-scale efforts by donor states (including military efforts and debt forgiveness) were entrenched in tied aid paradigms and largely benefitted the donor countries themselves.(3) Many assertions can be made regarding the challenges of donor state aid and the large impact this category of post-quake aid had on the ineffectiveness of the Haiti relief effort. However, it can be argued that the accountability of donor states lies primarily to their own citizens, thus foreign government aid does not carry the same expectations for on-the-ground outcomes that are expected from NGOs. While no true separation between donor government and NGO outcomes can be cleanly made because NGOs in Haiti receive significant funding from bilateral and multilateral organizations, this paper will focus on the actions of individual NGOs.   

Support for Health Systems Strengthening as a Primary NGO Responsibility
Acute humanitarian crises do not occur in a vacuum; the strength and dysfunction of the current health system strongly influences the efficacy and long-term sustainability of the response to acute crisis-related demands. In order to provide any sort of lasting improvements in health after a crisis, healthcare NGOs must not only understand the sociopolitical context that exacerbates the post-disaster health-related issues, they must strive to immediately rebuild and improve upon what remains of the local system.
In Haiti, it was apparent after the earthquake that the baseline conditions would challenge the efficacy of any quick fix healthcare strategies. The earthquake has been characterized as an “acute-on-chronic” event; prior to the earthquake, Haiti’s weak health system already struggled within a societal context of poor access to clean water, sewage facilities, and education.(4) To those who could afford it, healthcare services were often provided by a scattered network of private providers, and even the publicly funded General Hospital ran on a fee-for-service model. Pre-quake, the lack of patients who could pay and insufficient government funding meant that the General Hospital in Port-au-Prince had poorly paid employees, frequent labor strikes, and supplies that were chronically out of stock.(5) Prior to the quake, many NGOs were attempting to fill the gaps and strengthen the system, including Zanmi Lasante (ZL), the Haitian arm of Partner’s in Health (PIH), co-founded by Dr. Paul Farmer. Dr. Farmer reflected on the need for NGOs to tackle broad health systems strengthening, “because these patients were poor before they became sick, we needed something other than fee-for-service models. We also needed heavy investments in infrastructure, trainings, and direct services.”(5)
After the earthquake, the baseline weaknesses of Haiti’s healthcare system were compounded, and the need for health system strengthening increased. Humanitarian crises often mean huge losses of personnel and infrastructure, requiring significant external investment if ongoing health needs can be met beyond the acute stage. After the earthquake, Haiti lost 17% of civil service employees and almost all government ministry buildings were destroyed.(6) Thirty-Seven of Haiti’s 48 hospitals were incapacitated, including Haiti’s largest public hospital, with its adjacent nursing school flattened while classes were in session.(7) The Ministry of Health was also destroyed.(5) The damage extended to almost all other government buildings.(3) Despite courageous contributions from Haitians, including 95% of General Hospital employees and government ministry employees who returned to work unpaid, the already weak public health system was completely devastated.(4, 5) Not only could Haiti not respond to acute health needs on its own, but any government infrastructure that would allow for strategic long-term health system planning was suddenly largely nonexistent. Any NGO operating in Haiti in this environment thus had the logistical, and arguably moral, imperative to consider long-term strategy.
It also must be recognized that acute responses provided by relief NGOs, such as basic needs delivery, have little effect on long term health outcomes given their inability to address the societal determinants of health.  As Associated Press journalist Jonathan Katz points out, not only are acute relief interventions person-limited, “there is a finite amount of aid to be pushed through to a finite number of people in need; there are only so many times you can give someone a hygiene kit,” but the short-term assistance provided by tarps, food aid, water, and hygiene kits are immediately overshadowed by systemic issues of housing, employment, food insecurity, and access to long term healthcare.(6) Again, Dr. Farmer highlights the feebleness of acute healthcare interventions in the wake of such a disaster, “we could tend to the injured, but what about the homeless? We could treat the sick, but what about burying the dead? We could insert intravenous lines, but what about…the thirst of millions?”(5)
 Fortunately, NGOs with long histories of local and governmental partnerships are uniquely poised to leverage their donor base to both address acute demands and assist with sustainable rebuilding through effective government partnerships. After the earthquake, NGOs that were experienced and well-established in Haiti were far more nimble than Haiti’s shattered public sector or even the IHRC and were able to more quickly spend their donor funding with fewer bureaucratic and political delays.(5)
For example, St. Damien’s Pediatric hospital, located near Port-au-Prince’s airport, is run
by an NGO that has been working in Haiti since the 1980’s. With most of St. Damien’s structure remaining standing after the quake, the hospital was able to quickly receive international operating and healthcare teams to perform emergency orthopedic surgeries and amputations and provide prosthetics and therapy programs.(8)  In addition to acute relief, St. Damien’s also quickly recognized a gap in maternity coverage when the General Hospital was damaged. Although St. Damien’s had never previously been a birth center, they established a maternity program, serving 4,799 expectant mothers in 2011. St. Damien’s continues its maternity program to this day, demonstrating an ongoing investment in health systems strengthening.  
            On an even larger scale of success, PIH and ZL, as longstanding NGOs with local government partnerships, were able to able to make massive contributions to Haiti’s health system after the earthquake. PIH-run University Hospital in Mirebalais (UHM) in Haiti’s central plateau was the largest reconstruction project in the health sector after the earthquake.(9) UHM, originally planned as a more modest hospital, ballooned beyond its originally intended size in response to post-quake needs and, due to the specific request of Haiti’s Health Minister, UHM is now a 300-bed teaching hospital, hosting seven residency programs.

Dissent for Health System Strengthening as a Primary NGO Responsibility
Unfortunately, these positive case studies were not the norm during Haiti’s post-earthquake reconstruction, and unfortunate examples of NGO failures and shortcomings support the opinion that NGOs should not be involved in health system strengthening after disasters. Many international relief NGOs do not have the in-country staff, local connections, or expertise to effectively integrate with the current health system in order to address health systems issues beyond the acute phase. The most public post-quake failure was the Red Cross, who, despite raising $500 million in an aggressive advertising campaign after the disaster, had only three staffers on the ground when the quake began, and most dispatched staff had no experience in Haiti and did not speak Haitian Creole.(6, 10) Thus, the Red Cross struggled to allocate their massive funds and their ineffectiveness on the ground has been widely criticized, including a failed plan to build 700 permanent shelters in Campeche, a hillside neighborhood of Port-au-Prince. After spending $24 million on the project, only six permanent homes were built, and the project has since stalled.(10) Ten months after the quake, NGOs overall had managed to provide 20,000 transitional shelters for the 1.5 million displaced Haitians, but there were no new permanent dwellings built.(4) In ad campaigns, the Red Cross promulgated its lofty goal of helping 4.5 million Haitians ‘get back on their feet,’ a massive number equaling the entire urban population of Port-au-Prince.(10) This naïve statement demonstrates the ingenuousness of one of many international organizations attempting to fix a widespread system who were unfamiliar with Haitian law and land use issues and had few inroads in the local system.
Besides the high risk of ineffectiveness, NGO participation in health system strengthening can duplicate public programs, undermine government authority, and compete for resources, further weakening a fragile government infrastructure. With thousands of NGOs operating in Haiti and no system to count them much less regulate them, these fragmented organizations have no accountability to local governments and minimal coordination with each other.(3) Post-quake aid exacerbated this problem by withholding all but 1% of foreign assistance from the Haitian government. Despite recognition by the World Health Organization that health support through Haiti’s Ministry of Health is cheaper than through international organizations, by September 2010, only 15% of international reconstruction pledges were delivered, and only 0.3%  of the $1.8 billion went to the public sector.(5, 7) According to Farmer, “this approach might sustain the NGOs and multilateral aid machinery but wouldn’t suffice to build adequate capacity in the Haitian public sector itself.”(5) By bypassing local institutions in favor of NGOs, aid to Haiti will continue to weaken government capacity.(3)
Finally, NGOs are accountable in their outcomes only to their donor base, so they may be disincentivized to respond to long term local priorities in an effort to produce superficial reportable outcomes for donors. Even well-meaning NGOs who initially attempt to bolster the health system do not have a mandate to stay and thus do not provide the stability necessary for sustainable systems growth. As recently as July 2018, citing the end of their temporary mandate in Haiti, Médecins Sans Frontières is being criticized for closing two hospitals in Haiti despite requests from the Ministry of Health to keep them operational.(11) Additionally, a widespread lack of program evaluation and reporting is noted among NGOs in Haiti, whose inflated operating costs are not justified by the paltry reporting of their outcomes.(3) A paradox then occurs as the international community pressures local governments to improve transparency and efficiency as prerequisites for aid.

Given a situation with immense destruction and a weak baseline health system, such as Haiti’s 2010 earthquake, it is the responsibility of NGOs responding to acute humanitarian crises to attempt to address broader improvements in health systems. Despite problematic examples of international NGOs ineffectively applying superficial approaches to health system strengthening and challenges with coordination and transparency, there are avenues for success with positive examples provided by NGOs with long histories of local cooperation and government partnerships.

1.         Concannon B, Lindstrom B. Cheaper , Better , Longer-Lasting : a Rights-Based Approach To Disaster Response in Haiti. Emory International Law Review. 2011;Vol. 25, p:1145-91.
2.         Parti T. Haiti Earthquake: Six Months Later, are Relief Efforts Dragging? Christian Science Monitor2010.
3.         Ramachandran V, Walz J. Haiti: Where Has All the Money Gone? Washington, D.C.: Center for Global Development; 2012. Report No.: 004.
4.         Beaubien J. Against a Hard Landscape, Haitians Persevere. NPR2011.
5.         Farmer P. Haiti After the Earthquake. United States: PublicAffairs; 2011.
6.         Katz JM. The Big Truck That Went By. New York: Palgrave MacMillan; 2013.
7.         Watts J. Haiti making good progress in health but challenges remain. The Lancet. 2014;384(9955):e56-e.
8.         Rayno J. St. Damien Pediatric Hospital Report.
9.         Marsh RH, Rouhani SA, Pierre P, Farmer PE. Strengthening emergency care: Experience in central Haiti. The Lancet Global Health. 2015;3(S2):S5-S7.
10.       Sullivan L. In Search of the Red Cross' $500 Million in Haiti Relief. NPR2015.
11.       Charles J. Haiti's maternal mortality rates among the lowest. So why is this hospital closing? Miami Herald. July 19 2018.