2 October 2012, Port-au-Prince - In follow-up to the Call for Action for Cholera Elimination in Hispaniola, and in partnership with PAHO, CDC and UNICEF held a meeting in January 2012. An expert national force led by the Ministry of Health in Haiti has been established to elaborate a National Plan of Action for Cholera Elimination. Water and sanitation is a fundamental component for the success of this initiative over the short, medium and long term. In June 2012, a Coalition on Water and Sanitation was established among several partners including the CDC, UNICEF, AECID, World Bank, and the IADB, with PAHO as the Secretariat.

A Technical Advisory Group (TAG) on Water and Sanitation – composed of a small core of international experts – has been established to make recommendations to the Coalition Secretariat and Government of Haiti as to how the proposed strategies, activities and budget line items of the water and sanitation components of the National Plan of Action for Cholera Elimination may be strengthened. Recommendations are also aimed at fostering the confidence of new funding partners to increase investments in this key component of the National Plan of Action for Cholera Elimination. In particular, the remit of the TAG is to make recommendations on water and sanitation infrastructure development, water sector management and cost recovery approaches in Haiti, based upon lessons learned and experience gained internationally.

Coordinated by Dr Jon Andrus, Deputy Director of PAHO and chaired by Dr Jordan Tappero, CDC, the TAG on Water and Sanitation met with the Ministry of Health in Haiti and DINEPA in Port-au-Prince, Haiti on 2nd October 2012. The TAG was privileged to obtain elucidations on the rationale for and content of the draft National Plan of Action for Cholera Elimination by the representatives of the Ministry of Health in Haiti and DINEPA.

The TAG acknowledges DINEPA is a relatively new organization which has done a remarkable job particularly in the face of the 2010 earthquake and subsequent cholera outbreak by protecting the displaced population against diarrheal diseases such that the risk of death from disease has dropped from 6% to 1%–remarkable accomplishment!

The TAG recognizes the outstanding work that has already gone into the development of the national cholera elimination plan and commends efforts for integration with the Dominican Republic aimed at the development of a Binational plan. In an effort to help make the plan even more appealing to potential donors, the TAG respectfully makes the following recommendations:

1. Install a high level national intersectoral steering committee charged with: governing the process of implementing the plan; advocating for stronger legal and regulatory frameworks; expediting an effective decision-making process; harmonizing management and administrative functions; monitoring and reporting on progress, and identifying barriers. (include Ministries of Health, Public Works Transport and Communications, Agriculture, Environment, Industry, Commerce and Finance, etc.)
2. At the operational level, continue to use and maximize the inter-sectoral approach, particularly between MTPTC (DINEPA and SMRCS) and MSPP.  PAHO, CDC UNICEF and TAG members will be pleased to facilitate the approach.
3. Considering describing DINEPA’s experience from the cholera control campaign of the past two years, in sufficient detail such that technical professionals in each field can assess the content, which would thus (1) greatly strengthen the case for increased financial support from international sources and (2) contribute to the quality of the plan’s implementation into new areas beyond emergency response.
4. Better Identify short-term, medium, and long-term objectives, including priority targets.  Examine what priority and other milestones might be accomplished in 2 yrs, 5 yrs, and 10 yrs so as to facilitate the monitoring and evaluation of progress and costs in the implementation of actions. A matrix of specific priorities and timelines will help donors identify which areas they could potentially support. Take advantage of your present and management processes and use thee to better reflect the plan for donor.  Also, this will allow for identifying successes to showcase in the early years.
5. Provide more detailed references to the rules, regulations and engineering development plans informing the national plan of action to eliminate cholera. Also make these materials available to the TAG so that more detailed and helpful comments might be provided.
6. Continue GIS mapping of priority intervention areas which show greatest risk for cholera transmission.  Use data from MSPP and DINEPA (like population density, cholera attack rates, access to WATSAN to create the maps.
7. Implement a monitoring system for water quality and broader WATSAN indicator which measures impact on cholera rates and other water borne diseases and measures the impact on absenteeism at school and work places.
8. Better define the roles of the public sector, private sector and civil society in the implementation of the National plan to eliminate cholera. These roles should be made explicit and their rationale should be illustrated.
9. Consider providing continuous opportunities for public participation in decision making on water and sanitation at different levels: planning and budgeting; management and operations; regulation and compliance, monitoring and evaluation. This would strengthen governance and contribute to the development of a sense of ownership and responsibility.
10. Capacity development is vital for the successful and sustainable implementation of the National Plan to eliminate cholera. Elaborate further the strategy for complementary innovative partnerships for capacity development.
11. Prioritize components of solid waste management that would impact the elimination of cholera.  For example focusing on household waste, infectious or hospital waste, has an impact on cholera transmission.
12. Sanitation is an enormous and important issue, so consider focusing on direct links with reduction of cholera risk and as mentioned in the plan, the improvement of current systems. Consideration should be given to investing in household connections to conventional sewerage systems while recognizing the need for flexibility in how to improve household sanitation – e.g. by examining options like community septic systems and or sewage systems depending upon topography and household conditions.
13. Consider making a high quality documentary film which highlights and shows the problems and accomplishments made and communicate the WASH needs to the donor community (this film should be short and impactful).
14. Ensure strong bi-national coordination as agreed to on March 13, 2012 between the Governments of Haiti and Of the Dominican Republic for implementation of the national strategy for cholera elimination.
15. Highlight the environmental aspects of WASH and how they affect the watershed and living environment in future planning efforts. Environmental awareness is important for identifying how surroundings are used and the impact of that use on human health and quality of life.

The Tag submits the above recommendations for the consideration of MSPP and DINEPA.  Members will be pleased to provide additional feedback or clarification on these recommendations.

One final but critical note: To ensure success of the national plan for cholera elimination and the improvement of water, sanitation and hygiene for Haiti it will be essential to maintain accountability, transparency, and stable financial mechanisms. Perhaps the steering committee identified in recommendation #1 could assist in addressing the administrative issues as mentioned.