Rapport final du projet HLP

THE USAID HEALTH LEADERSHIP PROJECT FINAL PROJECT REPORTMay 2, 2019–March 15, 2023 This product is made possible by the generous support from the US Agency for International Development (USAID) under Agreement No. 72052119CA00004. The contents are the responsibility of Management Sciences for Health and do not necessarily reflect the views of USAID or the US Government. Contents Acronyms and Abbreviations...........................................................................................................................................i Executive Summary .......................................................................................................................................................... 3 Achievements............................................................................................................................................................. 3 Objective 1: Build GOH Capacity to Lead and Finance the Health Sector......................................... 3 Objective 2: Improve GOH Planning and Oversight of the Health Workforce................................. 4 Local Solutions Partners Capacity Building.................................................................................................. 4 Introduction ....................................................................................................................................................................... 5 Challenging operating environment............................................................................................................... 5 HLP’s technical approach and results framework..................................................................................................... 7 Project Activities and Achievements..........................................................................................................................10 Objective 1: Build GOH Capacity to Lead and Finance the Health Sector...............................................10 Result 1.1: Sustainable financing for health increased .............................................................................10 Result 1.2: Public financial management improved...................................................................................15 Result 1.3: Governance and accountability improved.............................................................................19 Objective 2: Improve GOH Planning and Oversight of the Health Workforce ......................................25 Result 2.1: GOH health workforce leadership improved ......................................................................26 Result 2.2: Distribution of the health workforce improved ..................................................................31 Local Solutions Partners Capacity Building .......................................................................................................35 Lessons Learned..............................................................................................................................................................42 Annex 1: Summary of HLP Achievements: 2019–2023 .........................................................................................44 Annex 2: List of Health Facilities that Received Electronic Cash Registers from HLP ..................................46 Annex 3: List of HLP Success Stories........................................................................................................................47 Annex 4: Financial Management Capacity Tool.......................................................................................................48 Annex 5: OSCAR Tool..................................................................................................................................................49 Annex 6: NUPAS Tool ..................................................................................................................................................50 HLP Final Project Report Page | i Acronyms and Abbreviations ASCPs agents de santé communautaire polyvalents CCM Country Coordinating Mechanism CDC Center for Disease Control and Prevention CFET Centre de Formation et d’Encadrement Technique CHARESS Le Centre Haïtien pour le Renforcement du Système de Santé COP Country Operational Plan DAB Direction d’Administration et du Budget DG Director General DOSS Direction d’Organisation des Services de Santé DPSPE Direction de Promotion de la Santé et de Protection de l'Environnement DRH Direction des Ressources Humaines DSI Direction des Soins Infirmiers ESF equipe santé familiale FPS Fonction Publique de la Santé GC Group Croissance GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria GHESKIO Groupe Haïtien d'Étude du Sarcome de Kaposi et des infections Opportunistes GOH Government of Haiti GRFM Gestionnaire des Ressources Financières et Matérielles HFG Health Finance and Governance HLP Health Leadership Project HLP/HF Group Croissance as direct implementer HLP/HRH Centre de Formation et d’Encadrement Technique as direct implementer HLP/MSH MSH as support to Group Croissance and Centre de Formation et d’Encadrement Technique HR human resources HRH Human Resources for Health HSD Health Service Delivery MEF Ministry of Economy and Finance HUEH Hôpital d l'Université d'Etat d''Haïti MESI Monitoring Evaluation et Surveillance Intégrée MSH Management Sciences for Health MSPP Ministère de la Santé Publique et de la Population NUPAS Non-US Organization Pre-Award Survey OMRH Office de Management et des Ressources Humaines OSCAR Organizational Synthesis of Capacity Assessments for Award Readiness PAHO Pan American Health Organization PEPFAR US President’s Emergency Plan for AIDS Relief PES Paquet Essentiel de Services PNLS Programme National de Lutte contre le SIDA PSDRHS Plan Stratégique de Développement des Ressources Humaines pour la Santé 2030 PY project year Q quarter SIGRH Système d'Information de Gestion des Ressources Humaines SPS statut particulier de la santé SSC Service de Santé Communautaire HLP Final Project Report Page | i TOR terms of reference TWG technical working group UADS Unité d’Appui à la Décentralisation Sanitaire UAS Unité d’Arrondissement Sanitaire UEP Unité d’Etudes et de Programmation UGP Unité de Gestion de Projet UNDP United Nations Development Programme UNFPA United Nations Population Fund USAID US Agency for International Development USG United States Government WISN Workload Indicators of Staffing Needs WHO World Health Organization HLP Final Project Report Page | ii Executive Summary The US Agency for International Development (USAID)-funded Health Leadership Project (HLP) builds Government of Haiti (GOH) capacity to lead and finance the health sector and improve planning and oversight of the health workforce, moving away from a reliance on external support. The project was implemented by Management Sciences for Health (MSH) and two local solutions partners, Groupe Croissance (GC) and the Centre de Formation et d’Encadrement Technique (CFET). HLP was launched in May 2019, and MSH led the implementation of the project for the first three years while simultaneously strengthening CFET and GC’s organizational capacity. Both partners then received direct funding agreements from USAID to implement project activities through October 2024. MSH supported the partners to implement HLP in a transition period through January 31, 2023, and then closed the award on March 15, 2023. This report details the period May 2019–January 2023. HLP was implemented during extremely challenging times in Haiti. The COVID-19 pandemic came less than a year into implementation, limiting movement and activities and necessitating shifts in Ministère de la Santé Publique et de la Population (MSPP) priorities as they responded to the health crisis. At the same time, the country saw a dramatic rise in insecurity related to the president’s assassination and gang activity, further impacting the ability to travel and move about the capital. In light of these conditions, HLP had to constantly adapt strategies to achieve the project’s objectives. ACHIEVEMENTS Objective 1: Build GOH Capacity to Lead and Finance the Health Sector In close collaboration with the MSPP, HLP facilitated the development of the country’s new health strategic plan 2021–2031 (Plan Directeur). This will guide all MSPP interventions to improve access and quality of care under the goal of establishing universal health coverage. This plan built on HLP’s evaluation of the previous health strategic plan. The project also helped develop a costed three-year operational plan to facilitate the implementation of the Plan Directeur. To improve public financial management within Haiti’s health system, HLP, working with the Direction d’Administration et du Budget, developed the public financial management assessment tool and assessed 10 departmental health directorates and 39 health institutions. The assessments resulted in action plans to address identified weaknesses. HLP also supported the MSPP priority to install 36 electronic cash registers in 14 hospitals to better control internal revenue. Solar panels and inverter batteries were also provided to ensure power for their consistent use. The project supported the ministry’s Unité d’Etudes et de Programmation (UEP), or Studies and Programming Unit, with a series of studies to guide policy decisions on health financing. HLP conducted an assessment on the management and use of internal revenue in health institutions and also helped the UEP prepare for future studies on health insurance and the determinants of catastrophic spending on health. To improve governance and accountability within the health sector, HLP assisted the MSPP to establish a mechanism to put into action the Unite d’Arrondissement Sanitaire, or District Health Units, to facilitate the decentralization of health services to the district level, thereby enabling a better response to the HLP Final Project Report Page | 3 needs of the population. To assess the impact of COVID on health facility functioning, HLP supported Direction d’Organisation des Services de Santé, or Health Services Organization Directorate, staff to evaluate sites. The project also helped the MSPP plan for rolling out the delivery of an essential package of services at health facilities. HLP standardized the intersectoral meeting guidelines to facilitate partner coordination and helped relaunch the MSPP forum to improve communication between the central level and departments to help them align priorities and map resources to avoid duplication of efforts. Lastly, HLP supported the strategic monitoring unit of the country coordinating mechanism to ensure the oversight of ongoing grants from the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Objective 2: Improve GOH Planning and Oversight of the Health Workforce HLP worked very closely with the Direction des Ressources Humaines (DRH) to help advance many priorities that resulted in seminal documents. A key strategy for attracting and retaining health workers in remote/difficult posts is to define the special status of all health workers based on the type and location of their posts. HLP supported the MSPP to put in place a human resources management judicial framework adapted to the health sector, known as the Fonction Publique de la Santé. To improve health workforce retention and decrease reliance on donors, HLP helped develop a plan to transition 4,001 health personnel paid by the US President’s Emergency Plan for AIDS Relief (PEPFAR) to the MSPP budget over the period 2020–2030. To increase HIV services offered at the community level, HLP developed a task-sharing plan among the various health actors, including community health workers, and updated job descriptions for these personnel. The project worked hand-in-hand with the DRH to improve important processes, such as annual performance reviews of health personnel and supportive supervision. HLP assisted the DRH to conceptualize ways of revitalizing the family health team model. The project also helped finalize the mapping of community health workers, develop a health worker competencies index, and set the stage for a workforce allocation analysis. HLP aided the DRH in evaluating their last Human Resources for Health (HRH) strategic plan and also to build the operational plan for the National HRH strategic plan. In response to the COVID-19 pandemic, HLP supported the DRH to recruit an additional 956 frontline health workers. Local Solutions Partners Capacity Building In addition to the work with the MSPP, HLP also supported the US Government’s (USG’s) localization approach, working jointly with GC (for health finance) and CFET (for HRH) to strengthen their capacity to become prime implementors with USAID. To do so, HLP assessed the capabilities of both partners using the Organizational Synthesis of Capacity Assessments for Award Readiness (OSCAR) tool. This tool was developed by the project and incorporates elements from both the Non-US Organization Pre Award Survey (NUPAS) and organizational capacity assessment (OCA) to comprehensively assess the institutional capacity of an organization and readiness to receive USG funding. Based on the results of the initial assessments, MSH worked with both partners to develop action plans and provide focused and targeted mentoring and coaching support in the weakest areas/domains. With the support of MSH, both partners were ultimately able to pass the NUPAS and sign agreements with USAID on April 1, 2022, to continue HLP project implementation through October 2024. HLP Final Project Report Page | 4 Introduction The USAID-funded Health Leadership Project is a five-year project launched on May 2, 2019, with the goal of strengthening the Government of Haiti as a steward of the health sector. Haiti is increasingly in control of its own financial and human resources through a coordinated system that is less reliant on external partners for equitable delivery of quality health services. HLP’s two objectives are: ■ Objective 1: Build GOH capacity to lead and finance the health sector ■ Objective 2: Improve GOH planning and oversight of the health workforce HLP is implemented by Management Sciences for Health and local solutions partners Group Croissance and the Centre de Formation et d’Encadrement Technique. In project year I (PY1) and PY2, MSH was USAID’s prime implementing partner and was accountable for achieving the targets and deliverables for HLP’s objectives, in collaboration with GC and CFET. MSH also worked closely with GC and CFET to strengthen their organizational capacity to ensure they met the technical and financial standards to receive direct funding from USAID in PYs 3–5. In PY 3, HLP continued to provide technical and organizational development support to CFET and GC to ultimately succeed in passing the Non-US Organization Pre-Award Survey requirements. On April 1, 2022, both partners received agreements for direct funding from USAID to implement project activities through October 2024. From April 1, 2022, to January 31, 2023, CFET and GC implemented project activities with MSH’s technical assistance and guidance. MSH closed its award on March 15, 2023. This report describes MSH’s HLP activities from May 2, 2019, to January 31, 2023. In this report, HLP refers to the project in its initial configuration, with MSH as prime and CFET and GC as subs. HLP/MSH refers to MSH in its support role to CFET and GC as prime. HLP/HF refers to GC as direct implementer for health financing-related activities, and HLP/HRH refers to CFET as direct implementer for human resources for health-related activities. Challenging operating environment The period of implementation for HLP was marked by unprecedented challenges that greatly affected project activities. Within less than a year of starting the project, the COVID-19 pandemic brought much of life to a standstill. Restrictive measures put in place in 2020 by the GOH to slow the spread of COVID-19, as well as shifting priorities for the Ministère de la Santé Publique et de la Population (MSPP), or Ministry of Public Health, to respond to the pandemic, led to many activities being postponed—in particular, HLP’s support for supervision activities. Where possible, the HLP team responded and adapted to using virtual platforms to carry out planned activities or reprogrammed activities as needed. To comply with the new restrictions, the HLP office had to limit hours, and most project staff shifted to working remotely from home. Much of HLP’s work was dependent on being able to work closely with MSPP staff, and so the restrictions greatly limited the work that could be done. Although it took some time for the MSPP to decide that its staff could work remotely, many were hampered by the lack of internet connectivity throughout the metropolitan area of the capital as well the recurrent power outages. HLP Final Project Report Page | 5 The challenges of implementing activities during a global pandemic were significantly amplified by the extreme country-wide insecurity brought about by the devaluation of the local currency, inflation, and a rise in the cost of food and living. In 2019, Haiti President Jovenel Moise dissolved parliament and began ruling by decree, further exacerbating political tensions. With a rise in gang-related activity, the country also saw a drastic increase in kidnappings, particularly of professionals such as teachers and health workers, forcing many institutions to close their doors and stop operating. Gang control of fuel depots made gasoline almost impossible to purchase, hindering day to-day movement. During 2021, the metropolitan area of Port-au-Prince became completely controlled by gangs supported by opposition groups that were openly calling for the president to resign or ultimately face death. Criminal activities continued unabated, culminating in the assassination of the President of Haiti on July 7, 2021, an event that shook the country drastically and led to even more gang-related violence and kidnappings. The ongoing extreme insecurity (and lack of government response to these threats) sparked many dangerous and violent mass protests in 2019, the later part of 2021, and 2022 that led to a situation of “peyi lok” or “country lockdown.” HLP staff and partners had to stay at home, as being out on the streets was not safe due to the burning, looting, and vandalizing of public and private businesses, properties, and institutions. Many people were injured or killed during the protests, with numerous reports of human rights abuses. The health sector was significantly affected by the turbulent situation, and providing services to patients became more challenging for health workers. Many health facilities were unable to function at times due to the lack of electricity and disruption of supply chains that led to shortages of essential medical supplies, equipment, and commodities. Conducting site supervision visits has been very difficult. Moreover, some health-care workers have been kidnapped and killed. Further aggravating the country’s security situation, a new cholera outbreak was announced in October 2022, and more than 20,000-suspected cases had been reported throughout the country by January 2023. Many MSPP staff have had to prioritize the cholera response over project activities. All of these conditions have led to many Haitians, including MSPP staff, fleeing the country. Counterparts in many of the key directorates HLP worked with faced serious staff shortages, including at the leadership levels. Oftentimes, the status of leadership positions was unclear and critical decisions were severely delayed, thus impeding project activities. HLP Final Project Report Page | 6 HLP’s technical approach and results framework Haiti has prioritized achieving universal health coverage to ensure that all Haitians have equitable access to quality health services without experiencing financial hardship. Despite progress in advancing toward this objective, Haiti was unable to meet its United Nations Millennium Development Goal targets for the health sector. Haiti faces complex challenges within its health system, including a lack of governance and coordination, a shortage of financial resources dedicated to the health sector, financial barriers to accessing health services, and a shortage of qualified health workers. Poor governance, corruption, political instability/frequent leadership changes, a stalled decentralization process, and entrenched political and natural disasters have long prevented Haiti from reforming its health sector. In the absence of well functioning institutions and enforceable legal norms, many basic services, such as schooling, health, and infrastructure, are largely provided by non-governmental organizations (NGOs) and international donors, bypassing the GOH entirely. This has created parallel, unsustainable systems that take pressure off the GOH to improve its performance, generate revenue, and be accountable to citizens for the provision of essential services. Most financial, technical, and in-kind support to the health sector is provided through the USG, including USAID and the Centers for Disease Control and Prevention (CDC), the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), the United Nations Population Fund (UNFPA), and the World Bank. Project partners and other third parties—typically NGOs and international organizations—are the primary providers of health-related care. These organizations include some that formally work with the public system and an unknown number of charitable organizations working independently throughout the country. In September 2016, Haiti launched its Package of Essential Services manual and instituted the use of community health workers to improve access to primary health-care services. With the support of donors, the MSPP recruited, trained, and deployed more than 5,000 community health workers, or agents de santé communautaire polyvalents (ASCPs), within the country. However, in 2019, challenges remained in locally funding and operationalizing these essential services and those who deliver them (with 70% of ASCPs funded by donors). It is in this context that HLP set out to improve the MSPP’s stewardship of the health sector through a practical, results-driven strategy focused on sustainable solutions. HLP strengthened the MSPP as the steward of the health sector, increasingly in control of its own financial and human resources as well as a coordinated system that is less reliant on external partners for equitable delivery of quality health services. HLP worked closely alongside the MSPP to build its capacity to lead and finance the health sector (Objective 1) and improve its planning and oversight of the health workforce (Objective 2). HLP ensured close collaboration with the MSPP, relevant USG entities and implementing partners, and international stakeholders. HLP built upon the successes of recent support for strengthening governance, human resources for health, health financing, and advocacy for greater domestic resource mobilization for the health sector. HLP Final Project Report Page | 7 HLP’s technical assistance to the MSPP targeted specific capacity gaps using mentorship, coaching, learning-by-doing, peer-to-peer learning, and limited formal training. HLP aimed to strengthen the MSPP’s capacity to: ■ Lead and coordinate diverse domestic, international, private, and public stakeholders in planning ■ Use data for decision- and policy-making, with an emphasis on gender and social inclusion ■ Mobilize, manage, and allocate resources based on need ■ Continuously monitor and adapt to maximize impact HLP operationalized improved departmental- and facility-level financial and HRH management in coordination with the USAID-funded Health Service Delivery (HSD) project. It also took advantage of partners’ ongoing transparency and accountability work to support the MSPP to expand sustainable and inclusive mechanisms to engage Haiti’s diverse civil society—especially women; youth; lesbian, gay, bisexual, transgender, or intersex individuals; and the disabled—and the private sector, leveraging them as champions for universal health coverage. The Haiti HLP Logic Model is depicted in figure 1. HLP Final Project Report Page | 8 Figure 1: HLP Logic Model HLP Final Project Report Page | 9 Project Activities and Achievements OBJECTIVE 1: BUILD GOH CAPACITY TO LEAD AND FINANCE THE HEALTH SECTOR HLP’s strategy to build the Government of Haiti’s ability to lead and finance the health sector focused on two main priorities. The first was to help the government increase financing for health service delivery in a way that is sustainable and not donor dependent. The second priority was to improve public financial management within the health system and strengthen the MSPP’s capacity to manage its own financial resources. Result 1.1: Sustainable financing for health increased Result 1.1 focused on increasing sustainable financing for health. To address this, HLP supported the MSPP to develop the new health strategic plan, or Plan Directeur, as well as central- and departmental level costed implementation plans. The MSPP, through the Unité d’Etudes et de Programmation, or the Studies and Programming Unit, indicated the need to develop a new Plan Directeur for 2021–2031, serving as a follow-up to the 2012–2022 Plan Directeur. Far from being a bureaucratic formality, the Plan Directeur defines key areas of Haiti’s health-care system that need improvement and identifies strategies that can be implemented to reach these goals. HLP also designed three situational analysis studies of the health finance context to inform the development of the National Health Financing Strategy: an assessment of internal revenue management and use in departmental health directorates and health institutions; a situational analysis of health insurance; and an evaluation of determinants of catastrophic spending on health in households and health inequities in Haiti. The UEP was HLP’s main counterpart for Result 1.1, but the UEP faced many challenges at the top leadership level. During the project period, the person designated as the HLP’s main liaison at UEP changed three times. The last liaison left the UEP in November 2022 and has not yet been replaced. There was no handover during any of the transitions, so for each one the new liaison needed considerable time to understand and support the work that HLP was doing with the UEP. This, coupled with the challenges of remote working and changing priorities due to COVID-19, created many delays in HLP activities. Evaluation of the 2012–2022 Plan Directeur and development of a new plan A country’s Plan Directeur is the roadmap for achieving better health outcomes for its citizens. Haiti’s plan for 2012–2022 was coming to an end, and so the MSPP requested the support of HLP. HLP supported the MSPP to evaluate the 2012–2022 Plan Directeur, conduct a situational analysis of the Haitian health system, and facilitate meetings and the content development process. The evaluation of the 2012–2022 Plan Directeur included a literature review and secondary data analysis of plans implemented between 2012 and 2019, followed by field visits with key stakeholders to discuss findings from the literature review. The evaluation covered the period from 2012 to May 2020 and addressed all stages of the implementation of the 2012–2022 Plan Directeur, including the development process, implementation of HLP Final Project Report Page | 10 the plan, and monitoring of results. In addition, a focus was placed on structural problems related to the health system. HLP created a database, in collaboration with the UEP planning team, that includes all Plan Directeur activities implemented from 2012 to 2020 by MSPP directorates (including 24 central and 10 departmental health directorates) and all programs and units under the MSPP (including the national HIV, malaria, blood safety, vaccination, and nutrition programs). HLP also consulted national health studies (e.g., demographic health surveys, statistical reports, service provision assessments, and national health accounts) in the analysis. The evaluation assessed the achievements stemming from the 2012–2022 Plan Directeur and its contribution to the improvement of the health system; analyzed the factors that influenced the implementation of interventions and their impact on achieving the objectives of the 2012–2022 Plan Directeur, taking into account the political and social context; and identified the strengths and difficulties encountered in implementation in order to propose improvements for the development and implementation of the next Plan Directeur. The evaluation revealed that some progress had been made during the eight years of the Plan Directeur’s implementation, despite the volatile socio-political context and the successive health emergencies. An increase in life expectancy and a drop in maternal and infant mortality were realized.1 At the structural level, there was an increase in the number of health institutions, a strengthening of human resource management capacities, and the establishment and operationalization of the Système d'Information Sanitaire National Unique, or Single National Health Information System. The evaluation found that a relatively small portion of the MSPP budget was allocated to investments and that the lack of resources remained a crucial problem, considering the infrastructure needs. In PY2, in close collaboration with a MSPP technical working group, HLP facilitated the development of the new 2021–2031 Plan Directeur. This technical working group included the UEP and the key cross cutting departments of the MSPP (Direction d’Administration et du Budget [DAB], or the Budget and Administration Directorate; Direction des Ressources Humaines [DRH], or the Human Resource Directorate; Unité d’Appui à la Décentralisation Sanitaire [UADS], or the Health Decentralization Support Unit; Direction d’Organisation des Services de Santé [DOSS], or the Health Services Organization Directorate; and Direction des Soins Infirmiers [DSI], or the Nursing Unit). 1 Life expectancy increased from 62.3 in 2012 to 64.1 in 2020; maternal mortality decreased from 500/100,000 live births in 2012 to 480/100,000 live births in 2017; and infant mortality decreased from 56.4/1,000 live births in 2012 to 46.7/1,000 live births in 2020. World Bank. World Development Indicators, as reported on February 20, 2023. https://databank.worldbank.org/reports.aspx?source=world-development-indicators HLP Final Project Report Page | 11 Speech of the master of ceremonies, Dr. Jocelyne Marhone from MSPP, during the official launch of the Plan Directeur. Photo credit: Dr. Alexandra Emilien, MSH The new Plan Directeur was validated by the MSPP in the fourth quarter of PY2, with a preface signed by the Minister and the Director General (DG) of MSPP. The plan includes several guidelines to help eliminate barriers to health-care services at the community level. Its goal for the next decade is to address weaknesses in the health system to improve access and quality of care and achieve the overarching goal of establishing universal health coverage. The new Plan Directeur also focuses on safeguarding maternal and child health. It aims to decrease the current maternal mortality ratio from 529 to 350 deaths per 100,000 live births and to decrease the child and newborn mortality rates from 65 to 25 and 25.3 to 12 per 1,000 live births, respectively. Additionally, the proportion of health institutions offering emergency obstetrical and newborn care should almost double from 35% to 60% to increase the number of supervised deliveries from 42% to 60%. The plan also seeks to meet the goals of the Joint United Nations Programme on HIV and AIDS’ 95-95- 95 strategy: the percentage of people living with HIV who know their HIV status should increase from 79% to 95%; the percentage of people living with HIV on treatment should increase from 75% to 95%; and the percentage of people on treatment with a viral suppressed load after 12 months should increase from 64% to 95% (Source: Monitoring Evaluation et Surveillance Integrée (MESI) database, March 2021). Mobilizing financial, organizational, and human resources is required to reach these objectives. The Plan Directeur calls to increase the number of health-care workers per 1,000 inhabitants from the current level of 0.7 to 1.5 by 2031 to move Haiti closer to meeting the 4.5/1,000 minimum recommended by the World Health Organization (WHO) for universal health coverage. HLP Final Project Report Page | 12 A total of 1,000 copies of the strategy were printed for dissemination to key stakeholders. The launch of the strategy took place on September 16, 2021, with members from USAID, WHO/Pan American Health Organization (PAHO), Ministry of Economy and Finance (MEF), Ministry of Planning and External Cooperation, the MSPP’s Director General, and other central directorates of MSPP in attendance. During this official ceremony, MSPP representatives stressed the importance of this tool in guiding and strengthening Haiti’s health sector through 2031. During the presentation, UEP also acknowledged its appreciation for HLP’s support in this activity. “Thanks are extended to those in charge of the Health Leadership Project for their sustained commitment and their technical and financial support throughout this process, which made it possible to produce this document.” -Dr. Laure Adrien, Director General, in his introduction to the Plan Directeur Group photo of all the major stakeholders responsible for financing and developing the Plan Directeur. Photo credit: Dr. Alexandra Emilien, MSH Costed central and departmental implementation plans With the Plan Directeur completed, HLP collaborated with the UEP and other key actors to begin the development process of the three-year, national costed implementation plan (2021–2024). HLP provided technical and financial support to the UEP to organize a series of simultaneous workshops in February 2022, in collaboration with departmental and central level health departmental directorates, to identify and select priority health interventions and activities in alignment with the six pillars defined in the 2021–2031 Plan Directeur. During these workshops, HLP worked with MSPP counterparts (DAB, UEP, and DRH) to identify activities related to the mandate of the project in order to confirm implementation assistance. Following the workshops, HLP synthesized and consolidated the operational plans of all central and departmental directorates. HLP Final Project Report Page | 13 HLP provided technical and financial assistance to the UEP to finalize and validate the costed implementation plan at the central and departmental levels. HLP then coached the UEP during the implementation of the plans. The follow-up of this activity will be led by HLP/HF. Assessment of the management and use of internal revenue The GOH has undertaken several initiatives with a view to achieving universal health coverage. In 2019, to bring these initiatives to fruition, an evaluation of the financing of the health sector was recommended by the MSPP. This evaluation will make updating the evidence possible and improve guidance for policy decisions on health financing. This assessment is part of a series of analyses/studies and conferences planned by the MSPP. The UEP requested HLP’s support in carrying out this assessment. HLP—in collaboration with the UEP— conducted an assessment on the management and use of internal revenue in health institutions. In November and December 2020, 74 health facilities were sent surveys, and HLP received completed questionnaires from 61 of those institutions by March 2021 (the remaining questionnaires could not be analyzed due to the poor quality of responses and missing information). Among the 61 institutions, 79% were public organizations and the remaining 21% were mixed health organizations (private non-governmental or civil society organizations operating in a public structure institution). The types of institutions were identified to allow for representation of the different levels of care: primary, secondary, and tertiary. The assessment generated several recommendations: ■ The development and harmonization of pricing and exemption policies and the installation of electronic cash registers can significantly improve the recovery of funds at the level of health institutions. ■ The strengthening of public financial management must also be taken into account for transparent management of internal revenue. Thus, training sessions for administrative staff and ensuring the availability of normative documents at all health institution levels are actions to be undertaken in the short and medium term. ■ The assessment of financial management carried out by the DAB in November 2020 is an asset, taking into account these different aspects at the level of a recovery plan. In a public financial management capacity-building approach, the role of cashiers should not be neglected, as they are key personnel for the system. Their capacity will also need to be strengthened through training. ■ Internal revenue allocation practices and their integration into a consolidated budget will need to be implemented consistently at the institutional level. This study made understanding the level of revenue collection at these facilities and how the facilities use the revenue possible. In the current context, internal revenues are essential to the functioning of mixed and public health institutions in Haiti. Preparation for health finance studies At the start of the project, a priority for the UEP was conducting a situational analysis of health insurance in the Haiti context. HLP worked closely with the UEP to develop terms of reference (TOR) and a methodology that included a mixed approach of literature reviews and focus group discussions with key health stakeholders (including service providers, users, and beneficiaries). Because of the HLP Final Project Report Page | 14 worsening security situation, HLP had to modify the TOR and methodology to make carrying out the study feasible given the security environment. However, due to other important priorities, the UEP had put this study on hold and had yet to approve the TOR and methodology. Another early priority for the UEP was a study on the determinants of catastrophic spending on health in households and health inequalities in Haiti. HLP developed the TOR and a detailed survey methodology that involved nationwide focus group discussions with service providers and beneficiaries. This study was programmed for the 4th quarter of PY2; however, the rise in insecurity and a devastating earthquake and tropical storm in the South of the country made travel impossible, and the activity was postponed. In PY3, the HLP team organized a series of virtual technical meetings with the UEP team to continue to discuss its vision and plans for implementing this study. Due to competing priorities, the UEP had not yet decided to implement this study. In February 2023, the UEP requested technical assistance from HLP/HF to relaunch these activities to support evidence generation and consensus building efforts for the country’s stalled health financing strategy. In addition to the security and epidemiological challenges in the country, progress on the strategy has slowed due to skepticism from key stakeholders on its relevance for the country’s health sector. Therefore, UEP asked HLP/HF to draft a TOR for a consensus building webinar on the need for the strategy. UEP also requested support to draft a TOR to recruit a consultant to conduct the landscaping of the country’s health insurance mechanisms as well as a TOR summarizing the methodological and implementation arrangements for a facility-based study of the burden of catastrophic costs across different socioeconomic determinants. The results of these studies will be used to inform the interventions included in the health financing strategy once broad buy-in on the strategy is achieved through the webinar and any subsequent dialogues. While HLP/HF continued its search for a Health Financing Advisor to provide this type of technical support to the MSPP, HLP/MSH provided the urgent short-term support needed to move these efforts forward along the timeline desired by the MSPP. Result 1.2: Public financial management improved HLP implemented a set of activities to improve public financial management within the health system and strengthen the MSPP’s capacity to manage its own financial resources, including conducting trainings on implementation of the public financial management tool and installing electronic cash registers to improve revenue management and increase domestic resources. The DAB was the main counterpart at the MSPP for this result area, as it is responsible for the management of material and financial resources of the ministry. Out-of-pocket payments are the largest source of health financing in Haiti, accounting for approximately 50% of total health spending in the recent (2018–2019) National Health Accounts. To improve the financial control of funds collected at facilities, the DAB has established as a priority the installation of electronic cash registers in as many health institutions as possible, given the available funding. It followed that public financial management focal points should be identified and selected for training and supervision in all the 10 health directorates and a tool should be developed to this end. In this context, the DAB requested HLP’s technical and financial assistance to conduct these assessments in selected health-care institutions to help identify gaps in financial management practices, develop plans for capacity strengthening, and put in place a schedule of supervision visits to improve financial monitoring and reporting. Staff shortages and competing priorities at the DAB led to some delays in activities that needed the DAB’s input to move forward. HLP Final Project Report Page | 15 Public financial management training The DAB identified a need to assess the financial management capacity of health facility staff, with the objective of correcting weaknesses previously observed and improving the collection of internal revenue in selected categories of health institutions. HLP assisted the DAB with this initiative, first by holding a two-day session in October 2020 to train 16 DAB staff on the tool they would use to assess the public financial management capacity at the departmental health directorate levels. The public financial management tool was developed by HLP and involves conducting an assessment across a number of functional domains, developing an action plan based on identified gaps and weaknesses, and monitoring implementation of that action plan. The tool is designed to assess the capacity of actors in the health sector to properly manage financial resources (the budget allocated by the state, donor funds, and internal revenue) and material resources (goods and fixed assets). It is intended to be applied using an evidence-based participatory process, enabling institutions/health departments to identify areas requiring support to promote transparency, efficiency, and good management. It covers four domains: work environment, legal framework for public financial management, function of financial resources management, and function of material resource management. The tool can be used in a self-evaluation or by external evaluators. The assessment is conducted based on the standards and procedures necessary for effective management of resources. The assessment uses a triangulated approach combining a review of background documents, interviews, review of on-site organizational systems, and focus group discussions. This approach is used to collectively provide ratings for the different capacity domains by consensus of the participants, with input from the evaluators, based on the conclusions of the file review and the on-site system review. The evaluators draw up a report on all the elements of the assessment, and the ratings range from 1 (weak) to 4 (strong). Adjustments to the tool were made based on feedback received from the DAB team during the training, and the revised tool was subsequently used in the assessments of all departments. The DAB staff formed small teams and conducted assessments in all 10 departments between October and December of 2020. HLP participated in the assessment in the North, Northeast, and West departments. In each department, the team assessed the directorates and a sample of facilities. Data is entered into the tool by selecting it from a drop-down list, and it is then automatically analyzed and presented to participants in the form of dashboards. The evaluated institution therefore knows its final capacity score at the end of the exercise. The results are used to write a report that specifically lists the identified capacity gaps, and that report is subsequently shared with the MSPP (DAB, UEP, and the Director General), the MEF, and the Superior Court of Accounts and Administrative Litigation for verification and consensus. During the assessment of each department, the HLP and DAB teams conducted on-site training for focal points on thematic areas/concepts of public financial management. They also identified and noted weaknesses in public financial management, including the absence of normative documents, lack of petty cash, limited collaboration with the public accountant, and lack of procedures for managing material resources. In addition, evaluation teams shared the public financial management normative documents produced by the MEF with the staff of the 39 health institutions visited. A total of 190 departmental HLP Final Project Report Page | 16 administrators, accountants, logistics managers, assistants, stock managers, and archivists benefitted from this capacity building in public financial management. HLP developed reports analyzing the results of the 10 departmental health directorates and 39 health institutions assessed. The technical reports contained action plans, developed jointly with the DAB assessors and the institutions’ staff, with corrective actions to address weaknesses identified. Each technical report was shared with its respective institution for monitoring its action plan. Regular follow up was conducted by the DAB. The MSPP will roll out this type of assessment to other institutions to strengthen their public financial management, and it is expected that HLP/HF will provide support to DAB in this effort. Installation of electronic cash registers at hospitals HLP supported the MSPP in the installation of electronic cash registers to improve the management of hospital revenue and increase domestic resources. This decision was based on the good results from the use of cash registers that were funded by USAID in 2018, before HLP. A 2020 study demonstrated the effectiveness of the cash registers in increasing hospital revenue: from a 4.3% increase at the Hôpital Saint Michel de Jacmel to a 140.7% increase at Hôpital Immaculée Conception des Cayes (figure 2). Left to right: Mr. Louis Zicot, DAB computer scientist; Mr. Josma St-Louis, MSPP programming lead; Mr. Hibart Valny, DAB/MSPP electronic and computer engineer; Ms. Marie Carmelle Placide, responsible for the registers at the HSTH. Photo credit: DAB staff Figure 2: Evolution of internal revenues before and after the installation of cash registers (before HLP) Source: MSPP 2020 HLP Final Project Report Page | 17 The electronic cash registers became one of the top priorities for the MSPP, and HLP reallocated some activity funds for the acquisition of those devices. The installation of cash registers made it possible for facilities to increase and better control their internal revenues. With funds recovered through these efficiencies, the facilities are able to meet certain needs not covered by the MSPP budget. Electronic registers help facilitate accounting (collecting and managing revenue), improve the use of resources in hospitals (managing stock and monitoring services of care), Electronic registers at HUJ. Photo credit: DAB staff. and allow health facilities to provide quality patient care. In 2020, HLP and DAB staff conducted field missions to health facilities to assess the technical needs for installing the new electronic cash registers at five hospitals and ensuring the proper functioning of existing registers at two hospitals. Following these visits, the DAB confirmed the need to install 36 new electronic cash registers in 14 health institutions. HLP purchased and installed these registers, along with a