(2016) Yon nouvo apwòch fas ak kolera an Ayiti - Rapò Sekretè Jeneral la (A/71/620)

United Nations A/71/620* General Assembly Distr.: General 25 November 2016 Original: English 16-20491* (E) 011216 *1620491* Seventy-first session Agenda item 69 (c) Strengthening of the coordination of humanitarian and disaster relief assistance of the United Nations, including special economic assistance: special economic assistance to individual countries or regions A new approach to cholera in Haiti Report by the Secretary-General Summary On 19 August 2016, the Secretary-General announced a new approach by the United Nations to cholera in Haiti. In his accompanying public statement, he indicated that he deeply regrets the terrible suffering the people of Haiti have endured as a result of the cholera epidemic and that the United Nations has a moral responsibility to the victims of the cholera epidemic and to support Haiti in overcoming the epidemic and building sound water, sanitation and health systems. He stressed that eliminating cholera from Haiti will take the full commitment of the Haitian Government and the international community and, crucially, the resources to fulfil this shared duty. The new approach has two tracks. Track 1 involves intensifying the Organization’s support in order to reduce and ultimately end the transmission of cholera, improve access to care and treatment and address the longer-term issues of water, sanitation and health systems in Haiti. Track 2 involves developing a package that will provide material assistance and support to those Haitians most directly affected by cholera. These efforts must include, as a central focus, the victims of the disease and their families. The Secretary-General urged Member States to demonstrate their solidarity with the people of Haiti by increasing their contributions to eliminate cholera and provide assistance to those affected. * Reissued for technical reasons on 1 December 2016. A/71/620 16-20491 2/16 The new approach was rendered more challenging by Hurricane Matthew, which struck Haiti on 4 October 2016, causing immense devastation, loss of life and thousands of new cases of suspected cholera. The present report provides information on Tracks 1 and 2 of the new approach, identifies challenges in connection with its implementation and sets out a proposed timeline. The Secretary-General hopes that he can count on the support of Member States. A/71/620 3/16 16-20491 I. Introduction 1. The United Nations new approach is intended to intensify efforts to eliminate cholera from Haiti and assist and support those most directly affected. Cholera broke out in October 2010, only nine months after an earthquake had devastated the country. The country was ill-prepared to face this additional blow. Only one quarter of the population has access to decent toilets and one half to clean water, making it the country with the poorest water and sanitation infrastructure in the western hemisphere. Cholera has, to date, afflicted nearly 800,000 people and may have caused over 9,000 deaths. 1 Concerted international and Haitian efforts since the outbreak have resulted in a drastic reduction in the number of suspected cholera cases and deaths. The overall incidence of the disease has been reduced by approximately 90 per cent since its peak in 2011. However, cholera continues to take a heavy toll on the lives of Haitian people, and Haiti still reports the highest number of cholera cases in the world. The deterioration in the capacity to respond to and treat cholera due to reduced funding, the rainy season and Hurricane Matthew, which destroyed much of the southwest of the country, has contributed to increased risk and an increase in reported cases of suspected cholera. 2. Over the ensuing years, a variety of initiatives have been undertaken to mobilize the necessary resources and interventions for the elimination of the disease from the country. The Secretary-General has visited Haiti to assess the situation and to demonstrate his solidarity with the people. However, the measures taken were not enough to eliminate the disease, or to prevent a shadow being cast upon the relationship between the Organization and the people of Haiti. 3. For decades, the United Nations has stood by the Haitian people, supporting them in their quest for democracy, human rights and the strengthening of their institutions and helping to rebuild the nation after the earthquake. Globally, the Organization endeavours to deploy responsible peace operations that operate at minimum risk to people, societies and ecosystems. This is vital to the legitimacy and credibility of the United Nations and its global peace operations. The cholera outbreak became a stain on the Organization’s reputation. 4. It was for those reasons — for the sake of not only the Haitian people, but also the Organization, and in particular to protect the integrity of its peace operations in the future — that the Secretary-General became convinced of the need to do more. He wishes to propose a solution, not leave an unresolved problem, for his successor. These reasons informed his announcement, on 19 August 2016, of a new approach to cholera in Haiti. The new approach represents an act of good faith and a genuine effort to concretely demonstrate deep regret for the suffering of Haitians as a result of the cholera epidemic. The Secretary-General will elaborate further on this issue when he addresses the General Assembly on 1 December 2016. 5. The United Nations new approach has two tracks. Track 1 consists of a greatly intensified and better resourced effort to respond to and reduce the incidence of cholera in Haiti. The aim is to address the short- and longer-term issues of water, sanitation and health systems and to significantly improve access to care and treatment. Those steps, in addition to eliminating cholera in the long term, are __________________ 1 Figures are from the Ministry of Public Health and Population of Haiti. A/71/620 16-20491 4/16 essential to the achievement of many of the Sustainable Development Goals in Haiti, especially Sustainable Development Goal 6, ensuring availability and sustainable management of water and sanitation for all. 6. Track 2 is the development of a package of material assistance and support to those Haitians most directly affected by cholera, centred on the victims and their families and communities. Affected individuals and communities will participate in the development of the package. This will inevitably be an imperfect exercise, fraught with practical and moral hazards, and it has been complicated by the impact of Hurricane Matthew. The package is not likely to fully satisfy all those who have been calling for such a step, nor will it happen overnight. However, the Secretary- General has concluded that it is better to take this step than not to. It represents a concrete and sincere expression of the Organization’s regret for the fact that the people of Haiti suffered yet another blow when they had already suffered more than they should have to endure. 7. Eliminating cholera from Haiti and living up to our moral duty to those who have been most directly affected will require the full commitment of the international community and, crucially, the resources necessary to deliver on both Tracks. Just as peace operations are a collective endeavour by Member States, United Nations entities and partners outside the United Nations, so too is a lasting solution to the problem of cholera in Haiti. This is not an endeavour that the Secretariat or even the United Nations system can shoulder alone. The new approach outlined in the present report has been developed in this spirit. 8. The people of Haiti deserve this tangible expression of our respect and solidarity, as well as our regret, and the genuine support that comes with it. The United Nations should seize this opportunity to address this tragedy, which has also had a negative effect on its reputation and global mission. 9. At the strategic level, the Secretary-General has appointed David Nabarro to lead the new approach by the United Nations and Ross Mountain to lead Track 2. II. Overview: cholera in Haiti 10. Haiti is the poorest country in the western hemisphere. It has been beset by humanitarian crises, recurrent waves of violence and structural socioeconomic challenges, including endemic poverty, chronic malnutrition, weak health systems, low literacy rates and limited access to clean water, sanitation and other basic services. The earthquake of January 2010 is estimated to have caused 222,570 deaths, displaced millions and caused immense damage to the economy, and its effects are still felt today. 11. The first case of suspected cholera was reported on 21 October 2010 in the Artibonite Department. Cholera causes severe, acute, dehydrating diarrhoea that can kill children and adults in less than 12 hours. It is the result of infection by a pathogenic strain of the bacterium Vibrio cholerae, which is capable of producing a potent toxin known as cholera toxin. Depending on the severity of the infection, cholera may be treated with oral rehydration salts, intravenous fluids and/or antibiotics. The case fatality rate in a well-managed cholera outbreak should be less than 1 per cent. A/71/620 5/16 16-20491 12. Within 29 days of the first case reported, cases were confirmed in all 10 administrative departments in Haiti. Within three months of the first case reported, there was a downward trend in mortality, with a 14-day case fatality rate of 1 per cent or less in most areas. Overall, the cholera outbreak in Haiti accounted for 57 per cent of all cholera cases and 53 per cent of all cholera deaths officially reported to the World Health Organization (WHO) worldwide in 2010 and 58 per cent of all cholera cases and 37 per cent of all cholera deaths reported in 2011. 2 13. The table below illustrates the incidence of suspected cholera cases in Haiti between the beginning of October 2010 and 18 October 2016. The peak of the epidemic was in late 2010 and 2011, as demonstrated by the numbers of suspected cholera cases and deaths. Following an active response by national authorities and partners, the number of cases was reduced by 90 per cent. The impact of Hurricane Matthew shows the continued vulnerability of the population to the disease, which is preventable and treatable. The hurricane, combined with the rainy season, has contributed to a significant increase in the number of suspected cholera cases per month in the country, from just over 2,000 in September to nearly 6,000 in early November. 3 Table Incidence of suspected cholera cases between the beginning of October 2010 and 18 October 2016 Year Suspected cholera cases Total deaths Incidence rate (per 1,000) Fatality rate in hospitals (percentage) 2010 (October-December) 185 351 3 951 18.36 2.43 2011 351 839 2 918 34.33 1.04 2012 101 503 908 9.73 0.96 2013 58 574 581 5.57 1.05 2014 29 078 297 2.71 1.01 2015 36 045 322 3.90 0.75 2016 (1 January-18 October) 32 240 330 2.91 0.88 Total 794 630 9 307 Source: Ministry of Public Health and Population of Haiti. 14. The Secretary-General made support to the Haitian Government to eliminate cholera a key United Nations priority. From the outset of the epidemic, the United Nations family devoted considerable human and financial resources to the fight against cholera, guided by the priorities of the Government of Haiti. Much was done __________________ 2 Ezra J. Barzilay, Nicolas Schaad, Roc Magloire, Kam S. Mung, Jacques Boncy, Georges A. Dahourou, Eric D. Mintz, Maria W. Steenland, John F. Vertefeuille and Jordan W. Tappero, “Cholera surveillance during the Haiti epidemic — the first 2 years”, The New England Journal of Medicine, vol. 368, No. 7, p. 599. 3 According to WHO and the Pan American Health Organization, the figure increased from 2,377 in September to 5,840 on 5 November 2016, with the Grand-Anse and Sud departments most affected. A/71/620 16-20491 6/16 by the United Nations in the initial years after the outbreak to support national efforts to combat cholera in Haiti. Initiatives include the establishment of an early warning and alert system and a mechanism to rapidly respond to an alert within 48 hours, sensitization campaigns, household visits and activities to increase access to clean water and improve overall sanitation and hygiene. 4 15. To underline his support for those efforts, on 11 December 2012, the Secretary-General launched his own initiative to support the Initiative for the Elimination of Cholera in the Island of Hispaniola, established by the Presidents of Haiti and the Dominican Republic almost a year earlier. The initiative was focused on investment in prevention, treatment and education. At its launch, the Secretary- General also announced that Paul Farmer would serve as his Special Advisor on Community-Based Medicine and Lessons from Haiti to help galvanize support for the elimination of cholera in Haiti. 16. In February 2013, the Government launched its National Plan for the Elimination of Cholera in Haiti, a 10-year strategic plan outlining health, water and sanitation activities necessary to eliminate cholera and other such diseases. The Government also developed a two-year operational component for the Plan. The Plan was designed to focus on the long-term elimination of the disease through a large-scale development of public health, water and sanitation infrastructure. However, there has been limited progress on infrastructure development to date. To emphasize his support for those efforts, in August 2013, the Secretary-General appointed Pedro Medrano Rojas as his Senior Coordinator for the Cholera Response in Haiti, based in New York, to optimize United Nations resources and support the National Plan. Mr. Medrano held the position for a period of nearly two years. 17. During the same period, United Nations partners working alongside the Government of Haiti undertook significant efforts to provide care and treatment to cholera-affected patients and to work to prevent the further spread of the disease. United Nations agencies, including WHO — together with the Pan American Health Organization — the United Nations Children’s Fund (UNICEF) and others, worked closely with the Haitian Ministry of Public Health and Population and the National Directorate of Water Supply and Sanitation to ensure a rapid response to cholera outbreaks and to reduce transmission throughout the country. United Nations agencies provided significant support to national partners and authorities in supporting the key components of the Government’s National Plan. 4 In 2012, the Ministry of Public Health and Population, together with non-governmental organization partners, conducted the first-ever vaccination campaign in Haiti, targeting 100,000 people. The following year, the Ministry of Public Health and Population, with the support of the international community, including United Nations agencies, undertook a campaign to begin vaccinating more than 400,000 Haitians. This targeted vaccination campaign, now in its third year, is an important preventive measure when used alongside targeted clean water and sanitation interventions. 18. Efforts on the ground also focused on increasing access to clean water and decent sanitation. In July 2014, during a visit to Haiti, the Secretary-General and the __________________ 4 United Nations Support Plan for the Elimination of the Transmission of Cholera in Haiti (January 2014). A/71/620 7/16 16-20491 Prime Minister launched the National Sanitation Campaign, which, with support from UNICEF, is aimed at raising sanitation standards and improving health conditions, benefiting 3.8 million people. During that visit, the Secretary-General also met with communities and people affected by cholera and expressed his anguish at the pain they had to endure. He reiterated his belief that the United Nations has a moral responsibility to the victims of the cholera epidemic and to support Haiti in overcoming the epidemic and building sound water, sanitation and health systems. 19. Despite all those efforts, critical challenges remained to effectively respond to and limit the spread of cholera. Efforts were beset from the start by the challenge of insufficient funding, which has had a dramatic negative impact on the capacity to respond effectively to the disease. 20. In all its efforts, the United Nations family was guided by the priorities of the Government of Haiti. The United Nations country team and the Government of Haiti worked side by side for the elimination of cholera, and United Nations support to the Government of Haiti was fully aligned with national objectives. In April 2014, the Secretary-General, together with the Government, established a joint High-level Committee on Cholera to ensure the implementation of a common strategy for the elimination of cholera in Haiti and the provision of social and economic assistance to affected communities, with special emphasis on persons affected by the disease. The Committee was unable to make much progress, and in early 2016 there were worrying signs that the downward trend in cholera cases was spiking upwards again. This was due to several factors, prominent among them the lack of funding, which had an impact on even the most critical activities relating to rapid response. The Government prepared a new medium-term plan of action for 2016-2018, which prioritized the most urgent and critical activities needed to control, and ultimately eliminate, cholera. In October 2016, Hurricane Matthew hit the south of the country, with devastating consequences, making a renewed and more robust approach to combatting cholera both more urgent and more complicated. 21. Questions about the source of the cholera outbreak arose very quickly. On 6 January 2011, 10 weeks after the outbreak, the Secretary-General appointed an independent panel of four experts with a mandate to investigate and seek to determine the source of the 2010 cholera outbreak. The panel presented their report on 3 May 2011 and stated that their “research findings indicate that the 2010 Haiti cholera outbreak was caused by bacteria introduced into Haiti as a result of human activity; more specifically by the contamination of the Meye Tributary System of the Artibonite River with a pathogenic strain of the current South Asian type Vibrio cholerae”. 5 The panel concluded that the Haiti cholera outbreak was caused by a “confluence of circumstances” “and was not the fault of, or deliberate action of, a group or individual”. 5 The panel also noted that the source of the cholera was of no relevance to controlling the outbreak. 22. In a follow-up article in 2013 published independently in a scientific journal by the panel members, the panel stated that “the exact source of introduction of __________________ 5 Final report of the independent panel of experts on the cholera outbreak in Haiti, 2011. Available from: www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf. A/71/620 16-20491 8/16 cholera into Haiti will never be known with scientific certainty”, however, “the preponderance of the evidence and the weight of the circumstantial evidence does lead to the conclusion that personnel associated with the Mirebalais MINUSTAH facility were the most likely source”. 6 23. The panel made seven recommendations to the United N ations, the Government of Haiti and the international community to help in preventing the future introduction and spread of cholera. Of those recommendations applicable to the United Nations, all were accepted and acted on, with the exception of two (an expert group of the Pan American Health Organization and WHO advised against prophylactic antibiotics on scientific and medical grounds). The recommendations were: (a) ensure that all United Nations personnel travelling from cholera endemic area receive a prophylactic dose of appropriate antibiotics and/or are screened for cholera; (b) all United Nations personnel travelling to emergencies with concurrent cholera epidemics should receive prophylactic antibiotics and/or be immunized or both; (c) waste management at United Nations installations using on-site systems should be improved; (d) United Nations agencies should take specific actions to decrease cholera fatality rates; (e) the United Nations and the Government of Haiti should prioritize improved access to water and sanitation; (f) the international community should investigate the potential for using vaccines reactively after an outbreak; and (g) the surveillance, detection and tracking of cholera and other diseases should be improved. 24. Many steps have been taken to reduce risk and address performance on wastewater management in peacekeeping missions, including the use of systems contracts that have enabled missions to procure appropriate equipment for treating wastewater; the introduction of mandatory cholera vaccinations for uniformed personnel by troop- and police-contributing countries; and the development of a stronger policy framework to govern environmental management. Audits of waste management in seven missions in 2014 and 2015 highlighted challenges in several areas. By October 2016, all 27 “important” audit recommendations and all 12 “critical” audit recommendations had been implemented on the ground and formally closed by the auditors. Challenges remain, and on 29 November 2016, the Department of Field Support announced a new six-year strategy to improve environmental management. III. The new United Nations approach: guiding principles 25. The intensification of efforts to eliminate cholera from Haiti is widely acknowledged, in particular by Haitians themselves, as the most important contribution the United Nations can make to supporting Haiti. The other pressing priority for the Organization is to respond to the devastation caused by Hurricane Matthew. The Secretary-General is of the view that all other measures cannot be at the expense of those two overriding priorities. __________________ 6 Daniele Lantagne, G. Balakrish Nair, Claudio F. Lanata and Alejandro Cravioto, “The Cholera Outbreak in Haiti: where and how did it begin?”, Current Topics in Microbiology and Immunology, Vol. 379, pp. 145-164 (Berlin, Springer, 2013) . A/71/620 9/16 16-20491 26. The work undertaken under the new approach will be guided by a number of principles. First, all those engaged in the effort should exercise extreme care to ensure that the people of Haiti, who have already suffered so much, are not further harmed by the effort. Second, six central tenets will guide the United Nations implementation of the new approach: (a) act as quickly as possible; (b) consult with Haitian authorities, individuals and communities in developing the package of material assistance and support; (c) commit to and ensure impartiality, non-discrimination, fairness and transparency in the approach; (d) ensure gender- sensitivity; (e) put victims at the centre of the work and be responsive to their needs and concerns; and (f) reinforce government leadership in cholera elimination and response. The new approach will also reflect fundamental principles for project funding more generally, including: (a) cost-effectiveness, efficiency and practicability in the implementation process; (b) accountability for the use of funds; and (c) the sustainability of measures taken under the new approach. Third, coordination will be required between Tracks 1 and 2, as well as with other United Nations and humanitarian and development programmes. It would be expected that the United Nations Resident Coordinator would play a leading role in that regard. Delivering on the new approach will require actors from across the United Nations system as well as key partners. Great care must be taken under the new approach to avoid harm or unintended, negative consequences. IV. Track 1: eliminating cholera from Haiti 27. Haitian interlocutors are unanimous in calling for more robust international efforts to eliminate the disease. Track 1 of the Organization’s new approach is therefore to intensify the immediate efforts to decrease the transmission of cholera and improve access to care and treatment (Track 1A); and address the longer-term issues of access to clean water, sanitation and health-care systems (Track 1B). These intensified efforts will require some time to take effect. Track 1A, guided by the national priorities for eliminating cholera, will shadow the Government’s medium- term plan until the end of 2018 and be reassessed at that time with a view to extension in line with the longer-term National Plan, which covers the period until 2022. The need for further Track 1A action will depend on the progress of efforts towards eliminating cholera. The longer-term Track 1B, which will occur in parallel, is expected to last for a period of 10 to 15 years. 28. Tracks 1A and 1B are not entirely new activities. Concerted national and international efforts have been under way since the outbreak began. The number of suspected cases remains high, however, and recent outbreaks — in particular as a consequence of the hurricane — show the continued vulnerability of the population to the disease. There is a direct correlation between strong, well-funded efforts and successful disease management. A 2016 spike in cases prior to the hurricane can be attributed in large part to a reduction in the number of rapid response teams, which was due to lack of resources, combined with a period of heavy and early rainfall in May. 29. The last six years have also provided clear lessons on what works. Preparation is essential, as cholera outbreak management is complex. It calls for several elements to be in place at the same time: people mobilized with information and A/71/620 16-20491 10/16 basic requirements for prevention; surveillance for suspected cases; notification; coordinated and well-resourced rapid response mechanisms in communities; clinical care; a cordon sanitaire (investigation, hygiene sensitization, immediate rehydration, house disinfection and household water treatment and storage); the chlorination of water supplies; and the management of potentially infectious solid waste (sanitation). 30. The new approach under Track 1 is aimed at intensifying such efforts by mobilizing adequate funding for an increased number of rapid response teams; strengthened epidemiological surveillance; the rapid detection, reporting and treatment of cases; the combined use of cholera vaccinations with targeted water and sanitation interventions; more focused geographical targeting; improved communication and behavioural change strategies; and strengthened support to longer-term water and sanitation services. 31. For the past six years, both the immediate response and longer-term efforts have been severely hampered by funding shortages often imposed by short-term funding horizons, which have made it impossible to fully treat or eliminate what is generally a treatable and preventable disease. To date, the United Nations response activities have been primarily funded by humanitarian mechanisms. A fully resourced cholera response for the period 2016-2018 would enable activities to move reliably beyond short-term, one-year horizons to support the Haitian Government’s medium-term plan (for July 2016-December 2018) as a start, and then, beyond that, until the elimination of cholera is achieved. The shift to more reliable funding horizons would also enable a more successful transition from humanitarian-oriented interventions to more development-oriented programmes. The hurricane has complicated the immediate financial picture and proved revealing with respect to what funding might be available to support Haiti under the new approach. With the humanitarian flash appeal, which was recently revised to more accurately reflect humanitarian needs, only partially funded, a sobering reality presents itself. Cholera can be controlled and eliminated with sufficient funds. The United Nations new approach can only work with adequate resources. 32. Lives will be saved through rapid response and the treatment of new cases. The number of rapid response teams has been increased to 88 to ensure sufficient coverage and improved response times. Rapid detection and reporting of cases provides the bedrock of the cholera response and has proved to be one of the most important elements of the fight against Ebola. 33. The innovative and large-scale use of oral vaccines, together with water and sanitation interventions at the community and household level, hold great promise for cholera control. Work is already under way to provide oral vaccinations against cholera to people in areas with the highest cholera burden. WHO sent 1 million oral cholera vaccine doses to Haiti at the request of the Government of Haiti and on the recommendation of the international working group on oral cholera vaccination of the Global Task Force on Cholera Control, with the top priority going to those affected by Hurricane Matthew, in response to a spike in cholera as a result of the hurricane. On 8 November 2016, a campaign began for people living in the departments of Sud and Grand-Anse, the areas most affected by the hurricane. The vaccination programme will be subject to regular evaluation, requires additional A/71/620 11/16 16-20491 funding and partnerships and will provide important evidence for cholera control worldwide. Some 1.2 million people have now been vaccinated in the country. 34. A key element in cholera control is listening to at-risk populations regarding the challenges they face. These include access to and improved use of sanitation facilities in markets and transport hubs and greater attention to sanitary practices within cultural practices, such as respect for and treatment of the deceased. 35. The persistence of cholera in Haiti is due primarily to underlying infrastructural causes: the lack of household access to clean water and appropriate sanitation facilities. Therefore, in addition to intensified near-term response measures to treat and limit the spread of the disease, the United Nations system will redouble its efforts to support the Haitian Government in building sound water, sanitation and health systems, which constitutes the best long-term defence against cholera and other water-borne diseases. A longer-term objective within Track 1 is thus to ensure that all Haitians are able to access adequate supplies of clean water and functioning sanitation for better health (Track 1B). Work is under way for the establishment by early 2017 of a multi-actor consortium, with the participation of the World Bank, the Inter-American Development Bank and other public and private leaders in the water and sanitation sector, that will seek to achieve access to water and sanitation for all Haitians. The public-private consortium will commit itself to water and sanitation investment and innovative financing over a period of 10 to 15 years and will prioritize Haitian ownership of the sector. V. Track 2: providing a package of material assistance and support 36. Track 2 is intended to reflect the Organization’s recognition and acknowledgement of the suffering of the people of Haiti due to the cholera outbreak and its commitment to assist and support those most directly affected. It is aimed at providing a meaningful — but necessarily imperfect — response to the impact of cholera on individuals, families and communities. 37. The Secretary-General has pledged to consult with victims and their families and communities in developing that package. It is anticipated that the related consultations will take place once the electoral process in Haiti is completed. Securing funding adequate to enable the development of a meaningful package is essential to ensuring that the consultations are properly informed and useful and to avoiding raising expectations. To engage in consultations, and thereby raise expectations, without any assurance of funding for Track 2 would be counterproductive and ethically fraught. 38. To date, preliminary consultations have been held in both New York and Haiti with the United Nations country team, experts (both inside the Organization and outside it), human rights and advocacy groups and networks, non-governmental organizations, the United States Centers for Disease Control and Prevention, the Haitian Government and other Member States. In addition, information has been gathered with respect to the impact of cholera in Haiti, the systems established to record infections and deaths, and the records and data that might be available, in order to consider and assess the feasibility of potential elements of the package. A/71/620 16-20491 12/16 39. Consideration of the possible parameters and elements of the package has taken into account the following factors: prospective beneficiaries; the types of potential benefits; estimated resource requirements; and implementation capacity on the ground. 40. The prospective beneficiaries of the package have been identified as the communities most directly affected by cholera, including the families of those individuals who died of cholera and those who contracted cholera and recovered. 41. Consideration is being given to two possible elements to the design of the package of material assistance and support: (a) a community approach; and (b) an individual approach. Each possible element is described below. A. Community approach 42. Under a community approach, victims and their families and affected communities would receive assistance and support through community projects and initiatives focused on addressing and alleviating the suffering caused by cholera at the community level and strengthening community capacity to address proactively and sustainably the conditions that increase cholera risk; in particular, poverty, poor housing conditions and lack of basic services, and awareness of hygiene and public health. 43. Very importantly, the projects would be based on priorities established in consultation with communities and reflect, to the extent possible, buy-in and ownership by those communities, to ensure sustainability. To the degree appropriate, and consistent with consultations with the communities, these community projects and initiatives would be linked to and coordinated with Track 1, and with ongoing humanitarian and development work. Based on the preliminary consultations, communities might be interested in particular in projects and initiatives related to education, health care (including the equipping of health-care centres), financial services and cholera elimination at the community level (including measures to improve water filtration systems and local level sewage). Such projects and initiatives could include non-monetary in-kind individual benefits, such as education scholarships, access to adult literacy and education services, access to vocational training, micro-finance and support to small businesses. 44. Other types of projects and initiatives might include the provision of basic services (such as spring catchments, the construction, extension and rehabilitation of water adduction systems, the delimitation and protection of upstream water areas, household and public rain-fed water cisterns, the construction of public latrines and community-based solid waste management solutions), micro -hydropower infrastructures, community infrastructure (such as rural roads, sports and cultural facilities, local markets and the like), small urban infrastructure (such as street pavement, lighting, sidewalks and foot bridges), housing, access to livelihood projects, environmental rehabilitation and disaster risk reduction (such as the clearing of river beds, strengthening of the beds and banks of flood-prone rivers, construction works to conserve water and the soil, and groves of trees), small irrigation networks and other commonly owned agricultural infrastructure, and other projects and initiatives associated with community development plans. They could A/71/620 13/16 16-20491 also include projects or initiatives aimed at remembering or commemorating the victims of cholera, or other projects or initiatives proposed by the community. 45. Options for projects and initiatives would be established following consultations in the affected communities with victims and their representatives, community leaders, the Haitian authorities, civil society, local non-governmental organizations and possible implementing partners in order to determine the types of projects and initiatives that would be considered most beneficial. 46. The projects and initiatives would be structured to ensure the inclusion of women and vulnerable or marginalized groups within the community, in particular those stigmatized by cholera. Implementation would be designed to promote the engagement and participation of local communities, the recruitment of local labour and investments and purchases at the local level. It is foreseen that initiatives related to small community infrastructure projects could be implemented using cash-for-work programmes that would provide short-term employment opportunities in the communities. 47. All community projects and initiatives would be subject to financial limits, which would be established taking into account available resources. Since all departments in Haiti have been affected by cholera, communities would be prioritized based on the extent to which they have been affected by the disease in terms of cholera incidence, mortality rates and absolute numbers of deaths to date. 48. All approved projects and initiatives would be designed, implemented and monitored while drawing on the extensive experience and expertise of United Nations agencies and implementing partners in community-based development projects in Haiti. Such an approach is in line with the commitment of Member States and the United Nations to work together to ensure that the voices of the most vulnerable — those most affected by cholera in Haiti — are heard and included in the design of the proposed community-based projects, as enshrined in the Grand Bargain on humanitarian financing. Such a community-based project approach will ensure that projects are relevant, timely, effective and efficient and will help to create an environment of greater trust and transparency. 49. The proposal for the community-based approach will include assurances that an effective, transparent and monitored process for participation and feedback will be in place, and that design and management decisions are responsive to the views of affected communities and victims of cholera, even in the absence of an individual approach. Based on that participatory process, the design and implementation of projects could rely on multi-year, collaborative and flexible planning and multi-year funding instruments and will in turn enable documentation of the impact of the approach on programme efficiency and effectiveness, ensuring that implementing partners apply consistent funding arrangements and monitor and evaluate the outcomes of the response. 50. These community-based projects may require the strengthening of existing coordination mechanisms across humanitarian and development sectors to ensure a shared analysis of the needs that are highlighted by the participatory design process. In addition, given the parallel nature of Tracks 1 and 2, the implementation of each Track in parallel will increase the alignment and use of humanitarian and A/71/620 16-20491 14/16 development planning tools and funding and reduce the duplication of interventions, while still working towards collective outcomes. 51. This approach, importantly, recognizes that enhanced trust among Member States and the United Nations can be achieved by increasing accountability for delivering on the Grand Bargain commitments. 52. Community projects and initiatives would be implemented in close coordination with the Ministry of Planning and the Ministry for Interior Affairs and Territorial Communities and in close collaboration with the Ministry for Public Health and Population. 53. It is imperative to have an assurance of an adequate level of funding for community projects and initiatives prior to conducting consultations in the affected communities. Such funding must include resources for the identification of eligible communities and for community outreach and consultation and funding for the actual projects. To proceed in the absence of such assurance would create expectations that, if not met, would undermine the new approach by the United Nations and the spirit in which it has been made and further damage the reputation of the Organization. B. Individual approach 54. Under an individual approach, one consideration has been the payment of money to the families of those individuals who died of cholera. If this approach were adopted, payment or cash transfer could take the form of a fixed amount per deceased individual that would be the same for each household, regardless of the number of family members in the household. 55. This approach would require an accurate estimate of the number of cholera deaths, identification of the deceased individuals and their family members, in order to identify potentially eligible households. It would also require the certainty of a threshold amount of funding sufficient to provide a meaningful fixed amount per cholera death. As set out above, according to figures from the Ministry for Public Health and Population, over 9,000 individuals may have died of cholera. Some observers believe that deaths from other causes with similar symptoms may have erroneously been noted as cholera deaths. Conversely, other observers believe, based on community surveys, that cholera deaths may have been greatly underrecorded. 7 The matter is further complicated by the fact that individuals continue to die from cholera in Haiti and from other water-borne diseases, especially in the aftermath of Hurricane Matthew. __________________ 7 Francisco J. Luquero, Marc Rondy, Jacques Boncy, André Munger, Helmi Mekaoui, Ellen Rymshaw, Anne-Laure Page, Brahima Toure, Marie Amelie Degail, Sarala Nicolas, Francesco Grandesso, Maud Ginsbourger, Jonathan Polonsky, Kathryn P. Alberti, Mego Terzian, David Olson, Klaudia Porten and Iza Ciglenecki, “Mortality rates during cholera epidemic, Haiti, 2010-2011”, Emerging Infectious Diseases, vol. 22, No. 3 (March 2016). Four retrospective community surveys conducted by Médecins sans frontières to assess the extent of deaths during the first phase of the epidemic (mid-October 2010 through mid-April 2011) have suggested that the mortality rate was higher than that reported in the official statistics and that the number of cholera deaths may have been understated by a factor of three. A/71/620 15/16 16-20491 56. Following the outbreak of cholera in 2010, the Haitian health authorities established a national cholera surveillance system. Data was collected and reported to the Ministry for Public Health and Population by health authorities in the departments and communes. That statistical surveillance data was subsequently transmitted to and aggregated by the Ministry for Public Health and Population. 2 In addition to the surveillance system, a civil status registry was maintained by the Ministry of the Interior to record deaths. 57. The preliminary consultations suggest that the data have significant limitations for purposes of an individual approach. While the national cholera surveillance system became operational in late 2010 or early 2011, reporting in the early days of the cholera outbreak was not as complete or consistent as it is now. It is likely that deaths, particularly those outside of health-care facilities, were underreported. Moreover, given the stigma associated with cholera, some patients apparently did not give their real names or correct contact details, with the result that the identifying data may be unreliable. It is also understood that the civil status registry does not include all of the individuals who died of cholera. In short, in the event the records were made available by the Government of Haiti, they are unlikely to provide a comprehensive or accurate list of the numbers of individuals who died of cholera, their names and the names and contact details for their families. 58. The mechanisms by which the data limitations might be addressed would require further consideration and elaboration. The mechanisms might include community mapping, registration and verification exercises to identify those who died of cholera and their households. 59. An individual approach would require further consideration, including through consultations on the ground with victims and their communities, while recognizing the significant challenges, risks and constraints. VI. Way forward and timeline 60. Track 1A is anticipated to come to an end on 31 December 2018 and will be re-evaluated at that time. With respect to Track 2, it is contemplated that all approvals would be issued within two years of the effective commencement of Track 2, although some aspects of the implementation might extend beyond that date. 61. The United Nations Haiti Cholera Response Multi-Partner Trust Fund has been established to provide a rapid, flexible and accountable platform to support a coordinated response, addressing both immediate and long-term needs, from the United Nations system and partners, with the ultimate aim of eliminating cholera from Haiti and enhancing Haitian resilience. The Fund has the ability to receive donations from Governments, non-governmental organizations and private donors and to disburse to local actors as well as to the United Nations and international non-governmental organizations, with appropriate financial transparency and oversight. The Government of Haiti, represented by the Permanent Representative of Haiti to the United Nations in New York, will join the advisory committee that supports the Fund as an observer. A/71/620 16-20491 16/16 62. It is anticipated that funding for Track 1A will be channelled through the Trust Fund to the greatest extent possible, to ensure more predictable, transparent funding for a more robust response. As stated above, funding modalities for Track 1B remain to be worked out in consultation with all relevant stakeholders. 63. The consensus view expressed during the preliminary consultations is that the two overriding priorities for Haiti are to eliminate cholera and respond to the devastating effects of Hurricane Matthew. The United Nations new approach, outlined in the present report, is premised on the assumption that sufficient additional voluntary funding will be made available to deliver on Track 2 without detracting from Track 1. However, the possibility that the Secretary-General may need to propose a multi-funded approach cannot be excluded. VII. Reporting 64. It is proposed that the Secretary-General will present further reports to the General Assembly on the development of the new approach, including the feasibility, costs and risks of including an individual approach as an element of Track 2, and information with respect to consultations with the Government of Haiti and victims and communities in Haiti. VIII. Action requested of the General Assembly 65. The Secretary-General requests the General Assembly to take note of the present report.