Rapport final du projet HLP

THE USAID HEALTH LEADERSHIP PROJECT May 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. FINAL PROJECT REPORT HLP Final Project Report Page | i 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 | ii 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 | 3 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 | 4 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 | 5 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 | 6 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 | 7 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 | 8 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 | 9 Figure 1: HLP Logic Model HLP Final Project Report Page | 10 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 | 11 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 | 12 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 | 13 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. 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. “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 HLP Final Project Report Page | 14 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 | 15 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 | 16 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 | 17 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). Figure 2: Evolution of internal revenues before and after the installation of cash registers (before HLP) Source: MSPP 2020 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 HLP Final Project Report Page | 18 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), 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 solar panel system to ensure a stable power source for the register system. HLP also provided solar panel systems for five health facilities selected by the DAB/MSPP in consultation with the DG and UEP. The Hôpital d l'Universite d'Etat d'Haiti (HUEH), one of the five facilities, had three sites for installation: the maternity ward, the former military hospital, and the emergency room. All new electronic cash registers were delivered and installed by September 2020. Facility staff were trained on their use, with the DAB taking responsibility for continued maintenance. Electronic registers at HUJ. Photo credit: DAB staff. Left to right: Dr. Prince Sonson Pierre, Director of HSTH; Mr. Louis Zicot; Mr. Eustache E., Administrator of the HSTH; and Mr. Josma St-Louis. Photo credit: DAB staff. HLP Final Project Report Page | 19 As of January 2023, some sites have reported difficulties related to power outages and fuel shortages that limit the use of cash registers during periods when the sun has not been out to provide power through the solar panels. Opportunities exist for further support to upgrade the system, such as the installation of a wireless internet connection, as has been requested by the HUEH. Result 1.3: Governance and accountability improved HLP implemented a set of activities to improve governance and accountability within the health sector and to build the MSPP’s capacity to develop policies and procedures and regulate, manage, and monitor health system functions. This has included supporting the MSPP to: ■ Establish a mechanism to put into action the Unite d’Arrondissement Sanitaire (UAS), or District Health Units, to facilitate the decentralization process of health services to the district level, thereby better responding to the needs of the population ■ Standardize the tables sectorielles, or inter-sectoral meetings, practices to facilitate partner coordination ■ Relaunch the MSPP forum to facilitate better communication between the central level and departments ■ Strengthen the Paquet Essentiel de Services (PES), or the Essential Service Package, implementation initiated in 2017–2018 Since the inception of HLP, MSH had taken the lead in supporting the health governance work. In October 2021, both CFET and GC were introduced to the UADS and DOSS directorates to facilitate the transition of the project’s governance activities. However, communication around HLP/HRH’s first planned activity stalled in September 2022 because the former UADS director left his position at that time. MSH continued to coach the HLP/HRH technical advisor on a regular basis regarding the strategy the MSPP would like to implement. MSH provided guidance to develop all technical materials (scope of work, agenda, PowerPoint slides) that will be necessary to conduct some key activities with UADS. Those materials have been revised by the technical staff at the UADS under the leadership of HLP/HRH. MSH also led the first technical meeting on governance activities with the partners to coordinate implementation of each’s respective scope of work. To ensure a smooth transition of the governance activities to the local solutions partners, MSH and the partners agreed on future support. HLP/HRH will assist UADS for activities at the departmental level, supporting UADS for the tables sectorielles, and HLP/HF will support UEP for governance activities at the central level, conducting the donor tables sectorielles. Preparation for the Unite d’Arrondissement Sanitaire decentralization process The MSPP intends to implement a standardized UAS approach in all 42 of Haiti’s districts, where both administrative and health interventions will take place in the field. The UADS and the DOSS requested technical support from HLP to help put the UAS strategy in action. Starting in December 2019, HLP organized five meetings with committee members to plan for the development of the operational manual to guide implementation of the UAS across the country. Participants included representatives from key MSPP directorates (UADS, DOSS, UEP, DSI, and the Minister’s Cabinet), as well as PAHO/WHO. HLP Final Project Report Page | 20 In March 2021, teams assessed the capacity of four UAS (Aquin, Matheux, St. Michel de L’Attalaye, and St. Marc) to offer services. The team comprised representatives of the UADS and DOSS, in addition to other central directorates, including DSI, the Direction de Promotion de la Santé et de la Protection de l’Environnement (DPSPE, or the Department of Health Promotion and Environmental Protection), the Minister Cabinet, the Unité de Gestion des Urgences Sanitaires (Health Emergencies Management Unit), and the three departmental directorates (West, South, and Artibonite). During these visits, teams were able to collect information on the number of functional health facilities to inform the district mapping exercise. The team also collected data on specific maternal, newborn, child health, and communicable diseases indicators. Lastly, information on the district’s governance body was gathered. The findings from the visits were then presented as a case study to the MSPP in April 2021. The MSPP decided that the Matheux UAS should serve as a governance model to be replicated across the 42 districts in Haiti. Over a period of six months, HLP provided technical support to the UAS committee to develop the UAS manual, with input from the 10 departmental directorates and 5 district representatives. On September 30, 2021, the final UAS manual, entitled “Document cadre des Unites d’Arrondissement de Sante,” was presented at an official ceremony at which the Minister of Health, the DG, and representatives from PAHO and USAID expressed their appreciation for HLP’s technical and financial support in developing the manual. This document will be the reference manual to support the MSPP in rolling out the decentralization process. Official Presentation of the Document Cadre des Unites d’Arrondissement de Sante on September 30, 2021, with Dr. Gretta Roy Clement, Minister of Health, and her staff; Valerie Koscelnik from USAID; and project staff at the Hotel Montana, Port-au- Prince. Photo credit: Greslet Etienne, MSPP HLP Final Project Report Page | 21 Inter-sectoral meetings HLP worked with the MSPP to strengthen the functioning of the tables sectorielles. The tables sectorielles is an MSPP governance platform established at the central and department levels to help coordinate efforts among the MSPP, partners, and stakeholders and to share experiences and lessons learned. The tables sectorielles is a governing mechanism promoted by the Ministere de la Planification et de la Cooperation Externe (Minister of Planning and External Cooperation). HLP/MSH supported HLP/HF to develop a draft of the tables sectorielles standardized guide that provides a framework for the MSPP to conduct standardized and effective inter-sectoral governance at both the central and department levels and to better follow up on the decisions that come from those meetings. The final draft of the guide should be completed by March 2023. Once final, HLP/HRH will assist UADS in implementing activities at the department level, and HLP/HF will support the UEP in implementing governance activities at the central level and conducting the donor tables sectorielles. Relaunch of the MSPP forum The project provided technical support to the MSPP to relaunch the central and departmental forum, another governance mechanism used for sharing and exchanging information and strategies, aligning priorities, and mapping resources in order to avoid duplication of efforts. The forum had been paused due to ongoing insecurity and the COVID-19 pandemic, but one was held in Cap Haitien on January 16–19, 2023. The Minister of Health, the Director General, the Central Directors, and the Departmental Directors, along with technical staff from the departments, participated in the forum. Key topics of conversation included priorities for the next three years, department performance, identification of challenges and bottlenecks (including availability of blood supply, incomplete construction on some health facilities, and poor partner coordination), and consensus on adopting a standardized approach for the tables sectorielles. The MSPP also discussed follow up needed for the UAS approach and for management of human resources in the health facilities. During this meeting, the MSPP agreed that the forum should be held on a bi-annual basis and strengthen communication between the central and departmental levels. HLP/MSH coached the HLP/HRH and HLP/HF team in planning and structuring this forum with the key central directorates (UADS, UEP, and DAB). HLP/MSH revised the scope of work and agenda for the meeting and helped UADS and UEP develop templates for the presentations. The partners were also coached in managing the administrative aspects of the forum. HLP Final Project Report Page | 22 The MSPP central and departmental level forum held January 16–19, 2023, at the Hotel Roi Christophe, Cap Haitien. Photo credit: Greslet Etienne, MSPP Support for the essential package of services HLP supported the MSPP to advocate for strengthened MSPP ownership of the PES—a broad policy statement of those basic health services that the government has prioritized to reach the population equitably. The PES was developed with support from the USAID-funded and MSH-led Leadership, Management, and Governance project between 2012 and 2015. Since validation of the PES in early 2016, the MSPP had not been able to complete the implementation and monitoring plans as outlined in the manual and requested support to revisit the plans. Implementation of the essential package of services includes an assessment of the services currently being offered and the availability of providers at the facility and then, based on the results of that assessment, the development of a costed plan to address gaps identified at the primary and secondary level. In this regard, HLP developed and trained MSPP staff on using the supervisory tool to assess the level of services provided at the health facility level. To reinitiate the PES technical activities, HLP: ■ Supported the MSPP in establishing a secretariat to oversee and monitor PES implementation, while strengthening MSPP ownership. ■ Provided technical support to the DOSS to revise the PES technical working group scope of work. ■ Developed tools (such as the site evaluation tool) to help the DOSS standardize and monitor health services in alignment with the PES. HLP also ensured that the central directorates of the MSPP had the PES costing tool and implementation plan developed under the USAID-supported Health Finance and Governance (HFG) Project in 2017–2018. ■ Conducted a refresher training on formative supervision and put in place a multidisciplinary team to conduct site visits. ■ Tested the site evaluation tool in three DOSS-identified priority referral hospitals (hôpital communautaire de reference), in Beudet, Bon Repos, and Arcachon. Moving forward, HLP/HF and HLP/HRH will need to continue discussions with the DOSS to better understand what their priorities are and what support is needed with regard to PES implementation. HLP Final Project Report Page | 23 Formative supervision visits at the department level by UADS/DOSS Formative supervision visits are part of the DOSS governance strategy, and DOSS requested HLP’s technical and financial assistance for implementation. The COVID-19 pandemic disrupted so many aspects of life in Haiti, including health services, and conducting site visits was critical for the DOSS to assess the continuity of quality essential health services. In August 2020, HLP trained 37 individuals who would do the site visits on the principles of health facility supervision and the site evaluation tool that HLP developed for supervision site visits (see section 2.1 for more information on this tool). The 37 evaluators comprised staff of the DOSS and the MSPP directorates involved in the monitoring and surveillance of health services—including those in charge of nursing, family health, vaccination, and emergency care. Following the training, five multidisciplinary teams comprising MSPP health practitioners (doctors and nurses) and civil engineers who attended the trainings were established to conduct supervision visits using the supervisory principles for quality assurance that MSH developed. In August and September 2020, trained teams visited 78 health institutions, including the North, Artibonite, Southeast, Grand’Anse, and South health departmental directorates and five UAS. The key findings from these visits were quite similar across health facilities and included the challenges of absenteeism and lack of available practitioners in facilities, lack of proper waste management systems, dilapidated facilities, and weak application of PES norms. Because of the COVID-19 pandemic, some health institutions had noticed a considerable reduction in the number of patients seeking care. The teams were able to immediately address some specific challenges identified during the visits, including repairing three incinerators and some microscopes and installing infant and adult scales in facilities that did not have them. Following the visits, the findings were shared with the general directorates and other central directorates to take the lead in responding. For instance, the blood transfusion department was identified as a key directorate to intervene in the challenges of lacking blood supply that multiple hospitals are facing. The difficulty in traveling caused by insecurity and competing priorities led the DOSS to pause the visits. The DOSS has all of the tools and training it needs to continue and will seek additional support to pursue this intervention in the future. The MSPP was not able to move forward with rolling out the set of PES activities to facilities, given the difficulty of travel in the face of the COVID pandemic and the social and political instability. HLP/HRH and HLP/HF will discuss with the DOSS directorate if support for supervision will still be needed from USAID. HLP Final Project Report Page | 24 A forgotten remote health center gets a second chance The inhabitants of Morne à Brûler, a hard-to-reach community in la Vallée de Jacmel, located 100 km southwest of Port-au-Prince, were facing a significant challenge. Their health center closed three years ago after health providers were driven away because of the poor quality of the services they were providing. As a result, the population of this town had to either walk for hours or pay a heavy price for transportation to reach the closest health center. Governance support to find a solution The MSPP learned of this situation during a facility assessment visit. Concerned about the effect of the COVID-19 pandemic on routine service delivery, HLP provided technical and financial support to the MSPP to design and carry out an assessment of the level of services being provided at a representative sample of health facilities around the country. During this assessment, Dr. Ted Lazarre, Technical Officer for the Direction d’Organisation des Services de Santé, discovered the closed health center and worked with HLP to address the situation. Drawing on the HLP training on good governance practices and supervision tools, Dr. Lazarre organized a meeting with community members to develop a plan to reopen the facility. HLP helped facilitate the discussions with the Departmental Director to agree to staff the health center two days a week with health providers from a neighboring facility. Amazingly, the health center still had a good stock of unexpired medicines and supplies, and the facility was still in good condition. Because of this, the health center of Morne à Brûler was able to reopen just one week after the initial discussions were held. The people of Morne à Brûler are happy they can again seek services such as vaccinations and health consultations in their own community. With their new contacts with the DOSS, the community will be able to continue negotiating with the government so permanent, well-trained health staff can come to work at the health center. The actions of Dr. Lazarre and Morne à Brûler community leaders have shown that “men anpil, chay pa lou” (many hands make light work). The entrance to the health center after it reopened. Photo credit: Dieunot St Paulin “This work made me feel useful. I can see the concrete results of this assessment visit for the population. This assessment contributed to a better evaluation of the needs and constraints of the center to improve the health of the population.” -Dr. Lazarre, Technical Officer, DOSS HLP Final Project Report Page | 25 Support for the country coordinating mechanism At the request of USAID, the HLP project provided technical support to the country coordinating mechanism (CCM) for a one-year period (May 2021–May 2022) to support the strategic monitoring unit. HLP provided its technical and financial support to the CCM to ensure the oversight of ongoing grants from the GFATM. However, the CCM was shaken by the assassination of President Moise and related injury of First Lady Martine Moise on July 7, 2021. The First Lady, who also was serving as CCM’s president at the time, was evacuated from the country. Luckily, she survived. But because of the unusual situation, the CCM election was postponed, and a contingency plan was initiated. HLP provided technical and financial support to the CCM to supply continuity in the face of those events. A quarterly meeting with principal recipients (United Nations Development Programme [UNDP] for Malaria, World Vision for TB/HIV, and the Unité de Gestion de Projet (UGP) or the Project Management Unit, for health system strengthening) was held to harmonize and define priority activities, work on financial procedures, develop an operational plan for the system strengthening component of the grant, and reallocate resources. In addition, HLP provided technical support to the CCM in the following areas: ■ Revised the oversight tools utilized by the strategic committee. ■ Conducted a sub-recipient performance workshop in November 2021 to discuss gaps in the monitoring process. HLP suggested promoting the Global Fund's Code of Ethics and management procedures, particularly the articles concerning the relationship between the CCM and the principal recipients and between the principal recipients and their sub-recipients. The use of these procedures will facilitate more harmonious relationships among these entities. During the workshop, major challenges negatively affecting the Global Fund HIV and TB programs were identified and discussed. ■ Provided technical support at the CCM general assembly in December 2021, where the additional subsidy for COVID-19, totaling about $29 million divided among the two principal recipients— UNDP and World Vision—was discussed. ■ Developed the 2022 CCM oversight plan, which clearly defines the roles and responsibilities of the Oversight Committee to conduct planned tasks and activities. OBJECTIVE 2: IMPROVE GOH PLANNING AND OVERSIGHT OF THE HEALTH WORKFORCE The issue of human resources for health is one of the biggest challenges for the Haitian health system. Attracting and retaining qualified health professionals is an ongoing struggle. HLP’s assistance in HRH helped the MSPP identify and highlight the key challenges in the health system. Resource planning supported improvements to address structural challenges by allowing the MSPP to allocate funding to resources appropriately in order to meet the objectives in the National HRH Strategic Plan. HRH management activities supported improvements in structure, policy, and implementation of HRH recruitment, retention, and quality of care. HLP worked closely with the DRH on this objective and had to adapt the work plan when the DRH changed priorities due to the outbreak of COVID-19. HLP had HLP Final Project Report Page | 26 to align itself to the new priorities by helping in the recruitment and training of health workers to respond to the pandemic. Result 2.1: GOH health workforce leadership improved HLP implemented a set of activities to strengthen the capacity of the MSPP to roll out the national HRH strategy and determine needs, plan recruitment, and deploy health staff in an effort to sustainably optimize the health workforce given the limited resources available. Activities included support in developing key strategies and policies, performing optimization-related assessments, conducting targeted training and coaching, and implementing a learning-by-doing approach. Community health-care worker mapping In PY1, HLP provided support to the DPSPE to analyze data collected by the health departments prior to the start of HLP that mapped ASCPs. The ASCP mapping exercise was an important activity to identify the status and allocation of the community health workers in Haiti and to document who funds them in order to fully understand the national coverage for this health-care cadre. The ASCP mapping provided a means for decision-making related to the MSPP strategy, especially for strengthening primary health care, a critical part of HRH strategy implementation. HLP provided technical support to the Service de Santé Communautaire (SSC) or Community Health Service, to clean and analyze the data and prepare a final report. HLP helped develop proposed recommendations, including the need to: ■ Provide comprehensive training to all ASCPs in skills related to the PES (given that 20% are currently only “vertically trained” in one specific thematic area) ■ Develop a clear and effective transition plan for the national budget to cover the 70% of ASCPs still being funded by donors (see section 2.2 for further details) This report served as a basis for completing the situational analysis for the development of the community health strategy, in collaboration with UNICEF. Special status of health sector personnel guidelines 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 their type and location of posts and respective human resource considerations. Building on CFET’s work with the GOH’s Office of Management and Human Resources, 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 (FPS), or Health Public Service. This process specified the status of health workers at all levels by post and factors impacting staff motivation, including HR considerations such as work conditions. HLP assisted the DRH in drafting a roadmap for developing the statut particulier de la santé (SPS), or special status of health sector personnel guidelines, that covers both health-care providers and administrative personnel. HLP supported the DRH in establishing a technical working group (TWG) that would develop the SPS, including representatives from DRH, UEP, DOSS, Centre d’Information de la Formation en Administration de la Santé, and the legal department of the MSPP. Considering the HLP Final Project Report Page | 27 importance of the SPS, the Director General of the MSPP asked to take part in the work of the TWG. HLP reviewed SPS documents from other sectors, as well as other countries, in drafting the text, which was shared with the DRH and UEP in September 2021. The goal of the SPS was to set up performance- based management for HRH. The main reforms to HRH management include: ■ Introduction of flexibility in a health-care professional’s contract with respect to full-time or part- time service ■ Hourly pay ■ Attractive compensation and benefit packages for staff placed in rural and challenging areas ■ Payment of incentives ■ National roll out of results-based financing ■ A standard recruitment process for hospital executive directors that includes a presentation by each candidate on a hospital development plan ■ Career development profiles for each of the six professional cadres identified (medical doctor, dentist, pharmacist, nurse and midwife, lab technician, and health service management) to offer a path by which health-care professionals may progress ■ A retirement age for health-care workers (65 years for medical doctors, 60 years for all other health-care workers) ■ Guidelines for health-care personnel salary grid that are in line with those of professional associations The validation of the SPS was delayed because of competing priorities in the DRH. However, this activity was adopted by PEPFAR as a key objective for the success of a viable transition plan for health- care worker funding. HLP/MSH assisted HLP/HRH in June and July of 2022 to develop the process for the validation of the SPS when the DRH is ready. Competencies index for health staff A draft of a competencies index was developed under the HFG Project, which included the roles and responsibilities for each category of personnel as well as the job title and necessary skills/competencies for each position. In PY2, HLP organized a workshop with the West department to review the draft competencies index and develop (in collaboration with HIV care providers) 20 job descriptions for key HIV care personnel, including medical doctor (site coordinator, care physician, and medical specialist), nurse (nurse counselor, nurse care, nurse site manager, nurse case manager, nurse dispenser, and community health nurse), lab technician, pharmacist, social worker, psychologist, disease reporting officer, and data clerk. These newly developed job descriptions were used to complete the competencies index, which is available jointly with the SPS. Support better allocation of scarce human resources for health The Workload Indicators of Staffing Needs (WISN) is a WHO tool designed to assist countries in assessing their health-care staffing needs at the facility level to determine how many health workers of a particular type are required to cope with the workload of that given health facility. Using the WISN in Haiti will allow for better understanding of staffing requirements by departmental and facility level based HLP Final Project Report Page | 28 on population, service delivery data, and workload in order to better distribute health-care workers by actual need. In collaboration with the MSPP, HLP initiated a roadmap for the use of WISN in Haiti. Use of that tool will be planned and carried out in collaboration with WHO experts from Geneva, who will set up the tool to analyze and recommend workforce optimization strategies for facilities across the country. In September 2022, HLP/HRH established contact with the PAHO/WHO WISN focal point, who shared the updated WISN materials with HLP, and together they discussed the format of the WISN tool application to propose to MSPP. Two options were considered: customize the WISN tool based either on the health facility or on health-care cadres. The WISN tool customized to the health facility would include all the health workers in each type of health facility. The tool customized to health-care cadres provides a partial, transversal analysis based only on a specific category of health worker across all types of health facility. In either case, the tool should be implemented progressively to cover all types of facilities and health-care cadres. Experience in other countries has shown the many difficulties that can arise if the tool is too large for a first-time implementation. Following discussion, the team decided to propose to the MSPP applying the health facility-based option in a small category of health facility (Centre de Santé Communautaire or Centre de Santé). HLP/HRH will support the MSPP in the planning and implementation of the WISN in accordance with their work plan and in agreement with USAID. Periodic reviews of the human resource managers’ network and annual report on HRH management On an annual basis, HLP provided technical support to the DRH to conduct a human resources performance review of the public health sector. The two main objectives of the review were: ■ Système d'Information de Gestion des Ressources Humaines (SIGRH), or the Human Resources Information and Management System, quality control, which allows for periodically updating the SIGRH database ■ Monitoring of HRH management data with the HR departmental focal point The data collected and validated during stakeholder meetings was used to develop and publish the annual HRH management reports. Support for performance reviews of health personnel Annual performance evaluations are a key component of implementing the Système d’Evaluation de la Performance. HLP provided technical assistance to the DRH to review all tools available for performance evaluations, including staff performance evaluation charts (by job category), evaluation reporting tables to monitor performance, and guidelines for transmitting evaluation results to the DRH and Office de Management et des Ressources Humaines (OMRH), or the Management and Human Resources Office. Performance evaluations were conducted by supervisors each fiscal year in all health facilities and were required to be finalized by November 30 of each year. The DRH supervised the performance evaluations, and HLP provided support to MSPP to conduct the annual health personnel performance evaluation, disseminating 8,000 forms to all 10 departments. The departmental directorates were responsible for continuing to print and disseminate these forms for all remaining institutions. HLP Final Project Report Page | 29 The DRH expressed interest in revising its performance evaluation guide to link individual staff performance with results-based financing. This will allow the MSPP to provide incentives to staff based on their performance. In this respect, HLP drafted the concept note that will help steer the revision of the HRH performance evaluation guide. The concept note was validated by the DRH and the Unité de Contractualisation. As a next step HLP/HRH will continue supporting the revision and implementation of the performance guide. Support for supervision visits HLP assisted the DRH to develop a TOR and tools to conduct unplanned supervision/attendance checks at health facilities. HLP supported the DRH to conduct field visits to 21 health and administrative institutions between March and July of 2020, within the context of COVID-19, to ensure compliance with the new requirements imposed by the GOH as of March 2020 (including wearing masks, respecting physical distancing, and prohibiting gatherings of more than 10 people). Sites were visited in seven departments across Haiti (West, Nippes, Grand’Anse, North, Central, Northeast, and Artibonite), including a key COVID-19 treatment site in Port-au-Prince. During the HRH annual review workshop in September 2020, departmental HRH focal points discussed and addressed key problems and gaps identified during the unannounced visits. Some of the proposed recommendations included: ■ To address the issue of 255 cases where staff died or abandoned their positions at facilities around the country, it was agreed that HRH focal points must send correspondence to the DRH for administrative follow-up requesting the cessation of payment. ■ To address the issue of 59 cases of physical and mental incapacity, workshop participants recommended that the central office mandate that a medical team in each department’s health directorate investigate such cases and render a decision on continued employment. In PY2, the DRH, with technical and financial support from HLP, conducted orientation for HRH focal points on how to conduct supervision/attendance checks. Immediate supervision carried out by the HRH focal points focused on evaluating the recently opened COVID-19 treatment sites. Additional supervisory visits conducted by HRH focal points focused on performance of ASCPs and nurse auxiliary supervisors after they attended a five-month training by World Relief in the Southeast department. They also created a strengthening plan for a hospital in Nippes that is transitioning to becoming a referral hospital. The tools and capacity developed for these supervision/attendance checks allowed HRH focal points the means to support health-care workers and administrators to strengthen facility management and assist in ensuring quality of care at the service delivery point. Recruitment of health personnel Recruitment of health personnel is one of most important functions of the DRH, and HLP supported the DRH in that regard in various ways. For example, in fiscal year (FY)21, HLP provided technical support for the recruitment of two new unit heads for the DRH directorate. HLP also supported the Northeast departmental team to shortlist and interview the health personnel candidates. HLP Final Project Report Page | 30 With support from HLP, staff at the DRH developed a catalog of HRH needs in the public sector using data from the SIGRH to confirm current staffing numbers and identify gaps in staff needed to meet the requirements for the PES. With the onset of the COVID-19 pandemic, it was evident that more health-care workers would be needed. HLP advised the DRH on ways to quickly mobilize additional human resources, including recruitment of social service providers, graduating students, retired health professionals, and private- sector providers. In 2020, HLP worked closely with the DRH to recruit 330 additional frontline health- care workers across four COVID-19 sites in the area of Port-au-Prince. Haiti saw a spike in more serious and virulent COVID-19 cases in early 2021, relative to 2020. HLP again supported the DRH to recruit 841 health workers across the country. Many of these COVID-19-recruited health-care workers were hired on a contractual or temporary basis and therefore were not considered part of the MSPP’s regular recruitment plan in the HRH National Strategy (2018–2022). The temporary health personnel hired in response to COVID-19 could potentially be hired permanently by the MSPP if sufficient funding is available. Meeting continuing essential HRH needs is dependent on the allocated budget. In FY20, the MSPP requested a budget from the MEF of 24 billion HTG to meet the needs of new recruitment. The final MEF budget allocated to MSPP was 11 billion HTG, thereby requiring intense negotiation to set priorities. Clearly, this was significantly less than required for meeting health worker budget needs. In July 2021, Haiti's MEF froze all new recruitment for budgetary reasons, a decision that remains in effect as of this writing. HRH strategic plan evaluation The first five-year period (2018–2022) of the HRH strategic plan has just ended, and the DRH will evaluate the implementation of that plan. The assessment will identify constraints and lessons learned to inform the actions and interventions for the second five-year period (2023–2027). In August 2022, HLP/MSH supported HLP/HRH to draft the evaluation form. The evaluation should answer the following questions: ■ Did the implementation of the strategic plan go as anticipated (means, deadlines, etc.)? ■ What is the level of achievement of the expected results? ■ What were the constraints, weaknesses, and threats that prevented implementation as planned? ■ What were the opportunities and innovations identified during the implementation of the plan? HLP/HRH will work with the MSPP and TWG members to finalize the planning and conduct the evaluation. DRH 2023–2024 operational plan In February 2022, HLP supported the MSPP/DRH to develop the HRH section of Plan Directeur ’s triennial plan. The Plan Directeur’s triennial plan was validated and disseminated by MSPP in June 2022. The DRH will now need to develop an operational plan for FY23 based on the Plan Directeur’s triennial plan. Between September 2022 and January 2023, MSH supported HLP/HRH to develop the TOR (including the methodological approach) for this activity, supporting the DRH to develop and finalize the operational plan for the coming year. HLP Final Project Report Page | 31 Preparation for updating the SIGRH In the PY4, MSH/HLP provided guidance to HLP/HRH in planning and coordination of SIGRH activities. This included two sub-activities focused on the SIGRH update: ■ Regular monitoring of the health personnel ■ Updating the community health worker personnel database by commune and by department For efficiency, the two activities will be combined in a DRH-led and HLP/HRH-supported HRH final review workshop. The workshop will bring together the community health focal points who manage the ASCP for interaction with the HRH focal point to validate and integrate the information regarding the ASCP and the Auxiliaire Infirmière Polyvalente, or multidisciplinary auxiliary nurses, in the SIGRH. In August and September 2022, DRH and DPSPE/SSC, HLP/HRH, and HLP/MSH worked together to develop the TOR and methodological approach for the workshop. Due to the security situation in Haiti, the DRH decided to hold two decentralized workshops to avoid excessive travel. These two HR decentralized workshops were scheduled to take place in September and October of 2022, but the security situation was deemed too dangerous at the time. When safe, the first review for the northern region will take place at Cap-Haitien, and the second one covering the southern region will be organized at Les Cayes or Jérémie. A training session will be held at the beginning of the workshop to introduce the community health focal points to the DRH/SIGRH and provide an update for the HR focal points, especially the new ones (Nippes and Grand’Anse). The DRH is responsible for following up on the administrative preparation with the MSPP/DG. Result 2.2: Distribution of the health workforce improved HLP implemented a set of activities to improve health workforce retention and ultimately transition staff from donors to the MSPP budget. The workforce and budget optimization of Haiti’s health workforce included development and support for implementation of a transition plan 2020–2030 as well as task- sharing plans among Haiti’s health-care workers. HRH transition plan Developing the transition plan—The transition of financial responsibility for HRH to the MSPP is essential for ensuring the adequate distribution and management of the health workforce. To prepare for the development of a transition plan that would assist the MSPP in progressively transitioning funding for health professionals (doctors, nurses, midwives, laboratory technician, etc.) providing HIV services from donors to the Haitian government, HLP planned a working session with the HSD project for September 2019. In this meeting, participants developed a data collection tool to assist with the mapping of HIV health workers currently paid by HSD (with funding from USAID and PEPFAR) in different health departments. This Excel tool included information on the type of health providers (doctor, nurse, midwife, lab technician, community health worker, etc.) and their official titles in order to develop an HIV health workers inventory. This information helped to standardize titles and functions within the MSPP moving forward. HLP Final Project Report Page | 32 Together, HLP and HSD collaborated to consolidate the data and finalize the transition plan. The transition plan final report identified 4,001 health personnel paid by PEPFAR to be transitioned to the MSPP budget with a 10-year absorption period (2020–2030). For the first year (2020–2021), the transition plan projected the transition of 458 health-care workers from different categories, representing a total cost of USD 778,000. The transition plan was presented and accepted at a CCM meeting on September 10, 2020, with the participation of the First Lady and the DG of the MSPP. Operationalizing the transition plan—Following the development of the HIV health-care worker transition plan, HLP focused support in PY2 on developing the transition plan's operational plan for the transfer of staff previously paid by donors to be paid by the national budget. HLP worked with the UEP to prepare for the operationalization of the transition plan, identifying priority health personnel assigned to HIV care that should be transferred. The operational plan was completed following a workshop held in April 2021. At the DRH’s recommendation, the health department team selected 33 sites to implement the plan in FY21: ■ 14 Projet Santé (Consortium Caris-CMMB Catholic Medical Mission Board) sites ■ 13 Unité de Gestion du Projet/PEPFAR sites ■ 2 Haitian Health Foundation sites ■ 2 Centre pour le Développement et la Santé/Global Fund sites ■ 2 Zanmi LaSante/Partners in Health sites “The absorption of staff that was previously paid by donors’ agencies, specifically for HIV, shouldn’t be considered as an isolated intervention but as an integral part of the plan to strengthen the workforce for the care of the population.” Ms. Zita Dominique Paul, nursing care coordinator for the Hôpital Saint-Michel de Jacmel and one of the health staff transferred Data collection for the transition plan in one of the health facilities of the West heath department. Photo Credit: Laurent Konan, MSH HLP Final Project Report Page | 33 Based on the roll-out to sites, HLP supported the MSPP in conducting the evaluation of the year 1 transition operational plan, with a report developed from technical meetings and working sessions organized at different levels with the USAID/Haiti CDC Team (August 23, 2021), the MSPP/Haiti Managerial Team (August 29, 2021, with MSPP/DG and DRH), and the MSPP/Haiti Operational Team (September 29, 2021, with MSPP/HRH and HIV focal points). The evaluation reviewed the success of the transition to date, a gap analysis, collaboration with other stakeholders (OMRH, Le Centre Haïtien pour le Renforcement du Système de Santé [CHARESS]) to improve performance, and the results of a rapid survey addressing the perception of local actors (HRH focal points) on the first year of the transition plan. Additionally, four domains of transition plan management were analyzed for the formulation of recommendations—funding, human resources management, management tools, and training—for service delivery to meet MSPP service integration principles. At the end of Country Operational Plan (COP) 21, implementation of the transition plan achieved: ■ Total number of staff fully transferred: 47; 26 staff from UGP/PEPFAR and 21 from Projet Santé ■ Total number of staff partially transferred: 16; 6 from UGP/PEPFAR and 10 from Projet Santé ■ Total number paid by health institutions but not formally committed by MSPP: 3 ■ Other cases: 42; 16 end of contract, 21 resignations or abandonments, 4 deceased, 1 retired A total of 28% (63 out of 223) of health workers were either completely or partially transferred. Since the start of the transition process, the status of 108 health workers has been revised. As of July 2021, Haiti’s Ministry of Economy and Finance has frozen all recruitment and hiring for budgetary reason, which includes the transition of health-care workers to the MSPP budget. As a result of the evaluation, PEPFAR/COP 22 activities were reoriented to the creation of conditions for the success of the transition plan, mainly through: ■ An updated HRH transition plan, in collaboration with other stakeholders, including the Global Fund ■ Consolidation of the first draft of the statut particulier de la santé, developed under HLP leadership ■ Identification of motivating factors for the health-care workers that are to be transitioned (survey) Updating the transition plan—As Haiti emerges from the COVID-19 crisis and other emergencies, HLP/HRH will work with the MSPP to update the transition plan, including health-care workers funded by the Global Fund. HLP/MSH collaborated with HLP/HRH to ensure the transfer of all transition plan documentation. The update process will include re-use of costing tools and HIV facility service data available from the MSPP/Programme National de Lutte contre le SIDA (PNLS) or the National HIV/AIDS Program and MESI platform to ensure optimization. Nurse responsible for case management with a patient. Photo credit: MSPP/DSSE (HR Services) HLP Final Project Report Page | 34 HLP/MSH developed a transition plan update concept note to support HLP/HRH in finalizing the implementation process. Task-sharing to ensure HIV service delivery at the community level In December 2019, HLP met with the head of HIV services within the MSPP/PNLS to discuss how to finalize HIV care protocols at the community level. HLP advocated for the SSC to accelerate the completion of this document, an important component in defining task-sharing, and secure funding for the validation workshop. HLP conducted advocacy with the DPSPE/SSC to validate the HIV care protocol, which serves as a guide for ASCPs in conducting rapid diagnostic testing (a key component of the HIV community program). During FY20, HLP conducted two key activities to advance the implementation of task-sharing in Haiti: developing an HRH inventory or mapping of current HIV service providers and their roles and developing a task-sharing concept note and plan. To understand the distribution and roles of health-care workers involved specifically in the provision of HIV services, HLP conducted a mapping exercise specifically for HIV care personnel using a list of 150 health professionals. This mapping, which documented the job titles of personnel as well as their roles and responsibilities, served as the basis for identifying the key personnel to include in the task-sharing plan. In Q4 of FY20, HLP, in collaboration with the PNLS and service providers, developed updated job descriptions for these key personnel. Task-sharing among the various health actors, including ASCPs, constituted the basis of the task-sharing plan. The ASCP job description was revised to include rapid HIV screening tests (Oraquick). The revised job description was disseminated to all community health points during the Equipe Santé Familiale implementation workshop in August 2020. During Q4 of FY20, in a workshop held September 20–24, 2020, with the participation of the DPSPE/SSC, the DRH, and the MSPP IT department, HLP supported the development of a task-sharing plan with updated job descriptions for the ASCP and key personnel. In Q2 of FY21, USAID transferred the HIV rapid-test training for ASCPs (initially planned to be implemented in the task sharing plan) to CHARESS, a local PEPFAR implementing partner. In addition, it was agreed that Groupe Haitien d'Étude du Sarcome de Kaposi et des infections Opportunistes (GHESKIO), a local PEPFAR training partner since 2009, in collaboration with Quisqueya University, would train nurses on infectious diseases as part of the COP 21 work plan—a priority for MSPP to accompany the transition plan. In July 2021, HLP met with DSI and GHESKIO to plan the recruitment of future candidates for training, to reach the 538 nurses proposed in the transition plan. The capacity of these nurses was to be strengthened in the context of the task-sharing plan to qualify to work on infectious diseases. Deploying the equipe santé familiale (ESF) to achieve national coverage The ESF is a team of providers comprising medical doctors, nurses, and ASCPs within a district that are responsible for providing services to the population in that specific area. Since the structure of the ESF is HLP Final Project Report Page | 35 based on municipal territory, HLP assessed the status and needs of Haiti’s 142 municipalities with regard to ASCPs. Of those: ■ 5 municipalities had a balanced workforce (4%) ■ 58 municipalities were under-staffed (41%) ■ 67 municipalities were over-staffed (47%) ■ 12 municipalities had no integrated ASCP (8%) An ESF implementation workshop was held by the MSPP in August 2020 with the participation of community health focal points from the 10 departmental health directorates and with technical and financial support from HLP. The workshop made it possible to: ■ Describe the current situation on the ground with regard to the standards established in the Community Health Services Organization Model ■ Determine the appropriate actions/measures and the necessary resources for the constitution and/or the strengthening of the ESF ■ Develop a framework plan for the establishment or strengthening of ESFs in the municipalities at the level of each geographical department In March 2021, MSPP presented the community health strategy plan to partners, including HLP. In support of ESF operationalization, HLP submitted a draft of the development process for the ESF guide to the MSPP community health team. This draft process defined four key phases: ■ Phase 1: Technical and administrative preparation: Drafting the TOR, documentary review of the Carrefour pilot experience (2011–2015), and interview with the principal investigator (Dr. Jean Douly Caillot, now a WHO consultant) ■ Phase 2: Drafting the guide ■ Phase 3: Training the departmental team by using the cascade approach ■ Phase 4: Monitoring and evaluation of the implementing process The complete operationalization of the ESF team (to cover the entire country) was planned to occur over two to three years because it involves responding to the shortage of human resources, materials, and strategic supplies to make the team functional. LOCAL SOLUTIONS PARTNERS CAPACITY BUILDING One of the key goals of the HLP project is to build the organizational and technical capacity of GC and CFET to pass USAID’s NUPAS assessment and ultimately receive and manage direct funding from USAID. To do so, HLP provided assistance, primarily through learning-by-doing and mentoring approaches tailored to address technical and operational weaknesses identified within each partner. The NUPAS is a tool used by USAID to evaluate the ability of an organization to adequately fulfill the terms of an award. The NUPAS serves as a selection tool to determine an organization’s responsibility as well as whether any special conditions may be required in the final award. The NUPAS assesses the following areas of an organization: legal structure; financial management and internal controls system; procurement systems; human resources systems; project performance management; and organizational sustainability. HLP Final Project Report Page | 36 The first step in building the capacity of these organizations was to assess their capability to know what areas needed strengthening. To do this, the HLP team in PY1 developed the OSCAR, an innovative tool that incorporates elements from both the NUPAS and the organizational capacity assessment (OCA) to comprehensively assess the institutional capacity of an organization and its readiness to receive USG funding over time. The OSCAR tool provides a rating (from 1 to 4) across three essential sustainability factors: institutional, programmatic, and financial. The tool is used to assess seven domains and subdomains corresponding to the organizational capacity assessment and NUPAS sub-sections: ■ Governance and legal structure ■ Financial management and internal control systems ■ Administration and procurement systems ■ Human resource systems ■ Program management ■ Project performance management ■ Organizational management and sustainability In August 2019, HLP conducted a joint OSCAR stakeholder alignment meeting with GC and CFET. The objective of the alignment meeting was to introduce OSCAR to partners to ensure a common understanding of the tool. Under HLP, partners would use this tool to identify and assess gaps and weaknesses across the seven managerial domains to help them and HLP evaluate their institutional, financial, and programmatic sustainability and their capacity to receive and absorb direct funding from USAID. During the first two years of the project, HLP provided technical support to GC and CFET to conduct four OSCAR evaluations that enabled them to self-monitor and track their improvements across the OSCAR domains (and make adjustments where necessary) in order to meet the requirements for direct funding. At the end of the introductory sessions, GC and CFET validated the technical approach, noting that OSCAR is a user-friendly tool and is well presented compared to other organizational development tools. They appreciated the fact that OSCAR is set up to provide pertinent information, such as the means of scoring verification, and that it uses dashboards that help to easily present data and make it understandable, including with respect to each organization's stage of development. Soon thereafter, CFET and GC in late August and September of 2019 conducted their first facilitated organizational capacity self- assessments using the OSCAR tool, with support from HLP. Both received an overall score of two out of four, which means they would have to strengthen all three sustainability factors (financial, institutional, and programmatic) to pass the NUPAS evaluation. OSCAR baseline assessment at CFET, August 2019. Photo credit: Emmanuel Isma, MSH HLP Final Project Report Page | 37 The results of the first assessment constituted the baseline score of each organization’s readiness to receive direct USAID funding. The baseline sustainability scores are presented in figures 3 and 4. Figure 3: Sustainability scores for GC from the OSCAR tool, September 2019 Figure 4: Sustainability scores for CFET from the OSCAR tool, August 2019 HLP Final Project Report Page | 38 In light of their first OSCAR assessments, CFET and GC developed five-month action plans to address weaknesses identified in priority domains. HLP worked closely with both organizations to monitor and support the implementation of their action plans. HLP assistance included conducting learning events and providing direct coaching/mentoring to help partners close gaps in capacity identified during their assessment (e.g., governance policies and sustainability planning, branding and marking plans, sub-award monitoring plans). This coaching period enabled both partners to better prepare themselves for their next OSCAR self-assessments and improve in the areas identified as weakest during the first assessment. Between August 2019 and March 2021, the local solutions partners completed four OSCAR self-assessments to gauge their progress toward organizational capacity goals related to NUPAS requirements. By March 2021, both partners achieved overall OSCAR scores of 4—the highest score possible. During the capacity strengthening period, CFET and GC made significant progress on specific sub- domains of organizational functioning. For example, CFET worked to improve its capacity in external communications by developing its branding and marking plan and improved its human resources management by standardizing its timesheets, with MSH support. In addition, MSH supported both organizations in strengthening their governance structures by updating or developing their contingency and succession plans and board managerial procedures so they could formalize and standardize policies and procedures for elections, oversight, board meetings, and other governance capacities. Both organizations strengthened their managerial and administrative procedures by reinforcing their procurement processes and inventory systems. Both partners also worked to strengthen their financial reporting, with coaching from the MSH finance director, by revising the financial documents to be submitted to the Mission. MSH further supported the partners to establish and reinforce their monitoring systems by developing internal monitoring, evaluation, and learning (MEL) policy to ensure efficient project and program evaluation. During the first OSCAR assessment conducted with GC, only 13 out of 54 individual sub-domains received the highest score of four. As a result of ongoing capacity-building support from MSH, during GC’s fourth and final OSCAR assessment, the number of sub-domains receiving a score of 4 increased to 51 out of 54. Figures 5 and 6 show all the sub-domains that increased in score between the first and last assessment. The CFET and MSH teams at the second OSCAR evaluation at CFET’s office in August 2020. Photo credit: CFET staff member HLP Final Project Report Page | 39 Figures 5 and 6: GC Subdomains that improved in score between first and fourth OSCAR assessment During the first OSCAR assessment conducted with CFET, only 11 out of the 54 sub-domains received the highest score of four. As a result of ongoing capacity strengthening led by MSH, the number of sub- HLP Final Project Report Page | 40 domains with a score of 4 increased to 53 out of 54 during the fourth and final OSCAR assessment. Figures 7 and 8 show all the sub-domains that increased in score between the first and last assessment. Figures 7 and 8: CFET Subdomains that improved in score between first and fourth OSCAR assessment HLP Final Project Report Page | 41 Overall, major improvements were noted in the financial and managerial practices of both organizations (including holding regular staff meetings and enforcing rigorous travel policies, such as paying out only 75% of a per diem as an advance and the remaining 25% after the trip report has been submitted). However, some ongoing weaknesses were noted. For instance, both CFET and GC had ongoing needs to strengthen their information system security and also needed to hire some key positions, such as a monitoring and evaluation advisor and an internal controller. In addition to organizational capacity strengthening, HLP worked closely with GC and CFET to prepare them for better relationship management and technical assistance to increase their readiness to support the MSPP once they became responsible for project results. MSH conducted monthly meetings with staff from both GC and CFET to discuss project implementation and guide them in collaborating with the MSPP MSH technical staff accompanied the local partners during their transition period to reinforce their relationships with the MSPP, discussing MSPP priorities as the basis for their collaboration in the future. As the culmination of these capacity-building activities, the two local partners, GC and CFET, took part in their formal NUPAS evaluation with the USAID team in May 2021. Passing the NUPAS, both partners became eligible for direct contracting with the US Government. USAID issued Notices of Funding Opportunities for HLP/HF and HLP/HRH. Both GC and CFET signed direct agreements with USAID on April 1, 2022. Support to partners for their inception plans After the local partners became prime HLP contractors, MSH continued to provide coaching and technical support to both CFET and GC to assist them in project start-up. As requested, MSH provided technical assistance as they implemented their project inception plans between April and September of 2022 and addressed recommendations made by USAID after their NUPAS evaluations. To support both partners to address USAID’s recommendations, MSH held discussions with them to define the interventions within each domain that needed to be strengthened. Support for meeting USAID recommendations included the creation of a reliable record system for procurement, and MSH helped partners develop a filing system. MSH also ensured that both partners were aware of the screening platform available to ensure that the project’s beneficiaries or vendors can be contracted, confirming that the local partners are in full compliance with USG requirements when they engage with beneficiaries and vendors. MSH supported both partners in defining segregation of duties, policies, and procedures clearly within their operations manual in order to avoid conflicts of interest in the performance of their day-to-day operations. MSH helped the partners clearly define board members’ roles and functions and delegation of authority and to set yearly targets to ensure business continuity. MSH provided technical support to both CFET and GC to develop their respective MEL plans and address USAID’s feedback on their plans. To date, both have pre-validated versions of their MEL plans. The local organizations also received guidance from MSH in completing their SF-425 post-award reporting forms for submission on a quarterly basis. HLP Final Project Report Page | 42 On a monthly basis, MSH met with both partners to discuss challenges and identify solutions or approaches to address those challenges. For example, MSH discussed the unavailability of the UADS director that is slowing down the implementation of activities, and GC reiterated the support it will need to conduct a webinar on health financing strategy. These monthly meetings provided opportunities for MSH to see where there is a need to harmonize the administrative procedures of both partners, especially regarding the interaction they will have with their counterparts at the MSPP. Lessons Learned Adaptability in an ever-changing context Over the life of the project, HLP dealt with unprecedented challenges: the disruption of daily life due to the COVID-19 pandemic; the political instability caused by the dissolution of the parliament and the assassination of the country’s president; and the insecurity caused by gang takeover of much of the country. Movement around the capital and country was extremely restricted, and the HLP team had to devise ways to advance the work virtually. The team made use of technology platforms such as Google Docs to work collaboratively and WhatsApp to promote discussion and decision making. But this virtual work approach was limited by the logistical difficulties (mainly laptop and internet connection) of the MSPP’s cadres. The country’s situation led HLP to modify the format and modalities for the implementation of some activities. For example, decentralized meetings were held to limit the risk of travel (HRH review meetings and the Plan Directeur decentralized workshops). When possible, multiple activities were covered in the same decentralized workshop. The appearance of COVID-19 and outbreak of cholera in Haiti required the project to adapt interventions to align with the new MSPP priorities to address these health crises. HLP worked closely with the MSPP as they prioritized bolstering the human resources needed to address the health emergencies. Transitioning to local solutions partners Building the capacity of local organizations requires a common understanding of the target results. It has proven critical to establish a trusted relationship between the local partners and the organization leading the process. It is important to have a well-structured approach to conduct the capacity-building process. MSH developed the OSCAR tool for the purpose of this intervention, which encompasses the organizational capacity assessment and the NUPAS. This comprehensive tool was defined as being user friendly by the local partners introduced to it. To ensure that all organizational and managerial domains are well evaluated and gaps in capacity identified, a multidisciplinary team should be involved to coach and guide the partners during the process. At the same time, facilitated self-assessment should be undertaken, not only with the local partner leadership but also with the relevant staff in the organization. This will ensure that all staff within the local organization participate actively in the subsequent capacity strengthening process. It has proven beneficial to conduct the facilitated self-assessment using a team-based approach to avoid being seen as an auditor instead of a team member contributing to the development of the institution. HLP Final Project Report Page | 43 It is also important to maintain close communication with local partner leadership to ensure all stakeholders have a common understanding of the process and the results achieved along the way. Managing expectations is critical; for instance, during the negotiation of partnership goals for organizational development assistance, it is important that the local partner understands its own role in investing in its future by taking responsibility for improvements to meet its own vision and goals. This ensures local ownership and satisfaction in the end results. In HLP’s experience, facilitating introductions and transferring leadership to the local partners directly with the MSPP directorates was required for a smooth leadership transition of technical activities. It was important to guide and coach both partners and the MSPP to develop their collaborative year 1 implementation plans using an organized and consensus-based approach. It has also proven important to have a short period to mentor and coach the local organization, even after it signs its USAID agreement. Doing so gave MSH the opportunity to support start up and implementation activities in real time, allowing it to observe local partner implementation and encourage learning and adapting. Going forward, it will be important to establish good coordination mechanisms between USG-funded projects to strategically strengthen MSPP governance and leadership. Such a coordinated effort could increase local partners’ influence on governmental decisions and increase MSPP capacity to sustainably improve its financial and human resources. HLP Final Project Report Page | 44 Annex 1: Summary of HLP Achievements: 2019–2023 Area Planned Deliverables Achievements/ Status of Deliverables to Date Comments Health Financing: Result 1.1: Sustainable Financing for Health Increased 1. Assessment report on the management and use of internal revenue Completed 10 health department offices and 39 health institutions were assessed. 2. Study on the determinants of catastrophic spending on health in households and health inequalities study Ongoing The TOR and draft of the methodology for the determinants of catastrophic spending on health in households and health inequalities study have been developed. GC will complete this activity moving forward. 3. Assessment report on the health insurance context in Haiti On hold The TOR and draft of the methodology for the health insurance study have been developed. GC will complete the activity moving forward. 4. Workshop on health financing and support to the MSPP to facilitate sequential consultative meetings with government, civil society, and the private sector Ongoing The TOR for this workshop has been developed and shared with UEP for feedback. GC will complete this activity moving forward. 5. Evaluation report for the 2012–2022 Plan Directeur Completed 6. Plan Directeur 2021–2031 Completed 7. Operational plans (2021–2024) finalized and costed Completed Result 1.2: Public Financial Management Improved 1. Rapid assessment report on public financial management Completed 2. Public financial management tool Completed 3. Training reports on public financial management Completed 4. Installation of electronic cash registers Completed 36 electronic registers installed in 14 health facilities. Please see list in annex 2. 5. Workshop report on electronic cash registers shared experiences Not started The MSPP did not prioritize this intervention during the project’s implementation. Result 1.3: Governance and Accountability Improved 1. PES implementation roadmap Ongoing The technical committee has been reinitiated for this task, but the roadmap could not be completed due to a shift in priorities to address the COVID- 19 pandemic. HLP Final Project Report Page | 45 Area Planned Deliverables Achievements/ Status of Deliverables to Date Comments 2. Tables sectorielles operating manual Ongoing Drafted with MSH guidance— shared with UEP Director, pending validation from UEP. 3. UAS Operational Guide Completed 4. Provide technical assistance to CCM Strategic Monitoring Unit Completed, Developed 2022 CCM Oversight Plan Human Resources for Health: Result 2.1: GOH Health Workforce Leadership Improved 1. ASCP Mapping Final Report Completed 2. HRH section of the Plan Directeur 2021–2031 Completed 3. Special Status of Health Sector Personnel guidelines (statut particulier de la santé) Draft completed and submitted Pending validation from the MSPP. 4. Unplanned supervision visits reports Completed 5. HRH Strategic Plan Assessment Ongoing A first assessment was conducted in Cap Haitien Jan 21–24, 2023, under the leadership of CFET with oversight support from MSH. 6. HRH Performance Evaluation Reform concept note Completed MSH completed the concept note for the HRH Performance Evaluation Reform that will combine the performance evaluation system with results- based financing. CFET will continue to implement the performance review guide in accordance with the concept note. Result 2.2: Distribution of the Health Workforce Improved 1. HRH Transition Plan Completed 2. Transition Plan’s Operational Plan Completed 3. Task Sharing Plan Completed 4. Develop and implement the ESF operationalization guide across the country Ongoing HLP developed the framework to draft the ESF operationalization guide. CFET will continue to provide technical support upon request by the DPSPE to develop the guide. Capacity Building: Local Solutions Partners Capacity Building 1. Organizational Synthesis of Capacity Assessments for Award Readiness (OSCAR) tool Completed 2. OSCAR assessment results Completed Project transitioned to CFET and Group Croissance 3. Partner Action Plans Completed HLP Final Project Report Page | 46 Annex 2: List of Health Facilities that Received Electronic Cash Registers from HLP Name of Facility Department/City Number of electronic cash registers received Hôpital de l'Université d'État d'Haïti (HUEH) Ouest/Port-au-Prince 2 Hôpital Universitaire Justinien du Cap-Haitien Nord/Cap Haïtien 2 Centre d'Urgences Traumatologiques et Chirurgicales (CUTC, Delmas 2) Ouest/Port-au-Prince 2 Centre Hospitalier Eléazar Germain (CHEG) Ouest/Port-au-Prince 3 Hôpital Sanatorium de Port-au-Prince Ouest/Port-au-Prince 2 Centre Hospitalo-Universitaire Psychiatrique et Neurologique Mars & Kline (CHUPMNK) Ouest/Port-au-Prince 2 Hôpital Communautaire de Reference Raoul Pierre Louis de Arcachon 32 Ouest/Port-au-Prince 2 Hôpital Défilée de Beudet Ouest/Port-au-Prince 2 Hôpital Communautaire de Reference Ary Bordes de Beudet Ouest/Port-au-Prince 2 Hôpital Communautaire de Reference Zilda Arns de Bon-Repos Ouest/Port-au-Prince 2 Hôpital Notre-Dame de Petit-Goave Ouest/Petit- Goave 2 Hôpital Saint Nicolas de Saint-Marc Artibonite/Saint- Marc 3 Hôpital Immaculée Conception des Cayes Sud/Cayes 2 Hôpital Communautaire de Reference de Caracole Nord-Est/Caracole 2 HLP Final Project Report Page | 47 Annex 3: List of HLP Success Stories ■ A forgotten remote health center gets a second chance ■ Opening Doors for New Local Partners in Haiti ■ Transitioning a Health Care Workforce in Haiti’s Sud-Est Department ■ Haiti Approves Health Plan to Expand Access ■ Enabling Better Management of Hospital Finances: The Success of Electronic Cash Registers HLP Final Project Report Page | 48 Annex 4: Financial Management Capacity Tool See separate document HLP Final Project Report Page | 49 Annex 5: OSCAR Tool See separate document HLP Final Project Report Page | 50 Annex 6: NUPAS Tool See separate document le