Team 2

Reparative and sustainable
investment in Haiti’s future

FRESH CONSULTING, INC. (TEAM 2)
February 15, 2014

Stuart Craig, Brian Dunican, Nicole Patterson,
Maury Raycroft, Jason Suway

AGENDA

• Overview of the situation
• Desired outcomes
• Recommendations
• Questions

BACKGROUND

January, 2010
•Earthquake responsible for ~72,000 Haitian deaths
•“Without their help, it would be impossible for us to cope with the
situation” -President Preval
•43 international teams (1,700 people) carried out 90 rescues and
provided 2M liters of water and 17M meals per day.
October, 2010
• Cholera outbreak responsible for 650,000 illnesses and 8,300
deaths to date
• UN aid workers are implicated in the introduction of cholera
• Healthcare expenditures increased by $395M to treat cholera
patients in Haiti

Problem Statement:
How should the UN divide and prioritize $3B in international support to address
the epidemic and build a stronger Haiti?

DESIRED OUTCOMES
Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion

Objectives

Stop
Cholera

•
•

Prevent spread
Treat infected

Repair
Damages

•
•

Compensate families
Reimburse care

Invest &
Build

•
•
•

Produce clean water
Expand health infrastructure
Facilitate innovation

Engage Haitian resources to ensure long-term sustainability of UN intervention

RECOMMENDATION: INDIVIDUAL COMPENSATION
Stop Cholera

Legacy Fund

Repair Damages

Millions

Introduction

$500

Invest & Build

Conclusion

Projected Fund Valuation—2014 USD

$400

Total after payments
Interest earned

$300

Value of
Statistical Life:
$84,000

Annual
Payment:
$2,800

(120* GDP/capita)

($84,000 / 30yr)

$200
$100
$0
0

5

10

15

Year

Saves $388M versus immediate dispersal

20

25

30

RECOMMENDATION: SANITATION INITIATIVE
Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion

Water Sanitation is crucial to Haitian health
88% of diarrheal disease
is attributed to unsafe
water supply and
inadequate sanitation

Child mortality is 30%
higher without access to
improved sanitation

$9 for $1 USD spent

Testing &
Evaluation

Clean Water
Source

Filtration System

Investment results in
economic benefit:

Improved
Water
Sanitation

Distribution

Management &
Maintenance

RECOMMENDATION: SANITATION INITIATIVE
Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion

Stage 1: World Bank Sanitation Initiative receives 100M per year for 5 years
• Established program will capability for immediate action

$1.3B Investment

20

=

15

6.5M people with
improved access to
sanitation

Distribution of Funding in Stage 2

$40
$30

$ / NGO

10

$20

# NGOs

+

5

$10

20,448 avoided
childhood deaths/year

0

$0
2014

2016

2018

2020

2022

Millions

Stage 2: Allocate remaining 800M to NGOs dedicated to water access and sanitation
• Evaluations of NGO performance with reallocation of funds
• Number of NGOs receiving funds will decrease over 10 year period

RECOMMENDATION: EDUCATION & PUBLIC RELATIONS
Introduction

Stop Cholera

Repair Damages

Invest & Build

Train local community
workers

Promotion of claims
process via
newspaper, radio, etc.

Community
Awareness

Press releases from
Haitian government
regarding UN
settlement

Public health education
through NGOs

Conclusion

RECOMMENDATION: CLINICAL REIMBURSEMENT
Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion

Cost
$395M

Reimburse

• 1.69% increase in healthcare share of GDP since outbreak
• Reimburse Ministry of Health for ’11-’13 to allocate funds
to hospitals, clinics, government based on inferred cost

$10M

Prevent

• Children are more susceptible to contracting cholera than
adults (6.6% vs 6.0% of demographic)
• Provide oral vaccinations for all children under 5 years old

$171M

Treat

• Haiti lacks sufficient healthcare resources when compared
to other comparable developing countries,
• Construct largest teaching hospital to train doctors over
next 30 years, and cover cost of projected cases of cholera

$576M

Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion

Cost
Reimburse

to hospitals, clinics, government based on inferred cost

$395M

Cholera Outbreak

Prevent

• Children are more susceptible to contracting cholera than
GDP
adults (6.6% vs 6.0% of demographic)
UN Healthcare Exp
Haiti Healthcare Exp

124

132

9,000
$10M
139

8,000
7,000
6,000

460
455
• Construct largest teaching hospital 418 train doctors over 491
to
351
324

Treat

5,000
4,000

517

205

$171M
3,000
2,000

278

150

GDP (In $ millions)

Healthcare Exp (In $ millions)

700
650
600
550
500
450
400
350
300
250
200
150
100
50
0

183

1,000

$576M
0
2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion

Cost
$395M

Reimburse

to hospitals, clinics, government based on cost incurred

$10M

Prevent

• Children are 10% more susceptible to contracting cholera
than adults
for 5 years

$171M

Treat

• Construct largest teaching hospital to train doctors over

$576M

Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion

Cost
$395M

Reimburse

to hospitals, clinics, government based on cost incurred

$10M

Prevent

• Children are 10% more susceptible to contracting cholera
than adults
for 5 years

Treat

• Haiti’s healthcare resources are limited
• Train 200 doctors/year over the next 30 years
• Cover cost of future incidences of cholera

$171M
$576M

TRAIN


INNOVATION FUND
Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion

Call for applications from for-profit and nonprofit organizations for UN funding

Project
Criteria

Purpose

•
•

Provide funding for
innovative development
Competition between
organizations for cost
effective solutions

•
•
•
•

•
Inclusive of Haitians
Feasible and Sustainable
•
Addresses an unmet
•
need
Economic impact

Outcomes

Improved quality of life for
the people of Haiti
Economic growth
Job creation

INVESTMENT ALLOCATION
Introduction

Stop Cholera

Repair Damages

Total Cost
Sanitation

$1,300 M

Clinical

$576 M

Individual
Compensation

$452 M

Innovation
Fund

$300 M

10%

$50 M

Overhead
Total Cost:

Conclusion

% ALLOCATION

$322 M

Education &
PR

Invest & Build

2%
11%
43%
19%

$3,000 M

15%

GUIDELINES TO REDUCE LIABILITY AND IMPROVE UN INTERVENTION
Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion

Challenge 1: Coordinating entry and action in a sovereign state

Clarify UN rights and
autonomy to act

Form an effective intergovernment task force

Incorporate grand strategy
to understand the goals
and visualize the end

Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion


autonomy to act



Challenge 2: Paving inroads for successful UN integration and operations

Identify local resources

Form districts
(population, existing
borders, or need)

Comprehensive
planning

Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion


autonomy to act





Form districts
borders, or need)

Comprehensive
planning

Challenge 3: Sensitizing to complex local culture and building local ownership
Outreach to local reps to
gain understanding and
identify resources

Local action committee
formation

Leverage existing
technology, resources, an
d accumulate data

Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion


autonomy to act





Form districts
borders, or need)

Comprehensive
planning

Challenge 3: Sensitizing to complex local culture and building local ownership
Outreach to local reps to
gain understanding and
identify resources

Local action committee
formation

Leverage existing
technology, resources, an
d accumulate data

Challenge 4: Preventing introduction of contaminating disease/species
Establish ISO
standardization for UN
health clearance

Digitize health records

Four eye principle to
confirm personnel
clearance

EXECUTIVE SUMMARY
Introduction

Reasons

Impact

Risks

Conclusion

Use the $3B to enhance and build
Repair UN
reputation

Improve
sanitation and
health

Strengthen Haiti

Next Steps
Form Claims
Commission

Improve relationships
with Haitian government
and citizens

Recruit bids

RISKS, MITIGATION AND CONTINGENCY
Introduction

Stop Cholera

Repair Damages

Invest & Build

Conclusion

Risks

Mitigation

Contingency

Misappropriated
Funding

Invest in pre-screening
NGOs

Require collateral from
Haitian gov; stop
support

Haitian public
dissatisfaction

Boost initial PR
spending; work closely
with
IJDH, gov, communities

Wait longer, listen
more, and collaborate
more

Another
outbreak/disaster

Improving sanitation
and clinics are not
cholera-specific

Invest in robust systems
and Haitian adaptability

REFERENCES
• CNN Article: http://www.cnn.com/2010/WORLD/americas/01/19/haiti.earthquake/
• UN Civilian and Crisis Management (Independent study by Kaspersen and Sending)
•Cost of Disease Calculator
http://www.idcostcalc.org/index.html
• WHO vaccination: http://www.npr.org/blogs/health/2012/08/17/159014069/who-calls-for-emergency-stockpile-of-choleravaccine
• OMS/OPS, MSPP, WASH Cluster, Health Cluster:
http://reliefweb.int/sites/reliefweb.int/files/resources/Cholera%20in%20Haiti%20An%20End%20in%20Sight%20Key%20facts%
20and%20figures%20as%20of%2017%20Dec%202013.pdf
• World Health Organization. “Fact and figures: Water, sanitation and hygiene links to health.” Water Sanitation and Health.
March 2004. Accessed on Feb. 10 2014. http://www.who.int/water_sanitation_health/publications/factsfigures04/en/
• Fink, G. and Gunther, I. “Water and sanitation to reduce child mortality: The impact and cost of water and sanitation
infrastructure” Policy Research Working Papers. March 2011. Accessed on Feb. 10 2014.
http://elibrary.worldbank.org/doi/book/10.1596/1813-9450-5618
• Gunther, et al. “The effect of water and sanitation on child health: evidence from the demographic and health surveys 19862007.” Oxford University Press. May 2011. Acessed on Feb. 10 2014.
http://ije.oxfordjournals.org/content/early/2011/06/30/ije.dyr102
• BRAC “Attaining MDG Targets on Water and Sanitation in Bangladesh.” Brac’s Water, Sanitation, and Hygiene Programme.
Jan. 2006. Accessed on Feb. 10 2014. http://brac.net/oldsite/downloads_files/WASH_Proposal.pdf
• UN Water. “Sanitation is an investment with high economic returns.” 2008. Accessed on Feb. 10, 2014.
http://esa.un.org/iys/docs/IYS%20Advocacy%20kit%20ENGLISH/Fact%20sheet%202.pdf
• 120*gdp:
http://www.bath.ac.uk/e-journals/jtep/pdf/Volume_34_Part_2_169-188.pdf
• review of VSL studies:
http://search.oecd.org/officialdocuments/displaydocumentpdf/?cote=ENV/EPOC/WPNEP(2010)9/FINAL&doclanguage=en

APPENDIX 1: LEGACY ANNUITIES
•
•

•
•
•
•

•

Pending lawsuit requests $100,000 per death and $50,000 per injury
Cross-national review of contingent valuation studies suggests VSL is 120x GDP per capita
• Haiti’s GDP per capita was 671-732 during 2010-2011 period
• Yields a VSL of $84,000 per death
Life lost is financial and emotional burden to the community and the nation
Replacement of lost income maintains Haiti’s economic growth potential
Recommendation: Disburse $84,000 via 30 year annuity to immediate relation
Cover annuity cost from $452M pension-like fund, principle spent to $0 over 30 years
• Assume 5% real rate of return (UN pension is 5.1% over 25 years)
• Assume 10,000 claimants, all receive 30 years of compensation
• Save $388M over immediate disbursal
Regarding Injury
• UN is not liable for Cholera cases
• Each episode lasts 1-7 days $2 - $14 dollars lost wages
• Administrative cost too high for direct payments

APPENDIX 2: COST OF SANITATION PROJECTS

World Bank-Supported Initiative
• Average $833 Million for 1 Community Sanitation Intervention
• Project Includes:
• Attainment of secure water source
• Purification/Filtration System
• Distribution Kiosks for some
• Household Connections for some
• Public water fountains
• School latrines
• Household latrines for some
• Training of community water managers
• Health promotion and education for community members

APPENDIX 3: SANITATION CALCULATIONS
Deaths avoided by improved sanitation for the under-5’s
Clean water improves under-5 mortality by 25 per 1000
(Pop under 5) x (25 deaths/1000)*(prop. Reached) = 1,245,000*0.025*
(6,500,000/9,893,934) = 20,448 per year
Population with improved sanitation
*Based on World Bank model: reaches an estimated 50,000 for a $10M
investment
1,300,000,000*(50,000/10,000,000) = 6,500,000 individuals
NGO Payout Table
Total Payout
Year
75,000,000
75,000,000
75,000,000
150,000,000
150,000,000
150,000,000
156,250,000
156,250,000
156,250,000
156,250,000

Cum. Payout
# NGOs
2014
75,000,000
2015
150,000,000
2016
225,000,000
2017
375,000,000
2018
525,000,000
2019
675,000,000
2020
831,250,000
2021
987,500,000
2022
1,143,750,000
2023
1,300,000,000

Avg. Per NGO
15
5,000,000
15
5,000,000
15
5,000,000
10
15,000,000
10
15,000,000
10
15,000,000
5
31,250,000
5
31,250,000
5
31,250,000
5
31,250,000

APPENDIX 4: SANITATION PROJECT OPTIONS

Sanitation Technology
Water Source

Purification

Distribution

Disposal

Testing

• Surface water
• Borehole
• Deep tube well

• Sedimentation
• Chlorination
• Biosand Filters
• Ceramic Filters
• Pressure Sand Filters

• Piped Water Scheme
• Distribution Kiosk
• Public Fountain

• Pit Latrine
• Flush Toilet
• Standing Shower

• Pathogen test kits
• Nitrate/Nitrite test
strips
• Chloride test strips

APPENDIX 5: PREVENTION COSTS
Dept or PaP
Total Population Total Male Population Total Female Population Total >=18 years old Total <18 years old
ARTIBONITE
1,571,020
776,517
794,503
886,875
684,145
CENTRE
678,626
346,232
332,394
350,517
328,109
GRANDE ANSE
425,878
222,072
203,806
232,718
193,160
NIPPES
311,497
163,185
148,312
175,826
135,671
NORD
970,495
476,349
494,146
537,348
433,147
NORD EST
358,277
179,511
178,766
187,276
171,001
NORD OUEST
662,777
328,173
334,604
351,847
310,930
OUEST
1,187,833
590,019
597,814
680,890
506,943
PORT-AU-PRINCE
2,476,787
1,179,978
1,296,809
1,532,613
944,174
SUD
704,760
363,927
340,833
392,765
311,995
SUD-EST
575,293
286,550
288,743
309,590
265,703
Total

9,923,243

4,912,513

5,010,730
Size of Population/Age
Population <5 years old
New Borns for 5 years
Total Population to be Vaccinated
% Adoption
Cost Per Dose
Number of Doses
Total Cost/Patient
Total Cost to UN

5,638,265

4,284,978

$

238,054.33
1,190,272
1,190,272
2,380,543
80%
$2.73
2
$5.46
10,398,213

http://www.npr.org/blogs/health/2012/08/17/159014069/who-calls-for-emergency-stockpile-of-cholera-vaccine

APPENDIX 5: CHOLERA TREATMENT AND HOSPITAL
Treatment of Projected Cases:

Hospital
Clinical
Hospitalization Rate
Average Cost
Expected Cases/Month
Total Cases over 5 years
Total Cost

Cost of Constructing & Supporting a Teaching Hospital:
Assumptions:
• $40M to construct new teaching hospital
• $115M to fund 200 students for the next 30 years
• $10,000 tuition/student/year
• 5% interest in fund

$
$

50.68
9.96
54.5%
$
32.15
8484
509,040
$ 16,366,857.70

APPENDIX 6: CLINICAL INFRASTRUCTURE
“The problem with healthcare in Haiti is that there is no system, no structure, no
plan – at least, not one that has been implemented.”
Inadequate Healthcare Facilities
• Medical staff
• Support Staff
• Equipment and Treatment
Indicators

Indicators (per 1,000 people)
• 0.25 Physicians
• 0.8 Hospital Beds
• 0.107 Nurses and Midwives
Haiti

Regional

V%

Under-five mortality rate (per 1,000 live births)

70

16

338%

Adult mortality rate (per 1,000 population

258

160

61%

Maternal mortality ratio (per 100,000 live births)

350

63

456%

Life expectancy at birth (years)

63

76

-17%

46% of Haitian’s did not have access to healthcare before earthquake

APPENDIX 7: ONGOING MANAGEMENT
•

•

Compensation
• Disbursement of compensation
• Validation of claims and beneficiaries
Community Compensation and improvement
• Water Sanitation
persons served / $
• Cholera Eradication
cases / month
• Clinical infrastructure
persons served / $
•Support for 3rd party Solutions
• Annual project review by Evaluation board
• UN, Federal, and Haitian community leaders
• Support continued for half of project organizations

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