Ebola outbreak in Nigeria and how it was managed

Public Health Response to Cholera Outbreak in Haiti-2010: The impact and lessons learned

SLMS005-Comparative Health Systems

University of Northampton

Content:

1.0 Introduction …….3

1.1 Overview: 2010 Cholera Outbreak and related events: …….4

1.2 Background to the health and health care in Haiti- 2010 …….4

1.3 Globalization and Global Health Initiatives (GHI) in Haiti …….7

2.0 Outbreak Response …….9

2.1 National Response………………………………………………………………………………………10

2.3 International response ……12

2.3.1 The role of PAHO/WHO………………………………………………………………….12

2.3.2 Role of International non-profit organisations (INGOs)…….…………….13

3.0 Political, economic and social contexts impacting the response ……15

4.0 Conclusion and lessons learned …………………………………………………………………………….15

4.1 country profile and Haiti’s vulnerabilities: ……16

4.1.1 Lesson learned………………………………………………………………………………………….16

4.2 International aid impact health system recovery during emergencies………………16

4.2.1 Lessons learned………………………………………………………………………………17

4.3 Critical issues (effectiveness and appropriateness) …………………………………..……17

43.1 Lessons learned ………………………………………………………………………………17

5.0 Reference List………………………………………………………………………………………………………19

1.0 Introduction

In October 2010, an outbreak of cholera, a water born disease characterised by acute watery diarrhoea and dehydration (World Health Organisation (WHO), 2017a) appeared in Haiti and quickly spread throughout the country reaching an unprecedented scale (Centre of disease control and prevention (CDC) , 2010a) making it the worst epidemic in recent history (Jenson and Szabo, 2011); in 2016, the Ministry of Public Health and Population (MSPP) reported that the outbreak has killed 9,317 Haitian and sickened 780,140 (WHO, 2017d).

Cholera is a rapidly treated disease; when using rehydration fluids and antibiotics patients recover within days (WHO, 2017d). However, Cholera is transmitted by food or water that has been contaminated by faeces (Tappero and Tauxe, 2011). Thus with the extremely poor sanitary situation in Haiti (Gelting et al., 2013), the spread was shockingly fast ( Médecins Sin Frontiers (MSF), 2012) reaching adjacent countries of the Dominican Republic and Cuba (Pan American Health Organisation (PAHO), 2011).

The health interventions employed in response to the outbreak were of a wide attention; the Haitian government and several members of the international community including WHO regional office in Haiti- Pan American Health Office (PAHO), CDC and MSF collaborated to contain the outbreak (PAHO, 2011a). Nevertheless, to date Haitians are still falling victims to the disease and cholera became endemic in the country (Ivers, 2017). To this end, much of existing literature (such as Lantagne et al., 2010; Carthy, 2016; Robbins, 2014) has investigated the outbreak response and argued that that the actual action plan launched in 2010 to fight cholera crisis failed to eradicate the disease.

There is little clarity about the different relative factors influencing the outbreak response in 2010; many data and reports by different national and international actors exist and it is difficult to distinguish how the outbreak response was planned. However, it is evident that the outbreak has taken an immeasurable toll on the population and the health system in Haiti (Ivers, 2017). Thus there is a clear need for understanding the various factors that have impacted the response and to identify “lessons learned”; According to Beg (2016), evaluating public health interventions, under what conditions it has been applied, and for which populations is essential to inform future effective prevention and control strategies. Therefore, the aim of this report is to evaluate the cholera outbreak public health response-2010 and its impact on health status and health care system of Haiti.

To do this, the report starts first by providing a brief overview of the outbreak and related events, the nature of Haiti’s health care system including the role of global health initiatives and globalisation prior to the outbreak. The then paper focuses on analysing the various aspects of the outbreak response and Finally, the report formulates a conclusion and a number of recommendations/lessons learned based on the findings.

1.1 Overview: 2010 Cholera Outbreak and related events:

On October 2010, the Haitian MSPP recorded cases of acute watery diarrhoea in its Artibonite and Centre Departments (CDC, 2010c). That same day  V. cholera serogroup O1 was confirmed in the tested stool cultures and on the 22nd of October, the outbreak was publicly announced ( Center of Strategic and International Studies (CSIS), 2012). As noted above Cholera rapidly spread because of Haiti’s poor WASH ( Water, Sanitation and Hygiene) infrastructure which was further devastated by a catastrophic 7.0 magnitude earthquake that struck Haiti 10 months prior to the outbreak (WHO, 2010b) creating an idyllic settings for the outbreak to spread throughout the country (Lantagne et al., 2014).

One month later, on November 2010, Hurricane Thomas arrived killing thousands of Haitians and causing rivers to flood which further aggravated already bad sanitary conditions and favoured the more rapid spread of the disease (CDC, 2013). Simultaneously, the country was in the midst of a political crisis and election-related violence which had it is own complications on the outbreak spread and response (this will be further explained in later sections of the paper)(Fisman and Laupland, 2011).

Death tolls of the outbreak were described to be massive (Jenson and Szabo, 2011). By the end of 2011, the outbreak has caused 7,000 deaths and around 500,000 infections (almost 5% of the population)(WHO, 2012a).However, some relief agencies such as CDC and MSF stated that death cases were underreported because the government inability to track deaths in rural areas where there is a weak health infrastructure and people died before reaching a hospital or health centres (CDC, 2011; MSF, 2012). Fisher and Kramer (2012) estimated the number of deaths to be higher by at least 3000 more than the originally identified number.

1.2 Background to the health and health care in Haiti 2010

Haiti’s population have had the worst health indices in the American region (Gelting et al., 2013). Prior to the outbreak reports indicated that vaccination coverage was as low as 58% (Gelting et al., 2013) which is far behind WHO recommendation of at least 95% (WHO, 2017e), life expectancy at birth was 61 years (WHO/UNICEF, 2010), infant, child and maternal mortality rates reached an unacceptable rates (table 1) (Tappero and Tauxe, 2011; WHO/UNICEF, 2010). Table1 provides a comparison between the health outcomes of Haiti and the Dominican Republic- Haiti’s only neighbour, which is demonstrative of the extremely poor health status of Haiti (Rainey et al., 2012).

Table 1: Haiti and Dominical Republic health outcomes indicators (The Centre for High Impact Philanthropy, 2013)

Underpinning such poor health outcomes in Haiti is widely believed to be the limited health system financing. Over the past years, most research (Suter et al., 2012; SL/ HaitiLibre, 2011; New Internationalist,2013) argue that Haiti’s truncated health expenditure is the most important factor that has seriously impacted health services availability and accessibility. The above researchers highlighted that in Haiti health expenditure comprised only 4% of the

general government spending (GDP/ national budget) which is below regional average (8%) and WHO recommendation (15%) (Institute for Development of Freedom of Information (IDFI), 2014). This view is also supported by USAID (2013) who indicated that Haiti health system management personnel was incapable of allocation and/or mobilising financial resources for the provision of universally accessible basic health services.

According to WHO (2014a), universal health services /coverage implies that every individual of the population has access to an affordable preventive and curative health services without discrimination (guaranteeing that communities do not experience any financial hardship to receive these services). In Haiti, health services costs were based on out of pocket scheme where individuals had to pay for their own care (USAID,2013). In a country where the majority (>75%) of the population are extremely poor (living on less than 2 dollars/ day)(Poverties, 2013), this led to health inequalities and significantly reduced health services utilisation. Which is according to New Internationalist (2013,) has greatly impacted the population overall health status and contributed to the increased mortality and morbidity rates in the country.

While health finance plays a major role in access and availability of health services, it is important to consider another aspect of health systems- the national health workforce which has greatly impacted Haiti’s health status (Houndmills, 2009); WHO (2014) stated that a well-performing national health system should be structured to improve the quality health services by increasing the number of health workers throughout the country. Demographic surveys in 2010 indicated that Haitian health human resources were severely limited with less than 6.5 doctors per 10,000 Haitians (Houndmills, 2009)- the WHO recommends 25 per 10,000. This resulted in unequal distribution of health workers (particularly in rural areas) which further aggravated health inequalities and deprived communities from accessing appropriate and timely health services (Adam et al., 2012). Poor and delayed access to health care is another factor that has been evidenced to be largely linked to the increased mortality rates in Haiti (PAHO, 2010a; Europa, 2010).

According to WHO (2017f), a health system consists of all the resources (People, institutions and organisations) that deliver health care services to meet the population health needs. Thus it is important to recognise the role of international organizations (INGOs) in the country and it impacts on the Haiti’s health care structure. Nacla (2011) suggested that the very limited competence of Haiti health workforce and financing (highlighted above) has resulted in the presence of a very large number of INGOs (More than 10,000) in the country. These INGOs received funding from different foreign sources (such as Humanitarian aid fund and Global Fund) and have played a prominent role in Haiti’s health care system (Peace Brief, 2010) providing more than 75% of health services to the Haitians(Schuller, 2010).

Mixed views exist over the role and impact of INGOs in Haiti. Many (see Haiti Net (2010); Red Cross (2011 ) argue that the long-term presence of INGOs has largely helped to fill the gaps in Haiti’s health system and to develop the technical capacity of local government. However, evaluations by Schuller and Córdoba (2010) observed that these NGOs were self- contained working on the ground independent from local government. Schuller and Córdoba (2010) argued that the INGOs relative strengths (providing free and accessible quality health services to the population) outweighed the Haitian government competencies which guaranteed that they receive a large portion of the Humanitarian aid fund in comparison to the government (1% of the total funding) (Ramachandran, 2012)– see figure 3.

Figure3: Distribution of Humanitarian aid funds- 2010 (Ramachandran, 2012)

As a result, the government lost its leadership governance and accountability toward its population and failed to achieve basic health system outcomes including strategic policy regulations (Schuller, 2010). However, it is important to note that these weaknesses were also politically affiliated and have been largely attributed to the fact that Haiti has been politically unstable for decades (The Telegraph, 2011)- In 2010 the country experienced more political violence and turbulence related to four parliamentary and presidential elections (PAHO, 2010c). Dupas and Robinson (2012) claim that in such context governments tend to spend more resources on politically valued goods and healthcare often gets deprioritised.

These findings will be much scrutinized in relation to the outbreak, but there are some immediately dependable conclusions that a combination of all the above-highlighted factors has played a major role in Haiti poor health condition and outcomes in (PAHO, 2010c).

1.3 Globalization and Global Health Initiatives (GHIs) in Haiti

Globalization is mostly defined as the process of growing interconnection between societies where any event happening in one part of the world is progressively affecting peoples around the world (Samimi et al., 2014). It is regarded more often in economic terms, However, there has been a substantial discussion over the potential impact of globalising on health (Brolan et al., 2014). A large and growing body of literature (such as Worsnop 2017; Mason et al., 2016; see also Newell and Roberts, 2013) view globalisation as a framework for resolving many health issues, mainly referring to the dramatic increase, speed and ease of data flow which facilitate information and research sharing worldwide. Worsnop (2017) argues that this particularly useful during an epidemic outbreak to deploy a quick response. The most obvious finding in relation to this is the deployment of international experts from the Global Outbreak Alert and Response Network (GOARN) at the onset of the cholera outbreak in Haiti (This will be further explored in a later section of the paper) to help set up a surveillance system (CDC, 2010b). According to PAHO (2011), this sped up the pace of cases discovery and assisted in tracking cholera cases.

 

However, whilst acknowledging the benefit of globalization, it is important to consider it is threats; one important risks that globalisation poses to the health system is the migration of health personnel. As per WHO (2010c), there is an increasing concern around this issue particularly in developing countries (Clark et al., 2015). In Haiti, reports indicate that globalisation of labour markets has increased migration of national health workers (Tulenko, 2011). This has negatively impacted Haiti’s already limited and marginalised health status draining the national health systems and leaving it understaffed (Clark et al., 2015). This lack of humans resources, extremely poor health indices and weak health infrastructure in Haiti have raised global health concerns where infectious diseases such as HIV and tuberculosis can spread rapidly and cross countries borders (Golden, 2010).

In this context, Global health initiatives (GHIs) emerged in Haiti (Ivers, 2011). GHIs main focus is disbursing additional funds for health interventions targeting and/or preventing emerging global health threats such as immunization and infectious diseases treatments ( Malaria and HIV) (WHO, 2012d). In Haiti, the President’s Emergency Plan for AIDS Relief  (PEPFAR) and the Global Fund to fight AIDS, Malaria, and Tuberculosis initiatives have progressively become an essential part of the humanitarian aid framework (Partners in Health, 2010). Many reports by WHO and Partners in Health indicate that these initiative has leveraged additional resources to strengthen Haiti’s weak health system (WHO, 2015a; Partners in Health, 2010). However, critics ( such as Hanefeld, 2010; Biesma et al., 2009) argue that these interventions are selective aiming to achieve disease-specific targets thus have created an extra burden on Haiti already fragile health systems. A broader perspective toward these initiatives has been adopted by Ivers (2011) and Mills (2014) who highlighted the importance of acknowledging the acquired limitations of GHIs which are restricted by the weaknesses of Haiti’s health system including the poor health infrastructure which is required for service delivery. Other authors (Craveiro and Dussault, 2016; Spicer and Walsh, 2012) question the above arguments and argue that such expositions are unsatisfactory because the overall knowledge about the broader impact of GHIs on a country health care system is insufficient and more studies are required to realise the actual effect of these initiatives particularly within a scale of disaster and outbreaks and a fragile system such that of Haiti- further details on GHI and INGOs Impact on Haiti health system will be further analysed in relation to the outbreak response below.

2.0 Outbreak Response

Most of the published literature (PAHO, 2010b; CDC, 2010a; CSIS, 2012) reported that multi-sectoral efforts have been employed to contain the cholera outbreak. The Haitian government represented by ministry of public health and population (MSPP) and the international aid community including PAHO, CDC , and other INGOs such as MSF; Save The Children; and Merlin have deployed numerous resources for the outbreak management including supply of cholera treatment (oral rehydration solutions and antibiotics), reconstruction of water, sanitation and hygiene (WASH) sites; setting up Cholera Treatment Centres (CTCs) and promotion of hygiene education messages (WHO, 2017b; OCHA, 2011; MSSP, 2013).

By January 2011, the UN reported that the number of cholera cases in Haiti has been decreasing, and that mortality rate has been reduced from 9% at the onset of the outbreak to 2% by beginning of 2011 (Piarroux et al., 2011)- see figure 2 which illustrates the epidemic case fatality rate between 2010 and 2012.

Figure 2: Case fatality rate during cholera epidemic 2010-2012 (Barzilay et al., 2013)

According to WHO (2011a), a well-managed outbreak can be measured as case fatality rate between 1-2%. Thus it seems that the outbreak was well managed by the end of 2011. However, outbreak management is not only about decreasing the fatality rate; according to WHO (2011c) policy and guidelines for prevention and control of cholera outbreak, the outbreak management primary objective is the interruption of the transmission of the disease and elimination of the source as quickly as possible to stop the additional spread. Thus, while case fatality rate was decreased to 2% - in line with WHO standards- the source of the outbreak was not eliminated; the spread of the disease could not be controlled; the number of infected and death cases was huge and cholera became endemic in Haiti (Ivers, 2017).

Therefore, to understand how the outbreak was managed, the following sections of the paper will examine the response deployed by different actors (the government, WHO, and NGOs ).However, before proceeding to that, it is important to note that all of the above-mentioned actors were coordinated in the field using the cluster approach (figure 3), the cluster concept was introduced by the UN to facilitate the management of humanitarian aid in different emergencies (Humanitarian Response, 2016). The different clusters (WASH, Health, protection. etc ) in Haiti joined meetings chaired by the UN Office for the Coordination of Humanitarian Affairs (OCHA), these meetings served as a platform for the coordination and monitoring of different measures undertaken by various actors (Gulline,2011)

Figure 3: Cluster approach - (Humanitarian Response, 2016)

2.1 National Response

The key authorities at the national level were the MSPP and National Department of Potable Water and Sanitation (DINEPA) (Jenson and Szabo, 2011), both worked closely to distribute chlorinated water in various water supply networks to eradicate V. cholera bacteria (Gelting et al., 2013). The MSPP then gradually rolled out various phases of the outbreak management including the assessessment of the available supplies of oral rehydration fluids, contacting hospital, labs and health centres to prepare for cholera cases management and building a surveillance system to track cholera cases (MSSP, 2013). The various stages of the response and logistical support were carried out alongside the international aid community including PAHO and CDC (Santa-Olalla et al., 2013).

It has been commonly assumed that the MSPP and DINEPA response to cholera crisis was competent and very well planned in collaboration with the available INGOs (Tappero and Tauxe, 2011; Santa-Olalla et al., 2013). However, weaknesses of the national health system largely impacted the response and consequently Haiti health status and health system. One one hand, DINEPA was entirely funded by Inter-American Development Bank (IDB)- a water and sanitation devoted fund established for Latin America and the Caribbean with the Swiss government and World Bank (Walton and Ivers, 2011a), UN (2010) stated that these funds were dedicated for Haitain’s government technical support. However, USAID (2014) reported that due lack of operative capacity of the government, the funds were trusted to international NGOs to operate in the field. Hence out in the field, DINEPA did not have the competence to operate and distribute chlorinated water as quickly (Gelting et al., 2013). At the same time, to agree over the sites of water supply networks distribution, INGOs needed to coordinate with various authorities including local authorities (DINEPA and MSSP ) and other INGOs (MSF, SC, etc.) which was time-consuming (Farmer et al., 2011). This delay increased the risk of cholera transmission. According to CDC (2010c), the number of reported cholera cases continued to be substantially high for the first 5 months putting more pressure on Haiti’s already under-resourced health system and affecting the health sector ability to cope with continuously new emerging cases (Gelting et al., 2013).

On the other hand, The cholera epidemic appeared at the end of the hurricane season (UNICEF, 2011). Although one would imagine that to be a positive factor for containing the outbreak; assuming that health education messages and contingency plans (to minimise and/or avoid the consequence of such crisis) are already in place by the government (WHO, 2011c). This was not the case, at that time, there was no national contingency plan and disaster risk reduction strategies scored low in Haiti’s health system (European Union, 2010; Gautier, 2010). Thus cholera easily spread into yet unaffected areas where the population didn’t know about of the outbreak and had no knowledge on how to deal with it (Lantagne et al., 2014) in the absence of civil guidance on what should be done in the event of an outbreak (UNICEF, 2011). This caused more un-necessary avoidable deaths (Achora and Kamanyire, 2016).

In relative terms, the national response reacted fairly well once the disaster has occurred by applying the above measure. However, MSPP performed quite poorly in preparation for those disasters. According to (WHO, 2015b; 2012c), different disasters generally cause similar health vulnerabilities thus common disaster management policies ought to be integrated into the existing health system to create resilience, which was lacking in Haiti.

2.2 International response

2.2.1 Role of WHO/PAHO

In addition to the coordination between key partners (MSSP, DINPA and INGOs) as the health cluster lead. PHAO mobilized various resources to Haiti including water and sanitation supplies(Chlorinated water), laboratory and logistics goods, medicines and equipment needed for cholera treatments (Oral rehydration fluids and antibiotics) and international experts (WHO, 2010a). Specialists from the Global Outbreak Alert and Response Network (GOARN) provided crucial technical support to Haiti MSSPP in term of epidemiological surveillance and response organisation (PAHO, 2011).

Although Reports indicate that PAHO has played a conclusive role in the outbreak management (PAHO, 2010b), epidemiologist quickly critiqued PAHO's epidemic modelling (outbreak management policy) that was advised to local authorities; Chao et al., (2014) argued that PAHO model didn’t lead to an efficient aid delivery; the model failed to take into account the pattern of transmission of the disease - the sudden but expected increase in the number of infected cases caused by weather trends (reports indicated that the number of cases peaked during rainy seasons reaching 25,000 in the first few months (CDC, 2010d)). This sudden increase in cases depleted the local stocks of antibiotics and rehydration solutions (Barzilay et al., 2013). As per Ivers and Walton (2012), PAHO under-evaluated the virulence of the disease and did not establish provincial emergency stocks supplies. Which is a major problem in the case of cholera as cholera patient can die from explosive diarrhoea and vomiting within 2 days if left untreated (WHO, 2017b). Consequently, the delay in resupplying led to more suffering and deaths (CDC, 2010d)- the epidemic curve in Figure 2 shows the true association between the peaks of the outbreak and the additional deaths.

Moreover, while vaccination against cholera has been recommended particularly in endemic and complex settings (Date et al., 2011). PHAO as the main leading organisation for health in Haiti didn’t employ vaccination as part of the response (Ruiz Matus, 2011). WHO claimed that vaccine was not employed because of limited vaccine availability and complicated logistical supply chain procedures in Haiti particularly with the political and civil unrest (Ruiz Matus, 2011). However, Qadri et al., (2016) asserted that the use oral vaccination in outbreak and emergency situations is crucial; vaccination could provide long-term health solutions and considerably decrease the number of new cases. This strategy could have saved people from being infected on the long run and could have greatly diminished the number of Haitians who unnecessarily suffered and died; (Lam et al., 2017).

2.2.2 The Role of NGOs

Under the coordination of health cluster numerous NGOs worked closely with MSSP to develop cholera treatment and prevention materials, train health workers on cholera management, and to set up Cholera Treatment Centres (CTCs) (Kirsch et al., 2012), by the end of 2011 it was reported that 10,000 health workers were trained and over 3000 CTCs were established across Haiti (PAHO/WHO, 2011b).

These efforts along with WHO dynamisms met two needs, the supply of medicines and equipment’s required for cholera treatment and the support provided to the limited number of national health workers (UN, 2016). Nevertheless, reports indicate that most of the aid was highly concentrated in Port-au-Prince department- the capital city. In fact, MSF (2012) reported that health centres in other cities such as Grand'Anse, Nord and Saint-Louis-du-Nord only received scarce support and suffered shortages of life-saving oral rehydration fluids. Likewise, Cravioto et al., (2010) and Lantagne et al., (2014) indicated that most of the clinics in rural areas where cholera was flourishing were simply shut.

The most likely causes for aid concentration in Port-au-Prince is the presence of large number of INGOs which was magnified after the earthquake as it was the principal disaster area (Tappero and Tauxe, 2011)- see figure 4 which illustrates the unequal distribution of international actors across Haiti (CDC, 2010c). While this increase could be positive for fast recovery and better coordination with national authorities in the capital city (Tappero and Tauxe, 2011), it nonetheless reinforced health inequalities for Haiti’s population particularly in rural areas where healthcare access is already lacking (Ivers, 2011). This was evident by the high mortality rate that was reported to be two times higher in rural areas (35.4 deaths/1,000 in rural areas vs. 19.1 deaths/1,000 in Urban Haiti (Luquero et al., 2016).

Figure 4: INGOs Distribution in Haiti (Haiti MPHISE, 2011)

This also revealed a major dysfunctional gap in Haiti humanitarian aid network (Dhillon and Annunziata, 2012) in terms of coordination between different international partners in the field (Wamai and Larkin, 2011). According to (UNOCHA, 2012; WHO, 2012b), the clusters main role is to coordinate aid between all actors on the ground based on needs. However, reports indicate that the clusters were merely able of passing basic information between different actors (Binder and Andrea, 2013). While the efficiency of health response in crisis-affected fragile states such as Haiti depends almost entirely on proper articulation of different actions between all participating actors (UNOCHA, 2012), it seems that the cluster approach has led to scattered single un- oriented initiatives that were unable to meet the needs of the population and prevent further spread of the disease (The Gurdian, 2010).

While uncoordinated response continued to claims the lives of many Haitian (The Gurdian, 2010), it is important to note another particularly complex challenge in regard to the humanitarian aid presence. For the outbreak response, INGOs recruited highly qualified national staff and offered them and competing salaries in comparison to that of Haiti’s government (Wamai and Larkin, 2011). Although the health services provided by the NGOs was free and accessible to the public, this deprived the national system of a high number of their qualified health professionals (Kao, 2011). Banati and Moatti (2008) referred to this approach toward the national healthcare system as paltry where INGOs overlooked the pre-existing governmental health structures and ignored the long-term consequences on Haiti population health outcomes who will need an infrastructure that is capable of providing efficient health services in the future.

3.0 Political, economic and social contexts impacting the response

As noted above, at the time of the outbreak, the county experienced a pollical violence related to presidential elections. Worries over the devastating cholera outbreak and further spread of the disease due to overcrowded vote centres caused the MSPP to ask for holding the votes (Fisman and Laupland, 2011). While this was advised to prevent further spread of the disease, delaying the election only prolonged a political uncertainty (TIME, 2010; CNN, 2010b). Security Council Report ( 2010) reported that the delay has only caused indecision among donors; External aid to Haiti was tardy and deferred in many occasions because of the donor's fears of political instability and Haiti frail infrastructure. As a result, the national outbreak response was completely dictated by the when the fund will be received from the international donors. Because most cholera deaths occur during the first two days of illness and early access to care is crucial (Sack et al., 2004; Walton and Ivers, 2011b), the delay in receiving funds has further contributed to more deaths and infections.

Cholera impact in Haiti was not only limited to death and human suffering, cholera outbreak triggered a panic reaction disrupting the economic and social setting of Haiti and consequently obstructing the community development (Poulos et al., 2012). CNN (2010a) stated that a large amount of Haiti's farming crops were lost because of investors’ doubts of cholera contamination. CNN (2010a) also reported that many important meeting planned by an international organisation such World Bank and the Swiss government to discuss the economic situation of the country were postponed as many participants were frightened off by the outbreak.

All these factors impacted the response, and the county economic and social growth leading to poverty, hunger, and malnutrition which leads to more poverty (Carthy, 2016). According to Alsan et al., (2011), this has dragged the country into a vicious cycle of poverty and illness and further undermined the capacity of governments to address the poor health outcomes in the country.

4.0 Conclusion and Lessons learned:

This report interpreted cholera epidemic public health response in Haiti 2010 taking into account a combination of a) the specific characterise of the Haiti health care system, b) the impact of the national and international response on both health care system and population (mortality and morbidity) and c) the political and socioeconomic context. Three key themes emerged:

· Country poor profile and Haiti’s vulnerabilities.

· International aid impacting health system recovery and reconstruction during emergencies.

· Critical issues (Effectiveness and Coordination).

The following provides a summary of the main emerging themes and lessons learned from the outbreak response.

4.1 country profile and Haiti’s vulnerabilities:

The substantial vulnerabilities in Haiti, including weak governance, political instability, prevalent poverty, and natural hazards (Hurrican Thomas ) (Gelting et al., 2013) made Haiti a hot sport for thousands of international NGOs (Schuller, 2010). These NGOs in the absence of national clear response framework by Haiti’s health sector operated on the ground following their own agenda overlooking any support to the government health officials which led to a vague disorganised response with inadequate efficiency (Lantagne et al., 2014).

4.1.1 Lessons learned

· Developing a national policy for health system strengthening in crisis-affected states is a key component of functioning health system and is needed by the governments (WHO, 2011b). (Tion and Phot, see also 2012; Farmer et al., 2011) stated that these frameworks maximise the use of both country resource and global contributions, minimize disastrous outcomes and improve the health status of the population.

· Disaster risk reduction needs to be integrated into the health system (WHO, 2011b). This will increase health system resilience in response to the different crisis and maximise the mobilisation of the obtainable funding (Farmer et al., 2011).

· Cholera is a water-borne disease (Sack et al., 2004) thus to control the disease it is critical for Haiti to prioritize and invest in water and sanitation infrastructure throughout the country (American Council on the science and health, 2016).

· In a pollical unrest, active engagement with political leaders is essential to support the health care system response; according to Paul et al., (2014) this will help in establishing better communication channels and pathways to facilitate an easier and efficient funding mechanisms.

4.2 International aid impacting Health System Recovery and Reconstruction during Emergencies:

As noted above, various factors affected the health system recovery: The international community (WHO, CDC,..etc) underestimated the virulence of the disease; medicinal supply was daunting, and vaccines were not implemented as part of the control strategy (Luquero et al., 2016). Most of the response activities were provided by international aid partners with no thought of empowering and recovering the existing health structure. All this created a situation where NGOs worked as a standalone entity magnifying the weak leadership role of Haiti MSPP and impacting different component of Haiti health care structure (funding, national health workforce) and population (high mortality rate and health care disparities and inequalities)(Lantagne et al., 2014)

4.2.1 Lessons learned:

· Congruent prevention and vaccination should be the implement as one of the primary targets of outbreak prevention and control strategy especially when healthcare access is not readily available to minimise the number of infected cases and prevent further death (Midzi et al., 2013).

· Even though the basic infrastructure to which base health services is devastated in Haiti, governments and communities can recollect competencies to improve the health of its population (Kwamie, 2015). Thus valuing and building on the local government management approaches and resilience is necessary to better advice on the country recovery strategies (Regmi et al., 2015). Such strategies include not only providing a technical support but also empowering the affected health system to lead the humanitarian aid (WHO, 2016a; WHO, 2016b). According to WHO( 2017c), this would have not only boosted the response but also would have made the international humanitarian response more durable cheaper and robust.

4.3 Critical Issues (Effectiveness and Coordination )

This theme is very much related to the above two themes. However, it was repeatedly emerging in every aspect of the response, therefore, is presented as a separate theme.

As noted above, INGOs presence in Haiti was autonomous functioning outside the government healthcare system. Their overall response was also poorly-coordinated and failed to cover many of the affected areas throughout Haiti (The Gurdian, 2010).

4.3.1 Lessons learned:

· Affected government and societies should be consulted and involved in all response strategies, this will facilitate timely response by mapping outbreak hotspots and areas lacking health care structure (Luquero et al., 2016).

· Reliable partnerships between different aid partners responding to the outbreak is essential in order to avoid duplication of services and to better coordinate relief efforts according to the needs of the population (Gillmann, 2010)

· Long-term strengthening of the Haiti ‘s public health sector is a sensible and practical investment by the international aid, this guarantees the provision of basic services that can be employed in the events of crisis and further constructed to support the national health system in the long run (Walton and Ivers, 2011a).

Overall, the country circumstantial vulnerabilities (poverty, political instability, natural disaster, etc..) and enormous health needs, challenged Haiti's government and the international aid community response (Ivers and Walton, 2012), however, with the devastated water and sanitation infrastructure in Haiti (WHO, 2010b), the outbreak response saved thousands of lives (Robbins, 2014). Yet, Plausibly, the most significant dynamic the outbreak response has revealed is the need of strong national health system to improve the health outcomes of its population particularly in the time of crisis (Bayntun et al., 2012). If the healthcare system of Haiti to revive much of the highlighted above is to be addressed particularly the internal national issues (lack of governmental leadership and political instability) which have greatly affected how the international aid community operated on the ground.

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