C2C Response to COVID-19 in Haiti

With a national health system that is profoundly under-resourced, Haiti faces enormous challenges on a normal day. With little international aid available during this time, the health and economic crises COVID-19 has caused in developed countries will be much worse in Haiti.

C2C’s main goals are to prevent and limit the spread of COVID-19 in Haiti and treat any patient suspected of having COVID-19. Our solution focuses on community education and an efficient electronic medical record (EMR) retrieval systems to treat infected patients in Haiti. We have begun mobilizing our clinical staff to respond to COVID-19 and educate our communities on means of prevention, with the intention of lessening the severity of the pandemic’s impact in our region. We will be working with our EMR vendor to incorporate contact tracing and COVID-19-specific capabilities into our EMR system, and sharing this with organizations in Haiti and beyond in the OpenMRS community.

Haiti’s national public health system is profoundly under-resourced and inadequate in “normal” circumstances, but is especially ill-prepared to respond to the COVID-19. The government allocates less than 5% of its budget to healthcare, spending just $13 on healthcare per capita vs. close neighbors the Dominican Republic ($180) and Cuba ($781). With over half of Haitians living in poverty, and a quarter in extreme poverty, effects of this crisis will be absolutely devastating to a healthcare system and an economy already in shambles. The government’s response to the pandemic is limited, and the few resources it is disseminating are being primarily allocated to Port-au-Prince, Haiti’s crowded urban capital.

Exacerbating this problem is the disbelief among the Haitian population about the severity/existence of the virus. The communities we serve are hesitant to follow basic prevention practices such as wearing a mask and staying inside whenever possible.

Because of this lack of government response, C2C’s efforts to educate our communities and manage cases will be absolutely critical in preventing the spread of the virus. With few resources available, the Ministry of Health is relying on C2C to take action against the spread of COVID-19.

As a trusted primary care provider, we are limited in our capacity to treat severe COVID-19 cases, but we play a critical role in messaging about preventative measures, treating mild to moderate cases, and disease surveillance. Our mission is to prepare, train, and protect our healthcare workers, develop awareness campaigns for the communities we serve, and to improve our EMR system to track COVID-19 cases.

Key community education activities include (but not limited to): 

• Radio and TV announcements weekly from C2C medical staff

• Hire a local “mobile” (a pick-up truck with large speakers in the bed) to drive through communities and broadcast the Haiti Ministry of Health’s message on COVID-19 prevention

• Clinicians provide education sessions on COVID-19 during regular patient consultations and nurses in waiting room of clinics

• Training of the community leaders, elders, and local authorities with influence in their own communities on COVID-19

Enhancements to EMR system include (but not limited to):

• UI for recording, managing, and visualizing contact tracing

• UI for managing triage queues of COVID-19 (suspected) patients

• Alerts upon registering new patients based on

  • 1) contact tracing data and

  • 2) COVID-19 clusters localization info

• UI for managing Sars-Cov-2/COVID-19 related lab test orders

C2C serves some of Haiti’s most vulnerable communities in the North and Northeast Departments. C2C’s average patient lives on $2-$4 USD per day and receives household income through economic activities like resale vending, small-scale agriculture, and family remittances from abroad. We serve approximately 45% children, 35% women, and 20% men. 

Virus mitigation strategies that have worked in developed countries, such as social distancing and quarantining, will be difficult to sustain in Haiti. According to the World Bank, about 50% of Haitians live in urban areas, which are extremely overcrowded and usually lack proper sanitation. However, virus mitigation practices can and should be adapted to fit Haiti’s context. C2C is encouraging communities to observe no contact greetings, maintain one-way flows in public spaces, and respect curfews, and businesses to enforce social distancing and set up hand-washing stations wherever possible. To ensure we are meeting the needs of our communities and encouraging the dissemination of accurate information about COVID in Haitian Creole, we are working closely with authorities to make sure local leaders are equipped with the tools and resources they need to educate community members on ways they can protect themselves and their families from the virus.

COVID-19 has exposed the fragility of existing health systems and how governments are ill-prepared to handle pandemics. It has also reinforced the importance of primary care for the health and wellbeing of a population. While access to high-quality primary care is key to C2C’s mission, the preventative measures we are mobilizing to respond to COVID-19 and our enhanced disease surveillance capabilities will strengthen our response to future pandemics, ensuring we are better equipped. With an under-resourced national healthcare system and vulnerability to climate change, Haiti is especially susceptible to pandemics, and our actions now will help prepare for future events.

Our proposed EMR enhancement has enormous potential for scale beyond our clinic network and Haiti. Mekom (our partner) is a core contributor to the OpenMRS platform which is leveraged by healthcare providers across the globe. Once this enhancement is complete it will be “published” on OpenMRS and available to dozens of other organizations operating in developing countries on every continent including Bangladesh (Bahmni), Haiti (iSantéPlus), Kenya (KenyaEMR), Lesotho (Bahmni), Mozambique (Bahmni), Nepal (Bahmni), Tanzania (Bahmni), and Uganda (UgandaEMR). Mekom is a trusted EMR implementer which works closely with experts in the field (i.e. AMPATH, Regenstrief Institute, Partners in Health, Brown University) to keep updated on how OpenMRS is being used to track and manage COVID-19 globally. However, to date, there is not yet a UI specifically for recording, managing, and visualizing contact tracing and COVID-19 specific lab test ordering. This will be a critical innovation in responding to the virus over the next few years as well as any future pandemic.

We will be working with trusted EMR implementation partner, Mekom Solutions, to utilize OpenMRS, the world's leading open source enterprise electronic medical record system platform. OpenMRS is particularly focused on healthcare delivery in resource-constrained environments, like Haiti. For more information on OpenMRS, please visit https://openmrs.org/. 

Though our seven clinics are located across Northern Haiti in rural and peri-urban localities without reliable internet access, our EMR system is able to connect them all. Our current EMR solution creates a digital connection for a specified area, enabling clinic staff to connect and implement data collection devices on a local access network without the need for internet, Wi-Fi or a cell network. This solar-powered, rugged server and power management system is ideal for ultra-low resource settings like the communities in which we operate. This allows our monitoring and evaluation team to collect data in real-time to run reports and measure impact.

OpenMRS has been used by public health organizations and countries across the globe since 2004, however, it does not currently have a UI focused solely on COVID-19 management. We are confident that Mekom will be able to create this enhancement and that it can be utilized throughout the OpenMRS community.

Electronic medical records (EMR) are used in high-quality health facilities all over the world. When we created our model, we did not want to compromise on quality of care, even if EMR systems are not as common in Haiti. Indeed, most clinics rely on traditional paper records which are time-consuming, are more prone to errors, and can hinder doctor-patient communication. EMR is essential in reducing medical errors, facilitating treatment protocols, and helping doctors and patients to make better decisions together. We are fortunate enough to have a robust system that works in spite of our clinics being located in remote areas without access to a WiFi network. 

It is especially important in regards to our COVID-19 response. The enhancements to our UI will allow for recording, managing, and visualizing contact tracing in real-time. Clinical staff across our network will be able to communicate with each other about COVID-19 cases and relay that information to the Ministry of Health. This is absolutely critical in preventing the spread of the virus.

C2C Theory of Change: To reduce morbidity and mortality of adults and children in North and Northeast Haiti, C2C implements a multi-component quality primary health care (PHC) service delivery model, which includes demand creation activities to drive service utilization and adoption of prevention and treatment practices in C2C communities. C2C’s quality PHC services include affordable pharmacy and laboratory testing services, prevention programs (including antenatal care and family planning), urgent trauma care, and treatment of illnesses (including infections, communicable and non-communicable diseases in Northern Haiti).

In 2019, C2C saw 36,525 patient visits, a 77% increase over the year prior. We reached 11,917 additional people through community education and screening activities. In the coming year, we are on track to see 50,000 patient visits in total throughout our clinic network. In five years, we aim to reach 250,000 directly in our clinics. Because of the unpredictability of COVID-19, we are unsure exactly how many people we will reach through COVID-19 community education and clinical treatment, but our catchment area in Haiti is 250,000+.

C2C’s Board of Directors and Executive Director Scott Schroeder are developing a strategic plan for 2021-2023. The plan will be finalized by August; it will assume that COVID will continue to circulate well into 2021 while also setting goals to significantly expand our impact by growing our clinic network and enhancing our systems delivery and measurement processes all within the Public Private Partnership / Social Enterprise model we have piloted and proven.  

As a social business operating with a public-private partnership, C2C combines funds from three sources to implement its health programing: 1) Foundations, corporations, and individual donors, 2) Clinic revenue from small patient fees, and 3) Coverage of staff salaries and rent from the Haitian Ministry of Health. Our below-market patient fees at the current time do not cover all of our expenses, so for clinic startup costs and other programmatic costs, we rely on philanthropic support. Funding can be considered a barrier, but we do have substantial grants and multiyear support which helps us to continue our work. 

Political, economic, social, and environmental issues in Haiti can make it a difficult place to operate. Crises are common and general instability and political turmoil act as a barrier, however, even during mass demonstrations and fuel shortages this past year, our clinics continued to operate and our dedicated staff has always served their communities despite adversity. More recently, COVID-19 has worsened Haiti's fragile health system and economic crisis by essentially stopping the flow of remittances from abroad (a major contributor to GDP) and further devaluing the already weak currency.

We will continue to strengthen our partnership with the Haitian Ministry of Health. By replicating our model across different departments within Haiti, we gain more valuable relationships with government leaders and can weather significant uncertainty, both political and economic. In terms of environmental issues, while Haiti is uniquely susceptible to natural disasters, we will work with our team on the ground to refine our emergency preparedness plans to ensure our organization can withstand such disasters. Furthermore, because fuel shortages are a common issue which threaten the existence of most Haitian institutions, we are prioritizing funding the conversion of our clinics to solar power so that we are not vulnerable to the unpredictability in supply.

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C2C has been working in Haiti for over ten years. 95% of our staff is Haitian and work in the communities that they live in. They know better than anyone the unique challenges facing Haiti’s healthcare system and are the best fit to solve these issues.

C2C’s Executive Director, Scott Schroeder, is a development and management professional with broad experience spanning NGO leadership, small business development, marketing and strategy. He was the Chief Marketing Officer at Plan International, where he led the organization to raise over $30 million in revenue. He also led campaigns aimed at issues facing women and girls. After leaving Plan, he served as the Vice President of External Relations at Pathfinder International. Most recently, he served as the Chief Development Officer at the Maven Project, a telemedicine start-up. As C2C’s chief executive, Scott leads the strategic growth of the organization and optimization of the social business model. 

Our Chief Operating Officer, Dr. Samuel Bernard, completed his medical degree at the Faculté de Médecine et de Pharmacie of the State University in 2009 and studied Health Services Management. In 2010, after his residency, he was in charge of a satellite clinic of St Boniface Hospital in Cotes-de-fer. He managed nutrition, health and AIDS/HIV programs at SBHF funded by UNICEF, CDC, UN Office for the Coordination of Humanitarian Affairs, and the Catholic Medical Mission Board (CMMB). He received an award from CMMB for excellence in program management. He became St. Boniface Hospital’s Medical Director in October 2015.

C2C formalized a public-private partnership (PPP) with the Haitian Ministry of Health in 2018. This partnership allows C2C to have a more manageable path to scale. We work with Ministry of Health officials to decide which clinics to “rehabilitate.”

In most cases, communities in Haiti do not lack access to primary care--in all but the most rural locations we serve, there already was a clinic within 2km of most Haitians. Most of those clinics, however, were controlled by the Haitian Ministry of Health and were quite under-staffed and under-resourced. They often lacked any electrical power, lab testing equipment or pharmaceutical supplies. By rehabilitating existing clinics, the government provides access to the clinic building and facilities, staff, training and supplies; C2C invests in upgrading the clinic, adding dependable electricity, lab testing and pharmaceuticals and adding staff at every level to serve all patient needs efficiently. Finally, the fees for patient services are kept in a “closed loop” supporting ongoing clinic operations and ensuring long-term sustainability.

For the EMR enhancement portion of this project, we will be collaborating with our existing EMR implementation partner, Mekom Solutions. Mekom will build a new UI into our EMR system which can specifically facilitate our COVID-19 management, patient follow up, and contact tracing which is absolutely critical for preventing new cases and deaths.

1.     Efficient Operations: Staffed entirely by Haitian clinicians and drawing on local supply chains, each C2C clinic serves 400-600 patients every month. Patients receive a full range of primary care services i.e. consultation, labs, and prescriptions. We manage patient care through our customized EMR system.

2.     High Quality Primary Care: C2C clinics are staffed by highly qualified physicians, nurses, assistant nurses, and lab technicians – and each patient visit is guided by quality assurance protocols.

3.     Community Health: Preventive health education is central to our effort – giving families the tools and information they need to stay healthy. Our Community Health Workers (CHWs) visit households, convene weekly health screenings, and work with schools.

4.     Specialty Programs: C2C provides specialized care for pregnant women and children, as women and children <5 are uniquely vulnerable to health threats. We offer comprehensive maternal health services and education (antenatal and newborn care) and childhood malnutrition treatment. 

5.     Community Engagement: C2C promotes deep engagement with communities – we consider our patients to be our valued clients and our partners, not our beneficiaries.

6.     Financial Sustainability: As a social business, C2C is innovating a hybrid model that combines philanthropy funds to cover start up costs and revenue losses when clinics are launched. We charge small patient fees at below-market prices that ensure our clinics are financially sustainable.

7.     Government Collaboration: C2C’s partnership with the Haitian Ministry of Health to rehabilitate public clinics is the culmination of many years of collaboration with the Ministry. 

Our hybrid funding model incorporates three sources of revenue to ensure long-term sustainability of our programs: clinic income from small patient fees, support from the Haitian Ministry of Health through staff salaries and use of facilities, and philanthropy to cover start-up and some operating costs of new programs and new clinics.

Cost recovery is an important indicator of C2C’s financial sustainability and we monitor it closely. For 2019, our cost recovery across all clinics averaged at 81%, and in the next two years we will reach 90%.

COVID-19 is a complex global issue requiring innovative solutions right now, but it also provides the opportunity to plan for future pandemics, so that a crisis of this scale can be prevented from happening again. We believe our combined community education and data-driven clinical approach is an effective way to respond to the pandemic in Haiti and can be scaled to other developing countries with similarly under-resourced national health systems as well. This Solve challenge provides C2C with the opportunity to show that sophisticated EMR solutions can be successful in low-resource settings as well.

We welcome collaboration with partners, whether it be peer organizations, funders, mentors, or board members and advisors, in order to grow our organization by means of funding, media exposure, networking, board recruitment, etc. 

C2C would benefit from expanding our funding network to include larger global health funders. We would also welcome increased collaboration between other peer organizations operating in the intersection of Haiti and healthcare. Any partnership with MIT faculty/Solve members that could help in these regards would be greatly appreciated. 

C2C works directly to achieve goals 3, 9, and 17. 

Goal 3: 

Through our growing network of clinics in northern Haiti, we serve vulnerable communities by providing Haitians with high-quality primary care. The WHO estimates that 91% of Haitians live within 5km of a health facility, but only 23% – including just 5% of the rural population – have access to high-quality primary care. Most Haitians seek care from public sector clinics and/or private facilities operated by aid organizations. Facilities are often centralized in urban areas, and quality and reliability suffer as the system extends into less populated areas. The Haitian Ministry of Health is chronically under-funded and the result is a fragile national health system that has focused on hospital level tertiary care – at the grave expense of primary care and community health. At C2C, we are working to fill these gaps in the belief that comprehensive primary care that reaches everyone is the cornerstone of achieving universal health coverage.

Goal 9: 

Rather than launching new clinics to fill service delivery gaps, C2C invests in the overall clinic infrastructure of existing under-performing government clinics, providing a safe and clean place for patients. Hundreds of public clinics in Haiti are chronically under-resourced, suffering from financial deficits, lack of management and supply chain, no data collection, and – usually – no electricity or running water. The government saw a potentially transformative solution in C2C’s work: our commitment to primary care excellence, our high standards for cost-effective operations, and our focus on community integration. Together, we seized an opportunity to join forces through a PPP that would – rather than launch new clinics to fill service delivery gaps – rehabilitate existing underperforming government clinics across the country. The Ministry of Health is pressing C2C to expand our network by giving us a short list of clinics in the North and Northeast Departments which would benefit from our model for clinic management and operations to improve service quality.

One of our goals for the next year is to convert two of our clinics to solar power, with the long-term goal of having our entire network run on solar power. Solar panels are urgently needed, as our clinics rely on generators powered by gasoline. Last year, civil unrest, sparked by a widespread fuel shortage, essentially shut down the country in February/March and again in October/November. Fuel became extremely expensive and difficult to find. Converting our clinics to solar would support our goal of overall sustainability and would ensure that our infrastructure is environmentally-friendly.

Goal 17:

C2C’s partnership with the Haitian Ministry of Health to rehabilitate public clinics is the culmination of many years of collaboration with the Ministry. In the past, C2C and the Ministry have worked together on national priority programs such as childhood immunizations, family planning, and monitoring population health. Now, our public-private partnership will pave the way for wider patient reach, ensuring that C2C reaches more families with effective, affordable, high-quality primary care.

In early 2018, C2C established a formal agreement with the Haitian Ministry of Health to create a public-private partnership (PPP) that will “rehabilitate” existing public clinics across the region to achieve high benchmarks of service delivery and quality, by adopting the C2C model for clinic management.

At our first PPP clinic in 2018, C2C has lifted Haitian government quality scores from 40-80% (pre/post C2C involvement) and has reached 90% cost-recovery in just 6 months. The clinic has also shown increases in volume, revenue, pharmacy and lab capacity, and patient health-seeking behavior. The Ministry of Health has recognized C2C’s ground-breaking model and is pressing us to continue to grow our partnership.