Since 1984, FIDA/pcH has been providing resources to rural communities in Haiti who are motivated to become invested shareholders in their own productive agricultural cooperative.
The organization was established with a mandate to offer appropriate solutions to the poorest of the poor to be able to be at the centre of their own development. The cooperative business model was viewed as the most viable vehicle to transform the economic and social lives of farming men and women in Haiti. Agricultural activities became the focus of business as over 75% of Haitians depend on some form of agricultural production to make a living. Even though Haiti was once the richest colony in the New World, agricultural production in Haiti has been systematically undermined, to the extent that it is now viewed as the “poorest country in the Western Hemisphere.”
In brief, FIDA, and its working arm in Haiti, productive cooperatives Haiti (pcH), provides resources to men and women who are motivated to become invested shareholders in their own productive agricultural cooperative as governed by the Seven International Principles of Cooperative. We provide resources under what we refer to as the Three Pillars of Development: The Cooperative Development Pillar, The Agricultural Development Pillar, and The Member Capacity Development Pillar which at its heart is a comprehensive four level adult training/literacy program.
FIDA/pcH views the cooperative model as the most ideal infrastructure for sustainable socioeconomic development in Haiti. A cooperative is a group of people who have chosen to unite their resources in order to address a common adversity and to achieve a common goal. Cooperatives are owned and operated by shareholding members wherein everyone contributes to the benefit of the whole, has equal voice and benefit according to their investment. The cooperative model provides a structure for conducting income-generating activity, promotes equality between members, establishes a forum for discussion, enables the community to manage itself, and fosters trust, skill, and unity. In short, a cooperative exists to meet the needs of its members.
For the past 35 years, the focus has been on addressing agricultural production, increasing economy of members through the business model of cooperative and enhancing member capacity through a comprehensive adult literacy program. This has proven to be effective in ensuring the sustainability of cooperatives.
Following the outbreak of the cholera epidemic in 2012, FIDA/pcH received a small grant ($50,000) to train cooperative members (in Haute St. Marc) to recognize the symptoms of cholera and how to prepare a simple rehydration solution based on items and containers that the average rural home would have access to. Following these trainings, members vowed that “no one would ever die from cholera again in their community” and promptly asked if they could have more training. In particular, women expressed a desire to learn how to better manage their households, provide better nutrition and to be able to treat certain maladies.
FIDA/pcH began to explore how this could be accomplished within the cooperative context.
In May of 2015, FIDA/pcH met with members and leaders of cooperatives in four areas (Haute St. Marc, Zoranger, Fon Batis (two locations). Each group was comprised of approximately 25 participants. The discussion points essentially focussed on the following:
- What health care services do you have in your community?
- What are the challenges you face in meeting your health care needs?
- What is your ideal vision for health care service for your members?
- Would you be willing to invest in this vision?
The responses were fairly consistent in each area with some variations.
In all cases, a clinic did exist within the community. However, respondents all noted that services were inadequate or extremely limited. There were no professionals (such as a doctor or nurse) on site, medications were few and the cost varied according to whomever was managing the clinic. There was no support at all for psycho/social or mental health issues.
The challenges were many:
- Arranging transportation to adequate healthcare and specialists. Distance and mode of transport (moto or by foot) made accessibility particularly challenging for pregnant women or for emergency issues
- As peasants they are not often given priority in the villages
- Medicines/lab testing/specialists may not be on hand when diagnosis is made and the patient is forced to wait resulting in unforeseen costs for food and accommodation
- Follow up is often not an option due to the above
- While there may be visiting medical mission teams, diagnosis is inadequate, treatment is for general issues, and there is no possibility of follow up. Medicines are often inappropriate and cause more harm than good.
- There is no investment in training the population to meet their basic health care and family needs.
There was universal consensus of the vision each group of participants had in order to meet their needs:
- A mobile clinic that would consistently come to their community twice a month. (While there was some discussion as to frequency, each group did generally conclude that twice a month would be adequate.)
- The mobile service must come with a doctor/nurse equipped to diagnose their ailments
- The mobile clinic must be equipped with appropriate medication and lab testing services.
- Health care for women was a focus ranging from SDI’s to maternal care to mental health issues.
- Most importantly, the participants emphasized their desire to have training in preventative health care, nutrition and family management. (e.g. mothers commonly believe that “nutrition” is a full stomach and so will sell their more nutritional sorghum for imported rice). One member cited his belief that many families could provide better nutrition for their families more inexpensively if they had the knowledge.
- Literacy was viewed as an avenue to increase their knowledge. While some members had received literacy through previous pcH programs, new members and new cooperatives have not had access to this precious gift.
Of significant interest was the response to whether members would invest if the services they desired were provided. An amount of 250 Gourde per month was presented for discussion. Clarification was required as to how many family members would this include, would there be an age limit, who would be in control of the funds, would there be a limit to services (i.e. would the fee include surgery?). It was carefully explained that the monthly fee would not necessarily mean that they would use the clinic each visit but that the funds would be pooled and that in the case of a member requiring surgery, their fees would help offset the cost. (This was quickly understood and accepted). While some noted that no such decision could be made without full member consensus at an Annual Meeting, it was explained that what was being presented is for discussion only and that there would need to be considerable dialogue to determine the terms of the contract and the expectations of the cooperative and the service provider.
In all groups, it was unanimous that all members would definitely accept to pay 250 Gourde a month. One leader said that when he became aware of the meeting, he polled 75 of his members who all agreed. Based on this poll, he assured us that 100% of members would invest without reservation.
The Proposal: The Case for a Cooperative Business Model
Based on the above information and some 35 years of promoting/developing the cooperative business model in Haiti, FIDA/pcH began formulating a concept that would offer the desired health care services for women, men, and children through a sustainable funding model.
The productive agricultural cooperative model designed, implemented and practiced by pcH has been viewed as the most appropriate infrastructure for improving and supporting economic and democratic activities in rural communities in Haiti. Cooperatives are autonomous, self-initiated organizations that are owned and governed by its members. Control rests equally with all members, and everyone shares equally in the profits of the cooperative. Cooperatives are transparent and accountable to their members and are guided by the Seven International Principles of the Cooperative.
As a vehicle for development, the cooperative model is particularly well suited to rural communities in Haiti. This model is a response to challenges in a country where there is little national infrastructure and little individual capacity to address adversities. A study of Haitian history reveals a difficulty with administration, collaboration, and trust; a difficulty, but not an inability. Through membership in a cooperative and the introduction of literacy and sustainable practices, a crack is created in the cultural dynamic of mistrust and fear, making way for enduring cooperation and improvements in livelihoods.
Cooperatives strengthen the economic capacity of members through income generating activities. Cooperatives also build social capacity, empowering women and men to reach their full potential both individually and collectively. The true cooperative model is always bottom-up. Cooperatives elect their leaders, who in turn become spokespeople for their whole community. Where cooperatives exist, there is more social capital and capacity to respond and participate in community challenges. Through joining the cooperative business structure, women and men come to discover their own ability not only as individuals, but also begin to recognize the abilities of their fellow members. Trust between members is encouraged as they take on responsibility for development activities that will improve the lives for themselves and their families.
The cooperative model then is considered the ideal vehicle to facilitate healthcare services for its members. In so doing:
- The cooperative is upholding its purpose to meet the needs of its members
- A “health insurance” concept diversifies cooperative revenue and increases economic activity for the cooperative with potential for profit
- The services and economic activity reinforces and strengthens the institutional and economic capacity of the cooperative (responsibilities/employment).
- This in turn, positions the cooperative as a leader in the community, attracting more share-holding members, and/or providing a service to non-members at a higher non-member rate.
- The model positions the cooperative to consider other services such as eye care or dental care for additional fees.
- In exploring how to financially manage what could potentially be considerable funds for each cooperative, FIDA/pcH has considered proposing a separate elected “committee” within each cooperative in a particular area wherein the cooperatives would then create a federation or larger committee represented by elected members of the individual committees to manage the “health insurance” fund.
- Most importantly, the cooperative is in charge of its health care services and is not at the mercy of the irregular visits of mission teams or inconsistent and inadequate national services.
- Additional benefits less specific to the cooperative model is that the model eases the stress on overburdened village clinics (This was noted particularly by professionals at the Partners in Health hospital in Mirebelais who welcomed the concept).
- The model also provides a solution to interning nurses who are required to fulfil their “estage” in rural locations, away from their families with little resources while having to cover their own expenses. The mobile concept would provide a consistent schedule with organized patient lists and follow up systems (as the concept recommends a full-time support worker based in the field).
- Always there remains the potential for a young person or child witnessing this health care from medical professionals in the mobile clinics to be motivated to seek a career in healthcare and focus their educational years accordingly.
There are nine cooperatives in Fon Batis, representing approximately 3,000 members. Given that over 50% of cooperative members are women with young children, a community (preventive) health training program coupled with a minimum curative health clinic service is viewed as the optimum strategy to address health issues in rural areas such as Fon Batis. The idea is that the cooperative would offer the health insurance program to its members at an agreed upon fee, and contract the services to productive cooperatives Haiti (pcH) who would develop and implement the services as required by the cooperative. The expectations would be established through written agreements.
Each cooperative will identify the number of members who wish to participate in a health insurance program. A monthly or quarterly payment would cover each cooperative member and up to five members of his or her family. The cooperative would be responsible for collecting contributions and preparing the insurance portfolio, then sharing the information with pcH.
The cooperative would then essentially “contract” their health care service with FIDA/pcH. The mobile clinic would offer services to each participating cooperative two times per month. A coordinator of public health would provide training to cooperative members on topics such as nutrition, prevention of communicable disease, and pre and postnatal care. The coordinator would also actively participate in mobile clinic activities.
Responsibility of cooperatives: Cooperatives will identify members who wish to subscribe to the health insurance program. They will sign an agreement with the cooperative, who will then prepare a file for each individual family. Cooperative leaders will also be responsible for providing a location in their community for the mobile clinic activities. Cooperative leaders communicate more closely with cooperative members, and will have a better strategy for how to best serve the community in terms of both reach and quality of activities. pcH will have a coordinator (who will be a registered nurse) to work directly with the cooperatives.
Responsibility of pcH: pcH will provide qualified staff to support the project in partnership. The pilot will cover the costs of health personnel. All equipment, materials, and essential drugs will be provided under the pilot. The planning of mobile health clinic activities will be under the responsibility of the coordinator.
The innovation of this cooperative-based concept to provide health care services to a rural population has attracted significant partners:
Haitian International Telehealth Consortium
A unique and innovative aspect of the proposed services is the introduction of telehealth expertise within the mobile clinic contract. Dr. Joey Prosper, in partnership with the Ohio-based consortium, have been successfully delivering telehealth in Haiti for the past twelve years.
Telehealth uses telecommunications to advance healthcare, bring current medical information to the local population, offering real-time consultation with specialists, institutions and international expertise through electricity generated from the (proposed) solar-powered SolerCool cold shed to power internet connectivity
Cooperatives will have access to Internet connectivity to healthcare information on any subject from any source located anywhere in the world (CDC, WHO, NIS, universities, medical institutions, facilities, etc.) and have ability to communicate immediately to government ministries and medical facilities about potential outbreaks in remote locations.
While such will be possible, the intent of the pilot is to access expertise within Haiti.
The application of digital devices, electronic medical records, and online education has the potential to enhance healthcare for cooperative members. Earlier tests have confirmed that the area has the required connectivity.
The pilot will include such expertise as Christina Panetta, a physical therapist who has been working with Dr. Joey Prosper for a number of years and a graduate of the Haitian Society of Physical Therapists at the UNEH. Their training includes the ability to deal with wounds and emergency/triage procedures such as wound compression, Heimlich, CPR, tourniquets, etc. This addresses the type of training cooperative members are seeking in being prepared to respond to injuries and life-threatening situations until the appropriate assistance is available.
Arizona-based, GlobalMed is an ISO 9001 and ISO 13485 certified manufacturer, that designs and builds solutions with the utmost quality and precision. From carts to space-saving wall mounted units to mobile hard-cases and backpacks, they offer the hardware needed to provide telehealth services. With integrated video conferencing software and connected medical devices on all equipment, this pilot will be able to deliver quality healthcare any time, anywhere. Enabling over 55 modalities of virtual telemedicine, these integrated devices provide the data and evidence the pilot requires to drive clinically sound healthcare decisions. From gathering vitals with stethoscopes and otoscopes to capturing images of the skin, eyes, ears and other areas, the pcH health service team can obtain almost every kind of examination data. GlobalMed’s multi-functional cameras are best-in-class, providing high-quality live video and still images. Additionally, their examination cameras are compatible with other devices and examination stations. Their integrated devices can be mounted for easy accessibility without the hassle of cords and leads.
The software is designed to be flexible, allowing the team to follow workflow and documentation requirements. Features include scheduling, patient eligibility, payments, ICD-10 codes, mobile messaging and more. The software allows the health service team to offer video, phone, in-home or office consultations for patients from anywhere around the world.
|Note: Three months into the pilot, the pcH team is introduced to a revolutionary telehealth product that is essentially a “hospital in a bag” by GlobalMed representatives, Gigi Sorenson and Scott Johnson. They were in awe of its capabilities. GlobalMed explains that they have chosen the FIDA/pcH team to beta test this new technology to revolutionize healthcare around the world. Gigi expressed how honoured GlobalMed is to partner with pcH and the cooperative-based health service concept in bringing a progressive, quality care delivery model to Haiti. She went on, “Targeting remote communities with specifically designed, high technology and security oriented software and hardware solutions access to consistent, quality care will become a reality to rural communities starting with Fon Batis. The ability for the pcH medical team to provide virtual care to any community in Haiti and potentially be the medical hub in time of disaster in the Caribbean will set it above and beyond almost any other area in the world. This program can be used as a prototype model for other Caribbean nations.” She noted that the passion and commitment she observed of the team to provide accessible quality care will make this a reality and thanked them for allowing GlobalMed to journey with them.
The kits contain mobile medical digital devices such as vital signs, stethoscopes, dermascopes, otoscopes, ultrasound, and EKG. They are designed specifically to handle challenges such as we experience in Haiti: weather, inconsistent power, and spotty connectivity. The software is secure to allow for documentation of all visits and for ongoing electronic documentation that is held in cloud storage. The team marvelled as they experimented on each other, checking vital signs, probing ears and eyes. Presently two vital sign kits have been ordered and one complete telehealth kit. To support the kit, we have also purchased and implemented a handheld ultrasound unit called the Butterfly iQ, the first to be in use in the Caribbean.
pcH projects apply the participatory approach in undertaking all their activities. Through an ongoing dialogue, pcH listens to cooperative leaders and other community members to better hear the priorities as expressed by the community. Participatory methodology calls for the active participation of the local population and all other stakeholders who have an interest in the project or program in their community. This methodology is based on the belief that people have the ability to assess their own situation and ultimately make decisions that benefit their own lives.
Engaging community members in all stages of a project creates a dynamic atmosphere and leads to effective change in community development. The participatory approach also recognizes the traditional values and daily practices of many communities in Haiti. Community members are committed to preserving values that have been passed down in their families through generations. This approach promotes the emergence of both personal and community values.
Commitment to practicing the participatory approach requires considerable time, patience, and skilled facilitators. However, it is considered to be critical for sustainability. It encourages dialogue, respect, equality, and an awareness of individual capabilities and local resources. Although it requires a significant investment, it is considered to be a more cost-effective model for ensuring the long-term viability of project impacts.
Fon Batis is the proposed location for the pilot. For Batis is a remote, rural village at the summit of the Chaîne des Matheux mountain range located approximately 20 km north of Port-au-Prince with a population of some 35,000 men, women and children. Nine cooperatives totalling more than 3,000 member farmers work the land in this community to support their livelihoods. These cooperatives have received support from the (former) Canadian International Development Agency (CIDA), Hope International Development Agency (HIDA), World Accord, and the Foundation for International Development Assistance (FIDA) for cooperative formation, various agricultural inputs, adult literacy and water management systems. The cooperatives have constructed storage silos to store their harvests and have received training in new cultivation practices, storage techniques, market gardening, drip irrigation, poultry enterprise and the cultivation of a new drought-resistant bean. Most notably, three of the cooperatives were able to supply nine tonne of seed to three cooperatives in Grand Anse who had lost homes and harvests following Hurricane Matthew in 2016. Funded by World Renew and Canada Food Grains Bank, the Fon Batis cooperatives were the only source of the required seed in all of Haiti and earned $23,000 USD.
During the last two decades, the all-Haitian pcH staff has adopted the principle of ‘living within the community’ throughout project implementation. This has resulted in increased opportunity to observe and coach project participants in their own fields and to more readily address challenges when they arise. The cooperatives have developed self-sufficiency, confidence, and an ability to devise complex strategies to address the needs of their respective cooperative and its member farmers.
Despite the enduring improvements in food security and livelihoods in Fon Batis, health issues remain a serious challenge. The community is very remote and there exist few health services provided by government or other NGOs. Often, farmers must walk several hours or pay a moto taxi to access health care in a community at the base of the mountain. Viewed as peasants, they are often not given priority
At arranged meetings with cooperative leaders in Fon Batis, those in attendance sought to answer the question of how to help members more adequately address their health challenges. pcH conducted a small sample survey to see if cooperative members would be open to the idea of a cooperative health insurance program. The response was enthusiastically affirmative.
The pilot proposes that a second community be considered such as Duchity in Grand Anse (where there is three cooperatives also representing approximately 3000 members), in order to have a comparative study.
The object of the pilot is to explore the possibility of delivering a health care service that meets the needs of a rural population and wherein the community has the capacity to support the services they so desire. The cooperative model practiced by pcH requires that ALL members are financially invested shareholders. pcH-established cooperatives understand the concept of mobilizing resources and the benefits to them. Hence, members are very receptive to contributing additional funds to their cooperative to purchase land (for example) or for other cooperative-driven ventures. Discussions to date suggest overwhelming that this will hold true for health services.
In addition, our experience has found that when much needed services are offered by the cooperative (such as literacy), cooperative membership has increased up to 500%. As this represents financially invested shareholders, the economic viability of the cooperative is strengthened. It is anticipated that cooperatives will realize a significant increase in membership when a health care service model is introduced.
There are nine pcH-related cooperatives in the Fon Batis area representing about 3,000 cooperative members. At a proposed annual fee of 4,300 GDE or $45 USD, which has the potential to translate into approximately $135,000 USD per year to support health care services once the system has been established.
Additional support is likely by charging a slightly higher fee to non-cooperative members or supplemented by the cooperative itself by paying less dividends to its members.
The sustainability /scalability of this system is dependent on:
- A robust economy and local infrastructure capable of managing an insurance system
- A reasonably literate participant capable of understanding terms and conditions of their contract (NOTE: the pilot recommends supporting a health/nutrition focussed literacy component)
- A reliable service provider that has a clear and precise contract with the insurance holders
- Access to dependable energy/connectivity services to support the technology
The pilot is expected to demonstrate that agricultural cooperatives that practice the Seven Principles of Cooperative and whose members have had access to literacy have the greatest potential to support a health service system that meets their needs.
The pilot seeks to establish a service system to ensure the consistent delivery of services with the anticipation that such a model can be replicated when the above conditions are in place.
Key Indicators/Expected Outcomes
The introduction of a data collection system provides an opportunity to collect the most reliable data on rural health care in Haiti.
The pilot intends to introduce a system that has the ability to develop continuity and to assess the change in a patient and their families as well as compare cooperatives and communities Management of outcomes and ability to determine the effectiveness include but not exclusive to the following areas:
- % of pregnant women who have taken prenatal training sessions
- Number of families with access to the mobile clinic sessions.
- Number of families per month (number of men/women/children per month)
- Number of women speakers/month
- Number of patients treated by the telemedicine/month/year
- Number of doctors/nurses participating in the sessions of mobile clinic
- Number of mothers attending the training session on the topic of nutrition
- Quality and frequency of reports received by the doctors of the telemedicine system
- Number of beneficiaries participating in the training sessions on the topic of hygiene
- Number of participants paying their annual fee
- Number of non-cooperative members paying an annual fee
- Number of beneficiaries participating in training sessions on the theme relating to STIs
Preventive care results:
- Decrease in infant mortality rates
- Decrease in post natal mortality rates
- Improved nutrition for children 0-5 years of age
- Improved access to care for pregnant women
- Decrease in prevalence of STDs
- Improved knowledge in basic hygiene principles
- Decrease in prevalence of most common illnesses in Fon Batis
- Proper and quick responses to injuries and outbreaks prior to the arrival of professional medical personnel
- An informed population
Curative care results:
- Improved access to first level health services within the community
- Improved availability of essential medications
- Improved referrals to higher level health care when necessary
- Streamlined referral to neighboring hospitals or clinics due to telecommunication links
Cooperative development results:
- Strengthened social and financial capacity of cooperatives
- Strengthened trust and collaboration of cooperative members
- Improved ability of cooperatives to respond to need in the communities they serve
Project activities include:
- Coordinating partners
- Planning field activities
- Identifying target population
- Mobilization, awareness-raising, and motivation of cooperative members
- Training activities
- Preparation of insurance portfolios
- Establishing internet connectivity
- Developing professional field team
- Purchasing vehicles and equipment
- Developing systems forms for patient intake information
- Planning and coordination of mobile clinic activities
- Introducing and establishing a telehealth service component
- Monitoring and evaluation
- Preparation and transmission of regular reports
The Project Coordinator will work closely with cooperative leaders and partners to ensure communication and consistency of methodology. The Coordinator will also support cooperative leaders in the management of insurance portfolios and funds when required.
Notwithstanding the experience of FIDA/pcH in managing and executing projects in Haiti, the innovative aspects of this project add certain risks that must be considered when the aim is to ensure the sustainability and ability for replication.
- The primary innovation is that this pilot is based on discovering the potential of members of established cooperatives participating in paying for a structured health care service through a fee-based insurance system. While the pilot will require a level of investment to launch, the objective is to provide services that member fees can support. Consideration can be given to the cooperative itself supplementing costs by paying less dividends, non-cooperative members paying higher fees and/or additional costs for more specialized services.
- There is the aspect of financial management capacity of the cooperative. A consideration can be given separate health committees within each cooperative who could then form a federation representing all the cooperatives of Fon Batis.
- How do we motivate people for this concept? Already there are a number of members who are presently aware of this intended pilot; pcH is well experienced in working with the leaders of all cooperatives who can then begin to influence their members.
- While literacy has mitigated fear and mistrust, there will still be a challenge to ensure there is absolute clarity about all aspects of this insurance concept so there is no confusion about what it will cover and not cover.
- There is a potential for resentment from non-members in the community. Although they may be considered for services at a higher fee, it will also be important that the terms are clearly understood as it can be assumed that non-cooperative participants would not be literate.
- Fon Batis is in a fairly remote location and the road can become impassable at times. What happens when there are severe emergencies? Who will maintain the road? While FIDA/pcH has had a longstanding relationship with cooperatives in this area, it will be important to have a strategy in place to ensure continuity of services.
- Political instability is always a challenge in Haiti. This can affect access to communities due to protests and general insecurity.
- Weather and Haiti’s proneness to hurricanes, earthquakes and severe rainfall can also impact aspects of the pilot. In particular the innovative foundation of the service is the telehealth component, which is dependent on Internet connectivity.
- The innovative aspects of the pilot much appreciate how critical it is for all involved to understand that this pilot is cooperative-driven and the ownership of the vision is in their hands.
pcH recognizes that gender inequalities are a fundamental obstacle in alleviating poverty. The cultural awareness that pcH possesses in Haiti results in programming that respects and enhances the role of women in rural Haitian communities. pcH has partnered directly with existing local women’s groups in the past to help increase their capacity. pcH has also assisted cooperative members to establish new women’s organizations within their cooperatives. pcH staff have extensive experience facilitating projects that place a focus on gender equality and respond to local gender issues with appropriate training and coaching.
Gender analyses reveal that women occupy a very important role in agricultural communities in Haiti. For this reason, pcH seeks to educate cooperative leaders on gender issues in all their projects, and to motivate women to pursue leadership positions in the cooperative. The aim is to promote the equal participation of both women and men as decision makers in the development of their society. Women are motivated to participate in all project activities, project indicators are disaggregated by gender, and successes and challenges of women are highlighted in project reporting.
It is expected that the project will attract slightly more women participants than men. This expectation responds to the reality that women are often the primary caregivers in their families and in their communities.