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Final evaluation of the Mental Health and Psychosocial Program of CORDAID in Haiti 2010-2011

ECHO funded project nr 104299 SHO & TROCAIRE funded project nr 103063

November 2011

Final report

Geertruid Kortmann Ernst Mathurin Katia Henrys

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Acknowledgements We would like to thank the mental health team of Cordaid in Haiti for their openness to share with us their experiences, their views, their doubts and job satisfaction. We also thank the community workers, health professionals and the beneficiaries who received us with an open mind and open door. It is a privilege to experience their resilience and strength. We hope that such an earthquake will never happen again. We wish The MPHP, WHO and the working group on mental health all the support they need to get a system off the ground whereby people have access to primary mental health care, a basic right!

Abbreviations / acronyms MHPS Mental Health and Psycho Social MH Mental Health MPHP Ministry of Public Health and Population PHC Primary Health Care PoP Port-au- Prince PS Psychosocial REPHE SOE Service Oeucuminique d’Entraide SOFA Solidarite Fanm Ayisyen ToR Terms of Reference ToT Training of Trainers WHO World Health Organization

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Table of contents

1 Introduction ___________________________________________________________ 8

1.1 Introduction _____________________________________________________________ 8

1.2 National context of Haiti 2010-2011 __________________________________________ 8

1.3 The MHPS program ______________________________________________________ 10

2 Terms of Reference _____________________________________________________ 11

3 Methodology of the evaluation and limitations _____________________________ 12

4 Main findings _________________________________________________________ 14

4.1 Effectiveness of the organizational structure ______________________________ 14

4.2 Effectiveness of the strategies __________________________________________ 14

4.3 Effectiveness of the program in terms of objectives and expected results _______ 19

4.4 Monitoring, evaluation and reporting ___________________________________ 28

4.5 Efficiency and cost effectiveness ________________________________________ 28

4.6 Collaboration et coordination between mental health actors _________________ 29

4.7 Ownership and sustainability___________________________________________ 29

4.8 Impact of insecurity and related factors __________________________________ 31

4.9 Adherence to international guidelines ___________________________________ 31

5 Strengths and weakness ________________________________________________ 33

6 Lessons learned _______________________________________________________ 34

7 Challenges, with a focus on future interventions ____________________________ 34

8 Future perspectives and recommendations _________________________________ 35

8.1 Short term perspective till July 2012 ____________________________________ 35

8.2 Longer term perspective beyond July 2012 ________________________________ 35

Annexes __________________________________________________________________ 37

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Executive summary

In January 2010 a devastating earthquake hit Haiti and ruined the houses and lives of hundred thousands of people mainly in the coastal area in and around Port-au-Prince, Haiti’s capital. An estimated 3 million people were affected by the earthquake and over a million at risk of moderate of severe psychological stress. Cordaid, having strong links with Haiti since the 1980s and supporting several faith based and civil society organisations did not hesitate a single minute and decided to assist Haiti. Caritas Haiti requested Cordaid to come and assist because its own local Caritas bureaus and other partners of Cordaid felt incapable to respond adequately to the disaster alone. So a Cordaid office was set up and priorities for Cordaid’s humanitarian agenda set. Numerous international organisations had flocked in so it was important to find specific niches and avoid duplication. A shelter project got off the ground and a expatriate mental health expert was contracted to conceive a mental health and psychosocial project to assist people cope with the traumatic experience of death and massive material loss and displacement. Two projects got funded: one by the Dutch SHO with co-funding of TROCAIRE, the second one by ECHO with some co-funding of SHO. The ECHO project finished at 31 August while the TROCAIRE funded project will end by 30 November. This evaluation covers as much as possible both projects. The Mental Health and Psychosocial program (MHPS) covers both projects. The interventions are almost identical. The main components of the program are (i) training of community agents who can provide basic psychosocial assistance to affected individuals and families; (ii) training health workers in basic knowledge and skills to be able to provide primary mental health care to people with more serious mental problems that are beyond the capacity of the community agents; (iii) provision of the broad range of community oriented interventions such as group support, recreational activities, awareness raising on MH and PS issues, material assistance and social mobilisation around specific themes. All trainees were selected by partner organisations of Cordaid. Approximately 170 community agents were trained in 5 zones in Haiti: West, North, Northeast, Southeast and Artibonite to assist affected people cope with their psychological stress. In addition over 100 health workers were trained to get the basic knowledge and skills to be able to treat people with mental problems that are beyond the capacity of the community workers. In this way the program wanted to create some basic referral mechanism in the targeted communities and eventually prevent more serious mental illness. The more community oriented interventions were meant to improve the well-being and social cohesion in the community. The evaluation was undertaken by a small team of an internal public health consultant with longstanding experience in mental health1 and psychosocial support; a Haitian expert in monitoring and evaluation of different NGO projects and a young Haitian psychologist who assisted the team. An interpreter translated where necessary Major findings According to the ToR the evaluation assessed (1) the effectiveness of the organisational structure; (2) the effectiveness of the main strategies; (3) outcome of the program in terms of its specific objective and expected results; (4) monitoring and evaluation; (5) efficiency; (6) collaboration and coordination with MHPS actors; (7) sustainability and ownership; (8) impact of insecurity; (9) lessons learned and challenges; (10) future perspectives and recommendations

1 Geertruid Kortmann; www.phc-amsterdam.nl

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1. Effectiveness of the organisational structure The structure for the psychosocial component is well developed at the different levels with a management team in Port-au-Prince; a small team of 2 supervisors in the decentralized zones to support the community agents and plan the project activities with them; a mental health adviser for technical input in assessment, training module development, outcome evaluation tool development, proposal en report writing etc; and in all the zones a team of 10-30 community workers, selected by the partners of Cordaid and trained in phases by Cordaid MHPS team + external trainers. The program, based on a model developed in other post disaster countries, was effectively implemented from Cordaid Haiti level down to the affected families and individuals in the IDP camps, towns and city outskirts. For the mental health component the structure proved inadequate. Apart from the mental health adviser, contracted on a part time consultancy basis, there was no technical support to guide the team that had no experience with mental health projects. External Haitians mental health experts were hired as trainers but they have not coached the trained professionals. 2. Effectiveness of the main strategies The program is based on an externally conceived strategy and training modules. Because of the humanitarian profile of the program the interventions were formatted, not based on careful consultation of the partners and other stakeholders and laid down in targets that had to be reach. A vertical program. As a result Cordaid approached their old partners and a few new ones to assist in the implementation. Community agents and health workers were recruited by the partners but supervision and support was given directly by Cordaid staff. The partners were instrumental rather than equal partners of Cordaid. The strategy of linking theory and practice in training the community workers appears effective. The knowledge levels increased gradually and coaching on the job by the supervisors has equipped the agents with effective basic listening and counselling skills and some specific stress reduction techniques. Again, the health workers were not coached or supported between the training weeks and their overall motivation proved significantly lower than the community agents. A referral system could not be developed. Cordaid has underestimated the pre-conditions for a successful MH component 3. Outcome of the program in terms of its specific objective and expected results The main outcome pursued by the program is improved wellbeing and social cohesion and decreased stress in the targeted communities. The training has been a means not a goal. Pre- and post intervention tests and questionnaires show that the perceived stress levels have gone down and the overall wellbeing improved, both beyond the target set. Attributing these improvements solely to the program is however not justified as others factors may have contributed as well: other interventions by NGOs, time, gradual return to a more normal life etc. Almost 100.000 people have benefitted from individual and group support and community oriented activities and people have appreciated the assistance. Which of the interventions may have been most effective could not be measured. The package of psychological, social and material assistance has a positive outcome. 4. Monitoring and evaluation The program has developed a rather unique M&E system, based on targets and indicators set in the inceptions phase. Baseline data were collected and compared to the situation at the end of the project. Significant improvement in knowledge, skills, perceived stress levels, attitudes towards mental illness and wellbeing has been pursued. The level reached has not been considered; a missed opportunity. Comparison between zones and data utilization for improved management has not

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been well developed. The project staff did not monitor the competence of PS agents as foreseen, nor did they follow up the health workers training. 5. Efficiency Assessing whether the resources have been used in an optimal way is a difficult task. Almost 100.000 people have been reached and assisted. 1.3 million Euro has been invested and quickly spent under the pressure of the donor and the time. With more time the budget may have been spent more carefully. The positioning of supervisors in the zones appears efficient and effective. Not linking the projects to the shelter program of Cordaid may have impacted negatively on efficiency. 6. Collaboration and coordination with MHPS actors Overall there has been limited collaboration beyond information sharing with other NGOs in the field, the MoH and even the other project within Cordaid Haiti. But the MHPS team has been actively involved in the Mental Health forum and working groups to elaborate a mental health policy and operational plan. 7. Sustainability and ownership The humanitarian project, implemented within one year, has been too short to really get rooted and owned by the local partners and/or the government. Capacity of community agents has been built but they do not fit into an existing system as such and may look for other jobs after the program. The health workers fit in the health system but a lot of steps must be taken to get MH integrated in primary health care. Some partners appear interested to sustain part of the program: PS assistance to vulnerable groups. The MoH is writing the mental health policy and operational plan and wants to decentralize MH care to the departments. There may be possibilities and opportunities for partners to get involved but it needs a pro-active attitude. 8. Impact of insecurity A cholera epidemic, hurricane Thomas, political unrest due to elections and the Christmas recess has caused delay in the project implementation towards the end of 2010. The project has mainly taken off in 2011 which reduced the implementation period to approximately 8 months. 9. Lessons learned and challenges

o Reaching a balance and effective link between mental health care and psychosocial assistance without ‘medicalization’ of problems.

o Challenge to collaborate with the State Ministries of Health and of Social Work. Finding a balance between the role of civil society and the state in building the health and welfare systems

o Transition from a humanitarian project with short term objectives and short term budgets to a development oriented (pilot) project

o The transition from raising awareness among local partners on mental health and psychosocial care to mobilizing them to pursue a sustainable and structured MHPS action

o The recognition and consolidation of the capacities of community agents and health professionals. How can we ensure that they fit in a sustainable structure. Health professionals fit well in the health system but where do psychosocial agents fit? In the Social Welfare structure? In the churches?

o Capitalization of the experience of this MHPS program is essential so that it can be used for a strong lobby for mental health and psychosocial care at the level of the Haitian government and of the international development agencies

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o How can we avoid that the beneficiaries who gained a new perspective / some hope for their mental health problems get discouraged?

10. Main conclusions

o Very relevant program that has contributed to the demystification of mental health and psychosocial problems and related interventions. It has increased awareness and competences within Cordaid at the different levels and of some of its partners

o It has contributed to the achievement of its primary objective: to improve the well-being of the people who were affected by the traumatic experience of the Earthquake

o Humanitarian profile of the project has pushed the MH team to reach its defined targets and it succeeded to a very large extent. However the short term perspective and Cordaid driven approach has its price also. Ownership is limited, the mental health component could not be laid out well and sustainability of access to basic psychosocial care and primary health care is not ensured. It requires more time, more ownership, more resources, more actors.

11. Recommendations and future perspectives Short term – July 2012

Consolidate the achievements of the program in a concise summary document including lessons learned and present it to the MoH and share it with other actors in the area of MHPS

Explore whether there is an interest within Caritas Haiti (national level) to play a significant role in the development of a MHPS system, both for the psychosocial component and the mental health component. Explore what role the Commissions for Justice and Peace and the parishes could play in awareness raising, identification of mentally ill etc.

Develop a longer term approach to MHPS assistance and seek longer term funding Explore whether Cordaid could play a key role in the plan of the MoH and WHO to develop a

decentralized mental health care system with 18 multidisciplinary teams. The MoH is seeking partners who are willing to pilot and fund this decentralization strategy. Could Cordaid identify local partners who could play this role with support of Cordaid

Longer term beyond July 2012

Scenario 1: Cordaid could directly implement a MHPS program but this is not the preferred

option for the evaluation team Scenario 2 Caritas with financial support of Cordaid and/or other funding develops a longer term

mental health care and psychosocial support program that is based on a community health care approach whereby existing community structures are capacitated to render basic MHPS services o psychosocial assistance could be integrated in the faith based structures such as parish

groups, CJP etc o access to mental health care could be increased gradually by training first line health workers

with regard to identification of cases and basic treatment covering counseling, treatment with essential drugs and referral to more specialized care according to need

o right from the start a referral system will need to be developed to allow community based resource persons or structures to refer to the nearest health facility

Scenario 3: A Consortium of different organizations develop a joint project proposal for a longer term PSMH program. Such a Consortium could be identified during the MH Forum meetings.

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1 Introduction

1.1 Introduction In January 2010 a devastating earthquake hit Haiti and ruined the houses and lives of hundred thousands of people mainly in the coastal area in and around Port-au-Prince, Haiti’s capital. An estimated 3 million people were affected by the earthquake and over a million at risk of moderate of severe psychological stress (see proposal with references of literature). Cordaid, having strong links with Haiti since the 1980s and supporting several faith based and civil society organisations did not hesitate a single minute and decided to assist Haiti. In the Netherlands the Collaborating Aid organisations organized a fund raising campaign for Haiti – giro 555 - and collected approximately 300 million of Euro. Cordaid got its share of this money. Caritas Haiti requested Cordaid to come and assist in Haiti as its own local Caritas bureaus and other partners of Cordaid were seriously affected by the earthquake and felt incapable to respond adequately to the disaster alone. So a Cordaid office was set up and priorities for Cordaid’s humanitarian agenda set. Numerous international organisations had flocked in so it was important to find specific niches and avoid duplication. A shelter project got off the ground and a expatriate mental health expert was contracted to conceive a mental health and psychosocial project to assist people cope with the traumatic experience of death and massive material loss and displacement. Two projects got funded: one by the Dutch SHO with co-funding of TROCAIRE, the second one by ECHO with some co-funding of SHO. The ECHO project finished at 31 August while the TROCAIRE funded project will end by 30 November. This evaluation covers as much as possible both projects.

1.2 National context of Haïti 2010-2011 Ever since Haiti became a nation the country is marked by a social and economic antagonism that influences the political and economic structures, the social relationships, the culture and even the mentality of the people and socialization mechanisms. The social vulnerability before the earthquake The demographic situation in Haiti is worrying. In this country with a surface of 27.750 km2 and with a annual population growth rate of over 2%, the population increased from 7 million in the late 1980s to over 10 million today. Over 50% of the population are younger than 20 years. The percentage of the population living in urban areas increased from 20% to 40% in less than 20 years. Nearly 2.5 million people live in the metropolitan area of Port-au-Prince. Agriculture occupies over 65% of the labor force but is no longer a productive sector that gives sufficient income to producers because of the rudimentary nature of production techniques, overpopulation in the rural areas, depletion of land by erosion and the lack of adequate public policies in the sector. Until 2009 ovr three quarters of the population lived on less than 2 USD per day and 57% of the Haitians are undernourished. Basic services were extremely limited : only 10% of the rural population had access to electricity and less than 8% had access to drinking water. Health and education services hardly existed or were completely absent, and poor infrastructure made transport of goods in certain regions very costly. Due to its location in the Caribbean and the degradation of its natural environment Haiti is vulnerable to cyclones. In 2008 four successive hurricanes ransacked the agricultural- and road infrastructure and caused significant loss of life. Their passage further weakened the already mentally exhausted

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population because of the worsening economic hardships and the disintegration of social structures. For decades the violence that used to be exerted by authorities under the dictatorship of the Duvalier’s till 1986, spread new forms of social relationships because of the weakening of the State and the development of a criminal economy. Women and children bear the brunt of this increase in violence. The loss of lives and property damage following the earthquake that hit Haiti on the 12th of January 2010 with a magnitude of 7.2 on the scale of Richter are considerable given the conditions of poverty, vulnerability and psychological vulnerability already present. An estimated number of over 220.000 people have lost their lives and probably there have been as many wounded; more than a million people have lost their home and almost 800.000 have left the affected areas to seek refuge with family living in cities unaffected by the disaster. They became internally displaced. The damage is estimated at over 8 billion USD, which equals 120% of the Gross Domestic Product. The earthquake also affected the country significantly because state structures were not disaster prepared and the population had received very little information on the possibility of such an event. The whole country was affected by the earthquake and its impact even if it is the departments of the West, South East and Nippes that were actually hit by the earthquake. Immediately after the earthquake the population as a whole rose up to assist the victims and welcomed the affected people in their homes despite the pain. The Haitian Diaspora around the world and people around the globe have shown great solidarity towards Haiti. The management of the post-earthquake The deterioration of the living conditions of the population has accelerated particularly for those who live in very difficult conditions in the camps in temporary shelters and also for the displaced who live in host families. The people have become extremely vulnerable and turned to the churches for help to overcome the shock and the sadness, but spirituality and faith was oriented more toward eschatology and promoting conversion in order to avoid repetition of the « divine punishment ». The seats of the three branches of government key government buildings collapsed under the shock. Civil society and the church have been hit hard by the earthquake. The Catholic Church has had great difficulty in coordinating its own forces while the then-government did not take the leadership and withdrew into himself in a vacuum. The United Nations Stabilization Mission in Haiti affected by the loss of part of its civilian leadership came in silence. International actors have replaced the national actors. Bilateral and UN agencies have taken the lead. Thousands of non governmental organisations (NGOs) have invaded the country providing humanitarian assistance and other services, often with little respect for the dignity of the affected people, their culture and survival strategies. The interventions have generally not been geared towards capacitating the people of Haiti to take charge. A humanitarian emergency culture of specialized agencies and NGOs has been set up and is still developing till today without a strong coordination and not always in a rational and fair way. A National Reconstruction Plan was elaborated without consulting civil society. The civil society criticizes the plan because it does not adequately adress the real needs of the people and is steered by an imposed Interim Commission for National Reconstruction that contributes to the weakening of the government and to Haiti’s dependence vis-a-vis donors. The cholera epidemic that broke out 9 months after the earthquake has complicated the already precarious health and welfare situation. It has so far killed more than 5000 people and infected nearly 30.000 across the country. To avoid a crisis of legitimacy at the end of the mandate of President Préval, the government and some international players asked the people of Haiti to go to the polls in November 2010, under

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exceptional conditions : under a very contested law state of emergency and a Provisional Electoral Council, CEP, which nobody trusted. These presidential and legislative elections without consultation and without any real preparation resulted in an electoral crisis; the OAS had to intervene to impose a CEP mitigated solution. There are huge different opinions between the great winners of the electoral process: President Martelly and the parliamentary majority of the 49th Legislature. The potential conflict between parliament and the executive could plunge the country into a major political crisis over the next 5 years. Haiti has lived since the earthquake, a shocking interference of some makers of the international community in its internal affairs and interventions that are meant for the population do not always have the desired effect because of their outgoing nature. Mental health challenges for the State Psychosocial issues and mental health were not a priority for the government despite the natural disasters that hit the country in recent years. Through programmes related to the fight against violence, HIV/AIDS and some interventions after Hurricane Jeanne in Gonaives, the Ministry of Public Health and Population began gradually to consider the importance of the mental health of the people. The earthquake of January 2010 has reinforced that desire but lack of coordination of NGO interventions still play to the disadvantage of an integrated approach. The national mental health policy and strategic / operational plan are in the making. If this move will be successful it will be an important opportunity for the country and for the State to structure and coordinate the different interventions in this area which could also improve health in general.

1.3 The MHPS program The MHPS program, is made up of two projects with different funding sources and separate reporting but with almost identical interventions on the ground and managed by the same Team.

ECHO funded project – number 103063

Period : 01 October 2010 - 31 August 2011 (11 months). Request for extension not rewarded.

Covers 5 zones: Zone West, Artibonite, North, North East and South East

Estimated number of direct beneficiaries in the 5 zones: 42.000

Budget distribution

Contribution direct cost indirect cost

ECHO € 705,607.48 € 49,392.52 € 755,000.00

SHO Haiti € 46,992.45 € 3,289.47 € 50,281.92

Totals € 752,599.93 € 52,681.99 € 805,281.92

SHO + TROCAIRE funded project - number 103063

Period: 16 April 2010 – 30 June 2011; extended to 30 November 2011

Covers Delmas and Leogane in Zone West

Estimated number of direct beneficiaries : 13.000 Delmas; 10.000 Leogane

Budget distribution

Contribution direct cost indirect cost

TROCAIRE 160,000

SHO Haiti 400,368

Totals 560,368 € 560,368

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Though the projects have slightly different logical frameworks the actual activities are almost identical with training of community agents and health professionals as well as the provision of a broad package of community activities as main components. Both project proposals are based on an extensive assessment conducted in March and April 2010 under the guidance of Cordaid’s Mental Health Adviser. The results of the assessment were shared and discussed in May and June in Leogane and Delmas where Cordaid wanted to start a MHPS pilot project with the financial support of SHO and TROCAIRE. A MHPS team of three with health and social sciences background was formed in April. In June the WHO manual on mental health and psychosocial care developed in Pakistan after the 2005 earthquake was translated into French and a draft proposal for ECHO funding was elaborated. Four months later in October ECHO and Cordaid signed the contract. Due to a cholera outbreak the entire staff and recruited community agents were mobilized for the cholera control. The upcoming elections at the end of 2010 cause unrest and insecurity and further delay of the project take off. In January eventually partners were contracted by Cordaid: SOE, REPHE, SOFA and Caritas Gonaives, Jacmel, Cap-Haitien and Fort-Liberté in addition to IDEJEN as main partner for the TROCAIRE project. In collaboration with the partners 91 community agents and 19 coordinators were recruited. The MHPS team was expanded to be able to cover all the 5 zones. The first trainings of community agents and coordinators were conducted in January. The first training of health professionals took place in February 2011. For the training of the health professionals the recently developed mhGAP intervention guide of WHO served as the basis for the elaboration of the training material. Tests were developed as well Then the first interventions at community level started, primarily focusing in the early months on psychological and stress management support to people affected by the earthquake. Due to delay in project implementation Cordaid requested a budget neutral extension of both projects in July 2011 but only got approval from TROCAIRE. Cordaid also applied for an additional year of ECHO support but could not get funding due to other priorities of the donor. The final report of the ECHO project (attached to this evaluation report) provides detailed information on project objectives, activities, indicators and assumptions. A logical framework is included in the report.

2 Terms of Reference

The overall goal of the evaluation of Cordaid’s MHPS program is to measure to what extent Cordaid’s MHPS intervention managed to reach its main objective, which was to improve well-being of beneficiaries in targeted communities. Objectives of the final evaluation

o To assess to what extent Cordaid’s MHPS interventions managed to reach its three expected results:

- Improve the level of MHPS knowledge of community-level workers - Improve the level of MHPS knowledge of primary healthcare professionals, and also

their practices - Reduce level of distress in targeted communities.

o To assess the effectiveness of Cordaid’s MHPS strategy in Haiti in achieving expected results o To assess the effectiveness of the organizational structure of Cordaid-Haiti and Cordaid’s

MHPS team in Haiti in delivering expected results o To assess the sustainability of expected results o To make a record of lessons learnt, challenges, successes, positive and negative experience,

etc.

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Cordaid is particularly interested in an external evaluation of the following elements: o Degree of obtained ownership of the program by the local partners o Cooperation and information sharing with other organizations involved in MHPS activities in

Haiti, post-earthquake o Effectiveness and appropriateness of the monitoring/supervision and reporting system o Efficiency of the program. i.e. to what degree are financial resources converted to results

being delivered o Impact of security concerns and related issues to proper execution of field activities

3 Methodology of the evaluation and limitations

Meetings and discussions with programme staff at HQ and Haiti level:

a. Briefing by the Manager of the Emergency Response Team; Sector DRR & Emergency Response at Cordaid Headquarters in The Hague, Netherlands

b. Briefing by the Head of Mission of Cordaid Haiti c. Two round table sessions with the MH team including the teams of supervisors in the

Zones d. Several brief meetings with the MHPS Technical Adviser to the program e. More informal meetings with supervisors of the zones during travelling to and from the

sites

Focus group discussions were held with community-level workers and coordinators and with primary healthcare professionals who attended Cordaid’s MHPS trainings in three out the five zones reached by the program: West, Artibonite, North East. In Zone West the evaluation covered both the TROCAIRE and the ECHO funded projects. Zone North and South East could not be covered due to limited time

Round table with representatives of the majority of the partners: Caritas Gonaïves/Jacmel, SOE,

HELP, IDEJEN, SOFA and MSPP (MoH) Meetings and discussions with relevant organisations in the field of MHPS assistance:

f. Attending a meeting of the Mental Health Forum, chaired by WHO g. Meeting with representative of WHO h. Meeting with the MoH Focal Point for mental health

Review of data and indicators with regard to what has been delivered for both projects. Available

reports were used for this purpose and additional data were provided by the MH team at the request of the evaluation team

Review of programme documents and other relevant documents related to the program Site visits to Delmas, Leogane (West), Fort Liberté (North East) and Gonaïves (Artibonite) Debriefing with the Head of Mission, the management team of the program and the Technical

Adviser

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Limitations Given the available time and the large area of intervention the evaluation team could not visit all

the zones targeted by the program. Not all data were easily accessible particularly the data for the TROCAIRE project because the

project is still running and the final report to SOH/TROCAIRE is planned for December 2011. The MH team was apparently not fully informed that the evaluation was to cover both projects.

The Terms of Reference were written for the ECHO project evaluation and agreed by ECHO and subsequently used as TOR for both projects. Only the contract with Cordaid includes the evaluation of the TROCAIRE project. In terms of effectiveness, relevance, lessons learned etc. the distinction between the two projects is not very relevant. Objectives, interventions, organisation and management are almost identical. With regard to data this evaluation report is not comprehensive on TROCAIRE project outputs and test results.

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4 Main findings

4.1 Effectiveness of the organizational structure

The organizational structure for the psychosocial component proves very effective in getting and

keeping the project and its objectives on track with or without the involvement of the local partners. Cordaid has a strong and motivated management team of three people at Porte-au-Prince level with 6 small teams of 1-2 social scientists at decentralized level, all recruited and paid by Cordaid and responsible for planning and supervision of the community agents . They were also involved as trainers in the first training of community agent. The mental health expert functions as technical adviser with a significant input in the assessment, the development of the proposals, the reports and the development of all the training material and tests. The entire structure proves very instrumental for reaching the project objectives within a minimum of time and with precise ambitious targets. The structure proved effective for the PS component: the targets were reached and the outcome at beneficiary level satisfactory.

The mental health component however has not been embedded well in a structure of continuous follow up and support of the trained health professionals. Cordaid contracted the local mental health experts solely for the training and care of referred cases. Cordaid did not have sufficient in-house mental health expertise to guide the process of gradual integration of mental health into primary health care. It would have been more effective to have a permanent mental health coordinator in the team. The technical adviser has invested a lot of energy at management level but at implementation level there was no structure for follow up of training and referral. As expatriate the part time technical adviser remained at the sidelines of the program although indispensable. He contributed more than his mental health expertise. It is not clear whether the national team could manage a proposal write up independently today. Cordaid has apparently under-estimated the efforts and expertise it needs to put in place a mental health care system, even if only for the time of the project and in a humanitarian context. The PS and MH components tended to be treated as separate entities within the program.

There has been no separate structure for the two projects funded by ECHO respectively

TROCAIRE + SHO funding. As in the other zones a team of 2 supervisors has been responsible for project interventions in Delmas and Léogane in Zone West and guiding the community agents. The TROCAIRE project started as a pilot project in 2010 but as soon as ECHO funds were also granted the team was expanded with more staff and decentralized teams put in place in the other zones to guide the work in the field. The two projects have to a large extent been implemented as one program but reports to the donor were written separately and TROCAIRE-SHO project is still going on till the end of November 2011.

4.2 Effectiveness of the strategies

The main strategies evaluated by the team are: (i) Cordaid conceived initiative; (ii) partnership with existing and new partners; (iii) training of community agents and health professionals; (iv) broad package of community oriented services and activities (i) Cordaid’s overall strategy in Haiti is rather vertical: the objectives and approaches are

conceived without active involvement of the partners, the Ministry of Health (MoH) and the

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project staff on the ground in the zones. In fact the project was conceived and written up and only afterwards the partners were identified and paid for their involvement in the project. In this sense the partners have been instrumental to Cordaid to reach Cordaid’s objectives. Cordaid pays a price for this in terms of ownership by the partners but has on the other side managed to create demand for MHPS care and awareness among partners and beneficiaries.

The evaluation team is aware of the fact that the humanitarian one-off character of the program is the main underlying cause of this change of strategy and different relationship with the partners (see below). As a result of the pace and pressure on the program in the humanitarian context there has been much emphasis on a blueprint model of working.

(ii) Partnership strategy

Cordaid’s usual way of working with its partners changed all of a sudden. The project was no longer based on the demand of the partners but the partners were attracted on demand of Cordaid. Cordaid made a kind of “deal” with the partners. This new approach to partnership - linked to the humanitarian context - created tension and affected Cordaid’s reputation among partners. When meeting with the evaluation team they expressed a strong wish to be more involved in planning and monitoring and to meet among partners in order to enhance ownership and reflect on the future perspectives together. The internal organizational and institutional capacity of the partners could not adequately be strengthened to continue running a MHPS program on their own. Cordaid and Caritas appear to have a different way of dealing with the partner’s staff. According to the partners Cordaid is far more strict with local staff which is probably related to the pressure on Cordaid to reach the intended results as agreed with ECHO. Cordaid has not managed to establish a functional partnership with the MoH. Initially Cordaid expected to train the MoH staff in the PHC facilities but it did not work out. In the perception of the MoH Cordaid did not sufficiently respect the MoH as the authority that needs to validate projects and training activities. In the perception of Cordaid the MoH expressed repeatedly some verbal promises but could not act accordingly.

Since the onset of the program the relation with various partners proved problematic. Cooperation with REPHE was cancelled because of their poor reporting of activities and poor management of Cordaid’s funds; they were not paying their community- level workers. The contract with ICC was stopped due to poor financial reporting and IDEJEN showed poor financial management so Cordaid decided to pay the community agents directly but did not break the contract with IDEJEN.

In spite of numerous efforts to come to an agreement with the local health partners to implement mental health / psychosocial activities at primary healthcare level, no agreement has been finalized. Cooperation with local NGO health partners was materialized only in the form of mental health training of their primary healthcare staff and individual contracts instead of institutional contracts.

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(iii) Training Training of community agents Overall the training of the community agents has been successful in gradually building the

agents’ capacity (knowledge and skills) to an appropriate level to give basic psychosocial support and help the victims of the earthquake cope better with their stress. The level of knowledge at the end of the first and second training improved but proved still limited and probably insufficient (below 60% correct answers). The level at the end of the final training mid 2011 increased significantly to 75% correct answers. The training module proved useful. A specific facilitator’s guide could probably have helped the trainers even more. The decision of Cordaid to complement its own staff with external experienced professionals resulted eventually - in the final training - in significantly improved knowledge and skills at an acceptable level. Beneficiaries in each of the zones visited by the evaluation team expressed high appreciation for the psychological support given by the community agents. “They helped us handle our stress”.

The satisfaction questionnaires give insight in the most and least appreciated components of the

training. The overall appreciation is very high (more than 90% expressed high level of satisfaction). Areas for improvement concern (i) time allocated to questions; (ii) treatment of the participants, (iii) clarity and comprehensiveness of the presentations and (iv) adaptability of the training material to the local context.

The recruited community workers differed quite a lot in background and maturity. The IDEJEN

agents proved young and rather immature, without any background in health or social care. They all had recently received a vocational training in the area of construction. Caritas on the other hand recruited in Gonaïves adults with experience in health and/or HIV/AIDS and in Fort Liberté people who had background in informatics and management. They proved more mature and confident of their capacity and dealt better with the work. In none of the zones representatives from the target group itself were recruited as community agents. Particularly for the Camp context it could have been beneficial to train IDPs living in the camp instead of training people from outside the camp. A recommendation for future programming of PS care for vulnerable populations is to build as much as possible the capacity of existing structures within the target population to enhance intrinsic motivation, easy access to the services and sustainability.

There have been no drop outs of the trained community agents. They expressed interest in their

work, happy with a guaranteed monthly salary and proud of the appreciation of their assistance. The competence test which was developed by the program was not applied. It is therefore difficult to assess whether the community agents performed well. The training was limited but many learned by doing. PS programs in other settings and countries often train PS workers for several months with follow up refresher courses and intervision meetings to equip them with relevant skills to solve PS problems beyond addressing stress and loss. Cordaid has rightfully used the process approach of spreading the 3 training weeks with learning on the job but supervisors agreed that not all agents proved competent and committed enough.

Training of health professionals Training health professionals the basics of mental health diagnostics and treatment and basic

communication and counseling skills has proven very effective in other countries where mental health is being integrated into the primary health care system. In this sense the training initiated by Cordaid has been an excellent initiative. According to Cordaid’s mental health adviser it was – and the first training ever on MH for PHC staff. However, the evaluation was informed that other

17

NGOs also trained health workers on the mental health: IDEO, URAMEL and the centre de psychotrauma as well as Médecins du Monde France. There even has been a specific project on this matter with SOE and a Haitian psychiatrist. As the table in paragraph 4.3. shows, the training of the health professionals (doctors, nurses, psychologists and social workers) has increased their knowledge and skills beyond the foreseen improvement of 25%. However, the training of the health professionals has clearly been less successful, less appreciated and less of their interest than the training of the community agents. The health professionals have moreover been significantly less able to effectively apply their newly gained knowledge and skills. They missed coaching, access to essential drugs, absence of a clear referral system and quite a few lacked motivation. Areas for improvement according to the satisfaction questionnaire mainly concern: (i) quality of the treatment during the training; (ii) time allocation; (iii) adaptation of material to local context; and (iv) clarity & comprehensiveness of the training. Several health workers mentioned the need for a mobile mental health clinic which ‘was promised’ by Cordaid staff but never put in place.

Table 1 : Average satisfaction of all the 3 trainings for the two different target groups Zone West South East North North-East Artibonite

Target group Martissant Petit Goave

Community agents 93.9 93.9 91.3 90.9 98.1 85.3

Health professionals 60.4 77.7 80.8 71.9 75 76.3

Training followed by application of the newly gained knowledge and skills proved successful for

the PS component. The trained health professionals applied the newly acquired knowledge and skills to a much lesser extent; it was not monitored and not supervised. The strategy to train health professionals without ensuring a more optimal selection of motivated staff and without an organizational structure to coach them after the training has proven ineffective for the development of primary mental health care system integrated in PHC. Three psychiatrists were contracted, primarily for training but also for support in the field according to the MH adviser but the coaching never materialized.

An agreement with local health partners has not been reached in spite of numerous

negotiations, and also because of mistrust of PHC professionals towards their own health institutions that would probably not pay them their fees. The professionals were paid for their involvement in mental health care which is negatively affecting sustainability.

(iv) Interventions on community level The program, mainly through the community agents, delivered a broad range of psychosocial interventions in the targeted communities. Both material and non-material assistance was given throughout the project period from February 2011 – end of August 2011. The main elements were:

o Individual psychological support with different support techniques for different problems, recorded and reported effectively by the agents For the TROCAIRE project 28.474 people have benefitted from individual support; for the ECHO project 60.628. This means that on average one community agent has supported 474 people in Léogane and Delmas (TROCAIRE); in ECHO supported zones each community agent supported on average 546 people.

o Support groups for people with similar problems based on a peer support approach with

external support from the community agents. The database shows that depending on the zone 3% - 14% of the beneficiaries of individual support also benefitted from group support (see table 7 below).

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Table 2: Beneficiaries of individual and group support by community agents

Delmas Leogane West South East Artibonite North North East

Targeted number of beneficiaries 13000 10000 15000 4000 10000 10000 2000

Reached number of beneficiaries 12555 15919 18825 6538 18999 13948 7434

Male 18+ 3 686 4120 4923 1816 4688 3891 2041

female 18+ 4196 4847 5749 1977 6131 4665 2471

Youth 6-18 2566 4090 4515 1376 3661 3411 959

Children < 5 2107 2862 3638 1369 4519 1981 1877

% coverage 96,57% 122,45% 126% 163% 190% 139% 372%

Beneficiaries of only individual support 11478 14537 4673 16922 13.459 7197

% benefitting also from group support 8,57% 8,68% 3.60% 14% 11% 4% 3%

o Recreational and occupational activities: summer camps, football matches, domino

competition, songs, poems, dance etc. These activities were as much as possible also used for awareness raising on MHPS issues.

o Awareness raising on mental health and psychosocial problems and support o Distribution of material assistance and incentives such as toys, dolls and footballs for children

and youth, household assets for families, school material, serving meals after sensitization workshops etc.

The package of interventions has decreased stress levels in the community and increased the

resilience of the targeted households. Beneficiaries agree on this almost unanimously and the questionnaires provide ‘hard evidence’ for it as well. The problem of attribution remains a concern however. It is impossible to single out the project interventions as single cause for improved well-being. Post catastrophe experience elsewhere in the world has taught us that the majority of traumatized populations tend to cope rather well after some time, even without focused interventions.

The tendency to stigmatize mentally ill people and those suffering from epilepsy decreased in

three out of five zones. In the South East and North however, the questionnaire results present an opposite trend on ≥ 50% of the questions (see table 5). It may be caused by the post project sample of respondents that apparently was partly different from the pre -project sample but it needs follow up. Even if local beliefs on for instance epilepsy are very much traditional a post test would result in some improvement in understanding. If the mental health component could have developed more, than the community would also have got the chance to experience that epilepsy can be treated and that changes people’s mind. Epilepsy control program2 all over the world produce that lesson learned: start treating a few epileptics and many will follow.

The perceived improvement in coping with stress questionnaire was only used at the end of the

project. It is unclear how other interventions and time affect the outcome of the questionnaire.

The combination of non-material and material assistance has made it possible for the program to be implemented without major obstructions. Without the material assistance the community tended to consider the program inappropriate. “Only nice words, though highly appreciated, is not enough”. There have been incidents whereby Cordaid workers have been threatened and where beneficiaries have started fighting to get a lager share of the distributed goods. Time pressure and donor pressure to achieve the targets set and spend the money has affected the quality of the interventions and pushed Cordaid to spend more on material assistance than

2 A few interesting articles and a manual will be shared with the project team by the external evaluator on this

matter. She worked herself for many years with epilepsy control in a very stigmatizing environment.

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originally foreseen (community oriented interventions) to enhance social cohesion and well-being) has by far been the most costly. Approximately 70% of the total ECHO budget was spent on this third component of the program. Material support, though not considered a priority intervention by Cordaid, involved high costs: 38% of the ECHO budget was spent on material supplies with a 160% burn rate (gross overspending) for that budget line. The distribution of these goods allowed the project staff to move ahead fast towards reaching the set targets by the end of August. The burn rate by 1st October, after closing the program, reached only 80%.

The intervention package of Cordaid has been complementary to assistance rendered by other

NGOs, UN organizations and other institutions. The evaluation team did not find evidence for unnecessary duplication of services and considers the program unique in that sense and relevant. Most of the humanitarian organizations involved in MHPS services left Haiti by now. A few are still there such as MSF, World Vision, Handicap International and a few others such as the French Red Cross. They all cover specific geographical areas without overlap with Cordaid.

The mental health component has been under-developed at community level except for

awareness raising and some identification of mental illness and epilepsy in the community. Identified cases were referred to the supervisors in the zone who could de facto only refer the cases to psychiatrists in PoP. Whether referral materialized is not known. The link between the psychosocial and mental health components appeared weak and monitoring lacking.

As stated before, the data collected with the three questionnaires for stress level, well-being and

KAP provide a wealth of information that could be further analyzed and interpreted if time and capacity allows so. More lessons on the performance of the different zonal teams could be leaned. Analysis of data by the evaluation team revealed that the beneficiaries in the Western zone and in the North East reached the biggest improvement in well-being, stress levels and stigma towards mental illness (see table 4). The target communities in the South East benefitted least in terms of the three indicators unless the post test sample has been very different from the pre-test sample for all three tests. If so, the data for South East should not be used as post test data.

4.3 Effectiveness of the program in terms of objectives and expected results

To what extent has the program achieved what it intended and expected to achieve? According to the logical framework of the ECHO funded project document the principle (overall)

objective is to regain and strengthen the resilience of the earthquake-affected population and improve the level of their emotional, mental and social well-being, thereby also preventing development of more severe mental problems. The specific objective of the ECHO project was to improve the level of mental health and psychosocial well-being of earthquake affected people in 7 targeted areas. Three expected results were formulated as follows: 1. Increasingly skilled community agents and NGO workers and increased MH/PS capacity of

local NGO partners 2. Improved detection and treatment of mental problems by primary health care staff (doctors

and nurses) 3. Increased social cohesion and well-being of targeted beneficiaries

The overall objective of the SHO/TROCAIRE funded project is to improve the emotional and social well-being of the earthquake affected people and as a result reduce the number of people who

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develop mental illness. Specific objective: People use quality mental health services at PHC level. Two expected results: 1. Improved knowledge on MHPSS at community level 2. MH services in the PHC are accessible

1. For each of the expected results targets were set and indicators defined for both projects as presented in Table 3 and Table 4. Expected results 1 and 2 The project intended to improve the level of knowledge of community agents and NGO workers by at least 30% and the level of knowledge as well as recognition and treatment of mental problems by PHC staff by at least 25%. Both expected results have been achieved and the improvement was beyond the planned 30% (for community workers) and 25% (for health professionals). The table below presents the indicators as defined in the project document and the results achieved against the target. The blue rows present an additional indicator used by the evaluation team. Table 3: Indicators of success and results found during evaluation (ECHO project data) Indicator according to project document Result

Number of trainings for community agents; 4 trainings of 6 days each in 5 zones planned

17 training sessions in 3 phases (of 3-5 days) covering 5 zones

80 trained community level agents 112 (ECHO) + 62 (Trocaire)

8 local NGO staff trained 1 NGO staff member was trained

Increase of at least 30% in knowledge of community agents and NGO workers compared to baseline (this measures improvement irrespective of level)

Improvement post-test compared to pre-test Basic test: 34% improvement Advanced test : 12% improvement Final test: 93% improvement Overall average improvement 46%

Increased knowledge of community agents in terms of average % of correct answers to the questions of the test (measures level of knowledge)

Pre-test average Post – test average Basic test: 44% 58% Advanced test : 47% 52% Final test: 42% 77%

Number of trainings for PHC professionals 17 training sessions in 3 phases and in 5 zones

60 PHC professionals trained 75 profs trained (ECHO) : 21 medical doctors, 38 nurses, 8 psychologists and 8 social workers

Increase of at least 25% in knowledge of health professionals compared to baseline (measure of improvement irrespective of level)

Improvement post-test compared to pre-test Basic test: 29.7% improvement Advanced test : 40.48% improvement Final test: 152.2% improvement Overall average improvement: 74%

Increased knowledge of PHC professionals according to the level of knowledge reached expressed as % of correct answers to the questions of the tests

Pre-test average Post–test average Basic test: 39% 50% Advanced test : 47% 56% Final test: 34% 84%

Increased recognition and treatment of mental problems by PHC staff by at least 25% compared to baseline

Not monitored

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Table 4: Indicators of success and results found during evaluation of TROCAIRE/SHO Indicator according to project document Result

Number of people using the MH services No data available

Number of delivered PS individual interventions Delmas: 12555 Leogane: 15919

Quality of MH services in PHC is up to MoH standard

Almost no services yet and no monitoring

Increase of MHPS knowledge of the community by at least 30% compared to baseline

KAP survey? Knowledge tests done?

Increase of at least 30% in knowledge of the community agents compared to baseline (this measures improvement irrespective of level)

Improvement post-test compared to pre-test Basic test: 3.64% Advanced test : 3.53% Final test: 137% Overall average improvement : ……

Increased knowledge of community agents in terms of average % of correct answers to the questions of the test (measures level of knowledge)

Pre-test average Post – test average Basic test: 42.9% 58.7 % Advanced test : 42.2% 45% Final test: 32% 60 %

Improvement in the level of MHPS knowledge of PHC doctors by at least 25% compared to baseline

Average improvement pre-test versus post test Basic test 8.85% Advanced test 57.9% Final test 160%

Increased knowledge of PHC professionals according to the level of knowledge reached expressed as % of correct answers to the questions of the tests

Pre-test average Post–test average Basic test: 49% 53.8% Advanced test : 44,5% 70% Final test: 30% 78%

Number of delivered MH interventions in PHC No data available

Number of MH problems recognized and treated

No data; no competency tests

Number of referred people with more severe problems

No access to database in HF if at all

Cordaid trained its own staff for own week in the early phase of the program. It was not a

structured TOT training as such for the Cordaid Haiti mental health team by MHPS experts. However, the capacity of the mental health team of Cordaid in Haiti was built gradually and quite effectively in the course of the project. This as a result of (i) technical support by a mental health specialist consultant to the program; (ii) learning through organizing and implementing a training package for community agents and for health personnel and (iii) learning through regular monitoring. The Port-au-Prince (PoP) based team and the teams of supervisors of community agents have developed planning and monitoring skills as well as several techniques to cope with the most common psychological problems such as stress, anger, family disputes etc. The mental health team were involved as trainers in the basic training of both community workers and primary health care staff and it may be that their knowledge and skills by then were limited. The test results of the first basic training shows that on average only 50% of the questions of the post test were answered correctly. This is most likely a reflection of both the trainers and trainees’ capacities and the new subject of mental health and psychosocial support.

The evaluation team found evidence for an increase in knowledge and skills beyond the set

targets. According to the MH team the improvement was 33%, 12% and 93% for the three trainings in ECHO project. The results of the pre- and post-tests show (see table 3 above) that the recruited community agents gained new knowledge and skills during each of the three trainings,

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but the level of knowledge at the end of the first and second training (average score in terms of % of correctly answered questions) remained rather low. The evaluation team considers the improvement achieved by the first and second training insufficient to ensure quality assistance to the targeted communities. For both the basic and the advanced training the end score remained below 60% correct answers (58% and 52%). The table below presents all test results. In a school system this may not be enough to pass the exam. However the test results of the final training are very encouraging as on average 77% of the questions were answered correctly. The Cordaid MH team analyzed the results in a different way. They assessed the degree of improvement by taking the difference between the pre-test (baseline) and the post test and dividing that difference by the baseline score without taking the level of the end result into account. This may in some cases lead to misleading figures without the intention to mislead. For instance if someone answered 20% correctly in the pre-test and 45% in the post test, the improvement is over 100% (45-20 = 25 divided by 0.2 = 125%) but the level is still quite poor. The indicator of % improvement is therefore not very useful to measure capability of agents

Table 5 : Test results for (a) community agents and (b) PHC professionals for each zone (ECHO)

West Martissant

West Petit Gouave

South East North North East Artibonite Average correct

answers

Community agents ( # ) 13 9 22 25 9 33

Basic training – pre test 45 40 57.6 40.2 42.4 39 44%

Basic training - post test 59 50 58.8 60.8 63.5 56 58%

Advanced training pre-test 37.7 42.8 47.5 61.4 42.8 49.7 47%

Advanced training post test 41.2 47.8 53.2 64.8 47.9 58.9 52%

Final training pre test 35 n.a. 60 45 35 35 42%

Final training post test 87 n.a. 65 95 70 68 77%

Health professionals ( # ) 10 10 12 13 14 16

Basic training pre – test 29 40 44.4 45 37 39%

Basic training post - test 48 43.8 54.8 53 49 50%

Advanced training pre-test 41 41.6 41.6 55.8 51.05 51.25 47%

Advanced training post- test 71 67.5 56.25 62.1 60.7 72.8 65%

Final training pre –test 32 28 41 31 32 37 34%

Final training post – test 90 69 82 89 88 83 84%

All tests were filled anonymously so individual feedback could not be given and nobody could

‘fail’. From a perspective of reaching the target of 30% and 25% improvement it does not matter and it prevents offending individuals. But individual feedback to students can also have a positive effect on motivation and informs them more on where the gaps are.

Originally the program had foreseen a test to assess the competence and performance of the

community workers, but the test was never used. To get a good feeling of the agents’ competence the supervisors often met with the community agents (supportive supervision), coached them on the job (continuous education) and few meetings with all community agents per zone were held to discuss difficulties (inter-vision. The community agents indicated that they would have liked more meetings as a group to learn from each other. The overall M&E coordinator of the MH team also visited the field during meetings with community agents.

To reach expected result 2 a total number of 75 (+12 within TROCAIRE project) health

professionals from the five zones were trained with a partly different module from the one used for community workers. The group consisted of medical doctors, nurses, psychologists and social

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workers. The results of their pre- and post tests (see table above) indicate that similarly to the community workers the post-test scores improved but remained rather low. A qualitative questionnaire to measure the satisfaction of the participants revealed several challenges for the foreseen integration of mental health in PHC. According to the final training evaluation only 60% of the health professionals indicated to be interested in the training and quite a few had critical comments on content, methodology and environment. This means that their commitment to mental health services may be questionable. The Community agents however almost unanimously expressed a 100% interest in the training. For more detailed information on satisfaction see final report to ECHO.

The advanced for health professionals consisted of more case studies and was facilitated by

experienced mental health professionals (psychiatrists and general practitioners) and produced significantly better results (65% correct answers versus 50% at the end of first training). The final training had the best results (84 % correct answers) probably as a result of high quality trainers and growing comprehension of the matter. According to one of the trainers the questions of the tests were also rehearsed during the training. The very positive outcome could have been a good starting point for more and better mental health care delivery. However access of mentally ill to adequate care remained limited. The trained physicians still referred most serious mental cases to psychiatrists in Port-au-Prince. A few cases were identified and treated locally (see final report to ECHO). No referral system was developed, access to essential drugs could not been ensured and coaching of the trained health workers by experts could not be established. Time pressure and donor requirements have played a big role in addition to the absence of an organizational structure for the mental health component (except for the TA by Dr. Boris Budosan and access to mental health experts as trainers)

Both community and health workers have also gained practical skills during the training and on

the job. Their competence has not been monitored with a specific tool as planned, so there are no data available. The community workers have benefitted from the continuous education approach of the program whereby a small team of 2 supervisors, based in the field, coached the community workers. The program has however not managed to put a structure in place to coach the trained health professionals on the job, organize inter-vision sessions and supervision by mental health experts. As stated before, the foreseen referral system was also not put in place. The program has clearly underestimated the implications of developing a functional referral system for mental health care. Month after month setting up the referral system was planned according to the monthly reports to Cordaid/TROCAIRE; in vain.

Expected result 3: increased social cohesion and well-being of the affected target populations The program offered a wide range of different interventions in the targeted communities.

o Individual support sessions in the early months of the program o Group support sessions with mainly the same individuals but in groups according to

shared problems o Recreational activities such as football competitions for boys and girls o Sensitization and awareness raising on mental health and psychosocial issues o Distribution of different utensils, presents and other material assistance

As the graph on the next page shows the program reached far more beneficiaries than originally planned. Particularly the community agents in the West and in North East Haiti managed to reach far beyond the target. This is not the result of more community agents. Even the average number of beneficiaries reached per community agent per zone varies widely. The striking low output per community agent in South East zone and high output in West and North East deserves further interpretation by the mental health team of Cordaid Haiti. One reason given is the lower

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geographical accessibility of the area in the South East. It is more difficult to reach people particularly Cayes Jacmel and Bainet. Table 6 Reached versus targeted number of beneficiaries (by the area of intervention)

Project location

Targeted number of beneficiaries

Reached number of beneficiaries

Reached versus targeted number of beneficiaries (%)

Artibonite 10.000 18,999 190%

North 10.000 13,948 139%

Northeast 2.000 7,434 372%

Southeast 4.000 6,538 163%

West 15.000 18,825 126%

West Delmas 13.000 12.555 (till 30/11) > 100% by end of project

West Leogane 13.000 15.919 (till 31/10) > 125% by end of project

Graph 1: Targeted versus reached number of beneficiaries in each of the 5 zones (ECHO)

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

West South

East

Artibonite North North East

targeted number of beneficiairies

reached number of beneficiaries

Table 7: Coverage of beneficiaries reached and case load per community agents(ECHO) Zone West South East Artibonite North North East

% coverage 126% 163% 190% 139% 372%

# beneficiaries reached per community agent 835 212 594 538 799

The community workers in the Northeast and the West apparently worked more on their own and not in pairs of groups of three and could therefore reach more people. Has the project improved the wellbeing and social cohesion among the affected people? This is

not the mandate of the Cordaid program according to the evaluation team. The program rather has decreased stress and distress levels among beneficiaries and strengthened the resilience of the Haitian people. Even if the pre- and post test on wellbeing indicated an improvement, direct attribution of the effect to the Cordaid program is not justified. Other determinants play a role such as time, other interventions, access to economic activities etc. The logical framework points at the attribution problem as risk while they knew that the Cordaid interventions can not be singled out in this complex of factors.

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On a more global level the program has contributed to a demystification of mental health in the

targeted communities (10) and an increased awareness about the importance of psychosocial assistance after a humanitarian catastrophe like the earthquake. Over 67.000 people have been reached in the ECHO project and approximately 29.000 in the TROCAIRE/SHO project. The majority have been reached in the first 5 months of the project when each affected household was visited, registered and given some basic psychosocial support. Many of them were actively involved afterwards in more group and community oriented activities such as support groups, recreational activities, celebration of father’s day, mother’s day, distribution of material assistance etc.

However, the mental health component whereby community workers identify people in need of

mental health care and refer them to health professionals trained through the Cordaid program, has not been successful. Training has taken place but a system for referral, essential drug provision, coaching by professionals and monitoring and reporting has not been put in place. Cordaid has set an important first step but many years are needed to develop a functional integrated mental health system

The intervention package has been developed with the technical assistance of a mental health

expert who worked for may years in difference Asian countries, the Middle East and the Balkan. With his support also the training modules and tests were developed, mainly on the basis of the mhGAP of WHO. Training material was translated in French and Creole. Though existing literature on Haitian culture and health seeking practices was consulted, the program has apparently not taken traditional practices much in consideration. Healing through prayer or consultation of voodoo priests is not promoted. The techniques applied by the community workers in individual and group sessions are based on empathic listening and cognitive principles with simple relaxation techniques. More culture specific techniques have not been developed. The urgency of the intervention and the limited time available are among its causes.

The package of interventions offered by the program – ranging from individual and group

support sessions to recreational activities and distribution of household items and school kits intended to improve the wellbeing of the targeted people. The program developed several tools to be able to measure the impact of the program on (i) perceived stress levels, (ii) attitudes / stigma and (iii) well-being on a 7 points Likert scale. According to the pre- and post test for stigma and well-being there is a significant improvement. However attributing this improvement to the Cordaid program is not justified as several other factors may have contributed to the effect such as time and assistance rendered by other NGOs. With more time and capacity available Cordaid could have used the test results for a more in depth analysis and interpretation to assess differences between the 5 zones covered and to identify factors/areas of the well-being test that have most versus least contributed to the overall improved well-being. The test covers (a) economic situation; (b) family situation; (c) social life; (d) emotional life; (e) mental status; (f) religious/ spiritual life. The results of the initial well-being test could have informed the mental health team about the key areas of perceived well-being that need to be addressed. According to its specific objective the MHPS program focuses primarily on the family situation, social and emotional life and on the mental status. Less attention was paid to the economic situation and spiritual life. The time available has been a constraint in this respect and in depth study of program results and further analysis of the database may offer opportunities for further research.

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Table 8 Results of the 3 tests that measure the outcome of the community interventions(ECHO) ECHO project West

Martissant

South East

North

North East

Artibonite

Well-being test (7 points scale)3

pre-test 5.02 4.26 5.54 4.57 3.63

post test 2.04 3.08 3.38 1.6 2.65

% improvement 37,46% 16,87% 30,88

% 42,47% 14%

Perceived level of distress (5 point scale)4

post project test 3.47 2.96 3.12 3.37 2.95

% improvement 73.50% 48% 56% 68.5% 48%

KAP test (12 questions Y/N)

pre-test

Post test

% improvement 36% - 13.96% 23.53

% 41% 15.47%

Average # of questions answered correctly post test 11/12 4/12 6/12 12/12 12/12

Further analysis of the data provides the following insight: Well-being test The degree of improved wellbeing was measured by comparing the pre- and post test scores.

From the test results (see table) it is fully justified to conclude that the target population perceives its own well-being as significantly improved in all zones. The MH team did not assess in which domains the perceived improvement is biggest (economic life, family life, social life, emotional life, mental state, religious/spiritual life). On request the team analyzed the data for the North and found that there was improvement in all domains. The biggest improvement (as a result of the MHPS program) was in the area of spiritual life (41.4%), social life (34.7%) and family life (34.5%). Least improvement was in economic life (18.5%).

When assessing how “well” the people felt already before the project, the table shows that the

people in Artibonite (score of 3.63) were already feeling quite well before the Cordaid project, while the people in the North (5.54) felt the worst of all the zones. To what extent their well-being was determined by the earthquake or other factors is not known to the evaluation team. The people in the North East have apparently benefitted most from the program and/or other interventions including reception by their family members. Caritas registered all the IDPs and gave them vouchers for material and money assistance. This may have affected their well-being . Their coping with stress capacity has also improved a lot (second after West) as well as their KAP. Tentatively it may be concluded that the team in Fort Liberté and in the West zone have achieved better results than the others. It may need a more in-depth analysis of the underlying causes.

Perceived stress level Perceived stress test (only post project) (2 = same as before; 3 = more able to cope; 4 = much

better coping) . On the 5 point Likert scale the overall test result reflect an improved coping

3 The higher the test result the poorer the well being, e.g. 5.54 reflects a perceived ‘poor’ well-being

4 The higher the score the better the coping capacity e.g. 5 reflects greatly improved coping with stress

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capacity with stress in all the zones with the West showing the best capacity and Artibonite the least. To what extent the test results are valid without a pre-test is not known to the evaluation team. The questions ask about the perceived improvement after the MHPS program. Are beneficiaries capable of distinguishing what precisely caused the improvement?

Knowledge, Attitude and Practice (KAP) The KAP test results (see table below) deserve a closer look at the results per zone. The report of

the team on the test concludes that there is a significant improvement in all but the South East where there is an overall negative outcome (regression). The Cordaid MH team relates it to the fact that the post test sample of respondents was not precisely the same as the pre-test.

Table 5 : Results of the test on KAP / stigma at community level towards mental illness

Artibonite North North East West South East

Question Result Pre post Pre post pre post pre Post pre Post we should be afraid of mental patients

the lower the better 27 10.3 81 21 43 43 70 13 90 65

Mentally ill may be allowed to get married

the higher the better 37.5 75.8 20 26 29 99 43 63 65 40

Mentally ill may have children the higher the better 78.6 82.2 17 60 56 99 38 70 91 44

Mentally ill should be employed

the higher the better 36.6 57.6 61 27 22 97 47 80 57 51

Mentally ill may participate in family discussions

the higher the better 71.3 78.6 31 57 50 98 38 92 76 39

Mentally ill may eat at the same table

the higher the better 64.6 88.8 82 71 44 96 16 74 77 54

Mentally ill are dangerous the lower the better 76.7 48.7 85 72 72 1 74 49 84 75

Mentally ill could benefit from medical assistance

the higher the better 93.2 98.1 85 5 91 99 85 100 69 68

Mentally ill have the same rights as other people

the higher the better 73.2 73.9 41 76 60 98 32 53 92 35

epileptics are under influence of bad spirits

the lower the better 55.5 22.8 44 62 44 6 75 65 42 41

Epileptics are contagious the lower the better 28.4 24.7 32 45 46 3 25 80 35 54

one should remove the fitting epileptic to safe place

the higher the better 84.1 86 86 85 90 98 86 93 87 97

Number of questions with more incorrect post test answers than baseline 0 6 0 1 8

Improvement % (acc. MH team reports) 15 24 41.1 36 -14

Analysis of the answers per question and per zone indicates that:

- Artibonite and North East zones improved on all questions and West on all but one - However, South East respondents improved only on 4 of the 12 questions, a remarkable

regression. According to the staff this was due to a slightly different sample of respondents for the post test. The outcome suggests a very different sample or errors in processing the data

- In the North respondents improved on 50% of the questions only. So the project report’s conclusion that there is an improvement of 24% is misleading. A few questions may have been understood much better but overall the outcome does not justify the conclusion that there is significantly less stigma towards mental illness. On half of the questions more respondents hold false beliefs than before the program. Unless this is again related to a different sample than during baseline, the results are not encouraging with regard to the effect of awareness raising about mental health.

According to the evaluation team it is not entirely the mandate or mission of the Cordaid

program to act on the overall level of wellbeing in terms of offering a comprehensive package of

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interventions and acting on the organization of the camp/community. Achieving greater social cohesion and sustainable improved well-being requires more than a MHPS program. With regard to resilience and coping emotionally with the impact of the earthquake the program has effectively supported the families to better cope with stress and loss through more sharing of feelings; in the area of economic/financial problems the program has given various material assistance. The program did not have the ambition to strengthen people’s capacity to take care of themselves. The program clearly has a very humanitarian profile and mandate.

4.4 Monitoring, evaluation and reporting

Cordaid developed a rather unique monitoring system with baseline data collection for both

output and outcome indicators. This is rarely done so systematically as in this program, particularly for the ECHO funded project. All training outcome is assessed by pre- and post training tests and for the outcome of community targeted interventions several tools were used: a questionnaire on perceived well-being applied before and at the end of the program, a questionnaire on knowledge, attitudes and practice (KAP), also applied before and after the program and a questionnaire on perceived stress level, applied only once at the end of the program in August. Not all tools have been applied (yet) in the TROCAIRE area of intervention as the project is still going on.

Processing, analysis and interpretation of data constitute an important management tool. Data

can provide feedback on the effectiveness of the interventions. In the case of this program the data and comparative analysis are not fully exploited. Continuous time pressure on the team has taken its toll. Moreover ECHO is foremost interested in reporting on targets and has continuously pushed the project ahead. The post test and end of program results could have been shared more with the staff in the field, the beneficiaries of training and with the partners. It would have enhanced ownership and strengthened their understanding of the usefulness of data collection.

Information about the two projects within the MHPS program has been shared with other

relevant NGOs and with representatives of the Ministry of Health and WHO during the mental health forum meeting but the program was not validated by the MoH. In a meeting with the MoH resentment was communicated on the failure of Cordaid to have the program fully supported by the Haitian authorities. Cordaid has made a great effort in the early phase of the ECHO program to link with the MoH. However, according to the evaluation team, Cordaid made a strategic mistake by turning away from the MoH and giving in to time pressure that pushed Cordaid to opt for a stronger partnership with the NGO/CBO sector. This particularly holds for the mental health component.

4.5 Efficiency and cost effectiveness The question whether the program has used its human, financial and material resources in an optimal way is a complicated one. Could the resources have been used in a more efficient way? The evaluation team made a few observation that affected the utilization of resources:

o Several local organizations were contracted as partners in the projects but not all were kept till the end. REPHE dropped out, ICC’s contract was stopped because there was no interest from their side while IDEJEN could not comply to financial management procedures. The search for new partners took time and other resources

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o The ‘caseload’ of the community agents appears to vary significantly. In Léogane on average one agent handled 5 households per week. So one HH per day per community agents on average. In terms of caseload and coverage there is also a difference between where the community agents worked in teams and those with the capacity to work alone.

o The specific capacity of the sociologists - supervisors of community agents appears under-utilized. As sociologists they could have contributed more to the analysis of the community dynamics and development of interventions at that level

The ECHO+ TROCAIRE/SHO projects covered approximately 67.000 + 29.000 people with 1.3

million Euro. So the costs per beneficiary is 135 euro. Value for money? This is difficult to assess in an evaluation like this one. Maybe more people could have reached with the same budget if more time had been available.

4.6 Collaboration et coordination between mental health actors Actors in the field of mental health are meeting regularly in a forum steered by WHO. Two

working groups have been established to write up a mental health policy and a mental health strategic plan. Cordaid participates in both working groups.

Beyond the forum mentioned functional and operational collaboration has not developed very

much on the different levels: o Between the psychosocial support and the mental health program components o Between the shelter program and the MHPS program o Between Cordaid and other actors in the area of mental health such as MSF, Handicap

International, IMC. There is no evidence for duplication or big overlap but Cordaid could probably have learned more from the experiences of the other NGOs and vice versa.

Cordaid translated the WHO manual and developed training material based on mhGAP. This

material has been shared with WHO and is accessible for other agencies.

4.7 Ownership and sustainability

Because the program was primarily a mainly humanitarian program with the short term objective

of providing psychological and psychosocial assistance to the traumatized victims of the earthquake, sustainability was not a big issue. However the project also had a more medium and longer term ambition to get mental health care integrated in primary health care. To reach that high ambition the time available has been far too short and all agree on that. The resources in terms of human resources, financial resources as well as and technical and managerial capacity are not there yet and it will need a longer term perspective to get this assured.

However, whatever the character of the program – humanitarian or not- , working with partner organizations and training people requires an exit strategy right from the inception of the program. Cordaid did not develop such an exit strategy and experienced during the past few months that with funds ending people at all levels ask questions and express requests to continue with MHPS interventions. There are still huge mental health and psychosocial needs, not only because of the earthquake but in general. An exit strategy forces an organization to prepare itself as effectively as possible for an handing over to others, unless there is nothing to

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hand over. But people in Haiti will continue to have psychosocial and mental needs. Two years after the earthquake these needs are not resolved for ever.

Sustainability is closely related with ownership. Cordaid has pushed the MHPS program. It was

not at the request or demand of the partners and as a result ownership of the program is at stake. With only 7 (ECHO) +its inception phase of a few months and 12 months (TROCAIRE) the available time was extremely short to reach ownership of the humanitarian program. As said before, the partners have primarily been instrumental for Cordaid, more than owner and equal partner. At the time of the project conception several international Caritas organizations were present in Haiti. It would have been a useful opportunity to develop articulated and coordinated interventions with them.

Currently some Caritas partners and a few other partners have show interest to remain involved in mental health care and psychosocial assistance. SOE, Caritas Gonaives and Caritas Fort Liberté appear eager to seek funding for another MHPS project. SOE has already submitted a proposal while Caritas Fort Liberté is writing up a proposal for a PSS project targeting vulnerable people. Caritas Gonaives would like to work on the integration of mental health care in primary health care. Unfortunately Cordaid has not invited its partners around the table at all to discuss achievements of this project and future perspectives. The evaluation considers this a missed opportunity for Cordaid. There lies great potential in further building Caritas’s capacity to integrate psychosocial assistance in the activities of parishes while mental health care could gradually become part of the health services rendered by the diocesan / faith based health facilities. Cordaid could lobby actively at the level of Caritas Haiti to “mainstream“ psychosocial assistance in the church’s services.

Also the MoH has after all been very little involved. Cordaid has tried several times to meet with the MoH to discuss whether and how Cordaid could train MoH health staff in the health facilities. However, they failed to get the MoH on board and then decided to train health professionals working in the health facilities of the partners. At present the MoH with support of WHO is in a process of writing up both a mental health policy as well as a mental health strategic plan. Both documents are elaborated together with the main NGOs in the field of MHPS. The Haitian authorities show interest in developing a mental health care system, decentralized to the regions and based on a multidisciplinary approach. However, the State does not have adequate resources – human, financial, material – for it and is looking for partners what want to pilot and fund such a decentralized MH system. Priorities for the MoH are (i) depression; (ii) epilepsy and (iii) developmental problems / mental disability. Three priorities that are not specific for the earthquake or other humanitarian catastrophe. These 3 mental problems are in any community in the world and may get more prevalent in a context of extreme vulnerability such as this earthquake tragedy.

Cordaid made an essential first step towards an integrated mental health system. Training first

line health workers in primary mental health care has proven a cost effective intervention in many developing countries. For a full integration of mental health into primary healthcare, much more is needed such as development of mental health policy, allocation of mental health budget, on-the-job supervision of PHC workers by mental health professionals, etc., and this proved far beyond the capacity of this program.

Both the State and the partners have a problem of resources: very little financial resources and very limited technical capacity. Donors will be to be sensitized more to assist Haiti to develop a public mental health system over time and to render psychosocial services at community level.

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However, almost 2 years after the earthquake donor agencies appear less interested in the mental health of the Haitians. This trend is observed also in other parts of the world where initially the whole world wanted to help people overcome the traumatic events.

Cordaid will have to make up its mind also. There is no clear stand yet on priorities for 2012 and

beyond. At present the MH team of Cordaid is writing a proposal for a MHPS project of 6 months till Cordaid will close its office in July 2012. The six months project will focus on the development of a functional referral system, a component of the current program that has not been achieved. Cordaid will continue to support local partner organizations till 2016.

4.8 Impact of insecurity and related factors Elections by the end of 2010 caused insecurity that urged Cordaid to put the program

implementation on hold. More severe security measures had to be taken which resulted in higher costs than foreseen.

On the 6th of November 2010 Haiti was spared a direct hit of Hurricane Thomas at a time when

more than a million people remain in tent camps after the Jan. 12 earthquake. But the hurricane offered a reminder of Haiti's vulnerability. In Léogane families in tented shelters saw the floods coming right into their shelters.

A cholera epidemic in the same period had an additional delaying effect on the projects. Just

after the MHPS training of the community agents, the MoH requested all NGOs to avail their staff and agents on the ground for the control of the cholera. A training for them was organized. Although it delayed the project implementation the cholera emergency build new capacity which can be considered as an unexpected positive effect of the program.

4.9 Adherence to international guidelines In addition to the ToR the evaluation team looked into the compliance of the program with the international guidelines for mental health and psychosocial work: the IASC and SPHERE guidelines. Figure: Four layers of IASC framework for MHPSS services in emergency settings

AFTER THE DISASTER

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The interventions fit very well in the general framework of human rights to health including

mental health and mental health care (SPHERE guidelines 2004) and in the IASC guidelines (2007).5

It is recommended to pay attention to the ethics, equity, dignity and security of people. In this

context there need to be a code of conduct for the community agents and these four principles ideally need to be covered during the training.

Right to confidentiality and consent of the beneficiaries. Given the donor and time pressure

there is a risk that people are pushed to participate in order to reach the targets. In Fort Liberté for instance the community agents monitor who does not participate in group sessions after 4 individual sessions.

Training needs to be standardized and harmonized as much as possible with the national

programs. There were no available clinical guidelines for health problems after the earthquake, so government agreed to use the guidelines from MSF. With regard to mental health: the training of health professionals has not taken the existing curricula as such into consideration. The training material used is more standardized with international programs, with a strong input from WHO. Cordaid provided up-to-date mental health knowledge for PHC workers according to the health workers met during the evaluation. It refreshed their minds on the subject.

HIV/AIDS needs to be mainstreamed and violence addressed in the interventions.

The program developed a module Mental health and HIV/AIDS and wanted to deliver it to ICC, which was most involved with this issue. However, ICC did not express the interest to receive one such training. With regard to violence Anger Management was incorporated in the training of community agents and Psychiatric Emergencies (includes violent patients) in the training of PHC professionals. Also, some of the psychosocial interventions in communities, such as e.g. recreational activities tackled among other things boredom and potential violence in IDP settings and poor communities. Anger management was also used during individual and group psychosocial intervention to reduce violence in communities.

5 IASC: Inter Agency Standing Committee

3-4% of people may suffer from severe mental disorder. They would need specialized services.

100% of people need basic needs (food, water, health, shelter) and

security

Mental health

and

psychosocial

activities at all

four layers

should be

integrated

Layer 1

Layer 2

Layer 3

Layer 4

10-20 % of people may suffer from mild to moderate mental disorder. They can be assisted at this layer of primary health care.

30-50% of people may suffer from moderate to severe psychological distress and can be assisted by

community/family support

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With increasing awareness promoted the beneficiaries need to have access to relevant essential drugs at primary health care level. The current policy in Haiti is not yet enabling this access because only medical doctors are allowed to prescribe psychotropic drugs

Interventions need to be based on the socio-cultural context in which they take place. It is

therefore recommended to collaborate with community leaders, existing community structures such as the church and schools and with traditional healers.

5 Strengths and weakness

The program has several elements that are evaluated as real strengths. However the program has also its weaker elements. A summary of both are presented below Strengths The efforts and determination of the Mental Health Team of Cordaid to implement the quite

ambitious program in a relatively short time Effective demystification of mental illness in the targeted zones. “We all used to go to the

‘hougan’ , the witchdoctors”. The Cordaid MHPS program has created hope for the treatability of mental illness. Cordaid’s existing and new partners have been made aware also of mental health and psychosocial problems and ways to address them.

Combined package of psychological, psychosocial, recreational and material support proves highly appreciated by the target communities.

Geographic coverage of zones where no one else provides PS assistance Investing in capacity building of so many people is a potential valuable resource for future

projects The development and application of an excellent monitoring system. The data, if put and kept in

an electronic database, represent a potential source for future publications. Weaker elements Collaboration with the MoH Vertical, rather top down approach of the program and humanitarian logic. Has affected the

relationship with the partners, rendered them instrumental rather than real partners of Cordaid. High costs of the program compared with the socio economic reality of Haiti. Lack of organizational structure to promote integration of mental health in primary health care

including the development of a referral system. Of course this can not be done overnight and a first step has been taken by training health professionals.

Ownership by the local partners Underutilization of data for improving the program; limited sharing of data outcome with

partners, community agents and health professionals. Centralized management of data.

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Risk that the humanitarian approach has created dependency of partners and beneficiaries. Building the capacity of communities to take care of themselves and strengthening existing structures to incorporate psychosocial assistance is a more sustainable approach but may not be realistically applied in 7 months

6 Lessons learned

The vertical approach at the inception and throughout implementation of the program has

affected the relationship with the partners. They demand a greater say in what needs to be done to address the trauma of the earthquake.

The available time proves too short to effectuate what was originally planned. There has been

little time to reflect, a focus on achieving the results and a tendency to spend and achieve a high burn rate

It proves very difficult for NGOs and government authorities to harmonize approaches and

interventions in a humanitarian context with donor pressure, time pressure, beneficiary pressure.

It proves equally difficult to het the MoH on board. Implication of the MoH is considered a

precondition by the evaluation team if Cordaid wants to work towards integration of mental health in the PHC system. Cordaid tried, got little response and choose to change it strategy and work through its non governmental partners.

7 Challenges, with a focus on future interventions Several challenges and constraints encountered by the Cordaid team in the 2 projects have been covered in other paragraphs. In this paragraph the main challenges for any future MHPS project are summarized as an input for future planning. A few scenarios are presented in the chapter on future perspectives and recommendations Reaching a balance and effective link between mental health care and psychosocial assistance

without ‘medicalization’ of problems. Challenge to collaborate with the State Ministries of Health and of Social Work. Finding a balance

between the role of civil society and the state in building the health and welfare systems Transition from a humanitarian project with short term objectives and short term budgets to a

development oriented (pilot) project The transition from raising awareness among local partners on mental health and psychosocial

care to mobilizing them to pursue a sustainable and structured MHPS action The recognition and consolidation of the capacities of community agents and health

professionals. How can we ensure that they fit in a sustainable structure. Health professionals fit well in the health system but where do psychosocial agents fit? In the Social Welfare structure? In the churches?

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Capitalization of the experience of this MHPS program so that it can be used for a strong lobby

for mental health and psychosocial care at the level of the Haitian government and of the international development agencies

How can we avoid that the beneficiaries who gained a new perspective / some hope for their

mental health problems get discouraged?

8 Future perspectives and recommendations

8.1 Short term perspective till July 2012 Consolidate the achievements of the program in a concise summary document including lessons

learned and present it to the MoH and share it with other actors in the area of MHPS support Explore whether there is an interest within Caritas Haiti (national level) to play a significant role

in the development of a MHPS system, both for the psychosocial component and the mental health component. Explore what role the Commissions for Justice and Peace and the parishes could play in awareness raising, mediating in community conflict, identification of mentally ill etc. The program has not focused on strengthening community structures beyond family structures. It may be difficult to achieve that in the short time lapse of a 7 months project and in a context where community structures have been damaged. However the church and its parishes have survived the earthquake and could probably have played an essential role

Develop a longer term approach to MHPS assistance and seek longer term funding Explore whether Cordaid could play a key role in the plan of the MoH and WHO to develop a

decentralized mental health care system with 18 multidisciplinary teams. The MoH is seeking partners who are willing to pilot and fund this decentralization strategy. Could Cordaid identify local partners who could play this role with Cordaid as funding agency and provider of technical support if necessary?

8.2 Longer term perspective beyond July 2012

Scenario 1

Cordaid could directly implement a MHPS program but this is not the preferred option for the evaluation team. Cordaid indicated to have a keen interest in exploring possibilities to introduce socio-therapy as used in Rwanda. The evaluation team has some doubts about the appropriateness of this approach in the Haitian context as the method was particularly developed for post conflict situations6 to help people reconcile and heal their trauma. The

6 www.petercaldemanfoundation.org

Introduction: In post-genocide Rwanda, many different kind of interventions have been implemented on different

levels of society focusing on the healing of psychological problems and reconciliation between victims and

perpetrators of the previous political violence. This article presents the practice of community-based sociotherapy and

its impact in terms of healing and reconciliation as well as its specificity compared to other interventions.

Methodology: A variety of qualitative research methods were used with an emphasis on the most significant-change-

stories method.

36

method played a key role in uniting people in Rwanda. It may be a less relevant method to help people cope with the effects of the earthquake which is a natural disaster that is not based on conflict.

Scenario 2

Caritas with financial support of Cordaid and/or other funding develops a longer term mental health care and psychosocial support program that is based on a community health care approach whereby existing community structures are capacitated to render basic MHPS services o psychosocial assistance could be integrated in the faith based structures such as parish

groups, CJP etc o access to mental health care could be increased gradually by training first line health workers

with regard to identification of cases and basic treatment covering counseling, treatment with essential drugs and referral to more specialized care according to need

o right from the start a referral system will need to be developed to allow community based resource persons or structures to refer to the nearest health facility

Scenario 3

A Consortium of different organizations develop a joint project proposal for a longer term PSMH program. Such a Consortium could be identified during the MH Forum meetings.

Results: Sociotherapy was introduced in Rwanda in 2005. Sociotherapy groups of 10-12 people living in the same

neighbourhood meet once a week during 2-3 hours for a period of 15 weeks. The most significant problems people

suffer from due to the political violence is the destruction of social relations.

It is in the phase of care that is usually reached during the 4th of 5th session that a change in people’s

behavior and interaction with others, including former enemies, takes place. This change results in a rerouting of their

personal, family and community life which is experienced as a release of problems previously buried in people’s

hearts. While many of the interventions in Rwanda which are specifically aimed at reconciliation result at most, in

‘thin’ reconciliation, sociotherapy resulted, in many cases, in ‘thick’ reconciliation.

Conclusion: Justice and care should complement each other when the aim is healing from the wounds of a violent

past and reconciliation along ethnic lines.

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Annexes

38

Annex 1. Terms of Reference

FINAL EVALUATION OF CORDAID’S MENTAL HEALTH / PSYCHOSOCIAL PROJECT IN HAITI

Title of the project:

Proposal for Earthquake Relief: Community-based Integrated Mental Health / Psychosocial Support Program in the earthquake-affected areas and areas of displacement of the earthquake-affected population in Haiti.

Background:

About the country Haiti is a country with an approximate area of 28 thousand square kilometers. It is located in the Caribbean Sea, about 600 miles from Florida, making up approximately one third of the island known as Hispaniola, the other two-thirds consisting of the Dominican Republic. Haiti is a very poor country. In 2008, the estimated per capita GDP was $717. More than 50% of Haitians live in an extreme poverty; for rural Haitians, the figure is higher at two thirds. Of Haiti’s 4.9 million active workforce, 85% are employed in the informal economy, 10% in the private formal sector and 5% in the public sector, including NGOs. The relatively small formal sector lacks absorptive capacity, and employment opportunities are extremely limited. Haiti has a population of more than 9 million people and is growing at a rate of 2.2% per year. The sex ratio (men per hundred women) is 98. The life expectancy at birth is 49.1 years for males and 51.1 years for females. The population of the country is young, with approximately 50% under 20 years of age; many of these youth have never attended school and have very few skills on which to base livelihoods. Out-of-school youth (OSY) who are of school age number around 500,000.

Creole and French are the official languages of Haiti; however, French is written, spoken, and understood by only approximately 20% of the population, mainly by elite and middle class urban residents. Nearly everyone speaks Haitian Creole (Kreyol) as their first language. In terms of education, 72% of the population has only a primary school education. Only 1% of the population has a university level education. There is a low level of literacy; about 80% of people in rural areas and 47% in urban centers are unable to read French. For several decades, Haiti has suffered from war, political conflict, corruption, criminality, and social unrest. The long lasting presence of the UN peacekeeping forces Minustah was unable to stabilize the country and to reduce violence and criminality. Moreover, the country is prone to natural disasters, such as draught, floods and hurricanes. The government is known to be weak and poorly functioning. Religion plays a crucial role in all spheres of Haitian life, including politics, morals and health. Haiti is characterized by religious diversity, including: Roman Catholicism, Voodoo (which combines West African traditions and Catholicism), and various Protestant traditions. The 2010 earthquake in Haiti

On January 12, 2010 Haiti was struck by a catastrophic earthquake. Its epicenter was near the town of Léogâne, approximately 25 km (16 miles) west of Port-au-Prince, Haiti's capital. An estimated three million people were affected by the quake. According to the information from the Interior Ministry of Haiti from March 10, 2010, 222.653 people were registered as dead, 310.928 were wounded, more than 1.5 million were in need of basic assistance, and 661.521 people were displaced. An estimated 250.000 residences and 30.000 commercial buildings had collapsed or were severely damaged. Mental health needs/services in Haiti

There is no epidemiological study on prevalence of mental problems in Haiti. Pre-earthquake studies found high levels of symptoms of posttraumatic stress disorder (PTSD), depression, anxiety and somatic problems in victims of conjugal violence. It was reported in a literature that the majority of beneficiaries of a nutritional program implemented by Action Contre Le Faim suffered from depression after the 2008 hurricane in Gonaive. Some authors used a conservative estimate of 190.000 people (5% of 3.8 million inhabitants of Port-au-Prince) suffering from symptoms of post-traumatic stress after the 2010 earthquake. The capacity of the pre-disaster mental health system in Haiti was weak. The available data differ depending on the source, but basically there were no more than 12 functional psychiatrists in the country, i.e. only 1 psychiatrist per approx. 800,000 people. Most of the services provided by mental health professionals were in the private sector, and in Port-au-Prince. Novel psychiatric drugs were generally available on the market, but only a small number of people with private health insurance was able to get reimbursement on their purchase of drugs. The availability of follow-up community mental health treatment was very limited, and regardless of the type of illness, family members were usually the first to be consulted regarding treatment and advice. A very large number of Haitians, especially those of lower education and economic status, make use of traditional practitioners, i.e. herbalists (dokte fey) or religious healers, i.e. houngan and mambo (male and female voodoo priests) when faced with mental problems. Also, Christian churches in Haiti help people cope with mental and emotional problems. Dispensaries (religious health facilities) and herbalists were by far the most common choice for treatment (80% of all consultations), since they were less expensive and more easily available. Hospital clinics and other types of healers were physically less accessible and their treatments more expensive. Patients are therefore referred to them less frequently (only 6% and 5% of consultations, respectively) to treat more uncommon and severe mental problems. In recent years, Haitians have mobilized a network of community resources to sensitize the population to social and health issues related to various problems such as violence against women, HIV/AIDS and children’s rights. These grassroots organizations also served as self-help and support groups for people facing severe life events and ongoing stress. Many of these

39

organizations were affected by the recent earthquake in terms of destruction of their infrastructure and loss of lives of their staff, but most of them, with the help of international community, resumed their activities to some extent very soon after the disaster. A Mental Health & Psychosocial Support (MHPSS) Working Group was established within the cluster system in Haiti in the aftermath of the 2010 earthquake, and it issued a Guidance Note for MHPSS based on the IASC Mental Health and Psychosocial Support Guidelines in Emergency Settings (Inter-Agency Standing Committee, 2007). There were about 100 NGOs active in mental health in Haiti post-earthquake, offering 17 different modalities of MHPS intervention. Various models of providing MHPSS were applied including, for example: a) local and foreign mental health professionals providing short-term direct clinical care for mental health problems including psychiatric disorders, and training lay volunteers, local psychologists and primary health care (PHC) physicians on MHPS issues, b) organization of child friendly spaces c) individual and group psychological support, d) recreational activities to beneficiaries and e) advocating for mental health issues. About the organization: Cordaid Haiti In 2010, Cordaid received funding from European Commission Humanitarian Office (ECHO) to implement mental health / psychosocial (MHPS) project in five departments in Haiti, including Department West (hardest hit by the earthquake). The other four departments were selected because many people left earthquake-affected areas after the disaster, and returned back to their homes and families in other departments; Department South-East, Department Artibonite, Department North and Department North-East. After the 2010 earthquake, Cordaid has opened the office in Port-au-Prince and also the field office in Leogane. Cordaid’s MHPS activities in other departments were also accomplished by relocation of Cordaid’s MHPS staff to these departments; Department North, North-East. Artibonite and South-East. Organisational structure of Cordaid’s MHPS program in Haiti Cordaid-Haiti is managed by a Head of Mission with the assistance of an administrator and support staff in logistics, HR/admin and finance. Cordaid’s MHPS national team consists of a a line manager (primary healthcare physician), two program assistants (primary healthcare physician and social worker) and four psychologists and four social workers in the field. They are all supported by ex-pat Mental Health Advisor (a psychiatrist with M..P.H. degree). Cordaid’s strategy for providing integrated mental health / psychosocial support in Haiti Cordaid started providing MHPS support in Department West, hit hard by the earthquake, and replicated the model and expanded its activities to other targeted departments with a high number of displaced earthquake-affected population. The integrated MHPS support was provided in a cooperation with local NGO partners, and with the Ministry of Public Health and Population (MPHP) and local health departments. Community-level workers of local NGO partners would delivered community-based MHPS interventions in targeted areas, and identify cases for referral to PHC workers. Identification, recruitment and series of short (three to five day) mental health trainings of community-level workers would be accomplished by the Cordaid’s mental health team comprised of general practitioners, psychologists and social workers, and supported by general practitioners and international and local psychiatrists as outside consultants. At the same time the programme aimed to initiate a process of integration of mental health into primary health care by training PHC workers of local NGO partners and the government, thereby establishing a referral system between targeted communities and the health system.

Overall Goal of the Evaluation

The overall goal of the evaluation of Cordaid’s MHPS program will be measure to what extent Cordaid’s MHPS intervention managed to reach its main objective, which was to improve well-being of beneficiaries in targeted communities.

Objectives of the final evaluation

To assess to what extent Cordaid’s MHPS intervention managed to reach its three results: 1) Improve the level of MHPS knowledge of community-level workers, 2) Improve the level of MHPS knowledge of primary healthcare professionals, and also their practices and 3) Reduce level of distress in targeted communities.

To assess the effectiveness of Cordaid’s MHPS strategy in Haiti in achieving expected results

To assess the effectiveness of the organizational structure of Cordaid-Haiti and Cordaid’s MHPS team in Haiti in delivering expected results

To assess the sustainability of expected results

To make a record of lessons learnt, challenges, successes, positive and negative experience, etc. Cordaid’s specific areas of interest

Evaluation to which degree local partners have obtained ownership of the program

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Evaluation of cooperation and information sharing with other organizations involved in MHPS activities in Haiti, post-earthquake

Evaluation of effectiveness and appropriateness of the monitoring/supervision and reporting system, including

contract management

Evaluation of an efficiency of the program. i.e. to what degree are financial resources converted to results being delivered

Evaluation of impact of security concerns and related issues to proper execution of field activities

Methodology The evaluator will have access to relevant background material and documents.

The review will be carried out through:

2. Meetings and discussions with programme staff at HQ and Haiti level 3. Review of data and other quantitative parameters in regard to what has been delivered 4. Focal group discussions with beneficiaries, representives of local NGO partners, community-level workers and

coordinators, primary healthcare professionals who attended Cordaid’s mental health trainngs through field visits to selected programme areas/ sites.

5. Meetings and discussions with relevant organisations and actors, including government authorities relevant for programme implementation, World Health Organization and other international and national mental health NGO players.

6. Review of programme documents and other relevant documents related to the programme.

7. Site visits 8. Other relevant methodologies that the team in Haiti may determine as fitting in

addition to the above.

Outputs

An evaluation report is expected to be produced presenting the achievements, weaknesses, challenges, lessons learned and recommendations for possible replication. The evaluation report will be limited to 25 pages, including an executive summary and excluding annexes. An executive summary will be written in a separate paragraph providing the main analysis and core components, major conclusions in relation to the evaluation criteria, recommendations and lessons learned (total 3-5 pages). Debriefing of the findings will be presented: 1. In Haiti where participants will be programme staff and HoM of Cordaid-Haiti 2. In the Netherlands upon return. Team composition An evaluation team will be formed of which the composition will be:

1. One international external consultant / evaluator with extensive knowledge and experience of mental health / psychosocial projects in developing countries, preferably psychiatrist or senior psychologist / senior social worker

2. One independent local external consultant / evaluator with the proven record of experience in monitoring / evaluation of health and / or MHPS projects

3. One of Cordaid’s MHPS program staff , involved in the implementation of MPHS project. S/he will also act as a translator. Alternatives can be considered by Cordaid and the evaluator, according to availability and dependent on how best to constitute a supporting team

Timing The field work in Haiti will start in the first or second week of October, 2011 The schedule for the field work will be presented in a separate document to be produced by the Cordaid office in Haiti in collaboration with the consultant. The review will include two days of preparation and reading of background material, two travel days, three reporting days and 1 day debriefing in The Hague. Fieldwork in Haiti: 10 days (total 18 days) A draft review report will be submitted to Cordaid during the first week of November, 2011. Cordaid will study the draft report and submit their comments not later than mid of November, 2011. The final report will be submitted not later than third week of November, 2011.

Annexes

Project’s log frame Project’s monitoring & evaluation plan Project documents, including proposal, activity plans and budgets (on flash disk)

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Annex 2a : Outputs and outcome of the SHO & TROCAIRE funded project

SHO-Trocaire SHO-Trocaire SHO-Trocaire SHO-Trocaire

West West average % average %

Delmas Léogane correct

answers Improvement

Training community agents (total #) 31 31 %

and few others

first training pre-test 44,7 41 42,90%

first training - post test 60,4 57 58,70%

% improvement pre - post (M&E system) 34,80% 38% 3.64%

# participants 31 31

second training pre-test 45,3% 39 42,20%

second training post test 46,2% 44 45,00%

% improvement pre - post (M&E system) 1,7% 5,35% 3.53%

third and final training pre test 32% 32% 32%

third and final training post test 62% 58% 60%

% improvement pre - post (M&E system) 93,75% 181,3% 137%

West West

Delmas Léogane

Training health professionals (total #) 21 20

First training - pre test 58,60% 40% 49%

first training - post test 63,80% 43,8% 53.8%

% improvement pre - post (M&E system) 8,90% 8,83% 8,85% 8,85%

20 participants

second training pre-test n.a. 44,5% 44,5%

second training post test n.a. 70% 70%

% improvement pre - post (M&E system) n.a. 57,9% 57,9%

18 participants

third and final training pre test 30% 30%

third and final training post test 78% 78%

% improvement pre - post (M&E system) 160% 160%

West West

Delmas Léogane

Well-being test (Likert scale 7)

pre-test

Post - test

Beneficiaries of individual PS support 12555 15919 28474

Average caseload per community agent 474

Support groups

number of groups 65 78

total of people covered 765 1382

average number of session 4,16 5,6

42

Annex: Expectations and institutional benefits of partners in MHPS program Atteintes Apports au niveau organisationnel/institutionnel

SOE :

démystification du terme santé mentale

Formation reçue

Formation a un effet sur le personnel du centre et sur leur famille (application)

Renforcement du centre Caritas Gonaïves :

Formation sur la santé mentale permet une augmentation des savoirs faire dans le domaine de la santé

Expérience de travail pour ceux qui ont eu à travailler dans le projet (taux de chômage élevé et bon pour le CV des personnes qui y ont pris part)

Caritas Jacmel :

Démystification du terme santé mentale après le 12 janvier

Faire du bien à ceux qui sont dans les camps

Avoir des agents recrutés pour le projet IDEJEN :

Formation pour les jeunes dans un autre domaine

Emergence d’autres talents (aptitudes et attitudes)

Communauté a vu IDEJEN dans une autre dimension (agents pour aider)

Jeunes sont plus matures

Jeunes répliquent la formation dans le centre de formation de IDEJEN

Renforcement de la capacité des jeunes et ils deviennent une ressources pour l’organisation

MSPP Cayes Jacmel

Formation du personnel médical : démystifier la maladie mentale

Intégrer les soins de santé mentale dans les soins de santé primaire

SOFA, Cayes Jacmel :

La formation a permis aux travailleurs communautaires d’aider la population

HELP :

Formation du personnel de santé (médecins et infirmières) : sont mieux armés par rapport aux nouvelles pathologies liées au 12 janvier

Utile pour le travail lié aux droits des malades mentaux

Les cas mineurs sont traités sur place et il y a plus de références

SOE :

Connaître autres champs de travail de CORDAID

Meilleure relation, renforcement relation SOE-CORDAID

Caritas Gonaïves

Ouverture de possibilité d’autres projets avec CORDAID en santé primaire

Caritas Jacmel :

Meilleure compréhension du projet de santé mentale

IDEJEN :

Champ de travail plus large. Ex : ouverture de la filière santé mentale dans le centre de formation

MSPP :

Permet au personnel de mieux gérer les malades mentaux (faire des références)

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Annex 2b: Outputs and outcome for the ECHO funded project

ECHO ECHO ECHO ECHO ECHO ECHO ECHO ECHO

West West South East North North East Artibonite average % Average %

Martissant Petit Goave correct answers improvement

Training community agents (total #) 13 9 22 25 9 33

first training pre-test 45 40 57,6 40,2 42,4 39 44%

first training - post test 59 50 58,8 60,8 63,5 56 58%

% improvement pre - post (M&E system) 31% 25% 2,1 51,2 49,8 43,6 34%

# participants

second training pre-test 37,7 42,8 47,5 61,4 42,8 49,7 47%

second training post test 41,2 47,8 53,2 64,8 47,9 58,9 52%

% improvement pre - post (M&E system) 9,3 11,9 12 5,6 14,4 18,5 12%

third and final training pre test 35 60 45 35 35 42%

third and final training post test 87 65 95 70 68 77%

% improvement pre - post (M&E system) 148 n.a. 8 111 103 94 93%

West West South East North North East Artibonite

Martissant Petit Goave

Training health professionals (total #) 10 10 12 13 14 16

First training - pre test 29 40 44,4 45 37 39%

first training - post test 48 43,8 54,8 53 49 50%

% improvement pre - post (M&E system) 65,5 9,5 23,4 17,8 32,4 30%

second training pre-test 41 41,6 41,6 55,8 51,05 51,25 47%

second training post test 71 67,5 56,25 62,1 60,7 72,8 65%

% improvement pre - post (M&E system) 71 63,1 34 11,4 18,9 42,48 40%

third and final training pre test 32 28 41 31 32 37 34%

third and final training post test 90 69 82 89 88 83 84%

% improvement pre - post (M&E system) 181 142 99 187 185 124 153%

44

West West South East North North East Artibonite

Martissant Petit Goave

Well-being test (Likert scale 7)

pre-test 5,02 n.a. 4,26 5,54 4,57 3,63

# beneficiaries reached by different interventions 18.825 6.538 13.948 7.434 18.999 65.744

Individual psychological support 11977 6400 4673 13459 7197 16922 60628

average caseload per community agent 546

Support groups

number of groups 27 n.a. 40 65 40 163

total of people covered 448 n.a. 757 556 397 2077

average number of session 10 n.a. 2 8,5 4 5,3

45

Annex 3: Evaluation program and people met

Date Activity People met Function

7-11-2011 Welcome to the Cordaid office Dr. Rachel Bruno MHPS program manager

Dr. Boris Budosan Mental Health Technical Assistant

Briefing by the Head of Mission Piet Spaarman Head of Mission

Briefing on the project Rachel Bruno and Boris Budosan

Meeting with the MHPS team Dr Samuel Raymond MHPS program management team

Dieulita Dieudonné Field supervision teams (5)

Casseus Pierre Jude Psychologist, supervisor Delmas & Léogane (TROCAIRE)

Marie Juniste Claude Sociologist, supervisor Delmas & Léogane (TROCAIRE)

Dorsainvil Schelling Psychologist, supervisor zone WEST (Martissant & Petot Goave)

Gasner Guerrier Sociologist, supervisor zone WEST (Martissant & Petot Goave)

Gesnel Dor Sociologist, supervisor Gonaïves

Nathalie Désinor Psychologist, supervisor Gonaïves

Monique Télémaque Psychologist, supervisor zone North

Jean Baptiste Junior Ernst Sociologist, supervisor zone North

Nikencia Plaisimond Social worker, supervisor Northeast

Mézidor Michelet Psychologist , supervisor Southeast

8-11-2011 Observation Mental Health Working Group

Zohra Abaakouk Various NGOs

WHO focal point for Mental Health in Haiti

Visit to IDP camp Place des Arts Mr. xx Camp manager

,, Community agents of Cordaid program, IDEJEN

,, Few families Beneficiaries of the MHPS program in the camp

Exchange with the 2 supervisors See list above Supervisors Delmas and Léogane

Meeting at WHO Mrs Zohra Abaakouk MH focal point WHO

9-11-2011 Travel to Gonaïves

Visit Caritas Gonaïves Père Wilder Jean Baptiste Director of Caritas Gonaïves

Meeting with community agents 20 women and 3 men Community agents MHPS program Cordaid

Meeting Caritas staff Dr. Gidéon Reynold In charge of health within Caritas Gonaives

Return to Port-au-Prine

46

10-11-2011 Visit to MoH

Meeting with SOE at Fontamara 43 Dr. Mélissa Macé Health Centre of St. Michael, MoH/SOE

Meeting with trained health workers Dr. Madeleine Jean Baptiste In charge of the Health Center

Meeting community agents of the health centre

4 women and 1 men All community agents . 4/5 already working with SOE

Gasner and Casseus Supervisors zone West (TROCAIRE)

Meeting beneficiaries in Léogane Individuals and some families Beneficiaries of entire package MHPS program,

Meting community agents Léogane All community agents of IDEJEN

Meeting staff at HELP hospital Xxxxxxxxxxxxxxxxxxxxx Administrator, medical doctors (2), nurse

11-11-2011 Meeting Cordaid’s partners Dr. Madeleine Jean-Baptiste SOE, partner since 8 years

Jean Rico Piar Caritas Gonaives, partner since this project

Michaelle Brutus Caritas Jacmel, partner since this project

Chandeler Mérilien IDEJEN, partners sine 2006

Dr. Reynoald Rosemé MoH in Cayes Jacmel

Cléane Loussaint SOFA, partner since many years (?)

Eloi Bérilus HELP Hospital Léogane, partner since earthquake 2010

12-11-2011 Second meeting with MHPS team Rachel, Samuel, Junise, Dieulita, Boris

Management team MHPS program

xxxxxxxxxxxxxxxxxxxxxxxx Supervisors of the Delmas, Leogane, North, Notheat, Gonaives, West

Meeting trainer Maxo Psychologist, trainer of both cadres

13-11-2011 Travel to Fort Liberté

Briefing Nicensia Plaisimont Supervisor Zone Northeast

Meeting with trainer Olivia Marie Paul Interpreter, psychologist, trainer

Meeting beneficiaries 2 women in separate homes Beneficiaries Rue St Jean

Meeting supervisor Northeast

Visit Caritas Mednel Angrand Director Caritas Fort Liberté, parish priest Malfeity

Saint Hervé Therver Programme coordinator Caritas Fort Liberté

Meeting community agents 5 women and 2 men Community agents Cordaid MHPS program; mainly students

Meeting trained health staff 3 women and 1 man 2 doctors and 2 psychologists working in hospitals/health centre

14-11-2011

15-11-2011 Preparation debriefing

47

Debriefing Piet Spaarman Country Director

Dr. Rachel Programme coordinator

Dr. Samuel Assistant program coordinator

Dr. Boris Technical assistant

Follow up missing information

Agreement on tasks with evaluation team

Nene Mathurin Katia Henrys Geertruid Kortmann

16-11-2011 Departure to the Netherlands