Message from Paul Farmer, Special Adviser to the Secretary-General on Community-Based Medicine and Lessons from Haiti

Since 1983 I have worked in Haiti in many capacities, including as a physician aiming to improve medical care. For the first decade of that endeavor, I operated as many nongovernmental organizations (NGOs) still do today: my assumption was that my colleagues and I could do a much better job of caring for the poor and the sick than any Haitian public institution. This was an unconscious assumption: ignorance, not arrogance, was the primary driver of this approach. After ten years of struggle in my initial headstrong, do-it-yourself mode, I began to see that my philosophy, not the Haitians’, needed to change. If Haiti was ever to have a healthy, robust means of caring for its citizens, then working with and through public institutions was the only way to achieve meaningful results.

Since my colleagues and I came to that realization, we have been gratified to see some significant success in Haiti and elsewhere. At Zanmi Lasante, our Haiti-based partner, only a handful of the thousands of employees are non-Haitian. My hope is that others who are spending time and resources in various sectors for the country's recovery will benefit from my past mistakes and adopt accompaniment as their modus operandi.

Accompaniment is a two-pronged approach. The actor who aims to help—be it a foreign government, a multilateral institution, or an NGO—must first work with the Haitian ministries to develop and implement policies which reflect the needs of all citizens. It must then strengthen the relevant Haitian public sector entity to support that institution’s local staff and the population it serves. Both of these prerequisites require time and financial support.

What does accompaniment look like in practice? It includes direct budgetary support for national and local government entities; strengthening existing infrastructure in the public sector; training of public sector employees; and supporting staff salaries. In our effort to provide direct services to the people of Haiti we have to remember that we cannot and should not try to replace public sector activity, for it is the foundation for sustainable self-sufficiency.

Accompaniment of public sector employees includes working shoulder-to-shoulder with Haitians on a daily basis. For every dollar spent in Haiti, we have to ask: What is the investment for the long-term? Are we building infrastructure that has been included in local development plans? Are we creating local jobs? Are we paying salaries of teachers, doctors, nurses, police, and civil servants? Are we giving money directly to government agencies that provide services? In the end, we have to accompany Haiti at both the national and community level. Doing so requires us to think differently about the way we work. It’s not easy; it will be frustrating; but doing “business as usual” will only repeat our past failures. Let’s learn from our mistakes and make every effort to accompany the government and people of Haiti.

A strong public sector is what will lead to better outcomes and sustained social programmes in Haiti. The ultimate guarantor of social, economic, civil and political rights is a country’s democratically elected government and government agencies which develop, implement, and fund policies based on citizen needs. If we truly mean to help Haiti, it is toward the strengthening of these institutions that we must work the hardest.

Paul E. Farmer
Special Adviser to the Secretary-General on Community-Based Medicine and Lessons from Haiti