BOUCAN CARRE, Haiti — The people who live in this part of Haiti’s Central Plateau need more of pretty much everything that makes life safe, comfortable and predictable.
Three-quarters of families do not have enough food and two-thirds do not have access to clean water. Thirty percent of households are headed by women, and 40 percent of children are not in school. One in four children is unvaccinated, and half are underweight. About 80 percent of houses do not have latrines, and 60 percent of farmers do not own the land they cultivate, according to a survey of 5,200 families in the commune, or county, of Boucan Carre.
Is it realistic for people to make headway against so many problems on their own? Several centuries of poverty would suggest the answer is no.
Would a personal assistant help? An experiment here may answer that.
Half of the commune’s 10,000 households are being assigned a “household development agent” — a neighbor who will work as a health educator, vaccinator, epidemiologist, financial analyst, social worker, scheduler and advocate all at the same time. With the agent’s help, a family will assess its needs and come up with a plan to make things better.
“The idea is to forge a relationship from the get-go,” said Maryanne Sharp, an official at the World Bank, which is overseeing the $4 million project. “We want the family to say, ‘Yes, we own the plan, and we will work on these objectives on this timetable.’ ”
The commune’s other 5,000 households will function as a control group, continuing as they have, scrounging out a living in one of Haiti’s poorest and most isolated places.
In two years, the families will be resurveyed and their children and houses reexamined. If those with agents are doing better, then the strategy of coaching people out of poverty may be expanded throughout the country.
The experiment, aided by Haiti’s health ministry and run by two charities, Zanmi Lasante and World Vision, acknowledges several realities of life here.
One is that fixing just one of a poor family’s many problems — say, access to medical care or substandard housing — may not make much difference. The second is that house calls are the most efficient way to reach people in rural areas. The third is that finding help in a place where more than 900 nongovernmental organizations operate — and provide 70 percent of the health care — can be daunting and confusing.
The all-encompassing nature of the job is not the only unusual feature of the project, which is called Kore Fanmi — “family support” in Creole. The agents will also be eligible for pay-for-performance (P4P) bonuses.
“If their families perform better, they will receive more salary,” said Francesca Lamanna, a World Bank economist who oversees the project. “This will help them do their jobs better.”
P4P is rapidly becoming a feature of American medicine, including with Medicare. But it is “kind of a new fad in global health,” said Amanda Glassman, an economist at the Center for Global Development in Washington. Evidence suggests it improves outcomes, at least for a while. Critics worry that it may lead to people gaming the system and undermine professionalism.
“These World Bank experiments are going to be very useful to generate knowledge, not just for Haiti but for other countries that are interested in doing this,” Glassman said.
Three communes are getting agents. Boucan Carre has a population of 50,000. About 3,200 people live in town; the rest live in smaller settlements down numberless tracks and footpaths.
Zanmi Lasante, the organization co-founded by physician Paul Farmer, has worked in the area for more than two decades and is running the development-agent experiment. On a recent day, commune leaders were invited to come hear about it.
The town is 45 minutes up an unpaved road from the highway. The trip in is a glimpse of life in a Haitian valley.
A man in a black suit and a woman in a white dress saddled horses to go to a funeral. Three men stopped at a stream the road crosses to wash their motorbikes. Girls in school uniforms and matching hair ribbons walked past tethered goats grazing, farmers hoeing and people sitting. Some of the houses are detailed in pastel colors; others are covered with cracked stucco tinted merely by dust.
On a hillside above town, the 21 community leaders sat in a gazebo with a roof held up by concrete pillars. All were men. They included several pastors and at least one voodoo priest. Leading the discussion was Adrienne Noel, a 40-year-old nurse with Zanmi Lasante. Her T-shirt had a slogan in Creole saying approximately, “The great national effort for the health of children.”
She told them that the agents were already collecting information about each household — the data included measurements of each child’s arm circumference to gauge nutritional status — that would be used to calculate a “vulnerability score.” The score would determine the priorities of the development plan and the frequency of visits, up to twice a month.
Twice monthly, Noel said, the agents would hold gatherings called “rally posts” at which they would immunize children or hold educational sessions for targeted groups, such as teenagers and young mothers. Each agent would have an up-to-date “opportunity map” — essentially a Yellow Pages to government offices and charities, the services they offer and how to apply for them.
She emphasized, however, that Kore Fanmi is not a giveaway program. There have been many of those in Haiti, especially since the earthquake of January 2010.
“It is important to have the family contribute. If they get help building a latrine, the family can at least dig the hole or carry the materials,” Noel said. “It is important not to promise things, because people would then expect you to do things for them.”
After three hours, the meeting wound down. Lunch — beans and rice, chicken and vegetables — was brought in from town in urns and dished into plastic bowls.
Most of the men had met the agents in their communities. The meeting nevertheless was a revelation to many.
“I now realize the program isn’t about getting a free house, or sacks of rice and containers of oil,” said Francois Charles, a 37-year-old wearing a red Carlsberg beer shirt. “It is about working with people.”
“And working with people with respect,” said a man a few seats away.
The group stood, and a man prayed and wished everyone a safe trip home. A few who lived close by stayed around and helped clean up, tossing chicken bones to dogs scavenging beneath the gazebo.
The agents, about 50 of them, arrived the next day and gathered in the same gazebo. The meeting began with the singing of a hymn.
Hired in January, they have on average a ninth-grade education. Even with that level, which was lower than planned, few women qualified.
They spent multiple week-long stays in the nearby town of Hinche learning what a vaccine does, how to calculate a dosage and how to give an injection. They learned about ways to purify water and get a micro-finance loan. They learned how to raise consciousness, even as theirs was being raised.
“The human rights framework is a very new view for a lot of them,” said Kate Thanel, a 28-year-old American employee of Zanmi Lasante who helped write the illustrated booklets the agents use. “Things like domestic violence and the rights of women and children are things we’re just starting to talk about in these rural areas.”
Each agent is assigned about 100 families. The salary is $177 a month. (One woman quit a $125-per-month job as a teacher to become an agent.) They are eligible for a 20 percent bonus based on their performance, as judged by records and audits, and on the improvements in their families’ status, as judged by things such as children being in school and fully vaccinated.
One of the agents is 22-year-old Mirlande Renelien. She and her husband live on rented land in a 20-house settlement called Trenka. They grow corn, wheat and millet, and hope her salary will allow them to also buy some animals.
Renelien, in a bright green top, stood out not only because she was one of the few women but also because she was seven months pregnant. She had walked five hours to the meeting.
The meeting did not get finished until midafternoon — too late for starting the trek back to Trenka. Renelien would spend the night with a cousin in Boucan Carre.
Carrying her Kore Fanmi backpack, she headed down the hill into the village. At dawn, she would trudge back home, one weary soldier in a battle to make life in Haiti a little bit easier.