C2C Maternal Health Program

Haiti has the worst maternal and infant health outcomes of any country in the Western Hemisphere. Two of our clinics offer our Maternal Health Program which includes all necessary vaccinations, counseling with a midwife, consultation with an OB-GYN, ultrasounds, lab tests, prescriptions for any infections and for prenatal vitamins, and a birth plan, which increases the chances of giving birth in a health facility with a skilled attendant. Our EMR system tracks each pregnancy and ensures quality by monitoring adherence to birth plans and recording visit information in one place.

Too many women in Haiti do not have access to quality prenatal care. Most of our clinic communities have no other option for high-quality healthcare, especially maternal care. Scaling our solution across Haiti and globally to similar geographies would provide more women with the care and resources they deserve and lower maternal and infant mortality and morbidity in vulnerable communities.

Care 2 Communities (C2C) is working to address maternal and newborn health challenges in Northern Haiti. Only 67% of pregnant women receive the WHO-recommended prenatal visits which are crucial to monitor fetal growth, manage hypertensive conditions, screen for complications, and prepare women for safe, assisted deliveries. Only 41.7% of women in Haiti give birth with a skilled attendant and only 39% of women deliver in a health facility. In the postpartum period, women are at risk for hemorrhage and infection and newborns are vulnerable to poor feeding practices and compromised nutrition. Although more than 96% of Haitian women initiate early breastfeeding after delivery, only about 41% of infants are exclusively breastfed for the first three months of life.

This grim reality for Haiti’s most vulnerable citizens is exacerbated by the fact that people cannot access high-quality health facilities. Despite all of the foreign aid interventions in Haiti, the nation’s public health system is profoundly under-resourced and under-capacitated. A study in the Bulletin of the World Health Organization found that while 91% of Haitians live within 5km of a health facility, only 23% live within 5km of a high-quality health facility.

Care 2 Communities' Maternal Health Program is a part of our primary care model. We strongly believe that no woman should die due to preventable causes related to pregnancy/childbirth. Our program ensures that pregnant women in Northern Haiti have access to prenatal visits; have safe birth plans in place well before delivery; have accurate information about prenatal and postnatal care; and that as healthcare providers we emphasize counseling/education at every stage of the ANC protocol to encourage health-seeking behaviors. C2C educates women on keeping their infants healthy following delivery and we provide free immunizations to all children under five.

This quality of care would not be possible without our EMR system, which allows our staff to track each pregnancy as well as the health of mother and child after delivery. Our clinical staff capture data from each patient visit which is then collated into reports that, over time, show important trends in the patient population. C2C also performs in-depth community surveys for general feedback, reasons for coming to the clinic, and whether they will return. Our technology solution enables us to record and report patient data that help measure services and impact and ensure patients receive the highest quality care.

In a catchment area of 250,000+ people. Our Maternal Health Program serves 2,000+ women annually with specialized antenatal care (OB/GYN or nurse/midwife visits, diagnostics including ultrasounds, pharmaceuticals, counseling, and the development of safe birth plans), education, and social support through our clinics at Camp Coq and Acul du Nord.

Our clinics serve approximately 45% children, 35% women, and 20% men. C2C’s clinic model has always included a local Steering Committee, comprised of community members and stakeholders who advise about clinic operational decisions and community relations. We have formed a similar Women’s Advisory Committee to provide input and guidance about how our maternal health and related sexual and reproductive educational programming is developed.

As an organization, C2C employs its “Theory of Change” to evaluate our impact across all areas (primary care, maternal health, family planning). We posit that four key pillars are essential to achieving meaningful health impact: Access, Quality, Health-Seeking Behavior, and Financial Sustainability. By improving access, quality, and health-seeking behavior, poor/low-income patients will realize improved health outcomes (both short-term and long-term gains). Expanding access to high-quality, affordable healthcare to all the patients we serve throughout our network is at the core of our organization, and this applies specifically to newborns, pregnant women, and new mothers within our Maternal Health Program.

No other organization in the North of Haiti provides healthcare in the way that C2C does. Haiti’s health services market is dominated by low-quality public clinics, high-cost private clinics, and siloed and fragmented aid interventions. The WHO estimates that 91 percent of Haitians live within 5km of a health facility, but only 23 percent – including just 5% of the rural population – have access to high-quality primary care. There are many church and NGO groups providing free and subsidized care, but those clinics operate only as long as donor contributions are available. There are also highly-priced private sector clinics, making these clinics inaccessible to the poor. C2C clinics fill this huge gap in the market by combining a social business approach (charging small fees for primary care and offering subsidized services for maternal health and family planning) with a public-private partnership with the Haitian Ministry of Health (in which we rehabilitate and manage the operations of government clinics while maintaining salary support from the government). Our unique approach ensures sustainable, reliable reproductive health care and access to family planning.

C2C’s custom EMR system sets us apart even further, especially in Haiti. Many of our clinical staff members remark that they have never worked with electronic records before coming to C2C and how much it improves communication and quality of care. Our EMR system is especially crucial for our Maternal Health Program, as it allows our staff to track pregnancies and ensure adherence to birth plans.

Our EMR system is the core technology behind our unique healthcare delivery model. Our business model relies on this technology to ensure smooth clinic operations, quality of care, and tracking of business metrics. Our community-based social enterprise “solution” to healthcare in Haiti incorporates a public-private partnership with the Haitian Ministry of Health, “one-stop-shop” comprehensive primary care services, specialty services including maternal health and malnutrition care, community health and education, local supply chains and locally hired staff, and financial sustainability.

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

Electronic medical records (EMR) are used in high-quality health facilities all over the world. When we created our model, we did not want to compromise on quality of care, even if EMR systems are not as common in Haiti. Indeed, most clinics rely on traditional paper records which are time-consuming, are more prone to errors, and can hinder doctor-patient communication. EMR is essential in reducing medical errors, facilitating treatment protocols, and helping doctors and patients to make better decisions together. It is especially important in regards to our Maternal Health Program, as it allows our clinical staff to track the duration of the pregnancy and record each visit, while ensuring that women attend all necessary prenatal visits and stick to their birth plan. We are fortunate enough to have a robust system that works in spite of our clinics being located in remote areas without access to a WiFi network. 

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

In 2019, C2C’s clinics saw 2,245 maternal health visits. We currently offer our Maternal Health Program at two of our seven clinics, but are prioritizing the expansion of it to the rest of our network. If we can expand to just one more clinic this year, we would be on track to have 3,000+ maternal health visits for 2020, and if we can expand to the rest of the clinics currently in our network in five years, that number could jump to 7,000 visits by 2025.

Our Executive Director, board, and leadership team are currently finalizing a three year plan which will guide the organization through significant growth. We will continue to expand our network of clinics to other departments within Haiti where we can replicate our model and have widespread impact. We are also turning our vision outside of Haiti and towards other parts of the Latin America and Caribbean region. Our model can be adjusted to fit within other regional healthcare systems and in collaboration with other national governments. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Maternal and Newborn Health Challenge from MIT Solve provides C2C with the opportunity to present our Maternal Health Program as a true solution to a complex global problem, especially in the ever-challenging context of Haiti. Solve will give our organization the chance to grow and learn from like-minded organizations and reaffirm our focus on women’s health in developing countries. We know that women in Haiti need greater access to quality prenatal and postnatal care, and even though many barriers exist, that only motivates us more to deal with this challenge.

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

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

Our innovation is women-focused, as we strive for improved health outcomes for women and children in our catchment area. Our program is reliant on our electronic medical records system which records each maternal health patient visit and facilitates communication between staff and patients, ensures adherence to birth plans, tracks that women are attending all necessary prenatal care visits, and keeps track of all lab work, medications, and other vital patient information. Haiti has the poorest maternal and infant health outcomes in the Western Hemisphere, and with our Maternal Health Program, C2C is working with the communities we serve to change that so that fewer women and children die from preventable causes related to childbirth.  

C2C's maternal health staff are committed to improving the lives of the women and children they serve. We ensure that our staff have the best training available and the tools and resources they need to provide the highest quality of care. This includes our customized EMR system. Our EMR sets us apart from organizations doing similar work in our catchment area and we make sure our staff has the training they need to operate the system successfully, as many have never used electronic medical records before--rather, other hospitals and clinics in Haiti oftentimes still use paper records which are prone to human area and impede on quality. Our EMR is especially key to the success of our Maternal Health Program, as it helps our staff track pregnancies and remind women to attend all of the WHO-recommended prenatal visits to prepare them for safe delivery and healthy babies.